Splenic-gonadal fusion of the continuous type in an adult female

The use of autogenous fat for augmentation of the paralyzed vocal fold is a promising substitute for alternate injectable material such as Teflon (polytef paste, polytetrafluoroethylene; Ethicon) and Gelfoam (absorbable gelatin sponge; Upjohn). Long-term histologic evaluation of fat grafts to the larynx has not previously been reported in the literature. We present a case report of autogenous fat augmentation of a paralyzed vocal fold with documentation of persistent fat graft present 5 months after transplant.     

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.     

The role of complex formation in the neurotoxicity of crotoxin components A and B

Human adipose tissue was transplanted to the mouse mutant nude (nu/nu). All the grafts were accepted and contained fat cells easily distinguishable from those of the mouse. No detectable relation between the histological pictures before and after grafting was found. In some transplants nerve tissue, and in others macrophages containing fat droplets, were found. The fat tissue graft might be useful for investigation of the influence of various hormones on human fat cells.     

Long-term followup of patients with autogenous resection arthrodesis of the knee

Arthrodesis of the knee may be indicated for the reconstruction after resection of tumor around the knee. Since the introduction of this technique, resection arthrodesis using segmental autogenous grafts has been the principal method of reconstruction. From August 1967 to February 1985, 73 patients underwent resection arthrodesis using autogenous grafts. All procedures were performed for malignant or potentially malignant lesions. Ten-year followup was available on 40 patients. The reconstructive procedure was performed using an intramedullary rod and hemicortical femoral or tibial grafts with a single autogenous nonvascularized fibula or with dual nonvascularized fibulae. Despite a high surgical complication rate, the majority of patients achieved successful limb salvage. Independent ambulation was achieved by 86% of the patients. A Musculoskeletal Tumor Society functional evaluation in 32 available patients at a mean of 17 years showed the majority of patients functioning satisfactorily. Long-term followup of these patients shows continued durability of the reconstruction and a persistent high level of function and patient satisfaction. Resection arthrodesis using massive autogenous grafts should continue to be in the armamentarium of the orthopaedic oncologist.     

Love, courage, and honor

OBJECTIVES: Despite the increasing success of whole-organ pancreas transplantation, the success of clinical islet allografts has remained limited. One of the factors limiting the success is the difficulty in monitoring islet allografts after transplantation. The aim of these studies is to develop a method of "biopsying" human islet allografts using a forearm islet implantation site. METHODS: A subtherapeutic number of isolated human islets were placed in the forearm under the muscle fascia in three human recipients with Type I insulin dependent diabetes. All of the recipients had undergone successful cadaveric renal transplantation at least one year prior and were maintained on their baseline immunosuppression. Aliquots of the islet grafts were removed 7 and 14 days to assess engraftment and graft infiltrate. To verify that the islets were viable, 400 were handpicked and transplanted into B6-scid mice made diabetic with streptozotocin. RESULTS: The biopsy site was found in all three cases. In one patient, no islets were recovered. In two other patients, viable islet tissue was recovered 7 days after transplantation. Immunohistology at 7 days showed the presence of both insulin and glucagon-staining cells in the islets. At 14 days in these two patients, a mononuclear cell infiltrate was observed in the explanted islet biopsies. Immunohistology showed the relative absence of insulin-staining cells with intact glucagon-staining cells. This finding is consistent with recurrent autoimmunity in the islet grafts. DISCUSSION: This preliminary study shows that the forearm biopsy site is a useful method to retrieve human islet grafts after transplantation. The islets engraft and are easily found in the first weeks after transplantation. These data suggest that recurrent autoimmunity may affect islet allografts. Further studies will be needed to determine if the histology in the forearm will correlate with the fate of intraportal or intraperitoneal islet allografts. Although they were shown to reduce the incidence of early allograft failure, their influence on the long-term graft survival remains to be proven.     

Mandibular onlay grafting using prefabricated bone grafts with primary implant placement: an experimental study in minipigs

The aim of this experimental study was to evaluate the use of prefabricated autogenous bone grafts as onlay grafts to the mandible. Excess bone of 10 x 12 x 40 mm was produced inside blocks of pyrolyzed bovine bone under a polylactic membrane coverage on the outside of the mandible in 15 adult G?ttingen minipigs. After 5 months, this bone was harvested and transferred to the premolar region of the mandibular body in 10 animals. Onlay grafts of mandibular bone were used as controls for the transplanted prefabricated grafts. All grafts were fixed by primary placement of one titanium implant each. Five animals served as ungrafted controls. Evaluation was performed after 3 months and 5 months, respectively. Two animals were lost to evaluation, and one scaffold became infected. Eleven of the remaining 12 scaffolds showed sufficient bone ingrowth for grafting. Three months after transplantation, bone volume of the prefabricated grafts was almost completely preserved, with only minimal resorption in the superficial pores of the scaffolds, while the control grafts exhibited partial resorption. The titanium implants, which had been placed at the time of only grafting, exhibited direct bone-implant contact. Five months after grafting, all titanium implants showed complete osseointegration, with direct bone-implant contact. The grafted bone exhibited a significant increase in bone density by appositional bone formation. The control grafts were nearly completely resorbed at that time.     

Primary inherited defects in neutrophil function: etiology and treatment

A variety of materials have been employed in rhinoplasty for augmentation and reconstruction. While autogenous tissue remains the mainstay of nasal implants and are the clear choice for structural and augmentation grafting of the nasal tip, limited availability and unpredictable resorption or remodeling have made homologous and synthetic implants important considerations for dorsal augmentation grafting. This section discusses categories of graft materials, their physical properties, harvesting and preparation technique, and advantages and disadvantages. An algorithm for nasal implants for specific indications in support and augmentation is presented.     

The regeneration of soft tissue and bone around implants with and without membranes

The popularity of osseointegration for the replacement of anterior teeth has placed an increased demand on the preservation of normal gingival anatomy. This has led to the development of a variety of soft-tissue and bone-augmentation techniques that either prevent tissue collapse or restore previously damaged areas of the alveolus. With bone grafts, barrier membranes, and autogenous connective-tissue grafts used in combination with each other or separately, lost structures can be reconstructed into a normal configuration for optimum esthetic restorations.     

Elaboration of an alternative, segmental, cartilage-sparing tip graft technique: experience in 405 cases

Despite the value of tip grafting in many rhinoplasty patients, adequate donor cartilage may be unavailable in secondary and even primary patients whose donor sites have been harvested previously or whose septal cartilage is calcified. Furthermore, by enlarging the lobule, tip grafts can create undesirable postoperative disproportions in some patients. These two observations have stimulated the elaboration of a tip graft method (which evolved from the Sheen technique) that uses small amounts of autogenous donor material to augment only those lobular segments that require increased contour or support, without necessarily increasing overall lobular volume. This article reports experience with; the technique in a 405-patient study group. Segmental tip grafting is performed endonasally through access incisions along the caudal edge of one alar cartilage. Grafts augment each third of the tip lobule and anterior columella (corresponding to each of the alar cartilage crura) depending on the aesthetic objective; multiple grafts are always placed. Selective augmentation limits the overall increase in lobular size. The method is not suitable for those patients needing substantial augmentation (58 of 463 tip-grafted patients in the 6-year study period), in which case the author still prefers the Sheen technique. The records of the 405-patient study group (40 percent primary rhinoplasty, 60 percent secondary rhinoplasty) indicate a total nasal revision rate of 14 percent; 6 percent were tip revisions. Tip revisions were more frequent in secondary patients but not in patients with thin skin. Reoperation percentages decreased during the study term, so that the tip revision rate was 12 percent in the first 12 months of study but only 4 percent in the last 12 months (p < 0.0008). The primary indication for tip grafting has evolved since the author's earlier practice experience: in the past 3 years of the study, 77 percent of primary patients and 80 percent of secondary patients underwent grafting principally to improve lobular contour, not tip projection (p < 0.0005). A segmental, cartilage-sparing tip graft technique can provide both projection and contour for primary and secondary rhinoplasty patients. Nevertheless, tip imperfections remain the most common reason for revision in the author's practice.     

Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique--a preliminary report

A one-stage autogenous osteochondral grafting technique for the treatment of talar dome osteochondritis dissecans is described. Eleven patients with osteochondritis dissecans lesions, 10 mm or greater in diameter, were operated on using the mosaicplasty autogenous osteochondral transplantation technique. Osteochondral cylindrical grafts from the ipsilateral knee were delivered into the talar defect using specially designed tube chisels. These procedures were done by arthrotomy. With follow-up of 12 to 28 months (mean, 16 months), the patients returned to full activities and the results, using the Hannover scoring system, have been excellent.     

Speed, sex, gay men, and HIV: ecological and community perspectives

OBJECTIVE: To find a means of bladder augmentation that would avoid the complications encountered with the use of bowel segments, using a newly developed acellular biomaterial, the bladder acellular matrix graft (BAMG), as a homologous graft. MATERIALS AND METHODS: Thirty-four rats underwent a partial cystectomy (40-50%) and grafting with a BAMG of equal size. Eleven rats died within the first 72 h. probably from urinary leakage caused by obstruction of the bladder neck with stones or coagula; the surviving 23 were killed at varying intervals after cystectomy and examined. RESULTS: After providing initial bladder enlargement, the graft was progressively infiltrated by the vessels and smooth muscle cells of the host: furthermore, the mucosal lining was complete within 10 days. After 4 weeks, all bladder wall components were evident histologically in the graft. The ingrowth was complete after 8 weeks, except for neural regeneration, which was only partial. At 12 weeks, the bladder wall muscle structure in the graft was so well developed that it was difficult to delineate the junction between host bladder and BAMG. Neural regeneration continued to improve. Normal bladder capacities were maintained throughout the study. CONCLUSION: The BAMG appears to serve, without rejection, as a framework of collagen and elastin for the ingrowth of all bladder wall components. The reason for the better acceptance of the BAMG than of other bladder augmentation grafts requires further investigation.     

Long-term outcome after frontal sinus obliteration with an ionomer bone substitute in the cat. I: Histological results

BACKGROUND: Osteoplastic frontal sinus surgery in combination with sinus obliteration may occasionally be performed for indications such as severe sinus inflammations, extensive wall fractures involving the nasofrontal duct, or osteomas. The material most frequently used for this obliteration is autogenous adipose tissue. Autografts such as muscle, cartilage, and bone chips have been also recommended for this purpose. In order to avoid the surgical procedure required for harvesting an autograft from other body sites, alloplastic materials have been suggested for frontal sinus obliteration. METHODS: In an animal study using cats, the mucous lining of the frontal sinus was removed, the nasofrontal duct sealed with semifluid ionomer cement, and the cavity filled up with a solid and porous ionomer-based microimplant. RESULTS: Histological investigations were performed up to two years after surgery. Increasing obliteration of the sinus cavity by bone regeneration, starting from the sinus wall, as well as formation of connective tissue between the cement grains was detected as early as one month after implantation. Osteoblasts lining the osteoid layer were considered to be an indication of active bone regeneration. Osteogenesis inside the sinus cavity continuously progressed during the following months. Two years after implantation, osteoid and newly mineralized bone encircled the microimplants leading to an almost complete obliteration. There was no evidence for mucosal regeneration or foreign body reaction. CONCLUSIONS: Because of its osteoconductive effect, biocompatibility, and biostability the ionomer-based microimplant is a suitable alloplastic material for frontal sinus obliteration.     

Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts

Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty-two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 x 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split-thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow-up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra-abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9-year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.     

Cosmetic surgery of the neck as an office procedure

A simple office procedure to eliminate permanently double chin deformity and senile neck cords and with nearly invisible scars is described. Postoperative complications are mitigated by the use of autogenous fat grafts and constant aspiration of the wound cavity both during and after surgery. Most patients are able to resume their normal activities in several days.     

Histologic changes in the sinus membrane after maxillary sinus augmentation in goats

PURPOSE: Previous studies have reported on the morphologic aspects of bone regeneration after maxillary sinus grafting. However, no previous studies have examinated the morphology of the maxillary sinus mucosa after grafting. The purpose of this study was to evaluate the histologic changes in the lining membrane after sinus augmentation. MATERIALS AND METHODS: A unilateral osteotomy of the lateral maxillary wall, medial displacement of the bony segments, and elevation of the sinus mucosa were performed in 12 goats. An autogenous bone graft combined with coralline particles was placed on the floor of the sinus in three animals, and coralline particles alone were placed in three other goats. Six goats were not grafted and were used as controls. Samples were harvested at 2.5, 4.5, and 6.5 months. The maxillary sinus mucosa was examined using light microscopy and scanning and transmission electronic microscopy. RESULTS: The coralline particles were surrounded by fibrous connective tissue when used alone. The addition of iliac crest bone to the coralline particles stimulated bone formation. After the sinus augmentation, the mucosal lining showed a lack of glands in the lamina propria, and the epithelium showed an increase in goblet cells. CONCLUSION: It was concluded that the sinus mucosa undergoes physiologic adaptations and remains healthy and free of chronic sinusitis after maxillary sinus grafting.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Interrelations of soft and hard tissues for osseointegrated implants

Success in using osseointegrated dental implants-optimal function, esthetics, and phonetics-requires selection of the treatment modality that is optimal for the patient, protection of tissue blood supply, and adherence to a plan based on a thorough analysis of all deviations from the normal anatomy. The options for correction of hard-tissue deficiencies are mechanical modification of the implants and reconstructive surgery. Mechanical approaches reduce the time needed for reconstruction but direct the occlusal forces in unnatural directions. Surgical reconstruction is preferable. Any bone graft must be precisely fitted to the recipient site to facilitate revascularization. Restoration of hard-tissue dimensions usually requires soft-tissue coverage and augmentation. There are two basic options: (1) flaps with or without inlay or onlay grafts and (2) controlled tissue expansion. An onlay graft can help restore soft-tissue height and width. Inlay grafts have greater vascularity than onlay grafts, and the color matching is better. Controlled tissue expansion creates "like" tissue without a secondary defect, and fewer tissue transfers are needed. However, the technique is difficult, and the patient must make multiple visits to the office. For implant placement to be successful, the patient's expectations must be understood, and the benefit-to-risk ratio should be extremely high.     

The qualification of different free muscle transplants to reconstruct mimic function: an experimental study in rabbits

With the scutuloauricularis muscle, we developed a new model for experimental free transplantation of mimic muscles in the rabbit and studied the qualification of different muscles for free functional grafting into the position of the facial muscle, which is to be replaced. Forty adult female white New Zealand rabbits were distributed to four groups of 10 rabbits each. In group 1, the operative techniques of the new transplantation models were developed in the scutuloauricularis muscle, the pectoralis descendens muscle, and a comparable part of the rectus femoris muscle. In group 2, the scutuloauricularis muscle was transplanted orthotopically with microneurovascular anastomoses on the left side; in group 3, the pectoralis descendens muscle was transplanted into the position of the scutuloauricularis after its removal; and with the animals in group 4, a piece of the rectus femoris muscle was transplanted into the position of the mimic muscle after its removal. In all muscle transplants, the neurovascular supply was reestablished microsurgically by end-to-end anastomoses to the superficial temporal vessels and direct nerve coaptation to the facial nerve branches supplying originally the scutuloauricularis muscle. Nine months after transplantation, force measurements were performed in all transplanted muscles and the scutuloauricularis muscles of the control side. Cross-sections stained for ATPase after alkaline preincubation at pH 10.4 were used for computer-assisted planimetry of the muscle fibers. The orthotopically transplanted scutuloauricularis muscles reached with 2.84 (+/-1.04) N for maximal tetanic tension on the average 87.7 (+/-32.1) percent of that of the control scutuloauricularis muscles, the pectoralis descendens muscles with 4.25 (+/-2.15) N on the average 188.7 (+/-100.7) percent of that of the controls, and the pieces of rectus femoris muscles 6.62 (+/-2.16) N or 185.3 (+/-45.4) percent of that of the controls. All three muscles were identified as fast contracting muscles before and after transplantation. By transplantation, the content of type II muscle fibers changed from 58.2 to 68.0 percent in the scutuloauricularis muscle, from 62.4 to 74.4 percent in the musculus pectoralis descendens, and from 92.5 to 82.8 percent in the rectus femoris muscle. For the first time, an experimental model for free transplantation of mimic muscles was developed and functionally assessed. The most important result of this study was the fact that the double-sized muscle grafts developed twice the force of the control scutuloauricularis muscles, although reinnervated by the original muscle nerve branch. This result underlines the usefulness of overdimensioning during clinical muscle transplantation. It was also shown that parts of big muscles can be grafted with results similar to those experienced with complete smaller muscles.     

Growth and function of human parathyroid tissue transplanted to athymic mice

The morphology, cell proliferation and function of transplanted normal, hyperplastic and adenomatous human parathyroid tissue was studied after transplantation to athymic mice. The iPTH was evaluated in relation to morphology. Human parathyroid tissue collected during surgery for hyperparathyroidism was implanted subcutaneously into athymic mice (nu/nu-BALB/cA) and was analysed 1, 4, 7 and 12 weeks after transplantation. The transplants were examined by light and electron microscopy and by autoradiography after continuous infusion of 3H-thymidine. The relative amount of viable tissue was evaluated using a computer image analysing programme. Graft function was evaluated by measuring human iPTH in mouse serum. A transplant take ratio of 93% was observed. The proliferation rate in adenoma grafts at 12 weeks after transplantation was five and fifteen times that observed in normal and hyperplastic transplants, respectively. In normal and adenoma groups, a continuous increase in iPTH concentrations was observed, but in the hyperplastic group the iPTH remained on the same level. The secretion of iPTH in relation to the amount of transplanted tissue and the fraction of viable tissue was at the same level at 12 weeks in normal and adenomatous grafted animals. In conclusion, human parathyroid tissue was successfully transplanted and maintained its original structure. The growth potential, but not the iPTH secretion, was significantly higher in adenoma grafts compared to grafts from hyperplastic and normal glands.     

A paradigm of experimentally induced mild hyperthyroidism: effects on nitrogen balance, body composition, and energy expenditure in healthy young men

OBJECTIVE: To conceptualize, with fine needle aspiration cytology (FNAC), the early cellular events occurring in and around fresh autogenous and allogenic bone grafts during the first 40 postimplantation days. STUDY DESIGN: Forty-eight cases of bone grafts were studied by FNAC at serial intervals of 10, 20, 30 and 40 postimplantation days. Twenty patients were recipients of autogenous grafts, 16 received 0.6N HCI partially decalcified allogenic bone implants, and 4 received combined autogenous and allogenic bone grafts (included in the allograft group). There were eight control cases of closed fracture shaft femur, which were managed conservatively. RESULTS: The initial cellular responses in autogenous grafts, allografts and controls appear to be a part of the nonspecific reparative process followed by a more specific phase, with a steady increase in relative lymphocyte count from the 20th day onwards. Osteogenesis, as judged by osteoblasts and osteoclasts, was also comparable. CONCLUSION: Partially decalcified allografts appear to be a good substitute for autogenous bone grafts in clinical practice when adequate autogenous material is not available. FNAC is a good technique for studying bone graft responses without interfering with graft uptake. It is helpful in the early detection of subclinical infection or any other pathology at the graft site.