The extended brow lift: the toucan technique

Brow ptosis is the main consequence of aging in the upper third of the face. Many methods have been described to correct it: skin excisions of the brow hairline, skin excisions of the forehead natural creases, skin trimmings of the temporal, coronal, or forehead hairline flaps, and endoscopic methods [1,15,17,18,24,26,27]. The authors created a procedure which is based on a forehead-temporal subcutaneous flap and a muscular relocation. It treats the brow ptosis and its surrounding area—temporal ptosis, upper and lower lateral eyelid ptosis, crow's feet—and at the same time improves the sclera show or ectropion. The method preserves the sideburn and the temporal hairline and can reduce the width between the temporal hairline and the lateral end of the eyebrow. The method produces maximum improvement, with high-quality scars and minimal evidence of surgery. The procedure is called "The Toucan Technique," due to the shape of the skin resection which looks like a toucan bird [11,13,14].     

Evaluation of a new composite prosthesis (PL-PU99) for the repair of abdominal wall defects in terms of behavior at the peritoneal interface

This study was designed to evaluate the behavior of a new composite polypropylene-polyurethane (PL-PU99) when placed in direct contact with the visceral peritoneum during the repair of an abdominal wall defect. Full-thickness abdominal wall defects (7 x 5 cm) were created in 36 anaesthetized white New Zealand rabbits. The defects were repaired with polypropylene prostheses or PL-PU99 prostheses (comprised of PL and a polyurethane sheet glued to the PL with acrylic adhesive) to establish two study groups (n = 18 each). Animals were sacrified 14, 30, or 90 days after implantation and prosthesis/surrounding tissue specimens were subjected to light and electron microscopy and morphometric analysis of the newly formed peritoneum. Immunohistochemical analysis was performed using the rabbit specific monoclonal antibody RAM-11. The biomechanical strength of the implants was also assessed. Firm adhesions were detected in the PL implants, whereas adhesions were practically non-existent in the PL-PU99 implants. The surface area covered by adhesions was greater (p < 0.01) in the PL group (7.36 vs. 0.11 cm2). The neoperitoneum formed after the implantation of a PL prosthesis was disorganized in structure, whereas that formed at the interface with the PL-PU99 prosthesis was structurally similar to the host peritoneum. The excellent performance of the PL-PU99 prosthesis shown in this study warrants further investigation into its use for the repair of abdominal wall defects when the prosthetic patch needs to be placed in contact with the intestinal loops.     

Scrotal cystic hygroma in a 13-year-old boy

We describe a patient with cystic hygroma, in a rare location (scrotum). The hygroma was diagnosed incidentally after injury to the scrotum in a 13-year-old boy. The diagnostic methods used, the characteristics of this type of tumor, its treatment and its clinical course are described. We suggest that cystic hygroma be taken into account in the differential diagnosis of other more frequent causes of scrotal masses.     

Attitudes of Spanish and Mexican Resident Physicians Faced With Solid Organ Donation and Transplantation

Introduction

The attitudes of specialist physicians toward organ donation and transplantation are of great interest because promotion of this activity depends on them. Our objective was to analyze the attitudes of residents in health centers in Spain (MIR) and in Mexico (ENARM).

Materials and methods

A random stratified sample was obtained in six teaching hospitals: two in Spain (n = 246) and four in Mexico (n = 139) as part of the International Collaborative Program “Proyecto Donante, Murcia.” The sample consisting of 385 trainee physicians completed a psychosocial questionnaire as the instrument to test their opinions.

Results

Most residents (93%; n = 359), were in favor of deceased organ donation with 90% (n = 348) in favor of living kidney donation and 87% (n = 335) in favor of liver donation. Attitudes toward donation were similar among Spanish and Mexican residents regarding deceased donation (93% vs 94%; P > .05), living kidney donation (88% vs 94%; P > .05), and living liver donation (86% vs 89%; P > .05). None of the attitudes toward donation was associated with the classic psychosocial factors related to attitudes toward donation or job factors. Discussion within the family was associated with more positive attitudes toward deceased donation (P < .001), living donation of the kidney (P = .01), and of the liver (P = .019).

Conclusion

Attitudes toward various types of donation were favorable among both Spanish and Mexican trainee physicians, so that they could potentially act as a group to promote this activity, raising hopes for increased donation rates in the future.     

Surgical Technique in Cadaveric Donors for Partial Hand Allotransplant in Patients With Rheumatoid Arthritis

For patients with severe hand deformities due to rheumatoid arthritis, we propose an allotransplantation of an osteomyotendinose structure (OMTS), preserving the recipient's skin and sensory nerves. Our objective was to develop the surgical technique in a 10 cadavers, five as donors and five as recipients. The donor's hand was 10% to 15% smaller than the recipient's. Dissections were performed by two surgical teams under magnification. In the donor, the OMTS was procured at the distal third of the forearm, maintaining the integrity of the arterial system, with its concomitant veins and motor branches of the median and ulnar nerves, leaving the skin envelope. In the recipient, the OMTS was removed, taking care to preserve the cutaneous cover with the digital arteries in continuity with the superficial palmar arch and radial and ulnar arteries. Also, the digital nerves were maintained in the skin flap, in continuity with the median and ulnar nerves. Their motor branches were divided after emergence from the main nerves. The superficial dorsal veins and radial nerve were kept adhered to the cutaneous cover. Then, the donor OMTS was placed within the recipient cutaneous flap; all the anatomic structures were repaired. The average surgical time was 780 minutes. Methylene blue was present in the digital arteries. There were no difficulties in the anatomic repair. The surgical technique is quite laborious, especially the dissection of the recipient interdigital spaces. Due to the requirement for arterial system integrity, the cutaneous flap must be viable. Also, the allotransplanted OMTS has all necessary conditions to obtain good tissue perfusion for subsequent function. Procurement without skin permits a greater opportunity to find donors, and greater social and personal acceptance by the recipient.     

Treatment of acute antibody-mediated rejection: a single-center experience

Introduction

Acute antibody-mediated rejection (AMR) leads to graft loss. The combination of plasmapheresis (PP), intravenous immunoglobulin (IVIG), and rituximab (RTX) has been reported to be effective therapy.

Patients and methods

Between October 2005 and September 2009, 8 (4.7%) kidney transplant recipients developed AMR, diagnosed by severe acute rejection and extensive C4d staining in peritubular capillaries.

Results

All patients were treated with two to six sessions of PP with IVIG added after the last PP. In two patients, RTX was prescribed after PP and IVIG. Baseline immunosuppression was based on steroids, mycophenolate mofetil or azathioprine, and tacrolimus or cyclosporine or everolimus. The presence of subsequent significant decrease in anti-HLA class I antibodies was demonstrated in a highly sensitized patient before and after transplantation with PP treatment. An increase was observed before the diagnosis of AMR. After a mean follow-up of 10 months (range = 1-23), patient and graft survivals were 100% and 50%, respectively. Three patients lost their transplants to AMR refractory to treatment and one patient, due to interstitial fibrosis and tubular atrophy at 23 months after AMR. Finally, four patients recovered renal function, showing a mean serum creatinine of 2.2 ± 0.45 mg/dL.

Conclusions

Early diagnosis and treatment with PP, IVIG, and RTX may resolve AMR. PP before and after transplantation in high-risk patients may result in anti-HLA class I and class II antibody removal from plasma and prevention of AMR.     

Motor cortical hyperexcitability in idiopathic scoliosis: could focal dystonia be a subclinical etiological factor?

The aetiology of idiopathic scoliosis (IS) remains unknown; however, there is a growing body of evidence suggesting that the spine deformity could be the expression of a subclinical nervous system disorder. A defective sensory input or an anomalous sensorimotor integration may lead to an abnormal postural tone and therefore the development of a spine deformity. Inhibition of the motor cortico-cortical excitability is abnormal in dystonia. Therefore, the study of cortico-cortical inhibition may shed some insight into the dystonia hypothesis regarding the pathophysiology of IS. Paired pulse transcranial magnetic stimulation was used to study cortico-cortical inhibition and facilitation in nine adolescents with IS, five teenagers with congenital scoliosis (CS) and eight healthy age-matched controls. The effect of a previous conditioning stimulus (80% intensity of resting motor threshold) on the amplitude of the motor-evoked potential induced by the test stimulus (120% of resting motor threshold) was examined at various interstimulus intervals (ISIs) in both abductor pollicis brevis muscles. The results of healthy adolescents and those with CS showed a marked inhibitory effect of the conditioning stimulus on the response to the test stimulus at interstimulus intervals shorter than 6 ms. These findings do not differ from those reported for normal adults. However, children with IS revealed an abnormally reduced cortico-cortical inhibition at the short ISIs. Cortico-cortical inhibition was practically normal on the side of the scoliotic convexity while it was significantly reduced on the side of the scoliotic concavity. In conclusion, these findings support the hypothesis that a dystonic dysfunction underlies in IS. Asymmetrical cortical hyperexcitability may play an important role in the pathogenesis of IS and represents an objective neurophysiological finding that could be used clinically.     

Hinged Total Knee Arthroplasty in the Presence of Ligamentous Deficiency

Background  

Rotating-hinge total knee prostheses may be used for the treatment of global instability about the knee. The designs of previous generations were associated with suboptimal outcomes.