Decision Making and Planning

The surgeon may be confronted with the decision to attempt salvage or amputate a mangled, nonviable extremity. The appropriate decision is difficult, since recovery of function in a salvaged extremity may be limited or absent. Thus, multiple reconstructive procedures with associated morbidity, prolonged hospitalization, disability time, psychological distress and financial demands may be too expensive a price to pay for the end result of a useless and painful limb. In contrast to prostheses for...

Contributors

Deputy Consultant Orthopaedic Surgeon Department of Orthopaedics and Trauma Plastic, Reconstructive and Microsurgery Chairman, Division of Plastic Surgery Assistant Professor of Orthopaedic Surgery Reconstructive, Maxillofacial and Oral University of Pittsburgh Medical Center Reconstructive and Aesthetic Surgery Interdivisional Group of Microsurgery

Reconstructive Technique

The reconstructive technique chosen can include multiple modalities but the reconstructive ladder which applies to all defects is also applied in the oral cavity. This ladder includes direct closure, closure by secondary intention, skin grafting, local flaps, regional flaps and free tissue transfer in ascending order of complexity. Allowing the wound to granulate is an option in the oral cavity. It must be utilized however in the knowledge that the resultant contracture and scarring will not...

Traumatic Brachial Plexus Injuries in Adults

Although the first surgical procedure for brachial plexus laceration is dated back in the beginning of the 20th century, only in the last thirty years with the advent of reconstructive Microsurgery, a significant progress has been made in the operative management of brachial plexus injuries by A. Narakas (1977),1 H. Millesi (1984)2 and J.Y. Alnot (1987)3 and others. Knowledge of the anatomy of the brachial plexus and of the pathological changes of peripheral nerve lesions allows better...

W

D, One week following replantation of the forearm. A lattisimus dorsi free flap was used immediately for soft tissue coverage. An end-to-end reversed saphenous vein graft was used to reconstruct the brachial artery. The thoracodorsal artery of the latissimus dorsi muscle was supplied through an end-toside anastomosis to the reversed saphen-ous vein graft. E, Appearance of the extremity nine months following replantation.

Conclusion

Newborn palsy is a traumatic lesion occurring in overweight babies in cephalic presentation or in small babies in breach presentation. Spontaneous recovery of biceps contraction within three months predicts a good final result. No recovery of the biceps at three months of age is an indication for exploration and microsurgical reconstruction of the plexus. Surgery leads to better results than spontaneous recovery. If there is only a small recovery at six or nine months of age, the final result...

Omentum

The omentum is a visceral structure containing fat and blood vessels within a thin membrane. It extends from the stomach to the transverse colon and beyond covering the anterior peritoneal contents. It has two dominant pedicles right gastroepiploic artery and vein with a length of 6 cm and a diameter of the artery of 2-3 mm, and a left gastroepiploic artery and vein with a pedicle length of 4 cm and diameter of the artery of 2 mm. It may be as large as 40 x 60 cm2 (Fig. 8.11). Prior...

After Intercalary Resection in Malignant Bone Tumor 175

Luca Delcroix, Massimo Ceruso, Marco Innocenti, Rodolfo Capanna, Domenico A. Campanacci, Patrizio Caldora, Marco Materials and Methods The Surgical Discussion D. Clinical Application of Growing Bone Transfer 183 Marco Innocenti, Massimo Ceruso, Luca Delcroix, Marco Manfrini, Rodolfo Capanna Operative Results and 11. Microsurgery in Congenital Hand Malformations 196 Technique of Toe Transfer in Congenital Discussion 12. Traumatic Brachial Plexus Injuries in Adults and in Ph. Valenti, Z....

Choice of Free Flaps

Since the arrival of clinical microsurgery, reconstructive surgeons have reevalu-ated human anatomy, searching for vessels and tissues suitable for free tissue transfer. The nature of the defect and of the donor site must be considered in each case, in order to choose the most appropriate tissue for transfer. Fig. 7.1. D) Complete stump coverage with a free latissimus dorsi myocutaneous flap. Fig. 7.1. D) Complete stump coverage with a free latissimus dorsi myocutaneous flap. Fig. 7.1. E) The...

Info

A) Short below knee stump with exposed bone and lack of soft tissues. of the extremities can be achieved following tumor extirpation. Careful selection of the recipient motor nerve is essential to the recovery of function of the transferred muscle. In several occasions motor nerve reconstruction with long nerve grafts may be required, before the free tissue transfer. In conclusion free tissue transfer has extended surgical abilities in many directions and in none more dramatically...

Wound Location and Kinetics

In considering the tissue defect, thought must be given to the anatomic location and the etiology and nature of the wound and to the wounding agents and their kinetics. In high velocity wounds the zone of injury may be more extensive than the apparent size of the external defect. This effects the quality of local tissues that may be viable, but the degree of their contusion and circulatory impairment may be so extensive that any attempt to provide coverage by shifting them will cause necrosis....

Scalp Reconstruction

The scalp has several unique characteristics. The most obvious is that it is hair bearing. Secondly, the structure of the scalp, consisting of highly vascularized skin and subcutaneous tissue in close affinity with the rather unyielding underlying galea means that long narrow flaps can be designed with reasonable safety. For smaller defects local flaps are the best option as they fulfil all the criteria we outlined above i.e., replacing like tissue with like and keeping things simple. If one...

Palsies Resulting from Retro and Infraclavicular Lesions

In the first group, in which the diagnosis is difficult, the lesions are located at the level of the cords, behind or below the clavicle and are usually associated with bone and vascular lesions. Lesion of the posterior cord leads to deltoid paralysis and proximal palsy of the radial nerve (elbow, wrist and hand) with motor and sensory signs. Lesion of the lateral cord leads to palsies of the musculocutaneous nerve and lateral component of the median nerve. Isolated lesion of the medial cord is...

Prefabrication of Flaps

Prefabrication of flaps allows custom flaps to be constructed based on what is required for a specific defect. The exploration of this new frontier may increase the possibility of reconstructive capabilities and decrease the donor morbidity of classical reconstructions. Depending upon the specific application of the prefabrication, one or more of the following advantages may be offered 1. Specific preferred blocks of tissue, that are not naturally perfused by anatomically well defined axial...

Nerves

Nerves may have internal derangement without loss of continuity. They may be partially or completely disrupted. Contused or attenuated nerves are spared. If lacerated, the nerve ends should be debrided under the microscope to healthy appearing fascicles. Do not compromise the resection in order to preserve length. Nerve regeneration will not occur through scarred nerve tissue and nerves repaired under tension also do not recover well. Mobilizing the proximal and distal stumps to achieve primary...

Paraclinical Tests

In the emergency department plain radiographs of the cervical spine and shoulder are necessary for skeletal evaluation and the diagnosis of concomitant lesions (scapula, clavicle, humeral head, sternoclavicular joint, first rib, transverse process In cases of acute ischemia of the upper limb, an angiography in the emergency department will determine the level of the vascular lesion. If there is no clinical recovery within a period of 30 days after injury, myelogra-phy, computed tomography (CT)...

Vein Grafts

When direct circulatory access for free flap reconstruction is difficult or impossible, vein grafts may provide free flap circulation. In the lower extremity the short saphenous vein87 has many attributes, which make it ideal for use, when vascular access is not available and long vein grafts are needed. These include 1. Sufficient length of 40-50 cm depending on patient habitus. This length may be used to serve as a direct arterial graft from higher up on the limb, while local veins are used...

Microsurgical Techniques for Peripheral Nerve Repair

Bruno Battiston, Pierluigi Tos Introduction Nowadays, surgical resolution of a disability resulting from a peripheral nerve lesion is no longer an impossible task for the surgeon even if diagnosis and treatment still require a thorough knowledge of the pathophysiology of the nervous system together with the most recent sophisticated microsurgical techniques. Basic knowledge of the pathophysiological processes in a nerve trunk and its neurons after transection injury (degeneration and...

Femoral Head Osteonecrosis

The VICG has found application as a pedicled flap in the management of femoral head osteonecrosis. The graft is prepared on the deep circumflex iliac artery pedicle and then it is tunneled beneath the iliac muscle to reach the ipsilateral hip. The femoral head is exposed, following external rotation of the hip and division of the capsule, and a tunnel is created in the femoral neck leading into the osteonecrotic head. Avascular bone is removed, the femoral head is packed with cancellous...

Anatomical Basis

The brachial plexus (Fig. 12.1) is composed of the anterior primary rami of the last cervical nerves (C5, C6, C7, C8) and of the first thoracic nerve (T1) Anterior roots of C5 and C6 join to form the superior trunk. Anterior root of C7 forms the middle trunk. Anterior roots of C8 and T1 join to form the inferior trunk. Each trunk splits into an anterior and posterior division The anterior divisions join to form two anterior cords (lateral and medial) and their terminal branches...

Postoperative Management

In the immediate postoperative period the extremity should be splinted in an appropriate position to prevent capsuloligamentous shortening and tension on repaired structures. Elevation is necessary to reduce edema and help control pain. The patient's pain and anxiety should be adequately controlled. The ambient temperature should be at least 25 C and adjusted to the patient's body temperature. Hydration should be sufficient to maintain a urinary output between 80-100 cc hr. Anticoagulant...

Preface

Microsurgery, in other words performing surgery on miniature anatomical structures, was made possible in the second half of the 20th century, when technology allowed development of operative microscope, micro-instruments and micro-sutures made it possible. It started as an advanced surgical technique and its first application was the replantation of amputated digits. This fascinating surgery transformed what was once thought ofas a miracle into reality. Various disciplines have been brought...

Reconstruction of the Proximal Humerus

In spite of the obvious dimensional discrepancy between the epiphyses of the humerus and the fibula, the described procedure is indicated also in the reconstruction of the proximal humerus and provides good functional results. In this anatomical district the osteosynthesis is accomplished by plates. In order to improve the elasticity of the implant and to prevent possible fractures, which in Fig. 10D.3. In humeral reconstruction, the bone fixation is achieved by means of long reconstruction...

Reconstruction after Mutilating Injuries of the Hand

Great toe-to-hand transfer is indicated for thumb amputations at, or close to, the level of the metacarpophalangeal joint. Great toe transfer provides a broad area for oppositional contact, but can be too bulky. Great toe transfers cannot include a metatarsal, since the first metatarsal head must remain in the foot if severe gait disturbance is to be avoided. If metacarpal reconstruction is needed, a second toe donor site should be considered. Patients may prefer the cosmetic appearance of a...

Vascular Reconstruction

Definitive revascularization should be done once skeletal stabilization is completed. Lacerated vessels should be resected to healthy appearing vessel wall both proximally and distally. Contusion along the adventitia suggests injury within the intimal layer as well. A ribbon sign (convoluted or tortuous course of the digital vessels) indicates injury to the media layer of the vessel and requires resection of the length of the involved area and reverse vein grafting. Inflow should be assessed...

Fibula Anterior Ankle Surgery

B) Reconstruction of right breast with a free TRAM flap. resection. For longer defects, however, free vascularized bone flaps are indicated. These, unlike nonvascularized bone grafts, remain viable their blood supply is through the nutrient vessels. Bone healing occurs at a rate comparable to that of normal bone, creeping substitution does not occur and the quality of the recipient bed does not influence their survival. Many vascularized bone grafts have been described as a component...

Congenital Anomalies

It is also important to remember that children are remarkably adaptable to seemingly severe deformities. Microsurgical toe-to-hand transfers, however, have the potential for producing significant functional improvement in a number of different types of congenital anomaly. The congenital anomalies for which toe transfer is considered include adactaly (aplasia, preaxial dysplasia) thumb hypoplasia, and constriction band syndromes. The goals of reconstruction are to provide prehensile grip, pinch,...

Results and Discussion

Our personal experience with epiphyseal plate transplantation in upper limb skeletal reconstruction refers to a population of 20 patients ranging in age between 3 and 11 years.22 All of them were affected by malignant bone sarcomas located in the meta-ephyphisis of a long bone of the upper extremity. The described reconstructive procedure was used to replace the proximal humerus in 15 cases and the distal radius in five. The follow up period ranges between nine months and eight years. The...

Harvest of the Fibula

The lateral approach described by Gilbert is not applicable in case of fibula transfer based on the anterior tibial vascular system because it neither permits a safe dissection of the vascular bundle nor a sufficient view on the proximal tibio-fibular joint. An antero-lateral approach, thorough the intermuscular plane between tibialis anterior and extensor digitorum longus muscles, allows complete visualization of the delicate periosteal and juxtaphyseal vascular networks on which this transfer...

Brachial Plexus Palsy in the Newborn

The origin of newborn palsies is traumatic and not congenital the lesions are caused by the traction applied on the roots during combined lowering of the shoulder and inclination of the cervical spine to the contralateral side. The diversity of lesions depends on the mechanism but also on the anatomy of the roots (ligaments, angle of attachment, direction of the roots). The incidence of newborn palsy is approximately 2 per 1000 births and the percentage of spontaneous recovery is around 80-90 ....

References

Numerical variations. In congenital deformities of the hand. An atlas on their surgical treatment. Berlin Springer-Verlag 1981 120. 2. Boyer MI, Mih AD. Microvascular surgery in the reconstruction of congenital hand anomalies. Hand Clin 1998 14 135-42. 3. Bradbury ET, Kay SP, Hewison J. The psychological impact of microvascular free toe transfer for children and their parents. J Hand Surg. 1994 19B 689-95. 4. Buck Gramcko D. Hypoplasia and aplasia of the thumb. In...

Salvage or Amputation

For extremity reconstruction and particularly for the lower extremity, there is another consideration in the decision whether to use a free flap that is under what circumstances is salvage of the extremity indicated.35,46 If valid indications for amputation are present, the patient will not be served well by a free tissue transfer. This only postpones the inevitable and prolongs hospitalization and suffering, but also results in poorer outcome compared with patients treated with primary...

Major Limb Replantation

Nerve Replantation

Complications of major limb replantation can be life threatening and should be appreciated by the surgeon and the patient. In some cases, major limb replantation allows for better function than a prosthesis. The best of these results occur at the level of the midforearm to distal forearm. For more proximal injuries, the goal is to provide a functioning wrist and hand for simple hook-grasp and prehension with Fig. 4.9. A,B, A catheter is placed percutaneously adjacent to the median nerve to...

The Wraparound Flap

It has been devised for improving appearance of the reconstructed thumb thus giving the possibly to create a custom made new thumb. This is feasible through a combined tissue flap including part of the distal phalanx with the corresponding part of the nail, an extended flap with dorsal and plantar skin narrowed down to the size in which the soft tissue flaps can wrap it around. No joint or epiphysis is incorporated and has no growth potential. Therefore this procedure is not indicated in...

Indications Advantages Contraindications Disadvantages

The primary indication for free flap transfer is the presence of a tissue defect due to trauma or disease that cannot be closed by simpler methods. Less apparent indications include the need to improve local circulation by using a well vascularized muscle flap, as in the treatment of osteomyelitis, or radiation necrosis, the need for vascularized bone in reconstituting a long segmental bony defect, the need to give motion to the face following facial paralysis or to a paralyzed functionless...

Palsies Resulting from Supraclavicular Lesions

These are the most common (75 ) among all injuries of the brachial plexus. Total Palsy with Avulsion of the Lower Roots (C7, C8, T1) Repair depends on the number of upper roots spared In the cases that C5 is the only spared root, C5 is connected to the anterior part of the upper trunk through sural nerve grafts and the supras-capular nerve is neurotized by transfer of the spinal accessory nerve. The goal is to obtain stabilization of the shoulder, adduction of the arm (pec-toralis major),...

Donor Site Dissection Techniques Great Toe Harvesting Technique

Dissection is carried out under tourniquet control. The ipsilateral toe is usually selected. The limb is partially exsanguinated so that the vessels can be readily identified. The skin incision is planned to create distally-based dorsal and plantar triangular flaps at the level of the metatarsal phalangeal joint. The dorsal flap is planed such that it follows the course of the distal portion of the dorsalis pedis artery and the first dorsal metatarsal artery. In general, it is better to harvest...

Classification of Free Flaps

The following types of free flaps have been described The fascial or fasciocutaneous, the muscle or musculocutaneous and recently the perforator flaps and the special tissues, such as vascularized bone, nerve, tendon, intestine, omentum, etc. Fascial flaps consist of a circumscribed area of fascia. If the overlying skin and subcutaneous tissue is included, the flap is called fasciocutaneous. The vascular supply, usually a named artery, flows directly to these flaps and does not perforate...

Strategy of Repair

Nerve Repair

In the majority of cases a neuroma is found between the roots and the division of the upper trunk, at the level of the clavicle. After resection of the neuroma, the gap is bridged with grafts from the two sural nerves the grafts are secured in place with the use of fibrin glue (Fig. 12.3). The results are good if at least one root (C5 or C6) can be grafted. After nerve repair, good or excellent results on the shoulder are expected in more than 50 of cases. Sometimes, the quality of the root can...

Scapular Flap

The scapular flap remains probably the workhorse of skin flaps. It is a thin, usually hairless, skin flap from the posterior chest and can be de-epithliazed and used as subcutaneous fascial flap, pedicled or free flap. The flap is perfused by the cutaneous branches of the circumflex scapular artery (CSA) and drained by its venae comitantes. The CSA is a major tributary of the sub-scapular artery and the CSA is the artery supplying blood to the scapula, the muscles that attach to the scapula,...

Groin Flap

The groin flap provides a large skin and subcutaneous tissue territory based on superficial circumflex iliac (SCIA) artery and vein. The length of the pedicle is 2 cm and the diameter 1.5 mm. The dimension of the flap can be up to 10 x 25 cm2. Preliminary expansion of the lateral groin skin beneath the deep groin fascia will expand flap dimensions and allow direct donor site closure (Fig. 8.5).

Vein Wrapping for the Treatment of Recurrent Entrapment Neuropathies

Sotereanos Introduction Entrapment neuropathies are common entities in surgery of the upper extremity. The gold standard for operative treatment in this condition is surgical decompression of the entrapped nerve. Releasing the transverse ligament at the volar surface of the wrist for carpal tunnel syndrome and decompressing the ulnar nerve at the elbow for cubital tunnel are generally procedures with very satisfactory outcome. Despite the high success rates...

Dorsalis Pedis Flap

This is a thin sensate fasciocutaneous flap from the dorsum of the foot. It is based on the dorsalis pedis artery, which originate from anterior tibial artery and its venae comitantes.25 The length of the pedicle is 6 to 10 cm and the diameter of the artery is 2-3 mm. The nerve supply comes form the branches of deep and superficial peroneal nerves. The size of the flap is 6 x 10 cm2 and it can be raised as a skin flap alone or in combination with the second metatarsal bone as an osteocutaneous...

Peripheral Artery Disease And A-v Flstula

Linear slit arteriotomy for end to side anastomosis. 2. The short saphenous vein is thin-walled in comparison with the long saphenous vein, usually has a nearly constant diameter throughout its length and presents no problems with direct end-to-end anastomosis with the vessels of most transferred flaps. 3. The vein most of the time may be left in situ at its upper end. This reduces the amount of dissection necessary, avoids one anastomosis and provides double drainage into both the...

Factors Influencing Nerve Regeneration

Epineural Repair Nerve

Six groups of factors, which influence nerve regeneration, and consequently, the final result of a nerve repair may be distinguished, i.e., general factors, type and site of the lesion, timing, coaptation technique, biomolecular factors. In this group we include such parameters as the patient's age and general health. The age of the patient is a very important prognostic factor. It is well known that children generally have better functional recovery than do adults. This is due, in part, to a...

Medial Arm Flap

Comitantes of the radial artery but the flap can include the cephalic vein, the basilic vein or both. The flap can contain the lateral antebrachial cutaneous nerve or the medial antebrachial cutaneous nerve and serve as a neurosensory flap. The size of the flap can be 10 x 40 cm2. A portion of the radius can be included as a vascularized bone with this flap.16 The advantages of this flap are a long pedicle, and potential sensory inervation. The quality of the bone from the radius is mainly...

Contents

Microvascular Surgical Historical Microvascular Anastomotic 2. Microsurgical Techniques for Peripheral Nerve Repair 8 Nerve Lesions Factors Influencing Nerve 3. Vein Wrapping for the Treatment of Recurrent Entrapment Sokratis E. Varitimidis, Dean G. Sotereanos Indications for the Surgical Complications Discussion 4. Upper Extremity Replantation 32 Indications for Replantation Preoperative Surgical Management Major Limb Replantation Postoperative Care 5. Microsurgical Reconstruction of Type IIIB...

Versatility

The combination of these morphologic and biologic properties renders the FVFG a truly versatile flap that can be tailored to suit the need of the individual case. Both the configuration and the composition of the graft may be modified. The FVFG can not only be used in its naturally straight configuration, but due to its dual vascularity it can undergo a variety of osteotomies. Specifically, it can be transversely osteotomized in the middle of the diaphysis in order to produce 2 cortical struts...

Lateral Arm Flap

This flap can serve as innervated fasciocutaneous flap or as de-epithiliazed subcutaneous fascial flap. The lateral arm flap is based on the posterior radial collateral vessels (PRCA). The artery is a direct continuation of the deep brachial artery. The draining veins of this area are the venae comitants of the PRCA. The pedicle length is up to 7 cm. The external diameter of this artery is usually 1.5-2.0 mm but some times can be smaller, 0.8 mm. The vein's diameter ranges from 2.0-2.5 mm. The...

Congenital Pseudarthrosis

The FVFG offers significant advantages in the management of this challenging problem, which usually involves the tibia and in the past often resulted in amputation. It permits resection of all the pathological tissue, which otherwise would be hindered by the reluctance of the surgeon to create a large defect. Moreover, it facilitates reconstruction of the length and alignment of the affected bone. Excellent results have been reported by many authors with union in more than 90 of cases (Fig....

Arakaki Thumb Replantation Survival Factors And Reexploration

Replantation of fingers and limb parts. Techniques and Results. Chirurg 1977 48 353-359. 2. Ikuta Y. Microvascular surgery. Hiroshima, Japan Lens Press 1975 42. 3. Kleinert HE, Juhala CA, Tsai T-M et al. Digital replantation selection, technique, and results. Orthop Clin North Am 1977 8 309-318. 4. Lendvay PG. Replacement of the amputated digit. Br J. Plast Surg 1973 26 398. 5. MacLeod, AM, O'Brien BM, Morrison WA. Digital replantation clinical experiences. Clin Orthop 1978 133 26-34....

Surgical Indications

Incision Line Picture Branchial Cyst

The therapeutic approach depends on the recovery during the first month and the anatomopathological lesions defined by repeated clinical examination and paraclinical tests (CT myelography, EMG). In the majority of cases there is no indication for an emergency surgical exploration, except for acute upper limb ischemia the ideal strategy in these cases is to graft the vascular lesions and to locate potential nerve lesions, making a secondary nerve repair as easy as possible. In some cases,...

Free Flap Monitoring

Monitoring of the patency of microvascular anastomoses, tissue perfusion and viability of free flaps is essential. In large series of free tissue transfers the re-exploration rate ranged from 6-25 with success rates, between 91 and 99 .27,39,85,91 Therefore salvage of a large number of failing flaps is possible. Early warning of circulatory impairment and immediate return to the operating room are the most important elements in saving flaps in trouble. The ideal monitor should be a noninvasive,...

Indications for Replantation

The level and extent of injury are the most important determinants in the decision to proceed with replantation. In replantation, observation of functional results at different anatomical levels guides our indications. Good candidates for replantation include patients with amputating injuries of the thumb, multiple digits, hand, and wrist. When the amputation occurs through the forearm, at the elbow, or at the arm, only sharp or moderately avulsed injuries are considered favorable candidates....

Monitoring

Monitoring of free tissue transfer is essential to assure transplant success. Many different monitoring devices and techniques have been used with varying levels of success. As is true in many situations in medicine, the availability of many solutions to a problem suggest that none is superior or ideal. An ideal flap monitoring should satisfy several criteria. It should be harmless to the patient or the flap, objective, reproachable, applicable to all types of flaps and inexpensive. It is...

Clinical Examination

Clinical examination associated and the subsequent paraclinical investigations allows preoperative evaluation of the type of nerve lesion fourth and fifth degree lesions (Sunderland's classification) require surgical treatment whereas the first three degrees require only conservative treatment the level of lesion roots, trunks, terminal branches the severity of lesion violent trauma (motorcycle accident) characterized by high kinetic energy and sudden deceleration may lead to severe brachial...

Temporoparietal Fascial Flap

Temporoparietal

This flap can be used as a fascial or fasciocutaneous flap. The fascia covers the temporal muscle extending over the temporal fossa and lies superficial to the deep temporal fascia covering the temporalis muscle. It continues as the galea beyond the limits of the temporal fossa. Vascular pedicle Superficial Temporal Artery (STA) is the terminal branch of the carotid artery. The length of the artery is 4 cm and the diameter of the artery is 2 mm. The course of the vessels is on the fascia from...

D Microvascular Anastomotic Techniques

A large number of different techniques have been investigated for making microvascular anastomoses. Additionally, varying clinical situations demand that microsurgeons are familiar with a variety of different methods for making microvas-cular anastomoses. Techniques can be classified into two main categories Microvascular anastomoses can be classified according to the technique used for their construction c. end-to-side branch anastomosis The end-to-end anastomosis was the first technique used...

Flap Failure and Management Acute

Acute complications occur usually in the first 48 hours and includes venous thrombosis, arterial thrombosis, hematoma, and hemorrhage and excessive flap edema. Arterial insufficiency can be recognized by decreased capillary refill, pallor, reduced temperature, and the absence of bleeding after pinprick. This complication can be caused by arterial spasm, vessel plaque, torsion of the pedicle, pressure on the flap, technical error with injury to the pedicle, a flap harvested that is too large for...

Introduction

The advantages of vascularized bone transfer versus conventional nonvascularized autograft are well known. The ability to heal according to physiological rules, the possibility to reconstruct long bone defects even in scarred or infected beds, the bone remodeling and hypertrophy under the influence of loading are some of the most remarkable features of vascularized autografts. In skeletally immature patients, the harvest of vascularized epiphysis along with a variable amount of adjoining...

Final Remarks and Future Applications

In the complex therapy for lymphedemas, the role to be played by surgery versus medical-physical conservative treatment can be easily defined.10 Combined physiotherapy is the treatment of choice for most lymphedemas. In nonresponsive cases Fig. 14.1. Multiple lymphatic-venous anastomoses performed by microsurgical technique, using the operating microscope at 30x magnification. Fig. 14.1. Multiple lymphatic-venous anastomoses performed by microsurgical technique, using the operating microscope...

Corradino Campisi General Clinical Aspects

Among peripheral lymphatic disorders, lymphedema represents a pathology with a relatively significant incidence worldwide. Lymphedema, from the etiopathogenetic point of view can be divided as primary or secondary. Primary lymphedema, also called idiopathic, has no clearly recognizable etiology, although triggering etiological factors can frequently be found. Lymphedemas with onset at birth congenital are included in this category and sometimes are hereditary-familial Nonne-Milroy's disease ,...

Discussion

Chronic nerve compression is one of the most common clinical phenomena in the peripheral nervous system. Surgical decompression of entrapped peripheral nerves is generally efficacious. However, a significant number of patients do not experience good long-term results with this treatment, and the socioeconomic impact is enormous. Multiple attempts of surgical releases can create more scar tissue which develops and further compresses the nerve. The epineural surface of the nerve is surrounded by...

Microsurgery Cost and Outcome Evaluated Thoroughly

The time-consuming and costly nature of this microsurgery requires those appropriate indications and patient management is delineated to operate in this cost-conscious time, financial as well as functional outcome determinations are critical. Some groups, however have assembled cost estimates and made initial inroads into outcomes and measurements of cost effectiveness.63,64 The versatility and vascularity of free tissue transfers have made them indispensable tools for reconstructive surgeons...

Debridement

Radical debridement with elimination of all nonviable tissue is a crucial step in the management of these injuries and is performed under tourniquet control to provide the best visualization of the extent of injury and to prevent iatrogenic injury to intact structures. Once nerves and vessels are identified, the tourniquet may be released, to better assess the viability of the remaining tissue. Skin and subcutaneous tissue are sharply debrided back to bleeding edges. Muscle is debrided until...

Lymphatic Assessment

Based on medical history and objective examination, the time and conditions of onset, location, evolution, and extent, volume, and semiological features of lymphedema can be assessed and a differential diagnosis from phlebedema can be made. Lymphedema is hard to the touch, while venous edema is soft and has the typical fovea sign under finger compression. This difference above all depends on the stagnant lymph being an excellent pabulum for fibroblasts in the subcutaneous connective tissue,...