Bruce M. Achauer

Management of hemangioma of infancy: review of 245 patients.

A retrospective study of patients treated from May of 1981 to April of 1994 was conducted. A total of 245 patients with 299 hemangiomas were studied, which represents the largest series reported to date. The study consisted of 173 females and 72 males ranging in age from 1 day to 59 years, with the average age being 4 years and 7 months. Twenty-six were premature neonates (14 females and 12 males). An interesting finding was a 1:1 sex ratio among this group in contrast to the 3:1 female-male ratio frequently reported in the literature. Onset was at birth in 170, within the first month in 43, and after the age of 1 month in 32 patients. Among the 245 patients, 175 hemangiomas were located on the head and neck, 62 on the trunk, 49 on the extremities, and 13 in the perineal area. Five groups of patients were defined based on clinical management. As a result, these groups are not similar. The five groups are as follows: group I (48), observation; group II (9), steroid treatment; group III (27), excision and reconstruction; group IV (88), laser therapy; and group V (73), combined therapy. The involved area of hemangioma was as follows: group 1, 0.5 x 0.5 to 20 x 8 cm; group II, 2 x 2 to 8 x 8 cm; group III, 0.4 x 0.8 to 7 x 7 cm; group IV, 0.5 x 0.5 to 20 x 9 cm; and group V, 1.5 x 1.5 to 25 x 25 cm. The complications of hemangioma seen at the time of consultation were obstruction (28.6 percent), ulceration (20.4 percent), bleeding (14.7 percent), infection (4.9 percent), and pain (0.4 percent). Treatment periods ranged from 1 month to 11 years, with the mean period in each group as follows: group I, 4 years and 9 months; group II, 2 years and 5 months; group III, 1 year and 1 month; group IV, 2 years and 1 month; and group V, 3 years. The outcomes of each patient were evaluated based on improvement of volume, color, and texture by the following scale: 1, poor (0 to 25 percent); 2, fair (26 to 50 percent); 3, good (51 to 75 percent); and 4, excellent (76 to 100 percent). Each of these parameters was summarized for each of the five groups. Statistical analysis by the Irwin-Fisher test was used for analysis and comparison of the final results between groups. Statistically significant differences in outcomes between treatment groups were demonstrated. Laser therapy was shown to be statistically superior to observation with regard to length of treatment and with regard to outcomes of volume and texture (p < 0.05).

Augmentation of facial soft-tissue defects with alloderm dermal graft

Numerous materials, both autologous and nonautologous, have been used for augmentation of soft-tissue defects in the facial region. Each has its limitations. There is no ideal material for soft-tissue augmentation. Alloderm dermal graft (LifeCell Corporation, Woodlands, TX) combines the benefits of autografts and allografts. The authors report its use in 11 patients who have soft-tissue defects or scarring on the face. No serious complications such as rejection, mobilization, absorption, dislocation, or extrusion were encountered. The use of Alloderm in these patients minimized two problems: donor site morbidity and lack of adequate tissue for reconstruction. Alloderm is shown to be an excellent augmentation material for soft-tissue defects. The absence of a donor site defect, and adequate tissue for reconstruction are particularly helpful in the pediatric population.

COMPOSITE TISSUE (LIMB) ALLOGRAFTS IN RATS: II. INDEFINITE SURVIVAL USING LOW-DOSE CYCLOSPORINE

Cyclosporine has reawakened interest in transplantation of peripheral composite tissue allografts (CTA) of skin, muscle, bone, vessel, and nerves. The purpose of this study was to examine whether cyclosporine could produce indefinite survival of CTA. Two groups of LEW recipients of LBN limb transplants were given different long-term treatments of cyclosporine. Tolerance was achieved in many of the animals. Several possibilities for the mechanism of this tolerance are discussed.

Free osteocutaneous flap from a rib to the tibia.

A large bony defect of the tibia, covered with thin unstable scar, was repaired successfully with a free osteocutaneous flap composed of 10 cm of the ninth rib with a 9 X 6 cm area of overlying muscle and skin. Microvascular anatomoses were done between the intercostal vessels in the transplant and the anterior tibial vessels in the recipient area.

Transcutaneous PO2 in flaps: a new method of survival prediction.

SUMMARY We have shown a new clinical method for flap monitoring. This new method is noninvasive, continuous, quantitative, easy, and commercially available. If any oxygen can be detected or if there is a response to increased FIO2, flap survival is assured.

Prevention and treatment of side effects and complications of cutaneous laser resurfacing.

Over the past 15 years, cutaneous laser resurfacing has become a popular method of treatment for a variety of ultraviolet light-induced skin disorders. Continued refinement in laser technology and technique over the years has made safe treatment of photoinduced facial rhytides, dyschromias, lentigines, and atrophic scars possible, with low incidences of adverse sequelae.1–8 Derived from the principles of selective photothermolysis elucidated by Anderson and Parrish in 1983,9 an entire generation of lasers has been developed to improve tissue specificity. High-energy, pulsed, and scanned carbon dioxide (CO2) and erbium:yttriumaluminum-garnet (Er:YAG) lasers represent these newer systems. Early laser technology consisted of continuous wave mode CO2 lasers that produced nonspecific cutaneous injury because of prolonged exposure of tissue to laser light energy. The risk of scarring was high because of excessive and uncontrollable conduction of heat to uninvolved structures.10–12 Current systems emit higher fluences in short pulses, thus largely restricting energy deposition to targeted sites without significant collateral thermal damage. Pulse durations shorter than the thermal relaxation time of the targeted chromophore (intracellular water for resurfacing lasers) are used to also ensure selective tissue destruction.13–15 Although complication rates reported in association with cutaneous laser resurfacing are consistently low, many potential adverse reactions may occur. Even in the hands of an experienced laser surgeon, unexpected side effects may result. Complicating factors include poor intraoperative technique, failure to adhere to a strict postoperative recovery regimen, and the individual characteristics of each patient undergoing treatment (e.g., Fitzpatrick skin phototype, degree of ultraviolet light exposure, pretreatment, and medical condition). Clinical results from cutaneous laser resurfacing range widely from the expected posttreatment morbidity with eventual clinical improvement to permanent disfigurement. It is, thus, essential that the normal recovery process after cutaneous laser ablation be well understood and that side effects and complications are recognized and treated at the first sign of their development. Regardless of which laser system is used (CO2 or Er:YAG), some degree of posttreatment morbidity is experienced by all patients undergoing laser resurfacing. Fortunately, true adverse reactions are rare and can usually be differentiated from the typical responses of the skin to laser wounding. Resurfacing with either the high-energy, pulsed, or scanned CO2 or Er:YAG laser results in complete epidermal ablation and upper papillary dermal destruction with collagen remodeling. As a result, newly resurfaced skin lacks an intact epithelium, producing an exposed weeping wound with copious serous discharge. Complete reepithelialization occurs within an average of 8.5 days for CO2 laser-resurfaced skin, compared with 5.5 days for Er:YAG laser-treated skin.1,16 The high-energy, pulsed CO2 lasers produce greater wound depths, penetrating an average of 20 to 60 m with each pass and producing another 20 to 150 m of collateral thermal necrosis.1,10,12,13,17,18 The short-pulsed Er:YAG laser systems effect more shallow tissue ablation (2 to 5 m per pass) and less residual thermal damage (20 to 50 m ).19–22 Because the degree of postoperative erythema correlates directly with the degree of thermal necrosis, pa-

Development of stable mixed T cell chimerism and transplantation tolerance without immune modulation in recipients of vascularized bone marrow allografts

A consistent majority (62.5%) of immunologically unmodified rat recipients transplanted with vascularized hind-limb bone marrow allografts across a semiallogeneic transplant barrier developed tolerance with absence of graft-versus-host disease. A minority of recipients (37.5%) demonstrated lethal GVHD. Transplantation tolerance in the majority was associated with the induction of stable low-level mixed T cell chimerism, including donor CD5+, CD4+, and CD8+ lymphocytes. Chimeras were specifically immune nonresponsive to host alloantigenic determinants. These results emphasized a potentially important mechanism for low-level stable mixed lymphoid chimerism (SMLC) in tolerance induction, independent of immune suppressive effects due to irradiation or immunopharmacologic intervention. These vascularized bone marrow transplantation (VBMT) results may establish the experimental foundation for a novel approach to stem cell transfer and bone marrow transplantation.

Composite tissue (limb) allografts in rats. III: Development of donor-host lymphoid chimeras in long-term survivors

Eight LEW rat recipients possessing long-term-surviving (206-701 days) LBN vascularized hind limb allografts (CTAs) were tested for donor-host lymphoid chimerism. The recipients received various cyclosporine (CsA) treatment protocols in order to induce indefinite CTA acceptance. Histological examination of long-term-surviving CTAs demonstrated normal-appearing bone marrow in the donor limb. Lymphocytes isolated from host hemopoietic tissues (peripheral blood and/or spleen) by ficoll-hypaque density gradient centrifugation were tested against LEW-anti-BN antisera. Comparisons were made to standard curves employing various known concentrations of LBN and LEW cell combinations. The level of lymphocyte agglutination (dependent variable) showed a significant (P less than 0.025-0.005) linear relationship to the concentration of LBN donor cells (independent variable) present. Lymphocyte suspensions isolated from long-term CTA host peripheral blood and/or spleen showed a mean of 19.7% (+/- 9.7-95% confidence interval) donor LBN mononuclear cells present. Thus, it appeared that lymphoid cells originated from, and/or were released from LBN donor bone marrow into the circulation, resulting in chimeric repopulation of hemopoietic tissues. The presence of donor immunocytes in these limb allograft recipients may have been beneficial, and thus could have helped contribute to the long-term CTA survival observed.

A serious complication following medical-grade silicone injection of the face.

A serious complication following MDX4-4011 Dow-Corning silicone for injection to the face is reported. The patient developed inflammatory lesions 11 years after her last silicone injection for what was felt to be Weber-Christian disease. The patient also had a diagnosis of rheumatoid arthritis and a questionable history of mycoplasm infection. She eventually required excision of the right facial area with flap reconstruction. There is at least one other investigator who has had inflammatory complications following silicone injection to a patient with Weber-Christian disease. For these reasons, caution in using liquid silicone in patients who might have Weber-Christian disease is recommended.

Composite tissue (limb) allografts in rats. I: Dose-dependent increase in survival with cyclosporine

The dose-response effect of cyclosporine on rat limb transplant prolongation was investigated across the LBN-to-LEW histocompatibility barrier. This composite tissue allograft model has been shown to represent a strong transplantation barrier. Median limb allograft survival times increased in a dose-dependent manner with low cyclosporine doses, and then reached a plateau at higher levels. The cyclosporine dose that produced half-maximal survival based on a 20-day treatment was only 3.7 mg/kg/day. Histopathology revealed that the rejection process was distinctly different in limb allografts treated with cyclosporine compared with noncyclosporine-treated controls. Rejection appeared to be delayed or partly arrested in certain areas of cyclosporine-treated limb allografts. These studies represent an initial step in laying the experimental foundation for clinical transplantation of composite tissue allografts using cyclosporine-induced immune suppression.