Biomedical subjects
Publications and source records attributed to J B Lynch.
Ten patients ranging in age from 7 to 47 years have been treated for neurofibromas of the head and neck at Vanderbilt University Hospital during the last 14 years. Three of them had a positive family history of von Recklinghausen's disease; none has developed malignant degeneration. Serial subtotal excisions of the lesions was the primary treatment.
We have used the island gluteus maximus musculocutaneous flap to cover sacral pressure sores. In this report, we describe the surgical anatomy, cadaveric dissections (n = 25), and postoperative follow-up (one to 40 months) in 13 clinical cases. Our results compare favorably with those of other previously reported series. Postoperative complications are few (n = 2) and late recurrence is acceptable (n = 1). Since the surgical anatomy is consistent and the operative technique simple, this procedure may be the treatment of choice for sacral pressure sores.
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Cellular function and blood flow in acute, steroid-treated, and surgically delayed random skin flaps have been examined. In these studies, the period following flap elevation could be divided into early (0-2 hr), intermediate (4-6 hr), and late (12 hr) periods of ischemia, based on the cutaneous blood flow and cellular function measured by thallium-201 uptake. There was a close correlation (r = 0.98, 2 hr) between blood flow and cellular function during the early period of ischemia which became worse with time (r = 0.78, 12 hr). Blood flow studies demonstrated a significant difference (P less than 0.05) between the early and intermediate periods of ischemia which was abolished by surgical delay. Improvement in cellular function was accomplished by improved blood flow in the surgically delayed flaps, while steroid-treated flaps enhanced cellular metabolism by another mechanism. Cellular function approximated blood flow during the early and immediate period of ischemia. Steroids may augment cellular function without improving blood flow, while surgical delay improves cellular function by improving blood flow.
Six women with Bowen's disease of the anogenital area were treated by total excision of the anal mucosa, perianal skin and, in some cases, partial vulvectomy. Two patients had foci of microinvasive squamous carcinoma. Adequate tumor margins were determined by frozen sections. The resulting mucosal and cutaneous defects were grafted with medium split-thickness skin grafts applied to the anal canal and sutured circumferentially to the rectal mucosa. Grafts were held in place by a finger cot inserted in the anal canal and stuffed with cotton balls. Patients were constipated five or six days with codeine. The skin grafts healed per primam. One additional patient was similarly treated for a chronic herpetic ulceration of the anus and healed. Contrary to dire predictions, all patients were able to distinguish between gaseous and solid rectal contents and sphincter function was preserved. In one patient, Bowen's disease has recurred in the grafted perianal skin.
We reviewed our 20-year experience with cutaneous carcinoma of the hand and identified 70 cases (basal cell 23%, squamous cell 77%). The documented risk factors included solar radiation, trauma, and irradiation. Lesions were treated surgically with amputation, excision, skin graft, or flap closure, and nonsurgically with cryosurgery, curettage, 5-fluorouracil, or irradiation. The recurrence was lower with surgical treatment (3%) than with nonsurgical (33%). Regional lymphadenectomy was required in four patients for metastatic squamous cell carcinoma. Recurrence was greater (9%) and metastasis more common (38%) in patients with Marjolin's type of secondary squamous cell carcinoma than with solar-induced lesions. Cause is an important factor in outcome and should be considered in initial treatment and long-term management.
The free epigastric rabbit flap was used to observe morphological alterations in the microvasculature following prolonged hypothermic ischemic intervals. Free flaps were raised, cooled 1-6 days, and reanastomosed. The epigastric artery, vein, and dermal vessels were examined by electron microscopy. Efforts to keep flap tissues in the cold less than or equal to 5 days were successful (85% of flaps survived following reanastomosis N = 15). Flap failures were accompanied by extensive disruption to the endothelial cells of the epigastric vein. The findings support the efficacy of a cooling period less than or equal to 5 days for free flaps. The morphological alterations in the venous endothelium of the flap also suggest a plausible explanation for flap failures which occur in spite of patent anastomotic sites.
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We suggest the pectoralis major musculocutaneous flap is a simple and reliable technique in constructing a mediastinal tracheostomy. It has the advantage of excellent vascularity and reliability even in those patients who have undergone preoperative radiation therapy. In addition, a well-vascularized lobe of thyroid tissue placed over the pharyngogastric anastomosis may decrease anastomotic leaks.
A model to study the dermonecrotic effects of a crude fraction of venom from the brown recluse spider (Loxosceles reclusa) was developed using female New Zealand white rabbits. In the rabbit model, surgical excision of the sites of intradermally injected crude venom did not always prevent subsequent necrosis or wound dehiscence despite the use of fluorescein to determine the surgical margin. Heparin and steroids did not prevent the venom-induced necrosis and were much less effective than surgical excision or injecting a specific antivenom. When given within 24 hours, the specific antivenom raised against the brown recluse spider venom blocked or markedly attenuated the toxic effects of the venom in the rabbit model system.
The "island" pectoralis major myocutaneous flap has been used in nine patients for immediate hypopharyngeal and cervicoesophageal reconstruction following laryngopharyngectomy. Two patients underwent total hypopharyngeal and cervicoesophageal reconstruction. Postoperative evaluation revealed adequate lumens with no evidence of stricture. There was retained innervation of the flaps through the lateral pectoral nerve, but no additional innervation from the cricopharyngeal musculature could be demonstrated. Normal esophageal motility was maintained, but cervicoesophageal pressures were diminished. Donor site morbidity was minimal, and the complication rate was low. We present the pectoralis major myocutaneous flap as an alternate method for hypopharyngeal and cervicoesophageal reconstruction.
Malignant secondary parotid neoplasms are uncommon. Among 545 malignant parotid tumors, we found 52 (9%) that did not arise primarily in the parotid gland. Lymphomas or tumors of hematopoietic origin were excluded from this study. All patients had a parotid mass (two bilateral), one third of which were painful; 20% had facial nerve weakness. Fifty-four surgical procedures were performed on 51 patients. Radical neck dissection was done for deeply invasive or highly malignant tumors. Adjunctive radiotherapy was administered postoperatively for cutaneous squamous cell carcinoma, while chemotherapy was given for lung and breast carcinoma and melanoma. Follow-up, obtained in 51 of 52 patients, averaged five years.
Microvascular reconstruction of the mandible and soft tissues using the composite groin flap is ideal in selected patients. No other available bone so closely approximates the mandible in both thickness and curvature as does the iliac crest. The soft tissues are available for reconstruction and may allow the surgeon to avoid a second flap, except in cases where both lining and cover are needed. The deep circumflex artery is of generous size, usually 2 to 2.5 mm in diameter, allowing greater reliability in the microvascular anastomoses. The flap has a fairly long vascular predicle, 6 to 8 cm. The ability of this flap to withstand irradiation and infection because of its blood supply permits early institution of postoperative radiotherapy and prevents bone loss due to small intraoral wound dehisicence or total flap loss. Although the donor site requires extensive dissection, it can be closed primarily, eliminating the need for skin grafts or other flaps. As further experience is gained with this flap, both the functional and cosmetic results should be improved. In patients undergoing resection of the remaining portion of the mandible, the symphysis or the anterior portion of the mandible, a procedure of this type should be done primarily to prevent deformity and to minimize disability for the patient.
Our experience with a modified Bernard-Burow technique for upper and lower lip reconstruction is described with preservation of the muscular lip sphincter. The use of local skin and buccal mucosal flaps sliding over the preserved muscular sphincter enables reconstruction with an acceptable cosmetic result even when almost total lip resection is required.
We have found the tensor fascia lata myocutaneous flap to be exceedingly reliable with a consistent vascular pedicle; it can be elevated easily and rapidly in its subfascial plane. It is a useful flap in the paraplegic patient for colsure of ischial, trochanteric, and sacral pressure sores, and may also be used as a free flap with little donor morbidity. At present, we recommend this as the flap of choice for closure of trochanteric pressure sores. Additionally, it appears to have further applications in defects of the groin, perineum, abdominal wall, and lower chest wall. Eleven tensor fascia lata musculocutaneous flaps, utilized for soft tissue coverage for varying defects in 9 patients, are discussed.
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The pectoralis major musculocutaneous flap described by Ariyan has great potential in single stage reconstructions of the head and neck. The advantages of the flap are greater length, improved vascularity, bulk, and one-stage reconstruction of oropharyngeal defects. The flap was used successfully in eight patients to reconstruct large defects in the head and neck area. Experience to date indicates that this flap has greater versatility than the deltopectoral flap in one-stage head and neck reconstructions.
Twenty patients with well-differentiated thyroid carcinoma, 20 yr of age or younger have been treated at Vanderbilt University Hospital. The young patient with thyroid carcinoma frequently presents with far-advanced disease but enjoys an improved survival. Preoperative scintiscanning is useful in the evaluation of patients with childhood thyroid carcinoma. A new noninvasive scan is described and appears to be promising in the preoperative differentiation between benign and malignant thyroid lesions in children and young adults. There is a high instance of nodal metastases, but long-term follow-up would indicate that lobectomy and modified neck dissection are sufficient for most patients. However, total thyroidectomy can be performed safely in those patients with disease in both lobes. Additionalally, frozen section diagnoses were found to be helpful in diagnosing and staging thyroid carcinoma.