Applied anatomy of the latissimus dorsi free flap for refinement in one-stage facial reanimation.

BACKGROUND: The face can be reanimated after long-term paralysis by free microneurovascular tissue transfer. Flaps from gracilis and pectoralis minor usually require a two-stage procedure with a cross-face nerve graft. Latissimus dorsi has a much longer muscular nerve, the thoracodorsal nerve, which could avoid the need for a second cross-face nerve graft. Our hypothesis is that the neurovascular pedicles of small segments of latissimus dorsi would be long enough to reach the opposite side of the face and to provide a reliable blood and nerve supply to the flaps. METHOD: To test this hypothesis the thoracodorsal pedicle and its primary branches were dissected in eleven embalmed cadavers. The segmental vessels and nerves were then traced in a series of simulated flaps approximately 8-10 cm × 2-3 cm by micro-dissection, tissue clearing and histology. RESULTS: The thoracodorsal pedicle is 10-14 cm long to where it enters the muscle, and with intra-muscular dissection small chimeric muscle segments 8-10 cm × 2-3 cm can be raised with a clearly defined neurovascular supply. Using micro-dissection the neurovascular pedicle can be lengthened to reach across the face. Segmental arteries and nerves extended to the distal end of all the flaps examined. Artery, vein and nerve run together and are of substantial diameter. CONCLUSION: Small muscle segments of latissimus dorsi can be raised on long neurovascular pedicles. The vessels and nerves are substantial and the likelihood of surgical complications such as flap necrosis and functional disuse on transplantation appear low. Although in our opinion the use of cross-face nerve grafts and transfer of smaller muscle flaps remains the gold standard in facial reanimation in straightforward cases, the micro-dissected latissimus dorsi flap is a useful option in complex cases of facial reanimation. CLINICAL APPLICATION: Facial reanimation using micro-dissected segments of latissimus dorsi has been performed in four complex cases of facial paralysis.

Mutational analysis of the herpes simplex virus type 1 trans-inducing factor Vmw65.

The herpes simplex virus type 1 (HSV-1) polypeptide Vmw65 is a structural component of the virus particle and is also responsible for trans-induction of immediate early (IE) transcription. Functional domains of this polypeptide were investigated by constructing a series of 10 plasmids each with a 12 bp insertion in the gene encoding Vmw65. Plasmids were analysed for their ability to stimulate IE transcription in short term transfection assays, and the altered Vmw65 polypeptides were assayed for the ability to form an IE-specific protein-DNA complex (IEC) in vitro. A direct correlation was observed between stimulation of transcription and formation of IEC, strongly suggesting that IEC is an important intermediate in transcription activation. Plasmids were also tested for their ability to rescue the temperature-sensitive mutation in the HSV-2 assembly mutant ts2203, since marker rescue analysis indicated that this mutation maps within the gene encoding Vmw65. Five plasmids failed to rescue ts2203, thereby defining regions of Vmw65 required for virus assembly. The results show that distinct domains exist in Vmw65 for activation of transcription and assembly of virus.

An open comparative study of two diuretic combinations, frusemide/amiloride ('Frumil') and bumetanide/potassium chloride ('Burinex' K), in the treatment of congestive cardiac failure in hospital out-patients.

Forty elderly patients, aged 68 to 89 years, with congestive cardiac failure, who were attending a hospital out-patients department, entered an open, parallel group, comparative study of two diuretic combinations, 40 mg frusemide plus 5 mg amiloride per tablet and 0.5 mg bumetanide plus 573 mg slow-release potassium chloride per tablet. Patients were assigned at random to receive one or other combination for 8 weeks, dosage being determined by the severity of the individual patient's condition (range 1 to 3 tablets frusemide/amiloride; 2 to 6 tablets bumetanide/potassium chloride). Clinical assessments, including visual analogue scores for dyspnoea at rest and on effort, and laboratory measurements of serum potassium and magnesium levels were carried out on entry and after 2, 4 and 8 weeks of treatment. Other variables were monitored before, during and/or after treatment. Although significant decreases were reported in dyspnoea severity scores at rest and on effort only in the bumetanide/potassium chloride group, global assessment of the patients' condition by patient and clinician at the end of the study indicated that both treatments produced improvement, and a greater proportion of patients considered treatment as satisfactory in the frusemide/amiloride group. Both drug combinations were well-tolerated and only a few minor side-effects were reported. Serum potassium levels were maintained in both treatment groups but there was a significant decrease in mean serum magnesium levels in patients on bumetanide/potassium chloride. Hyponatraemia was also detected in 2 patients on this combination. An increase in body weight was recorded in both groups, the increase being significant in patients receiving bumetanide/potassium chloride.

Selection for long-term hospital care.

A formalized system for selecting patients requiring long-term hospital accommodation is described and our first two years' experience presented. Fifty patients were considered by the panel of whom 25 were designated as being suitable to be transferred to a long-term bed. Alternative solutions were considered more appropriate for the remaining 25; only 0.95% of all admissions to the unit finally required long-term hospital care.

Tardive dyskinesia in the elderly.

Four hundred and twenty-six elderly subjects were assessed for the presence of dyskinetic movements. Dyskinetic movements were present in 49 subjects (11.5%). Ninety-two per cent had orofacial movements, by far the commonest being chewing. Dyskinetic movements were present in 12.5% of women and 7.6% of men. Abnormal movements were present in 8% of the subjects who had never received neuroleptic drugs and in 20.8% of those who had. There was a statistically significant association between developing dyskinetic movements and receiving chlorpromazine and flupenthixol. There was no association between either advancing age or dementia and dyskinetic movements.

3-Aminobenzamide, an inhibitor of poly ADP-ribose polymerase, decreases the frequency of alkaline labile lesions and increases growth in human fibroblasts exposed to 3-methyl 4-nitroquinoline 1-oxide.

Normal human fibroblasts exposed to the mutagen 3-methyl 4-nitroquinoline 1-oxide (3me4NQO) were additionally incubated with or without the inhibitor of poly ADP-ribose polymerase, 3 aminobenzamide (3AB) either during or after mutagen treatment. The number of single strand DNA breaks detectable by alkaline sucrose sedimentation at any given time after exposure to this mutagen was reduced by the prior addition of 3AB, regardless of whether this drug was present during or after mutagen exposure. Furthermore, this effect is reversible upon 3AB removal. Finally, cell survival as analysed by cell growth was increased if cells were treated for one hour with 3AB directly following a 30 min exposure to 3-me4NQO. The data presented suggest an additional role for poly ADP ribose polymerase in DNA repair other than that of inhibiting the increase in ligase II, which occurs after exposure to monofunctional alkylating agents.

Poliomyelitis, rubella, and dengue antibody survey in Barbados. A follow-up study.

A follow-up study of poliomyelitis, rubella, and dengue antibodies has been made in light of results obtained in a 1972 health and serological survey in Barbados, W.I. Poliomyelitis antibody neutralization tests performed on sera from 307 children under age 15 using overnight serum/virus mixtures on microtiter plates at low serum dilutions revealed the absence of polio antibody at 1:2 dilution in 13.7% for type 1, 6.5% for type 2, and 14.3% for type 3 virus. A significant correlation of the presence or absence of poliomyelitis antibody to types 2 and 3 was seen with the response to immunization histories. Forty-three of 49 girls (88%) given rubella vaccine (RA 27/3) in 1972 had demonstrable haemagglutination-inhibition antibody 4 years later. Neutralization tests for dengue antibody confirmed the results of the complement-fixation tests and indicated that type 2 was probably the sole infecting strain.