Donald H. Parks

Comparison of serial debridement and autografting and early massive excision with cadaver skin overlay in the treatment of large burns in children

Thirty-two children admitted from 1977 through 1981 were treated by serial debridement of their burn wounds with 1:1.5 to 3:1 meshed autografting of granulating tissue as it became available. Thirty-two burned children treated from 1981 to 1984 were treated by early total excision to fascia with application of 4:1 expanded autograft and cadaver skin for complete closure. The ages (6.8 +/- 0.6 years), sex distribution, and mean per cent third-degree burn (64 +/- 1%) were the same in both groups. There were seven deaths in each group. Overall operating time (10.3 +/- 0.8 hours) and units of blood loss (28.3 +/- 3.5) were indistinguishable in the survivors of both groups. The survivors of the early excision group underwent fewer operative procedures, (5.8 +/- 0.5 vs. 7.6 +/- 0.5) and had a greatly decreased length of hospital stay (57 +/- 5 vs. 97 +/- 8). The ultimate functional and aesthetic consequences of the two techniques must be compared.

Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review.

A ten year retrospective review of 259 zygoma fractures is presented to highlight changes in epidemiology and treatment. Motor vehicle-related trauma resulted in a majority of the injuries (80.6%), with a high incidence of multiple facial fractures (43.2%). The number of zygomatic and other facial fractures decreased over the duration of the study (by 50.0% and 20.1%, respectively, p < 0.05), perhaps reflecting lowered speed limits and the increased use of seat belts. The proportion of fractures receiving open reduction and internal fixation (ORIF) remained relatively constant (46.3%). At present, miniplate fixation is the preferred surgical treatment, accounting for 61.5% of cases in 1988 and 1989. There was a trend toward the use of multiple fixation sites and more frequent use of the lateral maxillary buttress (20.0% increase over the study period). The need for orbital floor exploration decreased by almost half, possibly reflecting improved preoperative radiologic evaluation. Despite the recent popularity of cranial bone grafting for facial reconstruction, silicone rubber was the preferred material for orbital floor repair (59.6% of cases). Although overall surgical complications were few (1.5%) there was a high incidence of associated ocular injuries (36.3%).

Toll-like receptor 3 upregulation by type I interferon in healthy and scleroderma dermal fibroblasts

IntroductionIncreased levels of genes in the type I interferon (IFN) pathway have been observed in patients with systemic sclerosis (SSc), or scleroderma. How type I IFN regulates the dermal fibroblast and its participation in the development of dermal fibrosis is not known. We hypothesized that one mechanism by which type I IFN may contribute to dermal fibrosis is through upregulation of specific Toll-like receptors (TLRs) on dermal fibroblasts. Therefore, we investigated the regulation of TLR expression on dermal fibroblasts by IFN.MethodsThe expression of TLRs was assessed in cultured dermal fibroblasts from control and SSc patients stimulated with IFNα2. The ability of IFNα2 to regulate TLR-induced interleukin (IL)-6 and CC chemokine ligand 2 production was also assessed. Immunohistochemical analyses were performed to determine whether TLR3 was expressed in skin biopsies in the bleomycin-induced skin fibrosis model and in patients with SSc.ResultsIFNα2 increased TLR3 expression on human dermal fibroblasts, which resulted in enhanced TLR3-induced IL-6 production. SSc fibroblasts have an augmented TLR3 response to IFNα2 relative to control fibroblasts. Pretreatment of fibroblasts with transforming growth factor (TGF)-β increased TLR3 induction by IFNα2, but coincubation of TGF-β did not alter TLR3 induction by IFN. Furthermore, IFNα2 inhibits but does not completely block the induction of connective tissue growth factor and collagen expression by TGF-βin fibroblasts. TLR3 expression was observed in dermal fibroblasts and inflammatory cells from skin biopsies from patients with SSc as well as in the bleomycin-induced skin fibrosis model.ConclusionsType I IFNs can increase the inflammatory potential of dermal fibroblasts through the upregulation of TLR3.

Post-trauma reconstruction with free tissue transfer--analysis of 442 consecutive cases.

We reviewed 442 consecutive free flaps performed between July 1979 and December 1987 in 423 trauma patients. The ages ranged from 2 to 76 years. There were 339 males and 84 females. Soft-tissue coverage was the most frequent (56.3%) indication, followed by unstable wound, extensive bone loss, chronic osteomyelitis, insensate scar, loss of specialized tissue, and contour deformity. Most of the reconstructed defects (72.4%) were located in the lower extremity and the great majority (42.3%) involved the lower third of the leg. Motor vehicle accidents were the main (45.6%) cause of the defects followed by motorcycle injuries (28.6%), industrial accidents (15.1%), farming accidents (3.6%), and gunshot wounds (3.3%). Seventeen types of free vascularized cutaneous, myocutaneous, muscular, osseous, osteocutaneous, fascial, fasciocutaneous, sensate, and specialized tissue transfers were used. The latissimus dorsi free flap was the most frequently performed tissue transfer. Only 2.3% of the flaps were done within the first 48 hours post-trauma, although 76.5% of the transfers were completed within the first 2 weeks after injury. The overall success rate was 96.4% and the incidence of re-exploration was 14.7%. Free tissue transfers provide a very reliable method for dealing with difficult reconstructive problems in trauma patients.

Pharmacokinetic Evaluation of Single-Dose Intravenous Daptomycin in Patients with Thermal Burn Injury

ABSTRACT Daptomycin pharmacokinetics were evaluated for burn patients. Burn patients had decreases in the maximum concentration of the drug in serum (44%) and the area under the concentration-time curve (47%) and increases in the volume of distribution (64%) and total clearance (77%) compared to healthy volunteers. In burn patients, daptomycin at 10 to 12 mg/kg of body weight/day would be required to achieve drug exposures similar to those for healthy volunteers receiving 6 mg/kg.

Nasal surgery complications

This study examines the incidence of serious complications in nasal surgery and discusses the diagnosis and management of these complications. The authors review 259 consecutive cases performed between January 1, 1983, and August 31, 1988. One-hundred and ninety-live patients had septorhinoplasties, 29 had septoplasties, and 35 had rhinoplasties. Thirteen of these cases involved serious complications as follows: hemorrhage (5), perforation (4), infections (3), and pneumocephalus (1). All the patients with these serious complications had associated septal and/or turbinate surgery. The diagnosis and management of these complications will be discussed. In this small series of nasal surgery patients, the incidence of serious complications was 5.0 percent, with no fatalities reported. The higher incidence of serious complications occurred when associated septal and/or turbinate surgery was required. Awareness of these complications is essential because of the increasing number of patients presenting to plastic surgeons for nasal surgery in whom associated septal and/or turbinate surgery is necessary.

Management of Burns

An overview of the management of the acutely burned patient has been described. Adherence to the sound principles of early resuscitation, appropriate nutrition, wound management, and rehabilitation can provide hope for many of the victims of this tragic injury. Complications encountered throughout the burn illness present unique and perplexing problems for the physician, who must utilize all the clinical wisdom and facility available in the management of such complex problems.

Prognostic indicators in the elderly patient with burns.

Elderly patients with burns present unique challenges to the burn team. The present study was designed to evaluate the impact of specific preinjury health conditions, mechanisms of injury, and postinjury complications on their survival. A retrospective review of 252 patients more than 55 years of age evaluated demographic information, premorbid medical conditions, burn characteristics, clinical management, complications, and survival during a 12-year period. For comparison, these individuals were divided into four age groups: I (55 to 65), II (66 to 75), III (76 to 85), and IV (86 to 96). Although burn size did not change with age, patients more than 75 years of age experienced a significantly higher mortality rate (60.1%, groups III, IV vs 33.9%, groups I, II, p < 0.05). Preinjury health problems were observed in more than two thirds of the patients, and when two or more were present, there was a higher incidence of complications (65.4% vs 45.3%, p < 0.05) and death (53.0% vs 33.5%, p < 0.01). The effect of premorbid health problems on outcome was most evident in the youngest age group. Prolonged hospital stays and lower survival rates were observed when more than one complication occurred during hospitalization (1 complication, 60.8% survival; 2 or more, 28.0%, p < 0.001). Older age groups more commonly had infections (IV, 76.2%) and a fatal outcome when systemic sepsis occurred (IV, 100%). The lower respiratory tract was the most common site of infection (24.6%) and carried the highest incidence of sepsis (15.1%) and death (13.1%). Certain predictors of poor outcome have been identified in elderly patients with burns, which will aid our treatment of this patient population and facilitate family counselling.

Outpatient breast surgery under intercostal block anesthesia

During the past 3 years, we have performed various breast operations in 320 patients under local anesthesia, using intercostal nerve block. The amount of local anesthetic solution required has been about 20 ml 1% lidocaine for blocking both sides, and an additional 24 ml of 0.5% lidocaine during the surgery. This dosage is well within safe limits. We have found that various breast operations, ranging from augmentation mammaplasty to a staged reconstruction after mastectomy, can be done with this method of anesthesia. The complications attributable to the nerve block were nil in our series.

Primary cutaneous mucormycosis in trauma patients

Primary cutaneous mucormycosis in trauma patients has been rarely reported. We describe three cases occurring in noncompromised hosts and review the literature. Prompt diagnosis and aggressive treatment with vigorous local care and appropriate antibiotics are recommended.