Biomedical subjects
Publications and source records attributed to J W Futrell.
Op-Site is a popular skin-graft donor-site dressing. The formation of hematomas or seromas with their troublesome consequences is effectively prevented by the incorporation of a closed drainage system.
The rich vascular network of the gluteal and posterior thigh region provides for a larger range of flaps for reconstructive surgery than previously described. Facility with these flaps requires an appreciation of relevant anatomy, embryology, and anthropology. Structural changes in the gluteus maximus muscle are critical to the evolutionary advance toward an upright stance during walking. The superficial and deep segmentation of the gluteus maximus are best appreciated by phylogenic and ontogenetic study. Femoral arterial and gluteal arterial anastomotic hemodynamics are affected by the relative involution of the gluteal system in late embryogenesis. The gluteal thigh flap should include contributions from the femoral system when the cutaneous branch of the inferior gluteal artery cannot be identified. Huge sacral wounds can be closed with gluteus maximus myocutaneous flaps with maintenance of muscular function by detaching the entire origin, sliding the muscle medially, and reconstructing these attachments. By dissection between the divergent inserting fibers of the gluteus maximus, a long, superficial portion of the muscle can be raised that forms the basis of the extended gluteus maximus flap. The pedicle of the flap is at the level of the piriformis muscle and the skin paddle can be placed over the midportion of the posterior thigh. Finally, the first deep femoral perforating artery forms the basis of a posterolateral fasciae latae flap that is well suited for coverage of defects over the trochanter.
Meticulous anatomic dissection of the vasculature of the superficial anterolateral neck indicates that the platysma and overlying skin are supplied by direct cutaneous arteries measuring 0.5 mm in diameter. The small arteries are branches of the postauricular and occipital arteries in the upper lateral neck, the facial and submental arteries in the upper medial neck, the superior thyroid artery in the middle of the neck, the subclavian artery in the lower medial neck, and the transverse or superficial cervical arteries in the lateral aspect of the neck. These vessels traverse the undersurface of the platysma muscle to provide blood flow to the overlying skin. As opposed to this direct cutaneous system, the myocutaneous blood supply perforating through the sternocleidomastoid is scant. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. By following these guidelines, the platysma flap has been successfully used for facial reconstruction in 7 of 8 consecutive patients.
Inguinal lymph nodes in the Buffalo rat were autotransplanted to the popliteal fossa by an intact vascular pedicle or by microvascular anastomosis. These revascularized nodes had normal histology and made spontaneous afferent and efferent lymphatic reconnection with surrounding lymphatic vessels, as documented by ink and silicone rubber injection studies. Lymphoscintigraphy with 99mTc antimony sulfide colloid correctly predicted the 44 of 120 node transplants that had made afferent reconnection. To demonstrate immunologic activity of lymph nodes following transplantation, a cellular adherance assay was employed to detect cell-mediated cytotoxicity of lymph node cells isolated from rats sensitized to an allogeneic gliosarcoma. Cytotoxicity was detected in nontransplanted regional nodes sensitized to tumor (p less than 0.01) and in nodes transplanted by vascular pedicle and then sensitized to tumor (p less than 0.001). This study demonstrates that lymph nodes can be transplanted with restoration of functional lymphatic anatomy, and that following transplantation, lymph nodes retain the ability to mount an immune response against tumor.
The morphologic characteristics of a scar may render it an "immunologically privileged site" providing fertile ground for tumor occurrence and growth. We sought to extend this concept and to determine the effect of different stages of wound healing on tumor occurrence. Syngeneic strain-2 guinea pigs and a methylcholanthrene-induced liposarcoma (MCA-2) were used. Incisional flank wounds were created at appropriate intervals such that at the time of tumor inoculation each group of animals had a sequentially aged wound which was a) acute, b) three weeks old, c) nine weeks old, d) 11 weeks old, e) created one week after tumor injection, or f) no wound. Wounds which were three, nine, or 11 weeks old consistently caused a significant increase in tumor growth rate following inoculation of a single cell tumor suspension (<.001). The delayed wounds, or those created following after tumor injection, and the acute wounds did not promote increased tumor growth. This study demonstrates that the ability of a wound to amplify or retard tumor growth may vary with its age. As a postulate we suggest that the relative paucity of lymphatic regeneration within scar tissue may render it an "immunologically privileged site" such that early recognition and destruction of tumor cells within the scar may be delayed long enough for the tumor to grow to a "critical size." Subsequent to this regardless of the host's immunocompetence the tumor can no longer be destroyed by an immune mechanism. The general lack of progressive growth of tumor cells placed in acute wounds suggests that they were not protected from immunocompetent cells and were destroyed by the ongoing inflammatory response to injury. Therefore, different biologic characteristics of a surgical scar are important in potentiating or retarding tumor growth. Variations in such factors may account for the local recurrence of cancer in operative wounds.
The concentration of antibiotic in peripheral lymph reflects the tissue levels. Following microsurgical cannulation of the right lymphatic duct in 28 healthy rabbits, either penicillin-G, nafcillin, erythromycin, or cefazolin was given intramuscularly, and lymph and serum samples obtained at frequent intervals. Penicillin or nafcillin was administered to 14 additional rabbits with cellulitis of the right upper extremity. A serum sample drawn between one and two hours after an intramuscular injection, in general, reflects the peak lymph antibiotic concentration and hence the peak tissue concentration of the drug. After two hours the lymph level remains equal to or greater than the simultaneous serum level. The presence of inflammation did not alter the peak antibiotic levels. However, nafcillin required longer for equilibration in the inflamed state than in the uninflamed state, whereas penicillin-G equilibrated more rapidly in the presence of inflammation.
Bowen's disease has previously been associated with the development of other malignancies particularly in patients with a history of arsenic exposure. A review of the literature is combined with a discussion of current theories regarding arsenic exposure, lesion differentiation, and prognostic implications. This report of a bowenoid lesion of the plantar arch emphasizes the importance of close follow-up of patients with Bowen's disease, especially on unexposed surfaces.
The third case of presumably spontaneous rupture of a hypernephroma in a child is reported. This patient remains free of disease more than 5 years following radical nephrectomy, radiation and chemotherapy. Although renal adenocarcinoma in children remains a rare disease, more than 80 cases have appeared in the literature, making it necessary now to consider this tumor in the differential diagnosis of all childhood abdominal masses. Equally significant is the observation that presentation as an acute abdominal crisis in a child can occur, making it important that diagnostic considerations in such situations include hypernephroma, as well as Wilms' tumor. Review of the literature shows that occasional cures from spontaneous retroperitoneal rupture of hypernephromas have been reported in adults, but not in children, although this child has survived in spite of tumor spillage in the free peritoneal cavity.
Fourteen patients were treated for intraoral epidermoid carcinoma with a single stage reconstructive technic employing a myocutaneous flap based upon the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The flap has proved to be highly reliable and has significant benefits over many other technics commonly employed for head and neck reconstruction.
A technique for correction of sagittal synostosis with achievement of an immediately pleasing cosmetic result is presented. Even with replacement of bone and no attempt to inhibit bone union, premature reclosure does not occur. Moss' theory of dural tensions is discussed to explain the effect.
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Craniofacial surgery is an exciting new subspecialty of medicine. It is strictly a team project that will function well only in a tertiary medical center. Particular coordination is needed among the plastic surgeon, neurosurgeon, anesthesiologist, and pediatrician. This article considers many of the potential advantages and some of the disadvantages of performing craniofacial surgery on infants. It is difficult or impossible, based on current knowledge, to predict the ultimate limits of such new techniques. The history of surgical evolution, however, continues to demonstrate that what "at first observation" was thought to be impossible or undesirable often evolves, with more understanding, to be the desired course of action. It was entirely appropriate that the initial craniofacial surgical efforts be generally confined to adult-type patients, but the currently available technical refinements have developed such procedures to the point where they now have a definite place in infant surgery as well. Continued clinical investigative research will provide further information regarding the eventual benefits and perhaps will lead to surgical techniques in neonates that will actually prevent the development of certain predictable deformities.
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This study demonstrates that various suture materials have different influences on tumor take and growth. When used in an area containing 10(5) or greater tumor cells, all suture types studied potentiated tumor growth. At subclinical tumor cell doses- that is, 1,000 or fewer cells that do not normally grow to a clinically detectable tumor- silk and steel increased tumor occurrence. In comparison, monofilament nylon, polyglycolic acid, and chromic suture did not potentiate tumor growth. This phenomenon of increased tumor growth associated with certain suture types appears to be related to the physical characteristics of the suture involved, although the interaction of the chemical breakdown products of the suture material with the local tumor cells is under investigation. The type of suture material used may play a significant role in the subsequent development of local recurrence of cancer.
The question of whether or not to extend treatment to the regional lymph nodes when treating malignant disease remains unanswered. The clinician must individually approaise the pros and cons and derive a satisfactory treatment plan for each patient. Six reasons which are generally stated as indications for regional lymphadenectomy and seven potential arguments against lymphadenectomy are presented.
Every effort should be made to employ neck incisions that allow for the accomplishment of surgical extirpative goals and at the same time provide maximal functional and aesthetic rehabilitation. Incisions parallel to the normal skin tension lines best fulfill these criteria. When vertical incisions are used, they should be anteriorly directed so as to cross the skin crease lines at an acute angle rather than a perpendicular angle. Such incisions perpendicular to the normal skin crease lines usually result in the greatest degree of scar contracture. Significant improvement in both major and minor scar contractures can be achieved with conventional Z-plasty technics to redistribute the skin tension. A wide resection of the subcutaneous cicatrix in such cases is imperative for a successful result.
A case replantation of the upper extremity is presented using external fixation as the method to achieve bony stability. Although internal fixation may remain the method of choice for stabilization of a replanted limb, external fixation can also provide bony stability where more conventional methods are not applicable.