指背静脉动脉化逆行岛状皮瓣修复指端缺损

目的 介绍一种指端修复的新方法。方法 指背逆行岛状皮瓣通过指端的指动脉与皮瓣的静脉吻合形成静脉动脉比逆行岛状皮瓣修复指端缺损10例。结果 所有皮瓣均成活，外形满意。结论 方法易行，为指端修复增添了一种新的可供选择的方法，但需一定的显微外科基础。     

指背静脉动脉化逆行岛状皮瓣修复指端缺损

目的 介绍一种修复指端缺损的新方法。方法 指背逆行岛状皮瓣通过指端的指动脉与其静脉吻合,形成静脉动脉化皮瓣修复指端缺损10例。结果 所有皮瓣均成活,外形满意。结论 该方法易操作,需一定的显微外科基础,为修复指端缺损提供一种新方法。     

双瓣法在睑袋成形术中的应用

目的探讨采用皮瓣和肌瓣法（简称双瓣法）行睑袋成形术的操作方法和临床效果。方法对36例采用下睑成形术切口人路,分别形成皮瓣和肌瓣,在皮肤和眼轮匝肌表面与眶隔之间进行分离,直达眶下缘凹陷部,术中充分剥离松解弓状缘眼轮匝肌,特别是泪槽处眶下缘骨膜面的眼轮匝肌,将眶隔脂肪释放,缝合固定于眶下缘下方骨膜面上,行睑颊沟填充。然后设计眼轮匝肌瓣,将眼轮匝肌瓣上提和缝合固定,提升面中部使下睑区域达到年轻化效果。结果36例术后未出现血肿和下睑退缩现象。所有患者术后经3～18个月随访,均未出现睑外翻及面神经损伤等并发症。结论双瓣法既能矫正睑袋畸形,又能有效提升面颊部,达到面中部年轻化的效果,是一种较好的睑袋切除术式。     

儿童皮瓣移植手术75例分析

目的　回顾分析儿童皮瓣移植修复四肢软组织缺损的治疗效果。　方法　 1997年 1月～ 2 0 0 2年 5月实施了 75例儿童皮瓣移植手术。男 5 2例 ,女 2 3例 ,年龄 3～ 14岁。选择轴力或非轴形皮瓣移位、吻合血管的皮瓣移植 ,皮瓣范围 3cm× 5 cm～ 15 cm× 4 2 cm。其中急诊一期手术修复 2 6例 ,二期手术修复 4 9例 (感染性创面如骨髓炎、骨折术后钢板外露 )。手术修复部位 :前臂、手背、拇食指、小腿及足部等。皮瓣移植类型及应用范围 :轴形皮瓣移位或移植 39例(顺、逆行移位 2 7例 ,吻合血管的皮瓣移植 12例 )。非轴形皮瓣移位 36例 ,均是在伤口临近处设计的顺行或逆行皮瓣 ,其中 2 7例皮瓣长宽比例为 2 .5～ 3.5∶ 1,9例皮瓣长宽比例大于 3.5∶ 1。术前应注意麻醉的选择、术中无创操作及术后皮瓣的观察和护理。　结果　术后轴形皮瓣发生血液循环危象 2例 ,其中动、静脉危象各 1例 ,经积极处理后皮瓣成活 37例 ,失败 1例 ,部分失败 1例 ,手术成功率为 96 .2 % ;非轴形皮瓣成活 34例 ,部分失败 2例。手术成功率为 97.3%。术后随访 3个月～ 5年 ,皮瓣血运、弹性、质地均良好 ,功能满意。　结论　轴形或非轴形皮瓣移植 ,对一期修复患儿皮肤缺损或二期修复骨关节感染性创面有较高的成功率 ,要尽量选用非轴形皮     

Weichteildeckung der Fuß- und Sprunggelenkregion

Indications for soft tissue coverage in foot & ankle surgery are both acute defects after complex injuries and chronic defect situations.The management requires regularly an interdisziplinary and interprofessional therapeutic regimen. Prior to definitive defect coverage, soft tissue conditioning and bony stabilization is mandatory. The possibilities of defect coverage with local flap plastics in foot injuries are technical demanding and are limited due to a restricted mobilization of the tissue. Free microvascular flap plastics are chosen by the seize of the defect and offer a safe and effective treatment option because of a constant development in microsurgery (perforator flaps; supermicrosurgery) over the past decades.     

Reconstruction of Lower Extremity Fractures with Soft Tissue Defects

Abstract Reconstruction of osseous and soft tissue defects after high-energy lower extremity trauma remains a challenge in trauma surgery. An initial planning of the reconstruction management is crucial in the therapeutic concept of these severe injuries. In Gustilo type II and IIIa fractures with minimal contamination a primary definite osseous stabilization by internal fixation along with primary soft tissue reconstruction is preferable. A variety of local, regional, and even free microvascular flaps are available for acute wound closure in such cases. Staged reconstruction with initial external fixation and vacuum-assisted wound closure is recommended for severe contaminated wounds and extended defects. Early secondary osseous reconstruction of larger osseous defects can be performed either by distraction lengthening technique or by a free vascularized bone graft. Early secondary soft tissue reconstruction necessitates a wide therapeutic repertoire in order to plan the optimal individual strategy. With a modern therapeutic strategy limb salvage with an adequate function after reconstruction of lower extremity fractures with soft tissue defects can be achieved in the majority of patients.     

眼轮匝肌蒂皮瓣修复睑皮肤缺损

探讨使用一种血供确实可靠、即时移转的皮瓣修复眼睑皮肤缺损。方法　采用以眼轮匝肌为蒂的颧部、颞部皮瓣修复同侧上睑或下睑皮肤缺损。结果　修复上睑或下睑挛缩瘢痕切除松解后创面 (8例 )、色素痣切除后创面 (4例 ) ,取得满意效果。结论　以眼轮匝肌为蒂的皮瓣具有确实可靠的血供、易于移转和供区可以直接缝合等优点 ,是一种修复眼睑皮肤缺损可供选用的方法。     

化疗药物对轴型皮瓣血运影响的组织学观察

目的探讨抗癌药物动脉灌注后对局部轴型皮瓣血运影响的组织学评价。方法在猪腹部的腹壁上动脉插管灌注抗癌药物,10d后在猪腹部形成以腹壁上血管为蒂的岛状皮瓣,通过对灌注区域轴型血管供养的岛状皮瓣的成活率、光镜、透射电镜及血管铸型透明标本的组织学观察,显示其血管结构及构筑的变化。结果抗癌药物用于局部动脉灌注后,使局部轴型血管支配的血管网有损伤的表现,岛状皮瓣远端的血运显著降低。结论抗癌药物经动脉灌注后可影响局部轴型皮瓣的血运,使皮瓣血供的安全范围缩小,为提高相关修复手术的成功率提供可靠的科学依据。     

Free tissue breast reconstruction in older patients

We present the case of a 72-year-old woman who underwent mastectomy with immediate breast reconstruction using a free transverse rectus abdominis myocutaneous (TRAM) flap, to illustrate that age is not necessarily a barrier to microvascular reconstructive techniques for breast reconstruction.     

外伤性眼睑退缩的手术治疗

目的：探索采用异体巩膜移植行眼睑退缩矫正手术的疗效。方法：自上睑板上缘切断上睑提肌腱膜,或自下睑板下缘切断下睑缩肌,充分分离后使上下睑缘位置恢复正常,在上述腿膜与睑板之间植入 体巩膜片,以使上睑提肌腱膜或下睑缩肌延长。结果：本组18例22只眼,除1例轻度轿正不足和1例发生轻度上睑下垂体,其余均获得成功。结论：采用异体巩膜移植延长上睑提肌腱膜或下睑缩肌,是修复外伤或手术后眼睑退缩的有效手术方法。     

McGregor flap

Since it has been described in the early seventies [1], this flap has become an essential tool in reconstructive surgery, primarily due to the wide cutaneous surface it may replace. Its pediculate form is useful and it may be employed with significant benefit as free flap; it may even provide composite tissues. Also known as McGregor’s flap, groin flap, or iliofemoral flap, this axial pattern flap is based on the superficial iliac circumflex artery.     

Possible Role of an Endovascular Provocative Test in the Diagnosis of Glossopharyngeal Neuralgia as a Vascular Compression Syndrome

We utilized endovascular provocative techniques to identify the indications for microvascular decompression surgery in a serious case of glossopharyngeal neuralgia. This is the first reported case in which an endovascular provocative test was applied for diagnosis of glossopharyngeal neuralgia as a vascular compression syndrome. A 68-year-old woman presented with severe paroxysmal facial pain which could not be controlled by medical therapy. Partial effectiveness to carbamazepine led us to wonder whether or not the selection of microvascular decompression surgery would be appropriate. Pre-operative angiography was performed. During the examination a microcatheter was inserted into the right posterior inferior cerebellar artery (PICA), and an attack of typical glossopharyngeal neuralgia occurred. The patient thus underwent microvascular decompression surgery. The PICA was verified to compress the glossopharyngeal nerve and therefore was moved to induce decompression. The patient has since experienced no further pain for one year postoperatively. The diagnosis of glossopharyngeal neuralgia is sometimes complex and it is difficult to select the most appropriate surgical modality. In such cases this endovascular provocative technique may thus be useful for making a definitive decision or microvascular decompression surgery.     

Can Aesthetic Facial Reconstruction Be Judged in Black and White?

Aesthetic considerations of the face need to be evaluated in real-life full color. Staged contouring and insetting of a transferred free flap is sometimes required. This consists of debulking, thinning, and reshaping the flap. If the facial area is involved, however, color mismatch of a free flap represents an aesthetic challenge for the reconstructive surgeon, and often is missed with black and white photos.This article reports on a patient in whom a first dorsal metatarsal cutaneus free flap was used to reconstruct a full-thickness defect in the lateral orbit including upper and lower eyelids and outer canthus. The flap resulted in an unacceptable aesthetic outcome consisting of a bulky, hypopigmented deformity. Revisional surgery consisted of debulking the free flap and resurfacing it with a full-thickness skin graft taken from the postauricular area. This resulted in a pleasant, thin, and better color match reconstruction.The advantages of the first web space of foot free flap to the eyelid are well described. The authors are of the opinion that the flap does not match the color of the eyelid region, and therefore suggest that if used, prefabrication or a second procedure is needed.Evaluation of the postoperative results needs to be in color because black and white can mask the final aesthetic result.     

Application of microvascular surgery in reconstructive digestive tract surgery]

In our institutes, microvascular surgery has been effectively used in reconstructive digestive tract surgery, including esophageal reconstruction and hepatic arterial reconstruction. Free jejunal transfer combined with a gastric pedicle or microvascularly augmented elongated gastric pedicle has been utilized for total esophageal reconstruction. A microvascularly augmented jejunal pedicle or colonic pedicle has been applied in thoracic esophageal reconstructive cases with gastrectomy. Moreover, microvascular surgery has been performed in the reconstruction of the hepatic arterial system in the surgical treatment of pancreatic or bile duct cancer and living related-donor liver transplantation. Some pitfalls in selection of the recipient vessels and handling the intraperitoneal vessels for microvascular anastomosis are also described. Although microvascular surgery has been carried out by plastic and reconstructive surgeons in a team surgical approach, revisions in the medical educational system to create a new-type of surgeon with practical skills and clinical experience in both digestive tract and microvascular surgery will be required in future.     

Anaesthesia for reconstructive surgery

Reconstructive surgery is aimed at the restoration of shape and function following tissue loss due to trauma, oncological surgery, burns and infection. Techniques range from simple primary wound closure at the bottom to complex microvascular free tissue transfer at the top rung of the reconstructive ladder.Free flap surgery involves separation of the flap from its original vascular supply and microvascular reanastomosis at a distant site and is associated with substantial transient ischaemia of the transferred tissue. Anaesthetic management plays an important role in successful free flap surgery.All factors promoting vasoconstriction need to be eliminated in order to facilitate blood flow through the transferred tissue.In this respect, maintenance of an adequate arterial blood pressure, normothermia and normocarbia, institution of moderate hypervolaemic haemodilution and effective pain management are the main principles.In spite of studies describing the effects of particular drugs on the microcirculation no single ideal anaesthetic agent has yet been identified for this type of surgery.Free flap failure occurs mainly during the first 48 hours postoperatively with venous thrombosis being more common than arterial occlusion. Prompt surgical revision is the mainstay of flap salvage. The overall success rate of microvascular free tissue transfer in high volume centres exceeds 90%.     

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTIONChondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.PRESENTATION OF CASEA 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.DISCUSSIONThe outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.CONCLUSIONThis case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.     

皮瓣延迟与血管内皮细胞生长因子对大鼠背部皮瓣成活影响的比较

目的 将皮瓣延迟与采用血管内皮细胞生长因子（vascular endothelial growth factor，VEGF）对皮瓣成活的影响进行对比研究。方法3月龄SD大鼠30只，随机分为生理盐水组、皮瓣延迟组及VEGF组，每组10只。应用背部超长、宽比随意皮瓣模型。皮瓣延迟组采用双蒂皮瓣延迟，延迟时间为7d，之后断头端蒂，形成蒂部位于尾端的单蒂皮瓣；VEGF组形成单蒂皮瓣，于皮瓣中、远段均匀分为4点，局部皮下注射含400ng VEGF溶液100μl；生理盐水组于局部皮下注射生理盐水100μl，余同VEGF组。单蒂皮瓣完全形成后5d，计算皮瓣成活率，切取皮瓣组织，进行微血管密度分析、微血管直径测量和微血管断面面积测量。结果VEGF组皮瓣成活率与皮瓣延迟组接近，差异无统计学意义（P〉0．05）。皮瓣延迟组内部微血管平均直径明显大于VEGF组和生理盐水组，VEGF组皮瓣内部微血管密度明显大于生理盐水组和皮瓣延迟组，差异均有统计学意义（P〈0．05）。皮瓣延迟组和VEGF组相比，其微血管断面面积接近，差异无统计学意义（P〉0．05）。结论皮瓣延迟后皮瓣内部主要表现为微血管扩张，应用VEGF后，皮瓣内部主要表现为微血管增生。二者均能有效增加皮瓣内部微血管断面面积，提高皮瓣成活率，但其作用途径不同。     

Is microvascular decompression surgery a high risk for postoperative nausea and vomiting in patients undergoing craniotomy?

Purpose

Patients undergoing microvascular decompression surgery often experience postoperative nausea and vomiting (PONV). However, there is little information about the incidence of PONV after microvascular decompression. We hypothesized that microvascular decompression is an especially high-risk procedure for PONV in patients undergoing neurosurgery, and investigated risk factors related to PONV after neurosurgery.

Methods

All patients who underwent craniotomy in our institution during a period of 2 years were investigated retrospectively. Medical charts were reviewed to identify PONV during the 24-h postoperative period and related risk factors. Multivariate logistic regression analysis was conducted to elucidate the impact of microvascular decompression on PONV after craniotomy.

Results

Among 556 craniotomy cases, 350 patients met the inclusion criteria. Multivariate logistic regression analysis showed that microvascular decompression was an independent risk factor for PONV after craniotomy (odds ratio 5.38, 3.02–9.60), in addition to female gender, non-smoker status, amount of intraoperative fentanyl administered, and cerebrovascular surgery.

Conclusion

In this retrospective study, microvascular decompression surgery was an especially high-risk factor for PONV in patients undergoing craniotomy. It may be necessary to adopt a combination of prophylactic methods to reduce the incidence of PONV after microvascular decompression.     

Fibrin sealants in microvascular surgery: current status

ABSTRACT: During the last two decades, advances in fibrin sealant formulation have resulted in its investigational and clinical use in various surgical endeavors, including microvascular surgery. Several investigations have comparatively evaluated fibrin adhesive-enhanced microvascular anastomoses vs. conventional suture repair. The purpose of this review is to summarize the collective documentation on fibrin adhesives in microvascular surgery on the basis of the scientific performance parameters of vessel patency, bursting strength, anastomotic competence, and reendothelialization. In addition, other applications of fibrin sealants and other qualities unique to fibrin adhesives are addressed.