Faculty Bibliography

Total phallic reconstruction presents the genitourinary reconstructive surgeon with one of the most difficult surgical challenges. The development of microsurgical techniques and free tissue transfers have advanced phallic reconstruction by reducing the number of surgical procedures and by allowing more selectivity in choosing the best innervated donor tissue. During the last 5 years 16 patients underwent total phallic reconstruction using free tissue transfers from distant donor sites. The pudendal nerve was coapted routinely to the major sensory nerves of the donor free flap. The most accurate objective baseline parameters of penile sensibility are pressure and vibratory thresholds, and electrically evoked potentials. We examined 30 normal subjects and 7 patients at least 1 year postoperatively for penile (phallic) sensibility. A pressure aesthesiometer, a biothesiometer and electrodiagnostic studies were used for testing. The 7 postoperative patients (in all of whom the pudendal nerve was incorporated into the reconstruction) had an encouraging return of tactile and erogenous sensibility compared to normal subjects. This is a promising advance in phallic reconstruction

Efforts to improve functional recovery following nerve injury and repair have included studies of sutureless repairs. The rat sciatic nerve was used as an experimental model to compare the efficacy of laser nerve repairs with standard microsuture repairs. Electrophysiologic (Compound Action Potential), quantitative morphometric, and behavioral (toe spread) measurements were used for assessment, and tensile strength of the repairs was also determined. Electrophysiologic studies showed that microsuture-repaired nerves had significantly faster conduction velocities, but the areas of the waveforms and peak amplitudes showed no significant differences between the two repair groups. Axon counts revealed significant differences in the suture group proximal to the repair site, contrasted with laser repairs. Toe spread evaluations, carried out at three day intervals, demonstrated a significant difference between the two methods of repair in only three out of 22 test dates: in these isolated cases, the suture group measurements were superior. The tensile strength findings confirmed that, at four days, microsuture repair was significantly stronger but thereafter, there was no difference between the two nerve repair techniques

The skin of the dorsal aspect of the forearm is supplied by several cutaneous branches of the posterior interosseous artery. This vascular anatomy permits the surgeon to obtain an island flap of the dorsal forearm based on the distal anastomosis between the two interosseous arteries at the distal part of the interosseous space. This flap can reliably be transferred to different skin defects of the hand such as those created by correction of an adduction contracture of the first web space, or on the back or front of the wrist level. Its principal advantages are that it is a thin flap with excellent circulation and that it is possible to close the donor area primarily provided the island flap is not wider than 3 to 4 cm. The procedure has been employed in 25 patients with satisfactory results

The quantity of severe injuries to the extremities challenging the modern, civilian surgeon cannot compare with that produced at Gettysburg or other battles of the Civil War. Nonetheless, the extent and severity of the trauma to the extremity generated on our "civilian battlefields" match and often surpass the wounds confronted by our predecessors. In the Civil War, as it had been for many preceeding years, amputation remained the dominant approach to managing a great variety of injuries to the extremities. However, constant surgical progress, as reflected by a gradual reduction in recourse to amputation, had enabled each succeeding generation of surgeons to surpass and distance themselves from their predecessors. Amputation of the traumatized extremity had always defined and continues to represent the prevalent abilities and limitations of conservative and reconstructive surgical efforts. Operative treatment, for much of its existence, represented a collection of dangerous ablative procedures which were used reluctantly when all other measures were exhausted. Its transformation into a successful reconstructive endeavor evolved primarily in this century. The understanding of bone healing and the functional importance of the knee joint led to a transformation in amputation and to changes in the management of fractures which are still evolving. The next revolution in operative treatment came with the ability to restore blood flow in injured extremities. Finally, the recent introduction of a variety of free flaps enables the reconstitution of extensive soft tissue and bony defects and further lowers the number of obligatory amputations. These innovations enabled the surgeon to reduce his or her recourse to amputation of severely injured extremities. Nonetheless, the significant number of amputations still performed constitute a reminder that there is still work to be done.

Electrical burns of the oral cavity are relatively rare; a case is reported here. An acrylic splint fabricated for the patient helped prevent microstomia and the subsequent development of a deformity.

This preliminary study documents preoperative and postoperative changes in cerebral tissue as well as intracranial and ventricular volume in patients who underwent cranial vault remodeling for craniosynostosis. The documentation and calculations were provided from CT data according to a craniofacial protocol. Three-dimensional images were then obtained of the preoperative and postoperative skulls and cerebral tissues. From these data, comparisons of preoperative and postoperative volumes of the cerebral tissue and ventricles could be examined. In one case, a frontal bone advancement combined with anterior cranial vault remodeling was associated with an increase in intracranial volume of 110 cc (8 percent) and a ventricular volume increase of 112 percent. The reported technique should allow more complete evaluation of the preoperative pathology and documentation and prediction of the projected intracranial and ventricular volume changes