A muscle-sparing technique for reconstruction of the defect left after excisional hip arthroplasty.

Muscle flap closure is the treatment of choice for coverage of the failed hip arthroplasty defect. Several described muscle flaps work well, but they sacrifice functioning parts of the abdominal wall or quadriceps femoris mechanisms. The authors describe the use of the tensor fascia lata musculocutaneous flap for this purpose. The technique described has been previously used successfully to reconstruct over 100 trochanteric pressure sores. This flap spares more important muscles, requires no skin graft, and exposes the deep wound well for debridement.

Pilot study analysis of the histologic and bacteriologic effects of occlusive dressings in chemosurgical peel using a minipig model.

The histologic changes associated with chemosurgery are well documented, but the data concerning the effects of occlusive dressings (adhesive tape, gauze, or ointments) is largely anecdotal. Wide differences of opinion exist as to the best method of phenol application and postpeel wound care regimen. Using a Yucatan minipig as our animal model, we studied the histologic and bacteriologic differences that various commonly used occlusive dressings have upon the initial burn depth and the subsequent healing of peeled skin. We also compared chemical peel with dermabrasion and chemabrasion. Our results showed to statistical difference in peel depth between "wet" versus "moist" phenol application or between occluded versus nonoccluded dressings. Based upon this animal model, we recommend that phenol solutions be applied moist rather than wet and that an occlusive dressing other than adhesive tape be used and maintained for a minimum of four days.

Criteria for the forehead lift.

We have developed clinically useful measurements to assist the surgeon in deciding when to do the forehead lift and where to place the incision. Also, we have reviewed our experience over the past decade and discuss the four categories and applications of forehead lifts. We use three indications for forehead lift: ptosis, creases, and previous facelift (PCP). There are four basic surgical techniques applicable to the upper face: (1) direct browlift, (2) midforehead crease incision, (3) prehairline incision, and (4) posthairline incision. We determined more accurate guidelines from measurements taken on 50 volunteers, as well as patients seeking a facelift. The line of measurement in a vertical plane extends from the midpupil to the top of the eyebrow and up to the hairline. We have found that the normal distance from the midpupil to the upper edge of the eyebrow on average is 2.5 cm and that the distance from the upper edge of the eyebrow to the hairline is approximately 5 cm on average. If the distance from pupil to brow is less than 2.5 cm, then the patient may benefit from a forehead lift. If the distance from brow to hairline is less than 5 cm, then we use a posthairline incision in females. If this same distance is greater than 5 cm in females, we advise the prehairline incision. In male patients we strongly consider direct crease incision. The direct browlift is reserved for minimal ptosis, asymmetry, or patients who wish a minimal procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

The fasciocutaneous flap: a conservative approach to the exposed knee joint.

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.

Calibrated alar base excision: a 20-year experience.

Conflicting guidelines for excisions about the alar base led us to develop calibrated alar base excision, a modification of Weir's approach. In approximately 20% of 1500 rhinoplasties this technique was utilized as a final step. Of these patients, 95% had lateral wall excess ("tall nostrils"), 2% had nostril floor excess ("wide nostrils"), 2% had a combination of these ("tall-wide nostrils"), and 1% had thick nostril rims. Lateral wall excess length is corrected by a truncated crescent excision of the lateral wall above the alar crease. Nasal floor excess is improved by an excision of the nasal sill. Combination noses (e.g., tall-wide) are approached with a combination alar base excision. Finally, noses with thick rims are improved with diamond excision. Closure of the excision is accomplished with fine simple external sutures. Electrocautery is unnecessary and deep sutures are utilized only in wide noses. Few complications were noted. Benefits of this approach include straightforward surgical guidelines, a natural-appearing correction, avoidance of notching or obvious scarring, and it is quick and simple.

Modulation of the metabolism and cytotoxicity of iododeoxyuridine by 5'-amino-5'-deoxythymidine.

In HeLa and Vero cells the antiproliferative effects of iododeoxyuridine (IdUrd) were modulated in a biphasic manner by 5'-amino-5'-deoxythymidine (5'-AdThd). Low concentrations of 5'-AdThd increased the cytotoxicity of IdUrd whereas high concentrations of 5'-AdThd were antagonistic. Opposing effects on two enzymes, thymidine kinase (EC 2.7.1.21) and thymidylate kinase (EC 2.7.4.9), account for this unusual biphasic interaction. In the case of thymidine kinase, 5'-AdThd was found to antagonize the feedback inhibition which is normally exerted by the 5'-triphosphates of thymidine and IdUrd. Consequently, 5'-AdThd increased the rate of IdUrd phosphorylation. This stimulation (deinhibition) of enzyme activity was demonstrable in cell-free extracts and with a purified preparation of thymidine kinase provided that the 5'-triphosphates of IdUrd or thymidine were present. In their absence only enzyme inhibition was detected. In intact cells this stimulatory effect of 5'-AdThd was seen as a rapidly apparent, sustained increase in the steady-state levels of the phosphorylated IdUrd metabolites. As a result, IdUrd cytotoxicity was increased. Under these conditions, 5'-AdThd did not alter the relative abundance of the mono-, di-, and triphosphates of IdUrd. However, as the concentration of 5'-AdThd was raised, the percentage of IdUrd nucleotides present as iododeoxyuridylate increased dramatically. Corresponding reductions in the incorporation of IdUrd into cellular DNA and the associated cytotoxic effects were seen. These data suggested a second site of interaction, thymidylate kinase, the enzyme responsible for the conversion of iododeoxyuridylate to the diphosphate. In experiments measuring thymidylate kinase activity in cell-free extracts, 5'-AdThd effectively inhibited the phosphorylation of iododeoxyuridylate but not that of thymidylate. Additionally, 5'-AdThd did not produce an accumulation of thymidylate in intact cells. Thus, the ability of high concentrations of 5'-AdThd to antagonize the cytotoxicity produced by IdUrd without concomitantly inhibiting the phosphorylation of thymidylate and, thereby, reducing DNA synthesis was explained. Although the modulation of IdUrd metabolism produced by 5'-AdThd was qualitatively similar in Vero and HeLa cells, key quantitative differences were evident. Thus, 100 microM 5'-AdThd stimulated the uptake of 3 microM IdUrd in Vero cells but it was inhibitory in HeLa cells. Perturbation of nucleoside metabolism by agents such as 5'-AdThd may provide an important new way to achieve selective toxicity in cancer chemotherapy.