The anatomic and radiologic basis of the circumflex scapular artery perforator flap.

Microsurgical development has recently focused upon the perforator paradigm and primary thinning. Existing perforator flaps may require intramuscular dissection or lack reliable surface markings, whereas traditional scapular/parascapular flaps have low donor morbidity and reliable anatomy, but can be excessively bulky. Clinical application of a new flap based on a perforator from the circumflex scapular axis (CSA) has recently been published, but the vessel's anatomy has not been adequately characterized. The CSA was dissected in 115 sites in 69 cadavers. The number, external vessel diameter, and site of origin of perforators were measured relative to the CSA bifurcation. Color Doppler ultrasound was used to delineate the CSA and its perforators bilaterally in 40 volunteers. The number, origin relative to CSA bifurcation, diameter, length, and flow velocity of cutaneous perforators were determined. A CSA perforator was always present, running into the subdermal plexus, arising within 2.4 cm of the bifurcation. Cadaver studies: mean perforator diameter, 1.3 mm (SD, 0.66); 13% arose at bifurcation, 36% arose proximal (mean, 1.1 mm; SD, 0.63), and 52% distal to bifurcation (mean, 1.5 mm; SD, 0.88). Ultrasound: mean perforator diameter, 1.18 mm (SD, 0.41); mean flow velocity, 16.3 cm/s (SD, 3.65); perforator arose in 36% proximal, in 40% distal to bifurcation, and in 24% from the bifurcation. We definitively describe the anatomy of the perforator from the circumflex scapular artery upon which a new flap has been based. Its origin and dimensions are anatomically and radiologically reliable. The flap has certain potential benefits over existing perforator flaps.

Does a superficial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique.

An exact knowledge of the subcutaneous layers in the different regions of the face and neck is important in several surgical disciplines. In the parotid region, a superficial musculoaponeurotic system (SMAS) has been described. The existence of a SMAS as a guiding structure for the surgeon in the other regions of the face and neck has been discussed but is controversial. Therefore, the authors investigated the development of the subcutaneous connective-tissue layers in the different facial regions and in the neck. They studied these regions in 22 human fetuses using the technique of plastination histology and in three newborn and three adult specimens using sheet plastination. In addition, they dissected the neck and face in 10 fresh adult cadavers to identify the SMAS as in the surgical situation. The results show that no SMAS could be detected in any facial regions other than the parotid region. In the parotid region, it is thick and attached to the parotid sheath. However, it becomes very thin, discontinuous, and undissectable in the cheek area. No SMAS can be found in the neck, in which the authors are the first to describe a fascia covering both sides of the platysma. This fascia has close topographical connections to the subcutaneous layers of the adjoining regions. On the basis of these findings, the surgical pathways have to be defined regionally in the face. A "platysma fascia" can be considered as a surgical landmark in the neck. Therefore, the authors conclude that it is not justified to generalize a SMAS as a surgical guiding structure.

The innervated free toe web flap for clitoris reconstruction.

Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.

Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment.

OBJECTIVES: Urethra reconstruction in men remains a complex problem, particularly in patients who have had previous amputation for penile tumour or who have undergone gender reassignment. Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction. METHODS: During 1999-2004, nine patients underwent microsurgical reconstruction of the male urethra using the radial forearm fasciocutaneous free flap. Three patients underwent urethral reconstruction following previous subcutaneous penectomy for penile cancer. Another six patients had urethral reconstruction performed after failure of primary urethra construction as part of their gender reassignment surgery. RESULTS: The average age at the time of surgery was 35.1 yr (range: 22-55 yr) and average follow-up time was 41.8 mo (range: 13-55 mo). Flap reconstruction was successful in all cases, with no instances of free flap failure; however, two patients developed significant stenosis requiring revision, and no patients had postoperative fistula formation. Therefore, the success rate for urethral reconstruction after the first operation was seven of nine. Two patients with stenosis were treated operatively to release strictures with local flaps. Uroflowmetry demonstrated that these patients had satisfactory flow rates. CONCLUSION: Patient satisfaction and objective studies have demonstrated that urethral reconstruction with the use of radial forearm free flap is a good reconstructive procedure particularly when the patients need an extensive and long urethral reconstruction.

Macro- and microcirculatory assessment of cold sensitivity after traumatic finger amputation and microsurgical replantation.

INTRODUCTION: Finger replantations after traumatic amputation are associated with good prognosis and acceptable functional results. However, cold sensitivity is a common and sometimes disabling sequelae after digital replantation. The exact causes of cold intolerance are still unclear; neural as well as vascular mechanisms have been discussed. We examined the macro- and microvascular performance of replanted fingers using high-resolution color-coded sonography for the assessment of skin vessel density of the fingertips as well as nailfold capillary microscopy and laser Doppler anemometry. Subsequently, we correlated these findings with the presence of cold sensitivity of the replanted digits. PATIENTS AND METHODS: Thirty-seven patients (mean age 45 years; range 19-72) with 40 traumatic finger amputations and microsurgical replantations were studied. The mean time interval between amputation and examination was 57.7 months (range 13-95). Macro- and microvascular examination consisted of electronic oscillograms of both arms, photoplethysmograms of all fingers before and after cold test, duplex ultrasound of the finger arteries, high-resolution color-coded sonography of the fingertips and nailfold capillary microscopy with laser Doppler anemometry. RESULTS: Cold sensitivity was present in 33 (83%) of the 40 replanted fingers. Peripheral arterial disease of the upper extremity could be excluded as all oscillograms showed normal findings. A vasospastic reaction after cold test was documented in 74% (30 of 38) of the replanted fingers, compared to 24% (9 of 38) of the contralateral uninjured fingers. Raynaud's phenomenon was restricted to replanted fingers and occurred in 10 of 40 patients (25%). Compared with the contralateral fingertips, reduced skin vessel density was found in 27 of 36 (75%) replants. Nailfold capillary microscopy revealed uncharacteristic morphologic patterns. The capillary flow velocity was 0.28 +/- 0.12 mm/s in the replanted fingers and 0.48 +/- 0.23 mm/s in their unaffected counterparts (P < 0.001). Correlating these findings with the presence of cold intolerance, reduced skin vessel density in the fingertips was significantly different between cold-sensitive replants and those without cold sensitivity (P = 0.05). Reduced skin vessel density was not related to the extent of reconstruction of nerves (P = n.s.), arteries (P = n.s.) and veins (P = n.s.). CONCLUSIONS: Our results do not confirm hypotheses that cold sensitivity after finger replantations is caused by macrovascular problems nor do they support assumptions of a primary capillary microcirculatory failure. Our findings of reduced vessel density point towards diminished thermoregulatory capacities in the fingertips of cold-sensitive replanted digits.

The compound dorsal metacarpal artery tendofasciocutaneous flap: an attractive reconstructive tool for complex digital defects.

Different modifications of flaps based on the dorsal metacarpal arterial system have been reported as reliable tools for reconstruction of dorsal and palmar phalangeal soft tissue defects. For simultaneous reconstruction of the extensor aponeurosis and joint in complex injuries of the dorsal index, we used a distally based pedicled fasciotendocutaneus second dorsal metacarpal flap, including the complete vascularized extensor indicis tendon in 2 cases. Clinical results of this procedure have not been reported so far.

Urethra reconstruction following resection of penile leiomyosarcoma.

Leiomyosarcoma is a rare tumor, particularly in genital area. We present a case of penile lyomyosarcoma. Surgical treatment involved subcutaneous penectomy, preserving a sensate skin envelope, bilateral groin dissection and perineal urethrostomy. Reconstruction of the urethra and soft tissue was carried out using a free radial forearm flap. We believe that subcutaneous penectomy should be considered as a treatment option in selected cases of penile tumor as this facilitates urethral reconstruction.

Receptors for NGF and GDNF are highly expressed in human peripheral nerve neuroma.

Immunhistochemistry of 10 traumatic human peripheral nerve neuromas and 5 normal digital nerves revealed a high immunoreactivity for the nerve growth factor (NGF) receptors p75 and trkA and the glial cell line-derived neurotrophic factor (GDNF) receptor GFRalpha-1. Semiquantitative image analysis showed a significantly increased trkA immunoreactivity in the neuroma group. The presence of the receptors may provide a way to influence therapy of peripheral nerve neuroma by administration of neurotrophins or other substances with binding sites similar to those of a neurotrophic factor.

Plastic surgeons and the Internet: results of a worldwide survey.

To obtain information on the use of the Internet, 3,139 survey forms were sent out to plastic surgeons throughout the world. More than 90% of the 565 respondents have access to the Internet and 85.5% use electronic mail for professional matters. They use the World Wide Web to search the literature, to read scientific articles, and to obtain information on congresses. A substantial proportion of the contributors have a positive attitude toward virtual congresses on the Internet and most would welcome a newsgroup dedicated to plastic surgery. Perceived apprehensions include secure transmission of sensitive data, slow data transmission, and the lack of structure and of an authority to control the contents of the Internet. Virtual congresses and a newsgroup on plastic surgery seem to be worthwhile future goals. Some problems pointed out in this survey have already been solved, at least partially, and possible solutions for the rest are discussed.