- Email: [email protected]
Inverted free functional gracilis muscle transfer for the restoration of elbow flexion
144
Correspondence and communications
Table 1 Comparison of the maximal magnification capacity between the different surgical optics of the M525 F50 microscope, without and with the high-magnification enhancer. The maximal magnification is obtained at the minimal focal distance of 207 mm.
The quality of Japanese technology is again confirmed, in the field of microsurgery, by this new optical magnification enhancer. Its 27 magnification potential (i.e., 54 in the Mitaka MM50 surgical microscope) and high resolution make it an essential operative device to perform lymphaticovenular anastomosis safely.
Optics magnification
Maximal magnification
Maximal magnification with the magnification enhancer
Funding
10 12.5 16
12.2 15.2 19.5
17 21.4 27.3
Ltd., Nagano, Japan) and 11/0 nylon monofilaments on a 50-mm needle (Ethilon, Ethicon, Johnson & Johnson Co., USA). The mean operative time was 45 min to perform one end-to-end lymphaticovenular anastomosis (Figure 1(a)) and 55 min to perform one end-to-side lymphaticovenular anastomosis (Figure 1(b)). The mean number of lymphaticovenular anastomosis performed per patient was 8.
None.
Disclosure None.
Conflict of interest The author has no financial or conflict of interests, with any company quoted in the article, to disclose.
References 1. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000;16(6):437e42. 2. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg 2003;19(4):209e15. 3. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010;126(3):752e8. 4. Matsumura N, Horie Y, Shibata T, Kubo M, Hayashi N, Endo S. Basic training model for supermicrosurgery: a novel practice card model. J Reconstr Microsurg 2011;27(6):377e82. 5. Mihara M, Hayashi Y, Iida T, Narushima M, Koshima I. Instruments for supermicrosurgery in Japan. Plast Reconstr Surg 2012; 129(2):404ee6e.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected] Crown Copyright ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.012
Figure 1 Intraoperative views of a lymphaticovenular anastomosis. The anastomosis is performed with a 11/0 nylon monofilament on a 50-mm needle, under 27 magnification at a 207 mm focal distance. The blue colouration is due to a patent blue enhancement of the lymphatic network, performed preoperatively. (a) End-to-end lymphaticovenular anastomosis, between a 0.4 mm lymphatic vessel and a 0.5 mm subdermal venulae. (b) End-to-side lymphaticovenular anastomosis, between a 0.3 mm lymphatic vessel and a 0.9 mm subdermal venulae.
Inverted free functional gracilis muscle transfer for the restoration of elbow flexion Dear Sir, The loss of elbow flexion after upper extremity injury has devastating implications for a patient’s future daily
Correspondence and communications function. A range of elbow reanimation procedures after brachial plexus injury have been described, including nerve transfers or grafts, local tendon and muscle transfers, and free functioning muscle transfers.2 When motor endplate degeneration has taken place and motor recovery is no longer possible, free functioning muscle transfer is arguably the optimal reconstruction. Of the many muscle flaps described, the free functioning gracilis muscle transfer (FFGMT) is the best characterised for restoration of elbow flexion1e3 because of its length, proximally located neurovascular bundle of favourable dimensions, and tendons of origin and insertion.2 The standard procedure is described in detail by Kay et al.,1 and starts with recipient bed preparation and confirmation of the donor nerve to be used. The possible options include intercostal nerves, fascicles of the ulnar nerve, the spinal accessory or thoracodorsal nerve,1,2 and selection relates to the aetiology of the presenting condition. Fascicle transfer provides the shortest regeneration distance. The muscle is then inset orthograde,1,2 with its thin distal end woven into the biceps tendon, or inset to the radius or ulna. Vascular anastomosis is performed proximally, yet operating in this relatively confined area can sometimes be challenging, particularly in patients with restricted passive shoulder movement from related injury. However the gracilis muscle pedicle can be placed further down the arm by inverting the muscle (Figures 1
Figure 1 Standard insertion of gracilis flap from coracoid process to biceps tendon. Motor nerve neurosynthesis onto intercostal nerves in diagram, alternatively to ulnar nerve fascicle.
145
Figure 2 Inverted insertion of gracilis flap, proximal end of gracilis muscle onto biceps tendon. Motor nerve neurosynthesis onto ulnar nerve fascicle supplying FCU.
and 2), allowing wide access for vascular anastomosis in the mid-arm, including end-to-end onto the biceps pedicle and brachial vena commitantes when appropriate. This also places the bulkier, proximal part of the gracilis muscle the distal arm, mimicking the usual distribution of muscle bulk in the biceps brachii muscle, and improving cosmesis. The motor nerve is co-apted onto fascicles of the ulnar nerve selected by intraneural dissection and selective stimulation. Two patients underwent FFGMT for biceps reconstruction, 3 and 5 years subsequent to motorbike accidents that caused brachial plexus injury. In both cases, the functionless biceps muscles were wasted, atrophic and unresponsive to supramaximal intraoperative musculocutaneous nerve stimulation, so were excised. Selective stimulation within the ulnar nerve in the middle third of the arm identified nerve fascicles with good flexor carpi ulnaris (FCU) response, but no intrinsic activation. Standard gracilis muscle flaps were harvested with 10 cm of motor nerve. The proximal end of the gracilis was tubed around the biceps tendon and the distal end sutured to the coracoid process (2/0 Ethibond). Endeend vascular anastomoses were onto the biceps pedicle, and brachial artery vena commitans. Access for microvascular anastomoses was improved. Neurosynthesis was performed after shortening the flap motor nerve. Postoperative immobilisation and physiotherapy was as for a traditional FFGMT, but it proved simpler to protect the pedicle from compression than with a standard orthograde flap inset.
146
Correspondence and communications
Each patient has been followed up for a minimum of 14 months. Both flaps survived and regained volitional function. No loss of intrinsic muscle function occurred, and FCU function persisted. Co-contraction with FCU has not been significant, and no deterioration in hand function occurred. Both patients have improved volitional elbow flexion power (MRC 3 to MRC 4; MRC 0 to MRC 3), range (80 to 130 ; 0 to 120 ), and endurance. Case 1 became able to flex the elbow while maintaining grip. Cosmesis was improved over previous orthograde cases. Patient satisfaction in terms of function and cosmesis was high. When ulnar nerve fascicles are to motorise an FFGMT for elbow reanimation, use of an inverted inset improves access for microvascular anastomosis, provides a short regeneration distance, and improves cosmesis without compromising outcome.
Conflict of interests None.
Funding Support received from the Stephen Forrest Charitable Trust.
References 1. Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A. Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion. J Plast Reconstr Aesthet Surg 2010;63:1142e9. 2. Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin 2005:91e102. 3. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop A. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004; 16(5):E8.
K. Chin D. Vasdeki Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
Visualization of blood supply to the ‘vascularized nerve’ with anterolateral thigh flap using indocyanine green fluorescence angiography Dear Sir, The operative procedures of nerve reconstruction include vascularized and non-vascularized nerve grafts. In cases of transplantation to a poorly perfused area, such as perioperative radiation therapy cases, good perfusion of the grafted nerve is a very important factor in order to obtain a good result of nerve reconstruction. There are several reports on reconstruction with the flap involving vascularized nerve,1 but the evaluation of blood flow of grafted nerves has rarely been reported. The aim of this report was to visualize the perfusion of vascularized nerve graft during operation by using indocyanine green (ICG) fluorescence angiography. A 46-year-old woman underwent reconstruction with anterolateral thigh (ALT) flap involving vastus lateralis motor nerve (vastus lateralis branch of the femoral nerve) for the soft tissue and facial nerve defect after external auditory cancer ablation. Vastus lateralis motor nerve was harvested attached to the pedicle vessels and vastus lateralis muscle with about one-third of its full length, and about two-thirds of the nerve was dissected and free (Figure 1). After elevation of flaps, the blood supply to this vastus lateralis motor nerve was evaluated by ICG fluorescence angiography before ligature of pedicle vessels. For examination, ICG (Diagnogreen 25 mg/10 ml, Daiichi Sankyo Company, Tokyo, Japan) was administered intravenously in a dose of 0.1 mg per kilogram of body weight through peripheral intravenous catheter. During and directly following administration, the nerve and the surrounding tissue were monitored under a near-infrared video camera system (PDE; Hamamatsu Photonics, Hamamatsu, Japan).
A. Hart Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK Scottish National Brachial Plexus Service, National Services Directorate, UK College of Medical, Veterinary & Life Sciences, The University of Glasgow, Glasgow G12 8QQ, UK E-mail address: [email protected] ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. http://dx.doi.org/10.1016/j.bjps.2012.07.016
Figure 1 Elevated ALT flap with vastus lateralis motor nerve (arrow) and pedicle vessel (triangle).
Correspondence and communications
Table 1 Comparison of the maximal magnification capacity between the different surgical optics of the M525 F50 microscope, without and with the high-magnification enhancer. The maximal magnification is obtained at the minimal focal distance of 207 mm.
The quality of Japanese technology is again confirmed, in the field of microsurgery, by this new optical magnification enhancer. Its 27 magnification potential (i.e., 54 in the Mitaka MM50 surgical microscope) and high resolution make it an essential operative device to perform lymphaticovenular anastomosis safely.
Optics magnification
Maximal magnification
Maximal magnification with the magnification enhancer
Funding
10 12.5 16
12.2 15.2 19.5
17 21.4 27.3
Ltd., Nagano, Japan) and 11/0 nylon monofilaments on a 50-mm needle (Ethilon, Ethicon, Johnson & Johnson Co., USA). The mean operative time was 45 min to perform one end-to-end lymphaticovenular anastomosis (Figure 1(a)) and 55 min to perform one end-to-side lymphaticovenular anastomosis (Figure 1(b)). The mean number of lymphaticovenular anastomosis performed per patient was 8.
None.
Disclosure None.
Conflict of interest The author has no financial or conflict of interests, with any company quoted in the article, to disclose.
References 1. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000;16(6):437e42. 2. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr Microsurg 2003;19(4):209e15. 3. Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010;126(3):752e8. 4. Matsumura N, Horie Y, Shibata T, Kubo M, Hayashi N, Endo S. Basic training model for supermicrosurgery: a novel practice card model. J Reconstr Microsurg 2011;27(6):377e82. 5. Mihara M, Hayashi Y, Iida T, Narushima M, Koshima I. Instruments for supermicrosurgery in Japan. Plast Reconstr Surg 2012; 129(2):404ee6e.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected] Crown Copyright ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.012
Figure 1 Intraoperative views of a lymphaticovenular anastomosis. The anastomosis is performed with a 11/0 nylon monofilament on a 50-mm needle, under 27 magnification at a 207 mm focal distance. The blue colouration is due to a patent blue enhancement of the lymphatic network, performed preoperatively. (a) End-to-end lymphaticovenular anastomosis, between a 0.4 mm lymphatic vessel and a 0.5 mm subdermal venulae. (b) End-to-side lymphaticovenular anastomosis, between a 0.3 mm lymphatic vessel and a 0.9 mm subdermal venulae.
Inverted free functional gracilis muscle transfer for the restoration of elbow flexion Dear Sir, The loss of elbow flexion after upper extremity injury has devastating implications for a patient’s future daily
Correspondence and communications function. A range of elbow reanimation procedures after brachial plexus injury have been described, including nerve transfers or grafts, local tendon and muscle transfers, and free functioning muscle transfers.2 When motor endplate degeneration has taken place and motor recovery is no longer possible, free functioning muscle transfer is arguably the optimal reconstruction. Of the many muscle flaps described, the free functioning gracilis muscle transfer (FFGMT) is the best characterised for restoration of elbow flexion1e3 because of its length, proximally located neurovascular bundle of favourable dimensions, and tendons of origin and insertion.2 The standard procedure is described in detail by Kay et al.,1 and starts with recipient bed preparation and confirmation of the donor nerve to be used. The possible options include intercostal nerves, fascicles of the ulnar nerve, the spinal accessory or thoracodorsal nerve,1,2 and selection relates to the aetiology of the presenting condition. Fascicle transfer provides the shortest regeneration distance. The muscle is then inset orthograde,1,2 with its thin distal end woven into the biceps tendon, or inset to the radius or ulna. Vascular anastomosis is performed proximally, yet operating in this relatively confined area can sometimes be challenging, particularly in patients with restricted passive shoulder movement from related injury. However the gracilis muscle pedicle can be placed further down the arm by inverting the muscle (Figures 1
Figure 1 Standard insertion of gracilis flap from coracoid process to biceps tendon. Motor nerve neurosynthesis onto intercostal nerves in diagram, alternatively to ulnar nerve fascicle.
145
Figure 2 Inverted insertion of gracilis flap, proximal end of gracilis muscle onto biceps tendon. Motor nerve neurosynthesis onto ulnar nerve fascicle supplying FCU.
and 2), allowing wide access for vascular anastomosis in the mid-arm, including end-to-end onto the biceps pedicle and brachial vena commitantes when appropriate. This also places the bulkier, proximal part of the gracilis muscle the distal arm, mimicking the usual distribution of muscle bulk in the biceps brachii muscle, and improving cosmesis. The motor nerve is co-apted onto fascicles of the ulnar nerve selected by intraneural dissection and selective stimulation. Two patients underwent FFGMT for biceps reconstruction, 3 and 5 years subsequent to motorbike accidents that caused brachial plexus injury. In both cases, the functionless biceps muscles were wasted, atrophic and unresponsive to supramaximal intraoperative musculocutaneous nerve stimulation, so were excised. Selective stimulation within the ulnar nerve in the middle third of the arm identified nerve fascicles with good flexor carpi ulnaris (FCU) response, but no intrinsic activation. Standard gracilis muscle flaps were harvested with 10 cm of motor nerve. The proximal end of the gracilis was tubed around the biceps tendon and the distal end sutured to the coracoid process (2/0 Ethibond). Endeend vascular anastomoses were onto the biceps pedicle, and brachial artery vena commitans. Access for microvascular anastomoses was improved. Neurosynthesis was performed after shortening the flap motor nerve. Postoperative immobilisation and physiotherapy was as for a traditional FFGMT, but it proved simpler to protect the pedicle from compression than with a standard orthograde flap inset.
146
Correspondence and communications
Each patient has been followed up for a minimum of 14 months. Both flaps survived and regained volitional function. No loss of intrinsic muscle function occurred, and FCU function persisted. Co-contraction with FCU has not been significant, and no deterioration in hand function occurred. Both patients have improved volitional elbow flexion power (MRC 3 to MRC 4; MRC 0 to MRC 3), range (80 to 130 ; 0 to 120 ), and endurance. Case 1 became able to flex the elbow while maintaining grip. Cosmesis was improved over previous orthograde cases. Patient satisfaction in terms of function and cosmesis was high. When ulnar nerve fascicles are to motorise an FFGMT for elbow reanimation, use of an inverted inset improves access for microvascular anastomosis, provides a short regeneration distance, and improves cosmesis without compromising outcome.
Conflict of interests None.
Funding Support received from the Stephen Forrest Charitable Trust.
References 1. Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A. Microvascular free functioning gracilis transfer with nerve transfer to establish elbow flexion. J Plast Reconstr Aesthet Surg 2010;63:1142e9. 2. Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin 2005:91e102. 3. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop A. Gracilis free muscle transfer for restoration of function after complete brachial plexus avulsion. Neurosurg Focus 2004; 16(5):E8.
K. Chin D. Vasdeki Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
Visualization of blood supply to the ‘vascularized nerve’ with anterolateral thigh flap using indocyanine green fluorescence angiography Dear Sir, The operative procedures of nerve reconstruction include vascularized and non-vascularized nerve grafts. In cases of transplantation to a poorly perfused area, such as perioperative radiation therapy cases, good perfusion of the grafted nerve is a very important factor in order to obtain a good result of nerve reconstruction. There are several reports on reconstruction with the flap involving vascularized nerve,1 but the evaluation of blood flow of grafted nerves has rarely been reported. The aim of this report was to visualize the perfusion of vascularized nerve graft during operation by using indocyanine green (ICG) fluorescence angiography. A 46-year-old woman underwent reconstruction with anterolateral thigh (ALT) flap involving vastus lateralis motor nerve (vastus lateralis branch of the femoral nerve) for the soft tissue and facial nerve defect after external auditory cancer ablation. Vastus lateralis motor nerve was harvested attached to the pedicle vessels and vastus lateralis muscle with about one-third of its full length, and about two-thirds of the nerve was dissected and free (Figure 1). After elevation of flaps, the blood supply to this vastus lateralis motor nerve was evaluated by ICG fluorescence angiography before ligature of pedicle vessels. For examination, ICG (Diagnogreen 25 mg/10 ml, Daiichi Sankyo Company, Tokyo, Japan) was administered intravenously in a dose of 0.1 mg per kilogram of body weight through peripheral intravenous catheter. During and directly following administration, the nerve and the surrounding tissue were monitored under a near-infrared video camera system (PDE; Hamamatsu Photonics, Hamamatsu, Japan).
A. Hart Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK Scottish National Brachial Plexus Service, National Services Directorate, UK College of Medical, Veterinary & Life Sciences, The University of Glasgow, Glasgow G12 8QQ, UK E-mail address: [email protected] ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. http://dx.doi.org/10.1016/j.bjps.2012.07.016
Figure 1 Elevated ALT flap with vastus lateralis motor nerve (arrow) and pedicle vessel (triangle).