Application of wound dressing Molndal technique in clean and potentially contamined postoperative wounds--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons, particularly in patients with compromised immune system or in case where the wound is heavy contaminated or poorly perfused. Molndal technique of wound dressing has proven to be effective in prevention of infection. In our study we wanted to describe the benefits of the application of Molndal technique wound dressing compared to traditional wound dressing technique at potentially contaminated and clean postoperative wounds. We examined postoperative wound after radical excision of pilonidal sinus and after implantation of partial endoprosthesis in hip fracture. Molndal technique consisted of wound dressing with Aquacel Ag - Hydrofiber. Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 50 patients after radical excision of pilonidal sinus. 25 patients were treated by Molndal technique and 25 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (4%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration. In the traditional technique group 4 (16%) patients developed wound infection as inflammation and secretion as a sign of superficial infection. In the other group we analyzed the results of 50 patients after implantation of partial endoprosthesis after hip fracture. 20 patients were treated by Molndal technique and 30 patients by the traditional technique of wound dressing. In the group treated by Molndal technique no patient has revealed a wound infection (0%). In the traditional technique group 4 (13%) patients developed wound infection. All complication in both group were superficial incisional surgical infection (according to HPSC). There was no deep incisional surgical site infection or organ/space surgical site infection. Our results are clearly showing that Molndal technique is effective in preventing the postoperative wound infection.     

The influence of permanent magnetic field therapy on wound healing in suction lipectomy patients: a double-blind study

The authors present their experience with the healing influence of permanent magnets on postoperative wounds. The responses of 20 patients who underwent suction lipectomy and postoperative negative magnetic field therapy were studied in a double-blind fashion. Magnets in the form of patches (10 patients) or sham magnet patches (10 patients) were placed over the operative region in each of the patients. Pain, edema, and discoloration (ecchymosis) were evaluated at 1, 2, 3, 4, 7, and 14 days postoperatively. Our results show that the treatment group had significant reductions in pain on postoperative days 1 through 7, in edema on days 1 through 4, and in discoloration on days 1 through 3 when compared with the control group. These results demonstrated that commercially available magnets have a positive influence on the postoperative healing process in suction lipectomy patients.     

The reversal exchange technique of total calvarial reconstruction for sagittal synostosis

The role of total calvarial reconstruction in the treatment of sagittal synostosis remains controversial, especially in patients younger than 1 year of age. The purpose of this study was to prospectively evaluate the efficacy of a single surgical technique for total calvarial reconstruction (the reversal exchange technique) in patients younger than 1 year of age who had a radiographically confirmed diagnosis of sagittal synostosis. Twenty-three consecutive patients underwent the reversal exchange technique of total calvarial reconstruction at a median age of 3 months (age range, 6 weeks to 10 months). Quantitative assessments were performed on the basis of preoperative and postoperative (minimum, 6 months) measurements of the cephalic index (cranial width/cranial length x 100) taken from three-dimensional computed tomography scans, which were obtained in 18 of 23 patients. Aesthetic assessments were performed on the basis of the grading of preoperative and postoperative photographs, obtained in 17 of 23 patients, by three independent raters who were blinded as to the surgical technique. The mean preoperative cephalic index was 65.0, and the mean postoperative index was 76.4, yielding a mean improvement of 11.4 (17.5 percent). By photographic evaluation, 12 of 17 patients (70.6 percent) were classified as having a normal head shape (grade 4) and five of 17 (29.4 percent) as having minor residual deformities (grade 3). No patients were identified as having significant residual deformities (grades 1 or 2). There were two intraoperative complications and one postoperative complication, none of which resulted in permanent morbidity. It was concluded that the reversal exchange technique of total calvarial reconstruction provided significant improvement in head shape on the basis of quantitative measurements (cephalic index) and independent evaluations of aesthetic improvement.     

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps.Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.     

Long-term follow-up study of nucleus ventralis intermedius and ventrolateralis thalamotomy using a microelectrode technique in parkinsonism

Long-term observation over 3-8 postoperative years of cases of Parkinson disease operated by stereotactic thalamotomy using a microelectrode recording technique is reported. The procedure is specifically useful in the following four groups: (1) tremor-dominant cases, (2) hemiparkinsonism, (3) cases with marked asymmetry in motor symptoms and (4) juvenile parkinsonism presenting levodopa-induced dyskinesia.     

Widening of scars: foe coaxed into a friend? The Millard technique revisited

Widening of scars is a frustrating event that most if not all plastic surgeons have encountered. Several therapeutic modalities have been proposed, but frequently the result is disappointing. During revision surgery, it is advocated that the dermal scar be used in providing support to the tissues instead of being discarded. The author proposes a technique by which tension on the wound is carried by tough scar tissue instead of the suture line, thereby reducing the incidence of postoperative widening. This technique was used to treat 35 nonburn scars that had widened: 31 scars were facial (24 patients) and 4 were inframammary (2 male patients). All scars were at least 4 months old. The operations were performed between February of 1996 and December of 1998; follow-up was 9 to 14 months. Only one scar widened during the follow-up period. Overall, 71 percent of patients rated the improvement as marked. This is a revisiting of the original Millard's technique, which seems to have fallen into oblivion. The author recommends this technique in dealing with widened scars during revision surgery.     

Single versus double pass technique for preparation of ultrathin Descemet’s stripping automated endothelial keratoplasty tissues from donated whole eyes

This study was conducted to analyze the preoperative thickness profile and endothelial rating of ultrathin Descemet’s stripping automated endothelial keratoplasty (UT-DSAEK) tissues prepared with a single versus double microkeratome pass from donated whole eyes and corresponding eye bank postoperative results. Microkeratome-assisted UT-DSAEK tissues were prepared from freshly donated whole eyes with single-pass (SP) and double-pass (DP) technique in the Central Eye Bank of Iran. Preoperative thickness profiles and endothelial cell densities of UT-DSAEK tissues were obtained from optical coherence tomography and specular microscopy, respectively, and compared between groups. Corneal perforation rates during the eye bank preparation and postoperative reports of transplanted UT-DSAEK tissues were also compared. Over a 15-month period, 342 UT-DSAEK tissues were prepared: 248 via SP and 94 with DP technique. Mean donor corneal central thickness was 610?±?58 µm with SP and 790?±?100 µm with DP technique. Mean central thickness of UT-DSAEK tissues was not statistically different between the groups (84.8?±?11.0 µm with SP and 85.1?±?10.5 µm with DP technique, P?=?0.857). Mean increase of UT-DSAEK thickness from central to pericentral and peripheral cornea was not significantly different with both techniques. Mean differences between thicknesses of 2 pericentral locations and between those of 2 peripheral locations were not statistically different in the study groups. Corneal perforation of 1.6 and 1.1% occurred in SP and DP groups, respectively. Failed graft was reported 6 months postoperatively in 4 (1.6%) cases with SP and in 1 (1.1%) case with DP technique. Preoperative thickness profiles of UT-DSAEK tissues prepared from donated whole eyes via SP technique were not significantly different from those prepared with DP, showing a symmetric increase of thickness towards peripheral locations.     

llizarov骨搬运技术治疗胫骨骨缺损的疗效及术后延迟愈合或不愈合的影响因素分析

摘要 目的：探讨 llizarov骨搬运技术治疗胫骨骨缺损的疗效及术后延迟愈合或不愈合的影响因素分析。方法：选取 2016年 6月-2020年 10月本院收治的 90例胫骨骨缺损患者为研究对象,患者均给予 llizarov骨搬运技术治疗。对患者的手术效果指标、并发症发生率进行记录统计。并对患者进行门诊随访观察,统计患者延迟愈合或不愈合的发生情况,据此将患者分为愈合组和延迟愈合或不愈合组。采用单因素及多因素 Logistic回归分析患者术后延迟愈合或不愈合发生的影响因素。结果：患者住院时间为(12.11± 2.98)d、开始负重时间为(45.39± 7.78)d、完全负重时间(76.41± 11.23)d。患者术后并发症发生率为 8.89%(8/90)。经随访观察,共有 29例患者出现术后延迟愈合或不愈合,发生率为 32.22%（29/90）。而延迟愈合或不愈合组患者的伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动及有吸烟史的人数占比高于愈合组患者(P<0.05)。经多因素 Logistic回归分析显示：伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动、有吸烟史是患者术后延迟愈合或不愈合的危险因素(P<0.05)。结论：llizarov骨搬运技术治疗胫骨骨缺损的疗效较好,患者的手术时间短、术中失血量少、住院时间、开始负重时间均较短,并发症发生率低,治疗安全性较好,但患者易出现术后延迟愈合或不愈合现象,可能与伤口感染、合并软组织损伤、合并腓骨骨折、术后过早活动、吸烟史有关。     

应用双色FISH技术检测肝癌中HER—2的定量扩增及其临床意义

为探讨原发性肝细胞癌(HCC)中原癌基因HER-2的扩增激活情况及其与临床病理特征和预后的关系,应用双色荧光原位杂交(dualFISH)技术检测42例原发性肝癌间期细胞核中HER-2的扩增和17号染色体的数目及其比值,并用统计学分析HER-2的扩增与临床病理特征及预后的相关性.结果在42例肝癌中有9例HER-2扩增(amplification),占21.4%,其中高拷贝扩增(HC)有4例(9.5%),低拷贝扩增(LC)有5例(11.9%),HER-2的扩增与性别、年龄、AFP水平、HBV感染、术后复发及临床分期无关(P＞0.05),而与术后2年生存期相关(P=0.046)且HER-2扩增病人的肿瘤有比无扩增病人的肿瘤增大的倾向(P=0.085);同时,在42例肝癌中有3l例为HER-2拷贝数增加(gain),占73.8%,其中9例(21.4%)为扩增所致,22例(52.4%)为17号染色体多倍体或异倍体(polysomy17/aneusomy17)所致,HER-2拷贝数增加与性别、临床分期、肿瘤大小、术后复发及术后2年生存期无关(P＞0.05),但与年龄、AFP水平和HBV感染有关(P＜0.05).以上结果提示原发性肝癌中存在较低频的HER-2癌基因扩增激活及较高频的17号染色体异倍体/多倍体;HER-2癌基因的扩增激活可能与部分肝癌的发生发展有关,是肝癌术后生存期短的有价值独立预后因子.     

Modified operative technique for involutional lower lid entropion

The paper presents a modified operative technique for involutional lower lid entropion. The prospective noncomparative study of 101 lower eyelids of 88 patients undergoing surgery for involutional lower lid entropion was conducted in period from September 2005 until March 2012. Indication for the surgery was entropion, previously untreated, with moderate to severe horizontal lid laxity and no clinically relevant medial and lateral canthal tendon laxity. The operative technique is our modification of Quickert and Jones procedures. Photo was taken preoperatively and one month after surgery. Clinical follow-up was at 7th postoperative day, one month and six months after surgery and in case of the recurrence. Long-term follow-up was obtained via telephone interviews. There were 44 male (50%) and 44 female (50%) patients included in the study. The age of patients was in average 73.27 +/- 8.1 years (range 53-90 years). Early postoperative complication was localized lid swelling found in two patients starting 4-6 weeks postoperatively at the area of absorbable suture. It resolved spontaneously in two and three weeks respectively. There was recurrence of entropion in 11 eyelids (10.89%) of 10 patients. The mean interval between primary surgery and the recurrence was 17.45 +/- 14.84 months (range 4-48 months). In these eyelids Jones procedure was performed. However in four eyelids of four patients from the recurrent group an additional surgery needed to be performed after 6, 12, 12 and 17 months respectively. Our modification of surgical treatment for involutional lower lid entropion was effective in 89.11% of eyelids. Complications of the procedure were scarce.     

大鼠肝移植肝上下腔静脉不同缝合方式及手术体会

目的:探讨肝上下腔静脉不同缝合方式对大鼠原位肝移植的影响.方法:选取雄性SD大鼠60对,以SD大鼠为供体和受体,随机分成A、B两组,每组30对.两组均采用改良Kamada"二袖套法"进行大鼠原位肝移植,A组采用双定点连续缝合方式吻合肝上下腔静脉,B组采用单定点连续缝合方式吻合.比较两组肝上下腔静脉吻合时长、无肝期时长以...     

Repair of pharyngocutaneous fistulas with the submental artery island flap

Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, debridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 x 3 cm and the minimum size was 4 x 2 cm (average, 4.8 x 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donor-site morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed.     

术前HE4、FOLR1、NLR联合监测在上皮性卵巢癌术后复发中的临床应用价值

摘要 目的：探讨术前人附睾蛋白4（HE4）、叶酸受体1（FOLR1）、中性粒细胞淋巴细胞比值（NLR）联合监测在上皮性卵巢癌（EOC）术后复发中的临床应用价值,并分析EOC术后复发的危险因素。方法：选取2018年4月~2019年9月期间广东医科大学附属第二医院收治的114例EOC患者纳为EOC组,EOC组根据术后有无复发分为未复发组（n=42）和复发组（n=72）,选择同期在广东医科大学附属第二医院住院治疗的100例卵巢上皮良性肿瘤患者作为卵巢良性疾病组,另选广东医科大学附属第二医院体检中心的健康女性志愿者95例作为对照组。对比EOC组和卵巢良性疾病组术前、对照组体检当日的HE4、FOLR1、NLR。对比未复发组、复发组术前的HE4、FOLR1、NLR及其他临床资料。采用多因素Logistic回归分析EOC术后复发的危险因素,通过绘制受试者工作特征（ROC）曲线分析HE4、FOLR1、NLR单独或联合应用对EOC术后复发的预测价值。结果：EOC组、卵巢良性疾病组的HE4、FOLR1、NLR高于对照组,且EOC组高于卵巢良性疾病组（P<0.05）。复发组的HE4、FOLR1、NLR均高于未复发组（P<0.05）。复发组、未复发组在病理类型、临床分期、术中腹水细胞学检查结果、化疗周期、清扫淋巴结、组织分化程度、术后残留大小方面对比差异有统计学意义（P<0.05）。HE4偏高、FOLR1偏高、NLR偏高、临床分期Ⅲ ~ Ⅳ期、组织分化程度为低分化、病理类型为浆液性、术后残留大小>1 cm、术中腹水细胞学检查结果为阴性、未清扫淋巴结均为EOC术后复发的危险因素（P<0.05）。HE4、FOLR1、NLR这三项指标术前联合检测预测术后复发的曲线下面积（AUC）为0.911均高于各指标单独检测的0.777、0.782、0.770。结论：EOC患者术前HE4、FOLR1、NLR处于高水平,且术前联合检测HE4、FOLR1、NLR对于EOC术后复发具有一定的预测价值,同时应关注临床分期Ⅲ ~ Ⅳ期、组织分化程度为低分化、病理类型为浆液性、术后残留大小>1cm、术中腹水细胞学检查结果为阴性、未清扫淋巴结的EOC患者,给予相关干预,以降低术后复发几率。     

Phacoemulsification and silicone oil removal through the planned posterior capsulorhexis

The purpose of the study was to present operative technique and results of a passive hydrodynamic expression of silicone oil through planned posterior capsulorhexis during cataract surgery in patients after pars plana vitrectomy. The retrospective analysis was done on 57 eyes with cataract after a previous pars plana vitrectomy, operated on between 2001 and 2004 at the Clinical hospital "Sestre milosrdnice" Zagreb. Preoperative and postoperative best corrected visual acuity (BCVA), preoperative and postoperative intraocular pressure (IOP), and postoperative complications were reviewed. Visual acuity improved or stabilized in all patients with an attached retina. Retinal detachment occurred in 11 eyes. Transient vitreous hemorrhage, that resolved within 1 week of surgery without treatment, was observed in 4 eyes. Asymptomatic intraocular lens (IOL) decentration occurred in 2 eyes. Our findings suggest that silicone oil removal and cataract surgery can be performed as a single procedure in selected patients in the absence of macular pucker and retinal reproliferation, and in a presence of a stable retina.     

肝圆镰状韧带一体化包裹加强技术在质软胰腺胰十二指肠切除术中的应用分析

摘要 目的：探讨质软胰腺胰十二指肠切除术（PD）中应用肝圆镰状韧带一体化包裹加强技术的临床价值。方法：回顾性分析哈尔滨医科大学附属肿瘤医院2016年1月至2021年12月实施开腹PD或保留幽门的胰十二指肠切除术（PPPD）质软胰腺病人的临床资料。根据是否应用肝圆镰状韧带一体化包裹加强技术分为无包裹加强组（2016.1-2018.12,246例）及包裹加强组（2019.1-2021.12,244例）,比较两组病人基本临床特征、术中资料、术后资料、胰腺术后出血（PPH）病人治疗措施及转归。结果：术前基本临床资料中,两组病人在年龄、性别、术前高血压及糖尿病史、美国麻醉医师协会（ASA评分）、术前丙氨酸氨基转移酶、术前总胆红素、术前血清白蛋白、术前胆道引流、肿瘤位置及性质方面差异无统计学意义（P>0.05）。术中资料中,两组病人在手术时间、术中出血量、术中输血量、切除类型、PV 或SMV切除重建、主胰管直径方面差异无统计学意义（P>0.05）。术后资料中,两组病人在术后总体并发症、临床相关胰瘘（CR-POPF）及腹腔感染发生率、腹腔穿刺引流率、晚期腔外PPH及C级晚期腔外PPH发生率、PPH相关再手术率、总体再手术率、术后住院时间方面差异有统计学意义（P<0.05）;两组病人在术后胆瘘、延迟性胃排空障碍、早期PPH、晚期腔内PPH、A级及B级晚期腔外PPH、围手术期死亡率方面差异无统计学意义（P>0.05）。PPH病人治疗措施及转归资料中,两组PPH病人侵袭性治疗率差异有统计学意义（P<0.05）;两组PPH病人在不同侵袭性治疗措施及PPH病死率方面差异无统计学意义（P>0.05）。结论：肝圆镰状韧带一体化包裹加强技术能够降低质软胰腺PD术后总体并发症发生率、CR-POPF及晚期腔外PPH、C级晚期腔外PPH的发生率,同时降低病人腹腔感染发生率、腹腔穿刺置管引流率及再手术率,并缩短术后住院时间。     

TRAM flap breast reconstruction: tumescent technique reduces blood loss and transfusion requirement

The tumescent technique has been shown to be efficacious in reducing both operative and postoperative bleeding without significant deleterious side effects in suction lipectomy. In this study, the effects of the tumescent technique on postoperative complications in transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction are investigated. All women who underwent a TRAM flap breast reconstruction by the senior author (J.B.) at the Emory Clinic during the years 1990 to 1996 were pooled (n = 386). Any woman who had a preincision infiltration of 0.25% epinephrine-containing saline solution (>200 cc) around the donor site was included in the tumescent group (n = 59). Medical records were reviewed, and rates of partial flap loss, fat necrosis (> or =10 percent flap volume), flap full-thickness skin loss, donor-site complication (skin loss, hernia, or infection), and blood transfusion were determined. Group rates were compared. The infiltrated group had a significantly lower transfusion rate as compared with the control group (0.34 units versus 1.32 units, p < 0.001). The rates of partial flap loss and fat necrosis were less in the tumescent group, but not significantly (0 percent versus 4 percent, p = 0.232; and 1.7 percent versus 10.4 percent, p = 0.058). There were no significant differences in the incidence of full-thickness skin loss or donor-site complications. Donor-site infiltration before incision with a 0.25% epinephrine-containing saline solution significantly reduced the transfusion requirement in TRAM flap breast reconstruction patients without adversely affecting either breast mound or abdominal donor-site complication rates.     

Ultrasound-Guided Radiofrequency Ablation for the Treatment of Primary Hyperparathyroidism: An Efficacy and Safety Study

ObjectiveTo evaluate the efficacy and safety of radiofrequency ablation (RFA) for the treatment of primary hyperparathyroidism (pHPT).MethodsOur study enrolled 25 patients who were treated with RFA for pHPT from September 2015 to January 2020. The serum intact parathyroid hormone (iPTH), calcium, and phosphate levels were tested within 1 week before RFA and at 1 day, 1 month, 3 months, 6 months, and 12 months after ablation. The ablation areas were evaluated using ultrasound at 1, 3, 6, and 12 months after RFA. Postoperative complications, including voice hoarseness, hematoma, postoperative pain, incision infections, hypoparathyroidism, and hypocalcemia, were recorded.ResultsA total of 25 patients with pHPT (mean age, 53.9 ± 10.9 years; 22 women and 3 men) with 29 enlarged parathyroid glands were treated with RFA. Of the 25 patients, 22 were treated in 1 session and 3 were treated in 2 sessions. Serum iPTH and calcium levels decreased significantly on day 1 after RFA (all P < .05). A total of 21 patients had normal levels of serum iPTH and calcium after RFA, with a cure rate of 84%. At the 12-month follow-up, 26 treated parathyroid glands exhibited a volume reduction rate of >70%. There were only a few minor complications, including 4 cases of postoperative pain (in 4 of the 25 patients [16%]) and 1 case of mild postoperative transient hypocalcemia (in 1 of the 25 patients [4%]).ConclusionUltrasound-guided RFA is an effective and safe technique for the treatment of carefully selected patients with pHPT. However, larger sample size and longer follow-up are still needed to further confirm its clinical value.     

Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique

Do perforating lateral osteotomies cause less ecchymosis and edema compared with the popular continuous method? Many studies have demonstrated that perforated osteotomies cause less trauma and periosteal disruption. Numerous investigators have subjectively perceived less postoperative ecchymosis and edema, but no clinical study has compared the perforated methods versus the continuous technique in the same patient. This prospective, randomized, partially blinded study was designed to test the hypothesis that the perforating method causes less postoperative ecchymosis and edema compared with the continuous lateral osteotomy technique. The questions remain: does the type of perforating osteotomy affect the results? Does a percutaneous approach cause more ecchymosis and edema by the access maneuver of piercing the skin? The two perforating lateral nasal osteotomy techniques require the same 2-mm straight osteotome, so any genuine difference in postoperative ecchymosis or edema could only be attributed to the differing surgical approaches. Accordingly, this study also tests whether the external percutaneous perforating osteotomy causes more ecchymosis and edema than the internal transnasal perforating method. Twenty-five consecutive rhinoplasty patients (group A) requiring bilateral osteotomies (50 total lateral osteotomies) were randomized so that each patient received an internal/transnasal perforating lateral osteotomy (2-mm straight chisel) on one side and an internal/transnasal continuous osteotomy (4-mm curved, guarded osteotome) on the other. The next 25 patients studied (group B) received an external/percutaneous perforating lateral osteotomy (same 2-mm straight chisel as used in group A) on one side and the same internal/transnasal continuous osteotomy on the other. The final 25 consecutive rhinoplasty patients (group C) received an external percutaneous perforating lateral osteotomy on one side and an internal transnasal perforating lateral osteotomy on the other. The entry sites for the perforating osteotomies were either external (groups B and C) with a percutaneous skin puncture or intranasal (groups A and C) at the pyriform aperture. All 75 patients (150 total lateral osteotomies) initialed the surgical plan on the Gunter rhinoplasty worksheet, which has been approved by the Institutional Review Board of Abbott-Northwestern Hospital, Minneapolis, Minnesota (study no. 1341-1 M). All patients were evaluated for ecchymosis and edema on the left versus the right side of the face at 2 to 3, 7, and 21 days after the operation. The clinical evaluation was performed by two blinded examiners (clinic registered nurse and the patient with his or her family) and a partially blinded examiner (the surgeon, who did not refresh his memory about the randomization). To compare the two methods in each study (groups A, B, and C) for the six outcomes (edema and ecchymosis at 2 to 3, 7, and 21 days), the authors used an exact binomial test of the null hypothesis that the treatments do not differ. To compare the two methods in each study (groups A, B, and C) using all six outcomes simultaneously, the authors used a permutation test. By both testing methods, the perforating internal method was superior to the continuous technique (group A; p < 0.01 in both tests). Although the perforating external method gave better results than the continuous technique (group B) and the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method. A lateral osteotomy technique should be precise, reproducible, and safe, and it should minimize ecchymosis and edema. Since edema and ecchymosis are comparable regardless of osteotome size, this prospective randomized study confirms the subjective clinical impression that perforating lateral osteotomies with a 2-mm straight osteotome reduce postoperative ecchymosis and edema in rhinoplasty patients compared with the continuous osteotomy (4-mm curved, guarded osteotome). These findings should encourage te the use of perforating osteotomies rather than continuous osteotomies.     

Lymphatic Territories (Lymphosomes) in a Canine: An Animal Model for Investigation of Postoperative Lymphatic Alterations

Background

Lymph node dissection is often performed as a part of surgical treatment for breast cancer and malignant melanoma to prevent malignant cells from traveling via the lymphatic system. Currently little is known about postoperative lymphatic drainage pattern alterations. This knowledge may be useful for management of recurrent cancer and prevention of breast cancer related lymphedema. We mapped the complete superficial lymphatic system of a dog and used this canine model to perform preliminary studies of lymphatic architectural changes in postoperative condition.

Methods

Lymphatic territories (lymphosomes) were mapped with 4 female mongrel carcasses using an indocyanine green (ICG) fluorescent lymphography and a radiographic microinjection technique. Two live dogs were then subjected to unilateral lymph node dissection of lymph basins of the forelimb, and ICG lymphography and lymphangiogram were performed 6 months after the surgery to investigate lymphatic changes. Lymphatic patterns in the carcass were then compared with postoperative lymphatic patterns in the live dogs.

Results

Ten lymphosomes were identified, corresponding with ten lymphatic basins. Postoperative fluorescent lymphographic images and lymphangiograms in the live dogs revealed small caliber lymphatic network fulfilling gaps in the surgical area and collateral lymphatic vessels arising from the network connecting to lymph nodes in the contralateral and ipsilateral neck in one dog and the ipsilateral subclavicular vein in another dog.

Conclusion

Our canine lymphosome map allowed us to observe lymphatic collateral formations after lymph node dissection in live dogs. This canine model may help clarify our understanding of postoperative lymphatic changes in humans in future studies.