N. John Yousif

The Transverse Gracilis Musculocutaneous Flap

Through detailed anatomical study and latex injection of 24 cadaver legs, the blood supply to the skin overlying the gracilis muscle was examined. The proximal pedicle entered the gracilis muscle 10 ± 2 cm below the pubic tubercle. The dissections identified both septocutaneous and musculocutaneous perforators from the proximal gracilis pedicle. These branches had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending for <5 cm beyond the posterior margin of the gracilis muscle. This information led to a “new” transverse design of the gracilis musculocutaneous flap, such that the vascular perforators are invariably included in the cutaneous portion of the flap. In contrast, the traditional design, because of skin mobility, may allow elevation outside the skin territory of the muscle perforators.

The nasolabial fold ; an anatomic and histologic reappraisal

The nasolabial fold was analyzed by anatomic and histologic evaluation of the tissue planes that create and surround the fold. A fascial-fatty layer exists in the superficial subdermal space extending from the upper lip across the nasolabial fold to the cheek mass. The SMAS is present in the upper lip as the superficial portion of the orbicularis oris muscle. Traction on the SMAS or periosteum lateral to the nasolabial fold can deepen the fold, while traction on the fascial-fatty layer lessens the fold. The fascial-fatty layer and skin of the cheek mass are suggested as the primary ptotic elements responsible for facial aging. (Plast. Reconstr. Surg. 93: 60, 1994.)

THE LATERAL ARM FASCIAL FREE FLAP : ITS ANATOMY AND USE IN RECONSTRUCTION

Free fascial transfer has been used for reconstruction of gliding surfaces of the upper and lower extremities or when thin, pliable coverage is required (hand, heel, nose, and ear). In our experience with the lateral arm fasciocutaneous flap, we have found that the fascia alone is an excellent source of tissue for free flap transfer. A thorough investigation of the microscopic, gross, and radiographic anatomy of the lateral arm fascia was undertaken by the study of 25 fresh cadavers. Vascular pathways were mapped, their locations were analyzed, and then they were correlated with the elevation, design, and transfer of the flap. The lateral arm has a large fascial component located anterior and posterior to the lateral intermuscular septum, which itself lies between the triceps and the brachialis and brachioradialis muscles. It is perfused by the posterior radial collateral artery (PRCA), one of the terminal branches of the profunda brachii. This vessel (PRCA) provides at least four fascial branches from 1 to 15 cm proximal to the lateral epicondyle, the largest of which is located an average of 9.7 cm superior to the lateral epicondyle. Fascia up to 12 x 9 cm may be used with good axial perfusion. The histologic cross sections demonstrate the complex anatomy of the fascia itself, as well as its relation to the nutrient vessels. We have applied the lateral arm fascial flap in five cases of upper extremity reconstruction. We have also found this flap valuable in preservation of underlying anatomic detail for total reconstruction of the ear and nose when local tissue and more conventional flaps were not available.

The temporal branch of the facial nerve: How reliably can we predict its path?

A thorough examination of the temporal branch of the facial nerve was performed to characterize precisely the number of rami crossing the zygomatic arch and their location with respect to bone and soft-tissue landmarks. Fresh cadaver dissection was performed in 12 facial halves, dissecting the facial nerve superiorly from the stylomastoid foramen to identify all branches crossing the zygomatic arch. There were a median of three (range two to four) rami of the temporal branch crossing the lower aspect of the zygomatic arch, with distinct anterior and posterior divisions identified in each dissection. In 8 of the 12 dissections, one or more separate middle divisions of the nerve also were seen at the inferior aspect of the zygomatic arch. Superior to the zygomatic arch, frequent interconnections were noted between all divisions of the temporal branch, but no connections were noted to other branches of the facial nerve. Previous descriptions of the course of the temporal branch based on soft-tissue landmarks most closely correlated with nerve rami that were found in the present study to be located within the anterior division of the nerve. On crossing the inferior aspect of the zygomatic arch, the anterior and middle divisions of the temporal branch were located a median of 12 and 4 mm anterior to the articular eminence, respectively; the posterior division ranged in location from 10 mm posterior to 7 mm anterior to the articular eminence. The range over which rami of the temporal branch crossed the inferior aspect of the zygomatic arch was equally divided anterior and posterior to the articular eminence and covered up to 50 percent of the total length of the zygomatic arch. The present study confirms that the temporal branch is not a single nerve branch but consists of multiple rami that cross the zygomatic arch anywhere for over half the length of its inferior border. Techniques for localizing the nerve based on reference points from two soft-tissue landmarks are therefore unreliable.

Glomus tumor imaging: Use of MRI for localization of occult lesions

Magnetic resonance imaging has been performed in six patients with glomus tumors of the hand and correlated with clinical surgical histopathologic findings and with angiography in one case. Two of the patients had obscure pain without the classic clinical and radiologic findings of glomus tumors. The MRI examinations depicted the tumors in excellent detail and facilitated diagnosis in the two patients with atypical presentation. In all six cases the diagnoses were confirmed at surgery. The MRI proved valuable as a noninvasive and accurate means for the early diagnosis of occult glomus tumors.

The nasolabial fold: a photogrammetric analysis.

The nasolabial fold was analyzed by studying changes with aging in the nasolabial fold and adjacent soft-tissue features. Chronologic photographs were obtained from 19 older subjects, taken approximately every 10 years, from age 20 to their present age. In a separate phase of the study, facial portraits in repose and smiling were taken of young and old adult subjects with a mechanical frame used for setting an objective point of reference. Facial landmarks were identified and depth measurements were made in the anteroposterior direction. Relative lengths of selected points also were determined in the other dimensions (in the coronal plane) from photographs; these distances were normalized by using lower face length (distance from medial canthus to menton) for the vertical orientation and interpupillary distance to normalize horizontal dimensions. It was found that with aging there is anterior, lateral, and inferior displacement of the cheek mass with a resultant deepening of the nasolabial fold, while relationships between the upper lip and the fold itself remain constant.Also with age, the lateral commissure was found to move laterally, while the apparent angle of the nasolabial fold was decreased; this latter dimension was reflected by a decrease in the horizontal component of the fold length. These results support the theory that nasolabial fold deepening with age is caused by changes in the cheek mass and its support. (Plast. Reconstr. Surg. 93: 70, 1994.)

Sequential connection of flaps: A logical approach to customized mandibular reconstruction+

Microsurgery has improved the success rate for reconstruction of composite defects in the head and neck. Restoration of mandibular continuity alone is not adequate for reconstruction. Replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration. There is currently no ideal osteocutaneous free flap that provides unlimited length of bone, can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible, and provides thin skin for oral lining. Combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps. In six patients, a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects. In these selected patients, the fibula provided the blood supply for the second free flap, which was placed sequentially. The distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle. This approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited, such as following head and neck surgery and radiation.

Treatment of posttraumatic stress disorder after work-related hand trauma

Posttraumatic stress disorder frequently accompanies severe work-related hand trauma and, when a patient attempts to return to work it can potentially be as debilitating as the hand injury. Four techniques were examined for their effectiveness in the treatment of the symptoms of posttraumatic stress disorder. Confronting and reprocessing of intrusive thoughts, combined with coping skills training, effectively reduced all symptoms except avoidance reactions. An early return to the worksite was useful with those patients who experienced mild avoidance reactions, although many patients were not able to use this. Graded work exposure was a highly successful technique for those patients with moderate avoidance reactions. For those with severe avoidance reactions, on-site job evaluations were used with good success. We believe that actual exposure to the worksite greatly enhances the ability of occupationally hand-injured patients to return to work for their previous employer. An algorithm for treatment is proposed.

Flashbacks after traumatic hand injuries: Prognostic indicators

Flashbacks of a traumatic hand injury may compromise a patients rehabilitation process. This study examined the nature and significance of these flashbacks in a work-injured population. We also evaluated the ability of these patients to return to work at the site of the original injury. Sixty-one patients with work-related, traumatic hand injuries received psychological evaluation and treatment. All patients experienced flashbacks. The following three types of flashbacks were identified: (1) a replaying of the events occurring just before the accident and continuing until the injury (replay flashbacks), (2) an image of the injured hand just after the trauma occurred (appraisal flashbacks), and (3) images in which an injury that was more severe than the one that actually occurred were perceived (projected flashbacks). Regardless of the result of injury, patients with replay flashbacks were the most likely to return to their former employment (95.2%) after only 4.8 1-hour sessions of psychotherapy for control of symptoms. Patients with a combination of appraisal and projected flashbacks were the least likely to return to work (10.3%), despite the fact they received an average of 13.1 1-hour sessions of psychotherapy.

Identifying motor and sensory myelinated axons in rabbit peripheral nerves by histochemical staining for carbonic anhydrase and cholinesterase activities

Carbonic anhydrase (CA) and cholinesterase (CE) histochemical staining of rabbit spinal nerve roots and dorsal root ganglia demonstrated that among the reactive myelinated axons, with minor exceptions, sensory axons were CA positive and CE negative whereas motor axons were CA negative and CE positive. The high specificity was achieved by adjusting reaction conditions to stain subpopulations of myelinated axons selectively while leaving 50% or so unstained. Fixation with glutaraldehyde appeared necessary for achieving selectivity. Following sciatic nerve transection, the reciprocal staining pattern persisted in damaged axons and their regenerating processes which formed neuromas within the proximal nerve stump. Within the neuromas, CA-stained sensory processes were elaborated earlier and in greater numbers than CE-stained regenerating motor processes. The present results indicate that histochemical axon typing can be exploited to reveal heterogeneous responses of motor and sensory axons to injury.