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Biomedical subjects

D P Orgill

Publications and source records attributed to D P Orgill.

At least 37 records · Page 2Linked to original sources
PubMed1997

Single-stage, multimodality treatment of soft-tissue sarcoma of the extremity.

The present study describes the techniques available for single-stage sarcoma resection, soft-tissue reconstruction, and radiotherapy for limb preservation in patients who are unable to undergo primary wound closure after a complete soft-tissue resection of their primary sarcoma. From 1989 to 1994, 19 patients (age range, 18-79 years; mean, 51.2 years) underwent radical resection of extremity sarcomas followed by immediate reconstruction. Seven patients had tumors in the upper extremity and 12 patients had tumors in the lower extremity. There were 13 primary tumors and 6 recurrent tumors. Fifteen patients (79%) received radiation therapy, 7 patients by external beam and 8 patients by brachytherapy. Reconstruction included 16 regional flaps in 13 patients and 7 free tissue transfers in 6 patients. Commonly used flaps included the rectus abdominis (N = 5), the latissimus dorsi (N = 4), the anterolateral thigh (N = 4), the reverse-flow radial forearm (N = 2), and the gastrocnemius (N = 2) flaps. Complications included wound breakdown (N = 2), partial skin graft failure (N = 1), hematoma requiring operative evacuation (N = 1), and partial flap necrosis (N = 1). There were no operative mortalities. Eight patients underwent wide local excision, flap closure, and brachytherapy. Mean length of hospital stay for this group was 12.3 days compared with 13.8 days for the remaining 11 patients. There was one complication (13%) in this group and four complications in the remaining patients (4 of 11; 36%). Our study confirms the utility of soft-tissue reconstruction to permit wide local excision with clear margins as well as the delivery of postoperative radiotherapy. It demonstrates the ability of pedicled flaps and free tissue transfers to remain viable and provide sufficient wound coverage in the setting of early postoperative brachytherapy. In addition, this series illustrates the efficacy of a team approach and one-stage therapy for extremity soft-tissue sarcomas that includes excision, reconstruction, and early postoperative brachytherapy in a single hospitalization.

Adolescent↗
PubMed1997

Flap closure of postpneumonectomy empyema.

Empyema continues to be an uncommon, frustrating, and potentially lethal complication of pneumonectomy. Between 1990 and 1994 we treated 16 cases of recalcitrant postpneumonectomy (partial or total) empyema with combinations of pulse lavage, sharp debridement, muscle flaps, myodermal flaps, and thoracoplasty. We performed 11 pectoralis muscle flaps, 6 serratus anterior muscle flaps, 9 latissimus dorsi muscle flaps, 6 rectus abdominis muscle flaps, and 1 trapezius muscle flap for an average of 2.1 muscle flaps per patient. There was 1 omental flap. Of these flaps, 2 were free and the rest pedicled. Ten of the muscle flaps carried deepithelialized cutaneous paddles, and 6 were larger than 150 cm3. Thoracoplasty was done in 11 patients to decrease the volume of the postpneumonectomy empyema cavity. Of 16 patients, 4 failed initially because of persistent bronchopleural fistula or infection but resolved after one additional procedure. There was 1 perioperative death, 3 reoperations for bleeding, 1 patient with upper extremity deep vein thromboses, 1 seroma, and 1 patient with significant postoperative pain syndrome. In order to determine the efficacy of different operative approaches, patients were retrospectively divided into two groups according to the number of operations using flaps needed to resolve their postpneumonectomy empyema. Group A required only one operation using flaps to eliminate the postpneumonectomy empyema. Group B required two operations using flaps to remedy the postpneumonectomy empyema. Group B operations were further classified into B1, for the first operation, and B2, for the second operation. No patient needed more than two operations using flaps. Three significant variables were identified, the number of muscle flaps, the number of ribs in any thoracoplasty, and the preoperative serum albumin level. The A and B2 groups had significantly more muscle flaps transposed (p = 0.006) and ribs resected (p = 0.0002) than the B1 group. These findings suggest that filling the postpneumonectomy empyema space with muscle and collapsing any remaining space by thoracoplasty were the most successful strategy. The B2 group's average albumin level was significantly higher (p = 0.03) than that in either the A or the B1 group, suggesting that improved nutrition may have played a role in the lack of recurrence. Our goals of single-stage closure and decontamination of empyema cavities were best achieved by following these principles: removal of infected and necrotic tissue using sharp debridement and pulsed lavage, repair of bronchopleural fistulas with muscle flaps, and minimization of the dead space with combinations of muscle flaps and thoracoplasty.

Adult↗
PubMed1997

Ear replantation without microsurgery.

Reconstitution of the amputated ear remains a challenge to the plastic surgeon. Reattachment as a composite graft of the total or subtotal amputated ear is unreliable. Microsurgical replantation can be performed in a minority of cases; however, difficulty with adequate venous drainage complicates the technical complexity of these cases. To enhance survival of a reattached ear segment, Mladick et al. advocated use of the retroauricular pocket principle. This technique involves deepithelialization of the amputated part, followed by anatomic reattachment to the amputation stump and then burial in a retroauricular pocket. This simple technique increases the surface area of the avulsed segment in contact with surrounding nutrients, maximizing the probability of "take." The relationship between the dermis and cartilage is preserved, thus minimizing the deformity from cartilage warping. The undisturbed dermis on the involved segment can reepithelialize spontaneously, negating the need for a skin graft. We have used this technique successfully in five of six patients.

Adult↗
PubMed1996

Autopenetrating hernia: a novel form of traumatic abdominal wall hernia--case report and review of the literature.

Traumatic abdominal wall hernias remain relatively rare entities despite the increased incidence of blunt trauma. Mechanisms reported in the literature include a combination of a sudden increase in intra-abdominal pressure and powerful shear forces applied to the abdominal wall. These hernias are noteworthy in that they may be associated with significant intra-abdominal injuries. We describe a novel form of traumatic hernia with a unique mechanism. A blunt force leads to the fracture of a rib and penetration of the abdominal wall by the jagged costal remnant, creating a hernia defect. This autopenetrating hernia is presented in the context of a classification scheme for traumatic abdominal wall hernias.

Accidents, Occupational↗
PubMed1996

Traumatic avulsion and reconstruction of the midface.

Traumatic loss of midface soft tissue and supporting structures may result in communication between the oral and nasal cavities. Reconstruction requires both oral and nasal lining, as well as supporting structures. The need for multilaminar tissue, as well as the paucity of local tissue, creates a reconstructive challenge. This case report describes the reconstruction of a traumatic defect of the alveolus, hard palate, inferior orbits, and local soft tissues. An intraoperative alginate mold facilitated a three-dimensional understanding of the wound, and allowed translation of an osseomyocutaneous groin flap to reconstruct the defect in one stage.

Adult↗
PubMed1995

Tropical pyomyositis presenting in the upper extremity.

Tropical pyomyositis is a staphylococcal infection, usually of a single large muscle, most commonly seen in young men in tropical regions. The following presents a case of tropical pyomyositis in a 62-year-old man that affected all four extremities, including the muscles of the forearms. Computed tomography was a useful guide for directing surgical explorations. To decrease the degree of disability from the multiple operative sites, we successfully used limited longitudinal incisions and conservative débridements.

Arm↗
PubMed1995

Congenital fibrosarcoma masquerading as lymphatic malformation: report of two cases.

Two infants presented with a congenital cervicothoracic mass; both were initially diagnosed as having lymphatic malformation. A biopsy specimen for one child and excision for the other showed that both lesions were congenital fibrosarcomas. Postoperative chemotherapy was administered to both children. One died within 6 months of incisional biopsy from widespread metastatic disease; the other is still being treated. Congenital fibrosarcoma can be confused in its clinical presentation, radiographic findings, and histopathology with lymphatic malformation (cystic hygroma).

Axilla↗
PubMed1995

Use of the innervated platysma flap in facial reanimation.

The innervated platysma musculocutaneous flap replaces facial tissue with like tissue. The thinness of the flap, the color match, and the presence of functional subcutaneous muscle are unmatched by any other flap that does not originate on the face. The superior blood supply is reliably provided by the submental branch of the facial artery, creating a reliable axial flap. Rotation of the muscle into the cheek aligns the fibers of the platysma muscle to provide upward pull on the oral commissure to assist with facial animation. Three cases of innervated platysma flap rotation to reconstruct the contour of the cheek and assist with facial animation are reported. All the patients achieved an improved facial contour and all flaps demonstrated noticeable contraction, augmenting facial animation.

Adult↗
PubMed1995

Anterolateral thigh free flap.

The descending branch of the lateral femoral circumflex artery is a large-caliber artery that passes obliquely across the upper third of the thigh and descends between the vastus lateralis and rectus femoris muscles. It sends perforators through the septum between these muscles and through the vastus lateralis muscle and supplies a large area of skin on the anterolateral aspect of the thigh. We report our experience with our first 44 consecutive anterolateral thigh flaps, which were used for a variety of soft-tissue deficits. Twenty-five of these flaps were used for lower extremity reconstruction. 10 were used in the upper extremity, and 9 were used in the head and neck. The overall success rate was 96%. Six flaps required reoperation; of these, 2 flaps were lost, one from a venous thrombosis and the other from arterial thrombosis, both of which were in the lower extremity. In approximately one third of cases, the flap was raised as a septofasciocutaneous flap, but in two thirds it was necessary to include a small segment of vastus lateralis muscle as well as fascia with the flap. The flap has been particularly useful for lower extremity reconstruction, and in patients who are not fit for general anesthesia, it is possible to perform the flap transfer with epidural anesthesia. The flap has the advantage of a long vascular pedicle with large-caliber vessels and thus is suitable as a flow-through flap. It may also be sensate and has provided a versatile soft-tissue coverage option with minimal long-term donor-site complications.

Adolescent↗
PubMed1994

Local fasciocutaneous flaps for olecranon coverage.

In 1989 we began to treat soft-tissue defects around the olecranon process with local fasciocutaneous flaps as our preferred method of treatment. These soft-tissue defects are complications of bursitis, degenerative joint disease, and burns. They may also result from pressure necrosis over the olecranon in patients with impaired sensation. Because of the difficulty in treating these wounds a variety of local muscle, musculocutaneous, fasciocutaneous, distant, and free flaps have been described. Fasciocutaneous flaps have the advantage of using regional tissue in a single stage. Fasciocutaneous flaps around the elbow can be categorized as proximally or distally based. Proximally based flaps include the radial and ulnar forearm flaps as well as the posterior interosseous flap. Distally based flaps are based on upper elbow collaterals including the radial collateral artery, the middle collateral artery, and the anterior and posterior ulnar recurrent arteries. Eleven fasciocutaneous flaps were used in 10 patients with a follow-up of 1 to 3 years. All flaps survived and provided primary wound closure. Complications included 1 patient with recurrent ulceration after being healed for 6 months and 1 patient with a transient neuropraxia of the posterior interosseous nerve that resolved after 2 weeks. These flaps provide long-term stable coverage of olecranon wounds by using regional tissue with an acceptable donor site morbidity.

Adult↗
PubMed1994

Reverse peroneal flaps: two surgical approaches.

The peroneal vascular pedicle supplies the posterolateral aspect of the lower limb and can be used in a reverse-flow manner to reliably cover wounds of the lower third of the leg and ankle. Two surgical approaches may be used, medial and lateral, to treat a variety of soft-tissue deficits. For the medial approach, the patient is positioned supine and the flexor hallucis longus muscle along with the peroneal vascular pedicle is raised. This easily covers medial malleolar or distal anterior tibial defects. For the lateral approach, the patient is positioned prone and a fasciocutaneous flap is dissected and can be used to cover soft-tissue defects down to the proximal foot and ankle. A total of 13 patients underwent reverse peroneal flaps with a follow-up of 6 months to 3 years. All patients healed their wounds, but there were minor wound complications in 4 patients. When used in a reverse-flow manner, the peroneal vascular system can allow for a wide variety of flap designs to treat selected patients.

Adult↗
PubMed1994

Early clinical experience in endoscopic-assisted muscle flap harvest.

Two cases of endoscopic-assisted muscle harvest for lower extremity reconstruction are presented. Each case involved resurfacing the distal leg and dorsum of the foot with a split-thickness skin graft over a latissimus dorsi free flap. An endoscope with a video monitor and modified thoracoscopic instruments were used to assist in the muscle harvest. The principles of endoscopic muscle harvest include an incision long enough to remove the muscle, placed in the least conspicuous area that is within the reach of the instrumentation; retraction to optimize the optical cavity or visual working area; and use of video monitors to allow for coordinated assistance. The decrease in visible scarring is dramatic and represents the primary advantage over open techniques. We believe that the role of endoscopy will continue to expand as our experience increases and technology improves.

Adult↗
PubMed1990

Partial dermal regeneration is induced by biodegradable collagen-glycosaminoglycan grafts.

We have sequentially documented the early morphologic events that result in partial regeneration of the adult guinea pig dermis. This phenomenon occurs when a full-thickness skin wound is grafted with a highly specific collagen-glycosaminoglycan (CG) copolymer which has been seeded with autologous dermal and epidermis cells (Yannas IV, Lee E, Orgill DP, Skrabut EM, Murphy GF, Proc Natl Acad Sci USA 86:933-937, 1989). By day 7, ultrastructural analysis disclosed highly organized associations between mononuclear cells and CG fibers involving prominent extension of pseudopod-like processes toward the fiber surface. Spatial organization of cells was not evident in ungrafted wounds. By day 10, more than 50% of the CG grafts had been degraded and extensive neovascularization was observed in various stages of formation. By day 14, dermal fibroblasts in the graft site demonstrated random alignment of long axes, and a minor fraction (less than 10%) exhibited features of myofibroblasts. A majority (greater than 50%) of dermal fibroblasts in ungrafted wounds were identified as myofibroblasts at this time, and their axes were regularly aligned in parallel with the overlying epidermal layer. Scattered CG copolymer fragments were engulfed by macrophages by day 14, and complete dissolution occurred by day 21. Dermal blood vessels formed a discrete, subepidermal plexus oriented parallel to the epidermal plane by days 14 to 17 in grafted wound beds but not in ungrafted ones. Progressive, randomly oriented collagen deposition occurred at graft sites during the 1st year, whereas collagen fibers in ungrafted wounds were aligned in a horizontal plane atypical of a forming scar. By 1 year, the graft sites resembled normal dermis, with well-defined dermal papillae, normal anastomosing superficial vasculature, nerve fibers, and random collagen fiber morphology. Wound sites at this juncture resembled a mature scar, with a flattened dermal-epidermal interface; rare and disorganized vessels and nerves; and collagen fibers parallel to the epidermis. This investigation demonstrates the critical importance of highly specific extracellular matrix in induction of dermal morphogenesis.

Animals↗
PubMed1989

Synthesis and characterization of a model extracellular matrix that induces partial regeneration of adult mammalian skin.

Regeneration of the dermis does not occur spontaneously in the adult mammal. The epidermis is regenerated spontaneously provided there is a dermal substrate over which it can migrate. Certain highly porous, crosslinked collagen-glycosaminoglycan copolymers have induced partial morphogenesis of skin when seeded with dermal and epidermal cells and then grafted on standard, full-thickness skin wounds in the adult guinea pig. A mature epidermis and a nearly physiological dermis, which lacked hair follicles but was demonstrably different from scar, were regenerated over areas as large as 16 cm2. These chemical analogs of extracellular matrices were morphogenetically active provided that the average pore diameter ranged between 20 and 125 microns, the resistance to degradation by collagenase exceeded a critical limit, and the density of autologous dermal and epidermal cells inoculated therein was greater than 5 x 10(4) cells per cm2 of wound area. Unseeded copolymers with physical structures that were within these limits delayed the onset of wound contraction by about 10 days but did not eventually prevent it. Seeded copolymers not only delayed contraction but eventually arrested and reversed it while new skin was being regenerated. The data identify a model extracellular matrix that acts as if it were an insoluble growth factor with narrowly specified physiochemical structure, functioning as a transient basal lamina during morphogenesis of skin.

Animals↗
PubMed1982

Wound tissue can utilize a polymeric template to synthesize a functional extension of skin.

Prompt and long-term closure of full-thickness skin wounds is guinea pigs and humans is achieved by applying a bilayer polymeric membrane. The membrane comprises a top layer of a silicone elastomer and a bottom layer of a porous cross-linked network of collagen and glycosaminoglycan. The bottom layer can be seeded with a small number of autologous basal cells before grafting. No immunosuppression is used and infection, exudation, and rejection are absent. Host tissue utilizes the sterile membrane as a culture medium to synthesize neoepidermal and neodermal tissue. A functional extension of skin over the entire wound area is formed in about 4 weeks.

Adolescent↗
PubMedDate not supplied

Perfusion of medium improves growth of human oral neomucosal tissue constructs.

Tissue engineering of the oral mucosa may be useful in congenital cleft palate repairs, defects following extirpative oncologic surgery, and periodontal disease. One of the limitations of in vitro growth of oral mucosal constructs is central necrosis of 3-dimensional tissues. We tested the hypothesis that medium perfusion would enhance oral mucosal histogenesis in vitro. Normal human oral keratinocytes were obtained from young to middle-aged adults. Porous 3-dimensional matrices were prepared from collagen and chondroitin sulfate with some crosslinked with glutaraldehyde. Each device was seeded with 5.0 x 10(5) human oral keratinocytes. The seeded matrices were cultured with or without perfusion of medium at 1.3 ml/min. Histologic analysis of samples cultured for 3, 7, or 14 days showed superior viability and proliferation when perfused. At day 7, the average number of cell layers of the neoepithelium of sponges in the perfused culture system (9.4 +/- 1.0) was 88% greater than for the nonperfused culture system (5.0 +/- 0.9, p<0.005). Glutaraldehyde crosslinking did not influence cellular proliferation or the extent of matrix's shrinkage in either culture system. This study shows that medium perfusion enhanced cell viability and proliferation of human oral keratinocytes cultured in porous 3-dimensional matrices.

Cell Division↗
PubMedDate not supplied

Debridement of porcine burns with a highly purified, ananain-based cysteine protease preparation.

A novel enzymatic debriding agent was evaluated on experimental full-thickness porcine contact burns. This agent consists of a highly purified, ananain-based, cysteine protease preparation formulated in a hydrophilic cream vehicle. Debridement of full-thickness burns was found to be dependent on several factors including the concentration of enzyme in the vehicle, the duration of treatment, and the hydration status of the burn wound before treatment. With an optimized debridement regimen, burns were consistently debrided of all gelatinized tissue with two 5-hour treatments. Histologic evaluation of the debrided wounds revealed an acellular deeper dermis that was debrided of necrotic cellular debris; however, the collagen matrix of the deeper dermis remained intact. This observation was consistent with a demonstrated in vitro specificity of the ananain-based protease for gelatin over collagen. A direct comparison of debridement efficacy with sutilains ointment, showed the ananain-based, debriding enzyme preparation to provide more rapid debridement of gelatinized tissue. Enzymatically debrided wounds exhibited graft take only after surgical excision of approximately 1 mm of the remaining acellular, avascular dermis. This highly purified enzyme preparation offers the potential for rapid nonsurgical debridement of gelatinized burn tissue, but required additional surgical debridement for graft take in this porcine model.

Animals↗