A new model for heterotopic aortic valve transplantation.

A new model for heterotopic aortic valve transplantation in the rat is described. A composite allograft with an intact aortic valve and partial mitral valve was harvested from 4-month-old (400-450 g) Long-Evans rats and grafted heterotopically into the abdominal aorta of 4-week-old (80-100 g) rats with an optimal size match. At the end of a 1-month observation period, all experimental animals were alive and all showed 100% patency of the aortic valve allografts on microscopic evaluation after death (n=40). Unlike previously used methods, the proposed model allows for the preservation of all three aortic valve cusps and a more remote placement of the anastomotic suture line from the aortic valve annulus. The use of younger recipient rats improves size match and amplifies allograft calcification. The purpose of this study was to provide an animal model to evaluate modalities of preservation and chemical treatment for aortic valves used as allografts or bioprosthesis.

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.

Management of radiation wounds.

Radiation wounds caused by newer high-voltage radiotherapy techniques are very difficult to manage. Recent developments in flap design and transfer aid the surgeon in successfully treating these difficult problems.

Sleep apnea in mandibular hypoplasia.

Obstructive sleep apnea is an insidious and potentially life-threatening disorder that is probably more prevalent than has been previously diagnosed. Since there is generally some mechanism for relief of the respiratory obstruction, this is a very successfully treatable disorder. A strong index of suspicion should be held in cases of oronasal or pharyngeal abnormalities with a potential for respiratory obstruction. Loud snoring (particularly a recent change) and daytime hypersomnolence should alert us. In-hospital sleep monitoring and arterial gas measurements can provide a definitive diagnosis.

Crescent mastopexy and augmentation.

We have defined a group of patients with a lesser degree of moderate breast ptosis whose ptosis correction is not adequately improved by augmentation alone but requires some elevation of the nipple-areola complex. We have selected the crescent excision mastopexy to provide this additional needed lift. Experience with 26 patients employing this technique has helped to define the indications and limitations for this approach. It seems to adequately provide the additional needed lift when nipple descent has been no more than 1.5 to 2 cm below the inframammary crease. Complications such as scar widening (46 percent) were reviewed, but seemed to be well tolerated by the patients.

Circumosseous wiring in facial fractures: a safe percutaneous technique.

A precise and safe method for passing percutaneous circumzygomatic and circummandibular wires is presented. The advantage of this double-wire technique is that important soft-tissue structures are protected and oral contamination is minimized.

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.

Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis.

Deep venous thrombosis and pulmonary embolus are known risks of surgery. However, the incidence of these conditions in face lift is unknown. In this study, the incidence of deep venous thrombosis/pulmonary embolus after face lift is studied and factors associated with thromboembolic complications are evaluated. One-third of the active members of the American Society for Aesthetic Plastic Surgery were randomly selected. Participating surgeons completed a one-page survey providing information on face-lift procedures during a 12-month study period. A response rate of 80 percent was achieved, with 273 of the 342 surgeons responding to the survey. A total of 9937 face-lift procedures were reported in the 1-year study period. There were 35 patients with deep venous thrombosis (0.35 percent), 14 patients with pulmonary embolus (0.14 percent), and 1 patient death in the series. Although 43.5 percent of patients underwent face lift under general anesthesia, 83.7 percent of deep venous thrombosis/pulmonary embolus events occurred with general anesthesia. For prophylaxis for deep venous thrombosis/pulmonary embolus, 19.7 percent of the surgeons used intermittent compression devices, 19.6 percent used thromboembolic disease hose or Ace wraps, and 60.7 percent used no prophylaxis. Of patients developing deep venous thrombosis/pulmonary embolus, 4.1 percent were treated prophylactically with intermittent compression devices, 36.7 percent with thromboembolic disease hose/Ace wraps, and 59.2 percent with no prophylaxis. It was found that deep venous thrombosis/pulmonary embolus after face lift is a measurable complication experienced by one of nine surgeons surveyed. Deep venous thrombosis/pulmonary embolus is more likely to occur when the procedure is performed under general anesthesia. The majority of plastic surgeons surveyed used no prophylaxis for deep venous thrombosis when performing face-lift procedures. Intermittent compression devices were associated with significantly fewer thromboembolic complications, whereas Ace wrap/thromboembolic disease hose afforded no protection against deep venous thrombosis/pulmonary embolus when used alone. In conclusion, aesthetic surgeons should consider adopting intermittent compression devices when performing face lift under general anesthesia.

The transnasal--transsphenoidal approach for pituitary surgery.

The transnasal-transsphenoidal approach for pituitary surgery is an effective procedure that benefits nicely from a team concept utilizing the expertise of both the neurosurgeon and the plastic surgeon. Experience with eleven cases is presented along with a review of historical information and a description of the surgical technique.

A simple method for preventing misplaced electrocauterization.

A small segment of universally available and inexpensive rubber catheter can be easily fitted to insulate electrocautery tips. This technique can prevent numerous thermal injuries and potential litigation arising from accidently burning adjacent tissues. The routine use of this modification in the operating room can save time, anxiety, and potential litigation by preventing misplaced cauterization.

Intralesional corticosteroid therapy for infantile hemangiomas.

Intralesional corticosteroid injections were performed in 31 hemangiomas in 30 infants aged 1 to 10 months at first injection. One to five injections were given, spaced 6 weeks apart. Lesions were located throughout the head and neck region, except one that was on the buttock. A mixture of betamethasone acetate and triamcinolone acetonide was used. Four lesions (13 percent) virtually disappeared, ten (32 percent) showed greater than 50 percent reduction in volume, ten (32 percent) showed definite but less than 50 percent reduction in volume, and seven (23 percent) showed little or no decrease in size. None showed further growth. All injections were performed without anesthesia, and there were not significant complications. We conclude that intralesional corticosteroid injections are safe and effective in properly selected infants with hemangiomas.

Flap physiology and the prediction of flap viability.

Skin flaps are classified as random, axial, musculocutaneous, or fasciocutaneous according to the anatomy by which the skin receives its blood supply. The delay phenomenon allows larger and more reliable skin flaps to be transferred but requires additional surgical procedures. Efforts to mimic the delay phenomenon by pharmacologic means have, unfortunately, been disappointing. The major recent advances in flap design and reliability have come from increased knowledge of the anatomy of skin circulation, specifically musculocutaneous and fasciocutaneous circulation. In an effort to accurately predict flap survival, various monitoring techniques have been tried. These include visual inspection of fluorescein, fluorescein photography, dermofluorometry, surface temperature readings, photoplethysmography, ultrasound Doppler flowmeters, laser Dopplers, and transcutaneous PO2 monitors. Fluorescein has proved to be consistent and reliable, and the dermofluorometer has the advantage of using smaller fluorescein doses that can be frequently repeated. The other monitoring devices each have additional advantages and disadvantages.

The use of the osteocutaneous groin flap in gunshot wounds of the hand.

Since 1972, the groin flap has been used as an excellent source of skin coverage for the hand. This flap can incorporate the underlying iliac crest to provide both soft tissue and vascularized bone for the reconstruction of complex hand injuries. Three patients who sustained gunshot wounds of the hand with loss of the thumb metacarpal and extensive soft tissue were treated with a groin flap that included the iliac crest. Bony union was rapid and thumb stability was excellent in all patients 3 months after initial reconstruction. The advantages of the osteocutaneous flap include the ability to: (1) supply vascularized bone to what is frequently a poor recipient bed for a bone graft, (2) reconstruct both soft tissue and bony defects simultaneously, and (3) be used in facilities without capability for microvascular surgery.

The effects of streptokinase on ischemic flaps.

Prolonged ischemic periods may inhibit success in microsurgical procedures. Impairment of fibrinolytic activity could be a factor contributing to this problem. Ischemic epigastric flaps in the rat were used as a model to measure the potential of streptokinase to improve blood flow and tissue survival. A moderate but statistically significant improvement in flap survival was observed and is felt to be due to the enhancement of fibrinolytic activity previously impaired by ischemia. Saline irrigation alone in control animals was found to be detrimental to flap survival. Streptokinase might prove beneficial when dealing with an ischemic replant or free flap.

The treatment of cutaneous vascular lesions with the Nd:YAG laser.

The Nd:YAG laser is well suited for the treatment of cutaneous vascular lesions. The characteristic properties of the Nd:YAG laser emissions in tissue are a high degree of penetration with low absorption by unpigmented tissue. The result is a coagulative effect on tissue containing hemoglobin with relative skin sparing. The Nd:YAG laser was used to treat 116 patients with a variety of cutaneous vascular lesions. Good to excellent results were obtained with a low complication rate for deep cavernous and capillary lesions, port wine stains, and minor vascular ectasias above the lower extremities. Minor venous ectasias and varicosities located on the lower extremities responded poorly. The Nd:YAG laser represents an efficacious tool for the treatment of difficult vascular lesions, with the exception of venous lesions of the lower extremities.