Stephen J. Mathes

Coverage of the infected wound.

Fifty-four consecutive patients with chronic wounds were identified by the following criteria: (1) established infection for 6 months, (2) exposure of bone, mediastinum, or other vital structure, (3) mechanical and/or vascular limitations to delayed closure techniques, (4) no response to wound debridement in prolonged antibiotic therapy. These wounds were divided into four groups: osteomyelitis (21), pressure sore (17), soft tissue wound (10), and osteoradionecrosis (6). Wound treatment in all patients included debridement, muscle flap closure, and culture specific antibiotic therapy. These consecutively treated patients over a 4-year period presented with an average duration of chronic infection of 2.9 years. Ninety-three per cent of these patients after treatment have demonstrated stable wound coverage without recurrent infection with a minimum of 1 year and a maximum of 4.6 years follow-up. The results demonstrate safe, effective coverage (93% of patients) of chronic infected wounds associated with long bone and pelvic osteomyelitis as well as chronic perineal sinuses following proctocolectomy and osteoradionecrosis. Debridement with short-term (average 12 days) antibiotic therapy has been effective when muscle flap coverage is provided.

Ischial pressure sore coverage: a rationale for flap selection

The role of wound debridement and flap coverage in treating pressure sores is clearly established. However, criteria and supportive clinical data for specific flap selection and the sequence of flaps for coverage of the ischium remain ill-defined. From 1979-1995, 114 consecutive patients underwent flap coverage of 139 ischial pressure sores. Preoperative risk factors, prior flap history, defect size, flap success, complication rates, and the length of hospitalization were retrospectively evaluated and compared for 112 flaps in 87 patients. Flap success was defined as a completely healed wound. Average follow-up was 10 months (range: 1 month-9 years). Overall, 83% (93/112) of the flaps healed. In the majority of cases (75%, 84/112), wound debridement and flap reconstruction was achieved in a single stage. However, there were significant differences in the healing rates among the various flaps used. The inferior gluteus maximus island flap and the inferior gluteal thigh flap had the highest success rates, 94% (32/34) and 93% (25/27), respectively, while the V-Y hamstring flap and the tensor fascia lata flap had the poorest healing rates, 58% (7/12) and 50% (6/12), respectively. Flap success was not significantly affected by the age of the patient or the prior number of flaps used and preoperative risk factors were equally distributed across all types of flaps. The overall complication rate was 37% (41/112), most commonly from a slight wound edge dehiscence (n = 16) that healed with local wound care within one month postoperatively. Results of this study show that proper flap selection and the appropriate sequence of flap use significantly improve success rates for ischial pressure sore coverage in both the short- and long-term. Based upon flap reliability (successful healing rates), reusability, and the need to preserve as many future flap options as possible, a rationale for flap selection is presented which can be individualized to any patient.

Mixed allogeneic chimerism as a reliable model for composite tissue allograft tolerance induction across major and minor histocompatibility barriers.

Background. Although prolonged composite tissue allograft (CTA) survival is achievable in animals using immunosuppressive drugs, long-term immunosuppression of CTAs in the clinical setting may be unacceptable for most patients. The purpose of this study was to develop a model for reliable CTA tolerance induction in the adult rat across a major MHC mismatch without the need for long-term immunosuppression. Methods. Mixed allogeneic chimeras were prepared by using rat strains with strong MHC incompatibility [WF (RT1Au), ACI (RT1Aa)] WF + ACI→WF, n=23. The bone marrow (BM) of recipient animals was pretreated with low-dose irradiation (500–700 cGy), followed by reconstitution with a mixture of T cell-depleted syngeneic (WF) and allogeneic (ACI) cells. Additionally, the recipient animals received a single dose of anti-lymphocyte serum (10 mg) 5 days before bone marrow transplantation (BMT) and tacrolimus (1 mg/kg/day) from the day before BMT to 10 days post-BMT. Hindlimb transplants were performed 12 months after BMT. Five animals received a limb allograft irradiated (1000 cGy) just before transplantation. Rat chimeras were characterized (percentage of donor cells present within the bloodstream) by flow cytometry at 3 and 12 months after BM reconstitution and after hindlimb transplantation. Results. Peripheral blood lymphocyte chimerism (WF/ACI) remained stable >12 months after BM reconstitution in 18/23 animals. Multi-lineage chimerism of both lymphoid and myeloid lineages was present, suggesting that engraftment of the pluripotent rat stem cell had occurred. In animals with donor chimerism >60% (n=18) no sign of limb rejection was present for the duration of the study. All animals with chimerism <20% (n=5) developed moderate signs of rejection clinically and histologically. Gross motor and sensory reinnervation (weight bearing, toe spread) developed at >60 days in 14/21 rats. Postoperative flow cytometry studies demonstrated stable chimerism in all animals studied (n=10). Five out of five animals with irradiated limb transplants showed no sign of GVHD at >100 days. Conclusions. Stable mixed allogeneic chimerism can be achieved in a rat hindlimb model of composite tissue allotransplantation. Hindlimb allografts to mixed allogeneic chimeras exhibit prolonged, rejection-free survival. Partial functional return should be expected. The BM transplanted as part of the hindlimb allograft plays a role in the etiology of GVHD. Manipulating that BM before transplantation may influence the incidence of GVHD. This represents the first reliable rat hindlimb model demonstrating rejection-free CTA survival in an adult animal across a major MHC mismatch without the long-term need for immunosuppressive agents.

Microvascular joint transplantation with epiphyseal growth

The successful free microvascular transplantation to the hand of a second metatarsal phalangeal joint with associated epiphyses is described, with follow-up data 2 1/2 years later indicating epiphyseal growth.

The use of a rectus abdominis myocutaneous flap to reconstruct a groin defect

An inferiorly based rectus abdominis myocutaneous skin flap was used carrying a large transversely aligned superior abdominal skin paddle to close successfully an infected and seriously compromised wound in the contralateral groin. The versatility of the rectus abdominis myocutaneous muscle unit, with its dual blood supply, is indicated yet again.

The course of the inferior alveolar neurovascular canal in relation to sliding genioplasty.

The anterior course of the inferior alveolar neurovascular canal was determined in 52 hemiman-dibles using high-resolution radiographs. Significant variability was found in its course. It was noted that if the osteotomies for sliding genioplasty were performed at least 6 mm below the inferior border of the mental foramen, injury to the mental nerve would be reduced.

Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction.

Background: Although free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp, the superficial temporal artery and vein have historically not been considered adequate for microsurgical reconstruction and have rarely been described as recipient vessels. The purpose of this study was to determine the indications for and effectiveness of using the superficial temporal vessels for scalp and face reconstruction. Methods: Retrospective chart review on all patients undergoing microsurgical reconstruction for defects of the upper two-thirds of the face between 1996 and 2003 revealed 45 free tissue transfers in which the superficial temporal artery and vein were considered for use as recipient vessels. Flap success rates and postoperative course were evaluated. Results: Forty-three patients underwent 45 free flap transfers. The superficial temporal artery was used as the recipient artery in every case. In three cases, the superficial temporal vein was not suitable as the recipient vein and required use of a vein in the neck. The median length of follow-up was 4 years. Flap survival was 96 percent. Five patients required reoperation for vascular compromise. One of these patients ultimately had flap failure. In that patient, a subsequent attempt at microvascular flap reconstruction was successful using the same superficial temporal artery and vein as recipient vessels. Conclusions: Use of the superficial temporal artery and vein for scalp and face reconstruction is reliable and safe. The superficial temporal artery and vein should be considered as primary recipient vessels in microsurgical reconstruction of the upper two-thirds of the face and/or scalp.

INDUCTION OF NEUTROPHIL MAC-1 INTEGRIN EXPRESSION AND SUPEROXIDE PRODUCTION BY THE MEDICINAL PLANT EXTRACT GOSSYPOL

Gossypol is present in antiinflammatory poultices made from the medicinal treeThespesia populnea. Isolated human neutrophils exposed to 3–20μM gossypol for 15–90 min were assayed in vitro for superoxide production and surface expression of Mac-1 (CD11b/CD18). Gossypol increased superoxide production in a time- and concentration-dependent fashion consistent with a moderate, delayed respiratory burst. Surface Mac-1 expression was increased within 15 min by 3–5μ M gossypol, resulting in a 14-fold increase over controls and a threefold greater increase over that produced by PMA. Staurosporine failed to block gossypol induction of superoxide and Mac-1, while EDTA inhibited induction of Mac-1 only, implicating a calcium-dependent mechanism. Gossypol increased intracellular calcium to peak levels, but1 in a delayed fashion as compared to FMLP. These findings demonstrate that gossypol is a highly potent stimulant of Mac-1 expression and suggest at least two protein kinase C-independent pathways of neutrophil activation. The resultant exhaustion of neutrophils may account for the antiinflammatory properties of plants containing gossypol.

Repair of chronic radiation wounds of the pelvis

Radiation therapy is currently utilized for primary or adjuvant therapy for pelvic tumors. Although improvements in radiation delivery techniques have largely eliminated acute complications in the radiation field, occurrences of late wound complications persist and result in complex pelvic and perineal wounds. Since these wounds reflect underlying impaired local circulations secondary to obliterative endarteritis, local wound management frequently fails either to control secondary infection or to allow spontaneous wound closure. Twenty-four patients with chronic pelvic wounds have recently undergone successful wound repair with use of muscle, musculocutaneous, and fasciocutaneous flaps. This review of these patients will demonstrate the physiologic basis for vascularized flaps for wound closure. Specific flap selection is based on the location of the pelvic radiation wound in the anterior pelvis and inguinal region, perineum and pelvic cavity, and sacrum. Well-vascularized flaps must have an independent source of circulation distant to the site of radiation damage for reliable wound coverage. Muscle and skin fascial flaps are available based on reliable pedicles located in the anterior abdominal wall, anterior and posterior thigh, and posterior pelvic region with adequate arc of rotation to cover most pelvic defects. Flaps frequently utilized in this study included: rectus femoris, rectus abdominis, gracilis, and gluteus maximus muscle and musculocutaneous flaps, and the gluteal thigh skin fascial flap. Wound debridement and simultaneous coverage with well-vascularized flaps have been established as a useful and reliable method to repair complex wounds of pelvic radiation necrosis. Lirradiation est employée couramment pour traiter demblée ou secondairement les tumeurs pelviennes. Bien que les complications aiguËs intéressant les régions irradiées aient été éliminées grâce à lamélioration technique de lirradiation, les complications tardives persistent sous la forme de lésions pelviennes et périnéales complexes. En raison dune altération de la vascularisation locale secondaire à une endartérite oblitérante, le traitement de ces lésions échoue souvent et se traduit par une infection secondaire ou par une cicatrisation difficile. Vingt-quatre malades présentant des lésions radiques pelviennes ont été traités avec succes par des lambeaux musculaires, musculocutanés ou fascio-cutanés. Leur étude permet dexposer la base physiologique de la réparation par lambeaux vasculaires. Le choix du lambeau spécifique dépend de la localisation de la lésion: région antérieure du pelvis, région inguinale, périnée, cavité pelvienne et sacrum. Les lambeaux vascularisés doivent posséder un pédicule vasculaire provenant dune région qui na pas été irradiée. Les lambeaux qui conviennent peuvent provenir de la partie antérieure de la paroi abdominale, de la région antérieure ou postérieure de la cuisse, de la région pelvienne postérieure et doivent posseder un arc de rotation permettant de couvrir les zones victimes de lirradiaion. En conclusion lexérèse de la région irradiée suivie du recouvrement du défect pariétal par un lambeau bien vascularisé est une méthode réparatrice utile et fiable pour traiter les lésions nécrotiques postradiques du pelvis et du périnée. La radioterapia se utiliza en la actualidad como modalidad de manejo primario o adyuvante de tumores pélvicos. Aunque los avances en las técnicas de irradiation han eliminado casi por completo las complicaciones agudas sobre el campo irradiado, todavía se presentan complicaciones tardías en la herida, las cuales resultan en heridas crónicas de alta complejidad en la pelvis y el periné. Puesto que tales heridas son un reflejo de alteraciones circulatorias locales secundarias a endarteritis obliterativa, su manejo local con frecuencia falla en lo que se refiere al control de la infección secundaria o al logro de la cicatrización espontánea. Veinticuatro pacientes con heridas perineales crónicas han sido sometidos recientemente a exitosa reparación mediante el uso de mÚsculo y de colgajos musculocutáneos y fasciocutáneos. La revisión de estos pacientes demuestra las bases fisiológicas para el uso de colgajos vascularizados en el cierre de estas heridas. La selección de colgajos específicos se fundamenta en la localización de la herida pélvica de irradiación sobre la pelvis anterior y la región inguinal, el periné y la cavidad pélvica, y el sacro. Colgajos bien vascularizados deben poseer una fuente independiente de circulación ubicada lejos del lugar de la lesión por irradiación, si se quiere lograr una buena cobertura de la herida. Se puede disponer de colgajos musculares y fasciocutáneos alimentados por pedículos confiables ubicados sobre las regiones anteriores y posteriores del muslo y sobre la región pélvica posterior, con un arco adecuado de rotación para cubrir la mayorá de los defectos pélvicos. Los colgajos más frecuentemente utilizados en nuestro estudio incluyeron: mÚsculos rectus femoris, rectus abdominis, gracilis y glÚteos máximos, junto con colgajos mÚsculocutáneos y el colgajo fasciocutáneo gluteal y del muslo. La debridación de la herida y el cubrimiento simultáneo con colgajos bien vascularizados han quedado establecidos como método Útil y confiable para la reparación de heridas complejas de la pelvis resultantes de necrosis por irradiación.Radiation therapy is currently utilized for primary or adjuvant therapy for pelvic tumors. Although improvements in radiation delivery techniques have largely eliminated acute complications in the radiation field, occurrences of late wound complications persist and result in complex pelvic and perineal wounds. Since these wounds reflect underlying impaired local circulations secondary to obliterative endarteritis, local wound management frequently fails either to control secondary infection or to allow spontaneous wound closure. Twenty-four patients with chronic pelvic wounds have recently undergone successful wound repair with use of muscle, musculocutaneous, and fasciocutaneous flaps. This review of these patients will demonstrate the physiologic basis for vascularized flaps for wound closure. Specific flap selection is based on the location of the pelvic radiation wound in the anterior pelvis and inguinal region, perineum and pelvic cavity, and sacrum. Well-vascularized flaps must have an independent source of circulation distant to the site of radiation damage for reliable wound coverage. Muscle and skin fascial flaps are available based on reliable pedicles located in the anterior abdominal wall, anterior and posterior thigh, and posterior pelvic region with adequate arc of rotation to cover most pelvic defects. Flaps frequently utilized in this study included: rectus femoris, rectus abdominis, gracilis, and gluteus maximus muscle and musculocutaneous flaps, and the gluteal thigh skin fascial flap. Wound debridement and simultaneous coverage with well-vascularized flaps have been established as a useful and reliable method to repair complex wounds of pelvic radiation necrosis.RésuméLirradiation est employée couramment pour traiter demblée ou secondairement les tumeurs pelviennes. Bien que les complications aiguËs intéressant les régions irradiées aient été éliminées grâce à lamélioration technique de lirradiation, les complications tardives persistent sous la forme de lésions pelviennes et périnéales complexes. En raison dune altération de la vascularisation locale secondaire à une endartérite oblitérante, le traitement de ces lésions échoue souvent et se traduit par une infection secondaire ou par une cicatrisation difficile. Vingt-quatre malades présentant des lésions radiques pelviennes ont été traités avec succes par des lambeaux musculaires, musculocutanés ou fascio-cutanés. Leur étude permet dexposer la base physiologique de la réparation par lambeaux vasculaires. Le choix du lambeau spécifique dépend de la localisation de la lésion: région antérieure du pelvis, région inguinale, périnée, cavité pelvienne et sacrum. Les lambeaux vascularisés doivent posséder un pédicule vasculaire provenant dune région qui na pas été irradiée. Les lambeaux qui conviennent peuvent provenir de la partie antérieure de la paroi abdominale, de la région antérieure ou postérieure de la cuisse, de la région pelvienne postérieure et doivent posseder un arc de rotation permettant de couvrir les zones victimes de lirradiaion. En conclusion lexérèse de la région irradiée suivie du recouvrement du défect pariétal par un lambeau bien vascularisé est une méthode réparatrice utile et fiable pour traiter les lésions nécrotiques postradiques du pelvis et du périnée.ResumenLa radioterapia se utiliza en la actualidad como modalidad de manejo primario o adyuvante de tumores pélvicos. Aunque los avances en las técnicas de irradiation han eliminado casi por completo las complicaciones agudas sobre el campo irradiado, todavía se presentan complicaciones tardías en la herida, las cuales resultan en heridas crónicas de alta complejidad en la pelvis y el periné. Puesto que tales heridas son un reflejo de alteraciones circulatorias locales secundarias a endarteritis obliterativa, su manejo local con frecuencia falla en lo que se refiere al control de la infección secundaria o al logro de la cicatrización espontánea. Veinticuatro pacientes con heridas perineales crónicas han sido sometidos recientemente a exitosa reparación mediante el uso de mÚsculo y de colgajos musculocutáneos y fasciocutáneos. La revisión de estos pacientes demuestra las bases fisiológicas para el uso de colgajos vascularizados en el cierre de estas heridas. La selección de colgajos específicos se fundamenta en la localización de la herida pélvica de irradiación sobre la pelvis anterior y la región inguinal, el periné y la cavidad pélvica, y el sacro. Colgajos bien vascularizados deben poseer una fuente independiente de circulación ubicada lejos del lugar de la lesión por irradiación, si se quiere lograr una buena cobertura de la herida. Se puede disponer de colgajos musculares y fasciocutáneos alimentados por pedículos confiables ubicados sobre las regiones anteriores y posteriores del muslo y sobre la región pélvica posterior, con un arco adecuado de rotación para cubrir la mayorá de los defectos pélvicos. Los colgajos más frecuentemente utilizados en nuestro estudio incluyeron: mÚsculos rectus femoris, rectus abdominis, gracilis y glÚteos máximos, junto con colgajos mÚsculocutáneos y el colgajo fasciocutáneo gluteal y del muslo. La debridación de la herida y el cubrimiento simultáneo con colgajos bien vascularizados han quedado establecidos como método Útil y confiable para la reparación de heridas complejas de la pelvis resultantes de necrosis por irradiación.

The arterial anatomy of larynx transplantation: microsurgical revascularization of the larynx.

Advances in immunosuppression and selective reinnervation may soon make laryngeal transplantation a potential therapy for patients undergoing total laryngectomy. Successful transplantation requires a clear delineation of those vessels necessary to completely revascularize the larynx. Our hypothesis is that the arterial inflow provided by a single superior thyroid artery is sufficient to revascularize the entire larynx. To test this hypothesis, 8 cadavers were studied via either barium latex injection (n = 4) to assess contralateral tissue perfusion or India ink (n = 4), to determine the degree of mucosal perfusion. Following injection via a single superior thyroid artery, all larynges demonstrated either complete, bilateral tissue perfusion evidenced by x‐ray visualization of the barium latex injected specimen or bilateral mucosal staining with India ink. We conclude that bilateral perfusion of the entire larynx transplant, including laryngeal and epiglottic mucosa, would occur after revascularization of a single superior thyroid artery. These findings suggest that reliable revascularization of a larynx transplant is technically possible using modern microsurgical techniques.