Malcolm W. Marks

The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone

&NA; Lower‐extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower‐extremity wounds. Seventy‐five patients with lower‐extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open‐cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum‐assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours. Vacuum‐assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split‐thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years. (Plast. Reconstr. Surg. 108: 1184, 2001.)

Vacuum-assisted closure: state of clinic art.

Summary: Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted closure provides a new paradigm that can be used in concert with a wide variety of standard existing plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations. The ease of technique and a high rate of success have encouraged its adaptation by thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discusses multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems. This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.

Vacuum-assisted closure for the treatment of degloving injuries

Degloving injuries of the hand and foot pose difficult reconstructive and rehabilitation challenges. After an excellent experience with split-thickness skin grafting with the vacuum-assisted closure device, we began studies with full-thickness skin grafts and traumatized skin. The device has been used with successful reapplication of full-thickness degloved skin in two patients. The first patient suffered degloving of the foot; the second patient, degloving of the hand.

Single-stage approach to skin grafting the exposed skull.

Four patients are presented who suffered full-thickness loss of the scalp, exposing the skull. Removal of the outer table, immediate application of a split-thickness skin graft, and treatment with the VAC for 3 to 4 days resulted in approximately 100 percent graft take in each case without complications. When compared with the usual two-stage approach to skin grafting the exposed skull, this method spares the patient a longer hospital stay and a second operative procedure, and it results in a significant cost savings.

Utility of Rush Paraffin‐Embedded Tangential Sections in the Management of Cutaneous Neoplasms

Background. Mohs micrographic surgery (MMS) modified by the use of tangential, formalin‐fixed, paraffin‐embedded histologic specimens is advantageous in treating selected skin neoplasms. Objective. To review the use of our experience with a modification of MMS to treat lentigo maligna melanoma (LMM), lentigo maligna (LM) and other melanoma in situ (MIS) lesions, dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and angiosarcoma. Methods. Our experience utilizing a modification of MMS in the treatment of 77 patients with LM or other MIS, 23 patients with LMM, 11 patients with DFSP, 1 patient with AFX, and 1 patient with angiosarcoma was reviewed. Length of follow‐up and rate of recurrence were examined. A literature review of this pertinent modification of the Mohs technique was performed. Results. One hundred fourteen patients underwent MMS for melanocytic (LM, MIS, LMM), spindle cell (DFSP, AFX), and vascular malignant neoplasms. One patient developed locally recurrent LM and one patient with LMM developed satellite metastasis. Regional lymph node metastasis occurred in one patient with LMM and in a patient with angiosarcoma. Conclusion. The use of Mohs micrographic surgery in conjunction with rush formalin‐fixed, paraffin‐embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.

Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device.

Fasciotomy wounds can be a major contributor to length of stay for patients as well as a difficult reconstructive challenge. Once the compartment pressure has been relieved and stabilized, the wound should be closed as quickly and early as possible to avoid later complications. Skin grafting can lead to morbidity and scarring at both the donor and fasciotomy site. Primary closure results in a more functional and esthetic outcome with less morbidity for the patient, but can often be difficult to achieve secondary to edema, skin retraction, and skin edge necrosis. Our objective was to examine fasciotomy wound outcomes, including time to definitive closure, comparing traditional wet-to-dry dressings, and the vacuum-assisted closure (VAC) device. This retrospective chart review included a consecutive series of patients over a 10-year period. This series included 458 patients who underwent 804 fasciotomies. Of these fasciotomy wounds, 438 received exclusively VAC. dressings, 270 received only normal saline wet-to-dry dressings, and 96 were treated with a combination of both. Of the sample, 408 patients were treated with exclusively VAC therapy or wet-to-dry dressings and 50 patients were treated with a combination of both. In comparing all wounds, there was a statistically significant higher rate of primary closure using the VAC versus traditional wet-to-dry dressings (P < 0.05 for lower extremities and P < 0.03 for upper extremities). The time to primary closure of wounds was shorter in the VAC. group in comparison with the non-VAC group. This study has shown that the use of the VAC for fasciotomy wound closure results in a higher rate of primary closure versus traditional wet-to-dry dressings. In addition, the time to primary closure of wounds or time to skin grafting is shorter when the VAC was employed. The VAC used in the described settings decreases hospitalization time, allows for earlier rehabilitation, and ultimately leads to increased patient satisfaction.

Studies on the endogenous flora of the human breast

Identification of the endogenous microbiological flora of the human breast and its role in breast infections following subglandular augmentation or reduction mammaplasty was undertaken. A total of 231 cultures were performed on 59 breasts in 30 patients. Patients were followed for 12 months.No fungus was cultured from any specimen. Of the breasts cultured 53% were positive for coagulase-negative staphylococcus. Other aerobes found included diphtheroids, lactobacillus, D-enterococcus, micrococcus, and α-hemolytic streptococcus. Propionibacterium acne was the most frequent anaerobic bacteria cultured. Other anaerobes included peptococcus and clostridium sporogenes. There was no correlation with respect to the type of bacterium and the depth within the breast where the culture specimens were taken. Postoperative wound infections developed in 2 of 19 patients undergoing reduction mammaplasty. Bacteria identical to those cultured at the time of surgery were again cultured from the wound. Twenty subglandular augmentation mammaplasties were performed with a 25% capsular rate at one year. Two capsules were associated with no bacterial growth at the time of mammaplasty surgery, whereas three were associated with coagulase-negative staphylococcus, Propionibacterium acne, and diphtheroids, respectively. Of the 15 breasts with no capsular contracture after one year, operative culture revealed coagulase-negative staphylococcus in 8 and no bacterial growth in 7.Even breast tissue located deep within the gland away from the nipple contains a flora that is similar to that of normal skin. Cases of infection in which the endogenous bacteria were correlated with later infection was documented.

Selective use of serial expansion in breast reconstruction.

The use of expansion prostheses in breast reconstruction allows the surgeon maximal control over the size of the contour. Experience with 30 cases of breast reconstruction for malignant disease as well as developmental deformities is presented. No major complications were observed in these cases.

Conchal cartilage and composite grafts for correction of lower lid retraction.

Lower eyelid retraction may be due to vertical deficiency of the anterior lamella, supporting cartilage, or posterior lamella. We have used autologous cartilage grafts from the conchal bowl for reconstruction of the central lamella, reestablishing and augmenting support of the lower lid. The positioning of the graft is dependent on the specific anatomic deficiency, and the etiology of the lid retraction must be carefully evaluated. In patients with posterior lamella deficiency, the contracted lower lid retractors and conjunctiva are released and the graft is placed facing the bulbar conjunctiva and is allowed to reepithelialize. In patients in whom there is an associated skin deficiency, composite auricular grafts are used. We present our experience in 33 patients with lower lid retraction. Twenty-three patients required placement of a cartilage graft only, while 10 patients had an associated skin deficiency requiring placement of composite cartilage. In nine patients the cartilage graft was seated against the bulbar conjunctiva and allowed to reepithelialize. Reepithelialization was complete within 3 1/2 weeks in all but two of these patients. This technique has provided stable lid support in all 33 patients.

Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps : A case series

Exenterative pelvic surgery is commonly performed for advanced carcinoma of the cervix and selected cases of locally advanced colorectal cancers. Low-lying lesions that are locally invasive in contiguous organs require resection of the perineal body en bloc with the resected specimen. The resulting defect, both in the pelvis and the perineum, creates a difficult management problem. Dead space in the pelvis, especially with adjunctive irradiation, leads to delayed wound healing and prolapse of small bowel into the pelvis. Small bowel obstruction and/or fistula formation are the greatest sources of morbidity in the operative group. Fifteen patients underwent exenterative pelvic procedures (total exenteration, 1 patient; posterior exenteration, 8 patients; abdominoperineal resection, 6 patients). All patients were reconstructed by transpelvic placement of the rectus abdominis muscle (muscle only, 4 patients; muscle with skin grafting, 8 patients; musculocutaneous, 3 patients). Eighty-seven percent received radiation therapy. One patient had Crohns disease and all others had carcinoma. Healing was complete in 12 of 15 patients at discharge. There were no complications related to pelvic dead space (i.e., bowel obstruction, perineal fistula), with a mean follow-up time of 24.3 months. Small bowel was effectively excluded from the pelvis to the level of the acetabular roof by computerized axial tomography scan. The transpelvic rectus abdominis muscle flap is effective in preventing major morbidity after exenterative pelvic surgery.