Bone-lengthening for symbrachydactyly of the hand with the technique of callus distraction.

BACKGROUND: Bone-lengthening in the hand and foot is a relatively new application for distraction osteogenesis. We present the operative treatment and postoperative outcome for four patients with M ller type-D symbrachydactyly of the hand who underwent metacarpal lengthening with use of a distraction device to establish pinch function. METHODS: Four patients who underwent distraction osteogenesis for the treatment of congenital symbrachydactyly of the hand were evaluated over a thirteen-year period. The nondominant right hand was treated in two patients, and the nondominant left hand was treated in the other two. The patients included three boys and one girl; all patients had the operation between the ages of five and eleven years. Distraction osteogenesis was performed on the fifth metacarpal in one patient and on the fourth and fifth metacarpals in the remaining three, in whom both bones were lengthened simultaneously with use of a single device. Postoperative bone elongation was analyzed with radiographs made at the time of removal of the distractor. The sensory function of the treated fingers and any growth disturbance of the distracted bones were evaluated. RESULTS: The mean duration of distraction was 37.3 days (range, thirty-two to forty-nine days), and the distractor was removed at a mean of eighty-four days after surgery. The bones were lengthened by a mean of 22.3 mm (81.6% of their original length) at a rate of 0.6 mm/day. Pinch function was improved in all patients. CONCLUSIONS: On the basis of our limited experience, we found that distraction osteogenesis of the metacarpals was an effective technique for the establishment of pinch function. We also found that an intramedullary Kirschner wire could maintain the alignment of the osteotomized bone. Although distraction requires a longer treatment period, it is apparently more effective than bone-grafting in terms of achieving adequate bone length. Simultaneous lengthening of two metacarpals also was found to be an effective technique.

A case of midline cervical cleft.

Midline cervical cleft is a rare congenital developmental anomaly of the ventral neck. Less than 100 cases have been reported in published journals to date (Ayache et al., 1997). It is usually found as congenital scar-like skin defect or cord-like contractive abnormality of the skin at the ventral neck. Unlike "median cervical cyst" or "lateral cervical cyst" midline cervical cleft usually has no anatomical association with the hyoid bone. We will present a case of midline cervical cleft without fistula but with very small protuberant tissue. The subject was operated at the age of 5 months. We will discuss the clinical aspect and surgical management of this infrequent anomaly.

Subcutaneous pleomorphic adenomas in two different areas of the face.

A 41-year-old woman developed two subcutaneous pleomorphic adenomas on her face. Pleomorphic adenoma usually arises as a benign tumour of a major salivary gland and often develops multifocally within the gland. These two pleomorphic adenomas originated in the subcutaneous layer of the face, also multifocally. They were excised, she made a good recovery, and she had no signs of recurrence a year later.

Combined usage of hydroxyapatite and cross-finger flap for fingertip reconstruction.

Reconstruction for fingertip defects categorized as Type 3 and Type 4 in Allen's classification is challenging, because surgeons need to reconstruct not only the pulp but also great parts of the distal phalangeal bone. This paper introduces an original technique for the reconstruction of defects of these types. The defects of seven fingers (two small fingers and five index fingers) of seven patients (three males and four females; aged 14-44 years) were repaired. After the fingertip is divided in a fish-mouth fashion to expose the stump of the distal phalangeal bone, a curved block of hydroxyapatite is grafted to fill the phalangeal defect and straighten the nail bed. A rectangular flap is raised from the dorsal side of the neighbouring finger in the region between the PIP and DIP joints. Then the fish-mouth region carrying the grafted hydroxyapatite is covered with the rectangular flap to reconstruct the pulp. The rectangular cross-finger flap is separated 3-4 weeks postoperatively. In all seven cases, the flap survived completely. Infection developed in no case. In all cases, aesthetic appearance of the pulp and nail presented improvement, satisfying the patients. Combined usage of hydroxyapatite and a cross-finger flap from the neighbouring finger is an effective method for the reconstruction of type 3 and type 4 defects in Allen's classification.

Kimura disease: diagnostic imaging findings and surgical treatment.

We have encountered 11 cases of Kimura disease, comprising 10 males and 1 female. The ages at presentation ranged from 16 to 48 years, with a mean of 31.5 years. The sites of the subcutaneous masses were bilateral posterior auricular regions in two cases, frontal region in two cases, temporal region in two cases, head region in one case, parotid region in two cases, parotid and temporal regions in one case, and left earlobe in one case. The interval from onset to surgery ranged from 1 to 10 years, with a mean of 4.7 years. For diagnostic imaging, a combination of magnetic resonance imaging (MRI) and ultrasonography had a high diagnostic value. MRI depicted abnormalities at sites in contact with bone, such as posterior auricular regions, and sites with abundant soft tissue, such as parotid and cheek regions. Diffuse atrophy of subcutaneous fat was observed at the sites of the masses. On ultrasonography, the interior of lymph nodes was homogeneous and hyperechoic, whereas the periphery was hyperechoic, and blood vessels entering lymph nodes were clearly depicted. Surgery was performed in all cases. Postoperative adjuvant radiotherapy was conducted in one patient and radiotherapy and steroid therapy in one other patient. There were two relapses, and both were excised by repeated surgery. Surgical excision of the subcutaneous mass in Kimura disease has the advantages that the treatment period is short and precise histopathologic diagnosis can be obtained.

Multicenter study of wound healing in neurofibromatosis and neurofibroma.

Based on clinical experience, the senior author has become convinced that wounds produced to correct the deformities of patients with neurofibromatosis (NF-1) have produced remarkably good scars, the interesting feature being that progression to keloid or hypertrophic scar is rare. The other point noted was that this situation did not change, no matter the patient's race or skin color. There have been few reports describing or discussing this hypothesis. The purpose of this study was to investigate whether wounds produced in the patients with NF-1 produce keloid or hypertrophic scars. The patients with solitary neurofibroma were also included in this study; these were compared with the NF-1 group. This was conducted as a multicenter study. Patients with neurofibromatosis/solitary neurofibroma, who were operated on from 1990 to 2000, were evaluated by reviewing their medical charts and photographs retrospectively. The patients were treated in centers from five different countries. The analysis was undertaken based on the following points: 1) age and sex at surgery; 2) race of the patients; 3) past and family histories of hypertrophic scar and keloid; 4) surgical site(s); 5) diagnosis, NF1 or solitary neurofibroma; 6) surgical complications; 7) number of reoperations to manage the complications; 8) adjuvant therapy for the tumor; 9) depth of the tumors; and 10) incidence of malignant degeneration. A total of 101 cases with neurofibromatosis or solitary neurofibroma was analyzed. The age at surgery ranged from 1 year 6 months to 74 years; sex ratio was 47 males and 54 females. The racial distribution of the patients was 13 white, 13 black, 3 Hispanic, and 58 Asian. There was no past or family history of hypertrophic scar or keloid. The surgical sites were head and neck in 70 cases, trunk in 20 cases, upper extremities in 22 cases, and lower extremities in 20 cases. The clinical diagnosis was NF-1 in 57 cases, solitary neurofibroma in 35 cases, plexiform neurofibroma in four cases, and no distinct clinical diagnosis in five cases. There were no other types of neurofibromatosis. Hematoma and white wide scar were the main postoperative complications found in six cases of NF-1. Infection was also noted in four cases. However, no patient developed hypertrophic scar or keloid in the neurofibromatosis group, whereas two cases showed hypertrophic scar in the solitary neurofibroma group. The outcome showed that the patients with NF-1 and plexiform neurofibroma, no matter the racial group, produce good scars without keloid or hypertrophic changes, whereas solitary neurofibroma has a potential to cause hypertrophic scar.

Free dorsal middle phalangeal finger flap.

Three patients underwent finger reconstruction using free dorsal middle phalangeal finger flaps (DMF flaps). All flaps survived. The free DMF flap relies on blood flow from the dorsal branches of the digital artery and is harvested from the skin on the dorsum of the middle phalanx. The digital artery gives rise to four dorsal branches; two in the middle and two in the proximal phalangeal regions. The flap is based on the dorsal branch of the digital artery that passes near the center of the phalanx. The characteristic feature of the free DMF flap is that the dorsal cutaneous veins are used as drainage vessels. Unlike island flaps, blood congestion does not occur after free DMF flap surgery. Sensibility of the free flap may be obtained by inclusion of the dorsal branches of the digital nerves in the flap pedicle. Loss of the digital artery at the donor site can be circumvented with venous grafting. Surgery under brachial plexus block is an advantage of this flap. The free DMF flap is a useful technique for skin and soft-tissue defects.

Primary intrapelvic lymphaticovenular anastomosis following lymph node dissection.

Lymphedema of lower extremities occurs following surgical resection of malignant tumors and intrapelvic lymph node dissection and is a long-term problem for patients. We performed primary intrapelvic lymphaticovenular anastomosis to prevent postoperative leg lymphedema. The procedures were conducted in 7 patients (aged 35-61 years) with cancer of the uterine body. After completion of hystero-oophorectomy and intrapelvic lymph node dissection, the afferent lymphatics entering internal and external iliac lymph nodes were end-to-end anastomosed with branches of the deep inferior epigastric veins. The time taken for constructing 4 anastomoses was 100 to 120 minutes. The follow-up period ranged from 10 to 18 months (mean, 14 months). All patients were discharged and are independent in daily living. Apart from mild leg lymphedema in 1 patient, no lymphedema was observed in other patients up to the last follow-up. This surgical modality is effective in preventing lymphedema in lower extremities after intrapelvic para-aortic lymph node dissection.

Defining vascular supply and territory of thinned perforator flaps: Part II. Superior gluteal artery perforator flap.

BACKGROUND: Superior gluteal artery perforator flaps are surgical options in breast and pressure sore reconstructions. Based on the recipient site, primary thinning of these flaps may be necessary for final optimal contour. As the thinning of a superior gluteal artery perforator flap should be based on the knowledge of perforator vascular territories to prevent vascular compromise, the authors performed an anatomical study to determine the number, location, and diameter of the perforators present in the superior gluteal artery perforator flap. Accompanying veins and acceptable locations for surgical incisions were also determined. METHODS: Fourteen superior gluteal artery perforator flaps were harvested from seven cadavers. Perforator flaps were thinned to 8 to 15 mm, except for a 2.5-cm radius around the dissected perforator. Vascular territory areas were quantified before and after thinning by photographic and radiographic methods, and respective vascular territory maps were constructed. Surgical incision "danger zones" of vertical and horizontal axes were determined at specific depths (relative to the skin surface) for each flap. Danger zone measurements were determined with an automatic three-dimensional vascular tree construction using computed tomographic images and several modeling algorithms. RESULTS: Mean perforator artery diameter and number at the fascia level were 0.91 +/- 0.07 mm and 2.86 +/- 0.77 (mean +/- SD), respectively. Perforator pedicles were located midway between the posterior superior iliac spine and the greater trochanter. After thinning, skin surface and whole flap vascular territories were reduced 80.9 percent (photographic) and 76.9 percent (radiographic), respectively, compared with unthinned vascular territory areas. From the skin at 4-, 6-, and 8-mm thicknesses, elliptical danger zones (two vertical segments and two horizontal segments) had overall vertical segment axis length ranges from the pedicles of 59 to 66 mm, 51 to 57 mm, and 49 to 51 mm, respectively. Horizontal axis segment length ranges were 61 to 76 mm, 61 to 66 mm, and 60 to 57 mm for 4-, 6-, and 8-mm skin thicknesses, respectively. CONCLUSIONS: The superior gluteal artery perforator flap provides an excellent blood supply to adipose tissue but may be compromised when aggressively thinned. Surgeons may design and harvest partially thinned superior gluteal artery perforator flaps based on the anatomical vascular territory maps provided by this study.

Defining vascular supply and territory of thinned perforator flaps: part I. Anterolateral thigh perforator flap.

BACKGROUND: The anterolateral thigh perforator flap is increasingly being used for trauma and reconstructive surgical cases. With the thinned flap design, greater survivability and a decrease in donor-site morbidity are observed. To increase our knowledge of the vascular territories in these flaps, an anatomic study was performed to determine pedicle number, location, and diameter; accompanying veins; vascular territory; and where surgical incisions can be made safely during thinning, as opposed to the "danger zone." METHODS: Thirteen anterolateral thigh perforator flaps were harvested from seven adult cadavers. The largest perforator arteries were cannulated, and flaps were thinned to a thickness of 6 to 8 mm, with a 2.5-cm radius from the perforator retained. Vascular territories were quantified before and after thinning by nonradiographic and radiographic methods. A series of dyes were injected: red dye for skin (photography) followed by Omnipaque for the whole flap (radiography) before thinning, and blue dye for skin (photography) and lead oxide for the whole flap (radiography) after thinning. Pedicle locations were determined by ratios of anatomical landmarks. Danger zone measurements were derived at specific thicknesses using lateral radiographs of each flap. RESULTS: In anterolateral thigh perforator flaps, the mean perforator artery diameter at the fascia level was 1.00 +/- 0.08 mm (range, 0.84 to 1.11 mm) and the mean number of perforator arteries was 1.69 +/- 1.03 (+/-SD). Perforator pedicles were located near the midpoint of the line between the anterior superior iliac spine and the lateral aspect of the patella in the vertical axis. The mean vascular territories were 256 +/- 52.5 cm2 (photography) and 351 +/- 72.8 cm2 (radiography) in unthinned flaps and 211 +/- 65.7 cm2 (photography) and 289 +/- 106.6 cm2 (radiography) in thinned flaps. Differences in overall vascular territories after thinning were 83.3 percent (photography) and 81.8 percent (radiography) compared with unthinned flaps. Four respective vascular territory maps were drawn showing surgical territories using percentile confidence intervals (98th and 90th) and averages. From the skin at thicknesses of 4, 6, and 8 mm, the 98th percentile danger zones were 33 to 37 mm (proximal to distal), 30 to 35 mm, and 27 to 31 mm from the pedicle in the vertical axis, respectively; in the horizontal axis, they were 30 to 34 mm (medial to lateral), 28 to 31 mm, and 25 to 29 mm. CONCLUSIONS: These data define anterolateral thigh perforator flap pedicle location, number, and diameter before harvesting, surgical danger zones during thinning, and vascular territories after thinning. The authors' guidelines provide surgeons with anatomical vascular territory maps to design and harvest specific flaps for optimal results.

Indication for and surgical outcomes of the distraction method in various types of craniosynostosis. Advantages, disadvantages, and current concepts for surgical strategy in the treatment of craniosynostosis.

BACKGROUND: Various surgical techniques for the treatment of craniosynostosis using distraction devices have been described over the last few years and we have applied these procedures in seven patients with varying types of craniosynostosis. The aim of this report is to clarify the advantages and disadvantages of these surgical methods and to discuss current concepts for the surgical strategy in the treatment of craniosynostosis. MATERIAL AND METHODS: From January 2001 to March 2003, 25 patients with craniosynostosis were examined. Among them, 7 patients, 5 with Apert syndrome, 1 with Crouzon disease, and 1 with multiple-synostosis, underwent surgical treatment using the distraction method with internal distraction devices, according to our treatment strategy for craniosynostosis. All patients underwent preoperative and postoperative evaluations, which included the patient's neurological state, developmental quotient (DQ), and three-dimensional CT (3D-CT). RESULTS: The timing of the procedures undertaken was between the ages of 1 year 5 months and 12 years 6 months (mean age 4 years 11 months). Five patients had received previous treatment and this procedure was used as a secondary operation. Postoperative distraction distances varied from 7 to 20.5 mm (mean distraction distance: 14 mm). Satisfactory cranial volume expansion and aesthetically pleasing morphological states were achieved in all cases. Regarding complications, one patient required re-operation because of dislocation of the device and skin erosion caused by infection around the penetrated wound. Finally, in a second patient a distortion of the device occurred, but no re-operation was needed. CONCLUSION: The advantage of the distraction method is its applicability for Toddler or Elder Children Calvarial Reconstruction to correct cosmetic and functional problems. One disadvantage is the difficulty in using it for Infantile Calvarial Normalization because of thin calvarial bones and the necessity for re-operation to remove the device, which may result in it becoming a "fixation procedure," essentially contraindicated for the fast-developing brain and calvarias. However, the efficacy of this procedure is that the many advantages outweigh the disadvantages as sufficient calvarial expansion and good results using the distraction method, especially in toddler and elder children age groups, can be achieved.