Myofibers in tongues of Down's syndrome.

Muscle samples from the anterior part of the tongue in 15 patients with Down's syndrome (undergoing partial glossectomy), and 6 post-mortem controls, were examined histochemically. In most cases there was a Type 2 myofiber hypertrophy and preponderance, with frequent type 'grouplet' formation. In four cases examined ultrastructurally, hyperplastic, disorganized and atrophic neuromuscular junctions were seen. These preliminary ultrastructural findings suggest that synaptic morphometry could be a rewarding method of studying neuromuscular deficits in Down's syndrome.

Elevated concentrations of elements and abnormalities of neuromuscular junctions in tongue muscles of Down's syndrome.

X-ray spectrometry was used to measure the concentrations of calcium, iron, copper and zinc in tongue muscles from patients with Down's syndrome (DS) undergoing partial glossectomy. Similar measurements on samples from autopsies served as controls. Electron microscopy was used to examine neuromuscular junctions. The calcium and copper were significantly elevated and correlated in DS while the iron and zinc showed little change. The copper increase is probably connected with the known high level of Zn-Cu superoxide dismutase (SOD), coded for by chromosome 21. (In DS there is a trisomy 21). The excess of SOD may interfere with free radicals needed for excitation-contraction coupling and may be instrumental in damaging junctional membranes. The high calcium may result from such membrane damage. It is suggested that neuromuscular junction pathology, either genetic or free radical induced, may cause the tongue weakness in DS.

Surgical repair of the caudal end of the septum.

The repair of the caudal end of a severely deviated septum has been a challenge since the beginning of septum surgery. In the time of Freer and Killian, a caudal and dorsal strip was always left. Frequently, the most obvious portion of the septal deformity, the caudal end, was undisturbed and the deformity persisted. Metzenbaum, Fomon and Cottle procedures designed to correct this problem. The procedure described in this presentation utilizes the maxilla-premaxillary approach to the septum. The laporotomy of the rhinoplasty procedure is used to expose the upper lateral cartilages. These cartilages are submucously uncovered and separated from the dorsal margin of the septal cartilage. This provides complete exposure of the line of fracture usually responsible for the extreme deflection of the caudal end of the septal cartilage. A strip of cartilage including the line of fracture is removed. The caudal end is attached to the mucoperichondrium of the right side and now is completely mobile. The caudal end is placed over the maxillary spine and sutured in position by a chromic cat gut suture from the prespine fascia through the caudal edge of the septal cartilage. The upper lateral cartilages are sutured to the dorsal margin of the septum acting as a splint to hold the sections of cartilage straight and immobile until the tissues heal.

Split-thickness skin excision in severe open fractures.

Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.

Deep partial skin thickness burns: a reproducible animal model to study burn wound healing.

A reproducible deep partial skin thickness burn model using guinea-pigs to study the healing process of this injury is described. Round aluminium templates heated to 75 degrees C and applied for 5 s to the moistened, clipped and depilated dorsal skin produced the desired depth of injury. This model is applicable for the study of the three main components of the burn wound healing process: epithelialization, contraction and scar formation. It is recommended that the India ink injection technique be used to confirm the depth of the burn wound.

Phosphorous pentachloride chemical burn--a slowly healing injury.

A 51-year-old chemical engineer sustained phosphorous pentachloride partial skin thickness burns over 20 per cent of his body surface area. Although macroscopically and microscopically the wound seemed to be superficial, the course of clinical healing of this injury was very slow and painful. Retrospectively this burn should have been treated by early excision and grafting.

Silver sulphadiazine-induced haemolytic anaemia in a glucose-6-phosphate dehydrogenase-deficient burn patient.

A 20-year-old soldier sustained 35 per cent body surface area burns by open flames. He was treated with topical application of 1 per cent silver sulphadiazine (SSD) twice daily. Four days postburn he developed acute haemolytic anaemia. Withdrawal of SSD was followed by complete recovery. A glucose-6-phosphate dehydrogenase (G6PD) deficiency was proven by pathological Motulski tests. Although the hazards of SSD are well indicated by the manufacturers, there appear to be no written reports of haemolysis induced by this drug in G6PD-deficient patients.

Use of buried skin implants after recurrent failure of conventional skin grafting in a massive burn: the renewal of an old technique.

The technique of burying small pieces of skin under old granulation tissue after recurrent failure of conventional skin grafting is described in a patient with 95 per cent full skin thickness burns. This method of treatment, which was described in the past and neglected, is of value for massive burns or grafting in difficult areas. The technique is described again and the relevant literature reviewed.

Cyclosporin A treatment failed to extend skin allograft survival in two burn patients.

Prolongation of skin allograft survival by immunosuppression of burn casualties has been reported sporadically during the past two decades. Recently cyclosporin A (CycA) has been used effectively for such an indication. We report here two paediatric patients with extensive burns (85-95 per cent BSA) treated with fresh, family-related skin allografts that were rejected during CycA treatment after 14-18 days. One of these children survived while the other died with candida sepsis.

The cost of an extensive burn survival.

A 17-year-old male sustained 95 per cent body surface area burns (87 per cent full thickness skin loss). He was hospitalized in the Department of Plastic Surgery that also treats burns. After 232 days he was discharged home when he was functionally independent. He had 16 surgical procedures for excision of burn eschar and skin grafting; received a total of 128 units of blood; 899 units of fresh frozen plasma and had enteral hyperalimentation for 175 days. About 1000 physician-hours, 3000 nurse-hours, 1000 physiotherapy and occupational therapy-hours and about 250 dietician-hours were needed for his treatment. More than 1850 laboratory tests and 120 X-rays were performed, and more than 600 kg of ointment and creams were used, as well as half a ton of topical antimicrobial solutions. Ten different antibiotics were used for a total of 85 treatment days. Some 8500 m of dressing were applied with more than 6000 pieces of petroleum jelly gauze dressing. Hospitalization costs were found to be US$141,750, only 37.5 per cent of which were salaries. An analysis of these costs is given.

Chemical burn due to contact with soda lime on the playground: a potential hazard for football players.

Two football players were treated for chemical burns of their genitalia and medial thighs caused by contact with soda lime used to line a playground. The cases are reported and the unusual mechanism causing the injury is described.

How long can cryopreserved skin be stored to maintain adequate graft performance?

Skin graft preservation for the purpose of delayed application is still a basic tool in burn treatment and plastic and reconstructive surgery. As the demand for skin allografts has increased the responsibility for processing, storage and evaluation of graft performance of preserved skin has become an important issue of banking organizations. The present experiments were undertaken to determine how long can cryopreserved cadaveric skin be stored to maintain adequate graft performance? We applied a mouse recipient model, developed by us: Human cadaveric skin cryopreserved and stored for 5,6 or 7 years was grafted on Balb/c mice, and primary take was evaluated by gross observation and predetermined histologic criteria after 7 days. The results demonstrate that graft performance of cryopreserved skin decreased with time, as reflected in the lower percent of samples with high score of separate histologic criteria after prolonged storage. Nevertheless, paired comparison analysis between cryopreserved and fresh skin indicated that this decrease was not significant for storage of 5 years; whereas it was highly significant for 6 years of storage. Linear regression analysis indicated that there was no correlation between the score of the histologic criteria and storage period for upto 65 months. These results are in line with the paired comparison analysis. We feel that our in vivo model and analysis may be used as an evaluation procedure for transplantation performance of banked skin.

Terrorist bombing with a 'Molotov cocktail' inside travelling cars: an old weapon for a new burn syndrome?

The 'Molotov cocktail' terrorist weapon which is thrown into a travelling car has given a new type of injury to people who sustain massive smoke inhalation together with disfiguring burns of face, thighs, hands and chest, and post-traumatic psychological disorder. The combination of petrol ignition with the synthetic fumes inside the care is a unique occurrence with a high morbidity and mortality which is difficult to treat and to manage. We propose to show that the combination of all the above components can be defined as the 'Molotov cocktail' burn syndrome.

Costal osteomyelitis due to an electrical burn.

This article describes the case of a patient who suffered an electrical full thickness burn of the chest wall and a concomitant osteomyelitic complication of two ribs. A review of the existing literature on bone and joint changes after burns is presented. Osteomyelitis of ribs must be kept in mind while treating patients for chest wall burns.

Cryopreserved cadaveric allografts for treatment of unexcised partial thickness flame burns: clinical experience with 12 patients.

Partial thickness burns (PTB) usually heal within 3 weeks. Prevention of infection and desiccation of the wounds are crucial for optimal healing. Early tangential excision of the burn eschar and allografting prevent deepening of the burns, and are therefore advocated for treatment with the best functional and aesthetic results. For superficial partial thickness burns (SPTB) conservative use of topical antimicrobial agents with frequent dressing changes are implemented. We compared the conservative treatment for PTBs and SPTBs to grafting cryopreserved cadaveric allografts with no prior excision. Twelve patients with flame PTB areas were allografted after mechanical debridement without excision of the burn wounds. The allografts were cadaveric skin cryopreserved by programmed freezing and stored at -180 degrees C for 30-48 months. Matching burns for depth and area were treated with silver sulfadiazine (SSD) one to two times daily until healing or debridement and grafting were required. It was found that 80 per cent of the cryopreserved allografts adhered well and 76 per cent of the treated areas healed within 21 days, whereas only 40 per cent of the SSD-treated burns healed within 21 days. Partial thickness burns can be treated successfully with viable human allografts (cryopreserved cadaveric skin) with no prior surgical excision. The burn wounds heal well within 3 weeks. For deep partial thickness burns (DPTB) treatment with allografts has no advantage if they have not been previously excised.

Very deep burns of the hand due to low voltage electrical laboratory equipment: a potential hazard for scientists.

A low voltage (24 V) electrical deep burn of the hand injured a professor of applied physics when performing an experiment in his laboratory. The potential hazard of the equipment is described, the injuries are reported and the literature is reviewed.

An arbor flap: the tree-pattern flap, or how narrow may the base of a skin flap be? An experimental study.

Investigations were carried out employing pig skin flaps that were wider and shorter than the conventionally used longitudinal-rectangular flaps. The following main points summarize the findings of this experimental work. (1) Circulation flows radially through the base of the skin flap, creating a tree-foliage pattern, hence an arbor flap. (2) While a large area can survive on a narrow base and short narrow pedicle, the flap will not be viable if it has a long narrow pedicle. (3) Following initial distal necrosis of random flaps, narrowing of the base does not augment further necrosis. Therefore, to ensure good survival of a small flap, it is imperative that the flap be broadened immediately adjacent to its short narrow base, giving it a tree-foliage pattern, i.e., an arbor flap instead of a rectangular flap. In other words, very small random skin flaps should be constructed like trees and their distal ends should be broader than their bases.

Posttraumatic unilateral blepharospasm treated by selective facial neurectomy.

A patient who presented with posttraumatic ptosis of the right upper eyelid proved to be a case of unilateral blepharospasm with facial palsy of the forehead. He was successfully treated with selective facial neurectomy.

Flap and wound size tracing on polyethylene sheet.

A simple method for evaluation of size and shape of skin flap size and wound size in experimental animals and clinical cases is hereby described--marking their sizes on polyethylene sheet. The use of the compensating polar planimeter for size measurements is described.

Passing the cartilage graft through.

Cartilage grafts could be passed to their exact destination using suction-tube-needle combination so that fixation of the graft is more accurate. This is routinely used for tip grafts and dorsum of the nose grafts, and it could be used elsewhere.