The effect of smoking on muscle transposition.

Smoking has been shown to be a complicating factor in normal wound healing. Both nicotine and carbon monoxide adversely affect multiple stages of the healing process. From 1976 to 1990, 1034 muscle flap procedures were performed on 722 patients on a single surgical service. A retrospective review of 300 patients completed; patients were divided into three groups: group 1, no smoking history; group 2, smokers for at least 10 pack/years but had quit for at least 1 year; and group 3, active smokers at the time of surgery. Patients were omitted who had diabetes, had received radiation therapy or chemotherapy, had a recurrent malignancy, or used steroids. A total of 300 consecutive patients were entered into the study. Active smokers were shown to have a complication rate significantly higher in the immediate postoperative period compared with nonsmokers and smokers who had quit. The most common complications were partial muscle necrosis and partial skin graft loss. This series suggests that active smoking at the time of muscle transposition significantly increases the rate of postoperative complications.

Muscle-flap coverage for infected peripheral vascular prostheses.

Infection in a peripheral vascular prosthesis continues to be a serious complication in arterial reconstructive surgery and threatens the patient with loss of either limb or life. Infection rates at major centers are now low, ranging from 1 to 6 percent; however, limb loss and mortality rates for this complication range from 25 to 75 percent depending on the location of the graft and the extent of the infection. The use of muscle flaps in the management of acute wounds, infection-prone wounds, exposed orthopedic hardware, and osteomyelitis is now commonplace. Transposed muscle has been shown to be well-vascularized tissue that improves healing time and decreases local wound bacterial counts. After considering the preceding facts, we used muscle flaps for coverage of infected peripheral vascular prostheses in a highly select group of patients. These patients were "end of the line," and last-ditch efforts were made to salvage life or limb. Twenty-four infected vascular grafts in 20 patients have been analyzed. Ages ranged from 52 to 87 years. All patients had grade 3, stage I, II, or III peripheral graft infections, as previously defined by Szilagyi and modified by vonDongen. Aortofemoral reconstruction was the most common initial bypass procedure (14), followed by femoral popliteal (6), axillofemoral (2), iliofemoral (1), and subclavian/subclavian bypass (1). Staphylococcus aureus was the most common infecting organism. Muscles used for coverage were the rectus femoris (13), the sartorius (9), the rectus abdominis (1), and the pectoralis major (1). The graft material was composed of Dacron in 16 instances and polytetrafluoroethylene in 8.(ABSTRACT TRUNCATED AT 250 WORDS)

Muscle flaps in irradiated wounds: an account of 100 consecutive cases.

Radiation-related wounds challenge surgeons in all disciplines of surgery. Wound-healing complications are commonplace, and solutions for reconstruction are limited. Muscle and musculocutaneous flaps have improved this situation. We ask the question, Does previous radiation of the muscle to be transposed affect the outcome? One hundred consecutive previously irradiated wounds closed with muscle or musculocutaneous flaps composed the group under consideration. These 100 patients had 151 muscles transposed. The overall complication rate for muscle transposition to close a radiated wound was 25 percent. Of the 100 patients who received radiation, 43 patients had the muscle transposed for wound closure from the primary field of radiation. Fifty-seven patients were closed with nonirradiated muscle. When the transposed muscle had been radiated, the complication rate was 32 percent; in 14 percent, the entire muscle died, requiring total removal and a second tissue transposition from a nonirradiated source to achieve closure. The subgroup using nonirradiated muscle had a complication rate of 19.3 percent; no patient in this group had complete flap death requiring a second tissue transposition. Two postoperative deaths, one in each group, unrelated to the operative procedure were recorded. We feel that nonirradiated muscle is the best choice for closure of a radiated wound, if possible.

The solitary pulmonary nodule: a recent military experience.

During a 5-year period from 1983 to 1987, a total of 226 thoracotomies were performed at David Grant USAF Medical Center. Within this group, 62 patients (27%) had resection of a solitary pulmonary nodule. Fifty percent of the resected nodules were subsequently proven malignant, with 27 of 62 (43%) having a primary lung carcinoma. From 1958 to 1963, the Veterans Administration Armed Forces Cooperative Study evaluated a total of 1,134 patients with asymptomatic solitary pulmonary nodules. The data generated from that report has become the standard within the literature. We compared our recent 5-year experience to that data. The primary difference found in our series was an increase in solitary pulmonary nodules in our female population.

Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection.

Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.