Free muscle transfer with split thickness skin graft coverage in head and neck reconstructive surgery.

Sixteen patients (eight females and eight males) who underwent microsurgical free tissue transfers for head and neck reconstruction are reviewed. In this series, the flap reconstruction was completed on eleven patients with extra-oral defects and five with intra-oral defects. Split thickness skin graft coverage was used in all cases. The rectus abdominis free muscle flap was used in nine patients and the latissimus dorsi free muscle flap in seven patients. The choice of tissue reconstruction was decided by the size of the surgical defect. There were no failures of the tissue transfers and skin grafts. In skilled hands, free tissue transfer provides a reliable method of head and neck reconstruction, with a low incidence of recipient and donor site complications. In extra-oral defects, coverage of free muscle transfer with split thickness skin grafts, results in a better colour match than musculocutaneous flaps, and complements the appearance and pliability of the free muscle flap.

Report of a symposium on diagnosis and treatment of adult soft tissue sarcomas in the head and neck.

A series of presentations and discussions was held during a symposium on the diagnosis and treatment of adult soft tissue sarcomas in the head and neck (HNSTS). The purpose of this meeting was to define guidelines on diagnosis and treatment of HNSTS. The results of this symposium are summarized and condensed in this report. Recommendations are made for diagnostic strategies and for treatment. Diagnostic efforts in PET scanning and dynamic MRI need to be expanded to detect early recurrences. Firm pathological diagnosis remains the basis for further treatment strategy. Wide surgical excision, if feasible, in combination with radiotherapy is the treatment of choice.

Carpal Box radiography in suspected scaphoid fracture.

We have assessed the value of using a simple apparatus,the Carpal Box, in patients with suspected scaphoid fracture, to produce elongated and magnified radiographs of the carpus. The interobserver agreement between 60 observers of standard scaphoid radiographs and longitudinal and transverse Carpal Box radiographs (X-CB) was compared in 11 patients. Three-phase bone scanning was used as a comparative standard. If at least 75% of the observers agreed and the result was confirmed by three-phase bone scanning, the outcome was termed reliable. Scaphoid radiographs and the longitudinal X-CB films were reliable in four patients and the transverse X-CB films in six patients. The bone scan suggested a scaphoid fracture in five of the 11 patients. Agreement in the interpretation of the standard scaphoid radiographs was acceptable in only 36% of patients: in interpretation of transverse Carpal Box radiographs this figure increased to 55%.

Radiography and scintigraphy of suspected scaphoid fracture. A long-term study in 160 patients.

Radiographs of the scaphoid after injury are difficult to interpret, and bone scintigraphy is widely used to increase the accuracy of diagnosis, though many fractures suspected on scintigraphy cannot be confirmed radiologically. We have reviewed the clinical consequences, after one year, of managing suspected scaphoid fractures according to the bone-scan results. We studied 160 patients, 35 of whom had initially positive radiographs and were treated in a cast for 12 weeks. The other 125 had bone scintigraphy and were managed according to the result. After a minimum of one year 119 patients were reviewed. Scintigraphically suspected scaphoid fracture could not be confirmed radiologically in 25%. There were no cases of nonunion. The long period of immobilisation in patients with positive radiographs or positive bone scans did not influence the frequency or severity of late symptoms compared with those with a normal bone scan.

Bone scintigraphy of experimental composite bone grafts revascularized by microvascular anastomoses.

In these experiments the reliability of bone scintigraphy with 99mTc diphosphonate, to assess anastomotic patency and the viability of revascularized composite fibular grafts, was studied. It was shown that bone scintigraphy is very useful for the diagnosis of anastomotic patency, but only in the first postoperative weeks. Bone scintigraphy gives no information on the viability of bone grafts.

Tension decrease during skin stretching in undermined versus not undermined skin: an experimental study in piglets.

In a controlled study using 15 piglets, the efficacy of skin stretching using a skin stretching device was tested by quantifying the tension decrease during skin stretching in undermined and not undermined wounds. The viability of the skin margins was examined in both situations. Thirty standardized wounds was created: around 15 wounds on one flank, the surrounding skin was undermined; whereas around the 15 wounds on the opposite flank, the surrounding skin was not undermined. The force required to close the 9 x 9 cm defect was measured at the beginning, after undermining, and after 30 minutes of skin stretching. Also examined was the wound healing after 1 day and 1 week. A tension decrease of 3.02 N (13.6 percent reduction of the total force that is required to close the wound at the beginning) was seen due to undermining the surrounding skin. Skin stretching for 30 minutes without undermining the skin showed a tension decrease of 6.10 N (26.5 percent). Therefore, the tension decrease due to skin stretching was twice as high in comparison with undermining the skin margins alone. This has been statistically proven to be significant (-d (difference) = 3.08, 95 percent confidence interval = 2.16; 4.00, p < 0.001). When the undermined skin of the wound was stretched for 30 minutes, we measured a total tension decrease of 7.60 N (34.1 percent). There was a statistically significant but small difference in total tension decrease as a result of undermining combined with skin stretching in comparison with skin stretching without undermining (-d = 1.51, 95 percent confidence interval = 0.77; 2.23, p < 0.001). Undermining the surrounding skin involved cutting musculocutaneous perforating vessels. Looking at the viability of the skin, seven wounds, all found in the undermined group, showed skin necrosis after 1 week. Excessive seroma formation was seen in all wounds around which the skin was undermined. In the not undermined wounds, there were no problems in wound healing. In conclusion, skin stretching for only 30 minutes using a skin stretching device significantly reduces wound closing tension. The additional advantage of skin stretching over that of undermining alone is clearly shown. Undermining the wound margins before skin stretching gives a small additional tension decrease but has well-known complications, such as skin-edge necrosis and seroma formation.

Creation of an anal sphincter mechanism by bilateral proximally based gluteal muscle transposition.

A case report is given of a girl who, at the age of 17 years, lost her total posterior part of her perineum in a traffic accident. She was left with out an anal sphincter mechanism and a diverting sigmoidostomy was performed. Two years after the accident a new anal sphincter was constructed using bilateral transposition flaps of the gluteus maximus muscles. After 6 months of active training of this new "reanastomosed". The patient thereafter regained complete fecal continence by the natural route.

Modeling a fibula transplant in mandibular reconstructions: evaluation of the effects of a minimal number of osteotomies on the contour of the jaw.

The fibula osteocutaneous free flap has become the preferred method for most cases of mandibular reconstruction after oncologic surgical ablation. To recreate the parabolic form of the mandible, the fibula has to be divided up into segments using a closed wedge osteotomy technique. The number of osteotomies is preferably kept to a minimum so that segmental periosteal circulation is not compromised and also to keep operating time to a minimum. The limited number of osteotomies creates an angular contour. The aim of this study was to establish the degree to which overcorrection or undercorrection would occur when a subtotal reconstruction from ramus to ramus was simulated using five bony segments and four osteotomies. The study was carried out using 30 preserved jaws; the contour lines of the jaws were transferred onto tracing paper using a cardboard template. The contour of the mandible was divided into five sections (ramus, body, symphysis, body, and ramus). Because of the cutting off of the curvature in the original jaw outline, the lateral side of the body will become narrower and the chin broader. This also results in an underprojection (displacement) of the chin. To follow the original contour of the jaw as accurately as possible, all these anomalies must be minimized. The amount of under- and overprojection is calculated for a displacement of 1.0, 1.5, 2.5, 5.0, 7.5, and 10 mm of the chin. The most accurate reconstruction of the mandibular contour is achieved with a displacement of 1.5 or 2.5 mm. To preserve sufficient periosteal circulation, the minimum width of bone segments must be 15 mm or more. This concerns especially the symphysis section. On the basis of a fibula thickness of 14 mm, the internal bone width of the symphysis section is calculated. With a displacement of 1.5 mm, the average internal width of the bone segment is 14.8 mm, with a range of 9.9 to 23.0 mm (95 percent confidence interval, 12.8 to 16.7 mm). Therefore, a displacement of 2.5 mm with an internal bone width of 16.4 mm is preferred (range, 11.9 to 24.8 mm; 95 percent confidence interval, 15.5 to 18.2 mm). The loss of lateral projection is minimal (5.8 mm) and the resulting chin width is acceptable (average, 35.0 mm). In conclusion, we propose that in a subtotal procedure, an acceptable jaw reconstruction can be achieved with a limited number of osteotomies. The bone length of the symphysis section remains within safe limits. If the defect is of limited dimensions, then the resulting jaw contour is even more accurate.

Galactorrhea after reduction mammaplasty.

A case of extremely painful swelling of the breasts following a reduction mammaplasty is presented. There were no signs of an abscess or hematoma. A milky white fluid due to galactorrhea was evacuated at operation, and further galactorrhea was inhibited by medication. The pathogenesis of galactorrhea and its treatment are discussed.

Three-dimensional carpal kinematics in vivo.

OBJECTIVE: The purpose of this study was to accurately quantify three-dimensional in vivo kinematics of all carpal bones in flexion and extension and radial and ulnar deviation. DESIGN AND METHODS: The right wrists of 11 healthy volunteers were imaged by spiral CT with rotational increments of 5 degrees during ulnar-radial deviation and of five of them also during flexion-extension motion. One regular-dose scan was used and the subsequent scans during wrist motion were performed with one-tenth of the regular dose. A three-dimensional matching technique using the internal structure of the bones was developed to trace the relative translations and rotations of the carpal bones very accurately. RESULTS: Most of our results are in concordance with previously published in vitro data. We could, among others, substantiate proof to the statement that there is more than one kinematic pattern of the scaphoid. Furthermore, we could accurately describe small adaptive intercarpal motions in vivo of the distal carpal row. CONCLUSIONS: To our knowledge, this is the first time the three-dimensional in vivo kinematics of all eight carpal bones is quantified accurately and non-invasively. RELEVANCE: Kinematics of an injured wrist can be compared to these reference data. It may become possible that in this way a ligament lesion can be detected with high specificity and sensitivity, and that no other diagnostic modality will be needed. With these data we made animations with which the complex movements of the bones during different motions of the wrist can be viewed. In the future it may become possible that this analysis provides valuable information on the long-term results of operative interventions and possibly predicts results of operative techniques.

A very large neurilemmoma of the anterior interosseous nerve.

A very large neurilemmoma of more than 15 years duration, arising from the anterior interosseous nerve, is reported. To our knowledge, this is the largest ever described. While the symptoms and all other diagnostic findings suggested that the neurilemmoma originated from the median nerve, it needed angiography to provide the final diagnosis.

Treatment of volar instability of the metacarpophalangeal joint of the thumb by volar capsulodesis.

The metacarpophalangeal joint bears most of the stresses to which the thumb ray is subjected. Instability of this joint results in considerable functional impairment of the hand. Volar instability may be secondary to trauma, rheumatoid arthritis, or adduction spasms in cerebral palsy. The resulting hyperextension causes pain and weakness of pinch (Fig. 1). Various techniques have been described to correct this deformity. We prefer a volar capsulodesis as first described by Filler (1976), in which the whole volar plate is reinserted. Detailed knowledge of the complicated volar anatomy is essential. We have treated eight patients (two bilaterally) with this technique, all with satisfactory results.

The ulno-carpal abutment syndrome. Follow-up of the wafer procedure.

Seven wrists in six patients with ulno-carpal abutment syndrome were treated by a subchondral distal ulna resection (wafer procedure). The average follow-up was 36 months. Wrist function was evaluated using a clinical scoring chart. The parameters were pain, range of motion, grip strength and activities. One patient had a poor result, one a fair result and the remaining had good to excellent results. In all cases grip strength showed dramatic improvement. Complications were limited to palpable subcutaneous nylon sutures requiring removal in three patients and extensor carpi ulnaris tendinitis in one.

Carpal boss: destabilization of the third carpometacarpal joint after a wedge excision.

In a standard carpal boss procedure, the dorsal ligament of the involved carpometacarpal joint is cut in the process of performing a wedge excision. We studied the effect of such a dorsal ligament sectioning on the joint between the capitate and middle metacarpal bone in ten fresh-frozen wrist specimens. The passive range of motion of this joint was measured with the joint loaded into flexion and extension and in the unloaded neutral position. After the dorsal ligament of the carpometacarpal joint was cut, simulating a dorsal wedge excision, the passive range of motion was measured again. Analysis indicated that this simulated wedge excision approximately doubled the passive range of motion of the carpometacarpal joint. This study shows that such a procedure disturbs the normal anatomy and creates instability of the involved joint.

Rupture of a flexor pollicis longus tendon in Scheie's syndrome. Case report.

We describe a case of Scheie's syndrome with a closed rupture of the flexor pollicis longus tendon, probably caused by a combination of extrinsic and intrinsic tendon changes. Early detection of carpal tunnel syndrome in all patients who have some form of mucopolysaccharidosis in which this is a universal occurrence (such as Scheie's syndrome), is recommended. Release of the carpal tunnel prevents long term complications, as described in this case report.

[Fifty years of plastic surgery in the Netherlands. VI. Microsurgery]. / Vijftig jaar plastische chirurgie in Nederland. VI. Microchirurgie.

Use of the operating microscope created many new possibilities in plastic, reconstructive and hand surgery. Initially most work was done in digital replantation and, somewhat later, in transfers of toes for reconstruction of amputated thumbs. Microvascular surgery, however, appeared to be a technique suitable for more applications. Anatomical research of the blood supply of skin, fascia, muscle and bone identified flaps that could be carried by pedicle vessels. Transfer of these flaps and revascularization by microvascular anastomoses of the pedicle vessels set the stage for free flaps. In a few decades microsurgical techniques in plastic surgery fully matured. With free flap surgery single-stage and complex reconstructions could be achieved leading to earlier mobilization and better restoration of function with a shorter hospital stay. Today, microvascular free tissue transfer is an essential part of plastic and reconstructive surgery. Further advances in microsurgery and free tissue transfers deserve to be mentioned: pre-fabrication of free flaps, reduction of donor site morbidity, development of artificial conduits and instrumentation and finally homologous transplantations.

[Surgical possibilities in spastic paralysis of arm and hand]. / Operatieve mogelijkheden bij spastisch verlamde arm en hand.

OBJECTIVE: To determine the results of surgical correction of spastic paralysis of the hand due to cerebral palsy. DESIGN: Descriptive. SETTING: Academic Medical Centre, Amsterdam, the Netherlands, and rehabilitation centre De Trappenberg. METHOD: From 1-1-1990 until 1-6-1994 twenty patients with spastic upper limb in cerebral palsy were operated in our hospital. They were all seen preoperatively by our multidisciplinary team, and selected according to the Zancolli classification. Seventeen operations were aimed at improving hand function, the other three were performed for contractures or for cosmetic/hygienic reasons. Surgery was aimed at correcting the muscular imbalance, by weakening spastic muscles via tenotomy or lengthening and by reinforcing paralysed muscles via tendon transfer or rerouting. Often stabilisation of joints by tenodesis, capsulodesis or arthrodesis was necessary as well. RESULTS: Eighteen of the twenty patients were (very) happy with the results. In two patients there was no functional gain. Only once was a postoperative complication seen: pseudarthrosis of the first carpometacarpal joint. This was corrected successfully by rearthrodesis. We found we were able to predict the functional outcome fairly accurately. CONCLUSION: With accurate patient selection, surgical intervention in patients with cerebral palsy may restore hand function adequately and predictably.

[Reconstructive surgery of the head and neck region using free muscle flaps]. / Reconstructieve chirurgie van het hoofd-halsgebied met behulp van vrije spierlappen.

Twenty-seven patients who underwent microvasculosurgical free tissue transfers for head and neck reconstruction with a M. rectus abdominis or M. latissimus dorsi flap are reviewed. In this series the flap reconstruction was completed in 15 patients with extraoral defects, in six patients with an intraoral defect and in six patients with a combined intra and extraoral defect. Split thickness skin graft coverage was used in all cases. All free muscle grafts survived and good take of the split skin was obtained. In extraoral defects coverage of free muscle transfer with split thickness skin grafts results in a better color match than with musculocutaneous flaps and complements the appearance and pliability of the free muscle flap. Reshaping and three-dimensional positioning made reconstruction of every intraoral defect and combined intra and extraoral defects possible. In skilled hands, free tissue transfer provides a reliable method for reconstruction of almost every defect in the head and neck.