Lymphangioplasty: a ten year evaluation.

Sixteen patients with refractory primary and secondary lymphedema have had multifilament Teflon wick lymphangioplasties during the past 10 years. There were no operative deaths or operative complications. All patients experienced an early reduction of their edema, with objective improvement lasting 6 months to 5 years. The average duration of benefit was 13 months. Subjective improvement has lasted to 7 years. Lymphangioplasty is simple, virtually free of complications, and offers periods of control of edema and cellulitis that compare favorably with those obtained by other operative procedures. It should be considered for the management of patients with incapacitating lymphedema, especially those patients with a limited life expectancy.

Management of radiation wounds.

Radiation wounds caused by newer high-voltage radiotherapy techniques are very difficult to manage. Recent developments in flap design and transfer aid the surgeon in successfully treating these difficult problems.

Is reversed venous flow safe in free-flap transfer? A dilemma with the radial forearm flap.

The distally based radial artery forearm flap has become our workhorse flap for hand and finger coverage, relying on reversed or retrograde venous outflow through the venae comitantes. Free-flap transfer, however, has been used by us only with antegrade venous anastomoses. This study was intended to determine if a single retrograde venous anastomosis would be adequate for flap viability. Six groups of saphenous flaps were developed in New Zealand White rabbits. In situ flaps compared antegrade with retrograde venous outflow in groups 1 and 2. Microvascular venous anastomoses with antegrade or retrograde outflow were compared in groups 3 and 4. Free-flap transfer with antegrade or retrograde venous outflow was compared in groups 5 and 6. No significant differences in survival was found between groups 1 and 2. A significant difference in survival (p = 0.025) was found between groups 3 and 4, but technical differences make these groups incomparable. Significantly better survival (p = 0.014, chi-squared test) was found in group 5 with antegrade outflow versus group 6 with retrograde outflow.

Results of treatment of extensive volar wrist lacerations: the spaghetti wrist.

A series of 38 volar wrist lacerations is reviewed with regard to epidemiologic aspects and results. In general, return of tendon function was quite good, and return of nerve function in this series was also satisfying. We attribute the generally good results to immediate repair of all structures, microscopic repair of significant arterial injuries, microscopic grouped fascicular nerve repair, early mobilization (dynamic splinting and intensive occupational therapy), and a generally youthful group of patients. Review of this series has strengthened our opinion that aggressive primary repair of all injured structures is appropriate for these extensive lacerations.

A rat restraining cage for IV infusion in epigastric flap studies.

A rat restraining cage is described for use in epigastric flap studies requiring IV infusions of 24 hours or more. The device is simple, effective, and reliable; it appears to be less stressful for the rat than other methods of restraint.

Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device.

A technique for construction of external male genitalia in a transsexual patient is presented in detail. The McGregor groin flap is used for penile construction, and the Scott inflatable prosthesis is used to produce an erection. The shape of the penis is improved by secondary local excisions, and the clitoris is bivalved and inserted at the base of the penis to allow sexual sensation. The appearance and the function of the constructed genitalia have been deemed quite satisfactory by this transsexual patient.

Wound coverage using modified tissue expansion.

We describe the use of a "lacing apparatus" across large and complex wounds to accomplish wound closure. This technique utilizes the principles of tissue expansion (exploiting inherent extensibility of the skin, mechanical creep, and biologic creep) but is able to employ them in situations in which traditional tissue expansion (utilizing implantable expanders) is not practical. After preparation, the wounds are laced with large nylon suture, which is tightened on a daily basis, typically allowing closure of even massive wounds within 8 to 10 days. In this report, we describe the technical details of wound preparation, application of the lacing apparatus, and postoperative execution of the expansion leading to final wound closure. This technique is particularly valuable in the upper arm, trunk, and lower extremity but has limited application in the distal forearm and the distal third of the lower extremity.

Salvage of infected expanded scalp without loss of flap length.

This case presents the dilemma of a scalp infection emerging at the conclusion of soft-tissue expansion. Basic principles of wound infection would dictate that the foreign body (the inflatable prosthesis) be removed and that the infection be treated before inset of the flap. The prevention of possible loss of flap length due to skin contraction during treatment of the infection was avoided by stretching the flap over the intact scalp temporarily, thus maintaining its expanded status.

Microsurgical replantation of an ear in a child without venous repair.

Ear amputation can leave a devastating deformity; the application of microsurgical replantation techniques has allowed very favorable aesthetic outcomes when successful. We report a case of ear replantation in a child in whom a venous repair was not performed; instead medicinal leeches were used to decompress the ear in the immediate postoperative setting. This represents the third reported case of successful ear replantation without microsurgical venous anastomosis. A review of the literature reveals the high incidence of venous congestion requiring external decompression (57 percent) and the very high rate of salvage (80 percent) after replantation. Surgeons attempting ear replantation should be aware of the high rate of ear survival in the situation of no venous outflow (with appropriate decompression techniques) and should not abandon attempts at replantation because of the inability to establish venous outflow microsurgically.

Successful treatment of acute vascular insufficiency in a hand by intra-arterial fibrinolysin, heparin, and reserpine. Case report.

A patient is presented who presumably had multiple drugs injected intra-arterially in the right hand. Clinical signs and angiographic evidence of severe vascular insufficiency were well demonstrated. Therapy with fibrinolysin, reserpine, and heparin was followed by a return of normal circulation.

Primary closure of the donor site for the Littler neurovascular island flap transfer.

After successful transfer of the Littler neurovascular island flap, patients may be troubled by persistent problems at the donor site. We describe a technique that allows primary closure of this site, which has significantly improved appearance and sensation of the donor finger.

Microvascular angioscopy.

The desire for immediate assessment of endovascular pathology in hand and microvascular surgery has led to an investigation of the microvascular angioscope. This study evaluated three angioscopes of differing sizes and specifications to determine their ability to detect intimal lesions such as tears, crush injury, and surface clots. Studies were done in 80 Sprague-Dawley rats and in cadaveric hands. Angioscopic findings were correlated with gross and histologic inspection and found to be 100 percent accurate. We conclude that microvascular angioscopy can provide important information concerning the integrity of vessels less than 1 mm in diameter with excellent optical resolution and with minimal time expenditure.

Sleep apnea in mandibular hypoplasia.

Obstructive sleep apnea is an insidious and potentially life-threatening disorder that is probably more prevalent than has been previously diagnosed. Since there is generally some mechanism for relief of the respiratory obstruction, this is a very successfully treatable disorder. A strong index of suspicion should be held in cases of oronasal or pharyngeal abnormalities with a potential for respiratory obstruction. Loud snoring (particularly a recent change) and daytime hypersomnolence should alert us. In-hospital sleep monitoring and arterial gas measurements can provide a definitive diagnosis.

In search of the ideal female umbilicus.

The umbilicus is essential to the aesthetic appearance of the abdomen. However, little research exists on what characterizes an aesthetically pleasing umbilicus. Often, the plastic surgeon is called on to reconstruct the umbilicus. Although a variety of reconstructive methods are available, no real standards define the appearance of an aesthetically pleasing umbilicus. To ascertain the characteristics of an aesthetically pleasing umbilicus, a photographic analysis was undertaken using 147 female participants between the ages of 18 and 62 years. Each subject's age, height, and weight were recorded. Photographs of each participant's umbilicus were then taken from 30 cm and 50 cm away. The photographs were reviewed by the authors, and each umbilicus was categorized on the basis of size, shape, hooding, or protrusion. The photographs were then reviewed by a panel and given a score between 1 and 10 to rate attractiveness. Using linear regression analysis, the effects of body mass index, shape, hooding, and umbilical protrusion on attractiveness were assessed. The T- or vertically shaped umbilicus with superior hooding consistently scored the highest in aesthetic appeal, whereas the presence of any degree of protrusion and a horizontal orientation or distorted shape detracted from the score. Those with a large umbilicus tended to score consistently lower than those with a smaller configuration. A desirable goal in umbilical reconstruction is, thus, to create a small T or vertically oriented umbilicus with the addition of a superior hood or shelf.

Dynamic correction of unilateral paralysis of the lower lip.

We present a simple operation, performed under local anesthesia, to restore essential movement to the side of a lower lip paralyzed by injury to the mandibular branch of the facial nerve. The operation consists of a limited lateral resection of the paralyzed lower lip, plus transposition of the segment of orbicularis muscle from the paralyzed lower lip to the normal upper lip, through a subcutaneous tunnel.

The incidence of recurrence after endoscopic carpal tunnel release.

Endoscopic carpal tunnel release has been used to decompress the median nerve in carpal tunnel syndrome for over the past decade, with an advantage (over the traditional "open" release) being decreased pain in the postoperative period. The goals of this study were to attempt to define the recurrence rate after endoscopic carpal tunnel release and to determine if it differs from that of open technique. The charts of 191 consecutive carpal tunnel syndrome patients treated operatively at the University of Missouri were reviewed. For this study, recurrent carpal tunnel syndrome was defined as documented cases in which the symptoms had resolved following surgical release but subsequently recurred, requiring surgical rerelease of the carpal tunnel. All endoscopic releases were performed using the Chow two-portal technique. Statistical analysis was performed using Fisher's exact test. A total of 103 patient hands had open carpal tunnel releases; 88 were endoscopically released. Total follow-up time (from the initial release) averaged 29 months for the open group and 22 months for the endoscopic group. There were no recurrences in the open group and six recurrences in the endoscopic group (7 percent, p = 0.008). All six recurrences were in worker's compensation patients. The median time between endoscopic release and rerelease was 8.5 months. There seems to be a statistically higher incidence of recurrence of carpal tunnel syndrome after endoscopic release compared with the traditional "open" release in our cases. Although the pathogenesis of this increased rate of recurrence is not clear, this should be considered when planning surgical release of the volar carpal ligament for carpal tunnel syndrome.

An intraoperative stent for McIndoe vaginal construction.

We report an inexpensive, easy-to-apply vaginal stent for use in McIndoe vaginal reconstruction using Surgi-Stuf inserted in a sterile condom. This material's easy compressibility and good "memory" facilitate good apposition for the skin grafts while being easily placed into the depth of the new vaginal pocket.

Bone induction using demineralized bone in the rabbit femur: a long-term study.

While traditional bone grafting is the standard for replacement of segmental bony defects, alternative options (avoiding morbidity of autologous grafts) are attractive and continue to be sought. This study attempted to determine whether demineralized bone powder could be used reliably to replace a significant bony deficit at a weight-bearing site. The long-term functional characteristics of this induced bone were analyzed to determine whether it maintained its strength and shape and reacted normally to physiologic stress over an extended period of time (12 months). In 55 New Zealand White rabbits, a 1-cm length of femur was removed (approximately 20 percent of the total length of the rabbit femur). The femur was then reconstructed with a titanium mandibular plate, leaving the gap intact. In 38 of the animals, this gap was filled with demineralized bone powder in an attempt to induce bone to form across the defect. In group 1 (n = 23), the mandibular plate remained in place for the duration of the study (12 months). In group 2 (n = 15), the plate was removed 8 weeks after placement of the demineralized bone powder, and the animals were followed for an additional 12 months. In group 3 (n = 10), nothing was placed within the bony gap. In group 4 (n = 7), the gap was repaired with autologous bone graft. All the animals that received demineralized bone powder completely filled the osteotomy gap with new bone within 6 to 8 weeks after implantation. None of control group 3 formed bone across the gap (p < 0.001). Eighty-six percent of control group 4 (autologous bone graft) successfully formed bone across the osteotomy gap. In addition, 90 percent of control group 3 had hardware failure within 8 weeks after surgery compared with 0 percent (0 of 38) of the group that received demineralized bone powder (p < 0.001). In group 1, analysis after 12 months revealed that the bone formed ultimately became thin and easily fractured, most likely because of shielding from stress loading by the mandibular plate. In contrast, in group 2 (in which the plate was removed after 8 weeks), the bone remodeled and hypertrophied in response to the physiologic stress of weight bearing and at the end of the 12-month period was essentially identical to normal femur. In certain circumstances, reconstruction of bony defects using bone-induction techniques may be as good as autologous bone grafting, with the advantage of limiting the donor-site morbidity for the patient.

Evaluation of lymphovenous anastomoses in obstructive lymphedema.

Direct lymphovenous anastomoses were constructed in dogs with chronic obstructit on the course of the lymphedema. Early patency rates of the lymphovenous anastomoses of 100 percent related to a 32 percent decrease in the lymphedema. However, by 3 weeks, all lymphovenous anastomoses became occluded and the edema level returned to the original state or was somewhat worse. Patent lymphovenous anastomoses seem clearly capable of improving the lymphedema state. However, long-time patency was not maintained in this series. We postulate that effective decompression of the lymphedematous leg by the patent lymphovenous anastomoses results in decreased flow through the anastomoses with subsequent occlusion.

Bone formation by revascularized periosteal and bone grafts, compared with traditional bone grafts.

Three groups of dogs were studied to compare the bone formation obtained with traditional bone grafting techniques, and that obtained with revascularized periosteum or revascularized bone grafts--all in unstressed bone. Revascularized periosteum did not produce a significant amount of bone in this unstressed model. At 4 months the revascularized rib grafts had a slightly greater tolerance to stress at the callus site than traditional bone grafts, but the incidence of non-union was the same. We conclude that the use of revascularized bone grafts should be reserved for situations in which traditional bone grafting techniques are unlikely to be successful.