Biomedical subjects
Publications and source records attributed to F Nahai.
The inferior gluteal flap represents our second choice for free autologous tissue breast reconstruction when the TRAM is unavailable. The safety and reliability of the inferior gluteal flap has been demonstrated in 25 consecutive flaps. To make the free gluteal flap work, careful elevation and preparation of recipient vessels with the liberal use of vein grafts, and proper insetting are important factors.
The reconstructions of large debridement defects of the tibia are difficult and, at times, discouraging. To maximize the potential for limb salvage, a rigorous patient selection algorithm is essential. Each therapeutic option must consider various host factors, anatomic restraints, physician skills, and institutional resources. In this article, the cost effectiveness and morbidity of two distinct methodologies are compared to bring the guidelines for patient selection to perspective.
Microsurgical tissue transplantation initiated a new dimension in breast reconstruction and is the preferred method for carefully selected patients. The inferior gluteus maximus musculocutaneous flap provides abundant tissue for a permanently soft and well-contoured breast with a donor site that is often enhanced by tissue sculpting. As a knowledgeable and skilled member of a multi-disciplinary team, the professional nurse is in a position strategic to the success of breast reconstruction utilizing microsurgical tissue transfer.
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We evaluated the effect of topical epidermal growth factor treatment on healing of chronic wounds in a prospective, open-label, crossover trial. Five males and four females who ranged in age from 40 to 72 years (average 57 +/- 9 years) were enrolled. Four patients had adult-onset diabetes mellitus, two had rheumatoid arthritis, two had old burn scars, and one had a failed abdominal incision. The average duration of the ulcers prior to treatment with epidermal growth factor was 12 +/- 5 months (range 1 to 48 months). Following failure of the wounds to heal with conventional therapies, including debridement, skin graphs, and vascular reconstruction, wounds were treated twice daily with Silvadene alone for periods ranging from 3 weeks to 6 months. No evidence of healing was observed in any of the patients' wounds during Silvadene treatment, and patients were crossed over to twice a day treatment with Silvadene containing 10 micrograms epidermal growth factor per gram. Wounds of eight patients healed completely with epidermal growth factor-Silvadene treatment in an average of 34 +/- 26 days (mean +/- SD, range 12 to 92 days) and did not reoccur for periods ranging from 1 to 4 years. One patient failed therapy. These results suggest that topical treatment of chronic wounds with epidermal growth factor may stimulate healing.
Our experience treating perineal wounds secondary to abdominoperineal resection, either for inflammatory bowel disease or cancer, is presented. A total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection. All wounds were closed using the inferior gluteal myocutaneous flap. Fifteen of 16 patients have achieved healing, eight of whom had no complications. Only minor revisions or local wound care were required in the remaining patients, with only one patient failing to heal. Our results compare favorably with previous reports of treatment of this difficult problem.
Mediastinitis after open-heart surgery is a potentially disabling, even lethal, condition. The utilization of muscle flaps in treatment has lowered the mortality rate from 40 to 5 per cent and decreased the hospitalization time to 12 days. The authors recommend a single reverse turnover pectoralis major flap based on the internal mammary perforators as the procedure of choice in these cases.
The clinical records of 563 patients undergoing either abdominoplasty alone or in combination with other major surgical procedures were reviewed in order to determine the relative safety of combined procedures. One-hundred-seventeen patients had abdominoplasty alone; 230 had abdominoplasty with either an intraabdominal or major pelvic procedure with or without an additional major aesthetic procedure; 216 had abdominoplasty with one or more major aesthetic procedures (without intraabdominal or pelvic procedures). The rates of occurrence of major complications, including death, pulmonary embolus, and infection, among the three groups were examined. Also examined were morbidity factors such as length of hospital stay and the need for blood transfusion. In this study, the only risk factor identified in predicting major morbidity, specifically the occurrence of pulmonary embolus, was obesity, not the complexity of the surgical procedure.
Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.
The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.
We have been pleased overall with the results achieved using suction lipectomy in lymphedema patients. In appropriately selected patients, it is predictable and well-tolerated. It is, however, only palliative and temporary. It may be performed on a periodic basis. Compressive stockings are essential for success. Based on our experiences, we recommend suction lipectomy for mild temporary cases, specifically involving the upper extremity, and liposuction plus excisional debulking for more severe cases and for the lower extremity.
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Review of 101 patients who underwent 111 free jejunal autografts has demonstrated an absolute procedural failure rate of 13.5 percent. Salvage reconstruction with a second jejunum was successful in six of nine patients and one third-time jejunum was successful, giving an overall salvage rate of 70 percent. There were 33 patients experiencing pharyngocutaneous fistulas, 20 of whom had been previously irradiated. Of these patients, 15 experienced spontaneous closure and 9 others had successful surgical correction. The mortality rate was 5 percent. Eighty-three percent of patients were restored to adequate per oral alimentation. The jejunum, despite its relatively high complication rate, is an excellent method for pharyngoesophageal reconstruction, expeditiously providing return to function for patients with late-stage disease.
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A detailed investigation of the blood supply of the superiorly based rectus abdominis muscle flap and the transverse rectus abdominis musculocutaneous flap was done to improve the understanding of variations in flap viability and to explain the survival of the flap after internal mammary artery division and radiation. The study involved dissections of the internal mammary and superior epigastric systems, evaluation of pertinent angiograms, and impressions from observations of the vascular anatomy correlated with flap survival in over 600 clinical dissections. There is a diffuse intrathoracic collateral network involving the internal mammary system, with multiple branches and intercommunications on the same side, as well as across the midline. This enhances flap predictability and survival in some patients with internal mammary artery division or compromise. There is also a laterally based blood supply to the flap from the costomarginal artery at the costal margin which is sometimes well developed and may prevent flap compromise if preserved.
This paper reviews a 5-year experience using polyurethane-covered mammary prostheses in the treatment of capsular contracture following placement of smooth-walled devices, primary augmentation mammoplasty, and breast reconstruction after mastectomy. The rate of occurrence of clinically significant capsular contracture has been reduced in all patient groups. Results in terms of aesthetic and functional improvement have been excellent. Major complications have been rare.
Retrospective analysis by chart review, personal interview, and physical examination identified 88 patients who received 96 jejunal free flaps over a 10 year period. Seventy-nine of these patients had cancer. There were 13 operative failures (13.5 percent) in 10 patients. Failures were attributed to arterial thrombosis in four instances, venous anastomotic problems in four instances, fistula and infection in the neck in one instance, carotid blowout in one instance, psychosis with avulsion in one instance, and an unknown cause in two instances. Seven second attempts at salvage of jejunal flaps were performed with five successes. There were five deaths in the perioperative period (6 percent). Of these, one was directly attributed to graft failure. The following eight abdominal complications required operation: wound dehiscence (four instances), small bowel obstruction (one instance), Mallory-Weiss tear (one instance), gastrostomy tube leak (one instance), and acute gastric dilatation (one instance). Complications in the neck included infection (six instances), infection requiring operation (three instances), hematoma (three instances), and suture line dehiscence (one instance). Fistulas developed in 28 patients (32 percent), 12 of whom required operative closure (43 percent). Significant stenosis developed in six patients, two of whom required operative revision. Of 79 patients treated for cancer, 34 died from progression of disease which recurred an average of 9.7 months postoperatively. Death ensued an average of 16.7 months postoperatively. Ten patients died with no evidence of disease. At last follow-up, 28 patients were alive without apparent disease. Twenty-six of these patients have good swallowing function. Significant palliation and a high rate of restoration of function are possible with the free jejunal autograft. Careful patient selection should markedly decrease operative morbidity and mortality.
A large irradiated wound of the lumbosacral area is covered in one stage with a latissimus dorsi musculocutaneous flap by "extending" the vascular pedicle with 25-cm interpositional vein grafts.