Plastic Procedures Research Articles

Multimodality treatment and reconstructive plastic procedures in soft tissue sarcomas of the trunc and extremities

BackgroundLimb sparing resection in combination with mulimodality treatment options will lead to superior functional results without increasing oncological risk factors.MethodsReconstructive procedures for soft tissue replacement and primary functional rehabilitation techniques including salvage replantation are discussed.ResultsEarly integration of reconstructive plastic procedures diminishes wound healing disturbances, reduces the indication for amputation and allows for secondary corrections.ConclusionsReconstructive plastic techniques should therefore be integrated into treatment protocols of tumorboards involved in soft tissue sarcomas.

Ophthalmic Desk Reference

Part 1 Synopsis of clinical ophthalmology: ocular trauma and emergency care orbital disease ocular motility neuro-ophthalmology external eye disease uveitis the glaucomas retinal and choroidal vascular disease hereditary chorioretinal dystrophies intraocular tumors systemic disease nonstrabismic pediatric ophthalmology clinical refraction contact lenses. Part 2 Surgical topics: ophthalmic anesthesia common ophthalmic plastic procedures orbital surgery corneal surgery management of cataracts surgical management of the glaucomas retinal and vitreous surgery ophthalmic laser surgery refractive surgery miscellaneous ophthalmic surgical procedures. Part 3 Differential diagnosis. Appendices: glossary of ophthalmic terminology, eponyms and syndromes therapeutics genetics, embryology and anatomic drawings ocular dimensions and basic optical data intraocular lenses, sutures and needles selected diagnostic modalities laboratory norms and conversion tables.

Midfacial degloving: an alternative approach to the frontobasal area, the nasal cavity and the paranasal sinuses

Midfacial degloving can be characterized as an alternative surgical approach for exposing the bony structures of the midface. In combination with transient partial osteotomies the nasal cavities, the paranasal sinuses, the pterygopalatine fossa and the posterior parts of the anterior skull base are easily accessible. Using an intercartilaginous, a transseptal and a circumvestibular incision in the nose and a vestibular incision in the oral cavity the soft tissues of the upper face are mobilized and transposed cranially up to the infraorbital rim, the nasion and the lacrimal sac. Thus one can avoid scar formations in the face. In comparison with the common visible incisions in the face a bilateral exposure of midline structures is possible. The resected bone can be easily replaced and fixed with titanium miniplates for osteosynthesis. The soft tissue glove is replaced. A correct suture technique for readaptation especially in the nasal cavity is most important to avoid a circular stenosis of the nasal aperture. Between 1986 and 1991, 40 patients with various tumors (juvenile angiofibroma, inverted papilloma, esthesioneuroblastoma, squamous cell carcinoma of the maxillary sinus, benign tumors of the pterygopalatine fossa, clivus chordoma) underwent this procedure. Neoplasms and fractures of the anterior frontal skull base, the frontal sinus, the orbital cavity and the zygoma were less accessible due to the unsatisfactory exposure of these regions. Complications and side effects were rare. In five cases, a transient paresthesia of the infraorbital nerve and a facial edema were observed. In one case, a circular stenosis of the nasal aperture required a second plastic procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Valvoplastia mitral em pacientes jovens com cardiopatia reumática

No periodo, de setembro de 1988 a janeiro de 1992, 56 pacientes com ate 20 anos de idade (4 a 20 anos, media de 12,7) com insuficiencia mitral pura ou predominante de etiologia reumatica foram submetidos a valvoplastia mitral. Noventa e quatro por cento dos pacientes estavam em classe funcional III ou IV da NYHA. A tecnica cirurgica basica usada em todos os pacientes foi a anuloplastia assimetrica preconizada por Reed et alii 31, associada em 69,7% dos casos a outros procedimentos sobre as cuspides e aparelho subvalvar mitral. Dois pacientes foram submetidos, concomitantemente, a plastia da valva tricuspide e 4 a troca da valva aortica. Estudo ecodopplercardiografico per-operatorio foi utilizado apos a correcao em todos os casos e mostrou ausencia de lesoes residuais em 76% dos pacientes e insuficiencia mitral discreta nos demais. Nao houve mortalidade hospitalar. Ecopplercardiograma realizado antes da alta hospitalar mostrou boa correlacao com o estudo per-operatorio. Foi possivel colher informacoes do seguimento tardio de 53 pacientes. Ocorreu 1 obito tardio tres meses apos a cirurgia, por morte subita. Quatro pacientes foram reoperados e submetidos a troca valvar: uma paciente no 4o mes de pos-operatorio (PO), por falha primaria do procedimento, e outros tres no 6o, 34o e 38o meses de PO, por comprovada recidiva da cardite reumatica. Os demais encontram-se em classe funcional I e II (NYHA). Concluimos, baseados nos resultados apresentados, que a anuloplastia mitral assimetrica e um excelente procedimento para pacientes jovens com valvopatia reumatica, constituindo-se numa boa alternativa a troca de valva ou implante de aneis, sendo, no entanto, extremamente importante o controle de recidivas da doenca reumatica.

Comparison of mehlich‐1 and mehlich‐3 extractable soil boron with hot‐water extractable boron

Abstract The standard hot water extractant for soil boron (B) was compared with two extractants currendy in use by routine soil testing laboratories, Mehlich‐1 (M‐1) and Mehlich‐3 (M‐3). If routine extractants could be used for B, it would save the time and expense required for a separate extraction. Six states (Delaware, Maryland, Virginia, North Carolina, South Carolina, and Georgia) each selected 100 soil samples sent by growers to their State laboratories which were analyzed for routine properties (pH, P, K, Ca, Mg, and organic matter) and B by M‐1 or M‐3. The samples were then analyzed for hot‐water B (HWB) using a plastic pouch procedure and inductively‐coupled plasma emission spectrometry (ICP). M‐3 extracted more B than M‐1, and the correlation coefficients for M‐3 B with HWB were higher (r = 0. 82∗∗) than were M‐l with HWB (r = 0. 74∗∗). Correlations of soil properties with M‐l and M‐3 B were higher than with HWB, but none were notable with two exceptions. Extractable Ca was positively correlated...

Management of aortic insufficiency in chronic aortic dissection

From January 1980 to December 1988, 44 patients with chronic aortic dissection and aortic insufficiency underwent operation. This group of patients was analyzed to evaluate the outcome of those in whom the aortic valve was preserved compared with those having valve replacement. The overall preoperative characteristics of the two groups were similar except for the incidence of Marfan's syndrome. Valve replacement was the elected procedure in patients with valve degeneration or annuloaortic ectasia. In patients with leaflet prolapse with or without an enlarged annulus, a plastic procedure was used. In 48% of the patients, it was possible to preserve the valve. There were five hospital deaths (11%): three were due to low-output syndrome, one was due to bleeding, and one was due to neurological complications. There were two late deaths (5%). Follow-up of the 37 surviving patients ranged from 2 to 108 months (mean follow-up, 18 months). Seventy-eight percent of the survivors were in functional class I and the others were in class II. Two patients in whom the aortic valve was preserved had mild aortic insufficiency. Three patients with bioprostheses underwent reoperation because of prosthetic valve dysfunction. One patient who had aortoplasty and an aortic valve plastic procedure was seen with redissection and aortic insufficiency after 60 months and was reoperated on using the Bentall technique. The actuarial survival curves showed that patients who underwent valvoplasty had higher, but not significantly higher, survival rates than the valve replacement patients. We conclude the following: (1) valve resuspension is a satisfactory technique in patients with chronic dissection of the aorta, with a low mortality and fewer complications than valve replacement; (2) identification of the mechanism producing valvar insufficiency is fundamental to the choice of surgical procedure; and (3) aortoplasty should be avoided because of the high incidence of aortic redissection.

Cirurgia das dissecções crónicas da aorta ascendente com insuficiência valvar

No período de janeiro de 1980 a dezembro de 1988, foram operados 44 pacientes com dissecções aórticas crônicas e insuficiência aórtica. Esse grupo foi analisado para se avaliar a evolução comparativa dos doentes em que a valva aórtica foi preservada em relação àqueles em que houve substituição valvar. As características pré-operatórias eram semelhantes, sendo efetuada troca da valva quando havia degeneração valvar ou ectasia ânulo-aórtica. Nos casos de desabamento de válvulas com alargamento do anel realizou-se plástica valvar. Em 48% dos casos foi possível a preservação valvar através de suspensão da valva aórtica. Nos 23 doentes em que foi realizada a substituição valvar, a técnica de Bentall e De Bono foi utilizada em 16. Em seis pacientes foram associados outros procedimentos cirúrgicos. Em todos os doentes operados a partir de 1986 foi utilizada cola biológica. Em 41 (93%) pacientes a aorta proximnal foi substituída e nos três restantes realizou-se aortoplastia. Cinco pacientes (11%) tiveram morte hospitalar, três por baixo débito, um por sangramento e um por complicação neurológica. Dois pacientes (4%) apresentaram morte tardia. O seguimento dos 37 sobreviventes variou de dois a 108 meses, com média de 18: 78% estavam em classe I e os demais em classe II. Dois pacientes que tiveram a valva preservada apresentaram insuficiência aórtica discreta. Três doentes que receberam válvula biológica necessitaram reoperaçáo tardiamente, por disfunção da válvula. Um doente submetido, inicialmente, a aortoplastia e plástica valvar apresentou redissecção e insuficiência aórtica após 60 meses, sendo reoperado pela técnica de Bentall. No estudo com curva atuarial de sobrevida notamos que os pacientes submetidos a plástica valvar tiveram maior sobrevida. Podemos concluir que: 1) a suspensão valvar é uma técnica satisfatória em pacientes com dissecções crônicas da aorta, com baixa mortalidade e menor índice de complicações a médio prazo do que a substituição valvar; 2) a identificação do mecanismno da insuficiência valvar é fundamental para decisão da tática operatória; 3) o uso da cola biológica facilita o manuseio da aorta e pode diminuir o sangramento intra-operatório; 4) quando é necessária a substituição valvar tem-se preferido empregar prótese mecânica dada a maior dificuldade técnica na reoperaçáo nesses pacientes; 5) a aortoplastia não deve ser utilizada devido à alta incidência de redissecção aórtica.

Urological use of a disposable bipolar diathermy probe: An experimental in vivo study

The effects of monopolar and bipolar diathermy systems were studied in 12 male Sprague-Dawley rats. Fulguration was achieved by application of a standard current (13 W for 1 s) on the foreskin. Tissue damage was assessed by light microscopy. Results suggest that bipolar probe causes less tissue damage than its monopolar counterpart. It has proved to be of value in plastic and paediatric procedures and is recommended for the urologist's armamentarium.

The growth of circumferential scars of the major airways from infancy to adulthood

The factors affecting the development and prognosis of scarred airways in children are presented from a long-term follow-up study of 14 cases of tracheobronchial lesions following either injury or operation. Four children managed by endoluminal treatment developed severe stenosis and required treatment, later as adults, by laser resection in 2 cases and by laryngotracheal plastic enlargement and resection with anastomosis in 1 case each. The follow-up of 7 children managed by plastic procedures showed inconsistent results: they were good or excellent in 3 cases but with a decrease in the laryngotracheal diameter of 36%, 28% and 7% respectively. The laryngotracheal calibre decreased in 2 patients to 45% due to partial fibrous stenosis. Resection and anastomosis was required in the remaining 2 patients after 11 and 12 years for severe re-stenosis. The 3 patients who underwent immediate surgical resection all had an excellent clinical and morphological result, with a decrease in the laryngotracheal diameter of only 7%, 13% and 19% after a follow-up of 18, 20 and 15 years, respectively. These results show that the growth capacity of scars in children's airways is closely related to residual sclerosis following the initial treatment. It is thus suggested that primary resection and anastomosis should be performed in as many cases as possible. In the performance of plastic procedures, special attention should be paid to complete resection of the fibrotic tissues. Finally, a very long postoperative follow-up is always required in children in order to assess the development of the airway.

Yellow Professionalism-Reply

<i>In Reply</i>.—The correspondence referred to by Dr Reade and Dr Ratzan in<i>The New England Journal of Medicine</i>reflected substantial agreement with many of the points made by our article in theArchives. Specifically, Dr Reade and Dr Ratzan stated: "We agree that physicians trained in other surgical subspecialties [than general plastic surgery] may be competent to perform certain plastic procedures." They agreed that facial plastic surgeons, trained in otolaryngology, should be able to describe their specialization in facial plastic surgery under an appropriate heading in the yellow pages. Doctor Reade and Dr Ratzan also noted with "regret" an error in their methodology. Their correspondence was run under the rubric of a "correction." We stand by our more complete study, based on more complete data and corrected methodology, as published in theArchives. As the Chairman of the Federal Trade Commission recently testified before Congress, otolaryngologists provide useful and helpful

Tratamento cirúrgico da insuficiência mitral em crianças: dez anos de técnicas reparadoras

Entre abril de 1979 e janeiro de 1989, de 71 pacientes com idade entre 4 e 16 anos (média 11,5) portadores e insuficiência mitral (IM), 53 (74,6%) foram submetidos s procedimentos plásticos do aparelho valvar mitral, dos quais 29 com menos de 12 anos. Todos apresentavam IM, 21 deles com estenose mitral associada (dupla lesão mitral - DLM). Em 21 (39,6%) pacientes, foi observada regurgitação tricúspide à cineventriculografia direita. A etiologia reumática foi predominante (42 casos, 79,2%). Todos os pacientes, exceto três situavam-se na classe funcional III e IV. Foram empregados anéis de Carpentier em 41 pacientes e, nos últimos 10, anéis abertos Gregori-IMC, associados a procedimentos plásticos sobre as cúspides e o aparelho subvalvar. Em dois pacientes, a plastia mitral fo realizada sem o emprego do anel protético. Não ocorreram óbitos hospitalares. Três (5,7%) pacientes foram reoperados para troca valvar, todos pertencentes ao grupo com estenose mitral associada quando 1 faleceu, sendo o único óbito tardio de toda a série (1,9%). Na avaliação clínica, com tempo pós-operatório médio de 5 anos (1 mês a 10 anos), 2 (3,8%) estavam sem seguimento, 43 (81,1%) na classe funcional I, 4 (7,5%) na classe funcional II e 4 (7,5%) na classe III. Dos trés pacientes pertencentes à classe II no pós-operatório, todos evoluíram para a classe I. Dos 26 da classe III, 23 (88,5%) passaram para a classe I e 1 permaneceu na III. Dos 24 pacientes da classe IV, 15 (62,5%) passaram para a I, 4 passaram para a II, 3 passaram para a classe III e 2 sem seguimento. Vinte e dois pacientes (41,5%) encontravam-se sem sopros, 15 (28,3%) com sopro sistólico no foco mitral (SSFM) discreto (+/+ + + +), 10 (18,9%)com SSFM moderado( + +/+ + + +), 4 (7,5%) com SSFM importante (+ + +/+ + + +), 2 (3,8%) sem seguimento. Dos 3 pacientes com IM pura, 30 (93,8%) estavam na classe I, 1 (3,1) na classe II e 1 (3,1%) sem seguimento. Neste grupo, 16 (50%) pacientes encontravam-se sem sopros, 9 (28,1%) com SSFM discreto, 6 (18,9%) com SSFM moderado e 1 (3,1%) sem seguimento. Dos 21 pacientes com estenose mitral associada 13 (61,9%) situavam-se na classe funcional I, 4 (19%) na classe II, 3 (14,3%) na classe Mi e 1 (4,8%) sem seguimento. Neste grupo, 6 (28,6%) encontravam-se sem sopros, 6 (28,6%) com SSFM discreto, 4 (19%) com SSFM moderado, 4 (19%) com SSFM importante e 1 (4,8%) sem seguimento. O reestudo hemodinâmico foi realizado em média após dois anos (um mês a sete anos) em 32 pacientes (60,4%). Houve diminuição significativa da pressão sistólica em artéria pulmonar (55,4 - 41,9 P < 0,01), da pressão capilar pulmonar (26,0 - 19,6 P < 0,01) e do gradiente transvalvar mitral (9,6 - 5,7 P < 0,01), sndo que em apenas 6 (20%) este era superior a 7 mm/Hg (3 deles correspondem aos casos reoperados). Vinte e três (71,9%) pacientes apresentaram funcionalidade valvar bastante satisfatória, sendo 16 deles em regurgitação e 7 com regurgitação discreta; em 6 pacientes (18,8%), a regurgitação era moderada e em 3 (9,4%) havia regurgitação importante (casos reoperados). No grupo de pacientes com IM pura (17), em 14 (82,4%) a regurgitação era ausente ou discreta e em 3 (17,6%) era moderada. No grupo com DLM (15), em 9 (60%) a regurgitação era ausente ou discreta, em 3 (20%) era moderada e em 3 (20%), importante. Dos 2 pacientes sem anel protético, um não apresentou refluxo valvar mitral e outro, moderado. No grupo de pacientes com anel de Carpentier (22), 9 estavam sem refluxo valvar, 6 com refluxo discreto, 4 moderado e 3 importante. No grupo com anel Gregori-IMC (8), 6 não apresentavam refluxo mitral, 1 tinha refluxo discreto e 1, refluxo moderado.

Pore pressure predictions in finite element analysis

AbstractMany of the existing pore pressure models for FEM analysis are limited either to cases where the pore pressure component produced by the shearing stress is neglected (usually restricted to static analysis) or where the component produced by the mean confining stress is disregarded (usually restricted to cyclic loading, as in earthquake and offshore engineering). A pore pressure model including the simultaneous effects of shear and mean confining stresses is presented in this paper. The model is simple and applicable to static as well as cyclic loading. The conceptual relationship between strains and pore pressure is well recognized in soil mechanics; however, it is difficult to determine the strains by FEM with the necessary accuracy to ensure satisfactory pore pressure predictions, mainly in the range of strains where the concepts of stress path are best applicable. To overcome this limitation, the proposed technique introduces a pore pressure function, to be coupled to a potential and a loading function in an elastic—plastic constitutive model. For simplicity, it is assumed that the pore pressure response can be satisfactorily represented by a path dependent calibrating function determined to fit experiments over a given range of confining pressures. This procedure allows the independent determination of the pore pressure increment before the iterative elastic—plastic procedure is activated, thus supplying the constitutive model directly with the appropriate direction and magnitude of the effective stress increment. The advantages of this procedure during undrained loading are presented in the text.

Urethral placement through a bilateral myocutaneous gracilis flap neovagina

Malignant melanoma of the vagina is an uncommon genital tumor. When the lesion arises in the distal vagina, radical surgery has been the only treatment to produce long-term survivors. A total vaginectomy, vulvectomy, and bilateral groin node dissection is recommended to assure adequate margins. Sexual function is lost unless reconstruction is performed. The bilateral myocutaneous gracilis flap neovagina has been a successful plastic procedure after exenterative procedures that result in loss of bladder and/or rectum. The authors present a technique in which bladder function was preserved after creation of a gracilis flap neovagina in a patient with Stage I melanoma of the distal vagina. Placement of the distal urethra through the reconstructed gracilis flap neovagina resulted in preservation of urinary function and continence, primary closure of the vulvar defect, and satisfactory sexual function. Two and one-half years after surgery the patient has good bladder and vaginal function without significant sequele.

Balloon dilatation of pulmonary artery banding in dogs: an experimental study.

The technique at our institution for banding of the pulmonary artery (PA) makes debanding by balloon dilatation theoretically possible. Previously we tested this hypothesis in an in vitro study (see previous article in this issue). This study describes balloon dilatation in dogs. Eight Labrador Retriever dogs had a PA band placed early in life, and when their body weight had doubled, they were restudied and debanded by balloon dilatation or surgical removal. One dog died of a virus infection before debanding and was excluded from the study. Five of the dogs (groups 1 and 2) underwent balloon dilatation with satisfactory relief of the gradient across the PA band. Two dogs (group 3) underwent surgical debanding without a plastic procedure on the PA, and this also produced satisfactory relief of the gradient. All dogs in group 2 and 1 dog in group 3 were studied 3 months later, and 1 dog in group 2 was also studied 6 months after the debanding procedure. The systolic pressure gradient fell from a mean of 54 to 18 mm Hg after the debanding procedure. There was no difference in the gradient after debanding in the balloon group compared to the surgical group.

Artificial syndactylisation for congenital crossed toes

Congenital crossed toe is a common deformity which frequently causes disability. The fifth toe is affected and over-rides the fourth toe. Correction is carried out to relieve pain caused by pressure and to improve appearance. Methods of correction range from conservative manipulation and splintage to radical amputation. The method of syndactylisation is a plastic procedure which is simple, safe and reliable.

Hair Transplantation: A Review

Hair transplantation has developed into a refined art in the past 30 years. Refined techniques and instruments, appreciation of properly placed hairlines, better methods of harvesting donor grafts, and better cutting materials in punches have significantly improved results in one of the most frequently performed cosmetic plastic procedures.

F.E.M. ANALYSIS OF THE EFFECT OF ASPECT RATIO IN PLANE STRAIN COMPRESSION OF A PRESHAPED STRAIN HARDENING MATERIAL BETWEEN INCLINED TOOLS.

ABSTRACT Metal forming problems generally involve large plastic deformations. in cold forming most materials have a nonlinear strain hardening behaviour. F.E.M. solutions of. such problems require elastic plastic analysis and an incremental approach. While a number of such approaches exist they require fairly small step size and hence a large computational effort Madnaik, Maiti and Chaturvedi (1) had proposed a modification to the tangent modulus method of Yamada et al(2) and showed that this method is able to solve the problem of plane strain compression with considerably less computational effort and reasonable accuracy; and presented results to show the stress distributions at various levels of reductions and for different aspect ratios(3) This paper uses the same procedure termed the Modified Elastic Plastic Incremental Analysis Procedure (MEPIAP) for obtaining solution to another problem i.e. Plane Strain Compression of Preshaped Material between Inclined Tools.

Lower limb blocks for children

SummaryFemoral and lateral cutaneous nerve of the thigh blocks have been performed in a group of 50 children; the method has not previously been described in paediatric practice. The technique was judged to have been successful in 48 (96%) of the children. There were no early or late complications. It is concluded that these blocks are easy to perform, even in small children and infants, and that they can produce reliable postoperative analgesia for a variety of orthopaedic and plastic procedures.

A study of operative treatment and bacteriological examination of persistent oro-antral fistulas

A retrospective study of 35 patients with oro-antral fistulas of more than 2 weeks duration is presented. Treatment results by using the Rehrmann plastic procedure, as well as complications and sequelae are described. The results of bacteriological examination in 15 patients with maxillary sinusitis in association with oro-antral fistulas are presented. The bacteriological findings suggest that broad spectrum antibiotics in certain conditions should be administered in cases of persisting oro-antral fistulas associated with maxillary sinusitis. The results of the present study show that the Rehrmann-operation proves satisfactory even in treatment-resistent cases.

Butorphanol tartrate: an intravenous analgesic for outpatient surgery.

Many surgical procedures in otolaryngology, particularly those in the areas of facial plastic surgery, are best performed under a local anesthetic. The majority of these procedures may be done on an outpatient basis and require an intravenous analgesic of some form. This analgesic must be safe, predictable, easy to administer, have a rapid onset, and provide good amnesia. A short recovery period is imperative. Diazepam has been widely used in the outpatient setting, since it generally fulfills the requirements listed. However, the recovery time is often prolonged and unpleasant for the patient. Butorphanol tartrate, a synthetic narcotic, provides rapid analgesia in an intravenous dose, fulfills the other requirements for an analgesic agent suitable for outpatient use, and has a relatively short duration. Butorphanol tartrate has been used in an intravenous drip form for outpatient surgical procedures for the past 18 months. Its use in 400 cases representing a broad spectrum of facial plastic procedures has been closely monitored in both the operative and postoperative periods and the results tabulated. We have found butorphanol tartrate to be an excellent agent for local anesthetic procedures in the outpatient setting.