Neoplasms containing glomus cells are uncommon. Glomus cells within an angiomatosis, so called gl... more Neoplasms containing glomus cells are uncommon. Glomus cells within an angiomatosis, so called glomangiomatosis, is exceedingly rare with only three previously reported cases. We are describing the fourth case from a 17-year-old boy which involved his left hand, fingers, and distal forearm. We will review the previously reported cases.
A heterodigital vascularized island flap can functionally restore large soft tissue defects to th... more A heterodigital vascularized island flap can functionally restore large soft tissue defects to the injured fingertip in a single stage. It is optimally used for digits of unequal length so that the donor fingertip is not violated, and the skin island is best taken from the less dominant side of the donor finger. Because it is a transposition flap with a proximal axis of rotation, its transposition arc can also reach the dorsum of an adjacent digit. This article describes how the heterodigital arterialized flap preserves the donor finger digital nerve and distal pulp, thus reducing donor site morbidity. Indications, method of flap elevation, and flap design will be reviewed to optimize case selection, minimize donor site morbidity, and enhance safety of flap elevation and transposition.
Plastic and reconstructive surgery. Global open, Jul 1, 2020
Summary: Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Target... more Summary: Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.
Because of the large number of women now returning to their plastic surgeons with concerns about ... more Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture.
Purpose To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences... more Purpose To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences between the fingers and thumb will provide an improved clinical understanding of the thumb dorsal aponeurosis anatomy. Methods Ten fresh cadaver hands from 5 patients with an average age of 31.6 (range, 22e41) years were dissected. The thenar muscles were identified and insertion sites were documented. The fibers of the dorsal aponeurosis and contributions were identified. Results The flexor pollicis brevis superficial head contributed to the radial fibers of the dorsal aponeurosis in 8 specimens and contributed to the deep head in 1 specimen. The abductor pollicis brevis provided fibers to the radial dorsal aponeurosis in all 10 specimens. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. Conclusions This investigation provides a detailed anatomic study of the dorsal aponeurosis of the thumb with observation of both intrinsic and extrinsic contributions. Clinical relevance Understanding the anatomy of the dorsal aponeurosis of the thumb remains important not only for evaluation of the classic Stener lesion, but also for the appropriate treatment of deformity, contracture, and neuromuscular disorders involving the thumb.
This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to mi... more This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to microvascular tissue transfer. The simplest reconstructive option must be chosen to suit the defect and to achieve the least possible donor morbidity. The most suitable reconstructive choices are discussed for each of the following situations: to provide a large surface area, to provide hair-bearing tissue, to fill "dead space," to restore motor function, or to provide composite bone and soft-tissue structures.
Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated fr... more Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated from the abnormal proliferation of Schwann cells. Often, these tumors occur in isolation and are known as schwannomas or neurilemmomas. The presence of multiple schwannomas is known as schwannomatosis. The purpose of this article is 2-fold: (1) to review the relevant literature and describe a unique case of this rare condition; and (2) to emphasize salient clinical considerations in the diagnosis and treatment of schwannomatosis. Methods: In this report, we describe the case of a 52-year-old white man who presented with multiple recurrent soft tissue masses of the right hand. On initial presentation, he described pain across his right hand and index finger, which persisted despite numerous prior operations. The index finger had a flexion contracture around the location of the proximal interphalangeal joint, and there were multiple tender masses along the length of the finger and palm. Results: Segmental excision of the affected radial digital nerve was performed. A pulp flap based on contralateral neurovascular bundle resulted in a sensate, pain-free digit. Tissue pathology confirmed the diagnosis of multiple neurilemmomas. Conclusions: We report the success of a radial digital neurectomy in a patient with widespread neurilemmomas, who had previously excluded that painful digit from use. It was through careful consideration of the preoperative differential diagnosis, by valuing the preoperative imaging, and by considering all surgical options with specific attention paid to skin flap design that this good outcome of a fully sensate, pain-free, mobile index finger was achieved.
Injury-international Journal of The Care of The Injured, Dec 1, 2020
Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstruct... more Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.
Distraction osteogenesis is helpful for digit lengthening for congenital and post-traumatic defic... more Distraction osteogenesis is helpful for digit lengthening for congenital and post-traumatic deficits. Distraction lengthening is also helpful for soft tissue stretching such as for radial dysplasia. This article reviews some of these uses for distraction osteogenesis.
Normal and abnormal embryologic and postnatal development of the extremities, chest wall, breasts... more Normal and abnormal embryologic and postnatal development of the extremities, chest wall, breasts, and abdominal wall are described. Knowledge of development anatomy is helpful in forming a rational basis for planning and timing of surgical intervention. Clinical and potential clinical applications are described.
The treatment of especially complicated calvarial defects-e.g. cases where there have already bee... more The treatment of especially complicated calvarial defects-e.g. cases where there have already been multiple attempts at reconstruction-is a specialty of the department. We like to use titanium implants, which are inert and thus resistant to infection. The implants are computer-designed and thus fit without further corrections. In special cases expanders are used to stretch the skin so that it will be easer to close it together with the implant later on.
Neoplasms containing glomus cells are uncommon. Glomus cells within an angiomatosis, so called gl... more Neoplasms containing glomus cells are uncommon. Glomus cells within an angiomatosis, so called glomangiomatosis, is exceedingly rare with only three previously reported cases. We are describing the fourth case from a 17-year-old boy which involved his left hand, fingers, and distal forearm. We will review the previously reported cases.
A heterodigital vascularized island flap can functionally restore large soft tissue defects to th... more A heterodigital vascularized island flap can functionally restore large soft tissue defects to the injured fingertip in a single stage. It is optimally used for digits of unequal length so that the donor fingertip is not violated, and the skin island is best taken from the less dominant side of the donor finger. Because it is a transposition flap with a proximal axis of rotation, its transposition arc can also reach the dorsum of an adjacent digit. This article describes how the heterodigital arterialized flap preserves the donor finger digital nerve and distal pulp, thus reducing donor site morbidity. Indications, method of flap elevation, and flap design will be reviewed to optimize case selection, minimize donor site morbidity, and enhance safety of flap elevation and transposition.
Plastic and reconstructive surgery. Global open, Jul 1, 2020
Summary: Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Target... more Summary: Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.
Because of the large number of women now returning to their plastic surgeons with concerns about ... more Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture.
Purpose To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences... more Purpose To evaluate the thumb dorsal aponeurosis anatomy. Consideration of structural differences between the fingers and thumb will provide an improved clinical understanding of the thumb dorsal aponeurosis anatomy. Methods Ten fresh cadaver hands from 5 patients with an average age of 31.6 (range, 22e41) years were dissected. The thenar muscles were identified and insertion sites were documented. The fibers of the dorsal aponeurosis and contributions were identified. Results The flexor pollicis brevis superficial head contributed to the radial fibers of the dorsal aponeurosis in 8 specimens and contributed to the deep head in 1 specimen. The abductor pollicis brevis provided fibers to the radial dorsal aponeurosis in all 10 specimens. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. Conclusions This investigation provides a detailed anatomic study of the dorsal aponeurosis of the thumb with observation of both intrinsic and extrinsic contributions. Clinical relevance Understanding the anatomy of the dorsal aponeurosis of the thumb remains important not only for evaluation of the classic Stener lesion, but also for the appropriate treatment of deformity, contracture, and neuromuscular disorders involving the thumb.
This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to mi... more This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to microvascular tissue transfer. The simplest reconstructive option must be chosen to suit the defect and to achieve the least possible donor morbidity. The most suitable reconstructive choices are discussed for each of the following situations: to provide a large surface area, to provide hair-bearing tissue, to fill "dead space," to restore motor function, or to provide composite bone and soft-tissue structures.
Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated fr... more Background: Peripheral nerve sheath tumors (PNSTs) are neoplastic soft tissue masses generated from the abnormal proliferation of Schwann cells. Often, these tumors occur in isolation and are known as schwannomas or neurilemmomas. The presence of multiple schwannomas is known as schwannomatosis. The purpose of this article is 2-fold: (1) to review the relevant literature and describe a unique case of this rare condition; and (2) to emphasize salient clinical considerations in the diagnosis and treatment of schwannomatosis. Methods: In this report, we describe the case of a 52-year-old white man who presented with multiple recurrent soft tissue masses of the right hand. On initial presentation, he described pain across his right hand and index finger, which persisted despite numerous prior operations. The index finger had a flexion contracture around the location of the proximal interphalangeal joint, and there were multiple tender masses along the length of the finger and palm. Results: Segmental excision of the affected radial digital nerve was performed. A pulp flap based on contralateral neurovascular bundle resulted in a sensate, pain-free digit. Tissue pathology confirmed the diagnosis of multiple neurilemmomas. Conclusions: We report the success of a radial digital neurectomy in a patient with widespread neurilemmomas, who had previously excluded that painful digit from use. It was through careful consideration of the preoperative differential diagnosis, by valuing the preoperative imaging, and by considering all surgical options with specific attention paid to skin flap design that this good outcome of a fully sensate, pain-free, mobile index finger was achieved.
Injury-international Journal of The Care of The Injured, Dec 1, 2020
Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstruct... more Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.
Distraction osteogenesis is helpful for digit lengthening for congenital and post-traumatic defic... more Distraction osteogenesis is helpful for digit lengthening for congenital and post-traumatic deficits. Distraction lengthening is also helpful for soft tissue stretching such as for radial dysplasia. This article reviews some of these uses for distraction osteogenesis.
Normal and abnormal embryologic and postnatal development of the extremities, chest wall, breasts... more Normal and abnormal embryologic and postnatal development of the extremities, chest wall, breasts, and abdominal wall are described. Knowledge of development anatomy is helpful in forming a rational basis for planning and timing of surgical intervention. Clinical and potential clinical applications are described.
The treatment of especially complicated calvarial defects-e.g. cases where there have already bee... more The treatment of especially complicated calvarial defects-e.g. cases where there have already been multiple attempts at reconstruction-is a specialty of the department. We like to use titanium implants, which are inert and thus resistant to infection. The implants are computer-designed and thus fit without further corrections. In special cases expanders are used to stretch the skin so that it will be easer to close it together with the implant later on.
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Papers by David Netscher