Plastic and Reconstructive Surgery • January 2014 A plan for how to perform the incisions was devised to obtain a much clearer overview of how much skin would be needed to close the wound after the aponeurectomy. The planned incision was drawn onto the skin using a pencil. Classic partial aponeurectomy was performed, and the cord of the ray was completely resected in all patients. After the tourniquet was opened, hemostasis was achieved, and then the skin was closed in all cases. In this prospective case series, 11 patients with Dupuytren’s disease at Tubiana stage 3 or 4, and with affected metacarpophalangeal and proximal interphalangeal joints, were followed. The mean contracture was 129 degrees (range, 115 to 150 degrees). After percutaneous needle fasciotomy, the mean contracture was 88 degrees (range, 60 to 120 degrees). The mean reduction in contracture was 41 degrees; the contracture was reduced significantly in all cases. The t test for paired samples was used to calculate statistical significance. A normal distribution was present with a significance of 0.038 (p < 0.05). There were no nerve or vessel lesions, but there were two minor skin lesions after the extension maneuver at the distal palmar crease caused by severe adhesion of the skin to the cord. The lesions were easily covered using Z-plasty after the cord resection. Percutaneous needle fasciotomy is a well-known and established procedure for the treatment of Dupuytren’s disease at stages 1 and 2.5 A new technique is described that facilitates the approach for partial aponeurectomy in difficult cases. In all cases, the contracture can be reduced significantly at the same time as the partial aponeurectomy procedure. Obviously, the duration of surgery can be reduced. Nerve and vessel preparation are easier and safer with more extended finger positions. The prerequisite for this technique is a well-defined cord in the palm. This technique offers an easy way to reduce flexion contracture effectively and a simplified approach. DOI: 10.1097/01.prs.0000436802.12423.3f
Holger C. Erne, M.D. BGU Murnau Murnau, Germany
DISCLOSURE The author has no financial interest to declare in relation to the content of this article. REFERENCES 1. Piza-Katzer H, Herczeg E, Aspek R. Präoperative intermittierende pneumatische Extensionsbehandlung bei Dupuytrenscher Kontraktur im Stadium III und IV. Handchir Mikrochir Plast Chir. 2000;32:33–37. 2. Agee JM, Goss BC. The use of skeletal extension torque in reversing Dupuytren contractures of the proximal interphalangeal joint. J Hand Surg. 2012;37:1467–1474.
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3. Craft RO, Smith AA, Coakley B, Casey WJ 3rd, Rebecca AM, Duncan SF. Preliminary soft-tissue distraction versus checkrein ligament release after fasciectomy in the treatment of Dupuytren proximal interphalangeal joint contractures. Plast Reconstr Surg. 2011;128:1107–1113. 4. Messina A, Messina J. The continuous elongation treatment by the TEC device for severe Dupuytren’s contracture of the fingers. Plast Reconstr Surg. 1993;92:84–90. 5. Erne H, El Gammal A, Lukas B. Percutaneous needle fasciotomy: A serious alternative? In: Dupuytren’s Disease and Related Hyperproliferative Disorders. Berlin, Heidelberg: Springer-Verlag; 2012.
Three-Dimensional Printing of Perforator Vascular Anatomy Sir:
T
he use of three-dimensional printing has increased in recent years with the advent of commercially available three-dimensional printers and lower costs. Computed tomographic data can be obtained rapidly and incorporated into three-dimensional reconstructions visualized in two dimensions. This information can be used to produce a physical object using progressive layering of different polymers or materials with a three-dimensional printer. Production of three-dimensional models allows improved visualization and manipulation of anatomical structures compared with two-dimensional representations. They can be used for surgical planning, implant design, and education.1 Three-dimensional models have also been used for training on patient-specific models to simulate surgical procedures to help understand difficult anatomy, predict complications, and potentially reduce operating time.1–4 We produced a three-dimensional model to facilitate understanding of the regional anatomy of the internal mammary artery. We chose the internal mammary artery perforator system, as its relationship to surrounding ribs is important in the dissection and identification of the dominant perforator while raising the internal mammary artery perforator flap. To create a three-dimensional model of the dominant internal mammary artery perforator, a fresh cadaver was injected with the modified lead oxide technique described previously.5 The cadaver was obtained through the Dalhousie University Donor Program. Plain films and computed tomographic images of the cadaver were obtained and the data were analyzed using Materialise’s Interactive Medical Image Control System program (Materialise, Leuven, Belgium). Using the program, three-dimensional images of the dominant internal mammary artery perforator and surrounding structures were created (Fig. 1). The reconstruction was printed in three dimensions using a composite powder printing process on a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.). This produces a three-dimensional object by successively laying down the infiltrant to build the model slice by slice based on the reconstruction.
Volume 133, Number 1 • Viewpoints
Fig. 1. Three-dimensional reconstructions of the left bony thorax, internal mammary artery, and dominant left internal mammary artery perforator and lateral thoracic artery from cadaveric computed tomographic data using Materialise’s Interactive Medical Imaging Control System. (Left) Anterior-posterior, (center) oblique, and (right) posterior-anterior views (*, second internal mammary artery perforator; •, second rib; ♦, lateral thoracic artery).
We report the first use of three-dimensional printing to produce vascular perforator anatomy. The dominant internal mammary artery perforator can be seen branching off of the internal mammary artery, through the second intercostal
space and anastomosing with the lateral thoracic artery (Fig. 2). The use of three-dimensional printing to produce physical objects is the next step from three-dimensional reconstructions visualized on two-dimensional screens.
Fig. 2. Anteroposterior (left) and oblique (right) views of a three-dimensional model of the left bony thorax, internal mammary artery, and internal mammary artery perforator (*, second internal mammary artery perforator; •, second rib; ♦, lateral thoracic artery). The lateral thoracic artery was based on cadaveric data and printed using a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.).
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Plastic and Reconstructive Surgery • January 2014 It allows rapid manipulation and understanding of an individual’s anatomy by physically holding the object and being able to visualize it in multiple planes. This can be useful for teaching learners, and can be used as a tool to better explain the proposed surgery to patients using their own anatomy. One limitation of the process is the cost associated with production of the model, which can be anywhere from $400 to $1200. Also, due to the minuteness of perforator vessels, some smaller vessels do not endure the printing process due to the resolution limitations of the three-dimensional printer. This can be ameliorated with a larger model, albeit at a higher cost. Also, the materials used to make certain models are delicate, and rough handling can cause perforator branches to crack. However, postprinting processing with materials such as wax can create a durable model that can be used in clinics and teaching sessions. DOI: 10.1097/01.prs.0000436523.79293.64
Joshua A. Gillis, B.Sc., M.D. Steven F. Morris, M.D., M.Sc. Division of Plastic Surgery Dalhousie University Halifax, Nova Scotia, Canada Correspondence to Dr. Morris Division of Plastic Surgery Dalhousie University 4443-1796 Summer Street Halifax, Nova Scotia B3H 2A7, Canada [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article. REFERENCES 1. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D printing based on imaging data: Review of medical applications. Int J Comput Assist Radiol Surg. 2010;5: 335–341. 2. Klammert U, Böhm H, Schweitzer T, et al. Multi-directional Le Fort III midfacial distraction using an individual prefabricated device. J Craniomaxillofac Surg. 2009;37: 210–215. 3. Klammert U, Gbureck U, Vorndran E, Rödiger J, Meyer-Marcotty P, Kübler AC. 3D powder printed calcium phosphate implants for reconstruction of cranial and maxillofacial defects. J Craniomaxillofac Surg. 2010;38: 565–570. 4. Li B, Zhang L, Sun H, Yuan J, Shen SG, Wang X. A novel method of computer aided orthognathic surgery using individual CAD/CAM templates: A combination of osteotomy and repositioning guides. Br J Oral Maxillofac Surg. 2013;51:e239–e244. 5. Tang M, Geddes CR, Yang D, Morris SF. Modified lead oxide-gelatin injection technique for vascular studies. J Clin Anat. 2002;1:73–78.
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Reconstruction of Nasal Septal Perforations in Cocaine-Addicted Patients with Facial Artery Mucosa-Based Perforator Flap Sir: eptal perforation is one of the most frequent complications of snorting cocaine. A wide range of mucosal defects have been described, from a clinically asymptomatic state through pinpoint holes to the destruction of the dorsal support, or even the destruction of the maxilla. Various types of local flaps have been tested for reconstruction of the nasal septum.1 Because of the high risk of failure due to damage to adjacent tissue, the use of distant tissues or even distant free flaps is preferred.2 The problem with remote or free flaps is that their volume may be excessive and they may obstruct the passage of air. Other authors have described useful mucosal regional flaps, such as the facial artery musculomucosal,3 an axial flap centered over the facial artery, or the buccinator flap,4 based on the posterior buccal artery or the anterior segment of the facial artery. Anatomical studies performed by our group have identified direct perforators from the facial artery irrigating specific mucosal territories.5 On the basis of these findings, we have designed an island flap by selecting the areas with the best vascularization, that is, the anterior and middle facial artery perforasomes of the oral mucosa. To our knowledge, this is the first description in the literature of a mucosa-based perforator flap. Using Doppler sonography, we mark the path of the facial artery in the oral mucosa. We harvest the musculomucosal flap by extracting an area about 20 percent larger than the defect that we aim to cover. We attempt to ligate the facial artery in the gingival sulcus, taking care not to damage the perforators next to the buccinator and orbicularis muscles. We perform a retrograde dissection of the facial artery, taking extreme caution at the branching-off site of the superior labial artery bifurcation. The exit point of the superior labial artery will be 7.4 ± 9.98 mm laterally and 5.1 ± 7.6 mm above the oral commissure in a line parallel to the lower edge of the jaw, between the gonion and pogonion (95 percent tolerance limits).5 The area measures approximately 3 cm2. Once we reach the bifurcation of the superior labial artery, we ligate it and continue the dissection over the facial artery to the base of the nasal ala or to a point where we can easily insert our flap inside the nose (Fig. 1). On the septal orifice, we excise the borders of the defect until we find healthy tissue and attach our flap with strategically placed sutures (Fig. 2). At this point, if required, we modify the nasal tip by open rhinoplasty. Similarly, if cartilage grafts are required for the nasal dorsum or grafts or local plasty to release the nostrils, reconstruction is performed. These well-vascularized areas are optimal for reconstructing a septal defect, because they comprise
S
Holger C. Erne, M.D. BGU Murnau Murnau, Germany
DISCLOSURE The author has no financial interest to declare in relation to the content of this article. REFERENCES 1. Piza-Katzer H, Herczeg E, Aspek R. Präoperative intermittierende pneumatische Extensionsbehandlung bei Dupuytrenscher Kontraktur im Stadium III und IV. Handchir Mikrochir Plast Chir. 2000;32:33–37. 2. Agee JM, Goss BC. The use of skeletal extension torque in reversing Dupuytren contractures of the proximal interphalangeal joint. J Hand Surg. 2012;37:1467–1474.
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3. Craft RO, Smith AA, Coakley B, Casey WJ 3rd, Rebecca AM, Duncan SF. Preliminary soft-tissue distraction versus checkrein ligament release after fasciectomy in the treatment of Dupuytren proximal interphalangeal joint contractures. Plast Reconstr Surg. 2011;128:1107–1113. 4. Messina A, Messina J. The continuous elongation treatment by the TEC device for severe Dupuytren’s contracture of the fingers. Plast Reconstr Surg. 1993;92:84–90. 5. Erne H, El Gammal A, Lukas B. Percutaneous needle fasciotomy: A serious alternative? In: Dupuytren’s Disease and Related Hyperproliferative Disorders. Berlin, Heidelberg: Springer-Verlag; 2012.
Three-Dimensional Printing of Perforator Vascular Anatomy Sir:
T
he use of three-dimensional printing has increased in recent years with the advent of commercially available three-dimensional printers and lower costs. Computed tomographic data can be obtained rapidly and incorporated into three-dimensional reconstructions visualized in two dimensions. This information can be used to produce a physical object using progressive layering of different polymers or materials with a three-dimensional printer. Production of three-dimensional models allows improved visualization and manipulation of anatomical structures compared with two-dimensional representations. They can be used for surgical planning, implant design, and education.1 Three-dimensional models have also been used for training on patient-specific models to simulate surgical procedures to help understand difficult anatomy, predict complications, and potentially reduce operating time.1–4 We produced a three-dimensional model to facilitate understanding of the regional anatomy of the internal mammary artery. We chose the internal mammary artery perforator system, as its relationship to surrounding ribs is important in the dissection and identification of the dominant perforator while raising the internal mammary artery perforator flap. To create a three-dimensional model of the dominant internal mammary artery perforator, a fresh cadaver was injected with the modified lead oxide technique described previously.5 The cadaver was obtained through the Dalhousie University Donor Program. Plain films and computed tomographic images of the cadaver were obtained and the data were analyzed using Materialise’s Interactive Medical Image Control System program (Materialise, Leuven, Belgium). Using the program, three-dimensional images of the dominant internal mammary artery perforator and surrounding structures were created (Fig. 1). The reconstruction was printed in three dimensions using a composite powder printing process on a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.). This produces a three-dimensional object by successively laying down the infiltrant to build the model slice by slice based on the reconstruction.
Volume 133, Number 1 • Viewpoints
Fig. 1. Three-dimensional reconstructions of the left bony thorax, internal mammary artery, and dominant left internal mammary artery perforator and lateral thoracic artery from cadaveric computed tomographic data using Materialise’s Interactive Medical Imaging Control System. (Left) Anterior-posterior, (center) oblique, and (right) posterior-anterior views (*, second internal mammary artery perforator; •, second rib; ♦, lateral thoracic artery).
We report the first use of three-dimensional printing to produce vascular perforator anatomy. The dominant internal mammary artery perforator can be seen branching off of the internal mammary artery, through the second intercostal
space and anastomosing with the lateral thoracic artery (Fig. 2). The use of three-dimensional printing to produce physical objects is the next step from three-dimensional reconstructions visualized on two-dimensional screens.
Fig. 2. Anteroposterior (left) and oblique (right) views of a three-dimensional model of the left bony thorax, internal mammary artery, and internal mammary artery perforator (*, second internal mammary artery perforator; •, second rib; ♦, lateral thoracic artery). The lateral thoracic artery was based on cadaveric data and printed using a ProJet x60 series printer with a Z-bond 90 infiltrant (3D Systems, Rock Hill, S.C.).
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Plastic and Reconstructive Surgery • January 2014 It allows rapid manipulation and understanding of an individual’s anatomy by physically holding the object and being able to visualize it in multiple planes. This can be useful for teaching learners, and can be used as a tool to better explain the proposed surgery to patients using their own anatomy. One limitation of the process is the cost associated with production of the model, which can be anywhere from $400 to $1200. Also, due to the minuteness of perforator vessels, some smaller vessels do not endure the printing process due to the resolution limitations of the three-dimensional printer. This can be ameliorated with a larger model, albeit at a higher cost. Also, the materials used to make certain models are delicate, and rough handling can cause perforator branches to crack. However, postprinting processing with materials such as wax can create a durable model that can be used in clinics and teaching sessions. DOI: 10.1097/01.prs.0000436523.79293.64
Joshua A. Gillis, B.Sc., M.D. Steven F. Morris, M.D., M.Sc. Division of Plastic Surgery Dalhousie University Halifax, Nova Scotia, Canada Correspondence to Dr. Morris Division of Plastic Surgery Dalhousie University 4443-1796 Summer Street Halifax, Nova Scotia B3H 2A7, Canada [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article. REFERENCES 1. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D printing based on imaging data: Review of medical applications. Int J Comput Assist Radiol Surg. 2010;5: 335–341. 2. Klammert U, Böhm H, Schweitzer T, et al. Multi-directional Le Fort III midfacial distraction using an individual prefabricated device. J Craniomaxillofac Surg. 2009;37: 210–215. 3. Klammert U, Gbureck U, Vorndran E, Rödiger J, Meyer-Marcotty P, Kübler AC. 3D powder printed calcium phosphate implants for reconstruction of cranial and maxillofacial defects. J Craniomaxillofac Surg. 2010;38: 565–570. 4. Li B, Zhang L, Sun H, Yuan J, Shen SG, Wang X. A novel method of computer aided orthognathic surgery using individual CAD/CAM templates: A combination of osteotomy and repositioning guides. Br J Oral Maxillofac Surg. 2013;51:e239–e244. 5. Tang M, Geddes CR, Yang D, Morris SF. Modified lead oxide-gelatin injection technique for vascular studies. J Clin Anat. 2002;1:73–78.
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Reconstruction of Nasal Septal Perforations in Cocaine-Addicted Patients with Facial Artery Mucosa-Based Perforator Flap Sir: eptal perforation is one of the most frequent complications of snorting cocaine. A wide range of mucosal defects have been described, from a clinically asymptomatic state through pinpoint holes to the destruction of the dorsal support, or even the destruction of the maxilla. Various types of local flaps have been tested for reconstruction of the nasal septum.1 Because of the high risk of failure due to damage to adjacent tissue, the use of distant tissues or even distant free flaps is preferred.2 The problem with remote or free flaps is that their volume may be excessive and they may obstruct the passage of air. Other authors have described useful mucosal regional flaps, such as the facial artery musculomucosal,3 an axial flap centered over the facial artery, or the buccinator flap,4 based on the posterior buccal artery or the anterior segment of the facial artery. Anatomical studies performed by our group have identified direct perforators from the facial artery irrigating specific mucosal territories.5 On the basis of these findings, we have designed an island flap by selecting the areas with the best vascularization, that is, the anterior and middle facial artery perforasomes of the oral mucosa. To our knowledge, this is the first description in the literature of a mucosa-based perforator flap. Using Doppler sonography, we mark the path of the facial artery in the oral mucosa. We harvest the musculomucosal flap by extracting an area about 20 percent larger than the defect that we aim to cover. We attempt to ligate the facial artery in the gingival sulcus, taking care not to damage the perforators next to the buccinator and orbicularis muscles. We perform a retrograde dissection of the facial artery, taking extreme caution at the branching-off site of the superior labial artery bifurcation. The exit point of the superior labial artery will be 7.4 ± 9.98 mm laterally and 5.1 ± 7.6 mm above the oral commissure in a line parallel to the lower edge of the jaw, between the gonion and pogonion (95 percent tolerance limits).5 The area measures approximately 3 cm2. Once we reach the bifurcation of the superior labial artery, we ligate it and continue the dissection over the facial artery to the base of the nasal ala or to a point where we can easily insert our flap inside the nose (Fig. 1). On the septal orifice, we excise the borders of the defect until we find healthy tissue and attach our flap with strategically placed sutures (Fig. 2). At this point, if required, we modify the nasal tip by open rhinoplasty. Similarly, if cartilage grafts are required for the nasal dorsum or grafts or local plasty to release the nostrils, reconstruction is performed. These well-vascularized areas are optimal for reconstructing a septal defect, because they comprise
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