Microsurgery最新文献

Severe carpal tunnel syndrome (CTS) with advanced thenar denervation has limited reconstructive options, and reliable reinnervation remains challenging. Reverse end-to-side (RETS) nerve transfers have been described in other contexts but to our knowledge, have not been applied clinically to compressive median neuropathy at the wrist. Here, we present three patients, ages 59, 68, and 72 years, with severe CTS, visible thenar atrophy, and electrodiagnostic evidence of profound median motor axon loss who underwent carpal tunnel release with abductor digiti minimi (ADM)-to-recurrent motor branch (RMB) RETS transfer. All procedures were performed using a standardized microsurgical technique. Follow-up was 10 months (Case 1), 24 months (Case 2), and 8 months (Case 3). Postoperatively, each patient demonstrated early return of visible thenar contraction between 6 weeks and 4 months, with final abductor pollicis brevis (APB) strength of 4 to 4+. Sensory recovery improved across all cases, with two-point discrimination normalizing to 5–8 mm. Follow-up electrodiagnostic studies in two patients showed markedly greater APB compound muscle action potential (CMAP) amplitudes when stimulating through the ulnar nerve than through the median nerve, consistent with donor-derived reinnervation through the transfer. Patient-reported outcome measurement information system (PROMIS) upper extremity (UE) and physical function (PF) scores improved by 9–22 points. Although these early results suggest the potential for donor-derived reinnervation in severe CTS, the findings are preliminary and should be interpreted with caution. Larger prospective studies will be necessary to determine the true functional benefit, appropriate patient selection criteria, and comparative effectiveness of this technique.

Reconstruction of the columella, one of the smallest facial subunits, presents significant aesthetic and functional challenges due to its complex anatomy, limited local tissue for repair, and restricted vascularisation. Although many methods are described, literature on microsurgical solutions for complex secondary reconstructions, especially after conventional methods have failed, remains limited. This report introduces a tailored, single-stage approach that combines a first web space free flap from the foot with an iliac bone graft to provide both soft tissue coverage and structural support, while also reviewing other microsurgical techniques. A 24-year-old patient presented with a severe deformity, including a shortened columella, depressed nasal tip, and a scar extending to the right upper lip, causing alopecia in the mustache area due to a shrapnel injury during the Palestine War. After excising scar tissue and a necrotic L-strut from a previous failed surgery, a 2 × 3 cm columellar and septal defect was created. A fasciocutaneous free flap from the first web space of the foot was planned as a 2.5 × 4 cm rectangle, positioned transversely over the first web space and microsurgically transferred for end-to-end anastomosis to the angular artery and vein, then folded over an iliac bone graft to provide both external skin coverage and internal lining. The postoperative course was uneventful, and the patient was discharged on the fifth day. At the one-year follow-up, the reconstructed columella remained stable, and the patient expressed high satisfaction with the final aesthetic and functional results. This report shows that the first web space free flap, combined with a structural bone graft, offers a single-stage solution for complex columellar defects, providing a tailored approach when conventional methods have failed or are insufficient. The novelty of this approach lies in using an iliac bone graft, which offers strong and durable support capable of resisting scar contracture and maintaining long-term nasal tip projection despite heavily scarred tissue. Compared with other reviewed techniques, this single-stage approach avoids the multiple procedures required for prefabricated flaps and reduces donor site morbidity or bulkiness. Furthermore, its long vascular pedicle is an advantage over shorter-pedicled auricular or hand flaps, while the robust bone graft supplies a more durable framework against the contractile forces of compromised local tissue than cartilage-based reconstructions.

Reconstruction of pretibial defects remains challenging due to frequent bone exposure, lack of local flap options, and thin soft tissue coverage. These factors make achieving durable and aesthetically pleasing coverage difficult, often necessitating the use of free flaps to ensure successful reconstruction. This case report presents the case of a 68-year-old woman with a pretibial undifferentiated pleomorphic sarcoma treated with neoadjuvant radiotherapy and wide local excision, resulting in a 12 × 10 cm soft tissue defect with tibial bone exposure. Reconstruction was achieved using a combination of two perforator-based local flaps: A pedicled medial sural artery perforator (MSAP) flap for the medial aspect and a V-Y advancement flap based on an anterior tibial artery perforator for the lateral aspect. Postoperative recovery was uneventful. At one-year follow-up, the reconstruction showed stable coverage, satisfactory contour, and no signs of recurrence of the tumor or lymphedema. The combination of local perforator flaps offers a reliable and aesthetically favorable solution for complex pretibial defects. It allows surgeons to avoid microsurgical procedures, thereby reducing operative time, technical demands, and perioperative risks. This case highlights the potential of combining local flaps, preserving uninvolved donor sites, and minimizing overall morbidity. This solution represents a practical and effective alternative to free flap reconstruction and may contribute to expanding the reconstructive options available for managing complex lower limb defects.