Outcome analysis in patients with primary necrotizing fasciitis of the male genitalia.

OBJECTIVES: To characterize patients with primary necrotizing fasciitis of the male genitalia (Fournier's gangrene) and to identify risk factors and prognostic variables of survival. METHODS: Fifty consecutive patients with primary necrotizing fasciitis of the male genitalia treated at our institution during a 15-year period between 1984 and 1998 were retrospectively analyzed. Of these patients, 44 (88.0%) were found to be eligible for analysis of the outcome parameters. Univariate survival analysis was performed using the Kaplan-Meier algorithm followed by multivariate analysis of statistically significant variables. Six patients (12.0%) who were severely immunocompromised were studied separately. RESULTS: Medical comorbidities were prevalent, with diabetes being the most common condition (50%). The overall mortality rate was 20% (10 of 50). Three statistically significant predictors of outcome were identified among the variables analyzed. These were the extent of the infection (P = 0.0262), the depth of the necrotizing infection (P = 0.0107), and treatment with hyperbaric oxygen (P = 0.0115). Multivariate regression analysis of these variables identified the extent of the infection (P = 0.0234) as the only statistically significant, independent predictor of outcome in the presence of other covariables. CONCLUSIONS: The involved body surface area appears to be the most important prognostic variable, with a significant impact on outcome. Given the high mortality of the disease entity and a trend toward the improved survival of patients receiving hyperbaric oxygen, this treatment form appears indicated in more severe cases. Immunocompromised patients, who frequently have an atypical and fulminant clinical course, appear to constitute a separate group with a dismal prognosis.

Thoracic paravertebral block for breast surgery.

UNLABELLED: Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. Paravertebral nerve block (PVB) has the potential to offer long-lasting pain relief and fewer postoperative side effects when used for breast surgery. We compared thoracic PVB with general anesthesia for cosmetic breast surgery in a single-blinded, prospective, randomized study of 60 women scheduled for unilateral or bilateral breast augmentation or reconstruction. Patients were assigned (n = 30 per group) to receive a standardized general anesthetic (GA) or thoracic PVB (levels T1-7). Procedural data were collected, as well as verbal and visual analog pain and nausea scores. Verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea to GA alone. IMPLICATIONS: Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.

Intracapsular implant rupture: MR findings of incomplete shell collapse.

The objective of this study was to determine the frequency and significance of the MR findings of incomplete shell collapse for detecting implant rupture in a series of surgically removed breast prostheses. MR images of 86 breast implants in 44 patients were studied retrospectively and correlated with surgical findings at explantation. MR findings included (a) complete shell collapse (linguine sign), 21 implants; (b) incomplete shell collapse (subcapsular line sign, teardrop sign, and keyhole sign), 33 implants; (c) radial folds, 31 implants; and (d) normal, 1 implant. The subcapsular line sign was seen in 26 implants, the teardrop sign was seen in 27 implants, and the keyhole sign was seen in 23 implants. At surgery, 48 implants were found to be ruptured and 38 were intact. The MR findings of ruptured implants showed signs of incomplete collapse in 52% (n = 25), linguine sign in 44% (n = 21), and radial folds in 4% (n = 2). The linguine sign perfectly predicted implant rupture, but sensitivity was low. Findings of incomplete shell collapse improved sensitivity and negative predictive values, and the subcapsular line sign produced a significant incremental increase in predictive ability. MRI signs of incomplete shell collapse were more common than the linguine sign in ruptured implants and are significant contributors to the high sensitivity and negative predictive values of MRI for evaluating implant integrity.

Complex radial folds versus subtle signs of intracapsular rupture of breast implants: MR findings with surgical correlation.

Detection of intracapsular rupture of silicone breast prostheses using MR imaging is often performed by identifying the "linguine sign" [1]. The linguine sign is easily differentiated from simple radial folds that are seen in intact implants. However, more subtle signs of intracapsular rupture, including undulating subcapsular lines and the "teardrop sign," are less often recognized [2-5] and may prove difficult for the less experienced radiologist to differentiate from complex radial folds of intact implants. In this essay, we illustrate the MR imaging findings of complex radial folds in intact implants and compare them with findings of incomplete shell collapse in ruptured implants in a surgically confirmed series of explanted silicone breast prostheses.

Long-term sequelae following median sternotomy wound infection and flap reconstruction.

Use of muscle and omental flaps has been shown to provide reliable reconstruction of infected median sternotomy wounds; however, few reports emphasize the long-term sequelae of the complication and its treatment. This study was performed to evaluate the long-term problems, including patient satisfaction and survival rate, in 88 patients with median sternotomy infections treated with muscle or omental flaps. Forty-two patients were available for long-term follow-up by telephone interview, with an average length of follow-up of 42 months. Forty-three percent complained of chronic chest wall pain or discomfort, and 45% complained of sternal instability. After pectoralis major muscle flap reconstruction in 32 patients, 25% complained of upper extremity weakness, and 56% complained of chest contour deformity. Delayed septic costochondritis or osteomyelitis occurred in 8%. Despite these unfavorable consequences, 72% and 83% of patients were satisfied with the cosmesis of the operation and the overall result, respectively. Furthermore, after hospital discharge, these patients seem to enjoy satisfactory longevity. By emphasizing the potential sequelae, further research interest may be stimulated in delineating their causes and in refining techniques of reconstruction.

Prominent ears and their correction: a forty-year experience.

The technique described in this article correcting the protruding ear deformity has evolved over 40 years. The original procedures and our subsequent modifications are described, including 20-year followup results. The possible pitfalls in carrying out this procedure and how to avoid them are also described. A relatively standardized short procedure with minimal morbidity and maximum long-term results yields an aesthetically satisfactory looking ear.

Seromas in residual fibrous capsules after explantation: mammographic and sonographic appearances.

PURPOSE: To evaluate the mammographic and sonographic findings associated with seromas that develop in residual fibrous capsules after explantation of breast prostheses. MATERIALS AND METHODS: Preoperative and postoperative mammograms were reviewed in 86 patients (mean age, 51 years; age range, 24-71 years) who had undergone surgical explantation of breast prostheses. Six seromas were found in four patients 46-68 years of age. Imaging findings were correlated with surgical and laboratory results for three seromas. A presumptive diagnosis was made of the other three lesions. RESULTS: Mammograms demonstrated all seromas as large, elliptic, water-opacity masses, some with well-circumscribed and some with irregular borders. Sonograms showed thin, compressible masses, two of which were flat and anechoic and one of which was hypoechoic. Three patients' images were initially misinterpreted, leading to excision of two seromas and aspiration of one. Seromas were not identified in patients whose implants were removed by means of complete capsulectomy. CONCLUSION: Radiologists must be aware of the imaging findings associated with seromas and of a patient's surgical history to avoid biopsy of benign lesions.

Management of abdominal aortic graft complications.

OBJECTIVE: This study reviews the outcome of 61 patients who underwent 66 reoperations for complications of aortic grafts. There were 25 patients with false aneurysm of an aortic anastomosis and 41 patients with graft infection, 17 of whom had involvement of the gastrointestinal tract. SUMMARY BACKGROUND DATA: Significant late complications of aortic grafting occurred in 2% of patients. The mode of clinical presentation, the clinical characteristics, and outcome in these patients has not been emphasized. METHODS: This study reviews our experience with patients with complications of aortic grafts requiring graft excision or replacement with a view towards identifying prominent and important clinical characteristics and predictors of successful treatment. CONCLUSIONS: Patients with involvement of the gastrointestinal tract have higher mortality and morbidity than patients with simple aortic graft infection or those who require aortic graft replacement for pseudoaneurysm formation at the aortic anastomosis. These patients require longer hospitalization, more blood transfusion, and have higher operative and long-term mortality. Revascularization of the lower extremities should be attempted and has a high rate of limb salvage although revision or thrombectomy may be required. The authors recommend complete graft excision and extra-anatomic bypass for patients with aortic graft infections.

Evaluation of failed sphincter pharyngoplasties.

A review of 30 failed sphincter pharyngoplasties is presented. Failure may be caused by inappropriate surgical planning, inadequate surgical technique, or inappropriate patient selection. Problems with surgical planning and technique that lead to failure were low flap placement, flap dehiscence, and flaps not approximated in midline. Problems with patient selection that lead to failure were large velopharyngeal gap on videofluoroscopy, and residual speech (articulation) deficits. Careful pre- and postoperative evaluation has led to refinement of the surgical procedure and improved outcome. Success rate improved from 67.65% in the first 5 years to 86% in the last 5 years of this 15-year series.

Evaluation of the sphincter pharyngoplasty.

The results of the sphincter pharyngoplasty were evaluated in 139 patients with velopharyngeal incompetence (VPI) who demonstrated active velar elevation. All patients underwent perceptual speech evaluation and lateral phonation radiographic study; select patients underwent multiview videofluoroscopic, flexible nasendoscopic, and pressure-flow studies. All but one patient demonstrated improvement and 109/139 (78.42%) demonstrated resolution of VPI. Sixteen of thirty failed pharyngoplasties were revised. Revision was successful in 8/16 patients yielding an overall success rate of 117/139 (84.17%). Success rate was 67.65 percent for patients managed during the first 5 years and improved to 84.78 percent for patients managed during the last 5 years of this 15-year series. Analysis revealed that younger patients were treated more successfully than older patients, large velopharyngeal areas were treated as successfully as smaller ones, and circular closure patterns were treated more successfully than coronal patterns. The primary cause of failure was insertion of the flap below the point of attempted velopharyngeal contact.

Accessory parotid glands as a site of metastases from outside the head and neck: case report.

Metastases to the salivary glands from outside the head and neck are rare. The world literature reports 53 cases to the parotid, and 25 to the submandibular-submaxillary gland. This is the first report of a metastasis to the accessory parotid gland.

The effect of povidone-iodine solutions used as surgical preparations on the bacterial flora of the skin.

One hundred fifty hospitalized patients undergoing elective surgery were enrolled in an open study designed to assess the bactericidal and clinical efficacy of a preoperative skin preparation procedure--application of 7.5% povidone-iodine surgical scrub followed by 10% povidone-iodine antiseptic solution. Of 99 patients with bacterial colonization of the skin prior to surgery, 84 patients (85%) had no detectable levels of bacteria at completion of surgery; bacterial flora persisted after surgery in the remaining 15 patients (15%). The difference between pre- and post-surgical bacterial colonization was statistically significant (p = 0.004). Clinically, none of the 146 patients evaluable for analysis of efficacy developed infections at the incision or suture site and there were no incidents of skin irritation at the surgical site during the postoperative observation period. Thus, preoperative cleansing with povidone-iodine surgical scrub followed by povidone-iodine antiseptic solution is an effective, non-irritating bactericidal regimen for use at surgical incision sites.

The inferior dermal-pyramidal type breast reduction: long-term evaluation.

The evolution of the technique of breast reduction using an inferior dermal pyramidal flap is discussed, including the changes we have found to enhance this procedure. The recommended use of a wide-based pyramidal breast parenchyma with a dermal pedicle nipple-areola flap is based on our 12-year study of 1,001 breast reductions in 519 patients ranging in age from 13 to 73 years; 37 of the patients underwent a unilateral breast reduction. The weight of tissue excised ranged from 207 g to 3,350 g from each breast. Occult carcinomas were found in two of the breast specimens. The longest sternal notch-to-nipple distance was 52 cm. The essential goals of predictability of the result, retainment of nipple sensitivity, excellent aesthetic results, and the possibility of lactation are satisfied by the use of this surgical technique. This technique appears to have continued application in younger women, in whom nipple sensation and lactation are particularly important.

Factors improving survival in multisystem trauma patients.

This report analyzes the effect of air versus ground interhospital transport on survival following multisystem injury. There were 136 air-transported patients versus 194 ground-transported patients. The groups were similar in trauma scores, ages, mechanism of injury, and organ systems injured. There was a statistically significant survival advantage for air-transported patients with trauma scores between 10 and 5 (82.8% survival vs. 53.5%, p = less than 0.001). The time interval between accident and admission to the authors' institution was similar for both groups. Important therapeutic interventions contributing to better survival by the air-transported group included higher incidences of endotracheal intubation (50% vs. 25%), blood transfusions (32% vs. 10%), larger volumes of electrolyte fluid (3.3 L per patient vs. 2.1 L per patient) as well as the use of MAST trousers (60.3% vs. 34.9%). Transport charges for both ground and air services were similar. However, helicopter charges met only 15% of the operational budget of the aeromedical service. The remainder of the costs were generated from hospital patient revenues. Overall, total hospital charges were similar for both groups and were influenced by the variability of length of stay, particularly for orthopedic patients.

Mammary implants, diving, and altitude exposure.

Mammary implants were exposed to various simulated dive profiles followed by altitude exposures to stimulate aircraft travel and then were observed for bubble formation and volume changes. Minimal volume changes occurred after each dive. Numerous bubbles formed, however, reaching their maximum size in 3 hours. By comparison, when implants were exposed to high altitude following a dive exposure, significant volume changes occurred. This in vitro study showed that bubble formation and volume expansion occur after exposing implants to diving and altitude, but the circumstances required to produce these changes in vivo are extremely unlikely to occur normally.

The orticochea pharyngoplasty and primary palatoplasty: an evaluation.

A primary Orticochea pharyngoplasty with a primary palatoplasty was studied in 15 children with cleft palates. Although all children demonstrated velopharyngeal competence, radiographic, endoscopic, and oral examinations suggested that 54% of the children studied would not have needed a pharyngoplasty. In addition, 27% of the children demonstrated aberrant speech patterns associated with velopharyngeal incompetence. Emphasis is placed on the difficulty in identifying which cleft palate patients will have residual velopharyngeal incompetence and the need for continued study and development of techniques for more accurate prediction of which patients would benefit from a primary pharyngoplasty.

An aesthetic approach for nasal tumors.

An elongated columella flap has been found to give excellent exposure to the nasal dorsum, allowing satisfactory removal of soft tissue nasal masses such as dermoid cysts or hemangiomas. This approach provides a more acceptable scar than the standard vertical dorsal nasal incision.