Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery最新文献

Incomplete recovery of function and neuropathic pain are common problems after peripheral nerve injury. To develop new treatment strategies for peripheral nerve injuries we investigated whether the neurotrophic factor artemin could improve outcome after sciatic nerve injuries in rats. Artemin is a member of the glial cell line-derived neurotrophic factor (GDNF) family and exerts neuroprotective effects on sensory neurons as well as influencing behavioural thermal sensitivity. We additionally evaluated if fibrin sealant, which is sometimes used as a nerve glue, had any effects on neuropathic pain-related behaviour. After the sciatic nerve had been transected, 30 animals were randomised to one of three groups: treatment with a fibrin sealant that contained artemin in conjunction with sutures; fibrin sealant with no artemin (sham) in conjunction with sutures; or sutures alone (n=10 in each group). Motor function, sensory function, and autotomy were evaluated from 1 to 12 weeks after injury. Retrograde flourogold tracing 12 weeks after injury showed that the addition of artemin increased the number of regenerating motor neurons. However, it did not improve their performance, as measured by the Sciatic Function Index, compared with sham or suture alone. Animals treated with artemin had a non-significant increase in motor nerve conduction velocity compared with sham. However, artemin did not reverse nerve injury-induced pain behaviour such as cold or heat hypersensitivity. Fibrin sealant in itself did not ameliorate motor performance, or regeneration of motor neurons, or give rise to nerve injury-induced pain behaviour. The results indicate that artemin is of value as a treatment for peripheral nerve injuries, although the effects were limited. As the artemin high-affinity receptor GFRalpha-3 is present in Schwann cells and not in motor neurons, the effect on motor neuron axon regeneration may result from an indirect effect through Schwann cells in the injured nerve.

Cryptotia is the fourth most common congenital auricular deformity, and it is more prevalent among Asians. A number of techniques for its correction have been introduced, and relatively favourable results have been achieved. We describe our experience with a technique for its correction using the square flap method designed on the temporal scalp and skin over the auricle. From 2001 to 2006 a total of 19 examples in 12 patients were treated. Seven patients had bilateral, and five had unilateral, cryptotia. Traction was applied to the upper part of the auricle to draw it away from the scalp, and the square flap method, consisting of two triangular flaps and one square flap, were designed on the temporal scalp and skin over the auricle. After the skin had been incised, the three flaps were freed completely, and the abnormal insertion of the auricular intrinsic muscles was detached. The flaps were then transposed, advanced, and sutured. There were no problems of viability in any patient, and all healed well. The follow-up period was 3 months to 2 years, with relatively favourable results. Function and appearance were satisfactory in all patients. The length of the helix was extended, and it was possible to increase the width of the upper part of the auricle. This technique is indicated in cases of mild to moderate cryptotia, and has many advantages, including simple and easy design, provision of enough skin for the upper and posterior portions of the auricle, sufficient depth of the auriculocephalic sulcus, and no additional skin grafting.

Although various methods are available to treat scars, it is difficult to manage those with suture marks that look like fish-bones, mainly because a large amount of tissue between the suture marks must be discarded with the scar. We report the wavy line closure for revision of abdominal scars with suture marks in three children who were operated on for congenital abdominal diseases. The entire scar, including all the suture marks, was excised using an incision consisting of a pair of smoothly waved lines. This incision makes it possible to reduce the tension on the wound by preserving the normal skin between the suture marks, which is followed by fine scars. The resulting wave-shaped scar is less noticeable and more resistant to postoperative contracture than a straight scar.

Clinical assessment and various diagnostic tools, particularly magnetic resonance imaging (MRI), of tumours of peripheral nerves are used to get an accurate diagnosis and to plan surgical intervention. Our purpose was to examine the usefulness of MRI in assessing nerve tumours in the upper extremity. Medical records of 19 patients (20 MRI examinations) with 29 histopathologically verified benign nerve tumours were examined retrospectively. In 12/20 cases MRI suggested a correct diagnosis of the type of nerve tumour. An additional 3/20 cases had an uncertain diagnosis, but nerve relations to the tumour were established. In 5/20 cases MRI gave a doubtful diagnosis with no suspicion of the tumour being located in a nerve trunk. MRI can localise and diagnose a nerve tumour in the upper extremity in 75% of cases, but it is difficult to specify the type of tumour.

We used endoscopy and ultrasonic liposuction to remove lipomas from the forehead to facilitate early return to work. The tumours were approached through a pair of small remote scalp incisions behind the frontal hairline, which continued to subperiosteal dissection, thereby avoiding injury to the supraorbital or supratrochlear neurovascular bundles. The deep surfaces of the lipomas were identified easily through the periosteum by well-illuminated and magnified endoscopic views, and protruded through the periosteal incisions. An ultrasonic cannula was introduced to emulsify and aspirate the lipomas. Parts of the lipomas were extracted by forceps as solid specimens for histopathological evaluation. Preservation of the neurovascular bundles and complete resection of the tumours in the bloodless operative fields were confirmed by direct endoscopic monitoring. Of five patients treated, three returned to their jobs within two postoperative days, with no protective dressings on their faces. There have, to our knowledge, been few reports describing this combination of endoscopy and ultrasonic treatment of forehead lipomas.

We investigated the effects of direct gradual lengthening of the distal stump of a peripheral nerve and subsequent nerve regeneration in rats. A segment 10 mm long was resected from rat sciatic nerve. The distal nerve stump was fixed to a ring and pulled directly at a rate of 1 mm/day using an original external nerve distraction device. After distraction for 10, 15, and 20 days, the lengthened nerves were evaluated macroscopically and immunocytochemically. At day 20, the mean (SD) distances from the ring to the 3 mm and 6 mm distal part, which were marked with sutures on the epineurium, were 7 (0.5) mm and 12.1 (0.5) mm, respectively, and the number of Schwann cells in the lengthening group had increased to twice that of control group. The distal stump of a peripheral nerve including the epineurium, endoneurium, and proliferation of Schwann cells can be lengthened directly. This method also made it possible to lengthen the nerve stump longitudinally and to control both the rate and distance. We think that this method may be used in the treatment of peripheral nerve injury.

Our aim was to find out if a modified intravenous regional anaesthetic block technique, used for invasive surgical procedures on the distal forearm and hand, results in a drier operative field than traditional methods. Twenty consenting adult (age > 18) patients who were to have an operation on the distal forearm or hand were randomised into two groups (n=10 in each). The first group was using a traditional bier block, with a double upper arm tourniquet. The second group was using a modified regional anaesthetic block technique, with a single upper arm tourniquet, and a single forearm tourniquet. All operative fields were recorded photographically and judged by the operating surgeon as "wet" or "dry". Analgesic requirements and subjective pain were recorded. Plasma lignocaine concentrations were measured. "Wet" operative fields were seen in 6 of the conventional and 0 of the modified group (p=0.01). Patients in the modified group were more comfortable during the procedures (p=0.004). This benefit was not sustained postoperatively (p=0.57). Plasma lignocaine concentrations were higher in the conventional group (p=0.004). The modified technique was as safe as the conventional technique but has the benefits of a drier surgical field and improved intraoperative comfort for patients.

To improve the shape of the cleft lip nose preoperatively, we have developed the nasal alar elevator. This has been used routinely since 1996 on all our cleft lip patients who have an asymmetrical nose, from the first week after birth until the date of primary lip surgery. We present our 11-year-long experience of using the device on patients born with complete, unilateral cleft lip. In this study 56 children, born between 1996 and 2006 inclusive, with complete unilateral cleft lip, had preoperative treatment with the elevator. During this 11-year period, continuous evaluation during the preoperative period, and its effects on the cleft lip nose, were evaluated, both preoperatively and postoperatively. Our results show that the preoperative use of the device has led to less need for primary nasal surgery. Instead of having to have a primary rhinoplasty (McComb) together with a lip plasty, as a routine, now only about 30% of the patients need primary surgical correction of the nose. If nasal correction is needed, a rather limited undermining of skin over the ala on the cleft side will often be sufficient. The use of a nasal elevator reduces both the length and the extent of the primary intervention, without compromising the final result.

Forty-three women had reduction mammaplasty during the period 1992-2000 and the cosmetic outcome was evaluated using subjective and objective measures. The inferior pedicle technique was used in all cases. The mean (SD) weight of resected tissue was 1121 (415) g. All objective measurements were within the ideal range except for breast volume and nipple-to-inframammary-line distance, which were more than ideal. Overall, the median difference in measurements between the two breasts of each woman was less than 10%. However, the subjective evaluations given by both clinicians and the patients for overall symmetry and for general aesthetic appearance fell below the preset threshold. The shape of the breast correlated best with the grades of symmetry and general appearance. There was no correlation between the objective and subjective evaluations of symmetry. The disappointing subjective scores, which may be attributed to the specific characteristics of our sample group, are heavy breasts and overweight patients, a double team approach, and the inevitable pseudoptosis that develops with the inferior pedicle approach. These direct us to recommend searching for an alternative operative technique and to evaluate its long term results, as well as placing the nipple-areola complex lower than the standard inframammary fold projection.

Sclerotherapy is effective in the treatment of vascular malformations. However, in lesions with relatively high blood flow, its effect is not always adequate. We therefore developed a three-grade classification of vascular malformations to facilitate the selection of treatments according to vascular flow. We also developed the technique of embolosclerotherapy, in which transarterial embolisation is done before sclerotherapy to control blood flow in the lesion during sclerotherapy. We now have 14 years' experience with 112 cases of vascular malformations of the head and neck treated with sclerotherapy. Results were evaluated with pretreatment and post-treatment photographs, and reduction of volume was calculated on findings from magnetic resonance imaging. Clinical improvement in 110 cases was graded as excellent in 32 (29%), good in 48 (43%), fair in 19 (17%), and poor in 11 (10%). In 84 cases, mean rate of reduction of volume was 35%. The most common complication was haemolytic haemoglobinuria (n=37, 33%). Our results suggest that this three-grade classification is useful to judge resistance to sclerotherapy and decide on treatment. Our experience indicates that ethanolamine oleate (EO), with or without arterial embolisation, was effective using our classification of vascular dynamics. We consider EO to be equivalent or superior to other sclerosants such as ethanol.