Diabetes mellitus is a complex metabolic disorder whose components have several direct and indirect effects on the healing of wounds. This article examines how diabetes affects wound healing from the standpoint of alterations in the microvasculature, nerve function, and the immune system.

Diabetes Mellitus↗

PubMed1989

The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum.

Acute mediastinitis after cardiopulmonary procedures remains a devastating complication and a challenge to the reconstructive surgeon. A review of the literature and our own experience confirm the need for early aggressive drainage followed by timely reconstruction. In carefully selected patients, the sternum may be reclosed, provided that omental tissue has been transposed into the defect between the myocardium and the posterior cortex of the sternum. The technique is outlined and the results are analyzed and compared with three additional patient subgroups: (1) sternal wounds rewired over drains, (2) sternal wounds rewired with drains and irrigation catheters, and (3) wounds closed by sternal excision and muscle-flap transposition. To date, nine omental transfers have been performed with complete success. Mediastinal drainage routinely ceases after 3 to 5 days, and hospitalization has averaged 10 to 14 days. Early open debridement allows establishment of drainage and permits close evaluation of the character of the bony sternum. Muscle flaps may then be used in those patients with multiply fractured or frankly necrotic sternal tissue, while sternal closure over omental flaps may be used in all other patients. Adherence to this protocol has allowed for bacteriologic control of the wound, minimal morbidity, and no mortality.

Acute Disease↗

PubMed1987

Mammographic changes following reduction mammaplasty.

Mammographic findings after reduction mammaplasty may be similar to those seen with carcinoma. A knowledge of the expected mammographic alterations would be helpful in differentiating postoperative changes from those seen with carcinoma of the breast. Accordingly, the clinical records and mammograms of patients who underwent reduction mammaplasty at the Dartmouth-Hitchcock Medical Center between March of 1977 and July of 1985 were analyzed. Forty-two patients had at least one mammographic examination following reduction mammaplasty. Periareolar soft-tissue changes and inferior pole alterations were present in almost all examinations of patients during the first 6 months after operation, but they decreased during the next few years. Asymmetrical densities were present in approximately half the patients throughout the follow-up period but decreased in degree. Parenchymal calcifications occurred later; few x-rays showed these calcifications during the first year, but 50 percent were apparent after 2 years. Evidence of fat necrosis occurred in approximately 10 percent. Four patients had biopsies for suspicious densities. Chronic inflammation and inclusion cyst were reported. We believe that changes after reduction mammaplasty are predictable and can usually be differentiated from those associated with cancer.

Adipose Tissue↗

PubMed1987

Reconstruction of orbital wall fenestrations with polyglactin 910 film.

Medial orbital wall fenestrations were created bilaterally in 16 adult cats. The fenestrations were reconstructed with polyglactin 910 film, Dacron-reinforced silicone sheeting, or no implant. Polyglactin 910 was found to be well tolerated in this traumatized area of paranasal sinus bone and soft tissue and was totally absorbed in 4 months. Dacron-reinforced silicone sheeting induced a long-standing acute inflammatory reaction in a similar milieu. Partial osseus replacement of the orbital fenestrations occurred in all animals, but it was accompanied by distortion and erosion in apposition to the silicone sheeting. The study does not answer the question of whether orbital contour will be maintained on a long-term basis adjacent to a pneumatized sinus following reconstruction with a bioabsorbable implant.

Animals↗

PubMed1986

Preoperative irradiation potentiation with cisplatin: effect on rate of wound infection.

Platinum coordination complexes, such as cisplatin, potentiate the cytotoxicity of irradiation on squamous cell carcinoma and certain other solid tumors. Using a rat oro-cutaneous fistula model, an investigation was carried out to determine whether or not there was a concomitant potentiation with cisplatin of the deleterious effect of preoperative irradiation on the ability of a subsequent wound to handle a bacterial challenge. Auto-contaminated wounds were found to have increased rates of infection at single-dose orthovoltage pretreatments of 1,500 rads or more. Using quantitative bacteriologic techniques, would infection was found to be no more frequent after platinum-enhanced irradiation than after irradiation alone; however, there was the additive effect of weight loss associated with combined cisplatin treatment and irradiation.

Animals↗

PubMed1986

Cowden's disease: a further indication for prophylactic mastectomy.

Cowden's disease (multiple hamartoma syndrome) is a syndrome involving abnormalities of multiple organ systems. Transmitted in an autosomal dominant pattern, it carries a high frequency of mammary carcinoma in early middle age in affected women. The hyperkeratotic cutaneous and gingival markers of the disease are its principal overt manifestations. Prophylactic bilateral total mastectomy with optional immediate reconstruction is recommended for women Cowden's disease. An illustrative family with the disease is presented in which one affected young woman was found to have invasive mammary carcinoma with regional metastasis at the time of prophylactic mastectomy.

Adult↗

PubMed1985

The segmental pectoralis major muscle flap: a function-preserving procedure.

A function-sparing pectoralis major muscle flap is presented. The flap is a medially based segmental transfer of a single intercostal portion of the pectoralis major muscle supplied by a single perforating branch of the internal thoracic artery. The segmental terminal nerve distribution of the medial and lateral pectoral nerves permits preservation of the remainder of the muscle in situ. Six cases of this procedure are presented with five successful outcomes. The single exception was in the loss of the distal tip when used to cover an irradiated carotid sheath to the base of the skull.

Aged↗

PubMed1984

Island toe flaps in neurotrophic ulcers of the foot and ankle.

Eight plantar island toe flaps for the management of 7 neurotrophic ulcers of the foot and ankle are presented. The plantar vascular anatomy is reviewed with emphasis on functional features and alternate sources of supply. The surgical technique closely parallels that of the Littler neurovascular island flap in the hand. The release of the plantar fascia by incision is the most important technical step in the flap transfer. The procedure is advantageous because it substitutes weight-bearing skin, causes minimal disruption of the plantar anatomy, and is effective even in the presence of small vessel disease.

Adult↗

PubMed1984

Combined modality approach in the management of locally advanced head and neck cancer.

Twenty-five patients with stage III or IV locally advanced head and neck cancer were treated from February 1981 to November 1982 with a combined modality approach utilizing chemotherapy followed by irradiation and surgery. Induction therapy with cisplatin and bleomycin was followed by a sequence integrating weekly cisplatin into a program of locoregional irradiation. After the administration of 4800 cGy, patients received either "boost" irradiation or surgery. At the completion of all therapy, 20 of 23 patients evaluable for response had achieved complete remission. Toxicity was tolerable and all patients are being followed closely to assess durability of remission and overall survival.

Adult↗

PubMed1984

Upper extremity burns from woodstoves.

Twenty-one woodstove-related burns of the hand and forearm in preschool-aged children were reviewed concerning nature and mechanism of injury, treatment, and clinical course. Two distinct patterns of injury were seen: with infants less than 14 months of age, burns occurred almost exclusively when the child touched the stove intentionally, unable to distinguish it from another piece of furniture; in older children burns were always "accidental." Most burns epithelialized spontaneously with surgical intervention and without functional disability. Protective devices are available and could prevent childhood burns from woodstoves.

Accidents, Home↗

PubMed1983

Flaps of the latissimus dorsi muscle in difficult wounds of the trunk and arm.

The latissimus dorsi muscle is uniquely positioned for extraordinary utility as a reconstructive tool. Its versatility in transfer as a muscle or myocutaneous flap unit permits closure of a variety of difficult, complex wounds of the trunk and arm. Eight cases are presented which illustrate numerous variations of flap design for reconstructing large wounds of the scapular region, the sternocostal region, the anterior thoracoabdominal region, the axilla and breast, the vertebral and paravertebral regions, the intrathoracic cavities associated with pleurocutaneous fistulae, and the arm. The flap may be based on either the proximal or distal blood supply. It may be transferred in a single unit or split longitudinally. It may or may not carry overlying skin of any size or configuration. Transfer without overlying skin is advocated when the flap is placed intrathoracically for pleurocutaneous fistula closure.

Adult↗