Microsurgical Transplantation Research Articles

Nursing care of a patient after a craniofacial area microsurgical transplant in a teenage boy

Abstract Aim. The aim of the study was to make selected nursing diagnoses for a patient after a microsurgical transplant in the facial area, with the aim of providing the patient with comprehensive care in the perioperative period. Material and methods. The study describes the case of a child after microsurgical transplantation of a flap taken from the left iliac plate to the right submandibular region. The individual case method was used. Clinical interview, observation, measurement and medical documentation data were analyzed. Results. Four selected nursing diagnoses were presented along with planned interventions: risk of complications at the site of microsurgical flap transplantation, risk of donor site infection, discomfort caused by intense oozing of secretions from the postoperative wound in the oral cavity and the boy’s depressed mood caused by low self-esteem resulting from the changed postoperative facial appearance and the failure of the first surgical procedure. Conclusions. Nursing interventions should be adapted to the patient’s dynamically changing recovery process. They should be based on systematic inspection of the recipient and donor sites for the occurrence of complications. Education of the patient and the caregiver is an important element of the therapeutic process. It was not possible to significantly improve the child’s mood.

One-stage reconstruction of four fingers in children using microsurgical autotransplantation of foot tissue complexes

BACKGROUND: Toe-to-hand transfer is still the most promising and relevant method for restoring fingers that are missing from birth or after injury. In cases requiring the restoration of two or more digits, simultaneous transplantation of tissue complexes from both feet, including one or two toes, is possible and necessary. Thus, a maximum of four fingers can be restored during one operation. Such operations, according to the literature, are performed extremely rarely because they are very extensive and time-consuming.
 AIM: To present the results of simultaneous microsurgical autotransplantation of four toes to the hand in children with congenital and acquired pathologies.
 MATERIALS AND METHODS: The study used clinical, radiological, and biomechanical methods to assess the results of nine patients with congenital and acquired upper limb deformities who underwent simultaneous microsurgical autotransplantation of two tissue complexes from each foot, including toes II–III. The indications for performing this method of microsurgical reconstruction in children with the absence of four (or all five) fingers have been determined. The results, postoperative complications, and conditions of the donor and recipient zones were analyzed.
 RESULTS: To date, 914 such operations have been performed in children. In nine cases, four toes were simultaneously transplanted (two from each foot). The average age of the patients was 4.2 years. Two children had congenital malformations of the hand, and seven had consequences of trauma. In eight cases, fingers II–V were restored, and in one case, fingers I–IV were restored. Complications associated with impaired blood circulation in the grafts were observed in 22% of the cases; however, they were temporary. All transplanted grafts survived. All patients required continued surgical treatment after the toe transfer to improve their appearance and function. Biomechanical examination methods showed complete restoration of function on average of 4 months (±1 month) after surgery.
 CONCLUSIONS: This study showed the possibility and effectiveness of using toes for hand transfer in children with both congenital and acquired hand pathologies that require the restoration of four fingers. Simultaneous microsurgical transplantation of toes ensures the restoration of a good appearance of the hand and its functionality.

Creation of elbow joint in children with humeroradial synostosis. A clinical case

Humeroradial synostosis is a severe rare anomaly of the upper limb, leading to the development of disability. This congenital anomaly may be a separate nosological unit, or a part of a genetic syndrome. Multi-stage surgical treatment is correct for all components of the deformity. The most difficult stage of treatment is the creation of an elbow joint. There are few studies on this problem in the literature. The article presents the results of surgical treatment of two children with humeroradial synostosis, who had the elbow joint created using two techniques. Patient A. underwent microsurgical transplantation of 2–3 metatarsophalangeal joints into the area of the elbow joint that had been absent since birth. Patient B. underwent total arthroplasty of the elbow joint with an individual implant. The unsatisfactory result of the treatment of patient A. is associated with the impossibility of early development of movements in the elbow joint due to the presence of axial pins. The stable position of the endoprosthesis in patient B. made it possible to conduct a course of early development of movements and get a good long-term result. Due to small number of patients, it is impossible to reliably assess the advantage of one of the presented methods. Improvement of the results of treatment in children with humeroradial synostosis requires further research.

Treatment of long bone defects in children: Microsurgical transplantation of a fibular fragment for replacement of long bone defects: A systematic review

BACKGROUND: The use of a vascularized fibular graft during reconstructive interventions on the limbs in children is a promising direction in the replacement of extensive bone defects in children.
 AIM: This study aimed to conduct a systematic review of the literature on microsurgical transplantation of a fragment of the fibula in the replacement of long bone defects in children.
 MATERIALS AND METHODS: Articles were searched in systems such as eLibrary, PubMed, and Google Scholar, with a search time range of 10 years (from 20122022, last query 11/08/2022). The following keywords were used for searching in Russian-language search engines: replacement of bone defects in children and fibula transplantation in children, and in the English-language search engines, microsurgical and fibula, microvascular and fibula, and bone and defect were used. After sorting the published studies, 17 publications were analyzed.
 RESULTS: The study analyzed a total of 690 patients (mean age 12 2.6 years). The predominant cause of the defects was malignant tumors in 647 patients (93.7% of all patients). Benign processes were also noted, which accounted for 0.87% of all patients: osteomyelitis, 2.0%; congenital pathology, 2.17%, and trauma, 1.45%. The mean follow-up period was 4.8 2.4 years. The survival rate of patients with cancer was 78.4%. Donor-side complications accounted for 14.7% of all complications. Recipient-zone complications were frequent and accounted for 85.3% of all complications (n = 457 cases). The main type of complications reported in the studies was graft fracture or fracture at the graft-bone level (35.7% of all complications).
 CONCLUSIONS: The use of a fragment of the vascularized fibula in the replacement of extensive bone defects enables a one-stage reconstruction of the limb with good long-term results in large segmental defects of various features. Despite the complications, this technique is one of the few that enables simultaneous limb reconstruction. The decision to use microsurgical fibula autotransplantation is based on the preference and surgical experience of the surgeon.

Preclinical Studies in Vascularized Composite Allotransplantation

Introduction: Since 1998, when the first hand transplant was performed, Vascularized Composite Allotransplantation (VCA) field represents a new dimension in reconstructive surgery, offering a viable treatment option for injuries and defects that involve multiple layers of functional tissue, impossible to repair using conventional surgical techniques. Worldwide experience includes allotransplantation of upper and lower extremities, face, trachea, larynx, abdominal wall, uterus and penis, with promising clinical results. The major challenge remains at the immunologic level, translational ongoing studies being focused to develop less toxic immunosuppressant drugs and possibly achieve donor-specific tolerance. Materials and Methods: We conducted a series of preclinical studies of vascularized composite allotransplantation in preparation for further translation to clinical applications of this field. Our experience includes experimental vascularized allotransplantation models in rats exploring technical particularities and also analyzing the role of microchimerism in immunomodulation and promoting of the immune tolerance. Also, we performed a cadaveric study in order to explore the surgical techniques required in abdominal wall allotransplantation and the use of iliac crest as a potential microsurgical model of vascularized bone marrow transplantation(VBMT). Results: Working on small animal models allows the familiarization with microsurgical techniques in experimental composite tissue allotransplantation and evaluation of important immunological aspects: rejection dynamics, immunosuppression protocol testing and induction of immunologic tolerance. The surgical procedures performed in cadaveric models shown the feasibility of the abdominal wall allotransplantation procedure which may be translated to future clinical practice in association with organ transplantation. It may be possible to develop an alternative approach for iliac crest microsurgical transplant as tolerogenic strategy in solid organs or vascularized composite allotransplantation. Conclusion: Preclinical experience represents a mandatory step in developing a vascularized composite allotransplantation program, translating the knowledge obtained from experimental animal research and cadaveric studies to further clinical practice, ensuring optimal results for patients with complex tissue defects.

The Anterolateral Thigh Perforator Flap is a Versatile Resource for Reconstructive Surgery

The Aim of Work: The aim of this study was to increase the efficiency of reconstruction of extensive soft-tissue defects of various localizations by differentiated use of the anterolateral thigh (ALT) perforator flap. Methods: We have retrospectively reviewed 39 patients, who had undergone soft-tissue reconstruction using pedicled and free transposition of ALT flaps. Results: In this series, all cases ended with a complete recovery of patients with adequate restoration of integumentary tissues. In the postoperative course, we encountered complications during free flap transplantation in nine cases (23%), two of which were associated with arterial insufficiency (5.1%) and seven – with venous thrombosis (17.9%). Most of these complications were not critical, and the problem was resolved by conservative treatment; in two cases, partial tissue death required a secondary suture. In three cases (7.7%), the complications were critical and led to the loss of the flap. Conclusions: The unprecedented versatility and the minimal trauma of the donor area make the ALT perforator flap one of the most demanded skin flaps. Despite the variable vascular anatomy, the ALT flap is the most adaptable plastic resource for extensive soft-tissue coverage of abdominal, perineal, and hip joints as a transposition flap on the vascular leg and for closing distant defects in any area of the body using it as a free microsurgical transplant. Other advantages include its variability in size and the ability to harvest multiple tissue components in different combinations depending on the desired outcome.

Two clinical cases of the reconstruction of distal phalanges of hand in children by combination of the regional flap and scrap bone and nailbed graft

BACKGROUND: The hand and its distal phalanges, especially in children, are among areas mostly exposed to trauma while contacting the environment. Injuries causing loss of soft tissue and bone component are both challenging and interesting. This report presents the treatment results of children with soft tissue and bone defects of distal phalanges, in which reconstructions including combination of regional flaps, bone, and nailbed grafts were performed.
 CLINICAL CASE: This report presents clinical cases of the surgical treatment of 4- and 6-year-old children with fingertip injuries who underwent reconstructions including the combination of regional flaps, bone, and nailbed grafts. A combination of the scrap graft was performed in the first case with antegrade homodigital island flap and in the second case with thenar flap. The results were assessed 6 and 7 months after surgery.
 DISCUSSION: The primary aim of the surgical treatment of children with distal phalangeal defects is coverage of those defects. The restoration of the bone component of the defect is recommended to prevent postoperative deformations of the distal phalanges. Fingertip replantation or microsurgical transplantation of vascularized tissue complexes are technically difficult and require thorough care and monitoring of the childs condition in the postoperative period as all these measures may fail.
 CONCLUSIONS: The possibility to combine the scrap bone and nailbed graft with existing reliable surgical methods open new prospects for the successful treatment of fingertip injuries.

Microsurgical Transplantation of Pedicled Muscles in an Isolation Chamber—A Novel Approach to Engineering Muscle Constructs via Perfusion-Decellularization

Decellularized whole muscle constructs represent an ideal scaffold for muscle tissue engineering means as they retain the network and proteins of the extracellular matrix of skeletal muscle tissue. The presence of a vascular pedicle enables a more efficient perfusion-based decellularization protocol and allows for subsequent recellularization and transplantation of the muscle construct in vivo. The goal of this study was to create a baseline for transplantation of decellularized whole muscle constructs by establishing an animal model for investigating a complete native muscle isolated on its pedicle in terms of vascularization and functionality. The left medial gastrocnemius muscles of 5 male Lewis rats were prepared and raised from their beds for in situ muscle stimulation. The stimulation protocol included twitches, tetanic stimulation, fatigue testing, and stretching of the muscles. Peak force, maximum rate of contraction and relaxation, time to maximum contraction and relaxation, and maximum contraction and relaxation rate were determined. Afterwards, muscles were explanted and transplanted heterotopically in syngeneic rats in an isolation chamber by microvascular anastomosis. After 2 weeks, transplanted gastrocnemius muscles were exposed and stimulated again followed by intravascular perfusion with a contrast agent for µCT analysis. Muscle constructs were then paraffin embedded for immunohistological staining. Peak twitch and tetanic force values all decreased significantly after muscle transplantation while fatigue index and passive stretch properties did not differ between the two groups. Vascular analysis revealed retained perfused vessels most of which were in a smaller radius range of up to 20 µm and 45 µm. In this study, a novel rat model of heterotopic microvascular muscle transplantation in an isolation chamber was established. With the assessment of in situ muscle contraction properties as well as vessel distribution after 2 weeks of transplantation, this model serves as a base for future studies including the transplantation of perfusion-decellularized muscle constructs.

Surgical treatment of proximal forms of congenital ectromelia of the upper limbs in children

Three cases of the proximal form of congenital upper extremities ectromelia (two cases in 4 years and 1 case in 9 years old patient) are presented. The combination of symptoms of this rare malformation including the defects of the arm and forearm bones as well as aplasia of the radial rays of the wrist is described. Complex program for surgical treatment of ectromelia is suggested. The program includes the reconstruction of the arm length and formation of the shoulder using microsurgical transplantation of the fragment of the external border of the scapula, elimination of the forearm deformity by double-sided centering of the wrist, restoration of holding function using either the separation of one of triphalangeal fingers or transplantation of toes to the position of I radial ray. The results achieved in those three patients allowed to represent the new program as an alternative to the prosthetics.

Role of the Cadaver Lab in Lymphatic Microsurgery Education: Validation of a New Training Model

Background Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction. Methods 10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM). Results The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37). Conclusions This human cadaver model represents a new, reproducible “all-in-one” tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction.

Axenfeld-Rieger syndrome with congenital ankylosis of the temporomandibular joint, treatment challenges. Individual planning and reconstruction of the individual joint with implant in combination with the microsurgical transplantation of the fibula. Case report

Axenfeld-Rieger syndrome with congenital ankylosis of the temporomandibular joint, treatment challenges. Individual planning and reconstruction of the individual joint with implant in combination with the microsurgical transplantation of the fibula. Case report

Gender reassignment from female to male : Phalloplasty

The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals. The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty. Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25years. Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%. Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows ahigh heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

The impact of COVID-19 on the plastic surgery activity ina high-complexity university hospital in Brazil: the importance of reconstructive plastic surgery during the pandemic.

BackgroundThe Hospital das Clínicas - University of Sao Paulo Medical School (HCFMUSP) is the largest university hospital complex in Brazil. HCFMUSP has been converted into a reference center for coronavirus disease 2019. The Division of Plastic Surgery postponed non-essential surgeries and outpatient consultations, accomplishing new guidelines (ANG) of national and international organizations. Even with these challenges arising from the pandemic, alternatives were considered to maintain institutional characteristics. This study aims to analyze this new scenario and the impact on patients’ assistance and Plastic Surgery residents training.MethodsTotal number of surgeries, type of procedures, and outpatient consultations in 2020, before (pre-ANG) and after (post-ANG) ANG, were compared with the same period in 2019 (2019-pre and 2020-post).ResultsA marked reduction in the total number of surgeries and outpatient consultations was observed in the post-ANG period. In the post-ANG period, 267 operations were performed (26.7 ± 20.3/week), while in the 2019-post period, 1036 surgeries were performed (103.6 ± 9.7/week) (p = 0.0002). Similarly, 1571 consultations were conducted in the post-ANG period (157.1 ± 93.6/week), while in the 2019-post period, 3907 were performed (390.7 ± 43.1/week) (p = 0.0003). However, in the post-ANG period, an increase in the proportion of reconstructive compared with aesthetic surgery was observed. The maintenance of highly complex procedures such as microsurgical transplants was also identified.ConclusionsThe predominant profile of reconstructive surgeries at the Division of Plastic Surgery allowed the continuity of procedures at all technical complexity levels, patient care maintenance, and Plastic Surgery residents training.Level of evidence: not ratable

Abstract 3480: Potential impact of voluntary exercise on patterns of metastasis in a colorectal cancer model

Abstract Background: Physical activity (PA) is associated with a lower risk of colorectal cancer (CRC) initiation and death from CRC. However, evidence for a causal link between PA and disease progression is lacking. This study assesses the effect of voluntary exercise on metastases formation in a novel pre-clinical mouse model for late-stage metastatic CRC. Methods: Murine colorectal tumor organoids were transplanted into the livers of immunocompetent C57Bl/6 mice using microsurgery. Animals were fed ad libitum. Voluntary exercise in tumor-bearing (TB) mice was modeled by offering running wheels for 0h/day (n=12), 3h/day (n=12) or 24h/day (n=12). Running wheel revolutions were cumulatively measured every 30min. PA was monitored by infrared cameras. Tumor progression was monitored using in vivo Bioluminescent Imaging. Food intake was measured by weighing. Body composition was monitored by echoMRI. All animals were sacrificed 12 weeks after tumor initiation. Results: We have developed a novel model for exploring the effects of exercise on metastatic tumor progression in CRC. The model combines micro-surgical transplantation of tumor organoids, yielding spontaneously metastasizing CRC, with voluntary exercise. Voluntary exercise in both exercise groups led to an on average running distances of 2,3±0,3 km/night (total 221±29 km) in TB-3h animals and 6,6±3,0km/night (total 600±290km) in TB-24h animals. TB-3h and TB-24h animals developed more lean mass and lower fat mass compared to sedentary animals. Intermittent exercise had no effect on primary tumor growth and reduced metastasis. Vigorous exercise increased primary tumor growth (229606±186012) compared to TB-3h (152821±125902) and sedentary animals (165171±250993). Moreover, vigorous exercise non-significantly increased lung metastasis formation (2382±3539) compared to intermittent exercise (753±852) and to sedentary (1333±2902), while reducing metastatic spread to the liver and the peritoneal cavity was found. Conclusions: These results suggest that exercise has the potential to influence the patterns and extent of metastasis in CRC, and that the degree of exercise is likely to be an important variable. Confirmation of these results in additional models, for instance using patient-derived organoids, is now warranted. Citation Format: Liza A. Wijler, Daniëlle A. Raats, Miriam van Dijk, Anne M. May, Onno Kranenburg. Potential impact of voluntary exercise on patterns of metastasis in a colorectal cancer model [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3480.

Plastic surgery of extensive soft tissue defects of the lower leg in children with the use of a parotid flap after its prefabrication with tissue expanders (preliminary report)

Background. Extensive deep soft tissue defects in children are an indication for the microsurgical reconstruction using autotransplantation of a tissue complex. The use of a flap prefabrication before their microsurgical transplantation to various segments and areas is a promising approach in reconstructive surgery.
 Aim. The aim of this study was to evaluate the possibilities and immediate results of plastic surgery of extensive soft tissue defects of the lower leg with a tissue complex, after its prefabrication with a tissue expander, and the state of the donor area in different surgical treatment options.
 Materials and methods. Six patients aged 13 2.3 years were operated on for deep scar deformities of the lower leg and foot. For plastic surgery, a pericarpial flap was used. In two patients, the flap was prefabricated with tissue expanders at a volume of 720 ml. After filling the expander, the second stage of surgical treatment was performed. First, the expander was removed. Next, the flap on the artery surrounding the scapula was isolated. Last, it was transplanted into a soft tissue defect of the lower leg with the imposition of microvascular anastomoses. A layer-by-layer suture was applied to the donor wound. The Vancouver scale was used to assess the quality of the scar tissue in the donor area.
 Results. The removal of the tissue complex after the prefabrication with expanders made it possible to perform plastic surgery of extensive soft tissue defects of the lower leg in one stage of surgical treatment with the application of a cosmetic suture in the donor area. There were no complications in the postoperative period.
 At the examination after six months, patients who did not undergo flap prefabrication complained of cosmetic defects and discomfort when moving in the donor area.
 The evaluation of the quality of scar tissue by the Vancouver scale showed that the scars in patients after flap prefabrication were similar to optimal (total score in two patients is 2). In two patients without flap prefabrication, the total score was 7, and in two patients, it was 9, which indicated unsatisfactory cosmetic parameters of the postoperative scar.
 Conclusion. The prefabrication of a tissue complex using tissue expanders before microsurgical transplantation enables the collection of a large volume of tissue for plastic surgery of extensive defects. It also reduces the risk of trophic complications in the postoperative period and creates optimal conditions for closing the donor site.

Lengthening of radius in patients with congenital radial club hand, type II

Background. Congenital radial club hand (CRCH) is characterized by longitudinal underdevelopment of the forearm and hand on the radial surface. Underdevelopment can range from hypoplasia to aplasia of the radius. More than 50 methods to correct the forearm deformities, depending on the degree of radius underdevelopment, have been proposed.
 Aim. We evaluated the results of CRCH treatment using microsurgical technique and external fixation.
 Methods. We analyzed 16 patients (age, 4.6 0.9 years) with CRCH type II, according to the classification of Bayne and Klug, treated between 1994 and 2017. The patients were divided into two groups: Group 1 were patients undergoing microsurgical autotransplants of the epimetaphyseal second metatarsal bone with growth plate to the position of the radius defect and group 2 were patients treated by lengthening of the radius with external fixation. We analyzed the types of deformities, size of the radius defects, and range of motion in upper limb joints before the stage of the lengthening. External fixation index and number of complications also were determined. The type and number of recurrent deformities and timing of their detection were analyzed.
 Results. The observation period ranged from 12 months to 10 years (average, 3.8 years). In group 1, good results were obtained in 62.5% of cases. After transplantation of the metatarsal bone growth plate, the work of the growth plate continued, characterized by increasing radius length in the later observation period. In group 2, good results were obtained in 50% of cases. Clinical and X-ray examinations showed recurrent hand deviation and radius shortening, which required repeated radius lengthening.
 Conclusion. Microsurgical transplantation of the second metatarsal bone with growth plate is accepted more in reconstruction of the radial bone in patients with CRCH type II due to creation of a growth zone in the distal part of the radius. Radius lengthening via external fixation is applicable while maintaining the distal epimetaphysis and normal transverse dimensions of the radial bone.

Microsurgical toe-to-hand transfer in children with macrodactyly of the hand

Background. At present, there are multiple approaches to the treatment of macrodactylia in children. Additionally, there are no comparative data on the cosmetic and functional aspects of corrective surgery versus microsurgical transplantations performed in children with a marked disproportion of the segment, making this study particularly relevant.
 Aim. The aim of this study was to determine the role of microsurgical transplantation of the toes in the treatment of children with isolated macrodactylia, based on a comparative analysis of various surgical interventions.
 Materials and methods. Twenty-five children with congenital macrodactylia of the hand were examined and surgically treated in the department of reconstructive microsurgery from 2013 to 2017. Of these, 13 (52%) had macrodactyly of the 2nd and/or 3rd fingers, and of the total number of hyperplastic hand segments (n = 45), 17 rays had hyperplasia greater than 25%.
 Results and discussion. Stage-by-stage modeling resections of enlarged segments were performed in all children with ray hyperplasia that was about 25% of the size of intact fingers. In 4 cases, excision of soft tissues was combined with marginal resection of phalanges. When hyperplasia of the segment reached up to 10% of macrodactylia, single isolated modeling resection of soft tissues and bones was performed. Repeated modeling plasties in 16% (n = 4) of the children were accompanied by gross postoperative scars with the development of secondary angular deformities and loss of function of interphalangeal joints.
 Nine children (n = 14) underwent amputation of hyperplastic fingers followed by microsurgical reconstruction of rays by autografting of toes. In 4 cases, the first finger was reconstructed, and in the other 5 cases, toes of both feet were transplanted to the positions 2 and 3 (n = 4) or 3 and 4 of fingers (n = 1). It was found that in cases of significant hyperplasia of the affected segments of the hand (hyperplastic segment is 1.5–2 times greater compared to normal ones), microsurgical autografting of toes is more effective and acceptable compared to bone and soft tissue resections.
 Conclusions. In cases of segment hyperplasia less than 1.25-times the normal size, the optimal surgical interventions are stage-by-stage modeling resections. An alternative surgical treatment for children with hyperplasia of more than 1.25-times the normal size is microsurgical transplantation of the toes in the position of the involved rays of the hand, which results in good cosmetic and functional outcomes in these patients.

Functional pectoralis minor myocutaneous flap transplantation for reconstruction of thumb opposition: An anatomic study with clinical applications

To develop a myocutaneous flap for reconstruction of thumb opposition function in patients with loss of the thenar muscles and skin. An anatomic experiment on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers was conducted to evaluate the feasibility of microsurgical transplantation using part of the muscle for thumb opposition reconstruction. Based on these results, we performed surgical thenar reconstruction with a pectoralis minor myocutaneous flap in seven patients (34.7±9.8 years of age) from December 2007 to October 2010. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Six to twelve months after the surgery, follow-up assessment showed that all patients had recovered functional opposition of the carpometacarpal joint with survival of the skin and a muscle power of M4 to M5. Our results support the use of this new technique for thenar and opposition reconstruction in patients with severe loss of the thenar muscles and skin and damage to the median nerve and who wish to improve the appearance of the thenar eminence.

Fu-Chan Wei-Surgeon, Innovator, and Leader of the Legendary Chang Gung Microsurgery Center.

Fu-Chan Wei is a world-renowned plastic and reconstructive surgeon. He is clearly one of the most influential and innovative surgeons in the history of plastic surgery. The Taiwanese legend is the innovator of the osteoseptocutaneous fibula flap, which revolutionized the reconstruction of composite bone and soft tissue defects in the jaw and extremities. He has pioneered several perforator flaps, including the free style variety. He has taken toe-to-hand microsurgical transplantation to a whole new level. He is not only recognized for his surgical skills and clinical innovations, but also for his vision, leadership, and teaching. The establishment and development of the famous Microsurgery Center at Chang Gung Memorial Hospital is unparalleled anywhere. The international fellowship program in microsurgery there remains the envy of all microsurgical trainees. Dr. Wei and his colleagues have trained and influenced more than 1,500 surgeons from all over the world. The aim of this video article is to share what we learned by interviewing Fu-Chan Wei at Chang Gung. The story of Fu Chan Wei, his colleagues, and the development of the Microsurgery Center in Taiwan is worth knowing.

Ex Vivo Prefabricated Rat Skin Flap Using Cell Sheets and an Arteriovenous Vascular Bundle

Recently, research on tissue-engineered skin substitutes have been active in plastic surgery, and significant development has been made in this area over the past several decades. However, a regenerative skin flap has not been developed that could provide immediate blood flow after transplantation. Here, we make a regenerative skin flap ex vivo that is potentially suitable for microsurgical transplantation in future clinical applications. In rats, for preparing a stable vascular carrier, a femoral vascular pedicle was sandwiched between collagen sponges and inserted into a porous chamber in the abdomen. The vascular bed was harvested 3 weeks later, and extracorporeal perfusion was performed. A green fluorescent protein positive epidermal cell sheet was placed on the vascular bed. After perfusion culture, the whole construct was harvested and fixed for morphological analyses. After approximately 10 days perfusion, the epidermal cell sheet cornified sufficiently. The desquamated corneum was positive for filaggrin. The basement membrane protein laminin 332 and type 4 collagen were deposited on the interface area between the vascular bed and the epidermal cell sheet. Moreover, an electron microscopic image showed anchoring junctions and keratohyalin granules. These results show that we were able to produce native-like skin. We have succeeded in creating regenerative skin flap ex vivo that is similar to native skin, and this technique could be applied to create various tissues in the future.