First human facial retransplantation: 30-month follow-up.

BACKGROUND: Since the first successful facial transplantation in 2005, the benefits of this procedure in terms of aesthetics, functionality, and quality of life have been firmly established. However, despite immunosuppressive treatment, long-term survival of the allograft might be compromised by chronic antibody-mediated rejection (CAMR), leading to irreversible necrosis of the tissue. In the absence of therapeutic options, this complication is inevitably life-threatening. METHODS: We report facial retransplantation in a man, 8 years after his first facial transplantation because of extensive disfigurement from type 1 neurofibromatosis and 6 weeks after complete loss of his allograft due to severe CAMR. We describe the chronology of immune-related problems that culminated in allograft necrosis and the eventual loss of the facial transplant, the desensitisation protocol used for this highly immunosensitised recipient, the surgical technicalities of the procedure, the specific psychological management of this patient, and the results from follow-up at 30 months. FINDINGS: Although the patient had a complicated postoperative course with numerous immunological, infectious, cardiorespiratory, and psychological events, he was discharged after a hospital stay of almost 1 year. He has since been able to re-integrate into his community with acceptable restoration of his quality of life. INTERPRETATION: This clinical report of the first documented human facial retransplantation is proof-of-concept that the loss of a facial transplant after CAMR can be mitigated successfully by retransplantation combined with an aggressive desensitisation process. FUNDING: Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris.

Evaluation of long-term functional donor-site morbidity after deep circumflex iliac crest artery bone flap harvest.

PURPOSE: Free flap surgery can be associated with donor-site morbidity. The purpose of this study was to analyze long-term functional outcomes at the donor site after deep circumflex iliac artery (DCIA) bone flap harvesting. METHODS: Fourteen patients (8 men and 6 women, mean age 53.9 years; range 22-87 years) with mandible resection (8 carcinomas, 4 ameloblastomas, 1 osteonecrosis, and 1 myxofibroma) and DCIA flap reconstruction were included in an observational study. Ranges of motion in the hip and lumbar spine, Harris hip score (HHS), jumping mechanography, chair rising, and balance testing were performed on a ground force reaction plate (Leonardo Mechanograph, Novotec Medical GmbH, Germany). The primary outcome was the Esslinger fitness index (EFI, maximum peak power in W/kg normalized to age and gender). RESULTS: Functional assessment was performed preoperatively and 29.0 months postoperatively (range 12-51 months). Mean DCIA flap length was 6.3 cm (range 3.3-10.1 cm). Jaw reconstruction was successful in all cases. HHS (99.2 vs. 97.7 points, P = .004) and all ranges of motion in the lumbar spine and hip joint except for dorsal extension were significantly reduced postoperatively (range -4° to -11.0°). There was no significant difference between pre- and postoperative EFI (77.9% vs. 74.28%, P = .591) and body sway (1.25 cm2 vs. 2.01 cm2 , P = .806). Sensory deficits (n = 5), load dependent pain (n = 3), and limitations of daily activities (n = 3) were subjective complaints. CONCLUSION: Functional donor site morbidity after DCIA harvesting can be expected to be low in the long-term.

Abdominal Wall Transplant Surgery.

The evolution and success of intestinal and multi-visceral transplantation over the past 20 years have raised the issue of difficult or even impossible abdominal closure, a topic rarely encountered in other fields of transplantation. Different techniques have been proposed to address this topic. The choice depends on the transplant team's expertise and/or the availability of a plastic surgery service. Abdominal wall transplant is a type of composite tissue allograft that can be utilized to reconstitute the abdominal domains of patients who undergo intestinal transplant, and the results are encouraging. It is an effective option to achieve primary abdominal closure after intestinal transplant. In its full-thickness form, it may be useful for monitoring rejection or viability of visceral organs. Our aim is to review the role of abdominal wall transplant in achieving tension-free closure of the abdomen.

Inducción de tolerancia a endotoxina en un modelo de trasplante de tejido compuesto / Tolerance induction to endotoxin in a composite tissue transplant

Introducción y Objetivo: La tolerancia a endotoxina (TE) es un fenómeno biológico que consiste en la desensibilización de las células del sistema inmune ante exposiciones bajas al lipopolisacárido (LPS), haciendo que entren en un estado de anergia ante otros estímulos. El objetivo de este trabajo es valorar el efecto inmunomodulador del precondicionamiento con lipopolisacárido en el contexto de un trasplante de tejido compuesto. Material y Método: Realizamos transferencias de patas traseras entre ratas cruzando el Complejo Mayor de Histocompatibilidad. Los animales se dividieron en 2 grupos según el precondicionamiento que recibieron, LPS y suero salino fisiológico. Resultados: El grupo control presentó una mediana de supervivencia del alotrasplante menor a 15 días tras el cese del tratamiento inmunosupresor. El grupo precondicionado con LPS presentó una mediana de supervivencia superior a 30 días (p= 0.001). Conclusiones: El mecanismo de tolerancia a endotoxina aumenta la supervivencia del alotrasplante de tejido compuesto

Background and Objetive: Endotoxin tolerance is a biological phenomenon which consists in desensitization of immune system cells to low exposures to lipopolysaccharide (LPS). It leads to antigens anergy. The aim of this study is to asses the development of tolerance after precondicioning with LPS in the context of a composite tissue transplant. Methods: Transferences of hind legs were made between rats crossing the Main Histocompatibility Complex (MHC). The animals were divided into 2 groups according to the preconditioning they received, LPS and physiological saline. Results: The control group presented a median survival of the allograft less tan 15 days after the cessation of inmunosupressive treatment. The group preconditioned with LPS presented median survival greater than 30 days (p=0.001). Conclusions: The mechanism of tolerance to endotoxin increases the survival of composite tissue allotransplantation

Accommodation and related conditions in vascularized composite allografts.

PURPOSE OF REVIEW: The outcome of vascularized composite allografts (VCA) often appear unrelated to the presence of donor-specific antibodies (DSA) in blood of the recipient or deposition of complement in the graft. The attenuation of injury and the absence of rejection in other types of grafts despite manifest donor-specific immunity have been explained by accommodation (acquired resistance to immune-mediated injury), adaptation (loss of graft antigen) and/or enhancement (antibody-mediated antigen blockade). Whether and how accommodation, adaptation and/or enhancement impact on the outcome of VCA is unknown. Here we consider how recent observations concerning accommodation in organ transplants might advance understanding and resolve uncertainties about the clinical course of VCA. RECENT FINDINGS: Investigation of the mechanisms through which kidney allografts avert antibody-mediated injury and rejection provide insights potentially applicable to VCA. Interaction of DSA can facilitate replacement of donor by recipient endothelial cells, modulate or decrease synthesis of antigen, mobilize antigen that in turn blocks further immune recognition and limit the amount of bound antibody, allowing accommodation to ensue. These processes also can explain the apparent dissociation between the presence and levels of DSA in blood, deposition of C4d in grafts and antibody-mediated rejection. Over time the processes might also explain the inception of chronic graft changes. SUMMARY: The disrupted tissue in VCA and potential for repopulation by endothelial cells of the recipient establish conditions that potentially decrease susceptibility to acute antibody-mediated rejection. These conditions include clonal suppression of donor-specific B cells, and adaptation, enhancement and accommodation. This setting also potentially highlights heretofore unrecognized interactions between these 'protective' processes.

Costochondral Graft in Young Children With Hemifacial Microsomia.

Patients with severely hypoplastic mandibles usually require condylar reconstruction. This study aimed to describe costochondral graft (CCG) for condylar reconstruction and report subsequent outcomes of these grafts in young children with Pruzansky/Kaban type IIB and type III mandibular hypoplasia. This study included 4 young children with type IIB and type III hemifacial microsomia treated with CCG to reconstruct the condyle at the Department of Oral and Maxillofacial Surgery in our hospital from March 2008 to March 2014. Radiographic measurements and clinical examinations were conducted. The mean age of patients at operation was 3.8 years, ranging from 2.8 to 5.3 years. The mean follow-up period was 43.5 months, ranging from 23 to 63 months. Functional improvement was observed in all patients. The ribs had grown in all patients to date. Three patients had clinically improved face appearance with no significant chin point deviation and canting of the occlusal plane. Although the other patient had partly improved face appearance compared with preoperative condition, he still showed clinically significant facial asymmetry and chin deviation. Our results showed that condylar reconstruction with CCG is a feasible method in the treatment of type IIB and type III hemifacial microsomia in young children. These results will provide early preliminary suggestions of growth and stability of CCG in patients <5 years.

No-Touch Saphenous Vein Harvesting May Improve Further the Patency of Saphenous Vein Composite Grafts: Early Outcomes and 1-Year Angiographic Results.

BACKGROUND: Harvesting technique and surgical strategy may affect patency rates of saphenous vein (SV) grafts in coronary artery bypass graft surgery (CABG). We evaluated early clinical outcomes and 1-year graft patency rates of SV grafts that were harvested with a no-touch technique and used as composite grafts. METHODS: Three hundred sixty-eight patients who underwent off-pump CABG using SV composite grafts based on the left internal thoracic artery were studied. The results of 103 patients who received SV grafts harvested with a "no-touch" technique (group NT) were compared with the results of 265 patients who received SV grafts harvested with a "minimal manipulation" technique (group MM). A propensity score-matched analysis was also performed to minimize differences in preoperative and intraoperative variables (n = 98 in each group). Early clinical outcomes and early and 1-year postoperative angiographic results were compared. RESULTS: No differences in early mortality or postoperative complications were observed between the two groups. Early postoperative (1.6 ± 2.2 days) angiography demonstrated a significantly higher patency rate of SV grafts in group NT than in group MM before and after propensity score matching (before, 100% versus 97.2%, p = 0.002; after, 100% versus 97.7%, p = 0.003). One-year postoperative (13.0 ± 2.5 months) angiography also showed a higher patency rate of SV grafts in group NT than in group MM before and after propensity score matching (before, 97.4% versus 92.4%, p = 0.024; after, 97.3% versus 92.6%, p = 0.051). CONCLUSIONS: The SV grafts harvested with a no-touch technique further improved the early and 1-year patency of SV composite grafts. Midterm and long-term angiographic follow-up may be warranted to demonstrate the superiority of no-touch SV composite grafts.

Modified Furlow Palatoplasty Using Small Double-Opposing Z-Plasty: Surgical Technique and Outcome.

BACKGROUND: A smaller Z-plasty is applied in a modified Furlow palatoplasty. The purpose of this study was to assess its surgical and functional outcome. METHODS: The surgical technique included mucoperiosteal flap elevation in the hard palate, complete pedicle dissection and release, double-opposing Z-plasty using 5-mm limbs and muscle dissection in the soft palate, and the buccal fat pad covering lateral relaxing wounds. A retrospective chart review was conducted for 231 consecutive nonsyndromic patients undergoing modified palatoplasty from May of 2007 to December of 2014. The demographic, postoperative, and follow-up data were collected. Statistical analyses were performed. RESULTS: Average age at palatoplasty was 8.3 months. The overall oronasal fistula rate was 0.4 percent; oronasal fistula occurred in only one case with bilateral cleft. Other complications included postoperative bleeding in two cases (0.8 percent), postoperative airway obstruction in one case (0.4 percent), obstructive sleep apnea in one case (0.4 percent), stitch abscess in one case (0.4 percent), and distal uvula dehiscence in two cases (0.8 percent). One hundred twenty-seven patients had full speech evaluation, and seven (5.5 percent) were diagnosed with velopharyngeal insufficiency requiring surgical correction. CONCLUSION: This modified palatoplasty using a small double-opposing Z-plasty provided adequate cleft palate closure, with a low fistula rate and satisfactory speech outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Malignant Pyoderma Associated with Granulomatosis with Polyangiitis (Wegener Granulomatosis) as a Unique Indication for Facial Vascularized Composite Allotransplantation: Part I.

BACKGROUND: Granulomatosis with polyangiitis (Wegener granulomatosis) is a rare disease that commonly starts in the craniofacial region and can lead to considerable facial disfigurement. Granulomas and vasculitis, however, can involve many other tissues (especially pulmonary and renal). Dermatologic and subcutaneous components can lead to malignant pyoderma. METHODS: The authors describe a unique pathologic condition, where significant Le Fort type trauma was associated with subsequent development of granulomatosis with polyangiitis and malignant pyoderma. Successive operations to excise necrotic tissue and reconstruct the defects were followed by worsening inflammation and tissue erosions. Trauma and surgery in proximity to the eye and sinuses masked the initial clinical presentation and led to delay in diagnosis and disease progression. The resultant facial disfigurement and tissue loss were substantial. RESULTS: Despite multiple confounding factors, accurate diagnosis was eventually established. This was based on persistence of sinus inflammations in the absence of infective agents, proven sterility of lung lesions, and antineutrophil cytoplasmic antibody positivity with proteinase 3 specificity. Skin lesion biopsy specimens were identified as pyoderma gangrenosum and later as malignant pyoderma. Institution of immunosuppressive therapy allowed successful control of the disease and wound healing. The resulting craniofacial destruction, however, necessitated facial vascularized composite allotransplantation. CONCLUSION: Recognition of this rare pathologic association is essential, to prevent delays in diagnosis and treatment that can lead to major craniofacial tissue loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Anatomy of the Vascularized Lateral Femoral Condyle Flap.

BACKGROUND: The perforators of the free lateral femoral condyle flap have yet to be adequately described in humans. Therefore, the authors investigated the perforator vessels of the lateral femoral condyle flap in an anatomical study and discussed potential clinical applications with a particular interest in its indication with vascularized bone and/or iliotibial band for tendon repair surgery. METHODS: The authors dissected thighs of 28 cadavers to evaluate the anatomical properties of perforator vessels that branch from the superior lateral genicular artery and supply bone, cartilage, subcutaneous tissue, and the iliotibial band of the lateral femoral condyle. RESULTS: In each dissected thigh, the superior lateral genicular artery was present and the average pedicle length was 38 ± 10 mm. The average diameter of the superior lateral genicular artery, proximal to its distribution into the deep articular and superficial patellar branches, was 2 ± 0.5 mm. A communication between deep articular and superficial patellar branches was seen in 96 percent of the dissected thighs. In 24 cases (86 percent), the authors were able to show the iliotibial band perforating vessel and harvest a free lateral femoral condyle flap as an osteochondral fasciocutaneous bone flap with vascularized tendon. CONCLUSIONS: Altogether, the authors' results indicate that the blood supply of the lateral femoral condyle flap is consistent and the lateral femoral condyle flap could serve as a free composite flap for complex indications in hand or limb reconstructive surgery. Clinical studies to compare the lateral femoral condyle to other well-established microsurgical free flaps are warranted.

Evaluación clínico-radiológica de la técnica de aloinjerto compactado y vástago cementado en cirugías de revisión de cadera / Clinical-radiological evaluation of the impaction allografting and cemented rod technique in revision knee surgery

Objetivo. Evaluar a largo plazo, el resultado clínico-radiológico, la supervivencia y las complicaciones intra y postoperatorias de pacientes intervenidos de cirugía de revisión de cadera mediante esta técnica. Material y métodos. Estudio analítico observacional, prospectivo y no aleatorizado de 26 pacientes intervenidos de cirugía de revisión de cadera en nuestro hospital (1997-1998), a los que se les realizó un seguimiento clínico-radiológico y un análisis de la supervivencia del implante. Resultados. Se observan diferencias estadísticamente significativas en los valores pre y postoperatorios de las escalas de Harris y de Merle D'Aubigne. La supervivencia del implante teniendo en cuenta como punto final la cirugía de revisión fue del 84% a los 13 años. Hubo 9 complicaciones intraoperatorias (6 de ellas fueron fracturas) e influyeron de forma significativa en la estancia hospitalaria. El 70% de los pacientes no tuvo ninguna complicación postoperatoria. Ninguna de las variables analizadas influyó en el hundimiento radiográfico de los implantes. Discusión. Diversas técnicas intentan solventar el déficit de stock óseo en las cirugías de revisión de cadera, pero solo una intenta recuperarlo, el injerto compactado. Conclusiones. La técnica de Ling ofrece una mejoría clínica tanto en la escala de Merle D'Aubigne como en la de Harris, a medio-largo plazo. La presentación de complicaciones intraoperatorias incrementa la estancia hospitalaria y los días necesarios para iniciar la sedestación. La técnica de Ling es una buena opción a tener en cuenta en pacientes jóvenes en los que es previsible que haya una nueva cirugía de revisión en el futuro (AU)

Objective. Long term clinical and radiological evaluation of results, survival, and peri- operative and post-operative complications of the patients who have been operated on for revision total hip arthroplasty using the impaction allografting and cemented rod technique. Material and methods. An observational, analytical, prospective and non-random study was conducted on 26 patients who underwent revision total hip arthroplasty in our Hospital (1997-98). They were clinically and radiologically assessed, and a survival analysis of the implant was performed. Results. Statistically significant differences were identified in the pre- and post-operative values, according to Harris and Merle D'Aubigne scores. The femoral components survival was considered as an endpoint of the revision replacement, which was 84% at a mean of 13 years. There were 9 intraoperative complications (6 were fractures) and they significantly affected the length of hospital stay. No post-operative complications were observed in 70% of the patients. None of the analysed variables had any influence on the radiological subsidence of the femoral component. Discussion. Several techniques aim to solve the bone stock deficiency in revision total hip arthroplasty, but only impaction grafting attempts to recover it. Conclusions. The Ling's technique shows an improvement over the Merle D'Aubigne and Harris scores, in the medium-long term. The intraoperative complications are mainly an increase in the length of hospital stay and the number of days needed to be able to sit down. Ling's technique is a good option to consider in young patients where it is foreseeable that there is a new revision surgery in the future (AU)

El reto de las transferencias de colgajos libres en pacientes quemados ¿Cuál es el mejor momento para la cirugía? / The challenge of free flap transfers in burn patients. What is the best timing of surgery?

La transferencia de colgajos libres es una herramienta fundamental dentro del arsenal reconstructivo para el tratamiento quirúrgico del gran quemado. Durante años ha existido controversia sobre la influencia del momento de la cirugía sobre la tasa de complicaciones, así como el alto riesgo de complicaciones al realizar reconstrucciones con colgajos libres en pacientes quemados. Diseñamos un estudio retrospectivo de las reconstrucciones quirúrgicas mediante colgajos libres realizadas en nuestra Unidad de Quemados del Hospital Universitari y Politecnic La Fe, de Valencia (España) en el periodo comprendido entre 2001 y 2013, recogiendo todos los datos relativos al paciente, a la lesión, al procedimiento reconstructivo, a los resultados y relacionando todo ello con el momento en el cual se realizó la cirugía. Para el análisis de los datos y asociaciones entre distintas variables usamos tablas de contingencia y aplicamos el test de independencia de Chi-cuadrado. Exponemos además 2 casos clínicos representativos de la cirugía reconstructiva practicada en pacientes quemados. Recogimos en total datos de 21 procedimientos de reconstrucción mediante colgajo libre en pacientes quemados. En ninguno se realizó reconstrucción primaria inmediata (en los primeros 5 días), mientras que la reconstrucción primaria temprana (entre el día 5 y el 21) se realizó en el 28,57% de los casos, la primaria intermedia (entre el día 21 y las 6 semanas) en el 28,57%, la secundaria (más de 6 semanas) en el 9,5%, y la cirugía de secuelas en el 33,33% de los casos. Las tasas de complicaciones mayores y menores fueron respectivamente 19,05% y 9,5%. El 50% de complicaciones mayores ocurrieron en el periodo de reconstrucción primaria temprana, mientras que no registramos ninguna en el periodo primario intermedio. El resto de complicaciones se repartió a partes iguales entre el periodo secundario y la cirugía de secuelas (ambas con el 25%). No encontramos asociación estadísticamente significativa entre las variables en ninguna de las comparaciones realizadas. En conclusión, creemos que la reconstrucción mediante colgajos libres en pacientes quemados presenta un riesgo más elevado de complicaciones mayores cuando se realiza en el periodo primario temprano (entre los días 5 y 21 tras la quemadura) (AU)

Free flap transfer is an essential tool within the reconstructive repertoire for the surgical treatment of major burn patients. For a long time there has been controversy about the influence of the timing over the complication rate, as well as the increased complication risk when we perform reconstruction by means of free flaps in burn patients. We designed a retrospective study about free flap reconstructions performed in our Burns Unit at the Hospital Universitari y Politecnic La Fe, Valencia (Spain), in the period from 2001 to 2013, collecting data related to the patient, the lesion, the reconstructive procedure, the results, and all this data related to timing. For the data analysis and associations between the different variables we used contingency tables and applied the Chi-square independence test. In addition we present 2 representative clinical reports about burn reconstructive surgery. Data from 21 reconstructive procedures with free flaps in burn patients were collected. Immediate primary reconstruction (in the first 5 days) is not performed in any patient, while early primary reconstruction (from day 5 to 21) was performed in 28,57% of cases; the intermediate primary reconstruction (from day 21 to 6th week) was performed in 28,57%, the secondary reconstruction (more than 6 weeks) in 9,5% and sequelae surgery in 33,33% of the cases. Major and minor complication rate were 19,05% and 9,5% respectively; 50% of major complications happened in early primary reconstruction period, whereas no complication is registered in intermediate primary period, the rest of complications are equally divided between secondary reconstruction period and sequelae surgery (both of them 25%). No statistically significant association between the variables is found in any of the comparisons performed. In conclusion, we think that reconstruction with free flaps applied to burn patients presents a higher major complication rate when performed in the early primary period (from day 5 to day 21 after the burn) (AU)

Reintegração de amputação digital distal com enxerto composto e difusão plasmática ampliada distal no plano dérmico palmar - relato de um caso em criança de 2 anos de idade e revisão da literatura / Reintegration of distal digital amputation with composite graft and plasmatic diffusion expanded distally on the palmar dermal plane - a case report of a 2-year-old child and a literature review

Nas amputações mais distais da ponta dos dedos, o reimplante microcirúrgico pode não ser praticável. Nestes casos, o enxerto composto oferece os melhores resultados funcionais e estéticos, sendo, porém, incerta a sua reintegração. Várias técnicas foram aventadas para melhorar a sobrevida do enxerto volumoso, basicamente diminuindo o seu volume, associando ou não um retalho cutâneo. Outras técnicas criam uma superfície adicional de contato para difusão plasmática, o "bolso subcutâneo", sem diminuir o volume do enxerto composto, com altas taxas de sucesso. O presente artigo apresenta um caso de amputação da ponta distal do dedo mínimo (zona I de Ishikawa) numa criança de 2 anos de idade. Impossível de reimplante microcirúrgico, a reintegração foi feita com enxerto composto do coto amputado, sem desbridamento, e com a criação de uma nova superfície de contato para difusão plasmática, na extremidade distal do coto enxertado, no plano dérmico da região hipotênar, aumentando assim a área de contato e diminuindo a distância radial da difusão plasmática no enxerto composto. Doze dias após, esse contato adicional foi separado e ambas as superfícies apresentaram sangramento. A reintegração foi total, com mínimas cicatrizes no dedo e na região hipotênar. Uma breve revisão bibliográfica foi feita e discutidos os conceitos cirúrgicos, assim como os fatores que influenciam na sobrevida do enxerto composto. Na área receptora, o plano anatômico mais adequado e melhor vascularizado, para o contato adicional com o enxerto, necessita ser determinado.

In more-distal amputations of the fingertips, microsurgical replantation is not feasible. For these cases, composite graft provides the best functional and aesthetic results. However, its reintegration is uncertain. Several techniques have been proposed to improve bulky graft survival by basically reducing its volume, regardless of whether a skin flap is connected. Other techniques create an additional contact surface for plasmatic diffusion, the so-called subcutaneous pocket, without reducing the composite graft volume and yielding high success rates. This article presents a case of amputation of the distal tip of the fifth digit (Ishikawa zone I) of a 2-year-old child. Because of the impossibility of microsurgical replantation, a composite graft was used to reintegrate the amputated stump, without debridement, by creating a new contact surface for plasmatic diffusion at the distal end of the grafted stump, on the dermal plane in the hypothenar region, thereby increasing the contact area and decreasing the radial distance for the plasmatic diffusion of the composite graft. Twelve days later, the additional contact was separated and both surfaces presented bleeding. Full reintegration occurred with minimal scarring of the finger and hypothenar region. A brief literature review was conducted, discussing surgical concepts and factors that influence composite graft survival. The most appropriate and best vascularized anatomic plane for additional contact with the graft in the recipient area needs to be determined.

Analysis of the morphologic differences of the second toe and digits of the hand, and evaluation of potential surgical intervention to minimize the differences using computer-aided design technology.

BACKGROUND: Toe "narrow neck" augmentation and pulp-plasty are two aesthetic surgical refinements that are performed to minimize the visual differences between the transferred toe and digit following a second toe-to-hand transfer. To improve the aesthetic refinements in a second toe transfer, the authors investigated the real shape of the flap and factors affecting the flap design using computer-aided design technology. METHODS: The plaster models of the right first through fourth digits and right second toes from 20 volunteers were scanned by spiral computer tomography to obtain three-dimensional reconstruction data. Computer-aided design software was used to analyze the data and simulate narrow neck augmentation and pulp-plasty. Next, the three-dimensional shapes of the transferred and excised flaps were created by Boolean calculation. RESULTS: The simulated transferred flaps were classified into two types in terms of their shape: crab claw and cross. The simulated excised pulp flaps could also be divided into two types-water drop and elliptic. There were individual variations and gender differences in the second toe morphology that resulted in different flap shapes. The flap shapes in narrow neck augmentation and pulp-plasty were determined using the location of the palmar protruding part and contour of the distal margin of the toe tip, respectively. CONCLUSIONS: Accurate three-dimensional shapes of the flap could be obtained by computer-aided design, and there were individual variations and gender differences. The authors suggest that the affected factors should be considered, and computer-aided design could be used to improve the accuracy of flap design before surgery.

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea.

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30% following head injury and 15% were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60%) followed in frequency by the cribriform plate and the sphenoid sinus (20% each). Follow-up period was 12-24 months. We have achieved a 95% success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100% success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.