Sixty-four cases of thumb and finger reconstruction using transplantation of the big toe skin-nail flap combined with the second toe or the second and third toes

The purpose of this article is to introduce the results of thumb and finger reconstruction using transplantation of the big toe wraparound flap combined with the second toe or the second and third toes. Between August of 1981 and December of 1998, in a series of 64 cases involving 58 patients with digitless hands, either (1) the thumb and index fingers were reconstructed by transplantation of a big toe wraparound flap combined with the adjacent second toe harvested from the ipsilateral foot; or (2) the thumb, index, and long fingers were reconstructed by transplantation of an ipsilateral big toe wraparound flap combined with the adjacent second and third toes. The phalanx of the new thumb was usually an iliac block. The success rate of this series was 92.2 percent. At long-term follow-up, the average static 2-point discrimination was less than 10 mm. The distance between the tip of the new thumb and the new index finger ranged from 6 to 10 cm (average, 8 cm). Opposition action was nimble and forceful. The patients could lift a 6- to 12-kg weight with their reconstructed digits. All patients were satisfied with their new hands and were able to use them in their daily activities. The transplants for reconstructing the thumb and fingers are harvested from the same foot in a procedure known as one-foot donation. Function of the bilateral digitless hand can be recovered with this procedure.     

Pompholyx of the hands and feet

The term pompholyx, both because of historical priority and because it does not convey misleading implications about etiology, is the preferable designation for this condition. Irrespective of its localization, the primary lesion is the same: a deep-seated, sago-grain-like, pinpoint to pinhead size blister or pustule, embedded in the normal skin, primarily without inflammatory reaction, and appearing suddenly. Pompholyx, as microbiologic, histopathologic and immunologic investigations have proved, is an endoparasitic-hematogenous eruption, having a characteristic localization. It is caused by the circulating endoparasite,B. endoparasiticus Benedek, 1927. Due to an universal infection immunity it is not infectious and not transmissible. Other microorganisms, like hyphomycetes, yeastlike organisms, common bacteria, etc. play no causative role in any phase of the condition. Dermatophytes, molds as well as yeastlike organisms which may be found in the roof of the blisters and other scrapings of diseased tissues are incidental nosoparasites. Extensive statistical analysis is presented about the occurrence of pompholyx on the hands and feet in military personnel and in civilian patients. Pompholyx has only one etiologically directed therapy: the specific vaccine ofB. endoparasiticus. The vaccine is prepared from the S-type of the bacilli, cultured from the blood.     

Thumb reconstruction by free microvascular transfer of an injured index finger

Thumb reconstruction for amputation at the metacarpal phalangeal level was accomplished by microneurovascular transfer of the contralateral damaged index finger ray, including metacarpal phalangeal joint. This transfer accomplished a successful thumb restoration and removed a cumbersome index finger amputation stump, improving function in both hands. This case emphasizes the merits of spare part transfer in hand reconstructive surgery made possible by microneurovascular techniques.     

Simple maxillary reconstruction using free tissue transfer and prostheses

Prosthetic rehabilitation is essential for maintaining postoperative oral function after maxillary reconstruction. However, the maxillary prosthesis becomes unstable in some patients because of extensive palatomaxillary resection and drooping of the transferred flap. In such patients, maintaining sufficient oral function is difficult, especially if the patient is edentulous. To achieve prosthetic retention, the authors performed microvascular maxillary reconstruction with a slit-shaped fenestration in the midline of the hard palate. Maxillary defects after subtotal or total maxillectomy were reconstructed with rectus abdominis musculocutaneous flaps in five patients. Defects of the nasal lining and palate were reconstructed with the single cutaneous portion of the flap, and a slit-shaped fenestration was left between the cutaneous portion of the flap and the edge of the remaining hard palate. Postoperatively, patients were fitted with maxillary prostheses that had a flat projection for the palatal fenestration. In all patients, the prosthesis was stable enough for mastication and prevented nasal regurgitation. Speech function was rated as excellent on Hirose's scoring system for Japanese speech ability. The authors believe that their method of palatomaxillary reconstruction is both simple and reliable.     

Acrodysplasia (hands and feet) with scoliosis, by autosomal recessive transmission

Brachydactyly is reported in two brothers born to consanguineous parents (1/8). Additional abnormal features were scoliosis, spina bifida occulta, and carpal synostosis.     

Limb reconstruction by free-tissue transfer combined with the Ilizarov method.

In four complex cases of extremity reconstruction, we have been able to overcome the problems of combined bone and soft-tissue loss and length discrepancy by a combination of free-tissue transfer and the Ilizarov method of slow distraction. It is our observation that gradual distraction of a free tissue is a safe and viable procedure; the free tissue tolerates the pins of the circular external fixator well, and there is an equal degree of distraction and regeneration of the transferred free tissue and the native recipient tissue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Manipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for later microsurgical procedures or endanger the axial flow pattern of the transferred free tissue.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

The hands and feet of Archaeolemur: metrical affinities and their functional significance

Recent expeditions to Madagascar have recovered abundant skeletal remains of Archaeolemur, one of the so-called "monkey lemurs" known from Holocene deposits scattered across the island. These new skeletons are sufficiently complete to permit reassembly of entire hands and feet--postcranial elements crucial to drawing inferences about substrate preferences and positional behavior. Univariate and multivariate analysis of intrinsic hand and foot proportions, phalangeal indices, relative pollex and hallux lengths, phalangeal curvature, and distal phalangeal shape reveal a highly derived and unique morphology for an extinct strepsirrhine that diverges dramatically from that of living lemurs and converges in some respects on that of Old World monkeys (e.g., mandrills, but not baboons or geladas). The hands and feet of Archaeolemur are relatively short (extremely so relative to body size); the carpus and tarsus are both "long" relative to total hand and foot lengths, respectively; phalangeal indices of both the hands and feet are low; both pollex and hallux are reduced; the apical tufts of the distal phalanges are very broad; and the proximal phalanges are slightly curved (but more so than in baboons). Overall grasping capabilities may have been compromised to some extent, and dexterous handling of small objects seems improbable. Deliberate and noncursorial quadrupedalism was most likely practiced on both the ground and in the trees. A flexible locomotor repertoire in conjunction with a eurytopic trophic adaptation allowed Archaeolemur to inhabit much of Madagascar and may explain why it was one of the latest surviving subfossil lemurs.