Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe.

We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.

Contemporary postnatal plastic surgical management of meningomyelocele.

BACKGROUND: The goals of this study were to review the outcome of the surgical procedure and hospitalization associated with meningomyelocele repair, and to examine the results of different closure strategies. METHODS: Eighty-three consecutive patients having surgery for meningomyelocele over a ten year period form the basis of this study. Thirty-two closures with a mean defect size preoperatively of 11.5 cm(2) were performed by the neurosurgeon (ADP), and fifty-one closures with a mean defect size of 28.4 cm(2) by the plastic surgeon (MFA). RESULTS: Defects up to 12 cm(2) were closed with local advancement fasciocutaneous flaps. As defect size increased, latissimus muscle flaps were added in 30 (36%) and gluteus muscle in 16 (19%). In recent years, 18 patients (21.6%) with a mean defect of 29 cm(2) were treated with overlapping of deepithelialized fasciocutaneous flaps to add an additional layer of coverage to the dural closure. There were 9 major complications, 6 requiring reoperation. There were 10 minor wound failures managed conservatively. Mean hospital stay was 24.2 days. Re-operation increased length of stay to 45 days (p < 0.0001). Minor wound problems added 6 days to mean hospital stay. Wound failure did not correlate with either defect size or closure technique. Thoracic location was associated with increased wound failure (p < 0.05). Use of a shunt did not increase morbidity. All closures remained durable after discharge. CONCLUSIONS: Location in the thoracic area predicts major wound failure and need for reoperation. Wound complications significantly increase hospital stay. The use of a variety of techniques to achieve multi-layered closures leads to durable coverage for defects of all sizes.

Expression of inducible nitric oxide synthase in muscle flaps treated with ischemic postconditioning.

BACKGROUND/OBJECTIVE: Preconditioning has been considered promising for the treatment of ischemic flaps. In this study, the therapeutic effect of postconditioning was compared with that of preconditioning during ischemia/reperfusion (I/R) injury, and a role of inducible nitric oxide synthase (iNOS) in postconditioning treatment was also explored. METHODS: Sixty rats were randomly divided into four groups with 15 rats in each group. Ischemic injury was induced in a rat's gracilis muscle flap model. Preconditioning and postconditioning were performed respectively on the flaps in the pre-con group and the post-con group. No treatment was given to the flaps in the control group, and flaps without I/R injury were used as a sham control. Muscle viability ratio, histology, and gene expression of iNOS were examined at different time intervals (3, 12, and 18 h). RESULTS: A significantly higher survival ratio was observed in both the pre-con group (78.98 ± 3.39, 62.74 ± 3.7, and 54.42 ± 4.45 %) and the post-con group (77.42 ± 4.14, 59.74 ± 6.67, and 49.52 ± 4.13 %) than the control group (45.22 ± 3.69, 42.44 ± 3.76, and 33.2 ± 3.29 %) at 3, 12, and 18 h postoperatively (P < 0.05). There was no statistical difference between the pre-con group and the post-con group (P > 0.05). Histological examination showed delayed and attenuated tissue damage in both the pre-con group and the post-con group when compared to that of the control group. A higher expression of iNOS was observed in both the pre-con group and the post-con group than the control group and the sham group (P < 0.05). CONCLUSIONS: Significant improvement of flap survival could be achieved by both preconditioning and postconditioning treatments; however, better protection could be provided by preconditioning. The higher expression of iNOS may play an important role in the therapeutic effect of postconditioning during I/R injury.

Thumb basal joint arthroplasty using abductor pollicis longus tendon: an average 5.5-year follow-up.

PURPOSE: The goal of this study was to evaluate the 4-year minimum (5.5-y average) results of trapeziectomy and ligament reconstruction using a modified Thompson technique with the abductor pollicis longus tendon for the primary treatment of advanced-stage basal joint arthritis (Eaton stages III and IV). METHODS: We evaluated 25 thumbs in 18 patients after ligament reconstruction arthroplasty for surgical treatment of advanced thumb basal joint arthritis. Treatment consisted of piecemeal excision of the entire trapezium, ligament reconstruction and interposition using the abductor pollicis longus tendon, and 8 weeks of K-wire immobilization of the thumb metacarpal. We evaluated range of motion, lateral pinch, tip pinch, grip strength, and outcomes questionnaires including the Arthritis Impact Measurement Scales 2 Short Form before and at an average of 5.5 years after surgery. RESULTS: Seventeen of 18 patients reported excellent or good relief of pain and were satisfied with their operation, and all of the patients would have the operation again. Of the 25 thumbs, 24 adducted fully into the plane of the palm and opposed to the fifth metacarpal head. Preoperative and postoperative strength comparisons demonstrated an average increase in grip, key pinch, and tip pinch strength of 14%, 12%, and 6%, respectively. The outcomes data demonstrated noteworthy improvement in writing, buttoning a shirt, turning a key/lock, and arthritis pain categories. CONCLUSIONS: This technique restored a stable, pain-free thumb that yielded excellent strength and motion at an average of 5.5 years after the procedure. Compared with published reports of techniques that use hematoma distraction or harvest of all or part of the flexor carpi radialis tendon, this modified Thompson technique has similar pain relief, satisfaction, and motion but had less improvement in strength, which might have resulted from differences in the studied samples.

Arterialized venous flaps: a review of the literature.

The arterialized venous flaps are highly regarded in microsurgical and reconstructive surgeries based on advantages of ease of design and harvest without the need to perform deep dissection, no sacrifice of a major artery at the donor site, no limitation of the donor sites, and less donor-site morbidity. Many experimental investigations and clinical applications have been reported. However, their survivals are still inconsistent, and survival mechanisms remain controversial. In this review, we update the existing problems, experimental studies for survival mechanisms, clinical practices, and methods developed to improve their survivals.

Improvement of prearterialized venous flap survival with delay procedure in rats.

The purpose of this experimental study is to investigate the improvement in flap survival of prearterialization with delay procedure in venous flaps in rats. The transverse superficial inferior epigastric flap was utilized. Forty-six rats were randomized into four groups: group 1 as arterialized venous flaps, group 2 as venous flaps of prearterialization with delay procedure, group 3 as arterial perfusion venous flap, and group 4 as venous perfusion venous flap. Direct observation, histological analysis, and vascular perfusion examination by Indian ink injection were performed for flap assessment. The percentage of flap survival was 41.6 +/- 2.4%, 98.0 +/- 1.8%, 89.5 +/- 1.0%, and 11.3 +/- 0.8% in these four groups, respectively. Significant differences were noted between groups ( P < 0.05) except for between group 2 and group 3 ( P > 0.05). Vascular perfusion studies revealed that the Indian ink filled the entire flaps of group 2 in comparison with partially filled flaps in other groups. Histological examination showed more small vessels were observed through all layers of the flaps as well as dilated superficial veins in group 2 than those in other groups. In conclusion, prearterialization with delay procedure can improve the viability of the flap, and this method may be a strategy for flap prefabrication based on the venous network.

Immediate and delayed use of arteriovenous fistulae in microsurgical flap procedures: a clinical series and review of published cases.

In microsurgical flap procedures, creation of an arteriovenous fistula (AVF) is a technique of vein grafting where the vein graft is connected to recipient vessels as a flow-through loop prior to harvest and inset of the flap. Controversy exists whether this technique can be used as a 2-stage procedure with the loop and flap transfer accomplished in sequential operations or if the loop and flap transfer should be performed in a single operation. We performed 12 consecutive 1-stage AVF-flap procedures, with 1 flap failure. We combined this series with previously published reports to compare outcomes of 1-stage and 2-stage procedures. We found no significant difference in flap outcomes or complication rates between the 2 strategies. We conclude from our experience and this analysis that single-stage AVF-flap procedures are the optimum application of this technique.

Reconstruction of long cervical esophageal defects with the radial forearm flap.

The radial forearm flap has been used for reconstruction of the cervical esophagus most often as a patch or for circumferential repair of short defects (less than 5 cm). In the following three cases, the radial forearm flap was used to reconstruct circumferential cervical esophageal defects ranging from 5 to 12 mm in length. These procedures were successfully carried out in three patients in whom the intraoperative defect was unexpectedly large or the intra-abdominal viscera harvest would have been difficult. These patients had reliable esophageal function 8 to 24 months after surgery. We conclude that the radial forearm flap can be used for reconstruction of large circumferential defects of the cervical esophagus.

Effect of light irradiation and sex hormones on jurkat T cells: 17beta-estradiol but not testosterone enhances UVA-induced cytotoxicity in Jurkat lymphocytes.

In Eastern cultures, such as India, it is traditionally recommended that women but not men cover their heads while working in the scorching sun. The purpose of this pilot study was to determine whether there was any scientific basis for this cultural tradition. We examined the differential cytotoxic effects of ultraviolet A light (UVA) on an established T cell line treated with female and male sex hormones. CD4+ Jurkat T cells were plated in 96 well plates at 2 x 106 cells/ml and treated with 17beta-estradiol (EST) or testosterone (TE). These cells were irradiated by UVA light with an irradiance of 170 J/cm2 for 15min at a distance of 6 cm from the surface of the 96-well plate. Controls included cells not treated with hormones or UVA. The effects of EST and TE were investigated between 1 and 20 ng/mL. Cytotoxicity by fluorescein-diacetate staining and COMET assay generating single strand DNA cleavage, tail length and tail moment measurements were examined. The effect of estrogen (5ng/mL) on apoptosis and its mediators was further studied using DNA laddering and western blotting for bcl-2 and p53. We found that EST alone, without UVA, enhanced Jurkat T cell survival. However, EST exhibited a dose-related cytotoxicity in the presence of UVA; up to 28% at 20 ng/ml. TE did not alter UVA-induced cytotoxicity. Since TE did not alter cell viability in the presence of UVA further damaging studies were not performed. COMET assay demonstrated the harmful effects of EST in the presence of UVA while EST without UVA. had no significant effect on the nuclear damage. Apoptosis was not present as indicated by the absence of DNA laddering on agarose gel electrophoresis at 5ng/ml EST or TE +/- UVA. Western blot showed that estrogen down regulated bcl-2 independently of UVA radiation while p53 was down regulated in the presence of UVA treatment. EST and TE have differential effects on UVA-induced cytotoxicity in Jurkat T-lymphocyte which suggested that women may be more susceptible to the harmful effects of solar irradiation than men.

Evidence for alteration in chemical and physical properties of water and modulation of its biological functions by sunlight transmitted through color ranges of the visible spectrum-a novel study.

We investigated the changes in the properties of water when exposed to sunlight for 40 days. We hypothesize and prove that solar irradiation to water entraps electromagnetic radiation as potential energy, which becomes kinetic energy in various systems. It is postulated that photochemically-induced energy transfers, associated with individual spectral emission of visible spectrum of solar light, exert diverse influences on biological systems. Bottles of distilled water, individually wrapped in spectral-colored cellophane were exposed to sunlight and compared to an unwrapped bottle to determine chemical and physical changes as well as modifications of biological properties. Each bottle of water was named according to the color of cellophane paper with letter E (stands for exposed) as a prefix with (E-violet, E-indigo, E-blue, E-green, E-yellow, E-orange, and E-red). E-control (without wrap) was exposed to polychromatic sunlight. This study addresses two main issues viz., the chemical and physical changes in E-water and its effect on biological activities. Chemical and physical composition analysis using inductively coupled plasma atomic emission spectrometry; physical conductance by a Wheatstone Bridge type conductivity meter; osmolarity by a vapor pressure osmometer; and, salt solubility profile of 10% sodium bicarbonate were determined. Furthermore, testing the effect of E-waters on human lymphocyte proliferation, mosquito larvae hatching and seed germination determined the functional role of solar radiation through specific spectrum/s of visible light on various biological processes. We found that water exposed to visible spectral emissions of sunlight had an altered elemental composition, electrical conductance, osmolarity and salt-solubility, as well as differences in bio-modulatory effects. A gradual increase in leaching of Boron from E-violet to E-red was noted. E-indigo showed maximal increase in electrical conductance and maximal salt solubility of sodium bicarbonate. E-blue inhibited phyto-hemagglutinin-induced immune cell proliferation and mosquito larvae hatching. E-orange stimulated root elongation in seed germination. We conclude that 40-day exposure of water to specific solar spectrum changes chemical and physical properties and influences on biological activity.

Effects of static electromagnetic fields on characteristics of MG-63 osteoblasts grown in culture.

The effects of static electromagnetic fields (SEFs) on MG-63, a human osteoblast cell-line, were investigated. We examined proliferation, proline uptake and gene expression in an SEF approximately 1/728th the intensity of those previously reported. Cells were placed within an SEF apparatus (average field intensity of 0.618mT) with appropriate controls. Proliferation was measured by 3H-thymidine incorporation and showed a 34% decrease in cells exposed to SEF (P = .0001; N = 3). Proline, a major component of collagen necessary for bone formation by osteoblasts, incorporation was reduced 37% (P = 0.006; N = 3). Reverse-transcription-polymerase chain reaction revealed that collagen I, alkaline phosphatase, parathyroid hormone-receptor, and osteocalcin mRNA's were down regulated with the low intensity SEF. Exposure to very low SEFs affects the MG-63 osteoblasts in a manner that may be detrimental to bone formation.

Biochemical evaluation of serum and flexor tenosynovium in carpal tunnel syndrome.

In total, 41 consecutive patients with "idiopathic carpal tunnel syndrome" and abnormal electrophysiologic findings who underwent carpal tunnel release were studied prospectively. The focus of this investigation was the evaluation of the levels of specific chemical mediators within the serum and flexor tenosynovium of these patients. Blood was collected from these patients within 1 week prior to carpal tunnel release, and flexor tenosynovium was obtained at time of surgery. Specimens were then analyzed to determine the levels of interleukins 1 and 6, prostaglandin E(2) (PGE(2)), and malondialdehyde bis diethyl acetal. These values were compared to those of controls who had no evidence of carpal tunnel syndrome. A significant increase was noted in the serum malondialdehyde and tenosynovial levels of malondialdehyde, interleukin 6, and prostaglandin PGE(2) compared to controls. The elevated levels of these biologic factors and the absence of interleukin 1 elevation support a noninflammatory ischemia-reperfusion etiology for so-called "idiopathic carpal tunnel syndrome" that causes progressive edema and fibrosis of the tissues within the carpal canal. These findings correlate with previous histopathology reports. We believe that "idiopathic carpal tunnel syndrome" is an "-osis" not an "-itis."

Necrotizing fasciitis of the upper extremity resulting from a water moccasin bite.

Aeromonas hydrophila infection has been described as the cause of necrotizing fasciitis in patients with suppressed immune systems, burns, or trauma in an aquatic setting. We report a case in which severe necrotizing fasciitis involving hand, arm, chest, and lateral side of trunk, along with toxic shock, developed after the patient was bitten by a venomous snake. Mixed aerobic and anaerobic bacteria, including A hydrophila, were isolated from the wound culture. The patient was treated with antivenom, a diuretic regimen, broad spectrum antibiotics, and 18 separate surgical procedures. After the application of skin grafts, the wound completely healed. This case illustrates that a venomous snakebite may result in infection with A hydrophila and can cause severe necrotizing fasciitis. Early and aggressive surgical intervention should be implemented as soon as the necrotizing fasciitis is diagnosed.

Role of free radicals in necrosis of skin graft compromised with hematoma.

It has been observed previously that a hematoma affects skin flap survival adversely through free radical action. The current study was undertaken to determine whether similar mechanisms are operative in skin grafts. The experiment was divided into two parts. During part I, 2 x 2 cm2 split-thickness skin grafts (STSGs) were harvested from 18 Fischer rats and were divided randomly into three groups (each consisted of six grafts), and incubated with plasma, blood, and blood plus 70 mg deferoxamine for 48 hours respectively. Tissue samples were assayed for lipoperoxidation (malondialdehyde [MDA]), superoxide dismutase (SOD), and nitric oxide synthase (NOS). During part II, 36 STSGs were harvested and were divided randomly into three groups. The grafts were incubated as in part I for 48 hours. The STSGs were then affixed to the same dimension recipient beds created on the back of 36 inbred rats. Survival was evaluated 7 days postoperatively. The results showed that there was no significant difference in MDA and NOS levels between each incubated graft group in part I. Only the SOD level in both grafts incubated with plasma and blood plus deferoxamine were significantly higher than the grafts over blood alone (p < 0.05). During part II, there was no significant difference of the average STSG survival percentage between the groups incubated with blood and blood plus deferoxamine (35.8 +/- 6.5% and 52.0 +/- 9.5%). The survival percentage of the group incubated with plasma was 81.8 +/- 7.3%, which was significantly higher than the other two groups (p < 0.01). The authors concluded that unlike a distal flap model, the pathological importance of free radicals in survival of the STSG over a hematoma is insignificant. A more likely hypothesis, as suggested by others, is that a hematoma serves as a barrier preventing angiogenesis.

Chronic headache as a sequela of rigid fixation for craniosynostosis.

Rigid fixation has been used over the past 20 years for the long-lasting correction of traumatic and congenital craniofacial defects. It has been noted that the use of plates and screws can result in the migration of the hardware through the skull to the inner cerebral cortex where it embeds in the dura. In addition, there is controversy concerning the safety of using titanium plates in the pediatric population. We report here on an 8-year-old boy who presented to our clinic with a chronic headache after rigid craniofacial fixation using titanium plates 7 years before.

Beneficial effect of hyperbaric oxygen on island flaps subjected to secondary venous ischemia.

The potential for hyperbaric oxygen therapy (HBO) to decrease the untoward effects of a secondary ischemic event was studied in the rat superficial epigastric flap model. The secondary venous ischemic flap was created by cross-clamping the vascular pedicles for 2 h. Twenty-four hours later, the flap was reelevated and the venous pedicle was occluded for 5 h. Thirty-two rats were divided into three groups. In experimental group 1, animals received HBO treatment immediately prior to the initial flap elevation and ischemia at 2 atmosphere pressures for 90 min. In experimental group 2, the rats underwent a similar course except for a second 90-min HBO course immediately prior to the secondary venous occlusion. The rats without HBO therapy were used as controls. The results showed that all control flaps were nonviable at 1 week by clinical inspection and fluorescein injection. Complete flap survival occurred in 20% of group 1 flaps and 30.8% of group 2 flaps. Partial flap survival occurred in the rest of the flaps in these two groups, with mean survival areas of 48% and 55%, respectively. In conclusion, HBO treatments significantly increase the survival of flaps subjected to a secondary ischemia, even if administered before the primary ischemia. Administering HBO prior to secondary venous ischemia was marginal, which may be due to the effect of O(2) given by HBO not lasting longer than 5 h.