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Seventy-two patients with Gustilo grade IIIB open tibial fractures were treated with free-tissue transfers. If successful free-tissue transfer for soft-tissue reconstruction is performed within 15 days of injury, the risk of major complications is 3.6 percent. Long-term retrospective follow-up (mean 42 months) revealed successful limb salvage in 93 percent, good aesthetic results in 80 percent, and patient satisfaction in 96 percent. However, 66 percent of patients exhibited significantly decreased range of motion of the ankle, 44 percent experienced swelling and edema requiring elastic support and activity modification, and 50 percent occasionally required an assistance device for ambulation. The long-term employment rate was 28 percent, and no patient returned to work after 2 years of unemployment. In contrast, 68 percent of amputees after lower extremity trauma over the same period returned to work within 2 years. Patients need to realize the disruptive nature of this injury on their family, job, and future.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

Basic fibroblast growth factor (bFGF) was prepared from bovine pituitary glands and evaluated for its effect on the viability of pedicle skin flaps in rats. Pedicle flaps measuring 3 x 7.5 cm and based cephalad were created on the backs of animals. The treatment group received bFGF in saline solution intradermally by Dermo-jet injection 30 minutes before flap elevation. Skin flaps treated with a single application of 80 U of bFGF demonstrated a significant increase in viability from 40.8% to 69.7% of the flap area (p less than 0.001); the flaps treated with 16 U of bFGF exhibited little improvement. Intradermal administration of bFGF to pedicle skin flaps produced an increase in viability that approximates the increase obtained by a surgical delay procedure; treatment of flaps with exogenous bFGF may offer advantages over surgical delay procedures.

This review of patients after forehead rhytidectomy represents the longest published postoperative follow-up to date. Fifty patients who had undergone subcutaneous forehead rhytidectomy through an anterior hairline incision were assessed by chart review, detailed questionnaire, and physical examination. The mean follow-up was 7.5 years with a range of 1 to 17 years. Benefits of the technique described include maintenance of forehead size, a mechanically efficient lift, a direct attack on wrinkles, and a low incidence of hair loss. Patient assessment indicates that the benefits of the procedure are long lasting. The disadvantages include the added precision required in executing the incision, closure, and time-consuming dissection.

The effects of hyperbaric oxygen (HBO) during tissue preservation on flap survival have been investigated in free flaps in rats. Groin skin flaps were harvested, stored in either room air or HBO (100% oxygen at 2.9 atm absolute) at 23 degrees C for 18 hours, and transplanted to the contralateral groin. Free flaps exhibit a high incidence of complete necrosis in the room air control. The survival of free flaps stored under HBO increased from 10% to 60% (p less than 0.05) after 18 hours of preservation. Skin flaps exhibited an increase in tissue hypoxanthine by 3.6-fold normal after 18 hours of storage in room air. HBO preservation prevented the accumulation of hypoxanthine and inhibited xanthine oxidase. Inhibition of the xanthine oxidase system may be one of the mechanisms of improved success of skin flap transplantation.

The effect of hyperbaric oxygen, administered during storage, on the survival of replanted limbs was evaluated in rats. The right hindlimbs of male Sprague-Dawley rats were severed and were replanted by microvascular anastomoses after storage in either room air or hyperbaric oxygen (100% oxygen at 2.9 atm absolute) at 23 degrees C for 5 hours. The administration of hyperbaric oxygen during storage improved limb survival from 50% in the room-air, control rats to 100% (p less than 0.05). The gastrocnemius muscle of limbs treated with hyperbaric oxygen demonstrated a higher level of energy reserves (creatine phosphate, adenosine triphosphate, glycogen, and glucose) than the same muscle in room-air, control rats. The mechanisms of the beneficial effect of hyperbaric oxygen on limb survival appears to be related to preservation of high-energy phosphates and glycogen.

The effects of systemic heparin on the survival of island skin flaps have been evaluated. Island flaps measuring 3 x 6 cm were created in the abdomen/groin of rats based on an inferior epigastric neurovascular pedicle. The venous drainage from the flap was occluded for various lengths of time ranging from 5 to 10 hours in the control rats and from 8 to 15 hours in the heparin-treated group of rats. The rats in the treated group received 1 ml of heparin solution (300-400 U/kg) through the contralateral saphenous vein immediately prior to the onset venous occlusion and an equivalent dose every 4 hours during venous occlusion. The group of control rats received 1 ml of saline solution. Flap survival was evaluated daily for 7 days. The flaps of control rats demonstrated a gradual decline of the survival rate after 6 hours of venous occlusion and no survival after 10 hours of venous occlusion. The flaps of heparin-treated rats exhibited complete survival until 12 hours of venous occlusion and no survival after 13 hours of venous occlusion. Thus, systemic heparin prolonged tissue tolerance to venous occlusion from 10 to 13 hours. The flaps of control rats demonstrated a significant accumulation of inosine plus hypoxanthine to 260% of normal after 8 hours of venous occlusion. The flaps of heparin-treated rats exhibited little alteration of inosine plus hypoxanthine, and contained a greater concentration of glucose and lactate than the flaps of control rats after 8 hours of venous occlusion. The results demonstrate that systemic heparin can increase tissue tolerance to venous occlusion and improve significantly the flap survival following subsequent reperfusion.

Oxygen free radicals may have an important role in tissue injury, which occurs on reperfusion of previously ischemic skin flaps. Therefore, therapy directed against the toxic effects of reactive oxygen species may protect skin flaps from ischemia/reperfusion injury. Various scavengers of oxygen free radicals have previously been reported to be effective in ameliorating ischemia/reperfusion injury. In the present study, N-2-mercaptopropionylglycine (MPG), a free-radical scavenger, was evaluated for its effectiveness in limiting the extent of necrosis resulting from ischemia/reperfusion injury in rat skin. Island skin flaps were elevated in the abdomen and groin based on an inferior epigastric neurovascular pedicle. The venous drainage from the flap was occluded for 7 hours, and reperfusion was established. The majority of flaps in the control group exhibited complete necrosis on Day 7 postoperatively. Treatment with systemic MPG (20 mg/kg of body weight) significantly improved flap survival from 22 to 71% (p less than 0.01) when administered at the time of reperfusion. However, MPG administered 1 hour after reperfusion did not influence the survival of the flaps. The results suggest that MPG may exert its beneficial effects on flap survival by scavenging oxygen free radicals formed at the time of reperfusion following prolonged ischemia.

The effects of hyperbaric oxygen on survival were investigated in free flaps and island flaps. Skin flaps transplanted following 18, 21, and 24 hours of preservation at 24 degrees C demonstrated survival rates of 20%, 10%, and 0%, respectively. Treatment with hyperbaric 100% oxygen improved the survival rates to 66%, 67%, and 40%. A preservation time of 21 to 24 hours at room temperature appears to be the threshold of irreversible ischemic damage. In acute island flaps, flap survival was improved significantly from 35% to 53% and 64% of the random flap area by preoperative or postoperative treatment, respectively. Prolonged preoperative and postoperative treatment improved survival to 66%.

The purpose of this study was to investigate the effect of electrical stimulation on ischemia-induced tissue injury in skin flaps. Bipedicle skin flaps measuring 4 X 20 cm were created bilaterally on the flanks of 12 Yorkshire pigs. The ischemic central portions of the flaps were treated with 35 mA of electrical current at a frequency of 128 Hz for 30 minutes twice daily during the initial nine days following skin-flap elevation. The treatment schedule consisted of negative-electrode stimulation during the first three days, positive-electrode stimulation during the second three days, and negative-electrode stimulation during the seventh to ninth days. Five control pigs underwent either no treatment (n = 3) or sham treatment (n = 2). The mean area of the skin flaps exhibiting necrosis was 28.0% in the control animals and 13.2% in the stimulated animals. These areas were significantly different (p less than .001). The results indicate that pulsed electrical stimulation can improve the survival of skin flaps.

Overall glucose metabolism was evaluated by measuring the rate of oxygen consumption (QO2) and lactate production in the pedicle skin flaps of rats. Skin flaps exhibited increases in QO2 and lactate production in vitro. The distal portion of the flap is characterized by a greater deposition of glucose to lactate during the initial 3 days following flap elevation. The contribution of glycolysis and of the oxidative pathways to glucose metabolism in skin flaps approximates that in normal skin on day 7 postoperatively.

Xanthine:acceptor oxidoreductase activities were assayed in free skin flaps following prolonged preservation. In normal rat skin, xanthine dehydrogenase transfers electrons to NAD+ and accounts for 73% of total oxidoreductase activity, and xanthine oxidase transfers electrons to molecular oxygen and accounts for the remaining 27%. Xanthine oxidase activity increased significantly in skin flaps during ischemia: approximately 30 and 100% increases after 6 and 24 hr of ischemia, respectively. Allopurinol inhibited xanthine oxidoreductase activity: free skin flaps obtained from allopurinol-treated animals exhibited a low level of xanthine oxidoreductase activity throughout the period of preservation. Systemic allopurinol significantly improved the survival rate from 32 to 75% of free flaps transferred after 24 hr of preservation at room temperature. These observations suggest that the xanthine oxidase system is a major source of oxygen free radicals following ischemia/reperfusion in skin. The increase in xanthine oxidase is attributable to the conversion of xanthine dehydrogenase to oxidase, a conversion which involves sulfhydryl oxidation in skin flaps.

Is an intact thoracodorsal vascular pedicle necessary for clinical rotation of a latissimus dorsi myocutaneous flap? Our laboratory and clinical experiences indicate that it is not necessary. These are described herein.

Allopurinol was investigated in 3 x 6 cm congested island skin flaps in rats. Eight hours of venous occlusion produced total flap necrosis. Pretreatment with systemic allopurinol, an inhibitor of xanthine oxidase, enhanced the survival rate of hyperemic skin flaps. Xanthine oxidase activities were demonstrated in skin, and these enzyme activities were noted to increase in skin flaps during ischemia and reperfusion. Much of this increase in enzyme activity was prevented by allopurinol treatment. The xanthine oxidase system appears to be one of the sources of the superoxide radical, which may be involved in ischemic and reperfusion injury in skin.

1) Seven patients were seen and treated over a 1-year span with forearm hematoma and median nerve neuropathy following brachial artery puncture. All seven were anticoagulated. 2) A careful examination established the diagnosis. Prompt operative intervention is recommended. 3) The brachial artery should be avoided as a source for arterial blood gas sampling in the anticoagulated patient.

The distribution of glucose and hexokinase activity was determined in the epithelial tissue of delayed bipedicled skin flaps in guinea pigs. The periods of "delay" were 1, 3, 7, 14, or 21 days. The flap survival was maximal (100% of the flap) when the flap elevation was performed either 7 or 14 days following the "delay" procedure. When the flap elevation was performed 1, 3, or 21 days following the "delay" procedure, the result was partial necrosis. A differential distribution of epithelial glucose was found within the bipedicled flaps. The lowest glucose level (30% of normal) was at a distance of 2 to 3.5 cm from the end of the caudal pedicle during the first day after the "delay" procedure. This decreased glucose content recovered toward normal levels during the later part of the "delay" period. The bipedicled flaps exhibited increased hexokinase activity during the 3-week period of the "delay," and the responses of hexokinase activity and tissue glucose levels to the "delay" procedure were reciprocal in the caudal half of the flaps.

One-third of a group of 18 patients with hemifacial microsomia demonstrated velopharyngeal insufficiency of a significant degree. The ones with velopharyngeal insufficiency tended to have more severe soft tissue and skeletal deformities of the maxillary-malar complex, associated with a total unilateral palatal paralysis. Cinefluoroscopy was not helpful in diagnosing the velopharyngeal insufficiency. Fiberoptic nasopharyngoscopy, in contrast, proved to be an excellent diagnostic tool. We suggest that patients with hemifacial microsomia have a careful, periodic speech evaluation as an essential part of their overall management.

Three cases of epithelioid sarcoma of the upper extremity are presented. Information regarding 112 previously published cases is reviewed. It is concluded that epithelioid sarcoma must be included in the differential diagnosis of soft-tissue tumors of the extremities. Moreover, the diagnosis of epithelioid sarcoma demands prompt and aggressive surgical intervention. Irradiation therapy and chemotherapy have not been proven to be of value in the management of epithelioid sarcoma.

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.

Neurovascular island skin flaps were elevated in the right groin area of Sprague-Dawley female rats weighing from 200 to 250 gm. Survival rates of the flaps were determined following venous and/or arterial occlusions of the femoral vessels. All the flaps exhibited an 80 percent decrease in tissue glucose content and an increase in tissue lactate content 4 to 7 times normal during venous and/or arterial occlusion. In the groups occluded for 8 hours, venous occlusion resulted in loss of all the flaps; arterial occlusion yielded survival of 70 percent of the flaps; and occlusion of both vessels yielded survival of 30 percent of the flaps. The results indicate that venous occlusion is more detrimental to flap survival than arterial occlusion. Surviving flaps exhibited a glucose content of 3.5 times normal, and dying flaps exhibited a glucose content of 20 percent of normal and a lactate content of 5.1 times normal. The ratio of tissue lactate to glucose may serve as an index for tissue viability: normal flaps, 0.3, surviving flaps, 1.2, and dying flaps, 7.5.

A group of 18 patients received a high tension electrical injury of the upper extremity. The over-all results were dismal. Opportunity for improvement appears to lie in a regimen of rapid and complete removal of devitalized skin and muscle, avoidance of contamination and desication and the early provision of blood supply and wound coverage with pedicled flap coverage.

Reconstruction of the average oral commissure electrical burn deformity yields good results when performed as a delayed procedure. Our preferred technique utilizes available vermilion for reconstruction of the lower lip by a rotation flap, and a mucosal advancement flap for reconstruction of the upper lip. Since using this procedure, we have not had a recurrent contracture requiring reoperation.

The effects of some components of the coenzyme nicotinamide adenine dinucleotide (NAD) on tissue viability were investigated in acute island skin flaps which were constructed to exceed the blood supply provided by a unilateral pedicle of inferior epigastric vessels. Control flaps undergo significant necrosis. Treatment with nicotinamide or nicotinic acid, precursors of NAD, prior to flap elevation significantly improved the area of viability in the random portion of the flap from 44 +/- 9% (mean +/- SD) to 67 +/- 12 and 65 +/- 5%, respectively. Similarly, NAD improved viability to 68 +/- 10% (P less than 0.001). Treatment with other components, adenosine diphosphoribose or quinolinic acid, had no effect on flap survival. The results suggest that nicotinic acid and nicotinamide deserve therapeutic consideration with regard to the treatment of ischemia/reperfusion injury in skin.

The effect of a levator retrodisplacement procedure upon conductive hearing loss in cleft palate patients was evaluated. Forty-two children with cleft palates, operated upon between 1970 and 1975, were included in the study. The results suggest that 73.5% of those in the levator retrodisplacement group achieved normal hearing, compared with 37.5% among those whose palatoplasties did not include levator retrodisplacement. The degree of hearing impairment in patients with levator retrodisplacement was mild (20 to 40 db) in contrast to that in patients without levator retrodisplacement, whose impairment was severe (40 to 60 db).

The activities of acid phosphatase and beta-glucuronidase were assayed in fetal and neonatal mouse epidermis by microanalytical methods. The level of acid phosphatase activity was low in the epidermis on Day 15 of gestation. Acid phosphatase activity increased 10-fold between Day 15 of gestation and neonatalhood. On the other hand, beta-glucuronidase activity was high on Days 14 and 15 of gestation and low after Day 17 of gestation. The relative ratio of acid phosphatase to beta-glucuronidase activity appeared to represent a marker for the degree of differentiation in whole epidermis.