Search

Background: Infection complicating a plastic-surgery procedure can be a catastrophic event, both for the patient and the surgeon. Surveys published in 1975 and 1985 demonstrated the "usual and customary" practices of plastic surgeons with regard to the use of prophylactic antibiotics., Objective: The objective of this study was to determine plastic surgeons' current use of prophylactic antibiotics, to compare these data with similar data from 1975 and 1985, and to gain relevant information regarding newer aesthetic procedures., Methods: We conducted a survey of members of the American Society of Plastic Surgeons to elicit information on the frequency and timing of and modifying influences on their use of prophylactic antibiotics for plastic surgery procedures. The data we compiled were compared with the 1985 and 1975 data., Results: Respondents returned 1804 questionnaires, for a 35% response rate. Antibiotic usage increased by 100% in nearly half of the operative categories surveyed since 1985 (P = .001). Aesthetic procedures were most common in this group. In 7 procedures, usage increased by 200% (P = 0.001). These categories included rhinoplasty, blepharoplasty, rhytidectomy, and arm contouring., Conclusions: The use of prophylactic antibiotics by plastic surgeons is increasing, especially in aesthetic procedures. A review of the literature indicates that this increase in use is not based on scientific evidence of increased incidence of infection or on increased evidence of efficacy. The necessary data to provide scientific guidelines for antibiotic usage in plastic surgery do not exist. (Aesthetic Surg J 2003;23:177-183.).

Death is the most complex of religious issues and suicide is the most complex of philosophic issues. Our century has seen a massive technological expansion in our ability to prolong life, and unfortunately, to kill with unparalleled efficiency. Society has demanded that physicians explore with them whether death by suicide is a logical extension of palliative care. For surgeons, these profoundly spiritual concerns are, in many ways, beyond our education and training and may not be compatible with the current practice of surgery.

We all recognize and accept that adverse events occur with some frequency in surgery and that all departments meet regularly to review them. Since adverse events and "mistakes" have the potential for delaying recovery and injuring surgical patients, an ethical mandate exists to do all that can be done to prevent harm. This article suggests that there are 5 issues within the practice of surgery that have inhibited improvement in quality: (1) inadequate data about the incidence of adverse events, (2) inadequate practice guidelines or protocols and poor outcome analysis, (3) a culture of blame, (4) a need to compensate "injured" patients, and (5) difficulty in truth telling.

Pain management for partial-thickness burns and split-thickness skin graft donor sites remains a persistent problem. Topical capsaicin (trans-b-methyl-N-vanillyl-noneamide) has been successful for pain relief in postherpetic neuralgia, arthritis, and diabetic neuropathy. It is thought to work by inhibiting type C cutaneous factors and by releasing substance P, which is essential for wound healing. To evaluate the effects of topical capsaicin treatment on burn wounds and donor sites, an in vitro study was designed to consider cytotoxic effects of commercial concentrations of capsaicin on keratinocytes and fibroblasts. Human keratinocytes and human fibroblasts were grown in tissue culture and exposed to varying concentrations of capsaicin (0.025% weight/volume to 0.2% weight/volume). In addition, fibroblast-seeded collagen matrixes were exposed to capsaicin to evaluate the compound's ability to cause cytotoxic effects beneath the surface. Keratinocyte growth was reduced 21% to 31% in commercial concentrations of capsaicin 0.025% to 0.20% weight/volume. Fibroblasts were reduced 5% to 10% during the first 6 hours of exposure to capsaicin and 30% after 24 hours across the full range of concentrations tested. At concentrations of at least 0.1% weight/volume, capsaicin penetrated the collagen matrixes, resulting in fibroblast degeneration not only on the surface but also in the inner layers. On the basis of the fact that capsaicin was demonstrated to be cytotoxic to keratinocytes and fibroblasts and on the basis of its known detrimental effect on wound healing, it does not appear that topical capsaicin is indicated for the treatment of burns.

Plastic surgery residency programs often rely on a residents' aesthetic clinic to help train residents in aesthetic surgery. The television media may be used to help boost interest in such clinics. We report our experience with a local television station in helping to produce a "health segment" broadcast that chronicled the experience of an aesthetic patient in the residents' aesthetic clinic. As a result of this broadcast, approximately 150 people responded by telephone and subsequently attended a series of seminars designed to screen patients and educate the audience about the aesthetic clinic. A total of 121 patients (112 women and 9 men) signed up for personal consultations. The age distribution and requested procedures are presented. From the data, we conclude that there is a healthy demand for reduced-fee plastic surgery procedures performed by residents in plastic surgery. The number and variety of cases generated are sufficiently diverse to provide a well-rounded operative experience. The pursuit of media coverage of a not-for-profit clinic has the potential for generating large patient volume. Such efforts, although very attractive, are not without their own risks, which must be taken into consideration before engaging the media in the public interest arena.

To clarify the significance of the role of the immune system in the formation of proliferative burn scars, this study attempted to identify differential production of cytokines between patients with burn injuries with and without hypertrophic scars. Mononuclear cell fractions were isolated from the peripheral blood (PBMC) of each patient and incubated with and without antigenic or mitogenic stimulation. The resultant supernatants were then assayed by ELISA techniques for production of various cytokines. The production of IL-1, IL-6, TNF-alpha, and TGF-beta2 by unstimulated PBMC was elevated significantly in patients with proliferative scar compared to control patients. Production of TGF-beta2 by stimulated PBMC also was elevated significantly in patients with proliferative scar. This study suggests that an increase in the production of TGF-beta and of proinflammatory cytokines by mononuclear cells may play a significant role in the processes that lead to excessive scar formation after burn injury.

The essential prehensile nature of the human hand rests on the presence of a mobile, sensate thumb with adequate stability and length. The true significance of the thumb-to-hand function is variable and dependent on a person's vocation, expectations, and needs. The frequently stated opinion that the thumb represents 40% of hand function is too exacting and does not allow for flexibility in evaluating a patient's requirements after thumb injury or loss. It is our approach to consider each patient's specific needs for individualized planning of thumb reconstruction. The patient can often offer useful information regarding need for strength vs. precision, width of hand vs. requirements for fine motor function, and concern for the aesthetic nature of an abnormal thumb vs. the variable deformities resultant from thumb reconstruction. We offer a review of the basic anatomy and physiology of the human thumb, with emphasis on hand-and-thumb function. We present the alternatives for thumb reconstruction, the advantages and disadvantages, and the relationships to a specific patient's needs. Clinical examples of various methods of thumb reconstruction, including metacarpal lengthening, phalangization, osteoplastic reconstruction, pollicization, and toe-to-hand transfer are provided.

The safety of augmentation mammaplasty and its relationship to breast cancer has been a much debated topic. The authors previously showed a decreased incidence of breast cancer in rats who had received silicone implants 2 weeks before carcinogen stimulation. The present study was designed to determine (1) whether this protective effect is influenced by the location of the implant, and (2) whether tumor incidence could also be altered in spontaneous mammary tumor-forming animals, the C3H/OuJ mice. (1) A total of 110 rats received either a silicone implant or a sham operation in one of three locations: inframammary region, dorsum, or intraperitoneal cavity. Methylnitrosoured (MNU) injections occurred 14 days after implantation. Animals were examined weekly for tumor growth and were killed 250 days after MNU injection. Animals with silicone implants beneath the mammary gland had a statistically significant lower incidence of breast cancer formation (11.5 percent) compared with both dorsally implanted animals (45.8 percent) and sham controls (64 percent). (2) Sixty C3H/OuJ mice underwent implantation of either a silicone implant, free silicone gel, silicone sheet, or a sham operation. At 50 weeks of age, after weekly examinations, the animals were killed. The cancer incidence in mice with silicone implants was 17 percent compared with 50 percent found in sham controls. Exposure to a silicone prosthesis at an early age does not seem to increase tumor incidence and may even have a locally protective effect against breast cancer formation.

Biobrane remains an excellent biosynthetic dressing for thermal injury coverage. The present report of a probable case of toxic shock syndrome associated with its use does not question its efficacy as temporary coverage for partial thickness thermal burns. Instead, attention is focused on raising the index of suspicion of toxic shock syndrome in burn patients treated with Biobrane, or other occlusive dressings, who develop early signs or symptoms which may be consistent with the diagnosis.

The standard approach to loss of substantial amounts of calvarium and dura is replacement of the dura with pathches, usually of biologic material such as fascia. We question the need for such patches and offer experimental and clinical evidence to support a different approach. Treatment of large calvarium and dural defects in 20 rats divided in two groups showed no difference in dural regeneration between animals repaired with patches and those repaired with the scalp flap only onlay on the brain. An illustrative clinical case confirms the observations. The scalp flap only onlay repair of cranial defects involving the dura provides a reasonable means for reconstruction. (1) In experimental animals there appeared to be no histologic difference between dura repaired by autogenous patch and that repaired by the scalp flap only onlay. (2) Clinically, well-nourished galea effects an ideal onlay repair of the dura. Secondary reconstruction of the bony calvarium can be performed utilizing a modified crane technique. (3) The procedure is simple in design, requires no donor sites, and certainly has application in cases other than trauma.

We review 230 cases of tropical ulcers, includied reports of 7 cases with squamous cell carcinoma. We think the etiology may be a combination of the hot, humid environment, trauma, local infection, and malnutrition. Agressive treatment of these ulcers is advocated, to heal the wounds and to prevent malignant transformation.

Toxic epidermal necrolysis resulting from severe hypersensitivity to medication has a reported mortality of up to 66%. A patient surviving two episodes with more than a 50% skin loss is unprecedented in the medical literature. Mortality has been associated with many factors, including delayed reepithelialization, persistent skin slough, coagulopathy, severe hypoproteinemia, and sepsis. It may be possible to decrease morbidity and mortality by preventing the shearing of epidermis, thereby limiting the denuded areas. This case report describes the successful management of our patient's second episode of toxic epidermal necrolysis. The treatment of this patient in our specialized burn center consisted of careful fluid and electrolyte management, nutritional support, standard topical antimicrobials, and new modalities of local wound management.

Blood drawing through the fingerstick technique is growing in popularity. Generally considered harmless, it is widely used both in hospitals and at home for monitoring blood glucose concentrations. We report 2 cases of hand infections requiring surgery that resulted from fingerstick blood glucose concentration determinations in immunosuppressed patients. This potentially serious side effect of using the fingerstick technique may be minimized by drawing the blood from the volar forearm or from other areas of the body.

In an era of modern radiotherapy, problems associated with the indiscriminate treatment of benign disease have largely disappeared. Skin sparing effects of super voltage radiation equipment make the problems previously seen with orthovoltage equipment less frequent. Vigilance on the part of the workers in the field, in general, protects from the disasters that befell Thomas Edison's laboratory assistant. Despite these modern advances, the reconstructive surgeon often faces problems of managing acute local radiation injury from accident following planned therapeutic radiation or the ulcerations and breakdowns seen months or years after radiation therapy. The single most serious hazard to surgery in radiated tissue is the lodgment of bacteria in this tissue rendered avascular by the radiation and secondary necrosis from the infection itself. The principles of management are no different from those used for other chronic granulating wounds: local wound care, appropriate topical antibacterial therapy, systemic antibiotics during the perioperative period and, most importantly, adequate soft tissue coverage.

The history of scalp avulsions is presented, and one case is reported. A treatment plan for scalped patients is outlined.

The cleft lip nasal deformity is a result of imbalance of the structures caused by a collapsed alar cartilage, a widened nostril floor, and a lowered nasal orifice. This deformity can be corrected most readily by repositioning and supporting the collapsed alar cartilage of the cleft side. A technique has been developed to achieve this by releasing the ala from the nasolabial fold, elevating and supporting the alar cartilage, and repositioning the alar rim on its new deepithelialized base. One- to two-year follow-up of seven patients who underwent such repair has demonstrated satisfactory correction of the deformity.

A questionnaire designed to determine the pattern of usage of prophylactic antibacterials, similar to one used a decade ago, was distributed to plastic surgeons, of whom 1718 responded. The pattern of antibacterial use in 8 major categories and 55 separate operations and circumstances was reviewed. The timing and the influence of various modifying factors was evaluated. The data present the pattern of antibacterial use by plastic surgeons at this point and time, that is, what is "usual and customary".

Our initial experience with the lower rectus abdominis procedure for breast reconstruction in 19 patients is presented. Anatomic considerations, surgical technique, and results are reviewed. Errors in flap design and execution resulted in a disproportionately high complication rate, which improved following certain technical refinements. The lower rectus flap has proved to be an alternative to conventional techniques of breast reconstruction. As more experience is gained with this flap, its particular role in the reconstructive armamentarium will be more clearly defined.

A questionnaire distributed to plastic surgeons to determine their patterns of usage of systemic prophylactic antibacterial agents was answered by 1,025 respondents (73.7 percent). The patterns of usage among the respondents were determined for 29 circumstances and operations for the time of administration, and as influenced by 11 modifying factors. The data present the patterns of antibacterial use by plastic surgeons at this time.

A residency program for physician assistants (PAs) on a surgical service was undertaken to develop health professionals who could serve in a capacity similar to that of junior surgical residents helping to deliver preoperative and postoperative care under the supervision of surgeons and assisting in operations. As the number of approved surgical residencies and the number of individuals available for residency has decreased, a manpower void is occurring in some institutions in providing in-house services to surgical patients. The use of medical or family practice residents or full-time in-house surgeons is not totally satisfactory. A PA with special training in surgical case management and operative assisting meets many needs previously provided by surgical residents. The surgical PA is, indeed, a surgeon extender and seems, from our three-year experience, to be a good solution to this problem of surgical care in community hospitals. This program also provides an educational mission for the institution and the surgical staff.

Dependent upon the age, the occupation, and the requisites of an individual patient, the less important ulnar fingers may be of great value; in these the philosophy of discriminate preservation should be given considerable weight in the choice of treatment. Revascularization of fingers injured by a ring avulsion, and restoration of tactile gnosis with esthetic coverage make salvage of the valued ulnar fingers feasible. Three illustrative cases are described.

It is a biologic fact that all open wounds contain bacteria and remain contaminated with varying levels of bacteria until successful wound closure has been accomplished. The sine qua non in the management of the contaminated wound has been and remains adequate sharp debridement. In a standardized experimental model, three methods of irrigation were compared employing quantitative bacteriology of tissue to evaluate their effectiveness at decreasing bacterial levels and reducing wound infection. The pulsating jet lavate was found to be significantly better than gravity flow irrigation or wound irrigation with a bulb syringe. These data on tissue biopsies support previous reports using surface and wound exudate cultures.