Use of Medpor porous polyethylene implants in 140 patients with facial fractures.

Use of alloplastic materials in facial bone reconstruction is still controversial. Medpor porous polyethylene is a relatively new implant material that is well suited for this purpose and has a number of advantages over other alloplasts. It is a pure polyethylene with a unique manufacturing process and pore size. Technically, it is easy to work with; it can be carved, contoured, adapted, and fixated to obtain a precise three-dimensional construct. Physically, it is a pure, biocompatible, strong substance that does not resorb or degenerate. It demonstrates long-term stability, high tensile strength, resistance to stress and fatigue, and a virtual lack of surrounding soft-tissue reaction. Rapid tissue ingrowth occurs into the pores. Extensive vascular ingrowth creates the potential to transport cellular products that fight infection deep into the implant. The implant was used in 140 patients from June 1988 to August 1991 to treat acute orbitozygomatic injuries (71), acute Le Fort injuries (24), delayed orbitozygomatic injuries (33), and delayed onlay augmentation (12). In this series, there was 1 instance of implant infection requiring removal, and no implant migration, or exposure.

The extended deep inferior epigastric pedicle flap for lower extremity reconstruction.

Large soft-tissue defects of the lower extremity can present a challenging reconstructive problem. The extended deep inferior epigastric pedicle flap is a versatile and reliable flap that can be used for the coverage of complex lower extremity soft-tissue defects as far distal as the knee. We reviewed our 5-year experience with 20 consecutive extended deep inferior epigastric pedicle flaps used to cover lower extremity defects. All wounds, including 4 soft-tissue defects of the knee, were successfully covered. Two minor complications occurred. Flap anatomy, surgical approach, and new refinements in flap design are presented. The indications for the flap and its role in ablative tumor surgery are discussed. This flap has proved to be versatile, easy to raise, and extremely hardy. The ample skin island with its large arc of rotation is well vascularized, healing well even in irradiated wounds, and the flap tolerates both postoperative pressure and radiation.

Panniculus morbidus.

Eight patients with large panniculi are described where severe problems with hygiene, immobility, and chronic infection were caused by the lymphedematous, chronically infected pannus. Protracted nonsurgical management of the infected panniculus had failed in all 8 patients. Wedge resection without fat undermining removed diseased tissue. Infection and sepsis were eliminated and ambulation was restored in all patients. Formerly immobile patients were returned to normal activity. Significant self-induced weight loss was not observed in a 2-year follow-up period; weight gain, however, was not experienced. The primary anesthetic method was thoracic epidural reducing the requirements for general endotracheal anesthesia. The chronically infected pannus is a surgical problem deserving earlier recognition and resection.

Free nipple graft reduction mammoplasty.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

Le Fort fractures without mobility.

The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.

Metrizamide, iothalamate, and metrizoate: effects of internal carotid arterial injections on the blood-brain barrier of the rabbit.

Experiments were conducted on anesthetized rabbits to determine the effect of internal carotid artery injection of various contrast media on permeability changes in the blood-brain barrier. Changes in respiratory pattern, neuromuscular effects, and trypan blue extravasation were recorded after 3-ml injections of ionic and nonionic contrast media. Metrizamide and iothalamate meglumine were compared at iodine doses of 300, 400, and 500 mg I/ml. Metrizoate at 280 and 440 mg I/ml and diatrizoate meglumine at 385 mg I/ml were also included for comparison. The results demonstrated that metrizamide at all three iodine concentrations used caused minimal disruption of the blood-brain barrier, the effect being no greater, statistically, than saline controls. Iothalamate was benign at the lowest iodine concentration, but caused significant barrier breakdown at the two higher concentrations. These results suggest that alterations in blood-brain barrier permeability following angiography are mediated by both hyperosmolality of the contrast medium and the chemotoxicity of the contrast molecule.