Hemostasis at skin graft donor sites: evaluation of topical agents.

Blood loss from split-thickness skin graft donor sites may be significant. Various topical agents have been used to decrease this blood loss, including thrombin and epinephrine solutions of varying concentrations. We describe a K-Y jelly/epinephrine mixture that serves both as a lubricant for the dermatome and as a hemostatic agent. This mixture, in comparison with other topical agents, produces rapid hemostasis and offers the advantages of easy use, ready availability, and low cost. The blood loss savings based on this hemostatic technique is quantifiable and significant.

Surgical repair of pressure ulcers.

A team approach is required for the surgical management of the spinal cord-injured patient with a pressure ulcer, beginning preoperatively with patient selection and preparation, continuing through wound debridement and flap closure, and progressing to rehabilitation and patient education. Although possible surgical complications are numerous and the recurrence rate is relatively high, the surgical management of patients with pressure ulcers can be very rewarding. Goals for surgical closure of pressure ulcers include reduction of protein loss through the wound, reduction of rehabilitation costs, prevention of progressive osteomyelitis, and improvement of patient hygiene. The ultimate reward is the restoration of patients to the rehabilitated sitting position so that they can enjoy productive and happy lives.

Methods of reconstruction.

This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to microvascular tissue transfer. The simplest reconstructive option must be chosen to suit the defect and to achieve the least possible donor morbidity. The most suitable reconstructive choices are discussed for each of the following situations: to provide a large surface area, to provide hair-bearing tissue, to fill "dead space," to restore motor function, or to provide composite bone and soft-tissue structures.

Smoking: adverse effects on outcomes for plastic surgical patients.

Smoking is known to have a potentially adverse effect on the outcomes of plastic surgical procedures and, in particular, on wound healing. Numerous clinical studies have substantiated that cigarette smokers are at increased risk for wound healing problems. Cigarette smoke contains a number of toxic products. Of these toxins, nicotine has been studied in detail and is known to inhibit macrophages and fibroblasts, potentiate vascular thrombosis, and cause vasoconstriction. Carbon monoxide combines with hemoglobin to form carboxyhemoglobin, which reduces oxygen availability to tissues. When operating on cigarette smokers a few options exist that may improve outcomes: less undermining with rhytidectomy; sympathetic blockades; limited use of alternate nicotine sources; and of course smoking cessation, which is ideal.

General principles of flap reconstruction: goals for aesthetic and functional outcome.

Plastic surgeons are often requested to reconstruct defects following traumatic injury or after tumor ablation. These defects most commonly occur in the head and neck region and in the extremities. Reconstructions must balance the aesthetic and functional goals against morbidity of the donor site. This article provides a better understanding of reconstructive flaps through application of general principles. Flaps are classified according to type. Characteristics of both the donor site and the reconstructive recipient site are then explored. Case examples serve to illustrate the general principles enumerated.