Friday, August 31, 2007

More Dog than Cat

Thanks to Chrysalis Angel for this. As Fridays are my non-patient catch-up day (paper work, journal, and personal errands) I am sitting here in my "Dogs Rule" shirt, so am glad I "turned out to be more dog than cat". Have a safe Labor Day Holiday!

You Are: 60% Dog, 40% Cat

You are a nice blend of cat and dog.
You're playful but not too needy. And you're friendly but careful.
And while you have your moody moments, you're too happy to stay upset for long.

Thursday, August 30, 2007

Dermal Fillers

Unlike with the quilt (see Trapunto quilting) where you are taking the surface from flat to puffed, when dealing with the aging face the goal is to "fill" in a fold or crease that has lost volume to get it to a more "flat" surface. Soft tissue augmentation has become a popular means of addressing contour defects that result from aging, trauma and/or scarification (ie acne), or disease (ie HIV associated lipoatrophy). Photos are before and after--credit.

ArteFill is made of permanent, non-resorbable microspheres (20%) of polymethylmethacrylate (PMMA) which become part of the patient’s own tissue, filling in the wrinkle for enduring correction. These microspheres range in size from 30-50 microns in diameter. These microspheres are suspended in a gel carrier (80%) of purified bovine collagen and 0.3% lidocaine. After the injection, the collagen degrades over a period of approximately 3 months. At the same time, the PMMA becomes encased in the patient's own collagen which is produced in response to the foreign material. It was the first FDA approved dermal filler. It comes in syringes containing 0.8 cc and 0.4 cc ArteFill. ArteFill is contraindicated in anyone with a known allergy to bovine collagen or lidocaine. A skin test must be done. If the skin test response is positive, the patient must not be treated with ArteFill. If the skin test response is equivocal, it is recommended that a second skin test be administered in the opposite arm and evaluated prior to the initiation of treatment. It is used in the glabellar frown lines, nasolabial folds, upper lip line and mouth corners. Adverse reactions include granulomas. Technique is critical in minimizing these reactions. It is recommended that the linear retrograde tunneling method be used in working with ArteFill. It is a product of Artes Medical.

Juvéderm™ is a smooth consistency gel made of hyaluronic acid approved by the FDA in June 2006. It contains the highest concentration of cross-linked hyaluronic acid currently available. Juvéderm™ Ultra and Juvéderm™ Ultra Plus are indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds). Both are supplied in individual treatment syringes with 30- or 27-gauge needles for single patient use and ready for injection. Typically 1.6 cc is enough for each site. Correct only to 100% of the volume desired. It is important to avoid over correction. Patients should be limited to 20 mL of JUVÉDERM injectable gel per 60 kg (130 lbs) body mass per year. A linear-threading technique, serial puncture injections, or a combination of the two have been used to achieve optimal results. To avoid visible lumps and/or discoloration, avoid injecting too superficially. Side effects were usually mild to moderate lasting 7 days or less and included temporary injection site reactions like redness, pain, firmness, swelling and bumps. It is a product of Allergan.

Radiesse is composed of microspheres of calcium-hydroxylapatite suspended in an aqueous gel carrier. The biodegradable microspheres serve as a lattice upon which the body forms scaffolding for tissue infiltration. The spheres slowly degrade. The improvement is effective for 9-18 months. It also has the ability to stimulate new collagen formation. Radiesse was recently approved by the FDA for the correction of moderate to severe facial folds and wrinkles around the nose and mouth, including nasolabial folds. Radiesse is biocompatible and does not require pre-testing. It is provided in a sterile, pre-filled, single use syringe containing 1.3 cc intended for treatment or a 0.3cc syringe intended for touch-ups and small volume applications. Side effects may include swelling, bruising, pain, itching, and tenderness at the injection site. These conditions typically resolved on their own within one to two days. It is a product of BioForm Medical.

Restylane was approved by the FDA in 2003. It is a non-animal stabilized hyaluronic acid gel. Restylane is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. Restylane is indicated for the correction of moderate to severe facial wrinkles and folds. The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.

Sculptra is an injectable implant that contains microparticles of poly-L-lactic acid (PLA), a biocompatible, biodegradable, synthetic polymer from the alpha-hydroxy-acid family. It is reconstituted prior to use by the addition of sterile water for injection to form a sterile non-pyrogenic suspension. The particles of PLA stimulate the formation of new collagen in the skin, adding volume over time. The results are not immediate and a series of three or more treatments, spaced approximately one month apart, are usually recommended. PLA degrades more slowly than some filling substances, and longevity of 18-36 months (after 3 treatments) is possible. Sculptra may be injected either into the superficial dermis for the treatment of wrinkles and acne scars or subdermally to add volume to the cheeks, temples, and hands to correct contour deformities. The most common device related adverse effect was the delayed occurrence of subcutaneous papules, which were confined to the injection site and were typically palpable, asymptomatic and non-visible. It is a product of Dermik/Sanofi-Aventis.

Most are associated with minor adverse effects. Rarely more serious adverse effects will occur. These serious complications include the following:

  • Rarely, death (eg, secondary to anaphylactic shock or sepsis)
  • Stroke
  • Anaphylactic reactions
  • Blindness secondary to thrombus formation in the retinal artery after arterial injection periorbitally or from needle trauma: The use of higher viscosity materials (eg, Zyplast, Cymetra) should be avoided near the eyes or in the glabellar region. The needle should always be directed away from the eye.
  • Local skin necrosis secondary to occlusion of cutaneous arterioles. This complication can be recognized early as vasoconstriction (blanching) and pain at the injection site. Immediate administration of heat, massage, and nitroglycerin paste can help to minimize or reverse permanent injury.
  • Cystic reactions to implanted material or foreign body abscesses. These reactions are usually treated with incision and drainage and intralesional steroids.
Patients should expect to experience some degree of pain during injection, which varies for each product based on pH and whether the product is suspended or reconstituted in buffered lidocaine. Transient erythema can last as long as 36 hours after treatment, beyond which, hypersensitivity must be considered. Topical anesthetics and ice-cold compresses can be used to minimize the pain of injection.

References

  • Cosmetic Interventions for HIV-Associated Lipoatrophy by Graeme J. Moyle, MD, MBBS -- MedScape Article
  • Dermal Fillers by Roberta D Sengelmann, MD --eMedicine Article
  • The Aging Face: More Than Skin Deep by Tina Alster, MD & others--MedScape Article
  • Semipermanent and Permanent Dermal/Subdermal Fillers; Supplement to Plastic and Reconstructive Surgery, Vol 118, No 35, Sept 1, 2006

Wednesday, August 29, 2007

Trapunto Quilting

Trapunto is a whole cloth quilting technique which produces a raised surface on the quilt. Trapunto patterns consist of vines, leaves, grapes, cherries, etc. Photo credit--Karen McTavish quilt

Trapunto originated in Italy in the early 16th century. It made it's way through France into England. From there it came to the United States in the the late 1700's and remained popular until the Civil War. There was a revival in the early 1900's and again more recently.

Traditional Method was done by layering two pieces of fabric together. The design is completely quilted. The vines and straight line patterns are threaded with a soft yarn or cording. The rounder shapes of the motif are stuffed with small amounts of batting "teased" through the loosened fibers of the back. This was much easier with the homespun fabrics which were more loosely woven than today's fabrics.

Modern Method is done the same as the traditional method except that the batting or cotton balls used for stuffing the motif is inserted from a small slit made in the backing fabric. After the shapes are stuffed, the slit is whipped stitched closed. A second backing fabric is then added to the quilt and normal quilting is done all around the previously stuffed shapes.



John Flynn Method is done by beginning the sewing around the design motif, but leaving a space to insert his specially designed tubular rod that has been stuffed with batting. After inserting the stuffing the sewing is completed around the area.
Hari Walnar Cut-Away Method is done by marking all quilt designs, then placing a layer of high-loft polyester batt under the designs you want to stuff. That layer is pinned in place, and using water-soluble thread, the design is encircled with quilting to hold the batting in place behind each design. The excess batting is then carefully trimmed away. Then the quilt is layered with cotton batting and backing in the usual way, basted, and quilted with regular quilting thread (non-soluble). Use background fillers of various crosshatching and micro-stippling to make the pattern and its variations really pop out. When the quilting is finished, the quilt is submerged in cool water to dissolve the water-soluble thread. The water will also shrink the cotton batt somewhat, and the trapunto design stuffed with the poly batt will be enhanced by that shrinkage. You'll have stuffed designs with detailed quilting with the speed and power of a sewing machine.
It is very acceptable today to use machine techniques. One of these was perfected by Karen McTavish. Instructions for using her technique can be found here. Or to do shadow quilting which adds subtle color to some areas.

Sources for Whole Cloth Patterns:
M&L Designs
The Stencil Company

Books
Trapunto by Machine by Hari Walner
Trapunto and Stippling by John Flynn
Trapunto: The Handbook of Stuffed Quilting by Sue H. Rodgers

Tuesday, August 28, 2007

Stains in Cloth and Skin

Stains are not welcome whether on cloth or skin. When you get a stain in a treasured quilt, it is important to try to figure what caused the stain (blood, coffee, grease, etc). Some stains are better off left alone. Keep in mind you may damage your item irrevocably. It is recommended that products containing the ingredient Sodium Percarbonate be used. This is a white, free flowing granular chemical used in the formulation of laundry products and many other cleaning products. Sodium Percarbonate consists mainly of hydrogen peroxide and soda, and functions as a bleaching agent, alkali provider and water softener at the same time. It contains a high percentage of active oxygen which provides an excellent washing and bleaching effect. It is environmentally compatible as it will break down into water, oxygen, and soda ash. Unlike chlorine based bleaches, sodium percarbonate is non-toxic and biodegradable. For a complete guide see: Stain Removal Guidelines for Textiles and Other Items by Kris Driessen.

Hyperpigmentation (stains, if you will) disorders of the skin are common. [Photo credit.] The most common are melasma and postinflammatory hyperpigmentation (PIH). These "stains" are the result of an increase in cutaneous melanin deposition either by increased melanin synthesis or, less commonly, by a greater number of melanocytes. The amount of color change will depend on the location of the melanin deposition. Epidermal involvement will appear as brown-grey discolorations. Epidermal deposition of melanin is enhanced with the use of a Wood's lamp (dermal is not). The mixed type hyperpigmentation will have enhancement in some areas, but not in others with the Wood's lamp. Dermal hyperpigmentation is much more challenging to treat.

Melasma occurs mainly in women (more than 90% of cases) of all racial and ethnic groups, but particularly in those with Fitzpatrick skin types IV-VI. The cause of melasma is unknown, but factors such as genetic predisposition, UV light exposure, and estrogen exposure play a large part. Estrogen is thought to induce melasma as it often develops during pregnancy, with oral contraceptive (OC) use, and hormone replacement therapy (HRT) in postmenopausal women. Melasma in pregnancy will often clear within a few months of delivery. Discontinuation of OC or HRT, along with adequate sun protection, may also result in melasma clearance. Melasma presents as brown to grey macules and patches with irregular / geographic borders. The pigmented patches are usually sharply demarcated and symmetrical. There is a predilection for sun-exposed areas. The three major patterns of distribution are:

Centrofacial--cheeks, forehead, upper lip, nose, and chin (66% of cases)

Malar--cheeks and nose (20% of cases)

Mandibular--rami of the mandible (15% of cases)

Differential diagnosis of melasma should include cutaneous mercury deposits, drug-induced hyperpigmentation, erythema dyschromicum perstans, mastocytosis, lichen planus actinicus, and postinflammatory hyperpigmentation.

Postinflammatory Hyperpigmentation (PIH) is a pathopysiologic response to any cutaneous inflammation, such as acne, atopic dermatitis, lichen planus, trauma (burns, abrasions, postsurgical), insect bites, and psoriasis. Similar to melasma, it is more obvious in patients with Fitpatrick skin type IV-VI. It has no gender or age predominance. The lesions are usually limited to the site of the preceding inflammation and have distinct, feathered borders. Melanocytes can either be stimulated by the inflammatory process to become hypertrophic (thereby secreting more melanin) or the number of melanocytes can increase. Epidermal hyperpigmentation (ie associated with acne) occurs when increased melanin is transferred to keratinocytes. Dermal hyperpigmentation (ie associated with lichen planus and cutaneous lupus erythematosus) occurs when the basement membrane is disrupted and melanin falls into the dermis, residing within the melanophages.

Treatment goals for hyperpigmentation include promoting melanosome degradation, inhibiting the formation of melanosomes, and retarding the proliferation of melanocytes. All patients should limit sun exposure and use a daily broad-spectrum high SPF sunscreen. Topical treatment is the mainstay. Combination therapy is more effective than single agents used alone. and includes:
Hydroquinone (HQ) 2-4%--It inhibits the conversion of dopa to melanin by inhibiting the activity of tyrosinase. It has been proposed that it may also interfere with DNA and RNA synthesis, degrade melanosomes, and destroy melanocytes. It is applied in a thin layer over the affected areas twice daily for up to 12 weeks. It should not be used longer than 12 weeks, as there are no studies regarding safety in long term use. Side-effects include irritant and allergic contact dermatitis, PIH, nail bleaching and rarely ochronosis-like pigmentation. Toxicity studies have shown HQ is capable of inducing renal adenoma in rats and is fetotoxic in animals. Because of these studies, HQ is banned in many countries including Japan, the European Union, South Africa, and Australia. In August of 2006, the FDA issued a proposal to remove it from any OTC products. Currently, the only FDA-approved prescription form of HQ is Tri-Luma (Galderma Laboratories).
Retinoids-- Tretinoin 0.05%-0.1% reduces pigmentation by inhibiting tyrosinase transcription and by interrupting melanin synthesis. It typically takes at least 24 weeks to see clinical improvement in melasma reduction using tretinoin. It may also increase pigmentation secondary to the irritation. It commonly causes erythema and peeling.
Azelaic acid (15%-20%) is a C9 dicarboxylic acid. It is a reversible inhibitor of tyrosinase. It may have cytotoxic and antiproliferative effects on melanocytes. It has been shown to be as effective as HQ 4% wibut without the side effects. Used in combination with 0.05% tretinoin or 15%-20% glycolic acid, it may produce earlier, more pronounced skin lightening. Adverse effects include pruritus, mild erythema, scaling, and burning.
Kojic Acid (KA) 2% is produced by the fungus Aspergilline oryzae. KA is a tyrosinase inhibitor. It is generally as effective as the other therapies, but may be more irritating. Generally, it is used in combination with GA 10% for 3 months.
Glycolic Acid (GA) 5%-10% is an alpha-hydroxy acid. It decreases pigment by thinning the stratum corneum, enhancing epidermolysis, dispersing melanin in the basal cell layer of the epidermis, and increasing collagen synthesis in the dermis. Mild irritation is a common adverse effect.

Combination Therapy
HQ 5% + tretinoin 0.1% + dexamethasone 0.1%--The addition of tretinoin to HQ eliminates pigment and increases keratinocyte proliferation by preventing the oxidation of HQ and improving the epidermal penetration. The addition of topical corticosteroids reduces the irritative effects of hypopigmenting agents, and inhibits melanin synthesis by decreasing cellular metabolism. This combination was first introduced in 1975 by Kligman.

HQ 4%,+ tretinoin 0.05% + fluocinolone acetonide 0.01% (Tri-Luma®, Galderma) --Clinically significant improvement may be noted as early as 4 weeks. The most common adverse effects are mild local irritation, erythema, and skin peeling. The mixture should be applied to the entire affected area to avoid blotchiness.

Over-the-Counter Products--There are many OTC products available. There is some evidence to support the use of Olay® Definity® (N-acetyl glucosamine (NAG) and niacinamide).

Treatment of melasma in pregnant women is routinely deferred until after delivery for multiple reasons: 1) treatment resistance while hormone trigger persists; 2) most women will show significant improvement without treatment after the pregnancy ends; and 3) drug therapy is contraindication during pregnancy.

Treatment of PIH should begin with management and control of the underlying skin condition. Most of the therapies used for hyperpigmentation have been studied in melasma and the same treatment principles hold for PIH.

References:
Topical Treatments for Melasma and Postinflammatory Hyperpigmentation by C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC--MedScape Article

Skin Lightening and Depigmenting Agents by Alaina James, MD--eMedicine Article

Melasma by Deborah Zell, MD--eMedicine Article

Monday, August 27, 2007

Gynecomastia

Gynecomastia is defined as benign, excess breast tissue development in male individuals. Recent studies have reported an overall incidence of 32 - 36 %, and up to 64.6 % in adolescent boys. The incidence of bilateral involvement also varies in the literature from 25 -75 percent of patients. The underlying cause seems to be an increase in the ratio of estrogen to androgen activity. Photo credit

In general physiologic gynecomastia can be observed in three peaks during life.

  1. The neonatal period: 60-90% of infants have transient gynecomastia due to transplacental transfer of maternal estrogens.
  2. Puberty: 48-64% of boys at puberty have gynecomastia. Usually peak age of onset is between 13 and 14 years, followed by a decline in late teenage years.
  3. Late in life: The highest prevalence of gynecomastia is seen among men aged 50-80 years.

Pathologic gynecomastia occurs as a result of various metabolic disorders (alcoholic cirrhosis), endocrine disorders (hyperthyroidism, adrenal cortical hyperplasia), acquired hypogonadal states (orchitis, testicular trauma), congenital hypogonadal states (Klinefelter syndrome, congenital anorchia), and increased estrogen states (bronchogenic carcinoma, testicular tumors). (Table 1--MedScape article)

Pharmacologic gynecomastia occurs by several mechanisms, including increased direct estrogenic activity, increased secretion of estrogen, decreased testosterone synthesis, and decreased androgen sensitivity. There are also many drugs with poorly understood mechanisms that are associated with gynecomastia. (Table 2--MedScape article)

Clinical evaluation of patients with gynecomastia is very important. However, further workup is rarely indicated. History should include age, duration and onset of breast enlargement, symptoms of pain or tenderness, medications and recreational drug use, and psychological and social effects. A review of systems that covers all the above mentioned causes should be obtained. Physical examination of the breasts should involve assessment for glandular or fat predominance (by the pinch test), degree of glandular ptosis, skin excess, nodules/masses, and nipple abnormalities or discharge. Glandular or parenchymal tissue is characterized by rubbery breast tissue that is mobile and extends from a subareolar, centric position. Breast cancer accounts for 0.2% of all malignancies in men and generally presents as a unilateral firm mass, often eccentric in location rather than centered beneath the areola. This should be remembered if any suspicious nodules or masses are found. These may have abnormal firmness, overlying skin ulceration, eccentric location, or abnormal nipple discharge. The normal male breast is typically flat with some fullness around the nipple-areola complex. The nipple-areola complex is normally 2 - 4 cm in diameter (average, 2.8 cm) and located over the fourth intercostal space. Nipple to sternal notch distance is, on average, 20 cm. A muscular male chest may exhibit superior fullness with a transition to a flat inferior chest near the inframammary fold. Completion of the physical examination should in particular assess for testicular enlargement/atrophy and asymmetry, thyromegaly, hepatomegaly, pulmonary abnormalities, and abdominal masses. Additional diagnostic testing should be individualized to address abnormalities identified in the history or physical examination.

The majority of patients with gynecomastia require no treatment other than removal of the precipitating cause. If it is drug-induced, it may regress if the offending medication is stopped. Treatment of hyperthyroidism, correction of hypogonadism and surgical removal of testicular, adrenal or other causative tumors can also lead to regression. Treatment for gynecomastia is indicated in cases where it produces significant pain, embarrassment or emotional discomfort and therefore interfering with the patient's life. A patient should consider proceeding with surgical management once diagnosis of gynecomastia is established of nonphysiologic causes or of duration greater than approximately 12 months, because hypertrophic breast tissue beyond this stage usually becomes irreversibly fibrotic.

Classification of gynecomastia as defined by Rod Rohrich, MD & others is based on the amount and character of breast hypertrophy and the degree of ptosis.

Grade I patients --minimal hypertrophy (less than 250 gm of breast tissue).

  • Grade IA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
  • Grade IB--primarily fibrous breast tissue
Grade II patients -- moderate hypertrophy (between 250 and 500 gm of breast tissue).
  • Grade IIA--primarily fatty breast tissue. Suction-assisted lipectomy can be used with great success.
  • Grade IIB--primarily fibrous breast tissue
Grade III --severe hypertrophy (more than 500 gm of breast tissue), grade 1 ptosis
Grade IV --severe hypertrophy (more than 500 gm of breast
tissue), grade 2 or 3 ptosis

Ultrasound-assisted liposuction is effective in all grades of gynecomastia. Usually, no further treatment is needed in grade I or II gynecomastia. Often, single ultrasound-assisted liposuction treatment is all that is necessary for grades III and IV, especially in those with mild ptosis and good skin quality. If removal of redundant skin and/or resistant lipodystrophy is still required after ultrasound-assisted liposuction, a staged excision is delayed for 6 to 9 months to allow for maximal skin retraction and healing, thus potentially allowing down staging of the magnitude of the excisional technique (and therefore minimizing scarring)

REFERENCES

Classification and Management of Gynecomastia: Defining the Role of Ultrasound-Assisted Liposuction.;Plastic & Reconstructive Surgery. 111(2):909-923, February 2003; Rohrich, Rod J. M.D.; Ha, Richard Y. M.D.; Kenkel, Jeffrey M. M.D.; Adams, William P. Jr., M.D.

Breast Cancer in a Patient with Gynecomastia; Plastic & Reconstructive Surgery. 84(6):976-979, December 1989; Fodor, Peter Bela M.D.

Management of Gynaecomastia: An Update ; Int J Clin Pract. 2007; 61(7):1209-1215.; P. Gikas, MD; Kefah Mokbel, MS, FRCS (also a MedScape article)
Gynecomastia--eMedicine article by Ali Fawzi, MD

Sunday, August 26, 2007

The Greenery at Opryland Hotel

We're back home from our vacation to Nashville. I've spent the afternoon washing clothes, bathing dogs, watering the poor dry plants in my yard, and just getting ready to go back to the office tomorrow. I wanted to share a few photos with you of the lovely greenery at the hotel. It's like an arboretum inside the hotel. The first photo is from our room. We got a lot of exercise just walking around the place (no guilt about eating).


There are some lovely orchids, ferns, begonias, and more. There is a "Delta River" that runs through the hotel with boat rides.


















But some of the most surprising greenery was seen the afternoon before we left. Check out this beautiful ivy. Look closely.


Did you look closely? Did you see the beautiful woman?


The ivy is not real. It is a woman doing performance art!
Isn't she lovely!

SurgeXperiences 1.03

Check out Unbounded Medicine on surgery experiences--"Welcome to the third edition of SurgeXperiences, the first carnival of surgery. I’m honored to bring you this surgical carnival." Thanks for including my post on fingertip injuries.

Friday, August 24, 2007

Carnton House

Today we went just south of Nashville to Franklin, Tennessee. My husband who is a Civil War buff wanted to visit the Carnton Plantation and cemetery. Here are a few pictures. This was the site of one of the bloodest battles of the Civil War.





Thursday, August 23, 2007

Nashville Quilt Show

There are many beautiful quilts here in Nashville! Many are "no pictures allowed". I wish that weren't so. Here are pictures of some that "were allowed".




Tuesday, August 21, 2007

My Dogs' Life

My husband and I are leaving for Nashville in the morning for a short vacation. The dogs, Girlfriend (14 yo) and Rusty (4 yo) will be staying at the Chenal Pet Palace. I have gotten all their food and treats ready (each meal measured and labeled in zip-lock bags). Girlfriend's daily DeraMaxx (1/4 tablet) and glucosamine condroitin are in her food bags. What I can't leave are the belly rubs, walks, and general care. I know the folks at the pet palace will take good care of them, but I still feel apprehensive. They will have a yard (access three times each day) and an air conditioned room to share. At home, they have access to the yard at all times via a dog door. They also have access to the entire house (well, the bed is blocked during the day by a baby gate at the door). You can see where Rusty likes to sleep during the day.

I have done all the other pre-vacation preparations (do I sound OCD?)--held the mail, held the newspapers, gone to the bank, cleaned the house, cleaned out near-end-of-good-date food from refrigerator, and am almost completely packed. I need this vacation, so I am going and I am going to enjoy myself.

Monday, August 20, 2007

Scar Evaluation Report

I was first introduced to assessing a scar for a medico-legal report during my plastic surgery residency. We would see the patient who had been referred by his/her lawyer. These were patients we had never seen or treated in the past. We would ask the history of the scar (cause, treatment, etc). We would discuss the ways the scar, if any, might be improved. Then my staff physician would write the letter. I wish he had allowed us to read those letters and taught us how to write them. I have never felt comfortable writing them. photo credit

I did a "search" this morning looking for tips/suggestions on how to write a medico-legal report. I put in different tags--scar evaluation, scar assessment, medico-legal scar evaluation, etc. My best results were from the tag--writing a medico-legal assessment. It is called an Independent Medical Examination (IME) of a scar (or some other issue--likelihood of a chemical causing a disease) not a scar evaluation report. Here are some tips:

  • Even though only one side (either sides lawyer or the insurance company) pays for the report, you should take extra care to maintain a truly independent viewpoint.
  • Ask for all the medical information the requesting person has. This will help inform your conclusions and prevent surprises while on the witness stand if asked to testify.
  • Write the report based on your findings. Draw your own conclusions.
  • You must have consent from the patient in writing to release their medical information. Try to determine how the report will be used. Get clear instructions and a list of questions from the lawyer. A verbal explanation of what's expected can also be helpful.
  • Cover the basics first. For a scar evaluation--what accident or injury caused the injury that resulted in the scar? Was it work related? Give a brief description of what happened and when, and don't get into the question of who was at fault. Most of the time, we only have the patient's version of the story. Make a note that your report is based on this version.
  • For scars, the initial treatment is often important in the outcome. So the next thing to address is: How was the laceration/wound treated? Where was the treatment carried out? What was the follow up?
  • What is the patient's history of past health that might contribute to the scar? Is the patient a known keloid former? Does the patient smoke or a diabetic (impaired wound healing)?
  • Mention what the physical findings were initially after the injury, and on (preferably all) future visits. How did they change over time, with or without treatment?
  • Lastly, is the patient suffering from an impairment or disability? Is the scar causing a joint contracture (for example)? An impairment is defined as an anatomic or functional abnormality or loss. This is a medical diagnosis, which we're well suited and expected to make. Your report should cover whether an impairment is temporary or expected to be permanent. In other words, is the condition stable and has maximum medical rehabilitation been achieved?
  • The question whether an impairment constitutes a disability is settled by a decision-maker; the conclusion is based upon the patient's age, education, training, social situation, job requirements and other factors, including medical impairments.
  • You may indeed be asked to give a prognosis. It's understood that no one can predict a patient's future, but a physician can draw conclusions from experience with others and also from information on how the patient in question has coped with adversity in the past. Try to state whether or not an injury/impairment is likely to be long lasting (usually classified as > 1 year) and/or whether it'll have a severe impact on the person's life.
  • Decision-makers may also want to know what treatment the patient will need in the future. For example, if the scar has caused a contracture of a joint, the person may require surgery to correct the contracture and /or physical therapy, etc.
  • If asked to assess the patient's ability to return to work, don't fall into the trap of making this decision without a full description of his or her work duties.
  • For scar evaluation, I am often asked the cost of future treatment. I can only give them the best estimates on the treatments or procedures I would recommend. I do this based on procedure codes and current fees.
Patients may not be familiar with the type of relationship they will have with someone carrying out an IME. So you should be extra cautious in explaining the purpose of the assessment, how it will be performed, what body systems will be involved (usually only those relevant to the questions asked, not a full/total physical exam), what other tests may be required, where the report will be sent and how you will be paid. Make sure the patient understands that the report you write will be based on the examination and/or interview, any observations made during the meeting as well as other medical reports received. It's also important that the person is aware that no treatment or medication prescriptions will result from this assessment. You should document this discussion, as well as the times you start and finish the assessment.


References

Pain-free Medico-legal Reports, Taking the edge off a tedious task an interview with Michael Zitney, MD

an example of an IME report

sample or an IME report

Sunday, August 19, 2007

Fire Ant Bites

My neighbor asked me what the best way to treat her fire ant bites is. First some information on fire ants. (photo credit)

The fire ant is a wingless member of the order Hymenoptera, which includes wasps and bees. Fire ants are thought to have arrived in the United States between 1918 and the 1930s from South America by ships that docked in Mobile, Alabama. They are now found throughout the Southeast and are migrating rapidly. It is important to recognize and avoid the ant mounds.

The fire ant's attack is a two-part process consisting of a bite and a sting. The fire ant uses its mandibles to grasp its victim (bite). It then arches its body and drives an abdominal stinger into the skin to release the venom (sting). If the fire ant is not quickly removed, it will pivot around its mandibles and inflict further stings in a circular pattern. When the ant stings, it injects a venom that causes the release of histamine, a chemical in our bodies that can produce pain, itching, swelling and redness of the skin. Within seconds after the sting, discomfort occurs at the local site and a small red welt appears. The welt can enlarge rapidly, depending on the amount of venom that was injected and the victim's sensitivity to the venom. The reaction persists for up to an hour, and then a small blister that contains clear fluid will form. Over the next half day or so, the fluid in the blister turns cloudy (the sterile pustule), and the area begins to itch. The diameter of a sting wound is normally 2-4 mm. Most children experience only a small amount of redness around the sting site. A small percentage of people are sensitive to the venom and experience more extensive redness and swelling. Fortunately, only a very small number of victims have extensive allergic reactions such as breathing difficulties or widespread swelling of body parts.

For mild reactions:

  • Move away from the ant hill to a safe area to avoid more stings.
  • Scrape or brush off the stinger with a straight-edged object, such as a credit card. Wash the affected area with soap and water. Don't try to pull out the stinger; doing so may release more venom.
  • To reduce pain and swelling, apply a cold pack or cloth filled with ice.
  • Apply 0.5 percent or 1 percent hydrocortisone cream, calamine lotion or a baking soda paste (make with a ratio of 3 teaspoons baking soda to 1 teaspoon water ) to the bite or sting several times a day until your symptoms subside.
  • Take an antihistamine containing diphenhydramine (Benadryl, Tylenol Severe Allergy) or chlorpheniramine maleate (Chlor-Trimeton, Teldrin).

For severe reactions (anaphylaxis):

Severe reactions may progress rapidly. Dial 911 or call for emergency medical assistance if the following signs or symptoms occur:

  • Difficulty breathing
  • Swelling of your lips or throat
  • Faintness and/or Dizziness
  • Confusion
  • Rapid heartbeat
  • Hives or swelling more than 2 inches in diameter at the site
  • Nausea, cramps and vomiting

Take these actions immediately while waiting with an affected person for medical help:

    1. Check for special medications that the person might be carrying to treat an allergic attack (ie, EpiPen). Administer the drug as directed — usually by pressing the auto-injector against the person's thigh and holding it in place for several seconds. Massage the injection site for 10 seconds to enhance absorption.
    2. After administering epinephrine (or if no Epi available), have the person take an antihistamine pill (see above--Benedryl, etc) if he or she is able to do so without choking.
    3. Have the person lie still on his or her back with feet higher than the head.
    4. Loosen tight clothing and cover the person with a blanket. Don't give anything to drink.
    5. If there's vomiting or bleeding from the mouth, turn the person on his or her side to prevent choking.
    6. If there are no signs of circulation (breathing, coughing or movement), begin CPR.

If your doctor has prescribed an auto-injector of epinephrine, read the instructions before a problem develops and also have your household members read them.


References:
Fire Ants by James P Ralston, MD--eMedicine article
Insect Bites and Stings: First Aid--MayoClinic.com
Imported Fire Ants-FAQ--Univ of Texas at Austin
Diagnosing and Treating Animals for Red Imported Fire Ant Injury--Texas A & M University

Baby Quilt

Here is a baby quilt I finished recently using scraps and "orphan" blocks/squares left over from other quilts. It is for one of the CRNA's whom I work with at Little Rock Surgery Center. This is her first baby. I start with the quilt backing and the batting. Then I use the techniques of crazy quilting. I think of the entire baby quilt as "one block". The quilt is "semi-quilted" as I piece it. Afterwards, I use the fancy stitches on my Janome machine to embellish the quilt. Then I do the quilting as though it hadn't been partially quilted (clamshell, baptist fan, etc). Then I do the binding on. I either put a label on the back or use the sewing machine to "write" my name and date on the quilt. The quilt is 40" X 51" so will be nice for naps when the child is a toddler. The photo on the right is of the full quilt. The photo on the left is a section near the quilt center.


Saturday, August 18, 2007

A Real Quilter--Irma Gail Hatcher

Several of you have commented on my quilting skills, feeling that I must make perfect stitches, etc because I am a plastic surgeon. It isn't true. I consider myself a mediocre quilter who enjoys the craft but doesn't obsess about imperfections. That doesn't mean that I don't try to have "perfect" corners or even stitches, but I don't always take then out and redo them. If it is a quilt for a contest or for a very special person, then I do. Not so with baby quilts. As I have commented before, if I make them "too perfect" they won't get used and I want the baby quilts I make to be used.

We have several world class quilters here in central Arkansas. One is Irma Gail Hatcher (photo credit). Now she is someone I consider a great quilter. Irma Gail is a former elementary school teacher. She began quilting in1980, making a potholder at a craft class in Michigan. After moving to Arkansas in 1981 she attended a quilt show that hooked her. Her first quilt was made for daughter, Gailyn, in 1982, and she has been making quilts ever since. She has won numerous ribbons, and her quilts have appeared on magazine covers and inside many books and magazines. She teaches classes and lectures nationally. Her quilt, "Conway Album (I'm Not From Baltimore)," won the 1992 Founder's Award and a blue ribbon at the A/IQA show in Houston. In 1995 it qualified as a NQA Masterpiece Quilt, and was on exhibit as one of the 100 Best American Quilts of the 20th Century at the 1999 Houston Quilt festival with the others. Irma Gail was selected as one of 30 quilters in the World to have 3 of her quilts in the exhibit "30 Distinguished Quilters of the World" at the Tokyo International Great Quilt Festival in January, 2002. She is a member of the Conway Applique Society and QUEST Quilters of Little Rock. Irma Gail has written eight books on quilting. The books she has written include, Conway Album (I'm Not From Baltimore, Hot Fudge Sundae and Irish eyes plus 10 Secrets of Quilt Design, More Conway Album, Blocks-Hearts, More Conway Album Blocks - Baskets, Foundation Pieced Blocks of the Month, More Conway Album Blocks - Cross Sprays, and More Conway Album Blocks - Wreaths, More Conway Album Blocks - Blue Birds, and Baltimore Style Blocks.

Friday, August 17, 2007

Bioengineered Skin Substitutes (BSS)

Tissue engineered skin substitutes emerged in the 1980s. Development was motivated primarily by the critical need for early coverage of extensive burn injuries in patients with insufficient sources of autologous skin for grafting. Since then, skin substitutes have been widely used to address the prevalent problem of chronic wounds associated with non-burn etiologies (such as hard-to-heal, chronic, open wounds in patients with diabetes mellitus and /or arteriosclerosis). The annual incidence of serious burns in the United States is estimated at 70,000. The prevalence of venous leg ulcers is between 600,000 and 1,500,000; and 15 to 20 percent of people with diabetes eventually suffer a chronic foot wound. The direct cost, in the US, of dressings alone for all these conditions has been estimated at over $5 billion per year. photo credit
In the past wound management was essentially passive: to remove impediments to wound healing (e.g., uncontrolled diabetes mellitus, infection, and ischemia) and allow nature to take its course. Today, while not ignoring these basics, the approach seeks to actively intervene and improve upon natural healing using such modalities as hyperbaric oxygen, electrical stimulation, skin surface negative pressure, exogenous growth factors and bioengineered skin substitutes. Thus, a "one-size-fits-all" approach, whereby a clinician would use his favorite dressing on most wounds, has given way to individualization of therapy based upon the physiology of each particular patient and wound. It is very challenging to understand the relative merits and roles of each available technology. So I thought I would try to review some of the various commercial skin substitutes.
Important criteria for a biosynthetic skin substitute include: rapid and sustained adherence to the wound surface (most important), impermeable to exogenous bacteria, allow water vapor transmission similar to normal skin, inner surface structure that permits cell migration/proliferation/in-growth of new tissue, flexible and pliable so it can conform to irregular wound surfaces, resistant to linear and shear stresses, biodegradable (important for "permanently" implanted membranes), low cost, indefinite shelf life, minimal storage requirements, absence of antigenicity, and absence of local/systemic toxicity.
Biobrane®, Biobrane-L®is a bilayer temporary wound dressing. The outer epidermal analog is constructed of an ultrathin silicone film with barrier functions comparable to skin. It has small pores that allow for exudate removal and permeability of topical antibiotics. The inner dermal analog is composed of a three dimensional irregular nylon filament weave upon which type I collagen peptides are bonded. It is removed after re-epithelialization or prior to skin graft on excised wound. It has a long shelf life and can be stored at room temporature. It is clinically indicated in superfical to mid-partial thickness burns (debrided of nonviable tissue), excised burn wounds with or without meshed autografts, donor sites, and partial thickness skin slough disorders. Biobrane adheres firmly to the wound. It provides a barrier to evaporative water loss, avoids desiccation of wound tissue, provides a barrier to bacteria, optimizes healing environment, decreases pain from the wound, decrease wound exudate, is durable/flexible/non-toxic, and is permeable to topical antibiotics.

Tips for its use: Select appropriate wounds. Apply biobrane under modest tension, and secure to surrounding intact wound edge Apply gentle gauze pressure dressing. Immobilize for 24-36 hrs on a flat wound surface and 48 hrs over a joint surface. Change outer gauze dressings as needed until plasma leak stops. Aspirate fluid or bubbles. If there is increasing exudate, biobrane must be removed--switch to topical agent. Sulfamylon solution can be applied to burn wound surface if early infection suspected. Wait until biobrane appears opaque and dry before removing. If pain or bleeding is encountered, stop and wait several more days before removing.
TransCyte® is a bilayer temporary wound dressing. It's outer epidermal analog is a thin nonporous silicone film. It's inner dermal analog is layered human fibroblast products (collagen type I, fibronectin, glycosaminoglycan). It is removed after re-epithelization or prior to skin grafting. It must be kept frozen until use. It is used clinically for mid-dermal indeterminate partial thickness burns with viable wound surface, for excised burn wounds with viable wound surface, and for donor sites.

Tips for use: Select appropriate wounds (will not adhere to non-viable tissue). Apply to clean wound bed and apply gauze compression dressing. Immobilize for 24 hrs, longer over joints. Aspirate fluid and air bubbles. Remove when dry and opaque (as with Biobrane).

Integra® is a dermal analog of biodegradable wound care device comprised of a porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan. The epidermal analog is a thin semi-permeable polysiloxane (silicone) layer that provides environmental barrier protection and water vapor loss similar to skin. The collagen-glycosaminoglycan biodegradable matrix provides a scaffold for cellular invasion and capillary growth. After the neodermis formation, the epidermal analog (silicone) is removed and replaced with a thin epidermal autograft or cultured epithelial cells. Major causes of loss of the dermal analog are infection and shearing with devascularization. It is stored in 70% isopropyl alcohol.

Apligraf, is supplied as living bilayered, cell therapy. It's dermal analog is a collagen matrix populated with fibroblasts which have produced a dermal layer. These dermal elements are obtained from neonatal foreskin. The epidermis is a stratified and multilayer providing a biologic barrier function. The epidermis is also obtained from neonatal foreskin. The foreskin is decontaminated with antibiotics, antifungals, and an ethyl alcohol rinse. Production of cell stocks involves enzymatic digestion of the foreskin tissue and fibroblast/keratinocyte isolation. Apligraf is made by a process that take 20 days. There is a 7 day shipping window. It is individually packaged for use in a nutrient medium and sealed in a polybag. It is shipped overnight via courier. Keep Apligraf in the sealed poly bag, inside the shipping container at 20C-23C; 68F-73F, until use.

OrCel® is a composite living skin (bilayered) equivalent. It is described as comprising an epidermal layer of cultured keratinocyte cells, a layer of non-porous collagen, and a dermal layer of cultured fibroblast cells in a porous cross-linked type I bovine collagen sponge matrix. Donor dermal fibroblasts are cultured on and within the porous collagen sponge side of the collagen matrix while keratinocytes (epidermal layer), from the same donor, are cultured on the coated, non-porous side of the collagen matrix. It serves as an absorbable biocompatiable matrix. OrCel®'s first FDA approvals were obtained last year for treatment of acute surgical excisions, such as contracture release sites and donor sites in Epidermolysis Bullosa, patients undergoing hand reconstruction surgery, and donor sites in burn victims undergoing excision and autografting. Since the cells used to produce Orcel are extensively expanded in vitro, they cease to express significant levels of HLA-II antigens and, upon application to a wound bed, are apparently not immediately recognized by the recipientís immune system as foreign. Cryopreserved OrCel® can provide off-the-shelf wound treatment, available on demand at point of use. This device should be stored in a clean, dry location at room temperature. To use prepare wound area using standard methods to ensure wound is free of debris and necrotic tissue.

Cultured epithelial autograft (CEA) is an epidermal layer replacement only. It uses cell culture technology to grow a small sample of the patient's own keratinocytes up to 10,000 fold in surface area. It takes 2-3 weeks to grow the desired amount. It can be applied over an excised wound or over incorporated allograft dermis (Integra). If used alone, the epidermal-wound junction has an incomplete basement membrane and very low resistance to sheer forces. There is a 28-50% take on excised wounds and a 45-75% take on invorporated allograft dermis.

Alloderm® is not a bilayer product and acts strictly as a dermal transplant. It is an acellular dermal matrix derived from donated human skin tissue supplied by US AATB-compliant tissue banks utilizing the standards of the American Association of Tissue Banks (AATB) and Food and Drug Administration's (FDA) guidelines. Since AlloDerm is regarded as minimally processed and not significantly changed in structure from the natural material, the FDA has classified it as banked human tissue. When AlloDerm is prepared, the human donor tissue undergoes a multi-step proprietary process that removes both the epidermis and the cells that can lead to tissue rejection and graft failure, without damaging the matrix. Once the dermal tissue has been decellularized, the final step is preservation. The processed tissue matrix is preserved with a patented freeze-drying process that prevents damaging ice crystals from forming. The cells responsible for immune response and graft rejection are removed. What remains is a matrix or framework of the natural biological components, which allows the body to mount its own tissue regeneration process. It requires an application of a thin epithelial autograft.

The OASIS® Wound Matrix is a biologically derived extracellular matrix-based wound product that is compatible with human tissue. OASIS is unique because it is a complex scaffold that provides an optimal environment for a favorable host tissue response, a response characterized by restoration of tissue structure and function. OASIS is comprised of porcine-derived acellular small intestine submucosa. OASIS® Wound Matrix is indicated for the management of wounds, including diabetic ulcers, venous ulcers, partial and full-thickness wounds, pressure ulcers, chronic vascular ulcers, trauma wounds, draining wounds, and surgical wounds. It has a 2 yr shelf lift at room temperature. To use in a "wet" wound, hydrate the Oasis with saline after applying to the wound, cover with a non-adherent dressing, then an absorptive dressing (ie calcium alginate), and then secure in place. For a dry wound, hydrate the Oasis with saline after applying to the wound, cover with a non-adherent dressing, then Hydrogel, and then secure into place. The optimum secondary dressing is determined by wound location, size, depth, and user preference. Change the secondary dressing as needed to maintain a moist, clean wound area. Frequency of secondary dressing change will be dependent upon volume of exudate produced and type of dressing used. As healing occurs, sections of OASIS may gradually peel and may be removed during dressing changes. Do not forcibly remove sections of OASIS that may adhere to the wound. Alternatively, OASIS may form a caramel-colored gel, which can be rinsed away with gentle irrigation. On inspection, if OASIS is no longer covering the wound, place an additional piece of OASIS over the wound.

Safety: "BSS, namely Biobrane®, TransCyte®, Dermagraft®, Apligraf®, autologous cultured skin, and allogeneic cultured skin, are at least as safe as biological skin replacements or topical agents/wound dressings. The safety of Integra® could not be determined, nor could the long-term safety of BSS with respect to viral infection and prion disease."

Efficacy: "In managing partial thickness burns, BSS, namely Biobrane®, TransCyte®, Dermagraft®, and allogeneic cultured skin, are at least as efficacious as topical agents/wound dressings or allograft. Apligraf® combined with autograft is at least as efficacious as autograft alone. In managing full thickness burns, the efficacy of autologous cultured skin could not be determined, nor could the efficacy of Integra®."



Other References

Use of Skin Substitutes--BurnSurgery.org

New Skin for Old Developments in Biological Skin Substitutes; Arch Dermatol. 1998;134:344-349

Current Concepts in Wound Healing; Plastic and Reconstructive Surgery Suppliment; Vol 117, No 75, June 2006.


Wound Healing: Skin Substitutes and Blood-Derived Growth Factors --Medical Policy BCBS

Green Anole Lizard


I noticed this little "guy" while watering my bushes (need rain) this afternoon. Mush better pictures here. My little lizard did not show his dewlap.
For more information on anoles:
Wild Texas--Green Anole

Thursday, August 16, 2007

Fingertip Injuries/Amputations

Fingertip (or pad) injuries are very common. They range from simple lacerations to partial amputations. Simple lacerations are repaired by suture or Dermabond (I have even told family members to use super glue. The bleeding must be stopped. The finger must be cleaned with soap and water. There must not be any tension pulling the edges apart. The glue is used on the surface, never within the cut.) If Dermabond is used, it is best to avoid use of antibiotic ointments as these can “dissolve” the bond before the cut is healed sufficiently. (photo credit)
The question is much more complicated when there is loss of tissue. The main treatment objectives are 1) closure of the wound, 2) maximize sensory return, 3) preserve length, 4) maintain joint function, and 5) achieve a satisfactory cosmetic appearance. How these goals are achieved will depend on the amount of tissue lost, whether there is bone exposed, and which finger is involved. Injuries can be classified according to where the amputation has occurred or whether the injury primarily involves the pulp (soft tissue) or nail bed. These classification systems refer to the zone and the plane of injury.
Zone I is distal to the phalanx (bone)–There is no exposed bone and most of the nail bed is intact which will allow normal nail contours following healing. Treatment of these injuries is usually conservative, especially if the tissue loss is superficial and less than 1 cm square. The wound should then be left open to heal by secondary intention. Meticulous wound care and conservative debridement of these injuries are essential. A dressing of topical antibiotic ointments and non-adherent gauze left alone for several days will facilitate healing. Daily dressing changes can be done after the 4-5th day. As the scar contract, it will give an excellent aesthetic and functional result.
Zone II is distal to the lunula (growth matrix of the nail)–These are complicated by the bony exposure of the distal phalanx. The decision-making process begins with whether length should be preserved (necessitating coverage of the site) or whether sacrifice of length is justifiable in the given situation. The primary aim is to restore function to the individual, and many of these injuries can be converted to wounds with no bone exposed by rongeuring and then closure. If there is no possibility of direct closure, then cover can be accomplished by means of a local flap. The plane (slant of the injury) of zone II injuries helps determine what type of repair technique should be used.
Zone III is proximal to the lunula. –These involve the nail matrix and result in the entire loss of the nail bed. These injuries are most often treated by amputation (revising the end of the traumatic amputation and closing the stump). Replantations distal to the DIP are often not successful.

Methods of ClosureSplit
Thickness Skin Grafts (STSG)–are useful in Zone I injuries that are larger than 1 cm square. It’s advantage over FTSG is that it contracts as it heals and therefore keeps the resultant insensitive area as small as possible. Split-thickness skin from the hypothenar eminence or instep of the foot closely matches the native fingertip skin and is a good choice for the donor skin.
Full Thickness Skin Grafts (FTSG) can be taken from the hypothenar eminence, the lateral groin, the volar wrist crease, or the anti-cubital fossa (inner elbow crease). Some feel that this leaves a less conspicuous donor scar than the STSG.

Flaps are necessary when the loss of fingertip pulp is more than one-third the length of the phalanx. There need to be soft-tissue replacement to support the distal nail. Local flaps include:

Atosoy-Kleinert Flap (photo)
was first described in 1970. It is a triangular volar V-Y flap advancement for reconstruction of the distal pad. It help preserve length when the bone is exposed. It is not indicated in injuries where an oblique flap with more palmar skin loss than dorsal is present.

Kutler Lateral V-Y Flap (photo)
was first described in 1944. It employs two triangular flaps developed from lateral positions and reflected to cover the tip of the digit. This is most applicable to oblique palmar and traverse tip amputations. As the V-shaped skin flap is advanced, an incision line is created which resembles a “Y” when sutured.

Volar Flap Advancement (photo)
is credited to Moberg for coverage of thumb tip amputations. It may also be used for fingertip amputations where length is to be maintained. It provides a sensible covering (has feeling) by advancing volar skin on its neurovascular pedicle. Advancement is limited to 1 cm.

Cross-Finger Pedicle Flap (photo)
was first described by Gurdin and Pangman in 1950. It is useful in distal amputation of the index finger or thumb and in situations where multiple digits are injured and maintenance of length in the remaining injured tips is considered to be of critical importance. Cross finger flap uses skin and subcutaneous tissue from the dorsum of an adjacent finger to cover the fingertip injury. The defect created by “lifting” the flap is covered with a STSG. The pedicle is left attached for 12-14 days and then divided and “tailored” into place.

Thenar Pedicle Flap (photo)
was described in 1926 by Gatewood for coverage of injuries with exposed bone. It was modified by Smith and Albin in 1957 with a technique described as a thenar “H-flap”. The indications are similar to that for a cross-finger pedicle flap (preservation of length, exposed bone). The potential for joint stiffness with a permanent flexion contracture and /or unsightly scar in the donor area must be kept in mind. It is apllicable to injuries in the tips of the index and long fingers, but not the ring or small as the flexion required is not comfortable.Contraindications for use of the cross-finger or thenar flaps would be any general condition that might lead to stiffness (rheumatoid arthritis, Dupuytren’s contracture, etc). There is increased risk of joint stiffness with either flap in someone over 30 years of age.

Replantation of Severed Tip
Replanted single fingers can be stiff and impede the opposition of other fingers to the thumb and overall hand function. Replanted single-finger amputations can achieve better range of motion when the level is distal to the insertion of the flexor digitorum superficialis. Single-finger replantation can be considered when patients have injuries to other fingers of the same hand. All of these injuries require splint immobilization and rehabilitation that impedes immediate return to work. Single-finger replantation can be considered in special circumstances. The surgeon must not become absorbed in the technical challenge of the replantation and neglect the other associated injuries because poorer outcomes and greater financial cost (due to lost wages and cost of hospitalization and therapy) can result.


References
Information & Pictures from Operative Hand Surgery, 2nd Edition, David Green MD, Churchhill Livingstone
Fingertip and Nailbed Injuries by Joseph Donnelly, MD
The V-Y Plasty Technique in Fingertip Amputations by Edward Jackson, MD--American Family Physicians
Fingertip Injuries--Eaton Hand Center
Fingertip Injuries/Amputations--AAOS
Fingertip Injuries by Glen Vaughn--eMedicine article
Assessment & Initial Management of Hand Injuries--Zoltan Hrabovszky
Cohen, B. E., and Cronin, E. D. An innervated cross-finger flap for fingertip reconstruction. Plast. Reconstr. Surg. 72: 688, 1983

Wednesday, August 15, 2007

Knitting for Noggins

This will be the second year that our local children's hospital will participate in the Knitting for Noggins campaign. During the winter, the hospital gives a hat to each patient leaving the hospital. [Trying to think of cooler times as the temp is expected to hit 105F today] Even though they will be holding a knit-a-thon on Oct 14 at the hospital, they are encouraging folks to begin holding their own with friends so there will be lots of hats. Last year they had more than 27,000! Here are two that I have done. I plan on doing a few more while traveling to Nashville (the AQS Expo). My quilt (Flowers in a Vase) will be in the quilt show. I will knit while my husband drives.

Tuesday, August 14, 2007

Mallet Finger

The name, mallet finger, is a bit of a misnomer as the finger does not look like a mallet. It is commonly defined as a sports-related injury, but often is not. It is sometimes called a "baseball finger". It may also be called a "drop finger" which is a more accurate description. The long and ring finger are most commonly injuried, and it occurs more often in men than in women. A mallet finger occurs when the extensor tendon is damaged. Photo credit

Mallet finger deformity affects the distal interphalangeal (DIP) joint. It occurs as a result of a closed injury of the extensor tendon (ET) near its insertion into the distal phalanx (bone), resulting in a disruption of the tendon's continuity over the DIP joint.. There is then no intact extensor tendon to balance the forces on the DIP by the flexor tendons. The joint is flexed (bent) downward toward the palm by the inherent tension of the flexor tendons. Without an intact extensor tendon, there can be no active extension of the DIP.

This often results from direct trauma to the tip of the extended finger (as from a baseball striking the finger), but also from minor forces including household tasks such as bed making. It may also happen when tucking a sheet under a patient (as it did to a friend of mine). The forces damage the thin extensor tendon by either stretching or tearing of the tendon or by an avulsion of the tendon where it inserts on the dorsal lip of the distal phalanx base. The force of the blow may even pull away a piece of bone along with the tendon. In either instance, active extension power of the DIP joint is lost, and the joint rests in an abnormally flexed position. The finger will not be able to actively straighten itself.

After the injury at the DIP joint, a patient may notice an inability to actively extend the distal joint, even with a full extension. The dorsum of the joint may be slightly tender and swollen, but often the injury is painless or nearly painless. Some patients may think that the joint is only sprained until they notice loss of active extension days later. If untreated for a prolonged time, hyperextension of the PIP joint may develop giving rise to a swan neck deformity because of proximal retraction of the central band.


There are four types of mallet finger injuries:
Type I: Closed with or without avulsion fracture.
Type II: Laceration at or proximal to the DIP joint with loss of tendon continuity
Type III: Deep abrasion with loss of skin, subcutaneous cover and tendon substance
Type IV: (A) Trans-epiphyseal plate fracture in children; (B) Hyperextension injury with fracture of the articular surface of 20-50%; and (C) Hyperextension injury with fracture of the articular surface usually > 50% and with early or late palmar subluxation of the distal phalanx

Treatment:
Type I -- Continuous splinting of the DIP joint in extension is the recommended treatment for six weeks, followed by two weeks of night splinting. It is important to explain to the patient that the splinting is at all times (24 hr a day). This includes using the thumb to apply extension force to the distal phalanx of the injured finger when showering. Although splinting appears to be a simple and non invasive treatment, it has complications such as dorsal skin irritation or necrosis over the DIP joint that results from excessive pressure of the splint at that site and probably is potentiated by a hyperextension posture of the joint.
Type II --These require surgery. The injury may be repaired with a simple figure-of-eight suture through the tendon alone or a roll type suture incorporating the tendon and the skin in the same suture. The DIP joint is splinted in extension for 6 weeks, followed by 2 weeks of night splinting.
Type III --Because of the loss of tendon substance, these injuries require immediate soft tissue coverage and primary grafting or late reconstruction using a free tendon graft.
Type IV-A --These are best treated with closed reduction followed by splinting for 3-4 weeks.
Type IV-B --These have no palmar subluxation and yields good results with 6 weeks splinting and 2 weeks night splinting.
Type IV-C --These have palmar subluxation of the distal phalanx and are usually best managed surgically with open reduction and internal fixation using Kirschner wire and possibly a pull-out wire or suture. This should also be protected with a splint for 6 weeks, after which the wire is removed and motion started. A proximally displaced bone fragment not in continuity with the distal phalanx may also require open reduction and internal fixation.

References
Mallet Finger Deformity by Busi da-Silva (nice pictures and discussion of normal extensor tendon anatomy)
Mallet Deformity: (Baseball finger)--Wheeless' Textbook of Orthopaedics
Complication and Prognosis of Treatment of Mallet Finger--Wheeless' Textbook
Mallet Finger (Baseball finger)--American Academy of Orthopaedic Surgeons
Mallet Finger by Roy A Meals, Md--eMedicine article

Monday, August 13, 2007

Subungual Hematoma

Subungual means "under the nail". Hematoma refers to a collection of blood. A subungual hematoma is blood under the nail. You will see a discoloration (red, maroon, or other dark color) under the nail. Keep in mind that not all dark patches under the nail are subungual hematomas. Consider the diagnosis of melanoma, Kaposi's sarcoma and other tumors when the history of trauma and the physical examination are not consistent with a simple subungual hematoma. Photo credit

Subungual hematomas occur most often from a "crush-type" injury to the tip of the finger. These injuries include hitting your finger with a hammer, closing your finger in a door, etc. There is often intense pain when the injury occurs and later as the hematoma forms due to increased pressure that builds up between the nail and the very sensitive nailbed. Given time, the tissues surrounding this collection of blood will stretch and deform until the pressure within this collection of blood equilibrates. Within 24 hours the pain therefore subsides and, although the patient may continue to complain of pain with use of the finger/hand, performing a trephination (drilling a hole in the nail) at this time may not improve his discomfort to any significant extent and will expose the patient to the risk of infection. If you, the doctor, choose not to perform a trephination explain this to the patient who may be expecting to have his nail drained . There is some risk of missing a nail bed laceration under the hematoma, but, for most underlying lacerations, splinting by its own nail may be superior to suturing. When there are associated lacerations, open hemorrhage or broken nails, a digital block should probably be performed and the nail lifted up for inspection of the nailbed and repair of any lacerations. The pain may also be from other associated injuries such as a fracture to the underlying bone.

For you, the injuried:
  • If the pain is mild and the hematoma (blood collection) is less than 25% (one-fourth) of the area under the nail, then home care is recommended. This includes ice, elevation (keep your hand above your heart level), and anti-inflammatory medications such as ibuprofen.
  • If the hematoma is 25% or more of the area and/or the pain is severe, then medical attention is recommended. Remember a fracture or laceration under the nail may have occured from the crush injury. An x-ray will need to be taken to access the possibility of a fracture.
For you, the doctor:
  1. X-ray the finger to rule out an underlying fracture of the distal phalanx
  2. Check for a possible avulsion of the extensor tendon (mallet finger).
  3. Perform a trephination (clear instructions here) at the base of the nail, using the free end of a hot paper clip, electric cauterizing lance or drill. Tap rapidly with the cautery a few times in the same spot at the base of the hematoma until the hole is through the nail. When resistance from the nail gives way, stop. Further downward pressure may damage the nail bed.
  4. Presistant bleeding from this opening can be controlled with a folded guaze held firmly over the "hole" by the patient and elevation of the hand.
  5. Apply an antibacterial ointment, such as Betadine or Bacitracin, and cover the trephination with a Band-Aid.
  6. Instruct the patient to keep his/her finger dry for 2-3 days and not to soak it for a week (no dish washing, no swimming). This is to prevent infection.
  7. Inform the patient that he/she will eventually lose the fingernail. It will take 4-6 months to regrow.
  8. If there is an underlying fracture, an aluminum finger tip splint may be aide in comfort and protection. The patient should keep the finger dry for 10 days (added increase risk of infection) and be given instructions to return at the first sign of infection.
Some precautions
  1. Do not perform a trephination using a hot cautery device on a patient wearing artifical acrylic nails. These are flammable.
  2. Do not perform a trephination when there is an underlying fracture, as this converts a closed fracture into an open one. If there is sufficient pain to justify the trephination, then the patient should understand the increased risk of infection.
  3. There is no need to perform a trephination on a patient who is no longer experiencing any significant pain at rest.
  4. Make sure the opening (trephination) is large enough for free drainage.
  5. Do not send the patient home to soak his finger after a trephination. This will break down the protective clot and introduce bacteria.
  6. There is no need to routinely prescribe antibiotics for this injury.
  7. Do not remove an intact fingernail even with a large hematoma. it is not necessary to inspect the nailbed for lacerations or repair them with a closed injury.
References:
Subungual Hematoma by Craig Feied, MD, Mark Smith, MD, Jon Handler, MD, and Michael Gillam, MD; NCEMI

Comparison of Nail Bed Repair versus Nail Trephination for Subungual Hematomas in Children; Journ Hand Surg, 1999 Nov; 24 (6):1166-70; Roser SE, Gellman H

Fingertip Injuries--American Family Physician

Subungual Hematoma--eMedicineHealth article