Oral sedation allows for comfort and amnesia during office surgery.

Surgical procedures commonly associated with parenteral sedation or general anesthesia were completed in an office operating room with local anesthesia and oral medication. Diazepam and alprazolam were used in combination to produce a relaxed state, allowing local anesthesia to be instilled. Surgery was completed successfully in all patients, and no untoward effects were seen in the patients. Amnesia was associated with the drug combination, and a protective action of the long-lived drugs against lidocaine toxicity is theorized.

Permanent lip augmentation with serial fat grafting.

A simple technique for lip augmentation with autologous fat is presented. Local anesthesia is injected into those areas used for fat harvesting and the perioral areas that are to receive the grafts. The fat is taken with a large needle and syringe, washed over meshed gauze, placed into the syringe, and injected into the lip tissue. Multiple passes with a small needle deposit the strained fat in horizontal tunnels within the lips. Subsequent injections are performed at a minimum of 3 months. Lip swelling is short lived and permanent lip augmentation occurs when patients undergo two to three grafting procedures.

Poland's deformity reconstructions with a customized, extrasoft silicone prosthesis.

Chest and breast reconstruction with a customized prosthesis in 5 patients with Poland's syndrome are presented. The customized, textured silicone prostheses are fabricated from an extrasoft silicone polymer that more closely approximates the softness of natural tissue. Two women and three men underwent the reconstructive procedure. Both women had composite implants made of the solid, extrasoft polymer in the superior portion and silicone gel with a saline fill option for the breast portion. The men were reconstructed with solid, textured prostheses that filled the various chest deficiencies and irregularities of their Poland's deformity. Seroma formation was seen in 2 patients and needle aspirations were required to resolve the problem. All patients have comfortable, soft, and aesthetically acceptable results after a mean of 5 years. The reconstructive technique presented with this initial group of patients is a simple, alternative procedure to the more complex surgery of muscle transposition. The extrasoft polymer is an advance in implant technology that merits consideration for use in a customized prosthesis when reconstructing patients with Poland's syndrome deformity.

The mutagenicity of electrocautery smoke.

Careful analysis of electrocautery smoke produced during breast surgery has found organic compounds that are unidentifiable with current analytical techniques. The purpose of this study was to determine the potential mutagenicity of the smoke produced by the electrocautery knife during reduction mammaplasty. Multiple air samples were collected in the operating room during two reduction mammaplasty procedures. Airborne smoke particles were tested for mutagenic potential in both tester strains of Salmonella typhimurium (TA98 and TA100) using the standard Salmonella microsomal test (Ames test). All testing was performed by the Hazard Evaluations and Technical Assistance Branch of the National Institute of Occupational Safety and Health. The smoke produced with the electrocautery knife during reduction mammaplasty was found to be mutagenic to the TA98 strain. The Ames test, an established technique for evaluating the mutagenicity of a substance, was convincingly positive for the smoke collected during the breast surgery. Whether the smoke represents a serious health risk to operating room personnel is not known. Development of techniques to limit electrocautery smoke exposure in the operating room appears to be needed, and surgeons should attempt to minimize their exposure.

Intravenous nitroglycerin as a means of improving ischemic tissue hemodynamics and survival.

The effects of intravenous nitroglycerin infusion on experimental skin flap survival and fluorescein dye kinetics were studied in animals. Perfusion fluorometry was utilized to examine changes in flap hemodynamics and viability. An improvement in skin flap survival was found in the nitroglycerin-infused animals, whether the nitroglycerin was initiated 30 minutes before or 30 minutes after flap elevation. Dye elimination in the flap appeared to be significantly improved with the drug therapy, indicating an improvement in flap blood flow with nitroglycerin.

Entrapment of below-the-knee bypass grafts.

A case is presented in which a below-the-knee saphenous vein bypass graft was compressed between the sartorius and the semimembranosis, semitendinosis, and gracilis muscles. Angiography and noninvasive Doppler showed occlusion with leg extension but no obstruction to flow with flexion. Recognition of this entrapment syndrome and its prompt correction can preserve patency of the graft.

A new technique for evaluating cutaneous vascularity in complicated conjoined twins.

Ischiopagus tripus conjoined twins were recently encountered. All organ systems were thoroughly evaluated using radiographic, angiographic, radionuclide, and CT imaging techniques. None of these studies were capable of accurately assessing the vascular territories of the skin at the level of the pelvis, the most critical area in terms of separation. Qualitative visual assessment of tissue fluorescein delivery under ultraviolet illumination is subject to subjective errors. Perfusion fluorometry is a recently developed technique whereby tissue fluorescence can be quantitated over time in very small amounts, even with repeated injections. In these conjoined twins, using sequential fluorescein injections in each twin, it was possible to accurately determine which portions of the pelvis and the shared leg belonged to which twin and exactly where the skin incisions should be made. Additionally, during operation it was possible to accurately predict the viability of skin flaps used for closure. Both twins survived. This is the first time it has been possible to accurately assess vascular territories of the skin in a complicated form of conjoined twinning. The technique is also useful in the evaluation of flow patterns in various other parts of the body.

Assessment of neovascularization and timing of flap division.

These studies were undertaken to determine if perfusion fluorometry can provide an accurate, reliable means of monitoring neovascularization and predicting optimal time of flap division. An animal model was developed that permitted daily assessment of neovascularization of the flap using fluorescein injections and the fluorometer. An increase in fluorescence of the pedicle-occluded flap of approximately 12 percent the normal skin fluorescence was associated with 100 percent flap survival. This occurred after only 4 days in the rat. Fluorometry proved valuable in the evaluation of clinical flaps. The fluorescence of flaps during pedicle occlusion was observed to increase with each successive fluorometric evaluation performed at 3- to 7-day intervals. It appears that flaps after pedicle occlusion exhibiting at least 25 percent of the fluorescence of normal skin will tolerate pedicle division. Based on the neovascularization studies of the clinical flaps, all pedicles were severed earlier than originally anticipated. Two cross-leg flaps were successfully divided after 11 days. Quantitative assessment of serial fluorescein injections allows reliable evaluation of neovascularization in clinical interpolation flaps and is useful in the timing of flap division.

Evaluation of the burn wound with perfusion fluorometry.

Determination of depth of burn injury using vital dyes has been unsatisfactory. The present study evaluated the ability of the fiberoptic perfusion fluorometer to assess the depth of burn in the early postburn period. Sixty-three burns were examined with the fluorometer after intravenous administration of sodium fluorescein. The fluorescein kinetics were monitored for 1 hour within the first 48 hours and again between the third and sixth days postburn. The rate of fluorescein uptake and burn wound fluorescence was determined and compared to that of normal unburned skin. Depth of burn was confirmed by biopsy and healing characteristics. Fluorometric analysis during both study periods consistently distinguished between partial-thickness and full-thickness burns. Partial-thickness burns uniformly exhibited fluorescence within 10 minutes; full-thickness burns showed nil fluorescence. None of the patients experienced a change in skin color or complications from the small dose of fluorescein given.

Altered skin flap survival and fluorescein kinetics with hemodilution.

Isovolemic hemodilution is known to reduce blood viscosity. Reduction of either the blood cell concentration or the serum total protein has been found to improve blood flow and ultimate survival of skin flaps. Nutritive blood flow and tissue survival were examined in dorsal pedicle skin flaps in three groups of rats at three hematocrit levels--44% (controls), 31%, and 19%. After hemodilution by phlebotomy and crystalloid replacement, the dye kinetics of intravenously administered fluorescein were measured with the fiberoptic perfusion fluorometer. Skin flap survival at the different hematocrits were also examined. Hematocrits and serum total protein were measured before and after hemodilution and the elevation of the flap. The rate of fluorescein elimination and ultimate flap survival were significantly augmented in the two hemodiluted groups. The maximum benefit was seen in the group of animals hemodiluted to 19%. However, significant improvement in blood flow and skin flap survival was noted in the group of animals that were hemodiluted to a more clinically acceptable level (31%). The decreases in serum total protein following flap elevation did differ among the groups. This study supports the hypothesis that isovolemic hemodilution may be a valuable technique for salvaging marginally ischemic tissues.

Endocarditis complicating home hyperalimentation.

Catheter sepsis remains a persistent, though infrequent, complication of intravenous hyperalimentation (IVH). Those select patients requiring home hyperalimentation delivered through Silastic catheters are subject to this serious problem. Reported in this article is a case of Enterococcus endocarditis of the tricuspid valve in a patient receiving home IVH; the endocarditis was recognized early using two-dimensional echocardiography and was treated successfully with catheter removal and IV antibiotic administration. Ideal conditions exist for the formation of endocarditis in the setting of catheter sepsis with parenteral nutrition. Routine echocardiography is indicated when catheter sepsis is documented, since early diagnosis and treatment may reduce invasive cardiac tissue infection and permanent injury. The right atrial catheter generates reflections during echocardiography that require special attention for accurate interpretation.

The malpositioned subclavian catheter.

The results of a review of 524 consecutive infraclavicular subclavian vein catheterizations revealed inadvertent cannulization of the internal jugular vein to be a relatively common problem. No increased predilection for malpositioning was associated with either a right-sided or left-sided approach. The safety and efficacy of this repositioning technique using a guide wire, anatomic maneuvers and with and without the adjuvant use of fluoroscopy were investigated. The malpositioned subclavian vein catheter need not be removed and the patient need not undergo another percutaneous catheterization. The technique affords safe and simple repositioning of the catheter tip into the superior vena cava.

Scalp avulsions and review of successful replantation.

Microvascular surgery has greatly altered the handling of scalp avulsions. Review of the injury mechanism and of successful replantations has yielded some basic axioms concerning treatment of this tragic injury. Generally, larger avulsions contain vessels that are easily identified and anastomosed, and therefore have a better prognosis. Long periods of ischemia do not appear to threaten graft viability. The superficial temporal artery is the most reliable artery for scalp replantation; accompanying veins can normally be used for venous drainage, though vein grafts are often needed due to vessel disruption at injury. Replantation should be attempted with all scalp avulsions, though the size of the defect and its location will affect the outcome.