Neurovascular Anastomosis Research Articles

The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender surgery.

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc.

Different Aspects of Penile Amputation; Surgery, Forensics, and Psychiatry (Case Report and Short Review)

Penile amputation (PA) is a rare genitourinary injury. Three main etiologies of PA consist of iatrogenic, accidental, and self-mutilation. Eighty-seven percent of the self-mutilated patients suffer from psychiatric disorders. Nowadays, microsurgical techniques with neurovascular anastomosis are the best approach for PA. This paper insists on psychiatric and legal consequences, which may involve health-care team. A 25-year-old male patient presented to our emergency department with self-inflicted PA. As he had a history of some psychiatric problems, psychiatric consultation was requested. The patient did not accept any surgical interventions. We informed his relatives completely; however, they did not agree with surgical intervention because they predicted that he might repeat amputation again. According to the forensic medicine specialist consultation, we took the coroner's warrant for emergency surgical intervention and transferred the patient to the operating room without any consent. Microsurgical penile replantation was performed. There was no leakage in retrograde pericatheter urethrography on the 3rd postoperative week, and the urethral catheter was removed. The patient was able to void normally, and cystostomy tube was removed at the same time. Consent for all medical procedures is an important part of national and international human right law and medical ethics. Physicians should inform patients about their problem and take a reliable consent. If the patient was unreliable for informed consent, relatives could do it. However, in an emergency, there is an exception in the law that let surgeons do the operation without consent for these cases.

Whole-eye transplantation: a look into the past and vision for the future

Blindness afflicts ~39 million people worldwide. Retinal ganglion cells are unable to regenerate, making this condition irreversible in many cases. Whole-eye transplantation (WET) provides the opportunity to replace diseased retinal ganglion cells, as well as the entire optical system and surrounding facial tissue, if necessary. Recent success in face transplantation demonstrates that this may be a promising treatment for what has been to this time an incurable condition. An animal model for WET must be established to further enhance our knowledge of nerve regeneration, immunosuppression, and technical aspects of surgery. A systematic review of the literature was performed to evaluate studies describing animal models for WET. Only articles in which the eye was completely enucleated and reimplanted were included. Study methods and results were compared. In the majority of published literature, WET can result in recovery of vision in cold-blooded vertebrates. There are a few instances in which mammalian WET models demonstrate survival of the transplanted tissue following neurovascular anastomosis and the ability to maintain brief electroretinogram activity in the new host. In this study we review in cold-blooded vertebrates and mammalian animal models for WET and discuss prospects for future research for translation to human eye transplantation.

Endoscopic telemicrosurgery or minimally invasive robotically-assisted microsurgery for peripheral nerve repair

Microsurgery comprises a variety of surgical procedures such as neurovascular anastomoses, performed under optical magnification and with fine instrumentation. While refinements have been made since its advent in the 1960s, robotics offers the potential for major technological advancement. Endoscopic telemicrosurgery is minimally invasive, robotically-assisted microsurgery. This technique removes some limitations of conventional microsurgery and enhances visual and manual dexterity. Vision is enhanced through greater magnification, three-dimensionality, and functionalization, all through an endoscopic view. Manual dexterity is improved by suppression of physiological tremor and tremor filtration, while permitting useful enhancement of movement amplitudes and tactile feedback forces. Furthermore, better endoscopic ergonomics, new hand tools and the ability for multi-manual and remote work, confer a distinct advantage. Endoscopic telemicrosurgery is already in clinical use. Some of the advantages above are incorporated into the DaVinci ® robot, that is, used in brachial plexus surgery. Conventional brachial plexus surgery requires large incisions for exploration and neurotization, with its attending risks of unsightly scars, prolonged hospital stay, sepsis, and perineural adhesions that interfere with nerve regrowth. Endoscopic telemicrosurgery limits the incisions and these risks, with minimal compromise. Endoscopic telemicrosurgery, through the amplification of human capabilities may pave the way for a major advancement in the microsurgical field.

The free revascularized lateral upper arm flap in maxillofacial reconstruction following ablative tumour surgery

The lateral arm flap is well established in microvascular reconstructive surgery for covering small and moderate-sized defects both of the extremities and in the head and neck region. In the last 3 years 25 patients underwent a lateral upper arm flap for primary repair of tumour related defects of the tongue (n=10), floor of the mouth (n=7), mandible (n=4), inner cheek (n=2), oropharynx (n=1) and lower lip (n=1). Defects extended from the anterior floor of the mouth to the oral tongue in three cases and in four cases the defect reached the pharyngeal tongue. Two flaps had neurovascular anastomoses between the posterior cutaneous nerve of the arm and the lingual nerve. In all patients the donor defect was closed primarily. Twenty four lateral upper arm flaps healed uneventfully although six patients developed severe alcoholic delirium. One flap was lost on the fourth postoperative day due to venous insufficiency. There were no significant complications at the donor site. At the time of this report 16 patients were taking a normal diet while nine patients were taking pureed food. Among the advantages of this flap are anatomically reliable vascular supply, its good aesthetic quality, and position of the donor site. Furthermore the posterior radial collateral artery is a nonessential vessel of the arm. The flap is also potentially sensate. Among the disadvantages are smaller vessels for microvascular anastomoses. In conclusion, we believe that for repair of moderate-sized defects of the maxillofacial area the lateral upper arm flap can be recommended as the first choice.

Smile reconstruction using the gracilis muscle

Because of its convincing advantages, gracilis muscle transplantation became the most frequently used technique for reconstruction of a smile in the long-standing, irreversible facial palsy. In the unilateral palsy, it is most often combined with cross-facial nerve grafting. In the majority of cases, reconstruction by free-gracilis-muscle transplantation is concentrated on the smile function, whereas closure of the eye is achieved by transposing a part of the temporalis muscle to the upper and lower eye lid. If the latter possibility is no longer available, the gracilis muscle is transplanted by its two functional territories to the eye and the mouth. We are using this technique as a principle in children. If a proximal stump of the ipsilateral facial nerve is available, the gracilis muscle graft is reinnervated by the ipsilateral facial nerve. In Moebius syndrome, a part of the ipsilateral hypoglossal nerve is used for reinnervation. During harvesting of the gracilis muscle, drugs for relaxation should not be used. The design of the muscle transplant is transferred to the gracilis muscle after preparing the vessels and nerves in the recipient area. By preferring the superficial temporal vessels to the facial vessels, the skin incisions can be limited. Usually two thirds of the muscle width is taken for transplantation. Three fingers are prepared in different lengths with the gracilis muscle still in situ. Before cutting the muscle, the resting tension has to be documented. Insertion of the muscle graft is performed to the remnants of the paralytic orbicularis oris muscle. The origin is fixed to the deep fascia around the zygomatic arch. After the neurovascular anastomoses, tissue O 2 is monitored. Exercises of the facial movements in front of a mirror start 3 weeks postoperatively and electric stimulation 6 weeks postoperatively. After a functional plateau has been reached, the effectiveness and natural appearance can be improved significantly by a revision of the muscle graft and by additional static measures in the majority of patients.

遊離筋肉移植術後の血行モニタリング

This experiment establishes the principles of using the compound muscle action potential (CMAP) as a possible post-operative monitor for fee muscle grafts. 20 rabbits were divided into 2 equal groups to investigate the effect of arterial and venous ischemia respectively on the CMAP of muscles. The rectus femoris muscle model was used, isolated only on its single vascular pedicle. The contralateral muscle was used as the control. In all muscles, total normothemic ischemia was induced for 90 minutes, by occluding both the artery and vein. This is to simulate the time needed for transference and insetting of the flap and the completion of the neurovascular anastomosis. Blood flow was then re-extablished for 3 hours. In the arterial ischemia group, (n=10) the artery was then occluded for 1 hour 10 simulate a thrombosis occurring in the artery. The clamp was then removed for 3 hours. Similarly in the venous ischemia group, (n=10) the vein was clamped and unclamped for the same duration, to simulate a venous thrombosis. CMAPs were recorded regularly from all muscles at each stage of the experiment, using theshold (T), twice threshold (2T), and three times threshold (3T) intensity. During each ischemic period, the amplitudes of all CMAPs decreased and latencies became prolonged. During the revascularization period, both the amplitude and latency improved, although not to the original valus at the start of the experiment. The results show that CMAP monitoring can provide easily detectable, objective indication of vascular compromise to a muscle graft within as early as 10 minutes of total, arterial and venous ischemia. Changes in latency are more constant and predictable compared to amplitude changes.

Surgical removal of lower third molars after computed tomography

The lateral arm flap is well established in microvascular reconstructive surgery for covering small and moderate-sized defects both of the extremities and in the head and neck region. In the last 3 years 25 patients underwent a lateral upper arm flap for primary repair of tumour related defects of the tongue (n=10), floor of the mouth (n=7), mandible (n=4), inner cheek (n=2), oropharynx (n=1) and lower lip (n=1). Defects extended from the anterior floor of the mouth to the oral tongue in three cases and in four cases the defect reached the pharyngeal tongue. Two flaps had neurovascular anastomoses between the posterior cutaneous nerve of the arm and the lingual nerve. In all patients the donor defect was closed primarily. Twenty four lateral upper arm flaps healed uneventfully although six patients developed severe alcoholic delirium. One flap was lost on the fourth postoperative day due to venous insufficiency. There were no significant complications at the donor site. At the time of this report 16 patients were taking a normal diet while nine patients were taking pureed food. Among the advantages of this flap are anatomically reliable vascular supply, its good aesthetic quality, and position of the donor site. Furthermore the posterior radial collateral artery is a nonessential vessel of the arm. The flap is also potentially sensate. Among the disadvantages are smaller vessels for microvascular anastomoses. In conclusion, we believe that for repair of moderate-sized defects of the maxillofacial area the lateral upper arm flap can be recommended as the first choice.

最掌筋けんによる顔面神経麻ひの再建

For reconstruction of facial paralysis, dynamic operative methods such as cross-face nerve transplantation and free muscle transplantation with neurovascular anastomosis are often performed. However, optimal reconstruction of the muscles of facial expression is very difficult. An appropriate operative method should be selected in each patient based on age, the underlying disease, the degree of paralysis, and the patient's desire to be treated.We performed palliative operations in 2 patients with complete facial paralysis. Patient 1 (81 years old) with Bell's palsy was treated by suspension of the lower eyelid, tarsectomy of the central area, and skin resection of the lateral area. Patient 2 (79 years old) after operation for parotid tumor (mucoepidermoid carcinoma) was treated by suspension of the lower eyelid and mouth angle, and skin resection of the upper area of the eyebrow and nasolabial groove and around the lips. The tendon of the long palmar muscle was used for suspension in both patients, and adequate results were obtained.The improvement achieved by palliative suspension is expected to be maintained for 5-10 years. If quality of life is a goal, this operation is appropriate for reconstruction of paralysis in aged patients. In our patients, adequate results could be obtained by using the tendon of the long palmar muscle.

Transcoccygeal radical prostatectomy for localized prostate cancer: early clinical results.

Twelve patients with adenocarcinoma of the prostate underwent radical transcoccygeal prostatectomy. The methodology and outcome are described. Preoperative laparoscopic lymphadenectomy was performed on all patients. The average operative time for the prostatectomy using the transcoccygeal route was 3 h and 7 min, and no major postoperative complications occurred. Compared to the classic retropubic approach, preservation of the neurovascular bundles and urethral anastomosis seemed to be facilitated. It was concluded that radical prostatectomy can be performed safely using the transcoccygeal approach.

Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmannʼs contracture of the forearm

Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmannʼs contracture of the forearm

Functional aspects of free muscle transplantation: atrophy, reinnervation, and metabolism.

The atrophy, reinnervation, and metabolism of free muscle flaps were studied in a rat model, by syngeneic and orthotopic transplantation of abdominal wall muscle flaps with neurovascular anastomoses. The three parameters were examined at different time periods, using electrophysiologic and 31-P-spectroscopic measurements. Results show that a certain degree of atrophy (one-fifth of the original volume) must be expected, even when new axons grow throughout the nerve. This is explained by the early reduction of flap metabolism, leading to a loss of parenchyma until neuromuscular conduction is restored. As the maximum duration of ischemia is 2 hr, muscular damage due to reduced metabolism was not produced.

Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmann's contracture of the forearm

Some articles have reported the use of medical gastrocnemius transfer to repair soft-tissue defects caused by trauma and inflammation ( Morris, 1978; Feldman et al., 1978 ; Arnold and Mixter, 1983). However, we have not found any report describing the use of free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmann's contracture of the forearm. Since 1982, 20 cases of Volkmann's contracture of the forearm have been treated by transfer of medial gastrocnemius flap with neurovascular anastomosis. These 20 patients ranged in age from 6–18 years, with a mean of 10 years. There were 18 males and 2 females. All cases resulted from ischaemia of the extrinsic and intrinsic muscles of the forearm and hand. The most common causes were severe supracondylar fractures or, less frequently, fracture-dislocations of the elbow. Six to twenty months after operation, the transplanted muscles exhibited normal electromyographic potentials, good volume and contractile power with satisfactory functional recovery of the forearms. The deformities of the hand and wrist were also corrected. In this paper we describe the anatomy of the donor site and the operative procedure.

Palmar‐digital arterial networks in fifty pairs of human fetal hands: Arteriographic models for clinical consideration

Arterial networks in 50 pairs of human fetal hands, made visible by perfusion with radiopaque media, were compared between right and left hands. The imaged primary arterial networks in the fetal hands were also compared with those in adult human and rhesus monkey hands. It was found that superficial arch configurations and their primary ramifications are bilaterally similar in human fetal hands. The configurations of the primary arterial networks are established very early in prenatal growth and may be maintained into adulthood. The similarities in the arterial network arrangements between fetal human and rhesus monkey hands suggest that the rhesus monkey hand could provide an appropriate model for studies of surgical neurovascular anastomosis.

Pharmacologic Enhancement of Functional Recovery in Free Muscle Transfers

To date, most free muscle transfers have been marginally successful as functioning units, producing no more than 50 percent of the tension generated by an identical non-transferred muscle. Functional recovery depends both on revascularization and re-innervation, even after careful microvascular anastomosis, remains limited. Forskolin is a robust stimulator of adenylate cyclase and has been used to stimulate peripheral nerve regeneration in vivo; Forskolin may also directly increase capillary growth. Chronic infusion of Forskolin for the first 21 days following orthotopic transplantation of rabbit rectus femoris, with neurovascular anastomosis, stimulated a two-fold increase in the force-generating capacity of the transplant nine to 10 months after surgery. These results, in a model similar to clinical free muscle transfer, offer promise that Forskolin treatment can improve functional recovery by improving muscle re-innervation.

The microscopic morphology of orthotopic free muscle grafts in rabbits.

The flexor digitorum superficialis muscle was free grafted (without neurovascular anastomoses) in 122 rabbit forelimbs. Histologic nd histochemical examinations through 6 months after grafting were performed. An early ischemic necrosis of the entire graft, except for a few percent of fibers at the very surface, was consistently seen. Subsequently, there occurred a regeneration of muscle with reconstitution of up to 100 percent of normal numbers of fibers. There was a wide variation in the numbers of fibers regenerated; however, the fiber-free areas were then being replaced by connective tissue. Muscle grafts in 1-month-old rabbits regenerated faster and yielded muscle with evidence of more extensive reinnervation and less connective tissue than 3-month-old animals. In the early postgraft period, minced grafts appeared to be as good as whole ones, but after 1 month, they developed far more connective tissue. Differentiation into fast-twitch and slow-twitch muscle fibers and into high- and low-oxidative fibers began at 2 to 3 weeks after grafting but was not extensive until 3 months. At 6 months, grafts showed areas of normal-appearing muscle interspersed with areas that lacked signs of reinnervation. The earliest sign of regeneration is the appearance of several very elongated nuclei encircling each previously anucleate necrotic muscle fiber. A small amount of basophilic cytoplasm then appears around each new nucleus. As blood vessels grow into the graft, a centripetal wave of phagocytosis is seen, taking 2 to 3 weeks and leaving a bed of immature muscle fibers. We believe this to be the first documentation of regeneration's commencing prior to and thus independently of phagocytosis.

Microvascular segmental thumb reconstruction: A case report

The great toe provides an ideal source of tissue for both functional and aesthetic reconstruction of segmental defects in the thumb and can be used without mutilation of the foot. A successful case is presented of a 1-stage primary reconstruction of a segmental defect of the thumb using a composite free flap transfer from the great toe containing pulp, tissue, nail and bone, with neurovascular anastomosis. The donor defect on the great toe was repaired at the same time.

Surgical management of vagal chemodectomas

Vagal chemodectomas (tumors of the vagal glomus body) are histologically benign and insensitive to radiation therapy. Unless properly managed, these tumors may become life-threatening because of their eventual impingement on surrounding structures, particularly contents of the cranial vault. Patients with chemodectomas of the skull base may be surgically treated without significant functional or cosmetic loss, provided the surgeon possesses the following surgical abilities: 1. temporal bone dissection capabilities; 2. microsurgical skills, including techniques of middle ear reconstruction and neurovascular anastomosis; 3. implementation of simultaneous multiple approaches to the skull base and infratemporal fossa; and 4. the capability of managing technically inherent intraoperative and postoperative problems. Experience from nine patients, all successfully treated surgically, will be summarized.