John S. D. Davidson

Zygomatic fractures: comparison of methods of internal fixation.

We have analyzed different methods of internal fixation of simple displaced fractures of the zygoma in an attempt to define the simplest method(s) of achieving postreduction stability. Twenty-five combinations of interfragmentary wiring and miniplate and screw fixation of fractured zygomas on human skulls were compared for postreduction rotational stability against stresses simulating the muscular forces that act to displace the zygoma once it has been reduced. Analysis of the data suggests that while three-point fixation using either mini-plates or interosseous wires allows for virtually no displacement, two-point fixation and in some cases one-point fixation provide acceptable stability. In general, stable fixation is achieved by methods that involve the use of at least one miniplate and incorporate the frontozygomatic suture line as one of the points of fixation.

Microsurgical replantation of the lip: a multi-institutional experience.

&NA; Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow‐up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter <0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly onethird (4 of 13) patients suffered prolonged edema lasting >4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two‐point sensibility (≥10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi‐institutional experience, the data are remarkably consistent. Re‐establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits. (Plast. Reconstr. Surg. 102: 358, 1998.)

Antimicrobial activity of lidocaine against bacteria associated with nosocomial wound infection.

The authors characterized the in vitro antibacterial properties of clinical doses of lidocaine on isolates of a variety of bacterial pathogens commonly encountered in the setting of nosocomial wound infection (Enterococcus faecalis, Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus) as well as a number of resistant strains of methicillin-resistant S. aureus and vancomycin-resistant enterococci. Time-kill studies were carried out on bacteria exposed to various clinical concentrations of lidocaine (0%, 1%, 2%, and 4%) with and without epinephrine (1:100,000). Minimum inhibitory concentrations and minimum bactericidal concentrations were determined for some strains using a broth macrodilution method recommended by the National Committee of Clinical Laboratory Standards. Lidocaine demonstrated a dose-dependent inhibition of growth for all strains of bacteria tested. The greatest sensitivity to lidocaine was shown by gram-negative organisms; the least sensitive was S. aureus. The addition of epinephrine to the local anesthetic had no effect on the susceptibility of the bacteria to lidocaine. These observations suggest that the surgical benefit of local anesthesia may extend beyond its analgesic properties and may have a role in the prophylaxis and, in the case of methicillin- and vancomycin-resistant bacteria, the treatment of surgical wound infection, mandating a wider application of this modality.

Effect of lidocaine and epinephrine on Staphylococcus aureus in a guinea pig model of surgical wound infection

Postoperative wound infection, most often with, is of ubiquitous concern in surgical practice, occurring in an average of 1.5 to 5 percent of all procedures. The antimicrobial properties of local anesthetics have been documented over the past 25 years by in vitro studies. This study evaluates the effects of lidocaine preparations on in an in vivo setting. In a wound infection model using live albino guinea pigs, inoculum was introduced for the reproducible bacterial colonization of clean surgical wounds. One of two sites on the dorsum of each animal was infiltrated with a commercial lidocaine preparation (with and without epinephrine) prior to inoculation with (10 cfu/ml). The other site, inoculated with without preinfiltration with lidocaine, served as the control. Cultures from the sites treated with lidocaine were then compared with cultures from the control sites. All control sites had a consistent presence >or=10 cfu/ml, the threshold for bacterial inhibition of wound healing. Infiltration of the wound with 2 ml of 2% lidocaine prior to inoculation was associated with an average decrease in bacterial count of >70 percent ( n= 19). On the other hand, the addition of epinephrine (1:100,000) to lidocaine was associated with a 20-fold in bacterial counts compared with control values ( n= 10). This is the first study to demonstrate inhibition of by a local anesthetic agent in an in vivo model of a surgical wound. This information suggests a possible role for local anesthetics in prophylaxis against surgical wound infection.

Gluteus maximus musculocutaneous flap for the treatment of recalcitrant pilonidal disease.

Although conservative surgery should be the initial approach to pilonidal disease, there remains a select group of patients with recalcitrant disease who fail repeated interventions and for whom a more aggressive approach is justified. Use of a large gluteus maximus musculocutaneous flap to facilitate wide excision, to allow for primary closure with well-vascularized tissue, and to alter the anatomy of the gluteal cleft has been used in 5 patients with chronic recurrent recalcitrant disease. The use of this large muscle unit in these otherwise healthy adults has achieved control over their pilonidal disease with acceptable morbidity and no demonstrable functional sequelae.

Skin-stretching device for intraoperative primary closure of radial forearm flap donor site

The use of a skin-stretching device to close radial forearm donor-site defects in patients being treated for intraoral cancer is described. Intraoperative application of the device achieved primary closure of the donor site during the time course of the reconstructive procedure with no requirement for additional operative time. The device was used successfully in seven patients with two instances of marginal skin necrosis and delayed healing but good long-term functional and cosmetic outcomes in all cases.

Atypical fibroxanthoma: Clinicopathologic determinants for recurrence and implications for surgical management

Atypical fibroxanthoma (AFX) is an uncommon skin tumor occurring primarily in the head and neck region of elderly Caucasian males. Treated with local excision, the disease is thought to be fairly benign but can occasionally demonstrate aggressive local recurrence as well as distant metastasis.

The role of antibiotics and timing of repair in flexor tendon injuries of the hand.

The use of antibiotics and the timing of repair in the management of flexor tendon injuries of the hand have never been specifically addressed in the literature. In a retrospective study, 140 patients treated for simple open flexor tendon injuries were evaluated for postoperative wound infection. Patients were divided into four groups on the basis of early or late repair and use of parenteral perioperative antibiotic therapy. No significant differences were found among groups with respect to the low incidence of infectious complications observed. There is no evidence that mandates the use of prophylactic antibiotics and immediate repair in these types of injuries.

Using the world-wide-web to obtain feedback on the quality of surgical residency training

BACKGROUND Resident feedback can lead to an improvement in teaching performance. Compliance with our previous rotation evaluation system has been poor. METHODS Rotation evaluation forms were integrated to the departmental World-Wide-Web site. Anonymously completed evaluations are automatically sent to an appointed surgery professor via electronic mail (e-mail). They are then collated and transmitted to program directors. RESULTS Ninety-two percent (24 of 26) of our surgical residents have an e-mail account. During the 2-month trial, 18 residents completed 48 evaluations. This represents a 75% (18 of 24) compliance rate among residents with e-mail capabilities. The response rate was 82% (9 of 11) for core residents, 64% (7 of 11) for third- and fourth-year residents, and 50% (2 of 4) for chiefs. A second 2-month trial yielded a 75% (18 of 24) response rate and 43 evaluations. CONCLUSIONS The World-Wide-Web is a user-friendly medium suitable to obtain valuable feedback on the quality of residency training. Compliance was improved using this new system.

Histologic staging in malignant melanoma: Cross-sectional area revisited

Tumor thickness is considered the single most important predictor of survival in clinically localized malignant melanoma. A recent study found tumor volume a more sensitive predictor of survival than thickness. Volume measurement, however, is complicated, time consuming, and based on biologically imprecise mathematical models of tumor configuration. This report compares the prognostic power of cross‐sectional area (CSA), a simpler measurement than volume, with tumor thickness.