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Arterialized Venous Dorsal Digital Island Flap for Fingertip Reconstruction

&NA; Fingertip resurfacing is a challenging reconstructive problem; despite the existence of many different surgical methods, enthusiasm on developing versatile flap techniques has been continuing. In this report, we describe an arterialized venous dorsal digital island flap for fingertip reconstruction. The vascularity of the reverse dorsal digital island flap is augmented by performing an arteriovenous anastomosis between a dorsal vein in the flap and one of the proper digital arteries at the fingertip. Eight flaps were used in eight patients for the reconstruction of their fingertip defects. The ages of the patients ranged from 19 to 41 years, with an average of 28.4 years. In two cases, the flap was used as a neurosensorial flap by coapting the dorsal digital radial nerve to the digital nerve. The mean follow‐up was 11 months, and all but one flap totally survived. The operative technique is easy except for the necessity of performing standard microvascular surgery. The flap may be a good alternative for repairing fingertip defects in selected cases. (Plast. Reconstr. Surg. 102: 2368, 1998.)

A New Flap Model in the Rat: The Pectoral Skin Flap

The purpose of this study was to describe a new axial-pattern experimental flap model in the rat. Wistar rats weighing 200 to 250 g were used in the experiment. In 15 rats, the superficial anatomy of the ventral thoracic region was studied by anatomic dissection, dye injection, and microangiography, using 5 rats in each group. The anatomic studies revealed that the ventral thoracic skin derives its principal blood supply from the long thoracic artery--a branch of the common thoracic artery. Based on these anatomic studies, the pectoral skin flap model, pedicled on the long thoracic vessels, was created in the rat. The flap is bounded medially by the midsternal line, laterally by the anterior axillary line, and superiorly and inferiorly by transverse lines passing at the level of the suprasternal notch and the xyphoid process respectively. In 5 animals, bilateral flaps (N = 10) were raised and replaced in situ. In 15 animals, oversized flaps were created by extending the flap for both a greater width (N = 10) and length (N = 10). Although all the flaps limited to the cutaneous territory as described were found to survive totally, oversized flaps underwent partial necrosis distally. The authors conclude that the pectoral flap is a simple and reliable skin flap model for future biological and pharmacological study because it is very easy to raise, has a consistent vascular pedicle, and has well-defined borders with consistent landmarks.

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.

Metastatic malignant blue nevus: a case report.

This report presents a 63-year-old Caucasian woman with a malignant blue nevus, which is an extremely rare form of melanoma originating from or associated with a preexisting blue nevus. The background blue nevus on the left upper arm, which had been present for 5 to 6 years, increased in size and darkened in color for 3 months prior to histological diagnosis of malignant blue nevus. Although the tumor looked much like a nodular melanoma clinically, the diagnosis of malignant blue nevus was established histologically. The patient had a poor outcome due to metastatic spread of the tumor to the visceral organs 1 year following the initial excision of the tumor. To distinguish this rare tumor from other melanocytic lesions, strict histological criteria are needed to make the diagnosis of malignant blue nevus. Differential diagnosis includes cellular blue nevus, atypical cellular blue nevus, primary malignant melanoma, and metastatic melanoma to the dermis. Malignant blue nevus is most commonly seen on the scalp. The tumor has an aggressive behavior and metastasizes in the majority of patients. This paper describes the second reported case of malignant blue nevus involving the upper arm. Clinical and histological features of this uncommon tumor are presented, along with a review of the literature.

Semicircular lipoatrophy after intragluteal injection of benzathine penicillin

A 3-year old girl had localized lipoatrophy after an intragluteal injection of benzathine penicillin G. No associated abnormalities were found.

Botulinum toxin in closed treatment of mandibular condylar fracture.

Background:The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. The treatment of condylar fractures in adults is still a highly debated theme. Methods:Patients with unilateral subcondylar or condylar neck fractures of the mandibula without any significant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment was applied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reached through percutaneous extraoral route and 30 IU of the toxin was injected to each muscle. Additional 40 IU of the toxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medial and lateral pterygoid muscles as much as possible. An asymmetric occlusal splint was applied for maxillomandibular fixation to restore the vertical height for 10 days. Functional therapy with intermaxillary guiding elastics was advocated for 2 months. Results:There were no complications related to either toxin injections or splint application procedures. The toxin was effective on all occasions. Fractured condylar process and ramus of the mandibula were in good approximation and remained in reduced positions. None of the patients had any occlusal disturbance, mandibular asymmetry, or joint dysfunction in the follow-up period. Conclusions:We believe that modification of treatment options concerning the clinical situation of the patients is the best method for condylar injury. The purpose of this study is to present and discuss the results achieved in closed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin A was injected to relieve the spasm of muscles of mastication, along with special splint application.

A new flap model in rats: iliac osteomusculocutaneous flap.

Although osteomusculocutaneous flaps are used frequently in clinical practice to repair defects involving soft tissue and bone, there are still many questions that remain to be answered regarding their basic physiology. To accomplish such basic science studies, simple and reliable animal osteomusculocutaneous flap models are needed. The purpose of this study was to describe a new flap model in rats—namely, the iliac osteomusculocutaneous flap. Thirty adult Wistar rats weighing 200 to 250 g were used in this experiment. In 15 rats, the vascular anatomy of the iliolumbar vessels and their relation with adjacent soft tissues and the iliac bone was determined by anatomic dissection. Based on this anatomic study, the iliac osteomusculocutaneous flap model was created in rats. The flap is comprised of a skin island (3 × 3 cm) in the flank region, a 1 × 1-cm segment of iliac bone, and an abdominal wall muscle cuff. In 10 rats, the flap was raised as an island flap based on its vascular pedicle of iliolumbar vessels, and was replaced in situ. In the remaining 5 rats, the flap was transferred to the groin region as a free flap. Direct observation on postoperative day 7 revealed that the skin island of all the flaps was completely viable. Bone scintigraphy performed on postoperative day 3 in free flaps demonstrated radionuclide uptake, indicating viability of the bony segment. The dye injection study revealed ink staining within blood vessels of the bone, confirming its viability. Microangiography of the flap demonstrated vascularity of each component of the flap by the iliolumbar vessels, including a distinct branch to the iliac bone. The authors conclude that the iliac osteomusculocutaneous flap of the rat is a simple and reliable flap model that offers the following advantages: (1) It is a true osteomusculocutaneous flap, (2) it can be used as a free flap without the need for an isogeneic rat, (3) the vascular pedicle is consistent, and (4) it is harvested from a small-animal species.

Angiotensin-converting enzyme inhibitor enalapril reduces formation of hypertrophic scars in a rabbit ear wounding model.

Background: Angiotensin-converting enzyme inhibitors are widely used in medicine because of their antihypertensive and antifibrogenic effects. Angiotensin-converting enzyme activates angiotensin I to angiotensin II, which plays an important regulatory role in wound healing and collagen production. The authors investigated whether systemic administration of angiotensin-converting enzyme inhibitors has any effect on formation of hypertrophic scars using the rabbit ear wound model. Methods: Sixteen New Zealand albino rabbits were divided into four groups, and four punch defects were created on each ear. The first group received oral enalapril immediately after the creation of punch defects. The second group received oral enalapril on day 28 after the formation of scars. The third group received intralesional steroid injections on days 28 and 35. The fourth group was the control group. The rabbits were killed on day 40. The harvested specimens were analyzed histomorphometrically and immunohistochemically. Results: Early enalapril application decreased the scar elevation index and fibroblast and capillary counts significantly, compared with the values in the control group. Late enalapril application decreased fibroblast counts significantly; however, there was no difference in scar elevation index compared with the control group. There was no difference between early enalapril application and steroid therapy in terms of scar elevation index and capillary and fibroblast counts. However, early and late enalapril groups displayed lower collagen type III immunoreactivity compared with the steroid and control groups. Conclusion: Early application of enalapril following dermal injury reduces formation of hypertrophic scars, probably because of its down-regulatory effects on type III collagen production.

A new epineural nerve repair technique : Oblique nerve coaptation

Despite the existence of various nerve coaptation techniques, functional results of nerve repair are still inadequate. Potential benefits of developing modified coaptation techniques cannot be disregarded. The authors report a new coaptation technique in which the nerves are cut in an oblique fashion to increase the coaptational surface. The sciatic nerves of male Wistar albino rats were cut at an angle of 30 and 45 deg (experimental groups), and 90 deg (control group). The nerves were repaired with nine 10-0 epineural stitches. Functional and histological studies were performed at week 12 on 7 rats from the 30-deg group, 15 rats from the 45-deg group, and 7 rats from the 90-deg group. Mean sciatic function index values of walking track analysis were the following: 30-deg group, -42.4+/-15.4; 45-deg group, -44.7+/-17.9; and 90-deg group, -52.9+/-13.9 (p>0.05). The mean values of myelinated axonal counts for the 30-deg, 45-deg, and 90-deg transection groups were 196.2+/-3.7, 196.1+/- 3.7, and 176.1+/- 5.6 respectively for proximal nerve segments and 180.1+/-6.8, 178.2+/-3.8, and 114.1+/-17.3 respectively for distal samples. Both the 30-deg and 45-deg coaptational groups had a significantly lower reduction of myelinated axonal counts at the regeneration zone in comparison with the 90-deg group (p<0.01). Mean myelinated axonal diameters in the proximal nerve segments were 8.2+/-2.6 microm, 8.4+/-3.1 microm, and 8.1+/-3.2 microm respectively, and were 7.1+/-3.6 microm, 6.9+/-3.4 microm, and 6.7+/-3.4 microm respectively in the distal nerve segments (p>0.05). The oblique nerve coaptation technique may enhance nerve regeneration by enabling a larger sprouting and contact area for nerve fibers, but additional investigation by more experienced centers is needed before relying on the preliminary results of this simple modification.

A new technique for microvascular anastomosis: external metallic circle.

Vessel anastomosis is the most critical step in free tissue transfers and replantation surgery. We report on a new microvascular anastomosis technique that uses a metallic circle around the anastomotic circumference. Sutures are first passed inside the circle and tied outside and over the circle so as to stretch open the anastomotic site. By retraction of vessel ends, the circle is totally exteriorized and thus there is no contact with blood. In 48 rats, the external circle method was compared with the conventional technique for constructing end-to-end anastomosis between carotid arteries (1 to 1.2 mm) and femoral veins (1 to 1.5 mm). The external circle method proved to be superior to the conventional end-to-end technique in speed of execution for both arterial and venous anastomoses. Patency rates at the third week were significantly higher in the venous group using the metallic circle (100 percent versus 70.8 percent, p < 0.05). This new method may be applicable in clinical microvascular surgery.