Mustafa Akyürek

Clinical and scientific considerations in leech therapy for the management of acute venous congestion: An updated review

Any surgical intervention that involves the manipulation of veins, large or small, carries the risk of acute venous congestion. Venous congestion is the product of an imbalance between arterial inflow and venous outflow, and results in the stasis of blood in the tissues that are normally drained by the affected veins. The resultant lack of tissue perfusion causes hypoxia, acidosis, and arterial thrombi formation, which can potentially progress to tissue necrosis and wet gangrene. In the past several decades, the use of leeches (Hirudo medicinalis) has been rediscovered as an effective method of relieving acute venous congestion. This updated review of leech therapy focuses on the use of medicinal leeches in a variety of clinical conditions characterized by acute venous congestion, and points out the experimental use of leeches in other pathological entities. A discussion of the recent scientific findings that explain the possible mechanisms of action of leech therapy is also provided.

Fingertip Replantation at or Distal to the Nail Base: Use of the Technique of Artery-only Anastomosis

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base—namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1–41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in “distal” zone I amputations for approximately 7 days, and by the use of leeches in more “proximal” zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6–18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0–8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts

Ring avulsion replantation is a technically challenging procedure with a very low success rate. Because the zone of arterial injury is more extensive than what it appears to be in such avulsion amputations, a technique was developed to debride the avulsed digital artery for a long distance, extending well into the digital pulp, thereby creating healthy arterial ends to be bridged by one or two segments of long venous grafts. Using this technical approach, 7 patients with complete amputations of ring avulsion injury (Urbaniak’s class III) were operated. In all amputations the bone was disrupted at the distal interphalangeal level (except in 1 patient) and the soft tissues at the proximal phalanx level, with the proximal interphalangeal joint and the flexor digitorum superficialis tendons being intact. Results indicated that replantation was successful in all patients. However, 2 patients presented with unusually late arterial failure 28 and 30 days after surgery respectively. Although one of these cases was salvaged by reoperation, the other case (followed by conservative management) demonstrated partial distal necrosis. Therefore, the ultimate success rate in this series was 85% in the long term. At follow-up, sensibility was protective in all patients, with an average static two-point discrimination of 7.8 mm (range, 6–14 mm). The total active motion of the replanted digits was 194 deg on average (range, 155–205 deg) without loss of function of the proximal interphalangeal joint except in 2 patients who had late vascular problems. The authors conclude that microsurgical replantation of completely amputated ring avulsion injuries with an intact proximal interphalangeal joint and flexor digitorum superficialis tendon, is a worthwhile procedure that results in good functional and aesthetic results. Furthermore, using an aggressive approach for debridement of the avulsed digital artery, as described in this article, an experienced microsurgeon can replant successfully nearly all cases. However, one should be cautious in the follow-up of such patients, because late arterial failure may be encountered, as was observed in 2 patients in this series. The authors suggest immediate reoperation in such unusual circumstances.

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.

Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps.

Congenital aplasia of the nasal columella is a very rare anomaly. The deformity is characterized by the isolated absence of the columella from the nasal tip to the root of the philtrum, including the medial crura of the alar cartilages; surrounding structures such as the septum, nose, and upper lip are normal. To the best of our knowledge, only four such cases have been described to date. The embryopathogenesis for this uncommon disease is presently unknown. Our report describes a 14-year-old girl with congenital agenesis of the columella as an isolated anomaly. Her family history was positive for the presence of the same congenital deformity, which also affected her older brother; there was, however, no consanguinity between the parents. The columella defect was reconstructed with an internal nasal vestibular skin flap and bilateral upper labial mucosa flaps. There are many techniques available to repair columella defects, including free grafts from the ear, local flaps from the forehead, face, upper lip, and nose, distant flaps such as tube pedicle flaps, and free flaps from the ear. Each of these techniques has advantages and disadvantages. Because of this, the treatment of columella defects should be individualized.

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.

Free transfer of the radial forearm flap with preservation of the radial artery

One of the main disadvantages of the radial forearm flap is the sacrifice of a major artery. To overcome this drawback the authors describe a technique of free transfer of the flap with preservation of the radial artery. The flap is elevated as a distal row perforator-based fasciocutaneous flap with a very short segment of the radial artery included in the inverted-T-shaped arterial pedicle. The venous outflow of the flap is provided by the cephalic vein, with accompanying veins of the radial artery left behind. Although the donor radial artery is repaired primarily, the flap is transferred to reconstruct a soft-tissue defect resulting from the release of a neck contracture after radiotherapy in a 42-year-old patient who had previous excision of a mandibular osteosarcoma. The arterial anastomosis was performed end to end between the superior thyroid artery and one limb of the arterial pedicle, with the other limb ligated. The venous anastomosis was performed end to end between the cephalic vein and the external jugular vein. The flap survived completely and a satisfactory result was obtained. The radial artery is demonstrated to be patent long after surgery, both with Allens test and with a Doppler examination. Considering the possible sequelae of the sacrifice of the radial artery, this technique is obviously advantageous to such patients, even with a nonsatisfactory preoperative Allens test. This perforator-based radial forearm flap is very easy to raise and to transfer, with anastomoses of large-diameter vessels.

Adductor magnus perforator flap revisited: an anatomical review and clinical applications.

Background:The adductor magnus musculocutaneous perforator flap is a medial thigh flap whose utility is often overshadowed by that of its anatomic neighbor, the gracilis flap. It has a large, reliable pedicle and associated skin paddle. Few reports have been published describing the use of this flap as a local or free tissue transfer. The purpose of this study is to revisit and further characterize the anatomy of this extremely versatile yet underutilized flap. Materials/Methods:A total of 13 cadavers (n = 26 thighs) were dissected to identify the musculocutaneous perforators that supply the skin of the posteriomedial thigh. The vascular anatomy was studied using multiple modalities. Based on the anatomic data, a local V-Y advancement flap was designed. A total of 8 patients (n = 10 flaps) underwent reconstruction of locoregional defects. Results:Our anatomic studies confirmed the presence of multiple parallel musculocutaneous perforators that travel through the adductor magnus muscle and course obliquely in a posterior-inferior direction. We found that the primary perforator is reliably found approximately 8 cm distal to the groin crease and 2 cm posterior to the posterior border of the gracilis muscle. We discovered that it is consistently accompanied by a separate perforator located 2 cm distally. Minimal dissection into the muscle revealed a Y-configuration of these 2 perforators. This configuration was present in 100% of the cadaveric dissections and is supplied by the first medial branch of the profunda femoris artery. Computed tomography angiograms depicted vascular arborization of the perforators supplying the flap. Clinical experience showed that complete flap survival was achieved in all of the cases. Conclusion:The adductor magnus perforator flap is a reliable flap that offers robust blood supply, through a consistent vascular pedicle, to an extensive skin territory. Our anatomic studies revealed the consistent presence of 2 proximal perforators in the medial thigh that are linked by an intramuscular Y-configuration that provides enhanced blood supply to a local V-Y advancement flap design. The location of the skin paddle on the proximal medial thigh allows for minimal donor-site morbidity as it can be closed primarily with a V-Y advancement flap design, obviating the need for skin grafting.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days.

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.