Consideration on Flap Surgery in Vegetative Patients Having Nosocomial Infection

PURPOSE: The vegetative state is a clinical condition with complete unawareness of self and environment, but with preservation of brain-stem functions. Vegetative patients may have nosocomial infections in their wounds, such as pressure sores and infected craniums after cranioplasties. Flap surgery is usually necessary for those wounds, but decision of undergoing surgery is difficult because of various adverse conditions of vegetative patients. We share our experience of several successful flap surgeries in vegetative patients, and evaluate obstacles and requirements to obtain satisfactory results. METHODS: From December 2005 to September 2008, a total of 4 vegetative patients underwent surgeries. In case of 2 patients with infected artificial craniums, scalp reconstructions with free flaps were performed. In case of other 2 patients with huge pressure sores with sepsis, island flap coverage of wounds was performed. Retrospective study was made of hospitalization period, vegetative period, number of surgeries performed, underlying diseases, causative bacteria, and contents of informed consent. RESULTS: Mean hospital day was 14 months and mean vegetative period was 17.5 months. Patients underwent average of 4.5 surgeries under general anesthesia. There were several underlying diseases like hypertension, DM, CHF and chronic anemia. MRSA (Methicilinresistant Staphylococcus aureus) was cultured from every patient's wounds. Informed consent included a warning for high mortality and a need of attentive familial cooperation. CONCLUSION: There are three requirements for doing flap surgeries in vegetative patients. First, to prevent aggravation of brain damage and underlying diseases by general anesthesia, multidisciplinary team approach is needed. Second, operation should be beneficial for prolonging patient's lifespan. Third, because postoperative care is very difficult and long hospitalization is needed, detailed informed consent and highly cooperative attitude of family should be confirmed before operation.

Is It Necessary to Use Dextran in Free Flap Surgery?

PURPOSE: Low-molecular-weight dextran is one of the most frequently used antithrombotic agents in microvascular surgery, but there is controversy whether it has the real benefit in the clinical aspects or not. The purpose of this study is to evaluate the effect associated with postoperative use of low-molecula-weight dextran in breast reconstruction by free TRAM flap patients. METHODS: From January 2002 to October 2008, we reconstructed 88 cases of postmastectomy deformity using the free TRAM flap. They were divided into two groups: a group with no use of dextran(66 patients, control group, Group A) and a postoperative low-molecular weight dextran loaded group(22 patients, Group B). We assessed number of flap survival, rate of complication like hematoma or seroma, total amount of drainage from operative wound, duration of drainage, and amount of transfusion in each group. RESULTS: There was no total flap loss and every flap was survived. Total amount of drainage on post-operative 5 days were 857mL in group A and 1101mL in group B. Drain was kept for average of 7.3 days in group A and 8.7 days in group B. Packed red cell transfusions were made in average of 3.3 units for group A and 3.0 units for group B. Group B showed significantly higher values in former 2 comparative parameters than group A. CONCLUSION: There was no definitive advantage of anticoagulants in elective free-flap surgery in terms of success rate. However, groups with using anticoagulants had the increased bleeding tendency in immediate postoperative period. The routine use of anticoagulants in elective free-flap surgery should be reconsidered with postoperatively less bleeding and early recovery.

Clinical Considerations on Contamination Rates of Cryopreserved Autologous Fat

PURPOSE: Autologous fat graft is a widely accepted technique used for soft tissue augmentation. Nonetheless, the use of fat graft is limited due to unpredictable survival rates and repeated grafting. To avoid repeated grafting, cryopreserved fat graft technique has recently been widely used. On the other hand, the number of patients with chronic infection (who received cryopreserved fat injection) has currently been increasing. This study is focused on the safety of cryopreserved fat injection from the infection. METHODS: We collected 150 samples from local aesthetic clinics to examine the safety of cryopreserved autologous fat. To test for microbacterial contaminations of the cryopreserved fat specimens, microbacterial cultures & antibiotics sensitivity tests were performed. Then, we examined possible correlation between the preservation period and donor sites, focused on the results of microbacterial culture. RESULTS: Cultures were positive for Staphylococcus epidermidis in 5 samples (methicillinresistant Staphylococcus epidermidis in 4 samples), Micrococcus species in 3 samples. An average duration of preservation was 191 days and there found no significant correlation between the duration of preservation and microbacterial growth. CONCLUSION: Staphylococcus epidermidis was the leading cause of cryopreserved fat contamination, and the resistance to methicillin is common. Based on the above results, aseptic handling of fat during harvesting and preservation appeared to be most important.

Diverse Applications of Dermabond(R)(2-Octylcyanoacrylate) Pasting for Postoperative Wound Management

There are frequently limitations to general wound dressing in some cases. Dermabond(R) has been available as a skin closure alternative. The purpose of this study was to apply this topical skin adhesive in postoperative wound management. Dermabond(R) was used for postoperative dressing in total 62 cases; group A includes wounds of the perineum & anus, which have greater chance of contamination(N=16), group B includes wounds located in hairy areas, which are difficult to cover up (N=21), group C includes wounds in children or bed-ridden patients, who have poor compliance (N=6), and group D includes wounds in patients who underwent free flap operations(N=19). There were no infections in group A by separating the wounds from infection sources. Dressings in group B were done much more simply and comfortable. There was increased compliance of patients in group C, as patients could wash around the wound. It was possible to carry out real time monitoring in group D as the simply coverage of the wound. Using Dermabond(R) after primary closure was found to be efficient in the management of wounds near areas with greater chance of being contaminated, wounds which are hard to cover up with dressing materials, wounds in patients with poor compliance, and wounds requiring frequent observation.

Differences in mandibular anterior alveolar bone thickness according to age in a normal skeletal group / 대한치과교정학회지

OBJECTIVE: The purpose of this study was to determine the changes of mandibular anterior alveolar bone thickness with age. METHODS: Cephalometric radiographs of 160 skeletal class I patients (male 80, female 80) with normal vertical growth pattern was investigated by measuring the buccolingual thickness of mandibular alveolar bone on the basis of root axis. RESULTS: As the age increases, both male and female showed a significant decrease in buccolingual width of the mandibular anterior alveolar bone and in the width of mandibular anterior lingual alveolar bone except the CEJ area of females. However, there was no significant difference in the thickness of mandibular anterior buccal alveolar bone and in the width of maximum prominence of mandibular symphysis with age. CONCLUSION: From the above results, it is concluded that Korean children whose growth pattern is sagittally skeletal class I with a vertical normal growth pattern have a greater mandibular anterior lingual alveolar bone width than Korean adults; therefore, lingual movement of mandibular incisors, which is usually accompanied in extraction treatment, is considered to be more preferable in younger patients.

Ingestion of orthodontic anchorage screws: An experimental study in dogs

Foreign bodies with a sharp edge which are accidentally swallowed are likely to become lodged in the stomach. An animal study was undertaken to determine the outcome of orthodontic anchorage screw ingestion. The radiographic findings of ten Mongolian dogs that ingested a total of 10 orthodontic anchorage screws and 10 reamers (both a screw and a reamer per dog) were evaluated. The study showed that all orthodontic anchorage screws and reamers reaching the stomach spontaneously passed, with the exception of two reamers. Further investigation of clinical cases might be necessary to determine whether the results of our animal study are in accordance with clinical findings.