Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers.

Microsurgical toe transfer is an established procedure for functional reconstruction of fingers. However, even if the functional loss is minimal, the fingertip defect is often a large problem for patients for not only functional reasons but also aesthetic reasons. In these patients, although the normal appearance of the fingertip is very important, total toe transfer is not acceptable because of resection of an entire toe. With this background, partial toe transfer techniques have greatly progressed. On the other hand, various types of innervated finger flaps also have been developed in hand surgery. Based on this progress, we developed the combined technique of innervated finger flaps in the hand and osteo-onychocutaneous flaps from the toe. This technique provides better aesthetic results in fingertip reconstruction, thus broadening the indications for vascularized nail grafts. We have now experienced 60 flaps in partial toe transfer. In this report, a review of 60 consecutive flaps is presented, and the indications, technique, and postoperative treatment are discussed.

Salvage of fingertip amputated at nail level: new surgical principles and treatments.

In this study, a new classification of fingertip amputation based on the surgical treatment is reported. Specifically, the necessity for special procedures to prevent venous congestion in fingertip replantation at the nail bed level was studied. There are some reports of successful replantations without venous anastomoses. In order to avoid technical factors, clinical cases operated on by a single surgeon were evaluated to determine what treatment is necessary for amputations at various levels to avoid necrosis due to venous congestion. During the 5-year period from October 1987 to October 1992, 150 replantations in 137 patients were performed, including 49 fingertip replantations in 45 patients who were operated on consecutively by a single surgeon. The distal phalanx (DP) of the finger was classified as zone DP-I, IIA, IIB, and III from distal to proximal. This classification was based not only on the amputation level but also on the difference in surgical treatment. For amputations of zone DP-I, which extends from the fingertip to the most distal dividing point of the digital artery, the amputated fingertip is attached without vascular anastomosis and the whole finger is wrapped in aluminium foil and cooled in ice water for 3 days. For amputations of zone DP-IIA and IIB, anastomosis of the digital artery is performed in the central portion of the palmar region of the finger, but Kirschner wire fixation is not performed so as not to disturb the venous drainage through the medullary cavity. For amputations of zone DP-IIA, special treatment is not necessary for venous congestion, and for those of zone DP-IIB partial resection of the nail is done if necessary. For zone DP-II amputations, venous anastomosis must be performed for salvage. All patients were operated on according to the procedures based on this classification and final survival rate was 91.5%.

Long-term cryopreserved allogeneic nervous and vascular tissue transfers in monkeys.

Four adult Japanese monkeys were used. Donor tissues were harvested from the radial artery, saphenous vein and median nerve, 10 cm in length, and cryopreserved at -196 degrees C in a stepwise manner for long-term preservation for more than 6 months. After rapid thawing of the tissue, the allogeneic tissue transfer was performed of the radial artery to the radial artery, the saphenous vein to the ulnar artery and the median nerve to the median nerve between male and female monkeys. After one year follow-up, angiography was performed and the transferred tissue was harvested for scanning electron microscopic examination and histological examination. As a result, the allogeneic artery in the radial artery was completely patent with no stenosis, whereas there was obstruction of the allogeneic vein in the ulnar artery. Good axonal recovery of the median nerve was observed on histological examination. The cellular structure of neurovascular tissue can be maintained even after long-term cryopreservation. The antigenicity of tissue may be reduced significantly by being frozen, and cryopreserved allogeneic artery can be transferred successfully without the use of immunosuppressive agents. In this report, clinical aspects and the great potential of allogeneic neurovascular tissue transfer, especially in combination with arterial transfer, using cryopreservation are discussed.

Syndactylic toe transfer for fingertip reconstruction.

In the case of multiple fingertip reconstruction requiring toe transfer, double toes can be elevated in the syndactylic fashion with a single vascular pedicle for transfer, followed by separation a few weeks later. The biggest advantage of this procedure is that the problem of limitation of recipient arteries for multiple toe transfer is solved. We reconstructed fingertips of three patients by this procedure with three variations based on combinations between the wrap-around flap and whole-toe transfer. All three patients survived completely and achieved an aesthetically pleasing result. This report introduces the concept and technique of the syndactylic toe transfer for fingertip reconstruction.

Nasal reconstruction using free temporoparietal fascial flap transfer (Upton's method).

Reconstructive surgery for severe nasal deformity after radical operation of the maxillary antrum was performed by free temporoparietal fascia transfer to the nasal membrane, followed by secondary-rib cartilage grafting. Correction of nasal deformity caused by severe scar contracture and tissue defect in the nasal cavity has been considered difficult. However, skin grafting with temporoparietal fascia transfer to the nasal membrane can make it possible to perform cartilage grafting without exposure. This method should be nominated as a useful procedure for correction of severe nasal deformity caused by nasal membranous scar contracture.

Secondary correction of the bilateral cleft lip nose by excision of the columellar forked flap and nasal remodelling with reverse-U flaps: a preliminary report.

Although the forked flap procedure has been widely used as a technique to lengthen the columella in the bilateral cleft lip deformity, often the results are unfavourable. We describe a technique to achieve a more natural shape, in which the unsatisfactory forked flap is excised and the columella is reconstructed by mobilization and rotation of nasal skin, combined with bilateral reverse-U flaps. Five consecutive patients who underwent this secondary correction procedure are presented.

Use of the double-layered free temporal fascia flap for upper extremity coverage.

Two layers of fascia exist in the temporal region, the temporoparietal fascia and the deep temporal fascia. Both can be elevated on a single vascular pedicle based on the superficial temporal artery, the double-layered temporal fascia flap. In our study, six patients who underwent upper limb coverage using the double-layered temporal fascia flap are reviewed, and the versatility of this thin flap is discussed.

Extended palmar advancement flap with V-Y closure for finger injuries.

The technique of using volar advancement flaps with V-Y closure to the fingers is described. It is possible to perform volar flap advancements up to 15 mm and use V-Y closures in the distal palm, avoiding a skin graft. This method is based on knowledge of the vascular anatomy of the finger dorsum, to avoid devitalising dorsal skin. This method was applied to 14 fingers of 13 patients including finger amputations, claw nail deformities, and skin defects of the middle phalanx. Favourable results were observed.

Experimental study of cryopreserved allogeneic transfer of vessel: preliminary report.

It has long been known that the antigenicity of tissues is depressed when they are kept at a very low temperature. In this study, Lewis rats and Brown Norway (B.N.) rats were used because these species are significantly dissimilar at the major histocompatibility complex (MHC) Femoral arteries were harvested from Lewis rats, frozen while lowering the temperature in a stepwise fashion to -70 degrees C. After three weeks of cryogenic storage, the arteries were transplanted into Lewis and B.N. rats. At various times from the first to the twelfth week after surgery, grafted vessels were observed, and pathological and electron microscopic studies were carried out. The vessels were found to be in good condition at the end of the 12 week observation period. These results strongly suggest that prolonged cryopreservation of vessels makes allotransplantation without immunosuppression possible.

Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction.

A simple method using ice-water and aluminium foil for enhancing composite graft survival is reported. Cooling the entire recipient site retards cellular degeneration in the graft until neovascularisation occurs. The success of this technique in nasal reconstruction using auricular chondrocutaneous tissue and nonmicrosurgical fingertip reattachment is presented. The potential application to thicker skin grafts is also discussed.

A combination surgical method for preaxial polydactyly of the foot.

A combination procedure was performed on the medial two toes in a 6-month-old child with preaxial polydactyly of the left foot. The first toe had the appearance of a cosmetically intact great toe, but the second toe had better function. A method to combine the advantages of these two toes was therefore applied, with favorable results seen at 1.5 years after surgery.

Successful upper labial replantation after 17 hours of ischemia: case report.

This report presents successful replantation of the upper lip after 17 hours of ischemia. In spite of successful venous anastomoses, the postoperative use of leeches was necessary because of severe congestion. However, sensory and functional recovery was excellent.

Complete congenital duplication with incomplete separation of a lower extremity.

A case of a boy with complete duplication of the lower extremity and separation below the lower leg was described. Although x-ray examination revealed no femur, operation revealed a cartilage expected to become the femur in the future. A classification of duplication and separation of the lower extremity is proposed. The method and course of treatment in the present case were described in detail, including the application of tissue expanders on the deformity of the knee joint accompanied by a shortening of the sciatic nerve.

Transplantation of long-term cryopreserved allocutaneous tissue by skin graft or microsurgical anastomosis: experimental studies in the rat.

A step-wise method of freezing cutaneous soft tissue containing vessels to -196 degrees C for permanent preservation was developed. The methods of embryo cryopreservation were modified for soft-tissue preservation. Cutaneous tissue obtained from the abdominal wall of a Lewis rat was preserved for more than 3 weeks by this method and was then transplanted to a Brown Norway rat with the largest difference in major histocompatibility complex. Rejection reaction against the epidermal layer was markedly delayed, followed by a decrease in antigenicity of the dermis, with survival of the majority of the tissue for more than 6 months. A concept of artificial skin was formed based on these experimental results. A skin flap from the abdominal wall with a vascular pedicle consisting of the femoral artery and vein was similarly preserved and transplanted by vascular anastomosis. This transplant was made viable over a long period through the additional use of an immunosuppressant. Replantation of a rat hindleg also was successfully accomplished by using a skin flap from the abdominal wall with a vascular pedicle consisting of the femoral artery and vein, which had been cryopreserved for more than 3 weeks. These results with 65 pieces in five different treatment groups indicate the reliability of this method of preservation in maintaining the tissue in a state adequate for transfer without loss of viability over a long period. The applicability of this method of allograft preservation to the field of free-tissue transfer combined with microsurgical technique may introduce a new concept to the field of reconstructive surgery in the future. According to the results of the present experiment, the great potential for clinical application is described for the deepithelialized cryopreserved allocutaneous flap transfer.

A versatile one-stage neurovascular flap for fingertip reconstruction: the dorsal middle phalangeal finger flap.

The dorsal middle phalangeal finger flap is an extremely reliable flap that is indicated for fingertip injuries which require sensory reconstruction. This flap originates from the dorsum of the middle phalanx of the finger and is elevated with a vascular pedicle of the digital artery and the dorsal branch of the digital nerve. After transfer of the flap to the injured site, epineural neurorrhaphy is done between the digital nerve and the dorsal sensory branch of the flap. This flap can be thought of as an island flap of the innervated cross-finger flap that provides excellent sensory recovery and aesthetic improvement. We used this flap in a series of eight consecutive patients and were able to follow up seven patients for longer than 6 months (mean follow-up time 10.7 months). All patients achieved measurable two-point discrimination, with an average of 4.9 mm in the moving two-point discrimination. In this study, we report our consecutive series of the dorsal middle phalangeal finger flap and its versatile utility.

Cryopreserved allogeneic vessel and nerve grafts: hind-limb replantation model in the rat.

The authors have previously reported the permanent storage of skin and cutaneous flaps using cryopreservation. In this study, replantation of the hind limb was performed in rats, using an allogeneic femoral artery, vein, and sciatic nerve which had been cryopreserved for more than 3 weeks. Femoral arteries, veins of 2 cm in length, and sciatic nerves of 1.5 cm in length from Lewis rats were cryopreserved for more than 3 weeks to decrease antigenicity. The hind limb of a Brown Norway rat was completely amputated at its mid-length and the cryopreserved artery, vein, and nerve were interposed in the anastomosis of the femoral artery, vein, and sciatic nerve. Immunosuppressants were not used. Hind limbs were replanted in six rats, and all cases survived. Toe spread and gait-foot analysis revealed good results at 3 months postoperatively. Excellent axonal regeneration was observed in the pathologic examination of the sciatic nerve 1 cm distal to the transfer. This report introduces a long-term storage method for vessels and nerves and extends the possibilities for clinical use of cryopreserved vessels and nerves, using replantation in a rat model.

Clinical characteristics of vascular leiomyoma of the upper extremity: report of 11 cases.

Clinical features of vascular leiomyoma of the upper extremity which have not been described or have been described incorrectly are documented with a report of 11 consecutive cases seen within the past 11 years. All patients were followed without recurrence or surgical morbidity. Vascular leiomyoma has been described as a painful nodule found more frequently on the extensor surfaces, but in our experience spontaneous or paroxysmal pain is exceptional and the tumour tends to be located on the volar surface when it is in the hand. In the digit, they tend to be found at the base away from the midline, and not seen distal to the DIP joint.

Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation.

The cutaneous vascular anatomy of the finger dorsum was studied by dissection under loupe magnification of 71 fingers from 19 preserved cadaver hands. All specimens were injected with red latex or epoxy resin through a cannula in the brachial artery to identify the small vessels. The finger dorsum was supplied by the terminal branches from the dorsal metacarpal artery around the metacarpophalangeal joint. Other areas were nourished by the dorsal cutaneous branch from the proper palmar digital artery. There were two or three dorsal branches in the proximal phalangeal region and two in the middle phalangeal region. On the basis of these findings, we have developed a new method for one-stage reconstruction of finger pulp defect that restores sensation. Our innervated reverse vascular pedicle digital island flap includes the dorsal digital nerve and the proper palmar digital artery as a retrograde vascular pedicle. We have used the technique in three patients, with excellent results. The advantage of this procedure is that it provides a one-stage reconstruction of the pulp defect and restores sensation. The disadvantage is that the procedure requires neurorrhaphy.