Faculty Bibliography

A synthetic polyamino polymer with a glucose backbone was used for gene transfer in vitro and in vivo. Gene transfer in vitro to various human carcinoma cell lines was achieved with an efficiency superior to a commercially available cationic liposome preparation. The polymer was resistant to inhibition by serum, which allowed for efficient gene transfer in vivo. Direct Intracranial tumor injection using this reagent resulted in reporter gene expression levels comparable to those achieved by a recombinant adenoviral vector. Thus, this compound represents a new class of agent that may have broad utility for gene transfer and gene therapy applications.

Visualization of subcondylar fractures is limited, and rigid fixation technically difficult, employing standard open surgical techniques--especially when the condyle is displaced out of the glenoid fossa. The majority of condylar neck fractures are treated by closed reduction with maxillomandibular fixation, to obviate the potential for permanent injury to the facial nerve. The technique described employs an anterior parotid, two-layer, sub-SMAS (superficial musculo-aponeurotic system) approach via a rhytidectomy incision that reliably identifies and preserves the neural elements and provides direct access to the pericondylar region. The thirteen patients presented here exhibited satisfactory functional and aesthetic results. Complications included temporary nerve palsies, plate fractures, and a hematoma.

Surgical access to fractures of the ascending ramus of the mandible is limited when standard techniques are employed. A new method using a facial rhytidectomy technique is described, and seven cases treated by this method are presented. The advantage of this technique includes excellent exposure, predictable and safe dissection, inconspicuous facial scar and minimal postoperative complications.

The medical profession is besieged by concerns about cost containment. This in turn has focused attention on the use of ambulatory surgical facilities. However, the costs of hospital outpatient surgery programs usually prevent them from being competitive when compared with the costs of using office surgical facilities. To address the question of patient safety in office surgical facilities, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) sent a questionnaire to its accredited facilities. Two-hundred and forty-one (57.7 percent) of the 418 accredited facilities returned the anonymous questionnaires, a very high response rate. Or interest are the following findings: 400,675 operative procedures were reported during a 5-year period. Significant complications (hematoma, hypertensive episode, wound infection, sepsis, hypotension) were infrequent, occurring in 1 in every 213 cases. Return to the operating room within 24 hours and preventive hospitalization were less frequent. A death occurred in 1 in 57,000 cases (0.0017 percent). The overall risk is comparable in an accredited office (plastic surgical facility) and in a free-standing or hospital ambulatory surgical facility. This study documents an excellent safety record for plastic surgery done in accredited office surgical facilities by board-certified plastic surgeons.

Avulsion of the brachial plexus is considered the most severe injury of the peripheral nerve. The present study provides a description of the response of ChAT within the ventral horn of the rat cervical spinal cord following avulsion of the brachial plexus. The result demonstrates that the intensity of immunoreactivity of ChAT positive neurons and neuropil background increases in the first 3 days following avulsion and then decreases. The number of ChAT-positive motorneurons in the ventral horn in the lesion side is 84.4% compared to the normal side during the first 3 days post-avulsion, at 7 days the number of ventral horn neurons drops to 64.4% and at 21 days post-avulsion it becomes 44.1%. In the sixth week post-avulsion, only 24.8% of the ventral horn neurons still persist.

Nine patients with chronic severe pain due to end-stage traction neuritis of an intact peripheral nerve underwent external neurolysis and epineurectomy or epineurectomy and internal neurolysis followed by circumferential wrapping of the involved segment of nerve with a pedicle flap or free flap consisting of either subcutaneous fat tissue, fascia, or muscle. Seven patients (77%) followed for between 1 and 5 years had substantial relief of pain. Two patients (22%) had no decrease in their pain at all. Circumferential wrapping may cushion the nerve from external pressure on the overlying skin, may isolate the nerve from the traction forces of adjacent moving tendons to allow improved gliding of the nerve, and may promote revascularization of a scarred nerve. This surgery may be indicated for patients with persistent pain following multiple carpal tunnel or cubital tunnel surgeries.

Some spontaneous return of sensibility following autologous tissue breast reconstruction is often suspected but not well documented. In the present study, objective touch-pressure, pain, temperature, and vibratory sensibilities were recorded in 33 autologous breast reconstructions at an average of 25.2 months postoperatively. Correlation of the sensory return with patients' satisfaction toward reconstruction was done by a detailed questionnaire. All except one patient regained a variety of sensibilities touch pressure in 97 percent of patients (averaging 81.05 gm/mm2 versus control of 7.98 gm/mm2), pain in 88 percent of patients, heat in 64 percent of patients (45 percent of quadrants), cold in 82 percent of patients (67 percent of quadrants), and high- and low-frequency vibration in 100 percent of patients (high in 90 percent of quadrants, low in 96 percent). Subjectively, 94 percent considered their chest comfortable to touch following reconstruction compared with 34 percent following mastectomy. On a scale from 1 to 10, patients rated their reconstructions an average of 9.3. Our findings confirm the spontaneous return of sensibility following a variety of autologous tissue breast reconstructions. The value of the sensory return is suggested by the high degree of satisfaction in nearly all patients. Further attempts to correlate the degree of sensory return with the degree of satisfaction were inconclusive because of the uniformly high satisfaction reported by the patients. The mechanism of reinnervation appears to come both from the skin margins and from the deep surface of the flap. Future developments in breast reconstruction should take into consideration the eventual quality of sensory return.

Numerous reports of flap prefabrication have demonstrated good survival. The durability of these flaps compared with that of other flap types or normal tissue, however, remains unknown. The purpose of this study was to determine how prefabricated flaps respond to a bacterial challenge compared with identically sized normal random-pattern flaps. Rat abdominal cutaneous-panniculus carnosus flaps were prefabricated with a standard-sized groin fasciovascular tissue carrier and then inoculated with Staphylococcus aureus. The prefabricated flaps were divided into two groups. Group one (standard prefabricated flap, n = 24) received no growth factor. Group two (n = 24) received an angiogenic growth factor between the carrier and flap tissue. A random-pattern flap served as a nonprefabricated control (n = 12). Grading of the prefabricated flaps with growth factor versus the standard prefabricated flaps versus controls showed dehiscence (41 versus 37 versus 4 percent), ulceration (21 versus 29 versus 18 percent), erythema/cellulitis (40 versus 44 versus 8 percent), and necrosis (9 versus 29 versus 0 percent). The control flaps had significantly less dehiscence, erythema/ cellulitis, and necrosis than the standard prefabricated flaps. Similarly, the prefabricated flaps with angiogenic growth factor had significantly less necrosis than the standard prefabricated flaps. CONCLUSIONS: (1) prefabricated flaps were demonstrated to be less durable than random-pattern flaps against a bacterial challenge, (2) angiogenic growth factor may help to improve the durability of prefabricated flaps against bacterial infection, and (3) the biologic behavior of prefabricated flaps is not the same as that of normal tissue and deserves further investigation.