Norman Weinzweig

The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery : an anatomic and clinical approach

The axial-pattern reverse radial forearm fasciocutaneous flap has become one of the primary flaps for reconstruction of soft-tissue defects of the hand. The two main disadvantages of this flap are (1) sacrifice of a major artery that may possibly jeopardize hand viability and (2) morbidity and appearance of the donor site. In an effort to overcome these drawbacks, an anatomic study of a distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery was conducted. Seventeen fresh cadaver forearms were dissected to investigate the contribution of the distal radial artery and its superficial and deep branches to the fasciosubcutaneous plexus of the forearm. The blood supply to the radial forearm fasciosubcutaneous tissue was found to emanate from 6 to 10 septocutaneous perforators of the distal radial artery in the vicinity of the anatomic snuff box that fan out at the level of the deep fascia to form a rich plexus supplying the forearm fascia, subcutaneous tissue, and skin. There appeared to be a definite directional component, with the arterioles running longitudinally along the intermuscular septum. The deep fascia and subcutaneous tissue were found to have their own venous system accompanying the small perforating arterioles. Encouraged by these findings, we proceeded to utilize this fasciosubcutaneous flap for coverage of the thumb-index web space (three patients), the dorsum of the hand (two patients), and both the palmar and dorsal aspects of the hand (one patient). Five flaps had almost complete survival. The largest flap in our series suffered significant loss. Minor skin-graft loss occurred in a few cases, and we now delay skin grafting for several days. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery can be a very useful and reliable alternative for repairing soft-tissue defects of the hand, obviating the need for the classic fasciocutaneous flap or even a free flap. This flap not only preserves the radial artery, which is essential in cases where only the radial artery is functioning, such as following severe hand injuries, but also provides a more acceptable donor site.

Free tissue failure is not an all-or-none phenomenon.

A common misconception among microsurgeons is that free tissue failure is an all-or-none phenomenon. In other words, there is an instantaneous cessation of blood flow to a flap primarily due to thrombosis at the arterial or venous anastomotic site (primary thrombosis) with complete flap loss as a result. Contrary to this belief, we have found that free tissue transfers occasionally die a slow, progressive, and partial death. This most likely is due to gradual shutting down of the microcirculation by the showering of microemboli downstream from the arterial anastomosis (secondary thrombosis). We discuss our clinical experience during the past 6 years with 10 patients in whom free flap failure was not an all-or-none phenomenon and describe the expectant management of these failing free flaps. Microvascular reconstruction of the lower extremities was performed for recalcitrant sickle cell ulceration, chronic venous stasis ulceration in a patient with anti-thrombin III deficiency, dry gangrene of the plantar surface of the foot and toes secondary to posterior tibial artery injection in an intravenous drug abuser, Gustillo type IIIc injury requiring reconstitution of the femoropopliteal artery after an automobile bumper injury, Gustillo type IIIb injury resulting from gunshot wounds, an open ankle joint in a patient with severe peripheral vascular disease, and osteomyelitis. Other cases included cheek soft tissue reconstruction after wide resection of a recurrent dermatofibrosarcoma protuberans of the parotid gland, chest wall coverage after claviculectomy for osteoradionecrosis, and thumb replantation complicated by refractory vasospasm. Latissimus dorsi (four patients), rectus abdominis (three patients), scapular (one patient), and radial forearm fasciocutaneous (one patient) flaps were used. Flap compromise was detected between 4 hours and 6 weeks after surgery. Salvage attempts included Fogarty thrombectomy (four patients), anastomotic revision (two patients), streptokinase instillation (one patient), and leech application (one patient). Failing free flaps were managed expectantly with the use of daily dressing changes. This allowed for the survival of sufficient soft tissue to effect coverage of exposed bone, tendon, or joint. Hyperbaric oxygen was not administered. Tangenital excision of the eschar was performed between 6 and 51 days after free tissue transfer. Skin grafting was delayed for 15 to 80 days. In all cases, a successful outcome was achieved ultimately by either a single skin-grafting procedure (seven patients) or groin flap coverage (one patient). Follow-up ranged from 2 to 35 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Transposition of the greater omentum for recalcitrant median sternotomy wound infections

During a 3-year period, 25 patients underwent transposition of the greater omentum, either alone or in combination with muscle flaps, for treatment of recalcitrant median sternotomy wound infections. Most patients underwent radical sternectomy for deep and extensive sternal wounds; the others had significant defects involving the lower third of the sternum. The most common combination of flaps was omentum and bilateral pectoralis major musculocutaneous flaps (14 patients). Delay to reconstruction after the recognition of median sternotomy infection ranged from 2 to 36 days (average, 13.9 days) except for one patient treated outside by the “open method” for 18 months. Definitive closure was performed after an average of 1.8 debridements (range, 1-4). Hospitalization averaged 28.5 days (range, 13-42 days) in 16 of the 19 surviving patients. The majority of these patients had far more extensive sternal defects than those usually treated by muscle flaps alone. Healing was ultimately achieved in 95% of infected sternotomy wounds. Seventy-four percent of patients healed their sternal wounds uneventfully without subsequent problems. Flap site complications in the remaining patients included recurrent chondritis (16%) and partial (4%) or complete (4%) flap loss. Donor-site complications included abdominal wall herniation (21%), hematoma (8%), and seroma (4%). There were no problems with chest wall instability or intra-abdominal morbidity. Six patients (24%) succumbed to multisystem failure unrelated to sternal infection. We present our experience—including indications, technique, and outcome—with transposition of the greater omentum for recalcitrant median sternotomy wound infections. Pedicled omental flaps provide reliable coverage especially after radical sternectomy for deep infection, including osteomyelitis, chronic chondritis, and mediastinitis, as well as for extensive and lower third sternal wounds. To the best of our knowledge, this is the largest series of omental transposition flaps for coverage of infected sternal wounds reported in the literature.

Free tissue coverage of chronic traumatic wounds of the lower leg.

&NA; Thirty‐eight consecutive patients who underwent 42 free flaps for chronic wounds of the lower leg were identified over an 11‐year period. All wounds were open for a minimum of 1 month (mean, 40 months; median, 8 months; range, 1 month to 30 years). The average age was 37 years (range, 7 to 68 years), there were 31 male patients and seven female patients, and the average follow‐up time was 30 months (range, 12 to 72 months). The original injury was an open fracture in 28 patients, wound dehiscence after open reduction and internal fixation of a closed fracture in nine patients, and a shrapnel wound in one patient. A total of 23 patients had osteomyelitis, which was classified as local (involving less than 50 percent of the bone diameter) in 15 patients and as diffuse (involving greater than 50 percent of the bone diameter or infected nonunion) in eight patients. The wounds were treated with sequential debridement, antibiotics, and flap coverage. Ancillary procedures included antibiotic beads in 18 patients, saucerization in 16, Ilizarov bone transport in three, calcanectomy in two, and fibular resection and ankle fusion in one. Thirty‐four of 42 flaps survived, four having undergone a repeat free flap. There were three failures out of 25 flaps (12 percent) among those with a normal angiogram and five failures out of 15 flaps (33 percent) among those with an abnormal angiogram (p > 0.05). The failure rate of those with osteomyelitis was six of 26 (23 percent) versus two of 26 (13 percent) for those without osteomyelitis (p > 0.05). Successful reconstruction (bone healed, patient ambulatory and infection‐free) was achieved in 33 of 38 patients (87 percent). The failure of reconstruction for those patients with osteomyelitis was four of 23 (22 percent) versus one of 15 (7 percent) for others (p > 0.05). The failure rate of flaps in patients with diffuse osteomyelitis was three of eight (38 percent) versus two of 30 for others (7 percent, p = 0.053). The presence of diffuse osteomyelitis was associated with a lower rate of successful limb reconstruction. An abnormal angiogram and the presence of osteomyelitis both were associated with a lower rate of successful limb reconstruction, but this was not significant, probably because of the small size of the cohort. (Plast. Reconstr. Surg. 109: 592, 2002.)

Vitamin C reduces ischemia-reperfusion injury in a rat epigastric island skin flap model

Free radicals have been implicated in the cause of ischemia-reperfusion injury. Various agents have been used in an attempt to reduce ischemia-reperfusion injury pharmacologically, including free radical scavengers. Vitamin C (ascorbic acid), a well-known free radical scavenger, has not, to the best of our knowledge, been evaluated in this respect. Previous work at our institution has shown that vitamin C decreases capillary permeability, thus significantly reducing fluid resuscitation requirements in postburn cases. Because this is due in part to the scavenging effect of vitamin C on free radicals, we investigated the role, if any, of vitamin C on ischemia-reperfusion injury in a rat epigastric island skin flap model. Twenty-four adult Sprague-Dawley rats were divided into control and vitamin C groups. Superficial epigastric island skin flaps measuring 6.0 × 3.5 cm were raised. Pedicles were isolated and occluded with microvascular clamps for 6 hours. The flaps were then sutured back to their beds over Steri-Drape barriers. Fifteen minutes before reperfusion, the control group flaps were perfused via femoral artery cannulation with normal saline (2.5 ml/kg). The vitamin C–treated group was perfused in a similar fashion with 2.5 ml/kg of a vitamin C/normal saline solution (27 mg/ml). The animals were observed for 7 days, and the percentage of flap survival was determined using a paper template technique. The vitamin C–treated group demonstrated a significantly higher percentage of flap survival than did the control group (25.8% mean vs. 7.5% mean, p < 0.025). In this animal model, vitamin C reduced or limited reperfusion injury after 6 hours of ischemia. Its presumed mechanisms of free radical reduction and its relative safety make vitamin C a promising area of investigation in future animal studies as well as in human studies examining reperfusion injury.

'Spaghetti wrist': Management and results

&NA; A retrospective review of 60 patients with “spaghetti wrist” lacerations operated on by the authors between July of 1988 and June of 1996 was completed. Spaghetti wrist injuries were defined as those occurring between the distal wrist crease and the flexor musculotendinous junctions involving at least three completely transected structures, including at least one nerve and often a vessel. A total of 41 men and 19 women, average age of 29.0 years (range, 5 to 54 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (61.0 percent), knife wounds (23.7 percent), and suicide attempts (8.5 percent). An average of 7.8 structures were injured including 5.8 tendons, 1.2 nerves, and 0.73 arteries. The most frequently injured structures were flexor carpi ulnaris (66.7 percent), median nerve (60.0 percent), flexor digitorum superficialis 2‐5 (59.2 percent), ulnar nerve (58.3 percent), and ulnar artery (56.7 percent). A predilection for injury to the ulnar structures was observed. The flexor carpi ulnaris was more commonly injured than the more superficial central and radial palmaris longus (48.3 percent) and flexor carpi radialis (45.0 percent). The most common pattern of injury involved the ulnar nerve and artery and flexor carpi ulnaris, or so‐called ulnar triad (41.7 percent). Combined median nerve, flexor carpi radialis, and palmaris longus lacerations occurred in 26.7 percent. Simultaneous lacerations of both median and ulnar nerves occurred in 23.3 percent. No distinct pattern of injury was noted in patients with simultaneous injury to both nerves. Simultaneous lacerations of both ulnar and radial arteries occurred in 6.7 percent; neither artery was injured in 33.3 percent. In the subset of 19 patients available for follow‐up examination, range of motion was excellent in 12 patients and good in 7 patients. In 12 patients with sufficient follow‐up, intrinsic muscle recovery was good in 7 patients and fair to poor in 5 patients. Sensory return was disappointing: seven patients recovered only protective sensation and five patients demonstrated return of two‐point discrimination that ranged from 7 to 12 mm in three patients and from 2 to 6 mm in two patients. (Plast. Reconstr. Surg. 102: 96, 1998.)

Anatomy of the extensor tendons to the index finger

An anatomic study was performed to better delineate the extensor tendons of the index finger. Seventy-two cadaver hands were dissected. Classically, a single slip of the extensor digitorum communis (EDC) and a single slip of the extensor indicis proprius (EIP) are said to run to the index finger. The EIP is said to be ulnar to the EDC at the level of the metacarpal head. In dissections in this study, the classic description was noted in 58 of the hands. Ten hands had a double slip of the EIP. Two hands had a double slip of the EDC running to the index. Two hands had a single slip of the EIP either volar or radial to the EDC at the level of the metacarpal head. Thirteen hands (19%) showed anatomic variants of the EIP and EDC tendons at the level of the metacarpal head, differing from the classic description. Additionally, two hands showed aberrant tendons. A knowledge of these variants when performing tendon repair or EIP transfer is necessary.

Portals for arthroscopy of the trapeziometacarpal joint

We have studied the anatomy of the structures superficial to the trapeziometacarpal joint in cadavers in order to define safe entry points for arthroscopy of the joint.

Constriction band-induced vascular compromise of the foot: classification and management of the "intermediate" stage of constriction-ring syndrome.

Gangrene of an extremity secondary to a congenital constriction band may result from in utero or postnatal vascular compromise. Often ths process is completed in utero following spontaneous resolution of the vascular insufficiency, resulting in a healed wound by fetal repair and regeneration or in amputation of the distal part. When this process is progressive as a result of worsening lymphaticovenous and/or arterial obstruction with associated soft-tissue necrosis, salvage of the distal part can be accomplished by immediate decompression to evacuate the lymphedema fluid, staged band excision, Z-plasty closure, and topical antimicrobial therapy of the open wound. A revised classification of constriction-ring syndrome incorporating the intermediate stage (3B) of severe lymphaticovenous compromise with soft-tissue loss is introduced.

Radial, ulnar and median nerve palsies caused by a congenital constriction band of the arm : single-stage correction

Single-stage correction of a congenital constriction band of the arm in an infant with radial, ulnar, and median nerve dysfunction is reported with significant improvement in neurologic function. This was accomplished by thorough preoperative physical examination and neurologic evaluation, circumferential excision of the constricting band, decompression of the involved peripheral nerves, and multiple large Z-plasties for skin closure. Based on the case presented here and a review of the literature, management of patients with congenital constriction rings overlying major nerve trunks should include (1) complete neurologic examination, even in the infant, (2) electromyographic and nerve conduction studies if there is any evidence of nerve dysfunction, (3) early complete excision of the band in one stage if there is no evidence of edema seen with lymphatic or venous obstruction (otherwise, two-stage removal of the band should be planned), and (4) early exploration and decompression of all major peripheral nerves beneath the band if there is any neurologic dysfunction.