A review of 103 surgically closed pressure sores shows unsatisfactory results. Following a critical analysis of the various complications several alterations in the surgical treatment are suggested. The improvements include a more rational antibiotic treatment, two-stage operations, different flaps and the use of fibrin sealant.
The role of zinc in an occlusive, adhesive dressing (Zn-tape) was investigated in two experiments in the rat. In the first one Zn-tape was compared with a similar tape without zinc components and also with an inert plastic coated fabric with regard to the wound inflammatory reaction in excisional wounds. In the second experiment we attempted to assess possible systemic effects of zinc absorbed from Zn-tape-treated excisional wounds by studying the granulation tissue formation in subcutaneously implanted Ivalon sponges. The excisional wounds were treated with either the Zn-tape or a titanium tape in which the zinc oxide was replaced by an equivalent amount of titanium dioxide (Ti-tape). The granulation tissue produced was evaluated histologically, histochemically and biochemically. The plain adhesive mass and the Ti-tape elicited an intense inflammatory reaction as indicated both by high activities of alkaline phosphatases and histological examination. The Zn-tape reduced inflammatory processes in the granulation tissue of the excisional wounds. Zinc levels in serum and liver were raised in Zn-tape-treated animals. We conclude that zinc oxide in the Zn-tape affects inflammatory reactions in the granulation tissue of the wounds, possibly through a continuous release of zinc ions and by modifying the adhesive components of the Zn-tape. There was no evidence of a systemic effect of zinc absorbed from the excisional wounds on the granulation tissue formation in the implanted Ivalon sponges.
The authors present their trends in conservative clitoroplasty on the basis of 27 cases from January 1980 to August 1985. The technique described preserves as much of clitoral tissue as possible, and gives safe and very satisfying morpho-functional results regardless of the virilization degree. Preserved skin of clitoral shaft and of the foreskin is used to reconstruct labia minora. Erectile function is preserved by freeing and burying corpora cavernosa in the omolateral labial region. Clitoral glans, suitably trimmed when necessary, is preserved on its ventral muco-cutaneous pedicle.
The free scapular flap was used as an alternative to a conventional pedicle flap in resurfacing scarred areas and padding major nerve trunks on the upper extremities in a series of 8 patients. The free flap proved to be rather reliable (one failure), convenient to the patients and cheaper for the Health Service than a conventional flap.
Short-and long-term adaptation (two months and one year respectively) to bilateral subcutaneous mastectomy was studied in twenty-five consecutive patients operated upon at the Department of Plastic and Reconstructive Surgery, Malmö, Sweden. The results were related to preoperative personality and psychosocial profiles. Postoperative difficulties in accepting the surgical result, sexual dysfunctions and mental reactions with depression and anxiety were observed. Such reactions proved to be associated with specific personality characteristics.
Five patients with congenital blepharoptosis have undergone a simple adaptation of Müller's muscle to the tarsal plate. In two patients this led to a good postoperative result, in one to an over-correction, while two were not corrected enough. These results should stimulate further studies on the importance of Müller's muscle in congenital blepharoptosis.
In June 1982, a 9-year-old girl sustained a total scalp avulsion including the entire right eyebrow, the upper third of the skin of the dorsum of the nose and the medial half of the left eyebrow. On both sides the temporal skin was included and in the neck a border of just 1 cm of hairbearing area was left intact. The scalp was successfully replanted. The operative procedures, the pre-operative and post-operative treatment are described and discussed. The follow-up time is 3 years and the sequelae have been found to be minimal.
A modification of the Abbe flap is described. The pedicle is cut all around the vermilion leaving only a muscle cuff with the nutrient labial vessels. This increases the flexibility of the Abbe flap without reducing its viability. The division of the pedicle is a simplified procedure. The technique has been used on ten patients.
The principle of gnatoplasty using local periosteal flaps according to Skoog is employed, but an essential modification in reconstructing the cleft maxilla is suggested. The periosteum of the anterior aspect of the maxilla is transferred as an island flap instead of using it as a precarious pedicle flap. The island flap is based on the cheek tissues lying over the periosteum, thereby including the insertions of the mimic muscles. The vascular supply and the osteogenic activity of the periosteum is preserved, and satisfactory new bone production is obtained.
A case of traumatic dislocation of the scaphoid bone treated by open reduction is reported. The bone remained vital, being nourished by a slender connection to the surrounding tissue. Experience from the few cases reported in the literature shows that closed reduction is often successful. If surgery is necessary it seems that it should be limited to simple reduction of the dislocation and that there is no need for primary arthrodesis or arthroplasty. Stable fixation is necessary to avoid re-dislocation and later wrist instability.
The surgical treatment of pressure sores in paraplegics was, and still is, a very difficult and not at all solved problem, since these necrotic ulcers are not caused by any disease of the local tissue, but by lack of sensibility due to interruption of the spinal cord at a much higher level. For this reason all our efforts must be aimed at attaining two goals. First, we must replace the pressure sore by a supple, well-nourished cushion of soft tissue, which can support the weight of the body for a limited period of time. Second, we must prevent new pressure sores from developing by ensuring even distribution of the weight of the body and frequent change of body position.
The regeneration of adrenergic nerves in free microvascular groin flaps in the rat was investigated. The adrenergic nerves were revealed with glyoxylic acid-induced fluorescence and with formaldehyde-induced fluorescence methods. In the control specimens taken from the contralateral groin, adrenergic nerves were seen in the erector pili muscles and as networks around arteries and arterioles. In the free flap four weeks postoperatively, a few regenerating adrenergic nerves were observed at the margins under the flap and following the pedicle. Eight weeks postoperatively many tiny regenerating nerves were observed to invade the flap at the margins and under it. Many regenerating nerves were observed to reinnervate the artery and vein, forming a nerve plexus in the pedicle. The number of single nerve fibres invading the flap at the margins decreased sixteen weeks postoperatively, but more nerves were observed along arterioles in the flap and pedicle. Twenty-four weeks postoperatively some regenerating adrenergic nerves were observed around arteries and arterioles in different areas in the flap and in erector pili muscles. A rich network of nerves remained around the pedicle. However, the reinnervation of the vasculature of the flap remained patchy and inadequate, and many arteries and arterioles remained without innervation.
Reconstruction of the breast after radical mastectomy has become an integral part of the treatment and rehabilitation of the patient with breast cancer. Any variants of radical mastectomy are the mainstay of the treatment of the majority of patients with breast cancer. We prefer modified radical mastectomy according to the Madden-Auchincloss technique, because the breast reconstruction after this procedure is easier from the anatomic point of view. The three major questions raised in regard to breast reconstruction are: what patient is eligible for breast reconstruction; when should the breast reconstruction be performed; how should the goals of breast reconstruction be realised? There are two basic elements in our therapeutic choice in this field: collaboration of the patient, the evaluation of pTNM.
The case of an 18-year-old female with absence of the right breast, sternocostal part of the major pectoral muscle and total absence of the minor pectoral muscle and the latissimus dorsi muscle, is presented. She also had decreased sweating capacity and absence of terminal hairs in the central part of her right axilla. Histological examination of skin specimens from this area of the axilla demonstrated hypoplasia of the apocrine sweat glands, but normal eccrine sweat glands, indicating an apocrine dependent axillary sweating function. The breast was constructed using a direct subcutaneous prosthesis implant, giving a final result that was good in regard to shape and softness. This provides grounds for reconsidering the use of the latissimus dorsi muscle flap in breast constructions in Poland's syndrome.
Patients with abdominal wall reconstruction present a difficult management problem to the oncological surgeon. There were 36 patients treated for abdominal wall primary and secondary tumors between the years 1973 and 1982 at the Memorial Hospital. There were 25 abdominal wall sarcomas, 6 recurrent colon cancers, 2 recurrent bladder cancers, 1 cervical cancer, 1 recurrent endometrial cancer and 3 complications of radiotherapy treated by excision and reconstruction of the defect. The desmoid tumors were closed primarily. The recurrent sarcomas after radical excision, were reconstructed with Marlex mesh and local mobilization of skin and subcutaneous tissue. The recurrent colon bladder and endometrial cancers had been treated with over 5,000 cGy each. Three patients had significant full thickness skin loss secondary to radiotherapy. These patients comprised the group that required a myocutaneous flap to provide full thickness skin and fascia. The tensor fascia lata flap was used in eight patients. This group of patients did extremely well in contrast to the group of radiated patients with Marlex mesh reconstruction. There were less complications in the TFL group. We recommended the TFL flap for a large abdominal wall defect and for a previously radiated abdominal wall.
An experimental study was performed in rabbits to find out whether fibrin glue, used to simplify the procedure for graft fixation in perichondrial arthroplasty, would also allow earlier mobilization of the grafted joint, thereby reducing the risk for postoperative stiffness of the joint. The results indicate the possibility of reducing the time used for postoperative fixation from three weeks originally to one week, and still achieve the same results regarding graft healing and cartilage regeneration. Immediate post-operative mobilization caused loosening of the graft and endangered the results.
The authors report an anatomical study on the vascularisation of the subcutaneous tissue, which is an anatomical entity with a very rich vascular network. This leads to the concept of an original flap and suggests a modification of the concept of the fasciocutaneous flap.
The use of an extensive fascio-cutaneous flap with skin from the thorax and abdomen, starting from the lateral and subscapular area behind the posterior axillary line and going down to the homolateral pubic and inguinal area, is described. This type of flap is used for repair of very extensive skin loss on the thorax when free grafts, the only alternative, are unsuitable because of the need for more effective and definite covering.
A standardized method of surgical dismantelling of the face for access to the periorbital area is described in detail. Its use in 11 patients with periorbital tumors is described and illustrated by selected case reports. It was concluded that many tumors in the periorbital area that previously were considered inoperable with craniofacial disassembling techniques can be adequately treated without sacrificing eyes or mutilating the face.
Thirteen wrists with Kienböck's disease, stage III or IV, were denervated. Three wrists were examined repeatedly over a period of 2 1/2 years prior to operation, showing the natural course of lunate compression. The remaining 10 wrists were operated on sooner after diagnosis and the lunate compression was compared with the natural compression course. The hypothesis that wrist denervation was detrimental to the lunate was not supported by the present material.
