The modified buried vertical mattress suture. A new technique of buried absorbable wound closure associated with excellent cosmesis for wounds under tension

BACKGROUND

Recent modifications of mattress suturing techniques have been reported producing rapid and effective skin eversion and excellent tensile strength while producing cosmetically elegant results.

OBJECTIVE

Presented here is a new modification of the buried vertical mattress suture. Results employing this technique compared with conventional bi-layered wound closure are presented.

METHODS

One hundred patients were analyzed in a double-blind randomized study where excision was carried out on benign pigmented lesions of the upper back. Fifty patients were treated by a conventional bi-layered closure technique while another 50 patients were treated by the newly described buried vertical mattress suture technique. Parameters of infection, hypertrophic scar/keloid formation, dehiscence, suture reaction, wound spread, and patient satisfaction were examined.

RESULTS

The modified buried vertical mattress suture technique produced less hypertrophic scar/keloid formation (2% vs 16%) as well as less wound scar spread (6% vs 24%) compared with conventional bi-layered suturing techniques. In addition, it was associated with a high degree of patient satisfaction (96%).

CONCLUSION

The modified buried dermal mattress suture technique produces excellent cosmetic results in closing elliptical excisions on thick dermal cutaneous anatomic areas under considerable wound tension. Its decreased requirement for postoperative wound care makes it an excellent alternative for patients living long distances from physician referral centers.

Ultrapulse carbon dioxide laser removal of periocular wrinkles in association with laser blepharoplasty

Removal of periocular wrinkles is a common yet difficult problem. There are many techniques currently available, all of which have some drawbacks. With the advent of new generation ultrapulse carbon dioxide lasers, skin can now be resurfaced successfully with minimal risk and side effects. In our study of 36 patients we assessed the benefit of using ultrapulse carbon dioxide (CO 2) laser to resurface the periorbital skin in association with transconjunctival lower lid CO 2 laser blepharoplasty. We found that 36/36 (100%) patients had good to excellent results. The incidence of side effects was very low. We also found that 2/36 (5.6%) of patients developed mild clinically insignificant hypopigmentation and 1/36 (2.8%) developed mild scarring, which resolved with one injection of triamanalone 10 mg/ml. No patients had hyperpigmentation. In addition, 1/36 (2.8%) patients developed transient ectropion, which resolved spontaneously in 6 weeks. We conclude that ultrapulse CO 2 laser is an excellent method for treating periocular wrinkle lines and can be readily performed in conjunction with a transconjunctival lower lid blepharoplasty.

Migration of cultured vascular smooth muscle cells through a basement membrane barrier requires type IV collagenase activity and is inhibited by cellular differentiation

The migration of vascular smooth muscle cells (VSMCs) from the tunica media to the neointima is a key event in the development and progression of many vascular diseases and a highly predictable consequence of mechanical injury to the blood vessel. In vivo, VSMCs are surrounded by and embedded in a variety of extracellular matrices (ECMs) that must be traversed during migration. One of the principal barriers to cell movement in the intact vessel is the basement membrane (BM) that surrounds each VSMC and separates the VSMC-containing medial cell layer from the endothelium. We have used a Boyden chamber to monitor the ability of VSMCs to degrade a BM barrier as they migrate toward a chemoattractant and to define the role of extracellular proteases in this process. We show that cultured VSMCs can migrate across a BM barrier and that this ability was dependent on the phenotypic state of the cell. VSMCs maintained in a proliferating or "synthetic" state readily migrated across a BM toward a chemoattractant, whereas the migration of serum-starved/differentiated VSMCs was suppressed by > 80% (P < .001). By use of a number of peptides that inhibit matrix metalloproteinase (MMP) activity, the migration of proliferating VSMCs across the BM barrier was inhibited by > 80% (P < .0001), whereas migration that occurred in the absence of the barrier was unaffected. Northern blotting and zymographic analyses indicated that 72-kD type IV collagenase (MMP2) was the principal MMP expressed and secreted by these cells. Accordingly, antisera capable of selectively neutralizing MMP2 activity also inhibited VSMC migration across the barrier without significantly affecting the migration of VSMCs in the absence of the barrier. Finally, MMP2 activity was also regulated by the phenotypic state of the cells in that MMP2 activity expressed by serum-starved/differentiated VSMCs was < 5% of that measured in proliferating VSMCs. Extrapolating to the in vivo situation in which VSMCs reside in an ECM composed of various BM barriers, these results suggest that VSMC migration in vivo may be dependent on MMP2 activity. That activity, in turn, could be regulated by the phenotypic state of VSMCs and increase as these cells undergo the transition from a quiescent and differentiated state to that of a dedifferentiated, proliferating, and motile phenotype after injury to the vessel.

Testing sensibility, including touch-pressure, two-point discrimination, point localization, and vibration

Sensibility is much more than protective sensation, and the examiner needs to consider the various degrees of residual sensibility that influence both diagnosis and prognosis. Towards that end, objective tests of the extent and nature of peripheral nerve involvement should be employed. Objective tests reflect the current condition of sensibility and are not affected by cognitive influences, such as re-education. Most current clinical instruments used for measurement of sensibility fail to meet the criteria of an objective test because they: (1) can be shown to lack necessary sensitivity, and (2) are too variable. As a consequence, regardless of whether these instruments have been used in controlled clinical studies or are in common use, their results will not replicate with repeated testing. Unfortunately, therefore, sensibility changes will potentially go unrecognized in a large number of patients and many will be detected only in the later stages of peripheral nerve abnormality, when possibilities of treatment are less effective. This article discusses sensibility testing from the standpoint of what is known regarding strengths and weaknesses of various tests and sensory modalities, and makes an appeal for clinicians to review the instruments they use critically for sensibility measurement with regard to stimulus control. Clinicians must insist on validity and reliability in their instruments before they have confidence in the data obtained.

A survey of long-term care elderly patients in the South West Thames Region

This paper describes a survey which focuses on the patients in National Health Service long-term care beds. It examines the dependency levels and mental impairment of geriatric patients in 15 Departments of Geriatric Medicine, and determines the extent and distribution of patient dependency, including the number of independent patients. The findings support the view that there is a need for National Health Service long-term care beds.

Orotactile sensation, gustation and palatability: a pilot study

The hypothesis that deficits in orotactile sensitivity may affect gustation and palatability is not new. It is supported by animal models employing deafferentation; however, little direct evidence supports the application of the model to humans. Indirect evidence comes from four separate fields: (1) neuroanatomy, (2) physiology, (3) developmental biology, and (4) learning theory. The results of a pilot study with humans provide additional direct evidence that implicates the role of orotactile sensitivity in human gustation. In this pilot study, the oral cavity was topically anesthetized to determine whether gustation would be compromised to a similar extent as orotactile sensitivity. The time course of the degree of anesthesia was determined by prior measurements of oral-tactile sensitivity using an oral air-based aesthesiometer. Different concentrations of NaCl-solution were presented to subjects in order to determine gustatory thresholds before and after anesthesia. Analysis of magnitude-estimation data indicated that there were statistically significant decreases in gustatory sensitivity after anesthesia. Basic and applied implications of this area of research are discussed.

Splenic infarction. A new thrombotic manifestation of the circulating lupus anticoagulant

Thrombotic events are occasionally associated with circulating lupus anticoagulant and may take a variety of clinical forms. The authors report a thrombotic manifestation, spontaneous isolated splenic infarction that occurred in a young man with circulating lupus anticoagulant.

Lupus and non-lupus cutaneous manifestations in systemic lupus erythematosus

Mucocutaneous manifestations occur frequently in systemic lupus erythematosus (SLE). Common non-lupus dermatoses may be confused with lupus rashes, with important clinical consequences. A study of 84 consecutive patients with SLE was performed to determine the comparative frequency of lupus and non-lupus mucocutaneous abnormalities, the comparative sensitivity of routine histology and immunofluorescence in the diagnosis of lupus rashes, and the association of skin manifestations with other clinical and serological features. Thirty-five patients had dermatoses attributable to SLE (mean 3.7 per patient) and 58 had dermatoses which were not directly attributable to SLE (mean 2.1 per patient), highlighting the need for accurate diagnosis of skin rashes in SLE patients. Routine histology confirmed the clinical diagnosis of typical cutaneous lupus in 100% of malar lupus rashes and in approximately 90% of subacute cutaneous and discoid lupus rashes. Direct immunofluorescence of the affected skin provided supportive evidence of cutaneous lupus in 60% of malar lupus rashes and approximately 50% of subacute cutaneous and discoid lupus rashes. This reaffirmed the poor sensitivity of immunofluorescence, compared with routine histology, in the diagnosis of lupus rashes. The association of subacute cutaneous lupus with anti-Ro antibodies was confirmed.

Increased neurogenic inflammation in fibrositis syndrome

Mechanically induced vasodilatation or flare on the skin, known as dermatographia, is a common clinical observation in fibrositis syndrome and is thought to be a neurogenically mediated axon reflex response. In our study, mechanically and chemically induced flares were quantitated in 13 patients with fibrositis syndrome and 14 control subjects. There was a reduced threshold for chemically induced flare response and the area of flare was greater in patients compared to controls, although there was a wide range of responses in both groups. There was also a significant positive correlation between mechanically and chemically induced flares, and the number of tender points in all subjects correlated with the size of the chemically induced flare. We suggest that exaggerated neurogenic inflammatory responses in patients with fibrositis syndrome reflect increased activity of polymodal nociceptors of unmyelinated primary afferent nerves. This increased receptor activity may also contribute to the pain and tenderness experienced by these patients.

Livedo reticularis associated with increased titers of anticardiolipin antibodies in systemic lupus erythematosus

Seventy-eight consecutive patients with systemic lupus erythematosus were assessed for the presence of livedo reticularis. The possible association of livedo reticularis with other clinical and laboratory features including anticardiolipin antibodies was explored. Thirty-eight patients had livedo reticularis. Four cases were severe, 11 moderate, and 23 mild. There was a statistically significant association between the combined moderate and severe livedo reticularis group and elevated levels of anticardiolipin antibodies. The recognized association of anticardiolipin antibodies with thrombotic events suggests a possible pathogenetic role. The presence or history of central nervous system disease, renal disease, vasculitis, or lupus inhibitor was significantly associated with the moderate and severe livedo reticularis group. Livedo reticularis may be a cutaneous marker for the later development of important systemic events in systemic lupus erythematosus.

Stuttering: disappearance and reappearance with acquired brain lesions

Despite 60 years of study, the brain mechanisms for stuttering are unknown. In an effort to shed light on these mechanisms, we studied two cases in which the fluency of speech changed after brain damage in adulthood. The first, an ambidextrous man, ceased to stutter after a head injury. The second, a converted left-handed man, experienced recurrence of childhood stuttering after a stroke.

Preterm labor in the quadriplegic parturient

The occurrence of preterm labor is not uncommon in the pregnant quadriplegic. Early diagnosis is hampered by the inability of most quadriplegics to sense uterine contractions in the usual way. A patient we recently treated for preterm labor learned to recognize contractions by the associated symptoms of autonomic hyper-reflexia: flushing, headache, and piloerection. Tocolytic therapy was successful and a favorable neonatal outcome occurred. Increased awareness by the physician and the pregnant quadriplegic patient is encouraged so that symptoms of autonomic hyper-reflexia may be recognized as potentially indicative of uterine contractions.

Effect of exercise training and diet modification on serum lipids and lipoproteins in coronary artery disease patients treated with thiazides

The effects of chronic exercise training and diet modification on serum lipids and lipoproteins were measured in 17 hypertensive males and 41 normotensive males with documented coronary artery disease (CAD). Exercise consisted of aerobic activities which were performed at approximately 75-85% of the symptom-limited maximum heart rate for 30-40 minutes, three times weekly for 3 months. Each participant's diet was also controlled, the recommended daily intake of fat and cholesterol was no more than 40 g/day and 200 mg/day, respectively. Significant increases in estimated VO2max and total cholesterol/high density lipoprotein (HDL) and a significant decrease in serum triglycerides were documented after training. Significant differences in serum cholesterol and triglycerides between the nondiuretic and diuretic patients were also noted. No significant changes were found in low density lipoprotein (LDL), HDL, or body weight. Vigorous aerobic training and diet modification can favorably modify the deleterious effects of diuretic medications on serum triglycerides and total cholesterol/HDL in patients with documented CAD.

Localization and detection of visual stimuli following superior colliculus lesions in rhesus monkeys

Rhesus monkeys were trained to fixate a central stimulus and to detect and localize a 50 msec light flash presented 6-80 degrees on either side of the central stimulus. Following large lesions of the superior colliculus, they showed persistent deficits in localizing flashes presented 43-80 degrees from the fixation stimulus. However, they were not consistently impaired when the flashes were presented more centrally, and their performance with peripheral stimuli improved when the stimulus duration was 1 sec. Thus, the superior colliculus appears to be necessary for the localization of brief visual stimuli in the far periphery.