Perforator-Guided Drug Injection in the Treatment of Abdominal Wall Pain.

BACKGROUND: Pain from the abdominal wall can be caused by nerve entrapment, a condition called abdominal cutaneous nerve entrapment syndrome (ACNES). As an alternative to surgery, ACNES may be treated with injection of local anesthetics, corticosteroids, or botulinum toxin at the point of maximal pain. METHOD: The point of maximal pain was marked on the abdominal skin. Using color Doppler ultrasound, the corresponding exit point of perforating blood vessels through the anterior fascia of the rectus abdominis muscle was identified. Ultrasound-guided injection of botulinum toxin in close proximity to the perforator's exit point was performed below and above the muscle fascia. RESULTS: The technique was used from 2008 to 2014 on 15 patients in 46 sessions with a total of 128 injections without complications. The injection technique provided safe and accurate administration of the drug in proximity to the affected cutaneous nerves. The effect of botulinum toxin on ACNES is beyond the scope of this article. CONCLUSION: Perforator-guided injection enables precise drug administration at the location of nerve entrapment in ACNES in contrast to blind injections.

Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study.

BACKGROUND: The current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping. METHODS: Twenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed. RESULTS: First appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps. CONCLUSION: This study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov with identifier NCT02806518 .

Free Vascularized Fibula Graft as Primary Salvage Procedure for Acute Cervical Osteomyelitis Caused by Epidural Abscess.

Acute cervical osteomyelitis due to an epidural abscess and pyogenic spondylodiscitis in an immunosuppressed patient with progressive myelopathy is a challenge for the reconstructive surgeon. This report presents our novel approach to treat such a condition in a 56-year-old patient in whom antibiotic treatment and decompression of the medulla by laminectomy of C4-C6 failed. Under general anesthesia, debridement of all infected tissue, including anterior corpectomy of C4-C6, was performed. Simultaneously, a free vascularized fibula graft (FVFG) was harvested, adapted to the bone defect, and anastomosed to the superior thyroid artery and external jugular vein. The graft was stabilized with an anterior plate. A scheduled posterior stabilization was performed 1 week later. Staphylococcus aureus was cultured from bone samples and was treated with antibiotics. The postoperative course was uncomplicated besides a dorsal midline defect 6 weeks postoperatively that was closed with a sensate midline-based perforator flap. Five years on, the patient is infection free, and regular control computed tomography and magnetic resonance imaging scan images show progressive fusion and hypertrophy of the fibula to C3/C7 vertebrae. An FVFG combined with posterior stabilization could be a promising primary salvage procedure in cases with progressive myelopathy caused by acute cervical osteomyelitis due to spinal infection. The FVFG contributes to blood circulation, delivery of antibiotics, and an immunological response to the infected wound bed and can stimulate rapid fusion and hypertrophy over time.

The Value of Dynamic Infrared Thermography in Pedicled Thoracodorsal Artery Perforator Flap Surgery.

Dynamic infrared thermography (DIRT) is a noninvasive imaging technique that can provide indirect and real-time information on skin perfusion by measuring skin temperature. Although used in flap surgery, there are no reports on its value in procedures using a pedicled thoracodorsal artery perforator (TDAP) flap. The aim of this study was to assess the usefulness of DIRT in preoperative perforator mapping and in monitoring intra- and postoperative flap perfusion of pedicled TDAP flaps. METHODS: This prospective study comprised 21 patients (21 flaps) scheduled for reconstructive surgery with a TDAP flap. Perforator mapping was done by DIRT, handheld unidirectional Doppler ultrasound, and computer tomography angiography. Intra- and postoperative flap perfusion was assessed by clinical signs and with the use of DIRT and handheld unidirectional Doppler ultrasound. RESULTS: Perforator mapping with DIRT showed that first-appearing bright hotspots were always associated with arterial Doppler sounds and suitable perforators intraoperatively. Computer tomography angiography presented useful information on the thoracodorsal artery branching pattern but was less beneficial for perforator mapping. Intra- and postoperative flap monitoring with DIRT was more useful than handheld unidirectional Doppler ultrasound and clinical signs to detect early arterial and venous perfusion problems. DIRT demonstrated that TDAP flap perfusion is a dynamic process with an increase in perfusion during the first operative days. Nineteen flaps survived, of which 3 sustained distal necrosis. Two flaps were lost due to inadequate blood perfusion. CONCLUSION: DIRT provides valuable real-time information for perforator mapping and for monitoring TDAP flap perfusion intra- and postoperatively.

Triple Use of Autologous Amnion Graft in the Treatment of Meningomyelocele and Split Cord Malformation.

This article describes the triple use of autologous amnion graft as a new procedure in the treatment of myelomeningocele and in myelomeningocele with split cord malformation. The first amnion graft was used as a physical and mechanical barrier to protect the myelomeningocele (MMC) from desiccation and mechanical stress directly after birth. A second graft was used as a dura substitute to close the cerebrospinal fluid compartment. Autologous amnion seems to be the ideal dural graft for closure of an MMC and for an MMC with split cord malformation. A tension-free and watertight closure was obtained. With the epithelium side placed to the spinal cord and due to its beneficial effect on scar formation, the risk for tethering cord syndrome is reduced when using autologous amnion as a dural graft. The regenerative properties of autologous amnion may contribute to repair neural damage. Finally, a third amnion graft was placed beneath the perforator flap used to close the skin defect to provide a watertight barrier and to stimulate flap survival.

The sensate medial dorsal intercostal artery perforator flap for closure of cervicothoracic midline defects after spinal surgery: an anatomic study and case reports.

Complex cervicothoracic midline defects after spinal surgery are traditionally treated with the use of muscle and myocutaneous flaps. The authors introduce the sensate medial dorsal intercostal artery perforator flap as an alternative treatment for these defects. Following an anatomic study, the use of the flap is illustrated with 3 case reports. This well-vascularized flap is easy to harvest and causes minimal donor site morbidity. It can provide enough volume to obliterate dead space. Inclusion of the cutaneous nerve gives protective sensibility to the reconstructed area.

The value of dynamic infrared thermography (DIRT) in perforatorselection and planning of free DIEP flaps.

The aim of this paper is to evaluate dynamic infrared thermography (DIRT) as a technique to assist in preoperative perforator selection and planning of free deep inferior epigastric perforator (DIEP) flaps. Twenty-seven patients, scheduled for secondary autologous breast reconstruction with either a free DIEP flap or superficial inferior epigastric artery flap, were included in this prospective clinical study. Preoperative mapping of perforators was performed with a hand-held Doppler and DIRT. A multidetector computer tomography scan was additionally carried out in the last 8 patients. In 23 patients a DIEP flap was used. The perforator as selected from DIRT was a suitable perforator in all DIEP flaps. The location and quality of the selected perforator from DIRT corresponded well with the multidetector computer tomography scan results. Preoperative perforator selection and planning of DIEP flaps is facilitated with the use of DIRT. The technique is noninvasive and easy to use.

Intrathoracic Breast Transposition: A New Method in the Treatment of Bronchopleural Fistula and Empyema.

A bronchopleural fistula (BF) is a life-threatening complication. Optimal management of a BF is still debated although surgery remains the preferred treatment. Usually, the fistula is a result of inadequate healing at the bronchial stump after pneumonectomy. Successful closure of a BF after pneumonectomy depends on evacuation of empyema, coverage of the suture line after fistula closure with vascularized tissue, and obliteration of the residual pleural cavity. Extrathoracic muscles and omentum are the first choice for intrathoracal transposition. We report a unique case of a cachectic female patient with a BF from the left main stem bronchus complicated with empyema following right-sided pneumonectomy. Previous surgeries excluded the use of extrathoracic muscles or only omentum. The BF could not be closed with sutures. Using a parachute technique, omentum was sutured into the fistula opening resulting in a tension-free fistula closure. A well-vascularized breast was transposed into the residual pleural cavity to obliterate dead space and to support the omentoplasty, so it would be able to withstand changes in intrathoracic pressure. The postoperative course was uneventful. Tension-free closure of a BF can be obtained by suturing well-vascularized tissue into the fistula opening using a parachute technique. Intrathoracic breast transposition could be a new option in the treatment of a BF and associated empyema in a female patient. In selected patients, a large breast can obliterate the dead space after pneumonectomy and support the omentoplasty.

[Soft tissue defects treated with perforator flaps]. / Behandling av bløtdelsdefekter med perforatorlapper.

BACKGROUND: Treatment of soft tissue defects caused by trauma, tumour surgery or pressure sores is a challenge to the reconstructive surgeon. Although contour and function may be restored by tissue transposition, traditional methods often cause significant donor site morbidity. This article describes how increased understanding of vascular anatomy has led to the development of new techniques. MATERIAL AND METHODS: The article is based on textbooks of plastic surgery, selected articles and own clinical experience. RESULTS AND INTERPRETATION: Pedicled and free perforator flaps represent the latest development in surgical treatment of soft tissue defects. The use of perforator flaps can considerably reduce the disadvantages that are associated with other surgical methods. The use of perforator flaps demands microsurgical skills, but has many advantages. Reliable vascular supply and a good aesthetical result can be combined with minimal donor site morbidity. In many cases this technique may even give sensibility to the reconstructed area.

Ultrasound-guided Sympathetic Block of the Radial Artery with Botulinum Toxin to Treat Vasospasm.

Vasospastic disorders in the hand have been treated with surgical sympathectomy and recently with botulinum toxin A (BTX) injections in the palm. The purpose of this study was to evaluate if it is possible to obtain precise administration of BTX around the radial artery using a single ultrasound-guided injection. We present a novel technique using 1 single ultrasound-guided BTX injection around the radial artery to treat vasospastic symptoms. Ten patients were included in a pilot study. All patients were referred by a rheumatologist after been diagnosed with primary or secondary Raynaud. Under ultrasound guidance, BTX was injected around the radial artery and its comitant veins 3-5 cm proximal to the wrist. Ultrasound-guided injection of BTX allowed for a precise distribution of BTX into the perivascular space of the radial artery and its comitant veins. Intravascular injection could easily be excluded. One patient reported temporary reduced grip strength, most likely due to leakage of BTX to the flexor pollicis longus muscle. No other complications were registered. All patients reported reduced number of vasospastic episodes, warmer hands, and reduced pain. Ultrasound-guided injection enables precise administration of BTX in the space surrounding the radial artery and its comitant veins. This novel approach could be a promising treatment for vasospastic disorders of the hands in patients with primary and secondary Raynaud.

The distribution of hand fractures at the university hospital of north Norway.

BACKGROUND: The objective of this study was to describe the fracture pattern for hand fractures in the Arctic region of Norway. MATERIALS AND METHODS: Using the hospital's radiological information system and picture archiving and communication system all traumatic hand fractures in the year of 2010 were registered. Fractures in the carpal, metacarpal, and phalangeal bones were included in the study. RESULTS: A total of 593 patients with 691 fractures including 80 carpal, 200 metacarpal, and 411 phalangeal fractures were registered. The most commonly affected bone was the 5th metacarpal bone with a total of 99 fractures (14%), 22 of these (22%) were classified as subcapital or "boxer's fracture". Among male patients, the highest frequency of fractures was seen in the age group 10-60 years with a peak between 10-24 years. Adult female patients had most fractures in the age group 50-70 years. Generally, there were no seasonal variations, although a marked decrease of fractures could be seen in December. Triquetral fractures were more common during the winter season. Falling was the most common trauma mechanism. CONCLUSION: With a few exceptions, hand fractures were not related to particular seasons or weekdays in this material. The distribution of hand fractures was related to age and gender, and some trauma mechanisms were dominating.

Closure of Complex Posterior Midline Defects After Spinal Surgery With Sensate Midline-based Perforator Flaps and the Long-term Results.

STUDY DESIGN: Prospective study. OBJECTIVE: Evaluating the use of a midline-based perforator flap for closure of complex midline defects after spine surgery complicated with implant exposure and deep subfascial infection. SUMMARY OF BACKGROUND DATA: Traditionally, muscle flaps are used to close complex defects after spine surgery complicated by exposed spinal implants and deep subfascial infections. There are no reports on the long-term results on the use of perforator flaps to close these defects. METHODS: Information was prospectively registered of all patients in whom a medial dorsal intercostal artery perforator (MDICAP) flap was used for closure of a complex midline defect with exposed spinal implant and deep subfascial infection after spine surgery. RESULTS: In 9 patients, 10 MDICAP flaps were used. All flaps survived with only 1 flap experiencing marginal flap necrosis. The flaps provided stable coverage of all defects and spinal instrumentation could be retained in all patients. The perforator flaps provided in all patients, except in the patient with a meningomyelocele, protective sensibility in the reconstructed areas. The mean postoperative hospital stay after closure of the defects was 10 days (range 4-21). During follow-up (mean 65 mo, range 7-106) only 1 patient developed an infection in the operated area which occurred 81 months postoperatively. None of the patients had any functional loss at the donor site of the flap. CONCLUSION: The medial dorsal intercostal artery perforator flap seems to be a reliable alternative for treatment of complex midline defects with exposed spinal implants and deep subfascial surgical site infections. Protective sensibility may be obtained in the reconstructed area with this flap. Donor site morbidity is minimal. In case of recurrence, complex reconstructive procedures using muscle flaps are still possible. The use of this perforator flap may contribute to shorter hospital stays and reduction of costs. LEVEL OF EVIDENCE: 4.