Facing chronic illness: the family support model and its benefits.

With the aging of the population and the evolving health care system, it is more important than ever before that individuals be actively involved in selfcare activities and that individuals and families receive education and support to help them cope with chronic illness. This article describes a model family support program which operates within a hospital setting to provide information, education, support, and respite services. This model is based on an extensive research base which underscores the value of this model both for the individuals and families involved and for the health care system.

The pregnant plastic surgical resident: results of a survey of women plastic surgeons and plastic surgery residency directors.

Pregnancy during plastic surgery residency poses unique challenges to the resident herself, to her resident colleagues, and to her residency director. Studies of the effects of pregnancy have been conducted that have combined all medical specialties or have included all surgeons as a statistically uniform group. The Women Plastic Surgeons' Caucus Committee of the American Society of Plastic and Reconstructive Surgeons has conducted a survey in order to obtain objective data on maternal fetal complications, time off work, maternal leave policies, call coverage, and other important issues. Response rates were 40 percent for the women residents and 45 percent for the program directors surveyed. The results show a 57 percent overall complication rate (excluding miscarriages), a 26 percent elective abortion rate, and a 33 percent infertility rate in women plastic surgeons, numbers that are higher than those currently in the literature. Data obtained regarding issues such as time off work, planning of pregnancy, call coverage, productivity and income, perceived peer support, program directors' opinions and policies, and possible solutions that might provide a mutually rewarding outcome are presented for discussion.

Use of tissue expander for tamponade of presacral hemorrhage. Report of a case.

A silastic tissue expander has been used to tamponade severe presacral hemorrhage in a patient undergoing abdominoperineal resection for rectal carcinoma. This technique may be applicable in similar cases when tamponade is required for uncontrolled venous hemorrhage. The presence of an expandable pelvic prosthesis may be of use postoperatively in avoiding radiation-associated small bowel injury.

A one-stage nipple reconstruction with the "modified star" flap and immediate tattoo: a review of 100 cases.

Nipple reconstruction employing both grafts and local flaps has historically been a staged procedure. This paper presents a one-stage procedure using a local flap with immediate tattoo that has the advantages of high patient satisfaction and low cost. The procedure can be performed in a minor surgery suite with local or no anesthetic in 15 to 30 minutes. In this series of 100 nipples there has been only one partial necrosis, which was easily corrected with a "boost" procedure. Only 8 percent of patients required revision procedures in the office, and there have been no infections or wound complications. Patient satisfaction and compliance have been excellent because the procedure is fast and easy with minimal morbidity. Modifications in technique are presented, based on the type of breast reconstruction (implant versus flap), local scarring, and size and color of the opposite nipple-areola complex.

Immediate TRAM flap breast reconstruction: 128 consecutive cases.

The purpose of this article is to determine whether or not the transverse rectus abdominis musculocutaneous (TRAM) flap procedure is a practical operation for immediate breast reconstruction. Our series reports 128 consecutive patients who underwent immediate breast reconstruction with the TRAM flap from 1985 to 1990. Of these patients, 86 underwent conventional TRAM, while 40 underwent free TRAM breast reconstruction. Two-thirds of the patients underwent bilateral breast reconstruction. Comparison within this series of the free TRAM versus the conventional TRAM flap revealed improved statistics with regard to the free TRAM flap in a shorter hospitalization time and a decreased incidence of fat necrosis. There is no evidence to date that there is an increased chance of local recurrence with immediate breast reconstruction in this series, and chemotherapy was delayed in a single patient because of healing problems after immediate reconstruction. Operative times and the complication rate seem to be improving as compared with other series previously reported. The TRAM procedure, particularly the free TRAM procedure, is a primary choice for immediate breast reconstruction after mastectomy.

An analysis of Le Fort I maxillary advancement in cleft lip and palate patients.

We present a series of 24 consecutive cleft lip and palate patients aged 16 to 46 years (mean age 27 years) who underwent Le Fort I maxillary advancement by the senior author over the past 8 years. Two groups, one of 12 patients with wire fixation and one of 12 patients with miniplate fixation, were evaluated. Each group had 10 unilateral and 2 bilateral clefts. All patients were grafted with autogenous bone (8 cranial, 14 iliac, and 2 mandibular). Horizontal advancement was 3 mm to 2 cm (with a mean of 7.8 mm). Vertical movement ranged from a shortening of 5 mm to a lengthening of 1.3 cm (mean 2.3 mm of lengthening). The amount and timing of relapse were compared in both the horizontal and vertical dimensions. The plated group was more stable in both the horizontal and vertical dimensions (p < 0.05). No significant skeletal relapses occurred after the first year. Statistically significant dental relapse occurred only in the wired group. Three patients developed transverse collapse of the small maxillary cleft segment, and four developed incisor angulation to compensate for maxillary skeletal relapse. The presence of a pharyngeal flap at the time of advancement appeared to increase relapse in both horizontal and vertical dimensions (p < 0.03), but there were too few patients (7 of 24) with pharyngeal flaps to prove this conclusively. We also concluded that pterygomandibular grafting is not necessary to achieve excellent results using miniplate fixation; autogenous grafting of the anterior maxillary osteotomy alone provides the necessary stability.

Electroglottography and vocal fold physiology.

The electroglottogram (EGG) is known to be related to vocal fold motion. A major hypothesis undergoing examination in several research centers is that the EGG is related to the area of contact of the vocal folds. This hypothesis is difficult to substantiate with direct measurements using human subjects. However, other supporting evidence can be offered. For this study we made measurements from synchronized ultra high-speed laryngeal films and from EGG waveforms collected from subjects with normal larynges and patients with vocal disorders. We compare certain features of the EGG waveform to (a) the instant of the opening of the glottis, (b) the instant of the closing of the glottis, and (c) the instant of the maximum opening of the glottis. In addition, we compare both the open quotient and the relative average perturbation measured from the glottal area to that estimated from the EGG. All of these comparisons indicate that vocal fold vibratory characteristics are reflected by features of the EGG waveform. This makes the EGG useful for speech analysis and synthesis as well as for modeling laryngeal behavior. The limitations of the EGG are discussed.

Acoustic correlates of vocal quality.

We have investigated the relationship between various voice qualities and several acoustic measures made from the vowel /i/ phonated by subjects with normal voices and patients with vocal disorders. Among the patients (pathological voices), five qualities were investigated: overall severity, hoarseness, breathiness, roughness, and vocal fry. Six acoustic measures were examined. With one exception, all measures were extracted from the residue signal obtained by inverse filtering the speech signal using the linear predictive coding (LPC) technique. A formal listening test was implemented to rate each pathological voice for each vocal quality. A formal listening test also rated overall excellence of the normal voices. A scale of 1-7 was used. Multiple linear regression analysis between the results of the listening test and the various acoustic measures was used with the prediction sums of squares (PRESS) as the selection criteria. Useful prediction equations of order two or less were obtained relating certain acoustic measures and the ratings of pathological voices for each of the five qualities. The two most useful parameters for predicting vocal quality were the Pitch Amplitude (PA) and the Harmonics-to-Noise Ratio (HNR). No acoustic measure could rank the normal voices.

Histologic evaluation of the coronal sutures in trigonocephaly.

Thirteen cases of trigonocephaly, seven isolated and six syndromic cases, were evaluated by preoperative neurologic and genetic evaluation and by radiographic evaluation (CT scans). All 13 were treated in an identical surgical manner. Specimens from the coronal sutures were obtained during surgery for histologic evaluation. All of the isolated cases, except one, showed normal coronal sutures and had a good-to-excellent result from surgery. All of the syndromic or secondary cases showed an abnormality of the coronal sutures. Four of the six cases had bad results; two required subsequent surgical procedures. It is our opinion that if a coronal suture abnormality is noted on preoperative CT scans or if preoperative evaluation demonstrates an associated syndrome or CNS malformation, the results from surgery must be guarded.