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To evaluate the effect which cooling of burn wounds has upon dermal microvascular circulation, standard 10% BSA dorsal guinea-pig scald burns were created. In treated animals, the dorsal burned region was immersed in a circulating ice-water bath (0-3 degrees C) for 30 minutes at various time intervals postburn (10,20,30, and 60 minutes after scald). India-ink perfusion was used to determine the level of dermal vessel patency at 2, 4, 8, 24, 72, and 96 hours after burning. By 96 hours, significant differences could be seen in animals cooled 10, 20, or 30 minutes after burning. Those not treated until 60 minutes after burning had dermal perfusion essentially the same as control animals. 133Xe dermal washout studies were performed at 8 and 24 hours and corroborated these findings. Grossly, burn wounds cooled by 30 minutes after burn had markedly better healing than control animals and animals cooled 60 minutes after burning. We believe these data support the early use of cold water treatment of partial-thickness burn wounds, as demonstrated in this experimental study.

The breakdown products of arachidonic acid have been implicated as mediators of progressive dermal ischemia in both cold and thermal injuries. Increased tissue survival can be demonstrated experimentally with the preservation of the dermal microcirculation by using antiprostaglandin agents and thromboxane inhibitors. Thirty-eight consecutive patients (28 males and 10 females aged 2 mo to 46 yr) with frostbite injuries were treated at the University of Chicago's Burn Center in January 1982 with a protocol designed to decrease the production of thromboxane locally and prostaglandins systemically. All patients recovered without significant tissue loss. The average hospital stay was 5.6 days for acute injuries and 6.9 days for subacute injuries.

Twenty-one mastoid-occiput-based shoulder flaps have been used to reconstruct patients with head and neck cancer. When the tip of the flap does not extend beyond the midclavicle, this flap can safely be elevated and transferred into its final position without delay procedures. Not requiring secondary sectioning and implantation, the Mütter flap can successfully be used to reconstruct multiple defects within its arch. Its utility thus rivals the more commonly used medially based deltopectoral flap and forehead flap.

The presence of bacteria and local infection is an important factor in the local management of chronic pressure ulcers. For successful closure of the ulcer, the bacterial count should be 10(5) or less per gram of tissue in the granulating wound. In a prospective randomized study of 45 (eventually 40) hospitalized patients, silver sulfadiazine (Silvadene) cream and povidone-iodine (Betadine) solution were compared to physiologic saline for effectiveness in preparing pressure ulcers for closure. Quantitative bacteriologic techniques on tissue biopsy specimens were used for objective evaluation. In 100 percent of the ulcers treated with silver sulfadiazine cream (15 patients) the bacterial counts were reduced to 10(5) or less per gram of tissue within the three-week test period, compared to 78.6 percent in those treated with saline (14 patients) and 63.6 percent in those treated with povidone-iodine solution (11 patients). Moreover, the ulcers treated with silver sulfadiazine cream responded more rapidly, with one-third showing bacterial levels of less than 10(5) within three days, and half within a week.

Decreasing progressive dermal ischemia after burning could theoretically limit the amount of skin necrosis to the zone of coagulation. Methylprednisolone, aspirin, indomethacin, imidazole, dipyridamole, and methimazole have been shown to prevent dermal ischemia, suggesting that prostaglandins and/or thromboxanes may play a role in its pathogenesis. Specific antiprostaglandin antibodies (anti-PgE2, PgF2 alpha, PgI2, and TxA2) were reacted with tissue biopsies of burned guinea pig skin at various time intervals postburn. An immunoperoxidase technique with goat anti-rabbit immunoglobulin and horseradish peroxidase demonstrated the presence of the specific arachidonic acid metabolites. The burned tissue showed high levels of PgE2 and TxA2. The effects of three thromboxane inhibitors, imidazole, methimazole, and dipyridamole, on dermal ischemia were studied. Xenon133 washout studies were performed in burned and unburned areas. Tissue half-life of Xenon was prolonged in burned, untreated areas but this rapidly decreased in antithromboxane-treated burns. Repeated antiprostaglandin and antithromboxane antibody-immunoperoxidase studies on tissue from the thromboxane inhibitor-treated animals showed that PgE2, PgF2 alpha, and PgI2 were at the same levels as in untreated animals, but thromboxane (TxA2) was essentially absent, suggesting that thromboxane may be responsible for the progressive dermal ischemia after burning and that decreasing its production can increase dermal perfusion.

Five patients have recently been treated at this institution for skin ulcerations caused by mycosis fungoides and its treatment with total body electron beam radiation therapy. Both the disease and its treatment can injure epidermal appendages as well as the blood supply to the skin. As a result of this potential damage, there was initial concern that skin grafts might not take and donor sites might not heal in these patients. Though skin grafting has not been universally successful, we have been able to skin graft the majority of the ulcerated lesions in these patients with good results. Donor sites have healed, though more slowly than usual. Skin grafting can be effective for treating ulcers in patients who have undergone total body electron beam radiation therapy for mycosis fungoides.

Topical antimicrobial agents are essential to optimal burn care. However, exposure of WI-38 human diploid fibroblasts (ATCC CCL 75) and fresh donor human dermal fibroblasts to silver sulfadiazine and mafenide acetate results in a significant reduction in cell proliferation, as determined by hemocytometer cell counts and total matrix protein assays, within 48 hr of exposure. Changes in cellular morphology and progressive deterioration of cytoplasmic organelles and the nucleus are seen with phase-contrast microscopy and transmission electron microscopy. These findings may explain the clinical observation of delayed wound healing after the use of topical antimicrobial agents.

A review of the identification of foreign body hand injuries is presented with criteria for removal of a foreign body in the emergency department. Indications for acute surgical intervention are presented, and expectant management is discussed.

p6 experimental model has been designed to help study the acute effects of tobacco smoking on the cutaneous micro-circulation. Arterioles in the nude mouse ear are directly visualised by intravital microscopy and the blood flow is quantified. Arteriolar vasoconstriction and decreased blood flow are seen in response to smoking. The implications of post-operative smoking for the patient undergoing flap surgery are discussed.

The surfaces of 11 silicone mammary prostheses were examined by scanning electron microscopy (SEM) and energy dispersive x-ray spectrography (XES). Three of the prostheses were recovered from clinical cases and eight from guinea pig models. The surfaces of the prostheses were covered with an investing film and by 2- to 5-microns spheres aggregated in 40- to 200-microns-wide patches. The embeddedded spheres were blebbed and surrounded by pits. X-ray energy spectrography showed high levels of sodium, chlorine, and potassium. It is concluded from this evidence that phagocytic cells embed themselves within the envelope, perhaps by an immune-mediated phagocytic process.

Observations on early pathophysiology of burning suggests that the release of prostaglandins and thromboxanes plays a role in dermal ischemia. Because of the similarities of the early-phase frostbite wound, blister fluids were aspirated from 10 patients with frostbite, and routine biochemical analysis, immunoelectrophoresis, immunodiffusion, and evaluation of prostaglandins E2, F2 alpha, and thromboxane B2 were performed. Potassium, serum glutamic-oxaloacetic transaminase (SGOT), creatine phosphokinase (CPK), and lactic dehydrogenase (LDH) levels exceeded normal serum values. All blisters were found to have IgM, IgG, IgA, C3a, and opsonin. PgE2 was present in levels less than normal, but PgF2 alpha and TxB2 were markedly elevated. Since the vasoconstricting metabolites of arachidonic acid, PgF2 alpha and TxB2, are known to mediate dermal ischemia in burns and pedicle flaps, it is suggested they may play a role in the pathogenesis of frostbite.

A case of cor pulmonale occurred as a complication of a simultaneous palatoplasty and a superiorly-based pharyngeal flap. The patient, like two others found in the literature, had micrognathia. The cor pulmonale was not recognized in the immediate postoperative period but presented two years later with "failure to thrive." Therefore, surgeons must make other members of the health care team aware of this possible complication of combined palatoplasty and pharyngeal flap operations.

A questionnaire distributed to plastic surgeons to determine their patterns of usage of systemic prophylactic antibacterial agents was answered by 1,025 respondents (73.7 percent). The patterns of usage among the respondents were determined for 29 circumstances and operations for the time of administration, and as influenced by 11 modifying factors. The data present the patterns of antibacterial use by plastic surgeons at this time.

The use of a pneumatic tourniquet to release fibrous capsular contracture around a breast implant is described. This method protects the operator's hands and, we believe, is potentially safer for the patient and for the breast prosthesis.

An approach to the patient with a recurrent head and neck cancer following prior combined radiation, surgery, and possibly, chemotherapy has been outlined. Following a detailed evaluation of the patient's symptoms, the local extent of the recurrence, and the search for distant disease, resection of the recurrent tumor with immediate reconstruction of the resulting defect is advocated. Although reconstructive efforts may be taxing because of prior use of optimal tissue, imaginative planning and improvisation will allow functional and cosmetic restoration in many cases. Illustrative cases have been included to demonstrate the efficacy of this approach in treating patients with recurrent cancer of the head and neck.

It is a biologic fact that all open wounds contain bacteria and remain contaminated with varying levels of bacteria until successful wound closure has been accomplished. The sine qua non in the management of the contaminated wound has been and remains adequate sharp debridement. In a standardized experimental model, three methods of irrigation were compared employing quantitative bacteriology of tissue to evaluate their effectiveness at decreasing bacterial levels and reducing wound infection. The pulsating jet lavate was found to be significantly better than gravity flow irrigation or wound irrigation with a bulb syringe. These data on tissue biopsies support previous reports using surface and wound exudate cultures.

The eventual depth of tissue necrosis after burning is not immediately apparent. In all burn wounds, there exists a zone of stasis which shows progressive microvascular deterioration. These progressive changes have been prevented by methylprednisolone acetate, indomethacin, and ASA. All of these agents are known to inhibit prostaglandin synthesis. These data suggest that prostaglandins have a role in the progressive dermal ischemia after thermal trauma and that their effect can be prevented by specific antiprostaglandins.

We have devised an algorithm employing the exclusive use of biosynthetic dressing (Biobrane) to treat the less extensive burn wounds of patients under DRG 460. This protocol has allowed us to decrease the hospital stay of these patients by 46 percent and turn this patient group from a deficit for the hospital to a substantial profit.

Six cases of large defects of the scalp, skull, and dura following tumor ablation and radiation are presented. Each was accompanied by chronic infection in the irradiated defect. Efforts to reconstruct the resulting defects with local flaps were not successful. One-stage reconstruction was then accomplished in each case utilizing a latissimus dorsi musculocutaneous or myo-osteocutaneous free flap transferred by microvascular anastomoses. The versatility of the latissimus dorsi musculocutaneous and/or osseous flap allows single-stage reconstruction of these complex defects.

To achieve optimal hand function, wound closure becomes the most important ingredient in hand burns. This study documents the use of a biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. The glove allowed rapid active motion and minimized the pain of open wounds. Forty-two Biobrane glove applications were evaluated with 50 per cent applied over superficial hand burns and 50 per cent over deep partial thickness or full thickness injuries. In the superficial hand burns, the patients were discharged home after a mean time of 2.8 days. With the deep burns the dressing provided a closed wound after early excision of eschar without the use of an autograft or biological dressing. Based on these studies, we conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.

The concentration of cefoxitin was determined in fluid obtained from human surgical wounds during the first postoperative day. Intravenous administration of cefoxitin sodium at a dosage of 1 or 2 g every six hours rapidly produced wound-fluid concentrations greater than the minimal inhibitory concentration for most susceptible organisms. After three hours, wound-fluid concentrations surpassed the serum concentrations of cefoxitin. The higher dosage resulted in higher wound-fluid levels.

A series of 2,389 Emergency Department surgical admissions was assessed for quantitative indices of actual services rendered and time spent. Auto accident-related patients were compared to other Emergency Department surgical patients. The average diagnostic index for auto accident patients was 48 units compared to 25 units for all patients. Their workload for Emergency Department personnel was twice the average for non-automobile accident patients. Although they made up to 7.9% of all patients, they accounted for 15% of the total diagnostic services, 12% of the total therapeutic services, and 14% of the overall services rendered during the period of study. These data suggest strongly that auto accident-related patients are different from the average Emergency Department surgical patient and are quantitatively treated differently from other surgical patients.

The increasing incidence of illicit intravenous drug abuse has reached epidemic proportions in western society. Although the accompanying infectious complications such as hepatitis and acquired immunodeficiency syndrome receive the most notoriety, injection injuries are causing an increasing number of problems. A retrospective review of patients requiring admission for acute or chronic drug injection injuries of the upper extremities was made at the Detroit Receiving Hospital from 1980 through 1985. The demographical, historical, physical, microbiological, and follow-up data were analyzed. The majority of the injuries involved subcutaneous injections into the hand with accompanying inflammatory or infectious complications. The bacteriological data revealed unique characteristics and did not reflect patterns expected from inoculation of normal skin flora. A treatment regimen based on the data is proposed.

The physiological changes that allow increased flap survival after flap delay have never been clearly defined. Inflammation has been postulated as a critical factor in flap delay and prostaglandins are known to be mediators of the inflammatory response. To evaluate the role of prostanoid derivatives in experimental flap delay, 0.2% formic acid was injected under the outline of modified McFarlane flaps in 20 rats and saline was injected under the flap outline in 20 control rats. Two weeks later the flaps were raised on all the rats. Average flap survival one week after flap elevation was 65.5% after formic acid delay and 42.9% after saline delay. Biopsies were taken from the flaps both during the delay period and after flap elevation. The specimens were stained for PGE2, PGF2 alpha and thromboxane. Changes noted in the levels of these prostanoid derivatives suggest that they may indeed mediate flap delay.

It has been suggested that deep partial-thickness burns of the hand which remain unhealed by 14 days should be excised and totally resurfaced. Controlled data supporting this suggestion is not available. Therefore, a prospective randomized study was performed on 222 burns of the hand to evaluate if excision and skin grafting had any advantage over conservative management. Full-thickness burns were eliminated from the series by excision and grafting them as soon as possible after the diagnosis had been made. To eliminate the very superficial burns, randomization did not take place until the wound had remained unhealed for ten days and would not heal for at least another week. In the two groups, the first ten days were managed similarly with topical antibacterials, escharotomies when necessary, and splinting in the "safe" position. Conservatively managed hands were treated with scarlet red gauze dressing as soon as all eschar had been removed. Those cases randomized into the excision and grafting group were operated upon approximately day 14. Physical therapy was the same in both groups except for the immediate period after grafting. Results were recorded by active and passive joint measurements and photographs on predetermined days throughout the study. In this study, spontaneous healing, taking as much as five weeks, gave acceptable results, comparable to excision and grafting performed at two weeks. The use of range of motion exercises, accurate splinting and pressure allowed optimal healing and prevented stiffness and contractures in both groups. There was no significant difference between the two treatment modalities.

Our experience with 9 patients who have undergone reconstruction with free flap transfers following resection of squamous cell carcinoma in the head and neck area is presented. The dorsalis pedis flap was used in 3 patients, the iliofemoral (groin) flap in 4, and the latissimus dorsi myocutaneous flap in 2. Four patients had received preoperative irradiation. Despite minor partial flap necrosis in 3 patients and the development of oral cutaneous fistulas in 2, all the flaps were successful in providing the necessary coverage. Reoperation in 1 patient was necessary because of thrombosis of the venous anastomosis.

This study reports on the effects of early cooling on the morphology of partial-thickness burns. After 10% body surface dorsal scald burns at 75 degrees C for 10 seconds, guinea pigs were treated by ice-water immersion at 10 minutes postburn of only the burned surface for 30 minutes. Skin samples from treated and untreated burn wounds were examined at 2, 8, 24, and 96 hours postburn by light and electron microscopy. During the first 24 hours, cooling was associated with reduced loss of epidermis and reduced damage to the basement membrane. There was also less damage to the dermal microvasculature and less edema fluid compared to untreated burn wounds. At 96 hours, the cooled burn wounds demonstrated minimal dermal hemorrhage and polymorphonuclear leukocytic infiltration, compared to the untreated wounds. These results indicate that on a cellular level, cooling has beneficial effects on the experimental burn wound.

The following report reviews 851 applications of Biobrane on partial skin thickness burn wounds awaiting epithelialization. After the patients had been evaluated and resuscitated as needed, the burn wounds were cleansed and debrided. Those evaluated as shallow were treated with Biobrane application. Joint surfaces were splinted for immobilization. The wound was inspected at 24 and 48 h and if any fluid had accumulated it was aspirated and the wound was redressed. When the Biobrane was adherent, the wound was covered with a light dressing and joint immobilization was discontinued. Treatment with Biobrane dressing provided certain advantages over other topical wound care. As the dressing changes were performed less frequently outpatient care was possible, with a resultant decrease in both the length of hospital stay and the ultimate cost of burn care. Wound desiccation is prevented and pain is decreased. Accurate diagnosis of wound depth is crucial if Biobrane is to be used. Very deep wounds will not allow Biobrane adherence, neither will it occur if the wound has a high bacterial count. If joint surfaces are not splinted, the Biobrane will shear and not adhere to the wound. Convex and concave surfaces can be treated with Biobrane, which may need to be meshed.

Although silicones, as a class, are nontoxic in animal and tissue studies, implanted silicone prostheses and medical devices are associated with various local and systemic host inflammatory reactions. They also have been associated with a form of autoimmune disease. To test the hypothesis that silicones may evoke an immunologically mediated inflammatory reaction, 10 guinea pigs were stimulated for 1 month with intraperitoneal injections of sterile medical-grade silicone oil admixed with homologous serum and complete Freund's adjuvant. Ten controls were stimulated with saline. Four additional animals were passively sensitized with splenic homogenates from four sensitized animals. Intradermal antigenic challenges consisted of silicone-homologous serum, pure silicone, saline-homologous serum, and purified protein derivative. Cutaneous reaction patterns were graded grossly and microscopically. Silicone-serum and purified protein derivative antigens evoked three to four times greater palpable lesions in all 10 actively and all 4 passively sensitized animals at approximately 24 h compared to controls. Biopsies showed a moderate to marked lymphocytic infiltrate. Control sites and naive animals showed only edema at the challenge sites. The data suggest that silicone-protein complexes are potentially immunogenic.

Cigarette smoking is commonly prohibited after surgery involving flaps. This admonition against smoking has been justified on the theoretical grounds that flap survival could be decreased by the cutaneous vasoconstriction and increased platelet aggregation produced by smoking cigarettes. A smoke chamber was constructed to evaluate directly the effect of intermittent cigarette smoke exposure on the survival of a McFarlane flap on the dorsum of a rat. The O2, CO2 and temperature were monitored in the chamber during smoke exposures and consistently approximated values seen in room air. Average flap survival at 7 days in control rats not exposed to cigarette smoke was 75.2% while flap survival decreased to 40.1% in rats intermittently exposed to cigarette smoke. The difference was statistically significant (p less than 0.01). Changes in carboxyhaemoglobin levels similar to those observed in human smokers were also found in the smoke-exposed rats. These findings support the concept that post-operative cigarette smoking is detrimental to flap survival.

Wound healing disturbances can be systemic or local. Systemic disturbances at this point can be diagnosed but not necessarily treated. In the future, these disturbances may be reversed with a specific drug. More importantly, local factors responsible for most of the disturbances in wound healing seen in the emergency department are often under the control of the physician. These can be diagnosed and, frequently, corrected.

The exogenous contamination of a thermally injured patient by contact with the health are team has been a major concern of all burn units. Since the University of Chicago Burn Center routinely monitors each burn injury for sepsis by quantitative bacteriology and recently examined the microbial population present on the hands of the health care team, it was felt that these combined data would shed some pertinent information on exogenous burn wound sepsis. Twenty-nine patients with clinical burn wound sepsis and a bacterial level of greater than 10(5) bacteria/gram of tissue were studied. These patients yielded a variety of microorganisms with P. aeruginosa and Staphylococcus aureus being predominant, followed in incidence by Candida albicans. The resident and transient microflora isolated from each member of the health care team treating the specific individual concerned did not correlate with the causative agent of burn wound sepsis. The most frequent isolate from the staff personnel was Staphylococcus epidermidis followed by Micrococcus species. Though colonization of the thermally injured individual has been reported, these data strongly suggest that colonization is primarily one of an endogenous source rather than that of an exogenous one.

In 1965, Carpentier coined the term bioprosthesis to distinguish the characteristics of glutaraldehyde-treated porcine heart valves from untreated or synthetic valves. Observation that the valves functioned normally but were not incorporated by the host has stimulated interest in similarly preserved materials for use in hand surgery. This report outlines work that was initiated to learn the effects of glutaraldehyde treatment on tendon and a reticular substitute. In over 56 experiments with a chicken model, experience with glutaraldehyde-treated tendon grafts shows no acute rejection. There is good function clinically by 8 weeks with proximal fibrous ingrowth seen histologically. By 12 weeks, distal ingrowth has occurred. There is no ingrowth into the tendon graft within the fibro-osseous tunnel. Mechanical testing of the implant system shows a peak load at failure of 1.86 +/- 0.43 pounds and at 24 weeks it is 6.53 +/- 2.6 pounds. The failure site at time zero was distal. By 12 weeks, the distal attachment strengthened and the proximal attachment failed at a greater load. An interpositional substance with potential uses in hand surgery has been prepared by glutaraldehyde treatment of mammalian pericardium. Possible uses include interposition between fractured phalanx and the extensor tendon. This has been evaluated in feasibility studies in a rabbit model.

Appropriate study design and proper statistical analysis are necessary ingredients for improving the quality and reliability of the information in journal articles. General surgery and plastic surgery articles were compared for principal author's academic degree, a Ph.D.'s presence as a coauthor, the study type, the presence of statistical analysis, the analysis' appropriateness, and the types of errors in study design or statistical analysis. Ph. D. authorship was associated with increased percentage of articles using statistical analysis. When compared with general surgery articles, plastic surgery articles performed four times fewer statistical analyses. However, when statistical analyses were performed, there were few differences between these two specialties. Although there were no differences in the types of statistical analysis errors, there were differences in the types of study design errors. The causes of these discrepancies may lie in the nature of plastic surgery; they may be reduced by adherence to Feinstein's principles of study design and result interpretation.

Fibrous capsules surrounding silicone implants were investigated in a new guinea pig model to delineate some of the factors leading to capsular contracture. Both the implant surfaces and tissue capsules were examined by light and scanning transmission electron microscopy (STEM + SEM) with x-ray energy spectroscopy (XES). The capsular tissues were qualitatively similar to those recovered clinically, showing dense parallel collagen deposits, fibroblasts, myofibroblasts, macrophages, and foreign-body giant cells. Silicone was positively identified within intercellular vacuoles and the rough endoplasmic reticulum of macrophages by XES. Tissue recovered from the capsules that surrounded implants that were contaminated with S. aureus presented a qualitatively similar histologic spectrum. The contaminated specimens did show an accelerated response. SEM showed a cellular invasion of the silicone envelopes. We conclude that the model accurately simulates the clinical situation and suggests that immune mechanisms may play a key role in capsular contracture.

We have used a modification of a mucoperiosteal flap described by Lane for cleft palates in 3 patients with oral cavity defects from tumor ablations. The flap provides excellent lining for repairs when alternative flaps are unavailable. The vascularity of the flap and its texture allow a watertight closure which does not hinder the patient's ability to talk or eat.

Following an initial report urging conservative management of severe diabetic foot infections, the authors have managed 45 patients with a minimum 3-year follow-up. By using standard principles for soft-tissue infection, 78 percent of the patients healed minor amputation sites and maintained biped ambulation following the initial foot involvement. Only 22 percent required a major amputation at the time of the initial foot involvement. The 45 patients were followed and 22 (or 49 percent) developed a severe infection involving the contralateral foot within 18 months. Although 15 of the 22 patients developing contralateral infection (or 33 percent of the total series) required some type of amputation on the contralateral foot, the conservative approach allowed 64 percent of the patients with severe infections in both feet to maintain biped ambulation. This included 40 percent of the patients who required amputation of some portion of both feet.