The morphologic effects of simultaneous infusion of levarterenol and phentolamine on the canine myocardium.

The effect of simultaneous administration of levarterenol and phentolamine on the myocardium over a 3 hour period was studied in 15 adult mongrel dogs. All animals receiving levarterenol alone had moderate-to-severe subendocardial hemorrhage and necrosis. Four of the 6 animals receiving the simultaneous infusion of levarterenol and phentolamine had little or no hemorrhage or necrosis. These differences are significant (p less than 0.02). It is concluded that the administration of phentolamine simultaneously with levarterenol affords a significant protective effect on the myocardium.

Utility of lymphoscintigraphy in directing surgical therapy for melanomas of the head, neck, and upper thorax.

Lymphoscintigraphy with technetium99m antimony sulfur colloid or technetium99m human serum albumin helped direct the surgical management of 24 patients who had melanomas of the head, neck, and upper thorax. Eighteen (75%) patients had documented lymphatic flow to other than a single adjacent predictable lymph nodal group. Nineteen patients underwent lymphadenectomy. Availability of the scan altered surgical management in nine patients (47%) who required resection of nodes in addition to resection of adjacent nodes. The discovery of metastatic disease in one patient was clearly attributable to lymphoscintigraphy. This demonstrates the unpredictable lymphatic anatomy of this region and suggests that preoperative lymphoscintigraphy may be useful in directing the surgical management of cutaneous melanomas in which lymph node dissection is planned.

Mesenteric angiopathy, intestinal gangrene, and midgut carcinoids.

Twenty-six cases of carcinoid-related mesenteric angiopathy and intestinal infarction (three from our institution and 23 previously reported cases) were reviewed. Twenty patients presented with acute abdominal findings, including peritonitis (13 cases), intestinal obstruction (five cases), and bleeding per rectum (two cases). Fifteen patients (75%) experienced antecedent symptoms of abdominal pain and/or diarrhea, averaging 2.5 years in duration. Twelve patients (46%) exhibited symptoms of carcinoid syndrome. Mesenteric angiography in three cases demonstrated encasement and segmental branch narrowing or occlusion of major mesenteric vessels. Eleven patients underwent resection and primary bowel anastomosis with an early survival rate of 91%. Four additional patients who underwent lesser surgical procedures and five patients who did not undergo operation all died. Elastic vascular sclerosis (EVS) was identified in 19 of 22 cases with available histologic material (86%). These changes were observed in proximity to as well as distant to the primary tumor. In general, the severity of EVS did not correlate with the likelihood of gut ischemia. Although not the sole cause of intestinal gangrene in patients with midgut carcinoids, EVS may contribute significantly to the evolution of these ischemic changes.

Reconstruction of the chest wall.

Reconstruction of the chest wall can now be accomplished reliably and expeditiously. Past experience with local flaps and split-thickness skin grafts recommends their continued use when appropriate. Recent studies in blood flow have demonstrated that very large muscles with or without the overlying skin can be moved primarily and reliably. The four most reliable myocutaneous flaps for chest wall reconstruction are described. Microsurgery allows movement of large segments of skin and muscle from expendable areas of the body to the chest wall.

The effect of simultaneous administration of levarterenol and phentolamine on renal blood flow.

The effect of simultaneous administration of levarterenol and phentolamine upon renal blood flow was studied over a 3-hour period in 22 mongrel dogs. The infusion of levarterenol alone produced a fall in renal blood flow that ranged from 28 to 58% from the baseline value. When both drugs were administered simultaneously, renal flow fell only 17 to 22% from baseline (p less than 0.05). From these studies we conclude that the simultaneous administration of levarterenol and phentolamine in optimal ratios maintains renal blood flow near baseline levels.

A comparison of the hemodynamic effects of inotropic agents.

This experimental study was conducted to compare and contrast the cardiovascular effects of the drugs most commonly used to alleviate low-cardiac-output syndrome. Twenty-five adult mongrel dogs were infused with sodium pentobarbital (60 mg/min) until their cardiac output fell to 50+/-5% of the average control values determined by thermodilution technique prior to pentobarbital infusion. The dogs were then divided into six groups, and one of the following agents or combinations of agents was administered to each group: isoproterenol, glucagon, dopamine, dobutamine, levarterenol and phentolamine, or levarterenol and nitroprusside. All drugs, except for glucagon and the combination of levarterenol and nitroprusside, produced an increase in cardiac output above the nonfailure baseline values. However, this increase was accompanied by an undesirable, pronounced tachycardia except when levarterenol was used simultaneously with phentolamine. Both dopamine and the combined infusion of levarterenol and phentolamine proved the most effective in restoring systemic arterial pressure to near baseline values, and both were able to increase renal blood flow above the failure baseline values. While renal blood flow remained elevated with all dosages of levarterenol and phentolamine, it tended to decrease with larger doses of dopamine. These experiments demonstrate that there are major advantages in the use of simultaneously infused levarterenol and phentolamine for control of low-cardiac-output syndrome: increased cardiac output without elevated peripheral vascular resistance, restoration of systemic arterial pressure and consequent improved coronary flow, absence of tachycardia, and augmented renal blood flow.

Traumatic arteriovenous malformation of the external carotid arterial system.

Traumatic arteriovenous (AV) malformations of the face and scalp are rare lesions characterized by multiple endothelial-lined channels between the arterial and venous systems. If improperly managed they have a high propensity to recur, and may result in severe cosmetic deformity. Lesions should be delineated by arteriography unless small and localized. They are managed by complete excision and ligation of arterial feeding vessels. Five cases of traumatic AV malformation of the face and scalp and their management are reported.

The management of hemangiomas of the eyelid and orbit.

The growth of hemangiomas of the orbital region varies greatly; it is unpredictable. Most lesions never reach sufficient size to impair vision; a few, however, may grow sufficiently to cause disastrous complications. Nine children with complete or partial occlusion of the vision by hemangioma of one eye are reported. (Functional vision was preserved only in those patients who had early subtotal excision of the eyelid hemangioma.) Two children with complete occlusion developed amblyopia in the involved eye. One had optic nerve atrophy. One of the four children with partial occlusion of vision had a permanent decrease in visual acuity. Of the remaining three children with normal vision, two had been operatively treated early, and one had unusually rapid involution of the hemangioma. We recommend that when a child has complete or partial visual occlusion due to hemangioma, subtotal or total excision of the hemangioma should be carried out within 1 week of the onset of visual occlusion to prevent amblyopia.

Benign symmetrical lipomatosis (Madelung's disease).

Two patients with benign symmetrical lipomatosis (madelung's disease) have been followed for 7 and 9 years. Despite extensive surgical procedures, both patients have developed multiple recurrences. Lipomas and normal adipose tissue from the same patients were compared using chromatographic techniques. The lipomas contained significantly increased triglyceride fractions. Conservative surgical debulking is the recommended treatment.

Simulated metastatic carcinoma after breast reconstruction.

In two patients who had undergone mastectomies and reconstruction for breast carcinoma, suspicious lesions were noted on chest roentgenograms. Subsequent studies revealed the lesions to be shadows from the reconstructed nipples. The most frequently employed techniques for nipple reconstruction involve the grouping and overlapping of multiple local flaps which results in a round radiodensity on a roentgenogram. Patients with suspicious roentgenographic lesions after breast reconstruction should have oblique films taken to localize the lesion.

Tissue expansion.

Controlled tissue expansion began as a concept based on primitive ideas and observations. Its application to breast reconstruction has played a major role in the tissue and psychologic rejuvenation following surgery for breast carcinoma. During the last several years, controlled expansion of tissue has been applied to many other anatomic sites treating many difficult reconstructive and excisional surgeries which heretofore were either impossible or required several stages to accomplish. As experience has grown, the use of tissue expansion has become safer and has been applied to many excisional and reconstructive efforts. The future use of tissue expansion is extremely bright and limited only by the creativity of the surgeon familiar with the technique. In the future, under study is controlled expansion of bone, of nerves, and of other body parts that may prove to be valuable in the surgeon's armamentarium. The dermatologic surgeon should become familiar with the concept and practice of tissue expansion, whether or not it is used in his or her practice. By being familiar with what the reconstructive surgeon can do with tissue expansion, the dermatologist can treat entities perhaps not otherwise treated in the past. For the dermatologist experienced in cutaneous surgery, tissue expansion can be added to his armamentarium in the treatment of male pattern baldness, some local flaps, congenital nevi and larger excisions requiring serial excision in the past as well as tattoos.

Arachidonic acid metabolites: effects on inflammation of fetal rabbit excisional wounds.

Uncovered fetal rabbit excisional wounds do not exhibit any classic signs of healing; wounds covered with an impermeable cover do contract, reepithelialize, and exhibit inflammation. Prostaglandin E2 (PGE2) is elevated in amniotic fluid, acting as an immunosuppressant at the maternal-fetal interface. Full-thickness excisional wounds were made on 25-day gestational age rabbit fetuses. Half the wounds were covered with an impermeable cover. Tissue from covered, uncovered, and nonwounded fetuses was examined 72 h after wounding for arachidonic acid metabolites. Uncovered wounds had significantly (P less than or equal to 0.05) elevated levels of PGE2, PGF2 alpha, and 12-HETE versus covered wounds and control tissue. Covered wounds had significantly elevated levels of 15-HETE compared to uncovered and control tissue. The elevated PGE2 in uncovered wounds may act as a fetal immunosuppressant; covered wounds (lower PGE2) developed cellular inflammation. Further investigations of these interactions may permit modulation of adult inflammation.

Cellular inflammation of fetal excisional wounds: effects of amniotic fluid exclusion.

The development of an cellular inflammatory response secondary to mechanical wounding has not been observed previously in the fetus. The effect of amniotic fluid exclusion on the inflammatory response in fetal rabbits subjected to full-thickness dorsal excisional wounds on day 25 of gestation (term = 31-32) was examined. The fetuses were either returned immediately to the uterus; a silicone cover was sutured over the wound; or a silicone cover with a centrally located hole was sutured over the wound. Seventy-two hours after wounding, uncovered wounds (19 live fetuses) exhibited only occasional inflammatory cells. Covered wounds (14 live fetuses) showed a pronounced cellular inflammatory response. Partially covered wounds (six live fetuses) showed a peripheral, intermediate response. The findings suggest that amniotic fluid contains factors inhibitory to inflammation, which the cover effectively excludes.

Reconstruction of the breast by tissue expansion.

The use of tissue expanders has considerable merit and wide applicability in breast reconstruction. The majority of patients who have undergone conservative modified radical mastectomies in the past fifteen years can be reconstructed without extensive flap procedures. The expansion prosthesis greatly increases the number of patients who can be reconstructed simply with a submuscular prosthesis.

Tissue expansion in craniofacial surgery.

Craniofacial surgery has evolved through an era of refinement and finesse, both in techniques and in results. Tissue expansion offers an opportunity to improve the quantity and quality of tissue available for these procedures. It may also be of benefit in long-term molding of the craniofacial skeleton during growth of the child, obviating the need for multiple revisions. This adjunct to craniofacial surgery is being performed with minimal complications and results in improved appearance for the patient.

The correction of cleft palate with primary veloplasty and delayed repair of the hard palate.

Optimal repair of the cleft palate requires meticulous balance of the effects of the procedure on craniofacial growth, dentition, and speech. Aggressive, early closure of the entire palate was practiced by the senior author many years ago. Successful closure with reasonable speech was produced at the price of severe facial and dental disturbance. Patients were adversely affected for many years before the "antisurgery war-cry" of dentists and orthodontists tempered our enthusiasm. In the past 5 or 6 years, the din of speech therapists again advocating early closures has arisen. Besieged on both sides, the plastic surgeon must temper the demands of both camps, seeking the overall benefit of the patient. We believe that primary veloplasty and delayed hard-palate closure as demonstrated in this series provide superior speech with minimal deleterious side effects. The results of intravelar veloplasty, when combined with two-step closure, are especially gratifying. It is hoped that the further refinement of this technique in the past several years will improve results even further.

Rapid expansion: experimental and clinical experience.

One of the drawbacks of clinical expansion is delay of the final reconstruction and patient inconvenience. The authors have explored the physiologic response to rapid expansion in an animal model and present initial clinical experiences with three patients.

Burn management: the role of tissue expansion.

Tissue expansion has facilitated reconstruction in selected burn patients. For the past 5 years the authors have used this modality in 45 patients, reconstructing the head and neck, trunk, and extremities.

Advances in tissue expansion.

Tissue expansion offers a versatile new technique in the reconstruction of many areas of the body. The authors discuss laboratory studies that provide insight into the mechanism of the technique and present examples from clinical experience acquired over the past seven years, including applications in breast reconstruction and reconstruction of the scalp, head and neck, and extremities.

Histopathology of human expanded tissue.

In this article the authors summarize statistical data from 19 patients obtained during quantitative analysis of the thickness of expanded skin and soft tissues utilizing silicone expander procedures. Histopathologic and ultrastructural changes that take place in individual levels of expanded tissues are also illustrated.