Successful replantation of amputated facial tissues by supermicrosurgery.

BACKGROUND: Although replantation of amputated facial segments remains challenging in reconstructive surgery, it offers excellent aesthetic and functional outcomes. METHODS: From May 2004 to October 2019, 12 patients underwent replantation of amputated facial tissues by supermicrosurgery. The case details, such as the rationale for replantation, the operation method, and postoperative therapy, are described. Four cases are discussed to demonstrate the replantation of different facial parts. RESULTS: Facial tissue replantation was successful in all 12 patients without secondary surgery. The cases included the nose (1 patient), ears (8 patients), lips (2 patients), and one of the soft tissue segments surrounding the lower jaw. Venous congestion occurred in three patients who received a solitary arterial repair and were treated with bloodletting. All patients expressed satisfaction with the cosmetic and functional results at the final follow-up. CONCLUSIONS: Supermicrosurgical facial tissue replantation is a promising and effective procedure for providing patients with the best aesthetic and functional outcomes.

A thermosensitive chitosan-based hydrogel barrier for post-operative adhesions' prevention.

Post-operative peritoneal adhesions are common and serious complications for surgeons. They can cause pelvic pain, infertility, and potentially lethal bowel obstruction. We synthesized injectable hydrogels that formed by chemical modification through grafted hydrobutyl groups to chitosan chains. Gelation of hydroxybutyl chitosan (HBC) occurs in less than 60 s. Once formed, it can also be recovered completely. The residue time of hydrogels can extend to 4 weeks in Kunming mice. HBC hydrogels showed mild cytotoxicity to mice fibroblast cell (L929) and human vascular endothelial cell (ECV-304) in vitro and were biocompatible in the murine muscles, causing no adhesions for 4 weeks. HBC gels can form a durable barrier between defected cecum and abdominal wall. In a mice sidewall defect-bowel abrasion model, HBC gels showed significant efficacy in reducing adhesion formation.

An overview of skin flap surgery in the mainland China: 20 years' achievements (1981 to 2000).

Microsurgical anatomy and clinical applications have been widely and extensively practiced throughout the mainland of China since late 1970s. During the 1980s to 1990s, Chinese surgeons and anatomists developed many new flap donor sites and modifications, most of which were published in Chinese literature. These achievements were not fully realized by the Western surgeons. In this overview, we attempt to give a brief introduction of these contributions made by the Chinese authors in the mainland. Of the new flaps first or independently described by the Chinese, most were in the limbs. These flaps can be classified into three categories. First are free flaps with a main artery trunk, such as the radial forearm flap with radial artery, the medial leg flap with posterior tibial artery, and lateral leg flap with peroneal artery. Second are reverse-flow island flaps based on distal main vascular bundles (e.g., the radial artery and venae comitantes, the ulnar, the posterior tibial, and the peroneal arteries). Third are septocutaneous perforator flaps that avoid sacrifice of the main artery trunk, which include the anterolateral thigh flap, lateral lower-leg flap, dorsoulnar flap, distally adipofascial pedicled radial forearm flap, and so on.

Reconstructed bladder innervation below the level of spinal cord injury: the knee-tendon to bladder artificial reflex arc.

BACKGROUND/OBJECTIVE: To study the effectiveness of knee-tendon to bladder artificial reflex arc in dogs. METHODS: In 6 beagles, the proximal end of the right L5 anterior motor root and the distal end of the right S2 anterior root were anastomosed to build a knee-tendon to bladder reflex, whereas the right L5 posterior sensory root was kept intact. Action potential (AP) curves and electromyograms (EMGs) of the detrusor muscle, the intravesical pressure, horseradish peroxidase (HRP)-labeled neurons, and the passing rates of myelinic nerve fibers were calculated to evaluate its feasibility. RESULTS: AP curves and EMG detected in all 6 dogs were similar to those of the control. Six and 18 months after surgery, the means for bladder contraction induced by percussion of the right knee-tendon were 38 +/- 27% and 62 +/- 5% that of the normal control, respectively. The mean duration times induced by percussion of the right knee-tendon at 6 and 18 months after surgery were 51 +/- 37% and 84 +/- 12% that of the normal control, respectively. HRP retrograde tracing and neurohistologic observation indicated the feasibility of the artificial reflex arc. CONCLUSIONS: Our data showed the effectiveness of bladder innervation below the level of spinal cord injury producing urination by knee-tendon to bladder reflex contractions, and therefore, might provide a new clinical approach for restoring bladder function in individuals with paraplegia.

Staggered rhizotomy of anterior and posterior sacral roots for bladder reservoir function in spinal cord injury: a canine experimental study and preliminary clinical report.

OBJECTIVE: To report an experimental study and preliminary clinical results of staggered anterior and posterior sacral rhizotomy for restoring function of the bladder and preventing reflex incontinence in supra-conal spinal cord injury (SCI). METHODS: Ten T10 spinal cord transected mongrel dogs were divided into three groups. In group 1 (n= 2), laminectomy only was performed (control). In group 2 (n= 4), all L7-S3 posterior roots were microsurgically cut (complete deafferentation). And in group 3 (n= 4), the L7, S1, S3 posterior roots and S2 anterior root were cut (staggered deafferentation and deefferentation). Intraoperative electrical stimulation and postoperative cystometrography (CMG) were carried out. In the clinic, three patients with spastic bladder caused by a supra conal complete SCI underwent staggered rhizotomy and were followed up for 6 years. RESULTS: In the canine experimental study, resection of the S2 anterior root combined with L7, S1 and S3 posterior rhizotomy, stimulating the S2 posterior root (four dogs) resulted in a minimal rise in pressure in the bladder and urethra, which was only about 10% of that obtained by stimulating the S2 proximal posterior root while its anterior counterpart was intact (eight dogs, Student's t-test, P < 0.01). The CMG study showed that groups 2 and 3 had similar volume/pressure curves; in both groups the tendency was to develop flaccid bladders. In the clinic, three cases underwent staggered rhizotomy of the anterior and posterior roots in S3 and S4. Good bladder reservoir and compliance was achieved over six years of follow-up. CONCLUSION: Staggered rhizotomy of the anterior and posterior sacral roots at different spinal cord levels has the same denervation effect as a complete posterior rhizotomy, and good bladder reservoir function can be achieved by this procedure.

[Clinical observations of the effects on the lower limb function after lumbar or sacral nerve root transferring to reconstruct urination function].

OBJECTIVE: To observe the effects on the lower limbs function after lumbar or sacral nerve root transferring to reconstruct urination function. METHODS: Nine patients with bladder dysfunction and normal lower limb function after spinal cord injury were treated with anastomosis the S2 or S3 nerve root with the normal lumbar or sacral nerve root to reconstruct a new bladder artificial reflex arc. Then the alterations on the sensation and motor function of the lower limb after the surgery were observed. RESULTS: Myodynamia of the legs decreased slightly, and the decreasing about half grade of the myodynamia in the plantar flexion of the ankles were detected in 4 of 9 patients with S1 transferring. And the myodynamia recovered 3 months postoperatively. No obvious decreasing of the myodynamia appeared in the other cases. CONCLUSION: No obvious effects on the motor function can be found after the single lumbar or sacral nerve root transferring to reconstruct urination function.

Reconstruction of reflex pathways to the atonic bladder after conus medullaris injury: preliminary clinical results.

Neurogenic bladder dysfunction following spinal cord injury is a major medical and social problem for which there is no ideal treatment strategy. In this study, spinal root anastomoses were performed in 10 paraplegic patients with traumatic lesions of the conus medullaris, in an attempt to reinnervate the paralyzed bladder. For the operation, the functional T11 ventral root (VR) above the lesion was transected and anastomosed to the S2 ventral roots unilaterally through a nerve graft. The T11 dorsal root was left intact as the trigger for micturition after axonal regeneration. All patients underwent urodynamic evaluation before surgery and at follow-up. The mean follow-up duration was 2 years. Of the 10 patients, 7 (70%) regained satisfactory bladder control within 18-24 months after VR microanastomosis. In these seven patients, the average bladder capacity decreased from 508 +/- 83 (mean +/- SD) to 370 +/- 59 ml, residual urine decreased from 477 +/- 98 to 35 +/- 11 ml, and urinary infections were not observed. Patients with impaired renal function experienced a full recovery. Three patients failed to show any improvement after the operation. These results suggest that a restitutive process occurs in the bladder following reinnervation from new T11 VR connections to the bladder nerves. Spinal cord lesions that may benefit from such a nerve crossover surgery are those located at the conus, whereby a functional suprasacral nerve can be connected to the sacral roots to bypass the injury in an attempt to restore central connections to the bladder.

Intraocular pressure and endothelium cell counts after cataract surgery with chitosan and sodium hyaluronate (Healon GV): 3-year follow-up results of a randomised clinical trial.

INTRODUCTION: The purpose of this study was to evaluate the long-term effects of chitosan 0.1% and sodium hyaluronate 1.4% (Healon GV(R); Advanced Medical Optics, Santa Ana, CA, USA) on intraocular pressure (IOP) and endothelial cell loss. METHODS: This randomised study comprised 140 eyes of 140 patients with age-related cataracts undergoing phacoemulsification followed by posterior chamber intraocular lens (IOL) implantation; 70 received chitosan 0.1%, and 70 received sodium hyaluronate 1.4%. The IOP was measured with standard Goldman applanation tonometry pre-operatively and 1 day, 1 week, 1 month, 3 months, 1 year and 3 years postoperatively. Endothelial cell counts were performed pre-operatively and 1 week, 1 month, 3 months, 1 year and 3 years postoperatively using a Pro/Koester WFSCM contact endothelial microscope. RESULTS: There were no significant differences found in postoperative IOP levels among the chitosan and sodium hyaluronate groups (P>0.05). No significant differences were found in postoperative mean endothelial cell counts at all time points between the chitosan and sodium hyaluronate groups (P>0.05). CONCLUSION: Chitosan has the same effects as sodium hyaluronate on IOP and endothelium cells counts after cataract surgery and IOL implantation, and therefore may be an alternative ophthalmic viscoelastic device.

Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage.

BACKGROUND: Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point. METHODS: This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap. RESULTS: The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications. CONCLUSIONS: The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.

Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle.

The distally based sural fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. Here we report on a series of cases of foot and ankle reconstruction with a modified distally based sural flap. The vascular pedicle of the flap includes an axial perforator branch of the peroneal artery and two concomitant veins. This modified distally based perforator flap, measuring around 17 x 6 cm to 30 x 10 cm in size, was transferred for coverage of foot and ankle soft-tissue defects in 7 cases. All flaps survived completely. Neither arterial ischemia nor venous congestion was noted. As compared to other distally based sural flaps with neuro-veno-adipo-fascial pedicles, this modified sural flap with a thin perforator pedicle is easily rotated. The flap can obtain abundant blood supply through both axial perforator and longitudinal chain-linked vascular plexuses, and does not have the venous reflow problem. In conclusion, the invention of this perforator fasciocutaneous flap provides a valuable tool for repair of foot and ankle soft-tissue defects.

[Comparison of plate and Kirschner wire fixation in treatment of clavicular nonunion].

OBJECTIVE: To compare the results of plate and Kirschner wire fixation in treatment of nonunion of clavicular fracture. METHODS: From September 1991 to January 2002, 19 patients (9 with plate and 10 with Kirschner wire) were treated. The results were evaluated by reduction, bone union time, recovery of joint function, pain, and correction of deformation. RESULTS: The follow-up time was 6-23 months with an average of 11 months. Bone union occurred after a mean time of 11 weeks. In plate group, 7 patients gained excellent results, 1 good and 1 fair. In Kirschner wire group, 3 patients gained excellent results, 3 good, 3 fair and 1 poor. The result of plate is significantly better than that of Kirschner wire fixation(P < 0.05). CONCLUSION: Plate fixation is a good simple method for treatment of nonunion of clavicular fracture.

Distally based radial forearm flap with preservation of the radial artery: anatomic, experimental, and clinical studies.

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.

[Experimental study on preparing chitosan-collagen matrix and subcutaneous implantation].

OBJECTIVE: To investigate the feasibility of the chitosan-collagen membrane (CCM) as a dermal substitute. METHODS: Fresh bovine tendo calcaneus collagen was dispersed in 0.5 mol/L acetic acid, co-precipitated with chitosan and lyophilized. Dry membranes were cross-linked in 0.05% glutaraldehyde for 24 hours. In vitro its degrading rate was measured by use of collagenase degrading test. The chitosan-collagen membrane was implanted to subcutaneous dorsal sites of SD rats. After implantation, histocompatibility, vascularity and degradation were observed in vivo. RESULTS: The chitosan-collagen membrane was yellowish, translucent, and porous. Pore size ranged 50-250 microns, and collagen fiber bundles were reticular arrangement in the membrane. It had slower degradation than pure collagen membrane by collagenase in vitro. Subcutaneous implantation test showed the minimal inflammation, good histocompatibility and earlier vascularization. The membrane degradation was slower in vivo. Eight weeks after implantation, organized collagen structure was retained. CONCLUSION: The chitosan-collagen membrane has better physical and biological properties, ideal histocompatibility, earlier vascularization and slower degradation. Therefore, It is an optimum substitute for dermal scaffold.

[Clinical study on chitosan in prevention of knee adhesion after patellar operation].

OBJECTIVE: To investigate the clinical effect of chitosan in prevention of knee dysfunction due to adhesion after operation for patellar fracture. METHODS: From March to October 1999, 40 cases of patellar fracture were treated by internal fixation, with intra-articular injection of 2% chitosan in only 24 cases after fixation and with no chitosan injection in 16 cases (control group). The function of the knee joint, including extension and flexion, was evaluated 1 month and 1 year after operation respectively. RESULTS: One month after operation, the knees with chitosan injection could actively move in the average range of 104 degrees +/- 23 degrees, and the knees in the control group could move in the average range of 72 degrees +/- 16 degrees, which showed significant difference between two groups (P < 0.01); 1 year after operation, the range of movement of the knees with injection was 165 degrees +/- 38 degrees on average, and that of the knees in the control group was 110 degrees +/- 31 degrees, which also indicated significant difference between two groups (P < 0.05). CONCLUSION: Medical chitosan could effectively prevent or reduce the post-operative adhesion of knee joint after patellar operation.

[Experimental study on bacteriostasis of chitosan and sodium hyaluronate].

OBJECTIVE: To compare the effect and coverage of bacteriostasis of chitosan and sodium hyaluronate. METHODS: Each of the five bacteria, Proteus mirabilis, Escherichia coli, Candida albicans, Pseudomonas aeruginosa, Staphylococcus aureus, was cultivated for 33 tubes of broth culture. Leaving three tubes each group as control group, ploidy diluted concentration of high relative molecular weight chitosan, low relative molecular weight chitosan and sodium hyaluronate were added respectively in the broth culture. All the tubes were cultivated for 18 hours at 37 degrees C with homeothermia. Then the growth of bacteria was observed. RESULTS: The minimal inhibitory concentrations (MIC) of high relative molecular weight chitosan were: Proteus mirabilis 0.031%, Escherichia coli 0.063%, Candida albicans 0.063%, Pseudomonas aeruginosa 0.063%, Staphylococcus aureus 0.063%; and the MIC of low relative molecular weight chitosan were: Proteus mirabilis 0.125%, Escherichia coli 0.025%, Candida albicans 0.25%, Pseudomonas aeruginosa 0.25%, Staphylococcus aureus 0.125%; bacteria grew well in each tube of sodium hyaluronate group and control group. CONCLUSION: The above results show that sodium hyaluronate has no bacteriostasis, while chitosan has bacteriostasis on broad spectrum and high relative molecular weigh: chitosan has stronger effect.