Plastic Surgery最新文献

Background: Catheter-associated urinary tract infections (CAUTI) are the most common hospital-associated infection and can result in increased health care costs, morbidity and even mortality. In 2009, The Scott & White Memorial Hospital/Texas A&M Health Science Center (Texas, USA) system's CAUTI rate placed it in the upper quartile (ie, highest rate) for the country, necessitating a system-wide change.

Objective: To design and implement a guideline to reduce the incidence of CAUTI.

Methods: A multidisciplinary team was formed and completed both a root cause analysis and a review of the available literature. Consolidating the best evidence, the team formulated a best practice guideline detailing the proper indications for insertion of, improper use of and techniques to minimize infection with catheters. Included as part of this protocol was nursing and patient education, changes in identifying patients with a catheter and automatic termination orders. Three-, six- and 12-month reviews identifying additional opportunities for improvement at the end of 2010 were completed.

Results: In 2009, the hospital's CAUTI rate was 1.46 per 1000 catheter days. In 2011 - the first complete year of the finalized guideline - the hospital's CAUTI rate was 0.52 per 1000 catheter days, ranking the institution in the bottom quartile (ie, lowest rate) for the country. The surgery and plastic surgery subgroup analyses also demonstrated statistically significant reduction in both catheter use and CAUTI.

Conclusion: The incidence of CAUTI was successfully reduced at The Texas A&M Healthcare Center. The guideline, its development and how it applies to plastic surgery patients are discussed.

Recent experimental and clinical studies have demonstrated the negative effects of nicotine on the viability of skin flaps. Necrotic damage to skin flaps can result in significant complications including delayed wound healing, dehiscence and wound contraction. Phosphodiesterase type 5 inhibitors, such as sildenafil citrate, have a protective effect in ischemic injuries of the brain, kidney, myocardium, spinal cord, ileum and testes. In the present study, the authors evaluated the effect of sildenafil citrate on the viability of skin exposed to nicotine-induced ischemia in Sprague Dawley rats. In the preoperative period, the rats were divided into three groups of 10 rats each. Group C was treated with subcutaneous saline and group S and group N were treated with 2 mg/kg nicotine, administered subcutaneously twice per day for 28 days. McFarlane flaps were created in all experimental animals using an incision measuring 7 cm × 3 cm. Postoperative treatment varied among the groups: group S was treated with 20 mg/kg/day sildenafil citrate, while group C and group N were treated with equivalent doses of saline for seven days. A laser Doppler flow meter was used to monitor the microvasculature. Preoperative measurements of the microvasculature revealed decreased blood flow in group N and group S, both of which were treated with subcutaneous nicotine. During the postoperative evaluation, a trend toward increased blood flow was observed in group S compared with the group with nicotine-induced ischemia treated with saline alone postoperatively (group N). A visual fluorescein dye test was used to predict skin viability and demonstrated diminished skin viability in group N and group S (P<0.05) during the preoperative period. Following treatment with sildenafil for seven days, a statically significant improvement in skin viability was observed in group S (P<0.05). Nicotine decreased blood flow within the skin and impaired skin viability, while postoperative application of sildenafil significantly ameliorated the ischemic effects of nicotine and improved skin viability. Future studies will be required to evaluate the clinical use of sildenafil for the improvement of blood flow in ischemic injury of the skin.

Pyoderma gangrenosum is a great masquerader in wound diagnosis and management. Frequently misdiagnosed as a necrotizing infection, the elusive nature of its etiology and pathogenesis has thwarted the establishment of a standardized management algorithm, leaving immunosuppressant therapies as the mainstay of treatment. The present report describes a 61-year-old woman presenting with temporally discrete bilateral dorsal hand lesions successfully managed with distinctive multimodality therapies. The initial lesion was managed under the auspices of a necrotizing process using a combination of hyperbaric oxygen therapy and skin grafting with a negative-pressure dressing, both individually demonstrated to be effective for prompt wound stabilization and coverage. A subsequent contralateral hand lesion was similarly managed as a necrotizing infection before a diagnosis of pyoderma gangrenosum was considered. Stabilization and eventual resolution was achieved using intravenous and topical steroids followed by hyperbaric oxygen therapy, again highlighting the benefits of multimodality therapy in the setting of pyoderma gangrenosum.

Background: Keloids may complicate wound healing secondary to trauma, inflammation or surgical incision. Although various treatment modalities have been used with variable degrees of success, overall recurrence rates have remained unacceptably high.

Methods: The present study involved 80 patients with keloids of at least one-years' duration. Following total surgical excision of the keloid, a single dose of 5-fluorouracil was injected into the edges of the healing wound on postoperative day 9 together with botulinum toxin. The concentration of 5-fluorouracil used was 50 mg/mL and approximately 0.4 mL was infiltrated per cm of wound tissue, with the total dose <500 mg. The concentration of botulinum toxin was 50 IU/mL with the total dose <140 IU.

Results: Patients were followed-up for 17 to 24 months and a recurrence rate of 3.75% was found, which was significantly lower than in previously reported studies using other therapeutic modalities.

Conclusion: The author recommends that this treatment be routinely applied to all keloids because it is significantly more effective than those described by other authors.

Background: Symptomatic mammary hypertrophy impacts physical function and patient quality of life. Breast reduction mammoplasty, a surgical procedure performed to reduce breast size, has been used for many years to reduce these symptoms.

Objective: To evaluate variations in the surgical practice of breast reduction mammoplasty among women ≥15 years of age (approximately 6.4 million population in 2008) over a 17-year period in Ontario.

Method: A population-based, cross-sectional time series analysis was conducted to examine temporal trends in 87,049 breast reduction surgeries performed between January 1, 1992 and December 30, 2008.

Results: Breast reduction rates have been relatively stable over time, with 83 per 100,000 of the female population undergoing breast reduction surgery annually. However, a significant decrease in the rate of inpatient surgeries were observed over the study period (from 69.3 per 100,000 in 1992 to 25.7 per 100,000 in 2008). At the beginning of the study period, the highest annual rates of this procedure were observed among women 21 to 30 years of age (116.6 procedures per 100,000); however, by the end of the observation period, this shifted to women 31 to 50 years of age (109.9 procedures per 100,000). Furthermore, the annual procedure rate among women ≥51 years of age almost doubled, rising from 36.4 procedures per 100,000 in 1992 to 66.6 procedures per 100,000 in 2008. This was likely related to changing demographics and social factors.

Conclusion: These data suggest that breast reduction mammoplasty will continue to be requested, with an increased proportion of patients who are older and desire improved quality of life and physical function.

The present report describes the use of a nipple-sharing technique for nipple areolar reconstruction using a donor nipple that was initially grafted from the contralateral and healthy breast 12 years earlier. There are many different techniques available to reconstruct the nipple. Although nipple sharing is not feasible to use in all patients, when available, it is an ideal approach for matching the contralateral nipple in terms of shape, colour, texture and long-term projection.

The authors describe the correlation between 3-Tesla magnetic resonance neurography (MRN) and surgical findings in two patients who underwent multiple previous failed ulnar nerve surgeries. MRN correctly localized the site of the abnormality. Prospectively observed MRN findings of perineural fibrosis, ulnar nerve re-entrapment abnormalities, medial antebrachial cutaneous neuroma and additional median nerve entrapment were confirmed surgically.