Biomedical subjects
Publications and source records attributed to Donald A Hudson.
Burn contractures of the extremities present a clinical challenge. Flexion contractures are more common than extension contractures. The first component of treatment is adequate contracture release. A number of different methods are available for resurfacing the wound and these are reviewed. An algorithm is presented which permits a simple approach to managing burn scar contracture of the extremities.
Suspension sutures may be considered a method for elevating ptotic tissue. This method often uses a limited access incision, and commonly is used in cosmetic surgery. The caveats for the technique are not well described. This article describes eight caveats for successful suture suspension. A method for performing this procedure with a spinal needle is described, using the lateral eyebrow as an example.
Tissue expansion can arguably be regarded as one of the revolutions in reconstructive plastic surgery. Another three applications (illustrated by three case reports) for tissue expansion are presented.
Surgery is the definitive treatment for carpal tunnel syndrome. Conservative treatments, such as wrist splinting and steroid injections, are also effective for the relief of carpal tunnel symptoms, but their use remains controversial because they only offer long-term relief in a minority of patients. A prospective study was performed to assess the role of steroid injections combined with wrist splinting for the management of carpal tunnel syndrome. A total of 73 patients with 99 affected hands were studied. Patients presenting with known medical causes or muscle wasting were excluded. Diagnosis was made clinically and electrodiagnostic studies were performed only when equivocal clinical signs were present. Each patient received up to three betamethasone injections into the carpal tunnel and wore a neutral-position wrist splint continuously for 9 weeks. After that period, symptomatic patients received an open carpal tunnel release, and those who remained asymptomatic were followed up regularly for at least 1 year. Patients who relapsed were scheduled for surgery. At a minimum follow-up of 1 year, seven patients (9.6 percent) with 10 affected hands (10.1 percent) remained asymptomatic. This group had a significantly shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039, Mann-Whitney test) and significantly less sensory change (40 percent versus 72 percent; p = 0.048, Fisher's exact test) at presentation when compared with the group who had surgery. It is concluded that steroid injections and wrist splinting are effective for relief of carpal tunnel syndrome symptoms but have a long-term effect in only 10 percent of patients. Symptom duration of less than 3 months and absence of sensory impairment at presentation were predictive of a lasting response to conservative treatment. It is suggested that selected patients (i.e., with no thenar wasting or obvious underlying cause) presenting with mild to moderate carpal tunnel syndrome receive either a single steroid injection or wear a wrist splint for 3 weeks. This will allow identification of the 10 percent of patients who respond well to conservative therapy and do not need surgery.
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Although a number of studies compare different techniques of breast reconstruction there seems to be a paucity of information documenting the factors that affect breast shape and symmetry after immediate reconstruction. A photographic analysis by 5 plastic surgeons (who were blinded to the nature of the procedure) of 62 patients undergoing skin-sparing mastectomy and immediate reconstruction was undertaken in an endeavor to identify these factors. Autologous techniques used included deepithelialized pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps (n = 23; in 9 patients a bilateral breast reduction using inverted-T keyhole skin markings was performed, and the TRAM flap was used to fill the reduced skin pocket) and 4 patients had extended latissimus dorsi flaps. Prosthetic reconstruction was undertaken in 35 patients in whom a bilateral breast reduction skin pattern was used in 23 (prosthesis inserted submuscularly in 5 patients and subcutaneously in 18 patients) or, in another 12 patients the skin envelope was retained and the prosthesis was inserted partially submuscularly in 7 patients and subcutaneously in 5 patients. As a total group, the results of autologous reconstruction were better than prosthetic reconstruction (P = 0.048, Mann-Whitney U test). However, when a breast reduction pattern was used and the prosthesis was inserted subcutaneously, the results were not significantly better than when the reduced skin envelope was filled by autologous tissue (P = 0.64, Mann-Whitney U test). Failure to replace the areola leads to a smaller reconstructed breast and asymmetry. The skin envelope, when retained in toto, seems to be a major factor affecting breast shape. In patients with a reduction pattern applied, the skin envelope again seems to be a major factor affecting shape, because the results are similar whether the envelope was filled with autologous tissue or prosthetic material. The neoparenchyma is an important factor affecting breast projection. In patients undergoing prosthetic reconstruction, the results were significantly better with subglandular placement compared with submuscular placement (P = 0.007, Mann-Whitney U test). Patients who developed a complication (requiring debridement in the operating room or that took more than a month to achieve healing) had a poorer cosmetic result (P = 0.015, Mann-Whitney U test). These factors need to be considered when planning breast reconstruction to optimize the aesthetic result.
The amount of muscle that should be retained on the free fibula during harvest is unresolved. Muscle is used to protect the periosteum, but by harvesting a large muscle cuff, the recipient and donor site morbidity increases. A retrospective review of 47 free fibula flaps performed between January 1997 and March 2002 was undertaken. There was an average follow-up of 15 months. The dissection method used for all cases was a muscle sparing technique where the peroneal vessels were skeletonised anteromedially. Only a very thin rim of muscle (1-2 mm) was left attached to the fibula. The recipient and donor vessels were flushed with heparin saline solution intra-operatively and a Dextran 40 infusion was used for four days post-operatively in all cases. Of the 47 flaps, 39 were used for mandible reconstruction, six for maxillary reconstruction and two for long bone reconstruction following trauma. The average age was 47.7 years (range 13-82) and two-thirds (28/43) of the patients were male. There was one post-operative death. The overall failure rate was 10.9% (5/46). Two flaps were lost as a result of arterial thrombosis, one from venous thrombosis, one from sepsis and in one case the cause could not be determined. There were 2 (4.3%) recipient site haematomas. It is suggested that the low recipient site haematoma rate in this series may be related to the limited muscle bulk transferred with the flap. Harvesting less muscle also enables easier insetting and folding of skin flap, and reduces the donor site problems of haematoma and weakness of the foot. The blood supply to the fibula does not appear to be compromised.
Tissue expansion offers the advantages of supplying tissue similar in texture and colour to the defect to be covered. However, to maximise the result, the expanded tissue must be used in the most efficient way possible. Rectangular expanders have been shown to yield the most available tissue. A technique to maximise the use of expanded tissue with a rectangular tissue expander is described. The technique is one of an advancement flap that maximises the use of expanded tissue in both a vertical and horizontal direction by adding backcuts to the sides (and interposing triangles of local tissue into these backcuts) as well as the base of the flap. This technique has been successfully applied to 11 children (17 expanders) undergoing tissue expansion during a 19 month period.
Remote critical care consultations have been employed between the Naval Hospital in Guam and the Tripler Army Medical Center in Hawaii, a distance of 5300 km. During a 10-week study period there were physician-physician daily consultation rounds for patients in the intensive care unit at the Naval Hospital. Physiological data, video-images and sound were transmitted via a 768 kbit/s frame relay connection, albeit with a 1-3 s delay. During the study there were 87 consultations concerning 25 patients. Preliminary results showed that a broad range of critical care patients could be managed effectively through daily remote critical care consultation. Broader implementation of this strategy may represent a method of making critical care expertise available to front-line military health-care facilities and to remote civilian facilities with limited critical care expertise.
We have developed a Web-based e-learning tool for teaching nursing skills, using educational material from a hospital-based nursing skills 'fair'. Management software was used to track skill certification and continuing education contact hours. The content could be delivered over the Internet and through firewalls using Windows Media Player version 9. The content was structured in a manner that made it adaptable to an e-learning system that used the Sharable Content Object Reference Model (SCORM), a set of specifications for delivering educational materials through technology-based methods.
International medical education sessions have been successfully conducted by videoconferencing using Internet2. The sessions were between two tertiary care medical centres, in Honolulu and Bangkok. However, video quality was lower than for similar sessions using ISDN and audience satisfaction was less. The main reasons for the lower quality were network congestion and bandwidth allocation by the videoconferencing equipment. Software to ensure quality of service is available, but is not easy to implement. There were also network security problems and the costs were high. Our international videoconferences averaged 40-50 hours per year, an activity level at which connection costs were lower for ISDN than for Internet2. It appears that Internet2 videoconferencing for medical education is best reserved for academic institutions that have other high-bandwidth network requirements.
Breast mound reconstruction can be a particularly difficult procedure in patients who have delayed reconstruction. A technique in which two flaps are used is described. The lateral thoracodorsal flap is used to create a breast pocket, and the latissimus dorsi flap is used to fill this breast pocket. The advantages of the technique are one-stage autologous reconstruction with a skin envelope similar in color and texture to the opposite breast. The disadvantages include a larger scar.
The latissimus dorsi flap is enjoying resurgence in interest for breast reconstruction. A technique is described in which the pedicled latissimus dorsi flap (the whole muscle and overlying fat is harvested) is molded to resemble the shape of a breast. This enhances the shape and projection of the reconstructed breast, and prosthesis is no longer required. The disadvantages of the technique are the longer scar that is required to harvest all the muscle and overlying fat, and that there is still some limitation to the size of the breast that can be reconstructed. Harvesting the extended latissimus dorsi flap also leaves a contour defect on the back.
The objective of this study was to assess the efficacy and reliability of muscle flaps in the treatment of prosthetic graft sepsis. A retrospective analysis was performed to assess the outcome of all patients with prosthetic graft sepsis who were treated with a muscle flap at Groote Schuur Hospital between January of 1991 and July of 2000. The specific end points studied were flap survival, limb salvage rate, and mortality. A total of 27 muscle flaps were raised to cover 24 sites of graft sepsis in 21 patients. Twenty-five flaps were performed primarily and two secondarily. The mortality rate was zero. Limb salvage was achieved in 15 of 21 patients (71 percent), with no recurrent sepsis after an average follow-up period of 36 months. The groin was the most common site of infection, with an 86 percent incidence. Eighteen sartorius flaps were raised in the groin. Seventeen of the 18 sartorius flaps survived (94 percent), and a 71 percent limb salvage was achieved with no recurrent sepsis after 36 months of follow-up. This series supports the use of muscle flaps for the treatment of prosthetic graft sepsis. The sartorius flap has been shown to be reliable as a flap in the groin, with successful limb salvage in the majority of patients.
Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one-stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted-T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple-areola complex, the original areola (n = 3) or nipple-areola complex (n = 7) was retained as a full-thickness skin graft. The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple-areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de-epithelialized portion, which still allows two-layer closure). In the subgroup of patients with large breasts or marked ptosis, a single-stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple-areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple-areola complex may be retained as a full-thickness graft.
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Historically, it appears that the problems of capsule contracture, the alleged risk of human adjuvant disease, and the problems due to migration of smooth walled breast prosthesis have had a major impact on the techniques used in breast augmentation. As a consequence of the above, the primary cosmetic goal may have been lost (a naturally enlarged aesthetic breast). It is suggested, that from a purely cosmetic point of view, that the best result is obtained with a subglandular textured gel prosthesis. Reasons for selecting this method are advanced and well documented limitations to the submuscle pocket are highlighted. Various incisions are also discussed. The inframammary fold is a critical landmark of the breast and should not be violated in a cosmetic procedure.