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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The predictive value of electrodiagnostic studies in carpal tunnel syndrome.

In recent years, electrodiagnostic studies have become an expected component in the work up and evaluation of carpal tunnel syndrome. We conducted a retrospective review of 460 carpal tunnel decompressions to determine whether the accuracy of diagnosis and the prediction of therapeutic outcome could be related to the positivity and severity of findings on preoperative electrical studies. The 349 patients (460 hands) were divided into two groups: group 1 consisted of hands with the clinical diagnosis of carpal tunnel syndrome but with normal electrodiagnostic studies (n = 62); in group 2 the hands had a clinical diagnosis of carpal tunnel syndrome with confirmatory electrodiagnostic studies (n = 398). The number and distribution of signs and symptoms of carpal tunnel syndrome were not statistically different between these two groups. There was not a statistically significant difference in the success rate of surgery or the incidence of complications. The similarities between these two groups suggests that the distinction between them (the positivity of electrodiagnostic studies) is an artificial one and that the clinical diagnosis of carpal tunnel syndrome is sufficient to predict the presence of the disease, as well as outcome of surgery. On the basis of these data, strict adherence to electrodiagnostic studies to confirm the diagnosis will exclude 13 percent of the patients with legitimate carpal tunnel syndrome from receiving appropriate therapy.

Crescent mastopexy and augmentation.

We have defined a group of patients with a lesser degree of moderate breast ptosis whose ptosis correction is not adequately improved by augmentation alone but requires some elevation of the nipple-areola complex. We have selected the crescent excision mastopexy to provide this additional needed lift. Experience with 26 patients employing this technique has helped to define the indications and limitations for this approach. It seems to adequately provide the additional needed lift when nipple descent has been no more than 1.5 to 2 cm below the inframammary crease. Complications such as scar widening (46 percent) were reviewed, but seemed to be well tolerated by the patients.

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.

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.

Resolution of experimental microvascular spasm and improvement in anastomotic patency by direct topical agent application.

This two-part study investigated the topical treatment of vasospasm in the tail arteries of rats. In part A, an epinephrine-induced model of vasospasm was used to study a variety of vasodilating agents with actions on at least five different sites in the contractile mechanism of the vascular smooth-muscle cell. The most effective commercially available agents evaluated in this part of the study appeared to be 20% lidocaine and Thorazine (25 mg/ml). In part B, a model was established in which epinephrine-induced vasoconstriction was found to significantly impair anastomotic patency. Thorazine was shown to improve the patency rate of vessels in this setting, and it was found to be superior to 20% lidocaine in improving anastomotic patency.

Outcome analysis of reduction mammaplasty.

In an attempt to obtain objective analysis of outcome in reduction mammaplasty patients, a retrospective study was done for women having elective bilateral reduction mammaplasty. Participants were chosen from a pool of over 200 consecutive reduction mammaplasty patients at the University of Missouri-Columbia. Of those eligible for inclusion, 72 met the criteria and were available for long-term follow-up. These patients answered a panel of questions regarding weight change, brassiere size, exercise, activity level, symptoms, and a personal appraisal of appearance. Statistical analysis was done to evaluate the change in each variable in relationship to the time of surgery, i.e., before surgery, 6 months after surgery, and at the present time. The findings revealed a significant stable reduction of breast mass. The women reported a significant reduction of symptoms that had been associated with their macromastia. They also reported a significant increase in exercise and other physical and social activities.