Marina Ninkovic

Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention.

This prospective study reveals that the incidence of seroma formation after harvesting the latissimus dorsi muscle by scalpel is reasonably moderate. This incidence is lower when the resulting skin flaps are tacked to the underlying structures with resorbable sutures. In contrast, electrocautery dissection shows a significantly much higher rate of seroma formation, probably because of thermal injury of the wide fascial wound layers or the subcutaneous fat tissue. Fifty-eight patients were distributed among three groups. Within each group a specific way of latissimus dorsi muscle harvesting and donor site treatment was accomplished. The group of scalpel dissection and skin flap fixation to the underlying layers with additional tacking sutures shows the lowest rate of seroma formation (9.1%, N = 2) due to the avoidance of shearing effects. A clearly higher incidence is present in the group of scalpel dissection without tacking sutures (38.1%, N = 8), whereas seromas most frequently result after electrocautery dissection without skin flap fixation (80.0%, N = 12).

First forearm transplantation : Outcome at 3 years

We here report on the surgical procedure, postoperative course and functional results at 3 years following the first bilateral forearm transplantation. A 41‐year‐old male underwent bilateral forearm transplantation on February 17, 2003. After ATG induction therapy, tacrolimus, prednisone and MMF were given for maintenance immunosuppression. At 16 months, MMF was switched to everolimus. Hand function, histology, immunohistochemistry, radiomorphology, motor and nerve conduction and somatosensory‐evoked potentials were investigated at frequent intervals. A total of six rejection episodes required treatment with either steroids, basiliximab, ATG, alemtuzumab or tacrolimus dose augmentation. At 3 years, the patient is free of clinical signs of rejection despite a persisting minimal perivascular lymphocytic dermal infiltrate. No signs of myointimal proliferation in graft vessels were seen. Motor function continuously improved, resulting in satisfactory hand function. Intrinsic hand muscle function was first observed at 16 months and continues to improve. Although discrimination of hot and cold recovered, overall sensitivity remains poor. The patient is satisfied with the outcome. Bilateral forearm transplantation represents a novel therapeutic option after loss of forearms.

Status 5 Years after Bilateral Hand Transplantation

Graft survival and function early after hand transplantation is good. It remains unknown, however, whether long‐term survival is limited by chronic rejection. We here describe the clinical course and the status 5 years after bilateral hand transplantation with emphasis on immunosuppression (IS), function, morphology and graft vascular changes.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

Free flap reconstruction of the foot.

Free flap reconstruction of the foot has been widely performed in the last 20 years, but choice of a free transferred substitute for the soft tissue of the particular defect remains controversial. The authors present a series of 77 free flaps to the foot performed in 68 patients during October 1976 and September 1997. Long-term follow-up ranged from 12 months to 18 years (median, 44.4 months). Seventy-three flaps were transferred successfully (95%). The indications for a specific flap depended on the localization and extension of the foot defect. In weight-bearing areas the authors favored the use of a muscle flap covered with a split-thickness skin graft; the latissimus dorsi muscle was used primarily. This study shows a lower ulceration rate in muscle flaps covered with split-thickness skin grafts than in fasciocutaneous flaps in weight-bearing areas (27% vs. 60%). In nonweight-bearing areas, fasciocutaneous flaps were the best choice. In this series, the lateral arm flap was applied most often. The authors recommend free fascial flaps (serratus fascial flap or radial forearm fascial flap) covered by split- or full-thickness skin grafts for coverage of the malleolar region as well as coverage of exposed tendons of nonweight-bearing regions. Proper tailoring of the flap and postoperative care are very important to maintain a result without ulceration, as is avoiding having the suture line cross a weight-bearing area. Tactile sensation does not seem to be essential.

Outcomes with respect to disabilities of the upper limb after hand allograft transplantation: a systematic review

The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English, French, or German were reviewed systematically, with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty‐eight patients were reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (±19.04) points on the DASH score after HAT (P = 0.005). Lower DASH scores (P = 0.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow‐up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty‐two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.

World Experience After More Than a Decade of Clinical Hand Transplantation: Update on the Innsbruck Program

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

Lower lip reconstruction : Introduction of a new procedure using a functioning gracilis muscle free flap

Background: Subtotal and total reconstruction of the lower lip is a challenge for the plastic surgeon: this lip mainly contributes to the continence function of the oral sphincter. Fasciocutaneous free flaps and local flaps are better suited to the skin laxity of elderly patients; furthermore, larger defects extending to the chin area can be difficult to manage with only local flaps. Methods: In an attempt to restore very good function and aesthetics of the lower lip in a single procedure, the authors introduced the use of a functioning (innervated) gracilis free flap. The dynamic sphincter capacity was obtained with the coaptation between the motor branch of the gracilis muscle and the marginal branch of the facial nerve. A facial artery musculomucosal flap replaced the vermilion and the inner side mucosa, and a skin graft from the scalp covered the external surface of the gracilis. The procedure was performed in two cases. Results: In both cases, the authors achieved quite full physiologic lower lip movement with regard to symmetrical spontaneous and voluntary controlled lower lip function, whereas the skin grafts from the scalp and the supraclavicular region had a nearly perfect color match with the reconstructed area. The aesthetic result was excellent compared with the complexity of the reconstructed defect. Conclusions: A functioning gracilis free flap has to be considered among the techniques for complex lower lip reconstruction. It was able to restore very good voluntary function and an extremely fine aesthetic result in a single-stage procedure.

Anterior neck reconstruction with pre-expanded free groin and scapular flaps

To improve aesthetic and functional outcomes in the reconstruction of severe anterior neck burn deformities and to reduce donor-site morbidity, pre-expansion of free-flap donor sites was performed in eight patients. In the first stage of reconstruction, the tissue expander was placed and gradually inflated over a period of 6 weeks. In the second stage, the anterior neck scar was resected up to the limits of the aesthetic unit of the neck, radical release of neck contracture was achieved by transection of contracted platysma muscle, and immediate coverage with a pre-expanded groin or scapular free flap was performed. The early postoperative course was uneventful. Physical therapy was started 1 week after the reconstruction. Long-term follow-up (mean, 4 years) of patients who underwent reconstruction of extensive neck burn deformities demonstrated good aesthetic and functional results. The advantages and drawbacks of using pre-expanded free flaps in the treatment of neck burn contractures are discussed.

The psychological assessment of candidates for reconstructive hand transplantation

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at‐risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the ‘Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT‐PSP)’ which utilizes a semi‐structured interview and standardized psychological screening procedures and continuous follow‐up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT‐PSP. Psychological impairments including social withdrawal, embarrassment, reduced self‐esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi‐ or unilateral impairment, native or accidental loss of hand, and social integration.