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Purpose: The purpose of this study was to describe the burden and educational needs of informal caregivers of care-dependent older adults with urinary incontinence (UI)., Design: A cross-sectional, descriptive survey of informal caregivers recruited through Google Ads was performed., Methods: An online survey, including the Overactive Bladder-Family Impact Measure, was used to assess five areas of the experience of the informal caregiver that may be affected by caring for a person with UI and their educational needs., Findings: Respondents (n = 77) reported a substantial impact of their care recipients' UI on their lives, with concern, travel, and social subscales most affected. However, 42% never sought treatment on behalf of their care recipient. Educational needs included UI treatment strategies and guidance to select appropriate supplies., Conclusions: Caregivers underreported their care recipient's UI and need substantially more support from healthcare providers to manage the condition., Clinical Relevance: Nurses should assess for UI among care-dependent older adults and, if present, provide information and strategies to lessen the impact on caregiver lives., (Copyright © 2021 Association of Rehabilitation Nurses.)

Purpose: The paranasal sinuses are complex anatomical structures of unknown significance. One hypothesis theorizes that the sinuses, in the event of a traumatic injury, function as a crumple zone to distribute and absorb energy to protect the brain and other critical structures. The current study investigates the association between frontal sinus (FS) volume and the severity of cerebral insults following craniofacial trauma., Methods: All patients with FS fracture admitted to a level 1 trauma center from 2011 to 2014 were retrospectively reviewed. FS volumes were measured from computed tomography (CT) on admission using a proprietary region growing segmentation tool. Head injuries were classified based on the presence of specific types of intracranial pathology and their corresponding Marshall Score., Results: FS fracture was identified on the admission CT in 165 patients. Male patients had significantly larger FS volume compared to females (8.4 ± 6.3 vs. 4.0 ± 2.9 cm 3 , p < 0.001). Smaller FS volume was significantly associated with a worse Marshall Score (p = 0.041) and a higher incidence of cerebral contusion (p = 0.016) independent of age, gender, mechanism, ISS, and admission GCS. The inverse correlation between FS volume and the Marshall Score was also statistically significant (Spearman correlation coefficient r = -0.19, p = 0.015). Smaller FS volume was observed in patients who suffered intracranial insults, underwent neurosurgical interventions, and had worse clinical outcomes and trended towards significance with respect to an association with subarachnoid hemorrhage (p = 0.074) and subdural hematoma (p = 0.080), and had a statistically significant association with longer length of stay (p < 0.001)., Conclusion: FS volume is inversely correlated with the severity of intracranial pathology following craniofacial trauma. Our findings are consistent with the "crumple zone" hypothesis and suggest that the FS likely plays a role in mitigating intracranial injury. Furthermore, FS volume is significantly different between male and female patients. This is a novel finding that warrants further validation., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to identify factors associated with the decision to perform open reduction and internal fixation of mandibular condylar fractures., Methods: This was a retrospective cohort study of patients with mandibular condylar fractures managed by the plastic and reconstructive surgery, oral and maxillofacial surgery, and otorhinolaryngology services over a 15-year period. Bivariate associations and a multiple logistic regression model were computed for injury characteristics that were associated with open reduction and internal fixation. For all analyses, a value of p ≤ 0.05 was considered significant., Results: Six hundred fifty-four condylar injuries were identified in 547 patients. The sample's mean age was 36.0 ± 16.5 years, 20.5 percent were women, and 63 percent were Caucasian. The most common mechanisms of injury were motor vehicle collisions (49 percent), 53.4 percent involved the subcondylar region and 20 percent were bilateral injuries. Associated noncondylar mandibular fractures were present in 60 percent of cases; 20.7 percent were managed with open reduction and internal fixation. The overall complication rate was 21.6 percent. In a multiple logistic regression model, factors associated with an increased likelihood of open reduction and internal fixation were the presence of extracondylar mandibular injuries, condylar neck or subcondylar region injuries, increasing dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery (p ≤ 0.04)., Conclusions: Increasing severity of mandibular injury, lower level of fracture, joint dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery are associated with open reduction and internal fixation of mandibular condylar injuries., Clinical Question/level of Evidence: Risk, III.

Unlabelled: Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury., Methods: Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed., Results: A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels)., Conclusions: Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

Background: This study investigates the hypothesis that mechanisms of injury, fracture patterns, and burden to the health care system differ between geriatric and nongeriatric populations sustaining blunt-force craniofacial trauma., Methods: A 5-year retrospective chart review of patient records and computed tomographic imaging was performed. Demographic and outcome data were extracted for equally numbered samples of blunt-mechanism facial fracture patients aged 60 years or older (geriatric), and adult patients aged 18 to 59 years (adult nongeriatric). Comparisons were made between these two populations using t tests and multivariable logistic regression., Results: One thousand eighty-seven geriatric and 1087 nongeriatric patients were included. Geriatric patients were significantly more likely to be Caucasian, female, and have sustained fractures as the result of falling. They also had significantly longer hospital stays, were more likely to die, and were more likely to be discharged to home with services. Mandible fractures and panfacial fractures were significantly more common in the nongeriatric population. Geriatric age was associated with doubled length of hospitalization for patients with midface fractures. Logistic regression revealed that significantly higher incidences of orbital floor, maxillary, and condylar fractures in geriatric patients were dependent on geriatric age status, rather than mechanism of injury alone., Conclusions: Resource allocation for geriatric patients with craniofacial trauma should differ from that of their nongeriatric adult counterparts, with more resources allocated to supportive care during hospitalization and assistive care after discharge. The authors' data indicate that structural and biological changes in the craniofacial skeleton contribute to differences in fracture location independent of mechanism of injury., Clinical Question/level of Evidence: Risk, II.

Exploration of novel strategies in organ transplantation to prolong allograft survival and minimizing the need for long-term maintenance immunosuppression must be pursued. Employing vascularized bone marrow transplantation and co-transplantation of the thymus have shown promise in this regard in various animal models. Vascularized bone marrow transplantation allows for the uninterrupted transfer of donor bone marrow cells within the preserved donor microenvironment, and the incorporation of thymus tissue with vascularized bone marrow transplantation has shown to increase T-cell chimerism ultimately playing a supportive role in the induction of immune regulation. The combination of solid organ and vascularized composite allotransplantation can uniquely combine these strategies in the form of a novel transplant model. Murine models serve as an excellent paradigm to explore the mechanisms of acute and chronic rejection, chimerism, and tolerance induction, thus providing the foundation to propagate superior allograft survival strategies for larger animal models and future clinical application. Herein, we developed a novel heterotopic en bloc chest wall, thymus, and heart transplant model in mice using a cervical non-suture cuff technique. The experience in syngeneic and allogeneic transplant settings is described for future broader immunological investigations via an instructional manuscript and video supplement.

Background: Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision., Methods: Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion., Results: A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 ± 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15)., Conclusions: The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Knowledge of topographic skin thickness is important to plastic surgery of the face as it may guide resection and restoration in oncologic, aesthetic, and reconstructive procedures., Objective: The purpose of this study is to report the relative thickness of the face throughout 39 distinct subunits., Methods: Full-thickness punch biopsy samples were obtained at 39 predetermined anatomic locations of the face from 10 human cadaveric heads. Tissue was fixed in paraffin-embedded slides and analyzed using triplicate measurement of dermis and epidermis using computerized measurements. Data were analyzed using univariate statistical analysis and expressed as mean thickness values and relative thickness (RT) values based on the thinnest portion of the face., Results: The area of the face with the thickest dermis was the lower nasal sidewall (1969.2 µm, dRT: 2.59), and the thinnest was the upper medial eyelid (758.9 µm, dRT: 1.00). The area with the thickest epidermis was the upper lip (62.6 µm, eRT: 2.12), and the thinnest was the posterior auricular skin (29.6 µm, eRT: 1.00). Our results confirm that eyelid skin is the thinnest in the face. The thickest portions of the skin appeared to be in the lower nasal sidewall, but the measurements are comparable to those in the ala and posterior auricular skin, which are novel findings., Conclusions: The greatest epidermal, dermal and total skin thickness are found in the upper lip, right lower nasal sidewall, and left lower nasal sidewall respectively. The least epidermal skin thickness is in the posterior auricular skin. The least dermal skin thickness, and the least total skin thickness, are both in the upper medial eyelid., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Mandibular condyle fractures are common following facial trauma and carry an increased risk for concomitant blunt carotid artery injuries. Further elucidation of this relationship may improve vascular injury screening and management., Methods: A retrospective cohort study was performed for all patients sustaining condylar fractures presenting to a large trauma center over twelve years. Fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (1, condylar head; 2, condylar neck; and 3, extracapsular condylar base). Carotid artery injury severity was based on the Biffl scale. Severe vascular injury was defined as a Biffl score greater than I., Results: 605 patients were identified with mandibular condyle fractures consisting of 21.0 percent (n = 127) condylar head; 26.8 percent (n = 162) condylar neck; and 52.2 percent (n = 316) extracapsular condylar base. The incidence of vascular injuries in this population was 5.5 percent (n = 33), of which 75.8 percent (n = 25) were severe. Severe vascular injuries occurred in 1.6 percent (n = 2) of condylar head, 2.5 percent (n = 4) of condylar neck, and 6.0 percent (n = 19) of extracapsular condylar base fractures (p < 0.05). Extracapsular condylar base fractures were independently associated with a 2.94-fold increased risk of a severe blunt carotid artery injury compared with other condyle fractures on multivariable analysis (p < 0.05)., Conclusions: Extracapsular subcondylar fractures should heighten suspicion for concomitant blunt carotid artery injury. The data support a force transmission mechanism of injury in addition to direct injury from bony fragments., Clinical Questions/level of Evidence: Risk, II.

Introduction: The anatomy of the facial artery, its tortuosity, and branch patterns are well documented. To date, a reliable method of identifying the facial artery, based on surface landmarks, has not been described. The purpose of this study is to characterize the relationship of the facial artery with several facial topographic landmarks, and to identify a location where the facial artery could predictably be identified., Methods: Following institutional review board approval, 20 hemifacial dissections on 10 cadaveric heads were performed. Distances from the facial artery to the oral commissure, mandibular angle, lateral canthus, and Manson's point were measured. Distances were measured and confirmed clinically using Doppler examination in 20 hemifaces of 10 healthy volunteers., Results: Manson's point identifies the facial artery with 100% accuracy and precision, within a 3 mm radius in both cadaveric specimens and living human subjects. Cadaveric measurements demonstrated that the facial artery is located 19 mm ± 5.5 from the oral commissure, 31 mm ± 6.8 from the mandibular angle, 92 mm ± 8.0 from the lateral canthus. Doppler examination on healthy volunteers (5 male, 5 female) demonstrated measurements of 18 mm ± 4.0, 50 mm ± 6.4, and 79 mm ± 8.2, respectively., Conclusions: The identification of the facial artery is critical for the craniofacial surgeon in order to avoid inadvertent injury, plan for local flaps, and in preparation of a recipient vessel for free tissue microvascular reconstruction. Manson's point can aid the surgeon in consistently indentifying the facial artery., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The implications of allograft skin and mucosal biopsy findings on classification of rejection and treatment remain unclear., Methods: Following facial allotransplantation, scheduled surveillance allograft skin and mucosal biopsy specimens were obtained. Clinical concern for acute rejection prompted biopsies off schedule. Compilation of biopsy results, Banff grading, immunosuppression, and clinical correlation were critically reviewed for a 2-year follow-up., Results: A total of 39 biopsy specimens at 21 time points were obtained for analysis, including allograft skin (n = 21), mucosa (n = 17), and a lesion (n = 1). The patient had three episodes of acute rejection warranting treatment. Discordance between skin and mucosa occurred in 55.6 percent of biopsy specimens (p = 0.01). Mucosa concordance with the clinical evaluation occurred in 38.9 percent of biopsy specimens (p = 0.02), and skin concordance with clinical evaluation was present in 81 percent of biopsy specimens (p = 0.01)., Conclusions: The clinical utility of mucosal biopsy remains elusive. The authors' experience suggests that mucosal or skin biopsy, alone, should not drive the decision-making process in treatment. Skin biopsies are more likely to confirm clinical suspicion of rejection than mucosal histology. Data from other institutions are lacking, and future reporting may help elucidate the role of mucosal and skin biopsy in facial allotransplantation., Clinical Questions/level of Evidence: Diagnostic, V.

Background: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications., Methods: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed., Results: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2 ± 21.4 years (range, 23-90 years). All free tissue transfers (n = 20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6 ± 67.2 cm(2) (range, 35-285 cm(2)), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1 ± 87.3 cm(2) (range, 42-336 cm(2)). Early complications (<30 days following surgery) occurred in 21.1% of patients and late complications (>30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P = 0.079)., Conclusions: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.

Purpose: Abdominal compartment syndrome (ACS) is a severe complication of ventral hernia repair. The aims of this study were to investigate the effects of intra-abdominal pressure on the physiologic changes of abdominal wall reconstruction and component separation in a porcine model., Methods: Ventral hernia repair (VHR) was simulated by abdominal fascial imbrication of a 10 × 15 cm defect in 45 Yorkshire pigs assigned to five experimental groups. ACS was simulated by a Stryker endoscopy insufflator with intra-abdominal pressure elevated to 20 mmHg in two groups. Component separation was performed in one of these groups and in one group without ACS. Physiological parameters were measured before and after the procedures and monitored for 4 h. The animals were euthanized for histologic analysis of organ damage., Results: VHR led to an increase in intra-abdominal pressure, bladder pressure, and central venous pressure by an average of 14.89, 13.93, and 14.69 mmHg (p < 0.001) in all animals. Component separation was performed in 25 animals and the three pressures reduced by 9.11, 8.00, 7.89 mmHg (p < 0.001). ACS correlated with higher percentages of large and small bowel necrosis compared to groups without abdominal compartment syndrome., Conclusions: The results confirm that primary repair of large abdominal wall defects leads to increased intra-abdominal pressure, which can be reduced with component separation. In animals with ACS, component separation may reduce the risk of organ damage. Central venous pressure, bladder pressure, and other physiologic parameters accurately correlated with elevated intra-abdominal pressure and may have utility as markers for diagnosis of ACS.

Background: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment., Methods: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis., Results: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 ± 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm2 (range, 81 to 2500 cm2). The mean age of patients developing a complication was 72.8 ± 6.4 years and patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance., Conclusions: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.

Background: Despite inclusion of periorbital structures in facial transplants, critical assessment of posttransplantation short- and long-term periorbital function has not been reported. The purpose of this article is to report recovery of ocular and periorbital function, with critical appraisal of posttransplant blink in the setting of revision surgery., Methods: Prospective ocular and periorbital functional assessments were completed at multiple time points in a patient undergoing facial transplantation and subsequent revision operations. Function was evaluated using clinical ocular examinations, visual acuity assessments, photography, and video at various intervals from preoperative baseline to 13.5 months after transplantation. During this period, revision operations involving periorbital structures were performed at 6 and 9 months after transplantation., Results: Before transplantation, volitional blink was 100 percent in both eyes. Involuntary blink was 40 percent in the right eye and 90 percent in the left eye, with occasional full closure. Following face transplantation, voluntary blink was preserved, partial skin sensation was present, and involuntary blink improved to 70 percent in the right eye and 100 percent in the left eye. Following revision surgery, visual acuity and voluntary and involuntary blink were impaired. By 7.5 months after revision, improvement comparable to the pretransplantation assessment was observed., Conclusions: Adherence to principles of blink preservation is critical in periorbital transplantation. Involuntary blink is essential for preserving vision, and can be improved after transplantation. Revision surgery may temporarily impair advances made with initial allotransplantation. A comprehensive understanding of ocular biomechanics and function is invaluable to the reconstructive surgeon performing facial transplantation involving periorbital structures and posttransplant revision operations., Clinical Question/level of Evidence: Therapeutic, V.

Background: Vascularized composite tissue allotransplant recipients are often highly sensitized to human leukocyte antigens because of multiple prior blood transfusions and other reconstructive operations. The use of peripheral blood obtained from dead donors for crossmatching may be insufficient because of life support measures taken for the donor before donation. No study has been published investigating human leukocyte antigen matching practices in this field., Methods: A survey addressing human leukocyte antigen crossmatching methods was generated and sent to 22 vascularized composite tissue allotransplantation centers with active protocols worldwide. Results were compiled by center and compared using two-tailed t tests., Results: Twenty of 22 centers (91 percent) responded to the survey. Peripheral blood was the most commonly reported donor sample for vascularized composite tissue allotransplant crossmatching [78 percent of centers (n=14)], with only 22 percent (n=4) using lymph nodes. However, 56 percent of the 18 centers (n=10) that had performed vascularized composite tissue allotransplantation reported that they harvested lymph nodes for crossmatching. Of responding individuals, 62.5 percent (10 of 16 individuals) felt that lymph nodes were the best donor sample for crossmatching., Conclusions: A slight majority of vascularized composite tissue allotransplant centers that have performed clinical transplants have used lymph nodes for human leukocyte antigen matching, and centers appear to be divided on the utility of lymph node harvest. The use of lymph nodes may offer a number of potential benefits. This study highlights the need for institutional review board-approved crossmatching protocols specific to vascularized composite tissue allotransplantation, and the need for global databases for sharing of vascularized composite tissue allotransplantation experiences.

Vascularized bone flaps are the well-known standards of care for reconstruction of segmental mandibular defects ≥ 6 cm. We developed a large animal critical-sized mandibular defect model in which osseous free fibula flaps were used for reconstruction.In this study a total of eight 3-month-old Yorkshire pigs underwent 6 cm full-thickness resection of the left hemimandible. An osseous free fibula flap from the left leg was harvested and contoured to the mandibular defect. Bone placement and plate position was confirmed with fluoroscopy. Animals were followed with serial radiographs and clinical evaluations.Free fibulas were transferred successfully in all eight animals. The average operative time was 346 minutes, and the average flap ischemia time was 86 minutes. The average volume ratio of reconstructed hemimandibles to nonoperated control hemimandibles was 0.72 ± 0.33. The average maximum fracture load was 689 ± 262 N, and the average ratio of biomechanical fracture load for these samples compared with contralateral control hemimandibles was 0.88 ± 0.25.It is concluded that the porcine osseous free fibula flaps can be reliably harvested and viably transferred to critical-sized posterior mandibular defects with acceptable long-term results. The described microsurgical large animal model is acceptable for use in craniomaxillofacial experimentation., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

In preparation for the donor and recipient facial vascularized composite allotransplant (VCA), the marginal mandibular nerve branch should be identified and co-apted to the recipient's nerve to allow for re-innervation. We describe a method to identify the marginal mandibular branch of the facial nerve in facial VCA donors and recipients. Through cadaver dissections, the posterior facial vein was traced posteriorly to identify the marginal mandibular branch of the facial nerve. In cases where we were unable to use this relationship, we found the posterior facial venous system to be diminutive. This technique is useful for finding the marginal mandibular branch when dissecting anterograde to the parotid gland.

Background: As of July of 2013, 27 facial vascularized composite allotransplantations have been performed. The authors developed a classification system and treatment algorithm that is practical and surgically applicable., Methods: The majority of the transplants have been described in the surgical literature and the media, and a review of the data was performed. A classification system and a treatment algorithm were designed. Skeletal defects were defined by craniofacial osteotomies and soft-tissue defects by aesthetic facial subunits. The soft-tissue defect was subdivided into the following subunits: oral-nasal (type 1), oronasal-orbital (type 2), and full facial (type 3). The bony defects were subdivided into mandibular involvement (M), Le Fort 1 (A), Le Fort 3 (B), and monobloc (C)., Results: The mechanisms of injury included trauma (n = 13), burns (n = 8), congenital deformity (n = 3), oncologic resection (n = 1), and unreported (n = 2). According to the proposed classification system: one was type 1; one was type 1-M; one was type 1-MB; two were type 2; two were type 2-B; two were type 2-MB; six were type 3; one was type 3-B; and three were type 3-MB; eight could not be classified due to a lack of data. The treatment algorithm designed a vascularized composite allotransplantation that addressed the bony and soft-tissue components., Conclusions: Patient selection for these complicated procedures, currently dependent on lifelong immunosuppression, is crucial to their success. The authors describe a classification system and treatment algorithm for facial defects that may be ideally suited for facial transplantation. The proposed classification and algorithm may help centers define indications and ideally improve patient outcomes., Clinical Question/level of Evidence: Therapeutic, V.

Purpose: A core concept in plastic surgery has been the replacement of "like-with-like" tissue. Applying this concept to the lower extremity, the anterolateral thigh (ALT) perforator flap has become a frequently used free flap for restoration of soft tissue defects involving the distal lower extremity. The objective of this study was to evaluate the rate of early postoperative complications associated with the ALT perforator free flap for coverage of high-energy traumatic open fractures of the lower extremity (Gustilo IIIB) and explore related patient risk factors., Methods: A retrospective chart review of 74 patients undergoing free tissue transfer for lower extremity limb coverage was performed. Early postoperative complications were defined as any 1 or more of the following having occurred within 6 months from surgical reconstruction: hematoma, wound infection, deep venous thrombosis, thromboembolism, partial flap loss, complete flap loss, continued osteomyelitis, and progression to amputation occurring within the first 6 months after the injury. Statistical analyses were performed using GraphPad software. Fisher exact test was performed to identify risk factors associated with greater morbidity., Results: Of all patients, 26 (35%) were identified as those habitually using tobacco product and 48 (64%) were identified as nonusers of tobacco product. Moreover, 10 patients (14%) had other risk factors for atherosclerotic disease and 64 patients (86%) did not have other risk factors for atherosclerosis. Mean (SD) time to reconstruction was 4.74 (1.3) days (range, 3-8 days). Of all defects, 34 (46%) were reconstructed using adipocutaneous flaps and 40 (54%) were reconstructed using fasciocutaneous flaps. The most frequent complication was partial flap loss or superficial epidermolysis 4 (5.4%). Fisher exact test was performed, showing that patients who used tobacco product (cigarette smokers) and had other risk factors for atherosclerosis were significantly more at risk for complications (P < 0.001)., Conclusions: In this retrospective review, those patients who had a positive history of tobacco use at the time of injury and those with risk factors for atherosclerosis had a significantly increased risk of flap complications. Although this is not surprising given the vasoconstrictive effects of nicotine and the impaired blood flow to the lower extremity in patients with atherosclerosis, this study will allow the surgeon to better counsel patients who have a history of tobacco use through complex reconstruction of the lower extremity. This analysis is a preliminary investigation into the safety and efficacy of the ALT fasciocutaneous or adipocutaneous flap to reconstruct high-energy open fractures of the lower extremity.

Facial fractures resulting from blunt-mechanism trauma, although common, have been infrequently evaluated in large studies that do not include confirmation of fractures based on author review of available patient radiographic studies. An 8-year review (1998-2006) of the R Adams Cowley Shock Trauma Registry was performed with institutional review board approval. Patients diagnosed with blunt-mechanism facial fractures were identified by the International Classification of Diseases, Ninth Revision (ICD-9) codes and their facial fractures confirmed by author review of computed tomographic scans. Individual fractures were classified and grouped according to the facial thirds. Intra- and interreader variability was calculated, and confirmed fracture patterns were compared to fracture patterns listed by ICD-9 codes. Concomitant injuries and demographic data were additionally evaluated. Four thousand three hundred ninety-eight patients with 8127 fractures were identified. Intra- and interreader variability was 2% and 7%, respectively. ICD-9 coding misdiagnosed 12.5% of all fractures. Eighty-two percent of patients sustained associated injuries, including basilar skull fractures (7.6%) and cervical spine fractures (6.6%). 1.1% had at least one fracture in each facial third (panfacial fracture pattern). Significant relationships were found between demographic parameters, concomitant injuries, specific fractures, and fracture patterns. Studies investigating facial fractures should report fracture patterns confirmed by author review of available radiographic imaging. Large retrospective data sets containing confirmed fractures and capable of addressing rare fracture patterns can be compiled with low inter- and intrauser variability, and are useful for generating mechanistic hypotheses suitable for evaluation in prospective series or by directed biomechanical studies.

Background: Treatment of facial fractures in the setting of open-globe injuries poses a management dilemma because of the often disparate treatment priorities of multidisciplinary trauma teams and the lack of prognostic data regarding visual outcomes., Methods: Patients in the University of Maryland Shock Trauma Registry sustaining facial fractures with concomitant open-globe injuries from January of 1998 to August of 2010 were identified. Odds ratios were calculated to identify demographic and clinical variables associated with blindness, and multivariate regression analysis was performed., Results: A total of 99 patients were identified with 105 open-globe injuries. Seventy-nine percent of injuries were blinding, whereas 4.8 percent of globes achieved a final visual acuity greater than or equal to 20/400. Blindness was associated with penetrating injury, increasing number of facial fractures, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. Fracture repair was performed more frequently (62.5 percent) and more quickly (average time to fracture repair, 4.5 days) in cases of primary globe enucleation/evisceration when compared with complete (21.2 percent; 8 days; p=0.35) or incomplete (42.9 percent; 11 days; p=0.058) primary globe repair., Conclusions: Penetrating injury mechanism and zone of eye injury appear to be better indicators of visual prognosis than facial fracture patterns. Given the high rates of blindness, secondary enucleation, and delay of fracture repair in patients that were not primarily enucleated, the authors recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma., Clinical Question/level of Evidence: Risk, III.

Background: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result., Methods: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised. The strategy involved the foundation of a basic science laboratory, the cultivation of a supportive institutional clinical environment, the innovative application of technologies, cadaveric simulations, a real-time clinical rehearsal, and an informed and willing recipient who had the characteristic deformity., Results: After institutional review board and organ procurement organization approval, a total face, double jaw, and tongue transplantation was performed on a 37-year-old man with a central face high-energy avulsive ballistic injury., Conclusions: This facial transplant represents the most comprehensive transplant performed to date. Through a systematic approach and clinical adherence to fundamental principles of aesthetic surgery, craniofacial surgery, and microsurgery and the innovative application of technologies, restoration of human appearance and function for individuals with a devastating composite disfigurement is now a reality., Clinical Question/level of Evidence: Therapeutic, V.

Background: Reconstructing periorbital defects is challenging because of the simultaneous need for ocular support, corneal protection, and restoration of aesthetic subtleties. In patients with extensive periorbital tissue loss, microvascular free tissue transfer is a reliable reconstructive option for composite defects., Methods: The authors conducted a retrospective review of patients with periorbital craniofacial defects and identified those treated with microvascular reconstruction at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2010., Results: Twenty-four patients underwent free flap reconstruction for periorbital defects secondary to trauma (n = 12), oncologic resection (n = 11), and congenital deformity (n = 1). The majority were men (n = 13), and the average age of the patients was 47 years (range, 19 to 80 years). Microvascular reconstructions included fibula (n = 9), anterolateral thigh (n = 6), ulnar forearm (n = 7), and groin flaps (n = 2). Flap survival rate was 100 percent, with an average follow-up of 26.5 months., Conclusions: Microvascular reconstruction of the periorbit can be accomplished successfully through careful analysis of tissue loss, eye or ocular prosthetic support, donor-site morbidity, and patient preference. Despite the multiple flap options that fulfill periorbital reconstructive needs, the authors find that the fibula, anterolateral thigh, ulnar forearm, and groin flaps can be used reliably to successfully reconstruct these defects., Clinical Question/level of Evidence: Therapeutic, IV.

Background: With the transplantation of more extensive facial vascularized composite allografts, fundamental craniofacial and aesthetic principles become increasingly important. In addition, computer-assisted planning and intraoperative navigation may improve precision and efficiency in these complex procedures., Methods: Ten mock face transplants were performed in 20 cadavers. The vascularized composite allograft consisted of all facial skin, mimetic muscles, the tongue, the midface by means of a Le Fort III osteotomy, and the mandible by means of sagittal split osteotomies. Craniofacial computed tomographic scans were obtained before and after the mock transplants. Surgical planning software was used to virtually plan the osteotomies, and a surgical navigation system guided the osteotomies intraoperatively. Cephalometric analyses were compared between the virtually planned transplants and the actual postoperative results., Results: The combination of preoperative computerized planning and intraoperative guidance consistently produced a vascularized composite allograft that could be easily fixated to the prepared recipient, with only minimal burring of osteotomy sites necessary. Satisfactory occlusion was maintained, and postoperative computed tomography confirmed accurate skeletal fixation. Insignificant differences with regard to cephalometric analyses were noted when predicted and actual postoperative data were compared., Conclusions: The authors' experience treating severe craniofacial injury allowed consistent transfer of facial vascularized composite allografts, maintaining proper occlusion. Preoperative computer planning and intraoperative navigation ensured precise osteotomies and a good donor-recipient skeletal match, which greatly reduced the need for intraoperative adjustments and manipulation. This total facial vascularized composite allograft represents one of the most extensive described and is intended to represent a typical central facial demolition pattern.

Background: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery., Methods: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified. The family graciously consented to donation of a total face, double jaw, and tongue allograft and multiple solid organs., Results: A craniofacial computed tomographic angiogram was obtained preoperatively to define the vascular anatomy and facilitate virtual computerized surgical planning. The allograft was procured in 10 hours, with an additional 2 hours required for an open tracheostomy and silicone facial impression. The donor was coagulopathic throughout the recovery, resulting in an estimated blood loss of 1500 ml. Fluorescence angiography confirmed adequate perfusion of the entire allograft based on lingual and facial arterial and external jugular and thyrolinguofacial venous pedicles. The solid organ transplant team initiated abdominal organ isolation while the facial allograft procurement was in progress. After completion of allograft recovery, the kidneys and liver were recovered without complication., Conclusions: Before conducting a clinical face transplant, adequate preparation is critical to maximize vascularized composite allotransplantation outcomes and preserve solid organ allograft function. As more centers begin to perform facial transplantation, research procurement of a facial vascularized composite allograft offers a unique educational opportunity for the surgical and anesthesia teams, the organ procurement organization, and the institution.

Objective: Reconstruction of traumatic ventral hernias often requires additional techniques to the abdominal wall component separation, such as the use of interpositional reconstruction with an acellular dermal matrix or other mesh to bridge the defect., Methods: We have developed a new value termed the "Component Separation Index" to evaluate ventral hernia defects. Choosing a fixed point on a preoperative axial computed tomographic scan (aorta) and the medial leading edges of the rectus abdominus muscles, we determined the angle of diastasis of the hernia. This angle is divided by 360° giving a relative value of the transverse defect size as compared to the estimated circular body habitus for that specific patient. A retrospective review of 36 cases of ventral hernia repairs was performed. The Component Separation Index was calculated from the preoperative computed tomographic scans obtained before repair. Group 1 (n = 18) required component separation for closure. Group 2 (n = 18) required component separation and placement of interpositional mesh to span the hernia defect., Results: The Component Separation Index values were then compared using the student t test for each group. The mean Component Separation Index for group 1 was 0.11 with standard deviation of 0.06. The mean Component Separation Index for group 2 was 0.21 with standard deviation of 0.04 (P < .0001). As this value approaches 0.21, the likelihood of an interpositional repair in addition to component separation becomes much greater., Conclusions: While there is no substitute for clinical acumen when evaluating these defects, objective measurements can provide a valuable additional tool for the surgeon facing these challenging cases.

Introduction: The wrist represents a complex anatomic region in the upper extremity and a highly functional and intricate structural joint. Perilunate injuries have classically been described as involving a greater or lesser arc as described by Mayfield and imply a specific pattern of force transmission. The greater and lesser arc classifications do not include descriptions of when non-scaphoid carpal fractures occur as part of a perilunate injury., Methods/results: We present three cases of complex and rare perilunate fracture dislocation patterns and discuss the surgical management as a treatment model for these complex wrist injuries: the trans-scaphoid, trans-capitate perilunate dislocation, the trans-scapholunate ligament, trans-capitate dislocation, and the trans-scaphoid, trans-triquetral perilunate dislocation., Discussion: Although there is a low incidence of injury to non-scaphoid carpal bones, it is beneficial to understand the approach to the perilunate reduction and scaphoid fixation through a combined volar and dorsal approach, which will also allow for the reduction and fixation of more rare and complex carpal fractures.

Introduction: Many medical disciplines, such as emergency medicine, trauma surgery, dermatology, psychiatry, family practice, and dentistry have documented attempts at assessing the level of bioterrorism preparedness in their communities. Currently, there is neither such an assessment nor an existing review of potential bioterrorism agents as they relate to plastic surgery. Therefore, the purpose of this article is to present plastic surgeons with a review of potential bioterrorism agents., Methods: A review of the literature on bioterrorism agents and online resources of the Centers for Disease Control and Prevention was conducted. Category A agents were identified and specific attention was paid to the management issues that plastic surgeons might face in the event that these agents are used in an attack., Results: Disease entities reviewed were smallpox, anthrax, plague, viral hemorrhagic fever, tularemia, and botulism. For each agent, we presented the microbiology, pathophysiology, clinical presentation, potential for weaponization, medical management, and surgical issues related to the plastic surgeon., Conclusion: This article is the first attempt at addressing preparedness for bioterrorism in the plastic surgery community. Many other fields have already started a similar process. This article represents a first step in developing evidence-based consensus guidelines and recommendations for the management of biological terrorism for plastic surgeons.

High velocity injuries have traditionally been covered with free muscle flaps. We sought to evaluate the utility of the anterolateral thigh flap (ALT) flap as a primary choice in reconstructing traumatic injuries in Western patients.A retrospective chart review was conducted of 122 patients treated at the R Adams Cowley Shock Trauma Center and at the Louisiana State University Trauma Center. Data collected included defect size, donor site location, flap composition and size, number of anastamoses, number of perforators, donor site closure, and complications.A total of 127 ALT flap reconstructions were performed. About 74% involved the lower extremity, 12% head and neck, 11% upper extremity, 2% abdomen, <1% chest, and <1% pelvis. The success rate was 96% with 3 total flap failures and 2 partial flap failures. Average follow-up was 9.3 months.The results of this review confirm that the ALT flap is a reliable, versatile tool for managing composite traumatic injuries.

Unlabelled: Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region., Experimental: Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period., Experimental: Cadaver dissections confirmed a principal perforator at 11.4 +/- 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeon's armamentarium.

Background: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s)., Methods: An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled., Results: One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors' treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621., Conclusions: A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

Introduction: The reverse sural artery flap eliminates the need for long and technically demanding free tissue transfers, which have become the gold standard for significant tissue defects in the distal third of the leg and ankle. Unfortunately, the originally described reverse sural artery flap technique has a risk of partial or total flap necrosis as high as 25%. We hypothesized that delaying the flap (the delay time ranged from 48 hours to 2 weeks) and using a 4-cm wide pedicle would decrease the amount of partial flap necrosis that commonly occurs with this flap., Patients: Five patients (3 women, 2 men) with open wounds in the distal lower extremity were treated with delayed fasciocutaneous reverse sural artery flaps elevated on a 4-cm wide pedicle., Results: The patients ranged from 22 to 75 years of age and had sustained defects in the ankle region resulting from trauma. All five wounds healed with favorable functional and asthetic results without any evidence of flap necrosis., Conclusions: In patients with known vasculopathy, a surgical delay of 1 week and increasing the pedicle size to 4 cm may increase the likelihood of graft survival and decrease the amount of partial flap necrosis by dilating the arterial network.

Background: Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and requires recruitment of vascularized tissues from distant sites. The objective of this study was to evaluate the utility of the anterolateral thigh (ALT) flap for reconstruction of the traumatically injured lower extremity., Methods: Prospective data were collected on all patients who underwent lower extremity reconstruction with an ALT flap during a 3.5-year period at a primary adult resource center (PARC). Demographics captured included age, gender, Injury Severity Score, mechanism of injury, and size of defect and complications., Results: Fifty-six patients underwent a total of 59 ALT flap harvests during the study period. The majority of patients were male (75%) and sustained blunt injury (95%). The mean age was 37 +/- 14 years with a mean Injury Severity Score of 17.9 +/- 8. The mean flap size was 20.7 x 8.4 cm, with 64% harvested from the injured limb. Total flap success rate was 91.5%, with four total (6.7%) and one partial flap failure (1.7%)., Conclusion: The ALT flap is a useful tool for trauma reconstruction in lower extremity salvage. We have shown that the ALT flap can be performed successfully in the traumatically injured patient even when harvested from the ipsilateral lower extremity.

Various local and distant flaps have been used to repair pelvic defects, including sartorius, rectus abdominis, rectus femoris, tensor fascia lata, vastus lateralis, gracilis, and omentum, each with benefits and disadvantages. The pedicled internal oblique rotational muscle flap has been described to cover pelvic wounds but may be underutilized. We present our experience with 5 pedicled internal oblique flaps in 4 patients (3 male, 1 female). The mean patient age was 32 years (23-47 years), and the mean follow-up was 8 months. All patients required coverage of the lateral pelvis after failure of conservative measures. There were no major complications. One patient experienced decreased sensation in the lateral femoral cutaneous nerve distribution, which resolved fully within 3 months. The internal oblique muscle provides local soft-tissue coverage with a predictable blood supply, and its proximity to the pelvis offers an alternative for reconstruction of lateral pelvic defects, with minimal associated morbidity.

Objective: To assess the effects of heat and cold on quantifiable pain behaviors in an animal model of arthritis that minimizes the motivational-affective component of pain., Design: The effects of superficial heat (40 degrees C) and cold (4 degrees C) on pain behaviors in rats with knee joint inflammation were tested before and after induction of inflammation and after treatment with heat or cold., Subjects: Joint inflammation was induced in male Sprague-Dawley rats by intra-articular injection of the knee joint with 3% kaolin and 3% carrageenan., Main Outcome Measures: Withdrawal latency to heat applied to the paw (PWL) assessed secondary hyperalgesia; spontaneous pain behaviors assessed degree of weight bearing/ guarding; and joint circumference assessed joint swelling., Results: Cold treatment of the inflamed knee joint significantly reversed the PWL immediately after treatment (p = .003) without affecting spontaneous pain behaviors orjoint circumference. In contrast, heat treatment produced a small but significant decrease in spontaneous pain behaviors (p = .03) without affecting PWL or joint circumference., Conclusion: Acute arthritic pain can be treated with either superficial heat for reducing guarding or with cold for reducing pain or hyperalgesia outside the injury site.

An investigation of the acidic properties and molecular structure of the new natural amino acid beta-carboxyaspartic acid (Asa) is described. The four pKas of Asa were determined by using a microtitration technique and are 0.8 +/- 0.2, 2.5 +/- 0.1, 4.7 +/- 0.1, and 10.9 +/- 0.1. The three pKas of 5-hydantoinmalonic acid were similarly measured and are 1.85 +/- 0.05, 4.63 +/- 0.05, and 10.20 +/- 0.05. 5-Hydantoinmalonic acid was used as a model for Asa with peptide bonds. Asa crystallizes in the monoclinic space group Cc with four molecules per unit cell of dimensions a = 13.112 (3) A, b = 8.207 (3) A, and c = 7.292 (2) A and beta = 108.03 (2) degrees. The structure was solved by direct methods and refined to final values for the discrepancy indices of R = 0.029 and wR = 0.036. The two molecules of Asa are linked by a very strong hydrogen bond between one of the beta-carboxyls and the alpha-carboxyl group of an adjacent molecule. Analysis of the pKa data indicates that the predominate zwitterion in solution results from ionization of a beta-carboxyl group. The X-ray data indicate that in the solid state the negative charge of the zwitterion is distributed approximately equally between one of the beta-carboxyls and the alpha-carboxyl group.