Kenneth K. Yim

The sensate fibula osteoseptocutaneous flap: a preliminary report

The ideal oromandibular reconstruction calls for restoration of intraoral sensation as well as tissue replacement because the loss of sensation in the oral cavity impairs oral function. The versatility and flexibility of the fibula osteoseptocutaneous flap in complex three dimensional spatial positioning lends itself to be desirable in composite oromandibular reconstruction. It falls short of being ideal because the skin paddle of the flap is usually insensate and thus oral sensation is not restored. The skin paddle of the fibula osteoseptocutaneous flap is innervated by the lateral sural cutaneous nerve and this nerve can be preserved and reinnervated to restore sensation to the skin paddle. The sensate fibula osteoseptocutaneous flap may be the ideal flap for one stage composite reconstruction of oromandibular defects. This is a preliminary report on the sensory return of the sensate fibula osteoseptocutaneous flap in oromandibular reconstruction.

Use of 20 cm or longer interposition vein grafts in free flap reconstruction of the trunk

&NA; Between January of 1993 and September of 1995, six microsurgical free tissue transplants were performed using saphenous vein grafts ranging from 20 to 39 cm in length. All six free flaps survived. Two wounds were caused by radiation injury and two by tumor resection. The remaining two free flaps were performed for contour deformity and spinal cord coverage. All of the recipient sites were located on the trunk. In each case, an arteriovenous loop was created before the microvascular anastomosis to the free flap. There was one arterial thrombosis requiring thrombectomy and revision of the anastomosis. Three patients developed minor wound complications that responded to local wound care. Each of the flaps successfully provided wound coverage, and in two cases the flaps tolerated further radiation results. Long interposition vein grafts can be used for difficult microsurgical reconstructive procedures with reliable results when no local recipient vessels are available. Versatility is therefore afforded in placement of the flap and the choice of recipient vessels, making this option a useful one in the treatment of complex wounds of the trunk. (Plast. Reconstr. Surg. 101: 1262, 1998.)

Mycobacterium tuberculosis infection of the hand: a case report and review of the literature.

Despite the recent overall increase in cases of tuberculosis and other types of mycobacterial infection, the incidence of tuberculous hand infections remains extremely low in the United States. The rarity of this infection often results in delay in diagnosis and treatment. A case of Mycobacterium tuberculosis infection of the left thumb without pulmonary involvement is presented. The patients presentation and clinical findings were characteristic of M. tuberculosis infection. Prompt surgical debridement and tissue diagnosis are essential to the diagnosis and treatment of this rare infection.

Single third-toe transfer in hand reconstruction

Eighteen third-toe transfers to the hand were performed from 1984 to 1993 in 15 patients. These patients had multiple amputations, and follow-up ranged from 5 to 78 months with an average of 27 months. Single third-toe-to-hand transfer was elected when (1) the second toe was not available or not suitable for transfer, (2) the second toe was located in the same foot where the great toe had been transferred to the thumb and the second toe was, therefore, spared for gait, or (3) the third toe was a better size match.

Intraosseous wiring in toe-to-hand transplantation.

Although there are many reports on bony fixations in finger replantations, information pertaining to fixation methods in toe-to-hand transplantations is scarce. The results of intraosseous wiring were evaluated in 68 toe-to-hand transplantations in 47 patients. Clinical and radiological evaluation of bony union was conducted an average of 30 months after the procedure. There was no malunion. There was one painless pseudarthrosis, with an overall nonunion rate of 1.5%. Intraosseous wiring is a simple, quick, dependable, and consistent method of fixation in toe-to-hand transplantation.

Lemierre's syndrome: a case of postanginal septicemia and bilateral flank abscesses.

Lemierres syndrome is characterized by pharyngeal infections in young healthy adults with secondary septic thrombophlebitis and multiple metastatic infections. In the preantibiotic era, Lemierres syndrome was common and lethal. With the advent of antibiotics, Lemierres syndrome has become such a rare entity that the diagnosis is often delayed or missed. With prompt recognition, appropriate antibiotic therapy, and surgical drainage of metastatic abscesses, the majority of patients can be cured. A case of Lemierres syndrome in a 22-year-old previously healthy man treated on a plastic surgery service is presented. Surgeons who can be consulted for deep space infections should be aware of this disease so that the diagnosis and treatment can be initiated promptly to prevent patients from succumbing to this life-threatening but curable disease.

Eleven consecutive combined latissimus dorsi and serratus anterior free muscle transplantations.

We reviewed our experience with 11 consecutive combined latissimus dorsi and serratus anterior free-muscle transplantations from 1980 to 1990. All 11 flaps were successful and there was minimal morbidity. This combined muscle flap is ideal for soft-tissue coverage in extensive lower extremity wounds, in mutilating hand injuries with dorsal and palmar defects, and in situations when a long vascular pedicle is needed to get out of the “zone of injury.”

The role of the plastic surgeon in the management of surgical infection.

At our Medical Center, our reconstructive service has actively sought referrals of acute and chronic infections by declaring an interest in undertaking the integrated management and reconstruction of these cases. The practices of the two senior surgeons were reviewed for three academic years (1992 to 1995). Cases of surgical infection were analyzed as to site, ablative procedures, and reconstructive procedures. In total, 139 patients with 147 infections were identified. Sites of infection included head and neck (9.5 percent), trunk and pelvis (39.5 percent), upper extremity (22 percent), and lower extremity (29 percent). One-hundred thirty-one ablative procedures were done on this group, as were 126 reconstructive procedures, including 17 fasciocutaneous flaps, 26 pedicled muscle flaps, and 28 microsurgical flaps. With a mean follow-up of 14 months, 92 percent of these patients had resolution of infection. The 8 percent failure group included recurrences, amputation, and death. This series demonstrates that a plastic surgery service can attract a diverse population of surgical infections and manage them successfully with ablation and a wide variety of reconstructive procedures. The coordination of ablation and reconstruction may be optimally performed by the plastic surgeon.

Use of intercostal nerves as nerve grafts in hand reconstruction with rectus abdominis flaps.

Following complex crush and avulsion hand injuries with significant tissue loss and exposed vital structures, microvascular tissue transplantation can reliably provide soft tissue coverage in one setting. Rectus abdominis muscle free flaps are frequently used in hand reconstruction because of the ease of dissection, low donor site morbidity, reliable, large diameter vessels for anastomosis, and supine positioning of the patient, allowing two teams of surgeons to work simultaneously reducing the operative time.’ Because of the segmental innervation of the rectus muscle, it is not used for functional transplantation, and the innervating intercostal nerves are routinely sacrificed during harvesting of muscle. We propose that the intercostal nerves within the rectus sheath can be used for primary nerve grafting in complicated hand injuries when soft tissue loss requires rectus muscle free flaps for coverage and nerve grafting is attempted within the injury.

Muscle flap monitoring in a rat model with a variable gain quantitative fluorometer

&NA; A variable gain dermofluorometer with a wide range of sensitivities capable of quantifying fluorescein emission from both skin and muscle was tested in a rat latissimus dorsi island muscle flap model. Quantitative fluorometric readings directly from muscle and skin sites that did not undergo surgery were taken at intervals over 2 hours after intravenous fluorescein injection. Muscle flaps with intact pedicles gave an inflow‐outflow pattern. A no‐outflow pattern was seen in muscle flaps with ligated pedicle veins and a no‐inflow pattern was seen in muscle flaps with ligated pedicle arteries. These patterns were similar to the flow pattern seen with quantitative fluorometric monitoring in flaps with cutaneous components. These results suggest that quantitative fluorometry may be applicable to circulation monitoring in muscle flaps.