Transient Edema Research Articles

433. Micro-Utrophin as a Therapeutic Protein in rAAV Mediated Gene Therapy for Duchenne Muscular Dystrophy

Late infantile neuronal ceroid lipofuscinosis (LINCL), a pediatric neurodegenerative lysosomal storage disorder, results from mutations in the CLN2 gene that lead to a deficiency in tripeptidyl peptidase (TPP-I) and consequent progressive destruction of neurons. Studies in our laboratory have demonstrated long term TPP-I expression in the CNS following CNS gene transfer of AAV2CUhCLN2 (an AAV2-based vector expressing the human CLN2 cDNA) in the rat and non-human primate. To prepare for a possible clinical trial, the present study tests the hypothesis that direct CNS injection of AAV2CUhCLN2 to the CNS of rats and non-human primates at doses scalable to humans has an acceptable long term safety profile. Fischer 344 rats were injected bilaterally in the striatum with 2 × 1010 particle units (pu) of AAV2CUhCLN2, using PBS as a control. At 13 wk, vector and PBS-injected rats were sacrificed (n=6 /group), and blood was collected and the brain and distant organs were assessed by histopathology. The data showed no significant differences between control and vector groups for complete blood count, blood chemistry, and neutralizing anti-AAV2 antibody levels. CNS administration of AAV2CUhCLN2 did not result in any pathological changes in the brain that were attributable to the vector, although microscopic changes were observed along the tract consistent with needle trauma. Changes observed in distant organs were of the type commonly observed in rats and occurred at similar frequencies in AAV2CUhCLN2 and PBS-injected animals. A total dose of 3.6 × 1010 or 3.6 × 1011 pu of AAV2CUhCLN2 was administered to the CNS of 18 African Green monkeys at 12 locations targeting the caudate nucleus, hippocampus and overlying cortices. Monkeys (n=3) at each dose were sacrificed at 1, 13, and 26 wk following injection. The controls consisted of sham-injected, PBS-injected, and AAV2CUNull-injected (3.6 × 1011 pu) monkeys. Using ANOVA analysis for repeated measurements, there were no significant differences among vector-injected and control groups in any parameter of the general assessment or comprehensive mammalian profile (blood chemistry panel, complete blood count) pre-administration, on the day of administration, and day 3, 7, 14, 28, 56, 91, 180 post-administration. There were no abnormal behaviors observed in any group in videotaped neurological assessment where behaviors was quantified prior to administration compared to day 7, 14, 28, 56, 91, 180 post-administration. Histopathological examination of the CNS demonstrated that injection of AAV2CUhCLN2 produced slight to mild and transient white matter edema (spongiosis) with reactive glial cells in the corona radiata of the cerebrum along the injection tract and in the surrounding white matter. This abmormality likely attributable to the vehicle, was not observed at 13 and 26 wk. Together with the long term gene expression following gene transfer, these findings support the initiation of clinical trials to assess the safety of AAV2CUhCLN2 administration to individuals with LINCL.

Improvement of Neck and Cheek Laxity With a Nonablative Radiofrequency Device

OBJECTIVE Laxity of cheek and neck skin is a common cosmetic complaint of patients as they age. Improvement of skin laxity can be difficult to achieve without invasive surgical lifting procedures. The object of this study was to evaluate the safety and efficacy of a novel nonablative radiofrequency device in the treatment of cheek and neck laxity. METHODS Fifty patients (skin phototypes I to IV) with mild-to-moderate cheek laxity (n=30) or neck laxity (n=20) received one treatment with a radiofrequency device (ThermaCool; Thermage Corp., Hayward, CA). Topical anesthetic cream was applied under occlusion for 60 minutes before treatment of the skin extending laterally and inferiorly from the nasolabial folds to the preauricular regions and mandibular ridge for treatment of the cheeks and from the mandible to mid neck for treatment of the neck. Clinical improvement of treatment areas was independently determined by three masked assessors' evaluations of comparative photographs at baseline, immediately after treatment, at 1 week, and at 1, 3, and 6 months after treatment using a quartile grading scale (0=less than 25%, 1=25% to 50%, 2=51% to 75%, 3=more than 75% improvement). Patient satisfaction surveys were also obtained at each follow-up visit. RESULTS Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema, edema, and rare dysesthesia. No scarring or pigmentary alteration was seen. CONCLUSIONS Noninvasive radiofrequency bulk dermal heating of skin can achieve safe and effective tissue tightening of the cheeks and neck. Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined.

Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience.

Laxity of cheek and neck skin is a common cosmetic complaint of patients as they age. Improvement of skin laxity can be difficult to achieve without invasive surgical lifting procedures. The object of this study was to evaluate the safety and efficacy of a novel nonablative radiofrequency device in the treatment of cheek and neck laxity. Fifty patients (skin phototypes I to IV) with mild-to-moderate cheek laxity (n=30) or neck laxity (n=20) received one treatment with a radiofrequency device (ThermaCool; Thermage Corp., Hayward, CA). Topical anesthetic cream was applied under occlusion for 60 minutes before treatment of the skin extending laterally and inferiorly from the nasolabial folds to the preauricular regions and mandibular ridge for treatment of the cheeks and from the mandible to mid neck for treatment of the neck. Clinical improvement of treatment areas was independently determined by three masked assessors' evaluations of comparative photographs at baseline, immediately after treatment, at 1 week, and at 1, 3, and 6 months after treatment using a quartile grading scale (0=less than 25%, 1=25% to 50%, 2=51% to 75%, 3=more than 75% improvement). Patient satisfaction surveys were also obtained at each follow-up visit. Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema, edema, and rare dysesthesia. No scarring or pigmentary alteration was seen. Noninvasive radiofrequency bulk dermal heating of skin can achieve safe and effective tissue tightening of the cheeks and neck. Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined.

Osmotic demyelination syndrome in end-stage renal disease after recent hemodialysis: MRI of the brain.

Osmotic demyelination syndrome has been reported in patients with end-stage renal disease, but the specific MRI findings in this patient group have not been documented in detail. Our aims were to present the brain MRI findings during an episode after hemodialysis and at follow-up, and to identify possible factors that may contribute to lesion development. Seventeen patients with osmotic demyelination syndrome who had undergone hemodialysis at least once and had brain MRI examinations were retrospectively reviewed. Neurologic and MRI examinations were performed during a clinical episode. Serum levels of sodium, creatinine, blood urea nitrogen, and glucose were assessed, and serum osmolality and the ratio of blood urea nitrogen to creatinine (BUN:Cr) were calculated. Follow-up MRI was performed in nine cases. Laboratory and imaging findings were evaluated. An altered level of consciousness and convulsions were the most common neurologic symptoms. The pons was involved in 11 patients (65%) and extrapontine sites in 12 (71%). Four patients had dysequilibrium syndrome. Follow-up MRI showed complete resolution in six patients and lesion reduction in three within a short time. The most common biochemical changes at the time of MRI were hyponatremia and low BUN:Cr in the blood. Only one patient showed rapid correction of hyponatremia and a rapid change in osmolality during the acute stage. In patients who develop osmotic demyelination syndrome after hemodialysis, the lesions may involve the pons or the pons and extrapontine sites. Most lesions that were followed up resolved rapidly and almost completely, favoring transient edema rather than demyelination. Blood chemistries suggested underlying changes in osmolality, particularly as a result of urea shift from the extracellular fluid.

Treatment of Inflammatory Facial Acne Vulgaris with the 1450-nm Diode Laser

BACKGROUND The 1450-nm diode laser has been found to damage sebaceous glands selectively and to be effective for the treatment of inflammatory acne on the back. OBJECTIVE To evaluate the efficacy and safety of the 1450-nm diode laser in the treatment of inflammatory facial acne vulgaris. METHODS Nineteen patients with inflammatory facial acne were treated with the 1450-nm diode laser at 4- to 6-week intervals. There was no control group. Clinical photographs and lesion counts were obtained at baseline and after each treatment. Subjective evaluation of response to treatment and pain was assessed using a questionnaire. RESULTS All patients had a reduction in acne lesions. Lesion counts decreased 37% after one treatment (p<0.01), 58% after two treatments (p<0.01), and 83% after three treatments (p<0.01). Treatment-related pain was well tolerated, and adverse effects were limited to transient erythema and edema at treatment sites. CONCLUSION This is the first published report documenting the safety and efficacy of laser treatment for inflammatory facial acne. In our study, clinical improvement was seen in all patients and was generally dramatic, even in those refractory to previous treatment with oral isotretinoin. Topical anesthetics should be used to minimize pain associated with treatment.

Treatment of Inflammatory Facial Acne Vulgaris with the 1450-nm Diode Laser: A Pilot Study

The 1450-nm diode laser has been found to damage sebaceous glands selectively and to be effective for the treatment of inflammatory acne on the back. To evaluate the efficacy and safety of the 1450-nm diode laser in the treatment of inflammatory facial acne vulgaris. Nineteen patients with inflammatory facial acne were treated with the 1450-nm diode laser at 4- to 6-week intervals. There was no control group. Clinical photographs and lesion counts were obtained at baseline and after each treatment. Subjective evaluation of response to treatment and pain was assessed using a questionnaire. All patients had a reduction in acne lesions. Lesion counts decreased 37% after one treatment (p<0.01), 58% after two treatments (p<0.01), and 83% after three treatments (p<0.01). Treatment-related pain was well tolerated, and adverse effects were limited to transient erythema and edema at treatment sites. This is the first published report documenting the safety and efficacy of laser treatment for inflammatory facial acne. In our study, clinical improvement was seen in all patients and was generally dramatic, even in those refractory to previous treatment with oral isotretinoin. Topical anesthetics should be used to minimize pain associated with treatment.

Trocarin, a blood coagulation factor Xa homologue from snake venom, causes inflammation and mitogenesis

Trocarin, a Group D prothrombin activator from Tropidechis carinatus snake venom, has high sequence similarity to blood coagulation factor Xa (FXa). Both trocarin and FXa activate prothrombin to mature thrombin and have similar requirements for cofactors, such as factor Va, Ca 2+ ions and phospholipids. In addition to its hemostatic functions, human FXa causes inflammation and induces mitogenesis in several cell types due to its interaction with effector protease receptor-1 (EPR-1). The inter-EGF domain region (L 83FTKRL 88) of FXa implicated in EPR-1-binding is distinctly different in trocarin (K 83VLYQS 88). Here we show that, interestingly, trocarin also causes edema in the mouse footpad; the inflammation, accompanied by a large purplish clot, is more persistent than the transient edema caused by FXa. Histological examination indicates significant differences between edema induced by FXa and trocarin. Moreover, trocarin-induced edema is not inhibited by a synthetic peptide based on the FXa-binding region of EPR-1, indicating that the inflammation is probably mediated by a mechanism independent of EPR-1-binding. Trocarin, like FXa, also has a mitogenic effect on bronchial smooth muscle cells mediated by an EPR-1-independent mechanism. Hence trocarin, being closely related to FXa, has similar non-hemostatic functions in mediating inflammation and mitogenesis, yet appears to act by distinctly different mechanisms.

Transient Cardiac Dysfunction and Pulmonary Edema in Exertional Heat Stroke

Exertional heat stroke is a medical emergency that uncommonly results in severe cardiac dysfunction. The military physician diagnosed a 19-year-old military recruit from an elite unit to have exertional heat stroke. Immediate treatment in the field with rapid ice water cooling and vigorous fluid administration resulted in pulmonary edema. Transthoracic echocardiography on admission to the emergency department revealed moderate reduction in left and right ventricular function. After treatment, within a few days, rapid myocardial recovery was noted and persisted after 6 months of follow-up. Possible mechanisms of cardiac dysfunction in exertional heat stroke and treatment strategies are discussed. It is suggested that intravenous fluid administration to patients with suspected exertional heat stroke should preferably be done with appropriate hemodynamic monitoring and after cardiac dysfunction has been ruled out.

Maximal rowing has an acute effect on the blood-gas barrier in elite athletes.

The purpose of the study was to evaluate the effects of maximal exercise on the integrity of the alveolar epithelial membrane using the clearance rate of aerosolized 99mTc-labeled diethylenetriaminepentaacetic acid as an index for the permeability of the lung blood-gas barrier. Ten elite rowers (24.3 +/- 4.6 yr of age) completed two 20-min pulmonary clearance measurements immediately after and 2 h after 6 min of all-out rowing (initial and late, respectively). All subjects participated in resting control measurements on a separate day. For each 20-min measurement, lung clearance was calculated for 0-7 and 10-20 min. Furthermore, scintigrams were processed from the initial and late measurements of diethylenetriaminepentaacetic acid clearance. Compared with control levels, the pulmonary clearance measurement after rowing was increased from 1.2 +/- 0.5 to 2.4 +/- 1.0%/min (SD) at 0-7 min (P < 0.01) and from 0.8 +/- 0.3 to 1.5 +/- 0.4%/min at 10-20 min (P < 0.0005), returning to resting levels within 2 h. In 6 of 10 subjects, ventilation distribution on the lung scintigrams was inhomogeneous at the initial measurement. The study demonstrates an acute increased pulmonary clearance after maximal rowing. The ventilation defects identified on the lung scintigrams may represent transient interstitial edema secondary to increased blood-gas barrier permeability induced by mechanical stress.

Long Term Follow Up of Hair Removal By Long-pulse Alexandrite Laser in Oriental Patients

Within the past decade, many laser depilation systems have been developed. However, the parameters in the hair removal function of these devices emphasize the usage for white people with fair skin (Fitzpatrick types I-III). The oriental people usually have darker skin (Fitzpatrick type IV mainly, or even type V) and it makes hair removal more difficult because of a potential for post-treatment hypopigmentation, hyperpigmentation, blistering, crusting and scarring secondary to high absorption by competing epidermal melanin. From November 1997 to October 2002, the authors have colleCted 208 oriental patients who underwent treatment with the long-pulse alexandrite laser (wavelength 755 nm) depilation system, trying to determine the safety and efficacy of LPIR laser in hair removal for patients with Fitzpatrick skin type IV. The percentage of hair removal (clearance rate) has been maintained around 90% after receiving averaged 5 sessions of treatment with the fluence of 21-25 J/cm(superscript 2), and only transient folliculitis-like edema occurred immediately after each treatment. The clearance rates were even better than 95% after increasing the fluence to 26-28 J/cm(superscript 2) with 5 year long term follow up, and the complication rate didn't increase concomitantly. Fortunately, the complications including hyperpigmentation, blistering, erythematous change were all transient and subsided within 3 months.

Intramuscular vascular endothelial growth factor gene therapy in patients with chronic critical leg ischemia

Purpose We sought to investigate the safety and efficacy of intramuscular gene therapy with vascular endothelial growth factor (VEGF) in patients with chronic critical leg ischemia. Methods Gene transfer was performed in 24 limbs of 21 patients with rest pain, some of whom also had nonhealing ischemic ulcers (n = 16) due to occlusive peripheral arterial disease. Between 400 μg and 2000 μg of phVEGF 165 (400 μg, n = 2; 800 μg, n = 4; 1200 μg, n = 4; 1600 μg, n = 6; and 2000 μg, n = 8) was injected directly into the muscles of the ischemic limb; the same dose was injected 4 weeks later. The ratio of blood pressures at the ankle and brachial artery was measured before and after treatment. Results Mean (± SD) plasma levels of VEGF increased significantly from 26 ± 31 pg/mL to 63 ± 56 pg/mL ( P <0.005), and the ankle-brachial index improved significantly from 0.58 ± 0.24 to 0.72 ± 0.28 ( P <0.001). Magnetic resonance angiography showed qualitative evidence of improved distal flow in 19 limbs (79%). Ischemic ulcers healed or improved markedly in 12 limbs (75%). Rest pain was relieved or improved markedly in 20 limbs (83%). Amputation was performed in two limbs because of wound infection. Complications were limited to transient leg edema in six limbs. Conclusion Intramuscular gene therapy with VEGF 165 for patients with chronic critical leg ischemia is safe, feasible, and effective.

Commentary

HIGHLIGHTED TOPICSCommentaryGary C. SieckGary C. Sieck Editor Journal of Applied PhysiologyPublished Online:01 Oct 2002https://doi.org/10.1152/japplphysiol.00674.2002MoreSectionsPDF (20 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInEmailWeChat The Highlighted Topics article selected for this issue of the Journal of Applied Physiology, “Lung hypoxia: antioxidant and antiapoptotic effects of liposomal α-tocopherol,” by Minko and colleagues (p. 1550–1560), studies the effects of liposomal α-tocopherol on lung edema clearance. Pulmonary edema is a life-threatening condition caused by cardiovascular pathologies (e.g., myocardial infarct, mitral or aortic valve disease, cardiomyopathy), inhalation of noxious substances, and exposure to high altitude. Despite extensive research during the past 20 yr, effective prevention and therapy for pulmonary edema remains unclear. While investigating the mechanisms of lung injury under different pathological conditions associated with oxygen deficiency, Minko and colleagues found that “classical” lung edema associated with fluid infiltration into alveoli is preceded by transient interstitial edema. The mechanisms involved in this initial stage of pulmonary edema were found to be common to many etiologically different tissue hypoxias (e.g., those related to high altitude, hemorrhage, anemia, severe stress, etc.). Further analysis showed that lipid peroxidation and apoptosis are two main mechanisms responsible for damage to endothelial and interstitial barriers, increasing the permeability of these barriers and, consequently, the incidence of interstitial edema. These authors also found that antiapoptotic and antioxidant defenses are key mechanisms of cellular resistance to lung injury caused by hypoxia. Accordingly, they hypothesized that an increase in cellular defenses may reduce membrane damage and prevent limited interstitial edema from progressing into full alveolar lung edema. Liposomes were utilized to increase the cellular levels of the antioxidant α-tocopherol. Using liposomal α-tocopherol, these investigators pursued three main objectives: 1) to provide for the water solubility of the drug, 2) to increase the antioxidant cellular defense, and 3) to compensate (at least partially) for the alveolar phospholipid deficit caused by hypoxia. The results showed that liposomal α-tocopherol limited lipid peroxidation and apoptosis in lung tissues, reduced lung damage and disturbances in lung biomechanics, increased the efficacy of lung gas exchange, and significantly decreased the mortality of animals from lung edema, thereby supporting their hypothesis. These results indicate that liposomal α-tocopherol may be a useful therapy for the prevention and correction of lung edema.FOOTNOTES10.1152/japplphysiol.00674.2002This article has no references to display. Download PDF Previous Back to Top Next FiguresReferencesRelatedInformationCited ByTumor-specific targeting of an anticancer drug delivery system by LHRH peptide25 August 2005 | Proceedings of the National Academy of Sciences, Vol. 102, No. 36 More from this issue > Volume 93Issue 4October 2002Pages 1549-1549 Copyright & PermissionsCopyright © 2002 the American Physiological Societyhttps://doi.org/10.1152/japplphysiol.00674.2002History Published online 1 October 2002 Published in print 1 October 2002 Metrics

Preservation of muscle fascia to decrease lymphedema after complete axillary and ilioinguinofemoral lymphadenectomy for melanoma.

In patients with melanoma, there is considerable concern about the clearance of clinically negative nodes, partly because of the unacceptable morbidity reported after regional lymphadenectomy. The advent of sentinel lymph node biopsies has allowed us to select those patients with positive sentinel lymph nodes for completion node dissections. The purpose of this article is to demonstrate that when complete lymph node dissection is indicated, it can be performed with a low risk of lymphedema using the fascia-preserving technique. The records of 209 consecutive patients with melanoma who underwent fascia-preserving axillary (n = 116) or ilioinguinofemoral (n = 93) lymphadenectomy by a single surgeon between January 1984 and April 1998 were reviewed. In each operation, care was taken not to disrupt the muscle fascia at the site of lymphadenectomy. In the fascia-preserving axillary group, there were 59 men and 47 women with mean age of 53 years (range 21 to 79 years). There were three recurrences (3%) outside the borders of dissection. Transient upper extremity edema (8%) resolved over a median of 5 months, and permanent upper extremity edema occurred in 5% of patients. In the ilioinguinofemoral group, there were 19 men and 37 women with a mean age of 52 years (range 21 to 88 years). There was one recurrence (2%) outside the borders of dissection. Transient lower extremity edema (48%) resolved over a median of 12 months, and permanent lower extremity edema occurred in 14% of patients. Preservation of the muscle fascia during lymph node dissection results in a lower incidence of permanent edema, with no increased risk of recurrence.

Sequential changes of brain CT and MRI after febrile status epilepticus in a 6-year-old girl

Brain CT or MRI occasionally shows transient or permanent changes in the brain after status epilepticus (SE). The mechanism for these changes has not been well elucidated. We performed repeated imaging studies on a patient with febrile SE characterized by right hemiconvulsion. CT showed transient mild edema on both hemispheres immediately after the cessation of SE. The edema improved the next day. But aphasia and right hemiparesis were observed. On day 17, CT revealed edema on left hemisphere and MRI showed a high signal intensity in cortex and subcortical white matter of the left hemisphere on T2-weighted images. Although right hemiparesis and aphasia were improved, severe atrophy of the left hemisphere was noted on CT and MRI. The results suggest that brain edema observed in several days after SE but not edema observed immediately after the cessation of SE is more pathological for the permanent brain damage. Possible mechanisms of the initial brain edema and the second edema preceded severe atrophy in left hemisphere were discussed.

Treatment of Face Veins with a Cryogen Spray Variable Pulse Width 1064 nm Nd:YAG Laser

BACKGROUND Through the 1990s laser treatment of leg veins has been a challenge. Newer, longer wavelength lasers with variable pulse width have shown promising results for both telangiectasia and reticular leg veins. Experience with these lasers for treatment of facial telangiectasia and periorbital reticular veins is scant. OBJECTIVE To our knowledge this is the first prospective study to evaluate a variable pulse width, cryogen spray-equipped 1064 nm Nd:YAG laser for the treatment of facial telangiectasia and larger periorbital reticular veins. METHODS Seventeen volunteers, ages 32–67 years, skin types I–IV, with facial telangiectasia and reticular periorbital/temporal veins were treated once with the Nd:YAG laser at fluences of 125–150 J/cm2 with a 6 mm spot size and pulse widths of 25 msec for small vessels and 75–100 msec for reticular veins. Patients were examined 1 week and 1 month after the treatment. Pre- and posttreatment 35mm photographs were taken. Improvement was judged by two experienced physicians, both visually on patients and by comparison of pre- and posttreatment photographs. Results were graded as percent resolution, in five groups: 0%, 0–25%, 25–50%, 50–75%, and 75–100%. RESULTS All 17 patients completed the study. Thirty-two sites were treated (24 cheek, nose, and chin telangiectases, and 8 periorbital reticular veins). Greater than 75% improvement was observed in 97% of the treated sites. Greater than 50% improvement was observed in 100% of the treated sites. Notably, 100% of the facial reticular veins treated have essentially 100% resolution. Pain during treatment was variably perceived by patients, but occasionally sufficient for patients to express reservations about additional future treatment. Transient erythema and edema were common, but fine crusting was rare. Small areas of purpura were also quite rare. CONCLUSION The cryogen spray-equipped 1064 nm Nd:YAG laser was remarkably effective and safe for skin type I–IV patients. It is an excellent tool for treatment of facial telangiectasia with minimal risk of purpura. For the first time we appear to have a simple, safe, and effective treatment for 1–2 mm periorbital reticular veins. The use of topical anesthesia may be needed for some patients.

Treatment of face veins with a cryogen spray variable pulse width 1064 nm Nd:YAG Laser: a prospective study of 17 patients.

Through the 1990s laser treatment of leg veins has been a challenge. Newer, longer wavelength lasers with variable pulse width have shown promising results for both telangiectasia and reticular leg veins. Experience with these lasers for treatment of facial telangiectasia and periorbital reticular veins is scant. To our knowledge this is the first prospective study to evaluate a variable pulse width, cryogen spray-equipped 1064 nm Nd:YAG laser for the treatment of facial telangiectasia and larger periorbital reticular veins. Seventeen volunteers, ages 32-67 years, skin types I-IV, with facial telangiectasia and reticular periorbital/temporal veins were treated once with the Nd:YAG laser at fluences of 125-150 J/cm2 with a 6 mm spot size and pulse widths of 25 msec for small vessels and 75-100 msec for reticular veins. Patients were examined 1 week and 1 month after the treatment. Pre- and posttreatment 35mm photographs were taken. Improvement was judged by two experienced physicians, both visually on patients and by comparison of pre- and posttreatment photographs. Results were graded as percent resolution, in five groups: 0%, 0-25%, 25-50%, 50-75%, and 75-100%. All 17 patients completed the study. Thirty-two sites were treated (24 cheek, nose, and chin telangiectases, and 8 periorbital reticular veins). Greater than 75% improvement was observed in 97% of the treated sites. Greater than 50% improvement was observed in 100% of the treated sites. Notably, 100% of the facial reticular veins treated have essentially 100% resolution. Pain during treatment was variably perceived by patients, but occasionally sufficient for patients to express reservations about additional future treatment. Transient erythema and edema were common, but fine crusting was rare. Small areas of purpura were also quite rare. The cryogen spray-equipped 1064 nm Nd:YAG laser was remarkably effective and safe for skin type I-IV patients. It is an excellent tool for treatment of facial telangiectasia with minimal risk of purpura. For the first time we appear to have a simple, safe, and effective treatment for 1-2 mm periorbital reticular veins. The use of topical anesthesia may be needed for some patients.

Prevention of temporal alopecia following rhytidectomy: the prophylactic use of minoxidil. A study of 60 patients.

Temporal hair loss that results from traumatized hair follicles following rhytidectomy is an unsightly complication that can distress both the patient and the operating surgeon. Topical minoxidil is a proven therapy for androgenic alopecia and female senile alopecia. It has also been found to be useful in preventing the hair loss that commonly follows hair transplantation. To analyze through a retrospective study the effect of topical minoxidil on the incidence of temporal hair loss following facelift procedures. To our knowledge this is the first study to investigate the role of minoxidil in preventing post-rhytidectomy temporal alopecia. The charts of 60 women with a mean age of 58 years who underwent primary cervicofacial rhytidectomy were studied. Either a standard SMAS/flap technique or pliation was done in all cases. Each patient received either 2% or 5% topical minoxidil for 2 weeks before surgery and for 4 weeks after surgery, with a 5-day break period beginning on the day of surgery. Patients were monitored for complications immediately postoperatively and in 3-6 months of follow-up. Almost 80% of the patients underwent SMAS/flap procedures. Transient temporal alopecia was noted in only one patient, 6 weeks after discontinuing minoxidil. This resolved within 4 weeks of its reintroduction. The only other complications noted included minor hematomas (3.3%), skin slough/infection (1.7%), minor transient and localized edema (8.3%), minor ecchymosis (1.7%), a unilateral neuropraxia of the buccal nerve lasting 3 months (1.7%), and a minor temporary unilateral skin depression (1.7%). Side effects of minoxidil were not observed. On comparing our findings to results of larger rhytidectomy series in which minoxidil was not used prophylactically, and our experience before using minoxidil, we conclude that minoxidil plays a role in effectively preventing the temporal hair loss that occurs following primary cervicofacial rhytidectomies. We also found that minoxidil did not negatively impact on the risk of hematoma formation, skin necrosis, edema, or ecchymosis. Side effects of minoxidil did not present a problem.

Invited commentary

Invited commentary

Complications of type I thyroplasty and arytenoid adduction.

Unilateral vocal fold paralysis resulting in glottal incompetence can cause significant morbidity attributable to impaired speech, swallowing, and ability to protect the airway. Type I thyroplasty in combination with arytenoid adduction is a proven technique for medialization of the paralyzed vocal fold but must be evaluated in light of potential complications following laryngeal framework surgery. The charts of 237 patients who underwent unilateral vocal fold medialization surgery between July 1, 1991, and August 30, 1999, at a tertiary care cancer referral center were retrospectively reviewed. There were 98 cases of type I thyroplasty alone and 96 cases of type I thyroplasty with arytenoid adduction. The two groups had similar patient characteristics. Mean time of surgery (45 vs. 73 min, P <.0001) and length of hospital stay (1.1 vs. 1.8 d, P <.0001) were increased when arytenoid adduction was performed. Overall improvement of symptoms was similar in both groups (93%-94%), but posterior glottic closure appeared subjectively improved when arytenoid adduction was used (P =.0054). Overall complication rates were slightly higher in the arytenoid adduction group (14% vs. 19%), primarily because of transient vocal fold edema and wound complications (9 vs. 19 cases), but the increase was not statistically significant (P =.1401). Complications warranting medical or surgical intervention occurred in 8% of cases. Two patients who underwent type I thyroplasty with arytenoid adduction required tracheotomy as a consequence of postoperative complications. The three patients who had extrusion of the implant underwent type I thyroplasty alone. Using the appropriate technique, the potential benefits of improved glottic function following type I thyroplasty with arytenoid adduction outweigh the small risk of significant complications observed.

Acute corneal endothelial changes after laser in situ keratomileusis.

To report the acute effects of laser in situ keratomileusis (LASIK) on the corneal endothelium. Twenty eyes of 10 consecutive patients (mean age, 38.1 +/- 10.84 years) underwent bilateral simultaneous LASIK for myopic astigmatism (spherical equivalent ranging from -1.75 to -7.13 diopters) without any complications. Each eye was evaluated by slit-lamp biomicroscopy and noncontact specular microscopy preoperatively, within 15 minutes after LASIK and 1 day after surgery. Specular microscopy images were then analyzed to calculate endothelial cell density (ECD), coefficient of variation (CV) of cell size, and percentage of hexagonal cells. All corneas demonstrated marked alterations in endothelial cell morphology by slit-lamp biomicroscopy within 15 minutes after surgery that resolved by the first postoperative day. Central corneal endothelial analysis by noncontact specular microscopy confirmed pleomorphism with definite loss of hexagonality. Mean ECD was calculated to be 2,816.3 +/- 286.02 cells/mm(2) preoperatively, 2,750.85 +/- 327.95 cells/mm(2) on day 0 (p = 0.395), and 2,810.55 +/- 218.48 cells/mm(2) on day 1 (p = 0.461). Mean CV was 32.65 +/- 7.29 preoperatively, 34.4 +/- 6.19 on day 0 (p = 0.412), and 30.9 +/- 5.54 on day 1 (p = 0.067). Mean percentage of hexagonal cells was 63.35 +/- 10.76 preoperatively, 47.55 +/- 9.69 on day 0 (p = 0.000009), and 60 +/- 9.3 on day 1 (p = 0.00003). Qualitative and quantitative changes in endothelial cell morphology (i.e., decreased endothelial cell hexagonality) demonstrate that LASIK does induce an acute effect on the corneal endothelium that may represent transient endothelial cell edema.