Using an unconventional perfusion pattern in ear replantation-arterialization of the venous system.

Ear amputation is a devastating injury characterized by a conspicuous deformity that is not easily concealed and can result in tremendous psychological trauma in addition to the physical insult. While numerous different approaches have been proposed, microvascular replantation is widely considered to deliver the best esthetic outcome. In this article, the authors report a case in which an unconventional perfusion pattern (i.e., arterialization of the venous system) was chosen, as intraoperative anatomic conditions precluded conventional vascular reconstruction. A 25-year-old male patient sustained a human bite resulting in subtotal amputation of his left ear. In the setting of an adequate arterial donor vessel, that is, branch of the posterior auricular artery, and a single suitable recipient vein (0.4 mm), the decision was made to perform an end-to-end arterio-venous anastomosis without the use of vein grafts. Medicinal leeches were applied postoperatively to provide for venous drainage. The ear survived and the patient was discharged after 14 days. To the best of our knowledge, this is first case of a subtotal ear amputation that was successfully replanted by arterialization of the venous system without the use of vein grafts and with preservation of the superficial temporal vessels.

Secreted HoxA3 Promotes Epidermal Proliferation and Angiogenesis in Genetically Modified Three-Dimensional Composite Skin Constructs.

Objective: Homeobox (HOX) transcription factors coordinate gene expression in wound repair and angiogenesis. Previous studies have shown that gene transfer of HoxA3 to wounds of diabetic mice accelerates wound healing, increasing angiogenesis and keratinocyte migration. In this study, we examined whether HoxA3 can also improve angiogenesis, epidermal integrity, and viability of composite skin grafts. Approach: To determine the effects of HoxA3 on composite skin grafts, we constructed bilayered composite grafts incorporating fibroblasts engineered to constitutively secrete HoxA3. We then transplanted these composite grafts in vivo. Results: The composite grafts produced a stratified epidermal layer after seventeen days in culture and following transplantation in vivo, these grafts exhibit normal epidermal differentiation and reduced contraction compared to controls. In addition, HoxA3 grafts showed increased angiogenesis. Quantitative polymerase chain reaction (PCR) analyses of HoxA3 graft tissue reveal an increase in the downstream HoxA3 target genes MMP-14 and uPAR expression, as well as a reduction in CCL-2 and CxCl-12. Innovation: Expression of secreted HoxA3 in composite grafts represents a comprehensive approach that targets both keratinocytes and endothelial cells to promote epidermal proliferation and angiogenesis. Conclusion: Secreted HoxA3 improves angiogenesis, reduces expression of inflammatory mediators, and prolongs composite skin graft integrity.

Single-stage reconstruction of a devastating antebrachial injury with brachial artery, median nerve, and soft tissue deficit: a case report and review of the literature.

OBJECTIVE: We present a case of a 31-year-old man who fell through a skylight sustaining a deep laceration injury to his dominant arm. A single-stage radial artery flow-through free flap and cabled sural nerve graft for reconstruction of a complex antebrachial defect involving skin, soft tissue, muscle, brachial artery, and median nerve was performed. A technical description of the case and review of the literature are described. METHODS: Traumatic injuries to the arm and antecubital fossa often lead to devastating outcomes. Advances in microsurgical technique as well as improved skin and dermal substitutes have allowed improved outcomes as well as shorter hospital stays. In this case, surgical treatment involved microsurgical reconstruction of the brachial artery with a radial artery flow-through flap and a single-stage donor-site closure with an Integra dermal matrix template and split-thickness skin graft. RESULTS: Successful vascular flow and soft tissue coverage were performed with successful salvage of the limb. CONCLUSION: A single-stage reconstruction versus a multistage, delayed reconstruction of a devastating arm injury with a radial forearm flow-through flap and single-stage closure with Integra and autologous skin graft can provide a safe, effective, and clinically satisfactory outcome.

Surgical treatment options for subacute ischemia of the hand: case report and literature review.

PURPOSE: The most effective surgical approach to the treatment of digital ischemia has not yet been established. The purpose of this study is to review currently accepted options for revascularization in acute and chronic settings of digital ischemia, and to augment this discussion by describing the approach of our surgical team in a unique case of subacute ischemia. OPERATIVE TECHNIQUE: To restore blood flow to a patient's ischemic hand, we performed a microvascular reconstruction, using a reverse interpositional vein graft with 3 anastomoses: the ulnar artery was used for inflow and the superficial palmar arch and the common digital artery were used for outflow. RESULTS: The patient experienced immediate postoperative pain relief. Blood flow was restored, which prevented digital amputation. The graft remained patent at 18 months' follow-up and the patient exhibited normal motor and sensory function. CONCLUSIONS: Surgical reconstruction of the hand is a viable treatment option for carefully selected patients presenting with subacute digital ischemia. Other medical and surgical techniques have been described in the recent literature, but further study is needed to determine the long-term success of newer microsurgical interventions.