Christoph Heitmann

The thoracodorsal artery perforator flap : anatomic basis and clinical application

Based on the dissection of 20 fresh cadavers, the authors have detailed further the vascular anatomy of the thoracodorsal artery and its cutaneous perforator vessels. The thoracodorsal artery showed a constant bifurcation into a horizontal branch and a lateral branch, located on the deep surface of the latissimus dorsi muscle 4 cm (range, 3–6 cm) distal to the inferior scapular border and 2.5 cm (range, 1–4 cm) medial to the lateral free margin of the muscle. In 20 specimens there was a total of 64 musculocutaneous perforators larger than 0.5 mm. Thirty-six perforators (56%) originated from the lateral branch and 28 perforators (44%) originated from the horizontal branch. All perforators originated within a distance of 8 cm from the neurovascular hilus and ran in proximity with the horizontal or lateral branches. In 11 dissections (55%) there was also a direct cutaneous branch originating from the extramuscular course of the thoracodorsal artery before the neurovascular hilus. This cutaneous branch did not pierce the latissimus muscle but rounded the lateral muscle edge and supplied the overlying subcutaneous tissue and skin. It is hoped that the constant anatomy will encourage surgeons in the future to use the thoracodorsal artery perforator flap more often.

Treatment of Segmental Defects of the Humerus with an Osteoseptocutaneous Fibular Transplant

Background: There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity that are >6 cm in length, especially those that are associated with soft-tissue defects. The purpose of the present review was to report on our experience with fifteen patients who received an osteoseptocutaneous fibular transplant for reconstruction of a humeral defect.Methods: The study cohort included eight male patients and seven female patients with an average age of forty-one years. The indications for the procedure included segmental nonunion (nine patients), a gunshot wound (three), a defect at the site of a tumor resection (two), and failure of an allograft-prosthesis reconstruction (one). The fibular graft was fixed by means of intramedullary impaction in eleven patients, was used as an onlay graft in three, and was used as a strut between the intact diaphysis and the humeral head in one.Results: The average length of the segmental humeral defect was 9.3 cm. The average length of the fibular graft was 16.1 cm, and the average length and width of the skin paddle were 8.1 and 4.5 cm. The average duration of follow-up was twenty-four months. Three patients had venous thrombosis and underwent a successful revision of the anastomosis. Four patients had early failure of graft fixation. Three patients had a fracture of the fibular graft within the first year postoperatively. All but one of these latter seven patients were successfully treated with open reduction, internal fixation, and additional bone-grafting. One patient with an infection at the site of a nonunion and signs of graft resorption required a second fibular transplant.Conclusions: The osteoseptocutaneous fibular transplant is an effective treatment for combined segmental osseous and soft-tissue defects of the arm. However, the application of this technique to the arm is more complex than application to the forearm and is associated with a higher rate of complications.

Alternatives to thumb replantation.

LEARNING OBJECTIVES After studying this article, the participant should: 1. Have a variety of options for thumb reconstruction. 2. Know the advantages and disadvantages of the nonmicrosurgical and microsurgical techniques for thumb reconstruction. 3. Understand the decision making from the variety of thumb reconstruction techniques based on patient needs. 4. Have a basic understanding of the various thumb reconstruction techniques discussed. The traumatic amputation of the thumb is an absolute indication for attempted replantation. The profound disability of the hand resulting from absence of the thumb, with loss of pinch and grasp, obliges the surgeon to make every attempt to replant the amputated thumb and preserve hand function. However, not all attempts at replantation result in survival of the amputated portion, and unreconstructable damage to or complete loss of the amputated part may preclude attempted replantation. In such situations, the surgeon must have alternative methods of dealing with the sequelae of thumb loss. This article will discuss nonmicrosurgical and microsurgical techniques for thumb reconstruction.

The free musculocutaneous tensor fascia lata flap as a backup procedure in tumor surgery.

&NA; The musculocutaneous tensor fascia lata (TFL) flap provides a small muscle belly and a strong fascial layer in combination with abundant skin coverage (15 × 40 cm), which makes the flap an attractive unit for composite free tissue transfer. The free TFL flap was used in nine cases of recurrent cancer of the chest wall (N = 7) and the abdominal wall (N = 2). The mean size of the full‐thickness defects after tumor excision measured 12 × 25 cm. The operating time ranged from 4 to 8 hours (mean operating time, 5.5 hours). The operation was performed with two teams, and no repositioning of the patient was necessary during the operation. By raising the TFL flap, no additional area of the trunk was involved. The authors did not experience a prolonged ventilation time in their group of multimorbid patients. The donor site was closed directly (4 of 9 patients) or split skin grafted (5 of 9 patients). There was no functional deficit. In one patient the venous anastomosis had to be revised. There were no further complications, and no flaps were lost. The hospital stay was short (21 days on average), the outcome successful, and primary healing was obtained. The free TFL flap proved to be a reliable flap that is easy technically to harvest. Thus the free TFL flap is a valuable backup procedure in tumor surgery. Heitmann C, Pelzer M, Menke H, Germann G. The free musculocutaneous tensor fascia lata flap as a backup procedure in tumor surgery. Ann Plast Surg 2000;45:399‐404

High-dose vitamin C treatment reduces capillary leakage after burn plasma transfer in rats.

Oxidative stress after burn injuries leads to systemic capillary leakage and leukocyte activation. This study evaluates whether antioxidative treatment with high-dose vitamin C leads to burn edema reduction and prevention of leukocyte activation after burn plasma transfer. Donor rats underwent a burn (n = 7; 100°C water, 12 seconds, 30% body surface area) or sham burn (37°C water; n = 2) procedure and were killed after 4 hours for plasma harvest. This plasma was administered to study rats (continuous infusion). Rats were randomized to four groups (n = 8 each; burn plasma alone [BP]; burn plasma/vitamin C-bolus 66 mg/kg and maintenance dose 33 mg/kg/hr [VC66]; burn plasma/vitamin C-bolus 33 mg/kg and maintenance dose 17.5 mg/kg/hr [VC33]; and sham burn plasma [SB]). Intravital fluorescence microscopy in the mesentery was performed at 0, 60, and 120 minutes for microhemodynamic parameters, leukocyte adherence, and fluorescein isothiocyanate-albumin extravasation. No differences were observed in microhemodynamics at any time. Burn plasma induced capillary leakage, which was significantly higher compared with sham burn controls (P < .001). VC66 treatment reduced microvascular barrier dysfunction to sham burn levels, whereas VC33 had no significant effect. Leukocyte sticking increased after burn plasma infusion, which was not found for sham burn. Vitamin C treatment did not influence leukocyte activation (P > .05). Burn plasma transfer leads to systemic capillary leakage. High-dose vitamin C treatment (bolus 66 mg/kg and maintenance dose 33 mg/kg/hr) reduces endothelial damage to sham burn levels, whereas half the dose is inefficient. Leukocyte activation is not influenced by antioxidative treatment. Therefore, capillary leakage seems to be independent from leukocyte-endothelial interactions after burn plasma transfer. High-dose vitamin C should be considered for parenteral treatment in every burn patient.

Reduction of Skeletal Muscle Injury in Composite Tissue Allotransplantation by Heat Stress Preconditioning

Ischemia-reperfusion injury is a dominant factor limiting tissue survival in any microsurgical tissue transplantation, a fact that also applies to allogeneic hand transplantation. The clinical experience of the 12 human hand transplantations indicates that shorter ischemia times result in reduced tissue damage and, ultimately, in better hand function. Heat stress preconditioning and the accompanying up-regulation of the heat shock protein 72 have been shown to reduce the ischemia-reperfusion injury following ischemia of various organs, including organ transplantation. The aim of this study was to reduce the ischemia-reperfusion injury in a model of composite tissue allotransplantation. Allogeneic hind limb transplantations were performed from Lewis (donor) to Brown-Norway rats. Donor rats in group A (n = 10) received a prior heat shock whereas rats in group B (n = 10) did not receive any prior heat shock. Group C served as a control group without transplantation. The transplantations were performed 24 hours after the heat shock, at which time the heat shock protein 72 was shown to be up-regulated. The outcome was evaluated 24 hours after transplantation by nitroblue tetrazolium staining and wet-to-dry weight ratio of muscle slices (anterior tibial muscle). The nitroblue tetrazolium staining showed a significant reduction of necrotic muscle in group A (prior heat shock) (p = 0.005). The wet-to-dry ratio was significantly reduced in group A (prior heat shock), indicating less muscle edema and less tissue damage (p = 0.05). Heat shock preconditioning 24 hours before an ischemic event leads to an up-regulation of heat shock protein 72 in muscle and to a tissue protection reducing ischemia-reperfusion injury in composite tissue transplantation.