Revisitation of the vascular anatomy of the lumbrical and interosseous muscles.

Functional outcome after transmetacarpal replantations and revascularizations is discouragingly poor and often associated with a high incidence of intrinsic-related complications. In order to explore the hypothesis that intrinsic muscle ischemia may play a significant role, we revisited the vascular anatomy of the lumbrical and interosseous muscles. Six fresh-frozen cadaver hands were injected with latex-barium sulfate, and dissections were performed focusing on the contributions of the deep and superficial palmar arches and their branches to the intrinsic muscle vasculature. We found that the lumbrical muscles are supplied from both their volar and dorsal surfaces by both the superficial and deep palmar arches in both axial and segmental fashions. The dorsal and volar interossei receive their major blood supply from the deep arch and metacarpal arteries without any distinct pattern of axial or segmental vessels. These minute vessels cannot be repaired and are not reconstituted even with arch reconstruction. Moreover, with injuries distal to the arch, dissection of the digital arteries further disrupts this blood supply. These anatomic findings may have significant implications in clinical replantation and revascularization.

Replantation and revascularization at the transmetacarpal level: long-term functional results.

Thirteen consecutive transmetacarpal replantations and revascularizations in 12 patients were reviewed retrospectively. Ten patients (11 hands) sustained crush injuries, 1 withstood an explosive blast, and 1 suffered a guillotine amputation. Nine revascularizations (1 thumb and 31 fingers) and 4 replantations (1 thumb and 16 fingers), including bilateral procedures in 1 patient, were performed. Forty-four of 49 replantable digits (90%) were salvaged. Ten patients (11 hands) required secondary surgery (mean, 4.5 procedures per hand), 29 of 49 (60%) for tendon and joint scarring and 7 of 20 (14%) for nonunions or malunions. Range of motion averaged 109 degrees per digit. Intrinsic muscle function and pinch and grip strengths were weak or absent. Recovery of sensibility was poor. According to Chen et al.'s grading system of functional return, 4 (31%) were grade II, 4 (31%) were grade III, and 5 (38%) grade IV. The follow-up period ranged from 2.5 to 11 years. Only 1 patient resumed his prior occupation (as supervisor); 2 were permanently disabled, 3 pursued new and unrelated occupations, 2 were still in therapy, and 4 were lost to late follow-up evaluation. None of the manual laborers (11 patients) were able to return to their preinjury livelihood. Despite these discouragingly poor results, all patients were satisfied with the surgery.

Zone II flexor tendon repair: effects of vitamins A, E, beta-carotene.

Ninety-six adult Leghorn chickens each had the flexor profundus tendon in each middle toe sharply divided in Zone II with immediate repair (pentobarbital, ketamine anesthesia). Animals were then randomly assigned to receive unsupplemented standard chick chow or the chow supplemented with vitamin A (150,000 IU/kg chow), Vitamin E (1000 IU/kg chow), or beta-carotene (90 mg/kg chow). Eight animals from each of the four groups were examined at 7, 30, or 45 days post repair. After sacrifice, in situ composite wound breaking strength was measured in the amputated toe by constant speed tensiometry. Vitamin A-supplemented animals demonstrated breaking strength more than double that of control at each postoperative test day, while those animals receiving supplemental Vitamin E had breaking strength less than half that of control at Day 7 and Day 45. These results are statistically significant. Tensiometry curves differed markedly at all time points among the groups: Vitamin A curves being broader, higher, and having more spikes. These differences in the tensiometry curves, both qualitative and quantitative, may be due to differences in intrinsic tendon healing or to differences in adhesion formation or a combination of both. beta-Carotene supplementation had modest effect. We conclude that supplemental dietary vitamin A increases the breaking strength of composite tendon wounds and that supplemental dietary vitamin E decreases it.

Liaison consultation psychiatry with patients who have replantation surgery to the upper limb.

Thirty-eight patients who had replantation surgery to the upper limb were studied and findings, case vignettes and specific liaison-consultation issues are presented. The assessment of the patient for pre-existing psychopathology, such as drug and alcohol abuse and personality abnormalities, is emphasised; the possibility of the amputation having been a deliberate, self-inflicted act is noted; and the roles of pre-accident stress and emotional conflict are discussed. Data concerning adverse post-operative emotional reactions are presented and body-image changes, including the disruption to body integrity and the reintegration of the bodily part, are described. The psychological aspects of replantation surgery are compared to other forms of surgery, in particular amputation and renal transplantation.

Psychological reactions and processes following replantation surgery: a study of 50 patients.

Fifty consecutive patients admitted for replantation surgery received a psychiatric evaluation. In 28 percent of the patients there was evidence of preaccident psychopathology. Fifty-four percent of the patients reported a recent stressful life event predating the accident. Fifty-four percent of the patients were assessed as having an adverse postoperative emotional reaction. The presence of preaccident psychopathology, evidence of family dysfunction, and a history of a recent stressful life event were positively linked with an adverse postoperative emotional reaction. In addition, patients with hand or arm replants were significantly less likely to require a psychiatric intervention than patients with leg replants. The psychological processes pertaining to the replantation journey are described in five stages: the preaccident period, the initial response, the stage of uncertainty, the recognition of loss, and acceptance and reintegration. Finally, the role of a liaison psychiatrist on a replantation unit is outlined and further research is strongly urged.

Replantation of amputated parts of the penis, nose, ear, and scalp.

The primary restoration of traumatically amputated digits is now routinely possible through the use of microvascular and microneural surgical techniques. The anatomy of the scalp, penis, ear, and nose makes them suitable subjects for application of these techniques. It has been the belief of many authors, as summarized by Grabb and Dingman, that venous congestion is the usual explanation for failure of replanted tissue without microsurgical repairs. Unsuitable veins of small caliber and venous congestion remain as the bane of the microsurgeon. The relative infrequency of these amputations makes it necessary to continue careful study of all reports regarding their microsurgical replantation. There is every reason to believe that increased surgical experience will result in more favorable outcomes.

The parasternal paddle: a modification of the pectoralis major myocutaneous flap.

A modification of the pectoralis major myocutaneous flap has been described for head and neck reconstruction. The flap uses the skin overlying the sternum and parasternal area and may extend across the midline to the contralateral internal mammary perforators. The flap has been uniformly reliable in our experience. It is thin and easy to elevate, and donor-site morbidity is minimal. This flap is rapidly becoming our first-choice for head and neck reconstruction.

Growth in revascularized bone grafts in young puppies.

The results of microvascular transfers of growing ulnas in puppy forelegs have been studied. These transfers were carried out both heterotopically and orthotopically. The growth in the revascularized bone grafts has been compared to that in heterotopic, nonvascularized ulna transfers and to normal ulnar growth. The growth in the vascularized bone grafts was significantly greater than in the nonvascularized grafts, but significantly less than in normal ulnar growth. A metaphyseal contribution to the blood supply of the growing portion of long bones is suggested.

How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs.

The supplying vessels of microvascular free flaps in pigs were ligated at various intervals after transfer in order to study the revascularisation from the recipient bed. At 8 days of later survival occurred. Earlier, although necrosis was not inevitable, the results were unpredictable.

The versatile gastrocnemius myocutaneous flap.

The medial and lateral gastrocnemius myocutaneous flaps are described. Their usefulness, as direct flaps without a delay, in reconstruction of the lower extremity is described. In our practice, this flap has supplanted the cross-leg flap for most reconstructions in the lower extremity.

Intraoral reconstruction in head and neck cancer surgery.

Numerous techniques are available to resurface the oral cavity. These range from the very simple and straightforward to the very difficult and complex. Certainly for small lesions, local excision and direct approximation of mucosa is all that is necessary. For larger defects, particularly those which will require some other form of reconstruction, additional tissue must be brought into the operative defect. For superficial excisions, skin or mucosal grafts are adequate to resurface the mouth. For areas of extensive resection, flaps of some type are required. The use of local random flaps, regional arterialized flaps, and myocutaneous flaps have been described. The decision for their use must be as individual as each patient. Free flap transfer has specific theoretical benefits. The advantages and disadvantages of each technique have been presented and, it is hoped, will allow the reconstructive surgeon greater latitude in selecting a technique of reconstruction.

Clinical applications of free flap transfer in the burn patient.

Free microvascular flap transfer is indicated in situations in which flap coverage is required and no local flap is available. The technique of transfer of a groin flap based on the superficial circumflex iliac vessels was described. The procedure has been applied to two patients with acute electrical burns with extensive soft-tissue loss, three patients with scar contractures, and one with osteoradionecrosis. Satisfactory results were achieved in all patients. The procedure is contraindicated if recipient or donor vessels are abnormal or inadequate, and in the face of fulminating infection, general debility, and obesity. With scrupulous attention to indications and contraindications, the procedure is safe, reliable, and a valuable addition to the surgeon's armamentarium.