The anatomy of the lower serratus anterior muscle: a fresh cadaver study.

Forty fresh cadaver dissections were studied to determine variations in the anatomy of the lower portion of the serratus anterior muscle. In all cases, the lower three to five slips of the serratus anterior muscle were supplied by one to three branches from the thoracodorsal artery, the so-called serratus branches. Three vascular patterns were identified: type I with one branch (40 percent), type II with two branches (50 percent), and type III with three branches (10 percent). The mean dimensions of the lower serratus anterior flap were 18.0 x 9.0 cm (range 12.0 x 8.0 cm to 21.0 x 15.0 cm). The mean pedicle length was 11.3 +/- 2.8 cm (range 7.3 to 13.3 cm). A crow's foot landmark has been identified to facilitate flap dissection. This landmark marks the juncture of the long thoracic nerve and the dominant serratus branch. This juncture can be found at the superior border of the sixth or seventh rib. The lower serratus anterior flap is ideal for reconstruction of small to moderate-sized defects because of its flat, broad dimensions and its long vascular pedicle.

Surgical management of ulnar artery aneurysms.

In a ten-year review (1978 to 1988), ten ulnar artery aneurysms in nine male patients were studied. Blunt trauma led to 70%, penetrating trauma to 20%, and 10% had no history of trauma. Three cases were seen as asymptomatic palmar masses with brief antecedent histories of 4 weeks or less. Seven patients with aneurysms had persistent vascular hand symptoms for 6 weeks or longer. All seven symptomatic lesions proved to be sources of emboli. Diagnostic arteriography was done in all cases. Intraoperative digital plethysmography aided in operative decisions regarding the necessity for microvascular reconstruction. Five aneurysms were resected with end-to-end ulnar artery microvascular repairs, four resected without repair, and a single case treated with long-term anticoagulants. Follow-up, averaging 40 months, showed uniform improvement in vascular symptoms, with no loss of jeopardized tissues. Ulnar artery aneurysms, well studied preoperatively and intraoperatively, can be treated successfully with selective microvascular reconstruction.

Flap failure after microvascular free-tissue transfer: the fate of a second attempt.

In most cases, the loss of a free-tissue transfer is a disaster for both the patient and the surgeon. Seven patients received a second microvascular free-tissue transfer after loss of the first. The indications for free-tissue transfer included chronic osteomyelitis of the lower leg (four patients), acute traumatic defect of the leg (one patient), acute traumatic defect of the arm (one patient), and esophageal defect after surgical excision (one patient). In three patients, the interval between the first and second procedures was less than 2 weeks. The remaining four patients had their second free-tissue transfer performed 5 weeks to 21 months after the first. Six of the seven free flaps were successful. Two patients with venous obstruction occurring after the second free-tissue transfer were salvaged by reexploration. Partial loss of the flap was noted in one of these patients. It is concluded from this select group of patients that failure of a free-tissue transfer does not contraindicate a second microtissue transfer does not contraindicate a second microvascular free-tissue transfer.

Cleft earlobe repair.

This is a retrospective study of 9 patients who underwent a total of 11 repairs for cleft earlobe. Two repairs were performed using the simple technique, and 9 were repaired using the L-plasty technique. The mean follow-up was 5.5 months (range, 2-18 months). Both of the simple repairs were judged to have moderate notching along the inferior lobular border, and 1 of the 9 L-plasty repairs was judged to have a slight notching. There were no complications. We believe that the L-plasty technique offers a better cosmetic result in the repair of the cleft earlobe. This technique breaks the vertical component of scar contracture, resulting in a smooth lobular border. In addition, a variation on this technique allows for a simultaneous reduction of the lobule when indicated.

St. Clair Strange procedure: indications, technique, and long-term evaluation.

The pedicled ulnar nerve transfer (St. Clair Strange procedure) preserves the intrinsic blood supply to the transferred nerve and allows bridging of large defects in avascular, scarred wounds. We report our indications for this operation, describe the two operative stages, and report the results in seven patients. After operation progressive median nerve axonal growth in a proximal direction up the ulnar nerve was shown by a median nerve Tinel's sign. Five patients followed for a mean of 10 years achieved protective sensibility in the median nerve distribution. In two of the three patients in whom distal nerve repair was done to the median and ulnar nerve, protective sensibility also returned to the ulnar digits. Localization, stereognoses, and vibratory response was achieved in the majority of digits. All patients had active use of the hand, but none had meaningful two-point discrimination. No changes were found after a superficial radial nerve block excluded any radial nerve contribution. No intrinsic motor functional return was noted. Two patients are currently being followed.

Interpositional vein grafts to restore the superficial palmar arch in severe devascularizing injuries of the hand.

The use of an interpositional vein graft to restore inflow to the digits by recreating the superficial palmar arch is presented. This technique is best reserved for severe, devascularizing injuries to the hand, significant damage to the palmar vessels, and when they may a paucity of donor vein available.

Benign mixed tumor (pleomorphic adenoma) of the breast: ultrastructural study and review of the literature.

A patient is presented with a benign mixed tumor (pleomorphic adenoma) of the breast. There are 11 well-documented cases of this rare breast neoplasm. It is histologically and ultrastructurally identical to that seen in the salivary gland and follows a similar benign course. A central role of the ductal myoepithelial cell is proposed for the histogenesis of this tumor.

How to use a computerized data base for ward management.

As you well know, patient information must be collected, recorded, and communicated to attendings and other house staff on a daily basis. This tedious process can be improved with the use of a computerized data base. In this article, the authors discuss the ease with which this data base can be implemented and its various advantages.

Nerve regeneration through a synthetic microporous tube (expanded polytetrafluoroethylene): experimental study in the sciatic nerve of the rat.

Nerve grafts made of expanded polytetrafluoroethylene (PTFE) were used to bridge 10-mm gaps in the sciatic nerves of rats. The most prominent gross and histological finding was abundant neovascularization and capillary ingrowth through the microporous PTFE wall. Organized, myelinated nerve tissue was observed. After 4 months, regeneration through hollow PTFE tubes (N = 16) was equivalent to autogenous nerve grafts (N = 12) as measured by gastrocnemius muscle weights (P = 0.33). Nerve conduction velocity in the hollow PTFE tubes was 21.7 m/sec as compared to 50.6 m/sec in the control nerves (P less than 0.001).

Patency of synthetic microvenous conduits: an experimental study in the femoral vein of the rat.

A temporary arteriovenous fistula was used to enhance the patency of 1.5-mm expanded polytetrafluoroethylene grafts. A segment of polytetrafluoroethylene measuring 5.0 mm in length was interposed into the femoral vein of rats. In the control group (n = 4), no arteriovenous fistula was made and all were thrombosed at 30 minutes. In the experimental group (n = 18), the arteriovenous fistula was ligated after 2 days (n = 8), 14 days (n = 6), or not at all (n = 4). The animals were reexplored 40 to 70 days later, and all the grafts were found to be patent regardless of when the fistula was ligated (patency rate 100 percent). Light and scanning electron microscopy showed complete endothelialization. Presumably the arteriovenous fistula exposes the graft to a high-flow system, allowing a nonthrombogenic pseudointima to form which is later replaced by a true endothelium.

Effects of ileal interposition on body weight and intestinal morphology in dogs.

Interposition of a segment of terminal ileum into the proximal jejunum has been shown to cause weight loss and hypertrophy of the pancreas and intestines of rats. To further evaluate the potential of ileal interposition as an anti-obesity procedure, weight loss, liver histology and intestinal morphology were studied in normal adult mongrel dogs. A 40 to 45-cm segment of distal ileum was transposed isoperistaltically on its vascular pedicle to the proximal jejunum (n = 14). Control dogs (n = 4) underwent transection and reanastomosis without interposition. Interposition resulted in a mean weight loss of 3.9 kg or 16 percent of body weight, over a 12-week period compared to a mean gain of 2.6 kg (11 percent of preop.) in the controls (P less than 0.025). Liver histology (n = 3) showed minimal fatty infiltration in one dog. Grossly, the transposed ileal segment did not show any consistent elongation or thickening of the bowel wall. Microscopically, there was complete jejunalization of the mucosa of the ileal segment which was indistinguishable histologically from the adjacent jejunal mucosa. Because of the variability of the weight response (-8.6 to +0.9 kg), further studies are required to evaluate the potential of this experimental procedure to achieve weight loss.

Laceration of a mitral papillary muscle and the aortic root as a result of blunt trauma to the chest. Case report and review of the literature.

A case is presented of a steering wheel injury to the chest, in which the initial clue to significant cardiac injury was a new murmur and abnormal electrocardiogram. Precise preoperative echocardiographic evaluation revealed a combination of injuries consisting of (1) mitral incompetence secondary to partial laceration of a papillary muscle, (2) circumferential laceration of the aortic root contained by the adventitia, and (3) rupture of the pericardium. Operative correction of the mitral and aortic root lesions was performed 9 days after the injury. Twelve other cases of successful surgical correction of traumatic mitral incompetence are reviewed and compared.

One hundred percent patency of one-millimeter polytetrafluoroethylene (Gore-tex) grafts in the carotid arteries of rats.

Expanded polytetrafluoroethylene arterial interposition grafts with an internal diameter of 1.0 mm were placed in the carotid arteries of rats. At 2 weeks, 100% patency rate was achieved by the use of strict sterile technique in 23 rats. In contrast, only 1 out of 21 grafts remained open in rats operated using standard clean but nonsterile technique, 5% patency. All thrombosed grafts showed evidence of infection. Orally administered aspirin at therapeutic doses prolonged bleeding times in the rats but did not affect patency results in either group.