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Adjuvant therapy plays an integral role in the treatment algorithm for stage III and stage IV cutaneous melanoma. Current ongoing clinical trials are exploring the effects of neoadjuvant therapeutics, specifically for the presurgical treatment of high-risk, borderline resectable disease. In both the adjuvant and neoadjuvant settings, the early chemotherapeutic and biochemical antitumor agents are making way to newer immune therapies, mutation-specific targeted therapies, and oncolytic vaccines that are transforming the treatment of malignant melanoma. The use of these systemic therapies in addition to surgical resection has been shown to increase both overall and progression-free survival.

Purpose Targeted muscle reinnervation (TMR) has emerged as a treatment for, and prevention of, symptomatic neuromas and has been reported to be of benefit in the hand. Anatomical studies establishing landmarks for consistent identification of the motor entry points (MEPs) to the intrinsic muscles have not been performed. The purpose of this study was to provide details regarding the MEPs to the intrinsic muscles, determine which MEPs are identifiable dorsally, and develop recommended sensory to MEP nerve coaptations for prophylactic TMR at the time of ray amputation or for management of symptomatic neuromas. Methods Motor entry points to the intrinsic hand muscles were dissected in 5 fresh latex-injected cadavers. Number of MEPs, diameter, surface of entry, and distance from dorsal (Lister tubercle) and volar (hamate hook) landmarks were recorded for each target muscle. The digital sensory nerve diameters were measured for size comparison. Results Motor entry points were identified to all 19 intrinsic muscles through a volar approach and 12 through a dorsal approach. For all fingers, at least 2 MEPs were consistently identified dorsally at the base of each amputation site innervating expendable muscles. Motor entry points to the thenar muscles were only reliably identified through a volar approach. Two recommended nerve coaptations for each digit amputation were identified. All had a favorable sensory-to-MEP diameter ratio less than 2:1. Conclusions The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. Clinical relevance These results can be applied clinically to assist surgeons in identifying the locations of MEPs to the intrinsic muscles when performing TMR in the hand for both neuroma treatment and prevention.

The incidence of melanoma is continuing to rise in the United States, and head and neck melanomas account for 25% of all cutaneous melanomas. The National Comprehensive Cancer Network guideline recommendations for surgical margins and sentinel lymph node biopsy in head and neck melanomas are the same as cutaneous melanoma located in other regions, but require special considerations when performing wide local excision, sentinel lymph node biopsy, and completion lymph node dissection and reconstruction taking into account the location of the melanoma and structures involved in and around the suggested margins.

While primary treatment for melanoma consists of surgical resection and chemotherapeutics, radiation can be used as either definitive or adjuvant therapy in certain clinical scenarios. This chapter aims to explore the indications for primary definitive radiotherapy as well as adjuvant treatment following resection. Delivery, dose, fractionation, and toxicity of radiation treatment will be discussed. As our understanding of melanoma tumor biology increases, the role of radiotherapy may expand for more effective treatment of oligometastatic disease.

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Background: Limited methods exist to aid in deciding the appropriate donor limb lengths in bilateral upper limb amputees qualifying for vascularized composite allotransplantation. We hypothesized mathematical equations could be created using long bone length ratios, and applied to radiographs, to approximate the patient’s limb length prior to amputation. Methods: A data set of 30 skeletons’ unilateral upper limb long bones measured using osteometric board and calipers was used. Anatomic segment ratios were calculated based on humerus length after multivariate linear regression analysis. For clinical application testing, 5 cadavers’ upper limbs were radiographed. Radiographic bone lengths were then measured along the long axis of each long bone. These measured radiographic lengths were then compared with the predicted bone lengths, generated from the skeleton data set ratios, for each cadaver. Results: The chi-square goodness-of-fit test showed excellent fit ( P < .01) between the predicted and radiographically measured lengths for the 5 cadavers, and interobserver measurements showed no statistical difference. Depending on the cadaver, percent error in total limb length predicted to measure ranged from 0.9% to 2.7%. The variables to multiply an individual humerus length to calculate a given anatomic segment thus proved to be effective. Conclusions: If a bilateral upper limb amputee has 1 intact humerus, ratios to the humerus length can be reliably applied to calculate the preamputation limb length based on the patient’s radiographic humerus length. These formulas are indicated for finding the appropriate limb lengths, and smaller anatomic segments, for donor-recipient matching in upper limb transplantation.

This article describes the use of prefabricated flaps in burn reconstruction. Several case examples are provided that demonstrate the versatility and power of this approach to restoration of form and function after burn injury.

CASE A 61-year-old woman with left shoulder osteoarthritis underwent a left shoulder hemiarthroplasty. The wound was closed using the Dermabond Prineo system. The patient had a severe and progressive reaction during the first 2 weeks that necessitated debridement and skin grafting. Three months after surgery, the patient was doing well. CONCLUSIONS Severe reactions to 2-octyl cyanoacrylate are uncommon. The severity of the presented reaction is rare. However, surgeons using this closure method should be aware of potential reactions that may initially mimic infection. It is important to initiate appropriate treatment including removing the dressing, topical steroids, and/or oral antihistamines, antibiotics, and possible surgical wound debridement.

Background: Upper extremity transplantation is a quality-of-life enhancing treatment for select patients with upper extremity loss. This article reviews the preoperative, intraoperative, and postoperative challenges in the upper extremity transplantation process and the lessons learned from the first 2 decades of hand transplantation. Methods: Key components of the author’s hand transplantation protocol including patient selection, donor screening, surgical rehearsal, donor procurement, transplantation, immunosuppression, and patient outcome reporting/follow-up are reported to assist other teams who wish to establish a hand transplantation program. Results: There have been many advancements in the first 20 years of hand transplantation including better patient selection criteria, the recent addition of pediatric patients, improved surgical techniques such as the use of virtual surgical planning, and improved immunosuppression protocols. Improvement has also taken place in the tracking and reporting of hand transplant outcomes, but more work is clearly needed to fully define the benefits of transplantation, especially for pediatric patients. Conclusions: Over the past 20 years, significant progress has been made in upper extremity transplantation although a number of challenges remain including how to best document and share outcome measures, optimize immunosuppression, and diagnose/treat rejection. The authors encourage upper extremity transplant programs to report their experience and protocols to advance hand transplantation as standard of care for properly selected individuals.

Introduction: Osteosynthesis in forearm-level allotransplantation is technically challenging. Achieving adequate cortical contact simultaneously between the radius and ulna proves difficult due to differing bone morphology of donor and recipient. In addition, the large area of dissection around the osteotomy sites and use of immunosuppressants further deters osseous healing, making nonunion a significant risk. Methods: Seven distal forearm transplants were performed on cadavers using the Newclip Technics ulnar-shortening osteotomy system for both the radius and ulna. The donor bones were plated after placing two transverse 0.062 K-wires distally for DRUJ stabilization. The osteotomy cut-guides were screwed to the plates and oblique osteotomies were performed. Matching recipient osteotomies were performed using the same cut-guide system. The donor and recipient were then brought together and any discrepancies in length corrected. The osteosynthesis site is then compressed and an interfragmentary lag screw...

Improvements in critical care and burn victim resuscitation have led to increased survival of burned patients. Initial resuscitation, early excision of burned tissues, prevention of burn wound sepsis, and wound coverage remain mainstays of care. Many burn wounds require complex reconstruction. This is particularly important in the hand. Coverage of tendons, ligaments, joints, vessels, nerves, and bones of the hand requires healthy vascularized tissue to maintain viability and function. Local flaps or regional flaps may be within the burn zone of injury. Refined microvascular free tissue transfer techniques offer free tissue transfer as a procedure that can be safely performed.

The management of mutilated upper extremity wounds offers challenges for all hand surgeons. Loss of composite tissues usually requires grafts or flaps to gain coverage and restore function. Nonsalvagable digits or amputated parts are a source of spare tissues that can be used for reconstruction of the hand or limb. Immediate tissue transplantation is a resourceful technique for hand surgeons to limit donor morbidity while making the most out of a terrible injury to the hand or upper extremity. This article reviews the various methods by which immediate tissue transplantation can be employed in hand trauma.

Summary: Targeted muscle reinnervation (TMR) has been shown to decrease neuroma pain after major limb loss; however, it has not previously been described for the treatment of symptomatic neuromas in the hand after digit amputations. This report describes the use of TMR in the hand for treatment of a patient with recurrent neuromas after ray amputation of the index and long fingers that were refractory to traditional treatments. TMR was performed first for the superficial branch of the radial nerve 6 years ago to treat the dorsal neuroma pain. Following this, there was complete resolution on the dorsal aspect of the hand, however, continued neuroma pain on the volar aspect of the hand. This was treated more recently with excision of the neuromas and TMR to motor branches of the intrinsic muscles of the hand. Outcomes were measured with a numerical rating scale and Patient-Reported Outcomes Measurement System assessments and revealed decreased pain postoperatively and less interference of her activities due to pain. This report demonstrates the ability to perform TMR within the hand with good results when used for the treatment of symptomatic neuromas.

Primary bone healing fails to occur in 5–15 % of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12 % of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.

Background:. Historically, external ear melanomas have been treated aggressively, due to early perceptions suggesting they had poor prognosis and aggressive biological behavior. More recent evidence has not supported these notions. Methods:. We completed a complete review of the literature involving malignant melanoma of the external ear. We then completed a quantitative analysis on seventy-three cases from 8 reports that contained case-level data, assessing factors that influence recurrence, and assessing characteristics of the melanomas based on histological subtype. Baseline and outcomes data for all 20 studies were then compiled but not statistically evaluated. Results:. In our subanalysis, patients who had recurrence were significantly more likely to have had wedge resection versus wide-local excision, and those with no recurrence were more likely to have undergone wide local excision. Nodular tumors had significantly greater thickness. Overall, conservative excisions provided excellent outcomes. Conclusions:. Conservative treatment for external ear melanoma produces satisfactory outcomes. There is no evidence to support the use of radical amputation and little evidence to support the removal of cartilage or perichondrium. Sentinel lymph node biopsy is warranted only with positive nodes. There is no role for elective neck dissection. The roles for chemo/radiation therapy are unclear and guidelines for other cutaneous melanomas should be followed.

After a severe digital or extremity injury, the replantation surgeon should always seek to make the best use out of what tissue is available for reconstruction. Exercising sound surgical judgment and being creative allow the surgeon to restore function to critical areas of the hand or extremity by the judicious use of available tissues that would otherwise be discarded. The use of "spare parts" should, therefore, always be considered to facilitate digital or extremity reconstruction when routine replantation is not possible or is likely to produce a poor functional result. The surgeon should always try to use available nonreplantable tissue to preserve length, obtain soft tissue coverage, or most importantly improve the function of remaining less injured digits. This article presents several case studies that illustrate the principals of spare parts reconstruction performed at the time of the initial debridement using nonreplantable tissue to provide coverage or improve function.

Background Infected wounds impose a significantly negative effect on patient care and recovery, as infection hinders normal wound healing, resulting in increased patient morbidity and mortality. More attention is being focused on addressing the problem of multidrug-resistant bacteria and the staggering costs and consequences resulting from this. Recently, newly evaluated antimicrobial peptides have been shown to be active against a wide variety of bacteria in in vitro studies. This study evaluates the use of a particular antimicrobial peptide, D2A21 (Pittsburgh, PA), to combat infection in an acutely infected wound model. Methods Forty-eight Wistar rats were used to compare the effects of D2A21 to control vehicle, silver sulfadiazine (SSD), and Sulfamylon in this model. Two 1.5 x 1.5-cm full-thickness defects were created on the rat dorsum and were subsequently inoculated with 108 Pseudomonas aeruginosa. Animals underwent daily treatment with either D2A21 gel, control vehicle, SSD, or Sulfamylon. Animals were evaluated for survival differences. Results Survival analysis at 21 days for the different treatment groups were as follows: 100% for the D2A21-treated animals, 50% for control-treated animals, 83% for Sulfamylon-treated animals, and 33% for SSD-treated animals. Conclusion D2A21 antimicrobial peptide demonstrates significant activity compared with controls and standards of therapy. The promising effect of this topical peptide is clearly evident as shown by this study, and its further investigation as a potential agent in the fight against infected or chronic wounds is warranted.

The objectives of the treatment of mutilating hand injuries are to insure patient's survival, limb survival and ultimately limb function. Initially, patients are stabilized and cleared of other potentially life threatening trauma. The cornerstone to the early intra-operative management of the mangled hand includes irrigation and debribement. Skeletal stabilization, revascularization, replantation or the use of spare parts to restore functions are addressed at the initial surgery. Subsequent second or third look surgeries may be required to procure a clean wound bed. Regional flaps and free tissue transfer provides definitive coverage than soft tissue is required. Secondary procedures such as tenolysis, joint mobilization or toe transfers may be needed to restore dexterity to the healed yet dysfunctional hand. Adherence to sound safe principles help prevent further mobidity while fostering the restoration of hand function to return the patient to gainful activities.

In the resection of redundant orbital fat during lower blepharoplasty, selective excision is performed from the medial, central, and lateral compartments. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments. When performing a transconjunctival approach, the inferior oblique muscle is even more susceptible to injury because it lies in the direct path of dissection for fat pad exposure. Injury to the inferior oblique muscle can result in symptoms ranging from transient diplopia to a more debilitating permanent strabismus. Fresh cadaver heads were used to identify bony anatomical landmarks that would help to more accurately define the origin and body of the inferior oblique muscle. The orbital rim, infraorbital foramen, and supraorbital notch were chosen as guideline landmarks. The origin of the inferior oblique muscle was designated with respect to the above structures, and the muscle course was delineated. The inferior oblique muscle originates on the orbital floor, 5.14 +/- 1.21 mm posterior to the inferior orbital rim, on a line extending from the infraorbital foramen to 10 +/- 0.9 mm inferior to the supraorbital notch along the supramedial orbital rim. The muscle belly extends from this origin to its insertion into the posterolateral globe in an oblique direction toward the lateral canthal area. Identification of the orbital rim, infraorbital foramen, and supraorbital notch more accurately localizes the origin and course of the inferior oblique muscle, which may facilitate fat resection during lower blepharoplasty by preventing morbidity associated with inferior oblique muscle injury.

The benefits of reduction mammaplasty have been well documented in previous literature. Anticipating and correcting for pseudoptosis (bottoming-out), however, can impair the cosmetic outcome as the inferior skin envelope stretches and lengthens over time. We present long-term results on patients using the modified Robertson technique for reduction mammaplasty, which appears to have significant benefit in helping to prevent bottoming-out. Surveys were sent to patients undergoing reduction mammaplasty surgery with this technique from 1987 to 1997. Patients were queried regarding preoperative and postoperative symptoms, satisfaction, and outcome related to their surgery and were also offered free follow-up examinations. The patients who returned for follow-up were then evaluated by the attending surgeons for evaluation of scarring, nipple position, ptosis, pseudoptosis, shape, and overall appearance. Reduced breasts were also compared with cosmetically optimal breasts to compare for measured levels of pseudoptosis using our defined visual inferior pole ratio measurements. Average reduction size was 910 g and follow-up was 4.7 years from the time of surgery. There was significant improvement demonstrated in all areas questioned, with the greatest relief shown in back and shoulder pain, shoulder grooving, and difficulty fitting clothing. There was also demonstrated to be significantly less use of medical modalities postoperatively and significant increases in activity levels. Satisfaction for size, shape, symmetry, and overall results was 85, 94, 98, and 94 percent, respectively. Evaluations for pseudoptosis by the attending surgeons were rated good or excellent in 95 percent of patients. Measurements of the visual inferior pole ratio for pseudoptosis also demonstrated no significant differences when compared with aesthetically optimal breasts. The modified Robertson reduction mammaplasty is a reliable technique that can be used for both small and large reductions, giving both reliable and consistent results. This technique significantly improves symptoms, as do other reduction techniques, but has the added advantage of helping to avoid pseudoptosis postoperatively.

Doxorubicin is the most common antitumor drug implicated in serious extravasation injuries. Progressive tissue necrosis may lead to intense pain, chronic ulceration, and disfiguring tissue loss. This progressive necrosis is analogous to that seen with brown recluse spider bites, where dapsone is an established mode of therapy, minimizing the area of tissue loss by a proposed antiinflammatory mechanism. The backs of 50 Lewis rats were injected intradermally with 1 mg of doxorubicin in 1 cc of saline to simulate an extravasation injury. The rats were divided into five groups for treatment with oral dapsone 50 mg/kg/day: 10 were controls (no treatment), 10 were started the day before injury, 10 were started the day of injury, 10 were started the day after injury, and 10 were started 1 week after injury. The area of ulceration was calculated by planimetry. The data suggest that dapsone has little positive effect on healing extravasation ulcers.

Background Tendon without paratenon presents the reconstructive surgeon with a tissue coverage challenge. Integra® dermal regenerative template has been shown to initiate a stable, vascularized bed for skin grafting over tendon. However, histological processes that occur during incorporation have not been described. The purpose of this study is to characterize the pattern of changes that occur when Integra® is applied to an avascular tendon. We hypothesize that vascular incorporation will originate from the wound periphery and proceed toward the tendon center. Methods A full-thickness defect was created over a denuded Achilles tendon in a single hind limb in eight New Zealand white rabbits. Integra was placed over the avascular tendon, and the limb was dressed and splinted. Two animals were euthanized at each timepoint (weeks 1, 2, 3, and 4), and hematoxylin and eosin (H&E)-stained tissue specimens were microscopically evaluated. Results Week 1 specimens demonstrated limited adherence between Integra and the tendon, while myofibroblasts were found encircling the tendon. No cellularity was noted centrally. At week 2, the dermis–Integra junction had increasing vascularity and the central portion developed increasing cellularity. By week 3, Integra was completely revascularized. At week 4, Integra had the histological appearance of normal dermis. Conclusion Neovascularization of Integra® over exposed tendon occurs from the peripheral tissue. Ingrowth proceeds from the dermis–Integra interface toward the center of the graft. Four weeks after application to the denuded tendon, Integra has the histological appearance of native dermis.

Subungual melanoma typically presents as a darkened longitudinal stripe under the nail plate; however, this disease is frequently misdiagnosed, which leads to a delay in proper diagnosis. Subsequently, subungual melanoma historically has a relatively poor prognosis compared with other cutaneous melanomas, with the 5-year survival rate ranging between 16 and 80 percent. Historically, these lesions were removed using aggressive amputation. To date, the National Cancer Institute does not have guidelines for the treatment of subungual melanoma.The authors conducted a complete review of all cases within the literature involving amputation and/or wide local excision for the treatment of subungual melanoma.There is currently a trend toward a more conservative approach in treating subungual melanoma; however, the literature does not offer a high level of evidence, and definitive conclusions cannot be drawn.Overall, the studies within the literature involving amputation as the treatment for subungual melanoma could not prove a significant benefit, in terms of prognosis and/or survival, over the more conservative treatment of excision. The collective data imply that melanoma in situ can likely be treated appropriately with wide local excision. The literature lacks randomized, prospective, or comparative studies that would help elucidate whether amputation is superior to a more conservative, digit-sparing approach. Prospective randomized control trials are indicated.

The incidence of sternal wound infection following median sternotomy is 0.4 to 5 percent. Debridement and closure of the wounds with local and regional muscles, such as a pectoralis or a pedicled rectus abdominis, have been the mainstay of surgical treatment. Often, both pectoralis major muscles and the superior portion of a rectus abdominis muscle must be used to close large sternal wounds. Loss of these major muscles can be both debilitating and cosmetically disfiguring. Free-tissue transfer can be employed to limit the amount of tissue needed to fill the sternal defect. The authors present a series of 12 free-tissue transfers used in 11 patients to close large sternal defects in this subset of patients. Total flap loss occurred in one patient. Partial loss of the skin island was noted in three patients. Two patients developed abdominal hernias after rectus abdominis free flaps. Free-tissue transfer offers the ability to close these large wounds, using one muscle, in those patients where pedicled rectus abdominis flaps are not available.

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

Background Traditional management of lateral humeral epicondylitis (“tennis elbow”) relies upon antiinflammatory medication, rehabilitation, steroid injection, counterforce splinting, and, finally, surgery to the common extensor origin. The diversity of surgical approaches for lateral humeral epicondylitis (LHE) suggests perhaps that the ideal technique has not been determined. Denervation of the lateral humeral epicondyle is the concept of interrupting the neural pathway that transmits the pain message. Epicondylectomy may accomplish its relief of LHE by denervating the epicondyle. Methods Since it is known that the posterior branch of the posterior cutaneous nerve of the forearm innervates the lateral humeral epicondyle, 30 patients who were treated surgically for refractory LHE were retrospectively evaluated. Group 1 consisted of 17 patients who were treated with epicondylectomy alone, group II consisted of seven patients who were treated with lateral epicondylectomy plus neurectomy, and group III consisted of seven patients treated with lateral denervation alone. Results Denervation alone gave statistically significantly greater improvement in pain relief ( pConclusion It is concluded that denervation gives significant relief from LHE once traditional non-surgical treatment has failed.

We report a case of targeted muscle reinnervation of a muscle free flap for improved prosthetic control in a patient who had an amputation of the left upper extremity at the level of the shoulder after a severe electrical burn. The reinnervated muscle free flap receives signals from the brachial plexus, and these signals are amplified to provide an interface for a myoelectric prosthesis. This allows for more coordinated and efficient control of the artificial limb.

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Ischemia–reperfusion (I/R) injury is, in part, related to the burst of reactive oxygen species (ROS) generated after reperfusion. Vitamin E has been shown to exert its biological effects as an antioxidant, inhibiting the ROS. In this report, the effect of Vitamin E succinate (VES) on ischemia/reperfusion injury and NF-κB expression was studied in a rat skeletal muscle model during reperfusion following a 4-h ischemic period. The study group consisted of muscle flaps infused with 150 mg/kg of VES given intraperitoneally 1 h post-initiation of ischemia. Muscle viability based on nitroblue tetrazolium staining, edema, and Doppler blood flow was measured in a control and a study group. Muscle samples were analyzed by standard gel shift assay. The VES experimental group showed an increase in muscle viability compared to controls (average of 44.675% versus 31.925%, respectively, p=0.0415). Blood flow, measured by Doppler 24 h after reperfusion, was increased in the VES study group compared to controls (10.3 vs. 5.1 ml/g/s p=0.00355). Additionally, the VES group showed a trend of decreasing edema compared with the control; however, not at a level that was statistically significant ( p=0.1267). The VES-treated group showed a decreased expression of NF-κB as compared to controls ( p

This article explores issues related to tissue engineering and composite tissue allografts that employ physiologic and anatomic autogenous replicates to restore tissue loss. Composite tissue allotransplantation has become a controversial option for reconstruction, most prominently for reconstruction involving the hand and, recently, the face. While the side-effect profile of systemic immunosuppression continues to improve, the long-term risks of immunosuppression leaves composite tissue allotransplantation a domain for cautious exploration. Meanwhile, tissue engineering could, conceivably, be the gap between replantation and composite tissue allografts. Whereas the perils of immunosuppression may limit the routine use of allografts, employing constructions made of the patient's own cells negates the need for any antirejection therapy.

Background The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anesthesia (the wide-awake approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfer. Methods Seven patients underwent a wide-awake transfer of the extensor indicis proprius to the extensor pollicis longus between February of 2002 and May of 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach. Results All seven patients were able to extend their thumbs fully by means of extensor indicis proprius intraoperatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength. Conclusions The wide-awake approach has allowed the authors to adjust tendon transfer tension with active movement before skin closure without the risks associated with general or regional anesthesia. In addition, it has allowed them to observe immediate cortical adaptation in the context of a simple tendon transfer. The authors hypothesize that the brain's ability to immediately use extensor indicis proprius for thumb extension stems from the activation of preexisting synergistic cortical finger movement programs.

The admirable efforts of the surgeons, anesthesiologists, nurses, paramedical staff, and other volunteers offer a tremendous service to unfortunate individuals in underdeveloped countries. The authors have eloquently described their experience abroad, treating patients afflicted with a variety of ailments. Many patients in underdeveloped countries must bear the burden of living throughout their lives with various deformities. These deformities may result in functional loss that significantly impairs their activities of daily living. In fact, afflicted patients may be ostracized from their own community because of their deformity. There are many implications and ramifications of these medical problems not only for the patient, but also for their families and the local society. I too have traveled overseas for volunteer work, performing surgery on patients with burn contractures, nomas, congenital deformities, and other acquired disorders that impair function. The experience offers a multitude of benefits to these patients, their families, and the local community. These patients are extremely grateful and return to productive lives. Such trips require significant commitment and can actually be quite tiring. Depending on the location, the travel can be long and grueling, often involving various flights, bus rides, or other modes of transportation. Jet lag and fatigue are not uncommon during these trips. As the surgical team arrives, the equipment must be checked, calibrated, and/or repaired prior to performing any surgery. The instruments and supplies are removed from boxes and the operating rooms are set up to permit safe, reliable, and efficient surgery. The patients often arrive from miles around with the hope that they might be lucky enough to be operated upon by experienced, knowledgeable surgeons. The patients are usually screened by the surgeons, anesthesiologists, and staff to prioritize those who would be candidates for surgery. The short amount of time that the surgical team has at any given destination unfortunately limits the number of procedures that can be performed during each visit. The surgical team must therefore look to perform procedures that would have the greatest impact on patients, focusing primarily on restoring function. Following the surgical screening, the patients are assessed for operative risk factors, as safety is foremost in the minds of the entire team. In fact, the partnership and communication between the surgeons, anesthesiologists, and nurses are often more intense and constructive than at our own surgical theatres. The many surgeries can include cleft lip and palate repair, contracture release, free tissue transfer, skin grafting, and flap reconstruction. The patients therefore require surgeons with expertise in reconstruction of the head and neck, hand, lower extremity, and trunk. Postoperatively, nurses and paramedical staff care for the patients to aid in safe recovery. It is amazing to witness the care that the families provide in the recovery process of these patients. The surgical team uses the resources it has brought with them, as well is what is locally available, to provide adequate rehabilitation. The daily rounds on the patients after surgery are for caring and education. It is often astonishing to witness the makeshift dressings, splints, and wound care that are available from the local surgeons and HAND (2007) 2:25–26 DOI 10.1007/s11552-006-9020-4

The purpose of the current study was to determine the effects of vascular endothelial growth factor (VEGF) on muscle flap survival and vascularity in a rat gracilis ischemia-reperfusion model. A total of 12 adult male Wistar rats were divided into two groups (n = 6). The experimental group received the plasmid encoding VEGF165 cDNA plus lipofectamine (cationic liposome) injected directly to the gracilis muscle following 4 h of ischemia. The control group received lipofectamine only. The viability and vascularity of the flaps were evaluated after 7 days of reperfusion. The data demonstrated that the VEGF plasmid- and lipofectamine-treated muscle flaps had significantly greater total survival and capillary count 7 days after reperfusion compared with the flaps treated only with lipofectamine. These results indicate that VEGF exerts a protective effect on ischemic skeletal muscle flaps. © 2001 Wiley-Liss, Inc. MICROSURGERY 21:58–62 2001

Aggressive digital papillary adenocarcinoma (ADPA) is a rare tumor of sweat gland origin that may present in a nonspecific manner on the finger. The authors report a case of ADPA that was treated initially as a chronic infection of the finger, leading to a delay in diagnosis and definitive treatment. Failure of the wound to heal led to a biopsy of the lesion, which revealed ADPA. Because of the potential for aggressive local growth and distant metastases, amputation was indicated. This case demonstrates the importance of considering ADPA in the differential diagnosis of nonhealing wounds of the finger that have not responded to other forms of treatment. Wide local excision with clear margins and close surveillance for signs of recurrence or metastasis are indicated for this rare sweat gland neoplasm.