Release of hand burn contracture: comparing the ALT perforator flap with the gracilis free flap with split skin graft.

BACKGROUND: The use of microsurgery in the management of burn sequelae is not a new idea. According to the properties of various types of free flaps different goals can be achieved or various additional procedures have to be combined. We report the comparison of two different free flaps on a single patient for reconstruction of both upper extremities for burn sequelae. CASE REPORT: A 1-year-old child sustained severe burns on both hands, arms and thorax and was initially only treated conservatively. This resulted in severe contractures. At the age of 4-years a free gracilis flap was selected for reconstruction of his left hand and a free anterolateral thigh flap for the right hand. RESULTS: We noticed a better functional and esthetic result for the gracilis flap associated with a shorter operative time and a minor donor site morbidity. The intraoperative technique and time, postoperative complications, functional and esthetic results and donor site morbidities were studied in the two types of flaps chosen. A review of literature was also performed. CONCLUSION: Our experience reported a better success of the gracilis muscle flap covered with a split skin graft compared to the anterolateral thigh flap in the reconstruction of hand function after severe burn sequelae.

Reconstruction of the nose after cocaine abuse.

A 35-year-old woman with necrosis of the complete nasal tract due to nasal cocaine abuse is presented. Reconstruction was performed using a free radial forearm flap and rib cartilage grafts. Pre-existing skin of the nose was used for outer lining. The reconstruction led to an excellent functional and aesthetic result.

Retrieval of port-A catheter fragment from the main and right pulmonary arteries 3 years after dislodgment.

Vascular access (VA) is one of the serious problems that chemotherapy recipient cancer patients face. Fractures of catheter and cardiac migration rarely occur; the catheter fragments migrate distally along the blood stream finally lodging anywhere in the vena cava, right atrium, right ventricle, or the main pulmonary artery or one of its branches. Percutaneous retrieval method is always suggested first.

Predictors of mortality: a comparison between two burn wound treatment policies.

Retrospective review of outcomes and experiences of a single burn centre between two time periods during which a new wound care technique was employed after the first period. The time period was divided into two: 1977-1984 and 1984-1990. Due to the use of cerium nitrate-silver sulphadiazine, the introduction of serial excision and grafting became possible in the second time period. Multivariate risk-analysis was done by logistic regression analysis. The mortality rate decreased from 13.7% (1997-1983) to 4.7% (1984-1990). Results of multiple logistic regression analysis indicate that the change in periods was advantageous for patients with >50% TBSA, within the age group, 0 to 30 years. Obviously, the care which a patient receives has improved significantly. Many developments occurred simultaneously and it appears impossible to conclude that only the use of cerium nitrate-silver sulphadiazine was the reason for improved survival. Nevertheless, the use of cerium nitrate-silver sulphadiazine enables sequential excision and grafting and in consequence allows for many of these developments to occur.

Application of cerium nitrate-silver sulphadiazine allows for postponement of excision and grafting.

Early excision and grafting cannot always be performed due to patient's medical status, and the lack of adequate donor sites. The use of cerium nitrate-silver sulphadiazine cream, which causes the formation of a leather-like eschar with excellent resistance to infection, is an alternative method. In order to postpone operations by using cerium nitrate-silver sulphadiazine, we compared the differences in contamination of the grafted areas between early and delayed excision. Eighteen patients underwent excision and grafting within 5 days post burn and nineteen patients were surgically treated after 5 days. Twelve months later the grafted areas were evaluated. Contamination of the grafted area occurred in 17 patients. No differences in contamination occurred between the early and delayed excision group, 8 versus 9. Also no differences in type of organism cultured and follow-up results were found between the early and delayed excision group. Cerium nitrate-silver sulphadiazine allows surgical treatment to be delayed without an increase of contamination of the grafted area and does not adversely affect the long-term outcome.

Povidone-iodine ointment: no effect of split skin graft healing time.

In major burns, local treatment of the split skin graft after a burn injury is important to prevent serious infectious complications. Topical burn wound therapy may improve the bacteriological condition of the wound, which in turn may improve the successful take of a skin graft. Delay of wound healing is an undesired side effect of these topical anti-microbial agents. It is known that povidone-iodine has many clinical advantages. In view of this, the total healing time of the freshly grafted burn wound was studied. In this prospective study, comparable areas of the same patient were treated with povidone-iodine ointment or with simple vaseline gauze. There was no statistical difference in the total wound healing time between the treated and the control group.

Interrupted micro-mattress sutures solve vessel-size discrepancy.

Although technical refinements have improved microvascular techniques, the problem of vessel-size discrepancy between donor and recipient vessels is still unsolved and can decrease the success rate of free tissue transfer. In fact, if vessels with incongruent diameters are not adequately anastomosed, the risk of free flap failure is increased. In this paper, the authors present a new type of microvascular anastomosis to overcome the problem of vessel-size discrepancy. Interrupted mattress sutures are placed in end-to-end anastomosis narrowing the wider diameter and compensating for the diameter incongruency. The surgical technique and main clinical applications of the interrupted micro-mattress sutures are described in detail. Indications and advantages are discussed.

Increasing the flow output by Y-shaped microvascular anastomosis.

In this paper the authors present a new type of microvascular anastomosis to overcome two major inconveniences in microsurgery: "flow discrepancy" and vessel size discrepancy between the donor and the recipient vessels. A Y-shaped anastomosis is an end-to-end anastomosis between three vessels: two small ones on one side and a larger vessel on the opposite site. Both arterial and venous anastomoses can be performed in this way. The blood flow can go across the anastomosis in both directions. Hemodynamically, this increases the blood output through the anastomosed vessels. The surgical technique and main clinical applications of the Y anastomosis are described in detail. Indications and advantages are discussed.

Horseshoe expanded scapular free flap shows no venous congestion.

The free scapular flap is a reliable solution when a relatively thin cutaneous flap is required, but its dimensions limit its use in large defects. The pre-transfer expansion of the flap has extended its clinical applications, but problems still occur. Distal marginal venous congestion and subsequent partial necrosis of the flap can occur during the conventional round-shaped expansion of the flap. Here, we present a new pattern of flap pre-expansion: the 'horseshoe'-shaped expansion. The main indications for this procedure and the surgical details are described. Advantages and disadvantages over the conventional expanded free scapular flap are discussed.

Free flaps in burn reconstruction.

In this paper, we present our experience of free flap reconstructions in burned patients. It allows the preservation of otherwise unsalvageable deep burn injuries and secondary correction of contracted burn scars. We analyse the indications of different free flaps, according to different anatomic regions and defects: depth and width of the loss of tissue, different colour skin, texture and thickness of the receptor area, weight-bearing or not weight-bearing surface. Free flap reconstructions were successful in 50 of 53 cases (94%). They provide good aesthetic and functional results with low morbidity both in acute deep burn injuries as in delayed reconstructions.

Silicones in the rehabilitation of burns: a review and overview.

This article gives an overview of the use of silicones in the treatment and prevention of hypertrophic (burn related) scars. Of all non-invasive treatment modalities the use of continuous pressure and occlusive contact media, e.g. silicones, seem to be generally accepted as the only ones that are able to manage hypertrophic scarring without significant side-effects. A summary of the current opinions of the assumed working mechanisms of pressure as well as silicones is given. The use of silicones, either alone or in combination with pressure, is discussed. The recent development of custom made silicone devices has led to combinations of both modalities. Some of these, including the inflatable silicone insert systems (ISIS), are shown and discussed.

Reproducibility of repeated measurements on healthy skin with Minolta Chromameter CR-300.

BACKGROUND/AIMS: In this report the reproducibility of measurements with the Minolta Chromameter CR-300 on healthy skin was investigated. METHODS: Intra- and inter-rater reproducibility, reproducibility with two instruments and repeated measurements with a 1 week time lapse were examined on healthy skin of 30 volunteers by means of intra-class correlation coefficients (ICC) and standard error of measurements (SEM). RESULTS: Results showed excellent values for ICC in all the four conditions. CONCLUSIONS: On the basis of these results we concluded that the instrument provides reliable information and can be used in comparative clinical trials.

Microsurgery for intra-abdominal testicular retention.

OBJECTIVES: In cases of high intra-abdominal retention of the testis a standard technique of cryptorchidy treatment will not be able to bring down the testis into the scrotum. In this study we wanted to evaluate the feasibility and reliability of the technical aspects of testicular autotransplantations in children under the age of 5 years. STUDY DESIGN: A series of 25 microsurgical autotranslantations of testes performed on 17 boys since July 1984 are reviewed. Emphasis was placed on the microvascular transplantation technique, the age of the patient and the long term viability of the autotransplants. An end-to-end microvascular anastomosis between the deep inferior epigastric artery and the testicular artery was performed in an end-to-end way using mattress stitches to accommodate the difference in diameter between the donor and recipient vessels. Also the testicular veins were anastomosed to the deep inferior epigastric veins. RESULTS: Of the 25 transplantations (96%) were successful after a mean follow up of 24 months, the one failure was ascribed arterial thrombosis. CONCLUSION: Our results show a 96% survival of the transplanted testes using the end-to-end vascular anastomosis as described here.

The fate of the oblique abdominal muscles after free TRAM flap surgery.

During recent years, clinical research on the donor site morbidity after free or pedicled transverse rectus abdominis myocutaneous (TRAM) flap surgery has been focusing on the reduced flexion capacity of the abdominal wall. However, the rectus abdominis muscles have close interactions with their synergists and antagonists and collaborate with their neighbouring muscles. The purpose of this study was to examine the consequences of partially resecting the rectus abdominis muscle on the different muscle groups of the abdominal wall. Twenty free TRAM flap patients, 12-61 months (mean 32.1 months) after surgery, were clinically examined, evaluated for curl-up performance and underwent isokinetic dynamometry for flexion, extension and rotation. The patients were compared with 20 non-operated controls. Nineteen patients answered a questionnaire. Abdominal wall abnormalities occurred in 10 patients: umbilical asymmetry (n = 3), abdominal wall asymmetry (n = 4), lower abdominal bulging (n = 2) and hernia (n = 1). Curl-up performance was less in the TRAM flap patients (P = 0.001, Mann-Whitney). Isokinetic flexion, extension and rotation were also less in the TRAM flap patients (Fisher's exact test). This study indicates that what has been believed to be 'limited' surgical damage to the abdominal wall leads to an important reduction in flexion strength but to an even more important reduction of rotation strength due to bilateral displacement and damage of the insertion of the oblique muscles. Partial compensation by synergists is variable and unpredictable on an individual basis. These functional disorders can potentially lead to important changes in activities of daily life.

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Scanning electron microscopic analysis of the stapled microvascular anastomosis in the rabbit.

BACKGROUND: Despite the high percentages of experimental and clinical patency rates achieved using so-called mechanical anastomotic devices (Unilink; 3M, St. Paul, MN; vascular staples) they remain little known and occasionally used. METHODS: The VCS Auto Suture microstapler technique for microvascular anastomosis was tested experimentally and compared with the conventional "gold standard" 10/0 end-to-end microvascular technique. Thirty carotid arteries on one side of 30 rabbits were stapled using nonpenetrating 0.9-mm (small) VCS Auto Suture microclips, and the other 30 carotid arteries on the other side were sutured in a conventional way with 10/0 monofilament nylon. A 100% patency rate was achieved on both sides. Biopsy was performed in five groups of rabbits at different time intervals postoperatively, and the specimens were examined under scanning electron microscopy. RESULTS: All 60 anastomoses were patent. Histomorphologic examination of the anastomotic site revealed no major differences between sutured and stapled groups. CONCLUSIONS: Stapled microvascular anastomosis technique is fast and reliable.

Peritoneal healing after fibrin glue application: a comparative study in a rat model.

The influence of fibrin glue on adhesion formation and peritoneal healing is evaluated in a prospective, randomized, controlled study. In all, 20 Wistar rats underwent microsurgical suturing of two silicone sheets, one covered with a fibrin glue barrier, to the anterior peritoneum. Each animal thus served as its own control. After 10 days, adhesions and peritoneal healing were evaluated by a blinded observer through a second-look laparotomy. Adhesions were scored using a modification of the classification of Diamond. Tissue around the silicone sheet was examined histologically and by scanning electron microscopy to evaluate the inflammatory reaction and peritoneal healing (ingrowth of blood vessels and quality of peritoneal cells). Adhesion scores for treated and control sides were (mean +/- SD) 2.89 +/- 4.68 and 6.79 +/- 9.09 (P = 0.181) respectively, and the percentage of the sheet covered by peritoneum was 26.25 +/- 31.50 and 29.21 +/- 40.21 (P = 0.226) respectively. Using the paired Wilcoxon rank test, the P values for the ingrowth of blood vessels and peritoneal healing evaluated by histology and scanning electron microscopy were 0.842, 0.692 and 0.695 respectively. We conclude that although the mean adhesion score was reduced by > 50% by fibrin glue, there is no statistically significant difference concerning adhesion formation or peritoneal healing with the use of fibrin glue.

Microsurgical vasoepididymostomy in the treatment of occlusive azoospermia.

OBJECTIVE: To evaluate the practice and outcome of the end-to-end and end-to-side techniques of vasoepididymostomy for the treatment of occlusive azoospermia. PATIENTS AND METHODS: This retrospective study comprised 31 unselected patients (mean age 32 years, range 22-59) operated on with one of two techniques, more usually a modified end-to-side technique. Sperm quality and paternity were assessed in 24 patients during a 2-year follow-up. RESULTS: Of the 15 patients in whom sperm were found at anastomosis, sperm were retrieved from 11. Of 24 patients, 11 had patent anastomoses and paternity was achieved in three cases. CONCLUSION: Although performed by a proficient microsurgeon the operative success rate was low, partly because the operation was technically demanding but largely because of the difficulty in assessing intraoperatively the level of occlusion and the quality of the sperm. Better techniques for the evaluation of sperm during the operation should be developed.