Traumatic finger amputation is a severe injury, and several problems may remain after successful replantation. We applied free tissue transfer to resolve these problems in four cases. All patients were male, and the patients ranged from 8 to 34 years in age. A free scapular flap and thoracodorsal perforator flap were applied for reconstruction of the first web and palmar contracture combined with tendon grafts. Second toe transfer and second toe joint transfer were used in finger reconstruction. These secondary procedures were performed more than 3 months after the initial injury. Recipient vessels were taken proximal to the injured sites. All free tissue flaps survived. Free skin flap transfer for widening of the first web space improved grip function of the hand. Toe transfer ameliorated the esthetic appearance of the hand by restoring the number of fingers. However, it was difficult to improve the range of motion of the injured fingers. Meticulous surgical planning and rehabilitation programs are essential to obtain good outcomes, because replanted fingers have already been subjected to severe contracture caused by scar formation and tendon adhesion.
We performed fingernail reconstructions using a thin osteo-onychocutaneous venous flap from the 2nd-4th toes. This flap was modified as an onychocutaneous venous flap with a tiny bone under the nail. This series includes 5 cases, 2 patients with congenital nail defects and 3 posttraumatic patients. Four cases were scheduled for this flap operation in advance and one case that was scheduled for a vascularized osteo-onychocutaneous flap to the amputated thumb had been changed intraoperatively to a venous flap because of arteriosclerosis in the flap. As vascularity of the flap was unstable in 2 cases intraoperatively, intra-arterial infusion of anticoagulant and vasodilator was performed in these cases postoperatively. All flaps took. The thin osteo-onychocutaneous venous flap is well indicated for reconstruction of nail defects or nail deformities in the finger that retains the length and volume of the fingertip. This flap procedure is the first choice for reconstruction of congenital nail defects. This flap technique is uncomplicated and safe. In cases in which vascularity of the conventional vascularized nail flap is not stable, this procedure may be used as the salvage technique.
Laser Doppler flowmetry (LDF) has many advantages, including non-invasive examination, continuous monitoring, and real-time analysis. Pocket LDF recorders are easy to use due to their portability. We measured the blood flow in the skin in several areas of three healthy, young men using a pocket LDF recorder. The blood flow was 70-80 ml/100 g tissue/min in the fingertip and lip, and 10-20 ml/100 g tissue/min in other areas. The real-time recordings of fingertip blood flow indicated a transient reduction during changes of posture such as raising a hand, standing up from a sitting position, and beginning to walk. Afterwards, the blood flow recovered within 1-3 minutes. The pocket LDF recorder may be useful for assessing blood flow at surgical sites after microsurgical procedures.
Flap circulation disorder in free tissue transfer surgery is a critical complication as increasingly congestive conditions damage tissue more than ischemia. Flap congestion is caused by several factors and the aim of this study was to identify factors that influenced flap congestion with respect to onset time. This study analyzed a total of 204 cases of free tissue transplantation in the head and neck region, including 15 congestive cases. All microvascular reconstruction surgeries were performed at the University of Tsukuba Hospital from August 2008 to February 2017. Intra- and postoperative factors that influenced flap congestion were chosen and analyzed based on onset time of congestion. Within a 24-hour postoperative window, damaged endothelium, excess flap volume, hyper-strained sutures, and swelling of the surgical site were influencing factors. After the 24-hour window, damaged endothelium was the main factor that influenced flap congestion. In addition, we found that failures of the flap arrangement and neck rest, as well as recipient vessel troubles were crucial factors for preventing complications. Using time of onset to categorize flap congestion allows for preventative as well as rapid responses to problems.
The goal of this study was to determine the characteristics and surgical outcomes of elderly patients undergoing replantation of severed fingers. We examined 59 cases of severed finger replantation in 54 patients admitted to our hospital. Patients aged over 65 were classified as old patients ( n=17, 18 fingers ), and those under the age of 65 were classified as young patients ( n=37, 41 fingers ). In each case, we examined the status of trauma, the length of the postoperative bed rest period, presence of complications, and rate of functional restoration. In addition, patients with successful replantation were assessed for pain, the presence/absence of cold tolerance, excursion, tactile sensation, and the Disabilities of the Arm, Shoulder, and Hand ( DASH ) score. Old patients experienced proximal and incomplete amputations more frequently than young patients. The postoperative bed rest period was shorter for old patients than for young patients. There were no significant differences in the frequencies of severe perioperative complications or rate of functional restoration. Although excursion of the replanted fingers was poorer in old patients, the other outcome measures were similar in old and young patients.
We present our experience with the use of the osteocutaneous lateral upper arm flap for reconstruction of composite tissue defects with skin and bone in a digit. Bone and soft tissue defects in complex severe finger trauma can be reconstructed with vascularized bone grafts as composite osteocutaneous tissue transfer. This method was reported in cases using the toe phalanx, medial femoral condyle, or radial bones, but the skin paddles were unreliable. Bone graft from the distal humerus gives a width of 1.5 cm and a length varying from 2 to 11 cm. This size is ideal to replace any metacarpal or phalangeal bone loss. We recommend the use of the osteocutaneous lateral upper arm flap for reconstruction of composite tissue defects with skin and bone in a digit. This method offers a single-stage compound reconstruction with a favorable donor site.
Abdominal flaps are often used in breast reconstruction. We report a case of muscle-sparing ( MS-2 ) free transverse rectus abdominis musculocutaneous ( TRAM ) flap breast reconstruction after abdominal liposuction. A 65-year-old woman had right invasive ductal carcinoma. Unaware that she had a history of abdominal liposuction, we raised a free TRAM flap with the deep inferior epigastric artery and concomitant vein. During the operation, scarring was observed on the rectus abdominis fascia. Initially, we performed anastomosis between the right internal thoracic vein and deep inferior epigastric vein. Due to flap congestion, we attempted salvage with additional anastomosis using the superficial inferior epigastric vein ( SIEV ), but flap congestion did not improve. Finally, the right internal thoracic vein and left SIEV were anastomosed with a vein graft. It was then possible to alleviate flap congestion by anastomosing the SIEV to the left internal thoracic vein. When a patient has a history of abdominal liposuction, selection and adaptation of the flap for harvest should be carefully determined considering the possibility of TRAM flap congestion while harvesting the flap.
Previous studies have demonstrated the formation of collateral vascular circulation in a transferred free flap within a specified period. Some authors advocated that the flap may survive if microvascular thrombosis occurs at the anastomosed site in a specified period. However, it is unknown how long it takes to form abundant collateral microvascular circulation. In most previous studies, the free flap was transferred to a healthy recipient site on the animal body and the formation of collateral microvascular circulation was examined. We performed free flap transfer for a radiation-induced ulcer on the side of the chest. Microvascular venous thrombosis in the anastomosed site developed three times in two days after first surgery. These three microvascular venous accidents were each rescued by thrombectomy. Nine days after the third thrombectomy operation, venous congestion developed again. The fourth venous thrombosis was suspected, but another thrombectomy was not performed. Although partial flap loss occurred, most of the flap survived. The ulcer healed 3 months after the first surgery.
Patients who need reconstruction for defects of the lower extremities due to injury are often relatively young compared with patients who have ulcers on the lower extremities due to peripheral arterial deficiencies or diabetic foot. Reconstruction of the lower extremities requires not only functionally and cosmetically good results, but also an efficient method for early readjustment to society. The hospitalization period for lower extremity reconstruction tends to be longer because the lower leg is a difficult reconstruction site, and 1 or 2 weeks are usually needed for elevation of an affected limb after surgery. Herein, we review case reports on lower limb reconstruction after injury, and discuss each method as well as possible treatment strategies for early readjustment to society.
Bone grafting is the standard treatment for massive bone defects caused by osteomyelitis of the distal radius. Autogenous non-vascularized bone grafts may result in nonunion because of avascular bone. Free vascularized bone grafts ( VBGs ) are often used for forearm reconstruction and require vascular anastomosis during microsurgery. However, this technique is difficult to perform in elderly patients because they often have complex past medical histories and may experience post-operative complications after a lengthy surgery. We report a distal radius reconstruction using a pedicled VBG of the ulna based on the anterior interosseous artery in an 80-year-old man. This technique reduces operation time and stress, and has a lower donor site morbidity than free VBGs. Post-operative radiographs revealed union of the bone graft at 3 months. The range of motion was 60/80 degrees in pronation/supination due to preservation of the radial head. The patient reported no pain, and his disabilities of the arm, shoulder, and hand ( DASH ) score was 32.5 at the final follow-up. For elderly patients with high-risk complications, this technique is useful as a salvage operation.
A sixty-four-year-old female presented with a one year history of a gradually enlarging left axillary mass. She underwent breast-conserving surgery and radiation therapy for breast cancer twenty years ago. She was diagnosed with radiation induced sarcoma and tumor resection was planned. We reconstructed the axillary defect with the pedicled posterior arm flap ( PAF ). The donor site was closed and there were no postoperative complications. The Musculoskeletal Tumor Society ( MSTS ) rating scale was 27 out of 30 points. The PAF has been widely used since its original description by Masquelet et al, in 1985. The pedicled variant of the PAF is also a versatile fasciocutaneous flap that is suitable for axillary reconstruction in patients with hidradenitis suppurativa. However, there are few reports of the PAF for reconstruction after wide resection of axillary tumors. In this article, we report pedicled PAF for axillary soft tissue defects after wide resection of radiation-induced sarcoma from breast cancer.
To reconstruct esophageal defects, free jejunum or pedicled colon is commonly used if the stomach cannot be lifted to the neck. In the past 6 years, supercharged pedicled colon was indicated in 4 male patients aged 61 to 70 years old ( mean 66.3 y/o ) after total esophagectomy with or without gastrectomy. The colon is preferably harvested transverse to the left side instead of the right because it has a longer arc, less vascular variation and dilatation, and may orthodromically replace a defect. All cases were successful without major complications after approximately 50 months of follow-up, except in 1 patient who died due to a tumor 18 months after surgery. A monitor flap was not set in the surgical site, but the vasculature of the grafted intestine was checked with an echo Doppler probe immediately after the surgery and until 5 days after the surgery. Water testing was done on the 5th operative day and swallowing of liquid food was started after another 5 days. Food stagnation occurred temporally in one case, but improved in a few weeks. This procedure was demonstrated to be less stressful and reliable from a small series experienced by our team.