The Moberg volar advancement flap for digital reconstruction.

The volar advancement flap described by Moberg in 1964 has been used to restore normal sensation to soft tissue deficits of the thumb. Application of this same technique for finger tip injuries was later suggested by Snow, but differences in digital blood supply led to dorsal tip necrosis and selection of other reconstructive techniques by many surgeons. Other methods have the disadvantages of widened two-point discrimination, a tender pulp scar, or an unacceptable donor site. The volar advancement flap applied to fingers restores normal to nearly normal sensation, an adequate pulp with minimal deformity. Our experience with the volar advancement flap in 69 digits from 1969 to 1978 is reviewed. Preservation of the dorsal perforating vessels is most important in successfully executing this procedure. No dorsal tip or flap necrosis occurred. Two-point discrimination was normal or within 2 mm of contralateral values in every digit. Full range of motion, or less than 5 degrees extension loss, was recorded in all fingers that were normal prior to operation. Our results suggest this to be a safe as well as effective adjunct in the treatment of finger tip injuries.

Non-Hodgkin lymphoma of the parotid gland: diagnosis, evaluation, and treatment.

Malignant lymphoma of the parotid gland not infrequently presents as a solitary mass indistinguishable from other commonly occurring lesions. Two new cases are presented here with a comprehensive literature review. When encountered, the lesion should be excised with the superficial lobe of the gland. If it is within the deep lobe, the tumor should also be excised with preservation of the facial nerve. Recommendations for further evaluation and treatment are given.

Sutures and suturing--current concepts.

Currently available suture materials can be classified as nonabsorbable and absorbable types. Too often the surgeon selects the material on the basis of handling properties alone. The "perfect" suture material does not exist. Physical properties such as tensile strength, reactivity, size, and absorbability must be considered in light of current knowledge of wound healing. Placement of sutures is obviously as important as selection of material.

Evaluation of prognosis in Stage I cutaneous melanoma.

A review of the literature on melanoma indicates that age, sex, size, ulceration, presence of satellites, absence of melanin, and whether or not the tumor is markedly raised above the surface of the surrounding skin are all useful criteria in evaluating the prognosis in Stage I cutaneous melanoma. Histological factors include the tumor type, the mitotic rate, and the maximum thickness of the tumor. The last is accurate for prognosis--objective, reproducible, and directly proportional to the mortality rate. Tumors less than 0.76 mm thick rarely, if ever, metastasize--and it appears that the size of the resection margin can safely be reduced for such thin tumors. The level of invasion (Clark) is less accurate in predicting the mortality.

Intraoral field block anesthesia for extraoral lesions.

Intraoral field block anesthesia for extraoral surgical procedures provides a technique which is both extremely safe and easy to administer. As with all local anesthetics, injected volumes should be monitored at all times. Hemostasis may be augmented, if necessary, with topical epinephrine solution. When vasoconstrictors are contraindicated, mepivacaine, Carbocaine, may be substituted for its inherent properties.

Optimal size of resection margin for thin cutaneous melanoma.

The width of the resection margin for 62 melanomas less than 0.76 millimeter thick ranged from 0.10 to 5.50 centimeters, with 32 per cent being 1.0 centimeter or less. None of these patients has a local recurrence or metastases develop. It appears that these thin tumors should be treated conservatively, the size of the resection margin being dependent upon the anatomic location of the tumor. In most instances, skin grafting should not be necessary.

A technique for evaluating sepsis in TPN patients.

Sepsis continues to be one of the most feared complications of total parenteral nutrition. Many techniques have been advocated for dressing changes, solution preparation, and evaluation of patients with fever spikes. Our technique in evaluating such a patient with suspected sepsis is to remove the tubing and solution from the pumping mechanism and place the bottle below the patient, permitting approximately 10 cc of blood to flow into the tubing. The entire set-up of solution and tubing is then quickly replaced and the infusion resumed. The removed blood is transferred to a series of three standard blood culture bottles. The first bottle will be culturing blood; the second, a mixture of blood and infusate; the third, solution alone. When performed carefully, negative culture results appear to exclude TPN as a source of spesis. Positive results are obviously helpful, but must be interpreted with caution in that the blood, catheter, tubing, filter, or solution may be suspect.