J. William Futrell

The Critical Relationship Between Free Radicals and Degrees of Ischemia: Evidence for Tissue Intolerance of Marginal Perfusion

UNLABELLED Skin-flap ischemia has been associated with the presence of free radicals. In this study, two enzyme systems involved in free-radical metabolism were used to compare a distal skin flap to a skin graft. Forty-two rats were divided into several test groups. A 10 X 3 cm dorsal rat flap was used, and tissue biopsies for xanthine oxidase and malonyldialdehyde (MDA) were obtained 2.5, 5.5, and 8.5 cm from the base of the flap at the hours given. In group I (control), the flap was outlined but not elevated, and biopsies were obtained. In group II, the flap was elevated, and biopsies were obtained at 6 hours. In group III, the flap was elevated, the distal 4 X 3 cm was amputated and replaced as a full-thickness skin graft, and biopsies were obtained at 6 hours. In group IV, the flap was elevated, and biopsies were obtained at 12 hours. In group V, the flap was treated as in group III, and biopsies were obtained at 12 hours. In group VI, the flap was elevated, and biopsies were obtained at 24 hours. In group VII, the flap was treated as in group III, and biopsies were obtained at 24 hours. RESULTS Xanthine oxidase was significantly higher in all distal biopsies compared to proximal biopsies. Xanthine oxidase also increased with time. Malonyldialdehyde increased over time as well as with distance from the flap base. Distal flap biopsies at 24 hours had greatly increased levels of malonyldialdehyde compared to skin grafts (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Deferoxamine increases skin flap survival: additional evidence of free radical involvement in ischaemic flap surgery

This study presents further evidence of free radical involvement in skin flap necrosis in a dorsal rat flap model. Rats receiving deferoxamine, a free radical scavenger and iron chelator had significantly less necrosis (p less than 0.001) than saline treated rats. In a separate experiment, tissue determinations for malonyldialdehyde (MDA) were consistent with the survival results in showing a significant decrease in MDA in all biopsy sites (p less than 0.05 or less), indicative of reduced lipoperoxidation in the deferoxamine treated rats.

The cutaneous blood supply of the neck: relevance to incision planning and surgical reconstruction

Previous descriptions of the blood supply of the neck have been contradictory. Neck dissections were performed on 17 adult cadavers after perfusion with radio-opaque microfil silicone rubber compound. In four cadavers cervical incisions were created and flaps elevated prior to perfusion to help demonstrate vascular pathways. In all cadavers myocutaneous perforators were seen passing from the sternocleidomastoid, strap muscles, and trapezius to supply the dermal-subdermal plexus. Also, there were consistently identifiable branches of the superior thyroid, posterior auricular, occipital, facial and transverse cervical arteries, which supply both the platysmal vascular plexus and the overlying dermal-subdermal plexus. The dermal-subdermal plexus is continuous across the midline and this contralateral pathway is supplied chiefly from branches of the superior thyroid artery, facial artery, and myocutaneous perforators of the strap muscles. This information may be useful in the planning of cervical incisions and the design of platysma myocutaneous flaps.

Rapid Elongation of Arteries and Veins in Rats with a Tissue Expander

The saphenous arteries and veins of 40 rats were elongated with 20-cc tissue expanders underlying the leg adductor muscles. The mean rate of successful elongation of the vessels was 84 +/- 47 percent SD, with a maximum gain of 140 percent. The fastest mean elongation velocity reached 45 percent per day. Thrombosis occurred only with stretching velocities of more than 10 percent per day, which seemed to be a safe margin. Distribution of the volume into many intervals was safer than infrequent high-volume injections. Histology showed no reduction in vessel wall diameter or loss intimal integrity. Subendothelial cellular proliferation was an indicator of this rapid regeneration. Microvascular anastomoses performed in elongated arteries and veins had the same patency rate (90 percent) as in controls.

The Charles procedure: Misquoted and misunderstood since 1950

&NA; The Charles procedure, named for Sir Richard Henry Havelock Charles, is an eponym for a surgical treatment of leg lymphedema. Sir Havelock led a fascinating life, with his travels taking him to India, the Afghan territories, and the Court of King George V of England. At the turn of this century, Sir Havelock published material describing a series of 140 consecutive patients treated successfully for scrotal lymphedema. In a book chapter published a decade later, entitled “Elephantiasis Scroti,” Sir Havelock briefly described the treatment of leg lymphedema but did not document a single successful case report. The name of Sir Havelock Charles was absent from the literature until 1950, when Sir Archibald McIndoe attributed the treatment of leg lymphedema with radical excision and skin grafting to Sir Havelock. References to Charles for the treatment of leg lymphedema have proliferated since that time.

Preoperative cooling and warming of the donor site increase survival of skin flaps by the mechanism of ischaemic preconditioning: an experimental study in rats.

Recent studies show that survival of skin flaps can be increased by ischaemic preconditioning with repeated cycles of ischaemia and reperfusion before prolonged ischaemia or raising of the flap. In this study three cycles of cooling and warming of rat dorsal skin were used to regulate skin blood flow and to induce three cycles of ischaemia and reperfusion. In 10 Sprague-Dawley rats three cycles of cooling (-18 degrees C ice pack) and warming (45 degrees C running water) were used to regulate skin blood flow before the flaps were raised. Caudally-based skin flaps 11 x 2 cm were then raised to the left of the dorsal midline and sutured back. In the control group (n = 9) the flap was raised and sutured back without any treatment. Viability was assessed after seven days and the survival area calculated with planimetry. Viability increased from a mean (SD) of 61 (6)% in the control group to 77 (7)% in the experimental group (p < 0.0001). This study shows that preoperative cooling and warming of the donor site can be used to increase survival of skin flaps. The probable explanation is ischaemic preconditioning although the biochemical mechanism is unclear.

Glutaraldehyde: Species Comparisons of in Vitro Skin Penetration

AbstractIt has been reported that the major portion of the applied dose was recovered from skin at the application site in previously conducted in vivo rat and rabbit pharmacokinetic studies with 14C-labeled glutaraldehyde. To investigate this finding further, and to compare penetration of glutaraldehyde through human skin with absorption data for animal skin preparations, the potential for in vitro skin penetration of [1,5-14C]glutaraldehyde (CAS #111-30-8) was evaluated with samples of excised skin from Fischer 344 rats, CD-1 mice, Hartley guinea pigs, New Zealand White rabbits, and humans (women undergoing reconstructive mammoplasty). A flow-through skin penetration chamber design was used and the aqueous glutaraldehyde concentrations of 0.75% and 7.5% used in the previous in vivo rat and rabbit percutaneous study were applied. The in vitro results indicated that glutaraldehyde did not penetrate human or animal skin to any substantial degree following application of either a 0.75% or a 7.5% aqueous sol...

Improved chest wall fixation for correction of pectus excavatum

Pectus excavatum, the most common congenital chest wall abnormality, is manifested by deformity of the costal cartilages resulting in a depressed and often rotated sternum. Although there are conflicting data to support and reject the concept that physiologic improvement can be a consequence of surgical repair, correction is frequently indicated for aesthetic improvement alone. The most popular current repair involves resection of abnormal costal cartilages, sternal osteotomy and mobilisation, followed by fixation of the sternum in the corrected position. Improved fixation techniques have evolved, but generally have not employed current concepts of rigid fixation. The correction of pectus excavatum using reconstruction plates incorporates the benefits of rigid fixation, while allowing custom chest wall contouring and sternal reorientation. Reconstruction plate fixation of the sternum should be considered during correction of pectus excavatum in adult and adolescent patients.

Evaluation of facial fat distribution using magnetic resonance imaging.

Magnetic resonance imaging (MRI) provides noninvasive images of facial and neck fat for a variety of conditions. It accurately maps the soft tissues pre- and postoperatively, enabling surgeons to precisely and objectively assess results of soft tissue facial contouring and fat transplantation. The risks of MRI are few. It has the potential to provide aesthetic surgeons with a more “scientific” means of comparing various techniques of fat contouring.

Apoptosis and plastic surgery.

Apoptosis, or programmed cell death, is a phenomenon that is integral to development and cellular homeostasis. In the last decade, many of the essential molecules and pathways that control this phenomenon have been elucidated. Because apoptosis is involved in almost all physiologic and pathologic processes, the understanding of its regulation has significant clinical ramifications. This article reviews the basic understanding of programmed cell death in terms of the effector molecules and pathways. Areas of interest to plastic surgeons are reviewed as they pertain to apoptosis. These areas include allotransplantation, craniofacial and limb development, flap survival, wound healing, stem cell science, and physiologic aging. These topics have not yet been studied extensively in the context of cell death. In this review article, other related and more comprehensively studied scientific areas are used to extrapolate their relevance to apoptosis. Apoptosis is an increasingly better understood process. With the knowledge of how programmed cell death is controlled, combined with the improved ability to effectively perform genetic manipulation and to design specific chemical approaches, apoptosis is gaining clinical relevance. In the next few years, practical clinical breakthroughs will help the medical community to understand the phenomenon of apoptosis and how it relates to the needs of patients.