Biomedical subjects
Publications and source records attributed to R M Zuker.
Great strides have been made in both microsurgery and craniofacial surgery. Situations arise in which practitioners of both disciplines must work closely together to achieve a satisfactory reconstruction for the patient. This unified approach has set the stage for a new era in the treatment of pediatric craniofacial problems.
Scalp avulsion is a rare injury that has significant physical and psychological consequences. It may require emergency replantation or late, challenging surgical reconstruction, or both. The authors describe two patients who had scalp avulsion. Each patient got long hair entangled in the uncovered engine of a go-cart. One underwent unsuccessful replantation without vascular repair; the other had a large segment of scalp successfully replanted with microvascular repair. Both patients required late reconstruction with tissue expansion. The final results were good. When feasible, microvascular replantation is the treatment of choice. If replantation is not possible, temporary cover by skin grafts followed by later reconstruction with tissue expansion can be effective.
In facial and neck burns, attention to cosmetic details, in addition to preservation of function, is crucial. The authors describe use of the scalp as a graft donor site for such burns. The advantages include excellent colour match of the graft and minimal morbidity at the donor site. The technique for graft harvest is outlined, and the potential pitfalls are described. Based on their experience with this technique, the authors believe the scalp should be considered as a donor graft site during the acute phase of facial and neck burns.
A stereotactic system has been designed to address the problem of achieving symmetry in complex and extensive craniofacial defects. Preliminary testing suggests that such a system, which allows for the intraoperative application of preoperative CT planning, will be useful in guiding the reconstruction of congenital or acquired bony time, is being used to investigate the correlation of intraoperative globe position following enophthalmos correction with long-term outcome, particularly as it relates to the size and location of the orbital defect, and the timing of the procedure.
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Children are particularly prone to developing moderate to severe Volkmann's ischemic contracture following a supracondylar fracture of the humerus or its treatment. In order to treat such contractures, intensive hand therapy and a gracilis free muscle transfer to the digital flexors were used in 8 patients at an average age of 6 years 2 months. All transfers were successful. At follow-up (1 to 8 years, average 3 years), despite limited wrist extension in 5/8 patients and mean grip and pinch strengths between 22 and 43% of normal for age and dominance, all patients regained considerable finger flexor excursion (tip to crease distances of 0 to 5.0 cms, average 1.68 cms). Although fine motor assessment using the M.A.N.D. battery of tests placed the patients in the moderate disability range, 7/8 patients became independent in the tested activities of daily living with the exception of buttoning a cuff with the involved hand, which was difficult for 5/8 subjects. Quantifiable measurements underestimated the renewed importance of the operated hand. Compensatory motion at the shoulder allowed positioning the hand which changed from being nearly useless to becoming a functionally non-dominant hand well integrated into daily life.
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The pattern of injury seen in pediatric hand burns differs from adults because scald burns are most common. Many of these are difficult to assess at initial presentation. In addition, children develop less stiffness in response to immobilization. For these reasons, we have developed a conservative, expectant approach for treating most pediatric hand burns. Meticulous wound care, positioning, splinting, and exercise are required to safely accomplish the goals of rapid healing with minimal loss of function. These regimens are adapted specifically to suit the age of the child and are applied by the burn team. Normal hand function can be obtained in the majority of cases.
Facial paralysis in children is a complex condition. It may involve functional issues and always involves esthetic issues. Significant psychosocial problems may arise and family support systems are often necessary. In this brief article the etiology of facial paralysis in children is discussed and the common types described. The philosophical approach to the child and his or her family is emphasized. The timing of surgical intervention is addressed as well as a brief outline of the surgical techniques of cross-face nerve grafting and muscle transplantation. Although these latter procedures have added enormously to our capabilities to deal with this condition, further progress will be necessary through research and clinical ingenuity if we are to restore these children to normality.
The authors describe a case of a severe crush injury in a 28-year-old man, whose left hand was caught in a punch press. Several carpal bones and all structures at the wrist except the extensor tendons were destroyed. The hand was totally denervated and devascularized. This case represents the 500th reattachment performed by the University of Toronto microvascular team. The authors review the operative technique and discuss the functional results 9 months after operation followed by a rigorous program of rehabilitative therapy.
A major problem for the patient with Möbius' syndrome is the inability to smile. With the development of vascularized muscle transplantation, the possibilities for improved facial animation were explored. Muscle transplantation was carried out in 7 patients; innervation was provided by the hypoglossal nerve, the motor nerve to the masseter muscle, or in 1 patient a transfacial nerve graft. In this article the technical aspects of the procedure as well as the results are described in detail.
Functioning muscle can be transferred from one location to another using microneurovascular anastomoses. Reinnervation and useful muscle contraction are produced by suturing an appropriate motor nerve in the recipient area to the motor nerve of the transplanted muscle. Clinical experience and experimental investigations have led to an understanding of some of the important principles in extremity muscle transplantation. Successful deltoid and biceps reconstruction are reported.
Volkmann's ischemic contracture is a complex process that often results in a significant functional disability. Destruction of the forearm musculature can, in certain situations, be reconstructed utilizing muscle transplantation. Proper patient selection, attention to detail at the time of the surgical procedures, and patient compliance during rehabilitation are key factors in a successful outcome. Functional results have been very rewarding, although certain problem areas await resolution.
Sixty vascularized iliac crest free-tissue transfers were used for oromandibular reconstruction, 46 as osteocutaneous and 14 as osseous flaps. Forty-one patients had preoperative radiotherapy, and 8 had failed previous attempts at reconstruction. Forty-nine of the 60 reconstructions were carried out primarily, most commonly following ablative surgery for radiorecurrent squamous carcinoma. Ages ranged from 19 to 85 years, and follow-up ranged from 2 months to 5 years. Flap survival was 95 percent. Eight-six percent of patients returned to their previous activities. There were 2 perioperative deaths, and 31 patients were alive at follow-up. Horizontal defects from 5 to 16 cm were reconstructed, and in 22 patients, both oral lining and skin coverage were replaced. Radiographic evidence of bone union was noted in 96 percent of synostoses, and clinical union was seen in all but one patient. One patient required bilateral hemimandibular reconstructions for sequential primaries at different operative sittings. Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions. Several surgical principles evolved to minimize bulk and eliminate the need for intermaxillary fixation or external fixation postoperatively. To improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous. Cosmetic and functional results depend largely on three factors: the extent of the surgery, the leanness of the patient, and his or her position on the surgical learning curve.
Proximal upper limb amputation not only leads to serious local disability but carries with it substantial systemic implications. The replantation of an avulsed limb is all too frequently followed by disappointing functional results. In children, however, with secure bony stability, vascular reconstruction and immediate appropriate nerve repair the results of replantation can be most gratifying. Two such cases have been seen at The Hospital for Sick Children and are reported in detail. The late functional results as illustrated make this complex procedure a very worthwhile undertaking.
The authors present an unusual and bizarre missile type of maxillofacial injury in a 7-year-old girl, who was struck in the middle of her face by an iron hook. The area between her forehead and upper lip was obliterated, making a clinical and radiologic diagnosis impossible. The authors review the current diagnostic methods used in maxillofacial trauma, including standard and computed tomography, to emphasize the importance of a correct preoperative diagnosis in the management of maxillofacial injuries.
In this study, the long-term results of secondary common peroneal nerve repair are evaluated. The general consensus has been that the long-term outcome of peroneal nerve repair is poor, because of its mixed sensory-motor nature and the long-distance necessary for axon regeneration. Since the introduction of microneurosurgery and autogenous nerve grafting, an amelioration of poor results might be expected; however, recent reports on common peroneal nerve repair are not available. Four patients underwent either direct peroneal nerve repair (2) or nerve grafting (2) over a five-year period. Dorsiflexion was achieved with peroneal muscle power Grade 3 or above in three patients. The fourth patient is still regaining peroneal power and has not plateaued. These results show that secondary common peroneal nerve repair, even with autogenous nerve grafting, is a worthwhile procedure. The age of the patient, the timing of the repair, meticulous microsurgical technique, and avoidance of tension are critical factors in achieving a successful outcome.
Five children who had sustained multiple proximal upper limb nerve injury were reviewed at 18 months to 3 1/2 years after primary repair had been carried out. The findings show that nerve regeneration occurred significantly more rapidly than in adults, with good return of motor and sensory function to the hand, resulting in each of the patients having a useful, painfree and functionally capable upper limb. In two of the cases, the limb had been completely severed. The findings support the view that primary repair of severed proximal nerves in this age group--even in avulsion type injuries--can give good results.