eConsultation in Plastic and Reconstructive Surgery.

OBJECTIVE: Early studies of plastic surgery patient triage using telemedicine are descriptive and deal with feasibility rather than accuracy. The inpatient study arm compares on-site wound-evaluation accuracy with remotely viewed digital images. The outpatient arm prospectively compares on-site and remote diagnosis, management, and outcomes in a busy, urban, reconstructive-surgery clinic. The concurrent 6 patient case studies illustrate significant systems improvement by using remote consultation. METHODS: A total of 43 inpatients and 100 consecutive outpatients were evaluated by on-site and remote surgeons as performed in previous arms with digital-camera and store and forward technology. Consent was obtained from all patients participating. Agreements regarding diagnosis (skin lesion, hand injury, wound type, and scar character) and management (healing problem, emergent evaluation, antibiotics, and hospitalization) were calculated. RESULTS: In the first study arm, on-site and remote agreement (46%-86% for wound description and 65%-81% for management) generally matched agreement among on-site surgeons (68%-100% and 84%-89%). Moreover, when on-site agreement was low (68% for edema), agreement between on-site and remote surgeons was also low (57%). Remote evaluation was least sensitive detecting wound drainage (46%). On-site surgeons opted for more treatment, often prescribing antibiotics and admitting the patient. The second teleconsult arm provides further evidence of accuracy, overall agreement of 32%, sensitivity 48.55%, specificity 96.92%, positive predictive value 49.26%, negative predictive value 96.83%, and P < .001 regarding diagnosis (skin lesion, hand injury, wound type, wound problem, and scar character). Patient transfer, postoperative monitoring, and outcomes via electronic image transfer, as well as cost-benefit analysis of this clinic-based study, are presented. CONCLUSIONS: eConsultation renders similar outcomes to standard, on-site examination in a selected group of plastic surgery patients. Remote evaluation may assist triage decisions, thereby decreasing emergency room throughput time and office-visit frequency, supplementing satellite facility consultation by plastic surgeons, and providing real-time postoperative assessments, thereby improving quality and reducing costs.

Neuroma transposition and intramuscular implantation using the Mitek "soft-tissue anchor": a new technique.

The authors describe a new technique for intramuscular implantation of a nerve ending after peripheral neuroma excision. Sixteen peripheral neuromas in 10 patients were excised and then implanted into muscle tissue using the Mitek anchor. The positions of the anchors were documented by immediate anteroposterior and lateral radiographs. These views were repeated at 2 months to assess any migration. All patients had resolution of the symptoms related to their neuromas. No substantial migration was noted in any of the patients. The Mitek anchor can be used as a "soft-tissue" anchor to position a nerve ending reliably at a precise depth and tension in muscle tissue with minimal trauma.

CoStasis provides superior control of diffuse bleeding at muscle-flap donor sites, compared to manual compression.

This prospective, controlled trial evaluated the hemostatic effectiveness of an experimental collagen-based composite (CoStasis), compared to a collagen sponge applied with manual pressure at diffusely-bleeding muscle-flap donor sites. Hemostatic success, time to "controlled bleeding," and time to "complete hemostasis" were determined at raw muscle-flap harvest sites among 22 experimental and 25 control subjects. There was a similar distribution in large-sized (e.g., latissimus dorsi) and moderate-sized (e.g., rectus abdominis) muscle flaps evaluated between treatment groups. More than twice the percentage of experimental subjects achieved complete hemostasis within 10 min of observation, compared to controls (100 percent vs. 48 percent, p < 0.0001). Time to controlled bleeding and complete hemostasis also favored the experimental group at statistically highly significant levels (p < 0.0001 for both comparisons). For example, greater than 60 percent of experimental subjects achieved complete hemostasis within 2 min compared to only 5 percent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this investigational hemostatic agent to control diffuse bleeding at muscle-flap donor sites.

Serratus anterior-rib composite flap: anatomic studies and clinical application to hand reconstruction.

Because of its relative ease of dissection, increased length of the vascular pedicle, and excellent diameter for anastomosis, the serratus anterior-rib composite flap has been used to reconstruct bony and soft-tissue defects in the face and lower extremities. However, no data are available on optimal rib level or harvest location. The authors report the results of the vascular anatomy of this flap in 6 fresh cadavers and 2 clinical patients using this flap to reconstruct a defect in the hand. Arteriograms were performed through the thoracodorsal artery, and microscopic dissections were done at the rib periosteum. The sixth through the ninth ribs showed consistent filling of their respective intercostal vessels. The rib segments near the anterior axillary line had the most abundant communicating vessels between the serratus and the periosteum. In two patients, the serratus-rib composite free flap provided excellent bone and muscle length for reconstructing the first metacarpal defect.

The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants.

One hundred forty-seven flaps in 135 consecutive patients undergoing microvascular transplantation were monitored using a miniature Doppler ultrasonic probe. Using a modification of a technique described previously by Swartz, the probes were secured to the outflow vein of the flap with Vicryl mesh. Twenty instances of thrombosis or spasm were detected in 16 patients, and all flaps were salvaged (100 percent). There were four false positive and no false negative results. This probe allows for safe, continuous monitoring of flap blood flow, which permits the rapid detection and hence rapid treatment of postoperative complications. Our experience suggests that a significant improvement in the salvage rate of microvascular transplants may be attainable with the use of this device.

Blood-flow velocity as a factor in postoperative microvascular patency.

The authors attempted to develop a reliable and reproducible new animal model in which the blood-flow velocity to a flap could be varied. This model was utilized to study the effects of different blood-flow velocities on the patency rate of small 1- to 2-mm vessels after common microsurgical procedures. Male Sprague-Dawley rats, weighing 450 to 550 gm, were used to develop a model creating either a "high blood flow" or a "low blood flow" state by ligating the rat femoral artery, either distally or proximally, to an epigastric artery based on a groin cutaneous flap. Blood-flow velocities were measured by microvascular flowmeter, and statistical analysis was performed on the data collected. The model was next used to determine the effects of different blood-flow velocities on the patency rates of rat femoral vessels after primary anastomosis vs interpositional vein grafting. Interpositional vein grafting was subsequently repeated by a more senior microsurgeon, to determine the potential effects of increased surgical experience. The animal model was reliable, easily reproducible, and efficacious in producing two separate groups of rats with significantly different blood-flow velocities (3.98 vs. 2.14 +/- 0.5 ml/min), as was confirmed by electromagnetic flowmeter and statistical analysis. In experienced hands, decreased blood-flow velocity did not result in decreased patency rates of these small vessels after primary anastomosis, or even after vein grafting. As long as microvascular vein grafting and primary anastomosis procedures are done properly, even 1-mm vessels can tolerate significantly decreased blood-flow velocity without a decreased patency rate. Although many known factors can contribute to thrombosis and failure of anastomoses in clinical microsurgery, blood-flow velocity appears not to be a significant factor. Also described is a new, reliable animal model that can be used in small-vessel blood-flow velocity studies.

Using the Internet for rapid exchange of photographs and X-ray images to evaluate potential extremity replantation candidates.

OBJECTIVE: To implement a low-cost system of transmitting high-quality digital photographs of mutilating extremity injuries using the speed of the Internet. DESIGN: A high-resolution digital camera and simple hardware and software platform are used to take and transmit images via electronic mail. The images are received within minutes by the consultant, and an assessment can be made. RESULTS: A low-cost and high-quality system can easily be implemented. Images can be seen by consultants only a few minutes after they are obtained. The quality of the reproductions is excellent, and they are handled exactly as other photographs. CONCLUSION: This technique can be widely applicable and inexpensive to initiate in any emergency room. It allows rapid assessment of extremity injuries and x-ray images by expert consultants, who can then evaluate the replantation or revascularization potential of extremity trauma cases. This can eliminate unnecessary and often expensive transfer of patients who are not candidates for replantation.

Total ear replantation.

Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration.

A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis.

The choice of microvascular anastomotic technique, end-to-end versus end-to-side, is still an item of debate. A review of the literature reveals no difference in patency rates in animal models where there is no size discrepancy. The available clinical evidence stems from Godina's early experience, proclaiming a higher failure rate with end-to-end anastomoses. Factors such as size mismatch and use of injured vessels, rather than anastomotic technique, may have been responsible. This clinical study examines the fate of over 2000 microvascular anastomoses performed in more than 900 tissue transplants. Complications attributable to the anastomosis were considered failures of the anastomosis, were tabulated, and were compared between the two techniques. The end-to-end and end-to-side microvascular techniques were found to be equally effective when properly applied. The choice of technique therefore should be secondary to factors influencing the choice of recipient vessel, such as the condition of the vessel, its accessibility, and the preservation or augmentation of maximal distal flow to an extremity.

Salvage of the severely traumatized lower extremity.

The use of microsurgical techniques has significantly altered the management of lower extremity trauma. Indications for amputation or salvage continue to change, as microsurgical transplants have become more commonplace. Reconstruction of a severely traumatized leg usually involves multiple complicated procedures, each of which can cause its own set of complications. The historically high rate of complications of these procedures and the fact that the resultant limb is never completely normal has led some to the conclusion that severely traumatized limbs should not be salvaged. In order to evaluate our own results in light of these considerations we have reviewed our most recent experience with this difficult problem.

Contour restoration of large defects of the trunk and extremities.

Advances in reconstructive techniques have led to the ability to provide coverage of wounds previously considered inoperable. Severe deformities of the trunk from trauma, tumor extirpation, and congenital causes have been demonstrated to be manageable using local and distant flaps. This article presents a series of cases of severe contour deformities of the trunk and extremities treated with tissue transplantation.

Foreign-body sensation following 3M coupler use in the hand.

The 3M microvascular anastomotic coupling device has gained popularity because of its obvious advantages of speed and simplicity. Many reports attest to its safety and efficacy in microsurgery, including two reports on its use in the hand. We present 2 patients in whom the use of the 3M coupling device in the hand resulted in a palpable foreign-body sensation that was unpleasant to the patient and ultimately had to be removed.

Fibromuscular proliferation in finger arteries after hand replantation: a case report.

We report on a case where a digit of a previously replanted hand was amputated 3 years after injury. Histologically, the finger arteries demonstrated a marked intimal thickening due to fibromuscular proliferation, with narrowing of the lumen. The media showed muscular hyperplasia and fibrosis, whereas the adventitia was normal. These changes are probably a consequence of ischemia and reperfusion injury and might explain the persistent vasomotor insufficiency found in replantation patients.

[202 toe transfers to the hand]. / 202 Zehentransplantate an die Hand.

This retrospective study analyzed 202 toe-to-hand transplants performed over the last 20 years at the Davies Medical Center, San Francisco (USA). The overall success rate was 97%. Toe transplants for finger reconstruction yielded optimal functional and cosmetic results due to their anatomical similarity to fingers. The great toe was preferably used for thumb reconstruction, whereas the other toes were used for reconstruction of the long fingers. Early reconstructions, multiple simultaneous toe transplants, and interventions combining toe transplantation with free flaps seemed to be advantageous because of shorter rehabilitation and comparable results.

Salvage of wounds following failed tissue transplantation.

During the past 20 years, 972 microvascular transplantations have been performed for 783 patients, with an overall failure rate of 6.2 percent. Fifty-four of the 60 failed transplantations were available for long-term follow-up and were retrospectively reviewed with respect to the original indications for transplantation, the number, and the type of salvage procedures performed following transplant failure. This study illustrates that the choice of salvage procedures performed following transplant failure depends on the original indications, the location, and the severity of the resultant wound. Failure following transplantation for coverage of contour defects or unstable wounds can often be managed by non-microsurgical methods. In contrast, when the indications for transplantation included the transfer of specialized tissues for thumb or digit reconstruction, the restoration of motor or sensory function, or the coverage of a limb-threatening wound, requirements for reconstruction could be satisfied only by a second successful tissue transplant. Eighteen of the 54 cases underwent an additional transplantation, with an 89 percent success rate.

Soft-tissue reconstruction in orthopedic surgery. Secondary procedures.

The original consulting microsurgeon should be present to assist in the identification and protection of the vascular pedicle during secondary procedures on microvascular transplants. Flap elevation, trimming, and bone graft placement should be completed during a single tourniquet time, whenever possible. Flaps can easily be resutured on the original bed while the tourniquet is still inflated. Although proximal pedicle transection is possible, it should be avoided by careful planning, because the transplanted tissue cannot be predictably expected to survive, especially with muscle transplants. The distal muscle should be transected only in situations in which the muscle inset is extremely complex. Transection in the extramuscular portion of the main pedicle may require prompt microsurgical repair in immature muscle transplants. The safest approach is to avoid the pedicle whenever additional secondary procedures are necessary following free microvascular tissue transplantation. Placement of vascular pedicles such that the anterior crest of the tibia is avoided if the Ilizarov technique is required permit uncomplicated distraction osteosynthesis. Simultaneous Ilizarov fixation and microvascular tissue transfer are safe, practical procedures for limb salvage. Placement of the Ilizarov fixator at the time of microvascular transplantation provides stable fixation and eliminates the need for a subsequent anesthetic for fixator placement. This form of stabilization, when performed at the time of microvascular tissue transfer, allows the orthopedic surgeon direct visualization of the fracture site as the fixator is placed and eliminates the need for placement of the fixation device through the transplanted tissue. Tissue expansion or suction lipectomy are sometimes needed to optimize the clinical result.

Unrecognized injuries in patients referred for emergency microsurgery.

Replantation of amputated parts and emergency microvascular repair of injured extremities are the two most common applications of clinical microsurgery. A major complication of emergency referral of such cases is the existence of the other injuries unrecognized at the time of initial evaluation. We have reviewed this complication within a series of emergency microsurgical cases referred to this unit. Several reports examining this problem of missed injuries exist in the general trauma literature. To our knowledge this study is the first to look at this important problem in the context of acutely injured patients referred for emergency microsurgery. A retrospective analysis of patients referred to Davies Medical Center over a 7-year period was performed. Nine of 1100 patients (0.8%) transferred to our unit for microsurgical evaluation and treatment had unrecognized coexisting injuries that put those patients at high risk for injury-specific morbidity and demanded immediate changes in the original care planned at the time of referral. Brief case histories of these patients are outlined. We review the trauma literature of such injuries. A concise protocol elucidating the guidelines and pitfalls of emergency microsurgical referral is offered.

Hand reconstruction with partial toe and multiple toe transplants.

Microsurgical transplantation of toes to the hand can serve as an excellent method of reconstructing the severely traumatized hand. This article reviews the authors' experience with 188 great-toe and second-toe transplants. Detailed operative sequence and postoperative care are also discussed.

Treatment of chronic osteomyelitis of the lower extremities with debridement and microvascular muscle transfer.

Of our 55 patients treated for lower extremity osteomyelitis, 91% underwent debridement and microvascular muscle flap coverage with eradication of their infections and restoration of ambulation. This series of patients helps to solidly establish the efficacy of this approach to the treatment of osteomyelitis.