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The coracobrachialis muscle has been suggested for possible use in coverage in infraclavicular defects, specifically in postmastectomy reconstructive patients. This case report demonstrates the successful clinical use of this flap for coverage of exposed axillary vessels in the infraclavicular area. Anatomy and techniques of dissection are reviewed as well as potential disadvantages.
Infection in a peripheral vascular prosthesis continues to be a serious complication in arterial reconstructive surgery and threatens the patient with loss of either limb or life. Infection rates at major centers are now low, ranging from 1 to 6 percent; however, limb loss and mortality rates for this complication range from 25 to 75 percent depending on the location of the graft and the extent of the infection. The use of muscle flaps in the management of acute wounds, infection-prone wounds, exposed orthopedic hardware, and osteomyelitis is now commonplace. Transposed muscle has been shown to be well-vascularized tissue that improves healing time and decreases local wound bacterial counts. After considering the preceding facts, we used muscle flaps for coverage of infected peripheral vascular prostheses in a highly select group of patients. These patients were "end of the line," and last-ditch efforts were made to salvage life or limb. Twenty-four infected vascular grafts in 20 patients have been analyzed. Ages ranged from 52 to 87 years. All patients had grade 3, stage I, II, or III peripheral graft infections, as previously defined by Szilagyi and modified by vonDongen. Aortofemoral reconstruction was the most common initial bypass procedure (14), followed by femoral popliteal (6), axillofemoral (2), iliofemoral (1), and subclavian/subclavian bypass (1). Staphylococcus aureus was the most common infecting organism. Muscles used for coverage were the rectus femoris (13), the sartorius (9), the rectus abdominis (1), and the pectoralis major (1). The graft material was composed of Dacron in 16 instances and polytetrafluoroethylene in 8.(ABSTRACT TRUNCATED AT 250 WORDS)
In breast augmentation through the transaxillary subpectoral approach, previous studies have indicated that the implant was only covered by muscle to the upper third of its surface. In my experience with our method of dissection of the implant pocket, I had come to a different opinion about muscle coverage of the implant. In order to confirm the position of the implant, I have undertaken an anatomic study in 10 fresh female cadavers. A transaxillary subpectoral breast augmentation was performed, followed by an anatomic dissection of both sides. In all 20 implantation sites, it was found that the implant was totally covered by muscle. The muscles involved were the pectoralis major, serratus anterior, and obliquus abdominis externus. These findings have been confirmed in the clinical setting by endoscopic photographs. Since it is documented that total muscle coverage produces fewer capsular contractures, as well as fewer steroid-related complications, and considering the superior position of the scar, I today consider this approach to be most useful.
The concept of early "functional" soft-tissue coverage is demonstrated in three cases of severe skeletonizing avulsion/contusion injuries of the upper extremity, including the replantation of a "frozen" arm. According to the MESS score, all extremities would have been allocated to the amputation group. Therapeutic strategy consisted of primary repair of all neurovascular structures, serial debridements, and early definitive coverage with simultaneous restoration of the elbow flexor or extensor muscles. Flap survival was 100 percent in all patients, and the muscle strength achieved after vigorous physical therapy was rated M3 to M5. One patient was even able to return to competitive tennis.
In comparison with other regions of the trunk, defects located in the lumbosacral region are infrequent. However, these particular lesions sometimes present difficulties in reconstruction, arising from the quality of the surrounding tissue and the width of the defects. In this area, the skin adheres strongly to subcutaneous tissue and is difficult to mobilize. Attempts to perform local or regional flaps for covering defects of this area often end in necrosis of the flaps, with subsequent risk of infection and unstable wounds. The consequence is larger defects and the need for a wide, tension-free coverage, which can be performed after a wide debridement. The authors report on 10 patients presenting with wide, recurrent (and in some cases, infected) defects of the lumbosacral region, after already having undergone several reconstructive local or regional operations. In all cases, the authors harvested a free latissimus dorsi flap, lengthening the pedicle by means of an arteriovenous suralis loop connected to the thoracodorsal vessels (lumbar defect) or the femoral vessels (sacral defect). The procedure, already described in the past by others, has been revisited by the authors' group and used as the technique of choice in selected cases, that is, in the presence of wide, recurrent, and infected lesions; radiation; and scarring injuries. The authors thus obtained stable coverage with well-vascularized tissue and were able to save the patients any further operations. The authors suggest, therefore, that this procedure can be used in cases of wide and recurrent defects where other conventional procedures have failed. Advantages, disadvantages, and technical features of the method used are discussed in this article.
OBJECTIVE: To determine whether race is associated with health insurance coverage and health service use among gay and bisexual men in the Baltimore center of the Multicenter AIDS Cohort Study. METHODS: Data from eight semiannual study visits between 1991 and 1996 were used. Descriptive, stratified, and logistic regression analyses were conducted to determine whether race is associated with insurance coverage, medical, or dental service use, after controlling for socioeconomic variables. RESULTS: No difference was found between blacks' and whites' likelihood of having health insurance, private insurance, using inpatient, emergency department services, or antiretroviral medications. Whites were more likely to use outpatient services, particularly if CD4 cell counts were high, and were more likely to use dental services, although blacks were more likely to have dental insurance. CONCLUSIONS: Further research must be conducted to examine cultural, social, and psychological factors that help explain why white gay men use more outpatient and dental services, when other service use is unrelated to race. Investigators should be precise when using race as a variable in health services and epidemiologic research, emphasizing when racial differences truly exist versus when the variable race is a surrogate for another factor.
North Carolina's statewide, interagency Child Service Coordination Program (CSCP) serves children under five years of age with or at-risk for diverse health and developmental conditions. Preliminary assessment of the CSCP linked existing datasets to examine program coverage for two target populations: mothers < 15 year of age and infants < 1,500 g. The expectation that statewide program coverage would be higher for both risk groups in 1993 than in 1991 was true for mothers less than 15 years of age but not for infants < 1,500 g. This efficient method of evaluation can direct program outreach to the areas where it is most needed and provide a focus for more detailed program evaluation.
The purpose of this study was to compare National Immunization Survey (NIS) vaccine coverage rates with Texas Retrospective Immunization Survey (TRIS) vaccine coverage levels. Up-to-date rates for children 19 through 35 months of age as of October 1, 1994, were calculated for single vaccines and two vaccine combinations. The TRIS weighted statewide up-to-date rates for 4-3-1 and 4-3-1-3 were 66 percent and 60 percent, respectively, versus 71 percent and 68 percent for the NIS. Existing retrospective survey procedures can be modified to produce results that may be compared with the NIS.
To our knowledge new-onset psychotic symptoms have not been reported in connection with the September 11, 2001 terrorist attacks on the World Trade Center and the Pentagon. We describe two cases of brief psychotic disorder in adults who experienced the terrorist attacks from afar through television coverage. The patients were brought in for assessment to a medical center in the northeastern United States approximately 2 weeks after the attacks on September 11. We discuss the role of television coverage of stressful events in the induction of psychotic symptoms.
Medical coverage of recreational and competitive cycling events requires significant planning and cooperation among the race and medical directors, race officials, and local emergency medical services. The medical team should be proficient in treating minor and self-limiting injuries such as abrasions and minor trauma. The medical team should also have contingency plans for medical emergencies, such as cardiac events and major trauma, that ensure rapid stabilization and transport of the athlete to the appropriate medical facility. Stationary and mobile medical teams may be necessary for proper coverage of the event. Event day communication systems between individual medical staff as well as race officials and local emergency medical services is important to the success of the event.
BACKGROUND: Varicella vaccine effectiveness (VE) during outbreaks has been reported to be 71-100% against any disease and >90% against moderate/severe disease even in day-care centers (DCCs) and schools with low vaccination rates. A recent report suggested an effectiveness rate of 44% during a DCC outbreak despite a high vaccination rate. AIMS: To reassess vaccination coverage, VE and severity of disease among previously vaccinated children after exposure during DCC outbreaks in northern Israel, where vaccination rates are low. METHODS: During January to June 2003, active surveillance for varicella among children in northern Israel revealed outbreaks in 8 DCCs with children 3-6 years of age. Data concerning symptoms of the disease and the age at vaccination (for previously vaccinated children) were obtained from parents and health care providers for children who contracted the disease. Analysis of VE was limited to children who were continuously enrolled in DCCs during the outbreaks. RESULTS: The overall vaccination rate was 37%. The incidences of natural varicella and breakthrough varicella (BV) were 79 of 153 [52%; 95% confidence interval (CI) 44-60%] and 37 of 89 (41.5%; 95% CI 31-52%), respectively. VE was 20% (95% CI 0-40%) against disease of any severity and 93.4% (95% CI 75-98%) against moderate/severe disease. Ninety-four percent and 14% of children with BV and natural varicella, respectively, had mild disease (P < 0.001). The odds ratio for BV was 17 (95% CI 2.18-118) for children vaccinated >2 years before the outbreak. CONCLUSIONS: During varicella outbreaks in DCCs with low vaccine coverage, previous vaccination provided poor protection against chickenpox, mostly among children who had been vaccinated >2 years earlier, but the disease appeared to be much milder among children with BV than among nonvaccinated children.
PURPOSE: We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated. MATERIALS AND METHODS: A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass. RESULTS: The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1). CONCLUSIONS: The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.
PURPOSE: We review our experience repairing simple and complex urethrocutaneous fistulas using a de-epithelialized or full thickness skin advancement flap for 2-layer coverage over the fistula. MATERIALS AND METHODS: We reviewed the records of 1,092 hypospadias repairs performed at our institution. Urethrocutaneous fistula developed in 66 of those patients and 33 additional patients with fistula were referred from elsewhere. These 99 patients underwent a total of 94 fistula repairs. For simple repairs a de-epithelialized flap or a skin advancement flap was used. For complex repairs a variety of techniques were performed, all with a de-epithelialized skin flap for coverage. Stents were not left postoperatively in simple cases and repairs were routinely performed as outpatient procedures. RESULTS: Overall there were 6 (6.4%) failures. In 69 cases (73%) simple fistula closure was covered by a de-epithelialized flap or skin advancement flap, which failed in 3 (4.3%). Of 25 patients who required more complex repairs 18 underwent a tubularized or onlay urethroplasty incorporating the fistula, which failed in 2 (11.1%). Two patients underwent meatoplasty in conjunction with the distal fistula repair, which failed in 1. Two patients underwent urethroplasty in conjunction with separate repair of a urethrocutaneous fistula, and there were no failures. No fistula developed in 3 cases of re-do hypospadias repairs. CONCLUSIONS: Excellent results can be achieved for simple and complex urethrocutaneous fistula closure using a de-epithelialized or full thickness advancement flap. Moreover, almost all repairs can be performed in an outpatient setting. Simple closures do not require stenting postoperatively.
Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.
Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.
Traditionally, cross-leg flaps and microsurgical flaps have been used to reconstruct defects of the distal third of the leg. In the authors' experience, the soleus muscle has also provided suitable tissue for coverage of these lesions in a notable number of cases. During a 2-year period, the authors treated 28 patients who required flap coverage of defects of the lower third of the leg. In this group, the soleus muscle was used successfully in 8 patients. All of these procedures resulted in healed wounds. The remaining patients underwent reconstruction with microsurgical flaps, fasciocutaneous local flaps, and a gastrocnemius muscle flap. Their experience has demonstrated that the soleus muscle is a valuable tool and should be included in the treatment algorithm for reconstructing lesions of the distal third of the lower extremity.
Poststernotomy mediastinitis is an infrequent but highly dangerous complication following median sternotomy. Typically, such wounds are debrided aggressively of necrotic and foreign materials with subsequent flap reconstruction. Between December 1989 and January 2002, 69 patients were referred to the University of Maryland division of plastic surgery for mediastinal wound coverage. A total of 105 flaps of various types were used. Fifty-eight percent of the patients received a single flap. Ninety percent of the flaps used were pectoralis major flaps, whereas only 10% of the flaps were rectus abdominis, latissimus dorsi, or omentum flaps. Ten patients (14.5%) required reoperation. The most common comorbidity was diabetes mellitus. Those patients with diabetes mellitus were 9.1 times more likely to require reoperation after their sternal reconstruction compared with nondiabetic patients (95% confidence interval, 2.1-40.4). Four patients (5.8%) died less than 30 days from their flap procedure. The flap of first choice used in this series is the pectoralis major turnover flap, which is harvested in its entirety and split in the direction of its muscle fibers. Taking the entire muscle allows better coverage of the lower portion of the incision, resulting in far less frequent need for abdominal flaps and their associated morbidity.