The use of a chitosan dressing with silver in the management of paediatric burn wounds: a pilot study.

OBJECTIVE: Traditional burn dressings demonstrate unfavourable tendencies of shrinking when wet and failing to maintain their integrity when manipulated. To overcome these obstacles, gel-forming fibre dressings have emerged as an alternative. Our objective was to observe the clinical properties and healing ability in the setting of burn wounds in a paediatric centre of a chitosan-based dressing containing silver. METHODS: A sample of 12 partial-thickness burns in 10 children were identified for treatment with the chitosan-based silver dressing. The dressings were moistened before application, and monitored for any shrinkage on application. Patients were monitored for healing at outpatient follow-up visits and the dressings were allowed to separate as healing occurred. RESULTS: We treated 12 burns in 10 children with an average age of 5.2 years. The burns had an average proportion of total body surface area (TBSA) of 3.6 % and involved the trunk and all extremities. Wounds healed mostly or completely in an average of 8.3 days. Dressings retained their size when wet and integrity when removed. No burns were found to be infected at any point in the study. CONCLUSIONS: The chitosan-based dressing offered an optimal environment for moist wound management, and did not demonstrate the shrinkage or disintegration that diminishes the clinical usability of widely used hydrofibre dressings. The burns healed within an expected period of time, and did not undergo any infectious processes. Based on the results of this pilot study, the chitosan-based silver dressing is deserving of further study as an alternative to traditional burn dressings.

Porcine xenograft treatment of superficial partial-thickness burns in paediatric patients.

OBJECTIVE: Porcine xenograft (PX) has become a valuable part of the armamentarium of treatment options in a US paediatric burn centre. The use in adult patients has been well described in the burn literature, but there is minimal literature describing its use in children. The objective of this article is to describe a three-years' experience with PX use in paediatric burns. METHOD: A retrospective medical record review of patients with superficial partial-thickness burns treated with PX admitted to a paediatric burn centre between February 2009 and November 2012. RESULTS: A total of 164 patients met the inclusion criteria. Burn total body surface area (TBSA) ranged from 0.5% to 28%. After the placement of PX, significant decreases were seen in the need for narcotic analgesics and burn dressing changes. Only four of 164 patients (2.4%) developed infections, although only one of these infections was at the site of the xenograft. CONCLUSION: PX appears to reduce pain and eliminate the need for procedural intravenous sedation in many patients. This can make burn wound care more child-friendly and shorten hospital length of stay. The complication rate is low and manageable. The authors believe that PX is an effective and safe treatment for superficial partial-thickness burns in children. DECLARATION OF INTEREST: P. M.Glat, is a paid consultant and speaker for Mölnlycke Health Care, the manufacturer of EZ Derm.

Use of a copolymer dressing on superficial and partial-thickness burns in a paediatric population.

OBJECTIVE: Despite extensive research into the treatment of partial-thickness burns, to date there has not been the emergence of a preeminent modality. This pilot study, the first such study to be performed in a burn unit in the US, was designed to evaluate the efficacy and outcomes of the application of copolymer dressing (Suprathel; PolyMedics Innovations Corporation, Stuttgart, Germany) for both superficial and deeper partial-thickness burns. METHOD: The copolymer dressing was used as a primary wound dressing to treat superficial and deep partial-thickness burns (average 5% total body surface area) in paediatric patients. Burns were debrided within 24 hours, at bedside, in the burn unit or in the operating room. The copolymer dressing was then applied directly to the wound and covered with a non-adherent second layer and an absorptive outer dressing. After discharge, patients were seen every 5-7 days until healed. Parameters evaluated included average hospital length of stay, average number of intravenous doses of narcotics administered, pain score at first follow-up visit, average time to complete re epithelialisation, incidence of burn wound infection, and patient/parent satisfaction on a 4-point scale. We also evaluated our experience with the dressing. Data were evaluated retrospectively under an Investigational Review Board approved protocol. RESULTS: Of the 17 patients assessed the average hospital length of stay was 1.4 days during which the average number of intravenous narcotic doses administered before copolymer dressing application was 1.5 and after was 0.1 doses. At the first follow-up visit, average pain score was 1.2 on a 10-point scale and the average time to re epithelialisation was 9.5 days. There was no incidence of burn wound infection. Patient/parent satisfaction was average of 3.66 on a 4-point scale. The staff had found that the self-adherence and elasticity of the dressing made it easy to apply and stay adherent, especially in areas of difficult contour. There were no readmissions for further debridement or skin grafting. CONCLUSION: Our experience shows that patients may be discharged shortly after the application of the copolymer dressing, with manageable pain scores and ease of use as determined by the caretakers high satisfaction. This new, fully synthetic copolymer dressing is easy to apply, does not require any additional antimicrobial coverage and may be used to successfully manage deeper partial-thickness burns, donor sites or burns in areas of contour, where many other dressings might not be considered or be appropriate. DECLARATION OF INTEREST: None declared.

Clinical evaluation of a silver-impregnated foam dressing in paediatric partial-thickness burns.

OBJECTIVE: Mepilex Ag, a silver-impregnated foam dressing, was introduced to our institution in 2007 and our outcomes in the treatment of paediatric burns were observed to improve significantly. In order to confirm these observations, we wanted to evaluate the results of using the silver-impregnated foam dressing in partial-thickness paediatric burns. METHOD: In this retrospective study, the St. Christopher's Hospital burn registry was used to identify subjects, who were otherwise in excellent health at baseline, over an18-month period. Outcomes included length of stay, intravenous narcotic use, and time to healing. No direct comparative studies were performed. This was followed by a non-comparative prospective study involving 22 paediatric patients, aged 1-4 years, with partial-thickness burns. This was a sub-study of a larger randomised controlled trial involving adults with partial-thickness burns, comparing the silver-impregnated foam dressing with Silvadene. RESULTS: In the retrospective part of the study, the silver-impregnated foam dressing was used successfully for the treatment of partial-thickness paediatric burns, with few complications and infections, allowing a shorter hospital stay, fewer dressings, and less pain medication than for historical controls. In the non-comparative prospective study, of 22 paediatric patients 50% healed completely within 1 week of treatment. The mean length of stay was 3.77 days and the mean number of dressings used was 1.64. Although narcotic usage was not assessed, patient surveys showed stinging or burning to be recorded as 'never' in 13 patients, 'rarely' in 8 patients, and 'sometimes' in 1 patient. CONCLUSION: The silver-impregnated foam dressing is effective and safe for use in partial-thickness paediatric burns, eliminating the need for daily dressings. DECLARATION OF INTEREST: The study was supported by an educational grant from Mölnlycke Health Care.

Clinical characteristics of patients with unicoronal synostosis and mutations of fibroblast growth factor receptor 3: a preliminary report.

Clinical teaching dictates that isolated unicoronal synostosis is sporadic in occurrence and is possibly related to intrauterine constraint. Despite this, isolated reports document a familial occurrence. It has previously been recognized that there may be a familial pattern of inheritance. Recently, mutations in fibroblast growth factor receptors (FGFRs) have been implicated in several syndromic craniosynostoses. At the authors' institution, mutations in FGFR3, located at chromosome 4p16, have been found to cause coronal synostosis. Two cases of unicoronal synostosis were found to have the same Pro250Arg missense mutation in FGFR3. This finding suggested that all patients with a diagnosis of unicoronal synostosis be screened for the FGFR3 mutation. Between January and December of 1996, patients with a diagnosis of plagiocephaly at the Children's Hospital of Philadelphia were evaluated for the FGFR3 mutation. Thirty-seven patients with unicoronal synostosis had mutational studies. Two additional patients were known to have the FGFR3 mutation at the onset of the study. Of the 37 patients screened, four were found to have the FGFR3 mutation, for a total of six patients with both unicoronal synostosis and the FGFR3 mutation. All patients with unicoronal synostosis were evaluated for facial dysmorphology and operative outcome. The six patients with the FGFR3 mutation had more severe cranial dysmorphology and were more likely to need surgical revision than those without the FGFR3 mutation. The occurrence of the FGFR3 mutation among patients with unicoronal synostosis provides evidence for a genetic basis of certain forms of plagiocephaly. The clinical, radiologic, and molecular findings will be an important addition to the surgical management and counseling of patients with unicoronal synostosis.

Periorbital melanocytic lesions: excision and reconstruction in 40 patients.

The treatment of melanoma arising in the periorbital region is a difficult reconstructive problem. The abundance of vital structures in close proximity to one another makes the resection and subsequent reconstructive procedures extremely challenging. Reported here is experience with periorbital melanocytic lesions in 40 patients with the emphasis on the types of reconstruction performed. Forty patients with periorbital melanocytic lesions were treated between 1984 and 1995. The periorbital region was subdivided into five zones. These zones are the following: zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthus; zone IV, lateral canthus; and zone V, contiguous structures. Ocular melanomas were not included in this study. The distribution of the lesions in our 40 patients was zone I (n = 1), zone II (n = 14), zone III (n = 1), zone IV (n = 9), and zone V (n = 31). The ages of the patients ranged from 3 to 84 years at the time of reconstruction, with an average age of 57 years. Resection and reconstruction were performed simultaneously in all patients. Thirty-six of the patients were reconstructed with one procedure, three patients required two procedures, and one patient required five procedures. The tumor type was superficial spreading melanoma in 15 patients, melanoma in situ in 17 patients, malignant spindle cell neoplasm in 2 patients, desmoplastic melanoma in 2 patients, amelanocytic melanoma in 1 patient, epithelioid melanoma in 1 patient, and atypical melanocytic nevus in 2 patients in which an early, evolving melanoma could not be excluded. Elective lymph node dissection was performed in four patients for intermediate thickness lesions (1.5 to 4.0 mm). The types of reconstructions performed included full-thickness skin grafts, upper lid myocutaneous flaps, cheek advancement flaps, cervicofacial flaps, inferiorly based nasolabial flaps, tarsoconjunctival flaps, frontalis muscle flaps, medial transposition Z-plasty, and primary closure. The resection of periorbital melanomas can be difficult because of the number of important anatomic structures in the region. The challenge to the surgeon in handling head and neck melanomas in general lies in the need to provide the best functional and aesthetic result while still resecting the primary lesion with the intent of effecting a cure. We present our series to demonstrate that the adequacy of margins of resection need not be compromised to facilitate reconstruction and that excellent results are obtainable with reconstructive procedures performed after adequate resections. Several different types of flaps and grafts can be used, with the indications varying depending on the location of the lesion and the extent of resection. The major reconstructive options will be reviewed in detail.

Identification of a genetic cause for isolated unilateral coronal synostosis: a unique mutation in the fibroblast growth factor receptor 3.

To determine whether the autosomal dominant fibroblast growth factor receptor 3 (FGFR3) Pro250Arg mutation causes anterior plagiocephaly, patients with either apparently sporadic unicoronal synostosis (N = 37) or other forms of anterior plagiocephaly (N = 10) were studied for this mutation. Of 37 patients with unicoronal synostosis, 4 tested positive for the Pro250Arg mutation in FGFR3, and 33 were negative for this mutation. In three mutation positive patients with full parental studies, a parent with an extremely mild phenotype was found to carry the same mutation. None of the 6 patients with nonsynostotic plagiocephaly and none of the 4 patients with additional suture synostosis had the FGFR3 mutation. Because it is impossible to predict the FGFR3 Pro250Arg mutation status based on clinical examination alone, all patients with unicoronal synostosis should be tested for it. To assess their recurrence risk, all parents of mutation positive patients should be tested regardless of their clinical findings, because the phenotype can be extremely variable and without craniosynostosis.

Evolution of the lateral canthoplasty: techniques and indications.

Lateral canthoplasty is a useful method to restore eyelid function and to protect the ocular surfaces. The success of the procedure depends on the proper analysis of periorbital anatomy as it relates to the specific indication for lateral canthoplasty. We report the experience with 1565 lateral canthoplasties with emphasis on the evaluation of newer techniques that better address anatomic and functional requirements. Between 1981 and 1994, 1565 lateral canthoplasties were performed in 684 patients. Of these, 1369 "reconstructive" lateral canthoplasties were performed in 586 patients and 196 "cosmetic" lateral canthoplasties were performed in 98 patients. All operations were performed by a single surgeon (Jelks), and follow-up ranged from 1 to 14 years. The evolution of the operative technique for lateral canthoplasty has been toward an operation that corresponds with the anatomy of the individual. Indications for the procedure include lateral canthal dystopia, horizontal lid laxity, ectropion, entropion, lid margin eversion, lid retraction with or without soft-tissue deficiency, and aesthetic improvement. The types of procedures performed will be reviewed in detail. The evaluation of the newer forms of lateral canthoplasty as unique reconstructive tools and as adjuncts to aesthetic surgery will be discussed.

Vascular lip enlargement: Part I. Hemangiomas--tenets of therapy.

Vascular lesions involving the lips pose a difficult problem for both the surgeon and patient. Their removal by surgery may result in greater disfigurement and impairment than the original lesion. When nonsurgical modalities fail, using a well-planned strategy of sequential procedures can provide excellent results. Many hemangioma patients require judicious serial debulking of excess tissue mass, whereas enlargement from port-wine lesions may require direct aggressive surgery. Over a 10-year period, 38 patients underwent surgery for treatment of vascular lip enlargement. In 27 patients, the lip deformities were caused by hemangiomas. The remaining 11 patients had macrocheilia associated with port-wine vascular malformations. This paper specifically addresses hemangiomas of the lips, tenets for their removal, and reduction strategies. Of the 27 patients with hemangiomas involving the lips, 12 had had some form of previous treatment including corticosteroids (4 patients), embolization (3 patients), laser (3 patients), and interferon (2 patients). All 12 of these patients had unsatisfactory results. Specific tenets for the surgical management of these patients are presented. The distribution of the facial hemangiomas was as follows: 15 patients had isolated involvement of the upper lip, 7 lesions involved the lower lip alone and 5 involved both upper and lower lips. Additionally, 10 of these lesions involved the cheek(s), nose, or chin to some degree. Six patients experienced some form of functional impairment before our evaluation including difficulty with eating or drinking, visual obstruction, and psychosocial problems. All operations were performed following several principles established by the senior surgeon (B.M.Z.). By following the tenets presented in this report, he has achieved near-normal lip form, giving the patient marked improvement in appearance and function.

Vascular lip enlargement: Part II. Port-wine macrocheilia--tenets of therapy based on normative values.

Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are challenging reconstructive problems which, as a result, often go untreated. The surgical management of these lesions is not straightforward. Scarification by laser to diminish the discoloration has been performed with good results in some cases. However, laser treatment does little to correct three-dimensional tissue deformities such as macrocheilia, which must be addressed surgically. We present our experience with the treatment of port-wine macrocheilia in 11 patients over the 10-year period between 1983 and 1994. Basic principles for surgical and nonsurgical treatment of these patients are also discussed. Normative data about lip dimensions are important to surgical planning. We used 40 male and female volunteers, all less than 30 years of age, as a source for measuring normal lip dimensions, thereby creating a normative database. Preestablished points in the labial and perioral region were marked. Measurements were taken and then averaged. This information was used as a guide for surgical excision of large defects in some patients. In addition, in both the lower and the upper lip, if the opposite side is uninvolved, this database could serve as a template for reconstruction of the affected side. Between 1983 and 1994, 11 patients underwent surgery for port-wine macrocheilia. Of the 11 patients, 1 had previous treatment consisting of laser scarification. Four patients had port-wine vascular malformations involving the upper lip alone, four involved the lower lip alone, and three involved both lips. In six patients, other areas of the face and body were also involved. Our experience has led us to perform earlier surgical intervention than has previously been described for these patients. Basic reconstructive surgical principles and planning based on normative data and templates can lead to excellent results.

The inferior retinacular lateral canthoplasty: a new technique.

Lateral canthoplasty is a useful method of restoring lower eyelid position and thereby protecting the ocular surfaces. The success of the lateral canthoplasty procedure depends on the proper analysis of periorbital anatomy. Newer lateral canthoplasty techniques have become progressively refined in an attempt to avoid the drawbacks and pitfalls of older procedures. We present the inferior retinacular lateral canthoplasty, developed to effectively address the problems associated with lower lid laxity and/or malposition. The inferior retinacular lateral canthoplasty is a versatile reconstructive procedure that also can be used as an adjunct to aesthetic surgery. The evolution of the inferior retinacular lateral canthoplasty from over 15 years of clinical experience is discussed.

An experimental study of small-joint compression arthrodesis.

Arthrodesis of the interphalangeal and metacarpophalangeal joints is a technically demanding procedure with significant failure rates. A method of compression arthrodesis that was developed by one of the authors (RWB) using a compression clamp and crossed Kirschner wires is reported. This technique has been used without complication in the successful arthrodesis of 125 consecutive interphalangeal and metacarpophalangeal fusions by two of the authors (RWB and JAIG). An in vivo model of small-joint arthrodesis was then developed using the rabbit humeroulnar joint to compare this method of compression clamp arthrodesis with the tension band technique. Biomechanical testing at both 2 and 8 weeks postoperatively showed compression clamp arthrodesis to compare favorably with the tension band technique.

Reconstruction of breast asymmetry in Poland's chest-wall deformity using microvascular free flaps.

Poland's syndrome comprises a spectrum of chest-wall deformities affecting, to various degrees, the rib cage, the chest-wall muscles, the neurovascular structures of the ipsilateral arm, and the overlying breast. This study details our experience with nine female Poland's syndrome patients who had chest-wall and breast asymmetry corrected by microvascular free-tissue transfer. Nine female patients with Poland's chest deformity underwent 12 microvascular free flaps between 1989 and 1994. Donor sites for free-tissue transfer included eight transverse rectus abdominis flaps, two superior gluteal flaps, one inferior gluteal flap, and one contralateral latissimus dorsi flap. Recipient vessels were branches of the subscapular vascular axis in all patients. Patients' ages ranged from 18 to 47 years at the time of reconstruction. Chest-wall and breast asymmetry varied from accompanying severe pectus and rib cage deformities to isolated breast involvement. Complications were limited to a superior gluteal flap loss due to anomalous subscapular venous drainage. This patient underwent a successful second superior gluteal flap reconstruction utilizing the cephalic venous outflow system. Chest-wall and breast symmetry was restored in all patients. This study demonstrates that microsurgical reconstruction of chest-wall and breast asymmetry in Poland's syndrome yields excellent results with a high degree of patient satisfaction. Careful intraoperative assessment of the recipient vessels prior to flap transfer is mandatory. Because Poland's chest-wall deformity may include anomalies of the vascular system, preoperative vascular assessment with duplex ultrasonography should be considered in all patients, and use of preoperative angiography or venography in selected patients also appears justified.

Deep-plane cervicofacial "hike": anatomic basis with dog-ear blepharoplasty.

The temporal and cheek areas are particularly vulnerable to sun damage and therefore to skin cancers. Rotation-advancement flaps are used commonly in the reconstruction of these regions following resection of skin cancers. Such flaps usually are modifications of the Mustardé, cervicofacial, and Juri flaps. The drawbacks to these flaps relate to a random, unpredictable perfusion with skin loss at the distal flap tip, a vertically oriented dog-ear that predictably is located on the cheek, and the risk of gravitational and cicatricial forces acting on the lower eyelid causing ectropion. The deep-plane technique for raising cheek flaps, as has been described recently for use in rhytidectomy, allows the plastic surgeon to address both drawbacks of the standard cervicofacial flaps. The vertical "hike" deep-plane approach addresses both drawbacks of the rotation-advancement flaps by including better perfusion and superior mobility after release of restraining ligaments. We describe the anatomic rationale for the deep-plane dissection of the cheek in cadaver studies and present our clinical technique with a vertical "hike" cheek advancement with removal of the horizontally oriented dog-ear as in a blepharoplasty. This single-stage technique will be called the deep-plane "hike" flap. The vertically advanced flap must be slightly overcorrected by anchoring the flap to the periosteum just above the recipient defect. This deep fixation removes all tension from the skin and prevents ectropion. This single-stage reconstruction affords excellent cosmetic results without compromising any future reconstructive efforts.

The management of pigmented lesions of the nail bed.

Pigmented lesions of the nail bed, especially without a history of trauma, represent a diagnostic challenge to the clinician. These lesions are often categorized as melanonychia striata (MS), which refers to any linear tan-brown-black pigmentation of the nail bed. The differential diagnosis of MS includes subungual hematomas, onchomycosis nigricans, junctional nevi, melanoma in situ (MIS), and malignant melanoma (MM). Our algorithm at the New York University (NYU) Medical Center for the treatment of pigmented lesions of the nail bed is presented. A histopathologic diagnosis with any evidence of melanocytic atypia, however subtle, requires absolute confirmation by complete excision. The absence of a clear margin or recurrence requires total nail bed excision and reconstruction using a full-thickness graft. The diagnosis of MIS is similarly treated. The surgical management of subungual MM is discussed. All cases of MM of the hand treated at NYU were reviewed. In all, 30 patients were treated from 1982 to 1995. Follow-up ranged from 6 months to 13 years. In our series, there were 8 cutaneous and 22 subungual melanomas. There was a marked delay in treatment of both groups, with subungual melanomas more often erroneously treated as other pathology prior to correct diagnosis. The 5-year survival rate was 100% for patients with cutaneous lesions, but only 80% for those with the subungual variety. There was a statistical difference in the depths of the lesions (subungual, 3.68 mm; cutaneous, 1.36 mm) with a p-value of 0.008. The role of elective lymph node dissection in the absence of clinical metastases as well as intraoperative sentinel lymphatic mapping remains controversial and is discussed.

A classification of plagiocephaly utilizing a three-dimensional computer analysis of cranial base landmarks.

Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Previous classification systems based on the various etiologies of dysmorphic crania have been used in an effort to categorize the patients into groups and to assist in treatment planning. The system most commonly used today was described by Bruneteau and Mulliken in 1992. The authors separated frontal plagiocephaly into three types: synostotic, compensational, and deformational. The present study was undertaken in order to define a simple system for classifying plagiocephaly based on Bruneteau and Mulliken's system using the patients' preoperative craniofacial computed tomography scans. The involvement of the entire coronal ring in synostotic plagiocephaly led to the choice of 20 skull base landmarks as the basis of the analysis. Nine lateral landmarks (the superior orbital fissure, the optic foramen, the zygomatic arch, the greater palatine foramen, the foramen ovale, the mastoid tip, the hypoglossal canal, the external auditory canal, and the internal auditory canal) and two midline landmarks (the crista galli and the internal occipital protuberance) were used. The changes that occurred in these landmarks were analyzed in 30 patients. The results demonstrated that Bruneteau and Mulliken's classification system underestimated the number of different subtypes of plagiocephaly. As a result, three major types of frontal plagiocephaly and several different subtypes based on the different etiologies were described. Type I plagiocephaly includes plagiocephaly resulting from cranial suture synostosis. Type II includes those with a nonsynostotic etiology. Type III describes patients with craniofacial microsomia-associated plagiocephaly. Statistical analysis was unavailable because of the small number of patients in each subtype. With a larger number of patients, we hope to refine this system for use by the surgeon in preoperative diagnosis and surgical planning. The analysis is unique in its ability to quantitate changes from normal on the x-, y-, and z-coordinates, and therefore allows for identification of both horizontal (frontal bone deviation) and vertical (ear shear) growth disturbances.

The histomorphologic changes in vascularized bone transfer and their interrelationship with the recipient sites: a 1-year study.

In 13 New Zealand White rabbits with a mean age of 6 months, vascularized bone transfers incorporated as paired auricular anterior myo-osseous flaps were harvested; they were placed in either an inlay or an onlay position relative to the zygomatic arch. The onlay bone transfers were placed either in full contact or in partial contact with the zygomatic arch. The animals were sacrificed 1 year after transfer. At 1 year, the inlay transfer simulated the adjacent zygoma in width and thickness. Onlay full contact transfers maintained significant aug mentation in thickness of the zygoma, while the onlay partial contact transfers did not; the thickness of the augmented zygoma in the onlay full contact subgroup was significantly greater than that in the onlay partial contact transfers. The onlay partial contact grafts had remodeled into the zygoma in bone contact, where the orientation of mismatched osteons within the bone transfers had transformed to match that of the native zygoma. In areas of bone contact between the onlay and the host bone, full-thickness conversion from a cortical to a trabecular architecture had occurred in both the transfer and host bones. These findings have numerous implications regarding mechanisms that could be exploited clinically to optimize the survival of a bone transfer; they also raise questions regarding alteration of the recipient bed after placement of an onlay bone transfer.

Microsurgical reconstruction of the lower extremity using the 3M microvascular coupling device in venous anastomoses.

Microsurgical reconstruction of the lower extremity presents a difficult problem to plastic surgeons; the rate of failure is higher than any other anatomical site. We reviewed our recent experience with lower extremity microsurgical reconstruction using the 3M vascular coupling device. We believe the excellent patency rate of the coupler may minimize the well-described problem of venous thrombosis in this challenging group of patients. This study involves a consecutive series of 11 patients who presented for reconstructive microsurgery of the lower extremity at NYU Medical Center hospitals between June 1 and September 1, 1994. Ten of 11 patients had free flap transfer to traumatic lower extremity injuries, whereas the remaining reconstruction was in a diabetic individual with a chronic wound. Fifteen microvascular venous anastomoses were performed; all but 1 was performed using the 3M coupler. Our experience with 11 patients, involving 14 mechanically coupled venous anastomoses, demonstrated successful use of the coupler. No intraoperative or postoperative vascular complications occurred. The overall success rate of the 3M coupler for venous anastomoses was 100%, and all microvascular free flaps were successful. We recommend using the 3M coupling device for venous anastomoses during reconstructive microsurgery of the lower extremity. Our series demonstrates the safety and effectiveness of the 3M coupler in this challenging group of patients. In addition, a secondary benefit of the 3M coupler is a significant reduction in operative time.

Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free flap: critical evaluation of six cases.

Over a 12-year period between 1979 and 1991, 27 patients were operated on at the New York University Medical Center for salvage of below-knee amputation stumps utilizing free flaps. Six different donor sites were used. In 6 patients, the amputated foot was the donor site for a free flap to cover the tibial stump. There were 3 males and 3 females in this group. Five of the patients underwent immediate filet of foot reconstructions, while 1 patient had a reconstruction performed 69 days after injury, electively, when it was determined that below-knee amputation was the best option. All foot flaps survived and ultimately provided the major soft-tissue coverage for the below-knee amputation stump. The length of hospitalization ranged from 24 to 118 days. The time required from foot filet procedure to ambulation was 2, 4, 6, 7, 9, and 12 months in the 6 patients. Five of the 6 patients have resumed work or school after their injury. Foot flaps were based on the posterior tibial artery, anterior tibial artery, or both vessels. Nerve anastomosis of the posterior tibial nerve was performed in 5 patients. In 1 patient it was possible to maintain the continuity of the posterior tibial nerve. Five of the 6 patients were tested over a year after the flap, and all have good cold, pressure, and vibration sensation. Two of the 5 patients have heat sensation, and all 5 patients have at least protective pressure sensation. All the patients ambulate well with a below-knee prosthesis.

Limb salvage with microvascular free flap reconstruction using simultaneous polytetrafluoroethylene graft for inflow.

Microvascular free flaps have been successfully used to cover defects of the lower extremity. In patients with peripheral vascular disease and lower extremity defects, revascularization with in situ or reversed saphenous vein bypass graft combined with microvascular tissue transfer can salvage a limb that would otherwise be amputated. However, some of these patients may not have autologous vein available for the bypass procedure. We present a case of a 69-year-old man who underwent revascularization with a long polytetrafluoroethylene (PTFE) graft and a simultaneous microvascular free flap reconstruction using the PTFE graft as the inflow. The patient had undergone coronary artery bypass graft with saphenous vein and experienced a nonhealing wound of the distal saphenous vein harvest site and exposure of 8 cm of tibia. Angiogram revealed a significant stenosis of the common iliac artery, occluded superficial femoral artery, faint filling of the profunda femoris artery, and a faintly reconstituted posterior tibial artery. Because the patient had no available saphenous vein for bypass, he underwent an axillary-profunda and profunda-posterior tibial artery bypass with PTFE. A rectus abdominus microvascular free flap with direct anastomosis of the inferior epigastric artery to the PTFE was used to cover the exposed bone. The patient currently ambulates without difficulty. Limb salvage using bypass with PTFE combined with simultaneous microvascular free flap reconstruction is possible in selected patients.