Abdominal wall closure after selective aponeurotic incision and undermining

The tension required to pull the anterior and the posterior rectus sheaths toward the midline was studied in 20 fresh cadavers at two levels: 3 cm above and 2 cm below the umbilicus. The quotient of the force used to mobilize the aponeurotic site to the midline and its resulting displacement was called the traction index. These indices were compared in three situations: (1) prior to any aponeurotic undermining, (2) after the incision of the anterior rectus sheath and the undermining of the rectus muscle from its posterior sheath, and (3) after additionally releasing and undermining the external oblique muscle. A significant decrease in aponeurotic resistance was observed after each dissection. The anterior sheath showed higher resistance to traction compared with the posterior sheath on both levels. No statistical difference was noted in the comparison of the values of the aponeurosis above and below the umbilicus. These results suggest that these procedures are effective in assisting in the closure of abdominal wall defects because these maneuvers decrease substantially the tension required for advancement of the aponeurotic edges.

Contraction and myofibroblasts in restored skin

Myofibroblasts and the contraction of split skin-graft donor sites were studied in 18 patients. For each patient five samples were studied, taken on days 0, 14, 21, 28, and 35. On each occasion the extensions and densities of myofibroblasts were calculated. After the initial measurement, the subsequent extensions were expressed in percentages of the first, resulting in mean measurements of 100, 95, 97, 99, and 99%, respectively. The myofibroblasts in 10 dermic fields were counted under light microscopy at a magnification of 1000 marked with anti-alpha-smooth muscle actin antibodies using immunoperoxidase, resulting in the means of 0.2, 3.8, 1.3, 1.3, and 0.4, respectively. The contraction and the increase in density of myofibroblasts were transitory and significant in the samples measured on day 14, but in sample 35 neither of the variables was significantly different from the initial sample. These variables evolved concurrently, corroborating the hypothesis that myofibroblasts are responsible for the contraction.

Electrophoretic characterization of exposed outer membrane proteins in environmental and human Bacteroides fragilis strains

Bacteriodes fragilis isolated from aquatic environment, from infectious process and from human feces were compared as to their outer membrane protein electrophoretic profiles after staining with Coomassie blue and reacting with antibodies prepared against whole-cell antigens of a reference strain from a clinical source. A marked homogeneity was found among the strains with these methodologies. The profiles of all strains obtained after radio-iodination of the intact cell showed qualitative similarity when compared with the profiles obtained by the other methods. Thus, these data allow us to suggest the designation of the peptides observed in the autoradiograms as surface-exposed proteins. Differences observed in the autoradiograms in the expression of bands mainly detected at a molecular weight of 28 in the commensal strain 118,310 defined previously as avirulent, in addition to a distinction in the titres of agglutination with the sera tested and lower reactivity in the immunoblotting assays, suggest a relationship of the B. fragilis surface architecture with the virulence potential as well as with the origin of the strain.

Influence of stress conditions on Bacteroides fragilis survival and protein profiles

Bacteroides fragilis strains isolated from different sources, i.e. 1 strain (AA1) from an aquatic environment, 1 strain from normal flora (118310) and the type strain (ATCC 25285) originally isolated from clinical material, were analysed for both cell envelope proteins composition and surviving under oxidative stress starvation. All strains examined showed a similar survival response when cultured in drinking water with a ten-fold decrease in viable counts per day during the 7 days of analysis. The outer membrane protein (OMP) profiles of all strains were quite similar during the stress period as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). However, the periplasmic proteins of the strain 118310 showed two protein bands at 48 and 58 kDa, respectively, that were absent in the strains AA1 and ATCC 25285 during the incubation period in potable water. Whole cells and periplasmic 35S-labelled proteins from bacteria cultured in drinking water showed a significant increase in proteins at 16, 18, 24, 26, 35, 48, and 58 kDa and 18, 22, 24, 48, 58, and 70 kDa, respectively, in all strains when compared to cells grown in BHI-PRAS media as detected by autoradiography following SDS-PAGE. These data suggest that B. fragilis may have a synthesis mechanism that allows them to adapt to adverse environments.

Midfacial advancement by bone distraction for treatment of craniofacial deformities

Craniofaciostenosis is often associated with midfacial hypoplasia and has been treated traditionally using Le Fort advancement osteotomies and bone grafts. The surgical procedure requires a prolonged operating time, several osteotomies with a significant blood loss, and wide surgical exposure. According to the principles of bone lengthening, we performed midfacial advancement by bone distraction in 4 patients with midfacial hypoplasia to reduce the operative time and complication rate. In 2 patients with Crouzon's syndrome we performed a Le Fort III osteotomy and placed the distraction device behind the malar eminence and screwed it on the temporal bone bilaterally. In the other 2 children, with Apert's syndrome, we performed frontal advancement and remodeling before placing the device during the same surgery behind the malar bone without any midfacial osteotomy. It appears to us that patients with more severe deformities will need surgical procedures to offer more satisfactory results. In these patients, distraction is an initial therapy to reduce the severity of the deformity, making it possible to effect a better treatment afterward.

Whole-cell and periplasmic protein banding patterns of environmental and human Bacteroides fragilis strains

In order to investigate the relationship among virulent and avirulent Bacteroides fragilis strains, SDS-PAGE of whole-cell proteins (WP) and periplasmic proteins (PP) were used to establish a protein profile of strains isolated from human infections, fecal flora and environmental water. Despite different sources of the strains, no significant differences were observed as determined by the WP SDS-PAGE analysis. In contrast, the proteins obtained from the bacterial periplasm showed differences in the electrophoretic protein profile. Two distinct PP profile patterns were obtained. Pattern A included 6 out of the 8 virulent strains and pattern B, 6 out of 8 avirulent strains. Interestingly, an environmental strain that was capable of inducing abscesses in mice, had a PP profile highly similar to that of the virulent strains from human infections. These data indicate that PP from B. fragilis may be useful to characterize differences among virulent and avirulent strains. Moreover, strains isolated from environmental water may also be a source of exogenous infections by B. fragilis.

Comparison of extraction methods and detection systems in the gas chromatographic analysis of volatile carbonyl compounds

High-resolution gas chromatography (HRGC) with electron-capture detection (ECD), nitrogen-phosphorus detection (NPD), flame ionization detection (FID) or with mass spectrometry-selected ion monitoring (MS-SIM) was used in the analysis of volatile carbonyl compounds. Eighteen carbonyl compounds that are typically produced during lipid peroxidation were derivatized quantitatively with pentafluorophenylhydrazine (PFPH) at room temperature, to afford their corresponding water-insoluble hydrazones. These derivatives were extracted into non-polar phases by means of either liquid-liquid extraction (LLE) (hexane) or solid-phase extraction (SPE) on 3 ml C18 octadecyl-bonded phase cartridges. Detection limits of 10(-14) and 10(-12) mol/ml per aldehyde were achieved with the ECD and MS-SIM systems, respectively. The effects of extraction conditions on sensitivity and recovery were determined by performing parallel HRGC-ECD and HRGC-MS-SIM analyses of pentafluorophenylhydrazones of the eighteen compounds under study. Recoveries of 51.4-78.9 +/- 1.2-4.5 and 80.9-98.3 +/- 1.0-3.5% were obtained with LLE and SPE, respectively. The method was applied to the analysis of the volatile carbonyl compounds in various heated vegetable oils (corn, palm or sunflower) and to the analysis of volatile aldehydes in human urine.

Guillain-Barré syndrome and head trauma. Case report

The authors report the case of a 29 years old male patient presenting classical Guillain-Barré syndrome following head trauma. Only one other similar case is described in the literature. Head trauma as a precipitating event of the disease is discussed.

Surface vesicles: a possible function in commensal relations of Bacteroides fragilis

Surface vesicles (SV) defined by electron microscopy as outer membrane (OM) extrusions were detected in Bacteroides fragilis strains from distinct sources. A partial identity between SV and OM electrophoretic protein profiles, in addition to the microscopic analysis, may suggest the designation of OMSV. Sialidase activity, a virulence determinant, was associated with these sub-cellular structures in all the strains, but in an inverse relation to the vesicle quantity per cell. A commensal strain, previously defined as avirulent in an animal model, presented the lowest vesicle-associated sialidase activity and the greatest SV expression as opposed to what happened with clinical and environmental strains. These results seem to suggest that these surface components have a function in commensal stages of B. fragilis.

Epidemiology and antimicrobial resistance of B. fragilis group organisms isolated from clinical specimen and human intestinal microbiota

Epidemiological aspects and the antimicrobial susceptibility profile of the Bacteroides fragilis group isolated from clinical and human intestinal specimens were examined in this study. B. fragilis group strains were isolated from 46 (37%) of 124 clinical specimens and the source of the samples was: Blood culture (3), intraabdominal infection (27), brain abscess (2), soft tissue infection (17), respiratory sinus (3), pleural aspirate (9), breast abscess (3), surgical infected wound (22), pelvic inflammatory disease (22), chronic otitis media (9) and miscellaneous (7). Intraabdominal and soft tissue infections were responsible for more than half of the clinical isolates. Susceptibility to penicillin, cefoxitin, tetracycline, metronidazole, chloramphenicol and clindamycin was examined. All isolates were susceptible to metronidazole and chloramphenicol. For clindamycin and cefoxitin the resistance rates observed were 21.7% and 10.9% respectively. Susceptibility profiles varied among the different species tested. A total of 37 species of B. fragilis group isolated from intestinal microbiota of individuals who had no antimicrobial therapy for at least 1 month before the sampling was also examined. All strains were also susceptible to chloramphenicol and metronidazole and the resistance rates to clindamycin and cefoxitin were 19.4% and 5.4% respectively. A few institutions, in Brazil, have monitored the antimicrobial susceptibility of B. fragilis group strains isolated from anaerobic infections. The resistance rates to cefoxitin and clindamycin and the variation in susceptibility patterns among the species isolated in this study emphasize the need for monitoring of susceptibility patterns of B. fragilis group organisms isolated, especially at our University Hospitals.

[Pulmonary lesion in electric injury: report of a case]

Major electrical injuries constitute approximately 5% of all admissions to Burn Units. Visceral complications are associated with a high mortality rate. The most common visceral lesions associated to electric burns are cardiac lesions. Pulmonary compromise is rare, if compared to inhalation injuries in termical burns. Although, when the entry or exit ports are the toracic wall, pleural effusion, hemotorax and pneumonitis may occur. A rare case of high-voltage electrical injury with massive pulmonary lesion is presented, regarding to clinical course and roentgenographic patterns.

Isolation of Porphyromonas gingivalis strain from tubal-ovarian abscess

An unusual case of involvement of Porphyromonas gingivalis is described. Two anaerobic isolates, identified as Fusobacterium nucleatum and P. gingivalis, were recovered from the pus of a tubal-ovarian abscess in a 35-year-old woman. Identification of the P. gingivalis isolate was confirmed by randomly amplified polymorphic DNA fingerprinting.

The tegument resulting from the healing of burns

First the authors conceptualized healed burns, the tegument resulting from the healing of burns (TRH), and the 4 main species of teguments: 1--Regenerated skin; 2--Restored skin; 3--Grafts and 4--Scars. One hundred patients at the Unit Burn from the Division of Plastic Surgery, Faculty of Medicine, University of São Paulo, Brazil, were then studied prospectively, and the respective teguments which resulted from the healing of the burns were analyzed in their qualitative and quantitative aspects. From the qualitative point of view, TRHs were classified into 7 types. The extensions of the species which comprised each type were calculated as a % of the TRH. From this analysis it was seen that restored skin was present in all patients and that pos-burn restored skin was the most frequent and most extensive species. It also became evident that restored skin has not been considered as such, since it has been incorrectly referred to as scar. From this qualitative and quantitative analysis a Quality Index was drawn up to objectively evaluate healed burns and, indirectly the caliber of the treatment carried out. It also become clear how heterogeneous are the teguments that make up healed burns and the importance of this fact for treating patients.

[Kinetic distribution of cyclosporine after single dose subcutaneous administration; experimental study in rats]

Adequate dose of cyclosporin A shows immunosuppressor effect, and low toxicity. The doses reported previously ranged from 2.5 to 25 mg/kg every 24, 48 hours and even 7 days. Routes for cyclosporin A administration are subcutaneous or intramuscular preferentially. In the present study, cyclosporin A (CSA) single dose subcultaneous was administered to 21 Wistar-Furth rats, adult, males, weighing 350-450g. The animals were divided in 3 groups receiving 2.5 mg/kg (group 1), 5.0 mg/kg (group 2) and 10.0 mg/kg (group 3). Blood samples were collected at 1, 4, 8, 12, 24, 48 and 72 hours after drug collection into plastic tubes containing sodium EDTA. Blood cyclosporin A levels were determined by a commercially available radioimmunoassay kit (Sandoz RIE Kit Basel) after whole hemolysis using liquid nitrogen. Cyclosporin A blood concentrations vs time curve were plotted (log C vs t). Two compartment open model was applied to estimate the kinetic parameters as t(1/2) beta e beta. A model independent calculation was applied to estimate the kinetic parameters as AUCT, CIT and Vd. Initially, parametric and nonparametric tests were applied. Due to the high dispositional variability, nonparametric statistics (Wilcoxon's test) was applied for analysis of results obtained. Based on data obtained in the present study the authors suggest linear pharmacokinetics where Cmax AUCT showed proportional increases with the dose administered, remaining unchanged the Kinetic parameters as t(1/2) B,B, CIT and Vd.

[Skin aging and collagen]

The Aging process is a dynamic and unchangeable phenomenon which affects all systems in the body. In the skin, the old appearance is represented by wrinkles and sagging and results from structural alterations on the molecular level. Modifications in collagen, the most important protein of the connective tissue, era responsible for these anatomic changes. The investigation of the qualitative and quantitative distribution of the collagen fibrils has been very useful for understanding the structural and functional alterations that occur during the aging process. The modulation of this phenomenon will only be possible if we understand its physiopathology.

[Electrical burns of the upper limbs]

During a period of 27 months, between 1991 and 1993, 15 patients with upper limb lesions caused by electrical hazards were admitted in the Burn Emergency Service of the Hospital das Clinicas-FMUSP. This lesion is usually a dramatic condition and requires a sound physiopathologic knowledge by the surgeon. These accidents may have permanent incapacitating sequelae, and due to long periods of treatment (2 months), social-economic costs are very high. Based on our experience, we suggest a less aggressive approach (no amputation at emergency), and a close continuous surveillance.

[Reduction mammoplasty with shortened scars: surgical technique]

Reduction mammaplasty is nowadays one of the most frequently performed plastic surgeries. The main purpose is the reduction of the volume of breasts, but the resulting scars can jeopardize the result of the operation. The Division of Plastic Surgery follows the modern tendency of reducing the length of the incisions and thus the resulting scars. A technique that incorporates this principle was developed with good results. The technique is simple enough to be used in a training program.

Autologous fat grafts: a quantitative and morphometric study in rabbits

The aim of this study was to assess the fate of autologous fat tissue grafts harvested and processed by five different methods: blunt suction, sharp suction, dissection, treatment, and lavage. Fat was harvested from the subcutaneous tissue of the interscapular region in 25 rabbits and injected into the subcutaneous area of the convex surface of the ear. Harvesting was by either open surgical excision or suction. Where open surgical excision was used, the fragments were cut into smaller pieces with scissors. Suction in the blunt and sharp suction groups was through cannulas with blunt or sharp edged suction holes, respectively. In both suction groups and the dissection group the harvested tissue was injected without further processing. In the treatment group 2 ml of cell 199 culture medium and Earle's basic salt solution were added, and in the lavage group the tissue was washed with Ringer's lactate. Animals were killed at 7 (n = 9), 180 (n = 8), and 360 (n = 8) days. Serial cross sections were taken from each recipient area and the specimens processed for histology. The images from each section were digitised in a computer and, with the assistance of image analysis software, the volume of remaining fat cells was calculated for each recipient area. The percentage volumes of fat cells found in each group at 360 days were: blunt suction 14% sharp suction 35%, dissection 45%, treatment 27%, and lavage 16% (p = 0.003).

[Mitral valve prolapse and cusp elasticity]

PURPOSE

To verify if systolic bulging of floppy mitral cusps can to elastic behavior of their myxomatous collagen tissue.

METHODS

Five hearts with floppy mitral valves obtained from autopsies were distended with air (20 to 250 mmHg) through a catheter connected to the left ventricle. It was observed if some area of the atrial surface of the coapted cusps showed variable bulging according to the variation of air injection pressures. Molding of those surfaces (gypsum) allowed the same kind of analysis by other four researches. It was analyzed the cut surfaces of these radially sectioned molds. Lately, isolated tendinae chords were submitted to repeated tractions and observed if they exhibited elastic behavior. Histological study defined the presence of collagen myxomatous degeneration and quantified the amount of elastic tissue.

RESULTS

In no case it was detected elastic bulding of mitral cusps. Cut surfaces of the molds confirmed that no increment of the prominent areas occurred, even in those regions with extensive, histologically confirmed, myxomatous substitution of the native collagen tissue.

CONCLUSION

Increment of the degree of mitral bulging occurring during ventricular systole can not be ascertained to cusp elasticity but probably to papilar muscle traction.

[The use of microvascular free flaps in the repair of the skin of the upper limb]

Between 1980 and 1992 microsurgical free flaps were used in 35 patients for the repair the of skin defects in the upper limb. Twenty six patients were male and nine female. The scapular flap was done in 16 cases, the lateral flap in seven, the dorsalis pedis in four, the neurovascular first web space in four, the latissimus dorsi in two, the radical forearm flap in one and the gracilis in other one. The survival rate in this series was 88.57%. Early free flaps were performed in 12 patients of whom one developed infection at the recipient site. Two-point discrimination was achieved in four thumbs reconstructed with the neurovascular first web flap. No complications occurred at the donor areas.

Replantation of digits: factors influencing survival and functional results

Immediate survival and functional results were studied in 60 finger replants performed from 1980 to 1990. The follow-up ranged from 1 to 5 years with the mean of 2 years and 8 months. The survival rate achieved was 70% and was not related to the patient's age, the mechanism of injury, the level of amputation, the total ischemia time, the number of arteries and veins repaired or the type of vascular reconstruction. Sensory return was related to the mechanism of amputation and the total active motion was strongly correlated with the level of amputation. Of the 16 digits that had only one artery anastomosed, there were 10 survivals (62.5%), and in 15 digits with anastomosis of two arteries, the success rate was 86.66% (P = 0.1244). The success rate in those cases in which vascular grafts were employed was 62.96% (P = 0.4161). In replantations with one, two or three veins anastomosed, the survival rate was 50%, 79.16% and 100%, respectively (P = 0.1324).

Treatment of congenital pseudarthrosis of the tibia by microsurgical fibula transfer

Conventional methods for the treatment of congenital pseudarthrosis of the tibia (CPT) often lead to unsatisfactory results and so microsurgical fibula transfer (MFT) has appeared as an option to treat this challenging problem. In this series of 27 patients with CPT, we obtained satisfactory results in 23 as assessed by the timing of bone union and bone hypertrophy of the fibular transplant. The overall functional results were also good; in 18 patients, the residual shortening was less than 2 cm (with no limb shortening in 4) and in 7, shortening ranged between 2 and 4 cm. All 25 patients resumed normal walking without the help of braces after an average of 12 months. This report suggests that microvascular fibula transfers provide superior results in the treatment of CPT, especially when considering that many of such cases represented previous surgical failures.

Free flap reconstruction of tumors involving the cranial base

The authors describe their experience in treating 24 patients who underwent resection of tumors involving anterior, middle or posterior cranial fossa with immediate reconstruction. All were reconstructed with free flaps, 15 rectus abdominis, 4 radial forearm, 3 latissimus dorsi, 2 great omentum, and one scapular flap. There was one latissimus dorsi flap loss due to arterial thrombosis in a heavily irradiated patient. Three patients presented with a temporary cerebrospinal fluid leak, one of them with meningitis which resolved after intravenous antibiotics and continuous lumbar drainage. Fifteen patients were followed (mean 2 years). Five died of recurrence. Four presented local recurrence. Six patients are alive with no signs of recurrence. Free flaps, especially the rectus abdominis flap and the latissimus dorsi, are versatile flaps and may be easily positioned to cover several structures or anatomical surfaces.

Reconstruction of the foot with microvascular free flaps

Reconstruction of the foot using microvascular flaps has been widely performed in the last 15 years but the choice of flap to repair some areas in the foot remains controversial. We present a series of 128 free flaps to the foot performed during the period of 1975-1990. One hundred and seventeen had a successful outcome (91%). The etiology of the problem was traumatic in 94, congenital in 10, tumor in 9, and chronic ulcerations due to vascular problems in 15. The indications for a specific flap depended on the site and extension of the foot problem, and were divided into four groups: 1. Dorsum of the foot. Cutaneous parascapular flap was the best choice. 2. The sole-weight-bearing area. We favored the use of the latissimus dorsi muscle flap covered with a split thickness skin graft, done immediately. A proper tailoring of the flap and postoperative care by the patient are very important to maintain the result without ulceration. Tactile sensation does not seem to be essential. 3. The area over the calcaneus tendon. We have used cutaneous flaps such as the parascapular and lateral arm flap or fascial flaps covered by split thickness skin grafts (STSG). The fascia used were the serratus or the parascapular. 4. Complex trauma problems with extensive skin loss or chronic ulcerations due to vascular diseases: the latissimus dorsi musculocutaneous or muscle plus STSG was mostly used. The overall number of donor areas were 5 groins, 48 parascapular, 2 gluteal fold flaps, 4 lateral arm, 61 latissimus dorsi, and 8 fascial flaps.

Results of reconstruction of the facial nerve

The results of surgical treatment for facial paralysis are still difficult to compare as there is no universal scoring method. The purpose of this communication is to review the results of reconstruction of the extratemporal facial nerve with nerve grafts using our own evaluation system. Fifty-nine patients were operated on during the period 1981-1991. They had lacerations or other trauma to the face which resulted in loss of continuity of the facial nerve or branches. Three groups were considered: (a) 12 patients had injuries involving the trunk and extending up to the main branches of the facial nerve; (b) 32 patients had parotid laceration or contusion on the parotid area with resulting nerve defects extending from a main branch up to distal branches; and (c) 15 patients had injuries on the distal branches: frontal, zygomatic, or mandibular. The sural nerve was used as the graft in all instances. The grafting procedure was performed from three weeks to six months after the trauma. The method of evaluation compares the normal with the paralyzed side. A score is given of 0 (no motion), 1 (weak motion), or 2 (strong motion), for each of six voluntary contractions: forehead, closure of eyelids and lips, traction, elevation, and depression of the lips. The assessment of involuntary mimic actions was done while observing blinking, speaking, smiling, and laughing. Mass movements were scored negatively. The numbers were recorded and the ratio between the paralyzed and normal side gave an estimate of the lack of symmetry.(ABSTRACT TRUNCATED AT 250 WORDS)

[A program of adult health promotion by health care workers]

The purpose of this work is to evaluate an alternative methodology of education in adult health care undertaken with health care workers. The evaluation was made by the directional question: what did the Adult Health Course mean to you? The analysis consisted of detecting in the responses, the affirmatives that were respective and grouping them in seven categories: 01. Learning new things. 02. Learning to orient people who goes to the basic Health Unit. 03. Interaction with colleagues. 04. Feeling professionally appraned. 05. Worrisome with sons. 06. Improving way of life. 07. Suggestions. The results refers to the presuppositions presented in the introduction of the article, as well as, with the Epidemiologic Model proposed by BLUM.

Vascularized fibular graft for management of severe osteomyelitis of the upper extremity

The authors analyzed 14 patients with severe osteomyelitis of the upper extremity between 1985 and 1992, managed with the vascularized fibular graft. Eleven radii, two humeri and one ulna were reconstructed. Bone loss after resection ranged from 6 to 12 cm (mean 8.14 cm). Follow-up ranged from 8 months to 7 years and 10 months (mean 3 years and 3 months). The therapeutic applications of the vascularized fibular graft in severe bone infections of the upper extremity were discussed and the good results of this surgical procedure established it as a good option for treatment. Morbidity at the donor site was minimal.

Reconstruction of oropharyngeal defects utilizing a free radial forearm flap

The authors report their experience with free radial forearm flaps for oropharyngeal reconstruction. Fifteen patients who submitted to intraoral reconstruction with this flap were followed for periods ranging from 3 to 36 months, with a mean of 14 months. Ages ranged from 15 to 58 years with a mean of 41. The defects were secondary to tumor ablation (11 patients), complications of conventional treatment for congenital deformities (3 patients) and trauma resulting from a gunshot wound to the upper lip and palate (1 patient). Total necrosis of 1 flap occurred and 1 patient required reoperation on the first postoperative day for revision of the anastomoses. Our results enable us to recommend the radial forearm flap as the flap of choice for reconstruction of extensive oropharyngeal defects.

Extraplexual neurotization of brachial plexus

The authors reviewed 62 neurotizations of the brachial plexus in 71 patients performed between 1974 and 1989. The nerves used were the accessory, the motor or sensory branches of the cervical plexus, and the intercostals. Twenty-five suprascapular nerves, 19 musculocutaneous, 4 medial roots of the median nerve, and 12 lateral roots of the median nerve were neurotized. The authors concluded that useful results can be achieved using extraplexual neurotizations.

[Relationship between volume reduction of the left ventricle and the increase of mitral valve prolapse. An experimental study in dogs]

PURPOSE

To verify whether accentuated reductions of left ventricular volume lead to mitral valve prolapse.

METHODS

Seven mongrel dogs were bled through the internal jugular vein, the systolic systemic pressure being kept between 100 and 140 mmHg by means of continuous infusion of dopamine; the inferior vena cava vein, in tree other dogs, was partially obstructed for 4 to 6 seconds; epicardial echocardiography was carried out in all cases.

RESULTS

Reductions of volemia were about 50% of the estimated total blood volume. Systolic internal diameter of left ventricle decreased about 25% and systolic ostial diameter, about 12.5%. Three out of seven died suddenly from arrhythmia before one has reached a significant decrease in total blood volume; one showed momentary mitral valve prolapse, during a period of hypotension; however, this prolapse disappeared completely when systemic blood pressure was restored by increasing the dopamine dosage; one dog had slight systolic displacement of the anterior cusp toward left atrium (0.5mm) and the last two showed no change; one out of 3 dogs submitted to partial constriction of inferior vena cava had systolic displacement of anterior cusp of 1mm; in one case there was an equivalent degree of displacement of the anterior cusp toward the left ventricle and in the last one no change was detected. In all dogs there was a change in the dynamics of mitral valve closure: with accentuated reduction of left ventricular volume the posterior cusp became less mobile, the anterior cusp being the principal responsible for the systolic ostial occlusion.

CONCLUSION

Accentuated reduction of dog's left ventricular volume does not, necessarily, cause mitral valve prolapse but only slight displacement of the anterior cusp toward the left atrium in some animals or no displacement at all.

Calcium regulation of neural fold formation: visualization of the actin cytoskeleton in living chick embryos

The involvement of calcium ions during chick neurulation was studied by treating neural plate stage embryos with agonists and antagonists of calcium transport and with inhibitors of calmodulin activity. Organotypic shape changes were examined by light and scanning electron microscopy. Changes in size of cell apices were quantitated by computer image analysis of actin filaments labeled with fluorescent phallicidin in time lapse recordings of living embryos. Both ionomycin and A23187 caused precocious fold elevation around the median hinge point and convergence by bending at the lateral furrows only when Ca2+ was in the external medium. As judged by decreased perimeters of 100 fluorescent apical polygons, cell apices constricted medial to the lateral furrows but did not change significantly within the median hinge point. Pretreatment with dihydrocytochalasin B or cytochalasin D prevented precocious folding and apical constriction. Papaverine and verapamil prevented folding but could be reversed by subsequent ionophore treatment. Calmidazolium and trifluoperazine irreversibly blocked folding. The demonstration in living embryos of constriction of lateral cell apices in a calcium-dependent manner is consistent with a contractile process operating during the formation of neural folds.

[Necropsy study of the mitral valve according to 5 different echocardiographic planes]

PURPOSE

To study, in anatomic specimens, the regions of the mitral valve transected by the parasternal long axis, the apical five chamber, the apical four chamber, the apical two chamber and the left ventricle apical long axis echocardiographic views.

METHODS

15 patients' hearts, after fixation through intra-ventricular injection of formalin, were cut according to the five above referred echocardiographic views.

RESULTS

Only the apical five chamber view studied adequately the most anterior regions of both mitral cusps. The apical four chamber and the parasternal long axis views examine the most posterior segments of the mitral valve. Heart sections made according to the apical two chamber view are not adequate to study both cusps on a anatomo-pathologic view. The left ventricle apical long axis is the one which better defines the length of both cusps.

CONCLUSIONS

Its necessary to know precisely the regions of the mitral valve sectioned by different longitudinal echocardiographic views in order to visualize through that method localized mitral valve prolapse.

[The correction of cryptotia with tissue expanders]

Cryptotia is a congenital abnormality represented by the absence of the retroauricular sulcus in its superior portion. As the physiopathology of the problem involves the lack of skin tissue in the superior part of the ear sulcus, Mulliken suggested for the first time in 1988, the use of skin expanders as a method to obtain the extra skin necessary to correct this deformity. We bring forward our experience in the use of skin expanders in the treatment of three patients with cryptotia, bilateral in one of them. The technical aspects of the operations as well as the types of expanders used are described in detail. In all cases the correction of the cartilagenous deformities, freeing of the superior pole of the ear and redefinition of the retroauricular sulcus were performed. There were no significant complications. There was no change of the initial good results after a two years follow-up.

[Microsurgical transplants for facial depressions]

From 1877 to 1991, 23 patients, 15 female and eight male, age ranging from eight to 42 years were treated for hemifacial depressions with microvascular transplants. Eight had hemifacial atrophy, four had hemifacial microsomia and one sequelae of hemangioma treatment. Twelve of these patients received paraescapular flaps, five omentum flaps, five great dorsal flaps and one fascial tensor flap. Good result was achieved in 21/23 patients with good symmetry. Two flaps were lost by vascular thrombosis. On of these patients later received a second microvascular flap with good result. Two patients presented late "reabsorption" of the flap after good result in the first year of follow-up. One of them received a second microvascular flap and again the flap lost volume in a long term follow-up. Discussion focuses on this important finding in terms of physiopathology. The results of different kinds of reconstruction are compared and the fact that dermofat flaps achieved best results is emphasized.

[The treatment of residual exophthalmos by resection of the orbital fat]

The possibility of treatment of endocrine exophthalmos by resection of orbital fat has been discussed by Olivari. The orbital fat is located in two spaces: the outer space which surrounds the extraocular muscles the anterior extensions of which form the palpebral bags, and the inner space which surrounds the optic nerve, being crossed by the oculomotor, abducens and trochlear nerves. The surgical anatomy of orbital fat is discussed and the preliminary results of the resection of orbital fat for treatment of the residual exophthalmos are presented.

[The personality and motivational aspects of patients for mastoplasty]

Among the conscious or unconscious reasons that lead a woman to ask for an esthetic procedure are the need to improve his self-appreciation and the desire to receive more love and approval from other people. We have found no article in the Brazilian literature regarding the psychological aspects of patients submitted to mastoplasty. Fifty-three patients awaiting mastoplasty were studied in the period between September 1990 and january 1992 as for their motivation, as well as for characteristics of their personality. The method used included an interview and tests of "Human being figure drawn" and "Crown-Crisp Experimental Index (CCEI)". The results of the interview and the "Human being Figure Drawn" showed that the majority of the patients was young, without children or with only one child. They were determined, self-centered, with some difficulties, related to their sexuality and sociality.

[The civil responsibility of the plastic surgeon in esthetic procedures]

The authors discuss the professional liability of plastic surgeon for the results of esthetic procedures. In their opinion, plastic surgery was artificially divided in reconstructive and esthetic one. Legal decisions have also separated them and the success of results in esthetic procedures have been considered to be obligatory by the courts. The authors believe that in all cases of plastic surgery including esthetic operations the surgeon should use the adequate ways to achieve the best possible results that represent the average for the cultural and ethnic group in question.

[Immediate breast reconstruction with the use of a microsurgical flap of the rectus abdominis muscle]

Breast cancer in advanced stages is a condition still frequently diagnosed in the female patients of this hospital. The surgical treatment proposed tends to be radical and mutilating. The importance of the breast for the female self-image is recognized, as well as the sameness of the prognosis of the disease after breast reconstruction, for which different techniques may be proposed to the patients. Among them is the use of the m. rectus abdominis as musculo-cutaneous free flap. This paper reports our experience in regard to the indication, tactics, results and complications of this technique.

[Toxic shock syndrome after reduction mammaplasty: a case report]

The clinical features of the toxic shock syndrome are well established. It is rapidly developing disease and may be lethal if not recognized and treated in time. Once the syndrome was associated with the use of tampon by menstruating women. Recently this syndrome has been reported as due to Staphylococcus aureus infection. A severe case of toxic shock syndrome in a 18-years-old patient after reduction mammoplasty is reported, and the importance of an early diagnosis is emphasized.

[The use of MPG in preventing the post-reperfusion injury of an epigastric island flap: an experimental study in rats]

The objective of this work was to study the protective effects of the free radical scavenger N2-mercaptopropionylglycine used in a rat model of reperfusion of epigastric island flaps submitted to transient occlusion of their vascular pedicles. In one group the epigastic vein of the flap was occluded for 5 hours. In the second group the epigastric artery was occluded for 21 hours and in the third group both the epigastric vein and artery were occluded for 8 hours. The scavenger or equivalent volume of saline solution was injected 10 minutes before the vascular occlusion and 10 minutes before declamping. The flap viability was assessed on the seventh day after flap reperfusion. In the three types of vascular occlusion a significant, and differential, increase of the areas of flap survival was observed. The protective effect of N2-mercaptopropionylglycine in reperfusion injuries was demonstrated.

[The early correction of the hand deformities in Apert's syndrome. A preliminary report]

The correction of cranial and limb malformations of the Apert's syndrome requires efforts of a multidisciplinary team. The esthetic and functional repercussions that this syndrome brings to their carriers are severe and so the treatment should aim tom improve the function of the hands in order to integrate these patients in a more normal social live. In our Service, in the period from 1989 to 1992 five patients carrying this syndrome had their hand correction completed before the age of three years. It was observed that surgery was possible in this early stage with no additional complication rate. Quadrangular flaps for the neocomissure and for the coverage of the fingers were successfully used even with skeletal deviations. There was improvement of the esthetics of the hands, but their function could not be evaluated properly. Anyway, because of complex abnormalities the results will never be perfect. The early treatment of these alterations allows the gain of a better hand function and moreover accelerates the physical and intellectual development of the children.

Sialic acid as receptor of Bacteroides fragilis lectin-like adhesin

It was observed that sialic acid and macromolecules rich in this sugar were able to inhibit the hemagglutination activity (HA) of Bacteroides fragilis strains in low concentrations. Reversion of the HA and also of the adsorption to beads of Sepharose coupled to bovine submaxillary mucin, by this sugar residue corroborated the recognition capacity of the bacterial lectin-like adhesin. However, when erythrocytes were treated with clostridial neuraminidase, an increase in the HA of some strains was observed. Protease treatment of erythrocytes abolished the HA, indicating that cell receptors of B. fragilis are probably a glycoprotein moiety.

Abdominoplasty combined with other intraabdominal procedures

One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.

Effect of metronidazole on surface properties of Bacteroides fragilis

The effects of subinhibitory concentrations of metronidazole on the general morphology, ultrastructure and charge and hydrophobicity of Bacteroides fragilis were investigated using transmission and scanning electron microscopy, and measurements of zeta-potentials and contact angles. Metronidazole treatment induced morphological alterations in B. fragilis. Cells became filamentous and showed a significant loss of cytoplasm. The surface anionogenicity and hydrophobicity of B. fragilis were enhanced by the drug treatment. Metronidazole, by modifying B. fragilis surface properties, could alter, indirectly, interactions with host cells.

[Necropsy study of the mitral valve transected according to five echocardiographic planes]

PURPOSE

To study, in anatomic specimens, the regions of the mitral valve transected by the parasternal long axis, the apical 5 chamber, the apical 4 chamber, the apical 2 chamber and the left ventricle apical long axis echocardiographic views.

METHODS

15 patients' hearts, after fixation through intra-ventricular injection of formalin, were cut according to the five above referred echocardiographic views.

RESULTS

Only the apical 5 chamber view studied adequately the most anterior regions of both mitral cusps. The apical 4 chamber and the parasternal long axis views examine the most posterior segments of the mitral valve. Heart sections made according to the apical 2 chamber view are not adequate to study both cusps on a anatomo-pathologic view. The left ventricle apical long axis is the one which better defines the length of both cusps.

CONCLUSION

Its necessary to know precisely the regions of the mitral valve sectioned by different longitudinal echocardiographic views in order to visualize through that method localized mitral valve prolapse.

[Primary retraction in skin grafting]

In ten patients a study of skin grafts and of the changes that occurred in the donor area was carried out: the primary retraction of the grafts in relation to their thickness was determined as well as the distension of the donor area of the graft after the excision of the same and comparison of it's thickness with that of the residual skin. The average thickness of the grafts was 318.0 micra, which corresponded to 20% of the donor skin. The primary retraction was 17.6%. The mean thickness of the residual skin at the donor area was 1,287.0 micra or 85.2% of the mean thickness of the reticular derma: the distension of the donor skin area after the removal of the graft corresponded to 2.1% of the original size.

[Free flaps for large reconstructions following tumoral resections in the head and neck]

The treatment of 21 patients who had cranio-facial reconstructions for extensive malignancies is reviewed. Microsurgical flaps obtained from latissimus dorsi, rectus abdominis, greater omentum and para-scapular regions were used. Good results were obtained in 86% of cases. Three flaps were lost in this series due to thrombosis of the microvascular anastomoses. Donor site morbidity occurred in only one case in which a dehiscence required a re-suture.

[Association of congenital upper and lower double lip]

The frequency of the congenital double lip is scarcely mentioned in the literature. There is no previous report on the bilabial congenital double lip. This association consists of a mucosae fold at the free edge of the lip, which is projected at smiling and opening of the mouth. Histologically, the mucous salivary glands are either hypertrophic or normal with little connective tissue and covered by a cornified epithelium. There is no muscle tissue found. We present the report of two cases of bilabial congenital double lip treated surgically by the elliptical resection of the mucosae folds.