The fetal cleft palate: II. Scarless healing after in utero repair of a congenital model.

The role of fetal surgery in the treatment of non-life-threatening congenital anomalies remains a source of much debate. Before such undertakings can be justified, models must be established that closely resemble the respective human anomalies, and the feasibility and safety of these in utero procedures must be demonstrated. The authors recently described and characterized a congenital model of cleft palate in the goat. The present work demonstrates the methodology they developed to successfully repair these congenital cleft palates in utero, and it shows palatal healing and development after repair. A surgically created cleft model was developed for comparative purposes. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Six pregnant goats were gavaged twice daily during gestational days 32 to 41 (term, 145 days) with a plant slurry of Nicotiana glauca containing the piperidine alkaloid anabasine; the 12 fetuses had complete congenital clefts of the secondary palate. Repair of the congenital clefts was performed at 85 days of gestation using a modified von Langenbeck technique employing lateral relaxing incisions with elevation and midline approximation of full-thickness, bilateral, mucoperiosteal palatal flaps followed by single-layer closure. Six congenitally clefted fetuses underwent in utero repair, six remained as unrepaired controls. Twelve normal fetuses underwent surgical cleft creation by excision of a 20 x 3 mm full-thickness midline section of the secondary palate extending from the alveolus to the uvula, at 85 days of gestation. Six surgically clefted fetuses underwent concurrent repair of the cleft at that time; six clefted fetuses remained as unrepaired controls. At 2 weeks of age, no congenitally or surgically created clefts repaired in utero demonstrated gross or histologic evidence of scar formation. A slight indentation at the site of repair was the only remaining evidence of a cleft. At 6 months of age, normal palatal architecture, including that of mucosal, muscular, and glandular elements, was seen grossly and histologically. Cross-section through the mid-portion of the repaired congenitally clefted palates demonstrated reconstitution of a bilaminar palate, with distinct oral and nasal mucosal layers, after single-layer repair. In utero cleft palate repair is technically feasible and results in scarless healing of the mucoperiosteum and velum. The present work represents the first in utero repair of a congenital cleft palate model in any species. The use of a congenital cleft palate model that can be consistently reproduced with high predictability and little variation represents the ideal experimental situation. It provides an opportunity to manipulate specific variables, assess the influence of each change on the outcome and, subsequently, extrapolate such findings to the clinical arena with a greater degree of relevance.

The fetal cleft palate: I. Characterization of a congenital model.

Any animal model of a human congenital anomaly established by iatrogenic methods involving intrauterine fetal manipulation has limited clinical applicability. A congenital model that more closely simulates the etiopathogenesis of a human anomaly may provide data that can more readily be extrapolated to that anomaly and, therefore, be used in diagnostic and management strategies. The present work provides a description and characterization of a congenital model of cleft palate in the goat. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Sixteen pregnant goats were gavaged twice daily during gestational days 32 through 41 [term, 145 days] with a plant slurry of Nicotiana glauca containing the piperidine alkaloid teratogen anabasine. Gross analysis and measurement of fetal clefts were performed at 60, 70, and 85 days gestation (four fetuses were studied at each time point). Seventeen clefted kids were sacrificed at specific intervals after birth (2 weeks, and 1, 3, and 6 months); after skull debridement and preparation, they were compared with 12 unclefted control kids. Complete clefting of the secondary palate occurred in 97 percent of the fetuses. In all cases, the cleft extended from the posterior aspect of the alveolar ridge to the uvula; the majority of these clefts were bilateral, with complete detachment of the vomer. Morphologically, these clefts were similar to human clefts. Eighteen percent of clefted newborn kids demonstrated gross maxillary hypoplasia and midfacial retrusion at birth with a relative Class III malocclusion. Direct measurement of the congenital caprine skulls confirmed these findings. The incidence of midfacial growth abnormalities in these clefted animals raises questions regarding the etiopathogenesis of facial dysmorphology that is unrelated to scarring of the maxilla. This congenital cleft palate model is currently being used to explore these questions and others related to craniofacial growth and palatal function after in utero repair.

A symptomatic radial artery anomaly and its surgical treatment.

We report a case in which a bilateral superficial course of the radial artery at the wrist (A. antebrachialis superficialis dorsalis) became symptomatic, requiring surgical intervention bilaterally.

Buccal mucosal grafts for urethral reconstruction.

OBJECTIVES: Patients requiring urethral reconstruction but who have a paucity of usable genital tissue present a considerable technical challenge. Herein we report the experience of three centers in the use of buccal mucosa for urethral replacement. METHODS: From 1991 to 1996, 22 urethral reconstructions were completed using a graft of buccal mucosa. Eighteen of 22 patients had previously failed hypospadias repairs, while three had bulbar urethral stricture and one had penile carcinoma. Grafts were taken from either the inner cheek or the lower lip, and seven were used as a combined graft. Onlay grafts were used in 6 cases and tubularized grafts in 16 cases. RESULTS: Two patients developed complications at the donor site. Nine of 22 patients had complications of the urethroplasty-two had meatal stenosis, four developed a urethral fistula, and three developed urethral stricture. All complications have been managed successfully to date. CONCLUSIONS: Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties. It is readily available, in abundant supply, and has physical properties beneficial to free graft survival.

Split-thickness plantar skin grafts for coverage in the hand and digits.

The instep of the foot is an excellent donor site for split-thickness skin grafts to cover soft tissue defects of the palm and digits. The technique is described and three illustrative clinical cases are presented. The unique, specialized characteristics of plantar skin are described, emphasizing similarities to palmar skin. The indications for this technique are hyperpigmentation, hair growth, ulceration, hyperkeratosis, marginal scarring, or recurrent breakdown of a preexisting graft, but we have also employed it for primary reconstructions in selected circumstances. The instep graft provides ideal color and texture match and long durability for a palmar graft, with the added advantage of an inconspicuous donor site.

Thrombosis of microvascular anastomoses in traumatized vessels: fibrin versus platelets.

Thrombosis is the end result of two closely interrelated processes: the coagulation cascade and the platelet aggregation process. To determine their relative contribution, we used pharmacologic agents that selectively block each process. The specific effect of each pharmacologic agent on either fibrin deposition or platelet activity was confirmed morphologically by scanning electron microscopy and was substantiated with ADP-induced platelet aggregation and blood clotting time determinations. Forty-two rats had both femoral arteries subjected to a standardized crush-avulsion injury. A total of 84 femoral microvascular anastomoses were subsequently performed. None of the 24 control anastomoses treated with saline remained patent, whereas 6 of 24 of the anastomoses treated with dazmagrel (a selective thromboxane synthetase and platelet aggregation inhibitor), 2.5 mg/kg IV, remained patent and 18 of 24 of those treated with a single dose of heparin, 200 U/kg IV, remained patent. All 12 anastomoses treated with both drugs remained patent but developed a 33 percent hematoma rate. We conclude that in this microvascular model, fibrin mesh deposition is a more significant factor than platelet aggregation in the pathogenesis of occlusional thrombosis within traumatized arteries. Its temporary inhibition with a single dose of heparin yielded a 75 percent improvement in patency rate.

Decision making in the acute thermal hand burn: an algorithm for treatment.

Acute thermal hand burns require a systematic approach to obtain optimal results. Much has been written about the care of hand burns and the significant studies have been summarized here. Discussion still remains concerning the most appropriate treatment of the second-degree burn injury. Despite the residual controversies, a planned algorithm for treatment should help the hand surgeon decide the best approach when faced with a significant hand burn. Our algorithm for the acute thermal hand burn covers the spectrum of care with the ultimate goal of returning normal hand function.

Necrotizing fasciitis as a complication of chickenpox.

Necrotizing fasciitis is a rapid, potentially fatal soft tissue infection. Chickenpox is a common childhood illness not usually associated with severe complications. We present the case of an 8-year-old girl with necrotizing fasciitis of the upper back arising from superinfection of varicella skin lesions. Necrotizing fasciitis may have devastating sequelae, including septic shock, which mandate vigorous fluid resuscitation, appropriate antimicrobial therapy, and early aggressive surgical debridement.

One-stage arm-preserving shoulder resection with latissimus dorsi flap for basal cell carcinoma.

A 60-year-old man was found to have a large invasive basal cell carcinoma involving the skin and surrounding bones of the shoulder joint. The Tikhor-Linberg procedure, a technique for preserving the arm in a shoulder resection, was combined with a latissimus dorsi muscle flap reconstruction in one stage to achieve a satisfactory functional result.

Effect of ischemic skin flap elevation on tissue and plasma thromboxane A2 and prostacyclin production: modification by thromboxane synthetase inhibition.

The circulating prostaglandins have been implicated as mediators of microcirculatory derangements in skin and skin-muscle flaps. The study described here investigated the roles of thromboxane A2 and prostacyclin, measured as thromboxane B2 (TxB2) and prostaglandin 6-keto-F1a (PGF1a), in ischemic skin flaps, and the effects of thromboxane synthetase inhibition on flap blood flow and survival. A canine ventral island flap model was used to measure the appearance of TxB2 and PGF1a in the central arterial and venous plasma, and in the tissue and venous effluent of acutely raised flaps; with and without pretreatment with the specific thromboxane A2 synthetase inhibitor UK38485. Prostaglandin levels change significantly during flap elevation, and can be modified beneficially by thromboxane A2 synthetase inhibition, causing dramatic increases in flap blood flow and survival, as predicted by intravital dye penetration. The results presented in this article suggest that the manipulation of these compounds may provide a method of producing a pharmacological delay phenomenon and perhaps even allow effective intervention in the failing flap.

The gastrocnemius myocutaneous flap in lower-extremity injuries.

Coverage of full-thickness lower extremity wounds has been the bane of surgeons who care for patients with skin and soft-tissue losses. A prolonged period of convalescence may be avoided by immediate coverage with a gastrocnemius myocutaneous flap. Case reports demonstrating the successful use of medial and lateral gastrocnemius myocutaneous flaps are presented. Advantages are that large amounts of tissue can be moved in one step, shortening hospitalization, and most are reliable because of their excellent blood supply. Care must be taken to preserve deep fascia and to dissect the fascia from the Achilles tendon. Fluorescein examination is recommended.

Usefulness of the innervated tensor fascia lata flap in paraplegic patients.

Pressure sores in paraplegic patients are a well-known problem. Such patients can develop pressure necrosis and skin breakdown in spite of preventive measures and adequate surgical management. The occurrence and recurrence of these problems is due in large part to the patient's inability to perceive pressure discomfort in the insensible sitting area. Use of the innervated tensor fascia lata flap has great value in selected patients. A series of 9 patients is presented. In all patients, postoperative sensibility in the flap was maintained as in the preoperative stage. Follow-up of these patients shows that all flaps have remained healed and functioning The neuroanatomical features of the innervated tensor fascia lata flap make it a promising method for covering pressure sores and avoiding subsequent complications.

Combined use of vascular bypass and myocutaneous flap reconstruction in salvage of an ischemic limb.

Successful limb salvage and rehabilitation were achieved in a patient with chronic ischemia and a deep tibial ulcer by combining arterial reconstructive surgery with myocutaneous flap coverage of the defect. Without adequate and expeditious soft tissue coverage, recovery would have been prolonged, and the likelihood of successful rehabilitation would have been seriously jeopardized.

Hypoplasia of the latissimus dorsi muscle complicating breast reconstruction in Poland's syndrome.

Poland's syndrome includes anomalies of the breast, thorax, and upper extremity. Unilateral hypoplasia of the breast and pectoral muscle are seen most frequently, and the resulting problem of breast reconstruction must be addressed. The latissimus dorsi myocutaneous flap is one of the most useful reconstructive tools in this situation. A case is presented of Poland's syndrome with hypoplasia of the latissimus dorsi muscle-an abnormality not generally associated with Poland's syndrome. The latissimus dorsi muscle should be carefully evaluated preoperatively in such patients, to make sure it is adequate for reconstructing the absent breast and pectoral muscle.