Berish Strauch

A prospective clinical evaluation of autogenous vein grafts used as a nerve conduit for distal sensory nerve defects of 3 cm or less.

The purpose of this study was to determine the efficacy of autogenous vein grafts as nerve grafts (AVNC) for bridging of small peripheral sensory nerve gaps as compared with direct repair and with conventional nerve grafting techniques (ANG). Patients with painful neuroma or segmental nerve injury of 3 cm were chosen as the test group. Those amenable to direct repair were classified as controls. Between 1982 to 1988, a total of 22 patients were enrolled in this study. A total of 34 nerves were repaired, 15 with a venous nerve conduit, 4 with a sural nerve graft, and 15 with direct repair. Significant symptom relief and satisfactory sensory function return were uniformly observed. The two-point discrimination measurements indicated superiority of direct repair and probably of conventional nerve grafting. However, the universally favorable patient acceptance and the return of measurable two-point discrimination indicates the effectiveness of autogenous vein grafts as nerve conduits when selectively applied to bridge a small nerve gap (less than or equal to 3 cm) on nonessential peripheral sensory nerves.

Arterial system of the fingers

The arterial system in 141 fresh human cadavers was studied under the operating microscope using magnifications of 8 to 25 times. The vascular system was injected with latex material alone for identification of the vessels during dissection, and with latex and lead for x-ray contrast studies. An overall repetitive pattern in size, location, and distribution of the vessels was noted. The dorsal branches of the paired digital vessels in each phalanx were generally 4 and demonstrated a regular, repetitive distribution corresponding to: a, condylar vessel; b, metaphyseal vessel; c, dorsal skin vessel; and d, transverse palmar arch. Proximal and middle transverse palmar arches were found always in relation to the cruciate ligaments. The distal transverse palmar arch lay just distal to the insertion of the profundus.

Neovascularization of skin flaps: route and timing.

Axial flaps were elevated in a pig and rat model. Selective ligation of the vascular pedicles on days 1 to 7 following elevation of the flap demonstrated total necrosis of all flaps when the pedicles were ligated on the first, second, and third postoperative day in the pig, and up to 6 days inthe rat. Pedicle ligation beyond this time did not produce flap necorsis, indicating the establishment of adequate neovascularization for flap survival. Selective ligation of the artery or vein did not appear to be significant in the pig. In the rat flap, however, survival tended to occur sooner. Adequate neovascularization for flap survival was demonstrated as arising from both the wound edges and the bed, although vascular channels occurring from the bed appeared to be of greater importance. The relatively rapid rate of neovascularization that occurs for adequate flap survival suggests that if some way could be found to maintain flap viability during the first week, the feeding vessels need no longer remain patent and may be ligated or used for other purposes. This interesting observation has already allowed very early successful defatting of clinically transferred flaps.

Improved survival of island flaps after prolonged ischemia by perfusion with superoxide dismutase.

Perfusion of rat groin flaps after 10 and 11 hours of complete ischemia with superoxide dismutase, an oxygen free-radical scavenger, significantly improved the survival of these flaps. This finding provides further evidence for the important role that oxygen-derived free radicals play in ischemic injury. The study also demonstrates that while restoration of blood supply alone is not enough to ensure tissue survival after prolonged ischemia, chemical agents can be utilized to achieve viable flaps beyond what was believed to be “a point of no return.”

Pulsed magnetic fields accelerate cutaneous wound healing in rats.

Background: Previous studies of pulsed magnetic fields have reported enhanced fracture and chronic wound healing, endothelial cell growth, and angiogenesis. This study characterizes the biomechanical changes that occur when standard cutaneous wounds are exposed to radiofrequency pulsed magnetic fields with specific dosage parameters, in an attempt to determine whether return to functional tensile strength could be accelerated in wound healing. Methods: There were two study phases and a total of 100 rats. In phase 1, wounds were exposed to a 1.0-G pulsed magnetic field signal in clinical use for wound repair for 30 minutes twice daily for 21 or 60 days. Phase 2 was a prospective, placebo-controlled, double-blind trial in which rats were treated for 30 minutes twice daily with three different low-amplitude signals (0.02 to 0.05 G), configured assuming a Ca2+ binding transduction pathway, for 21 days. A midline, 8-cm, linear skin incision was made on the rat dorsum. Tensile strength was determined by measuring the point of rupture of the wound on a standard tensiometer loaded at 0.45 mm/second. Results: The mean tensile strength of treated groups in phase 1 was 48 percent (p < 0.001) greater than that of controls at 21 days; there was no significant difference at 60 days. In phase 2, the treated groups showed 18 percent (not significant), 44 percent, and 59 percent (p < 0.001) increases in tensile strength over controls at 21 days. Conclusion: The authors successfully demonstrated that exposing wounds to pulsed magnetic fields of very specific configurations accelerated early wound healing in this animal model, as evidenced by significantly increased wound tensile strength at 21 days after wounding.

The ten test.

&NA; The authors describe a new test for clinical sensibility, initiated in response to the need of the senior author for a rapid, reliable method to evaluate sensibility. Using this test, the patient develops a ratio between normal light moving touch and diminished moving touch. Subsequent determinations can detect serial changes. The ratios obtained can be compared with a standard scale of sensibility with a high degree of validity and reliability. The interexaminer and intraexaminer results obtained are reliable and repeatable. Statistical evaluations substantiating the validity of the test are presented. Simplicity and dependability recommend this test for use in a busy clinical setting.

The role of lateral pharyngeal wall movement in pharyngeal flap surgery.

A total of 202 patients with pharyngeal flaps were assessed with nasopharyngoscopy and multiview fluoroscopy to determine the role of lateral pharyngeal wall movement postoperatively. Variations in the construction of flaps resulted in three categories: namely, a long narrow flap with a high insertion, a short broad flap with a low insertion, and an intermediate-size flap that is inserted in a position somewhere between the first two. It was found that in all cases where there was no evidence of velopharyngeal insufficiency, the sole determiner of velopharyngeal closure was the medical excursion of the lateral pharyngeal walls to the sides of the flap. In flap failures, the causes for velopharyngeal insufficiency were inappropriate degree, level, and symmetry of the lateral pharyngeal wall motion. The success of pharyngeal flap surgery depends largely on the preoperative assessment of the velopharyngeal mechanism and the choice of a type of pharyngeal flap that will best assist closure of the velopharyngeal port during speech.

Digital flexor tendon sheath: An anatomic study

The flexor sheath of 72 fresh human cadaver digits was examined under the operating microscope utilizing fiberoptic and polarizing light sources. Magnifications of eight to 25 times were used during the dissection. The vascular system was injected with latex material, and longitudinal and cross sections of the tissues were studied histologically. The flexor sheath is seen to be a contained bursal environment with specialized anatomy to provide for flexion and extension. The formerly perplexing pulley system is now seen to be an orderly repeating system of proximal and distal pulleys. The anatomic relationships of the vessels to the proximal cul-de-sac and vincular system are described.

1457 years of microsurgical experience

&NA; Microsurgery is a relatively new field of surgery involving various methods and practices that are currently evolving. Our goal was to register the current practices employed by the members of the American Society for Reconstructive Microsurgery. A survey was mailed to the 319 members of the society, resulting in a response rate of 33 percent (106 of 319). The data reflect the combined experience of 10,839 free‐tissue transfers and 3487 digital and upper and lower extremity replants over a 4‐year period between 1990 and 1994. Practices employed, such as pharmacologic adjuvant therapy, monitoring techniques, flap types, and success rates reported by the members of the American Society for Reconstructive Microsurgery, were analyzed. (Plast. Reconstr. Surg. 100: 355, 1997.)

A technique of brachioplasty.

Various techniques for the management of upper extremity contour deformities have been suggested since aesthetic brachioplasty was first described. Such deformities are commonplace with aging, after normal weight loss, and especially after massive weight loss such as is seen following bariatric surgery. Despite the multiplicity of procedures described for the correction of these deformities, there are still problems associated with current brachioplasty techniques, including incorrectly placed incisions, widened hypertrophic scars, and postoperative contour deformities. In addition, postoperative skin laxity and ptosis in the axillary region are frequently encountered in the more extreme deformities. The authors present their technique for upper extremity brachioplasty. This technique is suitable for patients with severe brachial ptosis and skin laxity, with relatively little lipomatous tissue, which may extend from the olecranon to the chest wall. The described surgical approach provides excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour deformities.