Charles L. Puckett

The effect of herbal medicines on platelet function: an in vivo experiment and review of the literature.

Background: Herbal medicines are used by a considerable number of surgical patients. An increased risk of bleeding, substantiated by anecdotal reports, has been attributed to the use of certain herbs, and numerous in vitro experiments have identified some herbal extracts as platelet inhibitors. The purpose of this investigation was to determine whether standard commercial preparations of commonly used herbal medicines have an effect on platelet function in vivo and, by extension, to provide clinical scientific evidence of the safety of their use in the perioperative period. Methods: Five commercially available herbal agents were investigated, including Ginkgo biloba, garlic, Asian ginseng, St. John’s wort, and saw palmetto. In a blinded fashion, one of the agents was administered to 10 adult volunteers at the manufacturer’s recommended dose for 2 weeks. At the end of the 2-week period, in vivo platelet function was quantified using the PFA-100 assay. After a 2-week “washout” period, the protocol was repeated using a different agent. This 4-week cycle was repeated for each of the five herbal agents, as well as the control agent aspirin. Results: In vivo platelet function was not affected by the administration of any herbal agent and was markedly inhibited with the administration of aspirin. Conclusions: The herbal medicines investigated in this study do not affect platelet function in vivo. Neither this experiment nor a review of the literature supports the concern of perioperative bleeding in users of these herbal medicines.

Construction Of Male Genitalia In The Transsexual, Using A Tubed Groin Flap For The Penis And A Hydraulic Inflation Device

A technique for construction of external male genitalia in a transsexual patient is presented in detail. The McGregor groin flap is used for penile construction, and the Scott inflatable prosthesis is used to produce an erection. The shape of the penis is improved by secondary local excisions, and the clitoris is bivalved and inserted at the base of the penis to allow sexual sensation. The appearance and the function of the constructed genitalia have been deemed quite satisfactory by this transsexual patient.

A critical look at capsule contracture in subglandular versus subpectoral mammary augmentation.

A critical comparison of the contracture rate in subglandular versus subpectoral augmentations was done in a personal series (senior authors) of 100 consecutive augmentation patients, 50 with subglandular augmentation and 50 with subpectoral augmentation. The average followup for the series was 27 months. Bakers classification of capsule contracture was utilized. Overall contracture rate in the subglandular group was 58% (29 of 50 patients) while in the subpectoral group it was 22% (11 of 50 patients),p<0.0002. Considering only the more severe contractures (Baker III & IV), the subglandular patients had 48% (24/50) while the subpectoral patients had 14% (7/50),p<0.0002. Comparing the more severe contractures in individual breasts, the subglandular group had 41% and the subpectoral group had 8%,p<0.0001. We conclude that in this personal series of patients, subpectoral placement of the prosthesis has significantly reduced but not eliminated the occurrence of capsule contracture without sacrificing a normal breast appearance.

Ulnar artery thrombosis.

Forty-six patients with ulnar artery thrombosis were evaluated. A comparison of the results was made between those patients who were treated by sympathectomy and those in whom we attempted to reestablish the blood flow. A reverse vein graft was often used in the latter group. Based on the results of this study, we believe the preferred method of treatment for ulnar artery thrombosis is an attempt at the reestablishment of blood flow.

Augmenting the narrow-based breast: The unfurling technique to prevent the double-bubble deformity

Routine subpectoral or subglandular mammary augmentation in women with a small breast (particularly lower pole deficiency) often results in poor late results with the appearance of a double-bubble deformity. We describe our experience with a technique of unfurling the breast tissue at augmentation in an effort to avoid this complication and improve the long-term results.

Patterns of free-radical production after tourniquet ischemia : Implications for the hand surgeon

Since use of the pneumatic tourniquet is standard procedure for the hand surgeon, ischemic and reperfusion injury is a risk. To determine optimal periods of ischemia, 100 rabbit hindlimbs were subjected to various ischemic insults and analyzed for malondialdehyde (an indicator of free-radical production). Group 1 (3 hours of continuous ischemia) had 12.5 percent more reperfusion damage than controls (p < 0.05). Group 2 (three 1-hour ischemic insults) had 10 percent more damage than controls (p < 0.05). Group 3 (two 90-minute ischemic episodes) had 21 percent more damage than controls (p = 0.0001). Group 4 (4 1/2 hours of continuous ischemia) had 14.5 percent more damage than controls (p < 0.01). Group 5 (three 90-minute ischemic episodes) had 10.8 percent more damage than controls (p < 0.01). Group 6 (6 hours of continuous ischemia) had 17.5 percent more damage than controls (p < 0.002). Group 7 (four 90-minute ischemic episodes) had 14 percent more damage than controls (p < 0.01). Group 8 (three 2-hour ischemic episodes) had 22.5 percent more damage than controls (p < 0.003). And group 9 (two 3-hour ischemic episodes) had 42 percent more damage than controls (p < 0.0001). These results suggest a direct correlation in reperfusion injury with duration of tourniquet ischemia. Additionally, allowing specific reperfusion periods in some groups ultimately increased the amount of reperfusion injury.

A comparison of irrigation solutions for microanastomoses

A comparative study of irrigating solutions that contained various clot-active substances and/or vasodilating substances was done using a crush injury model of the rats femoral artery. A routine microanastomosis was done with one of seven irrigation solutions employed in the study. The patency rate of lactated Ringers solution (10%) (the control solution) was compared with solutions of heparin (35%) urokinase (50%), phentolamine (35%) tissue plasminogen activator (tPA) (15%), a combination of urokinase, heparin, and phentolamine (55%), and a combination of tPA, heparin, and phentolamine (42.5%). Statistically significant improvement in patency rates were obtained with heparin (p less than 0.0005), phentolamine (p less than 0.03), urokinase (p less than 0.001), the tPA, heparin and phentolamine combination (p less than 0.001), and the urokinase, heparin, and phentolamine combination (p less than 0.0001). There seems to be a benefit with the addition of either vasoactive agents or clot-active agents to the microvascular irrigating solution during construction of a compromised microanastomosis.

Studies of pathologic vasoconstriction (vasospasm) in microvascular surgery

Characterization and resolution of microvascular spasm were investigated in 170 studies with the use of tail or femoral arteries of the rat. Topical epinephrine reliably produced vasospasm and topical vasodilators which included 2% and 20% lidocaine (Xylocaine) and 0.75% bupivacaine (Marcaine) were applied to resolve the vasoconstriction. Extensive vessel dissection was necessary to obtain significant resolution of vasospasm, and adventitial stripping was associated with even more impressive results. Local anesthetics appear to have a concentration dependent ability to resolve vasospasm, and 20% Xylocaine is the most effective agent yet studied.

Follicular carcinoma with clear cell change arising in lingual thyroid

A case of follicular carcinoma arising in the lingual thyroid of a 23-year-old woman is added to the 22 previous reports. The embryology and the clinical and pathologic differential diagnoses are discussed. Histologic criteria useful in diagnosing follicular malignancy in this area include local and vascular invasiveness, hypercellularity, mitotic activity, and necrosis. The use of the immunohistochemical marker thyroglobulin and electron microscopy are described for the first time and confirm a thyroid follicular cell origin.

Resolution of experimental microvascular spasm and improvement in anastomotic patency by direct topical agent application.

This two-part study investigated the topical treatment of vasospasm in the tail arteries of rats. In part A, an epinephrine-induced model of vasospasm was used to study a variety of vasodilating agents with actions on at least five different sites in the contractile mechanism of the vascular smooth-muscle cell. The most effective commercially available agents evaluated in this part of the study appeared to be 20% lidocaine and Thorazine (25 mg/ml). In part B, a model was established in which epinephrine-induced vasoconstriction was found to significantly impair anastomotic patency. Thorazine was shown to improve the patency rate of vessels in this setting, and it was found to be superior to 20% lidocaine in improving anastomotic patency.