Double-Z rhombic technique for reconstruction of facial wounds.

The double-Z rhombic technique of repair of excisional defects is characterized by borrowing the required tissue from two nonadjacent opposite sides of the defect. Most other flaps borrow the required tissue from a single adjacent region or all adjacent directions. The "sharing" of tissue from two opposite regions minimizes tension in that direction, while not borrowing from the remaining regions prevents the distortion of anatomic landmarks located along that direction. The orientation of the final scar and direction of tissue tension can be controlled by rotating the rhombic defect about its central axis. This study was undertaken to assess the utility of the double-Z rhombic technique in terms of cosmesis and avoidance of displacement of mobile anatomic landmarks such as eyelids, eyebrows, nasal alae, and lips. Excisional defects resulting from removal of skin neoplasms in 30 patients in whom primary closure or reconstruction with direct tissue advancement was not feasible and displacement of facial landmarks was undesirable were reconstructed using the double-Z rhombic technique. No considerable asymmetry or facial anatomic landmark deformity was observed in any of the 30 patients. Our results are presented along with representative illustrations.

The extended digitorum brevis muscle flap.

The anatomy of the anterior tibial artery was studied in eight fresh cadavers. Consistently no major branches were found to the long toe extensor or anterior tibial muscle in the segment 15 cm preceding the lateral malleolus. This allowed the use of the extensor digitorum brevis muscle on a long anterior tibial vascular pedicle following release of the extensor retinaculum. The longer pedicle made this reliable muscle flap suitable for coverage of mid and lower tibial defects, in addition to ankle defects, as an alternative to free flaps. Its use is described in three complex cases.

Immediate Z-plasty for semicircular wounds.

Simple layered repair of semicircular and curved lacerations frequently results in elevation of the central area following contraction of the scar. Traditionally, immediate tissue rearrangement at the time of the injury has been discouraged. We performed single or multiple Z-plasties at the time of the initial repair on five consecutive patients with curved and semicircular lacerations of the face. None of the wounds formed the typical trapdoor deformity. Use of immediate Z-plasties in the acute management of semicircular flaplike lacerations seems to prevent the formation of the trapdoor deformity.

Effects of local heat on blood flow in infected and normal hands.

Changes in response to heat in the dermal, subcutaneous, and muscle blood flow in the hands of 10 patients with hand infections were studied using 133Xe and recording of clearance data. A further 15 normal hands were studied in a similar manner. The application of topical heat to normal hands resulted in a decrease in the dermal blood flow (p less than 0.001), an increase in the subcutaneous blood flow (p less than 0.05), and perhaps an increase in the intramuscular flow (p less than 0.1). This suggests that surface heat promotes a shunting of the blood from the skin to deeper tissue layers. In infected hands, the blood flow was found to be significantly increased threefold in the intradermal circulation (p less than 0.01) and eightfold in the subcutaneous circulation (p less than 0.03) when compared to controls. In contrast to normal hands, in the infected hands, the blood flow decreased in all three compartments by 50 percent following application of heat. The blood flow of the normal hand in patients with infection did not respond to heat in the normal pattern. We conclude that the application of local heat to normal tissues results in shunting of blood flow from superficial tissues such as dermis to deeper ones such as subcutaneous fat and muscle. In infected tissues, the blood flow was found to be much higher than normal; however, the traditional belief in the improvement in blood flow by the application of heat was not confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

Burn wound excision and local flap closure.

Eleven circumscribed, full-thickness burns were treated in 9 patients with immediate excision and primary closure of the defect or by using a variety of local random cutaneous and musculocutaneous flaps. The burns were located on the face, trunk, and extremities. In 2 patients this technique was used in the management of smaller burns on one surface of the body, thus facilitating skin grafting of larger wounds on the opposite surface. The cutaneous flaps utilized included advancement flaps, V-Y flaps, Moberg flaps, and S-plasties. The timing of the excision and closure varied from 2 hours to 2 weeks following thermal injury, with no postoperative wound infections. In selected cases primary excision of deep burns and closure by use of local tissue approach ideal treatment. With certainty of the depth of destruction, this procedure should be carried out regardless of locality when technically and anatomically feasible.

Hippocrates, the true father of hand surgery.

The methods used by Hippocrates for treating fractures and dislocations formed the basis for further development in operations performed upon the hand. He described the common distal radial fracture, and the method to reduce and immobilize it. Of carpal dislocations, he mentioned two patterns which are similar to the common "anterior dislocation of the lunate" and the "perilunar dislocation." He treated pressure sores and wound infection with frequent dressings, application of heat and mechanical debridement; limb necrosis was treated with delayed amputation, and tetanus, with immediate exploration and drainage of the wound. His general principles of fracture management include the value of early reduction, strict fluid diet after reductions of large joints, keeping sites of fracture warm and changing splints as the swelling resolves. It is obvious that many of the principles for the treatment of fractures and dislocations of the wrist and hand are still valid today. The genius of Hippocrates surpassed all those whom we know at a corresponding stage of civilization and for many years to come. The discovery of roentgenograms an antiseptics only furthered his established sound principles. On the basis of these principles, perhaps Hippocrates should be considered the true father of operations performed upon the hand.

Scapular free-flap dissection made easier.

An improved technique for the dissection of the scapular free flap is presented. It includes identification of the triangular space by palpation and delivery and deep dissection of the proximal flap pedicle by means of a counterincision in the axilla. This technique allows for a rapid, safe, and easy dissection of the transverse scapular flap.

Facial fractures: Hippocratic management.

Hippocrates, the famous Greek physician of the fifth century B.C., is considered to be the "Father of Medicine." Little, however, is known about his principles for the management of facial trauma. In this article, the Manuscripts in Ancient Greek, which deal with the management of mandibular fractures and dislocations, and with nasal and midfacial fractures have been translated and discussed. Hippocrates' methods for reducing mandibular dislocations and treating fractures of the mandible by wiring the teeth and immobilizing the jaw are described. His technique of closed reduction and immobilization of deviated nasal fractures with internal packing and rigid dorsal splints remains timeless. Hippocrates has taught us how to achieve medical wisdom through accurate clinical observation and practical creative ideas. The discovery of x-rays and antisepsis only furthered his established sound principles for the management of facial trauma.

Management of sclerodermal finger ulcers.

Ninety-three percent of 59 patients with scleroderma reviewed in this study presented with Raynaud's phenomenon at a mean age of 43 years; 65% of these developed fingertip ulcers within 4 years. Other common findings were sclerodactyly, distal phalangeal resorption, calcinosis cutis, and digital contractures. Medical management of the digital ulcers with systemic and regional vasodilating drugs was unsatisfactory. Sympathectomy, when performed early, temporarily relieved vasospastic pain but did not affect the course of the ulcers. Severe digital pain was the most incapacitating symptom resulting from vasospasm early in the course of the disease and irreversible arterial luminal narrowing later in the course. Conservative fingertip amputations for nonhealing ulcers constituted the management of choice to eradicate the ulcer, to reduce or eliminate the pain, and to return the hand to early useful function. A decision tree for the management of these ulcers is proposed.

Soft-tissue foreign body removal: management and presentation of a new technique.

A simple, effective, and easy technique is presented for the location of radioopaque foreign bodies in soft tissue, using paper clips, clear tape, ruler, and one set of AP and lateral radiographs. A variety of foreign bodies were located and easily removed using this method in six patients.

Periosteal chondroma: another cause of carpal tunnel syndrome.

Periosteal chondroma has not been previously described as a cause of carpal tunnel syndrome. This report describes a case of periosteal chondroma developing in the floor of the carpal canal and presenting as carpal tunnel syndrome.

Necrotizing sialometaplasia: report of five cases.

The natural history of necrotizing sialometaplasia as a self-healing process makes it essential for the surgeon and the pathologist to distinguish this entity from carcinoma. Seventeen of the 39 early cases were initially misdiagnosed as malignant. Occasionally, residual glands can be trapped in mucous lakes, giving the appearance of mucoepidermoid carcinoma. An awareness of the entity and adequate clinicopathologic correlation should lead to a correct diagnosis. A limited biopsy specimen may create a problem in diagnosis and may necessitate more adequate tissue for proper evaluation. Necrotizing sialometaplasia can present as an ulceration or a swelling beneath the mucosa, either of which can be painless or painful with radiation of pain to the ear, eye, or pharynx. Lesions presenting as a swelling will either convert to an ulceration or heal spontaneously, never forming an ulcer. The most commonly involved area is the palate (79 percent), but any area where glandular oral mucosa is present can be involved. The male-to-female ratio is 3:1, and it shows no predilection for race. The etiology of the disease remains unknown, but it may be associated with tobacco, alcohol, the use of dentures, and local trauma. Most investigators seem to favor an ischemic basis. Lesions heal spontaneously without treatment, and the only invasive procedure required is a biopsy.

Extensor indicis brevis: a rare anatomical variation.

We describe a rare anatomical variant, the extensor indicis brevis--a "short" index extensor originating from the ligament over the scaphoid bone. In our patient it presented as a tender mass. The knowledge of such anatomical variations is important in diagnosing dorsal hand masses and in planning tendon transfers.

Elective colon surgery: clindamycin versus metronidazole prophylaxis.

Orally administered clindamycin-neomycin as a prophylactic antibiotic in patients scheduled to undergo colon surgery was compared to orally administered metronidazole-neomycin. Clindamycin levels of the colon contents and the mucosa were 8 to 10 times higher than the serum levels. Three of the 43 patients who received metronidazole had wound infection whereas none of the 38 patients who received clindamycin did. Clindamycin may help to prevent staphylococcal infection, a known problem associated with metronidazole use. It may also play a role in preventing infection at the anastomosis in patients who undergo colon resection.

Endorphins in septic shock: hemodynamic and endocrine effects of an opiate receptor antagonist and agonist.

The pathophysiological role of endorphins in septic shock was studied in a porcine model. Septic shock was induced by the intravenous infusion of live Escherichia coli. Naloxone hydrochloride, an opiate receptor blocker, given during profound septic shock, increased blood concentrations of glucagon and cyclic adenosine monophosphate (cAMP), while BP and cardiac output increased transiently. Heart rate and hepatic glycogen value decreased, but insulin and cortisol levels remained unchanged. In contrast, exogenous morphine injection produced further reduction of BP, increased pulmonary wedge pressure, and increased substance P, while growth hormone level and cardiac output remained unchanged. Neither hormonal nor hemodynamic changes were noted in saline controls. Thus, the endogenous opiates appear partly responsible for the hemodynamic derangements during septic shock, and naloxone is able to reverse such depression, even though the effects are transient and relatively minor when naloxone is given late in the course of septic shock. Endogenous opiates also affect the hormonal homeostasis in shock, and there are indications that this may be mediated by the adenylate cyclase-cAMP system.