Haggai Tsur

Neovascularization of skin flaps: route and timing.

Axial flaps were elevated in a pig and rat model. Selective ligation of the vascular pedicles on days 1 to 7 following elevation of the flap demonstrated total necrosis of all flaps when the pedicles were ligated on the first, second, and third postoperative day in the pig, and up to 6 days inthe rat. Pedicle ligation beyond this time did not produce flap necorsis, indicating the establishment of adequate neovascularization for flap survival. Selective ligation of the artery or vein did not appear to be significant in the pig. In the rat flap, however, survival tended to occur sooner. Adequate neovascularization for flap survival was demonstrated as arising from both the wound edges and the bed, although vascular channels occurring from the bed appeared to be of greater importance. The relatively rapid rate of neovascularization that occurs for adequate flap survival suggests that if some way could be found to maintain flap viability during the first week, the feeding vessels need no longer remain patent and may be ligated or used for other purposes. This interesting observation has already allowed very early successful defatting of clinically transferred flaps.

Temperature monitoring during photodynamic therapy of skin tumors with topical 5-aminolevulinic acid application

Temperature monitoring during photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) cream application was performed on 22 patients with solar keratoses (SK) and basal cell carcinoma (BCC). The lesions were located on the forehead, nose, ear and cheek. Temperature measurements during photoirradiation, with a power density of 100 mW/cm2 from an incoherent light source (light delivery system for PDT), were carried out by noncontact (infrared thermal imaging radiometer) and contact (thermocouple) methods. Thermal imaging analysis revealed nonuniform temperature distribution in the irradiated areas. The temperature gradually increased from the peripheral to the central zone of the area. The results showed that photoirradiation induced heating of the skin tumors to 39.5-42.5 degrees C during the PDT procedure. The temperature of normal skin areas disposed symmetrically to the lesions on the contralateral side at the same conditions of irradiation (without prior ALA application) was about 42-43.5 degrees C. The surface temperature differences (delta T) between the normal and tumor tissues after 10 min of irradiation were 3.3 +/- 0.5 degrees C in the forehead areas, 2.5 +/- 0.4 degrees C in the nose areas and 0.8 +/- 0.3 degrees C in the ear areas.

RESTORATION OF SENSATION TO THE HAND BY A FREE NEUROVASCULAR FLAP FROM THE FIRST WEB SPACE OF THE FOOT

A neurovascular free flap from the first web space of the foot was used successfully in two patients for replacement of glabrous skin of the hand and fingers. The potential advantages of this flap are that (1) it may be used to replace large defects of glabrous skin, (2) it provides a rich vascular supply to the periphery of the hand, and (3) the sensation achieved approaches the normal for the intact glabrous skin of the hand.

Peutz‐jeghers syndrome and bilateral breast carcinoma

Bilateral breast carcinoma developed in a young woman with Peutz‐Jeghers syndrome. A review of the literature reveals that it is not uncommon for Peutz‐Jeghers syndrome to be associated with malignant tumors. A genetic predisposition to cancer development may be part of the spectrum of this syndrome. Patients with Peutz‐Jeghers syndrome should be examined carefully for early detection of cancer.

Multiple linear spiradenomas.

A case of eccrine spiradenoma (ESA) is described in a 35-year-old man. During an 18-year period, the original number of tumors grew in size and fused into large groups. Surgical excision of all tumors was performed successfully. The unusual features of the case were a linear distribution and giant multifocal tumors. The histology of the tumors and their appearance at the beginning and 18 years later is described.

Emotional and psychosocial adjustment of women to breast reconstruction and detection of subgroups at risk for psychological morbidity

Thirty-four women who had undergone breast reconstruction after mastectomy for breast cancer were evaluated as to their emotional and psychosocial adjustment. Standardized psychological tests and a self-report questionnaire were used, along with the surgeons evaluation of the aesthetic success of the reconstruction. Two psychodiagnostic tests were found to be of use in identifying maladjusted women who do not gain optimal benefit from the reconstruction: a questionnaire that evaluates the level of depression (Beck) and another that assesses the level of optimism (Cantrill). No correlation was observed between the surgeons evaluation of the reconstructions aesthetic success and the womens satisfaction. It was found that there are two groups of emotional-high-risk women: single women and women receiving adjuvant therapy. It is suggested that emotional-high-risk patients be given psychological support concerning the importance of the mastectomy and their reaction to breast reconstruction.

The thin malignant melanoma. Changing patterns of epidemiology and treatment

In the past few years a change has been noticed in the behavior of cutaneous malignant melanoma, with higher cure and survival rates. A retrospective review of all cases of primary cutaneous malignant melanoma during the years 1970–1979 in Chaim Sheba Medical Center reveals a possible explanation for this. The microscopic findings were reevaluated, diagnosis confirmed, and thickness of the tumor measured in millimeters. The number of cases diagnosed rose from eight in 1970 to 45 in 1979. A constant rise in number of thin melanomas (less than 0.75 mm in depth) was noticed. The percentage of thin melanoma rose from 11.1% of all melanomas in 1970 to 57.7% in 1979. Greater public and medical awareness of the danger of pigmented cutaneous lesions has probably triggered an earlier diagnosis of melanoma. Each suspected lesion is completely excised with a 1‐cm free margin. No further excision is undertaken if a thin melanoma is diagnosed (excluding the more malignant regressing melanoma) on frozen section. Of the patients seen in 1979, 57% were spared wide excision and general anesthesia.

Case report-microcystic adnexal carcinoma following radiotherapy in childhood

A 36-year-old man was treated by radiotherapy for tinea capitis many years before discovery of microcystic adnexal carcinoma (MAC). Because of patients refusal of any surgical intervention, we were able to follow the natural course of this tumor for 13 years. This case emphasizes the typical slow development of (MAC). The implication of the association of MAC and radiotherapy are discussed.

Mapping of the human body skin with the transcutaneous oxygen pressure method.

Transcutaneous oxygen pressure (TcPo2) measurements are studied to determine whether location, side of body, sex, and age affect the values at 23 different sites. Measurements were taken on 19 healthy volunteers on one side or the other of the body. Values were similar at all sites with the exception of the forehead, cheek, medial aspect of the leg, and the scapular region. There was no difference between sides of the body or between younger and older subjects. Women had significantly higher values. The results are discussed, and it is concluded that most skin regions can serve as controls for areas under investigation.

Heat Tolerance in Patients with Extensive Healed Burns

Some thermoregulatory parameters of 10 subjects with healed burns were studied. The subjects, 4 of whom had healed burns of over 40 percent (group A) and 6 with burns smaller than 30 percent (group B) were assigned in a climatic chamber to 3 hours bench stepping (30 cm height) under 40 degrees C and 50 percent relative humidity. Rectal temperature, weighted skin temperature, heat storage, and heart rate were all found to be significantly higher in group A than in group B or group C (control group of normal subjects). No significant difference was observed between groups B and C. A highly significant linear correlation (r = 0.89) was found between the sweat rate and percentage of burned area. In addition, 3 subjects of group A terminated the study after less than 90 minutes. Two subjects in group B terminated the study after 120 and 135 minutes, while all subjects of group C finished the entire 3 hour work. The study indicates that subjects with burns of over 40 percent could be classified as heat intolerant due to a pronounced reduction in perspiration area.