Reconstruction of Soft Tissue Defects after Snake Bites

PURPOSE: Substantial tissue necrosis after snake bites requiring coverage with flap surgery is extremely rare. In this article, we report 7 cases of soft tissue defects in the upper and the lower extremities caused by snake bites, which needed to be covered with flaps. Among the vast mass of publications on snake bites there has been no report that focuses on flap coverage of soft tissue defects due to snake bite sequelae. METHODS: Seven cases of soft tissue defects in tendon, ligament, or bone exposure after snake bites were included. All patients were males without comorbidities, the average age was 35 years. All of them required coverage with a flap. In 6 cases, the defects were localized on the upper extremity, in one case the lesion was on the lower extremity. Local flaps were used in 6 cases, one case was covered with a free flap. The surgical procedures included one kite flap, one cross finger flap and digital nerve reconstruction with a sural nerve graft, one reverse proximal phalanx island flap, one groin flap, one adipofascial flap, one neurovascular island flap, and one anterolateral thigh free flap. The average interval from injury to flap surgery was 23.7 days. RESULTS: All flaps survived without complication. All patients regained a good range of motion in the affected extremity. Donor site morbidities were not observed. The case with digital nerve reconstruction recovered a static two point discrimination of 7mm. The patient with foot reconstruction can wear normal shoes without a debulking procedure. CONCLUSION: The majority of soft tissue affection after snake bites can be treated conservatively. Some severe cases, however, may require the coverage with flap surgery after radical debridement, especially, if there is exposure of tendon, bone or neurovascular structures. There is no doubt that definite coverage should be performed as soon as possible. But we also want to point out that this principle must not lead to a premature coverage. If the surgeon is not certain that the wound is free of necrotic tissue or remnants of venom, it is better to take enough time to get a proper wound before flap surgery in order to obtain a good functional and cosmetic result.

Morphometric Study on the Arterial Palmar Arch of the Hand

PURPOSE: Deviations of arterial palmar arches in the hand can be explained on the embryological basis. The purpose of this study is to provide new information about palmar arches through cadaver's dissection. The values of the location and diameter in these vessels were analyzed in order to support anatomical research and clinical correlation in the hand. METHODS: The present report is based on an analysis of dissections of fifty-three hands carried out in the laboratory of gross anatomy. A reference line was established on the distal wrist crease to serve as the X coordinate and a perpendicular line drawn through the midpoint between middle and ring fingers, which served as the Y coordinate. The coordinates of the x and y values were measured by a digimatic caliper, and statistically analyzed with Student's test. RESULTS: Complete superficial palmar archs were seen in 96.2 % of specimens. In the most common type of males, the superficial arch was formed only by the ulnar artery. In the most common type of females, the superficial arch was formed anastomosis between the radial artery and the ulnar artery. The average length of the superficial and deep palmar arch is 110.3 +/- 33.0 mm and 67.9 +/- 14.0 mm respectively. Regarding the superficial palmar arch, ulnar artery starts -16.1 +/- 5.1 mm on X-line, and 2.5 +/- 24.5 mm on Y-line. Radial artery appears on palmar side 7.7 +/- 3.2 mm on X-line, and 20.9 +/- 10.9 mm on Y-line. But radial artery starts on 6.3 +/- 3.6 mm on X-line, and 3.4 +/- 5.1 mm on Y-line. Digital arteries of superficial palmar arch starts on 6.1 +/- 3.7 mm, 33.9 +/- 8.8 mm on index finger, 1.8 +/- 3.4 mm, 40.1 +/- 7.3 mm on middle finger, -3.2 +/- 4.9 mm, 42.6 +/- 7.0 mm on ring finger, and -8.9 +/- 5.1 mm, 42.5 +/- 80 mm on little finger in respective X and Y coordinates. Radial artery of deep palmar arches measured at the palmar side perforating from the dorsum of hand. It's coordinates were 9.7 +/- 4.8 mm on X-line, 21.7 +/- 10.2 mm on Y-line. Ulnar artery was measured at hypothenar area, and it's coordinates were -20.4 +/- 6.3 mm on X-line, and 30.6 +/- 7.4 mm on Y-line. CONCLUSIONS: Anatomically superficial palmar arch can be divided into a complete and an incomplete type. Each of them can be subdivided into 4 types. The deep palmar arch is less variable than the superficial palmar arch. We believe these values of the study will be used for the vascular surgery of the hand using the endoscope and robot in the future.

Correction of Cup Ear Using the Mattress Suture

PURPOSE: Constricted ear, which is named by Tanzer includes lop ear, cup ear, and sort of prominent ear. It has been classified into three groups by Tanzer. Especially the group I and IIA have been corrected by banner flap, Musgrave's technique, tumbling concha-cartilage flap, reversed banner flap and others. However, these techniques were too invasive for correcting mild degree of deformity. Therefore, we corrected the ear with mattress suture which is simple and less invasive. Method: The operations were done for 5 patients from March 2005 to April 2008. All the cases were unilateral ears with constriction including helix and scaphoid fossa without differences in length between both ears. Though a posterior auricular skin incision, the folded cartilage is exposed and two parallel incisions on superior crus were made. After mattress suturing in cartilage, the superior crus of antihelix was formed and its force enables the folded portion to be in a normal anatomic position. Result: All the 5 patients got satisfactory results. There were no complications like hematoma or skin necrosis, and no recurrence during follow-up period(the average period was 11 months). And we couldn't recognize the difference between height of both auricles. CONCLUSION: Mattress suture is simple, less invasive, and suitable in correcting mild deformity of constricted ear with better result, so here we suggest the method.