-
[show abstract]
[hide abstract]
ABSTRACT: A novel microvascular anastomosis technique is described. Forty-five male Sprague-Dawley rats were divided equally into three groups before undergoing femoral artery anastomosis. The first group received standard eight-suture anastomotic repair. Group 2 (muscle group) received three sutures plus autogenous muscle graft wrapped around the anastomosis. In group 3 (fascial surface group), a muscle graft was wrapped around the anastomosis with the fascial side of the graft facing the anastomosis. Significantly less time and suture usage were noted using both fascial surface and muscle groups compared with controls (p < 0.05). No significant difference regarding patency rates or aneurysm formation existed among the three groups (p > 0.05). Additionally, grade 2 anastomotic leakage was less frequent in the study groups compared with the control group (p < 0.05). This new microvascular anastomosis technique took less time and achieved better performance than standard anastomotic repair.
Journal of Reconstructive Microsurgery 06/2012; 28(8):501-8. · 1.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Hyperhomocysteinemia is an independent risk factor for atherothrombotic disease and venous thrombosis. The effects of hyperhomocysteinemia on the microcirculation were studied in vascular diseases. The authors aimed to investigate the effects of hyperhomocysteinemia on the microcirculation of random-pattern skin flaps.
Twenty-two male Sprague-Dawley rats, divided into two groups, were used in this study. The rats in group 1 (control) were fed the TD.07112 diet, and the rats in group 2 (experimental group) were fed the TD.07114 diet, enriched in methionine for 30 days, to induce severe hyperhomocysteinemia. The plasma homocysteine, folic acid, vitamin B12, and vitamin B6 levels were evaluated on days 0 and 30. Distally based skin flaps were elevated on day 30 and evaluated by direct observation, microangiography, and light microscopy on day 37.
Mean homocysteine blood levels were 211.76 ± 56.55 μM/liter in group 2 and 14.48 ± 2.00 μM/liter in group 1 on day 30. The rate of necrosis was significantly higher in group 2 (59.00 ± 4.38 percent) compared with group 1 (32.54 ± 6.13 percent; p < 0.01). Microangiographic findings were similar to direct observation results. Microvessel calibration was reduced in group 2. In group 1, structures of epidermis and dermis were normal; however, there was a slight mononuclear cell infiltration along with thick collagen fibers. A more prominent mononuclear cell infiltration with fields of loose epidermis, associated with inflammation and infiltration, were observed in group 2.
The authors demonstrated, for the first time, that hyperhomocysteinemia severely suppressed the microvasculature of skin flaps, as shown by increased flap necrosis and reduced microvessel calibration in the experimental group.
Plastic and reconstructive surgery 09/2011; 128(3):124e-130e. · 2.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We hypothesized that an osseous tissue can be prefabricated with a peripheral nerve by vascular induction, and by using a rat model, we tested this hypothesis.Twenty Wistar rats were used in the prefabricated neuro-osseous flap study. Bilateral sciatic nerves were placed linearly within the medullary cavities of the femurs. Left femurs were accepted as the experimental group. The right femurs of all the rats were used as internal control where the sciatic nerves were ligated at the bony entrance of the flap.After 6 weeks, all experimental femur flaps were viable. Radioactivity counts and metabolic activity studies showed viable and functional bone tissue in experimental group compared with control group (P = 0.001). On microangiographic evaluation, significant dilatation of the perineural vasculature was observed in experimental group. Histologic investigations showed viable bone tissue only in the experimental group flaps.Due to its easy applicability, reproducibility, and robust circulation, the prefabricated neuro-osseous flap would be an option in reconstructive surgery.
Annals of plastic surgery 08/2011; · 1.29 Impact Factor
-
Journal of hand and microsurgery. 06/2011; 3(1):28-30.
-
[show abstract]
[hide abstract]
ABSTRACT: Reconstruction for facial contour deformities is still a challenging process and treatment for most cases is achieved only by soft tissue augmentation. The use of free tissue transfer offers the advantage of one step vascularized soft tissue augmentation. This article summarized the authors' use of de-epithelialized free superficial circumflex iliac artery/superficial inferior epigastric artery flap for facial contour deformities. Of these patients, two had hemifacial microsomia, one depressed scar, and one had hemifacial progressive atrophy. Stable restoration of the facial contour was achieved in all patients. The advantages of this flap are numerous. Two surgical teams may work at the same time for flap harvesting and recipient area preparation. A wide flap may be planned for large contour deformity to achieve one single stage augmentation. Pedicle course of this flap allows primary de-fating without disturbing distal flap circulation when in need of a thin flap for mild contour deformity. Donor site may be closed with bikini (abdominoplasty) incision, which has excellent esthetic outcome compared to other flaps.
Microsurgery 07/2008; 28(5):333-8. · 1.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to demonstrate the new concept of a consistent and reliable skin-flap design supplied solely by the intrinsic vasculature of a split cutaneous nerve. A total of 88 Wistar rats were used in this experiment, which was divided into three parts. In Part I (n=20), the vascular anatomy and the fascicular anatomy of the lateral femoral cutaneous nerve were established. In Part II (n=44), split neural-island flaps were created. Two skin flaps (measuring 2x3 cm each) were harvested based solely on the lateral femoral cutaneous nerve, which was split into two based on its fascicles. In Part III (n=24), a surgical delay procedure was applied in order to augment the survival areas of split neural-island flaps. On postoperative day 7, the viability of all flaps was evaluated. The results of the anatomic studies demonstrated that the lateral femoral cutaneous nerve consisted of usually two (80%), rarely three, fascicles (20%). Meticulous dissection enabled us to separate these fascicles without disrupting the perineural vasculature around each fascicle. The mean flap survival rate in the acutely elevated split neural-island flap group in Part II was 6.2+/-3.1%, whereas survival in the graft group was 0.0%. Results of Part III of the experiment demonstrated a significantly higher survival rate for the delayed split neural-island flap (98.5+/-2.8%) compared to the acutely elevated split neural-island flap (P<0.05). In conclusion, this is a reliable skin flap that can be nourished solely by the intrinsic vasculature of an interfascicularly dissected ('split') nerve.
Journal of Plastic Reconstructive & Aesthetic Surgery 11/2007; 62(1):85-92. · 1.49 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although ring avulsion injuries are not common, when they do occur their management is still a challenging problem in reconstructive surgery. In this report, we present our microsurgical experiences with Kay's class III and IV ring avulsion injuries. A total of six patients with ring avulsion injuries were operated on between 2000 and 2004. Three patients were in class III with inadequacy of both arterial and venous circulation, and the remaining three were in class IV. The study consisted of four male and two female patients whose ages ranged from 23 to 43 (mean age 32). Average ischaemic time was 2.2 h (range 1-4 h). The ring finger was involved in all cases and microsurgical repair was performed using axillary block anaesthesia. The bone was detached at the level of the distal interphalangeal joint and soft tissues at the proximal phalanx level with the preserved proximal interphalangeal joint and flexor digitorum superficialis tendon in all cases. Because the zone of injury is more extensive, we debrided the avulsed digital artery over a long distance, and used long interpositional vein grafts radically in all patients. Venous drainage was accomplished by performing at least two vein anastomoses using vein grafts when necessary. Both digital nerves were repaired primarily after debridement. Results indicated that microsurgical repair had a success rate of 100%. The authors conclude that microsurgical reconstruction of ring avulsion injuries with intact proximal interphalangeal joint and flexor digitorum superficialis tendon yields superior results, both functionally and aesthetically, even in complete amputation.
Journal of Plastic Reconstructive & Aesthetic Surgery 02/2006; 59(5):451-9. · 1.49 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Since the introduction of flaps based on the vascular structures of the cutaneous nerves, these have gained increasing popularity in reconstructive surgery. The purpose of this study is to describe a new concept in which the flap is supplied solely by the intrinsic vasculature of a motor nerve. A total of 94 Wistar rats weighing 200-250 g were used in this experiment, which was divided into three sections. In section I, the neural anatomy of the posterior thigh region was investigated. In section II, the flap study using experimental and control groups, was performed. In the experimental group neuromuscular and neuromusculocutaneous flaps were created. The biceps femoris muscle was harvested based solely on its motor nerve as a neuromuscular flap, and together with its overlying skin it was similarly raised as a neuromusculocutaneous flap. In the control group, conventional muscle and musculocutaneous flaps were harvested based on the caudal femoral-popliteal artery vascular axis, and a graft subgroup was created ligating both the constant vascular structure and the motor nerve. In section III, with the intention of augmenting the survival areas of neuromuscular and neuroumusculocutaneous flaps, a surgical delay procedure was applied. On postoperative day 7, the viability of all flaps was evaluated using direct observation, microangiography, and tetrazolium blue stain techniques. The results of the anatomic studies demonstrated a consistent motor nerve arising from the sciatic nerve to the biceps femoris muscle with evident perineural vasculature. Average muscle viability levels of neuromuscular, neuromusculocutaneous, delayed neuromuscular, delayed neuromusculocutaneous, conventional muscle and musculocutaneous flaps were 20.6 +/-7.58, 22.4 +/- 4.21, 86.4 +/- 6.14, 85 +/- 4.21, 89.6 +/- 4.48, and 88.0 +/- 5.51%, respectively. Survival levels of the skin paddles of the neuromusculocutaneous, delayed neuromusculocutaneous, and conventional musculocutaneous flaps were calculated as 13 +/- 17.51, 67 +/- 30.29, and 97+/-4.21%, respectively. In the graft subgroup the viability of muscle and skin paddle was almost nil. In conclusion, our new flap model in a favored laboratory animal is of benefit to researchers in providing a means for future various types of investigations into this new concept. The technique might be considered in further experimental research studies and appropriate clinical situations.
Journal of Plastic Reconstructive & Aesthetic Surgery 02/2006; 59(3):279-90. · 1.49 Impact Factor
-
Plastic and reconstructive surgery 07/2005; 115(7):2062-9. · 2.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.
Plastic and reconstructive surgery 12/2004; 114(6):1467-77. · 2.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.
Plastic and reconstructive surgery 11/2004; 114(5):1118-22. · 2.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A case of nearly complete amputation of the alar wing is presented whereby a successful arterial revascularization was accomplished using an arterial rerouting technique. Venous stasis was overcome by means of stab-wound wiping. An excellent result was obtained following complete survival of the revascularized segment. The authors conclude that microvascular revascularization should always be attempted whenever possible, even if a skin bridge is preserved in nearly complete amputations of the nose.
Annals of Plastic Surgery 09/2004; 53(2):181-4. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This report presents a case of microsurgical replantation of a volar skin segment of the thumb. In a 24-year-old patient, a heavy object falling over the dominant thumb resulted in a crush-avulsion injury of a pure skin segment measuring 4 x 2 cm. Examination revealed that the distal fingertip as well as the bone-tendon structures remained intact. Exploration demonstrated that both neurovascular bundles were included in the avulsed skin segment. Microsurgical replantation was achieved successfully, repairing the radial digital artery at both ends with vein grafts as well as anastomosing a palmar vein. Both digital nerves were coapted proximally and distally. An excellent functional and cosmetic result was accomplished with a good sensory recovery. The authors conclude that microsurgical replantation should be attempted in cases of more proximal pure skin avulsions, even if the injury spares distal fingertip tissue or bone-tendon units. In such cases, replantation is superior to any other method of reconstruction. Liberal use of vein grafts is crucial to achieve success.
Annals of Plastic Surgery 07/2004; 52(6):614-6. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A deep burn injury of the right upper extremity in a 12-month-old boy was successfully reconstructed with a tensor fascia lata free flap taken from an acutely burned donor thigh, as a healthy donor site was not available elsewhere. The result was satisfactory.
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 02/2004; 38(6):370-2. · 0.94 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study presents a technique that preserves osseous viability in prefabricated osteocutaneous flaps with a soft-tissue vascular carrier, with a pedicled skin flap acting as the vascular carrier to neovascularize a partially devascularized bone segment before its transfer. Using a total of 50 New Zealand White rabbits, two groups were randomized as experimental and control animals. In the experimental group (n = 30), a bipedicled dorsal scapular skin flap was anchored with sutures to the scapular bone, by bringing it into contact with the exposed dorsal surface of the bone after stripping the dorsal muscular attachments. Following 4 weeks of neovascularization, the prefabricated composite flaps were harvested, based on the caudally-based dorsal skin flap, after stripping the ventral muscular attachments of the bone. In the control group (n = 20), non-vascularized scapular bone grafts were implanted under bipedicled dorsal scapular skin flaps with sutures. After 4 weeks, prefabricated composite flaps were harvested, based on the caudally-based dorsal skin flap. In both groups, on day 7 after the second stage, the viability of the bony component of the flaps was evaluated by direct observation, scintigraphy, measurement of bone metabolic activity, microangiography, dye injection study, and histology. Results indicated that the bone segments in the experimental group demonstrated a greater survival than in the control group. The authors conclude that this technique of osteocutaneous flap prefabrication preserves the viability of the bony component with a soft-tissue vascular carrier, in contrast to the conventional method of pre-transfer grafting. The technique may be useful clinically in selected cases.
Journal of Reconstructive Microsurgery 12/2003; 19(8):571-6. · 1.43 Impact Factor
-
Plastic & Reconstructive Surgery 09/2003; 112(2):589-92. · 3.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Taking pictures of microstructures is difficult, requiring sophisticated cameras coupled by the microscopes. Furthermore, it may not be feasible to find an operating microscope paired with a camera, especially in laboratory conditions. Considering the difficulty of obtaining microscopic photographs in clinical and laboratory settings, this report describes a practical method of digital photography of microstructures using a consumer-type digital camera. The technique can be summarized simply as placing the lens of a consumer-type digital camera over the eyepieces of a surgical microscope, whereby the anatomic structure of interest is focused. The image thus obtained is transferred to the computer, using easily available software programs. The authors conclude that this method is an inexpensive and practical way of capturing photographs of microstructures, obviating the need for using microscopes coupled by the cameras.
Annals of Plastic Surgery 03/2003; 50(2):204-6. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A modifed design for the distally-based radial forearm flap is presented, in an oblique direction rather than longitudinally, based on the existence of skin laxity in the proximal forearm region. The skin paddle of the flap is designed in an oblique fashion pedicled on one of the proximal-row septocutaneous perforators, and elevated in the usual manner supplied by the distal radial artery. The oblique radial forearm flap thus created was successfully utilized for reconstruction of seven dorsal hand defects. Results showed that all the flaps could easily be transposed to the defect through a wide arc of rotation and all survived totally, with direct closure of the donor site in five cases, and significant reduction in size in the remaining two cases. It was concluded that the oblique design for the skin island of the reverse radial forearm flap could allow creation of a flap that has a smaller donor defect and yet presents a longer pedicle length, with a wider arc of rotation and better adaptation to a dorsal hand defect, than a conventional longitudinal-design radial forearm flap.
Journal of Reconstructive Microsurgery 02/2003; 19(1):3-6. · 1.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study was performed to quantify the reinnervation of denervated muscle in a split-nerve transfer model and to determine any possible downgrading effects on the donor nerve and its end organ. Fifty-four adult Wistar rats weighing 200 to 250 g were used. The experimental design consisted of two groups. The motor nerve branch to the anterior tibial muscle and gastrocnemius muscle of the right hind limb were dissected in all rats. In the experimental group (N = 36), the motor nerve branch of the tibial nerve to the gastrocnemius muscle was exposed, cut, and ligated. The motor nerve branch to the anterior tibial muscle was split and transected longitudinally, and the medial half was routed posteriorly. End-to-end neural anastomosis was performed between this medial half of the split nerve and the distal stump of the gastrocnemius nerve. In the control group (N = 18), while the same surgical preparation was performed, the motor nerve branch to the anterior tibial muscle and gastrocnemius nerve were exposed and transected, and the nerve endings were ligated, but neural anastomosis was not performed between these nerves. The left hind limb of all rats served as a normal comparison side without any surgical intervention. Both of the groups were divided into three subgroups (12 rats each for the experimental groups and 6 rats each for the control group) to evaluate the results after periods of 1, 3, and 6 months. Electromyography, light microscopic and morphometric examination, and muscle weight measurements were used to document the results. Although stimulation of the peroneal and tibial nerves did not produce any compound muscle action potential (CMAP) recordings from either the anterior tibial or the gastrocnemius muscle in the control group, the normalized CMAP areas of the tibial nerve were (mean +/- standard deviation) 16.2 +/- 30.8% in the 1-month group, 63.4 +/- 34.7% in the 3-month group, and 72.4 +/- 16.3% in the 6-month group. For the peroneal nerve, the normalized CMAP areas were 17.0 +/- 32.2%, 53.4 +/- 29.4%, and 54.4 +/- 14.5% for the 1-, 3-, and 6-month groups in the experimental groups respectively. A high number of regenerating myelinated nerve fibers was identified in the distal part of the coapted motor nerve branch to the gastrocnemius muscle. The average number of myelinated fibers in the lateral half of the split nerve in the experimental group was 15,108 fibers per square millimeter, 14,167 fibers per square millimeter, and 19,830 fibers per square millimeter at months 1, 3, and 6 respectively. The average number of fibers proximal to the nerve anastomotic site was 15,423 fibers per square millimeter, 19,200 fibers per square millimeter, and 20,774 fibers per square millimeter. Distal to the nerve anastomotic site, the number of myelinated fibers was 17,941 fibers per square millimeter, 18,885 fibers per square millimeter, and 18,895 fibers per square millimeter at 1, 3, and 6 months respectively. There were no myelinated fibers in the control group sections. There were significant differences in muscle weight between the experimental and control groups at the end of month 6. The difference between the experimental side and the untouched normal healthy side was not significant in the weight measurements of both muscles. The results show acceptable reinnervation by split-nerve transfer with minimal functional impairment of the donor muscle. This study confirms that split-nerve transfer is a reliable method of reconstruction for paralyzed muscle with minimal donor area morbidity.
Annals of Plastic Surgery 12/2002; 49(5):532-40. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this report, a simple technique is described to restore the continuity of the recipient artery in cross-leg free flap procedure after end-to-end anastomoses. In the first stage, the latissimus dorsi flap was revascularized by end-to-end anastomosis between the posterior tibial artery of the noninjured leg and the thoracodorsal artery of the flap. After 4 weeks of neovascularization period, in the second stage when the pedicle was to be divided, the thoracodorsal artery was dissected until its bifurcation in the muscle, transected, and rerouted to the distal ligated end of the posterior tibial artery, accomplishing a simple end-to-end anastomosis between these two vessel ends. Thus, the continuity of the recipient artery was re-accomplished by replacing the normally discarded segment of the flap's arterial pedicle as an arterial graft, the patency of which was demonstrated clinically and by Doppler examination. The authors believe that this technique provides further benefit to the patient by accomplishing vascular flow through a major lower limb artery when the reconstructive pathway involves an end-to-end anastomosis in a cross-leg free flap procedure.
Annals of Plastic Surgery 11/2002; 49(4):430-3. · 1.32 Impact Factor
