S. R. Lewis

Perineural lymphatics: myth or fact.

Abstract A number of experiments designed to determine the mechanism of tumor extension along nerves are described together with clinical observations. The data presented indicate that perineural lymphatics are a myth and not a fact for the following reasons. (1) Lymphatics do not drain into nerves. (2) Perineurial spaces do not flow into lymphatics. (3) Intraneural injection of tumor cells in the rat and clinical observations concerning tumor extension along nerves show that tumor patterns are not compatible with lymphatic spread. (4) Special studies, including electron microscopy, indicate that there are no lymphatics within nerves.

The Quality of Life after Major Thermal Injury in Children: An Analysis of 12 Survivors with 80% Total Body, 70% Third-degree Burns

Twenty-one children admitted between December 1981 and May 1985, with greater than 80% total body surface area burn (TBSAB), underwent total excision and grafting of all of their wounds within 72 hours of injury. Twelve survivors (with an average TBSAB of 89%, 82% third degree) were studied in detai

Ten Years Of Experience In Managing Patients With Burn Contractures Of Axilla, Elbow, Wrist, And Knee Joints

Hypertrophy and contracture of scars are common sequelae seen in patients with severe burns. These changes may impair the movement of various joints. The surgical restoration of deformed joints can be difficult. Although the use of splints and continuous pressure across these joints has been effective in minimizing these problems,1,2 the true efficacy of this regimen in preventing joint dysfunction remains undefined. After we had noticed that the faithful use of splints in patients with neck burns decreased the incidence of neck contracture from 37 percent to 9 percent,3 we reviewed the records of 830 patients treated at our hospitals during a 10-year period to evaluate the efficacy of splints and pressure upon burn scars across the major body joints. An analysis of 625 patients who had sustained burns across the axillae, elbows, wrists, or knee joints indicates that the use of splints and pressure across these joints will not only greatly decrease the incidence of contractures but will also reduce the frequency and need for release operations. However, these appliances must be used for at least 6 months (longer, if possible), if substantial benefits are to be obtained.

A circumareolar approach in surgical management of gynecomastia.

Gynecomastia is a common deformity encountered among male patients. Surgery is primarily aimed at reducing the size of the breast mound and therefore should be considered aesthetic in nature. In an attempt to minimize the problems of hematoma formation, nipple necrosis, and unsightly scarring around the upper torso after the surgery, we have had the opportunity to utilize a circumareolar approach for breast tissue removal in 33 breasts (24 patients). This method, when compared with other techniques, has the advantage of leaving minimal scarring around the areolar margin while obliterating the dead space by imbricating the tissue stalk to minimize hematoma formation.

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.

Lymphatics of the mouth and neck

Abstract Research evaluation in 125 dogs and twenty-five human subjects through visualization of lymphatics with sky blue dye has led to newer concepts in the lymph flow of the tongue, as well as the cervical lymphatics. Cannulation of the lymphatics of the tongue and injection with radiopaque material followed by cineradiography gives an insight into normal and abnormal flow patterns of the lymph drainage. The importance of the valves in the cervical lymphatics, cross over of lymphatics, and obstruction of the lymphatics has a definite bearing on the course of metastatic disease. The cervical lymphangiograms correspond well to the anatomy book descriptions except in two areas: first, the lymph drainage from the tip of the tongue did not go to the submental nodes; second, lymphatics originating near the midline of the tongue did not cross over to the opposite side except those near the tip of the tongue or if chronic obstruction was present. The application of lymphangiography to the study of the tongue, floor of the mouth, and neck lymphatics has brought us closer to specific anatomic and physiologic knowledge, which will give a better understanding of means to combat neoplasia in these areas.

A histological study of the lower tarsus and the significance in the surgical management of a involutional (senile) entropion

The dimension of the lower tarsus diminishes with aging. Changes in the number and size of the meibomian glands and in the character of intermingling fibroconnective tissues are thought to be responsible. Furthermore, such alterations of the structural integrity play an important role in the pathogenesis of entropion encountered commonly m the elderly. We have advocated the use of an autogenous cartilage graft harvested from the ear to correct the deformity, especially in instances where the conventional methods of correction have failed.

Prevention and management of contractures in patients with burns of the neck

Two hundred patients with neck burns were analyzed to determine the incidence of contractures. It was found that only 8 per cent of patients with second degree burns had contractures, all of which were mild. Both the overall incidence of cervical contractures in patients with third degree neck burns and their severity can be decreased by the use of a custom-formed isoprene splint. Splinting should begin as soon as possible after the burn and continue until scar maturation is complete.

Burned feet in children: Acute and reconstructive care☆

Abstract Scarring and contractures of the foot can be very disabling sequelae of burn injury, leading to recurrent ulcerations and chronic problems in wearing shoes. Proper management during the acute phase and reconstruction can prevent most of these disabilities. At the Galveston Unit of the Shriners Burns Institute, split thickness skin grafts and local flaps have proved satisfactory for reconstructing almost all burn scars of the foot in children. We use skeletal traction immobilization for skin grafting, and firm elastic and orthopedic shoe support after healing. We have reviewed our experience in the acute and reconstructive surgical care of sixty-six patients with third degree burns of the feet including grafting, skeletal traction, Z-plasty, and local and cross-leg flaps. Amputation of a toe or extremity has rarely been needed nor has tendon lengthening been required.

Hand Deformities In Patients With Snakebite

Over the past 25 years, 83 patients have been treated at our hospitals for poisonous snakebites of the hand. Prior to 1970, polyvalent antivenin was used, either alone or in conjunction with cryotherapy, steroids, or incision and suction methods. Hand deformities, due to tissue necrosis, were encountered in 15 of 22 patients (68%) treated by these methods. In contrast, excisional therapy, without the use of polyvalent antivenin, was the sole method of treatment in 61 patients seen since 1970. The incidence of hand deformity in them was 8.2%. We have concluded that early excision of the envenomated tissues will not only curtail systemic toxicity from the injected venom, but will also minimize the extent of local tissue damage.