Usefulness of a first transferred free flap vascular pedicle for secondary microvascular reconstruction in the head and neck

The authors found that a previously transferred free flap vascular pedicle, distal to the first microvascular anastomosis, can be used as a recipient vessel for an additional free flap transfer. Free flap transfers were performed by using the standard procedure in patients with head and neck cancer. The mean age of the patients was 62 years. Five patients were men and three were women. A second free flap was transferred for secondary primary head and neck cancer in two cases, facial deformity in two cases, osteomyelitis of the skull in two cases, recurrent cancer in one case, and exposure of a mandibular reconstruction plate in one case. The interval between the two operations was from 4 months to 12 years (median, 21 months). All secondary free flaps were performed successfully. In two cases, the external jugular vein proximal to the previously anastomosed site was used for venous drainage. In another case, additional venous anastomosis was performed for flap congestion. It became clear that a previously transferred free flap vascular pedicle could be used as a recipient vessel for microvascular anastomosis. This is an excellent procedure for additional free flap transfers.     

Variable stimulation patterns in younger and older thenar muscle

Neuromuscular electrical stimulation (NMES) is typically used with older adults receiving rehabilitation therapies, but little is known about the stimulation patterns that maximize force output and minimize fatigue in this population. The purpose of this study was to apply variable patterns of stimulation to the thenar muscles of the hand in younger and older adults to determine if force production and neuromuscular fatigue effects were similar. Three submaximal stimulation patterns were administered: A 20Hz constant frequency pattern, a pattern that increased from 20 to 40Hz, and a pattern that incorporated two closely spaced (5ms) doublet pulses. The doublet stimulation produced significantly higher average forces and force-time integrals (FTIs) than the constant frequency and increasing frequency patterns in both age groups. Additionally, older adults showed less fatigue than the younger group during isometric contractions performed after the fatiguing stimulation patterns. These results suggest that variable pulse NMES patterns enhance force production in the hand in both younger and older individuals better than constant frequency patterns, which are typically used in clinical applications. Also, greater fatigue resistance to electrical stimulation protocols may exist in the older population; this is critical information for the design and application of NMES rehabilitation regimens used with older adults.     

Role of heterotypic tissue interactions in deer pedicle and first antler formation-revealed via a membrane insertion approach

Heterotypic tissue interactions play an indispensable role in organ generation and regeneration. In contrast to the classic examples of tissue interactions prevailing in the formation of tetrapod limbs or pectoral fins that can only take place when the interactive tissues are in intimate contacts, the interactions in deer antler formation are novel in that the inducer and the responder are separated by a distance of 1-2 mm. This feature offers a unique opportunity to explore the mechanism underlying tissue interactions by permitting membrane insertion between the two interactive tissues. Four experiments were conducted in this study. The results showed that the impermeable membranes inhibited antler formation. In contrast, the permeable membrane (0.45 microm in pore size) substantially slowed pedicle growth and antler initiation but did not stop them. Interestingly, the impermeable membrane/sheath only slightly retarded antler elongation. Overall, our results demonstrate that interactions between the two interactive tissues, antlerogenic tissue and the overlying skin, are indispensable for first antler initiation and are achieved through diffusible molecules rather than direct physical contact. As the heterotypic tissue interactions are only required during antler initiation but not elongation, they must be transient in nature, and thus differ from those operating in limb/fin formation that can only be sustained by continuous interactions. A system in which organ development is achieved only through transient tissue interactions must be novel, if not completely unique. Understanding this system will undoubtedly enrich the knowledge in the field of tissue interactions and organogenesis.     

Age-related changes in the twitch contractile properties of human thenar motor units

Doherty, Timothy J., and William F. Brown. Age-relatedchanges in the twitch contractile properties of human thenar motorunits. J. Appl. Physiol. 82(1):93-101, 1997.The purpose of this study was to examine theeffects of aging on the contractile and electrophysiological propertiesof human thenar motor units (MUs). Percutaneous electrical stimulationof single motor axons within the median nerve was used to isolate andexamine the twitch tensions, contractile speeds, and surface-detectedMU action potential (S-MUAP) sizes of 48 thenar MUs in 17 youngersubjects (25-53 yr) and 44 thenar MUs in 9 older subjects(64-77 yr). A wide range of twitch tensions, contractile speeds,and S-MUAP sizes was observed in both age groups. However, oldersubjects had significantly larger MU twitch tensions and slower MUtwitch contraction and half-relaxation times. These changes wereaccompanied by increased S-MUAP sizes. These findings suggest that thehuman thenar MU pool undergoes significant age-related increase in MUsize and slowing of contractile speed. Such adaptation may help toovercome previously reported age-related losses of thenar MUs.

     

Surface landmarks to locate the thenar branch of the median nerve: an anatomical study

The thenar branch of the median nerve can be injured during carpal tunnel release. The purpose of this study was to identify surface landmarks to consistently predict the location of the thenar branch of the median nerve. Surface landmarks were marked and incised in 28 cadaveric hands. The incisions were made along the longitudinal line of the third web space and the horizontal cardinal line from the hamate hook to the ulnar border of the thumb. The origin of the thenar branch was determined in relation to these longitudinal and horizontal vectors. The origin of the thenar nerve branch was consistently observed in the radial proximal quadrant formed by the aforementioned longitudinal and horizontal vectors. The thenar branch origin was observed to be an average of 8.6 +/- 1.9 mm radial to the longitudinal axis along the third web space. The origin of the thenar branch was observed to be an average of 6.3 +/- 2.0 mm proximal to the horizontal axis between the hamate hook and the ulnar border of the thumb. The thenar branch was observed precisely at the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial edge of the proximal metacarpophalangeal crease in all 28 cadaveric hands. On the basis of these 28 cadaveric dissections, the location of the thenar branch of the median nerve can be predicted by the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial aspect of the metacarpophalangeal crease.     

Ultrastructural studies on the brachiopod pedicle

Studies of the ultrastructure of representative articulate and inarticulate pedicles show that there are similarities in secretory activity between pedicle epithelia of both classes and the outer mantle epithelium of the inarticulates. Rootlet epithelial cells of the articulate pedicle produce small vesicles which pass to the junction between rootlet and substrate and probably play a part in the breakdown of the substrate. Scanning electron microscopy shows that dissolution of a bivalve shell acting as a substrate often follows the boundary of a single nacre tablet, and transmission electron microscopy shows that the rootlet extends its infiltration along the conchiolin walls. The inarticulate pedicle ending is modified to collect adherent sand grains.     

EMG analysis of the thenar muscles as a model for EMG-triggered larynx stimulation.

Paralysis of one or both sides of the larynx musculature compromises breathing and speech function. Currently there is no surgical remedy to restore adequate function of the larynx. A plausible alternative solution is triggered electrical stimulation of the paralysed larynx site using a laryngeal pacemaker. Triggering of the pacemaker succeeds via constant EMG measurement of the muscle activity of the healthy larynx side. The EMG data analysis described in this work is one possible approach for regulating pacemaker triggering. In this study we used EMG data from the thenar muscles as a model to calculate a trigger point.     

Congenital absence of flexor pollicis longus without hypoplasia of thenar muscles

A 7-year-old girl who was unable to flex her left thumb at the interphalangeal joint proved to have an extremely hypoplastic flexor pollicis longus with normal thenar muscles, which is very rare. The flexor digitorum superficialis of the ring finger was transferred to the inserting portion of the flexor pollicis longus tendon with good results. The patient's cooperation seems to be a factor determining the prognosis.     

Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case

Background

Biliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case.

Methods

Seven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD.

Results

One dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses.

Conclusion

In mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.     

Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction

A radial thenar flap combined with radial forearm flap was used for the reconstruction of the ipsilateral thumb in four patients. Vascular supply of the combined flap was based on the radial artery and extending the vascular pedicle to the superficial palmar branch of the radial artery. The flap was sensated by the palmar branch of the superficial radial nerve. The size of the flap averaged 15 x 5 cm and the innervated region of the thenar eminence was an area approximately 5 x 3 cm located over the proximal parts of the abductor pollicis brevis and opponens pollicis muscles. The flap was transferred as a free flap in three patients and as an advancement flap in one patient. The flaps survived completely without complications. Satisfactory restoration of sensation was achieved in the flap area, as shown by 6 mm of average moving two-point discrimination. This combined flap may be a feasible reconstructive option for large palmar defects of the fingers such as degloving injuries.     

Construction of the nipple with a mushroom-shaped pedicle

Construction of the nipple-areolar complex has been the subject of much interest and many papers. We believe that the best way to ensure nipple protrusion is by the entrapment of tissue above the skin surface so that it cannot retract. This, in principle, is similar to creating an irreducible hernia. This technique for nipple construction employs a circular split-thickness island of skin which has its central circulation preserved through its attachment at the new nipple site. This central stalk represents about one-quarter of the total surface area of the constructed areola. The total diameter of the areolar disk is usually determined by the size of the opposite nipple-areolar complex. The new areola is developed from a full-thickness skin graft taken from the area below the inguinal crease. Once removed, it is sutured over the elevated nipple segment with its central island. The full-thickness graft is sutured into place before a small cruciate incision is made in the center. It should be just large enough to permit the delivery of the dermal-epidermal flap on its stalk up through the opening. Nothing more need be done to the raw undersurface of the split-thickness skin. Its raw surface has no place to reattach because its bed is now covered with the full-thickness graft.(ABSTRACT TRUNCATED AT 250 WORDS)