Can a Plastic Surgeon be a Department Chairman? .Really?

There is significant responsibility in being a Department of Surgery Chairman within a medical school. The Chairman is appointed by the Dean of Medicine to lead surgery in a path that serves the mission of the school. The Department of Surgery Chairman is charged with facilitating the academic, operational, and programmatic surgical initiatives of the School of Medicine. Traditionally the Chairman of Surgery has been a general surgeon but now our educational and clinical experiences have changed making traditional leadership less intuitive. Plastic surgeons appointed as current Chairman of the Department of Surgery are rare in the United States. Whereas, general surgeons may have less interaction with other surgical sub-specialties today, Plastic surgeons have more interaction crossing all disciplines of surgery. Innovation and creativity that defines our discipline, seems to fit well with Department leadership where strategic planning, vision and curriculum development, and the pursuit of academic and clinical quality remain core essentials to plastic surgery. This article is an editorial of my philosophy as a plastic surgeon leading a Department of Surgery.

Transplantation of tracheal epithelial cells onto a prefabricated capsule pouch with fibrin glue as a delivery vehicle.

OBJECTIVE: The purpose of this study was to investigate whether in vitro cultured tracheal epithelial cells can be transplanted onto a prefabricated capsule surface in vivo for possible use in tracheal reconstruction. METHODS: Tracheal epithelial cells from 12 donor inbred rats were harvested for culture and expansion. In 16 recipient inbred rats, 2 sterile cylinders made of silicone rubber were implanted in each rat bilaterally in the folds of both the left and right anterior rectus sheath by wrapping the sheaths around the cylinders to induce a capsule formation. Ten days later, the cell cultures were divided and suspended in 1 of 2 delivery vehicles (standard culture medium or fibrin glue) and implanted onto the capsule surface. To compare the 2 delivery vehicles, we used fibrin glue on one side and the standard culture medium on the other. RESULTS: After 2 (group 1, n = 8) and 4 (group 2, n = 8) weeks, histologic findings, immunohistochemical staining, and electron microscopy demonstrated the capsule to be covered with a tracheal neoepithelium in group 1 and additional ciliated cells and secretory cells in a confluent layer in group 2 but only on the side with fibrin glue as the delivery vehicle. No viable epithelial cells were identified on the side with the standard culture medium in either group. CONCLUSION: We conclude that cultured epithelial cells can be successfully transplanted onto a prefabricated capsule surface with fibrin glue, which will differentiate into morphologic, nearly normal epithelium, showing potential for tracheal reconstruction.

Hepatic fibrosis and cytochrome P450: experimental models of fibrosis compared to AHR knockout mice.

Hepatic fibrosis is characterized by abnormal collagen deposition resulting from increased collagen synthesis and decreased collagen degradation. Cytochrome P450 mediates major drug metabolizing enzyme activity in the liver and this activity is reduced in hepatic fibrosis. In this study we assess cytochrome P450 and CYP 1A mRNA in livers of animals that have been induced to hepatic fibrosis using the heterologous serum induced model of fibrosis in rats compared to controls. Fibrosis was confirmed by assessing the collagen in liver sections as quantified by Sirius red/Fast green staining, a quantitative measure of fibrosis as well as by visualization of the hepatic fibrosis. Collagen levels in the liver sections of heterologous serum induced fibrotic rats was increased by 33% compared to controls and a typical fibrotic pattern was seen. Messenger RNA was prepared from heterologous serum induced fibrotic rats and compared to controls. CYP 1A2 was assessed using a specific probe and the CYP 1A2 level was significantly reduced in the heterologous serum induced fibrotic rats compared to controls. These results further suggest that cytochrome P450 is reduced in the presence of hepatic fibrosis. Thus, in three well established experimental models of hepatic fibrosis which had clearly developed hepatic fibrosis (as shown by Sirius red/Fast green staining), cytochrome P450 mediated enzyme activity, or specifically, CYP 1A messenger RNA is decreased. We then investigated a transgenic mouse, deficient in the arylhydrocarbon hydroxylase receptor (AHR), which has undetectable levels of CYP 1A messenger RNA. We quantitated the collagen in liver sections obtained from AHR knockout mice compared to controls, as an indication of the presence of hepatic fibrosis. Collagen concentration was significantly increased by 53% (P<0.0005) in sections from Ahr-/- (knockout) mice compared to wild-type controls. Collagen in livers of the Ahr+/- heterozygous mice was not different from wild-type controls. The increase in collagen concentration in liver sections is an indication of fibrosis in Ahr-/- mice. Collagen protein deposition was also elevated in liver sections from bile duct ligated rats (by 44%) compared to sham operated controls, was elevated in liver sections from heterologous serum induced fibrosis in rats (33%) compared to controls, and was elevated in liver sections from yellow phosphorous induced hepatic fibrosis (74%) compared to vehicle treated controls. In conclusion, these results indicate that cytochrome P450 and specific subtypes of P450, the CYP 1A subgroup, are significantly reduced in three experimental models of hepatic fibrosis when there is evidence of increased collagen deposition in the livers. These results also indicate that mice that are deficient in CYP 1A have elevated levels of hepatic collagen protein, an indication of hepatic fibrosis.

Management of nonmelanoma skin tumors of the hand.

A wide variety of tumors can afflict the hand. Nonmelanoma skin tumors are common and usually benign. The most common malignant tumor of the hand is a SCC. Whether benign or malignant, these need neoplasms and are often initially symptomatic, presenting as an area of discoloration or excoriation. The tumor mass may become disfiguring or impair function. It behooves all hand surgeons to be aware of these nonmelanoma skin tumors and to secure prompt recognition and early treatment, thereby optimizing long-term results.

Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection.

The trochlea and superior oblique muscle tendon separate the medial and central fat compartments in the upper lid. The purpose of this study was to determine anatomical landmarks to predict the location of and avoid injuring the trochlea and superior oblique muscle tendon with orbital fat resection during upper blepharoplasty. The trochlea and superior oblique muscle tendon were identified in 14 cadaver heads. Bony anatomical landmarks were identified to predict the oblique vector along which the trochlea and superior oblique tendon lie. The trochlea was measured in millimeters from the palpable superior orbital foramen. The oblique course of the superior oblique muscle tendon was measured from its medial location in the lateral direction in millimeters from the frontozygomatic suture. These measurements were obtained with 4.0-power loupe magnification. The trochlea was identified 10.0 +/- 0.9 mm inferior to the palpable superior orbital foramen. The superior oblique muscle tendon coursed laterally along an oblique vector to within 1 mm of the frontozygomatic suture for all 14 dissections. The vertical vector of the superior orbital foramen was measured 15.9 +/- 1.1 mm lateral to the medial canthus. The width of the bony orbit measured 42.2 +/- 1.6 mm. In two dissections, the superior orbital foramen could not be palpated, and the latter measurements were used to predict the superior orbital foramen. This anatomical study showed that when performing orbital fat resection with upper blepharoplasty, the trochlea and superior oblique muscle tendon can be identified and avoided with the above-described bony landmarks.

Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis.

The records of 75 patients admitted with pyogenic flexor tenosynovitis at two academic centers were reviewed. The functional outcomes of patients who received intraoperative irrigation only (n = 20) and those that had both intraoperative irrigation and continuous postoperative irrigation (n = 55) were compared. There were no statistically significant differences between the outcomes in the two groups.