William W. Dzwierzynski

psychological Adjustment in Children after Traumatic Disfiguring Injuries: A 12-month Follow-up

&NA; The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12‐month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3‐month and 6‐month evaluations, but 44 percent of the children continued to report symptoms at 12‐month follow‐up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re‐injury, mood disorders, body‐image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons. (Plast. Reconstr. Surg. 106: 1451, 2000.)

The innervated gracilis musculocutaneous flap for total tongue reconstruction.

A functional neotongue following total glossectomy requires both soft-tissue bulk and reconstruction of muscle function. We used innervated transverse gracilis musculocutaneous flaps to reconstruct total glossectomy defects in eight patients. The obturator nerve to the gracilis muscle was approximated to the hypoglossal nerve to reinnervate the gracilis muscle by using microsurgical technique. The cutaneous paddle of the gracilis flap easily supplies sufficient bulk to replace the total glossectomy defect. Follow-up of patients ranged from 3 to 47 months. All patients were able to resume oral feeding. Electromyographic studies performed on one patient showed reinnervation of the flap with active elevation of the posterior pharynx. Ultimately, seven patients died because of recurrence of their disease. The innervated gracilis musculocutaneous flap may benefit patients who have a total glossectomy by allowing them to achieve a more functional recovery.

Anatomic Considerations in Transconjunctival Blepharoplasty

To better identify the anatomy of the lower eyelid in relation to the transconjunctival approach to blepharoplasty, 20 fresh cadaver lower eyelids were dissected. Cross-sectional cuts of fresh cadaver specimens also were made and examined by whole-organ photomicrographs of the entire lower eyelid and its associated soft-tissue structures. These were correlated with magnetic resonance imaging studies in the living patient. Measurements were made of the relationship of the lid margin, tarsal plate, infraocular fat (including the three traditional fat compartments), inferior oblique muscle, and eyelid (on stretch). Our findings suggest that a transconjunctival incision closer to the fornix, directed toward the infraorbital rim, allows the surgeon a direct and safe approach to the fat compartments. No distinct anatomic compartmentalization of the periorbital fat as traditionally described was found. There was a consistent extension of the lateral pad, lateral to the lateral can thus of the eye. There are also accumulations of fat outside the orbital septum in the cheek and beneath the orbicularis muscle that contribute to the fullness of the lower eyelid and which cannot be addressed by the transconjunctival approach.

The Hand Injury Severity Scoring System and Workers’ Compensation Cases in Wisconsin, USA:

The Hand Injury Severity Score was retrospectively applied to a group of workers’ compensation cases in Wisconsin, USA. A statistically significant correlation was found between the score and the time interval between injury and the end of healing. These results are comparable to the findings in the original study of Campbell and Kay (1996). We provide some suggestions for further development of this scoring system.

Use of Mitek suture anchors in head and neck reconstruction

Attachment of soft tissue to bone is a common problem encountered in head and neck reconstruction. Soft-tissue attachment is encountered in the formation of slings to recreate oral competence. We report the use of the Mitek suture anchor in 7 head and neck reconstruction patients (5 underwent an attachment of a tensor fascia lata sling for oral competence and 2 underwent an attachment of a gracilis musculocutaneous free flap to recreate facial symmetry). Use of the Mitek anchor facilitates soft-tissue-to-bone attachment. Minimal dissection is required and secure bony fixation is obtained.

Compression neuropathy of the radial nerve due to ganglion cysts.

Ganglions of the upper extremity are common. Radial nerve dysfunction, particularly radial sensory dysfunction, is a rare finding in association with a ganglion. We present our experience with two such ganglia and a review of the literature.

Magnetic resonance imaging scanning in the diagnosis of zone II flexor tendon rupture

This study was undertaken to determine the usefulness of magnetic resonance imaging (MRI) in the diagnosis of flexor tendon rupture in patients who had prior surgery. Magnetic resonance imaging scans were performed on 11 digits (16 tendons) with the clinical diagnosis of flexor tendon rupture. Clinical suspicion correlated with MRI and surgical findings. Clinical examination yielded a 60% accuracy in diagnosis. MRI differentiated rupture from adhesions with a 100% accuracy rate. The MRI scan is a valuable tool in diagnosing tendon ruptures and may help reduce the incidence of unnecessary tendon explorations.

Improvement in resource utilization after development of a clinical pathway for patients with pressure ulcers

&NA; Clinical pathways are interdisciplinary patient care plans intended to reduce variance and improve quality of care while lowering health care cost. This study was undertaken to determine whether the development of a clinical pathway for care of patients with pressure ulcers can indeed decrease health care costs while preserving quality of care. A clinical pathway for surgical reconstruction of pressure ulcers was developed by standardizing the current practices of our plastic surgeon group. The pathway provided direction in optimal scheduling of physician interventions along with nursing, physical and occupational therapies, and spinal cord rehabilitation interventions. It covered all potential elements of patient care, including laboratory, radiology, dietary services, intravenous fluids, and use of specialty beds. It defined patient outcomes and outlined discharge planning. Pathways were distributed throughout all services caring for patients with pressure ulcers. Patient charts and billing data were reviewed for the 16‐month periods before and after initiation of the pathway. No other significant changes in treatment occurred during this time frame. Ninety‐seven patient charts were examined (54 before pathway and 43 after pathway implementation). Parameters evaluated included length of stay and total charges (including bed use, medications, laboratory tests, and radiology). Patient readmission rate was also examined. A significant reduction in patient length of stay and total charges was achieved after implementation of the clinical pathway. Reduction was seen not only for patients treated with flaps by plastic surgery but also for patients with pressure ulcers who were not specifically targeted such as those from other services. The readmission rate decreased slightly, although not significantly, after the pathway inception. Total cost saving was almost

Complications and salvage of an ectopically replanted thumb

11,000 per patient (23 percent). In conclusion, implementation of a clinical pathway, because it standardizes care and reduces variations and duplication of care, can reduce health care cost without impairing quality of care in the treatment of decubitus ulcer patients. (Plast. Reconstr. Surg. 102: 2006, 1998.)

Managing malignant melanoma.

The ectopic replantation of a thumb is described after a mutilating hand injury. The case was followed by a series of complications and surgical procedures to treat these complications. Through perseverance and multiple microsurgical procedures the patient attained a functional hand. The patients psychological and physical course is described.