Biomedical subjects
Publications and source records attributed to M I Dinner.
Design details of reduction of asymmetrical hypertrophy of the breasts are discussed. The concepts apply to nearly any breast reduction technique, although here they are presented in the context of the inferior segment method, which we favor. Although most of these points may seem self-evident to the experienced plastic surgeon, there has been little written about the details.
Meticulous attention to operative details is essential to the success of the transverse abdominal island flap in each phase of the procedure: raising the flap, transfer to the anterior chest wall, molding the flap, and repair of the donor site. This will culminate in a rewarding procedure for reconstruction of the breast by autogenous tissue.
The development of reliable flaps has made breast reconstruction possible for virtually any patient who has had a mastectomy. However, most breast reconstructions are performed with implants, without flaps. The authors give examples of the use of implants alone without flaps, in situations usually thought to require flaps.
Acute inflammatory responses to 10--0 Dexon and nylon were compared 2 weeks after experimental microvascular surgery in Sprague-Dawley rats. Statistical analysis revealed no significant differences, but the strength, long-term results, and minimal surrounding tissue reaction make Dexon a viable alternative to nylon. The main disadvantage of Dexon is its opaque blue-green color, which makes it nearly invisible in the operating field.
The transverse abdominal island flap is not just another myocutaneous flap. Although it derives its blood supply from myocutaneous perforators, the portion of the skin and fat that overlies muscle comprises only about 20% of its surface. The surface area of the flap by far exceeds the surface area of the entire muscle that carries it. Its hemodynamics are more complicated than usual and consist of delicate communications between the superior and inferior deep epigastric systems and the deep and superficial epigastric systems across the midline. Its use in breast reconstruction has been as exciting as it is complex. We describe our experience with 60 consecutive patients and 65 transverse abdominal island flaps.
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Endotracheal intubation of patients with limited bite opening is a serious task for the caring physician. Blind intubation can be frustrating and, very often, unsuccessful. Tracheostomy, even under ideal conditions, can create serious complications. Fiberoptic bronchoscopy has opened up a new era in intubation of patients with trismus. In this article, we discuss an organized illustrated procedure for intubation of such patients. We have used this procedure successfully in 16 patients over the last sixteen months in our craniofacial unit, with no complications and no failures.
Hyaluronidase has been shown clinically and experimentally to reduce the effects of tissue ischemia in myocardial infarction and hemorrhagic shock. Dimethyl sulfoxide (DMSO) has been shown to reverse the effects of cerebral ischemia in the primate model. A caudally based dorsal skin flap in the rat was used to study the effects of these two drugs in physiological doses on skin flaps, and to investigate their mechanisms of action. This study demonstrates that both hyaluronidase and DMSO, which are nontoxic in physiological doses, can increase the surviving length of an experimental skin flap. It is hypothesized that these substances exert their effect by decreasing tissue edema and by aiding in the transport of nutritive substances to the flap during its acute phase.
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We report a major modification of technique for the transverse abdominal island flap, namely, taking the anterior rectus fascia with the muscle. We believe that this protects the fine vascular network supplying the flap. This has resulted in a more reliable flap, confirmed by increased fluorescein uptake, and significant reduction in operating time.
The occasional patient will present for reconstruction after mastectomy who refuses a foreign-body implant or is desirous of reconstruction by autogenous tissue. An unfavorable midline abdominal scar that extends both below and above the umbilicus will preclude the use of the standard lower or upper transverse abdominal island flaps for such purposes. For these highly select circumstances, we present our experiences with two such patients where a combination of an L-shaped vertical and transverse rectus abdominis myocutaneous flap was employed. In this procedure, the vertical component is planned to provide the external skin cover, while the ipsilateral hemiellipse transverse component is deepithelialized and buried deep to the vertical component to provide the bulk and mound projection.
Most failure and recurrences after excision and grafting occur during the first five months postoperatively. We concluded that this most likely indicated inadequate excision rather than inefficacy of the procedure. For small pilonidal sinus with minor sinus tract and shallow natal cleft, excision with primary closure would seem to be the best procedure. However, for extensive or recurrent sacrococcygeal pilonidal disease, wide excision with primary split thickness skin grafting is superior. We reviewed 58 patients who had undergone excision of extensive or recurrent pilonidal disease, with primary skin grafting. More than 72 per cent of these patients had recurrent disease when first seen at the Cleveland Clinic. The average hospital stay was 9.8 days; the total disability period, time off work, was 28 days; recurrence rate, 1.7 per cent, and failure rate, 3.4 per cent. This procedure is recommended for recurrent or extensive pilonidal disease.
This study was undertaken to quantitate the effects of needle trauma to the arterial wall during microvascular anastomoses. End-to-end anastomoses performed on rat femoral arteries were used as a model. Two weeks post-anastomoses, the specimens were processed and measured with a planimeter. The results were analysed statistically to evaluate the effects of different types of needles on the arterial wall. We found significant thickening of the arterial wall (P less than 0.01) but no difference in the amount of thickening between any of the needles evaluated. We found that certain needles were easier to use than others and have applied this observation to clinical work.
We present a concept in muscle and myocutaneous flap transfer whereby distally based flaps can, under very special circumstances, be transferred with an augmented arc of rotation and more reliable circulation. The concept is the inclusion of adjacent longitudinal vessels in the elevation, within which vessels the flow is reversed. To our knowledge this concept has not been previously described. The soleus muscle and eight other muscles have been found to be potentially useful in this regard. We report here our experience with 3 clinical cases of the distally-based soleus flap with a reversed pedicle, exemplifying the vascular detour principle. Our limited experience indicates no impairment of blood supply to the limb in short-term follow-up. Until further studies confirm the safety of major vessel sacrifice in a limb, we recommend only judicious use of this flap in highly selected situations.
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