Outcome and treatment of electrical injury with immediate median and ulnar nerve palsy at the wrist: a retrospective review and a survey of members of the American Burn Association.

Electrical injury to the upper extremity with immediate median and ulnar nerve palsy at the wrist is uncommon but devastating. When it does occur, the immediate clinical questions are (1) will the nerves recover, and (2) should the carpal tunnel and Guyon's canal be released? Our review of the literature did not answer these two questions. Therefore, we reviewed our experience with such patients and surveyed approximately 10% of the physician members of the American Burn Association. We reviewed approximately 80 patients with electrical injuries treated between January 1983 and September 1988, and found 5 patients (8 extremities) who did not require amputation and who manifested immediate palsy of the median and ulnar nerves at the wrist. The questionnaire was returned by 83% of those contacted. We concluded that such nerve palsies can recover to a significant degree and that a majority of surgeons would release the carpal tunnel and Guyon's canal, expecting improved recovery. Although it is still not proven whether decompression is beneficial, we will continue to decompress the carpal tunnel and Guyon's canal in such circumstances.

Upper abdominal wall defects: immediate or staged reconstruction?

One-stage reconstruction of the central and lower abdominal wall with vascularized tissue has been well described. A few cases of one-stage reconstruction of the upper abdomen also are reported. We attempted this procedure in six of seven patients who had large abdominal wall defects that reached the xiphoid process. In three patients, the intraabdominal parts of the procedures went well and the reconstructive goals were accomplished. In three other patients, prolonged and difficult intraabdominal operations resulted in considerable intestinal dilatation that compromised the reconstruction. We therefore recommend being prepared to abort a planned immediate abdominal wall reconstruction following a difficult intraabdominal operation. The abdomen should be temporarily closed with skin flaps, skin grafts, or absorbable mesh, and definitive reconstruction of the fascia should be done at a later operation.

Topical growth factors and wound contraction in the rat: Part I. Literature review and definition of the rat model.

The isolation and production of growth factors and the observation that a platelet extract will promote wound healing in chronic wounds has led to an interest in the study of growth factors and wound healing. We wished to study the effect of platelet-derived growth factor on wound contraction. However, because studies of growth factors and wound contraction are quite recent, we could find only two models described in the literature and neither seemed ideal. Both used small wounds, which are difficult to measure, anesthetics with slow induction and recovery and which are difficult to titrate, and no dressings, which permits the animals to lick the wounds and possibly introduce other growth factors. We therefore reviewed wound contraction models used for other studies. In particular, we reviewed the animal used, anesthetic, wound size and shape, dressing methods, scab treatment, and measurement and comparison techniques. We then combined features of many of them into a model that solves the problems listed and permits the study of topically applied growth factors and wound contraction. The composite model to be described uses a large, circular wound on the rat, halothane anesthesia, and flexible, Tubigrip dressings.

The "sponge deformity" after tangential excision and grafting of burns.

Sequential excision and grafting of burns have resulted in several new problems. We have termed one of these the "sponge deformity," i.e., a grafted area where, in multiple small areas, the bed heals underneath the graft with or without slough of the overlying graft. If the graft sloughs, a pockmark forms. If the graft does not slough, an overlying bridge forms. In our experience, this deformity is very troublesome to patients because it is difficult to wash, catches on objects, bleeds, and looks quite unsightly. Between February of 1981 and June of 1986, we treated 16 patients with this deformity. All 16 patients were treated by simple excision of the bridges and pockmark edges with a curved iris scissors. In all patients, the wounds healed well and the resultant surfaces were considerably smoother. This retrospective review of the patients suggests that the deformity usually occurs around the periphery of the excised area where the excision was shallower and when thicker grafts are used. Perhaps the bed underneath the graft epithelializes from residual epithelial elements prior to vascularization of the autograft. If this is true, it might be possible to prevent the deformity by excising the wound deeper, by applying thinner grafts, or by applying allograft or xenograft, expecting that the area will heal promptly and not require autografting.

Occult breast carcinoma in patients undergoing reduction mammaplasty.

Seven patients who had breast reduction surgery and whose preoperative physical examinations were unremarkable were found to have breast carcinoma. In the five in whom mastectomy was performed, most closures were difficult, and in one patient bilateral mastectomy was complicated by wound dehiscence. In only one of these seven was it possible to obtain information regarding the hormonal binding status of the tumor cells. These and other sequelae would not have occurred had the tumors been diagnosed before operation. Because physical examination alone is not sufficiently sensitive for the diagnosis of breast cancer, we suggest that mammography be included in the evaluation of patients consulting surgeons for breast reduction.

Ischemic injury to enteric free flaps: an experimental study in the dog.

Enteric free flaps have proven to be useful for reconstructing the cervical esophagus. Although jejunum is favored, the rationale for this is not at all clear. We have postulated that resistance to warm ischemia varies in different regions of the gut. An experiment was carried out in 10 mongrel dogs in which 10-cm segments of proximal, middle, and distal small bowel were isolated on single vascular pedicles. In each portion of the gut there were three segments: a control, a segment subjected to 60 minutes of warm ischemia, and a segment subjected to 120 minutes of warm ischemia. The following day each animal was reexplored, and the viability of bowel segments was assessed visually and with fluorescein. All control segments were viable at 24 hours. Twenty segments were subjected to 1 hour of warm ischemia, and all but two were viable. Nineteen gut segments were subjected to 2 hours of warm ischemia. Seven of eight proximal segments were viable, two of five midsegments were viable, and zero of six distal segments were viable. Survival in the distal portion compared to the proximal portion was significantly less (p less than 0.01). It appears from this study that isolated distal small bowel segments are less resistant to warm ischemia than proximal segments.

A comparison of intramarginal and extramarginal excision of hypertrophic burn scars.

Hypertrophic scarring is common in burn patients. The treatment of such scarring is difficult, and recurrence of the hypertrophic changes after scar revision is not uncommon. It has been suggested that intramarginal excision diminishes the chances of recurrent hypertrophic scarring, but we could not find any papers in the literature actually comparing intramarginal and extramarginal excisions. We therefore reviewed our experience with intramarginal and extramarginal excision of hypertrophic scars. Between October 30, 1979, and March 26, 1986, we excised 50 hypertrophic scars in 23 burn patients. Thirty-one (62 percent) of the excisions were intramarginal and 19 (38 percent) were extramarginal. We compared the results and observed that the intramarginal excisions yielded better results than the extramarginal excisions.

Partial excision of residual burn lesions.

Most burn victims have unattractive residual lesions, which may include hypertrophic donor sites, unsightly skin grafts, hypertrophic scars, and mature scars with altered pigmentation or texture. Some of these lesions can be treated by total excision in one or more stages or they can be reconstructed utilizing grafts, flaps, Z-plasties, or tissue expansion. But frequently these procedures are either not indicated or not elected by the patient. In such a situation, the only surgical option is partial excision, with the goal of making the lesion less conspicuous and more easily concealed by clothing. Whether or not such partial excisions are worthwhile is the obvious question. We could not find an answer in the literature and therefore decided to review our own experience. Between 6/30/81 and 3/12/86, 92 such procedures were performed and followed in 25 patients. Partial excision of hypertrophic donor sites, unsightly skin grafts, and hypertrophic scars did yield improved appearance in most patients. However, partial excision of mature scars, ie, areas of altered pigmentation or texture, did not have the same success. We continue to treat the first three types of lesions in this fashion but no longer include the latter.

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery.

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

Care of pentamadine ulcers in AIDS patients.

Two cases of soft-tissue infection resulting from antibiotic therapy given AIDS patients are presented. Operative treatment resulted in a closed wound in one patient. In the other patient, who suffered from recurrent acute illnesses, nonoperative treatment resulted in slow wound contraction and epithelialization without secondary wound complications. Wound sepsis did not occur, despite the absence of normal immune function. Operation and additional hospitalization, with their attendant risks, were avoided.