Periodontal laser surgery

A gingivectomy performed with a laser is a short, easy procedure that produces an immediately dramatic effect. Compared to a scalpel gingivectomy, there is excellent hemostasis, which improves visualization, requires less need for periodontal packing, and results in minimal postoperative discomfort. Tissue rebound also is minimal. Use of lasers requires specific training. The only approved function in periodontics at this time according to the American Academy of Periodontology is soft tissue surgery. Some periodontal applications include frenectomy, soft tissue crown lengthening, distal wedge procedures, soft tissue tuberosity reductions, gingivectomy, gingivoplasty, stage II of implants, operculectomies, biopsies, coagulation of graft donor sites, hemorrhage disorder patients, and stripping procedures for various leukoplakias.     

Anxiety disorders in plastic surgery

Surgery is a stressful event, with the potential for profound disturbance to the patient's psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patient's reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patient's psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.     

Microvascular bypass surgery. Part 2: physiological studies

Intraoperative electromagnetic blood flow measurements were recorded in 15 patients undergoing extracranial-intracranial arterial bypass surgery. The initial average blood flow of 28.2 cc/min supplies 8.4% of the expected flow from one internal carotid artery. Blood flow probably increases postoperatively, as evidenced by angiographic enlargement of the bypass and its recipient cortical arteries.     

Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery

Octyl-2-cyanoacrylate is a long carbon chain cyanoacrylate derivative that is stronger and more pliable than its shorter chain derivatives. One hundred and eleven patients underwent elective surgical procedures by the same surgeon using either octyl-2-cyanoacrylate or sutures for skin closure at the University of Illinois at Chicago. Most patients underwent excision of benign skin lesions with a mean wound size of 112 mm3. Patients were randomized into either control (vertical mattress suture closure) or test groups (closure with octyl-2-cyanoacrylate). Surgical judgment was used to determine which wounds in each group required application of subcutaneous sutures to relieve tension and aid in skin edge eversion. Generally, full-thickness (through dermis) wounds larger than 1 cm3 required the use of subcutaneous sutures. The time required to close the epidermis with suture (mean, 3 minutes and 47 seconds) was about four times that of octyl-2-cyanoacrylate (mean, 55 seconds). Wounds were evaluated at 5 to 7 days for infection, wound dehiscence, or tissue reaction, and at 90 days using the modified Hollander wound evaluation scale. At 1 year, photographs of the wounds were evaluated by two facial plastic surgeons that graded the cosmetic outcome using a previously validated visual analog scale. There were no instances of wound dehiscence, hematoma, or infection in either group. Results of wound evaluation at 90 days determined by the modified Hollander scal revealed equivalent cosmetic results in both groups. Results of the visual analog scale ratings showed scores of 21.7 +/- 16.3 for the 49 patients treated with octyl-2-cyanoacrylate and 29.2 +/- 17.7 for the 51 control patients treated with sutures. The lower visual analog scale score represented a superior cosmetic outcome at 1 year with the octyl-2-cyanoacrylate as compared with sutures. This difference is statistically significant at p = 0.03. Additionally, patient satisfaction was very high in the group treated with octyl-2-cyanoacrylate.     

Computer-based multimedia in plastic surgery education

Computer animation complements text explanation, image documentation, and graphic analysis techniques. It is compatible with the development of interactive multimedia science. Computer animation may emerge as a critical tool to assist in the efficient processing and analysis of greater volumes of educational data in plastic surgery training. At St. Louis University, we have continuously developed multimedia plastic surgery teaching materials with full-fidelity digital sound, three-dimensional computer graphics, and "picture-in-picture" video capabilities since 1987. We have used these materials, many of which are illustrated in this paper, for patient informed consent and the education of medical students and residents.     

von Willebrand''s disease and plastic surgery

Von Willebrand's disease (VWD) is the most commonly inherited coagulopathy. In a group of 1,000 plastic surgery patients, 8 or 9 individuals are affected by this disease, making basic knowledge of VWD and its management imperative. In this investigation, 1,000 plastic surgery patients were studied for details of their clinical evaluation, history of bleeding and bruising, and excessive bleeding during or after surgery. If the patient reported a history of easy bleeding or bruising, in addition to routine coagulation studies such as PT, PTT, and platelet count, the bleeding time was measured. When the index of suspicion dictated, more extensive coagulation studies, such as factor VIII assay, were conducted. This resulted in the detection of VWD in 9 patients (8 female and 1 male). All patients had a positive history of easy bleeding or bruising. Six of the 9 patients had a bleeding time greater than 6 minutes. Seven patients were diagnosed to have VWD type I, 1 had type II-a, and 1 suffered from type II-b disease. Perioperative bleeding was controlled in all patients in this study with the administration of 0.3 microgram/kg of body weight (usually a total dose of 20 micrograms) of 1-deamino-8-D-arginine-vasopressin intravenously every 12 hours for the first 24 hours. Two patients with type II VWD required fresh frozen plasma and cryoprecipitate 1 week subsequent to surgery to control late bleeding.     

Competitive forces and academic plastic surgery

Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery. Declining clinical revenues, competition for patients and resources from other health care providers, and reductions in support of its education and research efforts necessitate a paradigm shift if it is to survive. Questionnaires were used to collect data from 92 of the 100 postgraduate training program directors of plastic surgery in the United States. The most common source of clinical income on a national basis was indemnity insurance. Sources of clinical income varied by region. The majority of programs, 80 percent, report that at least 75 percent of the income support for faculty came from practice income. Financial support for ancillary and research personnel, in large part, came from this same source. Resident salaries and benefits came largely from other resources. Generally as population density within the metropolitan area in which a program was located increased, so too did the number of competing plastic surgeons, including graduates of the program and nonacademic cosmetic and hand surgeons. However, levels of competition for cosmetic surgery in smaller metropolitan areas of some regions seem to be similar to those reported by programs in larger communities. Plastic surgery programs in very competitive communities received significantly greater amounts of their income from indemnity insurance and self-paying patients than did programs in less competitive metropolitan areas. Internal competition from other surgical and nonsurgical specialists within the same institution is likewise keen. Virtually all respondents, 93 percent, report that their institutions provided patient care in a least one designated center of excellence in the following disciplines: hand, microsurgery, craniofacial, cleft lip and palate, burn, and cosmetic surgery. This study suggests that centers of excellence are more likely to be present in metropolitan areas with fewer competing surgeons than in areas with large numbers of competing surgeons. The data did not demonstrate that the presence of a center of excellence substantially affected the sources or levels of clinical income. To survive as an academic entity, program directors must correctly perceive and fulfill the needs and wants of its stakeholders, particularly with regard to quality of life issues.     

Hygiene partnering, Part 2

Today's technology is full of magic and delight in the hygiene arena. Throughout the years, dental hygiene has shifted into a thriving career, and hygienists have welcomed the new role with open arms. Innovation, technology, and partnering have also taken the concept of codiagnosis and comprehensive care to a higher level in the hygiene department. These benefits, combined with more sophisticated patient-centered communication skills and team-centered management philosophies will, without doubt, secure the future of dental hygiene departments in practices worldwide. Moreover, smart practices remaining committed to attracting, training, and retaining only high-caliber staff with interdependent, overlapping talent will find the most reward in helping their patients achieve and maintain optimum oral health for a lifetime.     

Dental iatrogenesis, Part 2

To substantiate biocompatibility of dental materials and techniques, and thereby reduce iatrogenesis, tests for pulp and dentinal responses have been developed. These have shown that high-speed tooth cutting techniques are superior to low-speed techniques even when both incorporate air-water coolant sprays; pressure when placing restorative materials intensifies pulp responses induced by the cutting procedure, and that chemically self-cured resin composites requiring the application of a matrix to enhance adaptation intensify pulp response as compared to visible light-cured equivalents applied incrementally, fully cured throughout, and not requiring the pressure of a matrix. Most cements are irritating to the pulp when used as luting agents and when used less than 0.5 mm from it. Conditioning agents using weak acids for short periods induce little irritation while bonding agents appear to be beneficial by providing protection from subsequently placed restorative material. Clinicians should make every effort to minimize the development of pulp responses and reduce iatrogenic efforts.     

Digital imaging for plastic and reconstructive surgery

Porcine-specific polymerase chain reaction (PCR) and a pig-rodent somatic cell hybrid panel were used to map two members of the MyoD gene family. MYOD1 was assigned to pig chromosome 2 and MYF5 to chromosome 5.     

Instrumentation and setup for endoscopic plastic surgery

The use of endoscopic techniques mandates the need for basic understanding of endoscopic instrumentation and operating room setup in order to avoid procedural delays and surgeon frustration. The electronic systems for endoscopic surgery-cameras, light sources, monitors, and so on-have been well developed for other specialties and are fully adaptable to endoscopic plastic surgical procedures. Hand instruments, however, are in the early phases of refinement for subcutaneous plastic surgical procedures and will undoubtedly improve over the next several years. Adaptation of existing instrumentation and development of new operating tools continue and promise to make endoscopic plastic surgical procedures of the future more ergonomic and efficient. Similarly, while operating room setup for endoscopic plastic surgical procedures varies depending on individual circumstances, application of a few basic principles will help in making this step quick and simple. The knowledge and experience of scrub technicians and nurses experienced in endoscopic techniques can be invaluable to the surgeon just beginning to use endoscopic techniques in plastic and reconstructive surgery.