Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer.

BACKGROUND: A femoral nerve injury may result in cutaneous sensory disturbances of the anteromedial thigh and complete paralysis of the quadriceps femoris muscles resulting in an inability to extend the knee. The traditional mainstay of treatment for femoral neuropathy is early physiotherapy, knee support devices, and pain control. Case reports have used the anterior division of the obturator nerve as a donor nerve to innervate the quadriceps femoris muscles; however, a second nerve transfer or nerve grafting is often required for improved outcomes. We suggest a novel technique of combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer to restore the strength and stability of the quadriceps muscles. METHODS: This is a case series describing the use of a pedicled gracilis muscle transposed into the rectus femoris position with a concomitant nerve transfer from the adductor longus nerve branch into the rectus femoris nerve branch to restore quadriceps function after iatrogenic injury (hip arthroplasty) and trauma (gunshot wound). RESULTS: With electrodiagnostic confirmation of severe denervation of the quadriceps muscles and no evidence of elicitable motor units, 2 patients (average age, 47 years) underwent a quadriceps muscle reconstruction with a pedicled, innervated gracilis muscle and an adductor longus to recuts femoris nerve transfer. At 1 year follow-up, the patients achieved 4.5/5 British Medical Research Council full knee extension, a stable knee, and the ability to ambulate without an assistive aid. CONCLUSIONS: The required amount of quadriceps strength necessary to maintain quality of life has not been accurately established. In the case of femoral neuropathy, we assumed that a nerve transfer alone and a gracilis muscle transfer alone would not provide enough stability and strength to restore quadriceps function. We believe that the restoration of the quadriceps function after femoral nerve injury can be achieved by combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer with low morbidity and no donor defects.

Arterialization of the Venous System for Acute and Chronic Ischemia of the Hand: A Case Series With Prospective Duplex Ultrasound Assessment.

Background: Ischemia of the hand is a debilitating condition. In many cases, the cause of ischemia is diffuse atherosclerosis with no distal vessels available for bypass. In these situations, options are limited to restore perfusion, and there is a potential role for arterialization of the venous system to relieve ischemic pain and avoid amputation. Methods: This is a retrospective review of all patients at our institution who underwent arterialization of the venous system between 2010 and 2014 by 4 surgeons for acute or chronic ischemia of the upper extremity not amenable to bypass procedures. Indications, preoperative and postoperative findings, and the requirement for future digital amputations were recorded. The patients were then evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. Results: Eight patients with 10 upper extremities underwent arterialization of the venous system. All patients with chronic ischemia went on to heal their ischemic ulcerations with relief of rest pain and avoided amputation. Eight upper extremities had arterial Doppler and duplex ultrasound signals showing arterialized dorsal veins demonstrating flow from the dorsal veins heading volar via the intrinsic compartments into the digital arteries. Conclusions: This study illustrates the successful use of arterialization of the venous system of the hand in both acute and chronic hand ischemia. It reports on prospective imaging and duplex ultrasound studies confirming patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.

Patient Reported Outcomes Following Lower Extremity Soft Tissue Sarcoma Resection with Microsurgical Preservation of Ambulation.

BACKGROUND: Lower extremity soft tissue sarcoma treatment has evolved from primarily amputation procedures toward limb salvage. This series assesses whether soft tissue sarcoma tissue defects, extensive enough to require microsurgical reconstruction, can reliably result in preservation of ambulation, as well as objectively evaluate functional outcomes utilizing a patient-reported validated scale. It will also look at whether immediate functional muscle reconstructions and tendon transfers can be successful at restoring ambulation, potentially expanding the indications for limb salvage procedures. METHODS: A retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completed at our institution (2009-2013). Patients were additionally asked to complete the Toronto Extremity Salvage Score(TESS) quality of life survey. RESULTS: Over a 5-year period, 23 patients (mean age: 53 years) underwent free flap reconstructions for 23 sarcomas (mean follow-up: 14 months). Seventy-eight percent of patients received neoadjuvant radiation. The thigh was the most common tumor site (61%) and three muscles were resected on average. Perforator flaps were most frequently used (61%), and functional muscle transfers or immediate tendon transfers were used in four patients. There were no flap take-backs or failures, and 22 patients achieved independent ambulation. Three patients in the series died, two from metastatic disease found postoperatively and one from local recurrence. A 74% response rate was achieved for the TESS survey, with a mean score of 83. CONCLUSION: Microsurgical reconstruction of lower extremity sarcoma defects enables preservation of independent ambulation. Restoration of function utilizing immediate functional microsurgical reconstructions and tendon transfers should be considered.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

A Limited Submuscular Direct-to-Implant Technique Utilizing AlloMax.

This study evaluates a novel limited submuscular direct-to-implant technique utilizing AlloMax where only the upper few centimeters of the implant is covered by the pectoralis, whereas the majority of the implant including the middle and lower poles are covered by acellular dermal matrix. METHODS: The pectoralis muscle is released off its inferior and inferior-medial origins and allowed to retract superiorly. Two sheets of AlloMax (6 × 16 cm) are sutured together and secured to the inframammary fold, serratus fascia, and the superiorly retracted pectoralis. Thirty-seven breasts in 19 consecutive patients with follow-up at 6 months were reviewed. RESULTS: Nineteen consecutive patients with 37 reconstructed breasts were studied. Average age was 50 years, average BMI was 24.3. Ptosis ranged from grade 0-III, and average cup size was B (range, A-DDD). Early minor complications included 1 seroma, 3 minor postoperative hematomas managed conservatively, and 3 minor wound healing problems. Three breasts experienced mastectomy skin flap necrosis and were managed with local excision. There were no cases of postoperative infection, red breast, grade III/IV capsular contractures, or implant loss. A single patient complained of animation postoperatively. One patient desired fat grafting for rippling. CONCLUSIONS: The limited submuscular direct-to-implant technique utilizing AlloMax appears to be safe with a low complication rate at 6 months. This technique minimizes the action of the pectoralis on the implant, reducing animation deformities but still providing muscle coverage of the upper limit of the implant. Visible rippling is reduced, and a vascularized bed remains for fat grafting of the upper pole if required.

Free tissue transfer for necrotizing fasciitis reconstruction: A case series.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening infection requiring extensive debridement that may necessitate amputation. Free tissue transfer (FTT) is an option for reconstruction in difficult cases. Currently, only case reports have described FTT in the setting of NF, and comprehensive evidence on flap outcomes is lacking. The present study characterizes outcomes in patients with FTT following NF. METHODS: All patients admitted with NF between January 1, 2005 and December 31, 2011 to our level 1 burns/trauma referral center were retrospectively reviewed. RESULTS: No significant difference was found in patient demographics between FTT (n=12) and no FTT (n=212). Both groups had the same number of operations, same length of ICU stay, and length of hospitalization. The flaps used were 10 anterolateral thigh, 1 latissimus dorsi and 1 radial forearm. Recipient sites included: upper extremities (6), lower extremities (4), head/neck (1), and genitalia (1). No flap failures and no take-back operations were required. Upper extremities comprised 58.3% of FTT patients compared to 18.9% (p=0.004) in non-FTT patients. Flap operations occurred a mean of 11.6days post-admission with 1.1 operations prior to FTT. Mean FTT size was 213cm2. Flap complications included seroma (n=1), hematoma (n=1). Donor site complications included hematoma (n=1), exposed tendon (n=1) and necrosis (n=1). CONCLUSIONS: This study demonstrates that FTT provides a promising reconstructive option in the setting of NF without adversely affecting patient outcome.

The Economy in Autologous Tissue Transfer: Part 1. The Kiss Flap Technique.

BACKGROUND: All reconstructive microsurgeons realize the need to improve aesthetic and functional donor-site outcomes. A "kiss" flap design concept was developed to increase the surface area of skin flap coverage while minimizing donor-site morbidity. METHODS: The main goal of the kiss flap technique is to harvest multiple skin paddles that are smaller than those raised with traditional techniques, to minimize donor-site morbidity. These smaller flap components are then sutured to each other, or said to kiss each other side-by-side, to create a large, wide flap. The skin paddles in the kiss technique can be linked to one another by a variety of native intrinsic vascular connections, by additional microanastomosis, or both. This technique can be widely applied to both free and pedicle flaps, and essentially allows for the reconstruction of a large defect while providing the easy primary closure of a smaller donor-site defect. RESULTS: According to their origin of blood supply, kiss flaps are classified into three styles and five types. All of the different types of kiss flaps are unique in both flap design and harvest technique. Most kiss flaps are based on common flaps already familiar to the reconstructive surgeon. CONCLUSIONS: The basis of the kiss flap design concept is to convert multiple narrow flaps into a single unified flap of the desired greater width. This maximizes the size of the resulting flap and minimizes donor-site morbidity, as a direct linear closure is usually possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Excision With Interpositional Nerve Grafting: An Alternative Technique for the Treatment of Morton Neuroma.

INTRODUCTION: "Morton neuroma" is a common cause of forefoot pain with numbness frequently occurring in the distribution of the third common digital nerve. After the failure of nonoperative measures, decompression with excision of the neuroma is common practice. Residual numbness and recurrent pain has been reported as a consequence of this treatment option. This study describes excision of the neuroma with interpositional nerve grafting as a treatment option for Morton neuroma. This proposed technique has the benefit of reducing pain, reducing recurrent secondary neuromas and restoring postexcision sensory deficits. METHODS: A retrospective chart review of patients who underwent elective primary excision of a Morton neuroma with interpositional nerve grafting was undertaken. Patient demographics, surgical technique, and clinical outcomes, such as pain, neuroma recurrence, 2-point discrimination, numbness, and weight-bearing status at minimum of 1 year postoperation, are reported. RESULTS: Eight patients (9 neuromas) underwent excision of the Morton neuroma with interpositional nerve grafting after failing nonoperative measures. At final follow-up, all patients had improvement of pain and there were no neuroma recurrences. Sensation to the grafted hemi-toe returned in all but 1 case. All patients returned to full weight-bearing status. Although no major complications were reported, wound dehiscence secondary to a hematoma occurred in 1 case. CONCLUSIONS: Excision and interpositional nerve grafting is an effective treatment for Morton neuroma as it alleviates pain, numbness and restores sensation with minimal morbidity and complications.

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

A reliable frozen section technique for basal cell carcinomas of the head and neck.

Basal cell carcinomas (BCCs) of the head and neck treated by conventional techniques of surgical excision, curettage, cryotherapy and radiation therapy have recurrence rates of up to 42%. Mohs micrographic surgery (MMS) decreases the recurrence rate but can be expensive, delay definitive reconstruction and is limited in its availability. The authors report a series of 50 patients with head and neck BCCs treated by a surgeon-directed 'en face' frozen section technique that immediately evaluates the entire peripheral and deep margins during BCC resection, and potentially offers a more efficient and equally effective alternative to MMS. Patient demographics, pathology results, operative time, technique and outcomes are all reported. With a mean follow-up of three years, there was only one recurrence (1.7%). Mean total operative time was 1 h 47 min. The authors conclude that this surgeon-directed 'en face' frozen section technique does not require any specialized training, enables more rapid and reliable results than standard frozen section techniques that are currently used, and provides outcomes equivalent to MMS in the surgical treatment of head and neck BCCs.

Les carcinomes basocellulaires (CBC) de la tête et du cou traités par les techniques classiques d'excision clinique, de curetage, de cryothérapie et de radiothérapie ont un taux de récurrence pouvant atteindre 42 %. La chirurgie micrographique de Mohs (CMM) réduit le taux de récurrences, mais elle peut être coûteuse, peut retarder la reconstruction définitive et n'est pas très utilisée.Les auteurs présentent une série de 50 patients ayant un CBC de la tête et du cou, traités par une technique d'examen extemporané dirigée par un chirurgien sur place, qui permet d'évaluer immédiatement l'ensemble des bords périphérique et profond pendant la résection du CBC, ce qui pourrait se révéler plus fonctionnel et tout aussi efficace que la CMM.La démographie des patients, les résultats pathologiques, la durée de l'opération, la technique et les résultats sont tous présentés. Après un suivi moyen de trois ans, une seule récurrence a été observée (1,7 %). L'opération durait en moyenne 1 h 47. Les auteurs concluent que la technique d'examen extemporané dirigée par le chirurgien sur place ne nécessite pas de formation spécialisée, permet d'obtenir des résultats plus rapides et plus fiables que les techniques d'examen extemporané standards actuellement en usage et donnent des résultats équivalents à ceux de la CMM pour le traitement chirurgical du CBC de la tête et du cou.

Rethinking the superficial inferior epigastric artery flap in breast reconstruction: Video demonstration of a rapid, reliable harvest technique.

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.

La reconstruction mammaire à l'aide de tissu libre autologue prélevé sur l'abdomen a connu d'importants changements depuis dix ans. L'évolution a visé à limiter la morbidité au foyer du donneur. La transition du lambeau libre prélevé sur le muscle grand droit abdominal transverse au lambeau libre épargnant ce muscle, puis au lambeau perforateur libre de l'artère épigastrique inférieure a considérablement amélioré la reconstruction mammaire autologue à l'aide de tissu prélevé sur l'abdomen. Cependant, tous ces lambeaux exigent une incision traversant le fascia droit antérieur, qui risque d'endommager les nerfs moteurs et sensoriels intercostaux. Le lambeau de l'artère épigastrique inférieure superficielle (AÉIS) assure une perfusion fiable de l'hémiabdomen ipsilatéral, sans toucher le fascia ou d'autres nerfs moteurs. Par conséquent, on prévoit une incidence nulle de hernie, de faiblesse ou de bombement de la paroi abdominale. Néanmoins, le recours au lambeau de l'AÉIS demeure marginal. La dimension des vaisseaux, les problèmes de dissection et la mauvaise compréhension de l'anatomie perti-nente en ont limité l'acceptation. Le présent article décrit une technique de dissection rapide et fiable à l'aide d'un algorithme pour prélever le lambeau de l'AÉIS en cas de reconstruction mammaire autologue.

The transverse upper gracilis flap: Efficiencies and design tips.

The transverse upper gracilis free flap is a well-described option for breast reconstruction. The technique is a secondary choice for autologous breast reconstruction because the abdomen remains the primary donor site for breast reconstruction. However, in appropriately selected patients, the authors believe that the transverse upper gracilis flap remains a reliable flap for breast reconstruction. Its consistent anatomy, potentially reasonable donor site scar, limited functional morbidity and simultaneous two-team surgical approach make this flap a viable option for many patients. The technique, however, is not without drawbacks - known numbness of the medial thigh and the potential for chronic lymphedema of the lower leg, contour deformities of the medial thigh, and widening of the medial thigh scar need to be considered. The current article presents a harvest technique that is reliable, rapid and addresses each of the above-mentioned limitations with specific changes in the traditional technique. The article provides video documentation of the modified harvest technique using only monopolar cautery for the dissection.

Le lambeau supérieur transverse du muscle gracile est une méthode bien connue de reconstruction mammaire. Cette technique est un choix secondaire en cas de reconstruction mammaire autologue, car l'abdomen demeure le principal foyer de prélèvement en vue de ce type de reconstruction. Cependant, chez certains patients bien choisis, les auteurs sont d'avis que le lambeau supérieur transverse du muscle gracile demeure fiable pour procéder à cette reconstruction. Son anatomie uniforme, la cicatrice raisonnable potentielle au foyer du prélèvement, la morbidité fonctionnelle limitée et l'approche chirurgicale à deux équipes font de ce prélèvement de lambeau une option viable pour de nombreux patients. La technique n'est toutefois pas sans défauts : il faut tenir compte de l'engourdissement connu de la cuisse, du potentiel de lymphœdème chronique de la jambe inférieure, de la déformation du contour de la cuisse et de l'élargissement de la cicatrice de la cuisse de la partie médiale.Le présent article propose une technique de prélèvement à la fois fiable et rapide et remplace chacune des limites susmentionnées par des changements particuliers à la technique traditionnelle. Il présente une vidéo de cette technique, faisant seulement appel à la cautérisation monopolaire de la dissection.

Assessing flap perfusion: optical spectroscopy versus venous doppler ultrasonography.

OBJECTIVE: To use optical spectroscopy as a noninvasive method to monitor the viability of free flaps and to compare the near-infrared probe with the implantable venous Doppler ultrasound probe. DESIGN: Prospective, randomized series using an animal model. METHOD: Optical spectroscopy was used to measure variables that correlate with tissue perfusion and oxygenation. An epigastric artery island flap was raised in 20 rats. Vascular insults were simulated by clamping the vessels to the flap. Measurements were taken using near-infrared spectroscopy (NIRS) at the time of clamping and at 15, 30, 45, and 60 minutes of occlusion. The clamps were removed, and final NIRS measurements were taken. In the second experiment, a flap was raised in six rats, each of which underwent a series of short-lived occlusions. The occlusions were monitored with both NIRS and the implantable venous Doppler probe. RESULTS: In the first experiment, disruptions in flap perfusion resulted in significant changes in tissue hemoglobin oxygen saturation and total hemoglobin concentration as detected using NIRS. NIRS predicted vascular compromise with a sensitivity of 89.7% and a specificity of 97.9%. In the second experiment, NIRS predicted vascular compromise with a sensitivity of 63.3% and a specificity of 94.8%. The clinical assessment, based on recordings, yielded sensitivities and specificities of 70% and 94.8% (surgeon 1) and 71.7% and 94.8% (surgeon 2). CONCLUSION: Optical spectroscopy represents a reliable method of noninvasively monitoring free flaps. Further investigations as to the clinical utility of spectroscopy as an adjunctive monitoring device are currently being performed.

Axillary hyperhidrosis: a 5-year review of treatment efficacy and recurrence rates using a new arthroscopic shaver technique.

BACKGROUND: Axillary hyperhidrosis is a chronic condition characterized by excess axillary perspiration. This results in considerable patient morbidity, with no consistently efficacious medical or surgical treatment method described in the literature. METHODS: All cases of axillary hyperhidrosis over a 5-year period were reviewed retrospectively. Data were gathered by a chart review and telephone interview. Inclusion criteria included primary hyperhidrosis, failed conservative therapy, no prior surgical therapy, surgical management using a new arthroscopic shaver technique (R.L.B.-S.), and 6 months of postoperative follow-up. The technique used was consistent between surgeons. Sweating severity was assessed using a subjective numerical rating scale ranging from 1 to 10. Patient demographics, symptom history, results, and complications were analyzed. RESULTS: Average follow-up for 50 patients meeting the inclusion criteria was 28 months. The subjective severity scale demonstrated severity of 9.8 of 10 preoperatively and 2.3 of 10 postoperatively. Three patients (6 percent) reported mild recurrence of symptoms (4.6 of 10), which was not severe enough to seek further treatment. The average follow-up of those patients was 18.5 months. An overall subjective satisfaction of 96 percent was found, with a treatment success rate of 94 percent. Complications were minimal and self-limiting. The average time away from employment was 3.9 days and the average surgical operating room time was 46 minutes. CONCLUSIONS: The authors' new arthroscopic shaver technique is efficacious, with no significant morbidity, a 96 percent satisfaction rate, a subjectively measured 75 percent reduction of sweat, and a recurrence rate of only 6 percent. For cases of primary hyperhidrosis affecting the axilla not amenable to conservative treatment, the authors recommend an arthroscopic shaver technique as the first-line treatment of choice.