Timothy M. Whitney

The serratus anterior free-muscle flap: experience with 100 consecutive cases.

We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.

Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry.

Quantitative fluorometry has been used to monitor circulation in transplanted toes and cutaneous flaps in our unit since 1982. Analysis of 177 uncomplicated transplants monitored by quantitative fluorometry shows that this technique has low false indication rates for arterial occlusion (0.6 percent of patients) and venous occlusion (6.2 percent of patients). None of these patients was reexplored because of a false monitor reading, and except for single abnormal sequences, monitoring appropriately indicated intact circulation throughout the postoperative period. Quantitative fluorometry has correctly indicated vascular complications in 21 (91.3 percent) of 23 transplants over an 8-year period. The salvage rate (85.7 percent) of the fluorescein-monitored reexplored transplants was significantly higher than the salvage rates of similar reexplored transplants not monitored with fluorescein and of reexplored muscle flaps (which cannot be monitored with the fluorometer used at this unit). These clinical data indicate that quantitative fluorometry is a valid and useful postoperative monitor for transplanted toes and cutaneous flaps.

Postprandial Aeromonas hydrophila cultures and antibiotic levels of enteric aspirates from medicinal leeches applied to patients receiving antibiotics.

Increasing use of medicinal leeches has been accompanied by increasing numbers of reports of Aeromonas hydrophila infections after leech application on or near damaged tissue. We examined the enteric contents of postprandial leeches after their application to patients receiving antibiotics. We found measurable levels of antibiotic in the leech enteric contents, and in leeches applied to patients receiving an antibiotic effective against Aeromonas hydrophila, there was a significant decrease in positive Aeromonas enteric cultures. Suppression of leech enteric bacteria by antibiotic administration to the patient may be an effective strategy to prevent invasive infection by Aeromonas hydrophila as well as bacterial colonization of devitalized tissue that could be the source of late infection. Clinical studies will be required to clarify whether suppression of leech enteric flora results in a decrease in infections associated with leech use.

Clinical results of bony fixation methods in digital replantation.

Clinical results comparing different techniques of fixation in replanted digits have not been described in detail, and bony deformities after replantation have been documented only in limited series. We retrospectively analyzed our population of phalangeal replants over a 5-year period to assess the outcome of different fixation methods with regard to frequency of angulation, fracture instability, nonunion, and need for corrective osteotomy. Techniques evaluated included: single and crossed Kirschner wires, intraosseous wires with and without Kirschner wire support, and the tetrahedral (Cassel) wire. Initial results show similar early angulation deformities in all groups. Intraosseous wires alone were found to have the lowest nonunion and complication rate. The Cassel wire was found to have the highest number of digits with fixation problems. Overall, bony problems were seen in nearly 50% of replants in our series.

Gastrocnemius muscle transposition to the femur: how high can you go?

The gastrocnemius muscle flap has gained wide acceptance as a reconstructive technique for management of wounds of the knee and proximal tibia. The use of the muscle as a pedicle flap to the distal and middle femur has not been well quantified, and the proximal rotation arc has been underestimated. We report the use of the island gastrocnemius pedicle flap to reach two femur defects 21 and 26 cm above the joint line, achieved by taking advantage of the favorable location of the vascular pedicle above the joint line and the individual length of the medial gastrocnemius muscle belly. Evaluation of standard arteriograms suggests the location of the medial sural artery pedicle is an average of 32 +/- 14.5 (SD) mm above the inferior border of the femur. All vessel origins were found above the joint line by radiograph. A common sural artery origin was noted in 32% of patients at a mean distance of 35 mm proximal to the joint line. Despite a wide range, 62% of sural artery origins were within 1 cm of an axis drawn through the widest point of the femoral condyles.

Multiple microvascular transplants: a preliminary report of simultaneous versus sequential reconstruction

We review a 10-year experience with multiple microvascular transplants (MMTs) performed on 94 patients undergoing reconstruction of complex extremity and head and neck wounds. One hundred ninety-eight flaps were performed with an overall success rate of 95%. Patients were classified into two groups: Group I comprised 38 patients who received simultaneous MMTs (76 total flaps); two flaps were transplanted in the initial operative procedure. Group II consisted of 56 patients undergoing reconstruction with sequentially transplanted MMTs (122 total flaps). The success rates of the two groups were not statistically different (97% vs. 93.4%). Complications were similar in both groups, although sequential reconstruction of lower extremity wounds had a higher frequency of complications and flap failures than the simultaneous method. Patients receiving simultaneous MMTs required more emergent reexplorations, but salvage rates were high (87.5%), particularly in upper extremity reconstructions. We suggest that simultaneous MMTs are a reliable, cost-effective method of reconstructing complex injuries. They reduce patient morbidity by eliminating second hospitalizations and reoperations without increased complications or flap failure.

Magnetic resonance imaging findings in Secretan's disease*

Secretans disease is defined as hyperplastic, recurring hard edema of the dorsal aspect of the hand. Its etiology, pathology and treatment are unclear. Magnetic resonance images and surgical findings are presented in three patients who fit the clinical findings of Secretans disease. Magnetic resonance imaging scans with both T-1 weighted and T-2 weighted images showed soft tissue and tendon edema in combination with diffuse peritendonous fibrosis extending to the fascia of the dorsal interosseous muscles.

Reconstruction of the upper extremity with multiple microvascular transplants: analysis of method, cost, and complications

During an 8-year period, 131 multiple microvascular transplants were performed on 62 patients for upper extremity reconstruction of complex wounds. Patients were classified into two groups: In group I 35 patients received paired simultaneous transplantation of 70 flaps performed in 35 operations. Group II consisted of 27 patients who underwent reconstruction with 61 sequentially transferred flaps; each procedure consisted of a single transplant. No statistical differences in flap failure or complications were seen between groups, except that group I required emergency reexploration more frequently. Patients receiving sequential reconstruction required rehospitalization, leading to significantly elevated costs. In our experience, simultaneous multiple microvascular transplants, particularly in patients admitted with acute injuries, result in reduction of costs, total number of procedures, and duration of hospitalization without increased complications.

Sequential multiple free flap transfers for reconstruction of devastating hand injuries

Restoring function to a severely damaged hand can require complex reconstructions using multiple tissue transfers to replace skeletal, soft tissue, and nerve components. We present 2 patients with severe hand trauma treated with serial multiple flap transfers, an operative sequence not previously reported in detail. One patient underwent five flap transfers in three operations, whereas the second patient underwent four flap transfers in two operations. All the flaps survived. Total anesthesia time for these patients was 43.5 and 34.5 hours, respectively. Both patients obtained measurable functional restoration, and suffered no significant perioperative morbidity. These patients illustrate the clinical feasibility of serial multiple microvascular transplantations for complicated reconstructions.

Reduction of Ischemic Reperfusion Edema with Corticotropin-Releasing Factor (CRF) in Rat Hind Limb Replantation

Corticotropin-releasing factor (CRF), a peptide neurotransmitter, is suggested as a novel agent to reduce reperfusion edema following ischemia. In a rat hind limb replantation model, animals underwent amputation followed by 2.5 hours of ischemia with replantation and 2 hours of reperfusion. Animals were randomized to seven groups: a nonischemic control group and six experimental groups receiving treatment prior to reperfusion with (1) saline control, (2) alpha 9,41-CRF-a CRF receptor blocking agent (98 micrograms/per kilogram), (3) subcutaneous CRF (320 micrograms/per kilogram), (4) intravenous CRF (80 micrograms/per kilogram), (5) alpha-CRF and subcutaneous CRF, and (6) alpha-CRF and intravenous CRF. Comparison of preischemic amputated limb weight with weight after ischemia and reperfusion showed a reproducible and significant gain in limb weight after 2 hours (p = 0.004). A significant reduction in limb weight gain (49%) was achieved with both subcutaneous (p < 0.04) and intravenous CRF (p < 0.036). With the dose used in this model, alpha 9,41 CRF attenuated but did not completely block the effects of intravenous or subcutaneous CRF.