John D. Franklin

Management of the brown recluse spider bite

A model to study the dermonecrotic effects of a crude fraction of venom from the brown recluse spider (Loxosceles reclusa) was developed using female New Zealand white rabbits. In the rabbit model, surgical excision of the sites of intradermally injected crude venom did not always prevent subsequent necrosis or wound dehiscence despite the use of fluorescein to determine the surgical margin. Heparin and steroids did not prevent the venom-induced necrosis and were much less effective than surgical excision or injecting a specific antivenom. When given within 24 hours, the specific antivenom raised against the brown recluse spider venom blocked or markedly attenuated the toxic effects of the venom in the rabbit model system.

Effects of topical applications of epidermal growth factor on wound healing. Experimental study on rabbit ears.

In wounds in rabbit ears, the application every 12 hours of an ointment containing epidermal growth factor appears to produce faster and better healing. The resulting epithelium is thicker and more cellular than in the untreated ear wounds, and more fibroblasts appeared sooner during the healing process. Less wound contracture occurred in the EFG-treated wounds, and wound maturation occurred earlier. The healed wounds that had been treated with EGF more closely resembled the surrounding normal tissue, producing less local deformity than in the controls. It is too early to know whether this will have clinical application, but other experiments are under way to further investigate the effects of EGF on wound healing.

Use of the free dorsalis pedis flap in head and neck repairs.

Many defects of the head and neck can be readily repaired with a free dorsalis pedis flap, and we report success with these flaps in 9 of 12 cases. A precise knowledge of the anatomy of the arterial supply of the flap is necessary. Preoperative arteriography is recommended if the dorsalis pedis artery is not easily palpable, or if an anomalous distribution of the artery along the dorsum of the foot is sus pected. However, the transfer of the flap should be delayed for two weeks after preoperative arteriography is performed. The one-stage soft tissue reconstruction with a free dorsalis pedis flap has been associated with minimal morbidity and good acceptance by patients. A delay procedure for the flap seems to enhance the chances of complete survival which is so necessary in the repair of intraoral and pharyngeal defects. Careful attention to details and close monitoring of the flap will minimize morbidity. In case of an early failure of a flap, a secondary reconstruction by a different flap can be done in the first 48 to 72 hours. Early postoperative radiotherapy has been well tolerated over these free flaps.

Pectoralis major musculocutaneous flap: A new flap in head and neck reconstruction☆

The pectoralis major musculocutaneous flap described by Ariyan has great potential in single stage reconstructions of the head and neck. The advantages of the flap are greater length, improved vascularity, bulk, and one-stage reconstruction of oropharyngeal defects. The flap was used successfully in eight patients to reconstruct large defects in the head and neck area. Experience to date indicates that this flap has greater versatility than the deltopectoral flap in one-stage head and neck reconstructions.

Single-stage reconstruction of mandibular and soft tissue defects using a free osteocutaneous groin flap

Microvascular reconstruction of the mandible and soft tissues using the composite groin flap is ideal in selected patients. No other available bone so closely approximates the mandible in both thickness and curvature as does the iliac crest. The soft tissues are available for reconstruction and may allow the surgeon to avoid a second flap, except in cases where both lining and cover are needed. The deep circumflex artery is of generous size, usually 2 to 2.5 mm in diameter, allowing greater reliability in the microvascular anastomoses. The flap has a fairly long vascular predicle, 6 to 8 cm. The ability of this flap to withstand irradiation and infection because of its blood supply permits early institution of postoperative radiotherapy and prevents bone loss due to small intraoral wound dehisicence or total flap loss. Although the donor site requires extensive dissection, it can be closed primarily, eliminating the need for skin grafts or other flaps. As further experience is gained with this flap, both the functional and cosmetic results should be improved. In patients undergoing resection of the remaining portion of the mandible, the symphysis or the anterior portion of the mandible, a procedure of this type should be done primarily to prevent deformity and to minimize disability for the patient.

Fluorescein test for prediction of flap viability during breast reconstructions.

The fluorescein test is a useful ancillary procedure for predicting the viability of breast flaps in reconstructive procedures after subcutaneous mastectomy or radial mastectomy.

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.

Intraarterial drug injury: studies of etiology and potential treatment

Abstract By utilizing the rabbit ear as a vascular bed and examining the sequential angiographic and morphologic alterations following intraarterial Pentothal injury, one can conclude that intraarterial Pentothal is cytotoxic, causing intimal disruption and vessel wall necrosis with subsequent vascular occlusion and tissue loss. Furthermore, this injury is intensified by angiography and not significantly altered by intraarterial Priscoline—reserpine and low-dose Decadron. In contrast, pharmacologic doses of Decadron significantly reduce the extent of cellular injury and subsequent tissue loss.

Split Jejunal Free-Tissue Transfer in Oropharyngoesophageal Reconstruction

From January 1, 1981 to July 1, 1981, ten patients underwent immediate reconstruction utilizing split jejunal free-tissue transfers following resection of large oropharyngeal neoplasms. All 10 flaps were successfully transferred. Three patients were irradiated preoperatively and six patients were irradiated 2 to 3 weeks postoperatively. Nine patients were available for follow-up until their death from 10 to 39 months postoperatively (average 26 months). All but two patients died of their original tumor. Six of the nine patients had a good early functional result; taking semisoft or soft diets allowed them to maintain or gain weight. Three patients had poor early results with limited oral feedings due to repeated aspiration in two and severe gastroesophageal reflux in another. Postoperative graft biopsies were obtained in five patients, showing normal mucosa or mild chronic inflammation histologically even following irradiation. Postoperative barium studies showed varying degrees of graft peristalsis. Complication rates were acceptable, and donor-site morbidity was minimal. Neither preoperative nor postoperative radiation affected the viability of the grafts. Therefore, this technique should continue to find application as a reliable method of providing like tissue for reconstructing a variety of large oropharyngeal defects.

Fibrinolytic activator activity in human neoplasms.

The results of this study suggest that many malignant tumors contain low levels of fibrinolytic activator activity. Evidence is presented to suggest that this low activity may be due to the presence of an inhibitor of fibrinolysis. The presence or absence of measurable fibrinolytic activator activity, and/or inhibitor in neoplastic growths may enable one to predict the probability of viable metastases to a distant site.