Clusters within a general adult population of alcohol abstainers.

BACKGROUND: Our previous study found that alcohol abstainers use acute services more and preventative services less than safe level drinkers. The observed relationships between four categories of alcohol consumption and service use were J-shaped for acute services and inverted J-shaped for preventive services. The aim of this paper was to further investigate these relationships. METHODS: The design was a health and lifestyle survey of 41 000 randomly-sampled adults in SE England. The response rate was 60%. Distinctive subgroups within the alcohol abstainer group were investigated using cluster analysis, based on socio-demographic and health status variables. Odds ratios for services use for the abstainer clusters, and three alcohol consumption groups were estimated from a logistic regression model which included age, social class, ethnic group, employment status, household composition, whether the respondent was a carer, smoking habit, use of private health insurance, and health status. RESULTS: Two clusters were formed for both males and females. Cluster 1 comprised, on average, older, frailer, and more disabled people. Cluster 2 comprised younger, healthier people, a greater proportion of whom belonged to ethnic minority groups. Cluster 2 had similar rates of use of Accident & Emergency, GP, optician, and dental services compared with safe level drinkers. Cluster 1's rates differed from those of both Cluster 2 and safe level drinkers in almost all instances. CONCLUSIONS: The J- and inverted J-shaped relationships between alcohol consumption and service use are partly explained by a subgroup of abstainers who are older, of less good health, and who use hospital, clinic, and domiciliary healthcare services much more than safe level drinkers.

Reconstruction of the burned breast.

Fundamental principles of management of breast burns begin with recognition and preservation of any viable breast bud tissue. Reconstruction begins when the burned breast envelope is insufficient to allow unrestricted breast development. Complete contracture release is obtained by incision or excision of the restricting burn scar and thick split-thickness grafting. Occasionally, breast mound reconstruction with regional musculocutaneous flaps or tissue expanders is necessary. Balancing procedures, such as reduction or mastopexy of an opposite unburned breast, are often helpful. After a period of 6 to 12 months of compression garments, scar management, and settling, nipple-areola reconstruction is undertaken and consists of a combination of local flaps, full-thickness grafting, or composite grafts tailored to each patient's needs. Long-term follow-up is necessary to ensure that breast development continues satisfactorily and that contractures do not recur.

Tissue expansion in head and neck burn reconstruction.

The advent of tissue expansion has provided a useful tool for the reconstructive burn surgeon. As with many new techniques, there was an initial wave of enthusiasm surrounding the introduction of tissue expansion to burn reconstruction in the 1980s. High complication rates and many dissatisfying results followed. After early widespread use of tissue expansion, the authors have settled on a more refined approach to the reconstruction of head, neck, and facial burns. Today, head and neck burn reconstruction is accomplished best with a combination of skin grafting, local flaps, and occasional free flaps in addition to tissue expansion. In carefully selected head and neck burn patients and in many burn alopecia patients, tissue expansion can provide excellent functional and aesthetic results, with minimal donor site morbidity.

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.

Scalp autografts and hair transfer to the face in the burned child.

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.

Tissue expander complications in the pediatric burn patient.

Tissue expanders have become a useful adjuvant in pediatric burn reconstruction. We reviewed our experience with tissue expanders from June of 1984 to July of 1995. There were 403 expanders used in 301 patients. Complications relative to specific anatomic areas from July of 1987 to July of 1995 were compared with previously published data in the journal from June of 1984 to June of 1987. Complications were defined as absolute if they resulted in the loss of expanders or in additional surgery, or none of the preoperative plan was satisfied. The relative complications were defined as spotty alopecia, alopecia greater than 50 percent, or the operative plan was only partially satisfied, sometimes implying poor surgical judgment. The overall complication rate for the period June of 1984 to June of 1987 was 30 percent (37 complications in 122 expanders). In the July of 1987 to July of 1995 study, the complication rate was only 18 percent (51 complications in 281 expanders). This was a statistically significant decrease between the periods (p = 0.010). In the recent 8-year period, there was a decrease compared with the previous study in both the absolute and relative complications. The most common absolute complication in this period was infection (15 of 31, 48 percent) with 12 (39 percent) being early infection. With regard to the nine complications in the neck, face, ear, and supraclavicular area, two-thirds were related to leakage or exposure of the expanders, resulting from the tight anatomic area causing mechanical damage of the expanders as well as ischemia to the overlying skin. Early in the study, the lower extremities proved to involve difficult or unsatisfactory areas to expand, and lower extremity expansion was abandoned throughout the remainder of the study period. The overall decrease in absolute and relative complications is likely the result of increased operative experience as well as a developed protocol for the prevention of perioperative complications relating to infection and expansion in high-risk anatomic sites.

The effect of full-thickness abdominal wall burns sustained during childhood on subsequent childbearing ability.

The effect of full-thickness burns of the abdomen during childhood on subsequent pregnancy was evaluated. Eight hundred female pediatric patients treated for acute burns during a 14-year period (1975-1989) at the Shriners Burns Institute were reviewed. Through a combination of clinical follow-up, questionnaires, or phone interviews, data were obtained regarding the histories of 31 pregnancies in 19 patients who had required excision and skin grafting of > or = 50% of their abdominal wall during management of their acute burns. These patients sustained a mean burn size of 59.8% total body surface area (TBSA; range, 23-87%) with a mean full-thickness burn of 43.8% TBSA (range, 10-78%). The mean age at the time of burn was 7.6 years (range, 1.5-15 years). Normal rates of vaginal and cesarean section deliveries, prematurity, and infant mortality were observed in these 31 pregnancies. Despite a subjective sensation of increased tension on the scar in 25% of the patients, no interference with these patients carrying a full-term pregnancy directly attributable to the burn scar was identified. Follow-up and examination during the third trimester of pregnancy demonstrated how the burned and unburned portion of the abdominal wall accommodated the enlarged uterus. This review demonstrates that after extensive burns to the abdomen, which have been treated with excision and skin grafting during childhood, the scarred abdominal wall accommodates full-term pregnancy without the need for surgical release.

Cleft lip micronostril: the problem and proposed solution.

Micronostril is a cicatricial stenosis that may occur in the caudal-most portion of the nasal cavity of cleft lip patients. This stenosis can be severe and functionally debilitating. Previously proposed solutions have offered disappointing results. Our solution has three key elements: adequate scar release; restoration of the lining and support by way of chondrocutaneous composite graft; and post-operative custom acrylic splinting.

Metastatic implantation of an oral squamous-cell carcinoma at a percutaneous endoscopic gastrostomy site.

Percutaneous endoscopic gastrostomy (PEG) has become an important adjunct in the care of the head-and-neck cancer patient. When resection will likely affect swallowing, PEG can be performed just prior to cancer resection. However, it is unclear whether PEG should be the procedure of choice for establishing enteral access in head-and-neck cancer patients. In this report we describe a man with advanced oral squamous cell carcinoma who had a One-Step PEG button inserted immediately prior to his cancer resection. Six months later, the patient developed metastatic squamous-cell carcinoma at the PEG site. Although the mechanism of spread cannot be confirmed, direct seeding from passage through the cancer-filled oral cavity seems likely. Methods of establishing enteral access which avoid tumor-contaminated fields, such as use of an overtube during conventional PEG, open gastrostomy, or laparoscopic gastrostomy, may be more appropriate in head-and-neck cancer patients.

Comparison of postoperative wound complications and early cancer recurrence between patients undergoing mastectomy with or without immediate breast reconstruction.

The incidence of postoperative wound complications and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immediate reconstruction were younger and had less advanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0.05) in patients with and without reconstruction, respectively. The overall incidence of postoperative complications was similar in the two groups of patients: 31% and 28% in patients with and without reconstruction, respectively. The incidence of postoperative seroma was higher among patients with mastectomy alone (19% versus 3%, p < 0.05), whereas the incidence of other wound complications was similar in the two groups of patients. Prosthesis-specific complications occurred in 17%. Eight prostheses were removed because of complications. During the relatively short follow-up period (approximately 20 months), local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy (p < 0.05). There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immediate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complications associated with the procedure, especially if an implant is used.

Tissue expanders in the lower face and anterior neck in pediatric burn patients: limitations and pitfalls.

Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of free fasciocutaneous and muscle flaps for reconstruction of the foot.

Seventeen free flaps were used to reconstruct severe injuries to the foot over the last 36 months at the University of Cincinnati College of Medicine. The type of free flaps used included six fasciocutaneous free flaps and eleven free muscle flaps with split-thickness skin grafts. The fasciocutaneous flaps were either radial forearm or scapular flaps. The muscle flaps used were gracilis, rectus, or latissimus dorsi muscle flaps. Each type, with their specific advantages, disadvantages, and indications for use as they apply to the anatomical areas of the foot, are described. Regardless of the type of free flap used, careful preoperative planning, attention to the size and location of the anatomical defect, and correct contouring and insetting should allow for maximal functional result and minimize postoperative morbidity.

Technical successes and functional failures after free tissue transfer to the tibia.

A retrospective study evaluated functional outcome in 59 patients with 61 successful free tissue transfers performed after open tibial fractures. Twenty-one patients had transfers done within 7 days, 13 between 7 and 21 days, and 25 were done greater than 3 weeks after injury. All 59 patients had Type III injuries as classified by Gustilo and Anderson. Nineteen patients (32%) were identified as late functional failures. Each of these patients underwent as average of 10 procedures. In this group chronic osteomyelitis was noted in 13 of 19 patients and chronic venous insufficiency with skin ulceration in 9 of 19 patients. Fracture nonunion was seen in 8 of 19. Degenerative joint problems and foot deformities were identified in 7 or 19 patients. Seven patients (12%) ultimately required below-knee amputation. Functional failure did not correlate with the timing of flap application, but rather with the severity of the initial injury. Free tissue transfer is not a panacea. It is but one step in the overall reconstruction of complex tibial wounds.

Changes in articulation and resonance after tongue flap closure of palatal fistulas: case reports.

This paper describes speech changes in three patients after tongue flap closure of various sized palatal fistulas. In all three patients articulation and lingual mobility appeared to be unaffected by excision of tongue tissue for the procedure. However, a large protruding tongue flap was noted to interfere with the articulation of sibilants in one patient. All patients showed a reduction in overall hypernasal resonance and nasal emission, although one patient developed nasal turbulence postoperatively and another required a pharyngeal flap for total elimination of hypernasality. This paper points out the need for a systematic investigation into the effects of this surgery on speech.

Complications of controlled tissue expansion in the pediatric burn patient.

All patients at the Burn Institute reconstructed with tissue expanders between June of 1984 and June of 1987 were included in this review. There were 122 expanders used in 77 patients. Complications were defined as "absolute" (23 of 122 expanders, 20 percent) if they resulted in loss of expanders or additional surgery or none of preoperative plan was satisfied or "relative" (14 of 122 expanders, 11 percent) if they included spotty alopecia or alopecia greater than 50 percent or the operative plan only partially satisfied, reflecting poor judgment. The most common absolute complication was prosthetic exposure secondary to wound dehiscence occurring in the scalp area. Complications relative to specific anatomic areas were neck and face, 2 of 20 (10 percent); lower extremity, 1 of 4 (25 percent); trunk, 0 of 6 (0 percent); and scalp, 20 of 92 (22 percent). We feel that this high complication rate in the use of tissue expanders may be unique to the pediatric burn patient. Knowledge of indications for use and potential complications is essential to add this entity to the armamentarium of the burn reconstructive surgeon.

Classification and treatment of postburn proximal interphalangeal joint flexion contractures in children.

Two hundred and sixty-four surgically treated proximal interphalangeal joint flexion contractures in children were reviewed. A classification system on the basis of contracture severity was devised to assess the efficacy of treatment. Contracture severity was determined from preoperative radiographs and physical examination. Eighty-eight percent of the digits were successfully treated (postoperative contracture less than 20 degrees). Unsatisfactory results (12% of digits) were directly proportional to the severity of the contracture and tended to occur in older children with large total body surface burns. The time interval between burn and contracture release did not correlate with contracture severity or therapeutic failure. The most common cause of an unsatisfactory result was failure to fully release the contracture.

Carcinoma of the prostate metastatic to the mandibular condyle mimicking a parotid tumor.

An unusual case of adenocarcinoma of the prostate metastatic to the mandibular condyle that presented clinically as a parotid tumor is reported. Standard radiologic studies may be misleading in such cases, and a high index of suspicion is required for atypical masses in the parotid region.