Steven J. Blackwell

Treatment of burn alopecia with tissue expanders in children.

During the past 18 months, 60 tissue expanders were utilized in the reconstruction of 42 children with burn alopecia of the scalp not amenable to a single excision and primary closure at the Shriners Burns Institute in Galveston, Texas. The children were grouped according to the degree of alopecia. All patients with defects of 15 percent or less of the total hair-bearing scalp were able to obtain complete closure of their defects with two operations, i.e., one to place the expander and the second to remove the expander and advance the flaps. Some patients with defects up to 40 percent were closed with serial expansion. Patients with even larger defects had a significant reduction in the percentage of alopecia and benefited from re-creation of anterior hairlines. We have encountered a postoperative complication rate of 10 percent. When compared to previous methods of treating burn alopecia, tissue expansion allows a more rapid closure, fewer operations and coincident anesthetics, and decreased total length of hospitalization.

Epinephrine in digital blocks: revisited.

Digital block anesthesia with epinephrine, ring technique, and digital tourniquet have been implicated in causing finger gangrene. An extensive review of the literature provided no case of finger gangrene attributed solely to the adjunctive use of epinephrine with lidocaine for digital block. By causing vasoconstriction, epinephrine complements the local analgesic by prolonging the duration of action and providing a temporary hemostatic effect. Epinephrine augmentation of digital block anesthesia was used in the treatment of 23 finger injuries without a complication.

Characterization of the nasal, sublingual, and oropharyngeal mucosa microbiota in cleft lip and palate individuals before and after surgical repair.

OBJECTIVE To delineate inherent differences in the microbial milieu in cleft palate patients compared with cleft lip patients and to document changes in microbial flora before and after cleft lip and palate repair. DESIGN A prospective study of preoperative and postoperative culture results from the nasal, sublingual, and oropharyngeal surfaces of patients undergoing primary cleft lip repair and palate closure. SETTING Shriners Hospitals for Children, Galveston, Texas, and University of Texas Medical Branch, Galveston, Texas. PATIENTS Seventy-nine patients were included in a 3-year period. Ten patients with isolated cleft lip underwent primary lip repair. Twenty-five patients with cleft lip and palate underwent primary lip repair, and 44 patients underwent palatoplasty. RESULTS Cleft palate patients had a significantly higher rate of colonization by staphylococcal species, but not methicillin-resistant Staphylococcus aureus , when compared to cleft lip patients (p=.0298; chi-square test). Closure of the palatal cleft coincided with significant decline in the prevalence of Klebsiella and Enterobacter species (p<.05; McNemar test). The only major complication, palatal dehiscence, was believed to be directly related to infection with group A beta-hemolytic streptococci. CONCLUSIONS Despite a high prevalence of potential pathogenic and enteric flora preoperatively in primary palate repair, postoperative wound infection is rare in the prospective study population. However, the presence of beta-hemolytic streptococci was associated with a higher risk of repair dehiscence; therefore, screening for Streptococci prior to surgery should be performed routinely.

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.

Cross-chest lipoplasty and surgical excision for gynecomastia: a 10-year experience.

BACKGROUND Gynocomastia is a relatively common condition in men, with a reported overall incidence of 32% to 36% and as high as 65% among adolescent males in some series. OBJECTIVE We reviewed the senior surgeons experience over the past decade in the surgical treatment of gynecomastia using suction-assisted lipoplasty (SAL) with a cross-chest tunneling technique, performed alone or in combination with direct excision. METHODS Thirty-four patients with gynecomastia were evaluated and treated surgically at the University of Texas Medical Branch in the past 10 years. Twelve were treated with cross-chest SAL alone, 16 with cross-chest SAL and direct excision, and 6 with direct excision. Infusion of wetting solution was performed with the use of a 2.0-mm cannula, through an access site at the medial border of the contralateral nipple-areolar complex. Next, a 4.0-mm Mercedes-tip (Byron/Mentor Corp., Santa Barbara, CA) cannula was tunneled across the sternum to liposuction the contralateral prepectoral fatty breast. Patients with composite fatty and glandular tissue first underwent SAL, then direct excision through a periareolar incision; those with only retroareolar glandular tissue underwent direct excision alone. RESULTS All patients who underwent SAL alone or SAL combined with excision had satisfactory aesthetic results and no reported postoperative complications. In one patient who underwent excision alone, a hematoma developed. CONCLUSIONS Despite newer technologies, traditional SAL performed with a cross-chest technique and direct excision as indicated is a valuable approach that yields predictable success. This approach avoids scarring and offers a sculpted reduction of the retroareolar glandular and fatty elements, resulting in a natural, smooth breast contour.

Onlay Cartilage Graft of the Alar Lateral Crus for Cleft Lip Nasal Deformities

The onlay cartilage grafting technique is described for treatment of unilateral or bilateral cleft lip nasal deformities. The alar cartilage is exposed through rim and intercartilagenous incisions. The cephalic half of the alar cartilage is excised, similar to the technique of traditional tip rhinoplasty. The harvested cartilage is applied to the intact caudal cartilage in layered fashion and secured with absorbable sutures. If necessary, successive layers may be added. These grafts provide a sturdy, yet delicate framework for a more normal appearing alar rim. We have performed this procedure on 16 patients, ages 10 to 41. Follow-up intervals range from 13 to 40 months, with a mean of 19 months. Results have been rated good-to-excellent by patients and surgeons. There has been no recurrence of the deformity. The only complication has been one nasal vestibule synechia.

Dexmedetomidine Decreases Postoperative Pain and Narcotic Use in Children Undergoing Alveolar Bone Graft Surgery

Objective: Dexmedetomidine is a parenteral agent that combines the benefits of cooperative sedation, anxiolysis, and analgesia without the risks of respiratory depression. Off-label use has been reported in children. We have introduced dexmedetomidine for use in patients having undergone alveolar bone graft (ABG). The objective is to demonstrate the value and safety of postoperative dexmedetomidine infusion in a non-ICU setting following ABG. Design: A retrospective review was performed on patients who underwent ABG by the senior author. Patients were divided into 2 groups: those who received postoperative dexmedetomidine and those who received patient-controlled anesthesia. Main Outcome Measure(s): The primary study outcome measures included patient demographics, adverse events, length of stay, pain scores, and doses of narcotics during admission were collected. Results: Inclusion criteria were met by 54 patients; 39 received dexmedetomidine whereas 15 did not. There were no significant differences between groups in age, gender, and length of stay. The patients who received dexmedetomidine used oral narcotics less often (P = .01). In addition, more patients reported no pain after surgery (P = .05) and at the time of discharge if they received dexmedetomidine (P < .01). There were no reported adverse effects. Conclusions: Dexmedetomidine provided superior pain control after surgery and at the time of discharge, as well as a significant decrease in the use of oral narcotics. In our institution, it has since replaced the PCA as a postoperative pain control modality. Absent the risk for respiratory depression, dexmedetomidine has demonstrated a safe option for postoperative pain control in our focused group of pediatric patients.

An emergency multisystem screw removal module

There are several practical indications for the removal of screws and plates from the reconstructive patient. For the craniomaxillofacial surgeon there exists a wide array of screw and plating systems available. As patients relocate, it is unlikely that individual hospitals have the full collection of rigid fixation systems in their inventory. Therefore, a universal screw removal system was designed to facilitate the elective and emergency removal of all existing craniomaxillofacial fixation hardware. This system is a self-contained module containing a single handle and 12 interchangeable screwdriver blades. The universal screw and plate removal system has been used successfully in several patients—children as well as adults—in whom hardware was removed.