Usability of Nerve Tape: A Novel Sutureless Nerve Coaptation Device.

PURPOSE: Microsuture neurorrhaphy is technically challenging and has inherent drawbacks. This study evaluated the potential of a novel, sutureless nerve coaptation device to improve efficiency and precision. METHODS: Twelve surgeons participated in this study-six attending hand/microsurgeons and six trainees (orthopedic and plastic surgery residents or hand surgery fellows). Twenty-four cadaver arm specimens were used, and nerve repairs were performed at six sites in each specimen-the median and ulnar nerves in the proximal forearm, the median and ulnar nerves in the distal forearm, and the common digital nerves to the second and third web spaces. Each study participant performed nerve repairs at all six injury locations in two different cadaver arms (n = 12 total repairs for each participating surgeon). The nerve repairs were timed, tested for tensile strength, and graded for alignment and technical repair quality. RESULTS: A substantial reduction in time was required to perform repairs with the novel coaptation device (1.6 ± 0.8 minutes) compared with microsuture (7.2 ± 3.6 minutes). Device repairs were judged clinically acceptable (scoring "Excellent" or "Good" by most of the expert panel) in 97% of the repairs; the percentage of suture repairs receiving Excellent/Good scores by most of the expert panel was 69.4% for attending surgeons and 36.1% for trainees. The device repairs exhibited a higher average peak tensile force (7.0 ± 3.6 N) compared with suture repairs (2.6 ± 1.6 N). CONCLUSIONS: Nerve repairs performed with a novel repair device were performed faster and with higher technical precision than those performed using microsutures. Device repairs had substantially greater tensile strength than microsuture repairs. CLINICAL RELEVANCE: The evaluated novel nerve repair device may improve surgical efficiency and nerve repair quality.

Phalloplasty Flap Salvage Using a Superficial Circumflex Iliac Artery Perforator Propeller Flap.

Background: Partial phalloplasty flap loss presents an evolving challenge, largely due to the complex demands required for both aesthetics and function. We describe our novel experience using the superficial circumflex iliac perforator (SCIP) propeller flap for neophallus salvage when skin grafting alone provides insufficient soft tissue bulk or coverage. Methods: We retrospectively reviewed patients who underwent SCIP propeller flap reconstruction after phalloplasty partial flap loss. After suprafascial dissection, superficial circumflex iliac vessel perforator(s) were isolated toward the femoral origin. The flap was rotated 180 degrees and inset into the ventral or distal neophallus depending on the region of flap loss. If glans reconstruction was required, the flap was tubularized before inset. Division and inset were performed at a second stage, followed by subsequent glansplasty, urethral creation, and/or penile implant placement. Results: SCIP propeller flap reconstruction was performed for four patients after one to six debridements at a mean of 6.5 (range 1.0-19.2) months following the initial phalloplasty. Three patients had lost the ventral phallus due to venous insufficiency, arterial insufficiency, and excessive postoperative swelling, respectively. The fourth patient experienced near-total loss of the glans following penile implant insertion. Division and inset was performed at an average of 7.5 (range 5.0-12.0) weeks after SCIP flap. There were no complications related to SCIP flap viability. Conclusion: The SCIP propeller flap allows salvage of partial flap loss following phalloplasty by providing thin, pliable soft tissue bulk and skin coverage with minimal donor site morbidity, without the need for microsurgery, allowing progression with subsequent reconstructive stages.

Patency of radial arteries reconstructed after radial forearm flap harvest.

Poor patency is cited as a reason to not perform radial artery reconstruction after the harvest of the radial forearm flap. The need for a long vein graft and the presence of a patent ulnar artery are offered as explanations for thrombosis of the reconstruction in this setting. Similar arguments have been made regarding radial artery reconstruction in the trauma setting. In this study, the patency rate for patients undergoing radial forearm flap harvest with immediate reconstruction with reversed interposition vein grafting was evaluated. The mean follow-up time was 24 months, and all seven patients had patent reconstructions. Ultrasound examination revealed slightly larger diameters of the vein grafts compared with native arteries. No areas of stenosis were detected. No complications resulted from harvest of the vein. From these data, we conclude that radial artery reconstruction can be performed with the expectation of patency.

Effect of sequence, timing of vascular anastomosis, and clamp removal on survival of microsurgical flaps.

The effects of the timing and order of clamp removal in microsurgical transplants were studied in rat groin skin flap and rat latissimus dorsi muscle flap models. Forty rats were divided into four groups. In Group 1, the arterial pedicle of the skin flap was anastomosed first, and the clamp was released after the anastomosis was completed. The venous pedicle was then repaired after inflow was restored. In Group 2, the venous pedicle of the skin flap was anastomosed first. The venous clamp was not released until completion of the arterial anastomosis. In Group 3, the arterial pedicle was anastomosed first in the muscle flap. The venous anastomosis was then performed after the arterial clamp was released. In Group 4, the venous pedicle was anastomosed first, and both clamps were released simultaneously. The blood perfusion of the skin flaps was examined after both clamps were released in Groups 1 and 2. The flap survival status was examined 5 days postoperatively for skin flaps and at 3 days for muscle flaps. Skin flaps in an additional six rats were harvested for histology. The results showed that the flap blood flow for Group 1 was statistically significantly higher than for Group 2 flaps in the first 20 min after reperfusion. There was no significant difference of flow between these two groups during the 30 to 90 min after reperfusion. The difference in survival rates for the four groups was not significant. Histology revealed extensive congestion in the flaps from Group 1 after completion anastomoses, but the congestion was significantly decreased at 3 hr following reperfusion. In conclusion, a brief venous stasis during anastomosis, after establishment of arterial inflow, is not detrimental to flap survival. The sequence of anastomosis will not affect outcome for either the cutaneous flap or the muscle flap models. Early flap perfusion was increased when the arterial anastomosis was performed first.