Approach to Lymphedema Management.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

High-pressure injection injury: a case report and systematic review.

High-pressure delivery devices for paint and other substances can lead to severe injuries of the hand without immediate surgical debridement. We present a case of a high-pressure paint gun injury treated surgically with full resolution of function. A systematic review of the literature details outcomes of similar injuries.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

BACKGROUND: Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases. METHODS: Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap. RESULTS: All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications. CONCLUSION: The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Microsurgical ear replantation-is venous repair necessary?-A systematic review.

BACKGROUND: A common postoperative observation after microsurgical ear replantation has been venous congestion necessitating alternate modes of decongestion, frequently in conjunction with blood transfusion. A comprehensive literature search was performed to assess the relationship between mode of vascular reconstruction and postoperative outcome as well as postoperative transfusion requirement after microsurgical ear replantation. METHODS: The search was limited to cases of microsurgical ear replantation following complete amputation. Only articles published in English and indexed in PubMed were included. RESULTS: The initial search retrieved 285 articles, which was narrowed down to 40 articles reporting on 60 cases that matched the aforementioned criteria. Reconstruction of the arterial and venous limb (Group 1) was performed in 63.3% of patients and artery-only anastomosis (Group 2) was performed in 31.7%. Among measurable outcomes, only the duration of surgery was significantly different between groups (2.6 hours longer in Group 1 than Group 2; P = 0.0042). CONCLUSION: In light of contemporary data demonstrating successful artery-only ear replantation, replantation should not be abandoned when unable to establish venous outflow microsurgically. © 2015 Wiley Periodicals, Inc. Microsurgery 36:345-350, 2016.

Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage.

OBJECTIVES: To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage. DESIGN: Case series with retrospective review of outcomes with at least 6-year follow-up. SETTING: Academic tertiary care medical center. PATIENTS: Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005. INTERVENTION: Flap reconstruction and Ilizarov bone transport. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation. RESULTS: Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation. CONCLUSIONS: The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications.

BACKGROUND: The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous flap blood supply provide an autologous donor area with qualities favorable to microvascular breast reconstruction. The flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection, and has a consistent blood supply. The characteristics and skin color of the flap allow for immediate nipple-areola complex reconstruction in skin-sparing mastectomy. METHODS: From 2004 to 2007, the authors performed 32 free inner thigh flap microvascular breast reconstructions after mastectomy for breast cancer in 20 patients, in both delayed and immediate settings. RESULTS: All flaps survived without any soft-tissue loss or fat necrosis. Complications were a single take-back for venous thrombosis with salvage, donor-site skin breakdown in eight flaps, and five seromas. There was no functional loss at the donor site, and all patients resumed normal activity. CONCLUSIONS: Transverse upper gracilis musculocutaneous flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scarring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity.

BACKGROUND: With high success rates, flap survival should no longer be the sole criterion in judging success in dorsal hand and wrist reconstruction. The authors sought to determine the best flap for dorsal hand coverage in terms of aesthetic appearance, donor-site morbidity, and minimization of revision surgery. METHODS: A retrospective review of all free flaps for dorsal hand and wrist coverage from 2002 to 2008 was performed. Flaps were divided into four groups: muscle, fasciocutaneous, fascial, and venous flaps. Outcomes assessed included need for debulking, blinded grading of aesthetic outcomes, and flap and donor-site complications. RESULTS: A total of 125 flaps were performed with no flap losses. There was no difference in partial loss or infection among the different flap groups. There was a significant range in the need for future debulking procedures, with debulking required in 67 percent of fasciocutaneous, 32 percent of muscle, 5.8 percent of fascial, and 0 percent of venous flaps. There was a significant difference in aesthetic outcomes: venous flaps had the best overall aesthetic outcomes; fascia and muscle flaps scored equally in terms of overall aesthetics, color, and contour match; and fasciocutaneous flaps had significantly worse aesthetic, contour, and color match results compared with all other flap types. Fasciocutaneous flaps had greater donor-site morbidity in terms of need for skin grafting and wound breakdown. CONCLUSION: The aesthetic outcome of dorsal hand reconstruction is dependent on flap choice, with statistically significant differences in revision surgeries and aesthetics among flap types.

Standardized protocol for artery-only fingertip replantation.

PURPOSE: Artery-only fingertip replantation can be reliable if low-resistance flow through the replant is maintained until venous outflow is restored naturally. Injuring the tip of the replant to promote ongoing bleeding augmented with anticoagulation usually accomplishes this; however, such management results in prolonged hospitalization. In this study, we analyzed the outcomes of artery-only fingertip replantation using a standardized postoperative protocol consisting of dextran-40, heparin, and leech therapy. METHODS: Between 2001 and 2008, we performed 19 artery-only fingertip replants for 17 patients. All patients had the replanted nail plate removed and received intravenous dextran-40, heparin, and aspirin to promote fingertip bleeding and vascular outflow. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored by neovascularization. We used medicinal leeches and mechanical heparin scrubbing for acute decongestion. By postoperative day 6, bleeding was no longer promoted. We initiated fluorescent dye perfusion studies to assess circulatory competence and direct further anticoagulant intervention if necessary. The absence of bleeding associated with an initial rise followed by an appropriate fall in fluorescent dye concentration would trigger a weaning of anticoagulation. RESULTS: All of the 19 replants survived. The average length of hospital stay was 9 days (range, 7-17 d). Eleven patients received blood transfusions. The average transfusion was 1.8 units (range, 0-9 units). All patients were happy with the decision to replant, and the cosmetic result. CONCLUSIONS: A protocol that promotes temporary, controlled bleeding from the fingertip is protective of artery-only replants distal to the distal interphalangeal joint until physiologic venous outflow is restored. The protocol described is both safe and reliable. The patient should be informed that such replant attempts may result in the need for transfusions and extended hospital stays, factors that can help the physician and patient decide whether to proceed with replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bilateral breast reconstruction: the simultaneous use of autogenous tissue and identical twin isograft.

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.

Microsurgical reconstruction of the burned hand.

Although most thermal injuries to the hand can be successfully managed with excision and grafting, deeper injuries may require microsurgical techniques to provide stable, durable coverage and the optimal functional result. In delayed reconstruction, thin pliable flaps can be used to resurface the hand or allow for contracture releases. Proper patient and procedure selection are critical to the success of microsurgical reconstruction.

Patterns in blast injuries to the hand.

Blast injuries to the hand are not just a wartime phenomenon but also quite common in rural communities throughout northern California. The purpose of this study is to review our experience with blast injuries in the community and review the most common patterns in an attempt to identify the pathomechanics of the hand injury and the reconstructive procedures that are required. This is a retrospective study of blast injuries to the hand treated between 1978 and 2006. Medical records, X-rays, and photos were reviewed to compile standard patient demographics and characterize the injury pattern. Explosives were classified based on their rate of decomposition. Reconstructive solutions were reviewed and characterized based on whether damaged tissues were repaired or replaced. Sixty-two patients were identified with blast injuries to their hand. Patients were predominantly male (92%) with an average age of 27 years. Firecrackers were the most commonly encountered explosives. Thirty-seven patients were identified as holding a low explosive in their dominant hand and were used for characterization of the injury pattern. The apparent pattern of injury was hyperextension and hyperabduction of the hand and digits. Common injuries were metacarpophalangeal and interphalangeal joint hyperextension with associated soft tissue avulsion, hyperabduction at the web spaces with associated palmar soft tissue tears, and finger disarticulation amputations worse at radial digits. Given the mechanisms of injury with tissue loss, surgical intervention generally involved tissue replacement rather than tissue repair. Blast injuries to the hand represent a broad spectrum of injuries that are associated with the magnitude of explosion and probably, the proximity to the hand. We were able to identify a repetitive pattern of injury and demonstrate the predominant use for delayed tissue replacement rather than microsurgical repair at the acute setting.

Resurfacing of a complex upper extremity injury: an excellent indication for the dorsal thoracic fascial flap.

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.

Creation of a four-joint-digit after second toe to digit transplantation: restoration of form and function.

The authors describe the non-orthotopic insertion of an Ascension two-piece pyrocarbon proximal interphalangeal joint at the osteosynthesis level of bilateral toe-to-digit transplantations in an attempt to restore both anatomic length and composite fist formation after traumatic multidigit loss. The non-orthotopic joints provided an additional 30 and 35 degrees of stable flexion to the reconstructed index and longs digits enabling the patient to form a composite fist. There was no evidence of joint instability or loosening. Total active motion was 240 and 235 degrees at the index and long fingers, respectively. Creation of two four joint fingers by the addition of non-orthotopic joints in toe-to-digit reconstructions successfully restored form and function after multidigit loss.

Index finger salvage with replantation and revascularization: revisiting conventional wisdom.

Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty-eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty-three replants/revascularizations survived (100%). Total active motion was 170 degrees in zone 1, and 133 degrees for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided.

Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle.

Limb salvage techniques of traumatized extremities using free-tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6-28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and returned to independent ambulation. When performing free tissue transfer about the ankle, temporary spanning with a circular fixator is effective in preventing equinus deformity and provides a stable mechanical construct protecting the flap.

Partial muscle harvest: our first 100 cases attempting to preserve form and function at the donor site.

The authors report their first 100 partial muscle flaps as a strategy to preserve form and function of the donor site in muscle transplantation. Between 2003 and 2007, 62 partial superior latissimus (PSL) flaps and 38 partial medial rectus (PMR) flaps were transplanted for head and neck, upper and lower extremity, and chest wall reconstruction. All flaps survived. There were hematomas at the donor sites in two PMR cases. Form and function were preserved at the donor site in all cases. The PSL provided comparable muscle volume and pedicle length to the entire rectus abdominis muscle. An additional benefit was its use as a functional muscle. The PMR flap provided comparable muscle volume to the gracilis muscle. An additional benefit was a much longer vascular pedicle. Small to moderate sized flaps can be harvested from the fabric of the latissimus dorsi and rectus abdomenis muscles and be reliably transplanted. When positioned at the superior edge of the latissimus or medial edge of the rectus muscle, adequate blood flow and innervation to the residual muscle result in preservation of form and function at the donor site. The benefits of muscle transplantation can be realized without the associated morbidity of muscle harvest.