Ingemar Fogdestam

Distally Based Fasciocutaneous Flap from the Sural Region

Based on the principle of skin vascularization through perforating branches along intermuscular septa, a new distally based fasciocutaneous flap from the sural region is presented. Its use in reconstruction of defects in the middle and lower third of the leg is demonstrated by the clinical application in our sample of 3 cases. The limits of the extent and the exact basis of its vascularity have to be determined by further investigations.

Microsurgical epididymovasostomy in the treatment of occlusive azoospermia

In principle, azoospermia has two explanations: occlusion of the duct system and serious dysfunction of the testicular parenchyma. Some cases of duct occlusion are suitable for reconstructive surgery. The authors describe a reconstructive technique based on full mobilization of a single loop of the epididymal duct as caudally as possible with two-layer side-to-end anastomosis to the vas deferens. To ensure follow-up evaluation of each anastomosis, unilateral anastomosis was done primarily. In a few cases, cross-over anastomosis was necessary. In cases of reoperation, if possible, this was performed on the same side. When the epididymal duct system was found empty, the contralateral epididymis was explored. Patients with postoperative oligozoospermia were offered a supplementary contralateral operation. From 1980 to 1984, 41 patients underwent epididymovasostomy. At follow-up evaluation, 35 (85%) presented sperms in repeated tests. Fifteen of these patients (37%) have fathered children. Patients with postoperative normospermia and no antisperm antibodies had an excellent fertility prognosis. The single-loop dissection technique provides anatomic specificity and a high percentage of patent anastomoses and does not interfere with the possibilities of reoperation.

Microsurgical end-to-end and end-to-side epididymovasostomy to correct occlusive azoospermia.

Reconstruction of the duct system using microsurgical technique represents an anatomically more attractive approach to correction of occlusive azoospermia than the conventional sperm fistula operations. The microsurgical technique of Silber entails transection of the entire epididymis in progressively more cranial planes. After microsurgical dissections of testicle specimens, we developed a different technique: dissection of a single loop of the ductus epididymis and connection to the ductus deferens, performed either as a two-layer end-to-end or as an end-to-side anastomosis. To reveal patency of each single anastomosis, the operations were performed unilaterally. Twenty-eight men were operated upon. They were referred from urology departments after standard investigations including repeated sperm tests. In 7 patients (25%) the prerequisites for an anastomosis were not present. Twelve patients were primarily operated upon with the end-to-end technique. Six of them have produced sperms in their specimens. Nine patients were operated upon with the end-to-side anastomosis. So far, five of these have presented positive sperm tests but the follow-up period is relatively short in this part of the series. During the investigation, it became evident that both the identification of sperms or fragments in the epididymal fluid and an adequate flow are prerequisites for successful surgery.

Surgical Treatment of Hyperhidrosis Axillae

58 patients have been operated on for axillary hyperhidrosis by excision of the skin and subcutaneous tissue. The hyperhidrotic area was determined by application of a crêpe paper in the axilla. Either 60% or 90% of the hyperhidrotic area was excised, using a bat-like pattern. Only after excision of 90% of the hyperhidrotic area acceptable results were achieved. In a series of 22 patients with 90% excision bilaterally 18 had excellent results, three were good, and one was poor. The entire series was without complication. The advantage of this technique is its simplicity, freedom from complication, performance on an out-patient basis, and short convalescent time.

Direct puncture of large arteriovenous malformations in head and neck for embolisation and subsequent reconstructive surgery

Five patients with large arteriovenous malformations (AVM) of the head and neck, which were too large or inconveniently placed for operation alone, were treated by embolisation after direct puncture; two of them were subsequently operated upon. They all recovered without complications. Embolisation of the nidus and subsequent operation is a good alternative for the treatment of large AVM. Ligating the supplying arteries is not a treatment. If the arterial routes to the nidus have previously been closed by ligatures selective catheterisation is impossible, though direct puncture of the nidus is a possibility. The nidus of the AVM can then be obliterated by embolisation either as a treatment, or as a preoperative procedure.

Delayed Primary Closure. Blood-Flow in Healing Rat Skin Incisions

In an earlier study delayed primary closure (DPC) wounds were shown to develop higher biomechanical strength than primary closure (PC) wounds. In order to elucidate the underlying mechanism, local clearance of 133Xenon and thermography studies were undertaken. A paired comparison design with deposits of 133Xenon injected in the wound margins 3 and 4 days postoperatively, and directly into the wound tissue 10, 20 and 60 days postoperatively was used. Very pronounced differences, with higher blood-flows for DPC wounds, were found in the early measurements. In the later measurements there were significant but less obvious differences. With thermography no differences could be detected. It is concluded that DPC wound have a higher blood-flow, especially in the initial wound healing phase. This supports the hypothesis that an increased blood-flowing during early wound healing is beneficial for the development of mechanical strength in the maturing normal scar.

The Sleeve Anastomosis in Clinical Microsurgery: Case Report

Clinical use of the microvascular sleeve anastomosis in 6 elective free tissue transfers is reported. Arterial and venous anastomoses were performed. It was found that with the exception of the distal anastomosis of a vein graft to artery the sleeve anastomosis was simple and efficient. It was concluded that when the vessels to be anastomosed have suitable length and diameter the sleeve anastomosis may well be used. By its use time and effort can be saved, especially in cases requiring multiple anastomoses.

Microsurgical Replantation of a Total Scalp Avulsion: Case Report

In June 1982, a 9-year-old girl sustained a total scalp avulsion including the entire right eyebrow, the upper third of the skin of the dorsum of the nose and the medial half of the left eyebrow. On both sides the temporal skin was included and in the neck a border of just 1 cm of hairbearing area was left intact. The scalp was successfully replanted. The operative procedures, the pre-operative and post-operative treatment are described and discussed. The follow-up time is 3 years and the sequelae have been found to be minimal.

Energy metabolism during microsurgical transfer of human skeletal muscle assessed by high-pressure liquid chromatography and by 31P-nuclear magnetic resonance.

The effect of ischaemia and reperfusion on human skeletal muscle was studied during free vascularised muscle transfer. Muscle biopsy specimens were taken from patients having microsurgical muscle transfer, 18 cases (17 patients; 12 men, 5 women). The biopsies were taken three times: before transfer of the muscle (control), at maximum ischaemic time, and one hour after revascularisation. The biopsy specimens were analysed for purine nucleotides, by high-pressure liquid chromatography (HPLC), and by nuclear magnetic resonance (NMR) at 500 MHz. Phosphocreatine (PCr) recovered only partially (79%) and adenosine triphosphate (ATP) did not differ significantly from normal control after revascularisation and a mean ischaemic time of 114 minutes. NMR measurements showed an accumulation of glucose-6-phosphate (G-6-P) during the ischaemic period, indicating anaerobic metabolism. After three hours of ischaemia and one hour of reperfusion the PCr recovery was less than 60% ( r = 0.7). The results confirm those of previous animal studies, which set three hours normothermic ischaemia as a safe limit for tissue preservation when transferring skeletal muscle. Longer ischaemic times may cause serious postoperative healing problems and reduced muscle function.

Purine Metabolism During Microsurgical Transfer of Human Skeletal Muscle

The effect of ischaemia followed by reperfusion on energy metabolism was studied in human skeletal muscle after microsurgical free transfer. Muscle biopsy specimens from 11 patients treated by free muscle transfer for facial palsy, injury to an extremity, or scalp defect were studied. The biopsy specimens were taken during ischaemia and after one hour of reperfusion, respectively. They were analysed for ATP to uric acid and creatine phosphate by high pressure liquid chromatography. Ischaemia lasting one or two hours affected the energy metabolism of the muscle cell as evidenced by a 50% reduction in creatine phosphate; a 20% reduction in ATP and in the energy charge; a 100% increase in inosine monophosphate, and a 700% increase in hypoxanthine and xanthine. Reperfusion for one hour improved these figures somewhat, and induced the production of uric acid. Skeletal muscle can therefore tolerate ischaemia for up to two hours in the clinical situation without permanent damage to the tissues.