• Archives of Reconstructive Microsurgery
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• v.8 no.1
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• pp.10-14
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• 1999

Ear reconstruction is very difficult to perform and often results in a devastating deformity. The use of microsurgical replantation techniques has allowed very favorable anesthetic results. We report a case of a partial ear replantation without venous repair with the use of medicinal leeches to decompress the acute venous congestion during the postoperative care. The medicinal leech therapy can be very useful in a partial ear replantation in cases with no venous repair.

• Archives of Reconstructive Microsurgery
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• v.16 no.2
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• pp.75-81
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• 2007

Introduction: Microsurgical replantation of amputated digit have become common procedure in recent years. However replantation of fingertip amputation, Zone I by Yamano classification, is still difficult because digital arteries branch into small arteries and also digital veins are hard to separate from the immobile soft tissue. So, fingertip amputation was covered by volar V-Y flap, composite graft, cross finger flap and groin flap. But patients who have been treated by these methods experience shortening of digit, nail deformity, excessive tenderness and persistent pain. Replantation could solve most of these problems. Material & Methods: In our department, from March 2004 to August 2007, 36 digits in 32 patients with complete amputation at distal to nail base were replanted using a microsurgical technique. Results: The overall survival rate of the replanted finger was 75%. Venous anastomosis was possible in 8 cases and impossible in 28 cases. In latter cases external bleeding technique was applied with medical leech. Conclusion: After replantation, a few patient complained decreased sensibility, nail deformity and cold intolerance. But most of patients were satisfied with the functional and cosmetic appearance of the viable replanted digits. We believe the replantation should be the first choice in fingertip amputation.

• Archives of Reconstructive Microsurgery
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• v.14 no.2
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• pp.112-116
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• 2005

The auricle is easy to be amputated in the face due to its protruding position. When facial parts are amputated, the mechanism of injury usually involves some form of avulsion, which damages these fragile vessels over a distance and renders them unsuitable for anastomosis. Replantation of the ear remains a challenging problem because of the tiny vessels and the paucity of adequate veins for anastomosis. Reattachment as a composite graft of the total or subtotal amputated ear is unreliable. Microsurgical replantation can be performed in a minority of cases because of technical difficulties and long operation time. In this article, the authors report two case of a successful ear replantation of completely amputated auricle. Only one artery and one vein were anastomosed in first case. In the other case one artery was anastomosed without vein. Instead of venous repair, multiple incision was done with leech application therapy. and the outcome was successful. In spite of the technical difficulties and long operation time, microsurgical replantation of amputated ear is better than other reconstructive method or reattachment without microsurgery.

• Archives of Reconstructive Microsurgery
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• v.20 no.2
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• pp.126-131
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• 2011

Purpose: The subcutaneous pocket graft of the thumb tip amputation across or proximal to the lunula is chosen in case of impossible microvascular anastomosis and in patient who strongly desired to preserve the thumb tip after failed replantation. Materials and Methods: Two patients who underwent a subcutaneous pocket graft for a thumb tip reconstruction between August 2008 and November 2009 were reviewed retrospectively. They were all males with a mean age at the time of surgery of 48 years and had sustained complete thumb tip amputations across or proximal to the lunula. In one case, the microsurgical replantation was not feasible and the other one revealed arterial insufficiency at the 7th day after microsurgical replantation. Results: Authors had experienced 2 cases of flaps which survived completely. The results of sensibility was good, the range of motion at interphalangeal joint and tip to tip pinch was acceptable and color mismatch and loss of thumb finger nail was unacceptable after more than 1 year follow up with conventional successful thumb tip replantation. Conclusion: The subcutaneous pocket graft could be chosen in thumb tip amputation in case of impossible microvascular anastomosis as well as who strongly desires to preserve thumb tip after failed replantation.

• Archives of Plastic Surgery
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• v.39 no.4
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• pp.404-410
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• 2012

Background First suggested by Brent in 1979, the pocket principle is an alternative method for patients for whom a microsurgical replantation is not feasible. We report the successful results of a modified palmar pocket method in adults. Methods Between 2004 and 2008, we treated 10 patients by nonmicrosurgical replantation using palmar pocketing. All patients were adults who sustained a complete fingertip amputation from the tip to lunula in a digits. In all of these patients, the amputation occurred due to a crush or avulsion-type injury, and a microsurgical replantation was not feasible. We used the palmar pocketing method following a composite graft in these patients and prepared the pocket in the subcutaneous layer of the ipsilateral palm. Results Of a total of 10 cases, nine had complete survival of the replantation and one had 20% partial necrosis. All of the cases were managed to conserve the fingernails, which led to acceptable cosmetic results. Conclusions A composite graft and palmar pocketing in adult cases of fingertip injury constitute a simple, reliable operation for digital amputation extending from the tip to the lunula. These methods had satisfactory results.

• Archives of Plastic Surgery
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• v.38 no.5
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• pp.642-648
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• 2011

Purpose: The recent advances in microsurgical techniques and their refinement over the past decade have greatly expanded the indications for digital replantations and have enabled us to salvage severed fingers more often. Many studies have reported greater than 80% viability rates in replantation surgery with functional results. However, replantation of multi-level amputations still remain a challenging problem and the decision of whether or not to replant an amputated part is difficult even for an experienced reconstructive surgeon because the ultimate functional result is unpredictable. Methods: Between January of 2002 and May of 2008, we treated 10 multi-level amputated digits of 7 patients. After brachial plexus block, meticulous replantation procedure was performed under microscopic magnification. Postoperatively, hand elevation, heat lamp, drug therapy and hyperbaric oxygen therapy were applied with careful observation of digital circulation. Early rehabilitation protocol was performed for functional improvement. Results: Among the 19 amputated segments of 10 digits, 16 segments survived completely without any complications. Overall survival rate was 84%. Complete necrosis of one finger tip segment and partial necrosis of two distal amputated segments developed and subsequent surgical interventions such as groin flap, local advancement flap and skin graft were performed. The overall result was functionally and aesthetically satisfactory. Conclusion: We experienced successful replantations of multi-level amputated digits. When we encounter a multi-level amputation, the key question is whether or not it is a contraindication to replantation. Despite the demand for skillful microsurgical technique and longer operative time, the authors' results prove it is worth attempting replantations in multi-level amputation because of the superiority in aesthetic and functional results.

• Archives of Plastic Surgery
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• v.40 no.3
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• pp.214-219
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• 2013

Background We established the Microvascular Research Center Training Program (MRCP) to help trainee surgeons acquire and develop microsurgical skills. Medical students were recruited to undergo the MRCP to assess the effectiveness of the MRCP for trainee surgeons. Methods Twenty-two medical students with no prior microsurgical experience, who completed the course from 2005 to 2012, were included. The MRCP comprises 5 stages of training, each with specific passing requirements. Stages 1 and 2 involve anastomosing silicone tubes and blood vessels of chicken carcasses, respectively, within 20 minutes. Stage 3 involves anastomosing the femoral artery and vein of live rats with a 1-day patency rate of >80%. Stage 4 requires replantation of free superficial inferior epigastric artery flaps in rats with a 7-day success rate of >80%. Stage 5 involves successful completion of one case of rat replantation/transplantation. We calculated the passing rate for each stage and recorded the number of anastomoses required to pass stages 3 and 4. Results The passing rates were 100% (22/22) for stages 1 and 2, 86.4% (19/22) for stage 3, 59.1% (13/22) for stage 4, and 55.0% (11/20) for stage 5. The number of anastomoses performed was $17.2{\pm}12.2$ in stage 3 and $11.3{\pm}8.1$ in stage 4. Conclusions Majority of the medical students who undertook the MRCP acquired basic microsurgical skills. Thus, we conclude that the MRCP is an effective microsurgery training program for trainee surgeons.

• 대한미세수술학회:학술대회논문집
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• 1992.11a
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• pp.79-79
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• 1992

• Archives of Plastic Surgery
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• v.32 no.1
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• pp.124-130
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• 2005

In the microsurgical era, replantation with microvascular anastomosis is considered as the most superior method in aspects of texture, color, shape in case of nose amputation. There are some reported cases of replantation in nose amputation historically, but most of them are composite graft cases rather than microvascular anastomosis. Only a few cases of successful nasal replantation with microvascular anastomosis have been reported due to the reason that the size of vessels is usually very small and identifying suitable vessels for anastomosis is difficult. Microanastomosis of artery and microanastomosis of vein are ideal in replantation, but identifying suitable veins is often difficult. Without venous anastomosis, resolving the venous congestion remains to be a problem. We can carry out arteriovenous shunt if we can find two arteries in amputee. However, the smaller the size of amputee is, the more difficult it is to find two arteries. Instead of arteriovenous shunt, we can try external venous drainage(frequently swab, pin-prick, stab incision, IV or local heparin injection, dropping, apply of heparin-soaked gauze, use of medical leech). Here, we present three cases of replantation with microscopical arterial anastomosis (one angular artery, two dorsal nasal arteries) and external venous drainage (stab incision, application of medical leech and heparin-soaked gauze) even though the size of amputee may be as small as $1.5{\times}1.0cm$. In all cases, surgical outcomes were excellent in cosmetic and functional aspects. This report describes successful replantation by microvasular anastomosis in case that suitable veins are not found.

• Archives of Craniofacial Surgery
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• v.12 no.2
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• pp.116-120
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• 2011

Purpose: Scalp avulsion is a life-threatening injury that may cause trauma to the forehead, eyebrows, and periauricular tissue. It is difficult to treat scalp avulsion as it may lead to severe bleeding. Therefore, emergency scalp replantation surgery is necessary, and we must consider the function, aesthetics, and psychology of the patients. A case of scalp avulsion leading to massive bleeding was encountered by these authors, which led to a failure to achieve the proper operation conditions in an adequate time period. Methods: A 49-year-old female was hospitalized due to having had her head caught in a rotatory machine, causing complete scalp avulsion which included the dorsum of the nose, both eyebrows, and ears. Emergent microsurgical replantation was performed, where a superficial temporal artery and a vein were anastomosed, but the patient's vital signs were too unstable for further operation due to excessive blood loss. Three days after the microanastomosis, venous congestion developed at the replanted scalp, and a medicinal leech was used. Leech therapy resolved the venous congestion. A demarcation then developed between the vitalized scalp tissue and the necrotized area. Debridement was performed 2 times on the necrotized scalp area. Finally, split-thickness skin graft with a dermal acellular matrix ($Matriderm^{(R)}$) was performed on the defective areas, which included the left temporal area, the occipital area, and both eyebrows. Results: The forehead, vertex, right temporal area, and half of the occipital area were successfully replanted, and the hair at the replanted scalp was preserved. As stated above, two-thirds of the scalp survived; the patient could cover the skin graft area with her hair, and could wear a wig. Conclusion: Complete scalp avulsion needs emergent replantation with microsurgical revascularization, but it often leads to serious vital conditions. We report a case with acceptable results, although the microanastomosed vessel was minimal due to the patient's unstable vital signs.