Neuronal loss after transsection of the facial nerve: a morphological and neurophysiological study in monkeys.

Functional recovery after nerve lesions seems to depend on peripheral as well as central factors. To investigate the central neuronal loss after transsection of a pure motor nerve, the middle branch of the facial nerve on one side was transsected and immediately repaired microsurgically by epineural suturing. After a period of 6-15 months, a quantitative neurophysiological recording was made to estimate muscle response. A nerve tracer was injected into the mimic muscles innervated by the nerve to label the surviving motor neurons within the facial nucleus. The opposite side was used as the control in all cases. After the regenerative period, a mean loss of 15% of the total cell number was observed within the facial nucleus compared with the opposite side. The cell loss comprised all types of neurons. This amount of neuronal loss was followed by an even greater loss of muscle response when a quantitative neurophysiological recording was made after nerve regeneration. The results are discussed in relation to loss of nerve elements after nerve lesions and its effect on functional recovery.

Pharyngeal flaps after one- and two-stage repair of the cleft palate: a 25-year review of 520 patients.

Between 1962 and 1976, a one-stage surgical procedure was performed on 328 cases of cleft lip and palate or isolated cleft palate. From 1977 to 1986, a two-stage surgical procedure was performed on 192 patients. After one-stage repair, 22 (6.7%) required a pharyngeal flap at the age of 6 years, and 13 (7%) required a flap after two-stage repair. When the patients were 14 years or older, 56 (17%) needed a flap after one-stage repair, and 14 (24%) required a flap after two-stage repair. Two-stage repair at 24 months and 5.2 years resulted in more patients in need of pharyngeal flaps than those who had repair at 12 to 18 months and 3 years. In both groups, at age 10, the incidence of flaps was approximately 20% after closure of isolated cleft palate involving the hard palate, with 11 to 12% in patients with unilateral cleft lip and palate (UCLP) or clefts of the soft palate only, and 14 to 16% in patients with bilateral cleft lip and palate (BCLP). The pharyngeal flap was more often used in girls than in boys, especially in cases with CP only. Approximately 85% of the flaps were carried out before the age of 10 years, and only a few flaps may have been related to involution of the adenoid. The incidence of fistulas was higher after one-stage repair of cleft lip and palate (CLP) (p < .05) and lower in patients with CP only (p < .05), compared with the results after two-stage repair. Pharyngeal flaps were slightly more common after two-stage repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrin glue: its use for skin grafting of contaminated burn wounds in areas difficult to immobilize.

A human fibrin glue was used in patients with burns for fixation of skin grafts on slightly infected wounds in the axillas, perineum, and the gluteal folds. These areas had been left open after previous skin transplantations. There was stable and safe adhesion and little inflammatory reaction between the graft and the recipient area, resulting in favorable conditions for graft incorporation. By using the glue the last wounds in our patients healed earlier, and the patients' general condition improved.

Argon laser treatment of port-wine stains: the patients' evaluations of the result.

The argon laser is now a well-established method of treating port-wine stains (PWS) in the face and neck areas. Satisfactory results are reported in 44 to 75 percent of cases, but criteria for that classification and the patients' perceptions of the result are seldom given. In the present paper, a sample of 58 patients was used to assess the patients' own perceptions of the degree of lightening and scarring. Three felt the results were excellent, 23 good, 18 fair, and 14 poor. The treatment was considered as unpleasant by 76 percent, and 55 percent of the patients asked for a new consultation. Scarring was noticed by 50 percent. The patients' perceptions of the results and physicians' rating were the same in 69 percent. The best results were obtained in older patients with small port-wine stains. Such lesions also can be treated surgically with good results.

Experimental dynamic cardiomyoplasty in sheep.

To evaluate electrically stimulated muscle grafts for augmenting ventricular function in cardiac insufficiency, dynamic cardiomyoplasty was performed in nine sheep, using latissimus dorsi (LD) muscle wrapped as a pedicle around the left ventricle. Beginning 2 weeks postoperatively, LD was stimulated synchronously with the heart. After 6 and 12 weeks of stimulation, hemodynamic evaluation was done and biopsies were taken for histochemical and biochemical analysis. With intact heart function, stimulation of the muscle was not hemodynamically beneficial. During induced heart failure, cardiomyoplasty increased cardiac output by 25% in two sheep. Eight LD muscles contracted vigorously in synchrony with the heart, one was fibrosed and all were fixed to the thoracotomy incision by scar tissue. ATPase stain showed gradual transformation of muscle fibers into fatigue-resistant Type I. At 12 weeks only Type I were seen. Quantitative enzymatic analyses revealed increase in oxidative and decrease in glycolytic enzymes. Chronic electrical stimulation is concluded to change the muscle characteristics towards those of mainly oxidative and fatigue-resistant muscle, thereby improving opportunities for assisting the depressed heart. Dynamic cardiomyoplasty involves risks of adhesions to adjacent tissues and muscle trauma from chronic stimulation.

Osteocutaneous grafting from the forearm to the foot. Case report.

A vascularised osteocutaneous flap from the forearm was transferred to a crushed forefoot after a motorbike accident. Rapid bone formation and good coverage of the wound led to normal walking within nine months. This method can overcome the difficult problem of metatarsal bone and soft tissue loss and confers considerable benefit on the patient.

Angiographic findings and need for amputation in high tension electrical injuries.

Because it is difficult to estimate the extent of deep tissue injury clinically, angiography was carried out in 28 patients with signs of damage from current flow through the body. Eight of the arteriograms showed normal extremities, 6 showed changes of small arteries, and 38 showed injury to the main arteries. In the latter group there were 24 total arterial occlusions, narrow irregular lumens in 10, and 4 had occlusion and distal refilling. Changes in the main arteries were most often seen near major joints where the internal body resistance as well as the density of the current are higher. Injury to the main arteries resulted in severe neuromuscular damage or amputation of the limb, whereas injury to small arteries resulted in little functional deficit. Of the 25 amputations 19 were at the level of the arterial occlusion. Spasmolytic drugs did not increase filling. We conclude that early angiography is valuable for the detection of deep injury and often indicates the level of adequate amputation or the need for immediate exploration. In some patients it indicates the necessity for arterial reconstruction.

Cross-face nerve grafting followed by free muscle transplantation in young patients with long-standing facial paralysis. Reanimation of the cheek and the angle of the mouth.

For reanimation of the cheek in 8 young patients with long-standing facial palsy a method with cross-face nerve grafting followed by free muscle transplantation has been used. The sural nerve was used as nerve graft and placed in a subcutaneous tunnel across the face. In the normal cheek 3-4 fascicles of the nerve were anastomosed to facial nerve branches innervating muscles elevating the angle of the mouth. Four to 13 months later the extensor digitorum brevis muscle to the second toe or the palmaris longus was transplanted to the paralysed cheek. It was attached between the zygomatic arch and the angle of the mouth. The end of the nerve was sutured to the muscle after taking a biopsy. The follow-up period has been 7-30 months. At 7 months 6 patients had positive EMG, either on voluntary movement or on stimulation of the contralateral facial nerve. Three of them had also a slight movement in the cheek. Two patients are as yet only 7 months postoperative. In the remaining two cases, No. 2 and 4, there were no signs of reinnervation. At 18 months 4 out of 6 patients had a synchronous natural contraction in the cheek giving increased balance to the mouth. These patients had a positive EMG. In patients No. 2 and 4 there was neither innervation nor improvement. At 30 months there was additional improvement in two cases but as previously in patients No. 2 and 4 there was neither improvement nor signs of innervation of the muscle on the EMG. The other 4 patients have not reached this postoperative stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Freely transplanted peroneus longus muscle in the cat reinnervated by a single nerve: physiological properties.

Physiological properties (tetanic tension, single twitch, fatigability) of free autologous muscle transplants in cats were examined in vivo five months after transplantation. After 2 weeks denervation the peroneus longus muscle was placed isometrically in the abdomen with the omentum around the muscle and with the proximal end of a cut branch of the femoral nerve attached to the muscle. (In one case a sensory nerve was used.) Five months after transplantation the function of the muscle was controlled in vivo by nerve stimulation. In the case when a sensory nerve was connected to the muscle no contraction was obtained upon indirect or direct stimulation. All the other muscles contracted when the nerve was stimulated. The mean maximum tetanic tension was 16% of the mean for the control. The twitch-time was about the same as in the control muscle but the contraction time was longer and the half relaxation time shorter compared with the control. The transplanted muscles fatigued more slowly than the normal peroneus longus muscles. In spite of the unphysiological placement of the muscles in the abdomen where they have no natural function to fulfil, they became reinnervated and contracted as late as five months after transplantation.

Formation of neuromuscular junctions in transplanted peroneus longus muscles in the rat. A quantitative comparison with reinnervation of the muscle in situ.

The formation of neuromuscular junctions in free heterotopic muscle transplants in the rat has been studied quantitatively and compared with the reinnervation of the muscle in situ. The AChE-containing area and the nerve terminal were stained in the same longitudinal section and the length of end-plate, the average number of nerve terminal branch points within the end-plate and the terminal innervation ratio (TIR) were determined. In denervated muscles we noticed early disappearance of nerves whereas the AChE-stained end-plates were visible after eight weeks. The reinnervation of the muscle in situ and after transplantation showed considerable similarities. Early during reinnervation the number of AChE positive areas increased and many of them were innervated by more than one axon. Terminal axons were also seen innervating more than one end-plate situated on the same or on different muscle fibres. Later the number of end-plates decreased and they were innervated by only one axon. The end-plate length reached normal value in the reinnervated muscle in situ but remained smaller in the transplanted muscle. In all reinnervated muscles ultraterminal sprouting was found as indicated by an increased number of nerve terminal branch points within the end-plate area. The TIR was increased in all reinnervated muscles due to terminal and ultraterminal sprouting of the axon. No significant difference in reinnervation was noted between normal and predenervated transplants. The reinnervation of transplanted muscles obviously has similarities not only with the reinnervation of normal muscles but also with the development of muscular innervation during early postnatal growth. In spite of the plasticity of the peripheral nerve the transplanted muscles underwent considerable atrophy which may have been enhanced by the unphysiological placement of the muscles in the abdomen. However, this experimental model made it possible to study reinnervation of muscle fibres only originating from the graft.

Light- and electron microscopic findings in the distal end of human cross-face sural nerve grafts.

In five patients with long-standing facial palsy we have tried to improve the possibility of elevating the angle of the mouth by bringing regenerating axons from the facial nerve on the normal side through a sural nerve graft to a transplanted free muscle in the paralyzed cheek. In order to expect clinical improvement a sufficient number of axons must grow into and through the sural nerve graft, neuromuscular contacts must be formed, and the transplanted muscle must be vascularized and survive. In order to find out if axons had regenerated, light- and electronmicroscopic examinations of a biopsy from the tip of the sural nerve graft were carried out at the time of muscle transplantation. All the cases showed a very large number of unmyelinated axons located within the fascicles of the sural nerve graft. A considerable fraction of myelinated axons were, however, present particularly in biopsies removed 12-13 months after the nerve operation. There was also a marked increase in endoneurial collagen and at the very tip a neuroma was present. This investigation thus shows that regeneration of a substantial number of axons had occurred and that they had reached the zone which was surgically sutured to the transplanted muscle. One essential requirement for reinnervation of the transplanted muscle therefore exists in these patients, but the clinical outcome has not yet been evaluated due to the short follow-up period.

Reconstructing the antihelix of protruding ears by perichondrioplasty: a modified technique.

Using the experiences achieved by experimental studies on cauliflower ear, protruding ears have been operated on with a technique involving the neochondrogenic potential of the perichondrium. The underdeveloped or absent conchoscaphal angle is restored to a normal antihelix in a posterior approach by a perichondrioplasty, gently folding the cartilage. The mobilized perichondrium is used to generate new cartilage, molding the folded cartilage in the desired position. The method is described in detail and is a modification of the original technique, which, in a follow-up study, was found to give frequent recurrences. In a follow-up study on protruding ears corrected by our modified technique, a recurrence is seen in only 3.7 percent of operated ears.

Hyaluronic acid stimulates neutrophil function in vitro and in vivo. A review of experimental results and a presentation of a preliminary clinical trial.

Hyaluronic acid (HA) stimulates normal neutrophil function both in vitro and in vivo Stimulation was also achieved by subcutaneous administration of HA to patients with extreme susceptibility to bacterial infections. Clinical improvement of some patients was obtained in connection to the administration. It is premature at this time to conclude any therapeutic effect of HA in patients with extreme infection propensity. The data presented here, however, for certain merit further investigation on this matter.