Managed care's methods for determining coverage of plastic surgery procedures: the example of reduction mammaplasty.
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California↗
Biomedical subjects
M A Lesavoy
Publications and source records attributed to M A Lesavoy.
Upper airway obstruction after pharyngeal flap surgery.
Upper airway obstruction after superiorly based pharyngeal flap procedures for the treatment of velopharyngeal insufficiency is described in this series of 32 flaps performed in 29 patients at our institution between 1979 and 1993. A high incidence of upper airway obstruction symptoms (38%) occurred in the early postoperative period but resolved in all but 2 patients within 5 months. None of the patients required flap revision or other procedures for relief of upper airway obstruction. Velopharyngeal insufficiency was improved or completely eliminated in 87% of patients. Significant residual velopharyngeal insufficiency in 13% of patients was treated successfully in all flap revision cases. Race, gender, age at closure, and associated craniofacial anomalies did not correlate with upper airway obstruction or with the efficacy of treatment for velopharyngeal insufficiency. However, patients with transient postoperative upper airway obstruction were only half as likely to suffer residual postoperative velopharyngeal insufficiency. The inverse relationship between velopharyngeal insufficiency and upper airway obstruction (p = .008) suggests that the surgeon may sometimes need to accept some transient upper airway obstruction to achieve correction of velopharyngeal insufficiency.
Adolescent↗
A study of the effects of epinephrine infiltration on delayed bleeding in a rat flap model.
Infiltrating the operative site prior to incision with an epinephrine solution will provide vasoconstriction and a dryer operative field. However, some surgeons fear that as the vasoconstrictive effects of the epinephrine subside, smaller vessels will rebleed and a hematoma may result. In this study, 51 rats were operated with two flaps. The ventral pedicled flap, based on the inferior superficial epigastric arteries, and the McFarlane dorsal skin flap were utilized. The perimeter of all flaps was infiltrated with one of the following test infusions: (1) no infiltrate (control group), (2) 1% lidocaine hydrochloric acid (HCl), (3) 2% lidocaine HCl, (4) 1% lidocaine HCl and epinephrine 1:100,000, and (5) 0.5% lidocaine HCl and epinephrine 1:200,000. Flaps were replaced in their beds. Animals were sacrificed 24 hours postoperatively. Flaps were raised at 26 hours and the coagulum weighed. No statistically significant difference was found between the weights of the coagulum of the infiltrated flaps versus the noninfiltrated flaps. Statistical power calculations on the main study flap yielded values greater than 80%. This suggests that the difference in delayed bleeding between noninfiltrated flaps and flaps infiltrated with various combinations of lidocaine and epinephrine was insignificant.
Anesthesia, Local↗
A technique for correcting witch's chin deformity.
A new technique for soft-tissue correction of the retraced submental fold in the Witch's Chin deformity is described. An illustrative case report demonstrating our technique, results, and the pathogenesis of this condition is presented. An anatomical analysis of the underlying etiology of the condition and tailored treatment strategies are outlined.
Chin↗
Entrapment of the palmar cutaneous branch of the median nerve by a normal palmaris longus tendon.
An anomalous course of the palmar cutaneous branch of the median nerve was noted in a patient with symptoms of compression of the median nerve and its palmar cutaneous branch at the wrist level. The palmar cutaneous branch of the nerve pierced the tendon of a normal palmaris longus muscle near its insertion. Decompression of the median nerve and its palmar cutaneous branch was performed, with complete relief of symptoms.
Adult↗
Axillary breast tissue: clinical presentation and surgical treatment.
Aberrant breast tissue is usually present along the milk line above or below the normal breast location. Occasionally, it is found in unusual locations, such as the axilla, scapula, thigh, and labia majora. Accessory axillary breast tissue is present in approximately 2% to 6% of women. Although this finding has been reported in a variety of clinical journals, such as Radiology and Human Pathology, it has received little attention in the plastic surgery literature. Axillary breast tissue, presenting as palpable thickenings in the axilla, can undergo monthly premenstrual changes, such as tenderness and swelling, difficulty with shoulder range of motion, and irritation from clothing. These symptoms may be exacerbated and become more apparent during puberty and pregnancy. In addition, it is cosmetically unsightful, and consequently, patients often desire surgery for improvement. We present a study of 28 patients who underwent surgical removal of their axillary breast tissue. From these successful reports, we recommend that axillary breast tissue should be surgically removed.
Adult↗
Latex allergy: an intraoperative hazard.
First described in 1979, immediate hypersensitivity to latex has been occurring with increasing frequency. Though it has not been reported in the plastic surgery literature, hypersensitivity to rubber can present in the operating room with symptoms that range from mild urticaria to frank anaphylactic shock. Frequent contact with latex products appears to predispose certain groups to hypersensitivity. Diagnostic testing is not yet standardized and, when latex allergy is suspected, referral to an allergist is appropriate. Hypersensitive patients may be operated on safely with premedication and avoidance of latex products.
Adult↗
Forearm compartment syndrome following brachial arterial puncture in uremia.
Although compartment syndromes of the forearm are infrequently encountered, they are well described in the literature. Forearm compartment syndrome uncommonly occurs after percutaneous arterial blood sampling and is usually associated with anticoagulant therapy. Our review of the English literature revealed no other cases of forearm compartment syndrome after arterial blood sampling in patients with bleeding diathesis due to chronic renal failure. This article discusses a 30-year-old woman with Good-pasture's syndrome who developed a compartment syndrome after a brachial artery blood gas. The cause, diagnosis, and treatment of compartment syndrome and uremic bleeding, as well as a review of the literature, are discussed.
Adult↗
Correction of asymmetric nostrils (alae) by columella transposition.
A new method for correction of asymmetric alae is presented. Asymmetric alae frequently follow nasal, columellar, and alar reconstruction, and the resulting distortion can pose a reconstructive dilemma. Correction of these deformities can require complex composite grafting or tissue rearrangement procedures. By transposing the columella, we have equalized asymmetric nostrils without introducing new tissue to the region. Although not appropriate to all types of alar discrepancy, this novel method, where applicable, is safe, reliable, and does not produce significant visible scarring or donor site morbidity.
Aged↗
Umbilicus preservation with total abdominal wall reconstruction in prune-belly syndrome.
A technique to preserve the umbilicus in abdominal wall reconstruction for prune-belly syndrome is presented. Our technique has been utilized in 5 cases with success.
Abdominal Muscles↗
A new nerve pedicle for finger sensibility: the dorsal digital sensory nerve.
Restoration of sensibility to the traumatized finger can be a difficult problem. Two patients with insensibility to the volar distal finger after trauma underwent delayed digital nerve repair. In the first patient, the dorsal branch of the radial proper digital nerve was approximated to the distal stump as a pedicle to span a 12-mm gap resulting from neuroma excision. The second patient had a 14-mm defect after scar-tissue excision 8 months following primary neurorrhaphy after trauma. Reconstruction was performed by approximating the dorsal branch of the radial proper digital nerve to the distal stump. Both patients had fingertip sensibility restored 1 year postoperatively, as documented by two-point discrimination. Anatomic dissections of 12 fresh cadaver fingers revealed a consistent pattern. Of the 24 proper digital nerves dissected, 23 had a distal dorsal sensory branch arising at the midportion of the proximal phalanx. The dorsal branch-vascularized pedicle of the proper digital nerve has not been described previously as a method for restoring finger sensibility in cases not amenable to primary neurorrhaphy. We believe this technique should be added to the repertoire of the practicing hand surgeon.
Adult↗
Management of large scalp defects with local pedicle flaps.
Recent reports have emphasized free-flap reconstruction for large defects of the scalp and calvarium following resection of tumors, infection, or trauma. In most cases, however, a carefully planned local transposition or rotation flap may be equally effective, and the technical difficulties and donor-site problems associated with microsurgical tissue transfer are then avoided. We present 10 patients whose full-thickness scalp defects covered an average area of 241 cm2, or 27 percent, of the skull surface. Although this series included defects as large as 450 cm2, or 50 percent, of the skull surface area, each was easily managed with a local pedicle flap transfer. Four patients were reconstructed with parietal scalp transfer, four with an occipital scalp flap, and two with temporal scalp transfer. The technique and results are discussed.
Adolescent↗
Swimming upstream.
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Education, Medical, Continuing↗
Ligamentous anatomy of the medial carpal region.
The purpose of this study is to elucidate the ligamentous anatomy of the medial carpus in order to characterize the pathologic basis of pisiform subluxation secondary to traumatic ligament rupture. Medial carpal ligamentous anatomy has been studied in the past by anatomic dissection and analyzed in terms of comparative morphology. A review of this literature reveals that the anatomy of the region requires further definition. We have performed cadaveric dissections that reveal that the ulnar or medial carpal ligament complex is composed of three structures: (1) the triangular fibrocartilage, (2) the meniscus homologue, and (3) the ulnar collateral ligament. We conclude that the medial carpal ligament complex has an insertion into the pisiform bone.
Aged↗
Fibrin glue inhibits intra-abdominal adhesion formation.
To determine the effect of fibrin glue on intra-abdominal adhesion formation, 45 rats were randomized to three groups. Each animal received two adhesion models. Group 1 received no further treatment. Groups 2 and 3 had the adhesion models covered with fibrinogen from fresh frozen plasma (1.77 g/L) and cryoprecipitate (23.6 g/L), respectively. In group 1, 13 of 15 rats had high-grade adhesions in both models. In group 2, high-grade adhesions were noted in nine of 15 rats in model 1 and in 12 of 15 rats in model 2. In group 3, however, high-grade adhesions were seen in only three of 15 rats in model 1, with 11 rats having no adhesions, and in only two of 15 rats in model 2. Histologic analysis suggested accelerated healing in group 3. We conclude that (1) fibrin glue inhibits intra-abdominal adhesion formation in rats, (2) the inhibitory action is dependent on the fibrinogen concentration of the fibrin glue, and (3) adhesions are reduced by fibrin glue regardless of whether the peritoneal defect is closed.
Abdominal Muscles↗
Traumatic rupture of the profundus tendon proximal to the lumbrical origin.
Traumatic flexor tendon ruptures are rare in patients without rheumatoid arthritis. A case of closed flexor digitorum profundus tenon rupture in the palm, proximal to the lumbrical origin, is presented. Thorough patient evaluation revealed no associated tendinous or bony pathology.
Hand Injuries↗
Upper eyelid ptosis correction by a revised tarsal resection technique.
Many techniques have been developed for the correction of eyelid ptosis. A new tarsal plate resection technique is described for use in cases of minimal ptosis with fair to good levator function. The procedure involves a horizontal lenticular excision of the tarsal plate, placed so that equal amounts of tarsus remain above and below the excision. The height of the excision is equal to the amount of ptosis correction desired, as determined in the preoperative examination. This precision in surgical correction is the chief advantage of the procedure. The technique also spares Müller's muscle, thus retaining the lid-elevating action of that muscle. Good results have been achieved in 6 patients, some showing excellent results after nine years.
Adolescent↗
Exposed endoprosthesis. Management protocol using muscle and myocutaneous flap coverage.
A tenet in the orthopedic community is that dehiscent wounds overlying exposed prostheses should be treated by implant removal and delayed reconstruction. A management protocol using thorough debridement and irrigation and muscle flap coverage was accomplished in four patients with exposed endoprostheses after total arthroplasty or limb salvage surgery. Predisposing factors for late wound dehiscence in the four oncology patients were preoperative radiation and chemotherapy as well as multiple subsequent reoperations. In this study, all four prostheses and extremities were retained without the need for prosthetic removal or exchange. No infections developed. Late aseptic wound dehiscence with exposed conventional or tumor endoprosthesis need not be managed with prosthetic removal, arthrodesis, or amputation. This one-stage procedure avoided infection, allowed early mobilization, shortened hospitalization and, most important, avoided amputations.
Adult↗