Edwardsiella tarda as a Cause for Limb- and Life- threatening Soft Tissue Infections: What All Plastic Surgeons Need to Know.

Edwardsiella tarda (ET), a Gram-negative bacterium, causes an extremely uncommon, yet highly aggressive, soft tissue infection. Although plastic surgeons are frequently involved in the primary care, debridement, and secondary reconstruction of difficult soft tissue infections, infections caused by ET have received scant attention in the plastic surgery literature, perhaps because of the rarity of occurrence. We present a case of a 58-year-old man with alcohol abuse and hepatitis C who developed an upper extremity soft tissue infection after a catfish injury, which rapidly deteriorated to cause multiorgan failure and death within 5 days of admission. We will discuss the management of this rare but potentially lethal infection as well as the review of the current literature.

Abbe Flap Reconstruction of the Upper Lip.

Reconstruction of substantial-sized upper lip defects may require an Abbe flap reconstruction to avoid excessive tightness and deformity. The design of the Abbe or lip switch flap harvested from the lower lip is important for a satisfactory aesthetic and functional result. Harvest of the flap is performed to enable a definitive inset into the defect. The video that accompanies this article depicts rotation of an Abbe flap into a philtral defect created by basal cell carcinoma excision.

Frontal Sinus Fractures: Management and Complications.

Frontal sinus fractures are relatively rare maxillofacial injuries (only 5-15% of all facial fractures). The appropriate management of frontal sinus fracture and associated pathology is controversial. Diagnosis and treatment of frontal sinus fractures has improved with the advances of high-resolution computed tomography technology. Treatment of frontal sinus fractures depends on several factors, including contour deformity of anterior table; the presence of CSF leak or air-fluid level in the sinus, likelihood of nasofrontal duct obstruction, and degree of displacement of posterior table. Nasofrontal duct patency should be checked if fracture pattern is highly suspicious of ductal injury. Cranialization is performed in cases of severely comminuted posterior wall fracture. Long-term complication of frontal sinus fracture can occur up to 10 years after initial injury or intervention; so, judicious long-term follow-up is warranted. This article presents the management and complications of frontal sinus fractures.

Chitosan as a Bone Scaffold Biomaterial.

The current standard of care for bone reconstruction, whether secondary to injury, nonunion, cancer resection, or idiopathic bone loss, is autologous bone grafting. Alternatives to autograft and allograft bone substitutes currently being researched are synthetic and natural graft materials that are able to guide bone regeneration. One promising material currently being researched is chitosan, a highly versatile, naturally occurring polysaccharide, derived from the exoskeleton of arthropods that is comprised of glucosamine and N-acetylglucosamine. Research on chitosan as a bone scaffold has been promising. Chitosan is efficacious in bone regeneration due to its lack of immunogenicity, its biodegradability, and its physiologic features. Chitosan combined with growth factors and/or other scaffold materials has proven to be an effective alternative to autologous bone grafts. Additionally, current studies have shown that it can provide the additional benefit of a local drug delivery system. As research in the area of bone scaffolding continues to grow, further clinical research on chitosan in conjunction with growth factors, proteins, and alloplastic materials will likely be at the forefront.

The Surgical Management of Nerve Gaps: Present and Future.

Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.

Radiomorphometric quantitative analysis of vasculature utilizing micro-computed tomography and vessel perfusion in the murine mandible.

Purpose Biomechanical, densitometric, and histological analyses have been the mainstay for reproducible outcome measures for investigation of new bone formation and osseous healing. Here we report the addition of radiomorphometric vascular analysis as a quantitative measure of vascularity in the murine mandible. To our knowledge this is the first description of using micro-computed tomography (micro-CT) to evaluate the temporal and spatial pattern of angiogenesis in the craniofacial skeleton. Methods The vessel perfusion technique was performed on 10 Sprague-Dawley rats using Microfil (MV-122, Flow Tech; Carver, MA). After decalcification, hemimandibles were imaged using high-resolution micro-CT. Six separate radiomorphometric vascular metrics were calculated. Results Radiomorphometric values were analyzed using three different thresholds on micro-CT. Experimentally, 1000 Hounsfield units was found to be the optimal threshold for analysis to capture the maximal vascular content of the bone. Data from seven hemimandibles were analyzed. Minimal statistical variance in each of the quantitative measures of vascularity resulted in reproducible metrics for each of the radiomorphometric parameters. Conclusions We have demonstrated that micro-CT vascular imaging provides a robust methodology for evaluation of vascular networks in the craniofacial skeleton. This technique provides 3D quantitative data analysis that differs significantly from laser Doppler and microsphere methods, which simply measure flow. This technique is advantageous over labor-intensive 2D conventional analyses using histology and X-ray microangiography. Our data establish the appropriate thresholding for optimal vascular analyses and provide baseline measurements that can be used to analyze the role of angiogenesis in bone regeneration and repair in the craniofacial skeleton.

Alteration in volumetric bone mineralization density gradation patterns in mandibular distraction osteogenesis following radiation therapy.

BACKGROUND: The use of mandibular distraction osteogenesis for tissue replacement after oncologic resection or for deformations secondary to radiotherapy could have immense therapeutic ramifications. Radiotherapy, however, drastically impairs bone healing, potentially precluding the use of mandibular distraction osteogenesis as a durable reconstructive option. The authors have previously demonstrated significantly decreased mechanical and histologic metrics of the mandibular distraction osteogenesis regenerate after 36 Gy. The authors' goal is to now investigate the effect of these same radiation dosages on bone densitometrics using micro-computed tomographic scanning. METHODS: Six Sprague-Dawley rats received 36-Gy fractionated radiotherapy sessions to the left mandible; six received none. All animals had external fixators placed, creation of osteotomies, distraction, and consolidation. Mandibles were scanned with micro-computed tomographic scanning. Volumetric density and microdensitometric measurements were analyzed. RESULTS: There was a significant difference in volumetric bone mineralization patterns in irradiated animals. Bone volume fraction and bone mineral density, however, demonstrated no significant differences. CONCLUSIONS: The authors discovered a significant increase of low mineralized, immature bone and a significant decrease of highly mineralized, mature bone in the irradiated regenerate. These findings corroborate the authors' hypothesis that radiation induces a diminution in cell function, impairing optimal bone regeneration. Overall densitometrics, however, were unchanged according to micro-computed tomographic measurements, despite documented significant changes in biomechanical and histologic metrics. An optimal radiation dose must now be sought that demonstrates a higher degree of reproducible degradation, but not irreversible destruction, in all three outcomes. Such an approach will allow formulation of therapeutic interventions designed to enhance mandibular distraction osteogenesis so that it may be used as a viable reconstructive option.