Showing papers in "Plastic and Reconstructive Surgery in 1991"

Synthetic polymers seeded with chondrocytes provide a template for new cartilage formation.

Abstract: A new approach for tissue creation using synthetic biocompatible and biodegradable polymers as templates onto which cells are seeded is presented This report concerns the generation of homogeneous plates of stable mature cartilage in vivo The delivery of chondrocytes on synthetic polymers configured to provide a large surface area for cell attachment and thus to allow cell function and survival by diffusion of nutrients has resulted in the creation of macroscopic plates of up to 100 mg of new cartilage subcutaneously in 19 of 21 animals The approximate dimensions and configuration of the original templates were maintained as new cartilage was formed and the polymers resorbed

Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning.

Abstract: Skin-sparing mastectomy by definition describes the procedure of mastectomy, either simple or modified radical, with a minimum amount of skin excision The surgical skin excision must: (1) include the nipple-areola complex, (2) include the biopsy site, and (3) allow for access to the axilla for possible dissection In 27 mastectomies, the senior author has had direct input in the preoperative skin planning All patients underwent immediate breast reconstruction In large-breasted women, the mastectomy was performed to a Wise-type pattern In small-breasted women, the mastectomy involved minimal skin excision followed by reconstruction Non-continuous incisions were frequently used in small-breasted women, thereby minimizing breast scarring When appropriately applied, skin-sparing mastectomy can greatly improve the final aesthetic result of the breast

Transplantation of purified autologous fat: a 3-year follow-up is disappointing.

Abstract: The idea of autologous fat microtransplants has recently resurfaced because of interest by the press. Past experiments have shown that small amounts of fat may be transplanted with an expected survival rate between 10 and 50 percent without ectodermis. A great fund of knowledge exists showing that skin grafts will survive quite dependably if their thickness is up to about 0.0020 inch. For the first week or so, they live by diffusion and inosculation, and then neovascularization enables them to continue viability. I have developed a technique whereby fat is harvested through a blunt cannula with minimal vacuum to prevent explosion of the cellular fat globules. Fibrin and cellular debris are removed, and the fat globules are separated from the free fat, blood, and other constituents of the aspirate. Individual, free-floating 1- to 3-mm adipose fragments are then suspended in nutrient solution and injected through an 18-gauge needle. Multiple radial pathways, with each fat segment being separated from the other by host tissue, maximizes the host-prosthesis interface and the possibility for exchange of nutrients. I have attempted this procedure in more than 100 patients with widely varying results. In acne pits of the face, no significant improvement could be noted 6 weeks after injection. For the first few weeks, a near-perfect result was obtained, but none of these transplants in scarred areas of this kind have been of benefit. Injection of 10 to 50 cc in other areas has resulted in some cells (perhaps 10 percent) surviving over 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative antigenicity of components of a vascularized limb allograft.

Abstract: At present, the transplantation of vascularized limb-tissue allografts can be achieved only with generalized host immunosuppression, which results in significant systemic toxicity, thereby precluding their clinical use. A better understanding of the immunogenic mechanisms of these allografts may permit less toxic and thus clinically applicable means of host immunosuppression. In this study, individual vascularized limb tissues (skin, subcutaneous tissue, muscle, bone, and blood vessels) and a whole limb were transplanted microsurgically across a strong histocompatibility barrier in rats. The respective cell-mediated and humoral immune responses generated in the hosts were determined by means of mixed lymphocyte cultures by radioactive 51Cr release assays and compared. No single tissue predominated in the elicited immune response. Rather, the various tissue components interacted with the host immune system in a complex but predictable pattern with differing timing and intensity. Surprisingly, the whole-limb allograft elicited less immune response than did allografts of its individual components. The data presented here also serve as a foundation for further elucidation of the immunogenic mechanisms of vascularized limb-tissue allografts.

Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management.

Abstract: A retrospective, multivariate statistical analysis of 129 consecutive nonsyndromic patients undergoing cleft palate repair was performed to document the incidence of postoperative fistulas, to determine their cause, and to review methods of surgical management. Nasal-alveolar fistulas and/or anterior palatal fistulas that were intentionally not repaired were excluded from study. Cleft palate fistulas (CPFs) occurred in 30 of 129 patients (23 percent), although nearly a half were 1 to 2 mm in size. Extent of clefting, as estimated by the Veau classification, was significantly more severe in those patients who developed cleft palate fistula. Type of palate closure also influenced the frequency of cleft palate fistula. Forty-three percent of patients undergoing Wardill-type closures developed cleft palate fistula versus 10, 22, and 0 percent for Furlow, von Langenbeck, and Dorrance style closures, respectively. The fistula rate was similar in patients with (30 percent) and without (25 percent) intravelar veloplasty. Age at palate closure did not significantly affect the rate of fistulization; however, the surgeon performing the initial closure did not have an effect. Thirty-seven percent of patients developed recurrent cleft palate fistulas following initial fistula repair. Recurrence of cleft palate fistulas was not influenced by severity of cleft or type of original palate repair. Following end-stage management, a second cleft palate fistula recurrence occurred in 25 percent of patients. Continued open discussion of results of cleft palate repair is recommended.

Superficial fascial system (SFS) of the trunk and extremities: a new concept.

Abstract: Surgeons and anatomists have largely ingored the superficial fascia of the body. In fact, many anatomists have doubted the existence of this fascia as a distinct entity. The superficial fascia does exist and is functionally important. Understanding the anatomy and pathologic changes with age of the superficial fascial system (SFS) of the trunk and extremities may help explain body-contour deformities and provide the anatomic basis for surgical correction. The anatomy of the superficial fascial system was studied in 12 fresh and embalmed cadavers, cross-sectional cadaver segments, and 20 body-contour patients. The superficial fascial system is a connective-tissue network that extends from the subdermal plane to the underlying muscle fascia

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment.

Abstract: The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.

The Surgical Anatomy of the Scalp

Abstract: Cadaveric dissections and surgical observations have led to the description and clarification of the boundaries. blood supply, and nomenclature of the layers of the scalp. Special attention was directed to the layer of "loose connective tissue" that lies beneath the entire galea and above the cranial periosteum centrally, and the temporalis fascia laterally. It has been named the subgaleal fascia (SGF). The subgaleal fascia is a trilaminar structure with unusual potential in reconstructive surgery. Histologic study reveals the subgaleal fascia to be composed of a central dense collagenous layer surrounded by vascularized areolar tissue. It is readily dissected from surrounding galeal and periosteal layers. The subgaleal fascia was probably included in previously described "pericranial flaps," which were often based beyond the periosteum. The blood supply of the subgaleal fascia originates from the proximal portion of the peripheral vessels of the scalp and continues within the areolar lamina. The subgaleal fascia is an exceptionally thin, malleable, and well-vascularized flap useful for facial reconstruction.

Free vascularized thin corticoperiosteal graft.

Abstract: This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks.

Aesthetic improvements in free-flap mandible reconstruction.

Abstract: Mandible reconstruction with free flaps has become a well-established technique. Efforts are now focused on obtaining superior functional and aesthetic results. Improvements in the quality of the latter are possible with a systematic approach to shaping the bone graft. Important elements in this approach have been defined based on experience in 50 consecutive cases. Preoperative studies include the lateral cephalogram and a transverse plane CT scan from which mandible templates are constructed. These templates are models of the mandible in two planes and are used to shape the bone with a high degree of precision. They allow the bone to be completely shaped while still attached by the pedicle at the donor site. The surgical specimen serves as an additional key visual reference and as a source of measurements to determine overall bone-graft length. Miniplates alone provide sufficient fixation to stabilize the bone as it is shaped segment by segment. Intermaxillary fixation is used only to prevent errors in total bone-graft length. Hemimandible and anterior defects represent two completely different bone-shaping problems. Although the bone-shaping methods described have been developed primarily with the fibula, they have been successfully applied to the scapula and radius donor sites as well.

The Bipedicled Osteocutaneous Scapula Flap: A New Subscapular System Free Flap

Abstract: Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.

The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment.

Abstract: Preliminary reports have indicated that debridement of the bony sequestrum followed by muscle-flap coverage allows successful treatment of chronic osteomyelitis. To determine the long-term effectiveness of this procedure, 34 consecutive patients with chronic osteomyelitis of the distal lower extremity treated with debridement, a 10- to 14-day course of culture-specific antibiotics, and immediate muscle-flap coverage were evaluated. Patients were treated from 1979 through 1984, and long-term (greater than 5 years) follow-up was available for 27 (79 percent). Twenty-three (85 percent) of these patients underwent microvascular muscle transplantation (gracilis or latissimus dorsi), and four underwent local muscle flaps (gastrocnemius or soleus) for immediate wound coverage. Twenty-four patients (89 percent) healed and were without recurrence over long-term (greater than 5 years, mean 7.4 years) follow-up. Of the three with recurrence, two were cured (greater than 5 years follow-up) after additional muscle-flap procedures. Thus the overall success rate was 96 percent, with a minimum 5-year follow-up. Guidelines for muscle-flap selection and treatment techniques in current use are presented. Debridement and immediate muscle-flap coverage provide effective, single-stage treatment of chronic osteomyelitic wounds and allow antibiotics to be restricted to short-term use. Furthermore, muscle flaps covered with skin grafts provide durable coverage while allowing subsequent ancillary procedures (i.e., bone grafts) to be performed under the flaps.

Experimental and clinical applications of fibrin glue.

Abstract: A 2-year experience with laboratory and clinical applications of fibrin glue is presented. An autologous technique, which eliminates the danger of multidonor preparations, has been developed in our blood bank. While one can obtain different fibrinogen concentrations from the same amount of a patient's blood, in vitro mechanical testing demonstrated that at higher fibrinogen concentrations there is an increase in shear adhesive strength. Evaluation of skin-graft take in 16 Sprague-Dawley rats did not demonstrate significant differences in healing when adhesive use was compared with suture technique. In a clinical study, four different groups of patients (facial burns, hand burns, difficult graft sites, and miscellaneous surgical applications) benefited from autologous or single-donor fibrin glue for a total of 82 cases. There are several distinct advantages to the use of fibrin adhesive: The autologous technique eliminates the risk of transmissible viral diseases (AIDS, hepatitis); it can be used as a sealant in the treatment of seromas, dural leaks, and lymphoceles; and it improves hemostasis and early graft adherence. Face and hands are resurfaced with sheet grafts in a single procedure, obtaining a better aesthetic result with complete graft take and immediate start of physical therapy. Neither sutures nor pressure dressings are required. The minimal postoperative care associated with early return to normal activities seems to increase the satisfaction of patients and nurse personnel.

The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation.

Abstract: The subperiosteal face lift described by Psillakis has been criticized for not showing a more dramatic improvement over conventional brow/face lift procedures. His approach also has a significantly high incidence of nerve injury. This study reports our anatomic findings and surgical modifications, which have permitted a significant improvement in the safety of execution and clinical results using the subperiosteal face lift concept. Pertinent points of applied local anatomy and dissection techniques are as follows: First, we use extensive interconnected subperiosteal dissection that includes the entire zygomatic arch. This allows better repositioning of the deep soft tissues of the entire upper face, most of the midface, and indirectly, key structures of the lower face. Second, the upward pull of the muscles of the cheek and mouth will produce an elevation of the corner of the mouth, affecting positively the smiling mechanism, the oral frowning, and the jowls. Third, the dissection deep to both layers of the temporal fascia decreases the risk of injury to the frontalis nerve. Fourth, the temporal fascia is used as a lifter and anchoring element of the entire cheek-perioral soft tissues as opposed to the periorbital fibrofatty tissues. This will decrease the risk of injuring the frontal and zygomatic branches of the facial nerve. These modifications have been used in 28 patients. Our rate of patient satisfaction has been high, and no complications with regard to nerve injury have been observed. This compares favorably with our initial 60 patients, in whom the Psillakis or Tessier approach was used. In these patients, there was an 11 and 20 percent rate of nerve injury, respectively.

Abdominal wall function after rectus abdominis transfer.

Abstract: The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the rectus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.

Transpalpebral decompression of endocrine ophthalmopathy (Graves' disease) by removal of intraorbital fat: experience with 147 operations over 5 years.

Abstract: From 1984 to October 1989 at the Plastic Surgery Unit in Wesseling, we carried out 147 operations on 75 patients with Graves' disease. Intraorbital fat was removed through a transpalpebral incision to achieve decompression. The average amount of fat was 6.0 cm3. We have made a long-term follow-up (more than 6 months postoperatively) study of 57 patients who experienced 108 operations. The first results were published in September 1988. When we compared the results to a traditional decompression operation (with resection of one or two orbital walls), we found that the postoperative complication rate was significantly lower and that the success rate was much higher. Thus the range of indications for surgery may be much wider than previously considered. Patients who are about to lose their vision as well as those experiencing lesser symptoms can be much improved with this operation. At the beginning, before the technique was fully developed, complications such as supraorbital nerve palsy occurred.

Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face.

Abstract: The use of craniofacial surgical techniques, extended open reduction, rigid fixation with plates and screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the treatment of complex facial fractures has been applied to the management of severe gunshot wounds o

Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap.

Abstract: Four cases of total lip and chin reconstruction are presented. In three, the composite radial forearm-palmaris longus free flap was used for reconstruction. In the fourth case, the palmaris longus was separated from the flap but still used as a lower lip sling. In all cases, the entire lower lip and the soft tissue of the chin were reconstructed in one stage. All patients healed primarily, and the three who underwent radiotherapy tolerated it without complications. Lip seal and speech were good, and there was no problem with drooling. Postoperative results emphasize the importance of respecting the aesthetic unit of the lower lip and chin.

Stimulation of healing of chronic wounds by epidermal growth factor.

Abstract: We evaluated the effect of topical epidermal growth factor treatment on healing of chronic wounds in a prospective, open-label, crossover trial. Five males and four females who ranged in age from 40 to 72 years (average 57 +/- 9 years) were enrolled. Four patients had adult-onset diabetes mellitus, two had rheumatoid arthritis, two had old burn scars, and one had a failed abdominal incision. The average duration of the ulcers prior to treatment with epidermal growth factor was 12 +/- 5 months (range 1 to 48 months). Following failure of the wounds to heal with conventional therapies, including debridement, skin graphs, and vascular reconstruction, wounds were treated twice daily with Silvadene alone for periods ranging from 3 weeks to 6 months. No evidence of healing was observed in any of the patients' wounds during Silvadene treatment, and patients were crossed over to twice a day treatment with Silvadene containing 10 micrograms epidermal growth factor per gram. Wounds of eight patients healed completely with epidermal growth factor-Silvadene treatment in an average of 34 +/- 26 days (mean +/- SD, range 12 to 92 days) and did not reoccur for periods ranging from 1 to 4 years. One patient failed therapy. These results suggest that topical treatment of chronic wounds with epidermal growth factor may stimulate healing.

Use of the AO plate for immediate mandibular reconstruction in cancer patients.

Abstract: Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.

Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study.

Abstract: The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia

Hyperbaric oxygen therapy in plastic surgery: a review article.

Abstract: The most important effects of hyperbaric oxygen (HBO), for the surgeon, are the stimulation of leukocyte microbial killing, the enhancement of fibroblast replication, and increased collagen formation and neovascularization of ischemic tissue. Preoperative hyperbaric oxygen induces neovascularization in tissue with radionecrosis. Refractory osteomyelitis and necrotizing fasciitis appear to respond to adjunctive hyperbaric oxygen. Crush injury and compartment syndrome appear to benefit through preservation of ATP in cell membranes, which limits edema. Hyperbaric oxygen in burn injury permits shorter hospital stays, a reduced number of surgeries, and less fluid replacement. Skin grafts and flaps are reported to take more completely and more rapidly. The same mechanisms may apply in ischemic problem wounds such as infected diabetic extremities. Contraindications and side effects are described. Hyperbaric oxygen will not heal normal wounds more rapidly but may, under certain circumstances, induce problem wounds to heal more like normal ones.

Microsurgical free-tissue transfer in the elderly patient.

Abstract: During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as "elderly." There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).

The Effect of Carbon Dioxide Laser Surgery on the Recurrence of Keloids

Abstract: The efficacy of carbon dioxide laser excision as a primary modality for the treatment of keloids was evaluated This retrospective study focuses on 31 patients with one or more keloids, 23 of whom were available for follow-up after carbon dioxide laser excision The patients' ages ranged from 5 to 72 years There were 16 females and 7 males One patient was Caucasian, 22 patients were non-Caucasian, and there were no Asians The keloids that were excised ranged in size from 1 to 30 cm in greatest diameter One patient had no recurrence of her keloid after carbon dioxide laser excision, 9 patients required steroids to suppress recurrences, and 13 patients were considered failures Reasons for the failure of this modality, as well as speculation regarding the future of this procedure, are discussed

Experience with 50 free TRAM flap breast reconstructions.

Abstract: The data from the first 50 patients undergoing free TRAM flap breast reconstruction in two units were examined. Average patient age was 42 years, and average weight was 62 kg. Forty percent of patients were chronic smokers, and 26 percent had low abdominal scars. Twelve percent exercised their abdominal muscles regularly. Eighteen percent had undergone radical mastectomy, whereas 76 percent had undergone modified radical mastectomy and 6 percent had undergone subcutaneous mastectomy. Postoperative radiotherapy had been given in 16 percent of patients, and 54 percent had received postoperative chemotherapy. The average time from mastectomy was 32 months, whereas six breasts were reconstructed immediately. Average operating time was 5.6 hours, and average blood loss was 2.4 units. Average hospital stay was 11.2 days. Complications included three total flap losses (6 percent) and two partial flap losses (4 percent). Abdominal hernia occurred in two patients (4 percent).

An epidemiologic survey of facial fractures and concomitant injuries

Abstract: A 5-year review of facial fractures and concomitant injuries at a level 1 trauma center is presented. The anatomic location of the facial fractures, age and sex of the patients, cause of injury, and associated systems injuries are presented. The majority of facial fractures were found in males; the most prevalent age range was 16 to 30 years. Mandible fractures outranked zygomatic and maxillary fractures (6:2:1). Assaults and motor vehicle accidents were the most frequent causes of facial fractures, and lacerations followed by neurologic and orthopedic injury were the most frequently encountered concomitant injuries. Motor vehicle accidents were the most frequent cause of associated injury.

Ectatic blood vessels in port-wine stains lack innervation: possible role in pathogenesis.

Abstract: The innervation pattern of port-wine stains was investigated using indirect immunohistochemistry with antibodies to protein gene product 9.5 (PGP 9.5), neuron-specific enolase (NSE), calcitonin gene-related peptide (CGRP), and neurofilament (NF). The pathologically dilated vessels in the middle and deep dermis were found to have defective innervation with only single or no nerve fibers in their vicinity, while other structures in the skin showed a normal density of fibers. NSE- and PGP-like immunoreactive (-LI) nerve fibers were observed innervating vessels with a normal morphology and other structures in the skin, such as sweat glands and hair follicles, as free nerve endings and in nerve bundles. The nerve bundles were often seen to pass the ectatic vessels without giving off any branches. CGRP-LI nerve fibers were detected running toward epidermis, whereas no fibers were found around the ectatic vessels. NF-LI fibers were seen innervating normal vessels in dermis, while in relation to the dilated vessels, no or only occasional fibers were observed. The lack of innervation may be of importance for the development of the disease as a result of decreased tonus of the vessels and/or a loss of neuronal trophic factors.