A combination Verhoeff's elastic and Masson's trichrome stain for routine histology

A method for the combined staining of elastic, muscle and connective tissue for routine use in histopathology is described. The elastica, stained black by Verhoeff's technique, is contrasted with the muscle and connective tissue stained red and green or blue respectively by a modification of Masson's trichrome. Cell nuclei stain blue-black with Weigert's iron hematoxylin. The procedure takes approximately two hours and is most suitable for the study of vascular pathology in surgical and autopsy sections.     

A Combination Verhoeffs Elastic and Masson's Trichrome Stain for Routine Histology

A method for the combined staining of elastic, muscle and connective tissue for routine use in histopathology is described. The elastica, stained black by Verhoeffs technique, is contrasted with the muscle and connective tissue stained red and green or blue respectively by a modification of Masson's trichrome. Cell nuclei stain blue-black with Weigert's iron hematoxylin. The procedure takes approximately two hours and is most suitable for the study of vascular pathology in surgical and autopsy sections.     

Muscle injuries and repair: the role of prostaglandins and inflammation

Skeletal muscle injuries are a common problem in trauma and orthopaedic surgery. Muscle injuries undergo the healing phases of degeneration, inflammation, regeneration, and fibrosis. Current and experimental therapies to improve muscle regeneration and limit muscle fibrosis include conservative and surgical principles with the adjuvant use of non-steroidal anti-inflammatory drugs (NSAIDs) and growth factor manipulation. NSAIDs appear to have a paradoxical effect on the healing of muscle injuries with early signs of improvement and subsequent late impairment in functional capacity and histology. In vitro and in vivo studies have explored the role of the cyclooxygenases and prostaglandins in the biological processes of healing muscle, including precursor cell activation, myoblast proliferation, myoblast fusion, and muscle protein synthesis. Through use of more specific cyclooxygenase inhibitors, we may be able to better understand the role of inflammation in muscle healing.     

On-line control of atracurium induced muscle relaxation

We described recently a microcomputer system capable of controlling muscle relaxation during surgical procedures; the system was tested and evaluated in 42 clinical trials involving the use of the muscle relaxant, d-tubucurarine. The advent of new non-depolarizing neuromuscular blocking drugs with significant clinical advantages makes it essential that any automatic control system for muscle relaxation can also be used with such drugs, and benefit from their improved properties. This paper describes a series of 22 clinical trials in which our controller was used successfully to control muscle relaxation using atracurium. We also investigated an alternative control strategy, taking advantage of the rapid elimination of atracurium from the body.     

Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new, reliable approach

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and often severely limiting mouth opening. Previous surgical treatments have been disappointing. This article introduces a new surgical approach: reconstructing the bilateral buccal mucosa with two small radial forearm flaps. The surgical method includes the complete surgical release of fibrotic buccal mucosa and, if necessary, a bilateral coronoidectomy and temporalis muscle myotomy. From 1997 to 1999, 15 patients with moderate-to-severe trismus received reconstructive surgery, for a total of 30 small radial forearm flaps after surgical release. The flap size was between 1.5 x 5 and 2.5 x 7 cm. All donor sites were directly closed, and all flaps survived completely, except for one with partial necrosis. Six flaps required minor revisions because of size redundancy. Two patients developed buccal cancer in the area of reconstruction. At an average of 12 months' follow-up, the inter-incisal distance averaged 33 mm, an increase of 17 mm compared with the preoperative value. The donor-site morbidity was minimal, except in one heavy smoker who developed dry gangrene of his fingertips. The use of two small free forearm flaps for buccal mucosa reconstruction allows more radical release of fibrotic tissue. Coronoidectomy and temporal muscle myotomy further contribute to the effect of trismus release. The combined effects of this approach have consistently given good results. An aggressive approach toward surgical treatment of this precancerous lesion also facilitates the detection of cancer at an early stage.     

Microcomputer system for the analysis of muscle function

Though skeletal muscle function has recently been increasingly studied, a system for routine clinical examination in patients is not widely available. A microcomputer based system has been developed for the measurement and analysis of force-frequency characteristics, relaxation rate, fatiguability and endurance in the adductor pollicis muscle. The mobile system consists of a modified displacement transducer fitted with a linear-output Hall-effect sensor, a specially designed signal processing unit and a microcomputer for control of both the electrical stimulus and a suite of menu-driven, user-interactive programs. One hundred normal volunteers have been studied to produce a normal database for comparison with malnourished surgical patients. The system compares favourably with other systems in use for objective measurement of skeletal muscle function and introduces a refined technique for evaluating endurance.     

Surgical Responses of Medial Rectus Muscle Recession in Thyroid Eye Disease-Related Esotropia

We evaluate the surgical outcomes and surgical responses of medial rectus muscle (MR) recession patients with thyroid eye disease (TED)-related esotropia (ET). The surgical dose-response curves 1 week postoperatively and at the final visit were analyzed. Univariable and multivariable linear regression analyses were applied to investigate factors influencing surgical dose-response. A total of 43 patients with TED-related ET that underwent MR recession were included. The final success rate was 86.0% and the rate of undercorrection was 14.0%. The surgical dose-response curves of TED-related ET showed a gentle slope compared with those of standard surgical tables. In the univariable model, simultaneous vertical rectus muscle recession was the only significant factor influencing surgical dose-response of MR recession in TED-related ET (β = -0.397, P = 0.044). In a model adjusted for age, sex, type of surgery, and preoperative horizontal angle of deviation, simultaneous vertical rectus muscle recession showed marginal significance (β = -0.389, P = 0.064). The surgical dose-response curve of TED-related ET was unique. Simultaneous vertical rectus muscle recession was associated with increased surgical dose-response in TED-related ET.     

The influence of limb alignment and transfemoral amputation technique on muscle capacity during gait

Many factors influence successful outcomes following transfemoral amputation. One factor is surgical technique. In this study, the influence of limb alignment and surgical technique on a muscle’s capacity to generate force was examined using musculoskeletal modeling. Non-amputee and transfemoral amputee models were analyzed while hip adduction, femur length, and reattached muscle wrap position, tension and stabilization technique were systematically varied. With muscle tension preserved, wrap position and femur length had little influence on muscle capacity. However, limb alignment, muscle tension and stabilization technique notably influenced muscle capacity. Overall, myodesis stabilization provided greater muscle balance and function than myoplasty stabilization.     

Latissimus dorsi free muscle flap in lower-extremity reconstruction

The free latissimus dorsi skin-muscle flap has gained wide popularity to solve a variety of difficult reconstructive surgical problems. However, the donor site of this skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap requires staged defatting procedures. This case demonstrates the use of the latissimus dorsi muscle flap for lower-extremity reconstruction, where a new blood supply and soft-tissue coverage are required to solve a chronically infected, open ankle joint. By taking the latissimus muscle only through a short, axillary incision, much of the donor-site deformity is minimized, and after transfer, the muscle can be molded and shaped to fit the recipient site with split-thickness skin graft coverage. This combination of free muscle flap transfer and skin graft would appear to provide a flexible, contoured, well-vascularized muscle with a relatively inconspicuous incision and skin-graft donor site.     

Bladder Smooth Muscle Strip Contractility as a Method to Evaluate Lower Urinary Tract Pharmacology

We describe an in vitro method to measure bladder smooth muscle contractility, and its use for investigating physiological and pharmacological properties of the smooth muscle as well as changes induced by pathology. This method provides critical information for understanding bladder function while overcoming major methodological difficulties encountered in in vivo experiments, such as surgical and pharmacological manipulations that affect stability and survival of the preparations, the use of human tissue, and/or the use of expensive chemicals. It also provides a way to investigate the properties of each bladder component (i.e. smooth muscle, mucosa, nerves) in healthy and pathological conditions.The urinary bladder is removed from an anesthetized animal, placed in Krebs solution and cut into strips. Strips are placed into a chamber filled with warm Krebs solution. One end is attached to an isometric tension transducer to measure contraction force, the other end is attached to a fixed rod. Tissue is stimulated by directly adding compounds to the bath or by electric field stimulation electrodes that activate nerves, similar to triggering bladder contractions in vivo. We demonstrate the use of this method to evaluate spontaneous smooth muscle contractility during development and after an experimental spinal cord injury, the nature of neurotransmission (transmitters and receptors involved), factors involved in modulation of smooth muscle activity, the role of individual bladder components, and species and organ differences in response to pharmacological agents. Additionally, it could be used for investigating intracellular pathways involved in contraction and/or relaxation of the smooth muscle, drug structure-activity relationships and evaluation of transmitter release.The in vitro smooth muscle contractility method has been used extensively for over 50 years, and has provided data that significantly contributed to our understanding of bladder function as well as to pharmaceutical development of compounds currently used clinically for bladder management.     

Electromyographic response is altered during robotic surgical training with augmented feedback

There is a growing prevalence of robotic systems for surgical laparoscopy. We previously developed quantitative measures to assess robotic surgical proficiency, and used augmented feedback to enhance training to reduce applied grip force and increase speed. However, there is also a need to understand the physiological demands of the surgeon during robotic surgery, and if training can reduce these demands. Therefore, the goal of this study was to use clinical biomechanical techniques via electromyography (EMG) to investigate the effects of real-time augmented visual feedback during short-term training on muscular activation and fatigue. Twenty novices were trained in three inanimate surgical tasks with the da Vinci Surgical System. Subjects were divided into five feedback groups (speed, relative phase, grip force, video, and control). Time- and frequency-domain EMG measures were obtained before and after training. Surgical training decreased muscle work as found from mean EMG and EMG envelopes. Grip force feedback further reduced average and total muscle work, while speed feedback increased average muscle work and decreased total muscle work. Training also increased the median frequency response as a result of increased speed and/or reduced fatigue during each task. More diverse motor units were recruited as revealed by increases in the frequency bandwidth post-training. We demonstrated that clinical biomechanics using EMG analysis can help to better understand the effects of training for robotic surgery. Real-time augmented feedback during training can further reduce physiological demands. Future studies will investigate other means of feedback such as biofeedback of EMG during robotic surgery training.     

Malignant hyperthermia in plastic surgery

Malignant hyperthermia is a seemingly rare genetic myopathy. Hypermetabolic crisis accompanied by a rise in body temperature to as high as 44 degrees C is its hallmark. Malignant hyperthermia is usually triggered by potent inhalated anesthetics and/or depolarizing muscle relaxants. Because of the extraordinary risk of death in patients who are at risk, plastic surgeons may be reluctant to operate on these patients. Five such patients were referred to the Plastic Surgery Service and the UCLA Malignant Hyperthermia Center for anesthetic and surgical management following plastic surgical procedures aborted for first episodes of malignant hyperthermia. They were anesthetized with nitrous oxide, barbiturates, opiates, tranquilizers, and nondepolarizing muscle relaxants. The patients were not treated prophylactically with dantrolene. Cardiac monitoring, end-tidal pCO2, and rectal temperatures were followed. After completion of their plastic surgical procedures, all five patients had a vastus lateralis muscle biopsy performed and subsequent caffeine/halothane contracture studies completed. The contracture study was positive in all patients studied. No anesthetic or surgical complications were encountered. This study demonstrates that patients at risk of developing malignant hyperthermia crisis can have plastic surgical procedures performed safely while undergoing appropriately selected general anesthesia.     

Temporalis muscle hypertrophy: a new plastic surgery procedure

Bilateral hypertrophy of the temporal muscle can give the impression of a harsh facial appearance that manifests itself as a morphopsychological conflict for the subject involved (Minotaur syndrome). This article describes a new facial aesthetic surgical procedure in the area of the temporal muscle. The author describes the surgical technique and the surgical instrument that he developed specifically for performing aesthetic contouring of the temporal area by reducing the muscle volume discrepancy ("myosuction"). The follow-up results of 11 cases demonstrated that this procedure renders valid results in the overall aesthetic reharmonization of the face and an improvement of individual psychological well-being.     

The changing role of platysma in face lifting

Since the 1970s, surgical procedures on platysma muscle, aiming to achieve better results in face lifting, became popular and turned out to be an important surgical step for the plastic surgeon. Many plastic surgeons have contributed to the topic throughout these years, as several articles on the subject have been published. Articles dealing with platysma muscle still bring great interest among plastic surgeons. My concern with platysma muscle began in the mid-1970s and since then has grown continuously. I have steadily been studying the importance of the platysma muscle in the surgeries for facial rejuvenation, involving its anatomy, the techniques proposed, the results obtained, the recommendations for the best surgical procedure for each patient, and the complications. My experience and studies regarding platysma muscle, and the contributions I have brought into this field, are thoroughly described and discussed in this article.     

Advances toward tissue engineering for the treatment of stress urinary incontinence

Suburethral pubovaginal sling placement is a common surgical procedure for the treatment of stress urinary incontinence. A wide variety of graft materials is available, each associated with inherent desirable and undesirable characteristics and complications. In this article, we discuss the rationale for and application of small intestinal submucosa (SIS) in lower urinary tract tissue engineering, with emphasis on the use of SIS as a suitable and biologically compatible sling material. In addition, we discuss exciting research regarding the engineering of true functional sphincter reconstruction using this biologic scaffold and pre-seeded muscle cells.     

MANAGEMENT OF PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

The proper use of medical therapeutic agents in the management of peripheral arterial occlusive disease must be based upon a thorough understanding of the factors controlling vasomotor tone and vasospasm, mechanisms regulating blood flow in skin and muscle, factors favoring nutritional and shunt flow, effects of the diversion of blood from one vascular bed to another, muscle contraction as a factor which may limit the blood flow to a part, epinephrine sensitivity after sympathectomy, and the effects of vasodilator drugs on the local and total circulations.There are six major classes of therapy for peripheral arteriosclerosis: General medical care, administration of vasodilator drugs and administration of anticoagulants, sympathectomy, direct vascular operation and amputation. In many cases the most successful treatment is a combination of medical and surgical therapy.     

Volkmann's contracture of the extraocular muscles following blowout fracture

In the past decade there has been considerable controversy over the surgical indications for treatment of blowout fractures of the orbit. It has been well recognized that some fracture patients develop an ischemic contracture of the inferior rectus muscle. We have found that a Volkmann's type of contracture of the inferior rectus muscle does exist and is similar to that found in the distal extremities. A specific group of fracture patients is at greater risk for development of a contracture. Elderly patients, hypotensive patients, patients with small fractures, and those with high inferior rectus compartment pressures are more prone to developing a contracted extraocular muscle. We have measured compartment pressures in 18 patients who were surgical candidates following orbital fracture. Our conclusions indicate that surgical intervention following blowout fractures in these high-risk patients may be more prudent than medical management. Patients with persistent diplopia due to a contracted inferior rectus are extremely difficult to treat many months after fracture. We still believe it prudent to surgically repair orbital fractures in patients with diplopia, enophthalmos, and a risk for muscle contracture. The documentation of this additional sequela of unrepaired fractures lends more strength to this belief. There is no evidence to indicate that a Volkmann's contracture would be possible after early repair of a blowout fracture.     

Measurement of the isometric dorsiflexion and plantar flexion force in the ankle joint]

This article describes an easy to use test equipment for measuring the isometric force in the ankle joints in dorsiflexion and plantar flexion. The combination of the test equipment for measuring the voluntary maximal isometric muscle force in the ankle joint, the surface electromyograms and the motion analysis of the measured leg allow an objective comparison of the strength of the muscular force between the left and right leg. It might be also used as a control setup during rehabilitation after surgical treatment or injuries.     

Anatomical basis for a technic of cutting flaps out of the musculus rectus femoris for creating a rectal sphincter apparatus

As demonstrate the surgical anatomy investigations of the m. rectus femoris performed in 100 preparations, obtained from corpses of persons belonging to various age periods, in connection with sphincteroplasty the vascular-nervous hilus of the muscle is projected at the level of the upper third of its medial part. The ascending branch of the lateral femoral circumflex artery with the vein of the same name and the muscular branch of the femoral nerve get into their composition. The intramuscular course of the vessels and nerves of the I-III orders of branching and that of the muscular fasciculi coincide. For the sphincteroplasty it is expedient to use muscular-tendinous flaps, cut out from the medial part of the musculus.