Frederick R. Heckler

Internal topography of major nerves of the forearm and hand: A current view

Fresh cadaver nerves were examined by serial cross-sections and microdissection with the operating microscope. The findings are compared with those of previous authors, primarily Sydney Sunderland. Our study confirms and amplifies Sunderlands findings: although it is true that funicular prexus formation and interchange takes place in the nerves of the human forearm, these connections are not of such a degree as to preclude operative procedures such as intraneural neurolysis, fascicular nerve repair, and interfascicular nerve grafting. Individual branches and bundles can be identified and traced within the main nerve trunk for considerable distances without significant trauma to conducting fibers. This arrangement lends itself to the application of modern microneurosurgical techniques. Clinical applications of these findings in the repair, lysis, and grafting of the major nerves of the forearm are described. The possibility of using such branches as the dorsal cutaneous branch of the ulnar nerve(if irreparably damaged) as a donor nerve for grafting is noted.

Potential dangers of oxygen supplementation during facial surgery.

The use of local anesthesia and intravenous sedation has made same-day outpatient surgery a viable option for many aesthetic and reconstructive procedures. These procedures often include the use of supplemental oxygen. Oxygen-enriched environments increase the combustibility of most materials, and “oxygen pooling” has been suspected to play an integral role in intraoperative fires. A personal experience with an intraoperative explosion and fire during a cosmetic blepharoplasty compelled us to explore the potential danger inherent in the use of supplemental oxygen as well as potential strategies to minimize that danger. This study systematically examines the microenvironment created by the use of oxygen both in the operative field and beneath the surgical drapes under conditions simulating routine facial surgery and various recommended modifications of its delivery. With the use of oxygen supplementation, oxygen concentration beneath the drapes was found to be consistently elevated when compared with ambient air (20.9 percent) and reached levels as high as 53.5 percent. Oxygen concentration in the operative environment was mildly but not significantly elevated. Although criteria for the use of oxygen supplementation are not clear, when administration is deemed necessary, the use of a posterior pharyngeal catheter for its delivery had no advantage over nasal prongs. However, appropriate alternatives include the use of “open face” draping techniques, the use of compressed air beneath the drapes as a substitute for oxygen supplementation in unsedated patients, and cessation of oxygen supplementation for 60 seconds prior to the use of a possible ignition source with oxygen flow rates of less than 3 liters per minute. (Plast. Reconstr. Surg. 95: 978, 1995.)

Subciliary Incision and Skin-Muscle Eyelid Flap for Orbital Fractures

The lower eyelid skin-muscle flap is now widely used for cosmetic blepharoplasty, primarily because of the ease and speed of dissection it offers. We have used the same technique as a surgical approach in fractures of the orbital floor and rim. In a large clinical series seen over a three and a half–year period, no major complications were noted. This approach provides simple, extremely rapid exposure of the injured area and is an excellent alternative to other approaches to this site.

Sternocleidomastoid regional flaps: A new look at an old concept

The main blood supply of the sternocleidomastoid muscle enters it above from branches of the superior thyroid, posterior auricular and occipital arteries. The lower third is supplied by a branch from the transverse cervical artery and at this level there are few if any musculocutaneous branches. Long skin flaps with or without the underlying muscle should be checked with fluorescein before transfer.

Reconstruction of nonmarginal defects of the ear with chondrocutaneous advancement flaps

Marginal defects of the ear are usually reconstructed with the Antias chondrocutaneous flap. Reports of reconstruction of nonmarginal defects are scanty. The antia chondrocutaneous flap was adapted for reconstruction of defects up to 2 cm located in the triangular fossa, scapha, and the anthelix. For larger defects, the technique was further modified using composite chondrocutaneous flaps. The technique uses the principle of separation of the ear elements and redistribution for closure of defects in the nonmarginal areas of the ear with minimal sacrifice of the tissue, ear size, and ear shape. This technique is reliable, relatively simple, and a one-stage operation, as demonstrated in our series of seven patients.

Cutaneous surgery in patients on warfarin therapy.

Warfarin is a commonly used anticoagulant for patients with prosthetic heart valves, atrial fibrillation, stroke, deep vein thrombosis, or pulmonary emboli to prevent thromboembolic events. There is no clear consensus regarding the perioperative management of warfarin therapy for plastic surgery procedures. Our objective is to evaluate the safety and quantify any increased morbidity in patients on warfarin therapy, undergoing soft tissue surgery. In a retrospective chart review of prospectively collected data, patients undergoing cutaneous surgery on warfarin therapy from 2000 to 2006 were identified. Perioperative complications were evaluated, including major hemorrhage, incisional bleeding, hematoma, wound or flap complications, graft success, and cosmetic surgical outcome. A total of 26 anticoagulated patients who underwent 56 procedures were included. Intraoperative bleeding was controlled in all cases without difficulty. Minor postoperative bleeding was noted in 1 patient, and this was easily controlled with gentle pressure. All wounds healed without complication, including 2 split thickness skin grafts. The cosmesis of all scars was acceptable. Anticoagulation with warfarin can be safely continued in patients undergoing minor soft tissue procedures, thereby avoiding the risk of potentially devastating thromboembolic events.

Cartilaginous choristoma of buccal mucosa: a case report

A rare and possibly the first case of a cartilaginous choristoma of the buccal mucosa is presented. Careful examination at follow-up for over 11 months has revealed no clinical evidence of any recurrence.

Gastrocnemius muscle transposition to the femur: how high can you go?

The gastrocnemius muscle flap has gained wide acceptance as a reconstructive technique for management of wounds of the knee and proximal tibia. The use of the muscle as a pedicle flap to the distal and middle femur has not been well quantified, and the proximal rotation arc has been underestimated. We report the use of the island gastrocnemius pedicle flap to reach two femur defects 21 and 26 cm above the joint line, achieved by taking advantage of the favorable location of the vascular pedicle above the joint line and the individual length of the medial gastrocnemius muscle belly. Evaluation of standard arteriograms suggests the location of the medial sural artery pedicle is an average of 32 +/- 14.5 (SD) mm above the inferior border of the femur. All vessel origins were found above the joint line by radiograph. A common sural artery origin was noted in 32% of patients at a mean distance of 35 mm proximal to the joint line. Despite a wide range, 62% of sural artery origins were within 1 cm of an axis drawn through the widest point of the femoral condyles.

Muscle Flaps and Musculocutaneous Flaps in the Repair of Urinary Fistulas

Techniques for including muscle flaps and musculocutaneous flaps in the repair of difficult vesicocutaneous, urethrocutaneous, and vesicovaginal fistulas are described. These methods have been uniformly successful in 10 consecutive patients. The incorporation of such healthy, well-vascularized tissue into the standard techniques of urologic repair can be a major factor in the successful management of these problems.

The Iliacus Muscle Flap: An Anatomical and Clinical Evaluation

Background: The iliacus muscle is proposed as a new solution for coverage of small to medium defects where either a bulky flap or conspicuous donor sites are undesirable. Methods: Dissection and Microfil studies were performed on fresh cadavers to define the gross and microvascular anatomy of the muscle. Live evaluation of the muscle was performed in combination with multiple iliac crest free tissue transfer procedures. The muscle was then used as a free flap in four separate cases to cover difficult extremity wounds. It was used as a pedicled flap in conjunction with a free iliac crest in a fifth case to assist with a composite mandible and facial defect. Results: The iliacus originates from the inner aspect of the iliac crest and then fuses with the psoas at the level of the inguinal ligament. Its primary blood supply derives from a large branch off of the deep circumflex iliac artery. The isolated muscle resulted in a pancake-like flap measuring approximately 8 × 8 cm with a 6- to 8-cm pedicle (deep circumflex iliac artery). The muscle was then used clinically both as isolated free flaps and as a pedicled flap in conjunction with a free iliac crest. All flaps survived, resulting in healed wounds without complication. Conclusions: These results demonstrate that the iliacus is a new muscle that should be added to the microsurgeons choices for free tissue transfer. It is easily harvested, has a large and well-defined pedicle, and is less prone to donor-site complications than some other muscles typically used for free tissue transfer.