David Chwei-Chin Chuang

Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers.

Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome. Methods: Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compromise was identified and correlated with salvage outcome. Results: Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed completely. Ninety-three flaps (82.3 percent) presented with circulatory compromise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the microsurgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p = 0.01). Conclusions: The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special microsurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes.

Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers.

During the 5-year period between 1987 and 1991, 99 patients with total root or upper root (C5, C6, or C7) injuries were treated by nerve transfer to obtain shoulder abduction. More than eight different combinations of coaptation between donor nerves (intercostal nerves, phrenic nerve, spinal accessory nerve, ipsilateral C7, or cervical motor nerves) and recipient nerves (suprascapular nerve, axillary nerve, and upper trunk or C5) were applied. All patients had at least 2 years of follow-up. Different results were obtained in each category. Simultaneous neurotization of the suprascapular and axillary nerves with the phrenic and spinal accessory nerves obtained much better and more reliable shoulder abduction. Neurotization of the C5 spinal nerve by multiple nerve transfers was another good option that yielded good shoulder abduction in a single patient. If the phrenic nerve was traumatized, neurotization of the suprascapular nerve solely with the spinal accessory nerve was still capable of achieving an acceptable range of shoulder abduction.

Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: Evaluation of 66 patients

Intercostal nerve transfer is a well-established and effective technique for irreparable avulsed brachial plexus injuries. Between 1987 and 1989, 66 patients with brachial plexus injuries were treated by means of intercostal nerve transfer to the musculocutaneous nerve, with or without nerve grafts to obtain elbow flexion. The results were evaluated. Five clinical signs--(1) induction of chest pain by squeezing of biceps, (2) proximal biceps contraction, (3) distal biceps contraction, (4) active elbow flexion against gravity, and (5) active elbow flexion against weight--were identified and used as a guide for functional recovery. The overall success rate with motor function of grade 4 or more was 67%. The motor results were better in 1989 (81%) because of greater familiarity with the anatomy and improved surgical technique. The important factors in obtaining a good result are (1) early exploration (less than 5 months after trauma), (2) use of three intercostal nerves, (3) mixed nerve-to-mixed nerve coaptation, (4) nerve repair without grafts and under no tension, and (5) shoulder stability.

Results of functioning free muscle transplantation for elbow flexion

Thirty-eight patients underwent functioning free muscle transplantation for restoration of elbow flexion. Thirty-five patients had sustained brachial plexus injury and 3 had traumatic loss of the biceps muscle. The gracilis muscle was used in 37 patients and the rectus femoris muscle in 4. The transferred muscle was reinnervated by the musculocutaneous (n = 3), intercostal (n = 31), and spinal accessory (n = 4) nerves. Results were assessed by the Medical Research Council grading system and success was defined as a muscle strength of M4. Reinnervation with the musculocutaneous nerve resulted in success in all cases (n = 3) within 1 year. Success was obtained in 78% of patients following transfer of 3 intercostal nerves (n = 23) with recovery in an average of 2 years. Using the spinal accessory nerve (n = 4), strength of only M2+ was achieved, probably on account of the need for interposition nerve grafts in those cases.

Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction by using different recipient nerves

The objectives of this study were (1) to determine the extent of sensory recovery on hemitongues reconstructed with innervated radial forearm flaps and (2) to assess the influence of various clinical and surgical factors over the return of sensation, including the use of different recipient nerves for neurorrhaphy. Twenty-eight patients with tongue cancer who underwent hemiglossectomy and primary reconstruction with innervated radial forearm flaps over a 3-year period were studied. Mean postoperative follow-up was 18.2 months (range 6 to 32 months). Sensory recovery was assessed in a blind manner by two examiners that used (1) static two-point discrimination, (2) light touch sensation, (3) pain perception, and (4) hot and cold temperature perception. Different surfaces were assessed with each method on the reconstructed hemitongue and on the intact contralateral hemitongue (used as control). The following factors and their relationship with flap sensory recovery were analyzed: age, smoking history, size of the reconstructed defect, administration of postoperative radiation therapy, recipient nerve, and neurorrhaphy technique. Comparative statistical analysis (p < 0.05) between both hemitongues was performed using paired t test followed by Bonferroni correction for static two-point discrimination and light touch sensation. Fisher exact test analysis was used for pinprick and hot and cold temperature perception. The control side was ignored in analyzing the effects of the risk factors. The tip, dorsal aspect, ventral surface, and floor of mouth on the reconstructed hemitongue had comparable static two-point discrimination when compared with the intact hemitongue. Light touch sensation was also similar in the tip and dorsal aspect of both hemitongues; however, a statistically significant difference (p < 0.05) was observed on the ventral surface and floor of mouth of the reconstructed hemitongues. Likewise, pain perception was significantly decreased in the floor of the mouth, compared with other surfaces. No clearly dependent association was established between return of flap sensation and age, tobacco use, and size of the reconstructed defect. Light touch sensation, pain, and temperature perception were significantly decreased when the patients had received postoperative radiation therapy. In addition, all four sensory tests were significantly diminished (p < 0.05) when the recipient nerve used for neurorrhaphy was a nerve other than the lingual or the inferior alveolar nerve, and also when an end-to-side nerve repair was used. Sensation recovery of the innervated radial forearm flap after hemitongue reconstruction approaches normal compared with the contralateral intact hemitongue. Lower return of sensation may be anticipated in patients who receive postoperative radiotherapy. Good recovery of sensation is predictable when either the lingual or inferior alveolar nerve is used for neurorrhaphy, in contrast to using other recipient nerves.

A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial plexus palsy

&NA; Cross‐innervation (caused by misdirection of regenerated axons), muscular imbalance (caused by muscle paresis or earlier recovery), and growth are the three main causes of shoulder deformity due to obstetric brachial plexus palsy. If perioperative studies demonstrate the existence of muscle recovery by cross‐innervation, a new strategy of muscle transposition to minimize the influence of cross‐innervation is used. Release of antagonistic muscles (pectoralis major and teres major muscles) and augmentation of paretic muscles (transferring teres major to the infraspinatus muscle, reinserting both ends of the clavicular part of the pectoralis major muscle laterally) are performed for reconstruction. Since 1993, 29 patients having shoulder deformity caused by obstetric brachial plexus palsy underwent reconstruction utilizing this strategy of muscle transposition. The timing for the reconstruction was at an average of 8.5 years (range, 4 to 21 years). The average shoulder abduction following the muscle transposition was 151 degrees (i.e., average gain 104 percent, or 77 degrees) and that of external rotation was 72 degrees (average gain 200 percent, or 48 degrees). Compared with the patients who had no surgery for shoulder deformity caused by obstetric brachial plexus palsy and early nerve surgery for the infant obstetric brachial plexus palsy, the results of the strategy seem to be significantly impressive.

Cross-chest C7 Nerve Grafting Followed by Free Muscle Transplantations for the Treatment of Total Avulsed Brachial Plexus Injuries: A Preliminary Report

The number of donor nerves available for nerve transfer in the reconstruction of total root avulsion injuries of the brachial plexus is always insufficient. Use of the contralateral normal C7 cervical nerve as a donor nerve is a new approach to obtain more nerve fibers but also is a controversial procedure. Fifteen patients with total root avulsion of the brachial plexus received cross-chest C7 nerve grafting as the first stage of reconstruction. Eight of these patients, after an interval of 11 to 20 months, had free muscle transplantations (one to three muscles transferred per individual) to the affected limb. A long period of rehabilitation (at least 2 years) is required. The donor limbs of the 15 patients showed negligible deficits of motor and sensory function. Although independent movement of the transferred muscles from the contralateral limb has not been achieved, useful function of the reconstructed limb is possible. The preliminary results are encouraging. (Plast. Reconstr. Surg. 92: 717, 1993.)

Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation.

Lower-extremity injury may present as a composite soft-tissue and bone defect, resulting directly from trauma or subsequent debridements. These composite defects often require vascularized osteocutaneous flaps for an effective, staged reconstruction. Among various donor sites, the vascularized fibular flap is generally considered the best option because of its inherent advantages. However, when the fibular flap is not available, iliac and rib flaps become the alternative choices. The purpose of this retrospective study was to compare the functional results of the alternatively chosen bone flaps (iliac and rib flaps) with those of the fibular flaps.

Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction.

&NA; Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft‐tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system. (Plast. Reconstr. Surg. 108: 1624, 2001.)

Experience of 73 free groin flaps

The free groin flap has gradually lost its popularity due to the disadvantages relating to the pedicle and the plethora of new donor sites. The purpose of this article is to re-evaluate this time-honoured free flap and to demonstrate its reliability and versatility through a review of 73 free groin flaps performed between 1985 and 1990. 7% of free transfers (total 1096 cases) in our institution were free groin flaps. The complication rate was 8% (three complete failures and three partial failures). This result is acceptable and not so high as other reports have described. The artery discrepancy is the main cause of the complication rate. Two special techniques to gain additional diameter of vessel size to overcome the pedicle disadvantages are stressed. The groin flap has proved to be useful and still deserves consideration in reconstructive procedures.