The history of human composite tissue allotransplantation.

Restoration of amputations and disfigurement are represented in ancient mythology, but the modern history of composite tissue allotransplantation begins with World War II injuries that generated seminal immunologic experiments by Medawar and co-workers. These studies led to the first successful human allografts in the 1950s by Peacock with composite tissue and Murray and co-workers with solid organs. Pharmacologic immunosuppression brought rapid growth of solid organ transplantation over the next 50 years, but composite tissue transplantation virtually disappeared. This evolution was judged to be a consequence of the greater antigenicity of skin, which that was insurmountable by the available immunosuppression. In the mid-1990s, progress in immunosupression allowed skin-bearing grafts, led by successful hand transplants, which produced a renaissance in composite tissue allotransplantation. Since then, graft types have expanded to over 10, and graft numbers to over 150, with success rates that equal or exceed solid organs. The field has emerged as one of the most exciting in contemporary medicine, although accompanied by substantial challenges and controversy. This paper reviews the origins and progress of this field, assessing its potential for future evolution.

Ethical considerations in the early composite tissue allograft experience: a review of the Louisville Ethics Program.

This paper reviews the formulation and evolution of the ethical component in one of the earliest clinical composite tissue allograft (CTA) programs, the hand transplantation program in Louisville, Kentucky, USA. The purpose was to derive lessons and define principles to give guidance for future programs and introduction of new CTA. We reviewed the initial ethical considerations, including input from respected ethical scholars, guidelines for innovative procedures transparency in public and professional scrutiny, and compliance with human studies regulations (IRB approval). We found the initial focus on ethics, scholarly input, guidelines for innovative procedures, and human studies protection regulations to be valid. Moreover, we noted the effect of autonomy in subjective, quality-of-life benefits on equipoise and effective risk-benefit analysis in effective informed consent. We found that psychiatric screening and support to be exceptionally valuable in protecting autonomy, suitability for participation, assessing personality organization, and determining compliance ability. We conclude that the program ethical principles were validated. For future CTA programs and procedures, we recommend an ethical emphasis with adherence to high standards and transpire to independence to scrutiny and oversight. We recommend protection of autonomy judgments in equipoise judgment and informed consent. We recommend skilled psychiatric screening and support. We endorse scholarship, scientific accuracy, and data sharing.

Dynamic rectus abdominis muscle flap for intestinal stomal continence: a systematic approach.

Several attempts to create a continent stomal sphincter using dynamic myoplasty with limited success have been reported. Denervation atrophy and early muscle fatigue have plagued all reported attempts to make a continent stoma a reality. To address this problem in a series of experiments, we designed a stomal sphincter using the most caudal segment of the rectus abdominis muscle. Then, we performed a study to determine whether a sphincter created with a rectus abdominis muscle island flap could maintain stomal continence in the short term. We found that when stimulated using two different electrical stimulation protocols, in all cases the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mm Hg). All sphincters were able to maintain stomal continence at all intraluminal bowel pressures tested. We found one of these protocols to be far superior and reached 4 hours of stomal continence after 8 to 10 weeks of electrical stimulation.

Dynamic rectus abdominis muscle sphincter for stoma continence: an acute functional study in a dog model.

Fecal stomal incontinence is a problem that continues to defy surgical treatment. Previous attempts to create continent stomas using dynamic myoplasty have had limited success due to denervation atrophy of the muscle flap used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation. To address the problem of denervation atrophy, a stomal sphincter was designed using the most caudal segment of the rectus abdominis muscle, preserving its intercostal innervation as well as its vascular supply. The purpose of the present study was to determine whether this rectus abdominis muscle island flap sphincter design could maintain stomal continence acutely. In this experiment, six dogs were used to create eight rectus abdominis island flap stoma sphincters around a segment of distal ileum. Initially, the intraluminal stomal pressures generated by the sphincter using different stimulation frequencies were determined. The ability of this stomal sphincter to generate continence at different intraluminal bowel pressures was then assessed. In all cases, the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mmHg). In addition, each sphincter was able to maintain stomal continence at all intraluminal bowel pressures tested.

Electrically stimulated detrusor myoplasty.

PURPOSE: Many children with spina bifida and other causes of neurogenic bladder rely on clean intermittent catheterization to empty the hyporeflexic or areflexic bladder. Direct bladder and sacral nerve root stimulation have been met with limited success. We studied the electrical stimulation of a rectus abdominis muscle flap wrapped around the bladder to achieve bladder contractility and emptying. MATERIALS AND METHODS: The feasibility of performing rectus detrusor myoplasty in humans was first studied in 8 cadavers. In male and female cadavers it was possible to wrap the distended bladder completely with the rectus abdominis muscle. The rectus abdominis muscle was surgically dissected with preservation of its insertion on the pubis bone and rotation of its mid section behind the bladder to effect a complete bladder wrap. The deep inferior epigastric artery and veins, and 2 most caudal intercostal nerves were preserved. This unilateral rectus abdominis muscle flap was then electrically stimulated with 2 pairs of bipolar electrodes inserted into the muscle near the nerve entrance. Stimulation frequencies of 40, 60 and 80 Hz. were used in each of the 8 dogs. The increase in intravesical pressure over baseline, compliance and post-void residual were measured. Paired Student's t tests were used for statistical comparisons. RESULTS: The increase in intravesical pressure ranged 35 +/- 5 to 45 +/- 7 cm. H2O at stimulation frequency 40 and 80 Hz., respectively. Post-void residual was 27 +/- 4%, 22 +/- 3% and 26 +/- 3% at stimulation frequencies 40, 60 and 80 Hz., respectively. Intravesical pressure was significantly increased over baseline bladder pressure (p <0.05). CONCLUSIONS: Electrically stimulated detrusor myoplasty results in uniform increases in intravesical pressure and reasonable bladder emptying in an animal model. We are currently investigating detrusor myoplasty in a chronic study to determine whether it can be used for enhanced bladder emptying in children with poor detrusor contractility.

Osteomyocutaneous flap as a preclinical composite tissue allograft: swine model.

Composite tissue allotransplantation (CTA) constitutes one of the last frontiers of microsurgery. Prior to its clinical application, the long-term efficacy of modern immunotherapy must be tested in a pre-clinical CTA model. Based on the concept of osteomyocutaneous forearm flap, we developed a CTA flap model in swine. After identifying the vascular territory of the flaps in six pigs (vascular casting), flaps were transplanted from mismatched donor to recipient pigs (n = 6). Rejection was assessed daily by visual inspection and histopathology of biopsy specimens. Recipient pigs were able to ambulate immediately following surgery. There were no flap failures owing to technical or surgical complications. Rejection occurred over a period of 7 days as manifested by edema, cellular infiltration, epidermalysis, and thrombosis. This pre-clinical flap model is excellent for evaluating the effectiveness of modern immunotherapy because it is anatomically and immunologically relevant and because the minimal morbidity caused to the animal permits long-term studies.

Inferior angle of the scapula as a vascularized bone graft: an anatomic study.

In reconstructing patients with massive midface losses, the authors required a vascularized bone graft that could be used to reconstruct the palate and orbital floor, provide vertical maxillary support, and provide soft tissue. The inferior angle of the scapula appears to be a promising source of vascularized bone stock, and until now, there has been no clear description of its vascular anatomy. The purpose of this study was to define the vascular anatomy of the inferior angle of the scapula. Thirteen fresh cadavers were studied. The subscapular artery was injected with Microfil (Flow Tec, Carver, MA) at its origin. Two branches of the subscapular artery were found to converge on the angle of the scapula: the descending osseous branch of the circumflex scapular, and the transverse branch of the thoracodorsal. The descending osseous branch of the circumflex scapular artery supplied the inferior angle of the scapula in 100 percent of cases. The transverse branch of the thoracodorsal artery supplied it in 76 percent of cases. The descending osseous branch of the circumflex scapular artery is the principal artery supplying the inferior angle of the scapula.

Vascular delay and administration of basic fibroblast growth factor augment latissimus dorsi muscle flap perfusion and function.

Ischemia of the distal latissimus dorsi muscle flap occurs when the entire muscle is acutely elevated. Although this level of ischemia may not be critical if the muscle is to be used as a conventional muscle flap, the ischemia causes decreased distal muscle function if it is used for dynamic muscle flap transfer. This experiment was designed to determine whether or not the administration of exogenous basic fibroblast growth factor (bFGF), combined with a sublethal ischemic insult (i.e., vascular delay), would further augment muscle perfusion and function. Both latissimus dorsi muscles of nine canines were subjected to a bipedicle vascular delay procedure immediately followed by thoracodorsal intraarterial injection of 100 microg of bFGF on one side and by intraarterial injection of vehicle on the other. Ten days later, both latissimus dorsi muscles were raised as thoracodorsally based island flaps, with perfusion determined by laser-Doppler fluximetry. The muscles were wrapped around silicone chambers, simulating cardiomyoplasty, and stimulating electrodes were placed around each thoracodorsal nerve. The muscles were then subjected to an experimental protocol to determine muscle contractile function. At the end of the experiment, latissimus dorsi muscle biopsies were obtained for measurement of bFGF expression. The results demonstrated that the administration of 100 microg of bFGF immediately after the vascular delay procedure increases expression of native bFGF. In the distal and middle muscle segments, it also significantly increased muscle perfusion by approximately 20 percent and fatigue resistance by approximately 300 percent. The administration of growth factors may serve as an important adjuvant to surgical procedures using dynamic muscle flap transfers.

Use of the rectus abdominis muscle for abdominal stoma sphincter construction: an anatomical feasibility study.

Permanent fecal abdominal stomas significantly decrease quality of life. Previous attempts to create continent stomas by using dynamic myoplasty procedures have resulted in disappointing outcomes, primarily owing to denervation atrophy of the muscle flap that was used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation that is received by the flap to force contraction. On the basis of these problems, we designed two separate studies: an anatomical study addressing flap denervation and a functional study addressing muscle fatigue. The present study addresses the first topic and was designed to develop a rectus abdominis muscle flap into a sphincter that was anatomically situated to create a stoma while preserving as much innervation as possible. In 24 rectus abdominis muscles of human cadavers, the neurovascular anatomy was defined, then the anatomical feasibility of two different muscle flap configurations was considered. The flaps investigated were the peninsula flap and island flap designs, with both using the most caudal segment of the rectus abdominis muscle in construction of the sphincter. Neither flap design required the killing of a nerve for stoma sphincter creation, resulting in minimal muscle denervation. The conclusion of our comparison was that the above, in conjunction with other features of the island flap design, such as muscle overlap after sphincter formation and abdominal wall positioning of the sphincter, made the island flap design better suited to stoma sphincter construction.

Vascular delay of the latissimus dorsi provides an early hemodynamic benefit in dynamic cardiomyoplasty.

OBJECTIVES: Dynamic cardiomyoplasty (CMP) as a surgical treatment for chronic heart failure improves functional class status for most patients. However, significant hemodynamic improvement with latissimus dorsi muscle (LDM) stimulation has not been consistent. The current protocols do not allow early LDM stimulation after CMP surgery. We hypothesized that vascular delay of LDM would increase myocardial assistance after CMP and allow early (48-h) LDM stimulation after CMP. METHODS: Mongrel dogs (n = 24) were divided in four groups: 1) controls (n = 6), single-stage CMP; 2) Group ES (n = 6), single-stage CMP with early LDM stimulation beginning 48 h, postoperatively; 3) Group VD (n = 6), vascular delay of the LDM followed by CMP without early LDM stimulation, and 4) Group VDES (n = 6), vascular delay of LDM (14-18 days), followed by CMP with early stimulation (48 h postoperatively). Two weeks after CMP, global cardiac dysfunction was induced by injecting microspheres into the left coronary artery. LDM-assisted (S) beats were compared with nonstimulated beats (NS) by measuring aortic pressure (AoP), LV pressure, aortic flow, and by calculating first derivative of LV contraction (+/-dP/dt), stroke volume (SV), and stroke work (SW). RESULTS: In ES, LDM stimulation had no effect on the hemodynamic parameters. In the other groups, LDM stimulation significantly (p < 0.05) increased AoP, LVP, dP/dt, SV, and SW. However, these increases were much larger in VD and VDES. In VD, LDM stimulation increased peak AoP by 21.5+/-3.8 mm Hg, LVP by 22.1+/-4.1 mm Hg, dP/dt by 512+/-163 mm Hg/sec, SV by 10.4+/-2.3 mL, and SW by 22.1+/-5.4 g/m(-1). Similarly, in VDES, LDM stimulation increased peak AoP by 24.1+/-4.7 mm Hg, LVP by 26.2+/-4.3 mm Hg, dP/dt by 619+/-47 mm Hg/sec, SV by 6.5+/-0.7 mL, and SW by 16.7+/-4.1 g/m(-1). CONCLUSIONS: In dogs with global LV dysfunction, CMP after vascular delay resulted in a significant improvement in hemodynamic function measured 2 weeks after surgery. This improvement was not provided by single-stage CMP with or without early stimulation. Vascular delay of the LDM before surgery may play an important role for early benefit after CMP, shorten the overall muscle training period, as well as increase hemodynamic response to LDM stimulation.

Muscular urinary sphincter: electrically stimulated myoplasty for functional sphincter reconstruction.

PURPOSE: To reconstruct an electrically stimulated muscular urinary sphincter (MUS) using a tailored gracilis muscle free flap with intact nerve. MATERIALS AND METHODS: Unilateral surgically tailored gracilis muscle free flaps were transferred into the pelvis in eight dogs, leaving the obturator nerve intact. The muscle's pedicle vessels were anastomosed to the inferior epigastric artery and vein in the pelvis and the muscle was wrapped around the bladder neck. Electrodes were inserted into the MUS and connected to a programmable pulse generator. After 8 weeks of training the MUS, the pulse generator was programmed to be "on" for 4 hours and "off' for 15 minutes in a continuous cycle. Urodynamic studies were performed periodically, and at the end of the experiment the MUS and proximal urethra were harvested for histology. Three control dogs had sham operations. RESULTS: All MUS's functioned well following the procedure. Histology of the MUS/urethra complex showed no evidence of stricture. Except for one dog, all urethras were easily catheterized. CONCLUSIONS: This electrically stimulated innervated free-flap MUS technique effectively increases bladder outlet resistance without producing urethral obstruction.

Impediments to wound healing.

Chronic wounds will often heal in a short period of time if factors that inhibit wound healing are identified and managed. Recombinant growth factor therapy may provide an added stimulus to healing in certain types of chronic wounds. However, there remains no substitute for a physiologic environment conducive to tissue repair and regeneration, without which the efficacy of growth factor therapy is questionable. Some of the most commonly encountered and clinically significant impediments to wound healing include wound hypoxia, infection, presence of debris and necrotic tissue, use of anti-inflammatory medications, a diet deficient in vitamins or minerals, or general nutritional deficiencies, tumors, environmental factors, and metabolic disorders, such as diabetes mellitus. Treatment of chronic wounds should be directed against the main etiologic factors responsible for the wound. Moreover, factors that may impede healing must be identified and, if possible, corrected, for healing to occur.

Physiology and healing dynamics of chronic cutaneous wounds.

In the last few decades, a great deal of progress has been made in understanding the cellular and biochemical interplay that comprises the normal wound healing response. This response is a complex process involving intricate interactions among a variety of different cell types, structural proteins, growth factors, and proteinases. The normal wound repair process consists of three phases--inflammation, proliferation, and remodeling--that occur in a predictable sequence and comprise a series of cellular and biochemical events. A review of the biochemical and physiologic processes that regulate wound healing and the cascade of cellular events that gives rise to the healing process is presented here.

Serious wound infections after minimally invasive coronary bypass procedures.

BACKGROUND: Minimally invasive coronary artery bypass grafting has become an increasingly accepted therapy for selected patients with single-vessel coronary artery disease. Reported morbidity has focused on anastomotic problems, but the occurrence of serious wound complications after these procedures has not been well documented. METHODS: We reviewed our institutional experience with 35 patients to look for the incidence of serious wound complications. RESULTS: Three patients had serious wound problems after minithoracotomy for coronary artery bypass graft procedures. This represents an overall 9% wound morbidity rate and a 100% rate in the obese women. CONCLUSIONS: Wound complications at the incision site after minithoracotomy coronary artery bypass graft procedures seem to occur distinctly in obese women with redundant breasts.

Electrically stimulated free-flap graciloplasty for urinary sphincter reconstruction: a new surgical procedure.

In electrically stimulated (dynamic) graciloplasty for urinary incontinence, the gracilis muscle is transposed into the pelvis, and the distal part is used to reconstruct a neosphincter. Clinical outcomes using this technique have been disappointing due to stricture of the urethra caused by ischemia in the distal part of the gracilis and limited gracilis length available for neosphincter construction. Furthermore, the urethra is twisted by the contracting gracilis, rather than circumferentially squeezed. The purpose of the present study was to test the anatomical and functional feasibility of a new surgical approach to reconstruct a urinary sphincter, using the gracilis muscle as a free flap. In 12 human cadavers, the anatomical feasibility for creating a neosphincter by using the gracilis free flap was determined. In all cases, transfer of the gracilis muscle into the pelvis as a free flap (with the nerve intact) was feasible, and ample muscle was available to construct a neosphincter around the bladder neck. Gracilis neosphincter function was studied in seven dogs. The left gracilis muscle was subjected to transfer into the pelvis as an innervated free flap to create a neosphincter around the urethra. The right (control) gracilis muscle was lifted as a single pedicle flap, remained in situ, and was wrapped around a stent to mimic the urethra. Function (expressed as peak pressure generation and fatigue rate) and surface perfusion were determined for all gracilis muscles. In each dog, both sides were compared using the paired Student's t test for statistical analysis, and no significant difference was measured for the two groups. In conclusion, an innervated gracilis free flap can be used to create a neosphincter around the bladder neck. In an acute study in dogs, function and perfusion of the innervated gracilis free flap are not compromised.

Quantification of the morphological features of a full microvascular network.

Investigations into the changes that occur in microvasculature following the surgical procedure called delay have brought about the need for a computer system capable of quantifying the morphological features of a full microvascular network in terms of average vessel length, diameter, and tortuosity. Both the formulaic conventions that have been developed to measure these quantities as well as their implementation in the form of a HP-9000/UNIX based computer software system that we developed specifically for this purpose are discussed. Reliability studies performed using the final system to measure the microcirculatory network of a mouse latissmus dorsi muscle (LDM) showed 95% confidence intervals within 5% of means and coefficients of variability within 7% of means for all quantities measured in large (150-300 microns), medium (50-150 microns), and small (< 50 microns) diameter vessels. These variations were significantly smaller than the changes that were observed in a preliminary study comparing these microvascular network parameters before and after delay in the hairless mouse LDM, showing the proposed quantification methods to be well suited to the study of the microvascular changes following delay. It is hoped that the formulaic conventions, implementation process and reliability data will provide a useful comparison for other researchers interested in measuring similar features of microcirculatory networks.

Inhibition of wound contraction with locally injected lathyrogenic drugs.

BACKGROUND: Previous studies using systematically administered lathyrogens to inhibit wound contractures have produced inconsistent results. The purpose of this study was to investigate the effects of lathyrogenic drugs on wound contraction when injected locally. METHODS: Two symmetrical full-thickness wounds were made on the dorsum of either side of hairless (hr/hr) mice; thus, each animal served as its own control. Animals were divided into groups receiving daily local injections of beta-aminopropionitrile or D-penicillamine, or both beta-aminopropionitrile and D-penicillamine and normal saline vehicle (control side) for 5 or 10 days. The rate of contraction was determined by serial measurements of the surface area of each wound during the treatment period. At the end of the treatment period, the wounds were excised en bloc with the chest wall and prepared for blinded histological analysis. Granulation tissue thickness, number of fibroblasts in granulation tissue per unit area, number of inflammatory cells (neutrophils, lymphocytes, macrophages and mast cells) in subjacent muscle per unit area, and collagen deposition in subjacent muscle were determined. RESULTS: Wound contraction, granulation tissue thickness, and collagen deposition in subjacent muscle were decreased only in wounds treated with beta-aminopropionitrile plus D-penicillamine. Collagen deposition in subjacent muscle was also decreased in wounds treated with D-penicillamine alone. Neither drug alone nor the combination affected the number of inflammatory cells in subjacent muscle. Body weight was not affected by the experimental procedures. CONCLUSIONS: The combination of beta-aminopropionitrile and D-penicillamine is potentially useful for inhibiting contracture formation when injected locally.

Vascular delay in skeletal muscle: a model for microcirculatory studies.

Dynamic myoplasty is a relatively new use for muscle flaps and has led us to revisit the mechanisms of vascular delay as a means of optimizing blood supply to muscle flaps. Despite the well-documented effectiveness of vascular delay in skin flaps, vascular delay in muscle flaps has not been widely reported. Regardless of the many mechanisms postulated in the literature as contributors to the delay effect in skin, the one element common to all these hypotheses is the importance placed on changes in the microcirculation. Based on this factor, in the present study we developed and validated an animal model in which delay-induced microvascular changes could be measured in skeletal muscle flaps. We used the hairless mouse latissimus dorsi muscle flap because its vascular distribution is similar to that of humans and its thin structure will enable us in future studies to directly view and measure its microvasculature using videomicroscopy. In 12 animals, we found that delay significantly (p < 0.01) reduced necrosis of the distal part of the muscle from 57 +/- 9 percent in nondelayed flaps (n = 7) to 22 +/- 3 percent in delayed (n = 5) flaps. In these studies, we also determined that the hairless mouse latissimus dorsi muscle flap will serve as an excellent model for defining microvascular changes throughout delay.

Vascular delay improves latissimus dorsi muscle perfusion and muscle function for use in cardiomyoplasty.

Ischemia of the distal portion of the latissimus dorsi muscle occurs in muscle transfer for cardiomyoplasty and reduces distal muscle contractility and thus the mechanical effectiveness of cardiomyoplasty. We hypothesized that muscle function would be improved by a vascular delay procedure that increases distal muscle perfusion of the latissimus dorsi muscle. The latissimus dorsi muscles of 10 adult mongrel dogs were subjected to a vascular delay procedure on one side and a sham procedure on the other. Following 10 days of vascular delay, muscle perfusion was measured with a laser-Doppler perfusion imager before and after elevation of the muscles as flaps based only on their thoracodorsal neurovascular pedicles. The muscles were wrapped and sutured around silicone chambers (simulating cardiomyoplasty), a stimulating electrode was placed around each thoracodorsal nerve, and the muscles were stimulated to contract in both rhythmic and tetanic fashion. Circumferential (distal and middle latissimus dorsi muscle function) force generation and fatigue rates were measured independently. Circumferential muscle force, circumferential and longitudinal fatigue rate, and distal, middle, and overall perfusion were significantly (p < 0.05) improved in delayed muscle compared with nondelayed muscle. We found that a vascular delay procedure and a 10-day delay adaptation period significantly improve latissimus dorsi muscle flap perfusion and function, particularly in the distal and middle portions of the muscle. Delay should be considered as a means of improving the clinical outcome in cardiomyoplasty.