37 results on '"Evans, G. R."'
Search Results
2. Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction.
- Author
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Sharma S, Chang DW, Koutz C, Evans GR, Robb GL, Langstein HN, and Kroll SS
- Subjects
- Adult, Aged, Analgesia, Patient-Controlled, Dose-Response Relationship, Drug, Drug Therapy, Combination, Female, Humans, Ketorolac administration & dosage, Middle Aged, Morphine administration & dosage, Morphine adverse effects, Retrospective Studies, Risk Factors, Hematoma chemically induced, Ketorolac adverse effects, Mammaplasty, Postoperative Complications chemically induced, Postoperative Hemorrhage chemically induced, Surgical Flaps
- Abstract
Ketorolac is frequently used as an adjunct for postoperative pain relief, especially by anesthesiologists during the immediate postoperative period. It can be used alone as an analgesic but is more often used to potentiate the actions of narcotics such as morphine or meperidine in an attempt to reduce the total dose and side effects of those drugs. The manufacturer of ketorolac cautions against its use in patients who have a high risk of postoperative bleeding, for fear of increasing the risk of hematoma, but the risk in transverse rectus abdominis musculocutaneous (TRAM) flap patients has never been reported. In a study of 215 patients who had undergone TRAM flap breast reconstruction, it was determined that patients who received intravenous ketorolac (n = 65) as an adjunct to their treatment with morphine administered by use of a patient-controlled analgesia device required less morphine (mean cumulative dose, 1.39 mg/kg) than did patients who did not receive ketorolac (n = 150; mean cumulative dose, 1.75 mg/kg; p = 0.02). There was no increase in the incidence of hematoma in patients who were treated with ketorolac. The data presented in this study suggest that the use of intravenous ketorolac does reduce the need for narcotics administration in patients undergoing TRAM flap breast reconstruction, without significantly increasing the risk of hematoma.
- Published
- 2001
- Full Text
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3. Advances in head and neck reconstruction.
- Author
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Gurtner GC and Evans GR
- Subjects
- Face surgery, Humans, Larynx surgery, Mandible surgery, Mouth surgery, Pharynx surgery, Scalp surgery, Head and Neck Neoplasms surgery, Plastic Surgery Procedures methods
- Abstract
Head and neck deformities, which can be caused by trauma, congenital defects, infections, or neoplasms, produce a stereotypical constellation of functional and aesthetic deficits, depending on the specific anatomic region. These deformities can be classified into six major anatomic categories: intraoral, mandibular, midfacial, cranial base, cutaneous, and scalp. This article presents a reliable approach to the reconstruction of these six areas that is used at the University of Texas M. D. Anderson Cancer Center. The emphasis is on an analysis of the unique functional and aesthetic problems presented by each of these specific anatomic lesions, and the reconstructive options are selected to maximize outcomes. The problems and limitations of current methods are discussed, and areas of potential development are explored.
- Published
- 2000
4. Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.
- Author
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Tran NV, Evans GR, Kroll SS, Baldwin BJ, Miller MJ, Reece GP, and Robb GL
- Subjects
- Adult, Aged, Breast Neoplasms surgery, Combined Modality Therapy, Female, Follow-Up Studies, Humans, Middle Aged, Postoperative Complications surgery, Radiation Injuries surgery, Radiotherapy Dosage, Radiotherapy, Adjuvant, Reoperation, Breast radiation effects, Breast Neoplasms radiotherapy, Mammaplasty methods, Postoperative Complications etiology, Radiation Injuries etiology, Surgical Flaps
- Abstract
The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.
- Published
- 2000
- Full Text
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5. Reconstruction of large sacral defects following total sacrectomy.
- Author
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Miles WK, Chang DW, Kroll SS, Miller MJ, Langstein HN, Reece GP, Evans GR, and Robb GL
- Subjects
- Adult, Aged, Female, Humans, Male, Middle Aged, Rectal Neoplasms surgery, Retrospective Studies, Spinal Neoplasms surgery, Treatment Outcome, Plastic Surgery Procedures methods, Sacrum surgery, Surgical Flaps
- Abstract
Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.
- Published
- 2000
- Full Text
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6. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction.
- Author
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Chang DW, Reece GP, Wang B, Robb GL, Miller MJ, Evans GR, Langstein HN, and Kroll SS
- Subjects
- Adult, Breast Neoplasms drug therapy, Breast Neoplasms radiotherapy, Female, Humans, Incidence, Mammaplasty adverse effects, Middle Aged, Necrosis, Retrospective Studies, Risk, Surgical Flaps adverse effects, Treatment Outcome, Breast Neoplasms surgery, Mammaplasty methods, Rectus Abdominis transplantation, Smoking adverse effects, Surgical Flaps blood supply
- Abstract
Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent; p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent; p = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.
- Published
- 2000
- Full Text
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7. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction.
- Author
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Chang DW, Wang B, Robb GL, Reece GP, Miller MJ, Evans GR, Langstein HN, and Kroll SS
- Subjects
- Adult, Body Mass Index, Female, Graft Survival physiology, Humans, Middle Aged, Necrosis, Postoperative Complications physiopathology, Postoperative Complications surgery, Reoperation, Risk Factors, Wound Healing physiology, Mammaplasty methods, Obesity physiopathology, Postoperative Complications etiology, Surgical Flaps physiology
- Abstract
The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.
- Published
- 2000
- Full Text
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8. Free filet extremity flap: indications and options for reconstruction.
- Author
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Tran NV, Evans GR, Kroll SS, Miller MJ, Reece GP, Ainsle N, and Robb GL
- Subjects
- Adult, Aged, Chemotherapy, Adjuvant, Combined Modality Therapy, Extremities surgery, Female, Humans, Male, Microsurgery, Middle Aged, Neoplasm Recurrence, Local surgery, Neoplasms drug therapy, Neoplasms radiotherapy, Radiotherapy, Adjuvant, Reoperation, Amputation Stumps surgery, Neoplasms surgery, Surgical Flaps blood supply
- Abstract
Radical and extended forequarter and hind limb amputations have been used for curative and palliative intents. Concerns regarding wound healing and closure, especially in irradiated fields, have occasionally limited the extent of ablation. This article reports an experience with coverage of these large defects by using the free filet extremity flap. A retrospective review was performed of 11 patients who had undergone immediate reconstruction with free filet extremity flaps between 1991 and 1998. There were nine men and two women with an average age of 43.9 years. All except three patients received preoperative radiotherapy. Resections included four hindquarter and seven forequarter amputations for palliation of intractable pain, tissue necrosis, and infections. Donor vessels included the brachial artery, its venae comitantes, cephalic and basilic veins, and common femoral and popliteal vessels. Immediate reconstruction was successful in all cases by the use of the amputated limb as the free filet flap. All wounds healed despite irradiation inclusive of defects up to 50 cm x 70 cm (3500 cm2). The average follow-up time was 5 months with a mean survival of 3.5 months. Four patients currently are alive, and one patient died within 30 days of surgery. The remaining six patients have died of their disease within 9 months of the palliative procedures. Pain, tissue necrosis, and infections were improved in all patients after hospital discharge. Extensive defects can be reconstructed and healed successfully, even in irradiated wounds, with the use of the free filet extremity flap. Appropriate advanced preoperative and intraoperative planning is essential. Although survival was unchanged, this technique allowed healed wounds with an improvement in the quality of life.
- Published
- 2000
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9. The effects of cisplatinum and vincristine on peripheral nerve regeneration.
- Author
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Brandt K, Evans GR, Johnson M, Gürlek A, Lohman R, Nabawi A, Williams J, Hodges J, and Patrick CW Jr
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- Animals, Axons physiology, Chemotherapy, Adjuvant, Hindlimb, Random Allocation, Rats, Rats, Sprague-Dawley, Sarcoma, Experimental drug therapy, Sarcoma, Experimental surgery, Tibial Nerve drug effects, Walking, Antineoplastic Agents pharmacology, Cisplatin pharmacology, Nerve Regeneration drug effects, Tibial Nerve physiology, Vincristine pharmacology
- Abstract
Current treatment modalities for extremity sarcoma often include tumor extirpation plus neoadjuvant therapy. Limb-sparing surgery may require reconstruction of critical nerve defects. Neurotoxic side effects from adjuvant chemotherapy have been reported and raise concerns regarding the effects of chemotherapy on nerve regeneration. In an attempt to define the effects of adjuvant chemotherapy on peripheral nerve regeneration, cisplatin and vincristine were administered to rats following isografting of the posterior tibial nerve. Parameters used to assess peripheral nerve regeneration included walking track analysis and histomorphology. Sixty 250-g Sprague-Dawley rats were randomly allocated into one of three treatment groups. Each animal underwent a 15-mm reversed interposition nerve isograft from 30 donor rats into the right posterior tibial nerve. Ten animals served as control. The remaining animals were divided into two groups of 25 animals each. One group received cisplatin (75 mg/m2) and the other group received vincristine (1 mg/m2). Chemotherapy was administered at 4-week cycles for a total of six cycles (24 weeks). Walking track analysis was performed monthly. Nerve specimens were harvested from the grafted segment and the distal posterior tibial nerve for histomorphology. Walking track analysis demonstrated no statistical difference in print length between the control and chemotherapeutic groups at the conclusion of the study. The number of axons per square millimeter and nerve fiber density were not statistically different between control and chemotherapeutic groups. In the rodent posterior tibial nerve model, postoperative adjuvant therapy does not significantly alter functional outcome in peripheral nerve regeneration. The practice of immediate nerve grafting after tumor extirpation, despite planned postoperative chemotherapy, is supported.
- Published
- 1999
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10. Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up.
- Author
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Kroll SS, Khoo A, Singletary SE, Ames FC, Wang BG, Reece GP, Miller MJ, Evans GR, and Robb GL
- Subjects
- Breast Neoplasms epidemiology, Female, Follow-Up Studies, Humans, Incidence, Mammaplasty, Middle Aged, Retrospective Studies, Risk Factors, Time Factors, Breast Neoplasms surgery, Mastectomy, Subcutaneous, Neoplasm Recurrence, Local epidemiology
- Abstract
In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.
- Published
- 1999
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11. Skin graft survival after external beam irradiation.
- Author
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Tadjalli HE, Evans GR, Gürlek A, Beller TC, Ang KK, and Stephens LC
- Subjects
- Animals, Male, Radiation Dosage, Rats, Rats, Sprague-Dawley, Skin pathology, Skin radiation effects, Wound Healing radiation effects, Graft Survival radiation effects, Skin Transplantation
- Abstract
Difficulties with skin graft ulceration after radiation therapy for cancer have led many to question the suitability of this method of soft-tissue coverage and its cost-effectiveness. The objective of this study was, therefore, to assess skin-graft integrity subjected to postoperative external beam irradiation in a rat model. The model consisted of a rectangular full-thickness skin graft raised and reapplied to its original bed on the dorsum of each rat. Five groups of adult male Sprague-Dawley rats (n = 8 per group) were established. Group A was the control group and was not given postoperative irradiation. Groups B, C, D, and E received postoperative unfractionated cobalt60 irradiation 4 weeks after grafting for a total dose of 15, 20, 25, or 30 Gy, respectively. Weekly skin-graft evaluation was performed for the 4 weeks after irradiation (8 weeks after surgery) by measuring areas of graft loss using computerized planimetry. After the animals were killed, histologic samples were obtained from normal unirradiated skin and from both intact and ulcerated skin-graft sites. Graft loss after irradiation of < or = 20 Gy was similar to that of the unirradiated controls. Occurring as early as 1 week after treatment, a two-fold increase in graft ulceration was observed with doses of > or = 25 Gy (p = 0.0007). Only partial healing of ulcerations was noted by the fourth week after treatment. Histologic changes associated with the irradiation of skin grafts using doses of 25 Gy or higher included hyaline degeneration, fibrinoid necrosis, telangiectasia, and edema. Granulation tissue predominated as a mechanism of healing in areas of graft ulceration. The intensity of inflammatory cell infiltrate did not correlate with radiation dose. The authors concluded that postoperative, unfractionated irradiation can induce skin-graft loss at doses of 25 Gy or higher. Fractionated irradiation or longer intervals between grafting and irradiation may increase skin-graft tolerance; however, further studies are warranted.
- Published
- 1999
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12. Tongue reconstruction: outcomes with the rectus abdominis flap.
- Author
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Lyos AT, Evans GR, Perez D, and Schusterman MA
- Subjects
- Adult, Aged, Deglutition, Female, Glossectomy, Humans, Male, Middle Aged, Neoplasm Recurrence, Local, Postoperative Period, Speech, Treatment Outcome, Plastic Surgery Procedures, Surgical Flaps, Tongue Neoplasms surgery
- Abstract
Advanced carcinoma of the oral cavity is a devastating disease, with the potential for severe speech and swallowing dysfunction. This is a retrospective review documenting the outcome of 14 patients who underwent resection of at least 75 percent of their tongue with preservation of the larynx and an intact mandible. Reconstruction was accomplished with rectus abdominis free tissue transfer. There were seven male and seven female patients between the ages of 25 and 77 years (mean, 55 years) who underwent total (eight patients) or subtotal (six patients) glossectomy and reconstruction. Decannulation of the tracheostomy tube was performed in 12 patients (86 percent) at an average of 3.5 months postoperatively. One patient required interval laryngectomy for intractable aspiration 1 month postoperatively. Independent evaluation of speech, articulation, and deglutition was performed. Fifty percent of patients achieved oral intake of pureed foods or better. Sixty-four percent had acceptable speech. Reconstruction with rectus abdominis free tissue transfer is a viable method for rehabilitation, improving quality of life after total or subtotal glossectomy with laryngeal preservation.
- Published
- 1999
- Full Text
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13. Fat necrosis in free and pedicled TRAM flaps.
- Author
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Kroll SS, Gherardini G, Martin JE, Reece GP, Miller MJ, Evans GR, Robb GL, and Wang BG
- Subjects
- Abdominal Muscles surgery, Adult, Fat Necrosis diagnostic imaging, Female, Humans, Logistic Models, Mammography, Smoking, Fat Necrosis etiology, Mammaplasty adverse effects, Surgical Flaps
- Abstract
One purported advantage of the free transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction is that, compared with the conventional TRAM flap, it has a better blood supply and therefore a lower incidence of fat necrosis. We tested this claim by reviewing the incidence of fat necrosis, both clinically and mammographically, in a group of 110 patients with 116 TRAM flap breast reconstructions who had undergone mammography of their reconstructed breasts. Of the 49 breasts reconstructed with free TRAM flaps, 4 (8.2 percent) had clinically evident fat necrosis, and 1 (2.0 percent) had fat necrosis that was detectable by mammography. Of the 67 breasts reconstructed with conventional TRAM flaps, 18 (26.9 percent) had clinically detectable fat necrosis, and 9 (13.4 percent) had fat necrosis that was detectable mammographically. Both of these differences were statistically significant (p = 0.0113 for clinical fat necrosis; p = 0.031 for mammographic fat necrosis). Fat necrosis was more common in patients who were obese or had a history of smoking, but neither association was statistically significant. We conclude that the use of the free TRAM flap reduces the incidence of fat necrosis in the reconstructed breast.
- Published
- 1998
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14. A comparison of resource costs of immediate and delayed breast reconstruction.
- Author
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Khoo A, Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, and Schusterman MA
- Subjects
- Breast Neoplasms radiotherapy, Breast Neoplasms surgery, Female, Humans, Surgical Flaps economics, Time Factors, Hospital Costs, Mammaplasty economics, Mastectomy rehabilitation
- Abstract
The resource cost (cost to our hospital) of providing mastectomy plus breast reconstruction was calculated for 276 patients who had received both mastectomy and breast reconstruction at our institution. All patients had completed the entire reconstructive process, including reconstruction of the nipple. The resource costs of providing mastectomy with immediate breast reconstruction were compared with those of mastectomy with subsequent delayed reconstruction. We found that the mean resource cost for the 57 patients who had separate mastectomy followed by delayed breast reconstruction ($28,843) was 62 percent higher than that of mastectomy with immediate reconstruction ($17,801; n = 219, p < 0.001). Similar differences were found when patients were subgrouped by type of reconstruction (TRAM versus tissue expansion and implants), by laterality (unilateral versus bilateral), and by history of preoperative irradiation. We conclude that mastectomy with immediate breast reconstruction is significantly less expensive than mastectomy followed by delayed reconstruction and can potentially conserve resources.
- Published
- 1998
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15. Venous ulcers: improved healing by iontophoretic administration of calcitonin gene-related peptide and vasoactive intestinal polypeptide.
- Author
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Gherardini G, Gürlek A, Evans GR, Milner SM, Matarasso A, Wassler M, Jernbeck J, and Lundeberg T
- Subjects
- Aged, Female, Humans, Male, Middle Aged, Treatment Outcome, Calcitonin Gene-Related Peptide administration & dosage, Iontophoresis, Varicose Ulcer drug therapy, Vasoactive Intestinal Peptide administration & dosage
- Abstract
A study on the effects of iontophoretic administration of calcitonin gene-related peptide and vasoactive intestinal polypeptide on the healing of venous stasis ulcers of the extremities was carried out on 66 patients. Two randomized groups of patients were compared, one receiving standard treatment plus iontophoresis of calcitonin gene-related peptide and vasoactive intestinal polypeptide, and the other receiving standard treatment plus placebo iontophoresis. Calcitonin gene-related peptide and vasoactive intestinal polypeptide were administered locally by iontophoresis for 20 min three times weekly for 12 weeks. To determine the effects of the two treatments, the percentage surface area of ulcer healed and the number of healed ulcers were compared after 2, 4, 6, 8, and 12 weeks of treatment. The results demonstrate that there were significant improvements of the healing process in the group treated with calcitonin gene-related peptide and vasoactive intestinal polypeptide when compared with placebo iontophoresis, and support the use of iontophoresis administration of calcitonin gene-related peptide and vasoactive intestinal polypeptide in the treatment of venous ulcers.
- Published
- 1998
- Full Text
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16. From cadavers to implants: silicon tissue assays of medical devices.
- Author
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Evans GR and Baldwin BJ
- Subjects
- Adjuvants, Immunologic adverse effects, Adult, Aged, Autoimmune Diseases etiology, Breast chemistry, Breast Implants, Cadaver, Catheters, Indwelling, Chemical Phenomena, Chemistry, Physical, Connective Tissue chemistry, Environmental Exposure, Equipment Failure, Female, Freezing, Humans, Longitudinal Studies, Male, Middle Aged, Silicones adverse effects, Silicones analysis, Sodium Chloride, Spectrum Analysis, Tissue Distribution, Tissue Expansion Devices, Tissue Fixation, Prostheses and Implants, Silicon analysis
- Abstract
A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels in patients with saline implants or tissue expanders. We have compared these levels with tissue samples from a variety of patients with and without medicinal silicone devices from both the northeast and southwest United States over a 4-year period. All specimens were harvested by a "no touch" technique, non-formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was used to obtain the tissue silicon measurements. Silicon tissue values in cadaveric tissue (n = 20 cadavers; n = 120 specimens) averaged 2.2 mcg/gm of tissue with undetectable silicon levels in over 50 percent of the specimens (range 0 to 45 mcg/gm; median = 0). Silicon levels surrounding port-a-catheter devices (n = 15 patients; n = 15 specimens) averaged 8.04 mcg/gm of tissue (range 0 to 41 mcg/gm; median = 0). Tissue levels in the capsules surrounding saline (n = 10 patients; n = 22 specimens) and silicone implants (n = 31 patients; n = 58 specimens) averaged 292 mcg/gm (range 0 to 1380 mcg/gm; median = 110) and 1439 mcg/gm (range 0 to 9800 mcg/gm, median = 490), respectively. Tissue levels, however, from distant sites (n = 22 specimens) in these same patients were equivalent to the cadaveric nonaugmented values (average = 3.2 mcg/gm; range 0 to 5.8 mcg/gm; median = 2.7). The results imply that there is a continuum of exposure to silicone medical devices based on the mechanical properties of silicone. The data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicone exposure a person has over his or her lifetime. It is our hope that these levels will serve as a baseline for our continuing knowledge of implantable medical devices.
- Published
- 1997
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17. Drug-induced vasodilation in an in vitro and in vivo study: the effects of nicardipine, papaverine, and lidocaine on the rabbit carotid artery.
- Author
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Evans GR, Gherardini G, Gürlek A, Langstein H, Joly GA, Cromeens DM, Sukumaran AV, Williams J, Kilbourn RG, Wang B, and Lundeberg T
- Subjects
- Administration, Topical, Anastomosis, Surgical, Animals, Blood Pressure drug effects, Carotid Arteries surgery, Dose-Response Relationship, Drug, Follow-Up Studies, Ischemia drug therapy, Isotonic Solutions, Lidocaine administration & dosage, Lidocaine agonists, Lidocaine therapeutic use, Microcirculation drug effects, Microsurgery, Monitoring, Physiologic, Nicardipine administration & dosage, Nicardipine therapeutic use, Norepinephrine pharmacology, Papaverine administration & dosage, Papaverine therapeutic use, Rabbits, Regional Blood Flow drug effects, Single-Blind Method, Surgical Flaps blood supply, Ultrasonography, Doppler, Vasoconstriction drug effects, Vasoconstrictor Agents pharmacology, Vasodilator Agents administration & dosage, Vasodilator Agents therapeutic use, Carotid Arteries drug effects, Lidocaine pharmacology, Nicardipine pharmacology, Papaverine pharmacology, Vasodilator Agents pharmacology
- Abstract
Extreme arterial vasoconstriction (vasospasm) is a common problem encountered in microvascular surgery. An ideal pharmacologic tool able to counteract ischemia during microsurgery should be easy to apply and exert its action both locally and distally in the microcirculation of the flap. We have compared in vitro and in vivo vascular properties of nicardipine, papaverine, and lidocaine in the rabbit carotid artery. In vitro, rings from the rabbit carotid artery (n = 7) were bathed in Krebs-Ringers solution and stretched progressively to an optimal tension of 3.7 to 4.2 g. The specimens were contracted with norepinephrine (1 microM), and a cumulative dose response curve was established. In vivo, microvascular anastomoses were performed bilaterally in the rabbit carotid artery in 35 animals using 9-0 nylon suture and standard microsurgical techniques. During and after the anastomoses, nicardipine (0.1, 0.01 mg topical, or 0.1 mg/hour IV), papaverine (30 mg/cc topical), and lidocaine (2% with and without epinephrine) were applied (blinded) at the anastomotic site in five rabbits each. Heparinized sodium chloride was used as topical irrigation for control and to clean the anastomosis. Blood flow changes were monitored continuously with the transonic Doppler for 30 minutes after the procedure. The systemic blood pressure was also monitored in a group of pilot experiments. A documented decrease in blood flow was noted in all animals after the microvascular anastomosis. Nicardipine and papaverine evoked a concentration-dependent relaxation to precontracted rings to norepinephrine. Nicardipine was greater than papaverine in inducing relaxation. Lidocaine demonstrated a biphasic response with low concentrations potentiating contraction. Systemic nicardipine and papaverine significantly increased the blood flow in the rabbit carotid artery. Topical application of nicardipine and lidocaine did not significantly alter the blood flow; however, the application of nicardipine demonstrates a trend toward increased flow. Lidocaine with epinephrine significantly decreased the blood flow. No drug was found to alter the blood pressure of the animals. Our results demonstrate that nicardipine and papaverine seem to be pharmacologic tools able to increase the blood flow in anastomotic arteries. In contrast, the use of 2% lidocaine as a spasmolytic agent should be re-evaluated, since this substance may act as a partial agonist.
- Published
- 1997
- Full Text
- View/download PDF
18. The Málaga flap for vaginoplasty in the Mayer-Rokitansky-Kuster-Hauser syndrome: experience and early-term results.
- Author
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Gürlek A and Evans GR
- Subjects
- Female, Humans, Syndrome, Vagina abnormalities, Surgical Flaps, Vagina surgery
- Published
- 1997
- Full Text
- View/download PDF
19. Peripheral nerve regeneration: the effects of postoperative irradiation.
- Author
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Evans GR, Brandt K, Ang KK, Cromeens D, Peden E, Gherardini G, Gurlek A, Tinkey P, and Williams J
- Subjects
- Animals, Gamma Rays, Hindlimb innervation, Male, Peripheral Nerves cytology, Peripheral Nerves physiology, Radiation Dosage, Rats, Rats, Sprague-Dawley, Nerve Regeneration radiation effects, Peripheral Nerves radiation effects, Peripheral Nerves surgery
- Abstract
The purpose of this study was to evaluate the effects of postoperative external cobalt-60 beam irradiation on nerve regeneration. Sixty-five 250-gm male Sprague-Dawley rats were studied. Peripheral nerve regeneration was measured by walking track analysis and histomorphology of the proximal, graft, and distal nerve segments. These 65 animals underwent a 1.5-cm interpositional nerve graft into the right posterior tibial nerve. The left leg served as a control. Each animal was then randomly allocated into one of four groups. Group 1 served as control. Groups 2 through 4 were subjected to external cobalt-60 gamma-ray irradiation through a 2.5-cm circular portal for a total fractionated dose of 30, 50, and 70 Gy beginning on postoperative day 3. Radiation was administered in 2-Gy fractions, 5 fractions per week, with a top-up dose of 16 Gy given at the end of the fractionated irradiation. Walking track analysis was performed at 30, 60, 90, and 120 days after nerve grafting. At the conclusion of 120 days, sections of the proximal, grafted, and distal nerve were harvested, stained, and examined histomorphologically. Hematoxylin and eosin stains also were obtained. Evaluation of the print-length index demonstrated no statistical difference between the unirradiated controls and the irradiated groups. The total number of axons per square millimeter and nerve fiber density per square millimeter were significantly decreased in the distal segment of all the irradiated groups when compared with controls. Despite the reduction in myelinated regenerating fibers, no reduction in function was observed, as measured by walking track analysis. We would therefore recommend immediate reconstruction of peripheral nerve defects in the face of postoperative irradiation.
- Published
- 1997
- Full Text
- View/download PDF
20. The repair of multiple rectovaginal fistulas with the neurovascular pudendal thigh flap (Singapore flap).
- Author
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Gürlek A, Gherardini G, Coban YK, Görgü M, Erdogan B, and Evans GR
- Subjects
- Fascia blood supply, Fascia innervation, Fascia transplantation, Female, Follow-Up Studies, Humans, Middle Aged, Rectum surgery, Skin Transplantation pathology, Thigh, Vagina surgery, Rectovaginal Fistula surgery, Surgical Flaps methods
- Published
- 1997
21. Comparison of nipple projection with the modified double-opposing tab and star flaps.
- Author
-
Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, and Schusterman MA
- Subjects
- Female, Follow-Up Studies, Humans, Mammaplasty methods, Nipples surgery, Surgical Flaps methods
- Abstract
This study compared nipple projection after nipple reconstruction (following breast mound reconstruction) with either the modified double-opposing tab flap or the star flap. Areolar reconstruction and pigmentation of the nipple were achieved with tattooing. Nipple projection for 153 nipples was measured at least 6 months after the reconstruction, when projection was believed to have become stable. Mean follow-up was 2.27 years. In the 106 nipples reconstructed with modified double-opposing tab flaps, the mean projection was 2.4292 mm, while in the 47 nipples reconstructed with star flaps, the mean projection was 1.9681 mm (p = 0.021). We conclude that although both methods are effective, the modified double-opposing tab flap has slightly more projection after approximately 2 years. It is not known, however, whether this is because of reduced flap atrophy or longer initial projection by the modified double-opposing tab flap; further studies are ongoing.
- Published
- 1997
22. Silicon tissue assay: a measurement of capsular levels from chemotherapeutic port-a-catheter devices.
- Author
-
Evans GR and Baldwin BJ
- Subjects
- Adolescent, Adult, Age Factors, Alloys, Breast chemistry, Breast Implants, Cadaver, Child, Child, Preschool, Collagen Diseases etiology, Connective Tissue chemistry, Equipment Design, Female, Humans, Male, Middle Aged, Neoplasms drug therapy, Neoplasms radiotherapy, Sample Size, Silicones, Spectrum Analysis, Time Factors, Tissue Distribution, Vascular Diseases etiology, Catheters, Indwelling, Infusion Pumps, Implantable, Silicon analysis
- Abstract
A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels (n = 15) in capsules that form around chemotherapeutic port-a-catheter devices, which consist of a metal dome encapsuled by silicone. We have compared these levels with previously established silicon levels in augmented breast capsules, distant tissue sites in these same augmented women, and nonaugmented cadaveric tissues from various geographic locations in the United States. All specimens were harvested by a "no touch" technique, not formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was employed to obtain the tissue silicon measurements. Results demonstrated silicon values ranging from nondetectable in 9 patients to as high as 41 micrograms/gm. These values fell in between our cadaveric (0.5 to 6.8 micrograms/gm) and augmented tissue silicon levels (18 to 8700 micrograms/gm). Although the sample size is small and the power of statistical analysis is low, there was no correlation between the patient's silicon level and age, type of cancer, type of chemotherapeutic agent, radiation therapy, or length of time the port-a-catheters were in place. Although detectable levels of silicon identified around port-a-catheter devices were higher than expected, it is impossible to make any conclusions about these levels and the role of a potential collagen-vascular disease. What we have shown, however, is that silicone breast implants may not be the only medical device that can elevate tissue silicon levels. Our data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicon exposure a person has had at a particular time in his or her life. It is our belief that as we identify these tissue silicon levels, they will serve as a baseline and reference for further scientific studies.
- Published
- 1997
- Full Text
- View/download PDF
23. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps.
- Author
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Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP, Miller MJ, Robb GL, Baldwin BJ, and Schusterman MA
- Subjects
- Age Factors, Analysis of Variance, Cost Savings, Forearm, Graft Survival, Hospitalization economics, Humans, Length of Stay economics, Middle Aged, Mouth Diseases etiology, Mouth Diseases surgery, Muscle, Skeletal transplantation, Oropharynx surgery, Pharyngeal Diseases etiology, Pharyngeal Diseases surgery, Physicians economics, Postoperative Complications surgery, Rectus Abdominis transplantation, Retrospective Studies, Salaries and Fringe Benefits, Skin Transplantation economics, Surgical Flaps methods, Time Factors, Head and Neck Neoplasms surgery, Hospital Costs, Pectoralis Muscles transplantation, Surgical Flaps economics
- Abstract
A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.
- Published
- 1997
- Full Text
- View/download PDF
24. Cell adhesion and short-term patency in human endothelium preseeded 1.5-mm polytetrafluoroethylene vascular grafts: an experimental study.
- Author
-
Gherardini G, Haegerstrand A, Matarasso A, Gurlek A, Evans GR, and Lundeberg T
- Subjects
- Animals, Cell Adhesion, Cells, Cultured, Humans, Rabbits, Rats, Rats, Sprague-Dawley, Time Factors, Endothelium, Vascular cytology, Endothelium, Vascular physiology, Graft Occlusion, Vascular prevention & control, Polytetrafluoroethylene, Vascular Patency physiology
- Abstract
It has been shown that endothelialization improves short-term patency of 1.5-mm expanded polytetrafluoroethylene vascular grafts. A model for endothelialization of 1.5-mm expanded polytetrafluoroethylene vascular grafts with human endothelial cells is described. In this model, the adherence of endothelial cells was increased significantly in grafts coated with serum proteins and collagen. By means of this protocol, graft patency was tested after implantation in two animal models: the rat aorta and the rabbit common carotid artery. Anastomosis was performed with a 3M Precise Microvascular Anastomotic System. In both animal models, no significant loss of endothelial cells in the precoated grafts (rat, n = 8) were noted 1 hour after blood flow restoration. All uncoated grafts showed significant endothelial cell loss. In the rabbit model, all nonendothelialized grafts (n = 8) clotted 5 to 25 minutes after flow restoration. Seven (n = 8) endothelialized grafts showed no clotting during 1 hour's observation: one clotted immediately for a patency rate of 87.5 percent. These results indicate that endothelialization of 1.5-mm grafts is practical. Furthermore, adhesion of endothelial cells to the graft walls is not affected by short-term, pulsatile, high-pressure blood flow.
- Published
- 1997
- Full Text
- View/download PDF
25. Timing of pedicle thrombosis and flap loss after free-tissue transfer.
- Author
-
Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, and Baldwin BJ
- Subjects
- Graft Rejection prevention & control, Humans, Prospective Studies, Graft Rejection epidemiology, Surgical Flaps adverse effects, Thrombophlebitis epidemiology, Thrombophlebitis etiology
- Abstract
A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.
- Published
- 1996
- Full Text
- View/download PDF
26. Choice of flap and incidence of free flap success.
- Author
-
Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, and Baldwin BJ
- Subjects
- Female, Humans, Microsurgery, Postoperative Complications, Retrospective Studies, Risk Factors, Thrombosis etiology, Treatment Outcome, Breast Neoplasms surgery, Head and Neck Neoplasms surgery, Mammaplasty, Surgical Flaps
- Abstract
A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutaneous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis-based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non-rectus abdominis flaps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age, and previous irradiation had no significant effect on flap failure rates. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.
- Published
- 1996
- Full Text
- View/download PDF
27. Complex abdominal-perineal reconstruction: options after pelvic bone resection.
- Author
-
Evans GR, Goldberg DP, and Ames FC
- Subjects
- Carcinoma surgery, Hernia, Ventral etiology, Hernia, Ventral surgery, Humans, Male, Middle Aged, Pelvic Neoplasms complications, Penile Neoplasms surgery, Postoperative Complications surgery, Soft Tissue Neoplasms complications, Pelvic Neoplasms surgery, Perineum surgery, Prostheses and Implants, Soft Tissue Neoplasms surgery, Surgical Flaps methods, Surgical Mesh
- Abstract
Reconstruction of abdominal-perineal wounds after tumor extirpation presents the plastic surgeon with a variety of complex reconstructive options. These options are complicated by the resection of the bony pelvis. Two cases are presented that combine the use of synthetic mesh for pelvic ring and floor reconstruction with soft tissue to protect the intraabdominal viscera. Techniques and approaches to the patient undergoing such reconstruction are reviewed.
- Published
- 1996
- Full Text
- View/download PDF
28. Comparison of resource costs of free and conventional TRAM flap breast reconstruction.
- Author
-
Kroll SS, Evans GR, Reece GP, Miller MJ, Robb GL, Baldwin BJ, and Schusterman MA
- Subjects
- Female, Hospital Costs, Humans, Length of Stay, Mastectomy economics, Time Factors, Mammaplasty economics, Mammaplasty methods, Mastectomy rehabilitation, Surgical Flaps
- Abstract
Resource costs, which are the costs to the hospital of providing a service, were measured for 154 patients who underwent mastectomy and immediate breast reconstruction with TRAM flaps. Unilateral and bilateral reconstructions were evaluated separately. The resource costs required to perform mastectomy and reconstruction with free TRAM flaps were then compared with those required when conventional TRAM flaps were used. The mean total resource cost in the free TRAM group was slightly higher than in the conventional TRAM group, but the difference was small (4.1 percent) and not statistically significant (p = 0.290). The mean resource cost of performing bilateral mastectomy and reconstruction was higher than that of unilateral mastectomy and reconstruction, but the difference was only 5.0 percent (p = 0.046). This study shows that the cost to an institution of providing breast reconstruction with free TRAM flaps is not significantly higher than that of performing reconstruction with conventional TRAM flaps. Also, our findings show that the resource costs of performing bilateral mastectomy and reconstruction are not much higher than those of treating only one breast.
- Published
- 1996
- Full Text
- View/download PDF
29. Silicon tissue assays: a comparison of nonaugmented cadaveric and augmented patient levels.
- Author
-
Evans GR, Netscher DT, Schusterman MA, Kroll SS, Robb GL, Reece GP, and Miller MJ
- Subjects
- Abdomen, Adult, Aged, Aged, 80 and over, Axilla, Breast chemistry, Cadaver, Female, Humans, Liver chemistry, Lymph Nodes chemistry, Male, Mammaplasty instrumentation, Middle Aged, Nipples chemistry, Reproducibility of Results, Skin chemistry, Spectrum Analysis, Spleen chemistry, Breast Implants, Silicon analysis
- Abstract
Tissue silicon assays were performed on 10 nonaugmented cadavers and 25 augmented women to confirm our previous cadaveric data and to establish silicon levels at local and distant sites in augmented women undergoing explant and further reconstruction. All assays were performed by inductively coupled plasma atomic emissions spectroscopy (ICP-AES). Cadaveric tissues were sampled from six sites: liver, spleen, breast, nipple, axilla (soft tissue and nodes), and subcutaneous tissue (abdominal). Augmented women undergoing explant surgery had a portion of their implant capsule, breast tissue, and for those undergoing autogenous reconstruction, a portion of the autogenous donor site or distant tissue sampled. Twenty-four women had silicone implants; one had saline. Results revealed baseline silicon levels in all 10 non-augmented cadavers. These results were equivalent to our previous data, confirming the validity of these baseline data. Silicon tissue levels in the 25 augmented women revealed elevated levels within the implant capsule and surrounding breast tissue. However, silicon levels obtained from distant sites in augmented women were equivalent to the baseline nonaugmented cadaveric levels. There was no correlation between intact or ruptured implants and symptoms of collagen-vascular disease. In conclusion, study validates our original data of baseline silicon levels in nonaugmented cadavers. Contrary to what some may perceive as silicone floating throughout the body, we have found elevated levels around the implant only, and levels at distant tissue sites were equivalent to the baseline cadaveric data.
- Published
- 1996
- Full Text
- View/download PDF
30. Comparison of resource costs between implant-based and TRAM flap breast reconstruction.
- Author
-
Kroll SS, Evans GR, Reece GP, Miller MJ, Robb G, Baldwin BJ, and Schusterman MA
- Subjects
- Cost-Benefit Analysis, Female, Follow-Up Studies, Humans, Mammaplasty methods, Mastectomy, Postoperative Complications, Breast Implants economics, Hospital Costs, Mammaplasty economics, Surgical Flaps economics
- Abstract
Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.
- Published
- 1996
- Full Text
- View/download PDF
31. Reconstruction and the radiated breast: is there a role for implants?
- Author
-
Evans GR, Schusterman MA, Kroll SS, Miller MJ, Reece GP, Robb GL, and Ainslie N
- Subjects
- Female, Humans, Mammaplasty methods, Middle Aged, Postoperative Complications, Postoperative Period, Preoperative Care, Retrospective Studies, Breast Implants, Radiotherapy, Adjuvant adverse effects
- Abstract
The use of breast implants in irradiated patients is controversial. Recently, 39 irradiated implants were compared with 338 nonirradiated implants in 297 patients between January of 1975 and October of 1994 at The University of Texas M. D. Anderson Cancer Center. Tissue expanders and follow-up time of less than 6 months excluded patients from the study. Five groups of patients were identified. Group 1 consisted of 7 patients and 7 implants who received postoperative adjuvant radiotherapy after implant placement. Group 2 consisted of 5 patients and 7 implants who received preoperative adjuvant radiotherapy prior to implant placement. Groups 3 and 4 consisted of 2 and 12 patients (2 and 19 implants) placed beneath latissimus dorsi flaps who had postoperative and preoperative adjuvant radiotherapy, respectively. Group 5 contained 4 patients with 4 implants placed beneath a transverse rectus abdominis myocutaneous (TRAM) flap who had preoperative radiotherapy. All implants were placed submuscularly or beneath autogenous flaps. The average irradiated breast received 50 Gy. For statistical purposes, two categories were identified. Capsular contracture (Baker III or greater), pain, exposure, and implant removal in 6 of 14 implants that received radiotherapy were compared with similar complications in 33 of 266 implants without irradiation (p = 0.001). The second category contained 10 complications in 25 implants placed beneath autogenous reconstructions with radiotherapy compared with 6 of 72 similar complications in implants placed beneath autogenous reconstructions without radiotherapy (p = 0.000). Results showed that irradiation has significant negative effects on the reconstructive outcome with implants. Autogenous reconstruction did not appear to offer a protective role when placed over implants.(ABSTRACT TRUNCATED AT 250 WORDS)
- Published
- 1995
32. Lower back reconstruction: an approach to wound closure in the cancer patient.
- Author
-
Evans GR and Reece GP
- Subjects
- Female, Humans, Male, Middle Aged, Back surgery, Neoplasms surgery, Surgical Flaps methods
- Abstract
Repair of the lower back wound in the patient with cancer presents the surgeon with a plethora of challenges. Frequently, the wide range of the surgeon's armamentarium of flaps must be used to provide stable wound coverage. We present the reconstruction techniques used in five patients with cancer who had lower back wounds below T10 and of at least 100 cm2. The approach we used to evaluate the lower back wound and to determine surgical techniques and options for reconstruction is discussed.
- Published
- 1995
33. Technique for costochondral graft placement.
- Author
-
Evans GR, Clark N, and Manson PN
- Subjects
- Adolescent, Adult, Bone Plates, Bone Transplantation instrumentation, Cartilage transplantation, Humans, Internal Fixators, Joint Dislocations surgery, Male, Mandibular Fractures surgery, Ribs transplantation, Surgical Mesh, Temporomandibular Joint surgery, Vertical Dimension, Bone Transplantation methods, Mandibular Condyle injuries, Mandibular Condyle surgery, Temporomandibular Joint injuries
- Abstract
The use of costochondral grafts in the acute trauma setting is controversial. This new technique has recently been utilized in two patients with severe condylar head fractures using a newly designed Synthes AO mesh plate with microscrews (0.8 mm) and 1.5-mm fixation. The technique provides superb rigid fixation. This fixation technique is multifaceted and can be used in all settings of acute and chronic costochondral graft replacement.
- Published
- 1994
- Full Text
- View/download PDF
34. A variation in the appearance of melanoma-in-situ (Clark's level I malignant melanoma).
- Author
-
Evans GR and Manson PN
- Subjects
- Aged, Biopsy, Facial Neoplasms epidemiology, Facial Neoplasms surgery, Female, Humans, Male, Melanoma epidemiology, Melanoma surgery, Middle Aged, Skin Neoplasms epidemiology, Skin Neoplasms surgery, Facial Neoplasms pathology, Melanoma pathology, Skin pathology, Skin Neoplasms pathology
- Abstract
Recently two cases of atypical melanoma-in-situ have been treated. The role of assessing this lesion, its clinical presentation, and margins of resection is reviewed. Early diagnosis and biopsy are essential.
- Published
- 1994
- Full Text
- View/download PDF
35. Silicon tissue assays in nonaugmented cadaveric patients: is there a baseline level?
- Author
-
Evans GR, Slezak S, Rieters M, and Bercowy GM
- Subjects
- Aged, Aged, 80 and over, Cadaver, Female, Humans, Male, Middle Aged, Prostheses and Implants, Reference Values, Silicon analysis, Tissue Distribution
- Abstract
Microscopic silicone in various tissues in the bodies of females with breast implants has led to the possible incrimination of these implants with connective-tissue disorders. Current technology precludes accurate silicone measurements, but all compounds containing the element silicon (which would include silicone) may be measured accurately. Direct positive correlations of silicon assays with silicone measured levels were confirmed by adding known amounts of silicone oil as a control. With the ubiquitous nature of organosilicons (food containers, syringes, etc.), we hypothesized that baseline silicon levels could be detected in tissues of cadavers without silicone breast augmentation. Ten cadavers were examined. Tissue samples were derived from subcutaneous fat, nipple, breast tissue, liver, spleen, and axillary nodes. Nine of 10 cadavers had silicon levels in various tissues. Measurements were performed by direct current atomic emission spectroscopy. The baseline data were compared with those from four augmented patients who underwent capsulectomies and implant removal. Silicon levels were fivefold higher in the augmented patients than in the nonaugmented cadavers. No difference in levels was noted if the patient had an intact or ruptured implant and/or was symptomatic versus asymptomatic for immunologic disease. This study was designed to measure baseline silicon levels in the normal population. It also has established an accurate level of measurement of tissue silicone.
- Published
- 1994
- Full Text
- View/download PDF
36. Vascular prosthetic complications: success of salvage with muscle-flap reconstruction.
- Author
-
Evans GR, Francel TJ, and Manson PN
- Subjects
- Aged, Female, Gram-Positive Bacterial Infections epidemiology, Humans, Male, Middle Aged, Prosthesis-Related Infections epidemiology, Prosthesis-Related Infections microbiology, Reoperation, Retrospective Studies, Staphylococcal Infections epidemiology, Treatment Failure, Blood Vessel Prosthesis adverse effects, Gram-Positive Bacterial Infections surgery, Prosthesis-Related Infections surgery, Staphylococcal Infections surgery, Surgical Flaps
- Abstract
Prosthetic vascular complications such as exposure and infection represent one of the most challenging and devastating complications in surgery. Nineteen patients underwent a retrospective review of the efficacy of soft-tissue flap coverage in the management of vascular prostheses complications. These patients were divided into three groups. Group 1 included 14 patients with documented culture-positive infection. Group 2 comprised 4 patients with culture-negative exposed grafts. Group 3 included 1 patient with autogenous vein and documented culture-positive infection. The most common vascular procedure requiring flap reconstruction was aortobifemoral in groups 1 and 2. One femoral-distal reconstruction was performed in group 3. Graft complications occurred at an average of 4.8 months after vascular reconstruction in group 1, 11 months in group 2, and 1 month in group 3. Follow-up was obtained on all patients. Initial flap reconstruction was successful in 43 percent of group 1, 100 percent of group 2, and 100 percent of group 3. Reoperative therapy for flap coverage in group 1 was successful in 62.5 percent. Overall, 79 percent of patients obtained a closed wound after reconstructive attempts in group 1. Recurrence appeared to be independent of graft material, microbiology, or graft location. Debridement and muscle coverage of exposed or infected vascular grafts has produced clinical salvage.
- Published
- 1993
37. Hip joint communication with pressure sore: the refractory wound and the role of Girdlestone arthroplasty.
- Author
-
Evans GR, Lewis VL Jr, Manson PN, Loomis M, and Vander Kolk CA
- Subjects
- Adult, Female, Femur Head surgery, Hip Joint microbiology, Humans, Male, Middle Aged, Osteomyelitis complications, Osteomyelitis surgery, Postoperative Complications, Pressure Ulcer microbiology, Recurrence, Retrospective Studies, Surgical Flaps methods, Arthroplasty methods, Hip Joint surgery, Pressure Ulcer surgery
- Abstract
Fifteen patients who underwent Girdlestone arthroplasty (proximal femoral head resection) were reviewed at The Johns Hopkins Hospital and Northwestern Memorial Hospital. Ages ranged from 24 to 57 years (mean 36.7 years). All patients were paraplegics or quadriplegics (C7-L3). All patients presented with signs of sepsis and had evidence of osteomyelitis. Soft-tissue reconstruction was most commonly performed with the vastus lateralis, and no femoral stabilization was used. There were no deaths. Recurrent ulcers at the site of the Girdlestone arthoplasty were found in 23 percent of patients in whom follow-up was possible. No recurrence was noted at the original site in 77 percent with a mean follow-up of 20 months. Additional pressure sores occurred at other nonsurgical sites in six patients at a mean of 23.3 months. Girdlestone arthroplasty with soft-tissue coverage is mandatory for successful treatment of pressure sores with hip joint involvement.
- Published
- 1993
- Full Text
- View/download PDF
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