Using the autospreader flap in primary rhinoplasty.

BACKGROUND: When performing dorsal reduction in primary rhinoplasty, one must pay close attention to the height of the upper lateral cartilages. They are in part responsible for the dorsal aesthetic lines and often require a lower profile. METHODS: The technique the authors describe uses the transverse portion of the upper lateral cartilages rotated medially to function as a local spreader flap while reducing the profile of the dorsum and preserving the aesthetic lines. This is a surgical technique that adjusts the height of the upper lateral cartilages in a precise and safe manner while preserving the function of the internal valve. RESULTS: The authors present two patients seen at 1 and 3 years after undergoing the autospreader flap technique. In the experience of the senior author (H.S.B.) with this procedure over the past decade, preoperative surgical goals were achieved reliably. CONCLUSIONS: The authors review the anatomical indications in which they found this technique to be simple, reproducible, and effective in shaping the dorsal midvault while preserving the function of the internal valve. Autospreader flap rotation should be considered when dorsal reduction is required.

Use of suture anchors in the reconstruction of soft tissue defects with pedicled muscle flaps.

Suture anchors have been commercially developed to facilitate stable attachment of soft tissues to bone. Although their use is well characterized in orthopedic literature, suture anchors may also be of benefit in the reconstruction of large soft tissue defects by plastic surgeons. Suture anchors (Mitek Surgical Products, Inc., Westwood, MA) were used to fasten pedicled muscle flaps to exposed bone in 7 patients at Duke University undergoing reconstruction of large soft tissue defects. The suture anchor appeared to provide stability for the advancement flap, and there were no suspected postoperative muscle dehiscences or suture breakages. The suture anchor provides an easy, secure method to attach soft tissue to exposed bone, and preliminary experience appears to support their use in certain soft tissue reconstruction procedures by plastic surgeons. Suture anchors should be reserved for cases in which a large muscle flap is needed to cover exposed bone and poses a risk of shearing away from the bone, or adequate periosteum and soft tissue is not available for standard suture techniques.

Breast necrosis following use of the internal mammary artery for coronary artery bypass.

Coronary artery bypass grafting is a common surgical procedure for myocardial revascularization. This operation usually involves the use of the left internal mammary artery to bypass the left anterior descending coronary artery. The internal mammary artery and its perforators are also an important blood supply to the female breast, though not considered a critical blood supply. Due to an abundant blood supply from multiple sources, complications of the female breast are rare. We present a case report of a patient who developed necrosis of the entire medial left breast and superior abdominal wall following coronary artery bypass grafting which used the left internal mammary artery.

Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis.

OBJECTIVE: Poststernotomy mediastinitis, although infrequent, is a potentially life-threatening complication of cardiac surgery that continues to have a significant morbidity and mortality despite aggressive therapy. Vacuum-assisted closure uses controlled suction to provide evacuation of wound fluid, decrease bacterial colonization, stimulate granulation tissue, and reduce the need for dressing changes. METHODS: One hundred two patients from Duke University Hospital, The Durham Veterans Administration Hospital, and referring institutions underwent vacuum-assisted closure treatment. There were 63 men and 39 women, with a mean age of 67. The infection was noticed between postoperative days 8 and 34, at which time the wounds were opened and debrided. RESULTS: Ninety-six of the 102 patients received vacuum-assisted therapy while the remaining 6 underwent daily multiple dressing changes without vacuum-assisted therapy. Fifty-three of the 96 patients required only sternal debridement, followed by wound vacuum therapy and closure by secondary intention, while the remaining 43 had an additional procedure. Of these, 33 patients underwent omental transposition and 10 patients had a pectoralis flap. The length of stay for all patients was 27 +/- 12 days. This was related in part to intravenous antibiotics. Hospital mortality for all patients was 3.7% (4 patients). Two of these patients underwent vascular flap and succumbed to multisystemic organ failure, while the other 2 received only wound vacuum therapy following debridement and succumbed to overwhelming sepsis. CONCLUSION: Vacuum-assisted drainage is an effective therapy for mediastinitis following debridement or before placement of a vascularized tissue flap.

Simple approach to the radiated scalp wound using INTEGRA skin substitute.

The chronic irradiated scalp wound remains one of the most difficult reconstructions for the plastic surgeon. With its inherent radiodermatitis and poor healing potential, chronic ulcers down to bone will result if coverage cannot be achieved. Reconstructive procedures as simple as a skin graft have a high complication rate in the irradiated wound and often fail. Local tissue transfer also has a high failure and complication rate because of the decreased vascularity of the wound bed and radiation damage to the surrounding scalp tissue, limiting its manipulation. The authors report two cases using a simple method with INTEGRA bilaminate skin substitute (Integra Life Sciences, Plainsboro, NJ) for repair of difficult wounds of the radiated scalp. Case one involves a patient with nonhealing radiation ulcers that had failed local wound care, hyperbaric oxygen, and split-thickness skin grafting. Case two involves a patient with extensive squamous cell cancer of the scalp that recurred despite total scalp radiation, requiring resection of more than 50% of the total surface area of the scalp. Both these patients were successfully treated using INTEGRA artificial skin substitute (Integra Life Sciences). This simple method using INTEGRA (Integra Life Sciences) resulted in complete healing of the radiated scalp wound and an acceptable, functional, and cosmetic outcome with minimal morbidity to the patients.