Elevated levels of plasminogen activator inhibitor-1 may account for the altered fibrinolysis by keloid fibroblasts.

Using a 3-dimensional fibrin gel model system simulating fibroplasia of wound repair, we investigated the interaction between keloid fibroblasts and fibrin matrix and compared it with that of normal fibroblasts. Normal skin fibroblasts caused fibrin gel degradation under serum-free conditions, whereas keloid fibroblasts did not cause microscopically detectable gel degradation. Fibrin gel degradation occurred through plasmin-mediated fibrinolysis, which was initiated by fibroblasts exhibited high uPA but low plasminogen activator inhibitor-1 (PAI-1) activities, and transforming growth factor-beta 1 prevented fibrinolysis of normal fibroblasts by upregulating PAI-1 while downregulating uPA activities. In contrast, keloid fibroblasts exhibited an intrinsically high level of PAI-1 and a low level of uPA. This change in the ratio of activator and inhibitor activities was attributed to altered fibrin degradation by keloid fibroblasts. The PAI-1 increase was also demonstrated at the RNA level by Northern analysis. In terms of the pivotal role of the plasmin/plasminogen activator system in matrix remodeling, the elevated PAI-1 level exhibited by keloid fibroblasts may have significant consequences not only in altered fibrin degradation, but also in subsequent repair steps that lead to keloids and fibrosis.

Hair-thread tourniquet syndrome .

We have witnessed six cases of the hair-thread tourniquet syndrome, an entity characterized by strangulation of an appendage (toes, fingers, or external genitalia) by hair or hair-like fibers in the pediatric population. All six of our cases were in infants, 12 days to 5 months of age. The offending fibers were hair in three of the four patients with toe injuries and synthetic fibers from mittens in the finger cases. All six patients were treated by immediate removal of the constricting fibers, and, in spite of the worrisome appearance of the tissue distal to the constriction, all six eventually healed without significant tissue loss. A review of the literature indicated 60 similar cases of this type reported, 24 involving toes, 14 involving fingers, and 22 involving genitals. The majority of the toe and external genitalia cases were caused by hair, whereas the majority of finger strangulations were caused by thread from mittens. At greatest risk for strangulation are the middle finger and third toe, followed by the index finger and second toe. Patients with finger or penile involvement were more likely to suffer significant complications from the injuries than those patients with toe involvement. Based on our own experience and that described in the literature, we recommend prompt removal of the offending fiber, followed by prolonged conservative management of the damaged distal tissue, in the hope of maximal tissue salvage. Increased physician awareness of this syndrome is mandatory for prevention, diagnosis, and early treatment.

Cost of treating advanced leg ischemia. Bypass graft vs primary amputation.

We compared the hospital costs of 94 patients undergoing femoropopliteal bypass grafts with those of 53 patients undergoing primary amputation. The total cost of uncomplicated bypass surgery averaged +20,300, compared with +14,000 for uncomplicated below-knee amputation. However, including the cost of prosthesis and rehabilitation, the total cost of primary amputation was +20,400, equivalent to that of the bypass operation. Complications requiring revision of a bypass graft increased hospitalization by 4.5 days with the total cost rising to +28,700; complications that ended with major amputation added 15 hospitalization days and had an average cost of +42,200. In contrast, complicated below-knee amputation cost +40,600 and added 12.5 hospitalization days. There is therefore no cost-benefit in primary amputation when compared with arterial reconstruction, and cost should not be used to deny a patient the opportunity for limb salvage.

The trapezius musculocutaneous flap in head and neck reconstruction: potential pitfalls.

Defects resulting from bulky tumor resection of the head and neck region represent a reconstructive challenge. The trapezius musculocutaneous paddle flap based on the transverse cervical vessels is a useful tool for the reconstructive surgeon. Failure to recognize the variable anatomy is discussed in relation to other musculocutaneous flaps used for the purpose of head and neck reconstruction. The trapezius muscle has a variably located vasculature and diverse nomenclature. The knowledge of the variance of its anatomical vasculature is essential in the successful use of the trapezius musculocutaneous flap.

Continuous transcutaneous oxygen monitoring during an intraoperative cardiac arrest.

A transcutaneous oxygen sensor was used continuously during surgical management of a ruptured abdominal aortic aneurysm. Closed chest compression initiated for intraoperative cardiac arrest gave an inadequate cardiac output on the basis of falling PtcO2 despite transmitted femoral pulses and an excellent PaO2. This discordance provided a rationale for open cardiac massage, which increased the cardiac output and tissue perfusion (PtcO2) needed for successful resuscitation. The PtcO2 sensor provides immediate, non-invasive, and continuous information regarding tissue oxygenation. It reflects the PaO2 in hemodynamically stable patients as well as providing a sensitive indicator for inadequate cardiac output during shock. In patients undergoing cardiopulmonary resuscitation, a falling PtcO2 with an acceptable PaO2 indicates poor tissue perfusion and, in select circumstances, may warrant open cardiac massage.

Arterialized venous perfusion of composite tissue.

The results of our experiment prove that arterialized venous perfusion is a viable means of nourishing complex composite tissue without using the arterial tree. Previous laboratory findings, coupled with the results of this experiment, demonstrate that as long as proximal arterial inflow is ensured, both the arterial and venous trees need not be intact to keep tissue alive. Rather, it seems that the prerequisites for tissue survival are that at least one of the two systems be intact and that there be sufficient inflow and outflow channels available. Whether these channels are arteries or veins is probably not important. The use of properly placed efferent or afferent arteriovenous fistulas allows one system to provide both physiologic functions. Whether the efferent arterial anastomosis stays open over the long term appears to be inconsequential. Survival is ensured by either direct perfusion with oxygen delivery through the venous tree or through the eventual ingrowth of recipient vessels into the flap by way of the delay phenomena. This perfusion technique is ideally suited for tissue with an inadequate arterial tree but with an intact venous system devoid of venous valves (most veins less than 1.5 mm in diameter). A well-vascularized recipient bed capable of providing vessel ingrowth into transferred tissue may be important in the case of delayed arteriovenous fistula occlusion secondary to intimal hyperplasia; therefore, further experimental study of these flaps must be undertaken before arterialized venous flaps can be recommended for placement in recipient sites compromised due to radiation, ischemia, diabetes, or other causes of small vessel disease in the recipient bed. Although efferent arteriovenous fistulas are currently used to provide arterialized venous perfusion in selected cases of end stage arterial occlusive and vasospastic disease, perhaps their greatest role is in the management of tissue transfer with an inadequate arterial tree. Much knowledge must be gained to understand the physiologic principles and requirements for optimal perfusion. Many questions are left unanswered. For example, in those arteriovenous fistulas that narrow or occlude secondary to neointimal hyperplasia or other causes, which channels (veins or arteries?) are used for perfusion during recipient vessel growth? Can intimal hyperplasia be reversed or prevented by drug therapy and would this be advantageous? Can venous valves be made incompetent so that this technique can be used for larger vessels?(ABSTRACT TRUNCATED AT 400 WORDS)

Early ambulation after skin grafting of depressed wounds of the leg.

Silicone molds can be fitted precisely to skin grafted, depressed surgical defects of the leg and can be secured in place with a tight-fitting elastic support. The gravitational effect and resultant edema under the skin graft can be reduced. Earlier ambulation and better results than have been reported in the past can be obtained.

Galeal-pericranial flaps in head and neck reconstruction. Anatomy and application.

Head and neck deformities of congenital, traumatic, or neoplastic cause often require reconstruction. At the University of Virginia over the past 14 years, we have used galeal, temporalis fascial, and pericranial flaps to correct these defects in more than 150 patients. Dissection of these flaps on both cadavers and reconstructive patients had demonstrated new anatomic findings different from those reported in standard textbooks. The galea is the most superficial layer of fascia. The pericranium is the next tissue layer. It is continuous above and separate from the temporalis muscle fascia. We may, therefore, consider three separate fascial layers for reconstruction. A rich vascular plexus arises from branches of the external and internal carotid arteries. Blood flow is axial to the galea and temporalis fascia. Pericranium has a dual supply from peripheral axial vessels and from perforating vessels from the overlying galea. Galeal, temporalis fascial, and pericranial flaps are reliable, thin, and supple and have a good arc of rotation and minimal donor site morbidity. They may be used to cover bone, cartilage, or implants, may be folded for bulk, may be used to carry blood to poorly vascularized recipient sites, or may be used to nourish bone, cartilage, skin, and mucosal grafts. Their versatility permits a wide variety of potential applications in head and neck surgery.

Computer-assisted burn care.

The use of a computer does not take the thought process out of burn care. Rather, it provides constant user reinforcement while emphasizing key elements of burn care management.

Leech therapy: when once is not enough.

Venous congestion is a constant threat in the survival of free flaps, pedicled flaps, tissue replantations and traumatized tissue. Leech therapy has proved effective in salvaging much of these compromised tissues. To be effective, leeches must be both readily available and hungry, requirements not always easily met. Our investigation seeks to establish a means to return sated leeches to their previous unfed, hungry state for reuse. Sated leeches were purged of their blood meals by placement in 3% hypertonic saline or by gentle finger pressure, then exposed to serotonin 0 microM (control), 10 microM, 30 microM or 90 microM for 20 min. Subsequent rebiting/refeeding was observed and analysed. Leeches bathed in serotonin rebit or reattached at nearly four times the rate of unexposed leeches; 30% vs 8% respectively. Biting, however, is not refeeding. Overall, 41 leeches were treated with serotonin with four (10%) refeeding. Those that refed consumed a significantly smaller blood meal than the initial feeding; 50% +/- 47% SD vs 348% +/- 143% SD of original body weight. None of the control group refed. As a method for routinely reusing leeches, serotonin bathing cannot be recommended. In the immediate postoperative period with the sudden emergence of venous congestion requiring leech therapy, but with an inadequate number available, this 20% [corrected] refeed rate after 10 microM serotonin exposure could potentially determine the success or failure of the flap/replantation until fresh leeches are made available.

Quality assessment of tetanus prophylaxis in the wounded patient.

New guidelines on tetanus prophylaxis in wound management have been prepared by the American College of Surgeons and are available in a poster format or in bulletins. The purpose of this study was to determine the impact of these educational brochures on tetanus prophylaxis in a hospital setting. The results of this study indicate that these informational brochures and posters had insignificant impact on the quality of prophylaxis against tetanus in our hospital. Innovative programs of information exchange and quality assurance are urgently needed to improve the delivery of health care.

The impact of Indian methods for total nasal reconstruction.

The Indian art and science of total nasal reconstruction comprise the first chapter in the history of plastic surgery. Remarkably, centuries after their first use, the original Indian methods utilizing the cheek flap and median forehead flap for total rhinoplasty remain the basis for most reconstructive rhinoplastic procedures.

Reconstructive considerations for limb salvage surgery.

Tumors in the musculoskeletal system are generally treated surgically, although radiation therapy and chemotherapy have greatly improved survival statistics of patients with high-grade sarcomas of the musculoskeletal system. The mainstay in treatment of nearly every primary tumor of the musculoskeletal system is surgical resection for cure. Radiation therapy and chemotherapy continue to be important adjuvants in the overall management of musculoskeletal tumors. Functional limb salvage following radical resection is now possible in most resectable cases by placement of an alloplastic prosthesis, homograft, or autogenous bone for skeletal reconstitution, followed by well-vascularized soft-tissue coverage.

The physiologic basis for nonconventional vascular perfusion.

It is traditionally thought that the exchange of oxygen occurs only at the capillary level, with both arterial inflow and venous outflow required. However, as early as 1970, studies have indicated that significant arteriolar and venular diffusion of O2 and CO2 occurs. The precapillary and postcapillary diffusion of oxygen and carbon dioxide and their potential regulation via the Bohr effect are key elements in understanding the success of nonconventional vascular perfusion (arterialized venous, total arterial, total venous), where the capillary circulation is bypassed. In retrograde "reverse-flow" island flaps, there is an anterograde blood flow through the capillary bed, with nonconventionally reversed flow within the arterial and venous systems, respectively. The reversal of venous flow is best explained as a combination of valvular insufficiency and the existence of vein-vein bypass channels via the venae comitantes.

Efficacy of topical nitroglycerin for random-pattern skin-flap salvage.

The efficacy of topical nitroglycerin in the augmentation of random-pattern skin-flap survival was studied. Our model consisted of a standardized cranially based random skin flap on the dorsum of Sprague-Dawley rats. Nitroglycerin was delivered transdermally through a semipermeable membrane from a constant delivery system. The four study groups included preoperative and postoperative nitroglycerin, postoperative nitroglycerin, semipermeable membrane alone, and a control flap. Surviving flap areas were measured by a computer-assisted system, and groups were statistically analyzed for significance. In the rat model, treatment of a compromised random skin flap by topical nitroglycerin demonstrates no improvement in survival. In light of previous studies, this suggests a fundamental drug response difference between axial- and random-pattern skin flaps. Moreover, the use of a semipermeable membrane dressing alone showed a clear benefit (p less than 0.05) over nitroglycerin-treated and control animals.

Improving the accuracy of burn-surface estimation.

A user-friendly computer-assisted method of calculating total body surface area burned (TBSAB) has been developed. This method is more accurate, faster, and subject to less error than conventional methods. For comparison, the ability of 30 physicians to estimate TBSAB was tested. Parameters studied included the effect of prior burn care experience, the influence of burn size, the ability to accurately sketch the size of burns on standard burn charts, and the ability to estimate percent TBSAB from the sketches. Despite the ability for physicians of all levels of training to accurately sketch TBSAB, significant burn size over-estimation (p less than 0.01) and large interrater variability of potential consequence was noted. Direct benefits of a computerized system are many. These include the need for minimal user experience and the ability for wound-trend analysis, permanent record storage, calculation of fluid and caloric requirements, hemodynamic parameters, and the ability to compare meaningfully the different treatment protocols.

Successful replantation in the face of absent venous drainage: an experimental study.

Inadequate venous outflow is the factor most responsible in digital replantation failure and is a common cause of tissue loss in general. An experimental replantation model utilizing the rabbit ear was used to study the extreme example of venous congestion: absent venous drainage in the replanted part. Results of this study support the use of single arterial inflow along with an efferent AV fistula for outflow in the management of replants with absent venous drainage. Potential indications for the use of an efferent arteriovenous fistula in digital revascularization include the following: (1) the finding of distal veins too small to reanastomose, as is often the case in children and at distal levels in adults; (2) preferential destruction of distal venous structures, as commonly seen in degloving or other dorsal injuries; and (3) in the management of postreplant venous thrombosis.

Chest-wall reconstruction for spondylocostal dysostosis.

A child with respiratory insufficiency due to a lethal syndrome known as spondylocostal dysostosis is described. Severe chest-wall deformities with resultant paradoxical chest-wall motion were successfully corrected by surgical reconstruction of the right thorax. We conclude that patients with the severe lethal form of the syndrome may benefit from aggressive surgical correction of the thoracic abnormality.

Emergent reuse leech therapy: a better method.

Tissues threatened by venous congestion often can be saved by timely leech therapy. Methods to restimulate sated leeches, particularly emergently, are only poorly described in the nineteenth-century literature. Sated leeches were purged of their blood meals by (1) posterior crop incision, (2) hypertonic saline (3 percent) immersion, (3) gentle finger pressure emesis, or (4) wood ash exposure. Their ability to reattach and refeed with or without serotonin stimulation was evaluated. All 20 leeches (100 percent) purged by posterior crop incision reattached, with 75 percent refeeding. After purging again, 87 percent of these refed leeches reattached, with 46 percent refeeding for a third time. Those leeches which did not initially refeed were exposed to serotonin 10 microM with 100 percent reattaching and 40 percent refeeding. None of the leeches purged by hypertonic saline immersion regurgitation reattached or refed. A single leech purged by finger pressure emesis reattached (20 percent) but did not refeed. After exposure to serotonin, two (40 percent) of each saline and finger pressure group reattached, with neither of the hypertonic saline group refeeding, while both finger pressure-purged leeches refed, consuming a meal 38 percent (+/- 29 percent) of original meal. None of those leeches which refed would reattach or refeed a third time. None of the wood ash-purged leeches reattached or refed even with serotonin exposure. The best method of purging leeches of their blood meals for emergent reuse is by posterior crop incision. Additional refeeding behavior can be achieved by immersion in serotonin 10 microM for 20 minutes.

Scalp infections in black children: think kerion.

Treatment of tinea capitis consists of a 5-week course of griseofulvin. A 1-week course of a systemic corticosteroid may be considered in addition to griseofulvin therapy to accelerate the subsidence of inflammation in kerion lesions. Kerion is an inflammatory form of tinea capitis which may progress rapidly into a fulminant infection if untreated. This case report underscores the need for prompt recognition and appropriate treatment of this disorder.