Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31‐year‐old female presented with a massive left‐sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep‐skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement. © 2005 Wiley‐Liss, Inc. Microsurgery 25:325–328, 2005.

Department of Cardiac Surgery, Department of Plastic and Reconstructive Surgery, Leopold-Franzens University, Innsbruck, Austria Correspondence to Dr. Huemer Department of Plastic and Reconstructive Surgery, Leopold-Franzens University, Anichstrasse 35, A-6020 Innsbruck, Austria [email protected]

BACKGROUND:Involvement of the metacarpophalangeal (MP) joints is one of the major problems in patients with rheumatoid arthritis (RA). Although several data about the cumulative influence of steroid intake on bone are available, the course of demineralisation in RA has not been described by quantitative methods until now. PATIENTS AND METHODS:Computed tomography (CT) sections of 96 MP joints in 12 RA patients and of 32 MP joints in four age-matched healthy controls were investigated. Patients were classified according to Steinbrocker. Densitometric evaluation of subchondral bone density was performed by CT osteoabsorptiometry (CT-OAM). Quantitative CT-OAM was used to evaluate mineralisation of the articular surfaces in MP joints. RESULTS:In the distal articular surface of MP joints, the number of density maxima was reduced from 3 to 2.1+/-0.3, 1.9+/-0.5 and 1.3+/-0.3 in RA patients with early, mild to moderate, and severe disease, respectively. Means of calcium concentrations were 633.4+/-35. 3 mg Ca2+/mL, 518.9+/-56.2 mg Ca2+/mL, 497.7+/-23.8 mg Ca2+/mL and 455.1+/-28.6 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. Mineralisation of the distal articular surface was significantly reduced in all groups of RA patients [probability (p) = 0.005]. Regarding the number of density maxima, no differences were detected in the proximal articular surface of normal and RA fingers. However, mineralisation of the proximal articular surface was significantly reduced in all groups of RA patients (p = 0.004). Means of calcium concentrations of the proximal articular surface were 494.1+/-48.5 mg Ca2+/mL, 413.0+/-16.2 mg Ca2+/mL, 406.0+/-51.4 mg Ca2+/mL, 390,4+/-41.1 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. CONCLUSION:Patients with early and untreated RA show loss of mineralisation and altered morphology of the MP joints of the hand, even before corticosteroid therapy. CT-OAM provides evidence for an early alteration of functional anatomy in MP joints.

During the past 30 years, much debate has centered around side effects of silicone breast implants. Meta-analyses rejected the presumed relationship between silicone breast implants and connective tissues diseases but, in seeming contradiction, case reports about connective tissue diseases and rheumatoid symptoms continue to be published. We analyzed the cellular and molecular composition of fibrous capsules removed from patients at various times after surgery for diagnostic purposes (breast cancer relapse) or to relieve painful constrictive fibrosis. Frozen sections of capsule tissue were immunohistochemically stained for subsets of lymphocytes, macrophages, dendritic cells, fibroblasts, smooth muscle cells, for collagenous and non-collagenous extracellular matrix proteins, for heat shock protein 60 (HSP60) and for adhesion molecules. Massive deposition of fibronectin and tenascin was observed adjacent to the implant surface. The capsule/silicone implant contact zone was consistently characterized by a palisade-like single or multilayered cell accumulation consisting of HSP60+ macrophages and HSP60+ fibroblasts. Mononuclear cell infiltrates consisting of activated CD4+ T-cells, expressing CD25 and CD45RO, as well as macrophages were detected beneath the contact zone as well as perivascularly. Importantly, many Langerhans-cell like dendritic cells (DCs) were found with a predilection at the frontier layer zone abutting the silicone implant. Also, at this site, massive expression of ICAM-1, but not VCAM-1 or ELAM-1 emerged. Endothelial cells of the intracapsular neovasculature were P-Selectin+. Our results show that silicone induces a strong local T-cell immune response and future studies will determine the specificity and function of these T-lymphocytes.

Background: It is common for traumatologists to see avulsion injuries with resulting composite skin flaps. Simply reattaching the avulsed flap by suturing it back into its bed may result in ischemic necrosis of the distal portion of the flap. Case report: The authors present a case in which an extensive avulsion injury of the dorsum of the foot with amputation of the fourth and fifth toe was treated by defatting the avulsed flap and reattachment as a full-thickness graft. Healing was uneventful and no skin necrosis was encountered. At 1-year follow-up there was a stable skin situation at the dorsum of the foot. The patient has no difficulties with wearing shoes. However, there is diminished sensibility. Conclusions: Indications for this type of surgical technique include all types of avulsion or degloving injuries that create composite skin flaps prone to undergo ischemic necrosis if simply reattached. This quick and easy method should be in the armamentarium of each surgeon possibly dealing with this type of injury.

Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.

In this report, the authors describe the application of a muscle-sparing technique to harvest a myocutaneous latissimus dorsi muscle flap, including only a tiny lateral muscle segment but carrying a large skin paddle, with the advantage of leaving intact innervation and function of the remaining latissimus dorsi muscle. According to the experiences and complications associated with the pure thoracodorsal artery perforator harvest at the authors' institution, the necessity of increasing the reliability of the vascular pedicle demands that a small muscle strip be left embedding the perforator vessels attached to the skin paddle. This procedure was applied in eight cases with only one minor complication, which was a distal flap tip necrosis in the largest flap used. The muscle function and aesthetic contour of the posterior axillary fold were preserved in every case. Harvesting a large skin paddle flap that is carried by a diminutive longitudinal segment of latissimus dorsi muscle circumvents thoracodorsal nerve damage and maintains muscle function. In contrast to a thoracodorsal artery perforator flap without muscle, the harvesting of which is a delicate procedure, this procedure is regarded as easier and safer.

To improve aesthetic and functional outcomes in the reconstruction of severe anterior neck burn deformities and to reduce donor-site morbidity, pre-expansion of free-flap donor sites was performed in eight patients. In the first stage of reconstruction, the tissue expander was placed and gradually inflated over a period of 6 weeks. In the second stage, the anterior neck scar was resected up to the limits of the aesthetic unit of the neck, radical release of neck contracture was achieved by transection of contracted platysma muscle, and immediate coverage with a pre-expanded groin or scapular free flap was performed. The early postoperative course was uneventful. Physical therapy was started 1 week after the reconstruction. Long-term follow-up (mean, 4 years) of patients who underwent reconstruction of extensive neck burn deformities demonstrated good aesthetic and functional results. The advantages and drawbacks of using pre-expanded free flaps in the treatment of neck burn contractures are discussed.

Allthough there has been dramatic progress in limb salvage in recent decades, management of nonhealing wounds in diabetic patients continues to present a dilemma for the reconstructive surgeon. However, the acceptance of free-flap resurfacing of diabetic foot ulcers has increased in recent years. This study reviews 10 microvascular free muscle flaps in nine patients over a mean follow-up period of 44 months. Five patients had evidence of peripheral vascular disease. There was one flap loss, and nine flaps were transferred successfully. No perioperative mortality was encountered. The operations required a long, costly hospitalization (average hospital stay was 40 days). Seven of eight patients whose flaps survived had complications related to the free-flap recipient site. These seven patients underwent 20 secondary surgical procedures due to arterial and venous thrombosis, partial necrosis of the skin grafts, minor local infections, and gangrene or necrosis of the remaining toes. In three patients, progressive ischemic necrosis of the remaining toes, with total survival of the flap, was attributed to a microvascular steal phenomenon. However, all eight patients whose flaps survived subsequently ambulated on their flaps. The study demonstrates that microvascular surgery may result in functional lower-extremity salvage in diabetic patients with foot wounds that are not treatable by local flaps or skin grafts, and are destined for amputation.

We report the induction and reduction of adenosine receptor A2a and A3 mRNAs, respectively, during maturation of human monocyte-derived dendritic cells. Adenosine, an immunomodulatory molecule, is unstable in vitro; therefore we tested a stable agonist, 5'-(N-ethylcarboxamido)-adenosine, to explore the effect of adenosine receptor activation on dendritic cell function. We clearly show that adenosine receptor engagement affects the migratory activity of dendritic cells in three distinct settings. In human skin explant culture experiments the emigration of epidermal and dermal dendritic cells was diminished by the addition of 5'-(N-ethylcarboxamido)-adenosine. In a murine contact hypersensitivity assay 5'-(N-ethylcarboxamido)-adenosine caused a reduction in the numbers of epidermal and dermal dendritic cells arriving in the draining lymph node. In a chemotaxis assay of human dendritic cells in response to macrophage inflammatory protein 3beta (MIP-3beta)/CCL19, adenosine caused a delay in transmigration. Expression of a number of molecules involved in dendritic cell migration (CCR5, MIP-3beta/CCL19, and MDR-1) was reduced. Importantly, all other features of dendritic cells tested--phenotype, antigen uptake, cytokine production, T cell activation, and the T cell subset induction--remained unchanged. Dendritic cells carry antigens from the periphery to secondary lymphoid organs, where initiation of immune responses occurs. Increased adenosine release may modulate immune responses by delaying the encounter of antigen-loaded dendritic cells with T cells.

Rainer, Christian M.D.; Meirer, Romed M.D.; Gardetto, Alexander M.D.; Schwabegger, Anton H. M.D.; Ninkovic, Milomir M. M.D. Author Information

An exact knowledge of the subcutaneous layers in the different regions of the face and neck is important in several surgical disciplines. In the parotid region, a superficial musculoaponeurotic system (SMAS) has been described. The existence of a SMAS as a guiding structure for the surgeon in the other regions of the face and neck has been discussed but is controversial. Therefore, the authors investigated the development of the subcutaneous connective-tissue layers in the different facial regions and in the neck. They studied these regions in 22 human fetuses using the technique of plastination histology and in three newborn and three adult specimens using sheet plastination. In addition, they dissected the neck and face in 10 fresh adult cadavers to identify the SMAS as in the surgical situation. The results show that no SMAS could be detected in any facial regions other than the parotid region. In the parotid region, it is thick and attached to the parotid sheath. However, it becomes very thin, discontinuous, and undissectable in the cheek area. No SMAS can be found in the neck, in which the authors are the first to describe a fascia covering both sides of the platysma. This fascia has close topographical connections to the subcutaneous layers of the adjoining regions. On the basis of these findings, the surgical pathways have to be defined regionally in the face. A "platysma fascia" can be considered as a surgical landmark in the neck. Therefore, the authors conclude that it is not justified to generalize a SMAS as a surgical guiding structure.

Ninkovic, Milomir M.D.; Schwabegger, Anton M.D.; Gardetto, Alexander M.D.; Moser-Rummer, Astrid M.D.; Rieger, Michael M.D.; Ninkovic, Marina M.D.; Rainer, Christian M.D. Author Information

To improve the aesthetic outcome in the reconstructed breast and in the flap donor area, the technique of skin expansion in the mastectomy site was used in eight patients who subsequently underwent breast reconstruction using the superior gluteal artery perforator (SGAP) flap. The authors think that skin expansion before final reconstructive surgery provides adequate ptosis and better positioning of the flap on the chest, leading to a more natural appearance and symmetry of the reconstructed breast. Furthermore, the skin expansion reduces the amount of free flap skin required for breast reconstruction, resulting in less donor site scarring and morbidity. They present their surgical refinements to improve the aesthetic appearance of the breast reconstructed using the SGAP flap.

Objective. During intensive care of newborns, a number of invasive techniques may be necessary for resuscitation. The margin of safety between effective treatment and iatrogenic damage is narrow. The objective of this study was to identify and discuss iatrogenic damage in females resulting from treatment of pneumothorax and to give neonatologists anatomically based advice for prevention.Patients and Methods. We report 2 female patients (aged 13 and 16 years) born prematurely in whom breast deformity occurred caused by drainage of multiple pneumothoraces during intensive care. In an additional anatomic study, both hemithoraces of 5 newborn female cadavers (n = 10) were dissected to measure the extension of the breast tissue.Results. The anatomic investigations in newborns demonstrate that breast tissue extends vertically from the second or third rib to the sixth rib and from close to the sternal edge medially, almost to the anterior axillary line laterally.Conclusion. Psychological distress and corrective surgery because of deformed breasts in adolescent girls who have undergone drainage of pneumothoraces as newborns can be avoided by placing the skin incision in the anterior axillary line, maintaining a distance of 4 to 5 cm inferior to the nipple, and by inserting the chest drain through the fifth or sixth intercostal space during neonatal treatment.

External assault to the skin is followed by an epidermal response including synthesis of DNA, lipids, cytokines and migration of antigen presenting cells. MIP-3 alpha (CCL20, LARC, Exodus-1, Scya20) is a recently described C-C chemokine, predominantly expressed in extralymphoid tissue, which is known to direct migration of dendritic cell precursors and memory lymphocytes to sites of antigen invasion. We assessed the expression of MIP-3 alpha in human skin using semi-quantitative polymerase chain reaction. In vivo, MIP-3 alpha mRNA was constitutively expressed at low levels in untreated human epidermis. After acute disruption of the epidermal permeability barrier MIP-3 alpha mRNA was upregulated in the epidermal fraction, whereas dermal MIP-3 alpha mRNA levels remained unchanged. In vitro, MIP-3 alpha was increased in cultured keratinocytes treated with IL-1 alpha and TNF-alpha and was present in immature and mature dendritic cells, THP-1 monocytic cells and activated T cells. Finally, skin biopsies from patients with psoriasis, contact dermatitis and mycosis fungoides showed abundant expression. In biopsies from atopic dermatitis and graft vs. host disease a weak signal was present, whereas no expression was found in scleroderma and toxic epidermal necrolysis. We conclude that regulation of MIP-3 alpha mRNA is part of the epidermal response to external assault. Its upregulation may represent a danger signal for increased immunosurveillance in barrier disrupted skin and inflammatory skin conditions with impaired barrier function to counteract potential antigen invasion.

Background. In the surgical repair of facial nerve paralysis, a tension-free end-to-end coaptation of the trunk or its branches with or without rerouting isfunctionally superior to grafting. Assuming that a lengthening of all branches of the parotid plexus can be attained by removal of the superficial part of the parotid gland and mobilization of the branches, we performed an anatomic study.Methods. The parotid regions of 10 cadavers were dissected to investigate the length gained for the branches of the parotid plexus by this technique. Every branch at the upper and ventral border of the gland was marked by a surgical suture. After removing the superficial part of the parotid gland, the branches were cut at the suture, and the proximal stump was drawn toward the distal stump. The distance of the overlapping stumps was measured by means of an electronic gliding caliper. In addition, in five specimens only the trunk of the facial nerve was dissected by the same method, and the distance of the overlapping stumps was measured.Results and Conclusions. The results demonstrate that removing the superficial part of the parotid gland may be sufficient to enable direct coaptation without nerve grafting. Cut temporal or zygomatic branches with a gap of up to 15 mm and cut buccal or marginal mandibular branches with a gap of up to 23 mm can be bridged by mobilization of just the proximal stumps. This technique may also be used to bridge a 17-mm gap of the trunk of the facial nerve. (C) 2002 Wiley Periodicals, Inc. Head Neck 24: 10471053,2002

Recent advances in cell biology and tissue engineering have used various delivery vehicles for transplanting varying cell cultures with limited success. These techniques are frequently complicated by tissue necrosis, infection, and resorption. The purpose of this study was to investigate whether urothelium cells, tracheal epithelial cells, and preadipocytes cultured in vitro could be successfully transplanted onto a prefabricated capsule surface by using fibrin glue as a delivery vehicle, with the ultimate goal for use in reconstruction. In the first step of the animal study, tissue specimens (bladder urothelium, tracheal epithelial cells, epididymal fat pad) were harvested for in vitro cell culturing, and a silicone block was implanted subcutaneously or within the anterior rectus sheath to induce capsule formation. After 6 to 10 days, when primary cultures were confluent, the animals were re-anesthetized, the newly formed capsule pouches were incised, and the suspensions of cultured urothelia cells (n = 40), tracheal epithelial cells (n = 32), and preadipocytes (n = 40) were implanted onto the capsule surface in two groups, one using standard culture medium as a delivery vehicle and the second using fibrin glue. Histologic sections were taken, and different histomorphologic studies were performed according to tissue type. Consistently in all animals, a highly vascularized capsule was induced by the silicon material. In all animals in which the authors used fibrin glue as a delivery vehicle, they could demonstrate a successful reimplantation of cultured urothelium cells, tracheal epithelial cells, or preadipocytes. Their animal studies showed that capsule induction in combination with fibrin glue as a delivery vehicle is a successful model for transplantation of different in vivo cultured tissue types.