Early intervention and aggressive management of infected median sternotomy incision: a review of 2242 open-heart procedures.

Infected median sternotomy following open-heart surgery is a devastating complication with an incidence of 0.4 to 5 per cent and mortality as high as 80 per cent. Management varies from irrigation, debridement, closure with muscle, and skin flaps. We present our experience of early intervention and aggressive single-stage operative management. A retrospective chart review of all open-heart surgery patients was conducted from September 1984 through September 1994. Of the 2242 patients, 52 had infected median sternotomy incisions (2.3% incidence). The mean length of stay for reconstructive procedures was 18 days. The median interval to detection was 15 days, whereas the median interval to intervention was 4 days. There were five (6.8%) failed procedures and nine (12.3%) staged procedures. There were six deaths (11.5% incidence), one prior to receiving operative intervention. There was one false aneurysm. Single-stage reconstruction is safe, with results better than multistage procedures. It may be safely performed with a high success rate (93%). Early recognition and intervention significantly decreases length of stay.

Bicoronal forehead lift.

Although aesthetic surgery on the upper third of the face has received relatively little attention in recent literature, it is an extremely important component of facial aesthetic surgery and often yields results that are quite dramatic. Periorbital rejuvenation, either alone or in conjunction with other aesthetic surgical procedures, offers facial enhancement to younger patients. In addition, older patients may benefit from a "forehead lift" performed in conjunction with lower facial surgery. This benefit is derived because lower facial surgery may create facial disharmony by yielding a more youthful lower face while leaving a more mature upper face. In these cases a forehead lift serves to unify the patient's facial appearance. The coronal browlifting technique described here is a personal interpretation and modification of periorbital rejuvenation techniques. This approach represents an ideal aesthetic procedure: It is a technically straightforward operation that yields results which are predictable, natural appearing, and long lasting with minimal morbidity.

Seizures abolished by excision of a cavernous hemangioma of the scalp and skull.

A large vascular malformation of the supraorbital and scalp areas was present in an adolescent girl who had seizures and headaches. Removal of the malformation included the outer table of the skull. The patient has had no seizures during a two-year follow-up.

Osteoradionecrosis of the thoracic wall and its surgical management.

Four patients with disabling radiation defects of the chest involving skeletal and soft tissues were successfully treated with a one stage breast flap. Closure of the defect resulted after an uncomplicated and safe operation. Safety and reduced morbidity are hallmarks of the breast flap repair for this difficult problem. Although alternative methods can be used, the preparation of staged flaps and postoperative problems in major myocutaneous flaps increase the risk of such therapy and the hospital stay for these elderly, debilitated patients. The low morbidity of this one stage flap with a minimal hospital stay make this treatment a very viable and appealing alternative for patients whose long-term prognosis is exceedingly poor.