Differences in alpha smooth muscle actin expression between fibroblasts derived from Dupuytren's nodules or cords.

Dupuytren's contracture is a fibrotic lesion of the palmar fascia that includes two distinct structures, the nodule and the cord. Histologically the Dupuytren's nodule has a high cell density with numerous myofibroblasts (alpha smooth muscle actin-expressing fibroblasts). The Dupuytren's cord has a rich connective tissue matrix containing a low density of elongated spindle-shaped fibroblasts. The cytoskeletal structures of cultured fibroblasts derived from Dupuytren's nodules and cords of surgically treated patients were studied and compared. Immunohistology showed no obvious morphological differences between Dupuytren's nodule and cord cultured cells, when focal adhesions (vinculin), intermediate filaments (vimentin), microtubules (alpha tubulin), or microfilaments (filamentous actin) were viewed. However, a greater proportion of nodule cultured cells were positive for alpha smooth muscle actin compared to cord-derived cells. The increased expression in nodule cells of alpha smooth muscle actin was confirmed by Western blot analysis. It appears that fibroblasts derived from Dupuytren's nodules or cords retain in vivo cytoskeletal characteristics, when grown in tissue culture.

Video microsurgery: evaluation of standard laparoscopic equipment for the practice of microsurgery.

Traditional microsurgery involves the use of bulky and expensive stereo microscopes that have limited portability. Recent advances in video technology have enabled the exploration of alternative visualization methods. The purpose of this study was to evaluate standard laparoscopic equipment for microvascular anastomoses. Eight surgeons completed anastomoses on rat femoral and synthetic vessels using stereo microsurgery and video microsurgery visualization systems. All surgeons had previous experience with stereo microsurgery and none had ever used video microsurgery. Data were collected on overall anastomosis and individual suture times. A sample of completed anastomoses was placed in a video database and evaluated by use of a quality rating scale (8 to 10, excellent; 6 to 7, adequate; less than 6, poor). All surgeons subjectively evaluated the video microsurgery system. A total of 48 anastomoses were completed. The average total anastomosis time for the stereo microsurgery was 1018.9 +/- 463.2 seconds versus 1738.9 +/- 460.1 seconds for the video microsurgery. The average individual suture placement time was 114.6 +/- 60.6 seconds for the stereo microsurgery versus 211.7 +/- 128.4 seconds for the video microsurgery (p < 0.05). Twenty-five of the anastomoses underwent quality review. The overall score of the stereo microsurgery group was 8.1 +/- 1.7, and the video microsurgery group had an overall score of 7.3 +/- 1.6. Survey results revealed that 75 percent of the participants thought that the video microsurgery would be useful for human operations and would improve surgeon comfort, but 87.5 percent would not use the present video microsurgery system over stereo microsurgery in their practice. Although significant differences exist in overall anastomosis and individual suture completion times, no difference was found in the overall quality. Video microsurgery could become a useful tool on the basis of surgeon ergonomics; however, optical parameters require further refinement.

Microvascular anastomosis using 2-octyl cyanoacrylate in the rat femoral artery.

Patency of the microvascular anastomosis is the most important requirement for tissue survival in free tissue transfer and in replantation. In efforts to improve on the standard suture method of microvascular anastomosis, new techniques such as limited-suture sleeve anastomoses and histoacryl glue anastomoses have been employed experimentally. However, as a result of factors such as tissue toxicity and suboptimal outcome, cyanoacrylates have not enjoyed clinical use. In addition, sleeve anastomoses continue to utilize suture, increasing the risks of intimal damage, platelet adhesion, and thrombosis. In an attempt to surmount these problems, the authors investigated the use of a new 2-octyl cyanoacrylate glue and a sutureless sleeve anastomosis. Anastomosis of 20 rat femoral arteries with a sutureless sleeve technique bonded with glue resulted in an 80% patency rate at 1 day to 3 weeks. Failures occurred in the first few attempts as the technique was evolving. These encouraging results suggest that 2-octyl cyanoacrylate may have applicability in quick, sutureless microvascular anastomoses.

Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction.

This study was performed to determine the degree of shrinkage over time in nipple projection after reconstruction. Nipple-areolar reconstruction was performed using the modified Anton-Hartrampf technique, and pigmentation was achieved with tattooing. This study looked at 28 consecutive patients with nipple reconstruction performed at The Milton S. Hershey Medical Center of the Penn State Geisinger Health Systems between September 1989 and November 1993. Two patients were lost to follow-up and 3 patients died of breast cancer. Thus, 23 patients and a total of 32 nipples were investigated. Initial measurements of nipple projection were taken 2 weeks postoperatively. Patients were followed an average of 38.7 months (range, 11-66 months). Ten patients (18 nipples) had tissue expansion and implantation for breast mound reconstruction. Thirteen patients (14 nipples) had autologous breast mound reconstruction. The mean decrease in projection of the tissue expansion and implantation group was 76.7+/-9.7%. The mean decrease in projection of the autologous reconstruction group was 64.3+/-12.1%. The mean decrease in projection for the entire group was 71.3+/-21.9%. Comparison between the two groups using a two-sample t-test showed p = 0.0047. The authors concluded that there is a significant reduction in nipple projection over time using the modified Anton-Hartrampf technique regardless of the type of breast mound reconstruction. In addition, their results also indicated that nipple projection on the breast mound reconstructed with an autologous musculocutaneous flap technique achieved a better long-term outcome. This study is potentially helpful in planning the initial size of the reconstructed nipple papule to match the opposite normal nipple. Additional studies need to be performed on other types of nipple-areolar reconstruction.

Aeromonas species isolated from medicinal leeches.

Aeromonas hydrophila infections are a recognized complication of the use of medicinal leeches. The authors performed an experiment designed to find a safe and practical way to sterilize the leech gut of pathogenic organisms. Leeches were incubated for a 12-hour period in solutions of antibiotic effective against A. hydrophila. The incubations in the antibiotic solutions failed to eradicate pathogenic bacteria from the gut of the leeches. The authors examined cultures of bacteria isolated from the guts of the commonly used Hirudo medicinalis (European leech) and found a wide variety of pathogenic organisms. A. hydrophila is widely believed to be the most common enteric pathogen, but the authors found A. sobria more frequently in their experiment. They also cultured the guts of the leech H. michaelseni recently used clinically in South Africa. A. caviae was the most common pathogen encountered in these leeches. A. caviae and A. sobria cause a spectra of disease similar to A. hydrophila. The authors endorse the current recommendation that all patients who have leech therapy for congested flaps or replants receive broad-spectrum prophylactic antibiotics. This appears to be the safest and simplest way to prevent leech-related infections.

Negative-pressure dressings as a bolster for skin grafts.

Contoured wounds needing closure with skin grafts are often located in complex anatomic regions or are in unusual positions, which make conventional skin graft stabilization techniques cumbersome and ineffective. Often after 72 hours, a skin graft covered with a bolstered dressing has poor take secondary to shear stresses, as well as hematoma formation or serum collection, negating the effectiveness of the stabilizing dressing. The Food and Drug Administration has recently approved vacuum-assisted closure (V.A.C.), an innovative technique using negative pressure, for closure of chronic wounds. This reportedly leads to enhanced granulation tissue formation and consequently more rapid reepithelialization of wounds compared with conventional packing with saline-moistened gauze. Experimental studies have demonstrated increased oxygen tension, decreased bacterial counts, and increased granulation formation occurring under negative-pressure systems. Extending the use of this concept, we have coupled skin grafting with negative-pressure dressings for closure of large, complex open wounds. Our results indicate greater than 95% graft take in all patients in this study. This technique is extremely efficacious, with increased graft take due to total immobilization of the graft, thereby limiting shear forces, elimination of fluid collections, bridging of the graft, and decreased bacterial contamination. Moreover we have noted decreased edema in rotated muscle flaps, improved contour conformity, and shortened hospitalizations.

Sensibility of finger fillet flaps on late follow-up evaluation.

Though the use of fillet flaps salvaged from damaged digits is a well-established technique to obtain soft tissue coverage for the badly injured hand, the sensibility of these flaps has not been evaluated. We examined a series of four patients who underwent digital fillet flaps following hand trauma. Static two-point discrimination measurements of the injured hand and the contralateral hand showed that all four patients retained sensibility in the fillet flap that was equal to or better than the intact skin surrounding the flap. In some cases, the sensibility of the flap was equal to the sensibility in the corresponding contralateral fingertips. No patients had complaints regarding the function of their fillet flaps as sensate coverage of major soft tissue defects.

Pre-reconstruction tattooing eliminates the need for skin grafting in nipple areolar reconstruction.

Tattooing the skin of the reconstructed breast as a prelude to reconstruction of the nipple provides a nipple areolar reconstruction that has a uniform color. There is no requirement for a skin graft donor site. Tedious tattooing of the nipple papule is avoided. It is much easier to tattoo a flat surface than a projecting papule, and this technique gives a more uniform color. We believe that this approach to nipple areolar reconstruction provides a simpler, dependable technique.

Tissue expansion of sensate skin for pressure sores.

The surgical treatment of pressure sores has improved with the development of many techniques to provide coverage of these defects. Few deliver sensate coverage. This report describes tissue expansion of back skin to provide definitive sensate coverage of a pressure sore, thereby preventing its recurrence. Follow-up of 5.5 years is presented with a review of the literature.

The role of the gastrointestinal tract in the development of burn sepsis.

Conceptualization of the gastrointestinal tract as the "motor" that drives sepsis and multiple-system organ failure has only recently been appreciated. Most of the investigation into the pathophysiology of gut-derived sepsis involves using animal models; however, some of the findings are already being corroborated in human studies. The gastrointestinal tract is a dynamic organ whose function as a front-line defense against infection needs to be appreciated. The development of lethal sepsis is a function of the microbial load and virulence, the status of the gastrointestinal barrier, and the magnitude of the host defense response. In assuming care of a critically ill patient, we must be judicious in the use of antibiotics in order to prevent intestinal overgrowth of potential pathogens. Providing proper nutrition by an enteral route (when possible) not only satisfies caloric needs but regulates the microflora and maintains the integrity of the mucosal barrier. Burn patients should receive enteral nutrition early, the first day if possible. This not only will protect the intestinal mucosa but also will blunt the hypermetabolic response following thermal injury. Lastly, the patient should not receive an excessive amount of narcotic or sedative, for these drugs have an inhibitory effect on gastrointestinal motility, encouraging bacterial overgrowth. In the near future, new therapeutic modalities may soon become available to protect and treat the compromised gastrointestinal barrier. These modalities may include, but certainly are not limited to, the use of glutamine and xanthine oxidase inhibitors to prevent stress-related injury to the gastrointestinal mucosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Soft-tissue expansion in lower extremity reconstruction.

Soft-tissue expansion in the lower extremities is typically well tolerated. The more proximal one is--that is, the closer to the thigh and buttocks--the easier and less complication prone the expansion will be. It is another valuable technique for resurfacing the lower extremity and for reconstructing defects in contour and in skin character. There are limitations to this technique, which generally is most useful in late reconstructions. Intraoperative expansion has no place in lower extremity reconstruction. Soft-tissue expansion may be limited by an unsuitable geometry or the sheer size of defects. It should not be used next to open wounds. Soft-tissue expansion offers significant advantage in that the coverage of a defect will be replaced with tissue like that lost. Seldom does one see necrosis of advanced flaps, so that there is little risk of tissue loss in using this modality. There is an excellent vascularity to the flaps and an excellent character to the skin. In addition, in this cost-conscious era, soft-tissue expansion is quite cost effective, and in many cases the procedures can be conducted on an outpatient basis with a minimum of hospitalization, if any. With care to select patients properly, design carefully, and conduct expansion in a leisurely fashion, soft-tissue expansion offers a valuable means of reconstructing both large and small lower extremity defects.