Cubital Tunnel Syndrome

The overall success rate of the different surgical procedures for cubital tunnel syndrome, which is the second most frequent nerve entrapment of the arm, is between 80 and 90 .5 Still, the debate on in situ (simple) nerve decompression versus anterior transposition continues.9,10,11 If in situ decompression gives the same good success rate,1213 one would think that a complex procedure, such as the anterior transposition of the ulnar nerve, especially its most aggressive submuscular version,...

Hand Transplants

The first hand transplantation was performed before the cyclosporine era of immunosuppression in 1963.2 The patient received steroids and azathioprine immunosuppressive treatment. The hand was rejected 3 weeks after transplantation. Since the first successful hand transplantation in 1998, in Lyon3,25 transplants (6 bilateral) in 19 patients have been reported 8 (6 patients) from China, 5 (3 patients) from France, 4 (2 patients) from Austria, 3 from Italy, 2 from the USA, 1 from Belgium, and 1...

References

Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The Gent consensus on perforator flap terminology preliminary definitions.PlastReconstr Surg. 2003 112 1378-1383 quiz 1383, 1516 discussion 1384-1387. 2. Manchot C. Die Hautarterien de Menschlichen Korpers. Leipzig F.C.W. Vogel, 1889. 3. Salmon M. Arteres de la Peau. Paris Masson, 1936. 4. Esser JFS. General rules used in simple plastic work on Austrian war-wounded soldiers. Surg Gynec Obstet. 1917 34 737. 5. Milton SH. Pedicled skin-flaps the...

Limb Salvage

Limb Salvage

We have learned a great deal about limb salvage compared to immediate amputation in the injured leg. We have clear indicators based on clinical assessment and scoring systems that we can share with patients before we amputate. For example, a limb that has multiple comminutions, or an elderly patient with a disruptive posterior tibial nerve, or an ipsilateral crush to the tibia and foot, cannot be salvaged (Figure 1-1). Patients that have protracted periods of ischemia with nerve disruption also...

The Future of Orthoplastic Surgery

The future of orthoplastic surgery will be based on the possibility of tissue transplantation. Short of this, the use of bone allografts combined with soft tissue reconstructive techniques have been effective in salvaging limbs. Other orthoplastic domains include reconstructing the mandible with rigid fixation and vascularized bone grafts. This reconstruction problem is similar to that created by osteomyelitis in the extremities. Often radiation-induced osteonecrosis, or tumors with localized...

Orthoplastic Surgery

Orthoplastic surgery as we define it is the principles and practices of both specialties orthopaedic and plastic surgery applied to a clinical problem, either by a single provider, or teams of providers working in concert for the benefit of the patient.5,6,7 More than 37 years after Tamai's report that generated interest from surgeons around the world, care of the mutilated hand with microsurgical technique is standard practice. The training of orthopaedic surgeons has shifted gradually toward...

Immunosuppression Induction Protocols

The aim of inducing immunosuppression after transplantation is to suppress the immune system for a short period (2 weeks) to reduce the possibility of hyperacute (within 10 days after transplant) and acute rejection (within 3 months after the transplant).26 Table 2-3. Immunosuppressive Therapy Regimens Used in Transplanting Composite Tissue Allografts Table 2-3. Immunosuppressive Therapy Regimens Used in Transplanting Composite Tissue Allografts ATG antithymocyte globulins MMF mycophenolate...

Midface Correction

Before And After Serums

Interest in correcting defects of the midface began in the early 1990s and has continued since. Standard facelift approaches for correcting the mid face in the sub-SMAS plane, the subperiosteal plane, and the subcutaneous plane, have all been recommended. Virtually all modern sub-SMAS facelift procedures that provide adequate midface correction involve releasing the major zygomatic cutaneous ligament and the upper masseteric cutaneous ligaments, with or without malar fat pad repositioning.20 29...

The Neck

The standard operation for correcting lower facial aging remains the cervicofacial rhytidectomy, but lesser approaches have increasing appeal. Over the past 25 years, surgeons have noted the increased ability of neck skin to contract Figure 9-7. An anterior lipectomy and platysmaplasty. a) Platysmaplasty completed through a submental incision. The dotted line indicates the extent of dissection. b) Postauricular incision for access to the posterior neck. Figure 9-7. An anterior lipectomy and...

Pronator Syndrome

Proximal median nerve compression is much less common than carpal tunnel syndrome, and it may be overlooked because the associated symptoms and physical signs may be vague. Pronator syndrome resembles carpal tunnel syndrome in that numbness occurs in the same digits, weakness may develop in the thenar muscles, and pain is reported in the wrist and forearm. Paresthesia of the median-innervated fingers without physical signs of carpal tunnel or chronic pain in the proximal palmar region of the...

Postbariatric Surgery

Given the epidemic of obesity that has af icted Americans, gastric bypass surgery its multiple variations known collectively as bariatric surgery has become increasingly popular. More than 103,000 bariatric surgical procedures were performed in 2003.75 Between 15 and 20 of patients undergoing bariatric surgery eventually seek plastic surgery once their weight has stabilized. A patient's weight must usually be stable for 1 year before plastic surgery is considered to correct skin excess....

Nerve Allografts

Mackinnon, MD, two decades of basic science research have established that 1) the Schwann cells of an allograft are rejected, 2) the host axons regenerate across the basement of the allograft, 3) the host Schwann cells repopulate the reconstructed segment after rejection of the donor Schwann cells, 4) immunosuppression can be discontinued and nerve function preserved after function has been restored, and 5) immunosuppression can be achieved with a regimen less...

Decompressing Nerves to Treat Symptomatic Neuropathy

Nestin Cre Mice

The hypothesis that the symptoms of neuropathy could be treated by decompressing a peripheral nerve was offered in 19887 and supported in a diabetic rat model in 1991s and 1994.9 This hypothesis was confirmed by a separate team in 2003 in the rat model and included the finding that intraneural neurolysis was of added value in improving gait.10 The hypothesis was confirmed yet again in 2005 in the same model, but this time findings included information specifically on the common peroneal nerve...

Types of Perforator Flaps

One of the first and most popular of all perforator flaps is the deep inferior epigastric artery perforator (DIEAP) flap. Its usefulness arises from the large area of lower abdominal tissue that can be sustained on a single perforator and the fact that the underlying subcutaneous tissue is thick. The resultant large, soft, bulky flap composed of skin and subcutaneous fat is an ideal like-for-like match for breast reconstruction (Figure 7-1).18-19 The ensuing flap, composed of only skin and fat,...

Nerve Conduits

More than two decades have passed since experimental models of neural regeneration, using various materials for nerve conduits, were first used to measure neurotrophic substances and to introduce substances related to the nerve regeneration process.41 Although silicone chambers were among the earliest conduits used experimentally, nerves do not regenerate more than 10 mm in them, primarily because they are non-porous. Furthermore, silicone around a nerve is one model of chronic nerve...

Perioral Rejuvenation

Gull Wing Lip Lift

The perioral area has also received increasing attention in recent years. This area is often inadequately addressed by cervicofacial rhytidec-tomy alone. Aging of the perioral area is exacerbated by a number of factors related to both bone and soft tissue. Perhaps most important is the loss of the alveolar ridge and tooth support.42 Tooth loss leads to alveolar ridge resorption, mandibular overclosure reduced vertical facial height, and maxillary retrusion. With a lack of support, the upper lip...

Tennis Elbow Including Radial Tunnel Syndrome

Thyroid Side Lamp Endoscopy

The cause of chronic pain in the lateral elbow, somewhat misleadingly termed tennis elbow, is still unknown, which may be why a variety of surgical procedures have been described to treat it, including denervation,18 extensor tendon release,15 and decompression of the posterior interosseus nerve (PIN).16 Surgery, in our opinion, is indicated if repeated attempts of nonoperative treatment have failed. Only in about 10 of our patients, where symptoms and physical signs suggest an isolated...

Partial Joint Denervation

Partial joint denervation is the concept of preserving joint function and relieving joint pain by interrupting the neural pathway that transmits the pain message from the joint to the brain. Traditional approaches to treating joint pain rely on musculoskeletal approaches to the joint itself and often require joint fusion or total replace ment arthroplasty. The concept of partial joint denervation offers the patient an outpatient, ambulatory operative approach that is join sparing and...

Other Applications of Orthoplastic Surgery

Osteomielite Tibia

One of the areas in orthoplastic surgery that deserves comment is osteomyelitis.40'41 Any patient who experiences suppuration has the right to ask the surgeon to explain how it occurred. This right was pointed out by Carrel in 1918 and is still true today. Cierney and Mader classify adult osteomyelitis by anatomical type and physiological class. The anatomic types are medullary, superficial, localized, and diffuse. The physiologic classes are normal, compromised, and treatment-deferred. A...

Radial Sensory Nerve Compression

Radial Nerve Sensory Course

Entrapment of the radial sensory nerve RSN at the mid forearm is certainly less frequent than the compression neuropathies mentioned above. Nevertheless, it is a cause of chronic pain and discomfort in the radial forearm. Many patients with this entrapment are referred with a diagnosis of de Quervain's tendovaginitis. They should be carefully examined to exclude the diagnosis of RSN compression. Both conditions can exist at the same time. The RSN is usually compressed between the tendinous...