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Background: Extensor pollicis longus (EPL) rupture and tenosynovitis of the third dorsal compartment is often described in association with a history of rheumatoid arthritis or in the setting of a distal radius fracture. However, the literature suggests multiple other potential factors that may lead to a seemingly spontaneous rupture., Methods: We performed a systematic review following guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search consisted of headings and keywords related to tendon injuries, tendinopathy, hand surgery, tendon transfer, and injections, as published in reports and studies. Citations were screened by title and abstract against predetermined inclusion and exclusion criteria by 2 independent reviewers, with a third reviewer resolving discrepancies. To be eligible, articles had to meet the following inclusion criterion: describe cases of spontaneous EPL rupture or tenosynovitis of the third dorsal compartment. The exclusion criterion was any history of distal radius fracture or rheumatoid arthritis., Results: We identified 29 articles that met the inclusion criterion., Conclusions: A myriad of prodromal events or predisposing factors ultimately led to EPL rupture or tenosynovitis of the third compartment. Methods of reconstruction described included primary repair, tendon grafting, and tendon transfer techniques; all with generally good outcomes. These results highlight the inherent fragility of this tendon and support the historical recommendation for early release of the EPL tendon in the setting of tenosynovitis of the third dorsal compartment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Chronic back pain is a physically debilitating condition that affects more than 80% of adults in the United States. A recent case series highlighted how abdominoplasty with plication can offer an alternative surgical approach for treating chronic back pain. These results have been corroborated by a large prospective series. However, this study excluded male and nulliparous subjects, who may also benefit from this surgery. Our group aims to investigate the effect of abdominoplasty on back pain in a more diverse patient population., Methods: Subjects older than 18 years undergoing abdominoplasty with plication were recruited. An initial survey called the Roland-Morris Disability Questionnaire (RMQ) was administered at the preoperative visit. This questionnaire inquiries about and grades the patient's history of back pain and surgery. Demographic, medical, and social history was also obtained. A follow-up survey and RMQ was then given 6 months after surgery., Results: Thirty subjects were enrolled. Subjects had a mean age of 43.4 ± 14.3 years. Twenty-eight subjects were female and 26 were postpartum. Twenty-one subjects reported initial back pain on the RMQ scale. Of these, 19 reported a decrease in RMQ score after surgery, including male and nulliparous subjects. A significant decrease in mean RMQ score was demonstrated 6 months after surgery (2.94-0.44, P < 0.001). Further subgroup analysis of female subjects demonstrated significantly decreased final RMQ score in parous women, vaginal or cesarean section delivery, and absence of twin gestation., Conclusions: Abdominoplasty with plication significantly decreases self-reported back pain 6 months after surgery. These results support that abdominoplasty is not purely a cosmetic procedure but can also be applied therapeutically to improve functional symptoms of back pain., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The hand is highly visible and contributes to an individual's aesthetic image and perceived age. Current perspectives on hand aesthetics are primarily based on expert opinion rather than on lay population perspectives, which are less understood. Our study explores general population perceptions on the features that contribute most to an attractive hand., Methods: Participants rated the attractiveness of 20 standardized hands as well as the appearance based on each characteristic: freckles, hair presence, skin tone, wrinkles, vein appearance, and soft tissue volume. The relative importance of each feature was assessed by comparison with overall attractiveness scores through multivariate analysis of variance., Results: A total of 223 participants completed the survey. Soft tissue volume ( r = 0.73) was most strongly correlated with overall attractiveness, followed by wrinkles ( r = 0.71), skin tone consistency ( r = 0.69), veins ( r = 0.65), freckles ( r = 0.61), and hair ( r = 0.47). Female hands were perceived as more attractive, with a mean rating of 4.7 of 10, compared with 4.4 in males ( P < 0.001). Participants correctly identified the gender of 90.4% of male hands and 65.0% of female hands. Age was strongly inversely correlated with attractiveness ( r = -0.80)., Conclusions: Soft tissue volume is the most important factor in lay perception of hand aesthetics. Female and younger hands were perceived as more attractive. Hand rejuvenation may be optimized by prioritizing soft tissue volume with filler or fat grafting, with secondary priority on resurfacing to address skin tone and wrinkling. An understanding of the factors most important to patients in aesthetic appearance is critical to achieving a pleasing result., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Postoperative hand therapy (HT) is important for regaining function and preventing complications in patients undergoing tendon repair of the hand and wrist. Loss to follow-up (LTFU) can hinder this process; so we sought to determine factors that predict attrition of these patients., Methods: Charts were retrospectively reviewed for patients who underwent extensor or flexor tendon repair of the hand, wrist, or forearm between 2014 and 2019. Demographic data, including age, sex, zip code, employment status, education level, and insurance type, were collected, and the rate of LTFU was calculated. Logistic regression was used to analyze factors., Results: A total of 149 patients were identified and analyzed. The rate of LTFU was 42%. Factors that predicted loss were younger age, male gender, lower educational degree, and a documented psychiatric history. Employment status, insurance type, and distance from the HT center did not predict attrition. The number of HT weeks recommended by the occupational therapist did not differ between those who were lost and those who were not. Lost patients completed, on average, 57% of their suggested HT course., Conclusions: The current study identified demographic factors associated with attrition in patients undergoing tendon repair of the distal upper extremity. Factors included patients who were younger, male gender, less educated, and had a documented psychiatric history. By identifying factors that predict LTFU, specific strategies can be developed to reduce attrition rates, particularly for at-risk populations, to improve patient care after tendon repair., Competing Interests: The authors have no financial interests to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Coronavirus disease 2019 (COVID-19) has placed an unprecedented strain on healthcare systems worldwide, but while high-income countries (HICs) have been able to adapt, low- and middle-income countries (LMICs) have been much slower to do so due to a lack of funding, skilled healthcare providers, equipment, and facilities. The redistribution of resources to combat the pandemic in LMICs has resulted in decreased surgical volumes at local surgical centers as well as a dramatic reduction in the number of humanitarian aid missions. Despite recent global investment in improving the surgical capacities of LMICs, even in the pre-COVID-19 era there was a vast unmet surgical need. This deficit in surgical capacity has grown during the pandemic and it will be a significant struggle to overcome the resulting backlog of patients. A topic of particular concern to the authors is the effect that the pandemic will have on the delivery of time-sensitive surgical care to patients with cleft palate deformities as delay in providing care can have enormous physical and psychosocial consequences. This paper draws increased attention to the lasting impact that the COVID-19 pandemic may have on cleft palate patients in LMICs. SSRN Pre-print server link:   https://papers.ssrn.com/sol3/papers.cfm?abstract&#95;id=3898055 ., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Background: Distal radius fractures represent some of the most common injuries to the upper extremity, yet current evidence demonstrates great variability in the management of this injury. Elderly patients, in particular, stand to benefit from the early mobilization provided by operative fixation with a volar bearing plate., Methods: We conducted a retrospective chart review on all patients 65 years or older who underwent unilateral open reduction internal fixation of distal radius fractures using a volar bearing plate at a single institution between January 2014 and January 2016. We excluded patients with bilateral injuries, multiple fractures, and major injuries to the same extremity., Results: Fifty-five patients met criteria for this study. By AO classification, we repaired 17 type A, 24 type B, and 14 type C fractures. At final radiographic measurements, average radial height compared with ulna measured -0.31 mm, average radial inclination measured 20.45 degrees, and average volar tilt measured 7.11 degrees. On discharge, 36 patients had wrist range-of-motion data consistent with a functional wrist. Four patients had limitations in the flexion/extension plane, 8 with radial-ulnar deviation, and 7 had limitations in both planes., Conclusions: Distal radius fractures in the elderly may successfully be treated with a volar bearing plate. Useful strategies include supraperiosteal dissection of the radius from the pronator quadratus, use of a longer plate for stronger proximal fixation in osteoporotic bone, and regional block. This methodology allows for a safe procedure facilitating the early return of hand and wrist function.

Wieacker-Wolff syndrome is a rare congenital syndrome with few reported cases in the current literature. It is traditionally described in males as an X-linked recessive disorder associated with congenital contractures of the feet, progressive neurologic muscular atrophy, and intellectual delay caused by ZC4H2 mutations. The purpose of this paper is to present a female individual with a classic phenotype and cleft palate, a previously undescribed finding in this syndrome. Recent reports have demonstrated that females are rarely severely affected and phenotypic expression is difficult to predict [Zanzottera et al. (); American Journal of Medical Genetics Part A 173A: 1358-1363]. This case supports the unpredictability of Wieacker-Wolff syndrome severity and prompts future questions regarding female mutations and phenotypic expression., (© 2017 Wiley Periodicals, Inc.)

Background: In the treatment of basal joint arthritis of the thumb, recent studies suggest equivalent outcomes with regard to long-term pain, mobility, and strength, in patients undergoing either trapeziectomy alone or trapeziectomy with ligament reconstruction and tendon interposition (LRTI). The goal of this study was to investigate risk factors for complications in carpometacarpal (CMC) arthroplasty., Methods: We conducted a retrospective chart review of 5 surgeons at a single institution performing CMC arthroplasties from November 2006 to November 2012. A total of 200 thumbs in 179 patients underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby procedure. The average follow-up was 11.6 months (range = 1-69 months). Data collection included sex, age, history of smoking or diabetes, and any other surgeries performed on the hand at the time of arthroplasty. Furthermore, we collected outcomes involving any adverse events, paying attention to those necessitating reoperation, antibiotics, or those who developed complex regional pain syndrome., Results: Seventy hands had a postoperative complication. Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions. On multivariate analysis, risk of total complications was significantly greater only in patients undergoing either trapeziectomy with LRTI or Weilby procedure in comparison with trapeziectomy with K-wire stabilization (odds ratio = 4.30 and 6.73, respectively)., Conclusions: Patients undergoing trapeziectomy with LRTI or Weilby had a greater incidence of reported complications when compared with trapeziectomy alone. These results suggest an advantage of simple trapeziectomy; however, further study is warranted.

Background: Operating rooms (ORs), combined with labour and delivery suites, account for approximately 70% of hospital waste. Previous studies have reported that recycling can have a considerable financial impact on a hospital-wide basis; however, its importance in the OR has not been demonstrated., Objective: To propose a method of decreasing cost through judicious selection of instruments and supplies, and initiation of recycling in plastic and hand surgery., Methods: The authors identified disposable supplies and instruments that are routinely opened and wasted in common plastic and hand surgery procedures, and calculated the savings that can result from eliminating extraneous items. A cost analysis was performed, which compared the expense of OR waste versus single-stream recycling and the benefit of recycling HIPAA documents and blue wrap., Results: Fifteen total items were removed from disposable plastic packs and seven total items from hand packs. A total of US$17,381.05 could be saved per year from these changes alone. Since initiating single-stream recycling, the authors' institution has saved, on average, US$3,487 per month at the three campuses. After extrapolating at the current savings rate, one would expect to save a minimum of US$41,844 per year., Discussion: OR waste reduction is an effective method of decreasing cost in the surgical setting. By revising the contents of current disposable packs and instrument sets designated for plastic and hand surgery, hospitals can reduce the amount of opened and unused material., Conclusions: Significant financial savings and environmental benefit can result from this judicious supply and instrument selection, as well as implementation of recycling.

Background: The lifetime cost of a child with an orofacial cleft is estimated at $101,000, which amounts to $697 million total for those born each year with orofacial clefts. There has been a trend toward outpatient procedures for cleft lip repair (CLR) and alveolar bone grafting (ABG), and studies have shown no disparities in safety or outcome between inpatient and ambulatory treatment. The financial implications of outpatient versus inpatient procedures have not been compared., Methods: Financial data were collected for outpatient (n = 33) and inpatient (n = 2) CLR, as well as outpatient (n = 7) and inpatient (n = 5) ABG during a 5-year period at our institution. We examined hospital charges and reimbursement for these procedures by private insurance plans and Medicaid Managed Care (MMC) plans., Results: The average total reimbursements for inpatient and outpatient CLR were similar at $6848 and $5557, respectively. Average facility reimbursement for CLR was greater for inpatient ($5344) than outpatient ($4291) procedures. Average professional reimbursement was similar between inpatient ($1504) and outpatient ($1266) CLR.For ABG, the average total inpatient reimbursement was $14,573, whereas outpatient was $8877. Average facility reimbursements were greater for inpatient ($12,398) than outpatient ($7183) ABG. Average professional reimbursement was similar between inpatient ($2175) and outpatient ($1693) ABG, with 35% and 31% of charges reimbursed, respectively.A substantial difference existed between reimbursements based on insurance types for both outpatient CLR and outpatient ABG. On average for CLR, commercial payers reimbursed 52% ($7344) of overall charges, whereas Medicaid and MMC reimbursed 9% ($1447). For ABG, commercial payers reimbursed an average of 78% ($11,950) of overall charges, whereas Medicaid and MMC reimbursed 10% ($1192)., Conclusions: Fewer patients' insurance companies are reimbursing for inpatient stays; in many cases, even patients who remain hospitalized up to 48 hours are treated as "day surgery" from a reimbursement perspective. For outpatient surgery, a greater percentage of CLR and ABG charges were successfully recouped compared to inpatient surgery. Awareness of higher payment for inpatient surgery and potential savings through use of the outpatient setting is crucial for hospitals and the US health care system as a whole.

Ulnar artery aneurysms are uncommon lesions. They are often caused by traumatic injury to the hand. Ulnar artery aneurysms have been reported in association with multiple sports-related activities, but never secondary to a basketball injury. The following is a case presentation of an ulnar artery aneurysm likely formed secondary to repetitive basketball slam dunking with accompanying review of diagnosis and surgical treatment of ulnar artery aneurysms.

Frontal sinus fractures have traditionally been repaired through a bicoronal approach. This incision provides a wide exposure, but is not without complications, particularly in the patient with or at risk for hairline recession. We present a series of 15 patients who underwent open reduction and internal fixation of anterior table frontal sinus fractures through a frontalis rhytid forehead incision and their results based on the scar appearance, forehead contour, frontalis function, sensation and fracture reduction. Paresthesias cranial to the incision in the supraorbital or supratrochlear distribution were noted in 12 of the 15 patients with resolution in all except 1 patient who did not regain sensation at 4 months follow-up. In all patients, satisfactory forehead contour and fracture reduction were achieved, as were scar appearance and frontalis function at 4 months follow-up. We thus recommend this approach in the treatment of anterior table frontal sinus fractures, with special consideration for the patient with or at risk for anterior hairline recession.

The perioperative management of cleft palate surgery remains controversial. Early literature supported hospital stays of 2-5 days, but more recent reports have supported 24-hour admissions in carefully screened patients without congenital syndromes. We retrospectively reviewed 65 cleft palate repairs performed by the senior author from August 1992 through November 2003. Procedures included repairs of the soft palate (n = 25), hard palate (n = 4), or combined hard and soft palate (n = 36). All repairs were performed using a Furlow double, opposing Z-plasty technique. Nine patients (14%) had associated congenital syndromes. Prior to January 1995, patients (n = 15) received perioperative antibiotics and local injection of lidocaine with epinephrine prior to incision. The average operative time to first oral feeding was 13 hours, and the average length of stay in this group was 2.4 days. Previous oral surgery literature has demonstrated the reduction of pain, edema, and trismus with the use of dexamethasone. As part of our recent operative protocol, all patients (n = 50) after January 1995 received perioperative antibiotics, local injection of a 50/50 mixture of 1% lidocaine with epinephrine, and 0.5% Marcaine with epinephrine prior to incision and 4 mg of intravenous dexamethasone perioperatively. The average time to first feeding was 7 hours and the average length of stay was 1.1 days. Postoperatively, patients from both groups were maintained on a liquid or soft diet, depending on their age without the use of bottles. There were no differences in the use of antibiotics or pain management between the 2 groups. Patients were assessed by the surgical team for evaluation of the surgical site and oral intake prior to discharge. Patients in the steroid/Marcaine group had earlier oral intake (P < 0.05) and shorter length of stay (P < 0.05). Of those patients receiving dexamethasone and Marcaine, 43/50 (86%) were discharged within 24 hours. Patients requiring longer hospitalization had initially inadequate oral intake. One patient required readmission for dehydration secondary to rotavirus. In conclusion, short-stay cleft palate surgery is safe, given adequate oral intake, competent parents, and a safe home environment.

Background: Traditional practice for alveolar cleft closure requires postoperative hospital convalescence in an unfamiliar, disruptive hospital setting. An outpatient iliac crest alveolar bone grafting protocol was devised to optimize patient care., Methods: A retrospective review of the senior author's experience over 5 years (1998 to 2004) of ambulatory alveolar cleft closure was compared with the previous 5-year period (1993 to 1998) of inpatient convalescence. An iliac crest donor site and standard techniques of alveolar grafting were followed in both groups. Although local analgesia with lidocaine and epinephrine was used in both groups, the ambulatory group received preemptive local anesthesia augmented with Marcaine. Postoperative nausea also was treated preemptively in the outpatient group with the addition of dexamethasone (Decadron) and ondansetron (Zofran), whereas the control patients were treated as needed. Patient charts were reviewed for demographic information, technical aspects, length of donor-site incision, bone graft volume, and time of operation. A Fisher's exact test was used for statistical analysis. Complications including morbidity, readmission, and reoperations were recorded., Results: Twenty consecutive patients were treated on an outpatient basis. Eight consecutive patients were convalesced as inpatients in the previous 5-year period. The ambulatory series average patient age was 12.1 years (range, 8 to 15 years). Four bilateral procedures were performed. The follow-up period averaged 3.5 years (range, 5 to 76 months). Two minor complications were identified: cellulitis at a donor site and a recipient suture line dehiscence with minor graft exposure. There were no readmissions, revision operations, hernias, wound infections, or graft losses identified. In the inpatient series, the average stay was 1.8 days (range, 1 to 3 days). One gingival suture line dehiscence requiring no further intervention was identified, for an average complication rate of 12.5 percent, which was not significant compared with the ambulatory group (10 percent) (p = 1.00)., Conclusions: Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient basis when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and reliable motivated parents or caregivers provide a comfortable postoperative setting. Safe outpatient surgery provides patients and family the opportunity to recover in the familiar home environment.

Carney syndrome is a rare clinical entity usually treated by plastic surgeons. We present a patient with Carney syndrome and review the literature emphasising the plastic and reconstructive surgical aspects of the syndrome.

Although widely utilized in the treatment of metacarpal fractures, plate fixation in phalangeal fractures remains controversial. Increased potential for infection, breakage, and added soft-tissue trauma leading to increased joint stiffness have been cited as important negative factors. A retrospective analysis of titanium plate fixation of phalangeal fractures over a 7-year period is presented. From 1991 to 1998, 16 fractures (13 men, 3 women; age range, 19-70 years) were managed with plate fixation using the Profyle titanium plating system as the primary modality of treatment. All plates were seated dorsally using an extensor tendon-splitting approach. The average follow-up period after surgery was 5 months (range, 3-28 months). Fracture patterns varied: 31% (5 of 16) were open fractures and 69% (11 of 16) were closed. Complications occurred in 25% of patients (4 of 16) and consisted of pain or other trigger that required removal of hardware, flexion contracture at the proximal interphalangeal joint, and extensor lag. There were no instances of hardware failure, infection, or malunion. The quality of recovery of joint motion was assessed using the Total Active Flexion Scale: nine digits were graded excellent, another six were categorized as good, and only one digit was judged as poor. A review of the current literature is presented along with suggested guidelines for the application of miniplate fixation for fractures of the phalanges.

Standard of care for cleft lip repair has included preadmission testing, surgical correction, and postoperative hospital care. Driven not by managed care economics but to speed the safe home care of infants by parents, the authors have gained experience in ambulatory cleft lip repair. In this retrospective study the authors evaluated the outcome of patients who underwent ambulatory cleft lip repair compared with those patients who were hospitalized after surgery. From 1989 to 1998, 24 cleft lip repairs in 24 patients performed by the senior author were evaluated. Two groups were treated. Group 1 (N = 11) consisted of ambulatory unilateral cleft lip repairs and group 2 (N = 13) consisted of inpatient unilateral cleft lip repairs. Important surgical factors considered were technique of cleft lip repair, performance of ancillary procedures, type of local anesthetic administered, and intravenous steroid administration. Time to first postoperative feeding and complications, including bleeding, spontaneous or traumatic wound dehiscence, and infection, were considered important outcome parameters. There were no differences in surgical technique or use of antibiotics and postoperative analgesics between the two groups. None of the patients in group 1 underwent ancillary procedures. Four patients underwent soft palate repair and 3 patients underwent insertion of myringotomy tubes among group 2 patients. The use of a 1:1 mixture of 1% lidocaine and 0.5% bupivacaine with epinephrine vs. 1% lidocaine with epinephrine as a local anesthetic and intravenous steroid administration was greater in group 1 (92%) than in group 2 (33%) patients. The average time to the first postoperative feeding was more than 1 hour sooner in the ambulatory group (p < 0.05) compared with the hospitalized group (excluding the 4 patients who underwent soft palate repair). There were no complications among patients with ambulatory cleft lip repair, and there were two cases of minor wound separation in patients who received postoperative hospital care. Although many variables factor into the outcome after cleft lip repair, these data support the safety and continued practice of ambulatory cleft lip repair.

This case report documents a unique thumb reconstruction performed at the authors' institutions. The amputated dominant right thumb of a manual laborer was electively reconstructed with microvascular transfer of the previously partially amputated little finger from the same hand. At 1 year postoperatively, the patient returned to work with excellent grip and pinch strength, thumb opposition to all digits, and 8 mm of static two-point discrimination. The technical details of the operation are described and compared with other analogous reports in the literature.

This study was undertaken to evaluate the effect of ketorolac (Toradol), a potent cyclooxygenase inhibitor used for postoperative pain, on microvascular thrombosis in an established thrombosis model. Bilateral 3-mm arterial inversion grafts (n = 66) were constructed in the femoral arteries of New Zealand White rabbits. ALZET (ALZA Corporation, Palo Alto, Calif.) osmotic pumps were implanted in the external jugular veins for drug delivery. The blinded protocol called for the experimental animals to receive intravenous doses of ketorolac of 1.72 mg/kg per day (group 1) or 3.44 mg/kg per day (group 2), while control animals received equivalent volumes of saline. Patency was assessed at 7 days. Whereas 52 percent (13 of 25) of control vessels remained patent, 70 percent (14 of 20) and 86 percent (18 of 21) of group 1 and group 2 vessels, respectively, were patent at 1 week. This decrease in microvascular thrombosis with delivery of ketorolac was statistically significant (p = 0.0094). Ketorolac, at experimental doses approximating 9 and 18 mg IV q6h in a 70-kg man, demonstrated a statistically significant reduction in microvascular thrombosis. This study supports its use in clinical microvascular surgery.

This retrospective study compares the success of iliac versus cranial bone autografts in the secondary grafting of alveolar clefts. The study group was 116 patients with complete records and radiographs from a pool of 186 consecutively grafted patients at Children's Hospital of Philadelphia. The quality of graft "take" was graded radiologically. Variables potentially influencing outcome were evaluated and included graft type (iliac versus cranial bone), cleft type (unilateral versus bilateral), cleft severity (complete unilateral or bilateral cleft lip and palate versus cleft of the alveolus only), age at grafting, and complications. Although graft "take" versus "nontake" seemed comparable in iliac and cranial bone graft groups, iliac bone showed a statistical superiority over cranial bone, with more radiologically excellent grades (p = 0.04) in all cleft types. Likewise, when the two graft types were compared in more severe clefts (complete unilateral and bilateral cleft lip and palate), iliac bone showed statistical superiority (p = 0.02) over cranial bone. However, they seemed comparable in less severe clefts of the alveolus only (p = 0.22). Recipient-site complications and their sequelae were comparable in iliac versus cranial graft groups, and no age-related differences were noted in children grafted above or below age 10.

Forty fresh cadaver dissections were studied to determine variations in the anatomy of the lower portion of the serratus anterior muscle. In all cases, the lower three to five slips of the serratus anterior muscle were supplied by one to three branches from the thoracodorsal artery, the so-called serratus branches. Three vascular patterns were identified: type I with one branch (40 percent), type II with two branches (50 percent), and type III with three branches (10 percent). The mean dimensions of the lower serratus anterior flap were 18.0 x 9.0 cm (range 12.0 x 8.0 cm to 21.0 x 15.0 cm). The mean pedicle length was 11.3 +/- 2.8 cm (range 7.3 to 13.3 cm). A crow's foot landmark has been identified to facilitate flap dissection. This landmark marks the juncture of the long thoracic nerve and the dominant serratus branch. This juncture can be found at the superior border of the sixth or seventh rib. The lower serratus anterior flap is ideal for reconstruction of small to moderate-sized defects because of its flat, broad dimensions and its long vascular pedicle.

The superficial inferior epigastric flap is a versatile free flap that has added to the techniques available for autogenous breast reconstruction. It is especially advantageous when previous thoracic radiation and/or abdominal surgery preclude the use of conventional transverse rectus abdominis musculocutaneous flaps. Eight superficial inferior epigastric flaps were used to reconstruct 7 breasts in 6 patients. In 4 patients the superficial inferior epigastric flap was used as part of a composite free flap. In 1 patient, a lower abdominal wall flap was transferred on bilateral pedicles. In another, bilateral flaps were raised to reconstruct both breasts. The superficial inferior epigastric flap offers several advantages. It uses relatively abundant lower abdominal wall skin and subcutaneous tissue while preserving the underlying fascia and rectus muscles. A cadaver study illustrates the clinical territory of this flap. The superficial inferior epigastric flap provides an excellent option for autogenous free flap reconstruction of the breast, alone or in combination with other flaps.

Although low molecular weight dextran is commonly utilized in clinical microsurgery, few experimental data are available documenting its efficacy. Bilateral 2-mm arterial inversion grafts were constructed in the femoral arteries of New Zealand White rabbits. The experimental group (n = 40 grafts) received a 5-day constant infusion of intravenous dextran 40 at 2.1 ml/hour, and the control group (n = 50 grafts) received no infusion. Whereas 85 percent (34/40) of the dextran grafts were patent at 1 week, only 48 percent (24/50) of the control grafts were patent (p = 0.0003). Scanning electron micrographs revealed a decrease in both platelet and fibrin deposition in the patent dextran arterial inversion grafts versus the patent control specimens. As a marked diminution in microvascular thrombosis was demonstrated at a clinically relevant dose, the continued use of intravenous dextran 40 in clinical microsurgery is supported by this study.

This study was undertaken to evaluate the patency rate of radial and ulnar artery repairs performed with use of the magnification afforded by the operative microscope. Color Doppler ultrasonographic imaging was chosen as a reproducible, noninvasive technique to evaluate patency and graphically display vascular flow characteristics. Twenty-eight consecutive patients with 35 arterial injuries form the study group. Twenty-four patients with 31 arterial lacerations were available for enrollment in the protocol. Follow-up ranged from 1 to 40 months (average, 10 months). Eighteen male and six female patients sustained 13 radial and 18 ulnar artery lacerations, all sharp. Four patients required interposition vein grafting. Overall patency after repair was found to be 84%, with 82% of single vessels and 86% of double vessels patent. The patency of single vessels repaired without the use of vein grafts was 100%. These results indicate that microscope-assisted repairs of the radial and ulnar arteries remain patent at a higher rate than is commonly cited.

The efficacy of ibuprofen in reducing microvascular thrombosis in a well-established experimental model was studied. Bilateral 2-mm arterial inversion grafts were constructed in the femoral arteries of New Zealand White rabbits. The experimental group (n = 40 grafts) received subcutaneous injections of ibuprofen 15 mg/kg t.i.d. beginning 1 day preoperatively and continued for 7 days postoperatively. The control group (n = 42 grafts) received injections of an equivalent volume of saline three times per day. Patency was evaluated at 7 days by the distal milking test. Seventy-three percent of the ibuprofen grafts were patent at 7 days, whereas 57% of the control grafts remained open. This difference in microvascular patency was not statistically significant. Representative scanning electron micrographs revealed a moderate reduction in aggregated platelets and overall clot density in the patent ibuprofen arterial inversion grafts compared with the patent control specimens. Although the use of ibuprofen as a sole antithrombotic agent cannot be recommended as the result of this study, it may be efficacious when used in conjunction with other agents such as dextran 40.

Epidural anesthesia is an effective means of providing pain control and chemical sympathectomy at the spinal nerve root level. The purpose of this study is to compare the efficacy of the combination of epidural and general anesthesia to general anesthesia alone in patients undergoing free flaps to the lower extremity. A retrospective review of 35 consecutive patients (36 operations) from November of 1988 to November of 1990 undergoing free tissue transfer to the lower extremity was undertaken. Sixteen patients had epidural and general anesthesia, and 19 (20 operations) had general anesthesia alone. There were no significant differences in the age or sex of the patients, the distribution between acute and chronic wounds, or the number of cigarette smokers in the two groups. There were no flap losses in the epidural group (100 percent success) and one major, but nonmicrovascular complication (6 percent). In the nonepidural group, there were one flap loss (95 percent success) and five major complications (25 percent). These included three microvascular complications (15 percent). There were significantly fewer patients with postoperative atelectatic fevers in the epidural group versus the nonepidural group. In this consecutive series of patients, epidural supplementation of general anesthesia for free flaps to the lower extremity was associated with uniformly successful flap survival and a lower rate of microvascular complications compared to general anesthesia alone.

Thirty-five consecutive applications of external fixation to the hand, including 27 acute cases and 8 reconstructive procedures, were studied. In both settings, external fixation was used not only for skeletal stabilization but also for management of the soft tissues. Twenty of the 22 acute fractures healed, and six arthrodeses with interposition bone grafts resulted in fusion. Three septic nonunions resolved, and two united successfully. There were no complications. We recommend external fixation systems in the hand, and several case reports are included in the study to illustrate the various applications.

During a 13-year period at the Massachusetts General Hospital, Boston, Massachusetts, 97 microvascular free tissue transfers have been performed for soft-tissue reconstruction in 96 patients following bone debridement for chronic traumatic bone wounds. These 96 patients comprise a continuation study of 18 original patients reported in 1982. During a 13-year follow-up period (mean, 77.1 months), 95.8% of these 96 patients have enjoyed complete wound closure with a lack of drainage after the debridement and free tissue transfer. Most of the patients (89.6%) encountered in this study are ambulatory without assist and 5.2% of patients have undergone amputation. Twenty-three per cent of patients required subsequent segmental bone defect reconstruction in the lower extremity after infection eradication. The pathophysiology of chronic traumatic bony wounds is different from that of chronic hematogenous osteomyelitis and thus a high incidence of long-term successful management can be seen through complete wound debridement and adequate soft-tissue coverage.

An experimental model for the study of canine flexor tendon adhesions was designed using a standardized crush-abrasion injury, meticulous sheath closure, and three-week limb immobilization. Ten animals in the experimental protocol were evaluated for visible adhesion formation. With use of a flexor tendon adhesion rating scale, consistent adhesion formation was documented with an average score of 10.4 +/- 2.1 (range, 0 to 12). Five additional animals had biomechanical testing. Applying an increasing load to the proximally divided profundus tendon (0 to 10 Newtons), it was found that the angle of distal interphalangeal joint motion and the displacement of the toe were significantly decreased, and the work generated significantly increased in the experimental versus control digits (p less than 0.05). The consistent production of visible adhesions thus correlates with biomechanical impairments in toe motion and work. The study of agents aimed at diminishing flexor tendon adhesions will thus be facilitated by this reliable model. Systemic or intrasheath administration of agents will be possible.

Severe lower extremity injuries are devastating in their impact on the patient, his or her family, and the future. A critical evaluation of the results of previous salvage efforts provides the basis for the formulation of a treatment strategy. Success can be measured only in terms of functional outcome. The type of therapy is perhaps less important than the effectiveness of establishing a coordinated multidisciplinary approach to these injuries.

In a ten-year review (1978 to 1988), ten ulnar artery aneurysms in nine male patients were studied. Blunt trauma led to 70%, penetrating trauma to 20%, and 10% had no history of trauma. Three cases were seen as asymptomatic palmar masses with brief antecedent histories of 4 weeks or less. Seven patients with aneurysms had persistent vascular hand symptoms for 6 weeks or longer. All seven symptomatic lesions proved to be sources of emboli. Diagnostic arteriography was done in all cases. Intraoperative digital plethysmography aided in operative decisions regarding the necessity for microvascular reconstruction. Five aneurysms were resected with end-to-end ulnar artery microvascular repairs, four resected without repair, and a single case treated with long-term anticoagulants. Follow-up, averaging 40 months, showed uniform improvement in vascular symptoms, with no loss of jeopardized tissues. Ulnar artery aneurysms, well studied preoperatively and intraoperatively, can be treated successfully with selective microvascular reconstruction.

A case is presented of lactation occurring ten days after mastopexy with augmentation mammaplasty. Milk-draining sinuses involving the operative incisions necessitated prompt diagnosis and treatment to avoid breast implant loss. Bromocriptine, an ergot derivative, was used to suppress a pathologically elevated prolactin level and successfully effect a rapid resolution of lactation.

Primary melanomas of the skin of the breast are uncommon lesions. Fifty-four patients were surgically treated for this lesion during a 13-year period, accounting for 3.8 percent of a total of 1431 patients with cutaneous melanoma. Nineteen patients were female and 35 were male. Most recently, in patients with high-risk lesions, such as those exhibiting an aggressive vertical growth phase or a Clark level IV or V, attempts at curative resection have utilized wide and deep excision to the level of the pectoralis fascia with axillary lymph node dissection in selected cases. Reconstruction of the significant breast deficit in five female patients utilized the latissimus dorsi myocutaneous flap. This technique results in an improved aesthetic appearance when compared to primary closure or skin grafting. Donor-site morbidity is minimal. Long-term cancer surveillance is not impeded, and all five patients expressed satisfaction with the reconstruction. Four of the five female patients are currently alive with no evidence of disease at a mean follow-up of 55 months after definitive therapy.

Using the implantable Infusaid Model 300 pump, several vasodilators (prostaglandin E1, isoxsuprine, bradykinin, trimethaphan, and reserpine) were infused intraarterially into an abdominal island flap in the rabbit. All produced a large increase in flap surviving area over saline controls at forty-eight hours, measuring as high as a 2.8-fold increase in random portions of the flap with prostaglandin E1. The agents possessed differing modes of action but had the common property of vasodilatation. The results raise questions concerning the possible physiological role of endogenous prostaglandins in the surgical delay phenomenon. The Infusaid pump was a valuable tool in the study and was well tolerated by the animals.

A free gracilis muscle transfer with skin graft was performed for reconstruction of a type IIIB lower extremity traumatic wound with acute exposure of the distal tibia fracture site and an extensive soft-tissue wound. The free muscle flap failed from a venous thrombosis that was recognized 12 hours postoperatively, and reexploration revealed extensive venous thrombosis throughout the lower leg. The flap was salvaged by direct catheter administration of heparin into the vena comitans of the gracilis artery, which bathed the newly repaired venous anastomosis with an anticoagulating dose of heparin without systemic elevation of the patient's PTT. Ultimate full flap survival and wound healing ensued.

The elective free microvascular cross-hand transfer of the right hand to the left distal carpus was successfully performed in a 35-year old professional photographer. Traumatic loss of the left hand with preservation of a useful thumb and concomitant right upper extremity injury leaving the right hand with an amputated thumb, but paralyzed and insensate from a brachial plexus palsy 5 years before transfer, set the stage for such a reconstruction. Multiple immediate tendon transfers and primary nerve grafting provided for finger flexion and extension plus functional sensibility in this first reported case of an elective cross-hand microvascular transfer. Five years follow-up demonstrates useful and powerful flexion, and functional extension of digits in the reconstructed left hand and right upper extremity function has been improved with a below-elbow prosthesis.