Nonmicrosurgical Techniques Research Articles

Auricular avulsion injuries: Literature review and management algorithm.

Traumatic ear avulsion (TEA) may have tremendous psychological consequences if not managed properly. There are no clear guidelines on the surgical management of these injuries, especially in developing countries where microsurgical facilities are lacking. We aimed to review the literature on surgical management of TEA with the main focus on direct re-attachment (DR) so as to develop a surgical management algorithm that can be applied in the absence of microsurgical facilities. We performed an extensive review of the relevant English literature on papers indexed in PubMed describing TEA repaired with DR without restriction to a specific publication time window. A total of 28 cases in 18 publications were reviewed and analyzed. Our results indicate that in the acute setting with no available microvascular expertise, DR of auricular avulsion injuries can be better than other nonmicrosurgical techniques in generating good esthetic results, especially in incomplete auricular avulsion and small segment avulsion. The operative approach depends on the clinical setting. DR of the auricular avulsion injuries is an accepted approach. It produces good cosmetic outcomes while preserving the auricular area for future reconstruction in case of re-attachment failure.

Reconstruction of Scalp Defects Using Non-Microsurgical Techniques

Introduction: Skin loss of the scalp with exposed underlyingstructures are reconstructed by plastic surgeons. In thisstudy, we highlight the non-microsurgical reconstructiveoptions.Patients and Methods: A retrospective study was conductedwhere data of 13 cases who underwent immediate scalpreconstruction were recorded and analyzed.Results: The causes of scalp defects were either congenital(7.7%), traumatic (53.8), electrical burn (7.7%) or after tumorexcision (30.8%). The extent of the scalp defects ranged from20cm X 8cm to 3cm X 4cm. The most affected regions weretemporal, parietal, occipital and forehead. The reconstructiveprocedures were transposition flaps, rotation flaps, skin graft,drill holes, integra, pinwheel flap and Ortichoa flaps.Discussion: To obtain successful scalp reconstruction,plastic surgeons need to understand the diversity of scalpdefects and mastering many reconstructive options. Whenmicrosurgical reconstruction of scalp is not available orcontraindicated, a number of more simplified techniques canachieve stable and efficient results.Conclusion: A variety of reconstructive requirements andchoices should be considered when undertaking scalp reconstruction.An algorithm is needed for management of differentdefects of the scalp. Defect size, location and depth are thecritical factors for the choice of the surgical technique.

A new classification to aid the selection of revascularization techniques in major degloving injuries of the upper limb

Difficulties in management of major degloving injuries of the upper limb are compounded by their relative rarity and a lack of clarity in decision-making regarding surgical treatment strategies. Management options include salvaging the degloved segment through revascularization techniques such as direct arterial anastamosis or arterio-venous (AV) shunting, and reconstructing the unsalvageable degloving injury with microsurgical or non-microsurgical techniques. This article focuses on the use of revascularization techniques as a means to salvaging a major degloved segment.We propose a new classification to aid decision-making in strategies to salvage the degloved skin. This is based on assessment of the degloved segment regarding its suitability for revascularization, the choice of revascularization technique, and its anatomical expendability. Major degloving injuries involving the palm but not the digits is a strong indication for AV shunting in isolation (Group 1). Major degloving injuries that include the digits as well require both AV shunting and digital artery revascularization (Group 2). Major deglovings involving the dorsum of hand or forearm are only relative indications for AV shunting and traditional management with flap reconstruction or skin grafting is equally appropriate. This new classification and its application are discussed in a number of case examples.

The reconstruction of large bone defects in the upper limb

Large bone defects in the upper limb pose many challenges in reconstructive surgery. Conventional and innovative methods have been described, employing the use of microsurgical and non-microsurgical techniques to overcome both bony and soft tissue defects. This article reviews the success and pitfalls of different techniques of reconstruction of large bone defects in the upper limb, including microsurgical transfer of the free vascularised fibula graft as a diaphyseal bone replacement and as a hemivascularised joint transplant, and non-microsurgical options using conventional bone grafting, the induced membrane technique and the role of callotatic distraction-lengthening procedures.

Non-Microsurgical Technique of Fingertip Replantation: A Report of Three Cases

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Pedicled Deep Inferior Epigastric Perforator Flap for Total Phallic Reconstruction

Total phallic reconstruction remains a great challenge in reconstructive surgery. The search for a suitable donor site is never ending. Based on the experiences in using free deep inferior epigastric perforator flap for breast reconstruction, the authors describe a new usage of the deep inferior epigastric perforator flap for phallic reconstruction. In this procedure, the neourethra is centrally located. The rigidity is provided with the 12th rib. The donor site can directly be closed. Over the past 4 years, this surgical procedure has been used successfully for total phallic reconstruction in 2 patients. Four years of follow-up has revealed that an aesthetically acceptable functional neopenis was achieved. The scar of the donor site is inconspicuous and is easily concealed by underwear. Moreover, this new procedure is a nonmicrosurgical technique. Although more clinical experience is needed, this flap can be chosen as an alternative option in phallic reconstruction.

Successful penile replantation using loupe magnification

Traumatic penile amputation is a rare condition requiring urgent surgical consultation with almost immediate surgical intervention. Although seen in both paediatric and adult populations, the majority are seen in the latter age group. These injuries are penetrating in nature, usually occur with the organ flaccid and most are self-inflicted by mentally unstable patients. Currently replantation involves meticulous microsurgery to reduce skin, urethra and graft loss, but these complications may still occur. Non-microsurgical techniques have been utilised with good post-operative outcomes. This report describes penile replantation in a 24-year old mentally challenged patient using 4.5× loupe-magnification to restore a functional, fully erectile penis without tissue loss and a 20-year problem free follow-up.

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patient's preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.

A True One-Stage Nonmicrosurgical Technique for Total Phallic Reconstruction

A True One-Stage Nonmicrosurgical Technique for Total Phallic Reconstruction

A True One-Stage Nonmicrosurgical Technique for Total Phallic Reconstruction

A new nonmicrosurgical technique for one-stage total phallic reconstruction is presented. In this procedure, an innervated anterolateral thigh (ALT) flap including the medial half of the fascia latae is combined with a sartorius perforator flap. Both flaps are elevated together as an island chimeric flap based on the lateral circumflex femoral vessels and tunneled to the recipient area. The neourethra is created with thin and hairless skin of the sartorius perforator flap, while the ALT flap is used to construct the shaft and glans of the neophallus. The rigidity was provided with a penile prosthesis covered with a neotunica albuginea created with vascularized fascia latae for the first time in the literature. The lateral femoral cutaneous nerve of the ALT flap is coapted to the pudendal nerve to provide erogenous sensibility. Here, a 15-year-old male in whom this new procedure was used for one-stage total phallic reconstruction is presented. Two years of follow-up revealed that an esthetically acceptable and functional neopenis with a nonhairy competent urethra, erogenous sensitivity, and a proper rigidity was achieved with no complication. This new technique, namely, the "Istanbul on the thigh" flap, is a one-stage, safe, and timesaving technique which fulfills all essential goals of phallic reconstruction but does not require microsurgical equipment and expertise. Moreover, the donor scar is located at an unexposed area, easy to conceal. Although more clinical experience is needed, this new procedure seems to be a useful alternative in phallic reconstruction.

Leech therapy in penile replantation: a case of recurrent penile self-amputation

Penile amputation is a rare urologic trauma for which immediate surgical replantation is indicated. Microsurgical techniques can reduce skin and graft loss complications; nonetheless, such complications are still highly prevalent. We report a case of self-inflicted penile amputation and describe a nonmicrosurgical technique for replantation. To improve postoperative edema due to venous congestion, we applied medicinal leeches to the penis. The edema quickly resolved, but overlying skin loss occurred, which required superficial debridement. At follow-up the patient had glans re-epithelialization with normal voiding, sensation, and erections. To our knowledge, this is the first reported case of nonmicrosurgical penile replantation with leech therapy.

COMPLICATION RATE OF MICROSURGICAL VARICOCELE LIGATION WITHOUT DELIVERY OF THE TESTIS

It is commonly assumed that the complication rate of microsurgical varicocele repair is lower than that of nonmicrosurgical techniques, particularly since magnification allows for preservation of lymphatic vessels and, thus, a theoretically lower incidence of hydrocele. However, review of the literature reveals relatively few papers on this subject. The authors reviewed their experience to determine the incidence of complications following microsurgical varicocele repair without delivery of the testicle in the adult population. From 1 July 1997 to 1 September 2001 139 men underwent microsurgical varicocele ligation without delivery of the testicle, with a mean follow-up of 22 months. Of the 139 men, 4 (2.9%) had complications. One (0.7%) had a recurrence, 1 (0.7%) had a wound infection, 1 (0.7%) had epididymitis, and 1 (0.7%) had an unintentional injury of the testicular artery. None of the men developed a hydrocele. The published complication rate for nonmicrosurgical varicocle ligation ranges from 5.4 to 7.2%, with the most common complication being hydrocele formation. In the authors' series, the overall complication rate was 2.9%, with no patient developing a hydrocele. Thus, microsurgical varicocele ligation without delivery of the testicle results in a lower complication rate and a lower incidence of hydrocele than nonmicrosurgical techniques.

Complication rate of microsurgical varicocele ligation without delivery of the testis.

It is commonly assumed that the complication rate of microsurgical varicocele repair is lower than that of nonmicrosurgical techniques, particularly since magnification allows for preservation of lymphatic vessels and, thus, a theoretically lower incidence of hydrocele. However, review of the literature reveals relatively few papers on this subject. The authors reviewed their experience to determine the incidence of complications following microsurgical varicocele repair without delivery of the testicle in the adult population. From 1 July 1997 to 1 September 2001 139 men underwent microsurgical varicocele ligation without delivery of the testicle, with a mean follow-up of 22 months. Of the 139 men, 4 (2.9%) had complications. One (0.7%) had a recurrence, 1 (0.7%) had a wound infection, 1 (0.7%) had epididymitis, and 1 (0.7%) had an unintentional injury of the testicular artery. None of the men developed a hydrocele. The published complication rate for nonmicrosurgical varicocle ligation ranges from 5.4 to 7.2%, with the most common complication being hydrocele formation. In the authors' series, the overall complication rate was 2.9%, with no patient developing a hydrocele. Thus, microsurgical varicocele ligation without delivery of the testicle results in a lower complication rate and a lower incidence of hydrocele than nonmicrosurgical techniques.

MICROSURGICAL REPAIR OF THE ADOLESCENT VARICOCELE

Purpose Since clinically apparent varicoceles may affect testicular volume and sperm production, early repair has been advocated. However, repair of the pediatric varicocele with conventional nonmagnified techniques may result in persistence of the varicocele after up to 16% of these procedures. Also testicular artery injury and postoperative hydrocele formation can occur after nonmagnified repair. The microsurgical technique has been successfully completed in a large series of adults with a dramatic reduction in complication and recurrence rates. We report our experience with the microsurgical technique in boys. Materials and Methods A total of 30 boys (average age 15.9 years) underwent 42 microsurgical varicocelectomies (12 bilateral). All patients had a large left varicocele. Indications for repair included testicular atrophy (size difference between testicles of greater than 2 ml.) in 20 boys, pain in 5 and a large varicocele without pain or testicular atrophy in 5. Six boys were referred following failure of conventional nonmicrosurgical techniques. All boys were examined no sooner than 1 month postoperatively (mean followup 12). Results Preoperative volume of the affected testis averaged 13.0 ml., and an average size discrepancy between testicles of 2.8 ml. was noted before unilateral varicocelectomy. No cases of persistent or recurrent varicoceles were detected, and 1 postoperative hydrocele resolved spontaneously. After unilateral varicocelectomy the treated testes grew an average of 50.1%, while the contralateral testes grew only 23%. Overall, 89% of patients with testicular atrophy demonstrated reversal of testicular growth retardation after unilateral varicocelectomy. In contrast, both testes showed similar growth rates after bilateral varicocelectomy (45% left testis, 39% right testis). Conclusions The meticulous dissection necessary to preserve arterial and lymphatic supply, and to ligate all spermatic veins in the pediatric patient is readily accomplished using a microsurgical approach, and results in low recurrence and complication rates. Rapid catch-up growth of the affected testis after microsurgical varicocelectomy suggests that intervention during adolescence is effective and warranted.

INDICATIONS FOR FREE SOFT-TISSUE FLAP TRANSFER TO THE UPPER LIMB AND THE ROLE OF ALTERNATIVE PROCEDURES

The aim of soft-tissue replacement to the upper limb is twofold. The first is to restore as much functional tissue as possible, and the second is to achieve this in the shortest possible time. Of lesser consideration is the desire to achieve a good cosmetic result. In any given clinical situation, no single reconstructive procedure will maximally satisfy these aims. The personal philosophy expounded in this article exposes disadvantages as well as advantages of the many operations available to the upper limb surgeon. Each clinical problem is different from any other, so no blueprint or computer program is available to help the surgeon select an operation. It takes judgment based on knowledge and experience on the part of the surgeon to make the most appropriate selection. During the last two decades, free vascularized transfers have superseded some of the conventional pedicled flap operations, and this has been acclaimed quite rightly as a significant advance. By the same token, indications for the "older" techniques should remain in the armamentarium of the surgeon because in certain situations these may yet offer the best solution. A spin-off of the microsurgical era is the reverse forearm island flap, and in my view, this has become a new "star" in the recent era. It is fitting that it should have prominence in the reconstructive arena because it straddles the border between microsurgical and nonmicrosurgical techniques. It is a modern reminder that there are many ways to treat defects of the upper limb and that the responsibility of the surgeon is to be both imaginative and wise in securing the best possible result for the patient.

Nonmicrosurgical Transfer of the Radial Forearm Flap for Head and Neck Reconstruction

In this article I present a nonmicrosurgical technique for transferring the radial forearm flap for reconstruction of defects in the head and neck. The technique is described briefly and experience with 7 patients is presented. The advantages of this method are discussed.

A 15-Year Followup of a Nonmicrosurgical Technique for Vasovasostomy

A 15-year followup was summarized for patients who had a nonmicrosurgical vasectomy reversal. Over-all pregnancy rates were 45 per cent (43 per cent for the first 8years and 49 per cent for the next 7years) and 73 per cent of the pregnancies occurred within 1 year after vasectomy reversal. Patients who achieved pregnancy compared to those who did not had significantly better sperm motility and a lower incidence of antisperm antibodies. The data indicate that nonmicrosurgical techniques can be used successfully to reverse vasectomy more economically and more rapidly than the microsurgical approach, while contributing to a reasonable pregnancy rate.

Vasectomy and Its Reversal

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.