An easy method for preparation of postage stamp autografts

A modified technique of postage stamp autografting is studied. By using quick cutting plates, chessboard tray, skiing technique and petrolatum gauze, skin islands can be uniformly located and correctly oriented on the gauze. Moving the skin squares on the stainless steel tray is relatively easy, and the expansion ratio can be predicted by means of the chessboard diagram. The skin island grafts adhere to the petrolatum gauze when the gauze is applied to the tray. Then, as in the modified Meek technique, the "autografting carrier" can be used to cover the burn wound. In comparison with the modified Meek technique, this method does not require expensive equipment. The quick cutting plates can take over the function of the modified Meek-Wall dermatome. The stainless steel trays and the petrolatum gauze are easily available. The advantages of this method include: (1) the expansion ratio can reach up to 1:9, (2) the preparation procedures are not time consuming, (3) regular distribution of these skin islands shortens the healing time, and (4) the cost of this method is relative low. The results of this technique are comparable to that of the modified Meek technique. This preliminary study reveals that this technique is an easy and economic alternative for the treatment of extensive burn patients.

Extensor digitorum brevis rotational muscle flap for lower leg and ankle coverage

BACKGROUND

Soft tissue reconstruction around the ankle has been a challenging problem. This article reports our experience using the extensor digitorum brevis muscle flap; some technical variations are discussed.

METHODS

The extensor digitorum brevis muscle flap is vascularized by the well-defined lateral tarsal artery, a branch of the dorsalis pedis artery originating at the level of the inferior extensor retinaculum. This flap was used for coverage of soft tissue defects in the lower leg and the ankle in 10 patients with various injuries.

RESULTS

All flaps survived completely. Complications included delayed healing of donor skin in two cases. Flap elevation was possible even in the traumatized donor foot.

CONCLUSION

The advantages of this flap include constant and reliable blood supply, easy and rapid flap dissection, adequate bulk, and one-stage procedure. However, disadvantages include the small size of the flap and the sacrifice of the dorsalis pedis artery.

Genome scan identifies a locus affecting gamma-globin level in human beta-cluster YAC transgenic mice

Genetic factors affecting postnatal gamma-globin expression--a major modifier of the severity of both beta-thalassemia and sickle cell anemia--have been difficult to study. This is especially so in mice, an organism lacking a globin gene with an expression pattern equivalent to that of human gamma-globin. To model the human beta-cluster in mice, with the goal of screening for loci affecting human gamma-globin expression in vivo, we introduced a human beta-globin cluster YAC transgene into the genome of FVB/N mice. The beta-cluster contained a Greek hereditary persistence of fetal hemoglobin (HPFH) gamma allele, resulting in postnatal expression of human gamma-globin in transgenic mice. The level of human gamma-globin for various F1 hybrids derived from crosses between the FVB/N transgenics and other inbred mouse strains was assessed. The gamma-globin level of the (C3HeB/FeJ x FVB/N)F1 transgenic mice was noted to be significantly elevated. To map genes affecting postnatal y-globin expression, we performed a 20-centiMorgan (cM) genome scan of a (C3HeB/FeJ x FVB/N)F1 transgenics x FVB/N backcross, followed by high-resolution marker analysis of promising loci. From this analysis we mapped a locus within an 18-cM interval of mouse Chromosome (Chr) 1 (LOD = 4.3) that contributes 10.9% of variation in gamma-globin level. Combining transgenic modeling of the human beta-globin gene cluster with quantitative trait analysis, we have identified and mapped a murine locus that impacts on human gamma-globin level in vivo.

Differential expression of protein kinases in cultured primary neurons derived from the cerebral cortex, hippocampus, and sympathetic ganglia

Protein kinases play pivotal roles in the development of the nervous system. They are involved in almost every stage of neuronal development, from initial proliferation and differentiation of progenitor cells to pathfinding of neurites and formation of synapses. Activation of protein kinases is also critical for neuronal cell survival. To gain further insights into kinases in neural development, we studied the expression patterns of protein kinases in three cultured primary neurons by degenerate primer-based reverse transcription-polymerase chain reaction (PCR) and DNA sequencing, taking advantage of all known kinases containing a conserved catalytic domain. Our data demonstrated that the expression patterns of kinases in various cultured neurons are not only different from those of non-neural tissues, but also distinct among neurons derived from discrete origins. For example, FGF receptor 1 is predominantly expressed in hippocampal neurons. As this approach may be biased during PCR and cloning steps, an RNase protection assay was employed to verify the expression levels of six kinases in cultured neurons. Results from the RNase protection assay did generally confirm those obtained by the PCR-based method. However, quantitative nature of the latter was dependent on numbers of clones analyzed, and discrepancy of expression levels of kinases detected by the two methods was sometimes observed.

Continuous intra-arterial infusion therapy in hydrofluoric acid burns

To determine the effect of continuous intra-arterial calcium gluconate infusion therapy on patients suffering from hydrofluoric acid dermal burns of the digits, clinical treatment was performed prospectively on 10 patients from January 1997 to December 1998 at the burn care unit of Kaohsiung Medical University Hospital. An arterial catheter was inserted transcutaneously through the radial artery of the involved hand. After confirmation of the proper position of the catheter, calcium gluconate was infused continuously with an ambulatory infusion pump. Rapid pain relief was achieved immediately after infusion. The rate of infusion was then tapered down gradually, and treatment was completed with no major therapeutic complication. All injured digits of these 10 patients were successfully salvaged with good cosmetic appearance and complete functional preservation. Compared with other conventional therapies, continuous intra-arterial calcium gluconate infusion therapy proved to be a safe, rapid, simple, portable, and effective method for treating hydrofluoric acid dermal burns.

Endoscope-assisted parotidectomy for benign parotid tumors

Sixteen cases of parotidectomy of benign tumors were performed by means of a short incision with the assistance of endoscopic surgery. The average length of the preauricular and retromandibular incision was 6.9 cm (range, 6.0-8.1 cm). This incision provided safe dissection of the facial nerve trunk and exposed a major part of the gland to direct vision. Identification and separation of the facial nerve branches in peripheral glandular tissue was performed by means of endoscopic surgery instead of wide exposure with a long incision. Because endoscopic surgery provided good illumination and magnification on the monitor, the operation could proceed clearly and sharply in a bloodless field. Therefore, the incidence of facial nerve injury and perioperative morbidity was minimized. In this series, tumors were removed completely, without injury to the facial nerve. Patients were also satisfied with the short and inconspicuous postoperative scars.

Correlation of intellectual impairment in Parkinson's disease with FDG PET scan

This study investigated the relationship between regional glucose metabolism with intellectual impairment in patients with Parkinson's disease using statistical parametric mapping. Regional cerebral glucose metabolism using [18F]deoxyglucose (FDG) PET scans were performed on 10 patients with Parkinson's disease. We used the intellectual impairment score from the UPDRS. PET scans were analyzed with SPM96. Patients showed significant positive correlations with left limbic structures such as the cingulate gyrus, parahippocampal gyrus, and medial frontal gyrus. Patients showed significant negative correlations with associative neocortical posterior structures such as bilateral parietal and occipital gyrus. There were significant relationships between regional glucose metabolism and intellectual impairment.

Aesthetic analysis of the ideal female leg

The aesthetics of the attractive leg are dependent on three principle factors: length, circumference, and shape. Advances in surgical techniques and instrumentation have the ability to predict an aesthetic result in contouring the leg. However, because of patient variability and differing opinions of the surgeon, the leg aesthetics criteria and thus surgical goals have not been clearly defined. We performed an evaluation of Taiwan Chinese female leg aesthetics by using two study groups. Popular fashion models were evaluated and compared with our attractive female population. We noticed subjectively that there are similar leg shapes in both groups. Criteria that contribute to the aesthetics of the attractive legs can be used as guides for doctors and patients to achieve a more aesthetic and predictable leg contour.

Correction of scar contracture deformities of the big toe with a multiplanar distraction device

A multiplanar distraction device was used in a 65-year-old woman for correction of multiplanar deformities of her right big toe. These deformities were caused by long-standing scar contracture after a crushing injury to the right foot. Without the necessity of other complicated procedures, the dorsal contracture and lateral deviation were corrected from 43 deg to 0 deg and from 22 deg to 0 deg respectively 3 weeks postoperatively. Kirschner wires were inserted temporarily for prevention of recurrence after removal of the frame, and were removed 6 weeks later. In follow-up after 8 months, the position of the big toe was stable and without recurrence of contracture. Application of the multiplanar distraction device simplified the surgical procedure to achieve this correction.

Endoscope-assisted correction of primary varicose veins

The purpose of this study is to evaluate the possibilities and results of application of endoscopic surgery in the operation of primary varicose veins. With good illumination and magnified viewing, the varicosities, incompetent perforating veins, and healthy veins were clearly visualized. The incompetent perforating veins were clipped and divided securely. The varicose veins and tributaries were dissected and removed completely after being clipped and divided. The healthy veins were preserved if possible. Primary varicose veins in 43 limbs of 37 patients were operated. The operation was conducted through one access incision in 31 limbs (72%), two incisions in 11 limbs (25%), and three incisions in 1 limb. The mean number of incisions was 1.3 in each limb. Hematoma formation occurred in 1 patient due to the slipping of one clip on the third postoperative day. The other patients had uneventful postoperative courses. All 37 patients were reviewed 4 to 30 months postoperatively. Only one limb had recurrent varices at a new site. Ninety-seven percent of limbs (42 of 43) had no recurrence of varicose veins. Seventy-eight percent of patients (29 of 37) were extremely pleased with this operation. Although the other 22% of patients (8 of 37) appreciated this operation, they were not completely satisfied because some preoperative complaints persisted. In this series, the recurrent rate of varicose veins was low (1 in 43 limbs) and postoperative scarring was minimized, in addition to the advantages of endoscopic surgery. These results demonstrate that endoscopic surgery is a worthy alternative procedure for correcting primary varicose veins.

Correction of the epicanthal fold using the VM-plasty

The VM-plasty combines the principles of YV-plasty and multiple Z-plasty. It consists of three V flaps. For correction of the epicanthal fold, both A and B V-flaps were designed on the outer surface and the C V-flap was designed on the inner surface of the fold. The vertical tissue deficiency of the epicanthal fold was reconstructed with the C V-flap which brought additional tissue from the inner surface of the fold. The VM-plasty for epicanthoplasty was used alone in 8 patients, in combination with double eyelid surgery in 51 young patients and in combination with blepharoplasty and double eyelid surgery in 26 patients who had blepharochalasis. Redness of the incisions was a common complaint but this settled within 2-3 months postoperatively. The zigzag incisions of the VM-plasty were blended with the anatomic lines.

The use of composite acellular allodermis-ultrathin autograft on joint area in major burn patients--one year follow-up

Scar contracture is a major long-term sequelae of meshed split-thickness skin grafts in the case of full-thickness burn injuries, and especially in joint areas. Severe contracture around joints may lead to loss of mobility. The thickness of the dermis in the autograft plays a major role in the functional and cosmetic outcomes of the third degree burn. How to replace lost dermis is a major problem in skin restoration following severe burns. The human allograft skin (AlloDerm) is an acellular dermal matrix with normal collagen bundling organization and intact basement membrane complex. We present 12 cases of clinical application of a composite grafting technique in which the allogeneic skin (AlloDerm) provided source of dermis, and an ultrathin autograft (0.004-0.006 inch in thickness) provided epidermis. In these patients, The composite grafts were applied to full-thickness burn wounds over various articular skin surfaces. The average skin graft take rate was 91.5%. These ultrathin autografts allow the donor sites to heal faster. The mean time of donor site reepithelization was 6 days. All patients had a nearly normal range of joint motion (average 95% of normal) after one year's follow up. Wound assessment over time has shown supple skin that has been resistant to trauma and infection. The cosmetic results were judged to be fair to good by surgeons and patients after one year's follow up.

The role of CD8+ cells and CD11a in the rejection-reaction of the allogeneic microskin grafting

By using histological tissue sections and immunohistochemical stains, the rejection-reaction of the allogeneic microskin grafting of rabbit-skin wounds was studied. The results revealed that the rejection started early in the days following transplantation. In the second week following transplantation, severe graft rejection with epithelial destruction was noted. In addition, an increase of CD8+ cells and expression of the adhesion molecule-CD11a-were also noticed and persisted throughout the days following transplantation. These findings suggest that the CD8+ cells and CD11a may play a major role in the rejection of allogeneic skin grafting.

The distally based lateral adipofascial flap

The distally based lateral adipofascial flap can be based either on the lowermost perforator or the anterior perforating branch of the peroneal artery avoiding sacrifice of the main peroneal artery. It has been used successfully to resurface soft tissue defects either on the lateral or medial aspect of the lower third of the leg in 13 cases. The size of these flaps varied from 2.0 cm x 5.0 cm to 4.5 cm x 15.0 cm in size. These cases had minimal donor site morbidity and had positive aesthetic results. The advantages were: 1. Choice of either the lowermost perforator or the anterior perforating branch giving a wide arc of rotation; 2. Preservation of the superficial peroneal nerve; 3. Primary closure of the donor site.

Apolipoprotein(a) yeast artificial chromosome transgenic rabbits. Lipoprotein(a) assembly with human and rabbit apolipoprotein B

The in vivo analysis of lipoprotein(a) (Lp(a)), an independent atherosclerosis risk factor in humans, has been limited in part by its restricted distribution among mammals. Although transgenic mice have been created containing Lp(a), the relatively small size of the mouse has precluded some studies. To examine the properties of this molecule in a significantly larger mammal, we have used a 270-kilobase yeast artificial chromosome clone containing the human apolipoprotein(a) (apo(a)) gene and a 90-kilobase P1 phagemid clone containing the human apolipoprotein B (apoB) gene to create transgenic rabbits that express either or both transgenes. Expression of both transgenes was tissue specific and localized predominantly to the liver. Average apolipoprotein plasma levels in the rabbits were 2.5 mg/dl for apo(a) and 17.6 mg/dl for human apoB. In contrast to observations in apo(a) transgenic mice, we found that apo(a) plasma levels in the rabbits were stable throughout sexual maturity. Also, apo(a) formed a covalent association with the endogenous rabbit apoB albeit with a lower efficiency than its association with human apoB. The analysis of Lp(a) transgenic rabbits has provided new insights into apo(a) expression and Lp(a) assembly. In addition, these transgenic rabbits potentially will provide an improved experimental model for the in vivo analysis of Lp(a) and its role in promoting atherosclerosis and restenosis.

Endoscopically-assisted adipofascial flap harvest for soft tissue defects of the lower leg

Five cases of soft tissue defect of the lower leg were reconstructed successfully with the distally based medial adipofascial flap which was harvested with endoscopically-assisted surgery. The size of these flaps ranged from 4.0 x 7.0 cm to 5.0 x 15.0 cm in size. All the flaps had good perfusion and uneventful course postoperatively. The donor site skin was intact except for an additional access-scar 2.5 cm in length. The donor site morbidity of the adipofascial flap was further minimised in this series.

The reverse lateral arm adipofascial flap for elbow coverage

The reverse lateral arm adipofascial flap covered immediately with a skin graft has been used successfully for reconstruction of a cubital fossa defect (caused by avulsion injury) and an exposed olecranon (resulting from recurrent bursitis) in 2 patients. The flap is nourished by the septal perforators of the posterior radial collateral artery, which in turn obtains its blood supply from the interosseous recurrent artery. The distal vascular pedicle should contain a sufficient amount of subcutaneous fat and its underlying fascia to enhance the arterial input and the venous drainage of the flap. The primary benefit of this technique is that the thickness of the flap can be tailored to fit into the defect, and the donor site can be closed primarily without tension. The advantages include satisfactory cosmetic results, a rapid one-stage procedure, no sacrifice of the main artery or local muscle, and avoidance of any long-term immobilization of the involved elbow joint.

A mixture of allogeneic dermal tissue and autologous microskin grafting of rabbit skin wound

In a rabbit model, transplantation of largely expanded microskin grafts (expansion ratio 25 X) were studied. In Group I, the autologous microskin grafts were transplanted onto the full-thickness skin defect on the back of a rabbit and were overlaid with Biobrane. In Group II, the autologous microskin grafts were mixed with allogeneic microdermal substance (expansion ratio 25 X) before the transplantation. The percentage of re-epithelialized area to the total grafted wound was analyzed by means of computerized planimetric analyses of photographs of the grafted wounds on days 11 and 13. Biopsies of the grafted wounds were done. On day 11, the mean percentage of Group I was 72.4% and that of Group II was 82.7%. On day 13, they were 82.3% in Group I and 92.3% in Group II. In Group II, the allogeneic dermal tissue did not cause obvious rejection in the neoepithelium. Histological features showed the existence of allogeneic dermal tissue in the grafted wound. The adding of largely expanded allogeneic dermal substance to autologous microskin grafts in Group II provided better circumstances than that in Group I for re-epithelialization of autologous mciroskin grafts.

Effect of growth factors on dermal fibroblast contraction in normal skin and hypertrophic scar

We have examined the effects of four 'exogenous' growth factors, i.e. PDGF-BB (5 ng/ml), TGF-beta1 (5 ng/ml), bFGF (10 ng/ml) and EGF (10 ng/ml) on the contraction of floating collagen type I lattices populated by human normal skin (NS) and hypertrophic scar (HS) fibroblasts (FPCL). Only TGF-beta1 enhanced the contractility of both NS and HS fibroblasts in the collagen lattice (P < 0.01). Other growth factors (PDGF-BB, bFGF and EGF) did not affect FPCLs contraction at 72 h (P > 0.05). The onset effect of TGF-beta1 on NS-FPCL contraction was relative early at 24 h after FPCL casting as compared to a 72 h delay on HS-FPCL contraction. Besides, PDGF-BB was found to be able to enhance HS-FPCL contraction (P < 0.05) but not on NS-FPCL contraction on day 4. On the other hand, three enzyme-linked immunosorbent assays (ELISA) were performed to demonstrate quantitatively the 'endogenous' growth factors that fibroblasts secreted into the culture medium 48 h after FPCL casting. No appreciable difference was found between 10 NS and 11 HS samples tested for PDGF-AB immunoassay (11.48 +/- 5.5 pg/ml versus 12.20 +/- 5.34 pg/ml). The same result existed in 7 NS and 13 HS samples for TGF-beta2 immunoassay (15.15 +/- 6.2 pg/ml versus 11.84 +/- 7.46 pg/ml). In bFGF immunoassay study, relative variable data was noted in both 7 NS (18.18 +/- 13.18 pg/ml) and 12 HS samples (20.41 +/- 22.36 pg/ml). In conclusion, we suppose that TGF-beta role in wound healing may be due to the secondary exogenous influences. The endogenous ability of TGF-beta2 secretion (quantity) in HS fibroblasts are the same as NS fibroblasts but with delayed timing responses (quality) to exogenous TGF-beta1 effect in the collagen lattice. Further studies with timing-regulated selective specific monoclonal antibodies against the growth factor receptors may provide the therapeutic applications on HS during wound healing.

Adipofascial flap of the lower leg based on the saphenous artery

The adipofascial flap of the lower leg based on the saphenous artery is a modification of the saphenous artery flap. It has been used successfully in 5 patients for reconstruction of soft tissue defects around the knee and superior third of the tibia. The size of these flaps ranged from 5 x 12 cm to 5 x 18 cm. All flaps survived completely. These cases had minimal donor site morbidity because their donor sites were closed primarily with the preserved overlying skin.

Squamous cell carcinoma of the nail bed

Squamous cell carcinoma of the nail bed is a rare disorder. Metastasis is extremely unusual. A case of primary squamous cell carcinoma of the nail bed with metastasis to the regional lymph nodes is reported. The tumor was successfully treated by amputation of the involved finger, block dissection of the regional lymph nodes, postoperative irradiation of the involved axilla, and systemic chemotherapy. Early diagnosis by biopsy, especially in patients with recurrent and persistent disease of the nail bed, is recommended, so that treatment can be instituted early while the tumor is confined to its primary site.

Early diagnosis of necrotizing fasciitis by utilization of ultrasonography

Necrotizing fasciitis is a rare and rapid progression soft tissue infection. The only identifiable feature is tissue necrosis along a single fascia plane. Because the skin is initially spared, it is difficult for early recognition prior to extensive tissue destruction. Ultrasonography was used for early diagnosis of this infection in five cases. All 5 patients presented with severe cellulitis. Under the suspicion of necrotizing fasciitis, ultrasonography was performed before surgical debridement. Tissue biopsy was done for histological confirmation of the diagnosis. Three patients were proven to have necrotizing fasciitis and two cellulitis only. The ultrasonographic findings of necrotizing fasciitis included: 1) irregularity of the fascia; 2) abnormal fluid collections along the fascia plane; and 3) diffuse thickening of the fascia when compared with the control site in the normal limb. However, in severe infectious cellulitis, the above mentioned findings were not observed. Our results indicate the usefulness of the ultrasonography for early diagnosis of necrotizing fasciitis.