The evolving role of the masseter-to-facial (V-VII) nerve transfer for rehabilitation of the paralyzed face.

In cases where the proximal stump of the facial nerve is unavailable for repair or interposition nerve grafting, and there are intact distal facial nerve branches and viable mimetic muscles, then the masseter-to-facial (V-VII) nerve transfer can provide an effective means of smile restoration. Positive attributes of the V-VII transfer include: limited donor site morbidity, anatomic consistency, a dense population of myelinated motor nerve fibers capable of producing strong motion, synergy with the facial nerve and potential for effective cerebral adaptation yielding an effortless smile. The technique can be utilized in isolation or combined with cross face nerve grafts to further enhance spontaneity and resting tone.

Osteochondroma as a causal agent in popliteal artery pseudoaneurysms: case report and literature review.

Osteochondromas are an infrequent, but significant, source of vascular injuries. Popliteal artery pseudoaneurysms are the most common sequelae, with a complex interplay of anatomic and developmental factors accounting for their prevalence. The authors present a case report, detailed discussion, and literature review of pseudoaneurysm formation in the popliteal artery.

Algorithms for the treatment of cleft lip and palate.

Developing standardized outcomes and algorithms of treatment is a constantly evolving task. This article examines four variables in this process: cleft type, operative technique, surgical experience, and timing. Input from international cleft lip and palate programs regarding techniques and treatment modalities provide a dynamic tool for assessment and the development of guidelines in the treatment of the cleft lip and palate patient.

A new design of the iliac crest microsurgical free flap without including the "obligatory" muscle cuff.

The iliac crest free flap has undergone a gradual evolution to provide more functional and cosmetic oromandibular reconstructions. The soft-tissue cutaneous component has largely resisted refinement and currently constitutes the flap's principal drawback. Conventionally, the cutaneous vessel's soft-tissue encasement and a protective cuff of abdominal muscle are harvested to ensure skin perfusion. These protective measures, however, produce a bulky flap that is tethered to the bone and difficult to inset into complex three-dimensional defects. A series of anatomic and clinical investigations has confirmed that in 30 percent of individuals, the skin island can be elevated on a dominant cutaneous branch from the deep circumflex iliac artery. Harvesting the skin as an axial pattern flap greatly increases its independence from the bone, improving maneuverability. A small collar of abdominal muscle is incised around the pedicle, obviating the need for the customary 2.5-cm protective muscle cuff. Exclusion of the abdominal muscular component reduces the flap's volume, decreases the need for secondary debulking, and reduces the donor site morbidity.

Gene expression and apoptosis in the spinal cord neurons after sciatic nerve injury.

To demonstrate a dependence of spinal cord motoneurons on the communication with their targets, the expression of immediate early gene c-fos and neurotrophin genes in the lumbar (L3-L6) spinal cord neurons was examined in Sprague-Dawley rats (male > or = 9-weeks-old) with unilateral sciatic nerve transection. Using in situ hybridization, we detected the expression of c-fos mRNA in the motoneurons of the spinal cord segments within 45 min to 3 h of peripheral nerve transection (n = 4 in each time point). The expression of c-fos mRNA was also correlated positively with the expression of Fos antigen using immunohistochemistry, while no change in calbindin and parvalbumin antigens were noted. The expression of BDNF mRNA increased at 90 min after sciatic nerve transection. However, no detectable enhancement in the expression of NGF mRNA was observed. DNA fragmentation in neurons was observed using the incorporation of digoxigenin-dUTP by terminal transferase into 3'-OH terminals of DNA fragments in the ipsilateral section of the spinal cords 48h after nerve injury. Nuclei that exhibited DNA fragmentation were not observed in the spinal cord of the control animals. Lastly, we observed that the majority of astrocytes did not have DNA fragmentation. Because the detection of DNA fragmentation using this assay is one of early detections of apoptosis or programmed cell death, the result suggested we could detect early cell death in spinal cord, and indicated a target dependence of the neurons in the spinal cord after transection of sciatic nerve.

Closure of upper extremity soft-tissue defects using the new "supra-crest" fasciocutaneous free flap.

A fasciocutaneous island (15 x 10 cm) can be elevated from the inferolateral abdominal wall in a region encompassing the iliac crest and extending to the lower costal margin. This new fasciocutaneous flap was named the "supra-crest flap," in accordance with its anatomic location and vascular pattern. The blood supply stems from the direct cutaneous branches of the lumbar arteries (L2-3), which pierce the abdominal musculature approximately 2.0 cm above the iliac crest in the midaxillary line. The arteries and two vena comitantes have an average external diameter of 2.0 mm, and their dissection can be extended deep into the iliac fosa to provide a pedicle 8 or more cm in length. Two cutaneous nerves accompany the lumbar arteries, furnishing the possibility of a sensate flap. These structures have been transferred as a free flap with the donor site concealed by conventional underwear and bathing suits. Additionally, this region could be harvested as an island flap wherein the arc of rotation may be sufficient to cover defects of the thoracic wall and lumbosacral regions.

The subcutaneous pedicle tensor fascia lata flap.

The presence of a consistent subcutaneous vascular plexus allows carrying of a distal skin island safely on the iliotibial tract. A distal skin island can be designed on the lateral thigh and can be raised on a subcutaneous pedicle that is proximally supplied by the lateral femoral circumflex artery. This technique preserves the lateral thigh skin and employs subcutaneous tunneling to overcome the traditional drawbacks of the conventional extended tensor fascia lata flap. The subcutaneous pedicle tensor fascia lata flap's sensate potential, thin skin, durable fascia, extensive reach, and 360 degree arc of rotation make it an appealing donor site for coverage of lower midsection and pelvic defects or for penile reconstruction.

Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures.

Eight years ago, the principal author (Shenaq) began employing high-power ocular loupes for microvascular anastomoses. Subsequently, 251 free-tissue transfers were performed with loupes as the sole means of magnification. Procedures included free flaps, toe-to-hand transfers, and digital replantations, with the external diameter of the vascular pedicles averaging 1.5 mm. Analysis of the series revealed a 97.2 percent overall success rate, a 1.2 percent partial flap necrosis rate, and an 8.3 percent revision rate for anastomoses (during the initial operative procedure), which compare favorably with the success rates frequently cited for microscope-assisted procedures. The most favorable results were achieved with free flaps and toe-to-hand transfers with 98.5 and 96.4 percent success rates, respectively. The 79.2 percent survival rate achieved with digital replantation falls within the range (74.0 to 94.2 percent) reported in the literature. This experience indicates that in practiced hands, high-power ocular loupes provide an alternative to the operating microscope for microvascular anastomosis of vessels 1.0 mm or greater in diameter. Loupe use is advocated on the grounds of cost-effectiveness, portability, and operator freedom.

How to help diabetic patients avoid amputation. Prevention and management of foot ulcers.

Foot ulcers are a weighty complication of diabetes whose significance is often underestimated. They are associated with a high degree of morbidity and mortality, and treatment is laborious and costly. The problem of susceptibility to foot ulceration is best addressed through a prevention program emphasizing patient education, pedal hygiene, regular follow-up visits, and lifestyle modification. Such programs are most efficiently administered by a healthcare team. When ulcers do occur, it is important to take a systematic approach to management, stressing infection control, metabolic stabilization, thorough debridement, and meticulous wound care.

Refinements in the iliac crest microsurgical free flap for oromandibular reconstruction.

Development of the iliac crest microsurgical free flap has greatly improved the surgical reconstruction of oromandibular defects. A decade of continuous utilization has established its efficacy and versatility. The utility of the flap has been continuously expanded by the introduction of new surgical techniques and adjunctive innovations. The advent of improved internal fixation systems, osteointegration, and neurocutaneous flaps has facilitated a more comprehensive oromandibular rehabilitation. The introduction of the split inner-cortex modification by the principle author served to refine the bony component and greatly reduces postoperative complications and donor site morbidity.

The iliac crest microsurgical free flap in mandibular reconstruction.

Development of the iliac crest microsurgical free flap has significantly enhanced the surgical restoration of the mandible. A decade of heavy clinical use has established the versatility and efficacy of this technique. A recent literature review suggests a 96% success rate has been achieved. This donor site provides a long vascular pedicle, appropriately shaped bone, skin, and soft tissue. These properties enable tailoring of the flap to precisely fit the defect. The flap has overcome bone size and movement restrictions imposed by regional pedicles. The retained blood supply induces rapid fracture-like healing and provides metabolic independence from the recipient bed. Incorporating an internal oblique muscle island enhances flap utility. The muscle provides a source of oral lining and sanctions the reconstruction of compound defects with a single flap. In an effort to refine the bony component and reduce donor site morbidity, the principal author has introduced the split inner cortex modification. This method has eliminated abdominal wall weakness and hernia, while improving postoperative pelvic contour. The split inner cortex microsurgical iliac crest free flap is the current standard for oromandibular reconstruction in our institution. Additional refinements to internal fixation, TMJ restoration, and osseointegration have resulted in a more refined, comprehensive reconstruction.