Experience with the modified defatted nasolabial transposition flap in nasal reconstruction

The nasolabial flap is the classic flap for reconstruction of nasal defects. During the last five years we have used a modified nasolabial flap in which the distal part of the flap is defatted leaving only the dermis and epidermis intact. This distal part of the flap is then folded and used as inner or outer lining which creates a reconstruction that is thinner than the original folded flap. We have used this technique in 11 patients and the results are satisfactory, with only three patients requiring minor corrections.

Dose response profiles of human growth hormone in subcutaneous wound chambers in rats

OBJECTIVE

To investigate dose response profiles of human growth hormone in soft connective tissue healing when it is given locally in subcutaneous wound chambers.

DESIGN

Placebo controlled parallel study.

SETTING

Institute of Medical Anatomy, Denmark.

MATERIAL

36 male Sprague Dawley rats, in three group of 12.

INTERVENTIONS

Stainless steel wire mesh cylinders 7 mm in diameter and 20 mm long were implanted subcutaneously in pairs in the upper and lower back on either side of the midline in three groups of male Sprague Dawley rats. Two groups were each given two different doses of growth hormone (group 1, 0.2 and 0.7 IU; and group 2, 0.02 and 2 IU) in two cylinders and vehicle alone in the two cylinders on the opposite side. Group 3 were given vehicle alone in two cylinders and needle puncture (sham) on the opposite side. Injections of growth hormone or vehicle (placebo) were given every three days for 16 days.

MAIN OUTCOME MEASURES

Body weight, weight of granulation tissue, and concentrations of hydroxyproline and aminoterminal propeptide of procollagen type III.

RESULTS

The dose response curves for weight of granulation tissue and deposition of collagen were upward convex (ANOVA p < 0.001 and 0.001, respectively). Growth hormone in doses of 0.2 and 0.7 IU stimulated formation of granulation tissue to means of 180% (95% confidence interval (Cl) 149% to 210%) and 174% (95% Cl 148% to 200%) more than in the placebo treated cylinders (group 3) (p < 0.05 and < 0.01, respectively). Doses of 0.2 and 2 IU, however, had less effect. The placebo cylinders in animals in groups 1 and 2 contained a mean of 157% (95% Cl 137% to 177%) more granulation tissue than the cylinders in group 3, indicating that locally applied growth hormone also had a systemic effect.

CONCLUSION

The clinical use of topical growth hormone in wound healing may be complicated by the relatively narrow therapeutic interval.

Topical zinc oxide treatment increases endogenous gene expression of insulin-like growth factor-1 in granulation tissue from porcine wounds

Application of zinc oxide has been shown to accelerate the healing of both chronic and acute wounds, but the mechanisms are unknown. We quantified the gene expression (mRNA) for one important growth factor, insulin-like growth factor-1 (IGF-1) in 12 full-thickness wounds in each of three domestic pigs treated with or without topical zinc oxide. We used a RNAase protection/solution hybridisation technique to measure IGF-1 mRNA concentrations, which were 50% higher in the granulation tissue in wounds treated with zinc oxide compared with control wounds on days 3-4 (p < 0.05), but not thereafter (up to postoperative day 11). Topical zinc oxide increased the healing rate of wounds compared to the control group (p < 0.01). The cell composition of the granulation tissue was similar in the two groups. The increased gene expression of IGF-1 may be one mechanism by which topical zinc oxide enhances wound healing.

Influence of human growth hormone on granulation tissue formation, collagen deposition, and the aminoterminal propeptide of collagen type III in wound chambers in rats

The influence of growth hormone on granulation tissue formation was investigated in wire mesh cylinders implanted subcutaneously in rats. Two groups of 10 rats (study 1) and 1 group of 12 rats (study 2) were used for the investigation. Growth hormone, 0.02 and 0.2 IU (study 1), 0.05 and 0.2 IU (study 2), or vehicle only, was injected into the cylinders every third day for 16 days. In study 2, wound fluid was aspirated before injection of growth hormone and saved for later analysis of the aminoterminal propeptide of collagen type III. In both studies, growth hormone significantly increased the formation of granulation tissue and of total collagen content dose-dependently, whereas the relative amount of collagen was unaffected by growth hormone treatment. Wound fluid aminopropeptide increased significantly after implantation of the cylinders until day 7, before declining slightly, with no difference between the groups. We conclude that growth hormone stimulated granulation tissue formation and collagen deposition dose-dependently in the wound cylinders when injected every third day. The results suggest that growth hormone treatment does not cause excessive collagen deposition in newly formed granulation tissue.

Increased gene expression of scatter factor-hepatocyte growth factor and basic fibroblast growth factor in granulation tissue in the rat

Scatter factor-hepatocyte growth factor is a protein secreted by fibroblasts which disperses colonies of epithelial cells and keratinocytes in culture. The factor is also a patent mitogen for hepatocytes, synthesized in the liver. Basic fibroblast growth factor, another heparin-binding factor, is most abundant in the brain but also plays a role in wound healing. Using a solution hybridization/RNAase protection assay, we have measured the abundance of messenger RNA for scatter factor-hepatocyte growth factor and basic fibroblast growth factor in granulation tissue obtained from subcutaneously Hunt-Schilling wound cylinders. The levels of scatter factor-hepatocyte growth factor messenger RNA increased after weeks 2 through 4 to a twofold higher level in weeks 5 through 7 after implantation of the cylinders, whereas no changes in basic fibroblast growth factor messenger RNA levels were noticed. At week 3 after implantation of the cylinders, scatter factor-hepatocyte growth factor messenger RNA levels in granulation tissue were more than threefold higher than in skin dermis fibroblasts but markedly lower than in the liver. The abundance of basic fibroblast growth factor messenger RNA was also significantly increased in granulation tissue compared with dermis but, as expected, markedly lower than in the brain. In conclusion, the gene expression of the scatter factor-hepatocyte growth factor, as well as basic fibroblast growth factor, is increased in granulation tissue. Because there was a time-dependent increase in the expression of scatter factor-hepatocyte growth factor, it is hypothesized that scatter factor-hepatocyte growth factor acts as a signal from fully developed granulation tissue to stimulate skin epithelial cells to scatter over the wound.

A new partly external device for extension of skin before excision of skin defects

Tissue expansion is a well established method for reconstructive surgery. As a complement, a new technique of skin extension has been developed, and tested clinically. The device consists of two holding bars with several straps placed between them, which usually is applied under local anaesthesia. It is an efficient, rapid, and inexpensive way of expanding skin before excision of skin defects. Thirty-two patients have been treated, three patients have had complications, and length of follow up ranged from 2-12 months.

Skin expansion. Long term follow up of complications and costs of care

To find out our rate of complications after tissue expansion, and the cost of treatment in terms of use of hospital resources and length of sick leave, we analysed our experience of 181 expansion treatments in 97 patients undertaken between 1986 and 1991. There were 60 women and 37 men, with a mean age of 22 (range 1-74). Twenty patients had more than one period of treatment (range 2-8). The most common conditions treated were naevi (n = 75); scars (trauma--n = 33, burns--n = 17, and operations--n = 16); and breasts that required reconstruction (n = 15). Of the 181 expansions there were 29 failures (16%), and 117 complete successes (64%); fifteen of the latter developed minor complications (8%), 35 were partly successful (20%). There were 77 complications in 71 treatments (38%), and 45 expanders (25%) had to be removed prematurely because of complications. The most common complications were skin penetration (n = 15), minor infection (n = 13), and breakdown of the surgical wound (n = 13). The median (range) inpatient hospital stay was 8 days (2-39); number of visits to the outpatient clinic for filling 7 days (0-20); and total treatment time/patient 82 (19-286). We conclude that skin expansion is a useful technique, but that there is room for improvement in reducing the rate of complications and the amount of time that patients spend being treated.

A simple variant of surgical correction of prominent ears. Description of the surgical technique and follow-up examination in 36 patients

A technically simple technique of otoplasty has been developed. An ovular skin excision is made on the posterior side of the auricle and then a transcartilaginous incision that corresponds to the future dorsal part of the antihelical fold. A parallel anterior incision of the anterior aspect of the cartilage helps to create a normal and harmonious configuration by smoothing the inward bending. Thirty-six patients were operated on and followed up for between six months and two years. The surgical results are satisfactory and there have been only two recurrences.

Prepared neurovascular forehead island flap for reconstruction of minor full thickness nasal defects. Case report

A forehead neurovascular island flap has twice been used for reconstruction of minor full thickness nasal defects caused by surgical removal of malignant tumours. The flap was raised one month before transposition, and a split thickness skin graft was applied to the inner surface of the galea of the flap. The periosteum of the forehead was also grafted, thus repairing the donor site before the flap was removed. The flap is based on the supraorbital artery, which was dissected to its origin at the incisura or supraorbital foramen. The advantages are those of a small flap with external as well as internal lining and with preserved sensibility.

Two stage correction of the constricted ear. Case report

A 3-year-old girl presented with a constricted ear (Tanzer type 2B) on the right. This was repaired in two stages: the helix was opened up and then, when she was 17 years old, the helical fold was reconstructed under local anaesthesia with a bipedicled tube flap from behind the ear. The cosmetic result was good, and the two ears were symmetrical.