Complex abdominal wall reconstruction, harnessing the power of a specialized multidisciplinary team to improve pain and quality of life.

INTRODUCTION: Patients who require highly complex abdominal wall hernia repair with composite soft tissue free flap coverage represent the most challenging population, and the most difficult to definitively treat. For many, this combined procedure represents their last chance to restore any sense of normalcy to their lives. To date, patient reported post-operative outcomes have been limited in the literature, in particular, quality of life has been an under-reported component of successful management. METHODS: Patient-reported outcomes were analyzed using the 12-question HerQLes survey, a validated hernia-related quality of life survey to assess patient function after complex abdominal wall reconstruction. Using synthetic mesh for structural stability, and microsurgical flaps for soft tissue coverage, ten consecutive heterogeneous patients underwent repair of massive abdominal wall defects. Baseline preoperative HerQLes and numerical pain scores were then compared to those obtained postoperatively (at or greater than 6 months). RESULTS: All patients experienced improvement in their quality of life and pain scores post operatively with average follow-up at 15.9 months, even in those who experienced complications. All microsurgical flaps survived. There were no hernia recurrences. CONCLUSION: Despite the extraordinary preoperative morbidity of massive abdominal wall defects, with an experienced General Surgery and Plastic Surgery multidisciplinary team, these highly complex patients are able to achieve a significant improvement in their pain and quality of life following repair and reconstruction with complex mesh hernia repair and microsurgical free tissue transfer.

Pediatric cranio-facial surgery. First-year's experience with a gun applying bioabsorbable tacks.

AIM: In 2001 a prototype of a gun to apply bioabsorbable tacks in cranio-facial surgery has been developed. METHODS: From May 2001 to May 2002 this device has been used in the University Hospital of Innsbruck (Austria) for different cranioplasty procedures, in 34 children, showing its reliability for cranio-facial bone fixation. The children were affected by isolated craniosynostosis or by syndromical synostosis (Apert, Crouzon) and in a case of benign tumor of the parietal skull vault. The range of age, at the time of surgery, was between 3 months and 204 months of age. Bone segments were fixed using self-reinforced polylactide plates and tacks. RESULTS: Firm fixation was obtained intra-operatively and the operative time was reduced about 25-30 minutes as compared to use of plates and screws. This device has just one limitation in its own spring force: sometimes the bone thinner than 1 mm has been broken applying the tacks. CONCLUSION: After the first-year's experience it is possible to confirm that this device reduces, in selected cases, operative time, blood loss, risk of infection and, as a result, the costs.

Neurogenic perspective on vascular endothelial growth factor: review of the literature.

Among a variety of approaches used to stimulate nerve regeneration in experimental settings, is the use of a class of proteins designated as nerve growth factors and various other growth factors. Of these, vascular endothelial growth factor (VEGF), has been demonstrated to possess a potential to stimulate nerve regeneration in addition to its angiogenic properties. A number of studies have investigated the role of VEGF in nerve regeneration, demonstrating that it has both neurogenic and mitogenic activity on cells in the peripheral nervous system. It is therefore likely that VEGF is a molecule of major significance for nerve homeostasis, especially during development, and possibly after nerve injury. This paper reviews the mechanisms of VEGF signal transduction in neurogenesis, and focuses on recent studies that have considerably widened the understanding of the way in which VEGF affects peripheral nerve regeneration. By emphasizing the possible therapeutic implication of VEGF in nerve pathology, the authors would like to introduce a new research approach to study the role of VEGF in the nervous system. They believe that in the future, the factor might become a powerful tool in enhancing nerve regeneration in clinical practice.

Paulus Aegineta, a seventh century encyclopedist and surgeon: his role in the history of plastic surgery.

Paulus Aegineta (625-690 ad), born on the island of Aegina, practiced medicine at Alexandria. The last of the eclectic Greek compilers in the Byzantine period, he wrote an Epitome of medicine in seven books. The sixth book, which is considered the best section of his work, is devoted mainly to surgery. The first edition, "editio princeps," of his Epitome was published in Greek by the Aldine press in Venice in 1528 and later translated into English for the Sydenham Society by Francis Adams of Banchory (1844-1847). Paulus was not only a compiler but also a competent and skillful surgeon. In addition to his achievements in general surgical progress, Paulus Aegineta, especially in the book on surgery, made valuable contributions in the history of plastic surgery. He may be considered as one of the originators of plastic surgery as it is known today. He described procedures varying from the treatment of nasal and jaw fractures to operations for gynecomastia, ganglion, and hypospadias. This Grecian master influenced not only his own but also the subsequent ages. Rhazes, Haly Abbas, Albucasis, Avicenna, and Fabricius ab Aquapendente were the greatest physicians influenced by Paulus Aegineta. Because the work of Paulus Aegineta was the only source for many of the surgical treatises of Arabian authors, his Epitome bridged Western and Eastern medicine and conveyed surgical experience and knowledge, including several plastic surgery procedures, to the subsequent ages.

A new test for superficialis flexor tendon function.

Diagnosis of flexor digitorum superficialis tendon injury is difficult if the profundus tendon functions properly. A new test, called the DIP extension test, to diagnose isolated flexor digitorum superficialis tendon injuries is described. The test is particularly useful for the index finger. During the test the patient is asked to flex the proximal interphalangeal joint of the injured finger while this finger is in a precision pinch position with the thumb. The distal interphalangeal (DIP) joint normally has to go in hyperextension after this action. Inability to hyperextend the DIP joint confirms a superficialis tendon injury. Fifteen isolated superficialis tendon injuries in 10 patients were evaluated with the DIP extension test. Nine of these patients were later explored and the diagnosis was confirmed in all patients.

A neurocutaneous island flap model: an experimental study in rats.

Neurocutaneous flaps have been popularized recently in clinical reconstructive surgery. However, controversies exist concerning their anatomy and physiology. The particular role of neural vasculature in the survival of these skin flaps is also quite undefined in the experimental setting, and additional studies on this subject are necessary. The goal of this study was to describe a neurocutaneous flap in a rat model and to investigate its blood supply. Thirty male Sprague-Dawley rats weighing 300 to 350 g were used in this study, which was conducted in two stages. During the first stage, the lower extremities of 10 rats were dissected for the anatomic study of the neurocutaneous flap. A constant cutaneous nerve innervating the anterolateral thigh skin was exposed. It arose either from the saphenous nerve or the superficial epigastric nerve and was accompanied by a constant longitudinal arterial plexus. The tiny neural vessels were conveyed by the superficial fascia along their course. A 30 x 30-mm cutaneous island flap, which was based only on the cutaneous nerve with its accompanying vessels and a strip of superficial fascia, was raised on the anterolateral thigh skin using an operating microscope. The well-perfused skin territory was marked after sodium fluorescein injection. The stained skin territory was located centrally and medially on the whole island flap, and it was approximately 10 x 20 mm. This finding was confirmed by the qualitative assessment of the vascularity for this skin territory in microangiography. After studying the pedicle anatomy and determining the optimal viable skin island, the second stage of the study was performed. The remaining 20 rats were divided into two groups. In the experimental group (N = 10), a neurocutaneous island flap (10 x 20 mm) was outlined on the anterolateral aspect of the thigh at its middle third. It was designed in such a way that its short and long axes lay in the center of the distance between the anterior superior iliac spine and the anterior aspect of the knee joint. After identification and dissection of the neurovascular pedicle, the flap was raised in a lateral-to-medial direction without including the deep fascia. At this point the flap remained connected only by the pedicle and a strip of superficial fascia surrounding it. It was sutured in the same place. In the control group (N = 10), the pedicle of the flap was severed and the skin island was sutured back as a composite graft. All the experimental flaps survived well. In the control group, none of the flaps survived except one that was partially viable. The flaps in the experimental group were reelevated as neurocutaneous island flaps on day 7 for microangiographic study, and specimens were processed for histologic staining. Microangiography revealed the extent of neural vasculature and vascularization of the skin through cutaneous perforators. Histologic investigation demonstrated the neural vessels that were related closely to the superficial fascia. The authors propose a neurocutaneous island flap model in the lower extremity of the rat in which the survival of the flap depended mainly on the neural arterial supply. It was also demonstrated that the superficial fascia played a role as a connective tissue framework for conveying tiny neural blood vessels to reach the skin. This model may serve as a reproducible and reliable neurocutaneous island flap model for additional studies in this field.

Use of fascial grafts as an interface in flap prefabrication: an experimental study.

An experimental study was conducted to investigate whether a fascial graft can be used as an interface between a vascular pedicle and target tissue to augment tissue survival in a prefabricated flap. Thirty-six male Sprague-Dawley rats were divided into three experimental groups according to the type of the recipient bed prepared for the vascular implantation. The left saphenous vascular pedicle was used as the vascular source. A 9 x 9-cm inferiorly based peninsular abdominal flap was elevated in each animal. In group I, the pedicle was tacked beneath the abdominal flap, in which the epigastric fascial layer was untouched. In group II, a 3 x 5-cm graft of epigastric fascia was harvested from the abdominal flaps under loupe magnification. The graft was sutured back into its original position after a 180-deg rotation. The vascular pedicle was then implanted just beneath the center of the fascial graft. In group III, the same size of epigastric fascia was removed in the same manner as group II, exposing the subcutaneous layer for pedicle implantation. Four weeks later, abdominal flaps were raised as island flaps connected only to the saphenous pedicle and were sutured in place. Flap viability was assessed visually on day 7. Overall, the ultimate flap survival in group I was the largest, with some necrotic areas at the periphery of the flaps. In group II, flap survival was typically centralized over the fascial graft, and crescent-shaped necrosis was noted superiorly. In group III, an almost linear pattern of survival overlying the vascular pedicle was observed. The mean surviving flap area of group I (12.13 +/- 1.615 cm2) was statistically greater than that of group II (8.83 +/- 0.663 cm2, p < 0.001) and group III (6.3 +/- 0.815 cm2; p < 0.001). There was a statistically significant difference between the mean flap survival in groups II and III (p < 0.001). Vascular arborization was examined by microangiography, and specimens were processed for histological staining. In group II, vascularization was distributed in a larger area along the fascial graft in comparison with limited vascularization around the pedicle in group III. In this study it was revealed that the interposition of a fascial graft as an interface between the vascular source and the target tissue seems to increase the size of the prefabricated flap.