For successful functional reconstruction using functioning free muscle transfer (FFMT), complete survival of the transferred tissue is essential. However, muscle tolerates a shorter period of ischemia than other tissues such as skin and bone. Therefore, the use of skin flaps as a monitoring tool cannot sensitively reflect the vascularity of FFMT, and may result in delayed detection of vascular compromise, leading to muscle necrosis with an intact skin flap. In order to obtain effective results with FFMT, early detection of vascular compromise is important. We here report the use of compound muscle action potentials (CMAP) as a supplemental method in the monitoring of free gracilis transfer. A sudden 50% decrease in CMAP amplitude within 1 hour is an indication for revision surgery. Between 2007 and 2017, we performed 188 FFMT procedures for brachial plexus injury reconstruction. Eight cases had vascular compromise. All cases salvaged by CMAP monitoring had a shorter ischemic time than with conventional skin flap monitoring. This technique is most useful for postoperative vascular monitoring of a buried muscle flap.
Objective: To examine the predictors influencing the graft survival rate after replantation in patients with digital amputations. Methods: We investigated the factors affecting the graft survival rate in 111 patients (131 digits) who underwent replantation after digital amputation between April 2010 and March 2016. Age, hypertension, diabetic status, smoking history, partial continuity status of the skin and hypodermal tissue of the amputated digit, level of amputation, and shape of amputation for engrafted and necrotized groups were compared. Results: Overall, 95 digits grafted successfully and 36 necrotized. The mean age in the necrotized group (46.1±16.3) was significantly older than in the engrafted group (39.7±14.6). The graft survival rate was 72.5%, and this was significantly higher in patients with clean-cut and blunt amputations than in those with crushing and avulsion amputations (86.3% vs 63.8%). It was also significantly higher when continuity of the soft-tissue was partially retained, compared with the absence of continuity (84.8% vs 65.9%). The lowest graft survival rate was for distal joint amputation (66.0%). Patients with hypertension, diabetes, and smoking history showed low graft survival rates. Conclusion: Age, soft-tissue non-continuity, crushing amputation, and avulsion amputation are predictors of poor outcome for graft survival.
In fingertip amputations, surgeons may encounter technical difficulties in vein grafting for anastomosis of small and fragile vessels. In this retrospective study, we evaluated the survival rate, complications, and surgical techniques for fingertip replantation with vein grafting. One hundred and twenty-five fingertip replantation procedures were performed in 116 patients between 1996 and 2017 at our hospital. There were 74 amputations in zone I and 51 in zone II. Twenty-five amputated fingertips in zone I were replanted with vein grafting for arterial or venous repairs. Among the 25 procedures with vein grafts, there were 11 with arterial repairs, 6 with venous repairs, and 8 with both arterial and venous repairs. In the procedures with vein grafting, vascular thrombosis was found in 6, of which there were 4 arterial and 2 venous thromboses. In 4 cases of arterial thrombosis, the circulation gradually deteriorated within 2 or 3 days and subsequent necrosis of the replanted fingertip occurred, presumably because of severe damage to the soft tissue. The overall survival rate of replantation with vein grafting was 84%. Although skillful microsurgical techniques and longer operation times are in high demand, our results using vein grafts for successful fingertip replantation are encouraging.
The digital artery perforator (DAP) flap has been applied for fingertip defect reconstructions. However, a high rate of venous congestion was reported, being a disadvantage of this procedure. Recently, the innervated DAP (IDAP) flap has been reported to be more advantageous than DAP flaps because of its low complication rate. We evaluated the results of fingertip reconstruction with IDAP flaps. Nine patients (9 fingers) underwent fingertip reconstruction with IDAP flaps at our institution. The mean age was 51.3 years (range, 24 to 64 years). The defect size was from 1.2×1.5 to 2.7×1.6 cm. The mean follow-up period was 5.2 months (range, 3 to 8 months). All flaps survived without contracture of the proximal interphalangeal joint. A static 2-point discrimination test on the flaps measured 5 mm in seven patients and 6 mm in two patients. All patients registered sensitivity on the 0.5-G (number 4, green) Semmes-Weinstein monofilament test. The IDAP flap is useful for fingertip defect reconstruction because it is a simple, reliable and minimally invasive procedure, with a low complication rate similar with PIP joint contracture.
We retrospectively investigated the clinical outcomes of soft tissue reconstruction for crushed and contaminated wounds in the extremities at our hospital. We examined 20 wounds in 18 patients: 8 on the hand, 2 on the forearm, 1 on the upper arm, and 9 on the lower leg. Eight wounds were associated with open fracture, 7 were contaminated by soil and/or organic matter, and 12 had bacterial infections. Eleven wounds were covered with free flaps and 9 with pedicled flaps. The average period to soft tissue reconstruction was 16 days. All wounds healed, and the average period until complete wound healing was 40 days. Nine wounds developed postoperative infection, including one case of delayed osteomyelitis. Eleven wounds required additional procedures, including additional debridement under the flaps in 7. All 4 wounds that were positive on wound culture before soft tissue reconstruction developed postoperative infection under the flaps. As it is difficult to perform debridement for contaminated wounds, wound infection can continue postoperatively. For wounds with infection after soft tissue reconstruction, additional debridement under the flaps should be performed, paying attention to flap circulation.
Introduction: Contouring the breast shape is one of the most time-consuming procedures in autologous breast reconstruction. We conventionally shape the breast during the last part of the operation through two separate procedures: envelope formation and flap volume adjustment. We performed envelope formation before the vascular anastomosis as predictive contouring, and were able to shorten the operation time. Methods : The time from the end of vascular anastomosis to the end of the operation was measured as the contouring time in 236 autologous breast reconstruction procedures between June 2008 and October 2017. The predictive contouring group and the non- predictive contouring group were compared. Results : The breast-shaping time was a median of 244 min in 42 in the non-predictive contouring group and a median of 170 min in 9 in the predictive contouring group for one-stage reconstruction (p<0.01), and a median of 234 min in 39 in the non-predictive contouring group and a median of 137 min in 27 in the predictive contouring group for second-stage reconstruction (p<0.01). Conclusion : Predictive contouring can shorten the operation time. A free operative field can be obtained irrespective of anastomosed vessels, which allows for simultaneous flap elevation and envelope preparation.
Surgical treatment is required for patients with chronic or refractory radiation ulcers. For reconstruction, distal pedicled flaps are preferable because the tissue surrounding the ulcer is often damaged by radiotherapy. We treated five patients with radiation ulcers using microsurgery. We herein summarize the surgical techniques and outcomes, and analyzed these data retrospectively. Two ulcers were considered to be due to early skin reactions, and the other three were thought to be late skin reactions because they had been treated by radiotherapy over 10 years prior to presentation. For one patient, a supercharged rectus abdominis musculocutaneous flap was used, and for the other four, free flaps were used. In two patients, reanastomosis was required because of venous thrombosis. In two patients, we used a vein graft. All flaps were successfully transferred without necrosis. In conclusion, reconstruction with vascular anastomosis is useful for surgical treatment of radiation ulcers when a pedicled flap cannot be used and the recipient vessels are suitable for anastomosis.
When bilateral internal jugular veins are sacrificed in bilateral neck dissection, staged planned neck dissection or simultaneous reconstruction of the internal jugular vein is advocated. We treated a patient who underwent bilateral internal jugular vein resection with simultaneous unilateral internal jugular vein reconstruction and free jejunum transfer for pharyngoesophageal reconstruction in whom the flap vein anastomosed to the reconstructed jugular vein. The jejunal graft exhibited congestion immediately after removal of the vascular clamp. Therefore, we changed the recipient vein to the cephalic vein, and the graft survived. It is common for the unilateral internal jugular vein to be sacrificed, and it is also common for the flap vein of the free flap to be anastomosed to the preserved internal jugular vein in head and neck surgery. However, a unilateral reconstructed internal jugular vein after sacrificing bilateral internal jugular veins is different from preservation of the unilateral internal jugular vein. Anastomosing the flap vein of the free flap to a reconstructed unilateral jugular vein should be avoided except in specific conditions. The important factors are the diameter of the reconstructed vein and stump pressure of the internal jugular vein.
Nerve transfers allow for re-innervation of the affected nerve from an adjacent nerve source in order to innervate a distal target muscle. We report a case involving extensive loss of soft tissue and loss of the ulnar nerve at the elbow joint. The size of the soft tissue defect was 20×14 cm, and the defect along the path of the ulnar nerve was approximately 20 cm. The defect in the soft tissue at the elbow joint was reconstructed using a thoracodorsal artery perforator (TAP) flap. The distal anterior interosseous nerve was transferred to the deep motor branch of the ulnar nerve to correct the nerve defect. Eighteen months after surgery, the patient was able to fully adduct the thumb. After the final follow-up, the pinch strength recovered to 2.5 kg and the Highet-Zachary scale grade was M3. The method of nerve transfer described here utilizes the distal anterior interosseous nerve to innervate the intrinsic muscles of the hand. It is a simple method of re-establishing hand functionality.
We performed vascularized medial femoral trochlea osteochondral grafting for a 64-year-old female with Bain Grade 2b Kienböck disease. At one year postoperatively, her wrist pain had disappeared, her active wrist range of motion was 90 degrees on flexion and extension, her Mayo wrist score was 80, her knee function at the graft donor site was almost normal, and she was satisfied with the results. The carpal height ratio and the radioscaphoid angle were maintained on X-ray, and fragmentation of the lunate had united on CT. Although there are few reports on vascularized medial femoral trochlea osteochondral grafts for Kienböck disease, it is possible to reconstruct the proximal articular surface of lunate and unite fragmentation of the lunate using this procedure, making it more advantageous than other procedures such as radial osteotomy, partial wrist fusion, and proximal row carpectomy. Therefore, the vascularized medial femoral trochlea osteochondral graft should be indicated for Bain Grade 1 and 2b Kienböck disease.