Approach to Complex Upper Extremity Reconstruction.

The management of complex upper extremity trauma can be overwhelming in its urgency and complexity. Having a systematic approach that maintains a clear set of priorities focused on hand and upper extremity function, operative efficiency, and long-term planning for future operations allows the reconstructive extremity surgeon to effectively treat these complex injuries. This article addressed these overall clinical considerations and details the approach taken at the Buncke Clinic including replantation and revascularization as well as osseous and soft tissue reconstruction.

Microsurgical Gender Affirmation Surgery.

Phalloplasty in the female to male transgender patient is a complex operation aimed at creating a functional and aesthetic phallus, external genitalia, and perineum. Functional goals include standing micturition and sexual function with erogenous and tactile sensation as well as the ability to participate in penetrative intercourse. Functional genital reconstruction relies on creating of a fully lengthened urethra from local tissues as well as the provision for additional length via tissue transplantation. This manuscript will review techniques for the creation of perineal urethral segment as well as primary flaps available for the creation of neophallus. Particular emphasis is given to our preferred method of reconstruction: single-stage urethral lengthening with radial forearm flap phalloplasty including a review of surgical techniques and complications.

Modification of the single-tube radial forearm phalloplasty technique to allow for urinary meatal reconstruction: A report of two cases.

The free radial forearm flap is the gold standard technique for transgender phalloplasty due to superior complication rates compared to other methods. However, reconstruction of the urinary tract, including urethral lengthening and creation of a pars pendula urethra within the flap, carries a high rate of complications. The risk of complications and a lack of desire for standing urination are reasons patients elect for single-tube phalloplasty. However, to date, single-tube phalloplasties lack creation of a urinary meatus, which affects the aesthetics of the reconstruction. The purpose of this report is to describe a technique for creating an aesthetic urinary meatus in single-tube phalloplasty. We herein describe the technique in the use of two healthy transgender males (ages 31 and 39). Both patients did not desire micturition through the neophallus, but still desired the appearance of a meatus at the tip of the neophallus. Single-tube radial forearm phalloplasty was performed for both patients. The radial forearm flaps for each patient were 14 × 15 cm. Meatoplasty was performed at the time of flap elevation utilizing an intact 1 × 4 cm intact strip of ulnar sided skin during flap tubularization. This strip of skin was then invaginated to create a neomeatal pouch. The postoperative course was uncomplicated for both patients following at 5-day hospital stay for flap monitoring. Follow up time was 7 and 8 months. The neomeatal pouch persisted in both patients and the patients were satisfied with the appearance of the tips of the neophalluses.

Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases.

PURPOSE: Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps. METHODS: We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. RESULTS: The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention. CONCLUSIONS: Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

Infrapubic Insertion of Penile Implants in Transmen After Phalloplasty.

OBJECTIVE: To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. MATERIALS AND METHODS: After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. RESULTS: In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. CONCLUSION: Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction.

BACKGROUND: Full-thickness injuries to the hand require durable soft tissue coverage to preserve tendon gliding and hand motion. We aim to investigate the cost effectiveness of hand resurfacing comparing free fascial flap reconstruction versus bilaminate synthetic dermal matrices. METHODS: Cost effectiveness was modeled using decision tree analysis with the rollback method. Total active range of motion was modeled as the common outcome variable based on systematic literature review. Costing was performed from a payer perspective using national Medicare reimbursements. The willingness to pay threshold was determined by average worker's compensation for hand disability. Probabilistic sensitivity analysis was conducted for range of motion outcomes and the costs using 10,000 Monte Carlo simulations. RESULTS: The average cost of free fascial flap reconstruction was $14,201.24 compared with $13,674.20 for Integra, yielding an incremental cost difference of $527.04. Incremental range of motion improvement was 18.0 degrees with free fascial flaps, yielding an incremental cost effectiveness ratio of $29.30/degree of motion. Assuming willingness to pay thresholds of $557.00/degree of motion, free-fascial flaps were highly cost effective. On probabilistic sensitivity analysis, free fascial flaps were dominant in 25.5% of simulations and cost effective in 32.1% of simulations. Thus, microsurgical reconstruction was the economically sound technique in 57.5% of scenarios. CONCLUSION: Free fascial flap reconstruction of complex hand wounds was marginally more expensive than synthetic dermal matrix and yielded incrementally better outcomes. Both dermal matrix and microsurgical techniques were cost effective in the base case and in sensitivity analysis. In choosing between dermal matrix and microsurgical reconstruction of complex hand wounds, neither technique has a clear economic advantage.

An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap.

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

The Pedicled Anterolateral Thigh Phalloplasty.

The anterolateral thigh (ALT) flap is a viable and reliable option for phalloplasty. The primary advantages of the ALT flap remain an inconspicuous donor site and flexibility in phallus length. The disadvantages of the ALT flap are a higher incidence of both flap and urethral complications compared with a radial forearm phalloplasty. Although the ALT phalloplasty can achieve the primary goals of standing micturition, penetrative intercourse, and an aesthetic phallus, multiple stages and revisions are often necessary. Careful patient selection is paramount in attaining acceptable results with the ALT phalloplasty technique.

Surgical exposures of the hand.

Surgical approaches to the hand are commonly executed in the treatment of fractures, ligament injuries, and less commonly in the resection of bony tumors. Careful design and execution of these surgical approaches translates into superior functional and aesthetic outcomes. We have provided a thorough review of commonly used approaches to the hand by evaluating each of these approaches in the context of core principles including safety, versatility, preservation of stability, and aesthetic outcomes.

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture.

PURPOSE: To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture. METHODS: Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests. RESULTS: Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed. CONCLUSIONS: The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Transverse tensor fascia lata myocutaneous flap for microvascular breast reconstruction: case report and review of the literature.

The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.

Skin graft loss resulting from collagenase clostridium histolyticum treatment of Dupuytren contracture: case report and review of the literature.

Treatment of Dupuytren disease with collagenase clostridium histolyticum is increasingly used among hand surgeons. Although it is generally safe and efficacious, complications related to enzymatic fasciotomy occur. Postapproval surveillance and communication among hand surgeons continues to refine the indications, contraindications, and complications recognized in the treatment of Dupuytren disease with enzymatic therapy. Major treatment-related adverse events previously reported include flexor tendon rupture and complex regional pain syndrome. We report a patient who experienced total loss of a well-established volar ring finger skin graft following collagenase injection and propose a potential mechanism of vulnerability. This case may illustrate the susceptibility of type I collagen, which is uniformly present in a healed skin graft bed, to degradation with collagenase. We propose a cautious approach when considering treatment of a Dupuytren cord with collagenase in the presence of an overlying skin graft, regardless of the age of the graft.

Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: case reports and review of literature.

Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

Advances in treating skin defects of the hand: skin substitutes and negative-pressure wound therapy.

Surgeons and scientists have been developing alternative methods of hand reconstruction that may play an adjunctive role to, or completely supplant, more traditional reconstructive modalities. This article provides an overview of these emerging techniques, with an emphasis on skin substitutes and negative-pressure wound therapy as they apply to the treatment of soft tissue defects of the hand. The indications, contraindications, and relative advantages and disadvantages of these techniques are discussed in detail.

Advances in the management of Dupuytren disease: collagenase.

Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

Free flap scalp reconstruction in a 91-year-old patient under local-regional anesthesia: case report and review of the literature.

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

Functional reconstruction of the hand: the stiff joint.

Proper hand function relies on a combination of strength and mobility. The intricate architecture that allows for hand mobility includes the articular surfaces of joints, periarticular ligamentous structures, tendon mechanisms, and the soft-tissue envelope. These structures are subject to injury and scarring. The net effect of a variety of etiologic factors is stiffness of the hand with diminution of hand function. This article reviews the biology of healing, pertinent anatomy of the hand, and operative and nonoperative treatment of the stiff hand.

Joint arthritis and soft-tissue problems of the hand.

The hand, by virtue of its position in space, complex anatomical composition, and characteristic biomechanical properties, is subject to a host of disease processes and traumatic injuries. This article reviews the presentation, evaluation, treatment, and outcomes of treatment in hand infections, high-pressure injection injuries, Dupuytren disease, and arthritis.