Free vascularized nail graft under digital block

The History and Innovations of Blood Vessel Anastomosis

Surgical technique and technology frequently coevolve. The brief history of blood vessel anastomosis is full of famous names. While the techniques pioneered by these surgeons have been well described, the technology that facilitated their advancements and their inventors deserve recognition. The mass production of laboratory microscopes in the mid-1800s allowed for an explosion of interest in tissue histology. This improved understanding of vascular physiology and thrombosis laid the groundwork for Carrel and Guthrie to report some of the first successful vascular anastomoses. In 1916, McLean discovered heparin. Twenty-four years later, Gordon Murray found that it could prevent thrombosis when performing end-to-end anastomosis. These discoveries paved the way for the first-in-human kidney transplantations. Otolaryngologists Nylen and Holmgren were the first to bring the laboratory microscope into the operating room, but Jacobson was the first to apply these techniques to microvascular anastomosis. His first successful attempt in 1960 and the subsequent development of microsurgical tools allowed for an explosion of interest in microsurgery, and several decades of innovation followed. Today, new advancements promise to make microvascular and vascular surgery faster, cheaper, and safer for patients. The future of surgery will always be inextricably tied to the creativity and vision of its innovators.

Does nerve repair influence the outcome of reconstruction of a digital nail defect using a free composite flap taken from the great toe?

We describe reconstruction of a nail unit defect in the finger using a free composite flap taken from the great toe, comparing the outcome in patients in whom neurorrhaphy between the dorsal digital nerve of the great toe and the dorsal branch of the proper digital nerve of the injured finger was performed to those in which no nerve repair was made. From January 2002 to March 2009, 47 patients with traumatic fingernail defects were treated. Twenty-two patients before February 2005 had no nerve repair and subsequently 25 patients had nerve repair. The mean size of the germinal matrix and sterile matrix defects was 9 × 8 mm, and the mean size of the nail bed flaps was 9 × 9 mm. The mean length of the arteries used for the flap was 2.2 cm. Outcomes were rated. In the nerve repair group, full flap survival was achieved in 24 patients. At the mean follow-up period of 25 months, there were 12 excellent, seven very good, four good, and two fair results. In the comparison group without nerve repair, there were seven excellent, four very good, four good, five fair, and two poor results. Donor site morbidities were similar in both groups. The use of a free composite flap taken from the great toe is a useful technique for reconstructing nail unit defects in the finger. Innervated nail flap reconstructions tended to show better outcomes than those in which no nerve repair was performed. There is no difference in function or donor site between those in whom the nerve was repaired compared with those in whom it was not repaired.

Clinical applications of venous flaps in the reconstruction of hands and fingers

In recent years, the venous flap has been highly regarded in microsurgical and reconstructive surgeries, especially in the reconstruction of hand and digit injuries. It is easily designed and harvested with good quality. It is thin and pliable, without the need of sacrificing a major artery at the donor site, and has no limitation on the donor site. It can be transferred not only as a pure skin flap, but also as a composite flap including tendons and nerves as well as vein grafts. All these advantages make it an optimal candidate for hand and digit reconstruction when conventional flaps are limited or unavailable. In this article, we review its classifications and the selection of donor sites, update its clinical applications, and summarize its indications for all types of venous flaps in hand and digit reconstruction.

Perforator flaps and supermicrosurgery

The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.