The tumescent technique to significantly reduce blood loss during burn surgery.

INTRODUCTION: Burn surgery is complicated by blood loss. The tumescent technique of subdermal injection of epinephrine has been utilized to decrease intraoperative blood loss. We hypothesized that this would safely decrease blood loss during burn surgery. METHODS: Twenty patients utilized the tumescent technique. The tumescent group had subdermal injections of epinephrine beneath the excision and donor site plus thrombin spray and warm saline soaked laparotomy pads. Ten patients grafted prior to adopting the tumescent technique utilized thrombin spray and warm saline soaked laparotomy pads for hemostasis. Blood loss was determined by operative estimation and calculation. Data were analyzed by Student's t-test and paired t-test. RESULTS: The two groups were demographically similar. The tumescent group had significantly less total blood loss and blood loss per unit area excised. There were no clinically detectable arrythmias, changes in heart rate or blood pressure noted. CONCLUSIONS: The tumescent technique significantly reduced intraoperative blood loss. It is safe, inexpensive and easy to use. The subdermal epinephrine/saline injection creates a smooth, tense surface which assists with debridement and donor harvest.

Selective inhibition of cyclooxygenase-2 suppresses growth and induces apoptosis in human esophageal adenocarcinoma cells.

Adenocarcinoma in Barrett's esophagus has been increasing in incidence at a rapid rate for more than two decades. Cyclooxygenase (COX)-2 appears to play an important role in gastrointestinal carcinogenesis, and COX-2 overexpression has been demonstrated both in esophageal adenocarcinomas and in the metaplastic epithelium of Barrett's esophagus. The aim of our study was to determine whether selective inhibition of COX-2 by NS-398 would alter the rates of cell growth and apoptosis in human Barrett's-associated esophageal adenocarcinoma cell lines. COX-1 and COX-2 expression in adenocarcinoma cell lines was determined using reverse transcription-PCR and Western blotting for mRNA and protein, respectively. Esophageal adenocarcinoma cell lines were treated with various concentrations of NS-398 (selective for COX-2 inhibition) and flurbiprofen (selective for COX-1 inhibition). Cell growth was compared in flurbiprofen-treated and untreated tumor cell lines; cell growth and apoptosis were compared in NS-398-treated and untreated tumor cell lines. COX-2 mRNA and protein were detected in two of three cell lines (SEG-1 and FLO); the third cell line, BIC-1, did not express COX-2 mRNA or protein under basal conditions or after stimulation with phorbol 12-myristate 13-acetate. Treatment with COX-1-selective concentrations of flurbiprofen did not affect cell growth in any of the three tumor cell lines. In contrast, treatment with COX-2-selective concentrations of NS-398 significantly suppressed cell growth and increased apoptosis in the cell lines that expressed COX-2 (SEG-1 and FLO), but not in the cell line that did not express COX-2 (BIC-1). We conclude that the administration of a selective inhibitor of COX-2 significantly decreases cell growth and increases apoptosis in Barrett's-associated adenocarcinoma tumor cells that express COX-2. These observations suggest a potential role for selective COX-2 inhibitors in the prevention and treatment of esophageal adenocarcinoma for patients with Barrett's esophagus.

Time course inhibition of gastric and platelet COX activity by acetylsalicylic acid in humans.

Aspirin causes peptic ulcers predominately by reducing gastric mucosal cyclooxygenase (COX) activity and prostaglandin synthesis. Because aspirin circulates for only a few hours, we hypothesized that aspirin's inhibitory effect on gastric COX activity must be prolonged. We performed a placebo-controlled experiment in healthy humans to determine the duration of inhibition of aspirin on gastric mucosal COX activity (PGE(2) and PGF(2alpha) synthesis rates). Recovery of gastric COX activity after stopping aspirin was slow and linear. Seventy-two hours after 325-mg aspirin, gastric COX activity was still reduced by 57% (P < 0.001). Duration of inhibition of gastric COX activity was estimated to be 7-8 days after 325-mg aspirin and 5 days after 81-mg aspirin. Recovery of gastric prostaglandin synthesis after 325-mg but not after 81-mg aspirin occurred at slower rates in subjects with Helicobacter pylori-associated gastritis than in those with normal histology. In conclusion, aspirin inhibits gastric COX activity for much longer than predicted from its pharmacokinetic profile, explaining why aspirin at widely spaced intervals is ulcerogenic.

Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures.

Objective data comparing sensitivity and accuracy between traditional and computed imaging techniques used for diagnosing mandibular fractures is sparse. To address the paucity of information the authors studied prospectively 33 mandibular fractures in 21 consecutive patients with standard mandibular series, panoramic tomography, axial computed tomography (CT), and coronal CT. Differences in diagnostic accuracy and sensitivity as compiled by four blinded reviewers were calculated. Although overall sensitivities of mandibular fracture detection were not statistically significant between the imaging studies, a distinction between the four methods did exist. Coronal CT was the most accurate imaging method, followed by mandibular series, panoramic topography, and axial CT. Excluding technically inadequate studies, panoramic tomography was 100% accurate and sensitive. Diagnostic accuracy and sensitivity did not correlate measurably with reviewers' impressions of the quality of a particular exam. Axial CT detected significantly fewer angle fractures than standard radiographs (60% vs. 98%, p = 0.006) and coronal CT (60% vs. 100%, p = 0.008). False-positives were unusual except for plain mandibular radiographs. The clear definition of both coronal and axial CT scans made their analysis simpler than the plain radiographs. Lack of fracture displacement was the single most important factor in missed fractures with all modalities. Despite reviewer concerns about the quality of the plain mandibular series, the high accuracy and sensitivity of this imaging technique and applicability in all patients, coupled with its low cost, make it an excellent screening exam for all patients with suspected mandibular fractures. In clinically stable and cooperative patients with mandibular trauma, panoramic radiography and coronal CT are recommended to confirm clinical suspicions when the mandibular series is equivocal. To supplement the mandibular series in the uncooperative or multisystem trauma patient, axial CT scans have not been beneficial. These diagnostic modalities do not obviate the need for a careful physical exam.

Staged sequential reconstruction of a total lower lip, chin, and anterior mandibular defect.

The combination of a total lower lip, chin, and anterior mandibular defect following cancer resection is an extremely complex problem that requires a sequence of operations to optimize functional and aesthetic results. One patient is presented in whom the defect was reconstructed with a free fibular flap followed by a series of ancillary procedures using both modern and traditional techniques. At the time of tumor ablation, the through-and-through oromandibular defect was reconstructed with a fibular osteocutaneous flap. The lower lip and gingivolabial sulcus was reconstructed later with a tongue flap. Tissue expansion was subsequently used to replace the fibular skin with expanded submental hair-bearing skin. A polyethylene implant was added later to the fibular bone for chin augmentation. Subsequently the lower lip was supported with a tendinous graft suspended to the anterior masseter bilaterally. Lastly, the vermilion border was elevated by removing a rim of the tongue flap and covering the secondary wound with a full-thickness skin graft. At the end of the reconstructive procedures, lip seal and oral aperture were good with no drooling and excellent speech.

Osseointegrated implants in the head and neck cancer patient.

BACKGROUND: Osseointegrated implants allow patients with oromandibular defects to obtain complete or partial dentition via implant-assisted or implant-borne prostheses. Implants restore masticatory and occlusal function, improving oral intake and articulation. However, use of implants in head and neck cancer patients has been discouraged due to lack of data supporting their utility in these patients. This study attempts to establish the validity of using osseointegrated implants for dental restoration in head and neck cancer patients. METHODS: Six patients who underwent resection/reconstruction for head and neck cancer received osseointegrated implants. Integration was assessed clinically, radiographically, and mechanically at 4-8 months; oral intake, mastication, and articulation were evaluated 6-12 months after receiving the dental prosthesis. RESULTS: Osseointegration occurred in 92% (24/26) of the implants: 100% (14/14) in neomandibles and 83% (10/12) in native mandibles. One patient had implants (2/5) that failed to integrate. The remaining patients' implants were immobile, free of infection, with no osteoradionecrosis. These patients tolerated a regular diet and experienced weight gain and improved articulation. CONCLUSIONS: The advent of osseointegrated implants and their compatibility with native and neomandible allows the restoration of functional dentition in patients undergoing ablative surgery for head and neck cancer.

Outcome analysis of 85 patients undergoing the pi procedure for correction of sagittal synostosis.

The authors present a retrospective review of their experience with 85 cases using the pi procedure to correct sagittal synostosis. A male preponderance of four to one was recognized in this group. Sixty-five infants underwent computerized tomography scanning of the head prior to surgery; these scans revealed unexpected intracranial pathology in 5% of cases. Surgical complications included three intraoperative dural lacerations. All children received blood transfusions with no complications. Cosmetic outcomes were excellent in 53%, good in 43%, and poor in 4% of cases. One patient required reoperation. All poor outcomes were in infants who were younger than 8 weeks of age at the time of surgery and who underwent a "reverse pi" procedure. Most of the excellent outcomes occurred in infants who were between 3 and 6 months of age at the time of surgery. Although more extensive than strip craniectomy, the pi procedure can be accomplished with minimal morbidity. In the authors' opinion, the pi procedure provides better immediate and long-term cosmetic results than synostectomy alone.

Double skin paddle fibular flap for a through-and-through oromandibular defect.

The fibular osteocutaneous free flap has become the most versatile method for reconstructing composite defects of the mandible. The complexity of the reconstruction increases substantially when both intraoral and extraoral defects are present, possibly dictating the need for an additional flap. For the smaller through-and-through defects, a single skin island may be sufficient, but may be limited by inadequate reach. Although not routinely necessary, the skin island may be split completely to enhance the effective reach of the second paddle. One patient report is presented for which a moderately sized through-and-through defect of the mandible was reconstructed using a double skin paddle fibular osteocutaneous free flap.

Synostectomy versus complex cranioplasty for the treatment of sagittal synostosis.

Although pediatric neurosurgeons traditionally have been trained to perform a sagittal synostectomy for the treatment of sagittal synostosis, numerous articles advocating modifications of this procedure or more complex cranial vault reconstructions point our the inadequacies of strip craniectomy in providing optimal short- and long-term cosmesis. This review addresses the major arguments for and against performing complex cranioplasties for sagittal synostosis, as well as issues regarding timing of surgery, mortality and morbidity, increased need for blood transfusion, and increased expense. The authors support the contention that for the majority of infants with sagittal synostosis, complex calvarial vault reconstruction provides a better outcome with little increase in operative risk.

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules.

Augmentation of the craniofacial skeleton with porous hydroxyapatite granules (Interpore 200) has been performed in 52 sites on 43 patients. Follow-up extends to 5 years, and 26 patients have been followed for greater than 1 year with excellent results. The procedure has been used for reconstruction of congenital and posttraumatic deformities and for purely aesthetic purposes. Areas that have benefited from hydroxyapatite augmentation include the skull, zygomaticomaxillary region, lateral mandible, perialar region, periorbital area, and temporal region. There have been no cases of infection, and only two patients have required minor revisions. Resorption has not occurred.

Congenital clefts of the nose: principles of surgical management.

Congenital clefts of the nose are rare and highly variable. Because there are few examples, standard methods for treatment do not exist. Therefore each patient must be evaluated and managed individually with respect to anatomic elements, timing, and sequence of reconstruction.

Evolving concepts of craniomaxillofacial fracture management.

Few areas in plastic surgery have changed as rapidly as the management of complex facial fractures. This article delineates five principles governing current management of the patient with injuries of the craniomaxilloficial skeleton.

Management of airway problems in lung cancer patients using the neodymium-yttrium-aluminum-garnet (Nd-YAG) laser and endobronchial radiotherapy.

This study summarizes our experience in the evolution of a management technique for unresectable or recurrent lung cancer using the neodymium-yttrium-aluminum-garnet (Nd-YAG) laser with high-dose endobronchial brachytherapy. The laser gave good palliation for hemoptysis and obstruction with a low complication rate, and the addition of endobronchial radiotherapy was a useful adjunct for maintaining airway patency. High-dose brachytherapy delivered by the Gammamed IIi remote afterloader proved to be the best method of delivering this treatment.

Alterations in plasma copper, zinc, and ceruloplasmin levels in patients with thermal trauma.

This review was undertaken to elucidate the trends in copper, zinc, total serum protein, and ceruloplasmin levels in patients with thermal trauma. Medical records of pediatric and adult patients were retrospectively reviewed. The findings showed a significant linear decline in mean plasma copper, ceruloplasmin, and total serum protein during the first three days postburn, followed in general by a gradual rise in levels; however, patients with burns larger than 60% TBSA maintained copper, zinc, and ceruloplasmin levels significantly below the lower limits of normal during the observation period. Significant decrements in copper, zinc, total serum protein, and ceruloplasmin levels have been demonstrated in these patients. Trace metal determinations should be obtained in patients with significant burns soon after admission and routinely throughout their hospital course. Specific trace metal supplementation should be administered when indicated.

The current evaluation of nonpalpable breast lesions.

To understand the suspected low yield of malignant neoplasms from biopsies guided by needle localization, we reviewed 122 biopsies performed from January 1985 to November 1986 at University Hospital and Arkansas Baptist Medical Center, Little Rock. The positive biopsy rates were 3.5% and 10.6%, respectively. After review of these cases, the following guidelines for biopsy were developed: (1) Do not perform a biopsy on a low-density mass less than 1 cm in diameter. (2) Do not perform a biopsy for asymmetric density or questionable mass. (3) Do not perform a biopsy for secondary signs of malignancy such as skin thickening or asymmetric vasculature. (4) Biopsy is indicated for clustered calcifications, a dominant mass greater than 1 cm in diameter, stellate lesions, or interval change from a previous mammogram. These changes resulted in a positive biopsy rate of 15% for the period from November 1986 through April 1987.

The effect of rapid resuscitation upon cardiac index following thermal trauma in a porcine model.

Minipigs were divided into four experimental groups: nonburned control (C); burn, minimal resuscitation (MR); burn, standard resuscitation (SR); and burn, rapid resuscitation (RR). Resuscitation was begun 30 minutes postburn and hemodynamics were measured through 24 hours postburn. At 30 minutes postburn, the three burn groups demonstrated a significant decrease in cardiac index % (CI%). At 1 1/2 hours postburn, the RR group CI% was significantly greater than for the SR group and not significantly different from that of controls. At 2 hours postburn, fluid was abruptly decreased in the RR group and the salutary effect on CI promptly dissipated. In this model, the early decrement in CI following thermal injury is responsive to rapid resuscitation, concluding that the etiology of decreased CI following thermal trauma is at least partially due to inadequate volumes of fluid administration in the early postburn period.