Double Trigger Wrist Caused by 2 Flexor Tendon Sheath Giant Cell Tumors.

ABSTRACT: Trigger finger is a relatively common condition affecting the smooth gliding of tendons in the hand. When this entity affects the gliding motion of the wrist, it is termed as trigger wrist. In this article, we report the extremely rare case of a double trigger wrist caused by 2 tendon sheath tumors resulting in 2 trigger points in the motion of the wrist and carpal tunnel syndrome. The patient was managed with surgical excision of the tumors and release of the flexor retinaculum with resolution of symptoms.

The V-Plasty: A Novel Microsurgical Technique for Anastomosis of Vessels with Marked Size Discrepancy.

BACKGROUND: The art of reconstructive microsurgery is still progressing after Carrel's original description of "vascular repair" in 1902. Reports of the successful repair of vessels smaller than 1 mm in diameter are currently commonplace. However, the technique of microvascular anastomosis to connect vessels with large diameter discrepancy, greater than 1 mm, has not yet been perfected. This article reports a novel option to anastomose two vessels of different sizes by adapting the diameters of the two stumps and creating a gentle slope that dramatically reduces turbulences in the blood stream. METHODS: The "V-plasty" consists in designing a v-shaped flap on the wall of the large vessel and a longitudinal incision on the small one. The V-flap is then introduced into the V-defect of the small vessel, creating a smooth transition of the diameters between the two vessels. Mathematical calculation of the dimensions of the V-flap was conducted with different ratios' discrepancies of the two vessels ranging from 1.5 to 4. Clinically, 14 microvascular V-plasty were performed in 8 patients. RESULTS: The theoretical simulation and our clinical experience of 14 cases allowed us to propose the different dimensions (length and width) of the V-plasty according to the ratio of vessels discrepancies. CONCLUSION: The V-plasty microanastomosis is an alternative method to attach vessels with size discrepancy. It simply equalizes the donor and recipient vessels' diameters. Its main advantage is to maintain a linear axis between the two vessels whatever the discrepancy ratio is.

Shortage of Plastic Surgeons in Lebanon: Impact of the 2019 Economic Crisis.

Background: Lebanon's ongoing economic crisis since 2019 has seen an unprecedented migration of professional healthcare workers. This article analyzes the adequacy of registered plastic surgeons in Lebanon in 2023. Methods: A list of registered plastic surgeons was obtained from the Lebanese Order of Physicians. Registered plastic surgeons were contacted via email or phone and were asked to fill in a survey questionnaire addressing their work status. Additionally, the number of plastic surgeon graduates, between 2018 and 2022, was obtained from Lebanese medical schools. Results: Of the 162 plastic surgeons registered with the Lebanese Order of Physicians in 2023, 158 responded to the survey (97.5%). The work settings of the active plastic surgeons fell into three categories: working in Lebanon full time, splitting work between Lebanon and abroad, and exclusively working abroad. The ratio of plastic surgeons practicing full time in Lebanon is 1.11 per 100,000 inhabitants, which is significantly below the recommended ratio of 2.01. Twenty eight percent of the plastic surgeons working in Lebanon are aged between 65 and 75 years. Meanwhile, an average of only three graduates (2018-2022) enter the workforce annually after completing training in plastic and reconstructive surgery residency. Among the various subspecialties within plastic and reconstructive surgery, aesthetic surgery was the most commonly practiced by those surveyed. Conclusions: There is a relative shortage of plastic surgeons in Lebanon that is compounded by a significant focus on aesthetic procedures. Implementation of strategies is needed to bridge this gap and meet the needs of the underserved people of Lebanon.

Omega "Ω" Pulley Plasty for Surgical Management of DeQuervain's Disease.

BACKGROUND: DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complications by describing techniques of pulley reconstruction after its release necessitating suturing the different flaps and subsequently promoting extensor tendons adhesions. The authors present an alternative procedure for the first extensor compartment pulley decompression: "Omegaplasty". METHODS: 25 Patients with 29 DeQuervain tenosynovitis cases were enrolled in a prospective, nonrandomized clinical trial from 2012 to 2016. At enrollment they were offered the option of Omegaplasty as a surgical treatment modality for their cases. The procedure is based on liberating the anterior attachment of the pulley from the anterior lip of the styloïd process while respecting its continuity with the periosteal flap as well as promoting expansion of the tunnel volume. All operated patients were evaluated using the "Opposition Kapandji Score". RESULTS: The authors present the results of 29 different "Omegaplasty" procedures. Based on the Kapandji opposition score, twenty cases scored 10/10 while the remaining nine cases yielded an 8/10 score each. CONCLUSIONS: The described technique is simple, reliable and respects the extensor tendons gliding physiology and biodynamics. By preserving the anatomical continuity of the first extensor compartment pulley at the wrist, the risk of adhesion formation is reduced. The preliminary results are encouraging and provide the "Ω" plasty the potential to be considered as a surgical option for treatment of De Quervain Tenosynovitis.

Reconstruction of blast injuries of the hand and upper limb.

Over recent years, hand surgeons in the Middle East and Arabic region have particularly had to deal with an increasing number of war blast injuries to the upper extremity, in the acute, subacute and chronic phases. Many have been referred from War Zone countries such as Iraq and, more recently, Syria, where the resources to treat such complex injuries are scarce. The present article is a comprehensive review of the basic principles of management of blast injuries based on the available literature merged with the authors' personal experience of these injuries. The state of the art in treatment of blast injuries to the hand, from ammunition physics and wound ballistics to radiological investigation and, ultimately, the principles of surgical management are discussed.

Iatrogenic penile glans amputation: major novel reconstructive procedure.

Circumcision is a very common urological practice. Even though it is relatively safe, it is not a complication-free procedure. We describe a patient that underwent a neonatal circumcision complicated by iatrogenic complete glans amputation. Reconstructive repair of a neoglans using a modified traditional method was used. Postoperative followup to 90 days is illustrated. Despite being a simple procedure, circumcision in unprofessional hands can have major complication impacting the emotional and sexual life of patients. Surgical reconstruction is possible with varying satisfactory results.

The cryopreservation of composite tissues: Principles and recent advancement on cryopreservation of different type of tissues.

Cryopreservation of human cells and tissue has generated great interest in the scientific community since 1949, when the cryoprotective activity of glycerol was discovered. Nowadays, it is possible to reach the optimal conditions for the cryopreservation of a homogeneous cell population or a one cell-layer tissue with the preservation of a high pourcentage of the initial cells. Success is attained when there is a high recovery rate of cell structures and tissue components after thawing. It is more delicate to obtain cryopreservation of composite tissues and much more a whole organ. The present work deals with fundamental principles of the cryobiology of biological structures, with special attention to the transfer of liquids between intra and extracellular compartments and the initiation of the formation and aggregation of ice during freezing. The consequences of various physical and chemical reactions on biological tissue are described for different cryoprotective agents. Finally, we report a review of results on cyropreservation of various tissues, on the one hand, and various organs, on the other. We also report immunomodulation of antigenic responses to cryopreserved cells and organs.

Xenotransplantation of cryopreserved composite organs on the rabbit.

Nowadays, It is easy to define optimal conditions (cryoprotective agent, speed and steps of freezing, speed of warming) for the cryopreservation of a homogeneous cell population or a one cell-layer tissue. Meanwhile, It is still hard to obtain cryopreservation of composite organs. Each tissue has its own requirements and its own reactivity to the cryopreservation process. The challenge consists of, on the one hand, to select the ideal combination of cryoprotective agents that can fit the needs of the different tissues, and the definition of adequate technical parameters, on the other hand. All the experimental trials have studied the survival rate of non-vascularized cryopreserved tissues. The aim of our experimental work is to demonstrate the feasibility of cryopreserving a composite organ with its nutrient vessels "artery and veins" in order after thawing to revitalize it by reestablishing the blood irrigation by microsurgical vascular anastomosis. We report our experimental results on the cryopreservation of composite organs-amputated digits-xenotransplanted in the rabbit. Digital segments were cryopreserved, then revitalized after warming using vascular microsurgical techniques. Preliminary results are encouraging and may pave the way in the future to the microvascular allotransplantation of cryopreserved composite organs.

Experimental and clinical experience with small composite tissue allotransplants and cryopreservation techniques.

Reconstruction surgery requires imagination, inventiveness, and creation-a quest that entails overcoming obstacles never before encountered. Over the past 25 years, with the advent in microsurgery of free revascularized transfers, it was believed that this fundamental breakthrough would be sufficient to resolve difficulties of whatever nature, and that little else would be necessary. Undoubtedly, the results obtained by using free autotransfers have been so remarkable that it is no longer possible to undertake reconstruction in plastic surgery without fully mastering these techniques. Nevertheless, limitations remain, especially with regard to form and shape, as there are areas where form and function merge. As a result, some clinical cases today continue to induce a sense of powerlessness, as was the case 25 years ago when surgeons were presented with large skin defects that are nowadays treated routinely and with a sense of confidence. The sense of powerlessness today clearly signals that another milepost needs to be reached; we believe this milepost should be allotransplantation. Yet allotransplantation should not remain within the realm of the exceptional; on the contrary, it should become routinely accessible. But in order for it to become so, cryopreservation, a pathway that has so far received little attention, and about which much remains to be learned, should be explored. Accordingly, in this article, we report our experience with xenotransplantation, a mainly clinical procedure in the area of hand surgery.

Use of the eponychial flap to restore the length of a short nail: a review of 30 cases.

BACKGROUND: Distal digital amputations may result in composite tissue loss, affecting both the fingertip and the nail complex. Most surgical procedures that are used for fingertip reconstruction do not restore the nail defect. METHODS: The eponychial flap is a new technique where a backward plication of the nail wall is used to expose the nail root and lengthen the visible part of the nail of the amputated digit. RESULTS: The authors describe the anatomical basis and the operative technique of this flap and also review a series of 30 eponychial flaps that were performed in 28 patients. All patients presented fingertip defects treated with volar advancement flaps. This procedure was followed by an eponychial flap that restored the length of the short fingernail. CONCLUSIONS: The eponychial flap procedure is an easy and reliable technique that is indicated in distal transverse digital amputations to lengthen the short injured nail. It can be associated with any method used for repairing the fingertip defect, thus enhancing the final cosmetic result of the digital reconstruction.