Biomedical subjects
Publications and source records attributed to M S Granick.
Plastic surgery has an ever-increasing role in the management of medical problems in the elderly. These procedures can be performed with minimal risk to the patient in order to maximize the quality of life for these patients and their families.
Osteomyelitis of the clavicle is an uncommon disease, but it should be considered in patients who present with pain, cellulitis, or drainage in the sternoclavicular area following head and neck surgery, irradiation, subclavian vein catheterization, or immunosuppression. An idiopathic presentation is possible. In contrast to primary osteomyelitis of the clavicle, which is occasionally seen in children, secondary osteomyelitis is quite rare. It is often mistaken for a fracture or a possible neoplasm on plain x-rays. Tomograms and CT scanning are confirmatory, and in early cases, technetium-99m bone scanning can be helpful. Treatment must include early, aggressive surgical debridement of all affected tissues, followed by wound coverage with a well-vascularized flap and perioperative antibiotics.
Necrotizing sialometaplasia is a benign disorder that histologically can mimic carcinoma. It is thought to develop as a result of ischemia or adjacent tissue injury. A patient is described who underwent a Mohs' micrographical fresh-tissue excision of one-third of the upper lip for basal cell carcinoma. By the time she was ready for reconstruction, a marked eczematous reaction developed to a polymyxin neomycin preparation (Neosporin ointment) at the wound edges. Reexcision of the wound margins before a flap reconstruction revealed necrotizing sialometaplasia on histopathological examination. This incidental finding fortunately was not mistaken for residual tumor. To prevent over-diagnosis and over-treatment of presumed malignancies, an awareness of necrotizing sialometaplasia is essential for all surgeons operating on mucosal surfaces in the head and neck.
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Detection of recurrent breast carcinoma following reconstruction of mastectomy defects is of concern to plastic surgeons and oncologists. During the past four years we have found recurrent, previously undetected breast cancer in 4 patients at the time of reconstruction. The recurrent disease presented differently in each patient: as fascial thickening, as a small node hidden under a pectoralis muscle stump, as a microscopical tumor contained within the mastectomy scar, and as a small mass which developed during the interim between the last office visit and the scheduled surgery. All of the patients received additional treatment and one has been reconstructed. Our study of these patients prompts the following recommendations: carefully reexamine the patient just prior to reconstruction; biopsy any abnormal tissue; submit all excised mastectomy scars for histological examination; create and examine the recipient pocket before raising a flap; and reconsider the patient for reconstruction following additional cancer therapy.
This report describes a severe case of perifolliculitis capitis with the rare complication of skull osteomyelitis, a combination not previously reported. The patient demonstrated the typical features of perifolliculitis capitis, namely, rubbery, hard, elevated nodules involving almost the entire scalp with multiple deep-seated abscesses. Bone was exposed in two areas and the diagnosis of skull osteomyelitis was confirmed by skull x-ray films and bone biopsy specimens, which grew Staphylococcus aureus. The patient was treated with enteral hyperalimentation, intravenous antibiotics, and multiple debridements of the scalp, including the involved periosteum and outer cortex of the exposed bone, followed by reconstruction with split-thickness skin grafts. A complete eradication of the disease with closure of all open wounds and clearance of osteomyelitis of the skull was achieved.
This study was designed to assess the effects of environmental factors on experimental muscle flap temperature and to critically evaluate temperature as a modality for assessing vascular patency. A brief overview of the physiology of tissue heat transfer is presented. The right vertebral head of the biceps femoris muscle was used in albino New Zealand rabbits for monitoring temperature. Temperature was recorded simultaneously by means of thermocouples placed into the tested muscle, the contralateral control biceps femoris muscle, the ipsilateral control thigh compartment, and rectally (core temperature). The muscle flap temperature was recorded as a function of time during the following flap manipulations: steady state, exposed muscle, muscle elevated and then replaced with pedicles intact, and pedicles ligated. In addition, the effects of environmental manipulations on muscle flap temperature were evaluated. The constant findings demonstrated that the dominant aspects of muscle temperature are the temperature of the surrounding tissue, as well as the prevailing environmental conditions. Vascular occlusion did not alter muscle temperature. In 3 patients who underwent successful free-flap transfer, muscle temperatures were monitored and found to be labile, and altered by environmental manipulations. We concluded that temperature is an unreliable, nonreproducible method of assessing the vascular status of a muscle flap, unless all environmental variables are meticulously monitored and controlled.
A neurovascular flap of interdigital web space skin based on the plantar circulation is described. The flap is useful for reconstructing distal plantar defects that do not have an adequate surface for skin grafting. It leaves a donor defect in a non-weight-bearing area and does not disrupt the structural integrity of the foot. The surgical anatomy and operative approach are detailed. The key to the approach is to preserve the fat pad around the neurovascular bundle during the dissection. Six patients have successfully undergone this procedure and have been followed for at least 2 years postoperatively. The plantar island flap is a reliable flap for repairing plantar defects overlying the metatarsal heads.
Surgical skin-marking inks and dyes are in everyday use for designing and planning incisions in plastic and reconstructive surgery. We have traced the historical development of surgical skin-marking techniques from ancient times to the present. The biochemical characteristics of the commonly used marking agents are discussed. A three-part experiment utilizing a pig model was carried out to test the tissue inflammatory response to the various dyes and inks when used intradermally as tattoos, the persistence of such tattoos, and the ease of skin erasure for each of eight stains. Methylene blue and gentian violet are recommended as the best all-purpose marking agents. The use of proprietary inks is discouraged.
A new method for the reconstruction of large thoracolumbar and lumbosacral meningomyelocele defects is described in which latissimus dorsi and gluteus maximus myocutaneous units are advanced medially and reapproximated in the midline, permitting primary closure of the defect in three layers. The flaps are based on the thoracodorsal and superior gluteal vessels and the intervening thoracolumbar fascia, providing tension-free, durable, and viable soft-tissue coverage over the dural repair. No lateral relaxing incisions, delays, or skin grafts are necessary. This technique has been used successfully in the repair of nine large meningomyelocele defects, and uncomplicated wound closure was achieved in all cases. The anatomic basis, technique, advantages, and functional implications of our approach are described. The flaps described do not alter the nerve supply of the muscles and merely redefine the muscle origins; therefore, no functional deficit from the reconstructive surgery is anticipated.
A patient with severe amniotic band syndrome and true proximal syndactyly of the hand and foot is presented. The occurrence of these two seemingly unrelated anomalies may be pathologically linked with amniotic band syndrome in some as yet unexplained way or less likely may occur with amniotic band syndrome coincidentally.
Mycoplasma hominis caused sternal wound infections with mediastinitis in three patients. One infection occurred in a nonimmunocompromised man after coronary artery bypass grafting. The wound did not heal after repeated debridement, closed irrigation of the mediastinum with povidone-iodine solution, and antimycoplasmal chemotherapy; muscle flap grafting was eventually required. Two infections occurred in recipients of heart-lung transplants after the isolation of mycoplasma from bronchial secretions. Although no Mycoplasma species were isolated after specific antimycoplasmal therapy was begun, the wounds still did not heal. Both patients died of other complications. Infection of wounds after sternotomy is another of an increasing number of infections caused by M. hominis in the normal and immunocompromised host. Familiarity with the morphologic characteristics of M. hominis on bacteriologic culture media may increase the recognition of this pathogen in atypical clinical settings.
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The treatment of scalp wounds is occasionally complicated by infection. Although infected scalp wounds are generally limited and readily treated, they can progress to devastating proportions if not promptly and aggressively managed. This report highlights three such cases of severe infection: extensive subgaleal abscess, fatal necrotizing fasciitis, and widespread carbunculosis. The authors emphasize the need for proper assessment of scalp wounds, meticulous cleansing and closure of all fresh wounds, definitive drainage of newly infected wounds, and adherence to sound surgical principles in managing these wounds.
Perineal decubitus ulcer with urethro-cutaneous fistula has previously been reported in paraplegics as a late complication following bilateral ischiectomy. This case report illustrates the occurrence of the problem in a male paraplegic without bilateral ischiectomy, and this has not been previously reported in the English literature. Successful reconstruction was accomplished with a full thickness skin graft tube and and gracilis muscle flap.
In recent years microvascular free tissue transfer has become a well accepted reconstructive technique. The current trend in flap research seems to be the development of more refined flaps to meet specific needs with minimal donor site morbidity. The internal oblique muscle provides a broad, thin, well-vascularized flap which is ideally suited for restoration of contour with excellent aesthetic results. In addition, the iliac crest may be raised in continuity based on the same vascular pedicle, i.e. the deep circumflex iliac vessels. The purpose of this article is to describe the anatomic details necessary for the clinical application of this versatile flap. Thirty specimens of the internal oblique muscle flap were dissected and studied using Microfil injection techniques, including xerograms. In about 80 percent of the flaps, a single ascending branch of the deep circumflex iliac artery (DCIA) enters the undersurface of the muscle, arborizing within the muscle. In the remaining 20 percent, two or three branches enter the muscle separately, originating on the DCIA. The arc of rotation extends into the ipsilateral groin for coverage of exposed femoral vessels, along the pubis and the anterior perineum. The length of the vascular pedicle is to 6 to 7 cm and the vessel diameter is 2.0 to 3.0 mm, making the flap suitable for free tissue transfer.
Hidradenitis suppurativa of the perineum and buttocks is a devastating disease often causing patients years of pain, discomfort, and eventual social isolation. The chronic form of the disease results from a lack of aggressive surgical intervention when the patient is first seen. It is characterized by a malodorous drainage from multiple sinus tracts encased in marked scarred and fibrotic tissue. In contrast to axillary involvement, the perianal form of hidradenitis suppurativa is associated with an increased frequency of anemia, fistulous communications with bowel and urinary tract, and the development of carcinomas. Several cases illustrating the debilitating nature of the disease and its optimal management are presented. This report illustrates that (1) a well-planned preoperative and postoperative bowel regimen can eliminate the need for a diverting colostomy, even in the most extensive forms of perianal disease, (2) radical excision is expedited and blood loss is minimized by the use of a Shaw hot knife (Oximetrix, Mountain View, CA), (3) the quilted application of meshed split-thickness skin grafts as a primary procedure provides rapid closure of the surgical defect and minimizes patient discomfort, and (4) aggressive surgical intervention in severe cases provides a chance for a rapid recovery from this crippling disease.