The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants.

One hundred forty-seven flaps in 135 consecutive patients undergoing microvascular transplantation were monitored using a miniature Doppler ultrasonic probe. Using a modification of a technique described previously by Swartz, the probes were secured to the outflow vein of the flap with Vicryl mesh. Twenty instances of thrombosis or spasm were detected in 16 patients, and all flaps were salvaged (100 percent). There were four false positive and no false negative results. This probe allows for safe, continuous monitoring of flap blood flow, which permits the rapid detection and hence rapid treatment of postoperative complications. Our experience suggests that a significant improvement in the salvage rate of microvascular transplants may be attainable with the use of this device.

Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons.

A discussion of occult breast carcinomas in breast reduction surgery has not occurred in the last 25 years. My recent experience in discovering two occult breast carcinomas in breast reduction specimens led to the creation of a survey of local plastic surgeons and a review of the literature with the goal being precise recommendations for such occurrences. Our survey of breast reductions performed on 2576 patients shows a 0.16 percent incidence of occult breast carcinoma, significantly lower than the 0.38 percent incidence seen in the Snyderman and Lizardo study of 1959. This decrease in the rate of occult breast carcinomas could be explained by many advances in early detection, improvements in patient education, and more thorough pathologic examination of the surgical specimens. The results of this survey and review suggest that we as plastic surgeons performing breast reduction surgery be well versed in all aspects of breast cancer detection, evaluation, and treatment.

Using the Internet for rapid exchange of photographs and X-ray images to evaluate potential extremity replantation candidates.

OBJECTIVE: To implement a low-cost system of transmitting high-quality digital photographs of mutilating extremity injuries using the speed of the Internet. DESIGN: A high-resolution digital camera and simple hardware and software platform are used to take and transmit images via electronic mail. The images are received within minutes by the consultant, and an assessment can be made. RESULTS: A low-cost and high-quality system can easily be implemented. Images can be seen by consultants only a few minutes after they are obtained. The quality of the reproductions is excellent, and they are handled exactly as other photographs. CONCLUSION: This technique can be widely applicable and inexpensive to initiate in any emergency room. It allows rapid assessment of extremity injuries and x-ray images by expert consultants, who can then evaluate the replantation or revascularization potential of extremity trauma cases. This can eliminate unnecessary and often expensive transfer of patients who are not candidates for replantation.

Total ear replantation.

Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration.

Abdominal-wall recovery following TRAM flap: a functional outcome study.

Abdominal-wall function was evaluated preoperatively and at intervals postoperatively in 25 consecutive patients undergoing breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flaps (single-pedicled TRAM flap, 14 patients; free TRAM flap, 9 patients; and bilateral free TRAM flaps, 2 patients). Objective measures of abdominal-wall function were performed with the B200 Isostation, a triaxial dynamometer. In addition, the patients were assessed by a physical therapist and filled out an activity questionnaire at each postoperative examination. Tests of abdominal-wall function demonstrated the greatest decrease in performance at the 6-week postoperative tests of flexion. The maximum isometric flexion torque of the pedicled TRAM flap group decreased to 58 +/- 10 percent, while the unilateral free TRAM flap group average was 87 +/- 11 percent of baseline. For the pedicled TRAM flap group this difference was significant (p = 0.004). By the 6-month evaluation, the maximum isometric flexion torque increased for both the pedicled and the free TRAM flap groups to 89 +/- 13 percent and 93 +/- 8 percent of baseline, respectively. The physical therapist evaluation of abdominal-wall strength and the activity questionnaire data showed no statistically significant differences between groups or over time. Rectus abdominis muscle harvest for pedicled TRAM flaps causes a greater insult to the abdominal wall than does free TRAM flap harvest. The ultimate clinical effect of the sacrifice of even an entire rectus abdominis muscle appears to be well tolerated by most patients. This is the first prospective outcome study of abdominal-wall function in TRAM flap patients. The clinical implications of this information will be discussed.

Salvage of the severely traumatized lower extremity.

The use of microsurgical techniques has significantly altered the management of lower extremity trauma. Indications for amputation or salvage continue to change, as microsurgical transplants have become more commonplace. Reconstruction of a severely traumatized leg usually involves multiple complicated procedures, each of which can cause its own set of complications. The historically high rate of complications of these procedures and the fact that the resultant limb is never completely normal has led some to the conclusion that severely traumatized limbs should not be salvaged. In order to evaluate our own results in light of these considerations we have reviewed our most recent experience with this difficult problem.

Contour restoration of large defects of the trunk and extremities.

Advances in reconstructive techniques have led to the ability to provide coverage of wounds previously considered inoperable. Severe deformities of the trunk from trauma, tumor extirpation, and congenital causes have been demonstrated to be manageable using local and distant flaps. This article presents a series of cases of severe contour deformities of the trunk and extremities treated with tissue transplantation.

Foreign-body sensation following 3M coupler use in the hand.

The 3M microvascular anastomotic coupling device has gained popularity because of its obvious advantages of speed and simplicity. Many reports attest to its safety and efficacy in microsurgery, including two reports on its use in the hand. We present 2 patients in whom the use of the 3M coupling device in the hand resulted in a palpable foreign-body sensation that was unpleasant to the patient and ultimately had to be removed.

Human immunodeficiency virus infection and subsequent melanoma.

Immunosuppression has been known for many years to be associated with the development of skin cancer, particularly squamous cell carcinoma. The association with melanoma is less clear. This report describes 4 patients with known human immunodeficiency virus (HIV) positivity who subsequently developed malignant melanoma. The subtypes and precursors of the tumors vary. Three of 4 patients treated using accepted surgical standards remained disease free an average of 33 months postoperatively. Treatment of the melanoma as in the non-HIV infected melanoma patient is advised. Epidemiological studies remain to be done to determine the significance of this association. In the meantime, melanoma remains a surgical disease and early, aggressive, standard surgical treatment is encouraged for these patients. Despite the immunocompromised state that their HIV status implies, surgical treatment offers local and regional control of disease and possibly cure.

An evaluation of fascial staples (a new technique) in wide fascial plication during reconstructive abdominoplasty.

The purpose of this study is to evaluate the fascial stapler (a new technique) in the plication of the musculoaponeurotic fascia abdominoplasty in comparison to conventional (sutured) techniques. Thirty-eight patients underwent abdominoplasty with rectus sheath plication. Patients were randomized into staple and suture groups. Similar degrees of plicationing were performed in both groups (range, 12-20 cm). Fascial repairs were evaluated postoperatively at approximately 1 month and 6 months. A small, but comparable, subclinical fascial separation was demonstrated immediately in both the stapled and sutured groups. No progression of fascial separation was observed in either group at 1 month and 4 months postoperatively. No complications attributable to the fascial closure were noted in either group. Operative time was considerably less with the stapled technique. The results, although early, suggest that the use of fascial staples for plicationing of the musculoaponeurotic fascia during abdominoplasty is comparable to conventional (sutured) techniques regarding complication rate and disruption rate, but appreciably decreases operative time.

Microvascular replantation of scalp and facial parts.

Replantation of fingers, hands, feet, and extremities has become a relatively common procedure. There are a number of reports of successful replants of facial parts. Since the feeding vessels are extremely small, these replants are most challenging. Venous outflow is the most common problem, and leeches and anticoagulants are commonly needed, resulting in considerable blood loss and transfusions. Nonetheless, the successful replantation of a facial part yields an aesthetic and functional result far superior to any other reconstructive option. We review our experience with 7 scalps, 4 ears, and 2 lips.

Chitosan: evaluation of a new hemostatic agent.

Topically applied chitosan fails to improve the control of bleeding in a liver laceration model when compared to pressure alone in both normal and heparinized rats, and both chitosan and pressure alone are significantly less effective in controlling bleeding than the application of thrombin. In addition, our histologic results suggest that there may be an increased inflammatory response by the healing liver following topical application of chitosan.

The diagnosis of osteomyelitis in patients with pressure sores.

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.

A simple, low-cost computer program for Scatchard plot analysis of binding data in steroid hormone receptor assays.

This paper presents a relatively simple computer program for Scatchard plot analysis of binding data in steroid hormone receptor determination. The program is written in BASIC and adapted to a low-cost desktop calculator. The program is designed to permit data input without demanding extensive technical knowledge of either computer systems or mathematical background of receptor binding assays.

[A new LH-RIA rapid test for determining peak levels of serum LH--a methodological contribution to in-vitro fertilization]. / Ein neuer LH-RIA-Schnelltest zur Ermittlung des LH-Peaks im Serum--Ein methodischer Beitrag zur In-vitro-Fertilisierung.

A highly sensitive, easy to operate LH-RIA rapid test was developed by changing the incubation period and temperature and by reducing the standard curve to three measurement data, using commercially available reagents. The results obtained by means of the LH-RIA rapid test correlate most loosely with those of a conventional 5-hour LH-RIA. The new LH-RIA rapid test is ideally suited for LH peak search at short intervals for exact determination of the time of ovulation as part of in-vitro fertilisation or insemination.