Graft Dimensions Research Articles

6 RECONSTRUCTION OF COMPLEX OBLITERATIVE ANTERIOR URETHRAL STRICTURES VIA SINGLE STAGE OVERLAPPING DORSAL + VENTRAL DOUBLE ORAL MUCOSAL GRAFT TECHNIQUE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery1 Apr 20116 RECONSTRUCTION OF COMPLEX OBLITERATIVE ANTERIOR URETHRAL STRICTURES VIA SINGLE STAGE OVERLAPPING DORSAL + VENTRAL DOUBLE ORAL MUCOSAL GRAFT TECHNIQUE Steven Hudak, Allen Morey, and Sanjay Kulkarni Steven HudakSteven Hudak Dallas, TX More articles by this author , Allen MoreyAllen Morey Dallas, TX More articles by this author , and Sanjay KulkarniSanjay Kulkarni Pune, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.067AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Augmentation urethroplasty in the context of a severely obliterated urethral plate is often performed via multi-stage reconstruction or via plate transection with focal resection. We present our initial experience with an alternative, single stage approach based on overlapping dorsal + ventral double oral mucosa grafts in men with severe anterior urethral strictures. METHODS A retrospective review of 696 urethroplasties performed at two tertiary urethroplasty centers from October 2007 to September 2010 was performed. Single stage urethral reconstruction utilizing urethral plate incision and/or excision and overlapping dorsal + ventral buccal mucosa grafts was utilized in 36 men (5%) with strictures found to be both complex and obliterative. Mean stricture length was 4.5 cm (range 1–16 cm). Dorsal grafts, applied to the most severely strictured segment, measured a mean 42% of the ventral graft length. Stricture location was bulbar (61%), penile (19%), or both bulbar and penile (20%). Failed prior treatment of urethral stricture disease was common (19%-urethroplasty, 61%-internal urethrotomy and/or dilation). RESULTS At a mean follow up of 13.9 months, 32 of the 36 cases were successful (89%). Repeat urethroplasty was performed in all 4 recurrences, 3 of which were successful at a mean follow up of 16 months. Five patients (14%) had early complications including transient urethrocutaneous fistula (1), superficial wound infection (2), and urinary tract infection (2). All resolved with conservative/medical therapy. CONCLUSIONS Single stage reconstruction of select patients with long, obliterative urethral strictures is safe, feasible, and effective using the overlapping dorsal + ventral double oral mucosal graft principle. The use of independently anchored overlapping grafts offers an alternative to multi-stage reconstruction, while avoiding primarily tubularized grafts. Graft Dimensions n Mean Graft Length (cm) Range (cm) Ventral Graft 36 5.4 3.5–12 Dorsal Graft 36 2.1 1–7 -w/ plate incision 10 2.0 1–4 -w/ plate excision 24 2.1 1–7 -w/ plate incision+excision 2 3.2 1–5.3 © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e3 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Steven Hudak Dallas, TX More articles by this author Allen Morey Dallas, TX More articles by this author Sanjay Kulkarni Pune, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Magnetic Resonance Imaging Evaluation of Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Tendon Autografts

Background: Recently, variations of the remnant bundle preservation technique, including selective bundle reconstruction and preservation of the anterior cruciate ligament tibial remnant, have produced good outcomes. The authors chose to investigate whether remnant bundle preservation in anterior cruciate ligament reconstruction would affect the remodeling process without inducing complications. Hypothesis: An anterior cruciate ligament reconstruction graft can be augmented with a tensioned remnant of the native anterior cruciate ligament fibers without increasing the tendency of cyclops lesions. The magnetic resonance imaging signal intensity in an anterior cruciate ligament graft using the remnant bundle preservation technique would be lower than that using the standard technique. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-one patients who underwent an anterior cruciate ligament reconstruction using the remnant bundle preservation technique with quadrupled hamstring tendon autograft were evaluated by magnetic resonance imaging at a mean of 6.3 ± 0.7 months after surgery. The control group included 41 consecutive patients who underwent a single-bundle anterior cruciate ligament reconstruction by the standard technique. The 2 groups did not differ significantly in gender, age distribution, mean time until postoperative magnetic resonance imaging, or other patient characteristics. The magnetic resonance imaging evaluation focused on 5 measurements as follows: (1) dimensions of the anterior cruciate ligament graft, (2) signal intensity of the anterior cruciate ligament graft using the signal/noise quotient (SNQ) from a region of interest analysis, (3) magnetic resonance imaging signal intensity and continuity of the preserved remnant bundle, (4) orientation of the anterior cruciate ligament, and (5) tibial tunnel placement. Results: The remnant bundle preservation group had a significantly larger mean anterior cruciate ligament graft (293.4 mm2) than did the standard group (219.6 mm2) (P < .0001). However, the SNQ values of the anterior cruciate ligament graft in the remnant bundle preservation group were not significantly lower than those in the standard group in any of the 3 zones. In the remnant bundle preservation group, magnetic resonance imaging signals obtained from preserved remnant bundles in 35 patients (85%) showed 14 knees with a grade I signal (homogeneous low intensity) and 21 knees with a grade II signal (a portion of the preserved bundle was edematous). The continuity of remnant bundles in 37 patients (90%) as determined by magnetic resonance imaging was partial in 20 patients and complete in 17. The 2 groups did not differ significantly in the number of cyclops lesions detected by postoperative magnetic resonance imaging. Conclusion: After anterior cruciate ligament reconstruction, magnetic resonance imaging showed significantly larger anterior cruciate ligament grafts in the remnant bundle preservation group than in the standard procedure group, and these preserved remnant bundles showed progressive remodeling in the anterior cruciate ligament graft with no increase in the incidence of cyclops lesions. To determine a clinical advantage for the remnant preservation technique, magnetic resonance imaging results such as these must be correlated with clinical findings.

Sterilization Effects on the Mechanical Properties of Human Bone–Patellar Tendon–Bone Allografts

Novel allograft processing methods are available from tissue banks to decrease disease transmission. This study evaluated the effects of 3 of these techniques on the initial mechanical properties of bone-patellar tendon-bone (BPTB) allografts: (1) aseptic harvest with low-dose radiation processing, (2) BioCleanse Tissue Processing System, and (3) Clearant Process. Ten-mm BPTB allografts were potted in an MTS 858 machine (MTS Systems Corp, Eden Prairie, Minnesota), cycled, and loaded to failure at a strain rate of 100%/s. Data were critically analyzed for graft dimensions and age and sex of donor. The 10th cycle and last cycle stiffness after 1000 cycles were measured at the toe region and at all points. The 2% yield stress (MPa), Young's modulus (MPa), elongation failure (mm), strain fracture (%), ultimate stress (MPa), and toughness (kJ) were measured. Forty-two tendons were tested (15 control, 11 BioCleanse, and 16 Clearant). No statistically significant differences were detected between the groups at their 10th cycle and last cycle stiffness (P>.05). Yield stress ranged from 19 to 28.8 MPa without a statistically significant difference (P>.05). Young's modulus ranged from 178.3 to 213.8 MPa without a statistically significant difference (P>.05). Similarly, elongation to failure, strain to failure, ultimate stress, and toughness showed no statistically significant differences among the 3 groups (P>.05). These processing techniques did not affect the time zero mechanical properties of the BPTB allograft tendons under these testing conditions. Clinical use of allografts should proceed with caution for selected patients.

Toward an “Off-the-Shelf” Fenestrated Endograft for Management of Short-Necked Abdominal Aortic Aneurysms: An Analysis of Current Graft Morphological Diversity

To examine the feasibility of an "off-the-shelf" fenestrated endograft repository to broaden the applicability of fenestrated endovascular aneurysm repair (f-EVAR) to a greater number of emergent cases. Graft dimensions of 438 consecutive customized fenestrated endografts for juxtarenal aneurysms were obtained from the commercial manufacturer, classified into tolerance ranges, and encoded in a database for statistical analysis. Limits of variability for tolerance ranges were set to maintain target vessel patency within acceptable surgical limits at deployment. Key independent structural variables were identified and analyzed for trends. Detailed analysis was performed of 282 (64%) 3-fenestration endografts, representing 232 structurally unique grafts. Seven key individual structural variables were identified, constituting 21,952 possible combinations. Only 8/232 (3.5%) graft configurations were compatible with > or =3 patients. Nearly a third of the patients (86/282, 30.5%) were treated by a range of 36 customized endografts. Graft dimensions were not uniformly distributed; there were modal sizes that were likely to recur at a median 39 cases (95% CI 17-121). Deploying endografts incorporating double diameter-reducing tie technology increased the tolerance such that 28 grafts would treat 81% of this population. The current design of fenestrated stent-grafts means that an "off-the-shelf" option is not practicable. However, there is evidence of recurrent patterns of morphology. Statistical modeling is capable of predicting demand for graft configurations. Innovations in f-EVAR endograft technology may decrease the required variability in graft morphology, paving the way for ready-to-deploy fenestrated stent-grafts.

Assessment of Fibrin Glue in Pterygium Surgery

To evaluate the efficacy and safety of fibrin glue in pterygium surgery with conjunctival autografting. This was a prospective noncomparative case series. Patients were recruited from the general clinics for pterygium surgery. For pterygium surgery, autologous conjunctiva was harvested from the superior bulbar conjunctiva after pterygium excision. The graft was secured to bare sclera at the site of the pterygium by Tisseel fibrin adhesive. Patients were followed up with a standard form. Key parameters included visual acuity, graft integrity, and graft size. The rate of pterygium recurrence was monitored. A total of 24 patients were recruited, and 29 pterygia were excised with conjunctival grafting. All conjunctival grafts were secured adequately with no cases of dislodgement. Graft dimensions tended to decrease slightly in the early postoperative period, followed by stabilization. There were no cases of serious adverse events and no reduction in visual acuity. One pterygium recurrence occurred at 3 months. One spontaneous subgraft hemorrhage occurred with no effect on graft stability. Tisseel fibrin glue provided adequate adhesion of conjunctival grafts to the ocular surface. Healing was characterized by a comfortable eye, minimal inflammation, and good cosmetic result. There were no significant complications and the results appeared similar to those reported in the literature for sutured grafts.

Experimental Measurement and Mathematical Modeling of Pulsatile Forces on a Symmetric, Bifurcated Endoluminal Stent Graft Model

The objective of this study was to measure the pulsatile forces acting on a symmetric, bifurcated endoluminal stent graft to validate a computational fluid dynamics (CFD) and analytic model so that they can be used for various graft dimensions. We used a load cell to measure the force owing to the movement of an acrylic model of a bifurcated stent graft under pulsatile flow. This was then simulated with a CFD and analytic model. The main features of the experimental pulsatile force data and the CFD results were consistent. The results showed that the total force was proportional to the inlet pressure cycle. The force rose from 3.32 N at 130 mm Hg systolic to 17.5 N at 250 mm Hg systolic pressure. For the more variable regions of the flow, the experimentally measured forces lagged the computational and analytic results. The CFD and analytic models provide approximate descriptions for the forces acting on a bifurcated stent graft subjected to pulsatile flow. Such models should be of assistance to designers of endoluminal stent grafts.

Cabrol Composite Graft for Aortic Root Replacement: Echocardiographic Imaging

A 55-yr-old woman with history of Marfan syndrome presented with an enlarging aortic arch aneurysm. Fifteen years ago, she had undergone repair of an aortic root aneurysm. A preoperative transthoracic echocardiogram (TTE) revealed normal biventricular function, 3+ tricuspid regurgitation, a small nonobstructive mechanical aortic prosthesis, and an aortic root graft. The distal ascending aorta and aortic arch were dilated, measuring 5 cm in diameter. Left heart catheterization showed normal coronary arteries originating from the aortic root graft, with the left adjacent to the right. The patient was scheduled for aortic arch reconstruction and tricuspid valve repair.

Checkpoints for Judging Tunnel and Anterior Cruciate Ligament Graft Placement

This article examines how the relationship between sagittal and coronal anatomy, anterior cruciate ligament (ACL) graft dimensions, and tibial and femoral tunnel placement affects the posterior cruciate ligament (PCL) and roof impingement, and their undesirable clinical consequences of motion loss and instability. Based on these interrelationships, a variety of checkpoints are defined that can be used intraoperatively to determine whether placement of the tibial tunnel guidewire avoids PCL and roof impingement, and whether placement of the femoral tunnel guidewire avoids PCL impingement with either transtibial or transportal techniques. A simple, 3-dimensional tibial drill guide that consistently places the tibial tunnel correctly without PCL and roof impingement so the femoral tunnel, when drilled through the tibial tunnel, restores the normal tension pattern in the ACL graft also is described. Arthroscopic and radiographic checkpoints that assess the final placement of the ACL graft and tibial and femoral tunnels are discussed.

Anatomical study of the greater palatine artery and related structures of the palatal vault: considerations for palate as the subepithelial connective tissue graft donor site

Palate is considered as a tissue graft donor site for dental surgical procedures. Therefore, the aim of this study was to investigate the anatomy of palatal structures, such as greater palatine artery, greater palatine foramen, and incisive fossa, in order to consider their topography at planning the graft dimensions and reduce the potential risk of injury of greater palatine artery. Direct inspection of 41 Thai cadavers was performed. The results showed the statistically significant differences as for the length of female and male palates (p = 0.017); however, vertical measurements were equally distributed in examined population. Main location of greater palatine foramen was palatal to the second molar (35.7%), as well as, interproximal to the second and third molars (35.7%) in women, and palatal to the second molar in men (65%). GPA was branching most frequently at the level of first premolar (38%) and at first and second molars together (43%) in women. In men, the branching on the alveolar process side was commonly observed at the level of first and second premolars together (56%), and at the level of second and third molars together (32%). In the area between maxillary first premolar and second molar, it appeared possible to harvest a connective tissue graft measuring at least 5 mm in height. The results of this research will provide the useful data for other comparative studies and for assisting periodontologists in planning the dimensions and harvesting the subepithelial connective tissue grafts from palate.

Atomic Force Microscopy Imaging and Dilute Solution Properties of Cyclic and Linear Polystyrene Combs

Large macrocyclic poly(chloroethyl vinyl ether)s (PCEVE)s of controlled ring size and narrow distribution were synthesized by a ring-closure process involving the intramolecular formation of acetal linkages between the two external blocks of linear ABC triblock precursors prepared by living cationic polymerization. The corresponding shape-persistent ring P(CEVE-g-PS) combs having macrocyclic poly(chloroethyl vinyl ether) backbones and polystyrene side chains were then synthesized by a "grafting onto" technique and characterized by size exclusion chromatography (SEC) analysis and atomic force microscopy (AFM) imaging of isolated molecules. Quantitative hydrolysis of the acetal linkages of the macrocyclic PCEVE backbone in acidic conditions yields the linear poly(chloroethyl vinyl ether)-g-polystyrene) homologue and allows a direct comparison of the characteristics and dimensions of cyclic and linear comb architecture. The influence of the chain architecture and PS graft dimensions on the dilute tetrahydrofuran (THF) solution properties, radius of gyration, and hydrodynamic radius of the comb copolymers is also studied and compared to data reported for linear and cyclic polystyrene chains.

ACL graft constructs: In-vitro fatigue testing highlights the occurrence of irrecoverable lengthening and the need for adequate (pre)conditioning to avert the recurrence of knee instability

The performance of ACL grafts in both the short and long term is only as good as the condition of the graft at the time of surgery. If the graft lengthens under load at the two fixation ends incorporation will take longer to occur. Previous studies have shown that the various grafts currently used are strong enough. However, data on strength came primarily from quasistatic single pull to failure tests with, in some cases, modest cycling to precondition the grafts. The present study examined the in-vitro biomechanical behaviour of model ACL grafts, which have been fatigue cycled to failure over a wide range of loads in physiological ambient conditions. Load/deformation curves and the stretch of the grafts was continuously recorded until final rupture. The grafts demonstrated typical creep-rupture like behaviour with elongation (non-recoverable stretch) and loss of stiffness leading to gradual failure. Some of the graft designs were consistently shown to elongate up to 20 mm in length within the first 2000 cycles at moderate physiological loads and a further 10 mm of elongation occurred between the initial preconditioned state and just prior to complete rupture. Not enough attention has been paid previously to the likely long term elongation patterns of ACL grafts post-surgery and even after the usual empirical preconditioning has been performed by the surgeon. Increased graft dimensions may result in recurrent knee instability and may also lead to failure of the graft to incorporate. Preconditioning in-vitro may still be a way to remove some slack and prepare the graft for its operational environment by stiffening in particular the tissue/fixation interface for those grafts that use soft polymer fixation ends.

Early biomechanical changes in lower extremity vein grafts—distinct temporal phases of remodeling and wall stiffness

The geometric and biomechanical changes that contribute to vein graft remodeling are not well established. We sought to measure patterns of adaptation in lower extremity vein grafts and assess their correlation with clinical outcomes. We conducted a prospective, longitudinal study of patients undergoing infrainguinal reconstruction with autogenous conduit. In addition to standard duplex surveillance, lumen diameter (of a defined index segment of the conduit) and pulse wave velocity (PWV) were assessed by ultrasound imaging at surgery and at 1, 3, and 6 months postoperatively. Graft dimensions and wall stiffness were correlated with clinical outcomes. There were 92 patients and 96 limbs in this study. On average, vein graft lumen diameter increased during the first month of implantation from 0.37 +/- .01 cm to 0.45 +/- 0.02 cm (mean +/- SEM; P = .002), representing a relative change of +21.6% (median +/- 14%; range, -31 to +67%) during this period. Of the entire cohort, 72% of grafts demonstrated appreciable dilation of the index segment during the first month. Index segment lumen diameter did not change appreciably beyond 1 month, with the notable exception of arm vein conduits, which showed continued tendency to dilate. PWV increased during the first 6 months (17.2 +/- 1.2 m/s to 23.2 +/- 2.4 m/s; P = .008), reflecting a nearly 40% increase in conduit stiffness (2.0 +/- .6 Mdynes/cm to 3.3 +/- .8 Mdynes/cm, P = .01). The greatest relative increase (25%) in PWV occurred from months 1 to 3. Loss of primary patency occurred in 24 cases (19 revisions, 5 occlusions), with a mean reintervention time of 7.6 months. Grafts that demonstrated early positive remodeling (lumen dilatation) had a trend of increased primary patency (P = .08, log rank). Among the grafts that failed, a trend was noted toward greater wall stiffness at 1 month, 2.7 vs 1.5 Mdynes (P = .08). Vein graft remodeling appears to involve at least two distinct temporal phases. Outward remodeling of the lumen occurs early, and wall stiffness changes occur in a more delayed fashion. Early outward remodeling may be important for successful vein graft adaptation.

Anterior and Posterior Cartilage Graft Dimensions in Successful Laryngotracheal Reconstruction

To describe the dimensions of cartilage grafts used for successful laryngotracheal reconstruction, with the goal of establishing appropriate sizes for "off-the-shelf" tissue-engineered cartilage grafts. A retrospective review of prospectively maintained operative illustrations of a single surgeon's experience. Two tertiary children's hospitals. A consecutive sample of 54 patients (tracheotomized or intubated) with a diagnosis of subglottic stenosis. Each patient underwent anterior (n = 30), posterior (n = 3), or anterior and posterior (n = 22) laryngotracheal reconstruction. Rib cartilage was used in 51 patients and thyroid cartilage was used in 3 patients. Successful or failed extubation. Of the 54 patients, 48 (89%) were successfully decannulated. The mean +/- SEM length of the anterior graft was 20.7 +/- 10.3 mm, and the mean width of the anterior graft was 7.7 +/- 2.5 mm. The mean length of the posterior graft was 13.9 +/- 2.9 mm, and the mean width of the posterior graft was 4.2 +/- 0.9 mm. With the prospect of tissue-engineered cartilage implants becoming available for laryngotracheal reconstruction, the most appropriate templates for designing these implants should be based on the geometric dimensions of grafts carved from native tissues in cases that have been successfully decannulated. Based on our analysis, the use of 2-mm increments for the posterior grafts suggests a set of molds that are 2, 4, and 6 mm wide and 22 mm long. Using 2 x 2-mm increments for the anterior grafts indicates that 36 mold sizes will be sufficient for 90% of predicted cases.

Connective Tissue Graft for Gingival Recession Treatment: Assessment of the Maximum Graft Dimensions at the Palatal Vault as a Donor Site

The palatal masticatory mucosa is widely used as a connective tissue donor site in gingival recession treatment. However, concern has been raised regarding the potential risk of damaging the greater palatine artery (GPA) due to anatomical variations in the palatal vault. The anatomy of the palatal vault in terms of size and shape may affect the maximum dimensions of the graft that can be safely taken from the palatal vault. In a cohort of patients free of periodontal disease, the purpose of this study was to assess the maximum dimensions of the graft, particularly the height and length, that could be safely taken from the palatal vault. Plaster impressions were made from 198 patients free of periodontal disease. Because the connective tissue graft is usually taken from an area extending from the mid-palatal aspect of the canine to the mid-palatal aspect of the second molar, this interval was measured and represented the maximum length dimension. The emergence of the GPA was assumed to be localized at the junction of the vertical and horizontal palatal walls of vault, and its course was marked on the plaster casts. The maximum height of the graft corresponded to the distances measured from the gingival margin to the marked course of the GPA of each tooth at its interproximal and mid-palatal aspects. The length of the maximum available tissue graft was 31.7 +/- 4.0 mm. The distance extending from the gingival margin to the greater palatine artery ranged from 12.07 +/- 2.9 mm at the canine level to 14.7 +/- 2.9 mm at the mid-palatal aspect of the second molar level. Therefore, in the premolar area, it was possible to harvest a connective tissue graft measuring 5 mm in height in all cases and 8 mm in height in 93% of cases. Our findings suggest that the maximum available tissue graft as measured in the palatal vault was large enough to allow a safe withdrawal from this donor site in a high percentage of our patient population free of periodontal disease.

Upper Eyelid Full-Thickness Skin Graft in Facial Reconstruction

The potentially available upper eyelid skin, as an alternative donor site, deserves more attention in clinical use. The objective of this study was to prospectively evaluate the clinical behavioral characteristics of upper eyelid full-thickness skin grafts in facial reconstruction. Sixteen patients who concluded the 12-month follow-up period were included in the study. Graft dimensions were measured in place before the graft harvest. Defect sizes were measured following lesion excision and postgrafting. Graft sizes were measured postoperatively at 1, 3, 6, and 12 months. The largest and smallest grafts were 46 x 22 mm and 40 x 15 mm (average 43.1 x 19.3 mm) in size, respectively. The largest and smallest defect dimensions were 33 x 23 mm and 17 x 9 mm (average 22.6 x 15.6 mm), respectively. The average postgrafting size was 21.1 x 14.6 mm. Grafts and donor sites healed very well. Generally, an acceptable to good texture and color match was observed beyond 6 months. Wound bed contraction was not observed beyond the first month (p<.05). Special characteristics of hairless skin, good color and texture matching, and inconspicuous and hidden donor scar make the upper eyelid a good alternative donor site for small- to medium-sized facial skin defects. The main disadvantages that limit its clinical use are the age of the patient, a lack of adnexal structures, comparatively limited sun exposure, and possible insufficient thickness, especially when deep defects are of concern.

Formulas for determining the dimensions of venous graft required for penile curvature correction

To evaluate the quantity of penile veins for use as patch material for the treatment of penile curvature, we devised two formulas: from the calculus of applied civil engineering and a diagram from the goniometry of the cadavers' penises, respectively, and the techniques for their application. From March 1995 to July 2003, a total of 65 consecutive patients with penile curvature - 41 men with Peyronie's deformity and 24 with congenital penile deviations - underwent grafting with autologous deep dorsal veins with or without cavernosal veins as patch material. The patched veins required were calculated from the formula (pi)r(2)theta/45 degrees , which is derived from calculus. The tunical incision sector was meticulously performed in accordance with our diagram which is interpolated from seven male cadavers via goniometry and consequently the length of patched veins required was 2 (pi)r(theta)(')/theta. The corporotomy defect was fashioned with the detubularized veins after they were adequately prepared and spliced. In these patients, the average available area of the veins was 4.9 x 2.2 cm(2) (range, 4.5 x 1.8 to 5.6 x 2.4), which seemed adequate in all cases for patching, although 11 of them required two patches. Overall, 21 patients required a modified Nesbit's procedure on the contralateral/ipsilateral tunica to attain a satisfactory penile shape. Because of its anatomical vicinity and its availability as material, the deep dorsal vein associated with the cavernosal vein may play an indispensable role in grafting even with local anaesthesia on an outpatient basis.

Hard Palate and Free Tarsal Grafts as Posterior Lamella Substitutes in Upper Lid Surgery

To present the surgical outcomes and postoperative complications in a series of patients who underwent upper lid surgery using autogenous hard palate grafts (HPGs) or free tarsal grafts (FTGs) as posterior lamella replacement material. Retrospective, comparative, interventional case series. Thirty-one consecutive patients who were operated in 2 oculoplastics centers between July 2000 and January 2005. All patients' clinical records were reviewed. Postoperative upper eyelid contour and viability, ocular discomfort, keratopathy, and corneal edema, as well as assessment for donor site complications and final graft dimensions. There were 31 patients who underwent upper lid surgery (15 HPGs, 16 FTGs). The complications in the HPG group included corneal edema or transient keratopathy (13.3%), partial graft dehiscence (13.3%), upper lid retraction (13.3%), and necrosis of the overlying skin flap (6.7%). There were no significant postoperative complications in the FTG group during a mean follow-up period of 13.5+/-5 months. Donor site complications included 2 cases of mild upper lid retraction and central peaking. There were an average of 17% decrease in FTG vertical height and a 24% decrease in HPG vertical height during the follow-up period. Hard palate grafts may be associated with a higher rate of complications in upper lid surgery relative to FTGs, although most complications are temporary. Graft contraction could be reduced by oversizing.

An Investigation Into the Cause of Distal Endoleaks: Role of Displacement Force on the Distal End of a Stent-Graft

To investigate if the forces developed by pulsatile flow on a stent-graft and dimensional changes of the graft material might contribute to distal endoleak and stent-graft kinking. An in vitro experimental model was used to measure the peak displacement force developed by pulsatile flow pressure on the distal end of a stent-graft. Polytetrafluoroethylene (PTFE) graft material (110 mm long, 22 mm in diameter) was evaluated in a flow circuit, with water as the circulating liquid. In addition, the effect of internal pressure on PTFE graft dimensions was measured under nonpulsatile conditions in 3 configurations (1 bifurcated and 2 straight). Pressure in the PTFE graft did not cause a change in graft diameter but did increase the length of the graft. The mean load required to prevent retrograde displacement was 208.5+/-2.5 g. Peak retrograde displacement force developed on the distal end of the stent-graft by the pressure of pulsatile flow was strongly associated with the systolic phase of the cardiac cycle. The distal end of the stent-graft is subject to a retrograde displacement force by the pressure of pulsatile arterial flow. In addition, pressure inside the PTFE graft causes its length to increase. Both of these factors may be important in the development of late complications of stent-grafting.

Upper Eyelid Full-Thickness Skin Graft in Facial Reconstruction

BACKGROUND The potentially available upper eyelid skin, as an alternative donor site, deserves more attention in clinical use. OBJECTIVE The objective of this study was to prospectively evaluate the clinical behavioral characteristics of upper eyelid full-thickness skin grafts in facial reconstruction. METHODS Sixteen patients who concluded the 12-month follow-up period were included in the study. Graft dimensions were measured in place before the graft harvest. Defect sizes were measured following lesion excision and postgrafting. Graft sizes were measured postoperatively at 1, 3, 6, and 12 months. RESULTS The largest and smallest grafts were 46 × 22 mm and 40 × 15 mm (average 43.1 × 19.3 mm) in size, respectively. The largest and smallest defect dimensions were 33 × 23 mm and 17 × 9 mm (average 22.6 × 15.6 mm), respectively. The average postgrafting size was 21.1 × 14.6 mm. Grafts and donor sites healed very well. Generally, an acceptable to good texture and color match was observed beyond 6 months. Wound bed contraction was not observed beyond the first month (p < .05). CONCLUSION Special characteristics of hairless skin, good color and texture matching, and inconspicuous and hidden donor scar make the upper eyelid a good alternative donor site for small- to medium-sized facial skin defects. The main disadvantages that limit its clinical use are the age of the patient, a lack of adnexal structures, comparatively limited sun exposure, and possible insufficient thickness, especially when deep defects are of concern.

Amniotic membrane grafting in the surgical management of primary pterygium

To evaluate the efficacy of amniotic membrane transplantation in primary pterygium surgery. Patients presenting to the outpatient clinic of the Royal Victorian Eye and Ear Hospital with primary pterygium requiring surgical management were included in this study. The pterygia were excised to bare sclera and the conjunctival defects were closed with amniotic membrane grafts. The primary outcome was pterygium recurrence. Twenty-eight pterygia of 26 patients were included. Twenty-three patients (88%, 25 eyes) completed 12 months follow up. By 12 months postoperatively 16 of these eyes (64%) had developed corneal recurrence and a further two had developed a limbal recurrence (9%). Five required repeat surgery during the 12 month follow-up period. No association was found between pterygium recurrence and pterygium size (P = 0.33), amniotic membrane graft dimension (P = 0.12), patient age (P = 0.53) or patient sex (P = 0.63). Amniotic membrane grafting for primary pterygium was associated with an unacceptably high recurrence rate in this population.