[Show abstract][Hide abstract] ABSTRACT: The incidence of community-acquired methicillin-resistant Staphylococcus aureus infections is rising at an alarming pace. Effective treatment has historically involved early débridement and antibiotic administration. This study was designed to prospectively determine the effectiveness of empiric therapy in treating hand infections.
A prospective randomized trial was conducted at a level I county hospital. Patients with a hand infection received either empiric intravenous vancomycin at admission or intravenous cefazolin. Outcomes were tracked using severity of infection, appropriate clinical response, and length of stay. Cost-effectiveness was calculated using total cost for each patient in both groups. Statistical analyses were performed.
Forty-six patients were enrolled in the study. Twenty-four were randomized to cefazolin (52.2 percent) and 22 (47.8 percent) to vancomycin. There was no statistical difference between cost of treatment (p < 0.20) or mean length of stay (p < 0.18) between the groups. Patients randomized to cefazolin had higher mean costs of treatment compared with patients who were randomized to vancomycin (p < 0.05). Patients with more severe infections had more expensive mean costs of treatment (p < 0.0001) and longer mean length of stay (p = 0.0002). Near the end of the study, the incidence of community-acquired methicillin-resistant S. aureus at the authors' county hospital was discovered to be 72 percent, which caused the study to be terminated prematurely by the institutional review board because of the high incidence precluding further randomization.
Appropriate early treatment for methicillin-resistant S. aureus has not been definitively established. No difference in outcome using cefazolin versus vancomycin as a first-line agent was identified.
Plastic and reconstructive surgery 04/2014; 133(4):511e-8e. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes. A cadaveric investigation was performed in an effort to further delineate the occipital artery-greater occipital nerve relationship.
Fifty sides of 25 fresh cadaveric posterior necks and scalps were dissected. The greater occipital nerve was identified within the subcutaneous tissue and its relationship with the occipital artery was delineated. A topographic map of the intersection of the two structures was created.
The greater occipital nerve and occipital artery have an intimate relationship, and crossed each other in 27 hemiheads (54.0 percent). The relationship between these structures when they crossed varied from a single intersection to a helical intertwining.
The greater occipital nerve and occipital artery have an anatomical intersection 54 percent of the time. There are two morphologic types of relationships between the structures: a single intersection point and a helical intertwining. Vascular pulsation may cause irritation of the nerve and is a possible explanation for migraine headaches that have the occipital region as a trigger point. Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation.
Plastic and reconstructive surgery 12/2010; 126(6):1996-2001. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Advances in the understanding of migraine trigger points have pointed to entrapment of peripheral nerves in the head and neck as a cause of this debilitating condition. An anatomical study was undertaken to develop a greater understanding of the potential entrapment sites along the course of this nerve.
The posterior neck and scalp of 25 fresh cadaveric heads were dissected. The greater occipital nerve was identified within the subcutaneous tissue above the trapezius and traced both proximal and distal. Its fascial, muscular, and vascular investments were located and accurately measured relative to established bony landmarks.
Dissection of the greater occipital nerve revealed six major compression points along its course. The deepest (most proximal) point was between the semispinalis and the obliquus capitis inferior, near the spinous process. The second point was at its entrance into the semispinalis. The previously described "intermediate" point was at the nerve's exit from the semispinalis. A fourth point was located at the entrance of the nerve into the trapezius muscle. The fifth point of compression is where the nerve exits the trapezius fascia insertion into the nuchal line. The occipital artery often crosses the nerve, and this frequently occurs in this distal region of the trapezius fascia, which is the final point.
There are six compression points along the greater occipital nerve. These can be located using the data from this study, serving as a guide for surgeons interested in treating patients with migraine headaches originating in these areas. Long-term relief from migraine headaches has been demonstrated clinically by using both noninvasive and surgical decompression of these points.
Plastic and reconstructive surgery 11/2010; 126(5):1563-72. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerve's foramen and intramuscular course.
The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks.
In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen.
The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.
Plastic and reconstructive surgery 04/2010; 126(2):435-42. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A study was undertaken to survey current practice patterns concerning primary breast augmentation. Members of the American Society for Aesthetic Plastic Surgery (ASAPS) were electronically surveyed concerning issues such as incision location, implant size and type, and complications, as well as information about the surgeons, their practices, and where procedures are performed. The survey response rate was 30%. Plastic surgeons from the South and Southwest made up 40% of respondents. Forty-six percent of respondents had more than 20 years of experience in practice. Forty-three percent of primary breast augmentations were performed in outpatient surgery centers. An anesthesiologist was in attendance in 60% of cases. The average operative time--indicated in 80% of responses--ranged from 45 to 90 minutes. Thirty-three percent of responding plastic surgeons used the base diameter to determine implant size and respondents most commonly used a smooth saline implant placed through an inframammary incision in a submuscular pocket. The most frequently reported complication was nipple sensation changes. Although the reintroduction of silicone gel implants was accompanied by expectations of a sharp increase in their use, this survey revealed that among ASAPS members, saline implants currently are used more often than silicone gel implants. However, both saline and silicone gel implants are used frequently, safely, and reliably. This survey represents a snapshot of current practice and future trends in primary breast augmentation will require additional assessment, although increased use of silicone gel breast prostheses over time is expected.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 01/2009; 29(2):116-21.
[Show abstract][Hide abstract] ABSTRACT: Nasal reconstruction with use of the forehead flap has been performed for hundreds of years. Forehead vasculature has been studied; however, anatomical relationships to the forehead flap have not been adequately examined. This anatomical study evaluated the vascular anatomy of the paramedian forehead flap.
Five fresh cadaver heads were used. Four underwent cannulation of internal and external carotids bilaterally followed by injection of a barium sulfate/gelatin mixture and three-dimensional computed tomographic angiography to evaluate vascular anatomy. In one specimen, the supraorbital, supratrochlear, and angular arteries were cannulated. Methylene blue dye was injected to identify vascular territory followed by injection of contrast media for dynamic four-dimensional computed tomographic angiography. A paramedian forehead flap was raised and the injections were repeated. Colored-latex was injected followed by dissection. Measurements were made on a computed tomography workstation.
A periorbital plexus extends to 7 mm over the orbital rim. The angular, supratrochlear, and supraorbital arteries communicated into the flap by means of the vascular plexus. The supratrochlear vessel ran axially into the forehead flap and continued across the transverse limb of the flap. The deep branch of the supratrochlear ascended the periosteum under the flap. Noncontiguous vessels were noted to back-fill with latex through the subdermal plexus in the distal flap.
Maximal three-vessel flow may be obtained by preserving periosteum at least 3 cm over the orbital rim and beginning the flap 7 mm above the orbital rim. The subdermal plexus of the forehead is robust, enabling preservation of the distal transverse limb of the forehead flap.
Plastic and reconstructive surgery 06/2008; 121(6):1956-63. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The following study was undertaken to address the following questions: (1) Why do soft tissues over the mandibular body appear to be tethered to the jaw, restricting inferior descent? (2) Why does characteristic surface anatomy appear as it does? (3) What is the anatomical basis of jowl fat?
Sixteen hemifacial cadaver dissections were performed after injecting methylene blue into subcutaneous regions around the mandibular body. Dissection was performed using loupe magnification.
Discrete compartments of subcutaneous fat were identified. Two subcutaneous compartments above the mandibular border make up the substance of the jowl fat: A superior compartment and an inferior compartment. A subcutaneous fat compartment below the mandibular border was identified. Buccal fat is distinct from jowl fat. Jowl fat is separated from the submandibular fat by a septum. This septum is adherent to the mandibular body. Fibers from the platysma interdigitate with the mandibular septum and both adhere to the anterior border of the mandible.
There are distinct overlapping subcutaneous fat compartments above and below the mandibular border that define jowl fat. Buccal fat is anatomically independent from the jowl fat. The mandibular septum, separating jowl from neck fat, travels across and is adherent to the anterior surface of the body of the mandible. The mandibular septum tethers skin to the border of the mandible. This anatomical relationship is similar to the temporal septa and cheek septa and further suggests that facial rejuvenation should be performed in a site-specific manner.
Plastic and reconstructive surgery 05/2008; 121(4):1414-20. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There exists some ambiguity regarding the exact anatomical limits of the orbicularis retaining ligament, particularly its medial boundary in both the superior and inferior orbits. Precise understanding of this anatomy is necessary during periorbital rejuvenation.
Sixteen fresh hemifacial cadaver dissections were performed in the anatomy laboratory to evaluate the anatomy of the orbicularis retaining ligament. Dissection was assisted by magnification with loupes and the operating microscope.
A ligamentous system was found that arises from the inferior and superior orbital rim that is truly periorbital. This ligament spans the entire circumference of the orbit from the medial to the lateral canthus. There exists a fusion line between the orbital septum and the orbicularis retaining ligament in the superior orbit, indistinguishable from the arcus marginalis of the inferior orbital rim. Laterally, the orbicularis retaining ligament contributes to the lateral canthal ligament, consistent with previous studies. No contribution to the medial canthus was identified in this study.
The orbicularis retaining ligament is a true, circumferential "periorbital" structure. This ligament may serve two purposes: (1) to act as a fixation point for the orbicularis muscle of the upper and lower eyelids and (2) to protect the ocular globe. With techniques of periorbital injection with fillers and botulinum toxin becoming ever more popular, understanding the orbicularis retaining ligament's function as a partitioning membrane is mandatory for avoiding ocular complications. As a support structure, examples are shown of how manipulation of this ligament may benefit canthopexy, septal reset, and brow-lift procedures as described by Hoxworth.
Plastic and reconstructive surgery 04/2008; 121(3):994-1001. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The legal system depends on the medical expert for evidence. Doctors readily complain about frivolous cases that go to trial, yet a lawyer cannot bring a frivolous claim to trial without a physician expert witness stating that the claim is not frivolous. An insurance company cannot raise premiums without medical expert witnesses servicing the increasing litigation against the insured. Physicians must look to themselves as a major contributor to rising malpractice insurance costs. For without the physician expert witness, no medical malpractice lawsuit can take place. It is the expert physician, not the attorneys or insurance companies, who defines "meritless" and "frivolous" and who ultimately controls the courts' medical malpractice caseload.
Plastic and reconstructive surgery 01/2008; 120(7):2095-100. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The lower third of the face is often an afterthought in aesthetic plastic surgery. Aging across the mandibular border may be described by several mechanisms: fat atrophy and volume loss; shifting of subcutaneous fat compartments; and mandibular septum dehiscence with submandibular fat hypertrophy. Accurate diagnosis of the apparent mechanism of jaw line aging is critical to successful facial rejuvenation. Diagnosis directs the plastic surgeon as to which key anatomic components in this region to manipulate to optimize rejuvenation. The senior author's technique for facial rejuvenation across the mandibular border is described with an algorithm for facial rejuvenation of the jaw line. Several consistent patterns of facial aging are apparent and a theory of their mechanism is suggested: (1) patients with thin skin and minimal jowling resulting from fat atrophy; (2) jowl ptosis with normal skin and loss of submalar hollow and midface fullness, caused by displacement of fat compartments; and (3) cascading confluent fat over the mandible, produced by septum dehiscence. Fat atrophy is treated with fat replacement, either injectable or autologous fat. Jowl ptosis is treated with septum release and superficial musculoaponeurotic system elevation to restore jaw line definition. Confluent fat is treated by septum release, superficial musculoaponeurotic system elevation, and direct excision of fat over the mandible. Application of techniques without proper analysis and definition may lead to an operated look with a swept jaw line. Undertreatment may not achieve jaw line definition.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 01/2008; 28(6):668-74.
[Show abstract][Hide abstract] ABSTRACT: Staphylococcus aureus is the most common cause of skin and soft-tissue infections. Methicillin-resistant S. aureus and community-acquired methicillin-resistant S. aureus have shown an increase in prevalence among soft-tissue infections over the past several years, with overall rates approaching 50 percent at the authors' institution in 2002. The object of this study was to determine the incidence of methicillin-resistant S. aureus with respect to hand infections, the antibiotic resistance pattern of methicillin-resistant S. aureus isolates, and implications for a change in antibiotic treatment algorithms for hand infections.
A retrospective chart review of 761 patients with hand infections tracked by International Classification of Diseases, 9th Revision codes for finger or hand abscesses from 2001 to 2003 was performed at Parkland Memorial Hospital, Dallas, Texas. Culture results were obtained from 436 patients and analyzed for type of organism, and sensitivity profiles were obtained for all methicillin-resistant S. aureus isolates.
The median age of 761 patients was 40 years (range, 16 to 77 years); 71 percent were male and 28 percent were female. Of the 436 cultures reviewed, 371 (85 percent) had organisms identified. Methicillin-resistant S. aureus was the dominant single organism in hand infections cultured in all 3 years. The overall methicillin-resistant S. aureus rate was 61 percent of all hand infections in 2003. The percentage of S. aureus isolates identified as methicillin-resistant S. aureus increased from 55 percent to 78 percent over 3 years, up from 34 percent in 2001. Fortunately, 86 percent of these methicillin-resistant S. aureus isolates demonstrated sensitivity to conventional antibiotics, but a trend of resistance is developing.
The incidence of community-acquired methicillin-resistant S. aureus increased from 34 percent to 61 percent over a 3-year period at the authors' county institution. An increasing trend of resistance patterns among conventional antibiotics was also demonstrated. As a result of this study, the treatment algorithm at Parkland Memorial Hospital has been modified to include abscess drainage accompanied by an antibiotic regimen targeted specifically at methicillin-resistant S. aureus. These data also have implications for broader application regarding simple skin infections and current antibiotic treatment algorithms.
Plastic and reconstructive surgery 04/2007; 119(3):935-40. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: After studying this article, the participant should be able to: 1. Discern the importance of the physician's office administrative capacity. 2. Recognize the necessity of a system for quality assessment. 3. Assess which procedures are safe in the office-based setting. 4. Know the basic steps to properly evaluate patients for office-based plastic surgery.
At least 44,000 Americans die annually as a result of preventable medical errors. Medical mistakes are the eighth leading cause of death in the United States, costing between $54.6 billion and $79 billion, or 6 percent of total annual national health care expenditures. Office-based procedures comprise a 10-fold increase in risk for serious injury or death as compared with an ambulatory surgical facility.
This article reviews the literature on office-based patient safety issues. It places special emphasis on the statements and advisories published by the American Society of Plastic Surgeons' convened Task Force on Patient Safety in Office-Based Settings. This article stresses areas of increased patient safety concern, such as deep vein thrombosis prophylaxis and liposuction surgery.
The article divides patient safety in health care delivery into three broad categories. First, patient safety starts with emphasis at the administrative level. The physician or independent governing body must develop a system of quality assessment that functions to minimize preventable errors and report outcomes and errors. Second, the clinical aspects of patient safety require that the physician evaluate whether the procedure(s) and the patient are proper for the office setting. Finally, this article gives special attention to liposuction, the most frequently performed office-based plastic surgery procedure.
Patient safety must be every physician's highest priority, as reflected in the Hippocratic Oath: primum non nocere ("first, do no harm"). In the office setting, this priority requires both administrative and clinical emphasis. The physician who gives the healing touch of quality care must always have patient safety as the foremost priority.
Plastic and reconstructive surgery 05/2006; 117(4):61e-80e. · 2.74 Impact Factor