Closure of Radial Forearm Free Flap Donor Site With Local Full-Thickness Skin Graft. van der Lei B. Spronk CA, de Visscher JG. Br J Oral Maxillofac Surg 37: I 19, 1999 When using a radial forearm free flap to reconstruct defects, 2 major disadvantages to the use of this flap have been the aesthetic deformity of the donor site when using a split-thickness skin graft and donor site morbidity, such as delayed healing and breakdown of the split-thickness skin graft overlying wrist tendons. Many techniques for closure of the donor site reported in the past have been suboptimal either because of aesthetic failure or the need for additional surgeries to complete reconstruction. These authors describe a technique previously proposed by Liang et al in 1994 and have successfully used it in 7 consecutive patients requiring flaps 4 X 6 to 5 X 9 cm in dimension. A rectangular-shaped radial free flap is harvested. Just proximal and contiguous with this free flap, a triangular-shaped full-thickness skin graft is harvested and advanced distally into the donor site. The radial and ulnar lengths of the free flap are each equal to the radial and ulnar sides of the triangular full-thickness skin graft. Closure is completed in a V-Y fashion. Advantages of this technique include the following: 1) it is a one-stage procedure with no secondary donor site, 2) there is good color match, and 3) there is no late wound breakdown. One disadvantage is the inability to perform this technique when harvesting a large radial forearm flap.-T.B. Reprint requests to Dr van der Lei: Department of Plastic, Reconstructive, Aesthetic Hand Surgery, Medical Center Lecuwarden, Hem-i Dunantweg
Osteoblast Progenitor Cell Responses to Characterized Titanium Surfaces in the Presence of Bone Morphogenie Protein-Atelopeptide Type I Collagen In Vitro. Ong JL, Bess EG, Bessho K. J Oral Implant01 25:95, 1999 Titanium (Ti) is currently the material of choice for oral and maxillofacial and orthopedic implants. Recently bone morphogenetic proteins (BMP) have been used as a means to achieve optimal bone-implant interactions. Differentiation of mesenchymalderived cells into cartilage and bone has been reported to occur when the cells are stimulated with BMP. However, because of the rapid diffusion of BMP when implanted in vivo, a carrier acting as a slow delivery system is required to deliver the BMP. In this in vivo study, atelopeptide type I collagen was used as a carrier for BMP. BMP was obtained from bovine bone. A mouse osteoblast progenitor cell line was used to evaluate the cellular response on Ti surfaces. Protein production was monitored using x-ray photoelectron spectroscopy, celI culture, protein assay, alkaline phosphatase activity and hexosaminidase activity studies. Protein production was observed to be statistically higher when the Ti surfaces were stimulated with BMP-atelopeptide type I collagen mixture in comparison with unstimulated Ti surfaces. ALP activity and hexos aminidase activity were observed to be the highest in cells exposed to BMP-atelopeptide type I collagen mixture. The study indicates that in vivo enhancement of osteoblast activity in the presence of BMP-atelopeptide type I collagen mixture, and that the atelopeptide type I collagen can be an effective carrier for BMP.-I.E. SHAMI Reprint requests to Dr Ong: University of Texas Health Science Center at San Antonio, Department of Restorative Dentistry, Division of Biomaterials, 7703 Floyd Curl Dr. San Antonio, TX 78274 7890.
Total Reconstruction of Upper Lip and ColumelJa With Bipedicled Depressor Anguli Oris Musculocutaneous Flap. Neto MS, Traber de Castillo H. Garcia EB. et al. Br J Plast Surg 52:411, 1999 Upper and lower lip reconstruction is discussed reviewing use of a bipedicled depressor anguli oris musculocutaneous flap. Total lip reconstruction provides several surgical challenges including replacement size of defect and donor flap designs. In this case report, a 64-year-old man with history of upper lip basal cell carcinoma desires upper lip reconstruction to address lack of hair growth and difficult) opening his mouth despite several reconstructive attempts. The authors contend that upper lip reconstmction in males should have donor flaps that provide bulk and hair growing skin for normal mustache growth. To address these concerns, the authors for the first time reconstruct the upper lip and columella with a bipedicled depressor anguli oris musculocutaneous flap. Other flaps are briefly mentioned as potential reconstructive options. Donor sites may include a microsurgical flap from the temporal or the occipital region, flaps from the mental and the cervical area. and hair bearing flaps from the scalp. The authors write that the preceeding options were flawed because of the need for additional surgical procedures and inappropriate mustache hair growth. The bipedicled depressor anguli oris flap is an excellent donor site because of the potential to provide close to normal mustache growth, the closeness to the recipient site, and the large amount of tissue transfer. The authors have used unilateral depressor anguli oris island flaps with success, but this is the first time a bipedicled method has been used. The satisfied patient did not experience any functional deficits and did have good mustache growth.-K. BENSON Reprint requests to Dr Neto: Department of Plastic Surgev, UNIFESP-ESP. Rua Napoleao de Barros. 7 153 and CEP Or024. Sao Paula. SP. Brasil.
Abdominal Computed Tomography for the Diagnosis of Intra-Abdominal Sepsis in Critically Injured Patients: Fishing in Murky Waters. Velmahos GC. Kamel E, Beme TV, et al. Arch Surg 134:83 1, 1999 Intra-abdominal sepsis occurs in 30% to 80% of patients with major trauma, and if not treated rapidly and appropriately, is associated with high mortality rates. Simple bedside radiographic tests, such as plain radiographs or ultrasonography, are difficult to interpret when used for suspected abdominal sepsis in these patients. Under these circumstances, reliance on abdominal computed tomographic (ACT) is necessary. This study focused on the use of ACT scans in the intensive care unit for critically ill patients with evidence of sepsis and their effect on patient treatment. Complications associated with transport to the radiology suite and risk factors associated with patients likely to have abnormalities on ACT scan were also reported. Eighty-five critically injured patients admitted to the intensive care unit in 32 months (6% of all intensive care unit admissions) who developed sepsis of unknown origin were prospectively included in the study. These patients underwent I61 ACT scans as part of their evaluation for sepsis on unknown origin. Forty-four patients had only 1 ACT scan and 41 had at least 1 follow-up ACT scan. Sensitivity and specilicity of the ACT scans and number of patients subjected to changes in treatment after an ACT scan were measured. Forty-nine patients (58%) had an intra-abdominal focus of infection identified on ACT scan. Penetrating trauma and emergent