Approach to Lymphedema Management.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction.

High-pressure injection injury: a case report and systematic review.

High-pressure delivery devices for paint and other substances can lead to severe injuries of the hand without immediate surgical debridement. We present a case of a high-pressure paint gun injury treated surgically with full resolution of function. A systematic review of the literature details outcomes of similar injuries.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

Background: Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases.

Microsurgical ear replantation-is venous repair necessary?-A systematic review.

Background: A common postoperative observation after microsurgical ear replantation has been venous congestion necessitating alternate modes of decongestion, frequently in conjunction with blood transfusion. A comprehensive literature search was performed to assess the relationship between mode of vascular reconstruction and postoperative outcome as well as postoperative transfusion requirement after microsurgical ear replantation.

Methods: The search was limited to cases of microsurgical ear replantation following complete amputation.

Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage.

Objectives: To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage.

Design: Case series with retrospective review of outcomes with at least 6-year follow-up.

Setting: Academic tertiary care medical center.

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen.

Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications.

Background: The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous flap blood supply provide an autologous donor area with qualities favorable to microvascular breast reconstruction. The flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection, and has a consistent blood supply. The characteristics and skin color of the flap allow for immediate nipple-areola complex reconstruction in skin-sparing mastectomy.

Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity.

Background: With high success rates, flap survival should no longer be the sole criterion in judging success in dorsal hand and wrist reconstruction. The authors sought to determine the best flap for dorsal hand coverage in terms of aesthetic appearance, donor-site morbidity, and minimization of revision surgery.

Methods: A retrospective review of all free flaps for dorsal hand and wrist coverage from 2002 to 2008 was performed.

Standardized protocol for artery-only fingertip replantation.

Purpose: Artery-only fingertip replantation can be reliable if low-resistance flow through the replant is maintained until venous outflow is restored naturally. Injuring the tip of the replant to promote ongoing bleeding augmented with anticoagulation usually accomplishes this; however, such management results in prolonged hospitalization. In this study, we analyzed the outcomes of artery-only fingertip replantation using a standardized postoperative protocol consisting of dextran-40, heparin, and leech therapy.

Bilateral breast reconstruction: the simultaneous use of autogenous tissue and identical twin isograft.

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction.

Microsurgical reconstruction of the burned hand.

Although most thermal injuries to the hand can be successfully managed with excision and grafting, deeper injuries may require microsurgical techniques to provide stable, durable coverage and the optimal functional result. In delayed reconstruction, thin pliable flaps can be used to resurface the hand or allow for contracture releases. Proper patient and procedure selection are critical to the success of microsurgical reconstruction.

Resurfacing of a complex upper extremity injury: an excellent indication for the dorsal thoracic fascial flap.

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved.

Partial muscle harvest: our first 100 cases attempting to preserve form and function at the donor site.

The authors report their first 100 partial muscle flaps as a strategy to preserve form and function of the donor site in muscle transplantation. Between 2003 and 2007, 62 partial superior latissimus (PSL) flaps and 38 partial medial rectus (PMR) flaps were transplanted for head and neck, upper and lower extremity, and chest wall reconstruction. All flaps survived.

Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle.

Limb salvage techniques of traumatized extremities using free-tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6-28 weeks).

Index finger salvage with replantation and revascularization: revisiting conventional wisdom.

Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty-eight cases of such index salvages were reviewed to test this hypothesis.

Creation of a four-joint-digit after second toe to digit transplantation: restoration of form and function.

The authors describe the non-orthotopic insertion of an Ascension two-piece pyrocarbon proximal interphalangeal joint at the osteosynthesis level of bilateral toe-to-digit transplantations in an attempt to restore both anatomic length and composite fist formation after traumatic multidigit loss. The non-orthotopic joints provided an additional 30 and 35 degrees of stable flexion to the reconstructed index and longs digits enabling the patient to form a composite fist. There was no evidence of joint instability or loosening.

Patterns in blast injuries to the hand.

Blast injuries to the hand are not just a wartime phenomenon but also quite common in rural communities throughout northern California. The purpose of this study is to review our experience with blast injuries in the community and review the most common patterns in an attempt to identify the pathomechanics of the hand injury and the reconstructive procedures that are required. This is a retrospective study of blast injuries to the hand treated between 1978 and 2006.

Microsurgical scalp reconstruction after a mountain lion attack.

Mountain lion attacks on humans are rare and potentially fatal. Although few victims experience minor injuries, permanent disfigurement and disability is common among survivors of these assaults. Since 1986, a steady number of mountain lion attacks have been noted in California.

Use of the venous flap for salvage of difficult ring avulsion injuries.

Ring avulsion can lead to soft tissue compromise resulting in eventual digit failure or restriction of motion. The authors present use of the venous flow through flap for simultaneous soft tissue and digital vessel reconstruction in severe ring avulsion injury. A retrospective review of ring avulsion injuries treated with transplantation of an arterialized (A-V-A) venous flap between 1999 and 2006 was conducted.

Simultaneous coverage of two separate dorsal digital defects with a syndactylizing venous free flap.

We report a case of a 58-year-old patient who sustained multiple finger injuries on the right hand. After thorough debridement, two dorsal defects of the middle and ring fingers were covered simultaneously with a single arterialized venous free flap from the right forearm. The flap was used to create a dorsally syndactylized digit which survived completely and was subsequently divided longitudinally.

Ring avulsion: injury pattern, treatment, and outcome.

Ring avulsion injury is classically believed to be one of the most challenging for the reconstructive surgeon. Injury patterns include a spectrum from laceration to complete amputation, with differential magnitude of injury to soft tissue, tendon, joint complex, and bone. Although ring avulsion injury can result in devastating functional and aesthetic loss to the hand, fear of even greater functional loss has made replantation a relative contraindication for this complex injury.