USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

BACKGROUND: Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases. METHODS: Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap. RESULTS: All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications. CONCLUSION: The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Microsurgical ear replantation-is venous repair necessary?-A systematic review.

BACKGROUND: A common postoperative observation after microsurgical ear replantation has been venous congestion necessitating alternate modes of decongestion, frequently in conjunction with blood transfusion. A comprehensive literature search was performed to assess the relationship between mode of vascular reconstruction and postoperative outcome as well as postoperative transfusion requirement after microsurgical ear replantation. METHODS: The search was limited to cases of microsurgical ear replantation following complete amputation. Only articles published in English and indexed in PubMed were included. RESULTS: The initial search retrieved 285 articles, which was narrowed down to 40 articles reporting on 60 cases that matched the aforementioned criteria. Reconstruction of the arterial and venous limb (Group 1) was performed in 63.3% of patients and artery-only anastomosis (Group 2) was performed in 31.7%. Among measurable outcomes, only the duration of surgery was significantly different between groups (2.6 hours longer in Group 1 than Group 2; P = 0.0042). CONCLUSION: In light of contemporary data demonstrating successful artery-only ear replantation, replantation should not be abandoned when unable to establish venous outflow microsurgically. © 2015 Wiley Periodicals, Inc. Microsurgery 36:345-350, 2016.

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

Approach to Lymphedema Management.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

Standardized protocol for artery-only fingertip replantation.

PURPOSE: Artery-only fingertip replantation can be reliable if low-resistance flow through the replant is maintained until venous outflow is restored naturally. Injuring the tip of the replant to promote ongoing bleeding augmented with anticoagulation usually accomplishes this; however, such management results in prolonged hospitalization. In this study, we analyzed the outcomes of artery-only fingertip replantation using a standardized postoperative protocol consisting of dextran-40, heparin, and leech therapy. METHODS: Between 2001 and 2008, we performed 19 artery-only fingertip replants for 17 patients. All patients had the replanted nail plate removed and received intravenous dextran-40, heparin, and aspirin to promote fingertip bleeding and vascular outflow. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored by neovascularization. We used medicinal leeches and mechanical heparin scrubbing for acute decongestion. By postoperative day 6, bleeding was no longer promoted. We initiated fluorescent dye perfusion studies to assess circulatory competence and direct further anticoagulant intervention if necessary. The absence of bleeding associated with an initial rise followed by an appropriate fall in fluorescent dye concentration would trigger a weaning of anticoagulation. RESULTS: All of the 19 replants survived. The average length of hospital stay was 9 days (range, 7-17 d). Eleven patients received blood transfusions. The average transfusion was 1.8 units (range, 0-9 units). All patients were happy with the decision to replant, and the cosmetic result. CONCLUSIONS: A protocol that promotes temporary, controlled bleeding from the fingertip is protective of artery-only replants distal to the distal interphalangeal joint until physiologic venous outflow is restored. The protocol described is both safe and reliable. The patient should be informed that such replant attempts may result in the need for transfusions and extended hospital stays, factors that can help the physician and patient decide whether to proceed with replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bilateral breast reconstruction: the simultaneous use of autogenous tissue and identical twin isograft.

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.

Resurfacing of a complex upper extremity injury: an excellent indication for the dorsal thoracic fascial flap.

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.

High-pressure injection injury: a case report and systematic review.

High-pressure delivery devices for paint and other substances can lead to severe injuries of the hand without immediate surgical debridement. We present a case of a high-pressure paint gun injury treated surgically with full resolution of function. A systematic review of the literature details outcomes of similar injuries.

Microsurgical scalp reconstruction after a mountain lion attack.

Mountain lion attacks on humans are rare and potentially fatal. Although few victims experience minor injuries, permanent disfigurement and disability is common among survivors of these assaults. Since 1986, a steady number of mountain lion attacks have been noted in California. We report a recent attack of a cougar on a couple hiking in California's Prairie Creek Redwoods State Park. The victim sustained a significant scalp injury that led to a life-threatening soft-tissue infection. We present an analysis of the injury pattern as it relates to the bite marks, the resulting degloving injury, and the surgical reconstruction. We also offer a current survey of the pathogens often found in cats' and mountain lions' bite wounds and the appropriate antibiotic treatment. Given the infrequency at which clinicians encounter mountain lion injuries, we recommend that after initial management and exclusion of life threatening injuries patients be transferred to a tertiary care facility capable of managing the various reconstructive challenges such as the one presented in this case.

Use of the venous flap for salvage of difficult ring avulsion injuries.

Ring avulsion can lead to soft tissue compromise resulting in eventual digit failure or restriction of motion. The authors present use of the venous flow through flap for simultaneous soft tissue and digital vessel reconstruction in severe ring avulsion injury. A retrospective review of ring avulsion injuries treated with transplantation of an arterialized (A-V-A) venous flap between 1999 and 2006 was conducted. Indications included digits which were debrided and required soft tissue and digital artery reconstruction. Eight venous flaps were transplanted for 3 Urbaniak class II and 5 Urbaniak class III ring avulsions. Average size of the venous flap was 6 cm(2). All flaps and digits survived without partial necrosis. The soft tissue envelope was supple in all cases. Total active motion (TAM) ranged from 160 to 210 degrees. The arterialized venous flow-through flap is a reliable solution for the complex ring avulsion injury which requires simultaneous soft tissue and digital vessel reconstruction.

Partial muscle harvest: our first 100 cases attempting to preserve form and function at the donor site.

The authors report their first 100 partial muscle flaps as a strategy to preserve form and function of the donor site in muscle transplantation. Between 2003 and 2007, 62 partial superior latissimus (PSL) flaps and 38 partial medial rectus (PMR) flaps were transplanted for head and neck, upper and lower extremity, and chest wall reconstruction. All flaps survived. There were hematomas at the donor sites in two PMR cases. Form and function were preserved at the donor site in all cases. The PSL provided comparable muscle volume and pedicle length to the entire rectus abdominis muscle. An additional benefit was its use as a functional muscle. The PMR flap provided comparable muscle volume to the gracilis muscle. An additional benefit was a much longer vascular pedicle. Small to moderate sized flaps can be harvested from the fabric of the latissimus dorsi and rectus abdomenis muscles and be reliably transplanted. When positioned at the superior edge of the latissimus or medial edge of the rectus muscle, adequate blood flow and innervation to the residual muscle result in preservation of form and function at the donor site. The benefits of muscle transplantation can be realized without the associated morbidity of muscle harvest.

Index finger salvage with replantation and revascularization: revisiting conventional wisdom.

Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty-eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty-three replants/revascularizations survived (100%). Total active motion was 170 degrees in zone 1, and 133 degrees for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided.

Creation of a four-joint-digit after second toe to digit transplantation: restoration of form and function.

The authors describe the non-orthotopic insertion of an Ascension two-piece pyrocarbon proximal interphalangeal joint at the osteosynthesis level of bilateral toe-to-digit transplantations in an attempt to restore both anatomic length and composite fist formation after traumatic multidigit loss. The non-orthotopic joints provided an additional 30 and 35 degrees of stable flexion to the reconstructed index and longs digits enabling the patient to form a composite fist. There was no evidence of joint instability or loosening. Total active motion was 240 and 235 degrees at the index and long fingers, respectively. Creation of two four joint fingers by the addition of non-orthotopic joints in toe-to-digit reconstructions successfully restored form and function after multidigit loss.

Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap.

We report a case of a 58-year-old patient who sustained multiple finger injuries on the right hand. After thorough debridement, two dorsal defects of the middle and ring fingers were covered simultaneously with a single arterialized venous free flap from the right forearm. The flap was used to create a dorsally syndactylized digit which survived completely and was subsequently divided longitudinally. With early flap division, excellent functional and cosmetic result was achieved. We consider the syndactylized venous free flap with early division as a useful option for simultaneous coverage of separate dorsal digital defects.

Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle.

Limb salvage techniques of traumatized extremities using free-tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6-28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and returned to independent ambulation. When performing free tissue transfer about the ankle, temporary spanning with a circular fixator is effective in preventing equinus deformity and provides a stable mechanical construct protecting the flap.

Ring avulsion: injury pattern, treatment, and outcome.

Ring avulsion injury is classically believed to be one of the most challenging for the reconstructive surgeon. Injury patterns include a spectrum from laceration to complete amputation, with differential magnitude of injury to soft tissue, tendon, joint complex, and bone. Although ring avulsion injury can result in devastating functional and aesthetic loss to the hand, fear of even greater functional loss has made replantation a relative contraindication for this complex injury. This article hopes to clarify the pathomechanics and anatomy of ring avulsion, such that the elements of injury, which lead to poor survival and poor function, can be adequately addressed in the surgical plan.

Cross-facial and functional microvascular muscle transplantation for longstanding facial paralysis.

Functional results continue to improve with advancing microsurgical techniques and monitoring to detect and correct problems within minutes [47]. However, failures do occur, even when one can project a 98% survival for the transplant. Figs. 9 and 10 show two of our early cases that were fortunately salvaged with a second microvascular transplant. Evaluation of the result is a continuing challenge--anatomically, physiologically, and psychologically [37]. If one can remove the stigma or stigmata of facial paralysis in the patient's mind. success has been achieved (Fig. II) [48].

The harvest and clinical application of the superficial peroneal sensory nerve for grafting motor and sensory nerve defects.

Potential donor nerves for autografting are finite and usually limited to cutaneous nerves of the extremities. The superficial peroneal nerve is the major lateral branch of the common peroneal nerve that innervates the peroneus longus and brevis muscles and provides sensation to the lateral aspect of the lower leg and the dorsal foot. It has generally been overlooked as a potential donor of nerve autografts. Cadaver dissections were performed on 10 fresh lower extremity specimens to investigate the anatomic characteristics of the superficial peroneal nerve and to refine a harvesting technique for the nerve. Thirty-one patients underwent nerve grafting of 39 upper and lower extremity nerves using the superficial peroneal donor. There were nine median nerves, four ulnar nerves, two radial nerves, two brachial plexus lesions, 16 digital nerves, and six lower extremity nerves grafted. The superficial peroneal nerve provided a consistently long donor, comparable in length to the sural nerve. The anatomic pattern is consistent, the patient positioning is simple, the surgical harvesting technique is straightforward, and the donor defect is acceptable. The superficial peroneal nerve provides a safe and valuable donor nerve, particularly in cases where multiple or very long nerve grafts are required.

Composite tissue allografting (CTA).

Composite tissue allografting (CTA) is a relatively new term that appears with increased frequency in the medical and surgical literature. The recent successful allografts, or homotransplantations, of hands has sparked a resurgence of research, both experimental and clinical. Plastic surgeons have long been interested--particularly in the field of skin grafts for extensive burns and wounds--but have been replaced by the organ transplant teams and immunogeneticists. The skin, one of the most strongly antigenic organs, has required such high levels of immunosuppressive drugs to date, that elective transplants of skin and other composite tissues have received little attention.