Increased serum neopterin levels in women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) occurs in 5-10% of premenopausal women. Studies suggest that PCOS is associated with increased risk of coronary heart disease (CHD). To investigate this relationship, 15 PCOS women (group 1) and 10 healthy women (group 2) were studied. Blood leukocyte counts (white blood cells, WBC) and serum levels of total cholesterol, HDL-cholesterol, LDL-cholesterol, sensitive C-reactive protein (sCRP), and neopterin were measured in the 2 groups. There were no significant differences in serum total cholesterol, HDL-cholesterol, or LDL-cholesterol concentrations between groups 1 and 2. Blood WBC counts and serum levels of neopterin and sCRP were significantly higher in group 1 than group 2. The median (min-max) levels were: WBC, group 1: 8.05 (5.10-9.70) cells x 10(9)/L, group 2: 6.25 (4.70-9.70) cells x 10(9)/L (p <0.01); neopterin, group 1: 10.6 (7.5-49.5) nmol/L, group 2: 9.6 (6.5-12.9) nmol/L (p < 0.05); and sCRP, group 1: 7.0 (1.2-12.0) mg/L, group 2: 2.0 (0.1-12.0) mg/L (p <0.01). This study shows that blood WBC counts and serum sCRP and neopterin levels are significantly elevated in women with PCOS. These findings support an increased risk for early-onset cardiovascular disease in women with PCOS. This is the first report that women with PCOS have higher serum neopterin levels than healthy women with regular menstrual cycles.

Nonmicrosurgical use of the radial forearm flap for penile reconstruction.

Although the era of microsurgical techniques has greatly expanded the number of possible solutions for penile reconstruction, additional options are still needed for some unusual situations when microsurgery is not available or not desired. This article describes the first nonmicrosurgical use of the radial forearm flap for penile reconstruction. With this technique, an osteocutaneous radial forearm flap 15 x 20 cm in size is elevated as a reverse-flow island flap and used to create a neopenis in the classic "tube within a tube" fashion. The neopenis is then transferred to the recipient site as a distant flap, without dividing its vascular connection with the forearm. Once a complete healing is ensured after the following 2 to 3 weeks, the pedicle is cut and the penile reconstruction is completed. Since 1995, this technique was used for total penile reconstruction in four patients: two with congenital penile agenesis, one with penile amputation as a result of a high-voltage electrical injury, and one with total loss of the external genitalia as a result of a shotgun injury. The patients have been followed up for 1 to 4 years. Good results were achieved in all patients. In conclusion, non-microsurgical use of the radial forearm flap seems to be a useful alternative to create an innervated functionally and aesthetically acceptable neopenis when microsurgery is not available or not desired. Although it is a multistage procedure, it is easy to perform. Moreover, this technique provides all well-known advantages of the radial forearm flap in penile reconstruction but does not require the sophisticated equipment and expertise of microsurgery. This is a great advantage that enables surgeons without microsurgical skill to use the radial forearm flap for phallic reconstruction. The author believes that the described technique will be extremely useful in developing countries that have limited resources and where microsurgery is difficult to obtain.

A new surgical procedure for phallic reconstruction: Istanbul flap.

A new surgical procedure is described for phallic reconstruction, which still remains a great challenge in reconstructive surgery. In this procedure, an osteocutaneous radial forearm flap is combined with a radial recurrent fasciocutaneous flap from the anterolateral aspect of the upper arm. While keeping a fasciovascular connection between them, both flaps are elevated as a combined free flap based on the radial artery. The forearm skin island is used solely to construct the outer skin cover of the phallic shaft, and the neourethra is created by using the radial recurrent flap. Over the past 4 years, this surgical procedure, termed the Istanbul flap, has been used successfully for complete phallic reconstruction in five patients. Although more clinical experience with this new technique is needed, it seems to be a useful alternative in phallic reconstruction. It remarkably minimizes the donor-site scar without sacrificing the length of the neopenis. In addition, this technique reduces the risk of a hairy urethra.

Expansion of venous flaps: an experimental study in rats.

In this study, the effects of controlled tissue expansion on the survival of unipedicled venous flaps were investigated in rats. In three groups of Lewis rats, a 3 x 6 cm unipedicled Lateral thoracic venous flap was studied with group 1 as control group (n = 30) without any manipulation, group 2 (n = 30) where an expander was introduced under the flap area but was not expanded and group 3 (n = 30) in which a 40 ml expander was introduced under the flap area and was expanded over a period of 10 days. Observations included gross and histological examination, reverse microangiography, reverse flow resistance and percentage of survival of flaps. Group 3 (expanded) showed more angiogenesis, a better delineation on microangiography, lower reverse flow resistance and higher survival rates as compared to group 2 (non-expanded). In the control group the survival rate of flaps was the poorest and the flaps showed higher rates of reverse flow resistance. Microangiography was not successful in the control group. In a pilot project prior to this experiment microscopic examination of the Lateral thoracic vein in 10 Lewis rats had confirmed the presence of two or three valves in this vein.

The effects of tissue expansion on the hemodynamic and survival characteristics of reverse-flow island flaps: an experimental study in rabbits.

The effects of tissue expansion on the hemodynamic and survival characteristics of reverse-flow island skin flaps were investigated in New Zealand White rabbits. The animals were divided into 3 groups of 15: group I (control) had no surgery prior to flap elevation, group II (nonexpansion) had a noninflated expander, and group III (expansion) had an inflated expander of 80 ml. After 3 weeks of expansion, a reverse-flow island flap based on the distal saphenous pedicle was elevated. A series of hemodynamic studies was performed to test reverse venous flow--in particular, valve competence. Besides observing the reverse flow under an operating microscope, the changes in the intravenous pressure were measured at 0, 5, 15, 30, 60, and 120 minutes after flap elevation. Moreover, reverse-flow resistance (RFR) was measured in each group to test the competence of venous valves. At each time interval, the values of intravenous pressure were significantly lower (p < 0.01) in group III than in the groups I and II. However there was no statistically significant difference between group I and group II. The RFR was measured as 126.7 +/- 33.52 mmHg in group I, 59.3 +/- 29.86 mmHg in group II (p < 0.01), and 25.1 +/- 7.68 mmHg in group III (p < 0.01). Ten days after flap elevation the mean survival of group III (100%) was statistically higher than that of group I (57.4 +/- 18.3%; p < 0.01) and group II (81.6 +/- 12.8%; p < 0.05). These findings simply suggest that controlled tissue expansion improves retrograde venous drainage and increases the survival of reverse-flow island flaps in rabbits. Abnormal dilatation of the venous tree and incompetence of the venous valves seem to be the main factors in explaining the decrease in the values of RFR and intravenous pressure in the expanded flaps. The potential mechanisms to explain the effects of tissue expansion, and the clinical implications are discussed.

Nonmicrosurgical use of an osteocutaneous parascapular flap for reconstruction of a complex hand defect.

We describe the nonmicrosurgical use of an osteocutaneous parascapular flap as a new application in reconstructive hand surgery for reconstruction of a complex hand defect resulting from a gunshot injury. This technique, namely the transaxillary parascapular flap, is easy to perform and does not require the sophisticated equipment and expertise of microsurgery. This is an important advantage, especially for developing countries in which microsurgical facilities are limited.

Venous changes in expanded skin: a microangiographic and histological study in rabbits.

So far, the venous side of vascular changes in expanded skin has been neglected by plastic surgeons. In this experimental study, using a rabbit saphenous flap model, the author attempts to document the changes in the cutaneous venous tree that occur following expansion. Fifteen male New Zealand White rabbits were divided into three groups, with 5 animals in each: group I (expansion), with an inflated expander; group II (sham), with a noninflated expander; and group III (control), with no surgery prior to flap harvest. After an expansion period of 3 weeks with an 80-ml round tissue expander, the flaps were harvested and underwent microangiographic and histological examination in all groups. Using both legs of each animal, 10 flaps were studied for each group. The results revealed that, in the expanded skin, the cutaneous venous tree shows an increased vascularity associated with neovessel formation. In addition to the entire venous network being remarkably enlarged, the collateral and communicating veins bypassing the venous valves in the axial veins were extremely dilated. The periarterial microveins and the perivenous arterioles were also dilated and increased in number. Moreover, the venous valves were found to be incompetent following expansion. Possible mechanisms to explain these changes in the cutaneous venous system following expansion are discussed.

A true osteomyocutaneous free-flap model in rats: the saphenous artery osteomyocutaneous flap.

A new composite free-flap model, namely, the saphenous artery osteomyocutaneous flap, is described in the rat. This is a true osteomyocutaneous flap composed of a skin island from the medial aspect of the lower leg, the gracilis and semitendinosus muscles, and a bone segment from the tibia based on the saphenous vascular pedicle. After anatomic studies in 10 rats, 20 flaps were transplanted microsurgically to the abdominal region in the recipient rats with a 90 percent success rate. In selected animals, arteriography was carried out. The results from gross observation of the flap survival and histologic and fluorochrome bone-labeling studies revealed a complete survival for each component of the flap in all animals with a patent vascular pedicle at 2 weeks after transfer. The model seems to be suitable for use in metabolic, vascular, and immunologic experimental studies on composite free flaps.

The rat saphenous flap: a fasciocutaneous free flap model without panniculus carnosus.

The rat saphenous flap is described as a new experimental model for free flap studies. This is a fasciocutaneous free flap based on the saphenofemoral vascular pedicle. The flap may include the entire medial aspect of the lower leg between the knee and ankle. Thirty flaps were harvested from 15 inbred rats. Each flap was transferred to the anterior neck of a recipient rat of the same inbred strain so that 15 flaps were vascularized free flaps using the standard end-to-end microvascular technique and the other 15 flaps were nonvascularized free grafts. All but two (technical failure) of the vascularized flaps showed complete survival, whereas all nonvascularized flaps completely necrosed 2 weeks after transfer. It was concluded that the rat saphenous flap has several advantages such as a long and consistent vascular pedicle, ease of harvest, and an all-or-none survival pattern. Furthermore, as a unique feature of this flap, histological analysis revealed that the rat saphenous flap is composed of the skin and underlying fascia without panniculus carnosus. We therefore suggest that the rat saphenous flap is the first true fasciocutaneous free flap model in the rat. In this paper, in addition to illustrating the anatomy of the saphenous vessels and describing a new fasciocutaneous free flap model based on these vessels, we have documented some anatomical details of the rat leg that have never been described in the literature related to the rat anatomy.

Onlay silicone and hydroxyapatite-tricalciumphosphate composite (HAP-TCP) blocks interfere with nasal bone growth in rabbits.

We investigated how a new type of synthetic porous hydroxyapatite ceramic (HAP-TCP) acts when it is implanted in growing membranous bone. Seventy-six New Zealand White infant male rabbits (4-week-olds) were used. Rabbits received HAP-TCP block or silicone block implantation in their right nasal bone. The left nasal bone was used for a sham. Serial or cross-sectional examinations by morphometry, radiology, blood biochemistry, and histology were carried out. Both the HAP-TCP and silicone groups exhibited no systemic growth disturbance in terms of morphometry and blood biochemistry. Dual energy x-ray absorptiometry (DEXA) revealed, however, a decrease in the bone mineral content (BMC) of the right nasal bone in the silicone group. Histology revealed a superior affinity of HAP-TCP to bone tissue than that of silicone. When a HAP-TCP block was implanted under the periosteum it bonded directly to bone tissue. However, sinking of the implants into the bone tissue were noted both in the HAP-TCP and the silicone groups in longitudinal observation. These results suggest that although HAP-TCP has superior affinity to bone tissue, this by itself is not enough sufficient reason to believe that HAP-TCP can be effectively applied during the growth period.

Tissue expansion-assisted prefabrication of the forehead flap for nasal reconstruction.

A new technique for nasal reconstruction is described. This method--expansion-assisted flap prefabrication--is essentially a simultaneous application of pretransfer grafting and tissue-expansion procedures for creating custom-made forehead flaps to meet varying requirements of nasal reconstruction. We have applied this new technique on seven patients, with full-thickness nasal defects during a 3-year period. Results from these patients are presented with a review of different use of flap prefabrication principles in nasal reconstruction.

Is bed isolation necessary during flap prefabrication? An experimental study in rats.

This study was designed to investigate whether isolation of the bed is necessary during flap prefabrication. A fasciovascular carrier was used to prefabricate a 3 x 8-cm epigastric flap in rats. The animals were divided into three groups of 42 each. During flap prefabrication, in group 1 (control), no bed isolation was done, whereas in groups 2 and 3, a thin silicone sheet was used to isolate the underlying bed from the flap and fasciovascular carrier partially or completely, respectively. In each group, 14 prefabricated flaps were raised at 3, 7, and 14 days after prefabrication. Flap survival was assessed at day 7 after flap elevation. In comparing to the survival rates of the prefabricated flaps for each time interval, there was no significant statistical difference between the control and experimental groups (p > 0.05). With further studies, including india ink injection study and microangiographical and histological examinations of the prefabricated flaps, it was concluded that, during flap prefabrication, isolation of the bed with a silicone sheet does not improve the survival of prefabricated skin flaps. Moreover, it may cause some complications, such as extensive seroma, infection, and exposure of the sheet, which further interfere with the evaluation of experimental results.

Anteromedial thigh: a source for phallic reconstruction.

The anteromedial thigh region is a fruitful site to create different types of fasciocutaneous flaps and compound flaps because of its versatile fasciocutaneous vascularization. On the other hand, phallic reconstruction is still a challenge. We used a proximally based, fasciosubcutaneous pedicle anteromedial thigh fasciocutaneous flap to reconstruct a penis for an electrical burn patient, including the gracilis muscle into the flap for additional bulk. This flap has the potential for sensory reinnervation, its application is easy with regard to a microvascular operation and it presents a remarkable option in phallic reconstruction.

Growth potential of autogenous cartilage grafts in expanded skin: an experimental study in rabbits.

The effect of tissue expansion on the growth potential of autogenous cartilage grafts was studied in 10-day-old New Zealand white rabbits. The rabbits were divided into two groups: In Group 1 (n = 12) after 2 weeks of tissue expansion by using a 10-ml tissue expander, a cranially based 4 x 4-cm dorsal skin flap was raised and a 1 x 1-cm autogenous cartilage graft from the midportion of the left ear was transplanted beneath the flap in each rabbit. In Group 2 (n = 12) elevation of dorsal skin flaps and transplantation of the grafts were performed in the same way but without a previous tissue expansion. The grafts were removed at 30 and 60 days after transplantation in both groups, for histological examination and measurement of the dimensional changes to determine the growth rate. In both groups, histological examination revealed characteristic findings for cartilage growth, however, Group 1 (expansion) demonstrated a statistically significant increase in the growth of cartilage grafts when compared with Group 2 (control) (p = 0.0001). The results of this study indicate, from the standpoint of acceptance and growth potential of autogenous cartilage framework, that there is no drawback to using this tissue expansion technique for reconstruction of the ear in childhood.

The split-lip advancement technique (SLAT) for the treatment of congenital sinuses of the lower lip.

In this paper we present 7 cases of Van der Woude syndrome and describe a new surgical technique for the treatment of congenital sinuses of the lower lip. Our technique is essentially a new modification of the elastic lip flap technique of Goldstein. We term this procedure the split-lip advancement technique, in which two opposite labial artery--based flaps including the whole thickness of the vermilion and the mucosal surface of the lip are used to repair the median defect that resulted from excision of the sinuses. To our knowledge, there have been no reports of the use of this technique in the treatment of congenital sinuses of the lower lip.

Intra-operative tunnel expansion to prevent tunnel compression following latissimus dorsi muscle transfers.

The intra-operative tunnel expansion technique is described to prevent tunnel compression following muscle transfers. The results of ten cases of latissimus dorsi transfer using this new technique are reported.