Recommendations for cerebrospinal fluid analysis.

Diseases of the central nervous system (CNS) mean for the human organism a potentially dangerous situation. An investigation of cerebrospinal fluid (CSF) provides important information about a character of CNS impairment in the decision-making diagnostic and therapeutic algorithm. The authors present a brief overview of available cerebrospinal fluid assays, shortened indication criteria, a recommended algorithm of CSF assessment in different suspected diseases, and a view of the external quality system. The whole portfolio of obtainable CSF methodology is further subdivided according to the adequate choice into the first and inevitable basic routine panel, and following complicated analyses of highly specialized character. The basic panel is considered for standard laboratories, the complete specialized assessment should be provided by a super-consulting laboratory.

Update: lifting the malar fat pad for correction of prominent nasolabial folds.

The malar fat pad suspension technique is a safe and effective method for rejuvenation of the aging midface. When combined with the SMAS-platysma rotation flap face-lift as a multi-vector technique, most of the changes that occur with aging are addressed and corrected in an anatomic fashion, resulting in an aesthetically pleasing result. Careful attention to the tension and position of the suspension suture enhances the improvement of the infraorbital flattening as well as correcting the excessive prominence of the nasolabial fold.

Use of lumbar periosteal turnover flaps in myelomeningocele closure.

OBJECTIVE: We report our experience with a previously undescribed method of myelomeningocele closure, which is the use of bilateral lumbar periosteal flaps as an additional tissue layer in complex cases. These flaps reinforce the dural repair, act to protect the spinal cord, and may help to contain any potential cerebrospinal fluid leak from the primary repair of the cord, thereby preventing pseudomeningocele formation. METHODS: The repair involves the development of bilateral thoracolumbar fascial flaps in conjunction with periosteal flaps, which are elevated from adjacent lumbar pedicles and transverse processes, thus forming a composite tissue flap. These periosteally based flaps may be closed in a "pants over vest" fashion to completely cover the spinal defect, reinforcing the neurosurgical repair. The flap anatomy and dissection are detailed. RESULTS: Two representative cases in which the lumbar periosteal turnover flap procedure was used are reported. One patient was operated on during the early neonatal period for primary myelomeningocele repair; the other was operated on at age 5 years after a tethered cord release. Durable, stable soft tissue coverage of the spinal cord was obtained in both patients, with a postoperative follow-up period of at least 12 months. There was no recurrence of the pseudomeningocele noted preoperatively in the second patient. CONCLUSION: The lumbar periosteal turnover flap may be used to reinforce tenuous spinal cord and dural repairs in the myelomeningocele patient. This method provides a secure and watertight closure over the primary repair of the cord, may help to contain potential cerebrospinal fluid leaks, and adds an additional autologous tissue layer to standard skin or muscle flap repairs.

The antithrombotic effects of ticlopidine and aspirin in a microvascular thrombogenic model.

In the effort to reduce a persistently significant failure rate in free tissue transfers and digital replantations, the efficacy of two oral platelet inhibitors, aspirin and ticlopidine, was examined using the arterial inversion graft, a known microvascular thrombogenic model. Forty male New Zealand White rabbits were used to create eighty 5-mm inversion grafts. Four groups were blindly given perioperative oral drug therapy: ticlopidine, aspirin, both, or neither (control). Vessel patency was evaluated at 1 hour and 1 week after surgery. The patency rate for the control group was 20 percent at 1 hour and 5 percent at 1 week. The drug-treated patency rates at 1 hour and 1 week, respectively, were 45 percent (p = 0.046) and 15 percent for ticlopidine, 35 percent and 10 percent for aspirin, and 45 percent (p = 0.046) and 20 percent for the combination therapy. This study shows that ticlopidine alone or in combination with aspirin significantly increases the 1-hour patency rates in a reliable thrombosis model, but it fails to show a significant increase in the final patency rates by either drug administered alone or in combination. The benefit in clinical microvascular surgery of either aspirin or ticlopidine is not determined by this study.

Experimental orthotopic transplantation of vascularized skeletal allografts: functional assessment and long-term survival.

Vascularized skeletal tissue allografts would greatly expand the domain of reconstructive surgery. Few studies to date have examined the functional aspects of these allografts or their long-term fate. An orthotopic transplant model of rat distal femur and surrounding muscular cuff was developed to assess graft function in fracture healing and weight bearing. Isografts (RT1l to RT1l, n = 40), weak-barrier allografts (RT1l to RT1lv, n = 40), and strong-barrier allografts (RT1l to RT1n, n = 40) were transplanted. As the histocompatibility barrier increased between the donor and recipient animals, the graft viability and performance deteriorated according to radiographic, histologic, and immunologic analyses. Administration of cyclosporine led to survival of strong-barrier allografts similar to that of isografts. A long-term study of these allografts (RT1l to RT1n) was then performed on various immunosuppressive regimens. After an initial 10-week course of cyclosporine to achieve bony union and remodeling, subsequent cessation (n = 20) or intermittent "pulsing" (n = 20) of the immunosuppressant was insufficient in maintaining graft survival. However, graft viability and function were preserved through 1 year on continuous daily cyclosporine (n = 32). There was no evidence of host renal or hepatic toxicity by serum chemistry or histologic sections. Thus long-term survival of functional skeletal allografts was achieved in this orthotopic model without significant host toxicity from immunosuppression.

Comparison of artifact from craniomaxillofacial internal fixation devices: magnetic resonance imaging.

This study compares artifact from craniomaxillofacial internal fixation devices in magnetic resonance images and examines heating and magnetic deflection effects on these devices. Stainless steel wires, microfixation plates of vitallium and titanium, and minifixation and mandibular reconstruction plates of stainless steel, vitallium, and titanium were evaluated. The plates were mounted on a dry skull and submerged in dilute copper sulfate solution. All images were obtained in duplicate by two independent, nonblinded teams of observers with a 1.5-T Signa magnetic resonance system. Each team ranked artifact size for each material by computerized measurement. The rank order of artifact size for each material within each fixation system group and between fixation groups was identical between the two teams. Bath and plate temperatures were recorded before and after imaging. Artifact production was related to hardware size and composition. Titanium hardware caused the least amount of "black-hole" artifact. Vitallium and stainless steel fixation devices of similar size produced significantly more artifact. No significant heating or magnetic deflection effects were seen with any of the fixation devices.

The effects of rigid fixation on craniofacial growth of rhesus monkeys.

A male infant rhesus monkey model was used to examine the growth effect on the craniofacial skeleton caused by osteotomy and three types of fixation: interfragmentary wiring, microplate and screw fixation, and "extensive" microplate and screw fixation. The animals (n = 12) were allowed to mature until cranial growth was at least 95 percent complete. Direct craniometric measurements were obtained and analyzed for differences in the three treated groups. A group of unoperated male animal skulls also was analyzed as controls (n = 5). A subtle visible and measurable restriction of growth in the operated area occurred in all treatment groups. Significant differences (p < 0.05) were found in only 4 of the 39 craniometric chords measured. Interfragmentary wiring showed fewer growth-restrictive effects than standard use of microfixation plates. Extensive use of rigid fixation devices caused the greatest degree of growth disturbance. Osteotomy and fixation in the infant rhesus monkey affect craniofacial growth, with the degree of growth restriction increasing with the amount of fixation hardware.

Comparison of CT imaging artifacts from craniomaxillofacial internal fixation devices.

This study compares the artifacts caused by craniomaxillofacial internal fixation devices in CT images. Mandibular reconstruction and "mini" titanium, Vitallium, and stainless steel systems, "micro" titanium and Vitallium systems, and stainless steel wires were evaluated. The hardware was placed on a nylon grid and submerged in water. CT images were obtained with both bone and soft-tissue window settings. All artifacts were compared and graded after a minimum of five observations each. The severity of "starburst" artifact was found to be related to the physical size of the fixation hardware and its composition. Titanium hardware caused the least amount of artifact. Vitallium and stainless steel fixation devices, with the exception of interfragmentary wiring, produced significantly more artifact. These results agree with theoretical predictions. The data indicate that when postoperative imaging is an important clinical consideration, (1) the least amount of implant material necessary to achieve stable fixation should be used, (2) the proximity of implant material to the area of interest should be considered, and (3) titanium implants produce less artifact than Vitallium or stainless steel implants.

An electronic device for surgical glove testing.

An electronic glove tester complying with safety regulations for electric current flow is described. In our laboratory, it was able to detect 100 percent of glove punctures caused by 4-0 and 6-0 surgical needles. When used regularly in the surgical suite, this device may help to minimize the surgeon's exposure to patients' blood and body fluids.

Augmentation mammoplasty: results of a patient survey.

A detailed survey on aesthetic augmentation mammoplasty was sent to patients who had undergone this procedure at the Massachusetts General Hospital between July 1973 and July 1991 to determine the incidence of postoperative complications after augmentation mammoplasty, and to qualify the factors related to patient satisfaction (n = 304). Surgical records of respondents were examined. After a mean follow-up of 8.2 years, there were no patients with known breast cancer or autoimmune disease after augmentation. Five implants (2.5%) were replaced due to leakage. Other complications were rare. Overall satisfaction was high and correlated inversely with capsular contracture ratings and elapsed time. Contracture ratings increased with time for silicone implants. Gel implants in the submuscular position were softer than subglandular ones after 5 years elapsed time. Most women are satisfied after augmentation mammoplasty, despite a significant incidence of capsular contracture. The incidence of other adverse effects after augmentation is low. Augmentation mammoplasty does not appear to be an inducer of autoimmune disease or of breast cancer.

Bacterial clearance capability of living skin equivalent, living dermal equivalent, saline dressing, and xenograft dressing in the rabbit.

Two new skin substitutes, Living Skin Equivalent (LSE) and Living Dermal Equivalent (DE), have recently been developed. In this experiment, the ability of the LSE and DE preparations to function as biological dressings in an acute wound model was tested. Forty full-thickness wounds were made in New Zealand White rabbits. Each wound was inoculated with 5 x 10(5) Staphylococcus aureus organisms. Twenty-four hours later, one of the following four dressings was applied: saline gauze, porcine-derived xenograft, LSE, or DE. Daily dressing changes and wound biopsies for bacterial counts were performed. At 96 hours after inoculation, split-thickness autograft was applied to all wounds. Skin graft take was assessed 5 days later. In all treatment groups, bacterial counts decreased over time (p = 0.02). At 72 and 96 hours after inoculation, wounds dressed with LSE or DE had significantly lower mean bacterial counts than wounds treated with xenograft dressing (p < 0.01). No significant differences were found among the LSE-, DE-, or saline-treated groups. Skin grafts took well in LSE- and DE-treated wounds. In conclusion, the LSE and DE were more effective than xenograft in reducing bacterial wound contamination in this model, thereby demonstrating their potential application as biological dressing materials.

Microfixation of acute orbital fractures.

Microfixation techniques were used as an adjunct to the use of miniplates and screws in the acute treatment of fractures involving the orbit in 42 patients over a 2-year period. Miniplates were used in all fractures at the Le Fort I level and at the zygomatic-frontal suture in high-energy injuries. Microfixation was used to stabilize all other fractures of the zygomatic, nasoethmoid, and frontal areas. Problems with plate visibility and objectionable palpability through thin periorbital skin were eliminated. The use of microplates allowed more precise positioning of small fragments than possible with miniplates or interfragmentary wires. Fracture reduction remained clinically stable in the frontal and nasoethmoid areas. Microplates were inadequate to resist soft tissue deforming forces along the infraorbital rim and the zygomatic arch in high-energy injuries.