G. Gregory Gallico

Permanent coverage of large burn wounds with autologous cultured human epithelium

WHEN burns are so extensive that skin grafts obtainable from remaining donor sites are insufficient to provide wound coverage, a new source of autograft must be found. Human epidermal cells from a ...

Cultured epithelial autografts for giant congenital nevi

Eight pediatric patients with giant congenital nevi confluent over 21 to 51 percent body surface area were treated by excision and grafting. The nevus was excised to the muscle fascia, and the open wound was grafted with cultured epithelial autografts and split-thickness skin grafts. The patients have been followed from 17 to 56 months. Seventeen operations were performed in the eight patients, excising a mean of 6.9 percent body surface area at each procedure. The mean duration of anesthesia was 3.7 hours, and the mean operative blood loss was 12.3 percent estimated blood volume. The mean “take” for the cultures epithelial autografts was 68 percent, and for the split-thickness skin grafts, 84 percent. Epithelialization of open wound areas adjacent to the grafts was somewhat slower for the cultured epithelial autografts than for the split-thickness skin grafts, but it led to a healed wound in all patients except one. Ten of the 17 areas grafted with cultured epithelial autografts resultee in small open wounds that required regrafting. Wound contraction under the cultured epithelial autografts and under split-thickness skin grafts was similar and depended more on the anatomic site grafted than on the type of graft employed. In 16 of 17 operations, the cultured epithelium remained as a permanent, durable skin coverage. The use of cultured epithelial autografts allowed a larger area of excision than would have been possible with split-thickness skin grafts alone and, therefore, a more rapid removal of nevus. Cultured epithelial autograft are an important new technique in the care of patients with giant congenital nevi.

Microvascular Transfer of Free Tissue for Closure of Bone Wounds of the Distal Lower Extremity

Extensive compound fractures of the distal lower extremity may result in chronic infection of the deep tissues and bone if primary healing does not occur. Treatment may require several operations and prolonged hospitalization. In an attempt to improve the management of such problems, 18 patients who had chronic bone-exposure wounds and four patients who had extensive compound fracture wounds of the distal lower extremity were treated with radical debridement, intravenous antibiotics, and microvascular transfer of vascularized tissues for immediate wound closure. All wounds healed, and there was no evidence of recurrent infection during a mean follow-up period of 19.3 months in the patients with chronic wounds and 16.3 months in those with acute wounds. In selected patients this free-tissue-transfer method of wound closure appears to have considerable advantages over conventional methods of management.

Free flaps to preserve below-knee amputation stumps. long-term evaluation

Five patients with insufficient soft-tissue coverage on below-knee amputation stumps have been treated with free-tissue transfer surgery to preserve a functional below-knee prosthetic level. The flaps employed include one latissimus dorsi myocutaneous flap, two latissimus dorsi muscle-skin graft flaps, one groin flap, and one foot-fillet flap. All five flaps survived; one patient required early venous anastomosis reexploration and revision. The patients have been followed for a mean duration of 5.5 years (range 3 to 8 years). The mean duration to first ambulation with a prosthesis was 3.6 months (range 2 to 7 months). Four of the five patients developed ulcerations on or adjacent to their flaps which required surgical revision. The patients required a mean of 1.28 prosthesis changes annually since surgery. The functional motion (mean active knee motion is 100 degrees) and ligamentous stability of the knee joints were well preserved in all patients. Five patients wear patella tendon-bearing prostheses, with one requiring an additional thigh corset. In two of the patients, nerve anastomoses to their flaps were performed. Both patients developed true cutaneous sensibility, but nevertheless experienced flap ulceration. All the patients are fully ambulatory on their free flaps. Free-tissue transfer can assist in preserving traumatic below-knee amputations so that patients can benefit from the functional advantage of a below-knee prosthetic device.

The role of external fixation in the treatment of posttraumatic osteomyelitis.

Summary: External skeletal fixation played a central role in the reconstruction of 30 limbs involved in posttraumatic osteomyelitis. The tibia was involved in 15, the femur in six, the ankle in five, and the foot and radius in two each. Of the thirty limbs, 27 were ununited. Positive bacteriology and/or histology was found in each case. A total of 36 frames were used with 20 unilateral half-frame constructs and 16 bilateral transfixion frames. The average duration of external fixation was 60 days. Specific procedures for soft tissue coverage were required in 21 cases and autogenous bone grafting in 26. Loosening and local infection occurred in three of 168 external fixation pins. There were no cases of pin-track osteomyelitis, fractures through pintracks, or neurovascular damage from pin insertion. Infection was controlled in 29 of 30 limbs, with one requiring a below-knee amputation. Skeletal union was achieved in all cases. At an average follow-up of 35 months, 20 of 28 lower limbs in 27 patients tolerated full weight bearing without ambulatory aides. Four used a patellar tendon-bearing polypropylene orthosis, two used a cane, and one a walker. In the 23 patients ambulating without upper-extremity aides, the average time from the start of treatment to reach this functional status was 14 months.

Low scar abdominoplasty with inferior positioning of the umbilicus.

Miniabdominoplasty with umbilical free float has received little attention in the literature in 15 years and has been criticized for an abnormally low umbilicus. We hypothesized the umbilicus in women presenting for abdominal contouring is positioned higher than ideal and thus may benefit from lowering. In addition, we felt modifications of the original umbilical float technique would improve aesthetic results. A retrospective review identified 60 patients aged 34 to 56 who had abdominoplasty with umbilical fascial transection and inferior positioning. Technical modifications included low placement of a full transverse abdominal scar, abdominal flap undermining to the rib cage, more inferior umbilical repositioning, flank liposuction, and plication of diastasis recti from xiphoid to pubis. Patients did not have enough excess skin to allow traditional abdominoplasty without a high-transverse or vertical midline scar. No umbilical or incisional skin necrosis occurred. To assess optimal umbilical position, plastic surgeons were asked to draw the ideal position on pre- and postoperative photographs from 5 patients. The mean ideal umbilical position was 2.2 cm lower than the actual position (P < 0.01) in preoperative photographs and was close to the true position in postoperative photographs. In conclusion, lower abdominoplasty with inferior umbilical positioning is an excellent choice for the middle age, postpartum woman with excess abdominal skin and full length diastasis recti but a normal body mass index.

Familial Bilateral Carpal Tunnel Syndrome: Report of Two Families

Cases of familial carpal tunnel syndrome without other associated conditions are rare. We report two families in which multiple members had bilateral carpal tunnel syndromes. The pattern was consistent with autosomal dominant inheritance. Electrophysiologic studies were performed on nine of the 15 patients, and they demonstrated bilateral pathology of the median nerves at the wrist in all but one patient, without evidence for subclinical, generalized peripheral neuropathy. Quantitative sensory testing was performed in two cases, and it corroborated the absence of peripheral neuropathy. Five of the six patients who underwent carpal tunnel release improved after surgery.

Upper extremity replantation

To contact the Transfer Center about an admission, call toll free 877-738-7286. We accept most major insurance plans, including Medicaid. General Principles of replantation 1. Many amputated parts can be replanted: arm, hand, finger, leg, foot, scalp, penis, nose, ear and tongue. 2. Replantation is most successful when initiated within six hours of injury. 3. Speed is Important, but do not overlook other injuries. Priorities of care airway – establish and maintain airway Breathing – establish adequate breathing Circulation – maintain hemodynamic status Establish IV line in uninjured extremity with large (14 or 16 gauge) percutaneous plastic catheter to infuse lactated Ringer’s solution. Examine for signs of internal bleeding (abdomen, chest, fracture). Altered level of consciousness

A socioeconomic analysis of digital replantations resulting from home use of power tools

Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was

Engineering a skin replacement.

7000 (surgeons fee) plus