E J Bulan

Georgetown University, Washington, D. C., DC, United States

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Publications (11)15.34 Total impact

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    ABSTRACT: Ischemic wounds of the lower extremity can fail to heal despite successful revascularization. The foot can be divided into six anatomic regions (angiosomes) fed by distinct source arteries arising from the posterior tibial (three), anterior tibial (one), and peroneal (two) arteries. This study investigated whether bypass to the artery directly feeding the ischemic angiosome had an impact on wound healing and limb salvage. Retrospective analysis was performed for 52 nonhealing lower extremity wounds (48 patients) requiring tibial bypass over a 2-year period. Preoperative arteriograms were reviewed to determine arterial anatomy relative to each wound's specific angiosome and bypass anatomy. Patients were divided into two groups; direct revascularization (DR, bypass to the artery directly feeding the ischemic angiosome) or indirect revascularization (IR, bypass unrelated to the ischemic angiosome). Wound outcome was analyzed with regard to the endpoints of complete healing, amputation, or death unrelated to the wound. Time to healing was also noted for healed wounds. Based on preoperative arteriography, 51% (n = 27) of the wounds received DR to the ischemic angiosome, while 49% (n = 25) underwent IR. There were no statistically significant differences in the comorbidities of the two groups. Revascularization was via tibial bypass using the saphenous vein (n = 34, 65%) or polytetrafluoroethylene with a distal vein patch (n = 18, 35%). Bypasses were performed to the anterior tibial (n = 22, 42%), posterior tibial (n = 17, 33%), or peroneal (n = 13, 25%) arteries based on the surgeon's judgment. One bypass failed in the perioperative period and was excluded from the analysis. The remaining bypasses were patent at the time of wound analysis. Due to a 17% mortality rate during follow-up, 43 wounds were available for endpoint analysis. This analysis demonstrated that 77% of wounds (n = 33) progressed to complete healing and 23% of wounds (n = 10) failed to heal with resultant amputation. In the DR group, there was 91% healing with a 9% amputation rate. In the IR group, there was 62% healing with a 38% amputation rate (p = 0.03). In those wounds that did heal, total time to healing was not significantly different--DR 162.4 days versus IR 159.8 days (p = 0.95). Revascularization plays a crucial role in the treatment of ischemic lower extremity wounds. We believe that direct revascularization of the angiosome specific to the anatomy of the wound leads to a higher rate of healing and limb salvage. Although many factors must be considered in choosing the target artery for revascularization, consideration should be given to revascularization of the artery directly feeding the ischemic angiosome.
    Annals of Vascular Surgery 02/2009; 23(3):367-73. · 0.99 Impact Factor
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    ABSTRACT: Les troubles trophiques d'origine ischémique des membres inférieurs peuvent présenter un retard de cicatrisation malgré une revascularisation réussie. Le pied se divise en six régions anatomiques distinctes (angiosomes), chacune alimentée par des artères sources, elle-même branches artères tibiale postérieure (trois), tibiale antérieure (une) et péronière (deux). Le but de cette étude était de déterminer si une revascularisation par pontage de l'artère alimentant directement l'angiosome ischémique avait un impact sur la cicatrisation de troubles trophiques et sur le sauvetage de membre. Une analyse rétrospective de 52 troubles trophiques persistants de membres inférieures (48 patients) nécessitant la réalisation d'un pontage distal sur une période de deux ans a été réalisée. Les artériographies préopératoires ont été revues afin de déterminer l'anatomie artérielle des angiosomes spécifiques de chaque trouble trophique et des caractéristiques des pontages. Les patients ont été divisés en deux groupes: revascularisation directe (RD, pontage sur l'artère alimentant directement l'angiosome ischémique) et revascularisation indirecte (RI, pontage non spécifiquement lié à l'angiosome ischémique). L'évolution des troubles trophiques a été analysée selon les critères de jugements suivants : cicatrisation complète, amputation majeure, décès non lié au trouble trophique. Le temps de cicatrisation a également été noté. Selon les données de l'artériographie préopératoire, 51% (n = 27) des troubles trophiques ont bénéficié d'une RD sur l'angiosome ischémique, alors que 49% (n = 25) ont bénéficié d'une RI. Il n'y avait aucune différence statistiquement significative pour ce qui concerne les comorbiditées dans les deux groupes. La revascularisation a consisté en un pontage distal en veine saphène (n = 34, 65%) ou en polytétrafluoroéthylène avec patch veineux distal (n = 18, 35%). Les pontages ont été implantés au niveau des artères tibiales antérieure (n = 22 et 42%) ou postérieure (n = 17 et 33%) ou au niveau de l'artère péronière (n = 13, 25%), selon le jugement du chirurgien. Un pontage s'étant occlus dans la période périopératoire a été exclu de l'analyse. Les autres pontages étaient perméables au moment de l'évaluation du trouble trophique. En raison d'un taux de mortalité de 17% au cours du suivi, seulement 43 troubles trophiques étaient analysables selon les critères prédéfinis. Cette analyse a montré que 77% (n = 33) des troubles trophiques ont cicatrisé et que 23% (n = 10) des troubles trophiques n'ont pas cicatrisé correctement et ont nécessité une l'amputation. Dans le groupe RD, le taux de cicatrisation était de 91% avec un taux d'amputation de 9%. Dans le groupe RI, le taux de cicatrisation était de 62% avec un taux d'amputation de 38% (p = 0.03). Parmi les troubles trophiques ayant cicatrisé, la durée totale de cicatrisation n'était pas significativement différente entre les deux groupes (RD: 162.4 jours vs RI: 159.8 jours; p = 0.95). La revascularisation joue un rôle crucial dans le traitement des troubles trophiques d'origine ischémique des membres inférieurs. Nous pensons que la revascularisation directe de l'angiosome contenant le trouble trophique est associée à un taux de cicatrisation et de sauvetage de membre plus élevés. Bien que beaucoup de facteurs doivent être considérés lors du choix de l'artère cible d'un pontage, la revascularisation de l'artère alimentant directement l'angiosome ischémique est primordiale.
    Annales De Chirurgie Vasculaire. 01/2009; 23(3):395-401.
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    ABSTRACT: La cicatrización de las heridas isquémicas de la extremidad inferior puede fracasar a pesar de lograr una revascularización satisfactoria. El pie puede dividirse en 6 regiones anatómicas (angiosomas) nutridas por diferentes arterias que se originan en la arteria tibial posterior (3), la arteria tibial anterior (1), y la arteria peronea (2). En este estudio se investigó si el bypass a la arteria que nutre directamente el angiosoma isquémico influyó en la cicatrización de la herida y el salvamento de la extremidad. Se realizó un análisis retrospectivo de 52 heridas no cicatrizadas de la extremidad inferior (48 pacientes) que requirieron un bypass tibial a lo largo de un período de 2 años. Se revisaron las arteriografías preoperatorias para determinar la anatomía arterial con respecto al angiosoma específico de cada herida y la anatomía del bypass. Los pacientes se dividieron en 2 grupos: revascularización directa (RD, bypass en la arteria que nutre directamente el angiosoma isquémico) o revascularización indirecta (RI, bypass no relacionado con el angiosoma isquémico). El resultado de la herida se analizó con respecto a los siguientes criterios de valoración: cicatrización completa, amputación o fallecimiento no relacionado con la herida. También se anotó el tiempo de cicatrización de cada herida. Sobre la base de la arteriografía preoperatoria, en el 51% (n = 27) de las heridas se realizó una RD del angiosoma isquémico, mientras que en el 49% (n = 25) se realizó una RI. No se observaron diferencias estadísticamente significativas en las comorbilidades de ambos grupos. La revascularización se realizó mediante un bypass tibial utilizando la vena safena (n = 34, 65%) o un implante de politetrafluoroetileno con un parche de vena distal (n = 18, 35%). Los bypass se realizaron a las arterias tibial anterior (n = 22, 42%), tibial posterior (n = 17, 33%), o peronea (n = 13, 25%) según el criterio del cirujano. Un bypass fracasó durante el período perioperatorio y fue excluido del análisis. Los bypass restantes seguían siendo permeables en el momento en que se evaluó la herida. Debido a una tasa de mortalidad del 17% solamente se dispuso de 43 heridas para el análisis de los criterios de valoración. Este análisis demostró que el 77% de las heridas (n = 33) progresaron a una cicatrización completa y que el 23% (n = 10) no lograron cicatrizar resultando en la amputación de la extremidad. En el grupo RD se produjo una cicatrización del 91% con una tasa de amputación del 9%. En el grupo RI se produjo una cicatrización del 62% con una tasa de amputación del 38% (p = 0,03). En aquellas heridas que cicatrizaron, el tiempo total hasta la cicatrización no fue significativamente diferente (RD 162,4 días frente a RI 159,8 días; p = 0,95). La revascularización desempeña un papel crucial en el tratamiento de las heridas isquémicas de la extremidad inferior. Creemos que la revascularización directa del angiosoma específico a la anatomía de la herida comporta mayores índices de cicatrización y salvamento de la extremidad. Si bien deben tenerse en cuenta muchos factores a la hora de elegir la arteria diana para la revascularización, es necesario considerar la revascularización de la arteria que nutre directamente al angiosoma isquémico.
    Anales de Cirugía Vascular. 01/2009; 23(3).
  • Scott L Spear, Erwin J Bulan, Mark L Venturi
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    ABSTRACT: LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the different variables that are inherent to breast augmentation. 2. Identify certain breast shape characteristics that make one approach more advantageous than others. 3. Take into account certain patient characteristics to develop a logical surgical plan for breast augmentation. SUMMARY: The optimal technique for breast augmentation has always been debated, and numerous variables fit the needs of the variously shaped patients in our population. The purpose of this article is to present the advantages and disadvantages of the various techniques available in breast augmentation so that, in conjunction with the patient's physical examination, a sound surgical plan can be developed for aesthetic augmentation of the breast.
    Plastic and reconstructive surgery 01/2007; 118(7 Suppl):188S-196S; discussion 197S-198S. · 2.74 Impact Factor
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    ABSTRACT: Ian Taylor introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries. Understanding the angiosomes of the foot and ankle and the interaction among their source arteries is clinically useful in surgery of the foot and ankle, especially in the presence of peripheral vascular disease. In 50 cadaver dissections of the lower extremity, arteries were injected with methyl methacrylate in different colors and dissected. Preoperatively, each reconstructive patient's vascular anatomy was routinely analyzed using a Doppler instrument and the results were evaluated. There are six angiosomes of the foot and ankle originating from the three main arteries and their branches to the foot and ankle. The three branches of the posterior tibial artery each supply distinct portions of the plantar foot. The two branches of the peroneal artery supply the anterolateral portion of the ankle and rear foot. The anterior tibial artery supplies the anterior ankle, and its continuation, the dorsalis pedis artery, supplies the dorsum of the foot. Blood flow to the foot and ankle is redundant, because the three major arteries feeding the foot have multiple arterial-arterial connections. By selectively performing a Doppler examination of these connections, it is possible to quickly map the existing vascular tree and the direction of flow. Detailed knowledge of the vascular anatomy of the foot and ankle allows the plastic surgeon to plan vascularly sound reconstructions, the foot and ankle surgeon to design safe exposures of the underlying skeleton, and the vascular surgeon to choose the most effective revascularization for a given wound.
    Plastic and reconstructive surgery 07/2006; 117(7 Suppl):261S-293S. · 2.74 Impact Factor
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    ABSTRACT: Knowing the arterial anatomy of the foot and ankle in addition to understanding the angiosome concept provides the basis for careful and safe planning of incisions. The Doppler allows the surgeon to map out the actual vascular anatomy that exists preoperatively and therefore allows for appropriate adjustment to the planned incisions. If the vascular flow is inadequate for the planned surgery, then the vascular surgeon has to intervene to improve the existing blood flow. If the vascular tree is so compromised that successful revascularization of the affected angiosome is impossible, then the revascularization is likely to fail. Serious consideration to a below-knee amputation should then enter the decision tree at that time. Most of the time, however, the blood flow is adequate or can be sufficiently augmented with vascular surgery. The foot and ankle surgeon can then perform preoperative mapping of the arterial blood supply with the Doppler. By making the necessary adjustments to the planned incision, surgery can proceed safely with uneventful healing.
    Foot and Ankle Clinics of North America 01/2002; 6(4):745-99. · 0.90 Impact Factor
  • C E Attinger, E J Bulan
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    ABSTRACT: Before addressing a wound, whether it is chronic or acute, clinicians must thoroughly assess the wound and the patient. An acute wound in a patient with normal blood flow and good medical and nutritional condition should go on to heal if appropriate care is given. This means that the wound has to be débrided adequately, dressed, and closed when appropriate. Getting back to healthy tissue is the key. In chronic wounds, healing is more difficult because the etiology of the wound is harder to determine, and the measures to reverse the medical abnormalities are often complex. When these have been sorted out and addressed, however, débridement again plays the key role. It converts the chronic wound into an acute wound so that it can then progress through the normal stages of healing. The key is for clinicians to be aggressive and not let concerns about the residual defect limit débridement. Subsequent healing then can be achieved by use of wound-healing adjuncts such as the V.A.C. device, hyperbaric oxygen, skin substitutes, growth factor, or plastic surgical techniques.
    Foot and Ankle Clinics of North America 01/2002; 6(4):627-60. · 0.90 Impact Factor
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    ABSTRACT: Background: Large-volume lipoplasty changes body composition during a single surgical intervention by selectively decreasing subcutaneous adipose tissue. Positive health benefits, previously reported for a cohort of 14 women at 4 months after surgery, include significant decreases in weight, systolic blood pressure, and fasting insulin levels. Objective: In the present study, we sought to determine whether the benefits of altering body composition by large-volume liposuction observed at 4 months are sustained over longer periods of time. Methods: Subjects were seen for an additional follow-up visit approximately 1 year (range 10 to 21 months) after surgery. Fasting insulin levels were measured in the 8 patients who had preoperative fasting insulin levels higher than 12 muU/mL. Weight, systolic and diastolic blood pressure, heart rate, and body circumferences were measured in all 14 subjects. Results: Compared with data obtained before surgery and 4 months after surgery, results at 10 to 21 months after lipoplasty showed that the improvements in body weight, systolic blood pressure, and fasting insulin levels observed 4 months after the procedure had been maintained. Conclusions: Should these results be confirmed in larger studies, lipoplasty may prove to be a valuable tool for reducing some of the co-morbid conditions associated with obesity. (Aesthetic Surg J 2001;21:527-531.).
    Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 12/2001; 21(6):527-31.
  • S L Spear, E J Bulan
    Plastic &amp Reconstructive Surgery 10/2001; 108(3):771-5. · 3.54 Impact Factor
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    ABSTRACT: In this study, the authors investigated the physiologic effects of the altered body composition that results from surgical removal of large amounts of subcutaneous adipose tissue. Fourteen women with body mass indexes of greater than > 27 kg/m2 underwent measurements of fasting plasma insulin, triglycerides, cholesterol, body composition by dual-energy x-ray absorptiometry (DXA), resting energy expenditure, and blood pressure before and after undergoing large-volume ultrasound-assisted liposuction. There were no significant intraoperative complications. Body weight had decreased by 5.1 kg (p < 0.0001) by 6 weeks after liposuction, with an additional 1.3-kg weight loss (p < 0.05) observed between 6 weeks and 4 months after surgery, for a total weight loss of 6.5 kg (p < 0.00006). Body mass index decreased from (mean +/- SEM) 28.8 +/- 2.3 to 26.8 +/- 1.5 kg/m2 (p < 0.0001). This change in body weight was primarily the result of decreases in body fat mass: as assessed by DXA, lean body mass did not change (43.8 +/- 3.1 kg to 43.4 +/- 3.6 kg, p = 0.80), whereas DXA total body fat mass decreased from 35.7 +/- 6.3 to 30.1 +/- 6.5 kg (p < 0.0001). There were significant decreases in fasting plasma insulin levels (14.9 +/- 6.5 mIU/ml before liposuction versus 7.2 +/- 3.2 mIU/ml 4 months after liposuction, p < 0.007), and systolic blood pressure (132.1 +/- 7.2 versus 120.5 +/- 7.8 mmHg, p < 0.0002). Total cholesterol, high-density lipoprotein cholesterol, plasma triglycerides, and resting energy expenditure values were not significantly altered after liposuction. In conclusion, over a 4-month period, large-volume liposuction decreased weight, body fat mass, systolic blood pressure, and fasting insulin levels without detrimental effects on lean body mass, bone mass, resting energy expenditure, or lipid profiles. Should these improvements be maintained over time, liposuction may prove to be a valuable tool for reducing the comorbid conditions associated with obesity.
    Plastic &amp Reconstructive Surgery 08/2001; 108(2):510-9; discussion 520-1. · 3.54 Impact Factor
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    ABSTRACT: No wound can heal in an orderly fashion unless it is clean, healthy, and free of infection. Débridement is key in achieving this goal providing that: (1) the wound is adequately vascularized, (2) the proper antibiotics are on board, and (3) all other medical aspects of the patient have been addressed. Surgical débridement is the quickest and most efficient way of getting the wound ready for healing. Exciting new products such as growth factor, hyperbaric oxygen, skin graft substitutes, and the V.A.C. can then be selectively applied to accelerate wound healing. For those wounds that require more than closure by secondary intention, plastic surgical techniques can then be used to provide a functional and effective wound closure.
    Clinics in Podiatric Medicine and Surgery 11/2000; 17(4):599-630.