Applied anatomy of the latissimus dorsi free flap for refinement in one-stage facial reanimation.

BACKGROUND: The face can be reanimated after long-term paralysis by free microneurovascular tissue transfer. Flaps from gracilis and pectoralis minor usually require a two-stage procedure with a cross-face nerve graft. Latissimus dorsi has a much longer muscular nerve, the thoracodorsal nerve, which could avoid the need for a second cross-face nerve graft. Our hypothesis is that the neurovascular pedicles of small segments of latissimus dorsi would be long enough to reach the opposite side of the face and to provide a reliable blood and nerve supply to the flaps. METHOD: To test this hypothesis the thoracodorsal pedicle and its primary branches were dissected in eleven embalmed cadavers. The segmental vessels and nerves were then traced in a series of simulated flaps approximately 8-10 cm × 2-3 cm by micro-dissection, tissue clearing and histology. RESULTS: The thoracodorsal pedicle is 10-14 cm long to where it enters the muscle, and with intra-muscular dissection small chimeric muscle segments 8-10 cm × 2-3 cm can be raised with a clearly defined neurovascular supply. Using micro-dissection the neurovascular pedicle can be lengthened to reach across the face. Segmental arteries and nerves extended to the distal end of all the flaps examined. Artery, vein and nerve run together and are of substantial diameter. CONCLUSION: Small muscle segments of latissimus dorsi can be raised on long neurovascular pedicles. The vessels and nerves are substantial and the likelihood of surgical complications such as flap necrosis and functional disuse on transplantation appear low. Although in our opinion the use of cross-face nerve grafts and transfer of smaller muscle flaps remains the gold standard in facial reanimation in straightforward cases, the micro-dissected latissimus dorsi flap is a useful option in complex cases of facial reanimation. CLINICAL APPLICATION: Facial reanimation using micro-dissected segments of latissimus dorsi has been performed in four complex cases of facial paralysis.

[Severe course of a rare non-tuberculous Mycobacteriosis (M. haemophilum) of the hand - case report and strategic comments]. / Schwerer Verlauf einer seltenen atypischen Mykobakteriose (M. haemophilum) an der Hand - Fallbericht und strategische Anmerkungen.

INTRODUCTION: Mycobacterium haemophilum belongs to the group of atypical mycobacteria and is rarely reported as a cause of upper extremity and hand infections. It is of low virulence. The bacterium seems to be ubiquitous. Sources and mechanism of infection are poorly defined. CASE REPORT: A 48-year-old female patient was admitted with chronic flexor tendon synovitis of the left palm and distal forearm site. Three debridements were carried out and wound swabs were taken. No proof of bacterial colonisation was found. Histologically a granulomatous infection with Langerhans cells was revealed. Effectively calculated monotherapy with ciprofloxacin was begun. Six weeks postoperatively Mycobacterium haemophilum was cultivated in a colaboration with the National Reference Centre for Mycobacteria in Borstel. Medication was changed to triple therapy with clarithromycin, ethambutol and rifabutin. The patient could carry out her daytime job three months postoperatively. One year after first admission functional impairment needed to be treated by scar excision and radical flexor tendon tendolysis. The palmar defect was resurfaced by using a transmetacarpal DMCA 2 flap at the same time. An almost full range of motion was achieved with intensive hand and physiotherapy after a total treatment period of 15 months. DISCUSSION: Patients with upper extremity infections caused by atypical Mycobacteria need qualified hand-surgical care. The decision about need and kind of medicamentous treatment is based on germ differentiation and should be made in cooperation with the National Reference Centre for Mycobacteria in Borstel. To shorten the diagnostic gap between first admission and detection of Mycobacteria in hand infections with a non-typical course of disease we suggest a standardised approach.

Prevention of paediatric ring avulsions - a cadaveric study.

Finger ring avulsion injuries can be functionally, cosmetically and emotionally devastating for the patient. This cadaveric study assessed a simple way to prevent ring avulsion injuries. Fresh cadaver fingers were used to test the incidence of avulsion injury with ordinary rings and when a single slot was cut in the ring. Intact rings mostly produced significant digital injuries, while the rings with slots did not.

The thin circumflex scapular artery perforator flap.

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.

Tertiary resurfacing after one of the first free flaps in Europe, a reflection on 30 years of microsurgical progress.

Free flaps have been used for over 30 years. During this period, improved anatomical understanding has increased donor options and available pedicle lengths, permitting safer, single-stage reconstructions with simpler anastomoses. Refinements, such as perforator flaps in particular, have greatly improved donor morbidity, recipient site cosmesis, and the ability to replace 'like with like' while retaining options for innervation. This case highlights the evolution from one of Europe's first free tissue transfers, effectively a perforator flap, through the advent of free muscle flaps to the current generation of contourable perforator flaps. Free flap transfer has become increasingly sophisticated, safer, and more predictable, yet the potential quality of reconstructive outcome has changed little.

[Modern concept for treatment of the female-to-male transsexual]. / Modernes Behandlungskonzept bei Frau-zu-Mann-Transsexualismus.

BACKGROUND: The experience of our multidisciplinary team in surgical treatment of female-to-male trans-sexualism is presented, and our treatment concepts described in detail. In addition, our preferred technique of neourethra formation using a prefabricated free fibula flap is described. PATIENTS AND METHOD: From 1996 to 2003, thirty-four patients underwent gender reassignment surgery as a staged procedure. The neourethra was constructed using an anterior vaginal flap and the prefabricated free fibular flap. RESULTS: There were four complete losses of the prefabricated fibular flap (11.7%). The neourethra stricture rate was 20.5% and the fistula formation rate was 14.7%. In 82.3% of the patients, the ability to micturate while standing was achieved. CONCLUSION: This modern concept reduces the complication rate and improves the quality of patient outcome.

Phalloplasty with free (septocutaneous) fibular flap sine fibula.

PURPOSE: The free prefabricated fibular flap has been used as a good alternative to the free radial forearm flap in female-to-male sex reassignment surgery. We describe a new technique of harvesting the flap without sacrificing the fibula. The neophallus is thinner, more elegant, less rigid and able to contain a hydraulic penile prosthesis. MATERIALS AND METHODS: Five biologically female patients underwent reassignment surgery using this technique. Average patient age was 30 years (range 24 to 37) and average followup was 25 months. All patients underwent total hysterectomy, salpingo-oophorectomies, vaginectomy and urethral prelamination 6 months before flap surgery. The lateral calf cutaneous island was raised on the peroneal artery septocutaneous perforators without disrupting the continuity of the fibula. Urethro-urethral anastomosis was done 3 months later. RESULTS: All patients sustained good results with no flap loss. Voiding from a standing position was achieved and the neophallus was esthetically acceptable. Donor morbidity was minimal with no disturbance to ambulation compared to the conventional method, in which the fibula is sacrificed. CONCLUSIONS: The free fibular flap without the fibula is a challenging refinement of neophallus construction that confers benefits to recipient and donor sites. It is a welcomed addition to the armamentarium for neophalloplasty.

[The deepithelialized cross-finger flap: a good method for covering large dorsal finger defects]. / Der deepithelialisierte Cross-finger-Lappen: Eine gute Methode zur Defektdeckung von grossen streckseitigen Fingerdefekten.

BACKGROUND: Injuries to the dorsum of the finger are common. Combination with exposure of important deeper structures needs reconstruction with a flap. The deepithelialized cross-finger flap is a good possibility for covering large dorsal finger defects. PATIENTS AND METHODS: From March 2003 to October 2003 six patients (two female, four male) underwent this procedure. RESULTS: Neither flap loss nor infection was observed. All defects were covered adequately, and no donor site problems occurred. One week after flap division, the function of the involved finger joints had the same range of motion as the contralateral finger joints. CONCLUSION: The deepithelialized cross-finger flap is a good and safe method for defect cover in large dorsal finger defects. The good postoperative range of motion supports the indication for this two-step reconstruction procedure.

Functional reconstruction of Achilles tendon defects combined with overlaying skin defects using a free tensor fasciae latae flap.

We present our experience in functional reconstruction of the Achilles tendon with large tissue defects following after trauma and infection. To cover the skin defect and to reconstruct the Achilles tendon we used the free tensor fasciae latae (TFL) flap. From 1997 to 2003 six males, ranging from 22 to 71 (average 38.6) years, underwent this reconstructive procedure. All of them had sustained a trauma with following loss of the tendon and of the overlying tissue. After initial debridements the reconstruction with a tensor fascia latae free flap was performed. To achieve a strong distal fascia lata attachment to the calcaneal bone, we developed a special method of fixation. After vertical osteotomy in the calcaneus the distal part of the fascia flap was introduced between the bone segments, which were fixed together with a spongiosa screw. For functional outcome, it was important to fix the foot in a 90 degrees position with tension on the vascularised fascia lata. The range of motion of the ankle of the reconstructed foot showed 93.7% in comparison to the normal foot. No flap failure occurred in any of the six patients. Simultaneous soft-tissue and function restoration of the foot with TFL free flap is in our opinion an optimal one-stage reconstructive procedure.

Evaluation outcome of replanted digits using the DASH score: review of 38 patients.

The ultimate usefulness of replanted fingers is related to the adequacy of nerve, tendon and bone repair. Thirty-eight patients with successful replantation of the thumb, a single finger or after multiple digital amputations were followed up clinically. The subjective disability after finger replantation was evaluated by means of the DASH score, and the presence of cold intolerance was assessed. The subjective outcome of the achieved replantation reached an overall DASH score of 12.3. Patients after thumb replantation reached a score of 10.0, after a single finger replantation DASH 11.2 and after multiple finger amputations and replantation of at least one finger, DASH 16.1. Cold intolerance was subjectively found in 86.7% of all hands with replanted fingers without a correlation to the patients DASH scores. The patient's evaluation of their limb function after replanted digits by means of the DASH score, when combined with an objective external assessment, represents a valuable comparative tool.