Biological analysis of flexor tendon repair-failure stump tissue: A potential recycling of tissue for tendon regeneration.

OBJECTIVES: Re-rupture is common after primary flexor tendon repair. Characterization of the biological changes in the ruptured tendon stumps would be helpful, not only to understand the biological responses to the failed tendon repair, but also to investigate if the tendon stumps could be used as a recycling biomaterial for tendon regeneration in the secondary grafting surgery. METHODS: A canine flexor tendon repair and failure model was used. Following six weeks of repair failure, the tendon stumps were analyzed and characterized as isolated tendon-derived stem cells (TDSCs). RESULTS: Failed-repair stump tissue showed cellular accumulation of crumpled and disoriented collagen fibres. Compared with normal tendon, stump tissue had significantly higher gene expression of collagens I and III, matrix metalloproteinases (MMPs), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and insulin-like growth factor (IGF). The stump TDSCs presented both mesenchymal stem and haematopoietic cell markers with significantly increased expression of CD34, CD44, and CD90 markers. Stump TDSCs exhibited similar migration but a lower proliferation rate, as well as similar osteogenic differentiation but a lower chondrogenic/adipogenic differentiation capability, compared with normal TDSCs. Stump TDSCs also showed increasing levels of SRY-box 2 (Sox2), octamer-binding transcription factor 4 (Oct4), tenomodulin (TNMD), and scleraxis (Scx) protein and gene expression. CONCLUSION: We found that a failed repair stump had increased cellularity that preserved both mesenchymal and haematopoietic stem cell characteristics, with higher collagen synthesis, MMP, and growth factor gene expression. This study provides evidence that tendon stump tissue has regenerative potential.Cite this article: C-C. Lu, T. Zhang, R. L. Reisdorf, P. C. Amadio, K-N. An, S. L. Moran, A. Gingery, C. Zhao. Biological analysis of flexor tendon repair-failure stump tissue: A potential recycling of tissue for tendon regeneration. Bone Joint Res 2019;8:232-245. DOI: 10.1302/2046-3758.86.BJR-2018-0239.R1.

The revitalisation of flexor tendon allografts with bone marrow stromal cells and mechanical stimulation: An ex vivo model revitalising flexor tendon allografts.

OBJECTIVES: The present study describes a novel technique for revitalising allogenic intrasynovial tendons by combining cell-based therapy and mechanical stimulation in an ex vivo canine model. METHODS: Specifically, canine flexor digitorum profundus tendons were used for this study and were divided into the following groups: (1) untreated, unprocessed normal tendon; (2) decellularised tendon; (3) bone marrow stromal cell (BMSC)-seeded tendon; and (4) BMSC-seeded and cyclically stretched tendon. Lateral slits were introduced on the tendon to facilitate cell seeding. Tendons from all four study groups were distracted by a servohydraulic testing machine. Tensile force and displacement data were continuously recorded at a sample rate of 20 Hz until 200 Newton of force was reached. Before testing, the cross-sectional dimensions of each tendon were measured with a digital caliper. Young's modulus was calculated from the slope of the linear region of the stress-strain curve. The BMSCs were labeled for histological and cell viability evaluation on the decellularized tendon scaffold under a confocal microscope. Gene expression levels of selected extracellular matrix tendon growth factor genes were measured. Results were reported as mean ± SD and data was analyzed with one-way ANOVAs followed by Tukey's post hoc multiple-comparison test. RESULTS: We observed no significant difference in cross-sectional area or in Young's modulus among the four study groups. In addition, histological sections showed that the BMSCs were aligned well and viable on the tendon slices after two-week culture in groups three and four. Expression levels of several extracellular matrix tendon growth factors, including collagen type I, collagen type III, and matrix metalloproteinase were significantly higher in group four than in group three (p < 0.05). CONCLUSION: Lateral slits introduced into de-cellularised tendon is a promising method of delivery of BMSCs without compromising cell viability and tendon mechanical properties. In addition, mechanical stimulation of a cell-seeded tendon can promote cell proliferation and enhance expression of collagen types I and III in vitro.Cite this article: J. H. Wu, A. R. Thoreson, A. Gingery, K. N. An, S. L. Moran, P. C. Amadio, C. Zhao. The revitalisation of flexor tendon allografts with bone marrow stromal cells and mechanical stimulation: An ex vivo model revitalising flexor tendon allografts. Bone Joint Res 2017;6:179-185. DOI: 10.1302/2046-3758.63.BJR-2016-0207.R1.

Factors associated with improved outcomes following proximal row carpectomy: a long-term outcome study of 144 patients.

UNLABELLED: We conducted a review of 144 consecutive patients who underwent proximal row carpectomy from 1967 to 2010 for the diagnosis of wrist arthritis. At a mean follow-up of 13.4 years, patients experienced good pain relief with preservation (but not improvement) of wrist motion. A total of 17 patients (12%) required revision surgery at an average of 44.6 months. Improved pain, function, and survival outcomes were seen in those who underwent proximal row carpectomy after the age of 40, had a preoperative diagnosis of Kienbock's disease, who underwent a concomitant neurectomy procedure, patients who were non-labourers, and patients who underwent surgery after 1990. Although 45% of patients developed moderate to severe radiocapitate arthrosis postoperatively, these findings did not correlate with clinical outcomes or risk of revision surgery. Patients with type II lunate and type II and III capitate shapes had higher rates of postoperative radiocapitate arthrosis. LEVEL OF EVIDENCE: III, Prognostic.

Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions.

BACKGROUND: Several methods have been used in the management of humeral nonunions. With the advent of modern microsurgical techniques, vascularized bone grafting is becoming increasingly used to improve local biology. We report our experience in the use of a vascularized corticoperiosteal bone flap from the medial femoral supracondylar region in the treatment of recalcitrant humeral nonunions. METHODS: A retrospective review was performed of all patients treated with this technique over a 4-year period within our institution. Patient demographics, nonunion characteristics, complications, and long-term outcomes were analyzed. RESULTS: Six patients underwent vascularized periosteal graft reconstruction. Prior to this, all had failed an average of three procedures with the length of nonunion ranging from 6 to 68 months. All six nonunions healed by an average of 6.8 months (range 2-12 months). Two patients required additional secondary procedures. Functional outcome improved in all patients as adjudged by disabilities of the arm, shoulder, and hand, Mayo elbow performance, and Constant Murley scores. CONCLUSIONS: The vascularized medial femoral condyle corticoperiosteal flap provides an additional treatment option for the management of humeral nonunions.

The arterial anatomy of the medial femoral condyle and its clinical implications.

The success of vascularized bone grafts from the medial femoral condyle in various clinical applications has sparked renewed interest in the microvascular anatomy of this region. This study describes the arterial supply of the distal medial femoral condyle and its implications in harvesting vascularized bone grafts. The location, branching pattern, internal diameter, and distribution of perforators of the descending genicular artery and superior medial genicular artery in 19 fresh cadaveric lower limbs were recorded. The descending genicular artery was present in 89% and the superior medial genicular artery was present in 100% of specimens with average distances proximal to the articular surface of 13.7 cm and 5.2 cm, respectively. The average number of perforating vessels was greatest in the posterior distal quadrant of the condyle. The blood supply of the medial femoral condyle is plentiful and consistent making it a useful source for free vascularized bone grafts.

The effect of tissue culture on suture holding strength and degradation in canine tendon.

The purpose of this study was to assess tendon metabolism and suture pull-out strength after simple tendon suture in a tissue culture model. One hundred and twelve flexor digitorum profundus tendons from 28 dogs were cultured for 7, 14, or 21 days with or without a static tensile load. In both groups increased levels of matrix metalloproteinase (MMP) mRNA was noted. Suture pull-out strength did not decrease during tissue culture. While the presence of a static load had no effect on the pull-out strength, it did affect MMP mRNA expression. This tissue culture model could be useful in studying the effect of factors on the tendon-suture interface.

Contraction of collagen gels seeded with tendon cells.

Knowledge of the adaptation of the soft tissue to mechanical factors and biomolecules would be essential to better understand the mechanism of tendon injury and to improve the outcome of tendon repair. The responses to these factors could be different for the distinct types of cells in the tendon: cells from the tendon sheath, fibroblasts from the epitenon surface, or fibroblasts from the internal endotenon. In this study, we examined the mechanical and histological characteristics of the rate of contraction of the collagen gel seeded with epitenon and endotenon fibroblasts. The rate of contraction and the mechanical property of the contracted construct depend on the gel concentration and also the treatment of TGF-beta1.

Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient.

Obesity can be a contraindication for TRAM flap breast reconstruction. This study reviewed the authors' experience with free TRAM and pedicled TRAM flap breast reconstruction in the obese patient to examine the complication rates associated with each reconstructive method and to determine whether TRAM flap reconstruction can safely be used in these high-risk patients. The records of 221 consecutive TRAM flap reconstructions were reviewed. Preoperative risk factors for morbidity were noted, as well as the incidence of TRAM flap success, operative time, length of hospital stay, and postoperative complications. Patients were categorized as obese if their body mass index was greater than 25.8 kg/m2. Data were tabulated using contingency tables and analyzed using chi-squared statistics. Multiple logistic regression was used to determine risk factors for flap complications. Of the 221 patients studied, 114 patients were found to be obese (body mass index >25.8 kg/m2). Of these 114 patients, 78 were reconstructed with free TRAM flaps and 36 were reconstructed with pedicled flaps. In these obese patients, the average body mass index was 32 kg/m2 in the free TRAM and 30 kg/m2 in the pedicled TRAM flap reconstructions. There were no significant differences between groups with regard to age or preoperative risk factors. Length of hospital stay and operative time did not differ significantly between the two reconstructive methods. The average duration of follow-up was 24 months in both groups. Complications occurred in 26 percent of free TRAM flap reconstructions and 33 percent of pedicled reconstructions. There was no significant difference between reconstructive methods with regard to overall complication rates. Increasing body mass index was found to have a significant effect on free TRAM flap complications (p = 0.008) but not on pedicled TRAM flap complications. There were no partial or total flap losses in obese free TRAM flap patients; however, there was one case of total flap loss and four cases of partial flap loss in the obese pedicled TRAM flap group. The incidence of flap loss was significantly higher when pedicled TRAM flaps were used for reconstruction in obese patients (p = 0.04). Obese patients who underwent reconstruction with pedicled TRAM flaps were more likely to experience a complication if they also smoked (p = 0.001). There was no significant difference in operating time or length of stay when pedicled and free TRAM flap reconstructions in obese patients were compared. There were more cases of flap necrosis in the pedicled TRAM flap group. Free TRAM flaps may provide some benefit in reducing partial flap loss in obese patients, but overall complication rates were not significantly different between reconstructive methods. Of 114 patients, there was only one case of total reconstructive failure. From these findings, it seems that the free or pedicled TRAM flap can be used successfully for breast reconstruction in the majority of patients with obesity. Surgeons should use the technique with which they are most familiar to obtain consistent results.

Soft tissue coverage options for dorsal foot wounds.

The soft tissue of dorsum of the foot consists of a thin pliable surface that allows for significant excursion and tendon gliding. Reconstructive options must preserve these important functions and allow for reasonable contour so the patient may wear a shoe postoperatively. Special attention must be given to the mechanism of injury and overlying pathophysiology involved with each wound. Local flaps can provide adequate wound coverage in settings in which the vasculature and subcutaneous structures have been preserved. In wounds in which the regional vascularity is compromised or in which tendon and bone have been lost, a free-tissue transfer can provide for more substantial coverage. The multiple options available with free-tissue transfer allows for the possibility of composite tissue transfer, including vascularized bone or tendon, and the ability to create a sensate flap with excellent contour.

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients.

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.

Effects of 5-fluorouracil on flexor tendon repair.

This study was performed to assess the effects of a single 5-minute exposure of 5-fluorouracil (5-FU) applied topically at the time of flexor tendon repair in an attempt to reduce postoperative adhesions. The flexor digitorum profundus tendon to the long and fourth toe of Leghorn chickens was lacerated and primarily repaired using a 2-strand technique. The repair site was then exposed to a single 5-minute application of 5-FU in concentrations of 5, 25, or 50 mg/mL. Legs were casted for 3 weeks. After death the tendon was examined for the work of flexion using a tensile testing machine and examined with light microscopy, scanning electron microscopy, and transmission electron microscopy for morphologic and histologic differences in adhesion formation. Forty-seven chickens were examined. Average work of flexion values were 0.12 J for normal tendon, 0.31 J for operative controls, 0.34 J for the 5 mg/mL group, 0.15 J for the 25 mg/mL group, and 0.19 J for the 50 mg/mL group. The work of flexion was significantly reduced in the 25 and 50 mg/mL groups compared with the operative controls (p =.008 and p =.03, respectively). Histologic sections as graded by a blinded pathologist revealed decreased adhesion formation in all the 5-FU-treated animals (p <.008). Histologic examination showed that the highest concentration of 5-FU was not as effective at reducing adhesions as the 25 mg/mL dose. This appeared to be due to increasing inflammatory changes seen around and within the tendons of the 50 mg/mL group. Overall, a single intraoperative application of 5-FU at concentrations of 25 mg/mL appears to be an effective mechanism for reducing postoperative flexor tendon adhesions.

TRAM flap breast reconstruction with expanders and implants.

Breast reconstruction has become an essential part of breast cancer management. The transverse rectus abdominis myocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. There are several incidences in which the volume of autogenous tissue cannot fulfill the requirements for symmetric reconstruction, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations.

Microvascular reconstruction of the breast.

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.

Urokinase protocol for free-flap salvage following prolonged venous thrombosis.

The incidence of free-flap failure is reported at 4 to 5 percent. Often, these failures are attributed to postoperative venous thrombosis with salvage rates reported at 42 percent. The use of thrombolytics has been effective in laboratory protocols; however, there have been only case reports to substantiate their use in humans. In this study, we establish a protocol for the administration of urokinase for postoperative venous thrombosis. Upon clinical evidence of venous thrombosis, all patients were urgently returned to the operating room, where the venous anastomosis was resected and a new venous anastomosis was performed. A solution of 250,000 units of urokinase was then infused over 30 minutes through a 25-gauge butterfly inserted into the recipient artery just proximal to the arterial anastomosis. Patients were continued on a daily aspirin (325 mg). More than 600 free flaps have been performed by our group since 1990. In that group of patients, five were diagnosed with postoperative venous thrombosis. Flaps consisted of four radial forearm flaps and one free transverse rectus abdominis muscle flap. All patients were diagnosed late based upon significant changes within the flap. Thromboses were clinically apparent on postoperative days 1 through 6, with an average of 3.6 days. All five patients received urokinase as described. The average age of the patients treated was 43. There were no postoperative hematomas, blood transfusions, or bleeding complications. There were no allergic or anaphylactic reactions to the urokinase. All flaps survived (100 percent) with a mean follow-up of 27 months. The use of urokinase as described in our protocol has been an effective thrombolytic, capable of reversing clinically advanced venous thrombosis when combined with repeated venous anastomosis. We believe this protocol provides a viable option for the treatment of postoperative venous thrombosis.

The combined use of the TRAM and expanders/implants in breast reconstruction.

The transverse rectus abdominis musculocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. However, we have found several incidences when the volume of autogenous tissue cannot fulfill the requirements for symmetry, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations. Here we present our experience with the use of the TRAM flap in conjunction with expanders and saline implants. Between June 1993 and November 1996, 4 patients underwent immediate TRAM reconstruction in conjunction with saline implants or tissue expanders. In 3 patients a tissue expander was placed beneath the pectoralis muscle following the microanastomoses and prior to insetting the flap. Expansion was initiated 2 to 6 weeks postoperatively and continued over a period of 1 to 3 months. Permanent implants were placed at 3 to 4 months following the initial procedure. The final patient underwent a bilateral free TRAM with the placement of bilateral saline implants at the time of the initial reconstruction. One implant was placed beneath the pectoralis whereas the other was placed beneath the TRAM flap. Saline implants were used in all patients. The decision to use the combination of implants and TRAM flap was multifactorial and included position of donor scar in all patients, large ptotic breasts in 2 patients, request for contralateral augmentation in 2 patients, and an absence of adequate abdominal tissue in all patients. In addition, large skin deficits were present in 3 patients following mastectomy requiring the skin coverage provided by the TRAM flap. The average age of the patients was 41 years. Expanders were left in place for an average of 16 weeks. Average final implant volume was 210 cc. The average follow-up was 24 months, during which time there were no episodes of flap compromise, partial flap loss, or fat necrosis. The TRAM flap in combination with tissue expansion and implants provides an additional alternative in postmastectomy reconstruction. This technique is particularly useful in those patients in whom the need for TRAM skin coverage is combined with inadequate autogenous tissue and the patient request for large ptotic breasts.

Free versus the pedicled TRAM flap: a cost comparison and outcome analysis.

Proponents for the free TRAM flap have advocated enhanced tissue vascularity, easier inset, and limited abdominal dissection. Equal aesthetic results without increased morbidity and without the risks of microvascular surgery have been suggested by surgeons using the pedicled technique. The free TRAM flap has been criticized for its considerably higher costs. The purpose of this study was to provide a cost comparison and outcome analysis of the free versus the pedicled TRAM flap. All patients who had had a TRAM flap performed in the authors' teaching institutions between March of 1990 and April of 1995 were evaluated. Outpatient and hospital records, and hospital and surgeon billing records, were reviewed for patient demographics, TRAM technique, delayed versus immediate, operating room time, length of stay, hospital and surgeon reimbursement, and surgical complications and their costs. All patients were sent a questionnaire asking about time back to work, abdominal strength, fitness, symmetry, and satisfaction. During the 5-year period, 125 TRAM flaps were performed. Of these flaps, 72 were free flaps and 53 were pedicled. Seventy percent were immediate reconstructions regardless of the technique used. Four percent of the free and 17 percent of the pedicled TRAM flaps were bilateral. There were no significant differences between the two techniques with regard to patient age, weight, or percentage of smokers, diabetes, hypertension, or preoperative chemotherapy or radiotherapy. Average operating room time was 7 hours with both techniques either delayed or immediate. Average length of stay was 7 days with the free (immediate and delayed) and 8 days with the pedicled (immediate and delayed) technique, although the difference was not significant. Average hospital reimbursement was $5300 for both the free and pedicled TRAM patients. Average surgeon reimbursement was significantly different, with $5000 for the free and $3500 for the pedicled TRAM flap. There were no differences in the occurrence of hematoma, partial/total flap loss, wound infection, hernia/bulge, fat necrosis, deep vein thrombosis, and pulmonary embolus with regard to the technique used. The cost of the treatment of the complications was not significantly different between the two techniques. There was a significant difference in the complication rate for the free TRAM patients compared with those treated by a routine reconstructive microsurgeon versus a more occasional microsurgeon. Ninety percent of both the free and pedicled patients responded to the questionnaire. There were no statistical differences between the free flap and pedicled flap survey results. The free flap patients returned to work 9 weeks after surgery; the pedicled flap patients returned at 10 weeks. Abdominal strength and overall fitness ranged from 74 to 79 percent for both groups. Symmetry and overall satisfaction averaged 3.4 of 4 for all. Average follow-up for the survey respondents was 20 months. This study did not demonstrate any significant differences in outcome or complications between the free and pedicled TRAM flaps. A modest cost difference of $1500 occurred for the free TRAM patients. An experienced microsurgeon had significantly fewer complications with the free TRAM patients. The authors recommend that surgeons use the technique with which they are comfortable and obtain predictable results.

Total lower lip reconstruction with a sensate composite radial forearm-palmaris longus free flap and a tongue flap.

The technique of total lower lip reconstruction with a composite radial forearm-palmaris longus free flap was further refined in this report. A ventral tongue flap enhanced the lip aesthetics by recreating the vermilion. Lip suspension was enhanced by securing the palmaris tendon to the malar eminences as well as to the cut ends of the orbicularis oris muscle. The patient achieved oral continence as well as dynamic movement of the lip during speaking and swallowing.

Cranial fasciitis.

We present the clinical, roentgenographic, light-microscopic, immunohistochemical, and ultrastructural findings in two children with cranial fasciitis. A 7-year-old boy and a 3-year-old girl presented with rapidly expanding masses on the scalp. Roentgenographic studies showed erosion of the underlying cranium in one case. Both lesions showed proliferations of elongated spindle cells in a focally myxoid matrix, together with areas of hemorrhage, vascular proliferation, and chronic inflammation. Occasional cells with atypical nuclei were observed, but mitotic figures were uncommon. Immunoperoxidase studies showed negative or equivocal staining for desmin, factor VIII-associated antigen, S100 protein, and macrophage antigen. In one lesion there was focal positivity for alpha 1-antichymotrypsin, and in another lesion, some cells stained positively for smooth-muscle actin. Electron microscopy showed cells with dilated endoplasmic reticulum, bundles of microfilaments, pinocytotic vesicles, and focal external membrane material, features of myofibroblasts. Both lesions were excised and there has been no recurrence in 7 years in one case and 1 year in the other case. Cranial fasciitis is closely related to nodular fasciitis, but it has a predilection for the scalp of children. Despite its rapid growth, it has a benign clinical course and is cured by excision with or without curettage of the underlying bone. Our immunohistochemical and ultrastructural observations indicate that, like nodular fasciitis, cranial fasciitis represents a proliferation of fibroblasts and myofibroblasts.