Paraformaldehyde effect on ruthenium red and lysine preservation and staining of the staphylococcal glycocalyx.

The utility of lysine in glutaraldehyde-ruthenium red fixatives for the preservation and/or staining of the fibrous staphylococci glycocalyx was improved by inclusion of paraformaldehyde. Short, 20 min prefixation times for paraformaldehyde-glutaraldehyde fixatives containing lysine, with or without ruthenium red, were compared to an extended overnight fixation. Samples were often lost in fixatives that did not contain paraformaldehyde at extended fixation times hampering the effective use of these fixatives for clinical or environmental applications. Inclusion of paraformaldehyde in the fixation with lysine permitted longer fixation times as well as stabilized the staphylococcal glycocalyx. Thus, the technical usefulness of fixatives employing lysine was significantly improved.

Superior preservation of the staphylococcal glycocalyx with aldehyde-ruthenium red and select lysine salts using extended fixation times.

The utility of lysine-based aldehyde-ruthenium red fixatives for the preservation and/or staining of the fibrous staphylococcal glycocalyx was improved by substitution of alternative forms of lysine for the free amino form. Paraformaldehyde-glutaraldehyde fixatives containing alternative lysines, with or without ruthenium red, were compared at short 20-minute prefixation times and at extended overnight fixation times. Although inclusion of paraformaldehyde made longer fixation times possible, the length of time for "safe" fixation varied per sample and could not be predicted. All alternative lysine forms permitted fixation of at least 24 hours without sample loss. The L-lysine monohydrochloride or L-lysine acetate forms permitted longer fixation times than the L-lysine free amino form, and they had comparable or better preservation of the staphylococcal glycocalyx. Thus, the usefulness of aldehyde-lysine-based fixatives with minor changes has been enhanced.

Surgical treatment of tracheomediastinal fistula from recurrent Hodgkin's lymphoma.

The role of surgery in the management of Hodgkin's disease is usually diagnostic because chemotherapy and radiation are often curative. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin's lymphoma.

Identifying motor and sensory myelinated axons in rabbit peripheral nerves by histochemical staining for carbonic anhydrase and cholinesterase activities.

Carbonic anhydrase (CA) and cholinesterase (CE) histochemical staining of rabbit spinal nerve roots and dorsal root ganglia demonstrated that among the reactive myelinated axons, with minor exceptions, sensory axons were CA positive and CE negative whereas motor axons were CA negative and CE positive. The high specificity was achieved by adjusting reaction conditions to stain subpopulations of myelinated axons selectively while leaving 50% or so unstained. Fixation with glutaraldehyde appeared necessary for achieving selectivity. Following sciatic nerve transection, the reciprocal staining pattern persisted in damaged axons and their regenerating processes which formed neuromas within the proximal nerve stump. Within the neuromas, CA-stained sensory processes were elaborated earlier and in greater numbers than CE-stained regenerating motor processes. The present results indicate that histochemical axon typing can be exploited to reveal heterogeneous responses of motor and sensory axons to injury.

Sequential connection of flaps: a logical approach to customized mandibular reconstruction.

Microsurgery has improved the success rate for reconstruction of composite defects in the head and neck. Restoration of mandibular continuity alone is not adequate for reconstruction. Replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration. There is currently no ideal osteocutaneous free flap that provides unlimited length of bone, can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible, and provides thin skin for oral lining. Combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps. In six patients, a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects. In these selected patients, the fibula provided the blood supply for the second free flap, which was placed sequentially. The distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle. This approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited, such as following head and neck surgery and radiation.

Enhancement of rehabilitation by use of implantable adjuncts with vascularized bone grafts for mandible reconstruction.

Restoration of mandibular continuity after trauma or cancer by means of vascularized bone grafts, as described by Taylor and coworkers in 1979, has become an established method of oral rehabilitation. Still considered by some an endpoint in reconstruction, we have found that the judicious application of newly described dental prosthetic materials can provide the patient with improved appearance and function associated with a fully restored mandible. Twelve patients who underwent vascularized bone grafting for mandibular reconstruction had adjunctive implantation to improve either dentition or to reconstruct the temporomandibular joint. Nine patients had dental implants to restore permanent stable dentition either by placement of the mandibular bone staple plate or osseointegrated implants. Three additional patients underwent placement of metallic condylar head prostheses placed on the vascularized bone graft at the time of transfer. These patients demonstrated good mastication and an excellent incisal opening which was maintained in the late postoperative period. Vascularized bone transfer for restoration of continuity of the mandible should not be considered an endpoint in and of itself. By using implantable dental devices to restore dentition and condylar head prostheses to improve both the aesthetic result and function of the mandible to complement the vascularized osteocutaneous flap, we can bring our patients closer to the goal of total rehabilitation. The majority of these patients would otherwise never have been offered a chance at restoration of dentition. All had beneficial effects with regard to mastication and the majority also had improved speech.

Soft-tissue reconstruction of the oral cavity.

In our early experience with head and neck reconstruction, we evaluated our results mainly by the final contour of the mandible. With further experience, the bony reconstruction has become more and more accurate, and it is the intraoral soft-tissue reconstruction that poses the continued challenge. Better preoperative and postoperative evaluation will improve our operative planning, and our results will continue to improve. We must be able to compare our cases with those of other centers by appropriately categorizing deficits into specific structures removed to allow relevant comparison of results. We should no longer accept the simple view of the oral cavity deficit as a uniform soft-tissue loss that requires nothing more than closure. Nor can we continue to accept the evaluation of postoperative results of head and neck reconstruction by a simple external photograph; rather, this must be combined with a true visual and functional assessment of the oral cavity. In this way, the combined effort of head and neck surgeons will help to advance the cause of oral cavity reconstruction as rapidly as has occurred with reconstruction of the mandible.

Management of osteoradionecrosis of the mandible.

Osteoradionecrosis (ORN) of the mandible is a severe complication that follows ionizing radiation therapy in patients undergoing treatment for head and neck cancers. The occurrence of ORN usually implies other coexisting problems and should not be thought of as a "bone only" defect. For treatment to be effective, all tissues involved must be addressed.

The lateral arm fascial free flap: its anatomy and use in reconstruction.

Free fascial transfer has been used for reconstruction of gliding surfaces of the upper and lower extremities or when thin, pliable coverage is required (hand, heel, nose, and ear). In our experience with the lateral arm fasciocutaneous flap, we have found that the fascia alone is an excellent source of tissue for free flap transfer. A thorough investigation of the microscopic, gross, and radiographic anatomy of the lateral arm fascia was undertaken by the study of 25 fresh cadavers. Vascular pathways were mapped, their locations were analyzed, and then they were correlated with the elevation, design, and transfer of the flap. The lateral arm has a large fascial component located anterior and posterior to the lateral intermuscular septum, which itself lies between the triceps and the brachialis and brachioradialis muscles. It is perfused by the posterior radial collateral artery (PRCA), one of the terminal branches of the profunda brachii. This vessel (PRCA) provides at least four fascial branches from 1 to 15 cm proximal to the lateral epicondyle, the largest of which is located an average of 9.7 cm superior to the lateral epicondyle. Fascia up to 12 x 9 cm may be used with good axial perfusion. The histologic cross sections demonstrate the complex anatomy of the fascia itself, as well as its relation to the nutrient vessels. We have applied the lateral arm fascial flap in five cases of upper extremity reconstruction. We have also found this flap valuable in preservation of underlying anatomic detail for total reconstruction of the ear and nose when local tissue and more conventional flaps were not available.

The brachioradialis forearm flap: anatomy and clinical application.

The blood supply to the brachioradialis muscle and the skin of the forearm was studied in latex-injected arms. The dominant perforator to the muscle arose from the brachial artery (27.3 percent), radial recurrent artery (33.3 percent), or radial artery (39.4 percent). In all cases, adequate perforators exist from the radial artery so that transfer as either a muscle or musculocutaneous free flap based on this vessel is possible. In 10 arms the septocutaneous perforators from the radial artery were dissected to determine the relationship between the forearm and brachioradialis flaps. Transfer of the brachioradialis muscle as a free flap or combined with the radial artery forearm flap based on the radial artery and either the venae comitantes and/or the cutaneous veins is feasible. Four clinical cases demonstrate the usefulness of this flap.

Salvage of ischemic digits using a lateral arm fascial flap.

Four patients underwent microvascular transfer of a lateral arm fascial flap to salvage severely ischemic digits by means of induction of neovascularization. The cause of the digital ischemia was direct trauma (crush injury) in one patient and chronic embolic phenomena (proximal arterial occlusion) in three patients. None of the patients had responded to traditional therapy, including treatment with one or more of the following: anticoagulation, lytic therapy, oral vasodilators, digital sympathectomy, and vein bypass grafting. Each patient underwent noninvasive (Doppler ultrasound, digital pressures, digital temperatures, vascular refill) and invasive (angiogram) vascular assessment preoperatively. After microvascular transfer of the lateral arm fascial flap, all patients reported symptomatic relief, and objective improvements were documented by both noninvasive and invasive assessment criteria. One patient developed a seroma at the donor site; another experienced a late complication of thrombosis of the flap after his wound dehisced. A 6-month follow-up evaluation demonstrated neovascular collateralization and stable improvement without regression in the remaining patients. The authors present their clinical experience and propose a treatment algorithm for patients with chronic digital ischemia.

Silicone gel infiltration of a peripheral nerve and constrictive neuropathy following rupture of a breast prosthesis.

Following rupture of a subpectoral breast prosthesis, massive amounts of silicone gel migrated into the arm of a patient. The patient developed painful paresthesias and decreased sensation in the cutaneous distribution of the superficial radial nerve. Nerve conduction studies showed both an increase in distal latency and decreased amplitude in this nerve compared with the normal opposite side. Subsequent neurolysis confirmed dense fibrosis surrounding the nerve. Silicone droplets also were observed within the thickened epineurium of the median nerve, but no electrophysiologic evidence of neuropathy occurred. Multiple debridements of the subcutaneous tissue of the arm were necessary. In one of these specimens, histologic sections demonstrated silicone gel infiltration of a subcutaneous nerve. This is the first reported case of silicone gel infiltration of a nerve and constrictive neuropathy associated with a prosthesis rupture.

Temporary ectopic implantation of an amputated penis.

A case of temporary ectopic implantation of an amputated penis to the forearm followed by subsequent return to its anatomic position is reported. The penis was amputated by a riding lawnmower, and massive contamination of the perineum and an extensive hematoma precluded immediate replantation. The penile vessels were attached to the radial artery and venae comitantes on the forearm, where it survived completely. After 4 weeks, the edema and hematoma of the perineum had resolved, and the penis was returned to its anatomic position by microsurgical technique. Arteries, veins, and nerves were repaired. The penis survived in its entirety. Return of sensation has been excellent. A urethrocutaneous fistula developed that required secondary closure with local flaps. Temporary ectopic replantation of the penis is a useful salvage procedure when the perineum is heavily contaminated or too extensively damaged for immediate replantation.

Reconstruction of lower third of face with three simultaneous free flaps.

A case of massive osteoradionecrosis is presented that required angle-to-angle resection of the mandible and replacement of skin of the chin and neck as well as the entire floor of the mouth. In this heavily irradiated patient, three microvascular free flaps were transferred in one operation. A large radial forearm flap was used to reconstruct the floor of the mouth. A second large radial forearm flap was used to reconstruct the chin and neck defects and a fibular osseous flap was used to reconstruct the mandible. All wounds healed primarily. For extremely complicated and large defects, the transfer of multiple free flaps may provide the best reconstruction.

The nasolabial fold: an anatomic and histologic reappraisal.

The nasolabial fold was analyzed by anatomic and histologic evaluation of the tissue planes that create and surround the fold. A fascial-fatty layer exists in the superficial subdermal space extending from the upper lip across the nasolabial fold to the cheek mass. The SMAS is present in the upper lip as the superficial portion of the orbicularis oris muscle. Traction on the SMAS or periosteum lateral to the nasolabial fold can deepen the fold, while traction on the fascial-fatty layer lessens the fold. The fascial-fatty layer and skin of the cheek mass are suggested as the primary ptotic elements responsible for facial aging.

The nasolabial fold: a photogrammetric analysis.

The nasolabial fold was analyzed by studying changes with aging in the nasolabial fold and adjacent soft-tissue features. Chronologic photographs were obtained from 19 older subjects, taken approximately every 10 years, from age 20 to their present age. In a separate phase of the study, facial portraits in repose and smiling were taken of young and old adult subjects with a mechanical frame used for setting an objective point of reference. Facial landmarks were identified and depth measurements were made in the anteroposterior direction. Relative lengths of selected points also were determined in the other dimensions (in the coronal plane) from photographs; these distances were normalized by using lower face length (distance from medial canthus to menton) for the vertical orientation and interpupillary distance to normalize horizontal dimensions. It was found that with aging there is anterior, lateral, and inferior displacement of the cheek mass with a resultant deepening of the nasolabial fold, while relationships between the upper lip and the fold itself remain constant. Also with age, the lateral commissure was found to move laterally, while the apparent angle of the nasolabial fold was decreased; this latter dimension was reflected by a decrease in the horizontal component of the fold length. These results support the theory that nasolabial fold deepening with age is caused by changes in the cheek mass and its support.

Short-term effect of silicone gel on peripheral nerves: a histologic study.

The effect of silicone gel on the peripheral nerve was studied in Sprague-Dawley rats. Silicone gel was placed either extraneurally (N = 36) adjacent to or injected directly in the sciatic nerve (N = 20). Nerve histology was studied every 2 weeks over a 20-week period. Extraneural silicone gel elicited an intense inflammatory response characterized initially by predominantly histiocytes with a few eosinophils, lymphocytes, and foreign-body giant cells. The cellular response peaked at 4 weeks, after which time collagen deposition increased and the thickness of the cellular infiltrate surrounding the gel decreased. The gel was temporarily contained by the inflammatory response, but throughout the time course of the study, gel migration and breakup into smaller droplets occurred. Each droplet appeared to initiate the inflammation-fibrosis cycle anew. Perineural fibrosis was marked by 20 weeks, but there was no penetration of the epineurium by the gel. Intraneurally injected silicone gel also caused a delayed, but similar inflammatory response, eventually followed by fibrosis surrounding the gel. Intraneural gel tended to remain in larger droplets and did not migrate over the duration of this study. No direct evidence of gel toxicity to peripheral nerves was observed in either the extraneural or intraneural gel groups despite the initial intense inflammatory response and subsequent fibrosis.

Elimination of the vertical scar in reduction mammaplasty.

We describe a technique to eliminate the vertical portion of the inverted-T incision in patients who have combined enlargement of the breasts and moderate to severe ptosis. Initial preoperative markings are made, placing the new nipple site at the level of the transposed inframammary crease. The nipple-areola complex is then retained on a vascularized pedicle, with major reduction of the breast tissue being done in the medial and lateral quadrants. The nipple and breast tissue are then tucked underneath the superior skin segment and placed in this new position as one would do with the umbilicus in an abdominoplasty. Excess vertical skin is removed, and horizontal excess is collected at the midline as a small dog-ear. We have found that this dog-ear reduces markedly with time, rounding out the inferior portion of the breasts. The remaining small amount of excess skin can then be removed under local anesthetic at a later date. We have performed this procedure on 20 patients, with follow-up from 6 to 24 months.

Scalp reconstruction with a prefabricated abdominal flap carried by the radial artery.

Custom prefabrication of free flaps provides an unlimited variety of applications, since flaps can be created with expendable tissues and without restriction to naturally occurring vascular territories. These principles also can be used to customize flaps that could not be completed by conventional means. We report a case of scalp reconstruction using a random-pattern abdominal flap in which a radial artery fascial flap was induced to serve as the vascular carrier. In addition to providing durable scalp coverage, the prefabricated free flap enabled salvage of an abdominal flap that would otherwise have been aborted after intermediate transfer to the forearm.

Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up.

The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12-month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3-month and 6-month evaluations, but 44 percent of the children continued to report symptoms at 12-month follow-up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re-injury, mood disorders, body-image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons.