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A defined, serum-free cell culture medium supplemented with nonsteroidal anabolic hormones, insulin, thyroxin, and growth hormone was found to accelerate wound healing by stimulating vascularized granulation tissue formation, epithelialization, and angiogenesis. The aim of this work was to study the effect of cell culture medium on the survival rate of cephalically based random dorsal skin flaps in an animal model. A total of 77 Sprague-Dawley rats were randomized into five treatment groups: pharmacologic delay with cell culture medium, flap enhancement with cell culture medium, surgical delay, biological delay with saline, and control. Statistically significant differences in distal flap necrosis were found among all groups (p

The single-pedicle transverse rectus abdominis myocutaneous (TRAM) flap is frequently associated with partial flap necrosis. Hyperbaric oxygen has previously been shown to increase the survival of skin flaps, although there has been no investigation of possible beneficial effects of hyperbaric oxygen on survival of the TRAM flap. The present study compares the effectiveness of hyperbaric oxygen therapy, normobaric 100% oxygen, a hyperbaric air-equivalent mixture, and no treatment at all (control group), in the prevention of TRAM flap necrosis in a rat model. Forty-eight animals were randomly assigned to one of the four above-mentioned groups. The surviving area of the flap was evaluated 7 days after surgery. The hyperbaric oxygen treatment protocol consisted of five 9-minute sessions breathing 100% oxygen at a pressure of 2.5 atmospheres absolute during the first 48 hours, starting within 1 hour of surgery. The areas of surviving skin paddles ranged from 38.5 percent in the control group to 52.5 percent in the group treated with hyperbaric oxygen. One-way analysis of variance indicated that flap area survival was significantly greater in the hyperbaric oxygen group (F = 2.69, p = 0.05). Tukey's pairwise comparison and the two-sample t test indicated that the group treated with hyperbaric oxygen differed significantly from the control group (Tukey's critical value = 3.8, rejection level = 0.05, t test p = 0.01). Our results suggest that the hyperbaric oxygen treatment protocol used improves survival in the rat TRAM flap. However, the optimal treatment protocol to achieve this objective even in the rat seems to be variable, and further studies are required before extrapolating these data to human applications.

Immediate breast reconstruction with the tissue expander is now established as an accepted procedure after mastectomy, and large series have been published concerning the technique and its complications. Unfortunately, only scarce information is available regarding the long-term aesthetic results and patient satisfaction achieved by immediate reconstruction using tissue expansion. In this study, we reviewed 52 patients who had undergone immediate breast reconstruction using the tissue expander with a follow-up of at least 1 year after completion of the reconstruction. We developed an objective assessment of patient satisfaction, aesthetic results, and the factors affecting them. The results show remarkable concordance of assessment by patient, surgeon, and independent observer: All gave good scores for aesthetic appearance (6.4 to 7.4 on a scale of 1 to 10). A total of 92.3 percent of patients rated their satisfaction as good to excellent. Symmetry was the main parameter influencing the patients' score, while the surgeon's score also was affected by the quality of the inframammary fold and capsular contracture. Breast size, chemotherapy, complications, time interval, and additional procedures had no relation to either scoring or patient satisfaction.

Chordee or ventral curvature of the penis is commonly associated with and occasionally without hypospadias. The usual recommended treatment is excision of the fibrous tissue that is responsible for the bowing. This results in a proximal retraction of the meatus. With a different concept and explanation of the ventral curvature, we treat this abnormal condition as a shortage of tissue. More than a hundred consecutive cases of chordee with and without hypospadias were treated by skin release and dorsal to ventral transposition of preputial skin as well as hypospadias repair. The whole procedure is simple, planned as a single-stage operation with less morbidity or fewer complications. The meatus is not pushed back proximally, no dissection distal to the meatus is performed, and there is no need for tissue excision. The results were very successful, with no recurrence of the ventral curvature.

A simple and reliable method for securing the cannulated polyethylene tube to the blood vessel wall prior to intravascular dye injection is described. The three-tie technique has been used in many vascular anatomic studies without any leakage of the injection fluid taking place around the tube.

Background: The treatment of distal tibial osteomyelitis represents a challenge for orthopedic and plastic surgeons. The affected tissues should be debrided and good vascularized tissue should cover the defect, but the option of a muscle flap covering the area is limited. Free flaps are used but require longer operating time and experience with microsurgery, may result in donor-site morbidity, and sometimes add bulky tissue to the area. The authors present their experience with a sural musculoneurocutaneous flap for the treatment of chronic osteomyelitis of the distal tibia. Methods: Over a 2-year period, nine distally based sural musculoneurocutaneous flaps were used in the treatment of chronic osteomyelitis of the distal tibia. Four patients had comorbid conditions (smoking, diabetes mellitus, venous insufficiency, or obesity). The clinical aspect was represented by drainage sinuses located in the distal part of the tibia. Five patients had postsurgical scars on the lateral malleolar region and one had medial and lateral malleolar scarring. Three patients had an Ilizarov device at the time of wound coverage. Results: All wounds were closed successfully. Dehiscence surrounding the flap was encountered in a single case that was attributable to inadequate bone debridement; this flap was raised to allow extending the debridement, and a local medial fasciocutaneous flap completed wound coverage. Distal tip necrosis of the flap was encountered in two cases. Conclusions: The sural musculoneurocutaneous sural flap was successfully used for treatment of distal tibia osteomyelitis. Although it is believed that lateral malleolar scars might compromise the flap, the flaps in the authors' series survived. This flap can also be applied to patients with external fixators without removing the apparatus.

Adipose tissue injection as a free graft for the correction of soft-tissue defects is a widespread procedure in plastic surgery. The main problem in achieving long-term soft-tissue augmentation is partial absorption of the injected fat and hence the need for overcorrection and re-injection. The purpose of this study was to improve the viability of the injected fat by the use of interleukin-8. The rationale for the use of interleukin-8 was its abilities to accelerate angiogenesis and attract inflammatory cells and fibroblasts, providing the injected adipocytes more feeding vessels and a well-established graft bed to enhance their viability. Human adipose tissue, obtained by suction-assisted lipectomy, was re-injected into the subcutis in the scalp of nude mice. Interleukin-8 (0.25 ng) was injected subcutaneously to the scalp as a preparation of the recipient site 24 hours before the fat injection and was added to the fat graft itself (25 ng per 1 cc of injected fat). In the control group, pure fat without interleukin-8 was injected and no interleukin-8 was added for the preparation of the recipient site. One cubic centimeter of fat was injected in each animal in both the study and control groups. There were 10 animals in each group. The animals were euthanized 15 weeks after the procedure. Graft weight and volume were measured and histologic evaluation was performed. In addition, triglyceride content and adipose cell sizes were measured as parameters for fat cells viability. Histologic analysis demonstrated significantly less cyst formation in the group treated with interleukin-8. No significant differences were found between the groups with regard to graft weight and volume or the other histologic parameters investigated. No significant differences were demonstrated in adipose cell sizes and their triglyceride content. In conclusion, less cyst formation, indicating improved quality of the injected fat, can be obtained by the addition of interleukin-8. Further studies of various dosages of interleukin-8 and their long-term effect are required before these encouraging results could be applied clinically.

Congenital auricular deformation is not an uncommon phenomenon, and it may cause substantial annoyance to the growing child. Many parents of affected children will seek surgical correction of the deformed auricles. The variety of techniques that have been described for the correction of this anomaly suggests that none has been considered satisfying. The consequent possible surgical complications should also be considered, when the surgical procedure can be replaced by an effective conservative treatment. The authors describe their experience using early splinting for congenital auricular deformities. Fifty-two newborn infants with lop, prominent, Stahl's, and constricted ears referred to us by the neonatal department staff were enrolled in this study. Putty Soft, a vinyl polysiloxane impression material, has been used for early molding of the auricles. Surgical tapes were used for the fixation of the mold and to fix the auricle to the scalp. The results were evaluated by one of the parents and by a layperson (medical student) 6 months after completion of the procedure. The above-described early splinting procedure was applied onto 92 auricles of 52 newborn infants aged 1 to 10 days, mostly around day 3. The mean treatment time was 6.8 weeks. All treated auricles were improved, 87 percent were rated as excellent improvement, and there were no complications related to the treatment. The authors conclude that early splinting of deformed auricles should be offered to parents of affected children, and the awareness of this procedure by neonatologists, pediatricians, and nursery staff should be increased.

Reconstruction of the vulva with V-Y advanced triangular myocutaneous gracilis flap(s) is reported. Seven patients were treated with this technique following radical vulvectomy with two minimal complications. The reliability of this known flap and the usefulness of the V-Y advancement are stressed and make it a simple and successful technique.

Injection of aspirated fat is now the most commonly used technique for the filling of depressed areas. Partial absorption of the injected fat is the main limitation of this procedure. Cariel T.M. is an enriched serum-free cell culture medium, its ability to enhance the survival of human aspirated fat grafts was investigated in the nude mouse model. A volume of 0.75-cc Cariel preprocessed fat was injected under the scalp skin of 16 nude mice in the experimental group, and the same volume of saline preprocessed fat was injected to 15 control group of mice. Significant maintenance of the weight, 46 percent in the experimental group compared with 29 percent in the control group (p < 0.008), and the volume, 44 percent in the experimental group compared with 31 percent in the control group (p < 0.026), was observed, after 15 weeks, in this newly used model. It seems that addition of the nutrients enriched with anabolic hormones enabled the survival and take of more adipose cells in the graft.

Intraoperative rapid expansion of soft tissue of the palate is reported. Tissue is recruited by repeated injections of an isotonic solution in a tumescent-like technique, thus producing increasing swelling of the palatal soft tissue. Straight direct closure of palatal clefts and fistulas is achieved with minimal scarring at the midline, no secondary healing of raw surfaces, and satisfactory and encouraging results.

A turnover contralateral cephalic alar cartilage flap is suggested for the correction of cleft nose alar deformity. The cartilage flap from the normal side wraps around the deficient medial crus and acting as a pulley reposition and augments the affected alar cartilage. The satisfactory and long-lasting results obtained in our small series seem to justify this approach for improving cleft nasal deformities, and we think it should be available in our surgical armamentarium.

The surgical anatomy of the upper eyelid fat in the medial compartment was investigated in 388 patients and in 12 cadavers. We found two individual fat pads comprising this compartment. The difference among the investigated cases was found to be the extent of their separation. In 16.7 percent of the cadavers' eyelids the fat pads were entirely separated, in 45.8 percent they were separated to about half their length, while in 37.5 percent only the tips were separated. Among the patients in whom only the protruded fat was inspected, 59.8 percent of the fat pads were separated, and in the rest, only the tips were isolated. On histologic examination we could always identify two well-circumscribed fat pads, each surrounded by a fibrocollagenous tissue. At the level of their interconnection, a loose fibroareolar tissue was found. In practice, during blepharoplasty, both fat pads should be addressed in order to achieve the expected results.

A turnover contralateral cephalic alar cartilage flap is suggested for the correction of cleft nose alar deformity. The cartilage flap from the normal side wraps around the deficient medial crus and acting as a pulley reposition and augments the affected alar cartilage. The satisfactory and long-lasting results obtained in our small series seem to justify this approach for improving cleft nasal deformities, and we think it should be available in our surgical armamentarium.

Autologous free-fat injection for the correction of soft-tissue defects has become a common procedure in plastic surgery. The main shortcoming of this method for achieving permanent soft-tissue augmentation is the partial absorption of the injected fat, an occurrence that leads to the need for both overcorrection and repeated fat reinjection. Improving the oxygenation of the injected fat has been suggested as a means of helping to overcome the initial critical phase that occurs postinjection (when the fat cells are nourished by osmosis), increasing phagocyte activity, accelerating fibroblast activity and collagen formation, and enhancing angiogenesis. In addition, the hyperbaric oxygen-mediated decrement in endothelial leukocyte adhesion will decrease cytokine release, thereby reducing edema and inflammatory responses. The purpose of the present study was to examine the effect of hyperbaric oxygenation on improving the viability of injected fat. Adipose tissue obtained from human breasts by suction-assisted lipectomy was injected into the subcuticular nuchal region in nude mice. The mice were then exposed to daily hyperbaric oxygen treatments, breathing 100% oxygen at 2 atmospheres absolute (ATA) for 90 minutes. The duration of the administered hyperbaric oxygen therapy was 5, 10, or 15 days, according to the study group. Mice exposed to normobaric air alone served as the control group, and each group included 10 animals. The rats were killed 15 weeks after fat injection. The grafts were dissected out, weight and volume were measured, and histologic evaluation was performed. In all of the study groups, at least part of the injected fat survived, giving the desired clinical outcome. No significant differences could be found between the groups regarding fat weight and volume. Histopathologic examination of the dissected grafts demonstrated a significantly better integrity of the fat tissue in the group that received hyperbaric oxygen for 5 days (p = 0.047). This finding was manifested by the presence of well-organized, intact fat cells, along with a normal appearance of the fibrous septa and blood vessels. The worst results were found in animals treated by hyperbaric oxygenation for 15 consecutive days. An inverse correlation was found between an increased dose of the high-pressure oxygen and fat tissue integrity (r = -0.87, p = 0.076). The toxic effects of highly reactive oxygen species on fat cells might explain the failure of an excessively high dose of hyperbaric oxygen to provide any beneficial outcome. The clinical relevance of these results should be further investigated.

We have shown in an animal model that complex ventricular arrhythmias produced by topical application of a phenol preparation that is used in face peeling can be prevented by a brisk diuresis at the time of application or by gradual application of the phenol preparation. We recommend that continuous cardiac monitoring and recording be performed in patients having topical phenol applications in order to determine the true incidence of cardiac arrhythmias and to ascertain if they are prevented by a forced diuresis, by the gradual application of the preparation, or by a combination of both.

Cartilage grafts could be passed to their exact destination using suction-tube-needle combination so that fixation of the graft is more accurate. This is routinely used for tip grafts and dorsum of the nose grafts, and it could be used elsewhere.