Microsurgery
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The fibular free flap is seen as one of the foremost technical options in mandibular reconstruction, especially in those defects where long bone is required. Cases with squamous-cell carcinoma of the floor of the mouth with mandibular spread and subsequent segmentary mandibular removal are the cornerstone examples. A case of squamous-cell carcinoma of the whole floor of the mouth with mandibular invasion is reported. ⋯ The fibular free flap is an excellent technique for mandibular reconstruction. Morphological deviations can modify the design of the flap. Achondroplasia is not a deterrent in successful use of the free fibula flap for reconstruction of the head and neck in adequately selected cases.
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Traumatic brachial plexus injuries in children, excluding birth palsy, are seldom reported. In this study, we report on 11 cases operated upon between 1995-1998, and followed for at least 30 months. All patients were males with an average age of 11 years (range, 3-16 years). ⋯ Harvesting the phrenic nerve and the contralateral C7 root resulted in no residual morbidity. Compared to adults, children have a higher incidence of root avulsion, no deafferentiation pain, a higher incidence of associated skeletal injuries, and the same recovery rate of elbow and shoulder functions following plexus reconstruction, but recovery is faster. Given the frequency of root avulsions, neurotization is often required.
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This study reports results in 12 patients treated with "completely vascularized single-stage approaches," so defined because skin, tendon, and nerve are transferred as a compound flap, and all are vascularized. A free dorsalis pedis cutaneotendinous flap was used in 7 patients, while a radial forearm cutaneotendinous island flap was transposed in 5 patients. A dorsalis pedis flap provides four vascularized extensor tendons (extensor digitorum comunis tendons), and the radial artery flap permits the inclusion of one completely vascularized tendon (palmaris longus) and two "strips" of vascularized tendons (flexor carpi radialis and brachioradialis). ⋯ The dorsalis pedis flap can be employed in the reconstruction of cutaneotendinous defects of the dorsum of the hand which require the use of three or four tendons grafts. We suggest the use of forearm cutaneotendinous flaps in cases of reconstruction of one or two extensor tendons. The "completely vascularized single-stage reconstruction" avoids prolonged hospitalization and results in a rapid restoration of near-normal function and appearance of the hand.
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Experimental and clinical studies have shown that a vein segment filled with skeletal muscle used to bridge a peripheral nerve defect (muscle-vein-combined graft) leads to good nerve repair. However, the molecular basis of the nerve fiber regeneration process along this type of graft still remains to be elucidated. The aim of this study was to verify the expression of two neurotrophins, nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF), as well as their receptors, trkA and p75, in an early stage of axonal regeneration in muscle-vein-combined grafts. ⋯ Many of these cells reacted for NGF, BDNF, and p75, but not trkA. In control grafts, i.e., immediately after surgery, no immunostaining was detected for any of the antibodies used in this study. These observations suggest that, very early after surgery, the muscle-vein-combined graft offers to growing axons an environment particularly favorable for regeneration, providing us with a possible explanation for the efficacy of this grafting technique for peripheral nerve repair.
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Case Reports
Repeated upper limb salvage in a case of severe traumatic soft-tissue and brachial artery defect.
We present the case of a 9-year-old male patient who suffered a gunshot injury to the right arm. The patient arrived in shock, his right arm severely traumatized, with soft-tissue loss involving the anterior surface and both sides of the right arm. The humerus was exposed. ⋯ After another blood transfusion, we performed a second reverse saphenous vein graft. The patient stayed at the hospital for 3 weeks. At follow-up 12 months later, the limb has good function and, except for the presence of a scar and skin graft, is equal in appearance to the left side.