Aesthetic aspects of reconstructive microsurgery of the lower extremity.
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Biomedical subjects
Publications and source records attributed to S J Mathes.
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Five patterns of muscle circulation, based on studies of the vascular anatomy of muscle, are described. Clinical and experimental correlation of this classification is determined by the predictive value of the vascular pattern of each muscle currently useful in reconstructive surgery in regard to the following parameters: arc of rotation, skin territory, distally based flaps, microvascular composite tissue transplantation, and design of muscle-delay experimental models. This classification is designed to assist the surgeon both in choice and design of the muscle and musculocutaneous flap for its use in reconstructive surgery.
The successful free microvascular transplantation to the hand of a second metatarsal phalangeal joint with associated epiphyses is described, with follow-up data 2 1/2 years later indicating epiphyseal growth.
The reliance on retained superior breast tissue beneath the reduced skin envelope may not provide adequate breast projection in reduction mammaplasty. Placement of preserved inferior dermal-breast pedicle beneath the tailored skin envelope in this group of patients has allowed control of both breast projection and size, but there are alternatives in the management of the nipple--areola complex with the use of this technique.
Techniques for transposition of muscles are described when function preservation may be important. Anatomic and clinical data are presented to support the technique of muscle transposition with function preservation.
The use of the muscle and musculocutaneous unit as a reconstructive tool by the plastic and reconstructive surgeon is expanding to all body regions. The initial four basic factors required in use of the muscle flap for reconstructive surgery now include such modifications as: (1) transfer of the sensory nerve to the musculocutaneous unit with the flap for sensory preservation; (2) use of minor vascular pedicles as a point of rotation for certain muscle flaps, (3) use of combinations of more than one muscle flap with common proximal vascular supply; and (4) transfer of the bony origin of the muscle unit with the muscle flap. Refinements and further additions to this list are demonstrated throughout this text and will certainly increase as the muscle flap is adapted for use in coverage of difficult wounds. An accurate knowledge of the vascular anatomy of muscles will allow safe modifications in the design of the muscle and musculocutaneous unit by the reconstructive surgeon.
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If there is a strongly dominant vascular pedicle, a muscle may be suitable for transfer as a free myocutaneous flap. The minor vascular pedicle(s) may contribute significantly to the arterial blood flow to the overlying skin, however. The concept of doing a delay procedure (ligating the dominant pedicle) to increase the survival of the skin component of a free myocutaneous flap is explored.
A case is reported in which a tumor containing elements of mature and immature ganglioneuroma, Schwannoma, clusters of apparently benign melanocytes and embryonal rhabdomyosarcoma presented as a right-sided facial mass in a six-month-old child. Different elements of the tumor were intimately intermingled without distinct borders. Embryogenesis of the tumor, which is thought to arise from remnants of migratory neural crest cells (ectomesenchyme), showing multidirectional phenotypic expression is discussed. It was felt that the lesion contributed additional evidence in support of pluripotentiality of the migratory, neural crest derivatives, and their susceptibility to mutagenic and oncogenic influences.
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The authors did direct fascicular suturing and interfasicular nerve graft repairs for gaps in the median and ulnar nerves in rhesus monkeys. They found that the fascicular type of repair, with or without the use of a graft, routinely produced good results in these animals.
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Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.