We reviewed the results of elbow and shoulder functions using nerve transfer after brachial plexus injury. There were 21 patients with an average age of 26.9 (15-68) years. Total palsy was noted in 11 patients, and upper palsy in 10 patients. Twelve patients were treated by intercostal nerve transfer, and 5 were treated by Oberlin procedure to reconstruct elbow function. Shoulder function was reconstructed simultaneously in 3 of 5 patients treated by Oberlin procedure using spinal accessory nerve to suprascapular nerve transfer. Free muscle transfer following Doi's method was performed in 5 total palsy patients to reconstruct the elbow and finger functions simultaneously, and in 2 patients with upper palsy to reconstruct elbow flexion alone. Four patients who underwent free muscle transfer had previously received treatment, such as intercostal nerve transfer, but the results were poor. The results of elbow function after Oberlin procedure and free muscle transfer were satisfactory (›grade 4 was achieved in all patients) in young patients while that of intercostal nerve transfer was unstable in our series. Useful shoulder function was reconstructed in all 3 patients after spinal accessory nerve to suprascapular nerve transfer.
Twenty-three patients with absent elbow flexion secondary to brachial plexus injury underwent nerve transfer using 1 or 2 fascicles of the ulnar nerve to the motor branch of the biceps muscle. Seven patients had root avulsion injury of C5 and C6; 12 had root avulsion injury of C5, C6, and C7; 1 had root avulsion injury of C5, C6, C7, and C8 and 3 had lateral and posterior cord injury with distal injury of the musculocutaneous nerve. The average reinnervation time for the biceps after surgery was 3.8 months. Seventeen patients were followed for longer than 1.5 years. Thirteen patients had biceps strength of M4, 2 patients had biceps strength of M3, and 2 patients had biceps strength of M2. Four patients experienced transient paresthesia in the small finger. Grip strength, and Semmes-Weinstein test in the small finger were measured before and after surgery. No loss of ulnar nerve function was noted after surgery.
Lip defects may result from trauma and resection of malignant tumors. The lips not only provide function in feeding but are important for speech and the maintenance of facial expression. Reconstructive surgeons have to consider how to reconstruct these functions. In this article, we describe the surgical techniques of functional lip reconstruction. When the amount of resected tissue includes the entire lip mass, reconstruction by a free flap should be considered. The most commonly used free flap is a radial forearm. The forearm flap can be used by sensate flap with attaching a sensory nerve. Furthermore, a forearm flap is usually transferred along with the palmaris longus tendon, and this tendon has been used for the suspension of the lower lip by suture to the perioral skin, periosteum, or remnant orbicularis oris muscle. However, the palmaris longus tendon graft is a so-called static reconstruction, in order to avoid downward distortion of the lower lip. Recently, lip reconstruction using the gracilis muscle was reported. By suturing the obturator nerve to the facial nerve, the gracilis muscle can move voluntary and work as the orbicularis oris muscle. However, to cover the gracilis muscle, a skin graft or other skin flap should be transferred. The sensation of the lip and oral surface is also important for feeding. The combination of innervated gracilis muscle and sensate forearm flap allows for the reconstruction of the dynamic function and sensations of the lip.
We report reconstruction for severe finger injuries using wrap-around flaps (WAFs) that include the second toes, distal second toe transfer, hemipulp flaps, arterialized venous flaps (aVF), free dorso-ulnar perforator flap (FDUPF), and free first dorsal metacarpal artery flap. We report the clinical outcomes and provide a discussion. This series included 37 fingers, from 32 men and 5 women ranging in age from 19-62 years, that sustained complete or incomplete amputations and crush injuries. WAFs were used for 16 fingers, distal second toe transfer for 3 cases, and hemipulp flaps for 7 fingers.FDUPFs were used for 5 fingertips, aVFs for 5 fingertips, and free dorsal metacarpal artery flap for 1 case, especially targeting reconstruction of the palmar soft tissues at the distal parts of the fingers, paying attention to both the esthetic appearance and function. All of the WAFs, the distal second toe transfers, hemipulp flaps, FDUPFs, and free dorsal metacarpal artery flaps survived. Superficial layer necrosis was observed in 1 case in which aVF was used. Our results suggested that WAFs were superior for the reconstruction of fingertips including nail reconstruction, from the points of view of both cosmetic appearance and functionality. For patients who do not want to undergo tissue transplantation from the foot, reconstruction using aVFs, which can be performed under conduction anesthesia, free first dorsal metacarpal artery flap, or using FDUPF, which have a small harvesting area, are also useful.
We investigated time-course sensory recovery after amputated digit replantation. Subjects were 10 patients with complete amputation of the distal phalanx of the finger undergoing replantation between September 2006 and September 2009 and could be followed for one year or longer. There were 9 males and one female, aged 18-64 years (mean: 46). No nerve suture was applied. We also investigated 3 patients after replantation of fingers completely amputated in Tamai's zone III in the same period. All 3 were male and aged 19-38 years (mean: 27). Bilateral nerve suture was applied in all 3. Semmes-Weinstein monofilament sensory tests were performed 3 and 6 months after surgery and every 6 months thereafter. In addition, relationships between the arterial reconstruction method (end-to-end anastomosis or vein graft), presence or absence of nerve suture, and severity of crush with sensory recovery were investigated. Sensory perception recovered with time, continuing one year after surgery in some patients. No significant difference due to the crush severity or arterial reconstruction method was noted. Sensory recovery was faster in Tamai's zone III cases receiving nerve suture than in the distal phalanx amputation cases, suggesting that earlier recovery is possible by applying nerve suture for Tamai's zone III amputation.
Free DIEP flaps and supercharged TRAM flaps have been widely used in breast reconstruction in recent years. Internal mammary vessels and main trunks of thoracodorsal vessels are chiefly selected as recipient vessels for microvascular anastomoses. The serratus anterior branch of thoracodorsal vessels are rarely reported as recipient vessels in breast reconstruction. Free DIEP flap and supercharged TRAM flap were transferred using the serratus anterior branch of thoracodorsal vessels as recipient vessels in patients. The age of the patients, irradiation history, the diameter of recipient vessels and flap vessels, and survival rate of flaps were studied. Two free DIEP flaps and three supercharged TRAM flaps were transferred. Three of the five were primary reconstruction, and the others were secondary reconstruction. The average age of the patients was 47.3. The average diameter of the recipient artery and vein were 1.6 mm and 1.7mm respectively. All flaps survived completely. The serratus anterior branches of thoracodorsal vessels have often been preserved in breast excision, even after axillary dissection. The main trunks of thoracodorsal vessels are preserved after using serratus anterior branch, and therefore, latissimus dorsi muscle can be elevated safely as a salvage surgery. These vessels are considered as one of the options for recipient vessels in supercharged TRAM flaps and free DIEP flaps.
We retrospectively analyzed five cases requiring revision surgery (fibula bone graft: 2, scapular cutaneous flap: 1, gracilis muscle flap: 1, latissimus dorsi musculocutaneous flap: 1) among 96 cases of free flap transfer. Twenty to 324 hours after surgery, vascular problems were recognized by color changes in the monitor flaps in four cases and a sudden decrease in surface temperature of the monitor flap in one case. Temperature-sensitive stickers were used for three cases; however, the stickers were not useful except in one case. The interval between transplantation and revision surgery ranged from 25 to 326 hours. Venous thrombectomy followed by vein grafts was performed in two cases. In one case, the anastomosis site was re-exposed and vascular patency was confirmed. In another case, although thrombectomy followed by re-anastomosis of the flap artery and anastomosis of the flap vein with a new vein in the recipient site was performed, flap necrosis occurred. In yet another case, repeat muscle transplantation was required because of partial necrosis of the transplanted muscle caused by vascular anomaly. These findings suggest that close and detailed observation of flaps, close cooperation between staff, and thorough preoperative investigation of patient risk factors for surgery as well as vascularity of grafts and recipient sites would help in increasing the success rate of surgery.
Two cases of combined injuries of the axially and suprascapular nerves were treated surgically by nerve transfers. Case 1: A 32-year-old male was injured in a motorcycle accident. The time from trauma to operation was 6 months. The surgical procedure for the suprascapular nerve was neurolysis, and that for the axillary nerve was transfer of two of the triceps lateral head motor branches. Shoulder abduction recovery was 90° and anterior flexion recovery was 100° at 20 months after the operation. Case 2: A 27-year-old male was injured in a motorcycle accident and underwent osteosynthesis of a humeral shaft fracture. The time from trauma to surgery was 7 months. The surgical procedure for the suprascapular nerve was transfer of the terminal branch of the accessory nerve with a sural nerve graft. The surgical procedure for the axillary nerve was transfer of two of the triceps lateral head motor branches. Shoulder abduction recovery was 140° and anterior flexion recovery was 90° at 26 months after the operation. These procedures consisted of motor nerve transfers to recipient motor nerves, and allowed the connection of the healthy donor and recipient nerves. In addition, nerve transfers can be performed close to the target muscles. The proposed nerve transfer procedures are therefore considered to be a valid strategy for treating combined injuries of the axillary and suprascapular nerves.