Showing papers in "Journal of Reconstructive Microsurgery in 2012"

Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic review.

Abstract: Pedicled-perforator (propeller) flaps for lower extremity reconstruction have gained popularity due to minimal donor site morbidity, relatively simple surgical technique, and replacement of tissue using "like-by-like" principles. We reviewed and analyzed the clinical use of these flaps in regards to patient age and gender, etiology and location of the defect, size and type of flap, arc of rotation, and complications to determine the reliability of this technique. A systematic review of the PubMed database using search terms to include perforator, pedicled, and propeller flaps in the lower extremity. Data from 15 case series provided 186 cases of pedicled-perforator (propeller) flaps for analysis using Chi-square tests. The Peroneal Artery Perforator (PAP) flaps and Posterior Tibial Artery Perforator (PTAP) flaps were the most frequently used flaps. The overall complication rate was 25.8% and the failure rate was 1.1%. No significant differences were found in complication rate related to age, gender, etiology or location of the defect, type or size of the flap. The most common complications were partial flap loss and venous congestion (11.3 and 8.1%). Pedicled-perforator flaps appear to be a reliable and safe procedure for the coverage soft tissue defects of the lower extremity based on favorable results reported in the literature.

A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry

Abstract: No universally accepted method of flap monitoring exists, and several techniques are in use. Repeated physical examination is most popular and is often supplemented with a handheld, external Doppler, and/or implantable Doppler probes; near-infrared spectroscopy is less commonly used. We investigated the nursing and resident house staff's experience and confidence with physical exam for flap monitoring. Also, a consecutive series of 38 patients with free flaps were monitored using physical examination, external Doppler, implantable arterial and venous Doppler probes, and near-infrared spectroscopy. Five patients developed signs of microvascular complications within 3 days of surgery; all were explored and salvaged. Neither the residents nor the nursing staff were universally trained or experienced in flap monitoring by physical exam. In all patients, changes in the appearance of the flap suggestive of a microvascular complication lagged 30 to 60 minutes after the adjunctive monitoring methods indicated that a problem had occurred. Near-infrared spectroscopy was the first warning sign in four of the five patients. Two patients were explored before thrombosis of the anastomoses occurred. Near-infrared spectroscopy may identify early microvascular complications more reliably than physical examination, external Doppler, or implantable Doppler.

The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction--a cadaveric and computer tomography angiogram study.

Abstract: We propose the profunda femoris artery perforator (PAP) flap for autologous breast reconstruction. We provide an anatomic basis for this flap. Ten cadaveric thighs were dissected. A perforator was dissected to its origin. The lengths of pedicle, vessel diameters, and weights were measured. The average distance inferior to the gluteal crease was 3.5 cm (1 to 5 cm). The average distance from the midline was 6.2 cm (3 to 12 cm). The average pedicle length was 10.6 cm. Diameters of the artery and vein averaged 2.3 mm and 2.8 mm. The flaps averaged 28 × 8 cm. The average weight was 206 g (100 to 260 g). Computed tomography angiograms of 20 thighs were examined. Measurements were taken from the gluteal crease and midline to the perforator. The average distance caudal to the gluteal crease was 4.4 cm (1.1 to 7.2 cm). The average distance lateral to the midline was 5.1 cm (2.5 to 9 cm). The data presented in this article provide an anatomic basis for the PAP flap.

Surgical aspects of a lower face, mandible, and tongue allotransplantation.

Abstract: Face transplantation is a novel treatment for the reconstruction of massive facial defects. To date 13 cases have been performed. The technical aspects of a composite lower face transplantation including the tongue, floor of the mouth, and most of the mandible are detailed. The transplantation was performed in August 2009 in an HIV-positive, postoncologic patient. A preparatory surgery for nerve identification was performed. Facial composite tissue was procured after cardiac cessation. Revascularization was performed to the right subclavian artery with an internal shunt between the internal carotid arteries. At 16 months posttransplantation the patient is swallowing, without evidence of malignancy recurrence or HIV replication.

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

Abstract: This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

Reconstruction of transoral robotic surgery defects: principles and techniques.

Abstract: Early functional and oncological outcome studies suggest that transoral robotic surgery (TORS) may have a role for early stage cancers of the oropharynx. Unlike with traditional mandibular swing or pharyngotomy approaches, access to the oropharynx for reconstruction in TORS cases is limited. Maintaining a good functional result necessitates preserving physiological function where possible. The principles that should guide reconstructive surgeons include maintaining a velopharyngeal sphincter to prevent velopharyngeal insufficiency, maintaining sensate mucosa and restoring bulk in the tongue base to prevent aspiration, maintaining separation between the cervical and pharyngeal components, and covering exposed vessels in the pharynx. We present here principles and surgical techniques of TORS to reconstruct oropharyngeal defects using a subsite-based approach using secondary healing, local musculomucosal flaps, and free tissue transfer guided by the above principles.

A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.

Abstract: Purpose Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications. Methods A retrospective cohort study was performed on patients undergoing free tissue transfer for scalp defects from 1997 to 2011. Patients were compared with respect to demographics, defect characteristics, intraoperative factors, flap choice, and postoperative complications. Results Forty-three flaps were performed in 37 patients with a success rate of 97.7%. Multivariate regression demonstrated that defect characteristics (size of defect) and patient-related factors (age and smoking) were associated with wound complications in scalp reconstruction. Outcomes were similar between the latissimus dorsi (LD) and anterolateral thigh (ALT) groups and the immediate cranioplasty patients with respect to all forms of complications Conclusions We report a 98% success rate using free tissue transfer for complex scalp defects and identify defect size, patient age, and smoking as factors associated with wound complications. Patient comorbidities were associated with major complications. We report equal efficacy in using the ALT and LD, as well as immediate cranioplasty. Level of Evidence Prognostic/risk, level III

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Abstract: Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Microsurgical techniques for the treatment of breast cancer-related lymphedema: a systematic review

Abstract: BACKGROUND: Upper limb lymphedema is one of the most underestimated and debilitating complications of breast cancer treatment. The aim of this review is to summarize the recent literature for evidence of the effectiveness of lymphatic microsurgery for the treatment of breast cancer-related lymphedema (BCRL). METHODS: A search was conducted for articles published from January 2000 until January 2012. Only studies on secondary lymphedema after breast cancer treatment and those examining the effectiveness of microsurgery were included. RESULTS: No randomized clinical trials or comparative studies were available. Ten case-series met inclusion criteria: (composite) tissue transfer (n = 4), lymphatic vessel transfer (n = 2), and derivative microlymphatic surgery (n = 4). Limb volume/circumference reduction varied from 2 to 50% over a follow-up time ranging from 1 to 132 months. Postoperative discontinuation rates of conservative therapy were only reported after composite tissue transfer, ranging from 33 to 100% after 3 to 24 months. Clear selection criteria for lymphatic surgery and lymphatic flow assessment were absent in most studies. CONCLUSION: We identified important methodological shortcomings of the available literature. Evidence acquired through comparative studies with uniform patient selection is lacking. Consistent positive findings with regards to limb volume reduction and limited complications are reasons to further explore these techniques in methodologically superior studies.

Surgical anatomy of the medial sural artery perforator flap.

Abstract: Background The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap. Methods Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks. Results The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases. Conclusion Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications. Clinical question: Therapeutic Level of Evidence: IV

Fasciocutaneous free flaps are more reliable than muscle free flaps in lower limb trauma reconstruction: experience in a single trauma center.

Abstract: Background Muscle (M) and fasciocutaneous (FC) free flaps are frequently used options in the reconstruction of traumatic lower limb injuries The use of one flap over another has remained the topic of controversy in the literature With a large experience, we sought to evaluate key outcomes of M versus FC free flap reconstructions in lower limb trauma in a single trauma center Methods A consecutive 7- year review of all free flap reconstructions for lower limb trauma performed at the Royal Melbourne Hospital was conducted Patient data were prospectively entered into a unit database and retrospectively reviewed Results One hundred three patients underwent 105 free flap reconstructions (M = 48 and FC = 57) in lower limb trauma We experienced a rate of 29% total flap failures and 114% partial flap losses Total flap failures represented 63% M and 0% FC flaps The partial flap failures included 158% of M and 53% of FC flaps Latissimus dorsi (40% of M group) and radial forearm free flaps (67% of FC group) were most commonly used in each group There was a statistically significant difference between groups in rates of reoperation (M = 44% versus FC = 16%), postoperative infection (M = 38% versus FC = 12%), fracture nonunion (M = 40% versus FC = 21%), and donor site morbidity (M = 25% versus FC = 4%) Nonstatistically significant differences were encountered with higher rates of osteomyelitis (M = 146% versus FC = 105%), unplanned bone graft (M = 146 versus FC = 105%), and inability to bear full weight at 1 year (M = 302% versus FC = 170%) found in the M group In our cohort, M flaps used for metal coverage resulted in higher rates of reoperation, postoperative infections, and flap loss than FC flaps (M = 61% versus FC = 25%, p Conclusion Statistically higher complication rates in key reliability markers were found in the M free flap group This study found FC free flaps to be more reliable for reconstruction of lower limb injuries in a major trauma center

Upper-limb lymphedema treated aesthetically with lymphaticovenous anastomosis using indocyanine green lymphography and noncontact vein visualization.

Abstract: We have described a procedure to minimize surgical wounds, in which lymph vessels and skin venules are identified by indocyanine green (ICG) lymphography and the AV300 noncontact visualization system (AccuVein, Cold Spring Harbor, NY), respectively. This approach allows accurate decisions regarding sites of incision for lymphatic venous anastomosis (LVA). This method was applied in a patient with right upper-limb lymphedema after breast cancer therapy. The low-invasive procedure can be used before and during surgery. The incision size is minimal, and the incision site is at the joint area. Thus, we aim to establish this approach as a standard method for identifying lymph vessels and veins that are suitable for LVA. This innovative vascular-imaging machine makes LVA less invasive and more effective without side effects.

Reconstruction after robotic head and neck surgery: when and why.

Abstract: The advancement of robotically assisted surgery during the last decade has seen a revolution in the approach to surgical oncologic resection, moving toward reducing patient morbidity without compromising oncologic outcomes. In no field has this been more dramatic than in the application of transoral robotic surgery (TORS), using the da Vinci surgical system for resecting tumors of the head and neck. This organ-preserving technique allows the surgeon to remove tumors of the upper aerodigestive tract without external incisions and potentially spare the patient adjuvant treatment. The introduction of TORS improves upon current transoral techniques to the oropharynx and supraglottis. The traditional conception of TORS is that it would be used for smaller tumors and defects would be permitted to heal by secondary intention; however, as head and neck surgeons pursue larger tumors robotically, robotic-assisted reconstruction has entered the paradigm. Given the relative infancy of these procedures, clear guidelines for when reconstruction is warranted do not exist. The current literature, thus far, has focused on feasibility, safety, and implement of the robot in reconstruction. We reviewed the current literature pertinent to TORS reconstruction focusing on patient selection, tumor size, and location. Furthermore, we briefly review our own experience of 20 TORS procedures involving robotic-assisted reconstructions. Finally, we provide an algorithmic approach to determining the need for reconstruction in a given patient. This focuses on four key criteria: tumor location, tumor extent, prior treatment, and patient-specific factors.

Robotic harvest of the latissimus dorsi muscle: laboratory and clinical experience.

Abstract: Minimally invasive harvest of the latissimus dorsi (LD) muscle is a desirable goal because of both the wide utility of this muscle and the length of incision required to harvest it. In this study, robotic harvest of the LD muscle was evaluated in a cadaver model and clinical series. Ten LD flaps were robotically harvested in eight cadavers. Positioning, port placement, procedural steps, instrumentation, and technical obstacles were all critically analyzed and reported. After modifying the technique based on experience gained in the cadaver study, eight LD muscles were robotically harvested and transferred in eight patients. Access included a short axillary incision and two additional port sites along the anterior border of the muscle. Insufflation was used to maintain the optical cavity. Indications included pedicled flaps for implant-based breast reconstruction and free flaps for scalp reconstruction. All flaps were successfully transferred without converting to open technique. In the clinical series, average time for setup and port placement was 23 minutes, and average robotic time was 1 hour and 51 minutes. There were no major complications. Robotic harvest of the LD is feasible and effective and permits full muscle harvest without a visible incision.

Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial.

Abstract: Microsurgical vasectomy reversal is a technically demanding procedure. Previous studies have shown the possible benefit of robotic assistance during such procedures. Our goal was to compare robotic assisted vasovasostomy and vasoepididymostomy to standard microsurgical vasovasostomy (MVV) and vasoepididymostomy (MVE). The use of robotic assistance for vasectomy reversal may provide the microsurgeon with improved visualization, elimination of tremor, and decreased fatigue and obviate the need for a skilled microsurgical assistant. This study provides the first clinical prospective control trial of robotic assisted versus pure microsurgical vasectomy reversal. The use of robotic assistance in microsurgical vasovasostomy and vasoepididymostomy may have benefit over MVV and MVE with regards to decreasing operative duration and improving the rate of recovery of postoperative total motile sperm counts based on our study.

Near infrared spectroscopy for monitoring flap viability following breast reconstruction.

Abstract: Free flap monitoring is essential to the early detection of compromise thereby increasing the chance of successful salvage surgery. Many alternatives to classical clinical monitoring have been proposed. This study seeks to investigate a relatively new monitoring technology: near infrared spectroscopy (NIRS). Patients were recruited prospectively to the study from a single center. During the research period, 10 patients underwent reconstruction with a free deep inferior epigastric perforator flap (DIEP). Measurements of flap perfusion were taken using NIRS in the preoperative and intraoperative phases and postoperatively for 72 hours. NIRS showed characteristic changes in all cases which returned to theater for pedicle compromise. In these cases, NIRS identified pedicle compromise prior to clinical identification. There were no false-positives. NIRS accurately identified all compromised flaps in our study. In most cases, there was an evidence of changes in oxygen saturation on NIRS prior to clinical observation. Further research, ideally double blind randomized control trials with large sample groups would be required to definitively establish NIRS as an ideal flap monitoring modality.

The role of fat grafting in reconstructive and cosmetic breast surgery: a review of the literature.

Abstract: The technique of autologous fat transplantation has been dramatically improved since its first introduction in 1893. This surgical approach has more recently been used in both the reconstructive and cosmetic setting, and has subsequently been the subject of much controversy. We sought to compose a detailed and systematic literature review of recent literature on the topic in order to provide surgeons with the data in an organized and easily accessible manner. We selected 19 studies and systematically documented trends in their methods, follow-up procedures, and outcomes, paying particular attention to complications. We chose to include studies that analyzed the outcomes of the surgical procedure in both reconstructive and cosmetic cases. Most authors reported satisfactory or greater results, and we concluded that it appears as though autologous fat transplantation to the breast is a safe option for patients seeking both reconstructive and cosmetic surgery.

Reconstruction of the Achilles Tendon and Overlying Soft Tissue by Free Composite Anterolateral Thigh Flap with Vascularized Fascia Lata

Abstract: Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

Lower extremity reconstruction with the anterolateral thigh flap.

Abstract: The versatility and location of the anterolateral thigh (ALT) flap make it well suited for lower extremity reconstruction. The purpose of this study was to evaluate surgical and functional outcomes by specific anatomic regions in the lower extremity to better define the role of the ALT flap in lower extremity reconstruction. A retrospective review of patients undergoing lower extremity reconstruction with an ALT flap between July 2002 and December 2010 was performed. Total 46 patients underwent lower extremity reconstruction with an ALT flap, of whom 29 (63%) had a pedicled flap and 17 (37%) a microvascular free flap. Defects were located in the hip/buttocks ( n = 8), groin ( n = 13), thigh ( n = 8), knee ( n = 5), leg ( n = 6), and foot/ankle ( n = 6). The mean postoperative follow-up was 4 months. Total flap loss occurred in two patients (4%). There were 11 recipient site complications (24%). The most common complication was recipient site seroma, which occurred in five patients (11%), all of whom had hip/buttock or groin defects. Overall, 38 patients (83%) returned to their preoperative functional status. The ALT flap is an effective method of lower extremity reconstruction. It can be performed as a pedicled or free flap, with good surgical and functional outcomes.

Computer-aided stereolithography for presurgical planning in fibula free tissue reconstruction of the mandible.

Abstract: Introduction Computer-aided imaging has facilitated presurgical modeling for free tissue mandibular reconstruction. The purpose of this study is to illustrate the utility of preoperative virtual surgical planning in fibula reconstruction of the mandible. Methods Eight patients, age 17 to 72 years, treated between November 2009 and January 2011 were reviewed. Each required segmental resection and reconstruction of the mandible and were managed with presurgical virtual planning. Results Our series includes five cases of squamous cell carcinoma (SCCA), one case of osteoradionecrosis (ORN), one leiomyosarcoma, and one odontogenic myxoma. All patients underwent a segmental resection of the mandible 5 to 14 cm in size (average 8 cm). In each case, prefabricated guides for segmental mandibulectomy and fibula osteotomy were employed and resulted in simplification of bony inset and reduced need for “fine tuning” of fibula segments. Conclusions Virtual surgical planning fosters multidisciplinary communication and provides accurate presurgical planning. This allows seamless reconstruction in patients requiring mandibular reconstruction via fibula free tissue transfer. The combination of mandibular and fibular cutting guides and templates allows for a precise and efficient surgical reconstruction. In our experience, this technology is most useful in the reconstruction of large mandibular defects requiring large reconstruction plates and multiple fibular osteotomies.

Air gun impactor--a novel model of graded white matter spinal cord injury in rodents.

Abstract: Understanding mechanisms of spinal cord injury and repair requires a reliable experimental model. We have developed a new device that produces a partial damage of spinal cord white matter by means of a precisely adjusted stream of air applied under high pressure. This procedure is less invasive than standard contusion or compression models and does not require surgical removal of vertebral bones. We investigated the effects of spinal cord injury made with our device in 29 adult rats, applying different experimental parameters. The rats were divided into three groups in respect to the applied force of the blast wave. Functional outcome and histopathological effects of the injury were analyzed during 12-week follow-up. The lesions were also examined by means of magnetic resonance imaging (MRI) scans. The weakest stimulus produced transient hindlimb paresis with no cyst visible in spinal cord MRI scans, whereas the strongest was associated with permanent neurological deficit accompanied by pathological changes resembling posttraumatic syringomyelia. Obtained data revealed that our apparatus provided a spinal cord injury animal model with structural changes very similar to that present in patients after moderate spinal cord trauma.

Technical aspects of the recipient operation in hand transplantation.

Abstract: The goal of hand allotransplantation is to achieve graft survival and useful long-term function. To achieve these goals, precise surgical technique is of critical importance. The key surgical steps and sequence of events in hand allotransplantation are similar to major upper extremity replantations, but are modified to accommodate major conceptual differences that exist between the two procedures.

Selection of recipient vessel in traumatic lower extremity.

Abstract: The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.

Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome.

Abstract: Flap loss due to postoperative flap edema and thrombosis of the anastomosis remains the predominant concern of reconstructive microsurgeons. Due to the lack of scientific evidence, there is no unanimous opinion on when to mobilize a reconstructed lower extremity, reflecting the uncertainty of plastic surgeons regarding the effect of the dangling procedure on flap microcirculation. Patients and Methods In this randomized controlled clinical trial, we included 31 patients undergoing free flap transfer to the lower extremity. The patients were randomly divided into two groups. Cohort I consisted of 15 patients starting the dangling procedure at day 7, and cohort II consisted of 16 patients in which an early aggressive postoperative dependency started at day 3. Wrapping and dangling of the flap was performed primarily with a duration of 5 minutes three times a day and increased daily by doubling the duration over a period of 4 days, reaching 60 minutes at day 5. Before and immediately after each dangling procedure the flaps were clinically monitored under direct observation for color, capillary refill, venous congestion, flap turgor, and flap temperature. Results In all cases the postoperative course was uneventful, resulting in a success rate of 100%. No adverse effects or flap compromise were seen due to the combined dangling/wrapping procedure. Conclusion An early and aggressive start of a combined dangling/wrapping procedure does not compromise flap circulation and allows mobilizing patients after free flap transfer to the lower extremity at an early stage. This approach improves patient comfort, shortens the hospital stay, and therefore reduces socioeconomic costs.

Harvest of an Entire Gracilis Muscle and Tendon for Use in Functional Muscle Transfer: A Novel Technique

Abstract: The use of the free functioning, innervated gracilis muscle has evolved to become an invaluable tool in the restoration of elbow flexion and prehension in patients undergoing reconstruction following brachial plexus injuries. Although there are many different methods of the gracilis muscle harvest, most if not all harvest methods begin proximally. The purpose of this article is to describe a novel distal harvest technique of the gracilis myocutaneous flap for brachial plexus patients requiring restoration of elbow or finger flexion. A harvest method commencing with a distal dissection either at the distal insertion of the gracilis at the pes anserine or at the distal medial thigh at the myotendinous junction will be described. The advantage of this novel method is to ensure that the entire gracilis muscle and its tendon are harvested to maximize the length of tendon that can be secured by a Pulvertaft weave into the biceps tendon or the finger flexors for elbow flexion and finger flexion respectively.

Robotic harvest of the rectus abdominis muscle: a preclinical investigation and case report.

Abstract: In an attempt to decrease donor-site morbidity for rectus abdominis muscle harvest during free tissue transfer, we developed a technique of minimally invasive harvest. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in two cadavers for dissection and harvest of four rectus abdominis muscles. After the cadaver dissections were performed, the technique was used in a 30-year-old woman to harvest the left rectus abdominis muscle for free tissue transfer to a lower extremity defect. Four cadaver dissections for harvest of the rectus abdominis muscle using the da Vinci Surgical System were performed. In the cadavers and actual case, three ports (11 mm, 11 mm, and 15 mm) were used to access the abdominal cavity and perform the dissection. An additional 3 cm incision was used to remove the muscle from the abdominal cavity. The patient has not developed any surgical-site morbidity, including bulge or hernia in the 6 months postprocedure. Minimally invasive harvest of the rectus abdominis muscle is possible with the assistance of the da Vinci Surgical System. Potential benefits may include decreased surgical-site morbidity. Also, this may provide an approach to minimally invasive transperitoneal reconstruction.

Objective evaluation of skill acquisition in novice microsurgeons.

Abstract: Introduction Medical training is increasingly focused on patient safety, limiting the ability to practice technical skills in the operative arena. Alternative methods of training residents must be designed and implemented. Methods Three expert microsurgeons were solicited to develop two drills to help residents acquire the basic subset of skills in microsurgery. The first drill was performance of five consecutive simple interrupted sutures on a rubber glove. Expert proficiency was considered a drill time of two standard deviations from expert mean. The drill was performed up to 10 times until completion of the task at expert proficiency. The second drill was performance of an anastomosis on silastic tubing. Residents performed the drill sequentially until performing two consecutive drills at expert proficiency. Results Eight residents with no microsurgical experience volunteered. Six of the eight residents were able to perform the rubber glove drill at expert proficiency within 10 attempts, with an average of 5.3. All of the residents were able to perform two consecutive silastic tubing drills at expert proficiency within nine attempts, with an average of 5.4. Conclusion Residents were able to acquire a basic subset of microsurgical skills within a reasonable time period using these drills.

Microsurgery in the Hypercoagulable Patient: Review of the Literature

Abstract: Improved techniques in microvascular surgery over the last several decades have led to the increased use of free tissue transfers as a mode of reconstructing difficult problems with a high success rate. However, undiagnosed thrombophilias have been associated with microsurgery free flap failures. We present a case of successful free tissue transfer in a patient with lupus anticoagulant and review the literature.

Augmentation of venous drainage in deep inferior epigastric perforator flap breast reconstruction: efficacy and advancement.

Abstract: Deep inferior epigastric perforator flap (DIEP) is the workhorse for autologous breast reconstruction because it is associated with less abdominal wall donor site morbidity; however, the high incidence of venous congestion of zone IV within the DIEP flap is the most important disadvantage. Venous augmentation may be an appropriate method for venous decompression of the DIEP flap. This study aims to assess retrospectively the efficacy of the venous augmented DIEP flap and to present an advanced technique for venous augmentation. A total of 79 breast reconstructions using DIEP flap from January 2006 to March 2011 were included. Thirty-two patients who underwent venous augmented DIEP flap were selected as the test group, and 47 patients who underwent the traditional DIEP flap were included as the control group. Three indices-operation time, flap size, and flap complication rate-were compared between the two groups. The operation time was 6.6 ± 0.7 hours in the test group and 6.1 ± 1.2 hours in the control group (p < 0.05). The mean flap size was 325.9 ± 20.6 cm2 in the test group and 294.7 ± 24.2 cm2 in the control group (p <0.05). In the test group, there was one partial flap loss (complication rate was 3.1%). In the control group, the total complication rate was 10.6% (p <0.05). Venous augmentation can successfully enhance the viability of a DIEP flap. The SIEV-SIEV (superficial inferior epigastric vein) reverse-flow anastomosis is an efficient and convenient method of venous augmentation for DIEP flap, with negligible drawbacks.

Technical recommendations for penile replantation based on lessons learned from penile reconstruction.

Abstract: Penile amputation is an exceptional surgical emergency. Immediate replantation yields a high success and low complication rate. We report a case of a self-inflicted penile amputation treated with successful microsurgical replantation. Postoperative edema caused minor skin slough and temporary venous congestion was treated with medicinal leech therapy. Follow-up at 18 months showed normal subjective sensation; voiding and erectile function were present. Surgical management and technique refinements are discussed, based on a review of the literature and on our experience in penile reconstruction.