J Oral Maxillofac Surg51:212-215.1993

Abstracts

Plasminogen Activators in Normal and Malignant Oral Ep­ithelium In Vim and In Vitro. Barlow Y, Southam J'C, ArchOral BioI 37:749, 1992

Plasminogen activators, both urokinase-type (uPA) andtissue-type (tPA) have been identified biochemically and im­munologically in normal tissues and neoplasms. Numerousarticles have cited evidence to indicate that an increase insynthesis ofplasminogen activators is an early and concom­itant event in cell transformation in vitro and that tumorigenicand metastatic potential of these transformed cell lines cor­relates well with increased synthesis ofplasminogen activator.Normal tissue specimens were donated by 19 healthy patientsundergoing third molar removal-a piece of the flap raisedbefore extraction of the teeth was used. Fresh oral squamouscell carcinoma tissue was obtained from 13 patients as partof the surgical excision of the tumor. Results showed thatuPA and tPA were identified in sulcus epithelium but not inorthokeratinized epithelium. Fibrinolytic activity in squa­mous cell carcinoma sections was present only over bloodvessels. Immunofluorescence did not demonstrate PA in sul­cular epithelium but both uPA and tPA were found in oc­casional squamous cell carcinoma cells. Fibrinolytic activityof culture fluids from epithelial explants of squamous cellcarcinomas was low in both supernatants and Iysates becauseofthe associated presence ofplasminogen activator inhibitors.Production of inhibitors by cultured oral squamous cell car­cinomas further casts doubt on the role of plasminogen ac­tivators in the zone of tumor invasion. However, the abilityofplasminogen to bind to a number ofcell types which pro­tects it from inhibitors suggests that the overall amountof inhibitor present may not limit the power of invasion.­G.T.JONES

Reprint requests to Dr Barlow: Smith and Nephew Research Ltd,Gilston Park, Harlow, Essex, UK.

The Ptotic (Witch's) Chin Deformity: An Excisional Ap­proach. Feldman JJ. Plast Reconstr Surg 90:2, 1992

Ptosis ofthe chin is a common condition that may be seenin patients ofall ages. The deformity is most commonly seenin older patients. Frequently a deep submental skin crease isassociated with the drooping chin. A common concern ofpatients is the appearance of chin ptosis when smiling. Theauthor presents a technique, based on a 14-year experience,for correction of this problem. The key element is to excisethe sagging excess ofskin, muscle, and fat and not to attemptto lift ptotic tissue. In dealing with correction of the deepsubmental crease, the author also believes that excision is allthat is needed. The various dermis, fat, and muscle flaps tra­ditionally used to address the crease are usually unnecessary,and at times may produce a slight bulge under the chin. Chinptosis is described as a developmental problem but iatrogeniccauses are discussed. The author presents a surgical techniquethat is performed after clinical evaluation ofthe patient, withoccasional use of radiographs to establish a soft tissue or softtissue/bony etiology. The surgical technique described is ac­complished by first making the ptotic tissue laterally with atransverse line that is connected anteriorly. The submental

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crease is also marked, but the actual skin incision will beslightly caudal to the crease as to excise the crease during theprocedure. A pattern for the strip of skin to be removed ismarked and is usually lenticular in shape. The scar createdby the skin incision will lie just below the chin shadow. Theskin incision is made to fat with a scalpel. Dissection continueswith electrocautery to create a thin, smooth, skin-fat flap toslightly above the level of the previously marked transverseline. Once this is achieved the cutting is directed deep toinclude muscle. A cephalic portion of the mentalis muscle isalways left intact. -The oval of ptotic tissue and fat is thenexcised. The excess chin skin and subcutaneous tissue pre­viously marked is usually excised en bloc. Closure is per­formed in two layers. Seven surgical cases are presented. Mildrecurrence was noted in several patients. The recurrenceswere in elderly individuals and were corrected with simplesecondary excision. The author further provides a review ofliterature on correction of static and dynamic chin ptosis, aswell as insufficient chin projection and deep submentaldepression. He concludes that his approach incorporates anumber of previously described methods with some addedmodifications. He states that this approach allows for cor­rection ofstatic and dynamic chin ptosis by the identificationand removal ofassociated muscle, fat, and skin. Additionallythis approach allows for correction of excess anterior chinprojection secondary to excess anterior soft tissue.­P.M. MONTEFALCO

Reprint requests to Dr Feldman: Doctors Office Building, Suite 304,300 Mount Auburn Street, Cambridge, MS 02238.

Primary Reconstruction of Major Human Bite Wounds ofthe Face. Agrawal K, et al. Plast Reconstr Surg 90:394, 1992

Primary reconstruction of human bite defects has beenadvocated only in the last decade and was limited to relativelysmall defects, treated within 24 hours after injury. Delayedprimary reconstruction was favored in patients with majordefects, infection, or wounds older than 24 hours. The authorsreport on 36 patients, ages 13 to 58, who presented over a4 lh-year period with major human bite wounds of the face.These wounds were clinically free ofgross infection. The pa­tients reported to the hospital from 2 to 84 hours after injury.A surface swab was taken preoperatively from each wound.The wound was cleaned thoroughly with chlorhexidine andcetrimide solutions and was debrided of all crushed devital­ized tissue. Debrided tissue was also submitted for bacterialculture. Reconstruction procedures were performed imme­diately by direct closure or by using local flaps. Postopera­tively, another swab culture was sent from patients in whominfection was encountered. All patients received systemicprophylactic antibiotics. Two patients developed marginalnecrosis of the wound edges 48 hours after surgery. Only onepatient had significant postoperative wound infection. Threepatients developed stitch abscesses. All infections were man­aged with antibiotics and dressings. The authors found a sig­nificant relationship between positive cultures, from both thesurface swab and the debrided tissue, and the time intervalafter injury. They surmise that human bite wound infectionsare mostly secondary infections due to the presence of de-

CURRENT LITERATURE

vitalized tissue. The authors conclude that primary recon­struction of all major human bites should be done irrespectiveof the delay in presentation, provided the wound is not clin­ically infected.-M.E. OSEAS

Reprint requests to Dr Agrawal: Department of Plastic Surgery,Jawaharlal Institute of Postgraduate Medical Education and Research,Pondicherry-605 006, India.

Transtympanic Endoscopy of the Middle Ear. Poe 0, RebeizE, et al. Laryngoscope 102:993, 1992

This study evaluated flexible and rigid endoscopy as analternative to surgical exploration of the middle ear. Fifteenpatients with various complaints and intact tympanic mem­branes wereendoscoped through a myringotomy incision overthe site of the anticipated pathologic process. Rigid fiberopticendoscopes with a L9-mm outside diameter and oblique cuttips of 5° and 25° as well as 0.4-, 0.7- and LO-mm outsidediameter fiberoptic flexible endoscopes were used. All en­doscopic procedures were performed in an outpatient officesetting with the use of topical anesthesia. At the conclusionof the procedure, the myringotomy incision was permittedto heal spontaneously if the margins were well adapted; ad­hesive tape was placed if the margins were uneven. Clinicallythe 0.4- and 0.7-mm flexible endoscopes had limited reso­lution and produced a very small image. The image size andresolution was greatly increased with the I.O-mm flexiblescope. The flexible endoscopes were more easily introducedthrough the incision and were easily manipulated past ob­structions. The L9-mm rigid endoscope was far superior inresolution, image size, and greater viewing area secondary tothe angled tip. The authors concluded that the examinationof the middle ear with the endoscopic technique should con­sist of use of the L9-mm rigid scope for excellent resolutionand field of view and the I.O-mm flexible scope to bypassobstructions, The described technique will eliminate the needfor surgical exploration of the middle ear.-B.M. CHERNY

Reprint requests to Dr Poe: Department of Otolaryngology-Headand Neck Surgery, Lahey Clinic Medical Center, 41 Mall Rd, Bur­lington, MA 01805.

Detection of Varicella Zoster Virus DNA and Viral Antigenin the Late Stage of Bilateral Acute Retinal Necrosis. Rum­melt V, Wenkel H, et al. Arch Ophthalmol 110:1132, 1992

Acute retinal necrosis (ARN) syndrome is a visually dev­astating disease. Viruses of the herpes group have been im­plicated as causing ARN syndrome. A case report is presentedin which varicella zoster virus (VZV) DNA and viral antigenwere demonstrated in the choroid and choriocapillaris of anenucleated eye affected by bilateral ARN (BARN) syndrome.A 61-year-old woman with loss of vision in the right eye anddecreased vision in the left eye was diagnosed with BARN.She was treated with acyclovir and prednisone acetate. Thevision in the left eye recovered but the right eye becameatrophic and painful. This eye was eventually enucleated.Microscopic examination revealed a diffuse full-thicknessnecrotizing retinitis, granulomatous choroiditis, optic neuritiswith ischemic optic atrophy, and peripheral cellular infiltra­tion of the retinal arteries. Immunohistochemical stains andDNA in situ hybridisation were used to identify VZV as thecausative agent. The virus was detected only within the cho­roid but not in any retinal vascular endothelium, the opticnerve, or the posterior cilliari nerves. The authors suggest aVZV-induced retinitis might occur following various ex­traoccular herpetic virus infection and as ARN syndrome.

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They further suggest that the route of viral dissemination ishemtogenous of either an endogenous virus, such as fromsensory ganglia, or following exogenous virus infection, suchas active herpes zoster skin lesions, rather than following aneural pathway.-A. ZICKMANN

Reprints requests to Dr Rummell: Department of Ophthalmology,University of Erlangen-Nuerenberg, Schwarzbachanlage 6, 8520Erlangen, Germany.

Bolus Dose With Continuous Infusion of Midazolam as Se­dation for Outpatient Surgery. Luyk NH, Zacharias M,Wanwimolaruk S. Int J Oral Maxillofac Surg 21: 172, 1992

This article presents a double-blind, randomized, crossovertrial of 41 patients undergoing third molar surgery. The pur­pose of the study was to evaluate the amnesic properties andpsychomotor recovery between a bolus injection of mida­zolam and a bolus injection followed by continuous infusionof midazolam. A visual analog scale, a critical flicker fusionthreshold, and a choice reaction time were used for evaluation.The authors indicate that in no instance was consciousnesslost or were there episodes of oxygen saturation decreasingto below 94%. There was no significant patient preferencefor one treatment over the other. The authors conclude thata bolus dose, followedby a continuous infusion of midazolam,appears to offer a safe and reliable sedative technique withimproved amnesia over bolus alone but at the expenseof a prolonged impairment of psychomotor function.­W.O. BAXTER JR

Reprint requests to Dr Luyk: University of Otago, Dunedin, NewZealand.

Teeth in the Fracture Line. Berg S, Pape H-D. Int J OralMaxillofac Surg 21:145, 1992

A retrospective study of 178 patients from 1988 to 1989treated by the Champy miniplate system with teeth in thefracture line was attempted. Forty-one patients were includedin the study and represented 78 "fracture line" teeth. Theteeth were compared to the corresponding contralateral tooth.Vitality tests, pocket depths, and postsurgical radiographswere recorded. The mean period of treatment from presen­tation to final review was 15 months. Of these 78 fractureline teeth, 18 were extracted at the time ofsurgery. One toothout of the remaining 59 study teeth was removed postsurg­ically because of infection. The remaining teeth studied dem­onstrated 13as non vital, 3 with apical root resorption, I withexternal resorption, and I with obliteration of the root canal.There was no evidence of periapical osteitis in any of theteeth. All teeth had no differences in mobility "and only in­creased pocket depth of I and 2 mm in one tooth. The criteriafor extraction of teeth at the time of surgery at Cologne Uni­versity was teeth with apical or marked peridontal bone lossor those damaged either by caries or trauma, and impactedwisdom teeth whose removal would not result in a loss ofbone at the fracture margin. Applying these parameters, theauthors claim a 98% (one tooth lost out of 58) successfulsalvage rate. They conclude that there is a good prognosisfor retained teeth in the fracture line and such teeth shouldbe extracted only when absolutely necessary.-T.e. KINCER

Reprint requests to Dr Berg: Department ofMaxillo-Facial Surgery,University of Cologne, Joseph-Stelzmann-Strafe 9, 0-5000 Koln 41,Germany.

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Degradation and Tissue Replacement of an AbsorbablePolyglycolide Screw in the Fixation of Rabbit FemoralOsteotomies. Bostman 0, et aI. J Bone Joint Surg [Br] 74:1021, 1992

Many studies have verifiedthe biocompatibility ofimplantsmade of polyglycolide. However, when cylindrical rods ofthis polymer were introduced into large-scale clinical trials,an unexpected complication developed . This complicationbeing the accumulation ofliquid polymer and the develop­ment of a sterile discharging sinus at the site of the implantin 4.5% to 22.5% of the patients receiving these implants 2to 4 months after implantation. The pathogenesis of thiscomplication is unknown, and therefore this investigationwas developed. The degradation ofa polyglycolide screw 4.5mm in diameter and 30 mm in length was studied histolog­ically and radiographically at sequential stages of resorptionafter fixation ofa transverse distal femoral osteotomy in rab­bits. In all specimens the degradation process of the implantwas the same. It began somewhere between the third andsixth week and was complete by the 36th week, which wasthe end of the study. During this time the implant is hydro­lyzed from a solid to a liquid and then phagocytized away.There was variability in the tissue response to the implant,which could be first discerned at the 12th week. Two patternsof tissue response emerge. The first is only minor reactivechanges with the implant being gradually replaced by alignedconnective tissue, then newly formed bone and bone ele­ments . The other pattern is a waIling off of the implant bycortical bone and gradual replacement of the implant by fi­brous connective tissue. The authors propose that the de­velopment of the sterile sinuses that occurred in the clinicaltrials with this material were a result of this second patternof implant degradation. Because the implants are walled offand filled with the now degraded liquid polymer and fibroustissue tries to fill in this cavity, there is an increase in pressureinside the walled cavity. A draining sinus then develops todissapate this increased cavity pressure.-E. RICHMOND

Reprint requests to Dr Bostman: Departmentof Orthopaedics andTraumatology, Toolo Hospital, SF-W260 Helsinki, Finland.

Asymptomatic Impacted Teeth in Edentulous Jaws Under­going Preprosthetic Surgery. A Long Term Evaluation. HuangH, Mercier P. Int J Oral MaxiIlofac Surg 21:147, 1992

Fifteen edentulous patients with 17 asymptomatic im­pacted teeth in the denture-bearing area were evaluated bothclinically and radiographically for 1 to 10 years for a meanobservation period of 4 years, In 15 of the cases the toothwas completely covered with bone and in the remaining twocases the teeth were superficial to the crest but completelycovered by mucosa. Ten patients had preprosthetic surgeryeither directly over the tooth or in close proximity to it andin 7 patients there were no surgical procedures performed.Annual examinations were done to evaluate for signs of in­flammation or tenderness over the involved sites. Radio­graphic examinations were used to monitor for any alterationin the position of the tooth or condition of the surroundingbone. No evidence of clinical or radiographic changes werefound . The authors contend that the severity of the atrophy,the type and location ofthe impacted tooth , and preprostheticsurgery do not influence the development of clinical symp­toms or radiographic changes. They do, however, recommendcontinued radiologic surveilance and extraction of the toothshould signs or symptoms arise.-J. LINDHOUT

Reprint requests to Dr Mercier: Room 2337, 3830 Lacombe Ave,Montreal, Quebec H3T IM5Canada.

CURRENT LITERATURE

The Oral Mucosa Punch Biopsy: A Report of 140 Cases.Eisen D. Arch Dermatol 128:815, 1992

The purpose of this article was to describe a simple andsafe method of obtaining an oral biopsy specimen. Onehundred thirteen patients with various oral lesions were eval­uated for biopsies. Biopsies that would require deep tissuesampling were performed by scalpel incision and were ex­cluded from this study. The nature of the biopsy procedurewas explained to the patients and informed consent was ob­tained . Local anesthesia was obtained with a 1% solution oflidocaine administered with a 30-gauge needle. A disposablepunch was introduced into the oral cavity and rotated throughthe mucosa. The depth of the punch was kept superficial inmost cases. Most of the biopsies were obtained using the 4­mm punch; infrequently the 3-mm and 6-mm punches wereused. After introducing the punch into the mucosa at theappropriate depth, the specimen was grasped with a forcepsand released with scissors, Hemostasis was obtained with theuse of sterile cotton-tip applicators. Electrodessication wasused to provide adequate hemostasis ifthe bleeding persistedbeyond IO minutes. All of the wounds were left unsuturedto heal by secondary intention. The patients were advised toavoid hot and cold foods for 24 hours and to use acetomi­nophen for pain. Patients were scheduled for evaluation 14to 21 days after the procedure. Of the 140 biopsies, no com­plications arose during the surgical procedure. On follow-upevaluation 20%ofthe patients noted mild discomfort, scarringwas seen in two sites, one site developed a hematoma, andthere were no infections. The study provides evidence thatthe oral punch biopsy is a simple and safe technique to eval­uate many mucocutaneous disorders, including oral ulcera­tions , pigmented lesions, and areas ofleukoplakia and eryth­roplakia. The author notes that this technique would be oflimited value in cases oftumors that would require a samplingof normal tissue in addition to the sample of the lesion.­K.S. ROTIMAN

Reprint not available.

Prospective Trial of Supranormal Values as Goals of Resus­citation in Severe Trauma. Hemming A, Bishop M, et al.Arch Surg 127:175,1992

The purpose of this study was to evaluate the effect of theearly postinjury attainment ofsupra normal values ofcardiacindex (CI), oxygen delivery (D02) and oxygen consumption(V02) on the survival rate ofpatients who have sufferedseveretrauma with significant blood loss. Thirty-three patients inthe protocol group, for whom the goal was to achieve pre­determined values ofCI, D02 , and V02 within 24 hours ofadm ission and maintained for at least 48 hours thereafter,were compared with the 34 patients in the control group, forwhom the goal was to achieve systolic blood pressure of atleast 120 mm Hg, a heart rate of less than 110 beats perminute, a hemoglobin level of IOg/dL, a urine output of 30to 50 mLth and a central venous pressure of8 to 12 mm Hg.Patients in both groups had similar trauma scores and injuryseverity scores. Ci, D02 and V02 were measured in bothgroups but were used as goals for resuscitation only in theprotocol group. In the control group CI, D02 and V02 werelower and mortality rate and the incidence of organ failureswere higher. The authors suggest that increased CI and D02

are compensations for increased metabolic requirements andthat they make up for previous oxygen debt.-A. ZICKMANN

Reprints requests to Dr Flemming: Department of Surgery, CharlesR. DrewUniversity of Medicine and Science, Martin Luther KingJr/DrewMedical Center, Wilmington Ave, LosAngeles, CA90059.

CURRENT LITERATURE

Gore-Tex Implants: Applications in Facial Paralysis Reha­bilitation and Soft Tissue Augmentation. PetroffMA, GoodeRL, Levet Y. Laryngoscope 102:1185, 1992

Gore-Tex expanded polytetrafluoroethylene (E-PTFE) hasbeen used for vascular grafts since 1971 with no reportedincidence of rejection. The authors have expanded its use tocosmetic and functional reconstruction of patients with facialparalysis secondary to ablative surgery as well as soft tissueaugmentation. Thirty-one patients were treated with one ofthree described techniques: 16 patients received passive sus­pensions with E-PTFE by supporting the labial commissureand nasolabial angle to the infraorbital rim and zygomaticarch; 7 patients with paralysis of the orbicularis oculi receiveddynamic suspension of the E-PTFE around the orbital rimand sutured to a temporalis transposition flap; and 8 patients

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received E-PTFE implants for correction of soft tissue defi­ciencies. Three cases were described, including one patientundergoing radiation therapy after placement of the Gore­Tex graft. A follow up period of 12 to 96 months revealedno cases of extrusion, rejection, or infection. The high successrate of the E-PTFE contrasts with other popular alloplasticmaterials, Plasti-Pore and Proplast, revealing a 58% and 25%exposure or extrusion rate respectively. The author recom­mends the use of E-PTFE over autogenous fascia becauseof the need for a second surgical site, additional operativetime, increased morbidity, greater postoperative relaxationand stretching, and need for greater overcorrection.­B.M. CHERNY

Reprint requests to Dr Petroff: 9155 SW Barnes Rd., Suite 931, Port­land, OR 97225.