William P. Graham

Soft-tissue Expansion: Concepts and Complications

Soft-tissue expansion complements existing reconstructive techniques and provides new vistas for the plastic surgeon. The technique finds use for overcoming a shortage of tissue, for obtaining skin with special desirable qualities, for creation of flaps otherwise not possible because of the resultant donor site or limited vascularity, for creation of flaps with functioning muscle and overlying soft tissue, and for minimizing flap donor-site problems. Careful planning should include patient counseling, optimum incision placement, and time for a leisurely, complete expansion. The surgery can often be performed under local anesthesia and expansion is tolerated well. Patients should be counseled that the incidence of major complications in an unselected series is 1 in 4 patients. Major complications, however, typically result in a delay in reconstruction and not tissue loss.

Skin expansion to eliminate large scalp defects.

In three children aged 3 to 8 years with large scalp defects temporary expanders of silicone elastomer were inserted under the scalp above the pericranium and under the galea through an incision at the junction of the defect and the normal scalp. Over the following six to eight weeks, the expanders were inflated weekly or semiweekly with injections of saline. During expansion, hair growth continued. When the scalp flap expansion was completed, the scalp margin was advanced. Two of the 3 patients required additional expansion, so a deflated expander was left under the scalp. The entire defect was covered in each case. This technique has wide application for a variety of reconstructive problems.

Combined parenteral hyperalimentation and chemotherapy in the treatment of disseminated solid tumors

Abstract Combined parenteral hyperalimentation and systemic chemotherapy have been employed in a group of ten patients with widespread malignant disease. Although only two patients had objective changes in the size of lesions, almost all patients had decreased analgesic requirements, improved performance status, increased appetite and oral intake, and reversal of the downward weight trend. There was a striking absence of gastrointestinal toxicity despite the administration of extremely large doses of chemotherapeutic agents over prolonged periods of time. Although the number of patients was too small to draw firm conclusions, the technic of combined hyperalimentation and chemotherapy appears to aid the management of patients with advanced symptomatic malignant disease.

Soft-tissue Expansion in the Lower Extremities

Soft-tissue expansion enjoys ever-wider use, but to date an experience using this technique in the lower extremity has never been presented. We reviewed our first 16 patients to describe the indications and contraindications for the use of tissue expansion in the lower extremity. Guidelines evolved from study of the data. Soft-tissue expansion merits consideration for coverage of problem wounds, in preparation for removal of large benign lesions, and for the repair of contour defects. The operator should know that an open wound below the knee predicts a complication if soft-tissue expansion is attempted in that location. In the thigh, incisions can be confidently placed at the edge of the defect. In every location, large expanders should be chosen so that they are as long as or longer than the adjacent defect. The increase in circumference of the limb should be followed. Simple designs for advancement flaps usually work well. As our experience has grown, reconstruction using soft-tissue expansion in the lower extremity has become safer and the results more predictable through better patient selection and diligent monitoring of intraluminal pressures, even if only by ensuring that the patient is always comfortable. Soft-tissue expansion has a role in reconstruction of the lower extremity.

Elevated nucleoside excretion by patients with nasopharyngeal carcinoma: Preliminary diagnostic/prognostic evaluations

Nucleoside excretion was monitored in the urine of patients with nasopharyngeal carcinoma, a difficult malignant disease to diagnose at early stages. Separation and quantitation of nucleosides were accomplished by using high performance liquid chromatography. Significantly elevated nucleoside levels were found for patients with newly diagnosed and recurrent carcinomas. The magnitude and timing of the increases indicate the value of monitoring these levels for diagnostic/prognostic evaluations for nasopharyngeal carcinoma.

Management of fractures of the supraorbital rim.

The frequency of supraorbital rim fractures is increasing as incidence of motorcycle and bicycle accidents increases. These fractures are frequently depressed, comminuted, and often extend into the frontal sinus. Open reduction and fixation are the treatment of choice. Adequate debridement and cleansing with preservation of periosteum and blood supply are recommended. Unstable fragments can be fixed to the frontal bone or stabilized by suturing the torn periosteum. Severely comminuted supraorbital frontal sinus fractures may require stabilization via frontal sinus pack or balloon. We feel the latter is preferable and both Foley and Fogarty catheters have been successfully used.

Effects of tourniquet ischemia and postischemic edema on muscle metabolism

In vivo interstitial muscle pressures measured by wick catheter, tissue gas tensions measured by mass spectrometer, and glucose and high-energy phosphate metabolism measured fluorometrically were studied in the anterior tibial (AT) and vastus lateralis (VL) muscles of primate limbs during and following tourniquet ischemia (2.5 hours; 400 mm Hg) to elucidate postischemic edema and its metabolic consequences. During ischemia, interstitial pressure in the VL rose, while in the AT it decreased, but 24 hours later pressures in both experimental muscles were significantly greater than those in the controls. In both experimental muscles PO2 decreased significantly within 15 minutes of ischemia. PCO2 increased significantly in the AT at 30 minutes and at 75 minutes in the VL muscle. Twenty-four hours later only PO2 in the experimental AT was significantly different than its matched control. During ischemia glucose and phosphocreatine (CrP) decreased significantly, and G-6-P and lactate increased significantly in both muscles, but at 24 hours glucose levels were 25% lower and G-6-P 16.2% higher in the experimental AT and CrP 34% lower in the experimental VL. This study shows that there are significant acute and delayed alterations in primate muscle metabolism following tourniquet ischemia and suggests that these changes may be related to the anatomic location of the muscle studied and the type of trauma it has sustained.

Correction of Ulnar Subluxation of the Extensor Communis

An effective technique for correcting ulnar subluxation of the extensor communis tendon off the head of the metacarpal has been described. A pedicle of the involved tendon with a distal base is developed on its radial side. This is anchored to the radial collateral ligament without compromising extensor tendon function.

Corynebacterium parvum versus BCG adjuvant immunotherapy in human malignant melanoma.

One‐hundred and sixteen patients with Stage I and Stage II malignant melanoma were randomized to treatment with either Bacillus Calmette‐Guerin (BCG) (Tice) or subcutaneous Corynebacterium parvum (Burroughs‐Wellcome). Life table analysis failed to reveal a difference between these two forms of treatment in 68 Stage I patients. The relapse rate was significantly reduced in Stage II patients trated with C. parvum.

Routine drainage is not required in reduction mammaplasty

&NA; To date, there have been no randomized trials documenting the efficacy of closed suction drainage when applied to reduction mammaplasty. Despite this, it has become the standard of care. A recent retrospective review suggests that closed suction drainage is not necessary. This study attempts to resolve this issue in a prospective, randomized fashion. The Institutional Review Board of the College of Medicine of The Pennsylvania State University approved the study. Forty‐nine consecutive patients who underwent reduction mammaplasty by the inferior pedicled techniques were enrolled. Each patient was randomized to having a drain in either the right or left breast. The other breast was undrained. Patients were followed up for rate of complications and for patient satisfaction. Their ages ranged from 17 to 62 years, with a mean of 33 years. Weight of reduction from the drained breasts ranged from 360 to 1090 g, with a mean reduction of 675 g. Weight of reduction from the undrained group ranged from 380 to 1011 g, with a mean of 620g. There were a total of 11 complications in the study. In the drained group, there were six complications out of 49 breasts (partial nipple loss in one, minor wound breakdown in two, fat necrosis in two, and hematoma in one). In the undrained group, there were five complications out of 49 breasts (partial nipple loss in none, minor wound breakdown in three, fat necrosis in one, and hematoma in one). Statistical analysis using the McNemar test revealed no significant difference between the two groups. A questionnaire revealed that the patients preferred the increased early postoperative comfort afforded by the absence of a drain. Performing reduction mammaplasty without the use of closed suction drainage is safe and is preferred by the patients. (Plast. Reconstr. Surg. 111: 113, 2003.)