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Biomedical subjects

Ronald P Silverman

Publications and source records attributed to Ronald P Silverman.

At least 19 recordsLinked to original sources
PubMed2007

Laparoscopically assisted components separation technique for ventral incisional hernia repair.

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.

Abdominal Wall↗
PubMed2006

Efficacy of a percutaneous A1 pulley release technique with identification of anatomic differences between genders.

BACKGROUND: This cadaver study investigates the efficacy and safety of the Biomet knife and technique for percutaneous A1 pulley release. We also evaluate the anatomic relationship between specific palmar surface landmarks and relevant underlying structures and identify differences between genders. METHODS: Eighty percutaneous A1 pulley releases, excluding the thumb, were performed on 20 fresh human cadaver hands (10 male, 10 female). RESULTS: Complete release was obtained in 60 of 80 fingers. Success rates for each surgeon improved markedly as the study progressed. There were no significant differences between males and females regarding the distance between a standardized incision site and the proximal edge of the A1 pulley. CONCLUSIONS: A learning curve exists for percutaneous A1 pulley release using the Biomet knife and technique. The extended distal palmar crease is a reasonable incision site for percutaneous release of the index, middle, and ring A1 pulleys in both men and women as the A1 pulley begins just distal to this surface landmark.

Female↗
PubMed2006

The effect of fondaparinux versus enoxaparin in the survival of a congested skin flap in a rabbit model.

BACKGROUND: The purpose of this study was to evaluate the effects of fondaparinux, a selective antithrombin III agonist, in comparison to the low-molecular-weight heparin enoxaparin in the survival of a congested skin flap. MATERIALS AND METHODS: Eighteen axial-pattern auricular flaps were performed on rabbits using a well-described congested flap model. Animals were randomized into 2 treatment groups, enoxaparin (n = 6) and fondaparinux (n = 6), and a control group (n = 6) that received no treatment. Skin flap survival area was measured postoperatively at 7 and 14 days. RESULTS: The groups that received fondaparinux and enoxaparin had similar mean flap survival areas and were not statistically different. However, both treatment groups significantly increased flap survival compared with controls (P < 0.014). CONCLUSIONS: Fondaparinux, like enoxaparin, significantly improves survival of congested flaps in rabbits. Its use instead of enoxaparin may be warranted, given that it eliminates the risk of heparin-induced thrombocytopenia. Further study in humans is warranted.

Animals↗
PubMed2006

Successful salvage of ventricular-assist devices in the setting of pump pocket infection.

Implantable ventricular-assist devices (VADs) have been approved for use both as a bridge to heart transplantation and as a destination therapy. Rising numbers of patients are surviving with these devices for several years. However, infections of these foreign bodies are serious and frequent complications, often requiring removal of the implant, with serious health consequences. Given the increased use of VADs as life-preserving destination therapy, explantation of these devices in the face of infection is impractical. We evaluated and successfully treated 2 patients with VAD pocket infections referred by the cardiac surgery service at our institution using aggressive surgical and pharmacologic therapy, with the goal of preserving the VADs. However, this is still a largely unsolved dilemma requiring further exploration into prevention and treatment since these devastating infections will likely become a more frequent reconstructive challenge.

Aged↗
PubMed2005

Incisional hernia repair in renal transplantation patients.

INTRODUCTION: Abdominal wall dehiscence in renal transplantation patients risks the survival of the transplanted organ. No clear treatment algorithm exists in the literature for this group of patients. METHODS: Between 1992 and 2001, the Division of Plastic Surgery at the University of Maryland treated 41 of 2499 renal transplant patients. Based on a retrospective review of these patients, an algorithm was developed to guide the management of midline and lower quadrant abdominal wall defects. RESULTS: Most lower quadrant defects were repaired with tensor fascia lata grafts. Most midline defects were repaired with the component separation technique. Use of a single- or multi-staged repair was based on the extent of infection. Hernia recurrence was 22% over 21 months. 80% of the transplant kidneys were functioning following repair. CONCLUSION: An algorithm for the repair of abdominal wall defects after kidney transplantation is presented taking into account the location and the extent of infection.

Abdominal Wall↗
PubMed2005

Internal mammary perforators: a cadaver study.

Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.

Aged↗
PubMed2005

Improving long-term projection in nipple reconstruction using human acellular dermal matrix: an animal model.

Reconstructed nipples rapidly lose projection. We describe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction.

Animals↗
PubMed2005

Pedicled internal oblique rotational muscle flap for reconstruction of lateral pelvic defects: report of 4 cases.

Various local and distant flaps have been used to repair pelvic defects, including sartorius, rectus abdominis, rectus femoris, tensor fascia lata, vastus lateralis, gracilis, and omentum, each with benefits and disadvantages. The pedicled internal oblique rotational muscle flap has been described to cover pelvic wounds but may be underutilized. We present our experience with 5 pedicled internal oblique flaps in 4 patients (3 male, 1 female). The mean patient age was 32 years (23-47 years), and the mean follow-up was 8 months. All patients required coverage of the lateral pelvis after failure of conservative measures. There were no major complications. One patient experienced decreased sensation in the lateral femoral cutaneous nerve distribution, which resolved fully within 3 months. The internal oblique muscle provides local soft-tissue coverage with a predictable blood supply, and its proximity to the pelvis offers an alternative for reconstruction of lateral pelvic defects, with minimal associated morbidity.

Adult↗
PubMed2005

Human acellular dermal matrix for repair of abdominal wall defects: review of clinical experience and experimental data.

The use of prosthetic mesh for the tension-free repair of incisional hernias has been shown to be more effective than primary suture repair. Unfortunately, prosthetic materials can be a suboptimal choice in a variety of clinical scenarios. In general, prosthetic materials should not be implanted into sites with known contamination or infection because they lack an endogenous vascular network and are thus incapable of clearing bacteria. This is of particular relevance to the repair of recurrent hernias, which are often refractory to repair because of indolent bacterial colonization that weakens the site and retards appropriate healing. Although fascia lata grafts and muscle flaps can be employed for tension-free hernia repairs, they carry the potential for significant donor site morbidity. Recently, a growing number of clinicians have used human acellular dermal matrix as a graft material for the tension-free repair of ventral hernias. This material has been shown to become revascularized in both animal and human subjects. Once repopulated with a vascular network, this graft material is theoretically capable of clearing bacteria, a property not found in prosthetic graft materials. Unlike autologous materials such as fascial grafts and muscle flaps, acellular dermal matrix can be used without subjecting the patient to additional morbidity in the form of donor site complications. This article presents a thorough review of the current literature, describing the properties of human acellular dermal matrix and discussing both animal and human studies of its clinical performance. In addition to the review of previously published clinical experiences, we discuss our own preliminary results with the use of acellular dermal matrix for ventral hernia repair in 46 patients.

Bioprosthesis↗
PubMed2004

Surgical management of hidradenitis suppurativa of the nipple-areolar complex.

Involvement of the nipple-areolar complex is an infrequent area of distribution of hidradenitis suppurativa. The difficulty of this particular distribution has been encountered in the past and resulted in bilateral mastectomies. The authors describe successful treatment of a patient with hidradenitis suppurativa of the breasts and nipple-areolar complexes using breast-conserving measures. Normal breast contour was preserved and overall cosmetic result was good.

Adult↗
PubMed2004

The effect of hyperbaric oxygen therapy on composite graft survival.

Auricular composite grafts are a useful reconstructive option, particularly for nasal reconstruction. This study evaluates the effect of hyperbaric oxygen (HBO) therapy on auricular composite graft survival in rabbits. Circular chondrocutaneous composite grafts of 0.5, 1, or 2 cm in diameter were resected from the ears of rabbits. The grafts were sutured back into position. Half the rabbits in each group received HBO postoperatively, consisting of 90 minutes at 2.4 atm. Rabbits received 7 treatments in 5 days. Control rabbits did not receive HBO. On day 21 the percentage area of graft survival was calculated from gross and histologic examination. Two-centimeter grafts treated with HBO (n = 8) had a mean graft survival rate of 85.8 +/- 15.7% compared with a survival rate of 51.31 +/- 38.5% for the control group (n = 8; P = 0.0478). There was no such benefit in smaller grafts. HBO could prove clinically useful for larger composite grafts.

Animals↗
PubMed2004

Localization of the arcuate line from surface anatomic landmarks: a cadaveric study.

The arcuate line is a relevant structure when reconstructing the abdominal wall after rectus abdominis musculocutaneous flap harvest. Its location is classically taught to be half the distance from the pubic symphysis to the umbilicus, but recent anatomic literature provides evidence to the contrary. Better understanding of the relationship between the arcuate line and surface anatomic landmarks could facilitate better preoperative planning when harvesting a rectus abdominis musculocutaneous flap. A total of 32 arcuate lines were dissected in 18 cadavers, and the location was correlated to various surface anatomic landmarks. The arcuate line was found to lie at 74.6% of the distance from the pubic symphysis to the umbilicus, and 32.7% of the distance from the pubic symphysis to the xiphoid. This location was 1.8 +/- 1.7 cm superior to the level of the anterior superior iliac spines (ASIS). This study provides further support for the finding in the anatomic literature that the arcuate line is substantially more superior than classically described. This knowledge may prove useful in preoperative planning of rectus abdominis musculocutaneous flap harvest.

Abdomen↗
PubMed2004

Split pectoralis major flaps for mediastinal wound coverage: a 12-year experience.

Poststernotomy mediastinitis is an infrequent but highly dangerous complication following median sternotomy. Typically, such wounds are debrided aggressively of necrotic and foreign materials with subsequent flap reconstruction. Between December 1989 and January 2002, 69 patients were referred to the University of Maryland division of plastic surgery for mediastinal wound coverage. A total of 105 flaps of various types were used. Fifty-eight percent of the patients received a single flap. Ninety percent of the flaps used were pectoralis major flaps, whereas only 10% of the flaps were rectus abdominis, latissimus dorsi, or omentum flaps. Ten patients (14.5%) required reoperation. The most common comorbidity was diabetes mellitus. Those patients with diabetes mellitus were 9.1 times more likely to require reoperation after their sternal reconstruction compared with nondiabetic patients (95% confidence interval, 2.1-40.4). Four patients (5.8%) died less than 30 days from their flap procedure. The flap of first choice used in this series is the pectoralis major turnover flap, which is harvested in its entirety and split in the direction of its muscle fibers. Taking the entire muscle allows better coverage of the lower portion of the incision, resulting in far less frequent need for abdominal flaps and their associated morbidity.

Aged↗
PubMed2003

Resolution of compartment syndrome after rattlesnake envenomation utilizing non-invasive measures.

Western diamondback rattlesnake envenomation is usually managed by administration of neutralizing antivenom. The development of compartment syndrome is a rare complication that has sparked considerable debate regarding medical vs. surgical management. We report a case of compartment syndrome resulting from a rattlesnake envenomation, which responded to large doses of neutralizing antivenom given concomitantly with mannitol and hyperbaric oxygen. This regimen obviated the need for surgical fasciotomy and its associated morbidity.

Adult↗
PubMed2003

Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap.

Orbital exenteration is a disfiguring operation that involves the total removal of the orbital contents with partial or total excision of the eyelids. Common methods of orbit reconstruction include pectoralis musculocutaneous pedicled flap and free tissue transfer. The purpose of this study is to illustrate that the entire temporalis muscle may be used by creating a large window in the lateral orbit, without resection of the lateral orbital rim. Orbital exenteration was performed on four cadavers. A window was created in the lateral orbit using a 4-mm pineapple burr. Three parameters were measured: (1) the distance between the zygomatic arch to the superior aspect of the temporalis muscle; (2) the width of the temporalis muscle; and (3) the length and width of the lateral orbit window. The free edge of the transposed temporal muscle was then sutured to the skin edge around the bony orbit. This procedure was then performed on a 73-year-old man who had undergone right orbital exenteration for ocular melanoma and then postoperative radiation. The dimensions of the bony windows in the cadavers were as follows: mean 3.3 cm (SD +/- 0.19 cm) x 1.9 cm (SD +/- 0.18 cm), n = 4. The dimensions of the temporalis muscle in the cadavers were the following: mean 8.45 cm (SD +/- 0.60 cm) x 10.5 cm (SD +/- 0.33 cm), n = 4. In the patient, the size of the bony window was 3.7 cm x 2.1 cm (n = 1), and the dimensions of the temporalis muscle were 8.1 cm x 10.2 cm (n = 1). The patient recovered well without complication, with a well-healed skin graft over the top of the muscle flap. An adequate bony window can be made to allow transfer of the entire temporalis muscle for orbital reconstruction without resecting the lateral orbital rim or entering the middle cranial fossa. This option is a good alternative to the other commonly performed methods of orbital reconstruction because of its completion in one operative stage, short operative time, and minimal donor site morbidity.

Aged↗