Biomedical subjects
Publications and source records attributed to E A Luce.
Although excision of nonmelanotic skin cancer carries a high cure rate, a potential exists in a small percentage of patients for not only significant morbidity, but mortality as well. Some prognostic variables and clinical guidelines have been developed that can be applied to individual patients.
Scalp and skull defects can be very difficult to reconstruct. Whereas small defects may require only primary closure, skin graft, or small rotation flaps, large defects involving full-thickness scalp can be much more problematic. These large defects may require free-tissue transfer for adequate soft-tissue coverage. The calvaria also may require reconstruction. If the underlying bone is not infected, it can be left in situ and covered with well-vascularized tissue. The bone should be removed only if it is infected. Calvarial reconstruction should then be delayed for 3 to 6 months. If the tissue has been irradiated, only selected defects are appropriate for coverage with local scalp flaps because adjacent tissues may have underlying damage. With a methodic, accurate assessment of the defect, successful reconstruction can be expected.
Midfacial and orbital defects after ablative oncologic surgery are difficult problems for the reconstructive surgeon. Our goal is to address the devastating functional and aesthetic consequences of these extirpations and to improve the quality of life for this unfortunate group of patients. Partial maxillectomy defects are best treated by skin grafting the residual cavity and reconstructing the maxillary defect by prosthetic means. Local tissues can be used when the defects are small and the bone loss is not extensive. For massive midfacial defects with insufficient bony support for prosthetic reconstruction, osseocutaneous free flaps have proved useful to restore contour and the necessary structural support.
A multitude of reconstructive options are possible for the patient afflicted with an intraoral malignancy. The reconstructive technique chosen depends on the stage of the disease and the extent of the soft- and hard-tissue defects after extirpation. A graded approach is applied to reconstruction. If local tissues are not available for reconstruction, the surgeon must look to more distant sites in choosing a reconstructive procedure. Microsurgical transfer of composite tissues have allowed us a high degree of success in effecting immediate one-stage closure of complex three-dimensional wounds.
Free tissue transfer has become a useful technique for reconstructing complex three-dimensional defects following the extirpation of head and neck malignancies. This technique, however, may be limited by inadequate vascularity in the recipient site when a patient has been subjected to operative procedures or radiation therapy. The use of serial flaps, with the first flap connected sequentially to the second, reduces the need for dual recipient vessels in a surgical field when two flaps are required for reconstruction. Although this procedure is more technically demanding than more traditional approaches, it can provide a satisfactory, reliable one-stage composite reconstruction under these difficult circumstances. Results have been functionally and aesthetically superior to those achieved with pedicled one-flap reconstructive methods.
Currently, several specialties (cardiothoracic, pediatric, and colorectal) require a full general surgery residency before specialty training. Plastic surgery has, in essence, a de facto requirement since most residents have had at least 5 years of general surgery training before initiation of a plastic surgery residency. Forces within both general surgery and plastic surgery will dictate that such a de facto requirement will not persist in the future. The pressures that compel plastic surgery to modify the traditional role of general surgery as preparatory training for requisite or specialty residency training can be extended by analogy to the other specialties as well. This article will hypothesize that the premises and the conclusions about the relationship between plastic surgery and general surgery apply equally well to the other specialties. If the traditional and historical role of full general surgery residency as prerequisite training for a specialty residency is discarded, careful thought must be given to any substitute system to graduate surgical education. In particular, attention must be directed to the three components of clinical skills to be acquired and to an expectation of operative or technical experience.
Advocates of chemotherapy plus radiation as the definitive treatment for patients with advanced laryngeal cancer often cite older studies that attribute cure rates of less than 50% to laryngectomy plus radiation. The outcomes of patients with stage III and IV laryngeal and pyriform sinus carcinoma from 1980 to 1989 (96 patients) were compared with those of patients treated from 1962 to 1977 (84 patients). Demographics, the extent of disease, and nodal involvement were similar between the groups. There were more operative complications (45% versus 22%; p < 0.01) and deaths (10% versus 2%; p < 0.01) in the patients who underwent irradiation preoperatively. Overall survival was improved in the recent group compared with the early group (73% versus 54% at 5 years; p < 0.03), as was disease-free survival (64% versus 38% at 5 years; p < 0.02). Results of treatment for advanced laryngeal and pyriform sinus carcinoma have improved significantly. These modern results should be used to evaluate newer treatment modalities.
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The last decade has witnessed a tremendous evolution in the management of maxillary fractures--an evolution that mirrors an overall more aggressive contemporary approach to complex maxillofacial trauma. This article briefly reviews past contributions to the current management of these fractures, the author's approach to management, and the future of this continually improving field.
The appropriate method and timing of the management of the myelomeningocele defect have prompted considerable discussion. Use of split-thickness skin grafts acutely has accomplished wound closure with low morbidity and mortality. This study was designed to address the question of long-term suitability of the technique of split-thickness skin grafting of the myelomeningocele patient. The incidence of late and/or severe skin ulceration and the presence of gibbus deformity were correlated with the method of skin closure. Long-term follow-up revealed a higher incidence of chronic skin ulceration in the split-thickness skin graft group as compared with the primary closure group. All skin breakdowns appeared in the presence of a gibbus deformity, and gibbus deformity was more prevalent in the split-thickness skin graft group. The incidence of skin ulceration and gibbus deformity was site-dependent. A thoracic or thoracolumbar myelomeningocele repair with split-thickness skin graft was significantly more likely to be complicated by skin problems than the defect in the lumbar, lumbosacral, or sacral region. This relationship was secondary to the frequency of gibbus deformity in the more cephalad defects than defects caudad. A treatment plan is outlined that is based on the primary variable of the location of the myelomeningocele and secondarily by defect size.
Four cases of total lip and chin reconstruction are presented. In three, the composite radial forearm-palmaris longus free flap was used for reconstruction. In the fourth case, the palmaris longus was separated from the flap but still used as a lower lip sling. In all cases, the entire lower lip and the soft tissue of the chin were reconstructed in one stage. All patients healed primarily, and the three who underwent radiotherapy tolerated it without complications. Lip seal and speech were good, and there was no problem with drooling. Postoperative results emphasize the importance of respecting the aesthetic unit of the lower lip and chin.
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If a multiply injured patient with severe head injuries, intra-abdominal and intrathoracic injuries is admitted, the diagnosis and management of the facial fractures may be shunted into the background. With the tremendous methods of modern medicine at hand, we are adequately able to resuscitate, treat, and discharge those patients. If the maxillofacial injuries go undiagnosed or untreated, the patient is left with some fairly significant sequelae in function and appearance that are difficult to treat on a delayed basis. Initial management of those injuries can be done concomitantly with management of the other serious life-threatening injuries and a successful outcome achieved. The traditional approach of waiting "until all the swelling goes down" before definitive correction of bony or soft tissue problems are addressed, has been shown to produce inadequate and disabling results both from a structural and functional viewpoint. Following the first or at most second week after injury, the process of bone healing and scar formation have usually progressed quite quickly. This is especially true in children who normally have a very high metabolic rate. A displaced facial fracture not corrected during the initial "golden" period will require major manipulation and even refracture in order to adequately reduce the segments into the proper position and a less satisfactory result than acute management. Similar considerations with respect to the skin and soft tissues are also important. Once scar tissue has formed it becomes very difficult to restore normal or near-normal appearance.(ABSTRACT TRUNCATED AT 250 WORDS)
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The effect of pentoxifylline, a hemorheological agent that increases erythrocyte flexibility and augments capillary blood flow, on the survival of the dorsal skin flap of the rat was studied. An experimental group received intraperitoneal injections of pentoxifylline twice daily, 50 mg/kg/day, and a control group was given identical volumes of saline. Standard McFarlane flaps sized 4 x 9 cm (n = 22) and narrower 2 x 6-cm flaps (n = 18) were constructed 14 days later. After a postoperative observation period of 7 days, no significant difference in tissue survival between the pentoxifylline-treated animals and the controls was found in either flap model. Fourteen days preoperative treatment with pentoxifylline appeared to have no effect on flap survival.