Changes in vascularization of sternocleidomastoid myocutaneous flaps

The first generation antifungal agent triazoles, fluconazole and itraconazole, have revolutionised the treatment of serious fungal infections such as mucosal and invasive candidiasis and cryptococcal meningitis. However, the treatment of some fungal infections, particularly aspergillosis, is still far from satisfactory and thus there is an important requirement for new broad-spectrum antifungal agents. The new second generation triazoles voriconazole and SCH-56592 show considerable promise in achieving this goal in the near future.     

Clinical features of primary and secondary atypical mycobacteriosis

A clinical investigation was carried out in 39 patients with atypical mycobacteriosis (AM). The patients at our hospital diagnosed as having AM during an 11-year period from 1981 to 1991 were reviewed in this study. The incidence of AM among all of mycobacterial infections has been increasing since 1988. The atypical mycobacteria detected included M. avium complex (MAC) in 79%, M. kansasii in 26%, and other organisms in 5%. Patients who had primary infection without underlying respiratory disease were compared with those who had secondary infection. In secondary infection, MAC was detected in the sputum of a high percentage of patients and was positive for more than 6 months despite therapy. Gamma globulin levels were also increased in patients with secondary infection. Cell mediated immunity was examined by the DNCB reaction and the detection of CD4- and CD8- positive T lymphocytes. The DNCB skin reaction was positive in 6 out of 26 patients with secondary infection. The percentage of CD8- positive T lymphocytes was higher in patients with secondary disease. Fischer's ratio (indicating the balance of plasma amino acids) was also examined as an index of the nutritional status. It was significantly lower in secondary infection compared with primary infection. Moreover, secondary infection was associated with a lower positive rate for the DNCB skin reaction and a lower Fischer's ratio when compared with pulmonary tuberculosis. Thus impairment of cell-mediated immunity, malnutrition, and a poor prognosis were significantly more common in secondary infection compared with primary infection.     

The management of unsalvageable free flaps

The loss of vascular flow in the early postoperative period will generally lead to free flap failure. When attempts at flap salvage are unsuccessful, conservative management with delayed flap debridement may be indicated. Seven unsalvageable free flaps were managed with observation and flap debridement 4 to 14 days following loss of vascular signals. At the time of debridement, six of the seven wounds had viable granulation tissue and were successfully closed with skin grafts. The seventh patient had loss of vascular flow to the free flap within 12 hr of surgery and, at the time of delayed debridement, had no evidence of granulation ingrowth. Local revascularization of flaps is known to occur and offers an explanation for these findings. Delayed debridement of unsalvageable free flaps is indicated for noncritical wounds, and may obviate the need for a second free-tissue transfer to obtain wound closure.     

Mode of vascularization of control and basic fibroblast growth factor-stimulated prefabricated skin flaps

This study, using 62 rabbits, examines the rate and pattern of vascular outgrowth from a subcutaneously implanted vascular pedicle, how the newly formed vessels connect to preexisting skin vessels, and whether local application of basic fibroblast growth factor can accelerate the angiogenic process. When the femoral artery and vein of rabbits are implanted beneath the skin, angiogenesis from both the pedicle and small blood vessels within the adjacent skin begins within 3 days. Perfusion with India ink reveals connections between the pedicle and dermal vessels as early as 5 days after implantation of the pedicle. Provided the pedicle does not thrombose, skin flaps based on it may survive completely when elevated as early as 2 weeks after implantation. Flap survival depends on the development of a small number of vascular connections between vessels arising from the pedicle and preexisting dermal vessels. If elevation is delayed until 4 weeks after implantation a flap may survive even if its pedicle has thrombosed. Prolonged release of basic fibroblast growth factor adjacent to the pedicle significantly increases the survival of flaps elevated 1 week after implantation but does not alter the survival of flaps elevated at 2 and 4 weeks.     

Cardiovascular prevention, primary or secondary, in high risk patients

Two groups of patients admitted to hospital consecutively for coronary artery disease in 36 university hospital departments were interrogated about the advice received and followed concerning cardiovascular prevention both before the clinical onset of the disease (Group I), those with disease of less than one month duration (primary prevention), or after this period (Group II), those with disease for over six months (secondary prevention). The follow-up of risk factors or medical advice concerning prevention (dietary and/or treatment) was more common, and compliance to the advice was better, in secondary prevention. However, in both groups, with the exception of hypertension, the diagnosis and follow-up of the risk factors were incomplete with 19% vs 41% (p < or = 0.001) of serum cholesterol levels unmeasured before the onset of clinical disease; during the last 5 years, 41% vs 12% (cholesterol, p < or = 0.001) and 27% vs 9% (serum glucose, p < or = 0.001) were not checked. At least one measure of prevention had been advised to 66% vs 80% (p < or = 0.001) of patients and the measures taken concern 53 vs 75% (p < or = 0.001) of patients: serum cholesterol 27% vs 51% (p < or = 0.001), hypertension 32% vs 36% (NS) and serum glucose 14% vs 21% (p < or = 0.05). Compliance with advice was mediocre with regards to diet and cholesterol lowering drugs. A large proportion of patients in both groups had higher than recommended levels, including those on diet or treatment. These observations, confirmed in France and abroad, suggest that cardiovascular prevention should be better organised.     

Deformation of materials based on thermally expanded graphite

Strain and strength in uniaxial compression have been examined for specimens with various densities made by uniaxial pressing of thermally expanded graphite powders, which have been produced by the heat treatment of intercalated graphite compounds. Low-density graphite specimens formed at 600°C have the highest strain resistance. Surface Chemistry Institute, Ukrainian Academy of Sciences, Kiev. Translated from Poroshkovaya Metallurigya, Nos. 5–6, pp. 18–23, May–June, 1998.     

Clinical application of volume estimation based on three-dimensional ultrasonography

The development of three-dimensional sonography represents a milestone in the history of diagnostic ultrasound. It has become possible to evaluate a region of interest not only in the horizontal and vertical planes but also in a third, i.e. the frontal, plane. Among other possible applications, this technique greatly facilitates volume estimation. The objective of the present study was to evaluate the accuracy and precision of volumetry based on three-dimensional sonography. The results demonstrate a good correlation between estimated volumes and the volumes measured by transvaginal needle-guided follicle aspiration performed under sonographic visualization. Our findings confirm the conclusion of previous studies that three-dimensional sonography is making a valuable contribution to imaging techniques.     

The current role of preoperative arteriography in free fibula flaps

Parathyroid carcinoma is one cause of primary hyperparathyroidism, a condition in which there is hypercalcemia and dysregulated hypersecretion of PTH. In normal, and in some neoplastic parathyroid cells, PTH secretion is mediated by the cell surface calcium-sensing receptor. We describe the first therapeutic use of a novel molecule, a calcimimetic, that has agonist action at the calcium-sensing receptor. A 78-yr-old man with parathyroid carcinoma was admitted with hypercalcemia, markedly elevated PTH, and a change in mental status. He was treated for 17 days with conventional therapy, which included saline hydration, furosemide, pamidronate, and calcitonin. This was ineffective, and on hospital day 18, calcimimetic at a dose of 50 mg, orally, every 6 h was added. On hospital day 25, the dose was increased to 100 mg, orally, every 6 h, and on hospital day 30, saline and furosemide were discontinued. He was discharged on hospital day 40. With several dose adjustments, he has been treated with monotherapy calcimimetic for over 600 days and has not required any other interventions for his parathyroid carcinoma. Mean daily precalcimimetic treatment values of serum ionized calcium and PTH were 1.83 mmol/L and 872 pg/mL, respectively. During hospitalization, at the lower dose of calcimimetic, calcium and PTH decreased to 1.67 mmol/L and 538 pg/mL; with the higher dose they further decreased to 1.51 mmol/L and 444 pg/mL. Since discharge, and despite increasing levels of PTH, serum calcium has remained high, but lower than the admission level and acutely responsive to changes in calcimimetic doses. This compound, a calcimimetic, the first of a new class of compounds with activity at the calcium-sensing receptor, has been used to treat a patient with parathyroid carcinoma. During 2 yr of treatment, no adverse clinical effects have been observed, and it appears to have been effective at controlling hypercalcemia.     

Clinical scrutiny of the de facto superiority of proximally versus distally based fasciocutaneous flaps

Just as the dogma that skin flap survival depends on rigid length-to-width ratios has been refuted as a consequence of advances in understanding the anatomical basis of the cutaneous circulation, the generalization that distally based flaps are inherently inferior to proximally based flaps also deserves to be challenged. All else being equal, the truly critical factor for flap viability in either case is the nature of their intrinsic blood supply rather than any arbitrary configuration or orientation. Previous laboratory evidence has proved this fact and is now further validated by a clinical experience with 194 local fascia flaps in 174 patients. There was a 22.2 percent overall incidence of complications, but no statistically significant difference in this rate was observed whether the flap was distally based (18.8 percent of 16 flaps) or proximally based (23.5 percent of 162 flaps) (p = 0.669). Major complications, usually a failure of the intended coverage, actually were more common for proximally based flaps (12.9 percent) than those distally based (6.3 percent), although not statistically different (p = 0.436). Bipedicled fasciocutaneous flaps, which should have had augmented perfusion from their dual sources of inflow, sustained complications in 12.5 percent of 16 flaps. Although none was classified as a major problem, again no difference was apparent when compared with proximally based (Pprox = 0.316) or distally based (pdis = 0.626) flaps. Some caution is prudent in interpreting these retrospective data, not because of an admitted bias for more frequent selection of proximally based flaps, but because the choice for any of these local fasciocutaneous flap always followed a careful assessment of the status of the fascial plexus adjacent to any defect. Audible or color Doppler ultrasound localization of available cutaneous perforators can predetermine the feasibility of any option, thereby ensuring a reasonable success rate regardless of pedicle orientation.     

Application of different types of free foot flaps in hand surgery

From 1987, nine types of free vascularized flaps or combined flaps from the foot were used to treat 26 cases of hand injury with tissue loss. They were: (1) combined flap of 4 toe dorsums, big toe pulp, first toe web, and dorsalis pedis flap with long extensor tendons of the toes, (2) composite skin flap with the second metatarsophalangeal joint, (3) wrap-around flap from the great toe, (4) first toe web flap, (5) toe pulp flap with only an artery and a nerve, (6) wrap-around flap of the great toe with a dorsalis pedis flap, (7) second toe with dorsalis pedis flap, (8) dorsalis pedis flap, and (9) first toe web flap with second metatarsal bone. All flaps survived. All the patients have used their reconstructed hand. Of the final motor functions of the reconstructed hands, 68.8% are excellent, 27.3% are good, 3.9% are fair. Of the final cosmetic results of the reconstructed hands, 76.9% are excellent, 15.3% are good, 7.8% are acceptable. Of the patients, 64.9% are satisfied with the final results of the donor sites, 31.2% feel it is acceptable, and 3.9% feel it is unsatisfactory. The selection, indication, merits and demerits of vascularized foot flaps and attentive points in the operations are discussed in this paper.     

Skin flaps and expanded full-thickness skin grafts. Indications in the repair of burn sequelae

The great majority of sequelae of deep burns concern the skin. Their correction essentially raises problems of replacement of scarred skin by good quality skin. Sequelae of burns logically constitute one of the best indications for progressive mechanical skin expansion by prosthesis, which allows for considerable improvement of the aesthetic results. This improvement is related to the use of skin replacement tissues with the same quality as the original tissue. Local expanded flaps and expanded full-thickness skin grafts are the two essential techniques used. The authors review the general rules concerning the use of expansion prostheses, then describe the various indications for expanded flaps and expanded full-thickness skin grafts in the sequelae of burns of the face, neck, thorax and limbs. The main indications are illustrated by clinical cases.     

Formation and properties of materials based on thermally expanded graphite

It is established that the properties of articles made from thermally expanded graphite (TEG) depend mainly on methods and conditions of their formation. Material formation occurs in several stages. The capacity of TEG to show a considerable elastic aftereffect after removing the external load plays a special part in forming anisotropic properties causing mechanical properties to change with a change in density. The materials obtained may be both elastic and elastoplastic. It is shown that continuous indenation may be used for nondestructive monitoring of local and bulk properties. The feasibility of a damagability criterion for EG materials is demonstrated. Institute of Surface Chemistry, Ukrainian Academy of Sciences, Kiev. Translated from Poroshkovaya Metallurgiya, Nos. 1–2, pp. 43–49, January–February, 1997.     

Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps

PURPOSE: The author outlines the care of patients receiving intravenous amphotericin B, with emphasis on the prevention and/or management of nephrotoxicity. OVERVIEW: The immunocompromised patient remains at risk for systemic fungal infections; however, therapeutic options are limited. Although amphotericin B has remained the drug of choice for more than 30 years, its toxic effects, particularly nephrotoxicity, warrant careful attention. Nephrotoxicity is the most serious and dose-limiting effect of amphotericin B therapy. Appropriate assessment before, during, and after therapy in patients receiving intravenous amphotericin B may help to minimize the potential for nephrotoxicity. CLINICAL IMPLICATIONS: To provide optimal patient care, it is imperative that the clinician understand the etiology of and the signs and symptoms associated with nephrotoxicity, as well as interventions to prevent nephrotoxicity, in the patient receiving amphotericin B.     

Microsurgical elimination of foot soft tissue defects with free vascularized flaps]

The results of 40 microsurgical transplantations of complex flaps in 37 patients with cicatricial-ulcerous foot deformations are analysed. The surgery was indicated in cicatricial soft tissues defects, unhealing trophic ulcers, inability to use local tissues for plastic surgery. The scapular flap was used in 34 cases, thoraco-dorsal flap in 5 cases, deltoid flap in 1 case. It was necessary to increase the square of the scapular flap in case of a vast cicatricial soft tissue defect of the talocrural joint and dorsal surface of the foot and the sole. A special expander was used for this purpose. The importance of ultrasound methods for evaluation of the vessels supplying the sole, as well as the state of the microvascular anastomoses in postoperative period is stressed. The long-term results were followed up for 1.5 to 5 years in 29 of 37 patients. The good results was noted in 18 patients, satisfactory in 7 patients, complications (unhealed trophic ulcers) in 4 patients. The complications were caused by calcanel tuber deformation with osteophyte, osteomyelitis, inradically removed scars.     

Topographic anatomy and arterial vascularization of the parathyroid glands. Practical application

During the last few years, surgery of primary and secondary hyperparathyroidism has seen remarkable progress. The risks of this surgery are represented essentially by persistant or recurrent hyperparathyroidism and hypoparathyroidism. On the other hand, indications of thyroidectomy are more and more relevant in thyroid pathology. One of the main complications of this surgery is hypoparathyroidism. In these circumstances, the surgeon should know the anatomy and vascularisation of the parathyroids. The purpose of this work is to recall the topographic anatomy and to finalize the origin of the arterial vascularisation in order to improve the results of the thyroid and parathyroid surgery and to diminish its complications.