Biomedical subjects

P A Clugston

Publications and source records attributed to P A Clugston.

11 recordsLinked to original sources

PubMed2000

Ipsilateral pedicled TRAM flaps: the safer alternative?

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has become a commonly performed procedure in the 1990s. The original description of the procedure was that of an ipsilaterally based pedicle procedure. Concerns about potential folding of the pedicle with possible compromise of the vascular supply led many surgeons to prefer the contralateral pedicle. Subsequently, there have been several large clinical series of pedicled TRAM flaps showing a relatively high complication rate related to flap vascularity problems. Partial flap necrosis rates in pedicled TRAM series range from 5 to 44 percent. These findings resulted in many centers favoring free TRAM flap breast reconstruction, despite an increase in resource use and negligible differences in complication rates. Ipsilateral pedicle TRAM flap breast reconstruction is not a commonly reported procedure and is reserved for cases for which scars preclude use of the contralateral pedicle. Simplicity and versatility of flap shaping, improved maintenance of the inframammary fold, and lack of disruption of the natural xiphoid hollow give ipsilateral TRAM flaps further advantages. This study reports on a series of 252 consecutive ipsilateral TRAM flap reconstructions in 190 patients. The majority of patients underwent muscle-sparing procedures with preservation of a medial and a lateral strip of rectus muscle. Immediate reconstruction was done in 104 of the 190 patients. Skin-sparing (69 patients) or skin-reduction procedures (21 patients) were used in 90 of the 104 patients (87 percent) undergoing immediate reconstruction. Complication rates were comparable to those of series reported for contralateral TRAM flaps, except that partial flap necrosis (2.0 percent) was less in this series. Risk factors were analyzed with regard to the most common complications seen in this study. Ipsilateral TRAM flap breast reconstruction is our preferred method, if available, because we believe that it has several advantages over the contralateral pedicled TRAM and this report suggests a lower partial flap necrosis rate than previously reported.

Adult↗

PubMed1999

Breast reconstruction in ectodermal dysplasia.

Patients with ectodermal dysplasia may request breast reconstruction. In addition to abnormalities of other ectodermally derived structures, the breast and nipple-areolar complex may be absent or hypoplastic. Although this group of patients may have concerns with hair, nails, teeth, or even upper limb malformations, this report focuses on reconstruction of the breast anomalies. Four unrelated patients with ectodermal dysplasia who have undergone breast reconstruction are discussed.

Adult↗

PubMed1998

Intraoperative vascular monitoring of ipsilateral vs. contralateral TRAM flaps.

Transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has become an increasingly common procedure in the 1990s. The original description of the procedure was that of an ipsilaterally based pedicled procedure. However, because of concerns about potential folding of the pedicle with possible compromise of the vascular supply, with full muscle harvest the contralateral flap soon became the flap of choice. Subsequently there have been several large clinical series of pedicled TRAM flaps reported showing a relatively high complication rate related to problems with flap vascularity. These findings resulted in many centers favoring free TRAM flap breast reconstruction, despite an increased resource utilization and negligible differences in complication rates. Ipsilateral pedicled TRAM flap breast reconstruction is not a commonly reported procedure, and is reserved for patients in whom scars preclude use of the contralateral pedicle. The ease of flap shaping and lack of tension on the pedicle is recognized by some, and the ipsilateral procedure has become the flap of choice for these surgeons. The authors hypothesized that ipsilateral TRAM flaps have less compromise of venous outflow as a result of the rotational tension effect of transposing the flap to the mastectomy site. To determine if the vascularity of the pedicled TRAM procedure is influenced by pedicle choice, an intraoperative clinical study was designed to compare intravascular pressures in the deep inferior epigastric artery and vein pedicle at various times from pedicle division to flap insetting. Ten consecutive ipsilateral TRAM flaps were compared with eight contralateral flaps. The deep inferior epigastric pedicle was cannulated with both an arterial and venous catheter, and pressures were monitored from the time of division of the inferior pedicle through to the time of flap insetting. The venous pressures of the contralateral flaps were significantly higher at flap rotation and flap insetting compared with the ipsilateral group (p = 0.014 and p = 0.022 respectively). Perfusion pressures showed a greater decrease in the contralateral group from the time of pedicle division to the point of flap rotation and flap insetting compared with the ipsilateral group (p = 0.081 and p = 0.055). The authors conclude that pedicle tension in contralateral TRAM flaps is more common and results in greater venous resistance and decreased perfusion pressures. Versatility in flap shaping, improved maintenance of the IMF, and lack of disruption of the natural xyphoid hollow gives ipsilateral TRAM flaps additional advantages.

Abdominal Muscles↗

PubMed1995

Revascularization of a seven-week-old infant lower extremity: case report.

A seven-week-old infant suffered a closed segmental fracture of the left tibia and fibula complicated by vascular disruption and a secondary compartment syndrome. Initial orthopedic assessment revealed a clinically mottled, cool, pulseless extremity 4 hr post-injury. Radiologic investigations showed multiple displaced fractures of both the tibia and fibula. The infant underwent four compartment fasciotomies and intramedullary nailing of the tibial fractures. The vascularity of the limb failed to improve significantly. Angiograms done 22 hr post-injury revealed disruption of arterial inflow just distal to the bifurcation of the tibial peroneal trunk and posterior tibial artery. Urgent revascularization utilizing a contralateral greater saphenous vein graft was undertaken with a successful outcome. Despite delay in transport from the community hospital and lack of definitive management of the vascular injury, the infant has had a good-to-excellent functional outcome.

Compartment Syndromes↗

PubMed1995

Evaluation of silicone-gel sheeting on early wound healing of linear incisions.

Topical silicone-gel sheeting has been shown to be beneficial in the treatment of established hypertrophic and keloid scars. Certain individuals and incisions in specific body sites appear to be at increased risk for the development of such scars. A simple, inexpensive, and preventive treatment in these individuals at increased risk could potentially minimize the extended period of pressure therapy and repeated steroid injections that are often required to optimize outcome. However, the effects of applying silicone-gel sheeting in the immediate postoperative period as a preventive measure have not been investigated to date. Because silicone-gel sheeting influences the remodeling and maturation phase of collagen formation, we believed it prudent to determine whether silicone-gel sheeting had any deleterious effect on early wound healing, as demonstrated by in vivo biomechanical testing of wound strength and histological assessment. To investigate the potential effects of silicone-gel sheeting on acute wound healing and its possible application for prevention of hypertrophic scars, a study was designed in the hairless guinea pig. In phase 1 of the study, bilateral dorsolateral incisions were made, allowing each guinea pig to serve as its own control. One wound was dressed with silicone-gel sheeting, and the control site was dressed with Nu-gauze dressing. Wounds were then assessed visually and with in vivo biomechanical analysis of wound strength at days 3, 5, and 7 postoperatively (n = 7 per group). Phase 2 of the study compared identical dressings in a similar animal model using a single dorsal midline incision, in which alternate halves of each wound served as the control.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1995

Autologous blood use in reduction mammaplasty: is it justified?

A study was undertaken to evaluate the current use of autologous blood predonation within 3 weeks of reduction mammaplasty in our institution. A retrospective study of 153 consecutive patients undergoing reduction mammaplasty between April of 1987 and October of 1992 was analyzed. Nine patients were excluded because of inadequate data, leaving 81 patients in the autologous blood predonation study group and 63 patients in the control group. The two groups were similar with regard to age, preintervention hemoglobin levels, technique of reduction mammaplasty, average number of grams excised per side, estimated blood loss, and duration of hospital stay. Those in the study group, despite preoperative iron therapy initiated just prior to the time of autologous blood donation, had significantly lower preoperative hemoglobin levels (p < 0.001). Seventy-two percent of those patients who donated blood preoperatively received all their blood intraoperatively or within 1 day of surgery. Eleven percent received 1 of their 2 units donated, and the remaining 17 percent were not transfused. Despite 83 percent of the study group patients receiving all or some of their predonated blood, their postoperative hemoglobin levels were not significantly different from those of the control group. We concluded that under our current program, autologous blood predonation for reduction mammaplasty is not beneficial to the patient in the immediate perioperative period.

Adult↗

PubMed1995

A rat transverse rectus abdominis musculocutaneous flap model: effects of pharmacological manipulation.

A study was designed to attempt to develop an experimental animal model for the transverse rectus abdominis musculocutaneous (TRAM) flap. The rat has a well-formed superior epigastric artery with musculocutaneous perforators that have been shown to support a musculocutaneous flap on a single superior pedicle. Despite the anatomical differences between the dominance of the axial longitudinal cutaneous circulation in loose-skinned animals compared with humans, as well as a dominant superior intramuscular pedicle, the rat TRAM model appears to be reproducible and has predictable zones of viability as well as areas that typically do not survive when based on a single superior pedicle. These areas of nonviability correspond to those zones at high risk of nonviability in the human clinical situation: zone 3 and 4 on the contralateral side and zone 3 on the ipsilateral side (tissue lateral to the superficial inferior epigastric supply). Once the reliability and reproducibility of this model was demonstrated (coefficient of variation 18.9%), a study was undertaken to determine whether pharmacological manipulation of this flap altered survival in those areas that are inadequately perfused. The two agents tested were allopurinol (xanthine oxidase inhibitor, antioxidant) and pentoxifylline (microcirculatory rheological agents that is a xanthine analogue and is also believed to have antioxidant potential). The study involved creating right unipedicled TRAM flaps in 30 male specific pathogen-free Sprague-Dawley rats weighing 375 to 450 gm. The transverse skin paddle was centered over the umbilical dimple and measured 5.5 x 2 cm.(ABSTRACT TRUNCATED AT 250 WORDS)

Allopurinol↗

PubMed1994

A rat model for capsular contracture: the effects of surface texturing.

There has been ongoing clinical and laboratory research to determine the role of surface morphology on capsular contracture. The purpose of this study was to develop a rat model in which capsular contracture occurred frequently and to determine whether surface texturing had any effect on the incidence or degree of capsular contracture as determined by in vivo biomechanical analysis of tissue modulus and histological examination of the tissue at the capsule-implant interface. A new sublatissimus implantation site in the rat was developed in an attempt to avoid subpannicular placement, which has been associated with inconsistent results because of contracture despite texturing, and a high rate of implant exposure secondary to trauma. Each rat (N = 43) was implanted with two devices--one smooth-surface 6-ml implant and one textured Biocell 6-ml implant--both with remote ports to allow for biomechanical analysis. Evaluation was carried out at 1, 2, and 3 months (n = 10) and 6 months (n = 5). Biomechanical evaluation of the implants was carried out in vivo and anonymously. The animals were then killed, and sectioning of the overlying capsule-implant interface from the dome of the implant was performed. Histological evaluation was carried out anonymously with regards to the implant type. Capsular contracture developed in smooth-surface devices in 95% of sites; this became evident on biomechanical analysis at 2 months and progressed to 3 months, after which it remained relatively stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1991

Detecting breast cancer after reduction mammoplasty.

Reductive breast surgery may give rise to parenchymal scarring that makes subsequent clinical and radiologic assessment of tumours difficult. The features that help distinguish benign from malignant lesions are discussed. Biopsy is still necessary. A screening protocol that includes preoperative mammography in patients at increased risk is proposed.

Breast↗

PubMed1991

Pyoderma gangrenosum after reduction mammoplasty.

The authors report a case of pyoderma gangrenosum in a 37-year-old woman that occurred at surgical sites after reduction mammoplasty. The diagnosis was delayed, but treatment with intralesional triamcinolone resulted in complete resolution o the condition. Pyoderma gangrenosum in this setting can mimic infectious causes of wound necrosis. Early recognition of its characteristics features may prevent unnecessary and ineffective treatment, thereby avoiding frustration for both patient and physician.

Adult↗

PubMedDate not supplied

Cultured epithelial autografts: three years of clinical experience with eighteen patients.

Eighteen patients with major burns (mean total body surface area burned was 49% and mean total body surface area with full-thickness burns was 38%) had cultured epithelial autografts applied to 2% to 35% of the body surface area. In six patients successful "take" of greater than 65% occurred, and in 12 patients less than 40% "take" occurred. Most wounds underwent early excision to subcutaneous fat or fascia, and the wounds of 16 patients had been treated previously with homograft. Cultured epithelial autografts were covered with either single or multilayered dressings. Perioperative wound cultures showed that all patients had microorganisms, and appropriate perioperative antibiotic coverage of Staphylococcus epidermidis and Pseudomonas aeruginosa was noted less frequently in the poor take group, which may have influenced subsequent cultured epithelial allograft take. Adherence and stability of cultured epithelial allografts lag behind adherence and stability of meshed split-thickness autograft. The anterior trunk and thighs are the best recipient sites. The number of autograft harvests that were required to close wounds and the length of hospital stay were not significantly decreased by the use of cultured epithelial allografts as compared with comparable full-thickness burns that were treated previously without cultured epithelial allografts. Presently, grafting with cultured epithelial allografts is an adjunct but not an alternative to conventional burn-wound coverage with split-thickness autograft, because engraftment is inconsistent.

Adolescent↗