Biomedical subjects
R C Wray
Publications and source records attributed to R C Wray.
Use of the rectus abdominis muscle flap to reconstruct an elbow defect.
A superiorly based rectus abdominis muscle flap was successfully used to reconstruct an infected elbow wound with exposed bone and metal screws. We could find no previous report describing the use of this muscle to cover elbow defects.
Repair of sensory nerves distal to the wrist.
Treatment of patients with severed distal sensory nerves is an exercise in simultaneous gratification and frustration. The gratification comes from realizing that the results of distal sensory nerve repair exceed those obtained after repair of other nerves. The frustration follows from the knowledge that truly normal sensation virtually never follows the most successful repair.
Comparison of early passive motion and immobilization after flexor tendon repairs.
Thirty-one flexor tendon repairs in 30 patients managed by early passive motion were retrospectively compared with 31 flexor tendon repairs in 30 patients managed by 3 weeks of postoperative immobilization. Repairs were performed by several surgeons, including plastic surgical residents. There were no statistically significant differences between the two groups comparing age, zone of injury, number of tendons repaired, nature of injury, or associated injuries. No statistically significant difference was found between the two groups when total active and total passive range of motion were compared for repairs in zone I, zone II, zones III and IV, and all zones combined. In the early passive motion group in zone II, there were 12 percent excellent results, 15 percent good results, 23 percent fair results, and 50 percent poor results. In the immobilization group, there were 18 percent excellent results, 8 percent good results, 23 percent fair results, and 53 percent poor results. There was no significant difference between the two groups (p less than 0.05).
A comparison of three techniques of palatorrhaphy: early speech results.
Sixty-two patients with cleft lip and palate or cleft palate were randomly assigned an operative technique for primary palatorrhaphy: V-Y pushback, Langenbeck, or Langenbeck with pharyngeal flap. Early speech results were evaluated in 52 patients. There were no differences among the treatment groups in late complications, hearing, middle ear disease, velopharyngeal competence, or need for speech therapy, speech bulbs, or secondary pharyngeal flaps. As previously reported, the in-hospital morbidity in these patients was greater with V-Y pushback (more blood transfusions) and Langenbeck plus pharyngeal flap (more upper airway obstruction) palatorrhaphies than with the Langenbeck procedure. The addition of a pharyngeal flap to primary palatorrhaphy seems unnecessary in at least 75% of patients. Therefore, we currently recommend the Langenbeck palatorrhaphy for primary cleft palate repair, although further longitudinal studies of these patients are needed to assess later speech results and maxillary growth.
Drug treatment and flap survival.
Some investigators found that isoxsuprine, propranolol, or heparin would increase skin-flap survival in loose-skinned animals. We evaluated the effects of these three drugs in the pig, an animal with skin circulation similar to that of humans. Four hundred ventrally based skin flaps that have a proximal axial portion and a distal random portion were made on the flanks of 40 pigs. There were eight study groups: control, isoxsuprine preoperatively and postoperatively, propranolol preoperatively and postoperatively, isoxsuprine postoperatively only, propranolol postoperatively only, heparin, single-stage surgical delay, and two-stage surgical delay. Flap survival was improved by the two-stage surgical delay when compared with the control flaps, flaps from pigs receiving a drug, or flaps from pigs having a single-stage surgical delay (p less than 0.001). When compared with the control flaps, neither isoxsuprine, propranolol, heparin, nor single-stage surgical delay significantly increased flap survival.
Flexible-implant arthroplasty and finger replantation.
We performed flexible-implant arthroplasty in three metacarpophalangeal joints in two patients at the time of finger replantation. We believe flexible-implant arthroplasty is preferable to permanent arthrodesis for most patients.
Proximal interphalangeal joint sprains.
We report the first series of proximal interphalangeal joint sprains and reviewed 50 sprains in 48 patients. The majority of patients were males injured at work. The radial collateral ligament was injured about twice as often as the ulnar ligaments. The little finger was injured significantly less than the others. Proximal interphalangeal joint sprains can be diagnosed by the following: pain localized to the injured ligament, swelling greatest at the site of the injured ligament, tenderness greatest at the site of the injured ligament, pain at the site of the injured ligament during lateral stress, and/or mild lateral instability on radiographs or physical examination during stress testing. All patients required several different splints for treatment; in decreasing frequency, we used immobilizing, coupling, dynamic proximal interphalangeal flexion, dynamic proximal interphalangeal and distal interphalangeal flexion, and dynamic proximal interphalangeal extension splints. The mean active range of motion before treatment was 70 degrees and after treatment was 95 degrees. Significantly more patients had loss of full extension than had loss of full flexion. Forty-six percent of the patients had no pain after treatment, 46 percent had mild pain, 8 percent had moderate pain, and none had severe pain. Patients treated within 4 weeks of their injury (group 1) gained significantly greater range of motion (35 degrees) than those treated between 5 and 14 weeks after their injury (10 degrees) (group 2).(ABSTRACT TRUNCATED AT 250 WORDS)
The dream fades.
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A randomized comparison of triangular and rotation-advancement unilateral cleft lip repairs.
We prospectively and randomly compared triangular and rotation-advancement unilateral cleft lip repairs in 35 patients. The most significant difference between the two repairs noted in this series was a greater frequency of hypertrophic scars following rotation-advancement repairs. The overall appearance of the lip and nose postoperatively was the same in both groups.
Force required for wound closure and scar appearance.
I am reporting the first objective documentation of the correlation between the force required for wound-edge approximation (closure) and eventual scar width. Seven patients undergoing reduction mammaplasty were studied, and 234 measurements of force required for wound-edge approximation were made. At follow-up 1 year after surgery, the scar width was measured and the appearance was noted and photographed. A significant correlation was demonstrated between the force required for wound-edge approximation and scar width at every location but one. In addition, the scars were significantly wider near the midline of the breast than at the ends of the reduction mammaplasty incision. Neither color match (to surrounding skin) nor scar elevation (hypertrophy) were related to the force required for wound-edge approximation.
The groin flap in severe hand injuries.
We reviewed 27 patients who required 28 groin flaps for repair of hand injuries. Flap necrosis due to ischemia developed in 18% of the patients. Flap ischemia did not develop after elevation of the flap or partial division of the pedicle. All flap necroses occurred after final (total) division of the pedicle (p less than 0.05). Flap necrosis was more common following immediate insetting of the flap than after delaying the inset, but this difference was not statistically significant. Flap necrosis did not develop if the pedicle was divided in two stages, with the first stage consisting of either preliminary ligation of the superficial circumflex iliac vessels or full-thickness division of a portion of the width of the flap. Our complication rate was much lower than that previously reported for groin flaps.
Effect of continuous load on the mechanical properties of tendon adhesions.
The restoration of tendon gliding after tendon repair or grafting is dependent upon alteration of the scar about the tendon. Application of a load (active range of motion exercises) is used clinically to effect this alteration. Using the chicken as a model, we are attempting to define the optimal timing, quantity and duration of the load. In these initial experiments, the effects of application of a continuous load for forty eight hours were evaluated in eighty nine chickens. A continuous load applied for forty eight hours had no significant effect on motion of repaired tendons or the scar "stiffness".
Free vascularized whole-joint transplants with ununited epiphyses.
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A randomized comparison of four incisions for orbital fractures.
We previously compared conjunctival and subciliary incisions for exposure of orbital floor and infraorbital rim fractures. A prospective randomized comparison of lower eyelid and orbital rim incisions was then undertaken and results compared with our previous study. Lower eyelid and orbital rim incisions provided more rapid access to fracture sites. Fracture exposure was adequate with all but conjunctival incisions; lateral canthotomy was added in 56 percent of cases to improve exposure. There were minimal or no intraoperative and postoperative complications except for a 42 percent incidence of ectropion following subciliary incisions. Scar appearance was similar in the four groups, except when an isolated conjunctival incision was used, which produced an invisible scar.
A randomized prospective comparison of fascicular and epineural digital nerve repairs.
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Treatment of impending nipple necrosis following reduction mammaplasty.
Despite careful preoperative planning and accurate surgery, nipple necrosis may follow reduction mammaplasty. Impending nipple necrosis developed following translocation of the nipple and areola on a dermal pedicle in two patients. An excellent result was obtained by converting the nipple-areola complex to a full-thickness graft and removing the avascular portion of the breast. We recommend this technique to the surgeon whose patients develop impending nipple necrosis after reduction mammaplasty.