Sheel Sharma

The dorsal scapular island flap: an alternative for head, neck, and chest reconstruction.

&NA; The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free‐tissue transfer for the reconstruction of defects in the head, neck, and anterior chest. (Plast. Reconstr. Surg. 111: 67, 2003.)

Thumb replantation: a retrospective review of 103 cases.

Replantation has become the state of the art reconstruction for an amputated thumb. The aim of our study was to review our series of thumb replantations over a period of 12 years at the Bellevue Hospital Center in New York City. The mechanism of injury, level of amputation, and use of vein grafts was reviewed and correlated with survival rates of the replanted thumbs. The overall survival rate was 91.3%. Of the 12 thumbs that were re-explored for vascular compromise, 75% were successfully salvaged. Our study also indicates that there is no statistical difference in survival of thumb replants when comparing the mechanism of injury, the level of amputation, and the use of vein grafts. However, the use of vein grafting seemed to be beneficial in the successful outcome of replantation in severe crush and avulsion injuries, even though the values did not reach statistical significance. We conclude that thumb replantation is associated with very high survival rate, regardless of the mechanism of injury or level of amputation, and should be attempted in all cases. An early reexploration for vascular problems yields a high salvage rate and should be performed in all cases. We also recommend the use of vein grafts in severe crush and avulsion injuries.

Comparison of minimally invasive versus conventional open harvesting techniques for iliac bone graft in secondary alveolar cleft patients

Background: Autologous bone grafts, often harvested from the iliac crest, are the criterion standard for secondary alveolar cleft repair. The best technique for harvest remains controversial. Minimally invasive techniques have been used for bone graft harvest in cleft patients, but outcome studies have been limited by small numbers of patients. Methods: A total of 104 patients undergoing bone grafting for alveolar cleft were reviewed. Fifty-five consecutive patients underwent minimally invasive iliac bone graft harvest using the Acumed power-driven trephine system performed by the same surgeon. These patients were compared with 49 control patients undergoing a similar procedure in which the traditional method of open iliac bone harvest with an osteotome was used. Results: Operative time for the bone graft harvest was significantly shorter with the Acumed device when compared with the osteotome (2.37 hours versus 3.26 hours, p < 0.001). Patients who underwent minimally invasive Acumed bone harvest required significantly less postoperative analgesia than did patients who underwent osteotome harvest, for both narcotic (0.31 mg/kg versus 1.64 mg/kg, p < 0.001) and nonnarcotic (15.1 mg/kg versus 27.2 mg/kg, p < 0.01) pain medication. Acumed patients had significantly less pain on discharge (0.26 versus 3.1 pain scores on a scale from 0 to 10, p < 0.001) and left the hospital more quickly (23.3 hours versus 30.1 hours, p < 0.001). Conclusion: Minimally invasive bone graft harvest technique using the trephine system offers a superior alternative to the conventional open iliac bone harvest method for patients undergoing secondary alveolar cleft repair, with shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Figure. No caption available.

Treatment and outcomes of fingertip injuries at a large metropolitan public hospital.

Background: Fingertip injuries are the most common hand injuries presenting for acute care. Treatment algorithms have been described based on defect size, bone exposure, and injury geometry. The authors hypothesized that despite accepted algorithms, many fingertip injuries can be treated conservatively. Methods: A prospectively collected retrospective review of all fingertip injuries presenting to Bellevue Hospital between January and May of 2011 was conducted. Patients were entered into an electronic database on presentation. Follow-up care was tracked through the electronic medical record. Patients lost to follow-up were questioned by means of telephone. Patients were analyzed based on age, mechanism of injury, handedness, occupation, wound geometry, defect size, bone exposure, emergency room procedures performed, need for surgical intervention, and outcome. Results: One hundred fingertips were injured. Injuries occurred by crush (46 percent), laceration (30 percent), and avulsion (24 percent). Sixty-four percent of patients healed without surgery, 18 percent required operative intervention, and 18 percent were lost to follow-up. Patients requiring operative intervention were more likely to have a larger defect (3.28 cm2 versus 1.75 cm2, p < 0.005), volar oblique injury (50 percent versus 8.8 percent, p < 0.005), exposed bone (81.3 percent versus 35.3 percent, p < 0.005), and an associated distal phalanx fracture (81.3 percent versus 47.1 percent, p < 0.05). Patients requiring surgical intervention had a longer average return to work time when compared with those not requiring surgical intervention (4.33 weeks versus 2.98 weeks, p < 0.001). Conclusion: Despite current accepted algorithms, many fingertip injuries can be treated nonoperatively to achieve optimal sensation, fine motor control, and earlier return to work. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Power-assisted Suction Lipectomy of Fasciocutaneous Flaps in the Extremities

Background:A bulky appearance is one of the major patient complaints after extremity reconstruction after fasciocutaneous flaps. Serial debulking procedures with staged excision are required to improve aesthetic and functional outcome, but these methods risk injury to the vascular pedicle and often require multiple procedures for adequate thinning of the flap. We suggest the use of power-assisted suction lipectomy for the debulking of fasciocutaneous flaps in the upper and lower extremities as a safe, effective, and efficient procedure. Methods:From 2006 to 2009, we performed power-assisted suction lipectomy on the upper and lower extremities of 16 flaps in 15 patients who had previously undergone reconstruction with fasciocutaneous flaps after a traumatic injury. Results:There was 100% flap survival without any complications. Only 2 of the 16 (12.5%) flaps required a secondary revision for further contouring. Conclusions:In our experience power-assisted suction lipectomy is a safe and excellent adjunct in fasciocutaneous flap debulking and reduces the number of secondary revision procedures necessary. We recommend its use as an adjunct in debulking and contouring flaps used in extremity reconstruction.

Closed mallet thumb injury: a review of the literature and case study of the use of magnetic resonance imaging in deciding treatment.

At present, the literature dedicated to closed mallet thumb injury offers conflicting evidence between conservative and operative approaches. Although conservative treatment is often successful, retraction of the extensor pollicis tendon may lead to improper reattachment and continued deformity. This discussion and case report serve to highlight the use of magnetic resonance imaging as an adjunct in selecting the proper treatment strategy for this injury at initial presentation.

Salvage of silicone-treated facial deformities using autogenous free tissue transfer.

Background: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. Methods: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. Results: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). Conclusions: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

Thumb metacarpophalangeal joint ulnar collateral ligament repair with condylar shaving

Introduction Injuries to the ulnar collateral ligament (UCL) are relatively common and are best treated in the acute setting. The acute version of this injury can often be repaired primarily but in the chronic setting the ligamentous remnants are often retracted making this method of repair difficult. We present a novel alternative approach for UCL repair after chronic injuries or difficult acute injuries. Methods We describe the procedure and postoperative results. A standard S-shaped incision over the dorsal ulnar aspect of the thumb is used. The adductor aponeurosis is identified and separated from the joint capsule. A proximally based and distally based rectangular flap containing the UCL remnants is elevated exposing the metacarpophalangeal joint. A burr is used to shave the condyles on the ulnar aspect of the metacarpal and proximal phalanx. The joint is stabilized with a Kirschner wire. A suture anchor is used to secure the proximally based flap. The distal flap is secured on top of this using the same sutures from the anchor. The repaired ligament is secured to the volar plate on the palmar aspect using a 4-0 Ethibond. Results This surgical technique has been used extensively by the senior authors; we present a representative case. At 3 months the patient had a grip strength of 85 lbs, tripod pinch of 12 lbs, lateral pinch of 5 lbs, 2-point pinch of 6 lbs, active range of motion at metacarpophalangeal joint of 0 to 70 and passive range of motion at the metacarpophalangeal joint MP of 0 to 85. Conclusion Despite a number of options for ligament reconstruction many of the described methods of repair are relatively complex and involve derangement of local tissues. We offer a novel adjunct to current methods of UCL reconstruction in which condylar shaving makes repair much more simple and avoids the use of a tendon graft. This approach provides a shorter course for the retracted UCL remnants allowing primary repair in the chronic setting and in the difficult acute repair.

Acellular Dermal Matrix for Temporary Coverage of Exposed Critical Neurovascular Structures in Extremity Wounds

Introduction:Large-volume soft-tissue defects often leave exposed neurovascular and vital structures not amenable to immediate flap coverage. We describe the use of AlloDerm, an acellular dermis allograft, in providing temporary coverage of these structures in multistage reconstruction of the extremity. Methods:A prospective study of 25 patients was performed using AlloDerm for temporary coverage of exposed vital structures secondary to trauma and oncologic ablation. A direct examination of neurovascular structures and the wound bed after allograft removal was performed as a monitor of outcome. Results:All allografts successfully covered the neurovascular structures at the time of removal with complete viability of neurovascular structures. Granulation tissue was appreciated in the wound bed with no clinical evidence of infection. The allograft was easily removed without damage to underlying structures. Conclusion:AlloDerm offers a safe and reliable alternative to cover critical neurovascular structures temporarily, before the definitive reconstruction of soft-tissue defects.

Submuscular Versus Subcutaneous Anterior Ulnar Nerve Transposition: A Rat Histologic Study

PURPOSE The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model. METHODS Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation. RESULTS Nerve health was assessed using a 4-part classification in which 4 = normal nerve, 3 = abnormal axons in one-third cross-sectional area (CSA), 2 = abnormal axons in two-thirds CSA, and 1 = abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3 = scar completely encasing nerve, 2 = scar formation partially surrounding nerve, and 1 = no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue. CONCLUSIONS On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method.