Abdullah Keçik

Fingertip Replantation at or Distal to the Nail Base: Use of the Technique of Artery-only Anastomosis

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base—namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1–41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in “distal” zone I amputations for approximately 7 days, and by the use of leeches in more “proximal” zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6–18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0–8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts

Ring avulsion replantation is a technically challenging procedure with a very low success rate. Because the zone of arterial injury is more extensive than what it appears to be in such avulsion amputations, a technique was developed to debride the avulsed digital artery for a long distance, extending well into the digital pulp, thereby creating healthy arterial ends to be bridged by one or two segments of long venous grafts. Using this technical approach, 7 patients with complete amputations of ring avulsion injury (Urbaniak’s class III) were operated. In all amputations the bone was disrupted at the distal interphalangeal level (except in 1 patient) and the soft tissues at the proximal phalanx level, with the proximal interphalangeal joint and the flexor digitorum superficialis tendons being intact. Results indicated that replantation was successful in all patients. However, 2 patients presented with unusually late arterial failure 28 and 30 days after surgery respectively. Although one of these cases was salvaged by reoperation, the other case (followed by conservative management) demonstrated partial distal necrosis. Therefore, the ultimate success rate in this series was 85% in the long term. At follow-up, sensibility was protective in all patients, with an average static two-point discrimination of 7.8 mm (range, 6–14 mm). The total active motion of the replanted digits was 194 deg on average (range, 155–205 deg) without loss of function of the proximal interphalangeal joint except in 2 patients who had late vascular problems. The authors conclude that microsurgical replantation of completely amputated ring avulsion injuries with an intact proximal interphalangeal joint and flexor digitorum superficialis tendon, is a worthwhile procedure that results in good functional and aesthetic results. Furthermore, using an aggressive approach for debridement of the avulsed digital artery, as described in this article, an experienced microsurgeon can replant successfully nearly all cases. However, one should be cautious in the follow-up of such patients, because late arterial failure may be encountered, as was observed in 2 patients in this series. The authors suggest immediate reoperation in such unusual circumstances.

Arterialized Venous Dorsal Digital Island Flap for Fingertip Reconstruction

&NA; Fingertip resurfacing is a challenging reconstructive problem; despite the existence of many different surgical methods, enthusiasm on developing versatile flap techniques has been continuing. In this report, we describe an arterialized venous dorsal digital island flap for fingertip reconstruction. The vascularity of the reverse dorsal digital island flap is augmented by performing an arteriovenous anastomosis between a dorsal vein in the flap and one of the proper digital arteries at the fingertip. Eight flaps were used in eight patients for the reconstruction of their fingertip defects. The ages of the patients ranged from 19 to 41 years, with an average of 28.4 years. In two cases, the flap was used as a neurosensorial flap by coapting the dorsal digital radial nerve to the digital nerve. The mean follow‐up was 11 months, and all but one flap totally survived. The operative technique is easy except for the necessity of performing standard microvascular surgery. The flap may be a good alternative for repairing fingertip defects in selected cases. (Plast. Reconstr. Surg. 102: 2368, 1998.)

Microvascular Ear Replantation with No Vein Anastomosis

In replantation of a totally amputated ear, the artery only was repaired with no vein repair. Venous stasis was successfully prevented by daily skin punctures during the first 4 days postoperatively. The elastic cartilage framework with no internally circulating blood constitutes the major percentage of the auricle mass. Thus the metabolic demand of the ear is relatively small, according to its small caliber nutrient vessels. Although the successful result in this single case report means neither a consistent procedure nor uniformly safe choice of treatment, the potential use of the single-artery repair with no accompanying vein anastomosis in ear replantations, we believe, deserves to be considered.

A New Flap Model in the Rat: The Pectoral Skin Flap

The purpose of this study was to describe a new axial-pattern experimental flap model in the rat. Wistar rats weighing 200 to 250 g were used in the experiment. In 15 rats, the superficial anatomy of the ventral thoracic region was studied by anatomic dissection, dye injection, and microangiography, using 5 rats in each group. The anatomic studies revealed that the ventral thoracic skin derives its principal blood supply from the long thoracic artery--a branch of the common thoracic artery. Based on these anatomic studies, the pectoral skin flap model, pedicled on the long thoracic vessels, was created in the rat. The flap is bounded medially by the midsternal line, laterally by the anterior axillary line, and superiorly and inferiorly by transverse lines passing at the level of the suprasternal notch and the xyphoid process respectively. In 5 animals, bilateral flaps (N = 10) were raised and replaced in situ. In 15 animals, oversized flaps were created by extending the flap for both a greater width (N = 10) and length (N = 10). Although all the flaps limited to the cutaneous territory as described were found to survive totally, oversized flaps underwent partial necrosis distally. The authors conclude that the pectoral flap is a simple and reliable skin flap model for future biological and pharmacological study because it is very easy to raise, has a consistent vascular pedicle, and has well-defined borders with consistent landmarks.

Rehabiliation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques

Çetin A, Dinçer F, Keçik A, Çetin M: Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques. Am J Phys Med Rehabil 2001;80:721–728. Objective: Kleinert (active extension, rubber-band passive flexion) and Duran (passive extension, passive flexion) protocols are two basic types of early motion programs for rehabilitation of flexor tendon injuries. Researchers have been working on various modifications or combinations of these two protocols to improve rehabilitation results. The purpose of this study was to analyze the quality of the functional results of flexor tendon repair after a postoperative regimen of early mobilization by use of a combined regimen of modified Kleinert and modified Duran techniques. Design: Thirty-seven patients (74 digits) with repaired flexor tendon injuries were treated. Functional results of the fingers were evaluated by the Buck-Gramcko system and total active motion measurements. Results: The results were excellent in 73% of the fingers, good in 24%, fair in 1.5%, and none was rated poor. Conclusion: Our results are comparable with the previous studies that used various postoperative rehabilitation techniques. This postoperative management provides an effective way of achieving satisfactory results. Patient-assisted passive exercises are very safe and more cost effective than therapist-assisted passive exercises.

Reconstruction of postburn breast deformities

Postburn breast deformity is a sequela of severe scar contraction of the burned chest. During the past 3 years, 24 female patients with such deformities required reconstruction, the surgery was performed in our department. These patients, the types of the deformities and the techniques used for reconstruction have been reviewed. For mild deformities (10 patients) reconstructions with skin grafts and local skin flaps were found to be satisfactory. For deformities which affected the mammary development (14 patients), mammary prostheses directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps were used. In three of our patients, reduction mammaplasty or mastopexy was needed to symmetrize the breasts.

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.

The effects of 5-fluorouracil on flexor tendon healing by using a biodegradable gelatin, slow releasing system: experimental study in a hen model

This study investigated the effects of 5-fluorouracil in a slow-release biodegradable gelatin system on tendon healing. Gelatin blocks prepared in a size of 10 × 20 × 1 mm were loaded with 10, 20, and 30 mg of 5–fluorouracil, and 30 adult white Leghorn chickens were used. The tendons to the third and fourth toes were severed and repaired. The extremities were casted for three weeks. After sacrifice, the tendons were examined histologically and biomechanically for adhesion formation. The 10 mg-loaded gelatin group showed a decrease in adhesion formation when compared with the operative control group; the 20 and 30 mg groups showed signs of severe inflammation. Low doses of 5-fluorouracil applied via a slow-release gelatin system reduced adhesion formation in flexor tendon healing.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days.

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.