Endoscopic exploration of the orbital floor: a technique for transantral grafting of floor blowout fractures

A cadaveric study was conducted with a twofold purpose--to perform diagnostic transantral endoscopy in pure blowout fractures of the orbital floor and to attempt restoration of bony defects in the orbital floor using the endoscope. Endoscopic visual access of the orbital floor allows precise determination of the fracture size and the presence and extent of entrapped periorbital fasciae. A bony defect was created surgically in the orbital floor of 6 fresh cadaver heads, and a split-thickness calvarial bone graft and an alloplast were used to repair the orbital floor. Grafting of the orbital floor with endoscopic visual access was successful, and the potential risks associated with the traditional eyelid incisions were minimized. The anatomic course of the infraorbital nerve was observed and protected. The study confirmed that endoscopy could be used successfully in obtaining visual access to the orbital floor.

Hereditary neuropathy with liability to pressure palsies is not a major cause of idiopathic carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a debilitating neuropathy affecting millions of individuals. Although there are published reports of familial associations of carpal tunnel syndrome, the molecular mechanisms are unknown.

OBJECTIVE

To determine the prevalence and potential role of the chromosome 17 microdeletion associated with hereditary neuropathy with liability to pressure palsies in patients diagnosed as having carpal tunnel syndrome.

DESIGN

Prospective study.

PATIENTS AND METHODS

Since hereditary neuropathy with liability to pressure palsies may present as carpal tunnel syndrome, we evaluated 50 patients with idiopathic carpal tunnel syndrome for hereditary neuropathy with liability to pressure palsies.

RESULTS

No hereditary neuropathy with liability to pressure palsies deletions were detected.

CONCLUSION

Molecular genetic testing for hereditary neuropathy with liability to pressure palsies in patients with idiopathic carpal tunnel syndrome is of limited value.

Enhancement of neointima formation with tissue-type plasminogen activator

PURPOSE

Indirect evidence suggests that tissue plasminogen activator (tPA) either limits or does not alter restenosis. However, tPA enhances tumor invasiveness through matrix remodeling, and several elements of degraded matrix enhance smooth muscle cell mitogenesis. We use either local adenoviral-mediated overexpression of tPA or systemic infusion of recombinant tPA combined with mechanical overdilation of rabbit common femoral arteries to evaluate the impact of tPA on neointima formation.

METHODS

Left common femoral arteries of New Zealand white rabbits were transfected in situ either with an adenoviral-construct-expressing tPA or a viral control (adenoviral-construct-expressing beta-galactosidase) or nonviral (buffer) control after balloon angioplasty injury. At 7 and 28 days, left common femoral artery segments were harvested (n = 4 for each group and time point). Vessel segments were examined for intimato-media ratio, smooth muscle cell proliferation, extracellular matrix, and inflammatory response. Thrombus formation was evaluated after 3 days (n = 3 for each group). In a second experiment, New Zealand white rabbits (n = 3 per group, per time point) underwent mechanical dilation followed by buffer treatment or systemic tPA infusion according to a widely clinically used accelerated infusion protocol. Treated artery segments were harvested after 7 or 28 days and processed for intima-to-media ratio determination and class-wide histochemical determination of collagenous extracellular matrix and collagen content.

RESULTS

Both rate and degree of neointima formation increase dramatically with overexpression (250%-461% relative to controls at 7 and 28 days). Substantial early matrix degradation is observed in vessels treated with local overexpression of tPA, although no increases in local inflammation or in smooth muscle proliferation occur. Late enhancement of smooth muscle proliferation emerges, consistent with secondary impact of perturbed matrix components. Systemic infusion of tPA according to clinical protocols also results in early and late enhancement of neointima formation in this model (34%-52% relative to controls at at 7 and 28 days), with significant early collagenous matrix degradation. Systemic infusion, although significant, did not attain the degree of neointima formation present with overexpression.

CONCLUSION

With some evidence of dose-dependence, tissue plasminogen activator enhances neointima formation after angioplasty in a rabbit model. Early matrix degradation precedes change in rates of proliferation and underlies this effect in spite of several antirestenotic actions including decreased thrombus and decreased macrophage recruitment in this model.

Thrombomodulin overexpression to limit neointima formation

BACKGROUND-These studies were initiated to confirm that high-level thrombomodulin overexpression is sufficient to limit neointima formation after mechanical overdilation injury. METHODS AND RESULTS-An adenoviral construct expressing thrombomodulin (Adv/RSV-THM) was created and functionally characterized in vitro and in vivo. The impact of local overexpression of thrombomodulin on neointima formation 28 days after mechanical overdilation injury was evaluated. New Zealand White rabbit common femoral arteries were treated with buffer, viral control, or Adv/RSV-THM and subjected to mechanical overdilation injury. The treated vessels (n=4 per treatment) were harvested after 28 days and evaluated to determine intima-to-media (I/M) ratios. Additional experiments were performed to determine early (7-day) changes in extracellular elastin and collagen content; local macrophage, T-cell, and neutrophil infiltration; and local thrombus formation as potential contributors to the observed impact on 28-day neointima formation. The construct significantly decreased neointima formation after mechanical dilation injury in this model. By histological analysis, buffer controls exhibited mean I/M ratios of 0.76+/-0.06%, whereas viral controls reached 0.77+/-0.08%; in contrast, Adv/RSV-THM reduced I/M ratios to 0.47+/-0.06%. Local inflammatory infiltrate decreased in the Adv/RSV-THM group relative to controls, whereas matrix remained relatively preserved. Rates of early thrombus formation also decreased in Adv/RSV-THM animals. CONCLUSIONS-This construct thus offers a viable technique for promoting a locally neointima-resistant small-caliber artery via decreased thrombus bulk, normal matrix preservation, and decreased local inflammation without the inflammatory damage that has limited many other adenoviral applications.

Increased free fat-graft survival with the long-term, local delivery of insulin, insulin-like growth factor-I, and basic fibroblast growth factor by PLGA/PEG microspheres

The present investigation evaluates the effects of long-term, local delivery of insulin, insulin-like growth factor-1 (IGF-1), and basic fibroblast growth factor (bFGF) on fat-graft survival using a poly (lactic-co-glycolic-acid)-polyethylene glycol (PLGA/PEG) microsphere delivery system. Twelve-micrometer PLGA/PEG microspheres incorporated separately with insulin, IGF-1, and bFGF were manufactured using a double-emulsion solvent-extraction technique. Inguinal fat from Sprague Dawley rats was harvested, diced, washed, and mixed with (1) insulin microspheres, (2) insulin-like growth factor-1 microspheres, (3) basic fibroblast growth factor microspheres, (4) a combination of the insulin and IGF-1 microspheres, and (5) a combination of insulin, IGF-1, and bFGF microspheres. The treated fat grafts were implanted autologously into subdermal pockets in six animals for each group. Animals receiving untreated fat grafts and fat grafts treated with blank microspheres constituted two external control groups (six animals per external control group). At 12 weeks, all fat-graft groups were compared on the basis of weight maintenance and a histomorphometric analysis of adipocyte area percentage, indices of volume retention and cell composition, respectively. Weight maintenance was defined as the final graft weight as a percent of the implanted graft weight. All growth factor treatments significantly increased fat-graft weight maintenance objectively, and volume maintenance grossly, in comparison with the untreated and blank microsphere-treated controls. Treatment with insulin and IGF-1, alone or in combination, was found to increase the adipocyte area percentage in comparison with fat grafts treated with bFGF alone or in combination with other growth factors. In conclusion, the findings of this study indicate that long-term, local delivery of growth factors with PLGA/PEG microspheres has the potential to increase fat-graft survival rates. Further, the type of growth factor delivered may influence the cellular/stromal composition of the grafted tissue.

De novo adipose tissue generation through long-term, local delivery of insulin and insulin-like growth factor-1 by PLGA/PEG microspheres in an in vivo rat model: a novel concept and capability

This study was undertaken to characterize the duration of long-term growth factor delivery by poly(lactic-co-glycolic-acid)-polyethylene glycol (PLGA/PEG) microspheres and to evaluate the potential of long-term delivery of insulin and insulin-like growth factor-1 (IGF-1) for the de novo generation of adipose tissue in vivo. PLGA/PEG microspheres containing insulin and IGF-1, separately, were produced by a double-emulsion solvent-extraction technique. In the first phase of the experiment, the in vitro release kinetics of the microspheres were evaluated for the optical density and polyacrylamide gel electrophoresis of solutions incubated with insulin-containing microspheres for four different periods of time (n = 1). The finding of increased concentrations of soluble insulin with increased incubation time confirmed continual protein release. In the second stage of the experiment, 16 rats were divided equally into four study groups (insulin, IGF-1, insulin + IGF-1, and blank microspheres) (n = 4). Insulin and IGF-1 containing microspheres were administered directly to the deep muscular fascia of the rat abdominal wall to evaluate the potential for de novo adipose tissue generation via adipogenic differentiation from native nonadipocyte cell pools in vivo. Animals treated with blank microspheres served as an external control group. At the 4-week harvest period, multiple ectopic islands of adipose tissue were observed on the abdominal wall of the animals treated with insulin, IGF-1, and insulin + IGF-1 microspheres. Such islands were not seen in the blank microsphere group. Hematoxylin and eosin-stained sections of the growth factor groups demonstrated mature adipocytes interspersed with fibrous tissue superficial to the abdominal wall musculature and continuous with the fascia. Oil-Red-O stained sections demonstrated that these cells contained lipid. Computer-aided image analysis of histologic sections confirmed that there were statistically significant increases in the amount of "ectopic" adipose neotissue developed on the abdominal wall of animals treated with growth factor microspheres. In conclusion, this study confirms the long-term release of proteins from PLGA/PEG microspheres up to 4 weeks and demonstrates the potential of long-term local insulin and IGF-1 to induce adipogenic differentiation to mature lipid-containing adipocytes from nonadipocyte cell pools in vivo at 4 weeks.

Superficial ulnar artery: embryology, case report, and clinical significance in reconstructive microsurgery

In this paper the authors describe and illustrate a rare anatomic variation of the ulnar artery, a superficial ulnar artery. The possible embryologic events responsible for this variation are discussed. In addition, they describe the surgical considerations that should be kept in mind when this abnormality is encountered in the clinical setting of free-tissue transfer and vascularized nerve grafting.

Gene therapy to promote thromboresistance: local overexpression of tissue plasminogen activator to prevent arterial thrombosis in an in vivo rabbit model

Tissue-type plasminogen activator (tPA) catalyzes the rate-limiting initial step in the fibrinolytic cascade. Systemic infusion of tPA has become the standard of care for acute myocardial infarction. However, even the relatively short-duration protocols currently employed have encountered significant hemorrhagic complications, as well as complications from rebound thrombosis. Gene therapy offers a method of local high-level tPA expression over a prolonged time period to avoid both systemic hemorrhage and local rebound thrombosis. To examine the impact of local tPA overexpression, an adenoviral vector expressing tPA was created. The construct was characterized functionally in vitro, and the function of the vector was confirmed in vivo by delivery to the rabbit common femoral artery. Systemic coagulation parameters were not perturbed at any of the doses examined. The impact of local overexpression of tPA on in vivo thrombus formation was examined subsequently in a stasis/injury model of arterial thrombosis. The construct effectively prevented arterial thrombosis in treated animals, whereas viral and nonviral controls typically developed occluding thrombi. This construct thus offers a viable technique for promoting a locally thromboresistant small-caliber artery.

Local overexpression of thrombomodulin for in vivo prevention of arterial thrombosis in a rabbit model

-Endothelial thrombomodulin plays a critical role in hemostasis by binding thrombin and subsequently converting protein C to its active form, a powerful anticoagulant. Thrombomodulin thus represents a central mechanism by which patency is maintained in normal vessels. However, thrombomodulin expression decreases in perturbed endothelial cells, predisposing to thrombotic occlusion. An adenoviral construct expressing thrombomodulin (Adv/RSV-THM) was created and functionally characterized in vitro and in vivo. The impact of local overexpression of thrombomodulin on in vivo thrombus formation was subsequently examined in a stasis/injury model of arterial thrombosis. The construct prevented arterial thrombosis formation in all animals, while viral and nonviral controls typically developed occluding thrombi. By histological analysis, nonviral controls exhibited intravascular thrombus occluding a mean of 70.52+/-3.72% of available lumen, while viral controls reached 86. 85+/-2.82% thrombotic occlusion; in contrast, Adv/RSV-THM reduced thrombosis to 28.61+/-3.31% of lumen in cross section. No significant intima-to-media ratio was observed in the thrombomodulin group relative to controls. Local infiltration of granulocytes and macrophages significantly decreased in the Adv/RSV-THM group relative to controls, while neutrophilic infiltration increased in viral controls relative to nonviral controls. This construct thus offers a viable technique for promoting a locally thromboresistant small-caliber artery, without the inflammatory damage that has limited many other adenoviral applications.

Local gene delivery: arterial thrombosis model for endothelial cell-targeted thrombolytic gene therapy research

The authors describe a rabbit arterial thrombosis model that employs vessel division followed by microsurgical anastomosis and transluminal sutures, to reliably induce thrombus formation in the common femoral artery (CFA). Using two objective measures, "evacuation/refill" evaluation of patency and computer-aided histomorphometric analysis of the thrombus area, thrombus formation was confirmed and characterized in the model at both short- and long-term observation time-points. In addition, a gene delivery method was developed in the CFA that employs an adenoviral vector solution injected through the inferior epigastric artery (IEA). Using this method, a marker transgene (beta-galactosidase) was delivered to endothelial cells locally and without trauma. By subsequently performing beta-galactosidase staining, effective endothelial transfection was demonstrated simultaneously with endothelial viability, with preserved endothelial synthetic function in the immediate environment of the occluding thrombus. The results suggest that these two techniques can be used together in one model, to effectively introduce a foreign therapeutic transgene into endothelial cells and to evaluate the effect of the expressed protein product in a consistent in vivo thrombosis system. This combined model may be used as one of several assays of efficacy in future endothelial cell-targeted thrombolytic/antithrombotic vascular gene therapy research.

Perioperative dilation for vessel-size discrepancy using a percutaneous transluminal angioplasty catheter

The problem of vessel-size discrepancy is still unsolved in microvascular-free tissue transfers. In an effort to develop a technique perioperatively to dilate smaller vessel diameters, the authors utilized a catheter customarily used in coronary angioplasties, the percutaneous transluminal coronary angioplasty (PTCA) catheter. Twenty New Zealand rabbits were divided into two groups: Group 1 consisted of 14 experimental animals; Group 2 of six control animals. In both groups, a segmental defect of 2 cm was created in the proximal portion of the femoral artery just below the inguinal ligament, where the vessel diameter is 2.0+/-0.1 mm. In Group 1 animals, an arterial graft was harvested from the superficial femoral artery in the contralateral lower extremity, where the vessel diameter is 1.0+/-0.1 mm. The arterial graft along its entire length was dilated, using a PTCA catheter up to 2 mm in diameter. The duration of dilation was 3 min with pressure applied at 2.5 atm. Before and following dilation, sections were obtained from both ends of the graft for histologic comparison. The grafts were then interposed within the defect and microvascular anastomoses were performed. In the control group, an arterial graft of the same length as in the experimental group was harvested from the contralateral upper femoral region, where the vessel diameter is 2.0+/-0.1 mm. These grafts were then interposed within the defect and microsurgically anastomosed. Seven days later, the patency of the anastomoses was evaluated in both groups. In 13 of 14 rabbits in the experimental group, the anastomoses were patent and the arterial grafts maintained their dilated diameters (2 mm). In all six control animals, the anastomoses were patent. A statistical comparison of vessel patency using Fischer's exact chi-square test showed no significant differences between the experimental and control groups (p = 0.7). Histologically, the dilated arteries demonstrated intact endothelial layers.

Vascular gene therapy

Gene therapy is an exciting frontier in medicine today. Radiologists will be involved in tracking the effects of these new therapies through imaging. Vascular and interventional radiology techniques also are ideally suited for minimally invasive, readily monitored gene delivery. Gene therapy is accomplished through gene augmentation or gene blocking. The latter is accomplished through antisense oligonucleotides or transcription factor decoys. Vectors are agents that facilitate gene delivery and expression and can be viral or nonviral. The vascular wall is an ideal target for gene therapy because of its central role in many biologic processes and its ready accessibility. Recombinant genes can be delivered ex vivo and in vivo, with the latter approaches involving open surgical, percutaneous injection, and endovascular catheter-based methods. Perforated, hydrogel-coated, and double balloon catheters have been used with varying success. Optimal catheter systems for gene transfer will enable delivery of the vector to the precise anatomic location with transfection limited to the cells of interest and will minimize shedding of the vector to distal sites, systemic effects of the therapeutic agent, and morbidity from the delivery method. Radiologists must become familiar with the basic rationale, strategies, and mechanisms of gene therapy and involved in its clinical trials to ensure an active role in this field.

Brachial plexus birth injuries and current management

OBPP is a condition that, for the majority of patients, resolves spontaneously with appropriate nonoperative treatment. However, those patients who do not improve spontaneously now have a better chance for recovery owing to recent advances in microsurgery and nerve-transfer techniques. The most important aspect of therapy is timely recognition and referral.

A new design of the iliac crest microsurgical free flap without including the "obligatory" muscle cuff

The iliac crest free flap has undergone a gradual evolution to provide more functional and cosmetic oromandibular reconstructions. The soft-tissue cutaneous component has largely resisted refinement and currently constitutes the flap's principal drawback. Conventionally, the cutaneous vessel's soft-tissue encasement and a protective cuff of abdominal muscle are harvested to ensure skin perfusion. These protective measures, however, produce a bulky flap that is tethered to the bone and difficult to inset into complex three-dimensional defects. A series of anatomic and clinical investigations has confirmed that in 30 percent of individuals, the skin island can be elevated on a dominant cutaneous branch from the deep circumflex iliac artery. Harvesting the skin as an axial pattern flap greatly increases its independence from the bone, improving maneuverability. A small collar of abdominal muscle is incised around the pedicle, obviating the need for the customary 2.5-cm protective muscle cuff. Exclusion of the abdominal muscular component reduces the flap's volume, decreases the need for secondary debulking, and reduces the donor site morbidity.

Closure of upper extremity soft-tissue defects using the new "supra-crest" fasciocutaneous free flap

A fasciocutaneous island (15 x 10 cm) can be elevated from the inferolateral abdominal wall in a region encompassing the iliac crest and extending to the lower costal margin. This new fasciocutaneous flap was named the "supra-crest flap," in accordance with its anatomic location and vascular pattern. The blood supply stems from the direct cutaneous branches of the lumbar arteries (L2-3), which pierce the abdominal musculature approximately 2.0 cm above the iliac crest in the midaxillary line. The arteries and two vena comitantes have an average external diameter of 2.0 mm, and their dissection can be extended deep into the iliac fosa to provide a pedicle 8 or more cm in length. Two cutaneous nerves accompany the lumbar arteries, furnishing the possibility of a sensate flap. These structures have been transferred as a free flap with the donor site concealed by conventional underwear and bathing suits. Additionally, this region could be harvested as an island flap wherein the arc of rotation may be sufficient to cover defects of the thoracic wall and lumbosacral regions.

A comparative study of gut suture, human amnion collagen, bovine skin collagen and Vicryl suture implants in rats

This study compares the persistence and histological characteristics of gut suture with those of human amnion collagen, bovine collagen, and Vicryl suture implants in rats. Gut suture and human amnion collagen more resembled living tissue than did bovine collagen and were characterized by their cellularity and the presence of numerous capillaries. The Vicryl suture implants were quickly absorbed. Picrosirius polarization revealed the synthesis of host collagen by rat fibroblasts which immigrated into the gut suture and human amnion collagen implants. The authors suggest the potential of gut suture as a soft tissue substitute to improve linear skin contour deficits.

Soft-tissue reconstruction following extravasation of chemotherapeutic agents

The incidence of chemotherapeutic extravasation injuries ranges from 0.5% to 6%. Chronicity and an indolent course are prominent characteristics of such wounds, as are severe pain and ulceration with no tendency to spontaneous healing. Prevention is the best treatment. Aggressive surgical debridement is recommended for patients with persistent pain or ulceration. Whirlpool therapy, wet-to-dry dressing changes, and a vigorous physical therapy program are all helpful. Soft-tissue coverage can be obtained by skin grafting, delayed flaps, various local muscle or fasciocutaneous flaps, or by free tissue transfer.

The subcutaneous pedicle tensor fascia lata flap

The presence of a consistent subcutaneous vascular plexus allows carrying of a distal skin island safely on the iliotibial tract. A distal skin island can be designed on the lateral thigh and can be raised on a subcutaneous pedicle that is proximally supplied by the lateral femoral circumflex artery. This technique preserves the lateral thigh skin and employs subcutaneous tunneling to overcome the traditional drawbacks of the conventional extended tensor fascia lata flap. The subcutaneous pedicle tensor fascia lata flap's sensate potential, thin skin, durable fascia, extensive reach, and 360 degree arc of rotation make it an appealing donor site for coverage of lower midsection and pelvic defects or for penile reconstruction.

Gene therapy for plastic and reconstructive surgery

In the future, gene therapy will become the standard treatment for enhancing wound healing and nerve and muscle regeneration and for preventing or treating vessel thrombosis, areas critical to the plastic surgeon and the patient. This review has focused on factors that are either currently used in a clinical situation or have the promise of being developed for clinical use. The role of gene therapy applied to these areas will be to locally place therapeutic genes at the site of injury or surgical repair, which will replace the need to systemically administer therapeutic agents that may have toxic effects, and to express factors in low abundance but at effective and safe levels. This strategy is to produce enough agent to have a therapeutic effect. The use of tissue-specific promoters will be beneficial in localizing the production of agents to certain cell types. Gene therapeutic approaches used in plastic surgery may have a significant impact on the health care system by increasing efficiency of treatment and reducing health care costs. The accelerated pace of basic research in gene therapy will result in clinical applications in the near future.

Fingertip and nail bed injuries. Repair techniques for optimum outcome

Most fingertip injuries can be treated in a procedure room, provided proper lighting and equipment are available. Sound judgment and knowledge of fingertip anatomy are essential. Determining the mechanism of injury is important, because it may indicate the degree of contamination, amount of tissue loss, and best treatment. Superficial wounds may be allowed to granulate and contract spontaneously. In children, even amputation may heal by secondary intention, with the fingertip sutured back in place as a biologic dressing. Split- and full-thickness skin grafts may be appropriate, but diminished sensibility limits their usefulness on volar surfaces. Local skin flaps are indicated when the wound bed is unsuitable for grafting or when skin is needed to cover exposed bone or tendon. Direct closure may be used in amputations of 2 to 3 mm. When the nail bed is lacerated, the nail plate must be removed and the wound repaired. Any free segments of nail bed should be sutured in place as a free graft. In children, treatment should be conservative, with emphasis on preservation of digital length.

Prefabricated flaps: experimental and clinical review

Prefabricated flaps are a useful tool for the reconstructive surgeon and present a number of advantages: 1. Specific preferred tissue composites, regardless of their native vascular origin, can be transferred as free or pedicled flaps. 2. Larger flaps of specialized tissue may be transferred safely. 3. Donor-site morbidity is reduced. 4. The functional outcome for the patients may be more satisfactory. The various methods of flap prefabrication include vascular induction through stage transfer; pretransfer delay, expansion, and grafting; the use of alloplastic materials; and tissue bioengineering. We have reviewed both the experimental and clinical research on flap prefabrication, describing the theory, technique, and advantages of each method.

Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures

Eight years ago, the principal author (Shenaq) began employing high-power ocular loupes for microvascular anastomoses. Subsequently, 251 free-tissue transfers were performed with loupes as the sole means of magnification. Procedures included free flaps, toe-to-hand transfers, and digital replantations, with the external diameter of the vascular pedicles averaging 1.5 mm. Analysis of the series revealed a 97.2 percent overall success rate, a 1.2 percent partial flap necrosis rate, and an 8.3 percent revision rate for anastomoses (during the initial operative procedure), which compare favorably with the success rates frequently cited for microscope-assisted procedures. The most favorable results were achieved with free flaps and toe-to-hand transfers with 98.5 and 96.4 percent success rates, respectively. The 79.2 percent survival rate achieved with digital replantation falls within the range (74.0 to 94.2 percent) reported in the literature. This experience indicates that in practiced hands, high-power ocular loupes provide an alternative to the operating microscope for microvascular anastomosis of vessels 1.0 mm or greater in diameter. Loupe use is advocated on the grounds of cost-effectiveness, portability, and operator freedom.

How to help diabetic patients avoid amputation. Prevention and management of foot ulcers

Foot ulcers are a weighty complication of diabetes whose significance is often underestimated. They are associated with a high degree of morbidity and mortality, and treatment is laborious and costly. The problem of susceptibility to foot ulceration is best addressed through a prevention program emphasizing patient education, pedal hygiene, regular follow-up visits, and lifestyle modification. Such programs are most efficiently administered by a healthcare team. When ulcers do occur, it is important to take a systematic approach to management, stressing infection control, metabolic stabilization, thorough debridement, and meticulous wound care.

Refinements in the iliac crest microsurgical free flap for oromandibular reconstruction

Development of the iliac crest microsurgical free flap has greatly improved the surgical reconstruction of oromandibular defects. A decade of continuous utilization has established its efficacy and versatility. The utility of the flap has been continuously expanded by the introduction of new surgical techniques and adjunctive innovations. The advent of improved internal fixation systems, osteointegration, and neurocutaneous flaps has facilitated a more comprehensive oromandibular rehabilitation. The introduction of the split inner-cortex modification by the principle author served to refine the bony component and greatly reduces postoperative complications and donor site morbidity.

The iliac crest microsurgical free flap in mandibular reconstruction

Development of the iliac crest microsurgical free flap has significantly enhanced the surgical restoration of the mandible. A decade of heavy clinical use has established the versatility and efficacy of this technique. A recent literature review suggests a 96% success rate has been achieved. This donor site provides a long vascular pedicle, appropriately shaped bone, skin, and soft tissue. These properties enable tailoring of the flap to precisely fit the defect. The flap has overcome bone size and movement restrictions imposed by regional pedicles. The retained blood supply induces rapid fracture-like healing and provides metabolic independence from the recipient bed. Incorporating an internal oblique muscle island enhances flap utility. The muscle provides a source of oral lining and sanctions the reconstruction of compound defects with a single flap. In an effort to refine the bony component and reduce donor site morbidity, the principal author has introduced the split inner cortex modification. This method has eliminated abdominal wall weakness and hernia, while improving postoperative pelvic contour. The split inner cortex microsurgical iliac crest free flap is the current standard for oromandibular reconstruction in our institution. Additional refinements to internal fixation, TMJ restoration, and osseointegration have resulted in a more refined, comprehensive reconstruction.

A simple technique for harvesting standardized skin grafts in the rodent

A simple technique for harvesting skin grafts of predetermined size, shape, and thickness in rodents is described. In this technique, the donor skin is immobilized and tensed by means of a tongue depressor, or similar template, inserted into the loose areolar tissue below the panniculus, stretching the overlying skin to permit easy dermatome harvesting of a skin graft.

Refinements in mandibular reconstruction

The new advances in the application of the prevascularized bone grafts, i.e., fibula and inner cortex iliac crest, have contributed a major advance in the field of mandibular reconstruction. Better understanding of rigid skeletal fixation and its ability during vascularized bone graft transfers further enhances flap survival and patient rehabilitation. Additional advances in techniques of osteointegration, TMJ reconstruction, and soft-tissue reconstruction have greatly augmented our ability for further refinements in this field.

Decubitus ulcers. How to prevent them--and intervene should prevention fail

Decubitus ulcers can develop in any chronically ill patient who is immobilized. Elderly patients and patients with spinal cord injury are at particularly high risk. Prevention is best achieved by identification of susceptible patients, alleviation of causative and predisposing factors, and early detection of ischemic skin changes. Treatment should be determined by the depth of tissue involvement. Conservative therapy is effective for shallow ulcers, whereas surgery, including the use of flaps, is reserved for deeper, more extensive lesions.

Pediatric microsurgery. Reconstruction by free tissue transfer

In the pediatric population, microsurgery has helped to overcome two of the problems particular to this group: the smaller size of their vessels and nerves and the need for future growth. Microsurgery will continue to play a major role in many difficult reconstructive problems in pediatrics in the future.

Pediatric microsurgery. Replantation, revascularization, and obstetric brachial plexus palsy

Revascularization and replantation of the amputated part is absolutely recommended for restoration of function, form, and future growth. From the beginning, microsurgery has been employed to treat children and infants, but as a group pediatric patients have not received much attention. This article discusses several areas in which reconstructive microsurgery plays a prominent role in the pediatric patient.

Total penile and urethral reconstruction with an expanded sensate lateral arm flap: case report

The use of cutaneous or musculocutaneous flaps for total phalloplasty requires the lack of hairy skin; otherwise urethral strictures most likely will occur. A case of simultaneous total penile and urethral reconstruction using an expanded lateral arm sensory free flap is presented. The use of an expander in a small area of hairless skin on the lateral arm results in a free flap of sufficient size. This procedure proves to be a useful addition to the reconstructive armamentarium in dealing with similar challenging cases of penile reconstruction.

Reconstruction of heel defects

In the mechanics of normal walking, the heel plays an important role, and injuries to the heel often result in limitation, and occasionally loss, of that ability. We review the three categories of heel injuries based on their severity and discuss the available methods of treatment for each. We also propose the addition of a fourth category for injuries requiring bony replacement. We discuss the appropriate use of skin grafts, local flaps, pedicle flaps, and vascularized free flaps in heel reconstruction. Successful treatment of heel defects often restores normal and pain-free ambulation.

Heel reconstruction with an iliac osteocutaneous free flap in a child

We report a case of heel reconstruction in a 13-month-old child in one stage. An iliac crest osteomyocutaneous free flap based on the deep circumflex vessels was transferred using microsurgical techniques. The apophysis of the os calcis was replaced with a portion of the iliac epiphysis to allow normal growth of the heel. At age 2 years, the patient is walking normally and wearing regular shoes of equal size. Gait analysis reveals normal ambulation.

Foot salvage in arteriolosclerotic and diabetic patients by free flaps after vascular bypass: report of two cases

Vascular bypass has been a successful procedure for the salvage of ischemic limbs. Amputation after vascular bypass procedures alone is common when extensive ulceration, osteomyelitis, or bone-tendon exposure is present, especially in the diabetic patient. We report two patients in whom the foot was salvaged by microsurgical free flap after revascularization with bypass grafting. Both patients are diabetic who presented with severe arteriolosclerotic foot, associated with extensive ulceration as well as bone and tendon exposure.

Evaluation of axonal specificity of the regenerating rat sciatic nerve using a fluorescent labeling technique

A double-labeling technique using fluorescent compounds, i.e., diamidino yellow and true blue, is described, with the divided rat sciatic nerve model. Tibial and peroneal fascicles were transected, and each freshly cut nerve end was placed in a vial containing either the true blue or the diamidino yellow label. After a 10-15 day survival period, animals were systemically perfused with fixative, and the lumbar enlargement and dorsal root ganglia corresponding to sciatic nerve roots were removed. Serial sectioning and examination with ultraviolet fluorescence microscopy and counts of the labeled cells were performed. Diamidino yellow in labeled cells was found localized to the nucleus, whereas true blue was found localized to the cytoplasm and nucleolus (control group n = 5). Intermixing of these pools was noted, with yellow cells seen among blue labeled cells following nerve autograft repair of a 1 cm segment of the rat sciatic nerve (experimental group n = 5). Double-labeled cells displaying a yellow nucleus and a blue cytoplasmic label were also seen. We believe that the double-labeling technique described, using the fluorescent retrograde tracers diamidino yellow and true blue, is a useful monitoring method for assessing the specificity of regenerating axons in the rat sciatic nerve.

Reliability of sciatic function index in assessing nerve regeneration across a 1 cm gap

To evaluate the validity of sciatic function index as a reliable functional parameter in assessing regeneration of rat sciatic nerve through a 1 cm gap, we undertook the following investigation. Sixty-three adult male Sprague-Dawley rats were assigned to four groups for repair of a 1 cm gap created in the right rat sciatic nerve; 19 rats were repaired with amniotic collagen conduits, 20 with nerve autograft, and 17 with silicone tubes. In seven rats, the gap was not repaired and served as a control. Functional recovery was assessed by de-Medinaceli SFI and by clinical observations, compared with quantitative and qualitative histological results at 4, 10, and 17 weeks postoperatively. The SFI results did not correlate with the histological findings and clinical observations over the observation period in all groups.

Nasal alar reconstruction with an ear helix free flap

Reconstruction of full-thickness defects of the nasal alae has always been a challenge. Local flaps are commonly used but often result in facial scars and bulky alae that require secondary revisions. The structural similarities between the nasal alae and auricular helices have allowed the use of free helical composite grafts to repair small nasal defects of less than 2.0 cm. Recent delineation of vascular territories of the ear has allowed the use of vascularized helical free flaps in the repair of large alar defects. Successful reconstruction of a 3.2 cm x 3.0 cm full-thickness alar defect, with a chondrocutaneous microsurgical free flap from the root of the auricular helix, is presented. The reconstruction was satisfactory as to contour, symmetry, and color match over a one year follow-up.

Reconstruction of complex cranial and craniofacial defects utilizing iliac crest-internal oblique microsurgical free flap

Reconstruction of complex cranial and craniofacial defects was accomplished in three patients. The defects were secondary to osteomyelitis, irradiation and infection, and failed reconstruction by alloplastic material. Defects averaged 11.5 x 12.5 cm in diameter. The iliac crest-internal oblique microsurgical free flap was used in reconstruction of these defects in combination with split rib bone grafts. Satisfactory restoration of contour and continuity of the cranium was achieved in all patients with minimal donor-site morbidity. We introduce this method for reconstruction of complex cranial and craniofacial defects as a new concept in reconstruction. The results of our experience, although limited, have proven its validity. The muscle portion of the flap enhances the survival of the nonvascularized rib grafts and their contouring effect.

Pretransfer expansion of a sensate lateral arm free flap

Tissue expansion as a reconstructive technique has gained widespread popularity in the field of plastic and reconstructive surgery since Radovan reported his original work in Boston in 1976. Reconstruction by free muscle or composite flaps transferred by microsurgery has preceded the use of tissue expansion. However, a combination of both modalities of reconstruction to fulfill particular reconstructive needs has not yet been reported. This article reports a case of a sensate lateral arm free flap that was expanded prior to its transfer to resurface a 12 X 18 cm defect of the ankle and foot in a child, with primary closure of the donor site. The initial successful resurfacing was followed by recovery of sensation in the entire flap over a period of six months, and the static two-point discrimination measured 9 to 11 mm, which was close to that of the corresponding area of the opposite arm. The child has resumed his sports activities with no problems over a one-year follow-up.

Treatment of bilateral axillary hyperhidrosis by suction-assisted lipolysis technique

Axillary hyperhidrosis, although not life-threatening, is a troublesome condition which produces a personal and social handicap of great significance to patients for many years before they seek a cure. Treatment has consisted of application of topical antiperspirants, systemic anticholinergic medications, excision and primary closure of the involved axillary skin, subdermal shaving of the subcutaneous fat pad containing the hypersecreting sweat glands, and combinations of all of the above. Medical treatment is frequently inadequate and surgical techniques so far described may carry significant morbidity. We have used the technique of suction-assisted lipolysis as an alternative method of treatment for this condition. The procedure has been employed successfully in one patient with no recurrence after one year of follow-up. The operation is done as an outpatient procedure under general or local anesthesia. Suction is carried out through a 1-cm incision in the anterior axillary fold and the entire surface of the dermis is fully "vacuumed" in all directions with 15 to 20 strokes, using a 5- or 7-mm diameter cannula. The area treated includes the area of maximal axillary hair growth and 5 to 6 cm beyond. Routine dressings are removed five days posteroperatively, with the patient generally resuming all activities within one week.

Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer

During a 2-year period, 15 lower and upper extremity amputees were treated by microsurgical free-tissue transfer in an effort to salvage their amputation stumps. Salvage of length and restoration of contour to aid in prosthetic rehabilitation were the two main indications for reconstruction. Included in the 15 transfers were 3 scapular free flaps, 11 latissimus dorsi musculocutaneous flaps, and 1 groin flap. Thirteen of the patients in this group were refitted with prostheses following reconstruction and did well with no pain or skin breakdown of the resurfaced stumps. The follow-up period on these patients averaged 16 months. One patient, in whom the flap succeeded, underwent stump soft-tissue revision and myodesis. One patient, in whom the flap failed, continued to develop recurrent ulceration in his stump. This clinical experience followed an extensive laboratory study of 12 above-knee amputation patients using noninvasive Doppler ultrasound measurements to determine weight-loading and interface-pressure distribution between the stump and the socket of the prostheses and their relation to stump length and circumference.

Use of human amnion for microvascular interpositional grafts

A major problem associated with vascular grafting employing an artificial graft is the inflammatory response provoked by the graft and subsequent complications of classical acute rejection phenomena when the graft is implanted subcutaneously into human volunteers. The favorable results obtained by a preliminary study of subcutaneous implantation of amnion in our laboratory have led us to a prospective study to determine its value as a vascular graft. Tubed conduits of glutaraldehyde-treated amnion were hand constructed of varying diameters and lengths. They were employed as segmental interpositional grafts in experimentally created femoral and aortic arterial defects in Sprague-Dawley rats. Patency rates varied from 60 to 90 percent, with all grafts showing remarkable reendothelialization within 3 to 4 weeks postoperatively. Morphology, antigenic reaction, blood flow, and patency of the different experimental amnion grafts were evaluated and compared to appropriate controls.

Benign skin and soft-tissue tumors of the hand

Tumors of the hand are relatively rare when compared to other body regions; the majority are benign in nature. Skin and soft-tissue benign tumors can be classified according to their tissue or origin. Proper diagnosis and differentiation of benign from premalignant or malignant lesions are the most important steps in the management of hand tumors. Surgical excision under adequate anesthesia with histologic diagnosis is the commonest and most accepted treatment.