Gabriel M. Kind

The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants

&NA; One hundred forty‐seven flaps in 135 consecutive patients undergoing microvascular transplantation were monitored using a miniature Doppler ultrasonic probe. Using a modification of a technique described previously by Swartz, the probes were secured to the outflow vein of the flap with Vicryl mesh. Twenty instances of thrombosis or spasm were detected in 16 patients, and all flaps were salvaged (100 percent). There were four false positive and no false negative results. This probe allows for safe, continuous monitoring of flap blood flow, which permits the rapid detection and hence rapid treatment of postoperative complications. Our experience suggests that a significant improvement in the salvage rate of microvascular transplants may be attainable with the use of this device. (Plast. Reconstr. Surg. 101: 1268, 1998.)

The diagnosis of osteomyelitis in patients with pressure sores

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.

breast Cancer in Reduction Mammoplasty: Case Reports and a Survey of Plastic Surgeons

&NA; A discussion of occult breast carcinomas in breast reduction surgery has not occurred in the last 25 years. My recent experience in discovering two occult breast carcinomas in breast reduction specimens led to the creation of a survey of local plastic surgeons and a review of the literature with the goal being precise recommendations for such occurrences. Our survey of breast reductions performed on 2576 patients shows a 0.16 percent incidence of occult breast carcinoma, significantly lower than the 0.38 percent incidence seen in the Snyderman and Lizardo study of 1959. This decrease in the rate of occult breast carcinomas could be explained by many advances in early detection, improvements in patient education, and more thorough pathologic examination of the surgical specimens. The results of this survey and review suggest that we as plastic surgeons performing breast reduction surgery be well versed in all aspects of breast cancer detection, evaluation, and treatment. (Plast. Reconstr. Surg. 101: 361, 1998.)

Using the Internet for rapid exchange of photographs and x-ray images to evaluate potential extremity replantation candidates

OBJECTIVE To implement a low-cost system of transmitting high-quality digital photographs of mutilating extremity injuries using the speed of the Internet. DESIGN A high-resolution digital camera and simple hardware and software platform are used to take and transmit images via electronic mail. The images are received within minutes by the consultant, and an assessment can be made. RESULTS A low-cost and high-quality system can easily be implemented. Images can be seen by consultants only a few minutes after they are obtained. The quality of the reproductions is excellent, and they are handled exactly as other photographs. CONCLUSION This technique can be widely applicable and inexpensive to initiate in any emergency room. It allows rapid assessment of extremity injuries and x-ray images by expert consultants, who can then evaluate the replantation or revascularization potential of extremity trauma cases. This can eliminate unnecessary and often expensive transfer of patients who are not candidates for replantation.

Total ear replantation.

&NA; Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration. (Plast. Reconstr. Surg. 99: 1858, 1997.)

The harvest and clinical application of the superficial peroneal sensory nerve for grafting motor and sensory nerve defects.

&NA; Potential donor nerves for autografting are finite and usually limited to cutaneous nerves of the extremities. The superficial peroneal nerve is the major lateral branch of the common peroneal nerve that innervates the peroneus longus and brevis muscles and provides sensation to the lateral aspect of the lower leg and the dorsal foot. It has generally been overlooked as a potential donor of nerve autografts. Cadaver dissections were performed on 10 fresh lower extremity specimens to investigate the anatomic characteristics of the superficial peroneal nerve and to refine a harvesting technique for the nerve. Thirty‐one patients underwent nerve grafting of 39 upper and lower extremity nerves using the superficial peroneal donor. There were nine median nerves, four ulnar nerves, two radial nerves, two brachial plexus lesions, 16 digital nerves, and six lower extremity nerves grafted. The superficial peroneal nerve provided a consistently long donor, comparable in length to the sural nerve. The anatomic pattern is consistent, the patient positioning is simple, the surgical harvesting technique is straightforward, and the donor defect is acceptable. The superficial peroneal nerve provides a safe and valuable donor nerve, particularly in cases where multiple or very long nerve grafts are required. (Plast. Reconstr. Surg. 109: 145, 2002.)

Arterialization of the venous system of the hand.

Background: The treatment of hand ischemia can be very challenging. In cases in which there are no reconstructible arterial lesions, treatment options are limited. Arterialization of the venous system of the hand is a straightforward surgical procedure that provides arterial blood to the distal soft tissues of an ischemic hand. Methods: The author conducted a retrospective review of the history, indications, technique, and results of this technique as applied to the treatment of five hands in three patients. Results: For each of these patients, the treatment included an anastomosis from the distal radial or ulnar artery to a dorsal hand vein. Blood flow was directed distally by ligating venous side branches. Valvulotomies were performed as needed to the base of the digits on the dorsum of the hand. This approach resulted in excellent pain relief in all treated hands and healing of digital wounds. Conclusion: This relatively straightforward salvage procedure provides arterialized blood to ischemic digits, resulting in wound healing and significant reduction in pain.

An evaluation of fascial staples (a new technique) in wide fascial plication during reconstructive abdominoplasty.

The purpose of this study is to evaluate the fascial stapler (a new technique) in the plication of the musculoaponeurotic fascia abdominoplasty in comparison to conventional (sutured) techniques. Thirty-eight patients underwent abdominoplasty with rectus sheath plication. Patients were randomized into staple and suture groups. Similar degrees of plicationing were performed in both groups (range, 12-20 cm). Fascial repairs were evaluated postoperatively at approximately 1 month and 6 months. A small, but comparable, subclinical fascial separation was demonstrated immediately in both the stapled and sutured groups. No progression of fascial separation was observed in either group at 1 month and 4 months postoperatively. No complications attributable to the fascial closure were noted in either group. Operative time was considerably less with the stapled technique. The results, although early, suggest that the use of fascial staples for plicationing of the musculoaponeurotic fascia during abdominoplasty is comparable to conventional (sutured) techniques regarding complication rate and disruption rate, but appreciably decreases operative time.