The effect of smoking and elderly age on digital replantation - a multivariate analysis.

INTRODUCTION: It is often questioned whether to perform replantation or revision amputation for amputation injuries in elderly patients and smokers. According to the current indication criteria, neither old age nor smoking in the absence of other risk factors are considered to be risk factors for replantation failure. However, many microsurgeons still may make the decision not to perform digital replantation based solely on these factors. MATERIAL AND METHODS: In order to evaluate the influence of both factors, we provided univariate and multivariate analyses of patients who underwent replantation at our centre during a 10-year period. We divided patients in two groups according to age (< and ≥ 60 years) and smoking status. RESULTS: In the univariate analysis, there were no differences in immediate results between the two age groups. In the multivariate analysis, no statistical difference was found in neither long-term nor short-term results between the two age groups and between smokers and non-smokers. CONCLUSION: Smoking and age should not be considered the only risk factors when deciding whether to perform digital replantation.

FREE-FLAP MONITORING: REVIEW AND CLINICAL APPROACH.

Microvascular free flap reconstruction is a routine option for coverage of a variety of tissue defects. Accurate monitoring in the postoperative period is a crucial part of successful flap surgery allowing early detection of vascular compromise and prompt intervention in flap salvaging. Despite that many safety procedures to assess flap viability have been developed, flap failure is consistently seen in 2-5% of free tissue transfers. In addition, great progress is being made in relation to various state-of-the-art technologies for flap monitoring. However, the gold standard still remains clinical monitoring at most institutions even though there is no standardized management protocol. The review should present a prospective optimal monitoring protocol and introduce some of the latest monitoring devices based on the recent literature and personal experience.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]. / Moznosti osetrení u zastaralých poranení hlubokých flexoru prstu ruky ­ primární transplantace slachovým stepem.

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

THE NASOLABIAL FLAP: THE MOST VERSATILE METHOD IN FACIAL RECONSTRUCTION.

The nasolabial flap was described 170 years ago and still remains one of the most frequently used methods in facial reconstruction. This technically easy and maximally effective procedure has become a real workhorse and an integral instrument for every plastic surgeon. Over time multiple modifications of this technique have been described. In this article, authors present an overview of nasolabial flap modalities and discuss advantages and disadvantages of these techniques.

POSTOPERATIVE FIXATION AFTER REPOSITIONING OF PREMAXILLA IN A PATIENT WITH BILATERAL CLEFT LIP AND PALATE - CASE REPORT.

This article presents orthodontic-surgical treatment in an eight-year-old patient with bilateral cleft lip and palate where premaxilla was surgically repositioned in the mixed dentition stage. By cranial and dorsal insertion of the premaxilla were created satisfactory occlusal relationship for ongoing eruption of permanent teeth, together with functional lip closure, improved pronunciation and a positive change in appearance of the centrofacial area. Reposition of premaxilla was associated with bilateral alveolar bone grafting of the cleft defect with cancellous bone from the iliac crest. Based on the model surgery were prepared rigid orthodontic wires, which ensured postoperative fixation of the segments of the upper jaw. The patient was wearing band fixed appliance for another 6 months after surgery. Healing was uncomplicated, the new position of the premaxilla was stable and more physiological. This procedure was friendly for a child patient and did not require fixation of the jaw segments by Sauer splint.

CURRENT TREATMENT OPTIONS OF DUPUYTREN´S DISEASE.

Dupuytren's disease (fibromatosis of the palmar fascia, benign neoplastic fibromatosis, Dupuytren's contracture) is a disease characterized by growth and successive contracture of single parts of the palmar aponeurosis. This condition is known and has been treated for several centuries. In the advanced stages of the disease, it leads to significant limitation of hand function, resulting in reduced quality of life of the patient. Dupuytren's disease (DD) is a life-long disease with a variable course and a heterogeneous clinical presentation. Therapy focuses on the clinical manifestations of the disease as well as on reduction of the functional limitation of the hand caused by the disease. In addition to conservative and surgical procedures, there are also some mini-invasive methods available. Treatment should be reserved for centres and experienced surgeons specialized in hand surgery.

SURGICAL TREATMENT OF MELANOMA.

Malignant melanoma is a serious disease, the incidence of which rises. Since the most important treatment method is sufficient wide skin and subcutaneous tissue excision, plastic surgeon is often the only specialist who is able to close the resulting defect. This paper deals with recommendations and treatment options for malignant melanoma from the point of a plastic surgeon. The primary width of excised safety rim of healthy tissue with regards to the depth of melanoma invasion differs. Safety margin is 0.5 cm for melanoma in situ, 1 cm in Breslow up to 2 mm and 2 cm in Breslow over 2 mm. Furthermore, there is indication for sentinel lymph node biopsy, which should be performed in melanoma with Breslow over 1 mm, and in risky melanoma in Breslow above 0.75 mm. Every patient with stage IIB malignant melanoma and above according to TNM classification should undergo adjuvant therapy in a specialized centre. Ideal condition for the patient is a permanent and close cooperation between a dermatologist, oncologist and plastic surgeon, who supplement each other in diagnostics, therapy and follow up of the patients.

Arterial supply of the thumb: Systemic review.

We offer a complete systemic review of the anatomy of arteries of the thumb, including their sources in the first web space. Eleven studies were selected from the PubMed, Medline, Embase, Scopus and Ovid databases. Data about each artery of the thumb were obtained; in particular, the incidence and dominance of each of these arteries were calculated. The ulnopalmar digital artery of the thumb (UPDAT) was found in 99.63%, the radiopalmar digital artery of the thumb (RPDAT) in 99.26%, the ulnodorsal digital artery of the thumb (UDDAT) in 83.39%, and the radiodorsal digital artery of the thumb (RDDAT) in 70.38%. The sources for the thumb arteries are the first palmar metacarpal artery (for UPDAT in 63.15%, for RPDAT in 78.88%, for UDDAT in 56.95% and for RDDAT in 41.48%), the first dorsal metacarpal artery (for UPDAT in 20.54%, for RPDAT 2.53%, for UDDAT in 20.62%, and for RDDAT in 4.81%) and the superficial palmar arch, either complete or incomplete (for UPDAT in 25.57%, for RPDAT in 23.04%, for UDDAT in 0%, and for RDDAT in 5.19%). The dominant source could be identified in 88.2% of cases: the first palmar metacarpal artery (66.2%), the first dorsal metacarpal artery (15.5%) and the superficial palmar arch, complete or incomplete (8.2%). Four arteries usually supply the thumb. Any artery in the first web space can be a source for the thumb arteries. We propose a new classification of the arteries of the hand, dividing them into three systems (superficial palmar, deep palmar and dorsal system), and suggest that the term "princeps pollicis artery" be reconsidered and systemic anatomical terms of the thumb arteries preferred. Clin. Anat. 30:963-973, 2017. ©2017 Wiley-Liss, Inc.

CURRENT CONCEPTS IN PERIPHERAL NERVE INJURY REPAIR.

Even though reconstructive surgery of the nerves underwent significant progress due to experimental and clinical research over the past 40 years, injuries to the peripheral nerves still remain a great challenge for microsurgery. Literature results of these procedures are often evaluated as very good but the final result is often characterized by an achievement of only a useful and not full function, which is rather rare. It is not only a simple suture; the success is also based on functional regeneration and interconnection of the nerve fibres. This is limited by correct surgical technique, the age of the patient, delay from the time of injury and the mechanism or localization of the injury. Some injuries even now remain untreatable (such as the most severe brachial plexus injuries or long traction injuries of the peroneal nerve). Apart from standard neurolysis and epi- or perineural suture with or without nerve grafts, distal nerve transfers (in case of proximal injuries) and end-to-side neurorrhaphy (mainly in trauma of sensitive nerves) have recently been frequently used. The future is however based on influence of nerve regeneration at the cellular level using substances with growth potential. The main prerequisite of successful surgery is however early indication of surgical revision in a specialized centre.

HAS A GLOMUS TUMOR ALWAYS A QUICK DIAGNOSIS?

INTRODUCTION: Glomus tumor is a rare and benign vascular tumor. Although symptoms specific for this tumor are quite clear, there is still a delay between the onset of symptoms, diagnosis and subsequent surgical therapy. The authors monitor the time from the onset of symptoms to the diagnosis and management of the problems. MATERIAL AND METHODS: Between 2004-2012, a total of 5 patients were diagnosed with subungual glomus tumor in the area of the distal phalanges of the hand. It involved 3 women and 2 men with the mean age of 32.2 years (26-47 years). During the first examination, we monitored the duration of symptoms, number and specialty of the doctors who examined the patient, and what examinations were performed. When the cold test was positive, MRI was performed and the patients were indicated for surgical revision. Tissue samples in all patients were histologically examined. Patients were followed for 2 years. RESULTS: It was found that the patients had clinical symptoms for an average of 2.4 years. In our group, the patients were examined by an average of 5.4 physicians (3-9 physicians). On examination before surgery, three patients reported changes in the nail bed and two patients reported no change. When following the patients 2 years after the surgery, relapse occurred in one patient and it was treated with reoperation. During regular follow-up 2 years after the surgery, 4 patients were without nail deformity. In one patient, there was resulting nail deformity. Relapse occurred in only one case. DISCUSSION: Because the glomus tumor is a rare lesion, occurring most frequently in the nail bed, early diagnosis is still a problem. Even in literature, we encounter a similar time frame from the onset of symptoms until the final diagnosis of 1.9 to 8 years. CONCLUSION: Although clinical signs and problems concerning the glomus tumor are very obvious, there still remains a long time for diagnosis. It would certainly be most beneficial for patients with persistent symptoms not to be referred to different specialists, but directly to a department that specializes in hand surgery.

[Perilunátní poskození zápestí]. / Perilunátní poskození zápestí.

PURPOSE OF THE STUDY Perilunate dislocations and perilunate fractures are serious wrist injuries which are often overlooked at primary treatment. Their inadequate therapy results in severe wrist damage and patient disability. An early diagnosis and correct therapy can prevent such conditions. MATERIAL AND METHODS A group of 25 patients with 26 wrist injuries is presented. It included nine patients with isolated perilunate dislocations (34%), 11 patients with trans-scaphoid perilunate dislocations (44%),two with trans-radial trans-scaphoid perilunate dislocations (7%) and next two patients with trans-radial perilunate dislocations (7%). One patients had, in addition to perilunate dislocation, injury to the capitohamat joint with damage to both portions of the interosseous ligament (4%). One patient (4%) sustained a trans-scaphoid perilunate dislocation with injury to the scapholunate ligament, in which the proximal pole of the scaphoid was separated and interfered with dislocation reduction. RESULTS The correct diagnosis was made on early examination in 16 patients (62%), within a week of injury in four patients (15%), within a months of injury in two patients (8%) and even later in four patients (15%). The results of treatment evaluation based on the Wrightington Hospital Wrist Scoring System were excellent in 19%, good in 54%, satisfactory in 19% and poor in 8% of the patients. The poor result in one patient was due to necrosis of the lunate bone;the diagnosis of a perilunate dislocation was made within a month of injury. The poor results in the other patient were associated with complex regional pain syndrome. DISCUSSION Perilunate injuries of the wrist are quite frequent and although the treatment procedure is commonly known, its principles are not always obeyed. A good outcome is related to an early diagnosis and correct reconstruction of the injured structures. In our group, the diagnosis was made at the first examination in only 62% of patients and later than a week after injury in 23%. The patient in whom necrosis of the lunate bone developed had the diagnosis made at 1 post-injury month. Early reduction of bone structures and reconstruction of ligaments also contribute to good results. CONCLUSIONS Good outcomes in perilunate injuries depend on an early and correct diagnosis, an appropriate therapeutic procedure and an orthopaedic surgeon who has experience with management of such injuries. A deep knowledge of wrist kinetics is necessary for this therapy as not all injuries happen according to textbook descriptions. Key words: perilunate dislocation, carpal instability, damage to carpal ligaments.

Penis augmentation by application of silicone material: complications and surgical treatment.

BACKGROUND: Complications resulting from enlargement of the penis by applications of unknown types of silicone and mineral oils are well described. Surgical removal of the tissue altered by inflammation leads to the development of defects of various sizes, often circular from the glans penis to the scrotum. The options of subsequent surgical treatment described in literature are not very extensive. Most defects are managed with skin grafting, rarely V-Y advancement or bilateral scrotal flaps. METHODS: We present a 36-year-old patient after application of unknown silicone material into the penis for cosmetic enlargement. After the application developed severe inflammation with ulceration and necrosis around the penis. Conservative treatment was not effective, therefore, the infiltrated skin with subcutaneous tissue of the entire penis was surgically removed. The resulting defect was covered by implantation of the penis under the skin of the scrotum. RESULT: There were no complications in the postoperative course, pain that was present before the surgery immediately subsided. Skin suture healed completely within 14 days. Three months after the surgery the patient returned to normal sexual life. CONCLUSIONS: Implantation of the penis under the skin of the scrotum is a fast, safe and effective method that can treat most of the circular skin defects of the penis. Scrotal skin is thin, soft, elastic and creates abundant and good cover around the entire penis.

Nasal reconstruction in children with the combination of nasolabial and island flaps.

BACKGROUND: The reconstruction of the nose is one of the most complicated aesthetic-reconstructive procedures. The difficulty of the procedure lies is in the necessity for reconstruction not only to capture the very complicated, various shapes of the nose but also to preserve the function of the nose: to allow the patient to breathe through the nose. MATERIALS AND METHODS: 12-year-old girl had loss injury of the part of left wing of the nostril. We used the compound nasolabial flap with a small excess to resolve the mucosal and skin defect. One year after the first operation relief of natural transition of the new wing of the nostril and cheek was created with small island flap. RESULTS AND CONCLUSIONS: The reconstruction of a wing of the nostril in multistage procedures with combined nasolabial flap and island flap allowed us to perform precise modelation of the nostril wing with the natural transition to the cheek. An island flap with its scars creates the required contour of a nostril wing and prevents the collapse and flattening of the nostril wing externally.

Diagnostic dilemmas of infantile sarcoma of the forearm.

The authors present an interesting case of a suckling baby treated for forearm tumour. All the preoperative examinations including the imaging methods are documented, as are the surgical procedures and the final results. The case report is interesting not only because such surgery is infrequent but also due to the unpredictable progress of the final diagnosis statement. Before surgery the tumour was diagnosed as an organising haematoma; based on clinical and radiological signs the diagnosis subsequently rose to rapidly growing haemangioma or vascular malformation causing arm paresis and vascular supply disorder. The diagnosis was changed to angiolipoma during surgery. The final histopathological statement was: infantile fibrosarcoma. Despite the virtue of imaging methods and meticulous clinical examination, the surgical and histopathological findings are not necessarily absolutely identical. Having presented this particular case the authors would like to share their experience.

The efficacy of magnesium sulfate on resolving surgically provoked vasospasm of the flap pedicle in an experiment.

BACKGROUND: Vasospasm frequently accompanies manipulation of small vessels during free flap surgeries and replantations. The purpose of this experimental study was to evaluate the effect of magnesium sulphate on vasospasm provoked by surgical manipulation (axial tension) on the flap pedicle. This kind of surgical manipulation of the vessel cannot be studied in a clinical environment without putting flap viability into risk. MATERIAL AND METHODS: Forty male Wistar rats weighing around 300 g each were classified in two experimental groups (n=20 in each). In the treatment group (group A) Magnesium Sulphuricum 10% (Biotika, Czech Republic) was applied; the second group (group B) served as a control. The vasopasm was provoked by pulling the pedicle of the right groin flap of the rat. The peripheral blood perfusion of the flap was continuously measured using laser-Doppler recording. In the study group, magnesium sulphate was applied topically on the flap pedicle to relieve vasospasm, and duration of the vasospasm was compared to the control group. RESULTS: A statistically significant difference (p=0.01) between the groups was found. The duration of vasospasm was significantly shorter in the treatment group A. CONCLUSIONS: We conclude that in an experimental environment magnesium sulphate is effective in relieving surgically provoked vasospasm of the flap pedicle. This finding is in accordance with our clinical observations.

The effect of blood around a flap pedicle on flap perfusion in an experimental rodent model.

BACKGROUND: The vasospasm has been studied to a considerable extent in the neurosurgical literature. Little experimental and basic scientific literature about vasospasm of flap pedicle is available in the field of reconstructive microsurgery. The purpose of the study was to investigate the effect of presence of blood around the pedicle on a flap perfusion. MATERIAL AND METHODS: Blood flow through a right groin flap was continuously measured using Laser Doppler flowmetry on 40 male Wistar rats. A segment of the flap's pedicle was surgically cleared of adventitia and bathed in blood. The blood used was either collected from the tail of the rat (group A) or from the bleeding branch of the pedicle itself (group B). The differences between the signal amplitudes before and after exposure of the pedicle to blood were recorded. RESULTS: The presence of blood around the pedicle resulted in a significant decrease in perfusion of the flap in both groups. However, no significant differences in the duration of impaired blood flow between the groups were observed. CONCLUSIONS: In conclusion, the presence of blood around the vascular pedicle may cause a significant decrease in the perfusion of a flap, while the origin of the blood does not appear to be an important factor.

"Coagulum suction": a simple trick for the reduction of postoperative hematoma associated with facelift.

BACKGROUND: Facelift is currently one of the most requested procedures among consumers of aesthetic plastic surgery. Like any operation, it is accompanied by a variety of potential complications, with postoperative bleeding probably the most frequent. Hematomas can cause hyperpigmentation,contour changes due to subcutaneous scarring, prolongation of healing, and necrosis of the skin flap. The most common treatment is manual expression of the blood coagula. Needle aspiration sometimes cannot be used because of the viscosity of the coagula. METHODS: Seven patients underwent a new method of hematoma removal from wounds. One to two sutures were removed above the hairline under local anesthesia and a short liposuction cannula, 2.5 mm in diameter and 10­15 cm in length with one or two openings, was used for coagulum suction. RESULTS: All treated patients had the hematoma suction procedure without complications and with satisfactory outcomes and no subsequent bleeding. CONCLUSION: Coagulum suction is a simple and fast method that can shorten the recovery following a facelift.This method cannot replace surgical revision in cases in which there is substantial and/or persistent bleeding.However, it can reduce hematomas that are large enough to delay healing and interfere with convalescence, yet too small to warrant surgical revision.

Reconstruction of defect after radical vulvectomy by the use of four-flap local transfer--a case report.

Malignant vulvar tumors must be treated by radical removal of the tumor as well as a sufficient amount of surrounding healthy tissue. The resulting defects can be resolved by skin transplants, local transfers, skin flaps, muscle flaps or free tissue transfers. We describe the case history of a patient who underwent radical vulvectomy for a malignant tumor with immediate reconstruction by local flaps from the area of inner thighs and mons pubis. The advantages and disadvantages of this method are compared to other reconstructive surgery methods.

Primary reconstruction of arterial supply in the palm after an injury: a case study.

The authors present a case study of a patient with ischemic subtotal hand amputation in the palm. They describe an option to primarily reconstruct the arcus palmaris superficialis and common digital arteries by using a venous graft from the vena saphena magna with its several branches.

Clinical anatomy of the dorsal venous network in fingers with regard to replantation.

The arterial system of fingers is anatomically well described, and so, usually no difficulties arise during its preparation and the making of anastomoses in replantation surgery. Difficulties may occur, however, during manipulation in the dorsal vascular bed of fingers, known only as a random venous network. There are minimal references to its existence and the location of its valvular apparatus. Using a microscopic preparation, a contrast staining, and a histological assessment, topographic relations and the course of veins of the dorsal venous network, as well as the existence and location of their valvular apparatus, was investigated on 72 three-phalanx fingers. The specimens were either harvested from fresh cadavers or traumatically amputated. We found that veins of rather significant caliber predominantly run along the dorsal aspect of the finger on both the radial and ulnar sides above the proximal phalanx of three-phalanx fingers. Proximally, venous systems of respective neighboring fingers connect in the interdigital space. The valvular apparatus was found at all levels ranging from metacarpophalangeal joints to the distal phalanx. The valves were always located distally from the confluence of two veins. Aside from this confluence, the existence of valves was not observed. The exact description of architecture of this venous system, in practice, contributes to faster orientation, better preparation, and the creation of safer anastomoses of these structures, and thus, to an increased success of replantation.