Joseph Bakhach

American University of Beirut | AUB · Division of Plastic and Reconstructive Surgery

Pigmented onychomatricoma (OM) is a very rare benign fibroepithelial tumor of the nail matrix. We report the case of a 23-year-old Lebanese man with 15-year history of nail plate dystrophy with longitudinal ridging, yellowish discoloration, excessive transverse curvature and late-onset melanonychia along the medial third of the right thumb nail. Ex...

La reconstruction secondaire des plaies des tendons fléchisseurs des doigts longs représente toujours un challenge pour le chirurgien de la main, en particulier, celles situées en zone II et le défi réside non pas à reconstruire l’anatomie du tendon mais à restaurer sa fonction. La technique que nous proposons consiste à transférer par microchirurg...

La réparation des ruptures des tendons fléchisseurs représente toujours un challenge pour le chirurgien de la main, en particulier, celles situées en zone II. Le problème essentiel réside dans la forme des tendons fléchisseurs « FCS–FCP » et celle des poulies annulaires dont les dimensions sont étroitement liées. Tout changement de forme d’un tendo...

Aim: The ideal flexor tendon repair should be a simple procedure and should provide enough strength to the tendon in order to ensure a good anatomical stumps connection. The surgery must be performed without impairing either the tendon shape or the gliding process, particularly in zone II. Many experimental attempts have been made by using a barbed...

De Quervain tenosynovitis is a chronic, debilitating condition that is more common in females. Multiple modalities of treatment have been proposed and no definitive guidelines have been set yet. In this paper, we present the different treatment options for this condition. Non-surgical treatment consists mainly of anti-inflammatories, steroids and s...

Lebanon is a small country situated on the eastern border of the Mediterranean Sea. It is located in an area of never ending wars and conflict. It is also one of the leading middle eastern countries for medical tourism. The American University of Beirut Medical Center (AUBMC) is one of the biggest tertiary centers in the Middle East North Africa re...

BACKGROUND: DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complications by describing techniques of pulley reconstruction after its release necessitating suturing the...

Background: DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complica- tions by describing techniques of pulley reconstruction after its release necessitating suturing t...

Phalangization of the thumb aims to create a functional thumb in order to restore fingers and hand pinching. It consists of exposing the remaining part of the thumb by deepening the first web space. It is a simple way to render an amputated thumb to become functional. Phalangization of the first metacarpal with dorsal rotational flap is an effectiv...

This chapter describes in detail the surgical steps for performing a groin flap for coverage of extensive soft tissue defect of the hand. The operative note has been generalized so that it can be applied to the hand as well as other areas of the body with appropriate modifications. The approach should allow for an elevation of the groin flap based...

Ulnar collateral ligament (UCL) rupture is often seen in patients practicing sports activities, particularly in ski falls. It usually occurs secondary to chronic metacarpophalangeal instability and degenerative osteoarthritis of the thumb. It is the result of repetitive stretching and abduction stresses of the ulnar collateral ligament and the addu...

This chapter describes in detail the surgical steps involved in replantation of amputated digit(s). Details of managing the amputated part and amputation stump are discussed. Tissue edges of the amputated part are freshened, and nonviable tissue debrided, bony open reduction and internal fixation are performed followed by arterial/venous anastomosi...

This chapter details the surgical steps involved in tendon transfer from the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) to restore wrist extension in patient with high radial nerve palsy. Pronator teres tendon is harvested and transferred subcutaneously around the radial side of the forearm where it is attached to the ECRB ten...

This chapter describes in detail the surgical steps involved in pollicization, creation of a thumb from an index finger. We discuss details of neurovascular bundle preservation, tendon release, metacarpal osteotomy and transfer followed by Kirschner wire-facilitated migration of the bones of the index finger. Indications, preoperative markings, sur...

Radial forearm flap is one of the workhorse flaps in reconstructive surgery. It is a versatile flap that is used for coverage of regional defects in the upper extremity especially the hand, forearm and elbow. However, when modified and used in a reverse pedicled fashion, it is useful for hand soft tissue defects after trauma or after tumor excision...

This chapter describes in detail the surgical steps involved in syndactyly release. Details of soft tissue digit separation and skin flap transposition to form the floor of the newly created web space are discussed. Contingencies for skin shortage leading to inadequate skin closure are also discussed. Indications, preoperative markings, surgical st...

Modern warfare has seen advances in both weaponry and personnel protective material, thus allowing for better survival of injured individuals. As a result, the medical system is faced with an increasing number and diversity of non-life threatening wounds, to the extremities especially, sustained by multiple mechanisms. These wounds have a thermal i...

Hand injuries have been one of the most devastating and disabling accidents that might happen to the civilian or military personnel. Almost all kinds of professions require a certain degree of hand dexterity, and such loss will rebound heavily on the family, society, and economical burden of the state, not only instantly, but also for many years to...

Peripheral nerve war injuries are notorious for their complexity and devastating consequences on patients’ mobility, performance of daily activities, and livelihood. The reconstructive surgical options for these injuries are multiple, intricate, and constantly evolving. A clear knowledge of these options, their correct timing, and the proper pre an...

Brachial plexus injuries can be devastating as they affect a patient’s ability to perform activities of daily living and earn a livelihood. War injuries to the brachial plexus are especially challenging since they comprise multiple mechanisms including penetrating, traction, and thermal injuries. Treatment of war wounds to the brachial plexus shoul...

Over the past years, plastic surgeons in the Middle East and Arab region are dealing with an increasing number of war blast injuries, particularly to the upper extremity and hand, in the acute, subacute, and chronic phases, referred from war zone countries like Iraq and Syria, where the resources to treat such complex injuries are scarce. This chap...

This text provides a comprehensive and state-of-the art approach to reconstruction of the war injured patient tailored to the types of injuries and patients mostly encountered from the Arab region over the past few years at the American University of Beirut Medical Center, one of the largest tertiary care and referral centers in the area and its af...

Background The art of reconstructive microsurgery is still progressing after Carrel's original description of “vascular repair” in 1902. Reports of the successful repair of vessels smaller than 1 mm in diameter are currently commonplace. However, the technique of microvascular anastomosis to connect vessels with large diameter discrepancy, greater...

Introduction: Blast trauma refers to a specific type of tissues injuries combining the adverse effects of the different mechanisms: the shock waves and the overpressure generated by the blast, tissue laceration caused by the fragmentation of the propelled object, injuries and fractures due to the projection of the victim and finally the burns cause...

The patient and operative site were identified and marked. He/she was brought into the operative suite and placed supine on the operating table. The patient was induced into general endotracheal anesthesia without difficulty/ or the patient underwent regional block of the involved extremity. IV antibiotics were administered. A tourniquet over soft-...

The patient was identified by anesthesia in the pre-op area and brought to the operating room. Patient was placed in a supine position on the operating table and all pressure points were padded. The R/L upper extremity was extended onto an arm board. After the induction of satisfactory general anesthesia, the R/L upper extremity was prepped and dra...

Over recent years, hand surgeons in the Middle East and Arabic region have particularly had to deal with an increasing number of war blast injuries to the upper extremity, in the acute, subacute and chronic phases. Many have been referred from War Zone countries such as Iraq and, more recently, Syria, where the resources to treat such complex injur...

Circumcision is a very common urological practice. Even though it is relatively safe, it is not a complication-free procedure. We describe a patient that underwent a neonatal circumcision complicated by iatrogenic complete glans amputation. Reconstructive repair of a neoglans using a modified traditional method was used. Postoperative followup to 9...

Cryopreservation of human cells and tissue has generated great interest in the scientific community since 1949, when the cryoprotective activity of glycerol was discovered. Nowadays, it is possible to reach the optimal conditions for the cryopreservation of a homogeneous cell population or a one cell-layer tissue with the preservation of a high pou...

Nowadays, It is easy to define optimal conditions (cryoprotective agent, speed and steps of freezing, speed of warming) for the cryopreservation of a homogeneous cell population or a one cell-layer tissue. Meanwhile, It is still hard to obtain cryopreservation of composite organs. Each tissue has its own requirements and its own reactivity to the c...

The reconstruction of digital pulp defects is still a challenge in hand surgery. Several reconstructive techniques are available, but in some cases, their advancement capacities are not sufficient for the flap to cover the whole defect. The Gigogne flap is a new, very simple and safe technique. It consists of harvesting two cutaneous flaps successi...

This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted o...

The mobility of our body structures is so intrinsic and natural to us that we tend to take it for granted. The very fact of being able to pinch your skin and lift it, then let it go and see it return to its initial shape and texture in just a few seconds may seem banal enough until you begin to think of all the elements involved. The same is true w...

A still unresolved issue in human physiology is the mechanism of natural organ intermobility. Nevertheless, in front of this physiological phenomenon, incorporating skin, arteries, nerves, tendons, and muscles, we have to ask new questions. But any explanation has to conform with current knowledge and technologies; it cannot rely on observations fr...

Reconstruction surgery requires imagination, inventiveness, and creation-a quest that entails overcoming obstacles never before encountered. Over the past 25 years, with the advent in microsurgery of free revascularized transfers, it was believed that this fundamental breakthrough would be sufficient to resolve difficulties of whatever nature, and...

Two cases of a human vascularized allotransplant of a complete digital flexion system are reported with detailed descriptions of the dissection technique and postoperative treatment. Satisfactory functional results open new prospects for this type of transplantation surgery.

Microsurgery and human allotransplantation progress as well as the improvement of immunosuppressive drugs actually allow the development of the composite tissue allotransplantation. One of the latest challenges in plastic surgery is to restore the anatomic and functional structures using similar tissues. Composite tissue allotransplantation will pr...

The cryopreservation of cells and human tissues has generated a great interest from the scientific community since 1949 when the cryoprotective activity of glycerol was discovered. For a homogeneous cellular group or a one-layer cellular tissue it is easy to define the optimal technique conditions of its cryopreservation (cryoprotective agents, spe...

The cryopreservation of cells and human tissues has generated a great interest from the scientific community since 1949 when the cryoprotective activity of glycerol was discovered. For a homogeneous cellular group or a one-layer cellular tissue it is easy to define the optimal technique conditions of its cryopreservation (cryoprotective agents, spe...

Two cases of a human vascularized allotransplant of a complete digital flexion system are reported with detailed descriptions of the dissection technique and postoperative treatment. Satisfactory functional results open new prospects for this type of transplantation surgery.

The authors present the results of their surgical experience based on an original approach in secondary reconstructing 71 flexor tendons of the hand. For 20 years, they have been using vascularized tendon transfers either islanded or as free transfers. Their techniques are based on extensive knowledge of the sliding mechanisms involved around the f...

Les travaux anatomiques récents ont puisé dans la face dorsale de la main une réserve de lambeaux précieux pour la reconstruction des pertes de substance des doigts. La présence d’une laxité cutanée naturelle, d’une peau fine et souple et d’une coloration identique à celle de la peau digitale dorsale font d’elle le site donneur idéal.

At the end of the seventy, we saw the reconstructive microsurgery developed to such an extent that it became a new and an independent surgical specialty. The development of the microsurgical instrumentation and the description of the surgical anatomy allowed the application of this technology to the most complex plastic reconstructions and particul...

At the end of the seventieth, we saw the reconstructive microsurgery developed to such an extent that it became a new and an independent surgical specialty. The development of the microsurgical instrumentation and the description of the surgical anatomy allowed the application of this technology to the most complex plastic reconstructions and parti...

The authors report a new cutaneous flap harvested from the dorsal and distal quarter of the forearm: the dorsoradial flap. The vascularisation type of the cutaneous paddle belongs this flap to the anterograde and axial family flaps. The anatomical study carried out on thirty six fresh cadaver upper arms showed a constant and a consistent cutaneous...

Les auteurs décrivent une technique originale de prise en charge chirurgicale de la ténosynovite de De Quervain. Cette ténosynovite correspond à un conflit d'ordre mécanique entre la poulie styloradiale et le tendon de l'abductor pollicis longus, de l'extensor pollicis brevis ou les deux. Le traitement chirurgical classique comprend des risques de...

The authors report a new cutaneous flap harvested from the dorsal and distal quarter of the forearm: the dorsoradial flap. The vascularisation type of the cutaneous paddle belongs this flap to the anterograde and axial family flaps. The anatomical study carried out on thrirty six fresh cadaver upper arms showed a constant and a consistant cutaneous...

Les auteurs décrivent une technique originale de plastie d'expansion des poulies ostéofibreuses du tunnel digital (A2 et A4). Il ne s'agit pas d'une procédure opératoire de reconstruction des poulies annulaires, mais d'une plastie d'agrandissement du périmètre de la poulie dont la structure anatomique est totalement respectée. La réparation primiti...

Distal digital amputations may result in composite tissue loss, affecting both the fingertip and the nail complex. Most surgical procedures that are used for fingertip reconstruction do not restore the nail defect. The eponychial flap is a new technique where a backward plication of the nail wall is used to expose the nail root and lengthen the vis...

The mobility of our body structures is so intrinsic and natural to us that we tend to take it for granted. The very fact of being able to pinch your skin and lift it, then let it go and see it return to its initial shape and texture in just a few seconds may seem banal enough until you begin to think of all the elements involved. The same is true w...

We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and...

Deux cas cliniques de revascularisation ectopique temporaire pour sauvetage d'amputations complètes de six doigts longs sont exposés. Dans le premier cas où deux doigts longs amputés sur quatre ont été récupérés, le site d'implantation ectopique sélectionné est la face dorsale du pied avec l'artère dorsale du premier espace intermétatarsien et la v...

Le but de ce travail est d’approcher les mécanismes qui assurent le drainage du sang veineux à contre-courant dans les lambeaux cutanés en îlot rétrograde. Un travail expérimental est mené sur douze lapins. Le modèle expérimental retenu est le lambeau cutané fémoral superficiel. Sur chaque lapin, deux lambeaux fémoraux superficiels sont levés : un...

Les auteurs décrivent un nouveau lambeau cutané prélevé sur le bord dorsoradial du poignet pour le traitement des pertes de substance dorsale du pouce et de la main. Un travail anatomique, effectué sur seize mains, met en évidence la présence d’une branche constante de l’artère radiale, à destinée cutanée, au niveau de la base de la première commis...

Les arthrodèses des 4 coins ne permettent pas d’obtenir des secteurs de mobilité satisfaisants, alors que les résections de la première rangée pêchent par le caractère aléatoire des résultats, même si la tête du capitatum est parfaite, ceci étant sans doute lié à l’incongruence des surfaces mises en contact. Les auteurs rapportent une série de leur...

Le principal écueil technique des transferts libres microchirurgicaux, lié au développement récent d’un grand choix de site donneur, est la réalisation de sutures terminoterminales artérielles ou veineuses, de vaisseaux de diamètre incongruent avec des ratios de 2/1 à 3/1. Les auteurs présentent une nouvelle technique : la plastie vasculaire en « V...

In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supr...

The authors describe a new chondrocutaneous reverse island flap from the ear helix for nose and eyelid reconstruction. Anatomic studies showed that the blood supply of the helix is derived from the superficial temporal system. The presence of vascular communications between the anterior frontal branch of the superficial temporal artery and the supr...

The dorsal digitometacarpal flap or extended distal pedicled dorsal metacarpal flap is a new skin flap, useful in reconstructing large distal defects on the dorsal aspect of the digits. It is raised on the dorsum of the hand, over an intermetacarpal space. Its vascularisation is provided by proximal dorsal cutaneous branches of the digital collater...

Reverse dorsal digital and metacarpal flaps use the dorsal skin of the digital or metacarpal areas, and they are based on the arterial branches anastomosing the volar and dorsal arterial networks of the fingers. These flaps are transposed as reverse island flaps. Dissection of the flap is easy, fast, and preserves the collateral nerve and artery to...

Two original operative techniques of raising the extensor digitorum brevis muscle flap are presented. These methods allow for covering distal foot defects that are difficult to cover by other reconstructive means. In the first technique, the flap is based on an extended distal pedicle supplied by the dorsal interosseous artery of the first intermet...

The author describes an original and new method to lengthen the fingernail plate in distal digital amputation. After digital amputation, the loss of substance concerns the pulp tissue and fingernail apparatus. Generally, most palmar falp techniques can restore functional and aesthetic pulp. The fingernail defect is obviously not tolerated by the pa...

We report a case of hypothenar hammer syndrome. The ulnar artery aneurysm was resected and a complete thrombectomy of the superficial palmar arch, the common digital and the proximal part of the collateral digital arteries was carried out. The arterial defect of the ulnar artery was repaired by a vein graft. Post-operatively, no clinical improvemen...

The authors describe an original technical modification of the extensor digitorum brevis muscle flap. As described, its use in a classical reverse flow manner allows the flap to reach only the metatarsophalangeal joints. The presence of the first dorsal interosseous pedicle offers the possibility to sacrifice the plantar anastomoses of the pedis pe...

From all of the flaps reviewed, it is important to know how to select the most suitable choice in each case. Aside from the technical expertise of the surgeon, the indication depends on the size and the location of the substance loss. For large defects in any location, the radial forearm flap remains the most reliable and safest choice. For childre...

The "extreme" lateral arm flap is a new method for covering the distal upper limb. This flap is a modification of the classical lateral arm flap allowing his transfer as a pedicled flap to cover the forearm and the wrist. This technique is based on a new concept: "the reverse flow VY pedicle advancement". This requires an arterial bifurcation of th...

A short arm stump was lengthened with a composite flap with four different tissue units based on the subscapular artery.

The parametacarpal ulnar flap is raised from the dorsal and ulnar aspect of the hand. It is vascularized by the distal division of the dorsal branch of the ulnar artery. The skin flap is innervated by the dorsal sensory branch of the ulnar nerve helpfull for the reconstruction of skin loss of the palm. At the level of the metacarpo-phalangeal joint...

The author has selected and updated four subjects in Plastic Surgery research. All flap monitoring procedures are detailed. They are still insufficient, as none of them can be used in all clinical situations. Free radicals have been implicated in the extension of necrosis after reperfusion of an ischaemic flap. Many substances have been tested for...

The ulnar border of the hand provides a new skin flap which is very useful in the reconstruction of defects of the palm of the hand and ulnar fingers. An anatomical study of the dorsal carpal branch of the ulnar artery and its various branches has led us to propose the ulnar parametacarpal flap either as a pedicle or free microsurgical transfer. Th...

Bone growth and the development of epiphyseal plates are disturbed after the replantation of amputated extremities in children, but the potential for continued skeletal growth is almost always maintained in the replanted part. In this reported series of 12 children, all younger than 15 years old, 13 amputated parts of the upper limb have been succe...

The authors present a new surgical procedure which allows the transfer of pedicled flaps distally to the origin of their vascular pedicle. They call this procedure the "reverse-flow YV pedicle extension of a flap". The idea is to raise a flap distally on a branch of a Y-like vascular bifurcation. The section of the trunk of the bifurcation turns th...

The authors present a new application of the procedure they called the "reverse flow YV pedicle extension" which allows a very distal pedicled mobilisation of the lateral arm flap. Until now, only the distally based lateral arm flap and the ulnar recurrent fascicutaneous island flap could to be transferred distally but reached only the proximal thi...