Lateral thoracic expansion for Jeune's syndrome: midterm results.

BACKGROUND: In 1995, we reported the use of lateral thoracic expansion in a patient with symptomatic Jeune's asphyxiating thoracic dystrophy. We have subsequently used lateral thoracic expansion 16 times on 10 patients during 7 years. This article reports our outcomes and provides surgical details. METHODS: Charts of all patients undergoing lateral thoracic expansion were reviewed. Eight of the 10 patients had symptomatic Jeune's syndrome. The other 2 had similar thoracic deformities limiting thoracic capacity. In half of the patients the procedures were performed bilaterally. RESULTS: All patients older than 1 year of age were symptomatically benefited by lateral thoracic expansion. Functional and anatomic measurements documented thoracic enlargement in several patients who had comparable preoperative and postoperative studies. However, 2 infants with significant underlying airway disease did not improve and went on to succumb to that aspect of their disease despite enlargement of the thorax. Fracture of the titanium ministruts has been a recurrent problem, and we now use larger struts. CONCLUSIONS: Lateral thoracic expansion is a safe and effective procedure in selected patients with Jeune's syndrome older than 1 year of age as judged by short-term and midterm follow-up. More experience and longer follow-up are required to discern the place of the lateral thoracic expansion in the overall management of these patients.

A prosthetic breast implant infected with Mycobacterium fortuitum.

Augmentation mammaplasty is a common operation performed in the United States. Postoperative wound infections are rare, but can be devastating. Most often, bacteria from the normal skin flora cause these infections, but more atypical organisms can lead to similar situations. The authors present a case of a prosthetic breast implant infected with Mycobacterium fortuitum after augmentation mammaplasty. The patient, diagnosis, and treatment are discussed so that others may recognize and treat this entity successfully before encountering major complications. Although it is an infrequent occurrence, plastic surgeons, infectious disease specialists, and primary care doctors who may see postoperative wound infections should be aware of this potential pathogen. It is important in any postimplant infection and especially crucial in cases of unresolving or recurrent infections with unusual or even clear drainage. With proper identification through acid-fast smear and culture, multiagent therapy can be initiated early. Additional complications, including implant removal, may thus be avoided.

Lateral thoracic expansion for Jeune's asphyxiating dystrophy: a new approach.

A new procedure is described for thoracic expansion in Jeune's asphyxiating dystrophy. The chest wall is enlarged by division of ribs and underlying tissue in a staggered fashion so that either rib or periosteum covers the lung. New bone formation has been demonstrated so that a viable enlargement has been obtained. The clinical result is excellent to date.

Lasting success in teenage reduction mammaplasty.

Symptomatic relief of macromastia following reduction mammaplasty in the adult female population is well documented. Teenagers undergoing breast reduction may be at risk for recurrent symptoms secondary to postoperative breast development. The psychological consequences of prominent scars, sensory loss, and inability to breastfeed may overshadow the early symptomatic relief gained from reduction mammaplasty. Eighty-six patients who had undergone bilateral reduction mammaplasty prior to 20 years of age from 1970 to 1990 were identified from hospital and office charts. Forty-eight patients (56%) were successfully contacted and completed a detailed questionnaire evaluating preoperative, postoperative, and present symptoms as well as physical and psychological consequences of their surgery. Patient age ranged from 15.0 to 19.9 years with a mean of 17.8 years. Average length of follow-up time was 5.9 years, ranging from 1.4 to 20.4 years. Sustained relief of symptoms in those patients with preoperative back pain, neck pain, shoulder strap pain, and submammary rash occurred in 76%, 78%, 89%, and 93%, respectively, despite the fact that 72% reported at least some regrowth of breast tissue. Seventy-three percent reported being happy with their current breast size, 94% would have the procedure now if they had not had the surgery as teenagers, and 94% would recommend breast reduction to a friend with macromastia. Teenage patients who undergo reduction mammaplasty do not suffer from marked return of symptoms, and long-term satisfaction remains high.

Evaluation of erythropoietin levels in the anemia of thermal injury.

Thermal injury is associated with an anemia of multifactorial etiology. Erythropoietin is a hormone that increases red blood cell production in response to tissue hypoxia and is now being produced in a recombinant form for treatment of some anemias. How erythropoietin levels change in response to thermal injury has not been adequately investigated to date. We studied 27 patients with burns of 10% to 85% total body surface area by serially measuring hemoglobin, hematocrit, reticulocyte count, and erythropoietin levels. Erythropoietin levels were determined by radioimmunoassay. Measurements were taken at admission, before surgery, and after surgery, or at least weekly for a period of up to 4 weeks. Twenty-five of the patients had a reticulocytopenic anemia by the end of the first postburn week. Twenty-three patients remained anemic throughout the study period. Erythropoietin levels increased appropriately as the patients became anemic. Erythropoietin levels related to hemoglobin in a logarithmic fashion with a correlation of -0.869. No differences were found on the basis of burn size or age. This study indicates that the anemia of thermal injury is associated with reticulocytopenia and an elevation of endogenous erythropoietin.

Nonsurgical management of burns to the lips and commissures.

Our results indicate that the nonsurgical approach in the treatment of burns of the mouth should be considered. The nonsurgical approach is less costly and less traumatic, and it yields a favorable result that is shown to be predictable.

Nutritional and metabolic consequences of thermal injury.

Major burns produce a variety of metabolic and nutritional consequences. The patient's metabolic rate is often doubled, and caloric demands of 3000 to 5000 calories per day are not uncommon. There are marked hormonal changes characterized by an increase in secretion of catecholamine and glucagon and a reversal of the normal insulin-to-glucagon ratio. Serum glucose increases primarily through hepatic gluconeogenesis to meet the increased demands of the burn wound and of the increased metabolic rate. Lipids may be available but they are an inefficient source of calories. Skeletal and visceral proteins are mobilized to meet the increased nutritional demands. The overall result is a severely catabolic patient in negative nitrogen balance, with decreased immunologic function and all of the wound-healing problems associated with protein and calorie malnutrition. Aggressive nutritional support (using enteral feeding whenever possible) is essential. Supplemental feedings should be started on all patients unable to reach their recommended calorie and protein requirements through regular oral diet. An increase in protein intake (calorie-to-nitrogen ratio of 100:1) may be beneficial. By establishing nutritional goals and monitoring daily weight, calorie count, protein intake, and biochemical parameters, the physician can significantly improve the chances of survival of even the most seriously injured patients.

Heparin does not reduce catheter sepsis during total parenteral nutrition.

Although it is recognized that the addition of heparin to total parenteral nutrition solutions reduces subclavian vein thrombosis from percutaneous polyethylene catheters, it does not affect the low thrombosis rate associated with polyurethane catheters. It has been suggested that heparin also reduces catheter sepsis during total parenteral nutrition. We reviewed the sepsis rate in 86 patients randomized to receive iv nutrition with or without heparin through polyethylene, polyvinyl, and polyurethane catheters. Blood was drawn from febrile patients for culture; if positive, catheters were removed and the tips cultured. Catheters were considered infected if blood and catheter tips were positive, or if fever disappeared within 48 hr after catheter removal, even if cultures were negative. Catheter sepsis occurred in two patients in both groups. It appears that heparin does not reduce sepsis from percutaneous subclavian vein catheters. Although its use may be indicated to reduce thrombosis associated with polyethylene catheters, there is no indication for its use to reduce sepsis with either type of catheter.

Clinical effect of nonthrombotic total parenteral nutrition catheters.

Radiographic evidence of subclavian vein thrombosis has been shown to occur in 33% of total parenteral nutrition patients. This incidence can be significantly reduced to 8% when heparin is administered concomitantly in total parenteral nutrition solutions. To evaluate the thrombotic risk of a newly developed polyurethane catheter, 20 concurrent patient pairs were prospectively cannulated with either a standard polyethylene catheter plus heparin or a polyurethane catheter without heparin in a sequential statistical study. Radionuclide venograms (Tc99m) were performed within 72 hr of catheterization, at biweeky intervals, and at termination of total parenteral nutrition administration. No patient in either group developed clinical (pain, arm swelling, collateral veins) or venogram evidence of thrombosis after catheterization during an overall cannulation period of 820 days. Use of polyurethane catheters and elimination of heparin in total parenteral solutions may be particularly important since contraindications to heparin use are common. Additionally, heparin elimination can decrease admixture work and confusion (ie, subcutaneous heparin double dosing) without increasing the risk of subclavian vein thrombosis.

The effect of perioperative adriamycin on skin-graft take and adherence in the rat.

This two-part study was undertaken to evaluate the effect of perioperative Adriamycin on skin-graft take and adherence in an animal model. Thirty-four male Fisher rats were divided into control and experimental groups. The controls received intravenous saline, and the experimental animals received Adriamycin 6 mg/kg (LD 10) 24 hours preoperatively. Each animal was then grafted with an autogenous split-thickness skin graft on a contiguous dermal and fascial bed. Skin-graft take was judged and measured at 7 and 14 days postoperatively. The average skin-graft take for controls was 6.1 cm2 on both the dermal and fascial beds. This was significantly better than the average skin-graft take sustained by the experimental groups of 4.3 and 3.5 cm2 on the dermal and fascial beds, respectively (p less than 0.01). Another 30 animals were divided into three control and three experimental groups. They were treated with saline and Adriamycin as before, and they underwent a similar surgical procedure. Skin-graft adherence, which was measured at 12, 24, and 48 hours postoperatively, was significantly less in the experimental groups compared with the control groups at all times measured. These data suggest that a single supratherapeutic dose of Adriamycin given preoperatively decreases skin graft take in the experimental model studied and that this decrease may be the result of a concomitant decrease in graft adherence.

Role of nutrition in wound healing.

Nutritional cofactors play a major role in the wound-healing process. Deficiencies of specific nutrients, especially proteins, vitamins, and minerals, may significantly impair the healing process. The recognition of deficits and understanding of methods of repletion are a critical part of modern surgical practice.

Meshed skin grafts versus sheet skin grafts on a contaminated bed.

An experimental model was designed to test the premise that meshed skin grafts survive better than sheet grafts on contaminated wounds. In this rat model, meshing of grafts significantly improved graft take, and expansion of the mesh led to an even greater improvement. The results of this study indicate a need for further investigation of this technique in the management of contaminated wounds.

Max Thorek: a surgeon for all seasons.

Max Thorek was a leader in the field of surgery during the first half of the twentieth century. His contributions to plastic surgery included both technical advances and the recognition of the psychological import of aesthetic surgery. His technique for reduction mammaplasty (free nipple graft) is still in use today, and his principles of abdominoplasty remain applicable to modern body contour surgery.

Innervated cross-leg tensor fascia lata fasciocutaneous flap for foot reconstruction.

A traumatic, extended first ray amputation in a child was treated with an innervated cross-leg tensor fascia lata fasciocutaneous flap. The flap provided thin composite tissue coverage, immobilization in a position of relative comfort, and sensory innervation to the weight-bearing surface. Consideration of this flap is recommended when dealing with large defects of the foot.

Evaluation of nitrogen utilization in patients receiving total parenteral nutrition.

This two phase study evaluates nitrogen utilization by the body as a function of fixed caloric intake but different nitrogen loads. Nitrogen use by the body was estimated from measures of nitrogen balance, net protein utilization, and urea accumulation rate. Phase 1 of this study included 411 measurements of nitrogen use in 120 patients assigned, according to clinical condition, to receive one of the four following therapies: dextrose (D) 25%, amino acids (CAA) 4.25% (Group 1); D 35%, CAA 4.25% (Group 2); D 25%, CAA 21.3% (Group 3); or D 35%, CAA 21.3% (Group 4). Forty patients in Phase 2 were assigned in a randomized, prospective, double blind manner, to receive one of the following regimens; D 35%, CAA 2.75% (Group 5); D 25%, CAA 2.75% (Group 6); D 35%, CAA 4.25% (Group 7); or D 25%, CAA 4.25% (Group 8). In Phase 1, positive nitrogen balance was achieved with the exception of Group 3 where neither the estimated caloric nor nitrogen needs of the patients were met. It appeared that protein utilization was maximal in patients receiving the therapy of highest calorie:nitrogen ratio (Group 4). Phase 2 patients achieved positive nitrogen balance to the same extent (p greater than 0.05) and although net protein utilization improved from 53 to 71%/d as the calorie:nitrogen ratio was increased, the differences were not significant (p greater than 0.05). There was a significant improvement in total iron binding capacity in Phase 2 patients (p less than 0.01) that was most prominent at the lower concentrations of amino acids (high cal:n ratio) (Groups 5 and 6). Smaller amounts of nitrogen appear adequate in producing a positive nitrogen balance and may be better utilized in hospitalized patients if the patients' caloric requirements are achieved.

Incidence and prevention of thrombosis of the subclavian vein during total parenteral nutrition.

In this study, we were able to document by radionuclide venogram the presence of thrombosis of the subclavian vein in seven of 22 patients receiving standard total parenteral infusions. By adding 3,000 U.S.P. units of heparin to each liter of infusate, we were able to reduce the number of instances of thrombosis to two in 24 patients. Although none of the patients in the heparin therapy group experienced laboratory or clinical manifestations of anticoagulation, we suggest that further studies be done to investigate the reduced heparin concentrations to determine the lowest effective level. Based upon these observations, we currently recommend that 3,000 U.S.P. units of heparin be added to each liter of total parenteral nutrition solution infused through a subclavian venous catheter.

Evaluation of Opsite catheter dressings for parenteral nutrition: a prospective, randomized study.

A prospective, randomized study compared the use of Opsite and standard gauze/tape dressings in 261 patients receiving parenteral nutrition. Eighty-four patients had a source of external drainage and were evaluated as a separate group. Catheter-related sepsis was assessed by blood culture, catheter tip culture, clinical sepsis, and clinical defervescence of fever after catheter removal. Although no statistically significant difference between Opsite and standard dressings could be identified, Opsite-treated patients consistently had increased parameters of catheter-related sepsis in all comparisons. As used here, Opsite is probably not a suitable catheter dressing system for parenteral nutrition.