Floor plan - 2013 Annual Meeting - American Association for Hand ...

HYATT REGENCY CENTURY PLAZA 

FLOOR PLAN

TABLE OF CONTENTS 

AAHS Board of Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

AAHS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 

AAHS Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

ASPN Council Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

ASPN Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

ASPN Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 

ASRM Council Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 

ASRM Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

ASRM Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 

Messages from the Program Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 

General Announcements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

Networking Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

2008 Exhibitor Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-17 

CME Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-20 

Presenters’ Disclosure Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 

Future Annual Meeting Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 

AAHS Wednesday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 

Specialty Day Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 

AAHS Thursday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 

Keynote Speaker: Ramez Naam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-28 

AAHS Friday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 

J. Joseph Danyo Presidential Invited Lecturer: Allen Van Beek, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 

Comprehensive Hand Surgery Review Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 

AAHS/ASPN/ASRM Saturday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 

AAHS/ASPN/ASRM Presidents’ Invited Lecturer: Aaron Vinik, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 

ASPN Friday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 

Invited Speaker: Prof. Andrew Schwartz, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-37 

ASPN Saturday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 

Invited Speaker: Jeff Licthman, MD, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 

ASPN Sunday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 

Invited Speaker: Prof. Neville Hogan, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 

ASRM Saturday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 

ASRM Sunday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 

Presidents Address: Lawrence B. Colen, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 

Presidents Invited Lecture: Luis Vasconez, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 

Godina Lecture: Peirong Yu, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 

ASRM Monday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Buncke Lecture: Berish Strauch, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 

ASRM Master Series in Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 

ASRM CTA Update Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 

ASRM Tuesday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 

Introductional Lecturer: Hans Steinau, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 

Abstract Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2007-2008 AAHS BOARD OF DIRECTORS 

President N. Bradly Meland, MD 

President-Elect Scott H. Kozin, MD 

Vice-President Nicholas Vedder, MD 

Secretary Keith Brandt, MD 

Treasurer Richard E. Brown, MD 

Treasurer-Elect Mark Baratz, MD 

Historian Matthew Concannon, MD 

Parliamentarian Warren Schubert, MD 

Past Presidents Susan Mackinnon, MD 

Ronald Palmer, MD 

Directors At Large James Chang, MD 

Steven McCabe, MD 

Peter Murray, MD 

Nash Naam, MD 

Affiliate Directors Julianne Howell, PT MS CHT 

Christine Novak, PT MS 

Rebecca von der Heyde, MS, ORT/L, CHT 

1

AAHS COMMITTEES 

Please join us in thanking the AAHS committees for their work in 2007 

BYLAWS COMMITTEE 

Warren Schubert, MD 

Brian Adams, MD 

EDUCATION COMMITTEE 

Jaiyoung Ryu, MD, FACS, Chair 

Timothy J. Best, MD, MSc, FRCSC 

Kevin Chung, MD 

Paula Galaviz, OT 

Kevin Plancher, MD 

Renata Weber, MD 

Aviva Wolff, BSc, OTR/L, CHT 

FINANCE COMMITTEE 

Richard E. Brown, MD, Chair 

Mark Baratz, MD 

Scott Kozin, MD 

N. Bradly Meland, MD 


MEMBERSHIP: ACTIVE COMMITTEE 

Steven McCabe, MD, Chair 

Amy L. Ladd, MD 

Steven L. Moran, MD 

Raj Sood, MD 

Robert Spinner, MD 

MEMBERSHIP: AFFILIATE COMMITTEE 

Carin Jean Wulf, OT, CHT, Chair 

Rebecca von der Heyde, MS, OTR/L, CHT 

NOMINATING COMMITTEE 


Paul Brach, MS, PT, CHT 

William Dzwierzynski, MD 

M. Ather Mirza, MD 

Roger Simpson, MD 

Dean Sotereanos, MD 

2 

PROGRAM COMMITTEE 

Michael Neumeister, MD, Co-Chairperson 

Craig Johnson, MD, Co-Chairperson 

Christine Novak, PT, MS, Co-Chairperson 

Randipsingh Bindra, MD 

Diana D. Carr, MD 


Gail Groth, OTR/L, CHT, MHS 

M. Ather Mirza, MD 

Jorge Orbay, MD 

A. Lee Osterman, MD, FACS 

Miguel Pirela-Cruz, MD 

RESEARCH GRANTS COMMITTEE 

Michael Neumeister, MD, Chair 

Loree K. Kalliainen, MD, FACS 

Steven Moran, MD 

Jorge Orbay, MD 

TECHNOLOGY COMMITTEE 

George Landis, MD, Chairman 


Coleen T. Gately, PT, DPT, MS 


Eric Rothenberg, MD, FACS 

Stephen Schnall, MD 

Hugh L. Vu, MD, MPH

AAHS HISTORICAL INFORMATION 

AAHS PAST PRESIDENTS 

J. Joseph Danyo, MD 1970-1972 

Henry Burns, MD 1972-1973 

Ray A. Elliott, Jr., MD 1973-1974 

James Borden, MD 1974-1975 

Kim K. Lie, MD 1975-1976 

Frank L. Thorne, MD 1976-1977 

Lawrence R. Werschky, MD 1977-1978 deceased 

Robert T. Love, MD 1978-1979 

Arnis Freiberg, MD 1979-1980 

Thomas J. Krizek, MD 1980-1981 

George L. Lucas, MD 1981-1982 

Garry S. Brody, MD 1982-1983 

James G. Hoehn, MD 1983-1984 

Peter C. Linton, MD 1984-1985 

Wallace H.J. Chang, MD 1985-1986 

Austin D. Potenza, MD 1986-1987 

Lee E. Edstrom, MD 1987-1988 

C. Lin Puckett, MD 1988-1989 

Robert J. Demuth, MD 1989-1990 

Wyndell H. Merritt, MD 1990-1991 

Frederick R. Heckler, MD 1991-1992 

Robert D. Beckenbaugh, MD 1992-1993 

David J. Smith, Jr., MD 1993-1995 

James W. May, Jr., MD 1995-1996 

Robert H. Brumfield, Jr., MD 1996-1997 

Robert C. Russell, MD 1997-1998 

Peter C. Amadio, MD 1998-1999 

William M. Swartz, MD 1999-2000 

William Blair, MD 2000-2001 

Robert Buchanan, MD 2001-2002 

Alan Freeland, MD 2002-2003 

Allen Van Beek, MD 2003-2004 

Richard Berger, MD 2004-2005 

Susan Mackinnon, MD 2005-2006 

Ronald Palmer, MD 2006-2007 

PRESIDENTIAL INVITED LECTURERS 

Harold E. Kleinert, MD 1989 

Arthur C. Rettig, MD 1990 

Paul W. Brand, MD 1991 

Ronald L. Linschied, MD 1993 

Guy Foucher, MD 1995 

Michael R. Harrison, MD 1996 

Dallas D. Raines 1997 

John Texter, MD 1998 

Vincent R. Hentz, MD 1999 

Nancy Dickey, MD 2000 

Michael Wood, MD 2001 

Francisco Rosas 2002 

Arnold-Peter Weiss, MD 2003 

Susan Mackinnon, MD 2004 

Elvin Zook, MD 2004 

Gavin Menzies 2005 

Peter Amadio, MD 2006 

Robert Beckenbaugh, MD 2007 

3 

KEYNOTE SPEAKERS 

William L. White, MD 1978 

John W. Madden, MD 1979 

Harold E. Kleinert, MD 1980 

J. William Littler, MD 1981 

Clifford C. Snyder, MD 1982 

Robert A. Chase, MD 1983 

Richard J. Smith, MD 1984 

James M. Hunter, MD 1985 

Bernard McC. O’Brien, MD 1986 

Erle E. Peacock, Jr., MD 1988 

Michael Jabelay, MD 1989 

Robert M. McFarlane, MD 1990 

James H. Dobyns, MD 1991 

Adrian E. Flatt, MD 1992 

John B. Carlson, PhD 1993 

Pat Clyne 1995 

David M. Evans, FRCS 1996 

Eugene Nelson, MD 1997 

Fritz Klein 1998 

Janet L.Babb 1999 

Frank E. Jones, MD 2000 

Joseph Buckwalter, MD 2001 

Linda Cendales, MD 2002 

Arnold-Peter Weiss, MD 2003 

Terry L. Whipple, MD, FACS 2005 

Jeff Lictman, MD, PhD 2006 

Richard Kogan, MD 2007 

Bob Jamieson 2007 

CLINICIAN/TEACHER OF THE YEAR 

Forst Brown, MD 1995 

Robert Beckenbaugh, MD 1996 

James Hoehn, MD 1997 

Alan Freeland, MD 1998 

Wyndell Merritt, MD 1999 

Peteramadio, MD 2000 

Anthony DeSantolo, MD 2002 

Michael Jabaley, MD 2002 

Maureen Hardy, PT, MS, CHT 2002 

Sterling Mutz, MD 2002 

Richard E. Brown, MD 2003 

Nash Naam, MD 2004

2007-2008 ASPN COUNCIL 

President Gregory R. D. Evans, MD, FACS 

President-Elect Robert C. Russell, MD 

Vice President Howard M. Clarke, MD, PhD 

Secretary Ivica Ducic, MD, PhD 

Treasurer Paul S. Cederna, MD 

Immediate Past President Rajiv Midha, MD, 

Past President Maria Siemionow, MD, PhD 

Historian Robert Spinner, MD 

Council Member at Large Loree K. Kalliainen, MD 

David T. J. Netscher, MD 

Gedge D. Rosson, MD 

4

ASPN COMMITTEES 

Please join us in thanking the following ASPN committees who have helped make the 2007 year successful. 

ASPN BOARD REPRESENTATIVE 

Paul S. Cederna, MD 


Melanie Urbanchek, MD, Chairperson 

Paul Cederna, MD 

William Kuzon, Jr., MD 


Gregory R.D. Evans, MD, FACS, Ex-Officio 

CODING AND REIMBURSEMENT COMMITTEE 

Keith E. Brandt, MD, Chairperson 

Brandon J. Wilhelmi, MD 

William A. Zamboni, MD 


David T.J. Netscher, MD, Chairperson 


Wyndell H. Merritt, MD 



Thomas H.H. Tung, MD, Chairperson 

David W. Chang, MD 

Robert C. Russell, MD 


AD-HOC GRANT GENERATION COMMITTEE 

Gregory R.D. Evans, MD, FACS, Chairperson 

Keith E. Brandt, MD 


Howard M. Clarke, MD 

Rajiv Midha, MD 


MEMBERSHIP COMMITTEE 

Robert C. Russell, MD, Chairperson 


Warren C. Hammert, DDS, MD 

Thomas H.H. Hung, MD 

Renata V. Weber, MD 

Gregory R. D. Evans, MD, FACS, Ex-Officio 

NEWSLETTER COMMITTEE 

Nash H. Naam, MD, Editor 

Robert Spinner, MD, Assistant Editor 

Christine Novak, PT, MS, Assistant Editor 

5 


Rajiv Midha, MD, Chairperson 


David T.W. Chiu, MD 


Eric L. Zager, MD 

Maria Siemionow, MD, PhD, Ex-Officio 


Jonathan M. Winograd, MD, Chairperson 

Gregory M. Buncke, MD 

Ranjan Gupta, MD 

William Lineaweaver, MD 

Nancy McKee, MD, FRCSC 

David Netscher, MD 

Joseph M. Rosen, MD 

Gedge Rosson, MD 



TIME AND PLACE COMMITTEE 

Howard Clarke, MD, PhD, Chairperson 


Ivica Ducic, MD, PhD 

Gregory R. D. Evans, MD, FACS 

Loree K. Kalliainen, MD 


David T.J. Netscher, MD 


Robert C. Russell, MD 

Maria Siemionow, MD, PhD 


WEBSITE COMMITTEE 

Paul Cederna, MD, Chairperson 



Gregory R.D. Evans, MD, FACS, Ex-Officio

ASPN HISTORICAL INFORMATION 

FOUNDING COUNCIL (Established April 19, 1990) 

Warren Breidenbach, MD 

Thomas Brushart, MD 

David Chiu, MD 

A. Lee Dellon, MD 

Richard Ehrlichman, MD 

Nelson Goldberg, MD 

Roger Khouri, MD 

Howard Klein, MD 

Susan Mackinnon, MD 

Hallene Maragh, MD 

Wyndell Merritt, MD 

Michael Orgel, MD 

Elliot Rose, MD 

Joseph Rosen, MD 

Brooke Seckel, MD 

Saleh Shenaq, MD 

Thomas Stevenson, MD 

Berish Strauch, MD 

Julia K.Terzis, MD, PhD 

Allen Van Beek, MD 

Bruce Williams, MD 

ASPN PAST PRESIDENTS 

Julia K. Terzis, MD, PhD 1990-1992 

A. Lee Dellon, MD 1992-1993 

Berish Strauch, MD 1993-1994 

H. Bruce Williams, MD 1994-1995 

Susan E. Mackinnon, MD 1995-1996 

Wyndell Merritt, MD 1996-1997 

Allen Van Beek, MD 1997-1998 

Saleh Shenaq, MD 1998-1999 

David T. W. Chiu, MD 1999-2001 

Nancy H. McKee, MD 2001-2002 

William M. Kuzon, Jr., MD, PhD 2002-2003 

Keith E. Brandt, MD 2003-2004 

Steven McCabe, MD 2004-2005 

Maria Siemionow, MD, PhD 2005-2006 

Rajiv Midha, MD 2006-2007 

6

2007-2008 ASRM EXECUTIVE COUNCIL MEMBERS 

President Lawrence B. Colen, MD 

President-Elect Neil F. Jones, MD 

Vice-President William A. Zamboni, MD 

Secretary Peter C. Neligan, MD 

Treasurer Keith E. Brandt, MD 

Treasurer-Elect Joseph M. Serletti, MD, FACS 

Immediate Past President L. Scott Levin, MD, FACS 

Senior Members-At-Large Geoffrey L. Robb, MD 

Michael W. Neumeister, MD 

Junior Members-At-Large Elisabeth K. Beahm, MD 

Alexander Y. Shin, MD 

Historian William Lineaweaver, MD 

7

ASRM COMMITTEES 

Please join us in thanking the following ASRM committees who have helped make the 2007 year successful. 

AD HOC – JRM 

L. Scott Levin, MD, FACS, Chairperson 

AD HOC MICRO FELLOWSHIP 

Charles Butler, MD, Chairperson 

Gregory Buncke, MD 

Joseph Serletti, MD 

Joseph Disa, MD 

Peter Neligan, MD 

William Zamboni, MD 

AUDIT COMMITTEE 

David Chang, MD, Chairperson 


Raymond Dunn, MD 


Elisabeth Beahm, MD, Chairperson 


Anthony Smith, MD 

BUNCKE LECTURESHIP COMMITTEE 


Lawrence Colen, MD 

Ming Huei Cheng, MD 

Guenter Germann, MD 

A. Lee Dellon, MD 

CLINICAL GUIDELINES & OUTCOMES COMMITTEE 

Raymond Dunn, MD, Chairperson 

James Higgins, MD 

Howard N. Langstein, MD 

Michael W. Neumeister, MD 

CPT/RUC COMMITTEE 

Keith E. Brandt, MD, Chairperson 


Raymond M. Dunn, MD 

Daniel J. Nagle, MD 

William C. Pederson, MD 

Michael R. Zenn, MD 


Howard N. Langstein, MD, Chairperson 

Maurice Nahabedian, MD 

Maria Siemionow, MD, Ph.D 

Peirong Yu, MD 

ELECTRONIC COMMUNICATIONS COMMITTEE 

Charles Butler, MD, Chairperson 

William Dzwierzynski, MD 

Howard N. Langstein, MD 


Keith E. Brandt, MD, Ex-Officio 

ENDOWMENT COMMITTEE 

Robert L. Walton, MD, FACS, Chairperson 


Joseph J. Disa, MD 

William A. Zamboni, MD 

8 


Neil Jones, MD, Chairperson 

Joseph M. Serletti, MD, FACS 

William Zamboni, MD 

Keith E. Brandt, MD, Ex-Officio 

GODINA FELLOWSHIP SELECTION COMMITTEE 


Zoran M. Arnez, MD, PhD 

Ming Huei Cheng, MD 


Lawrence Gottlieb, MD 

MASTER SERIES SYMPOSIUM 

Milan Stevanovic, MD, Chairperson 

MEMBERSHIP COMMITTEE 


Charles Butler, MD 


Milan Stevanovic, MD 

Michael Zenn, MD 

William Zamboni, MD, Ex-Officio 



Elisabeth Beahm, MD 

Gregory Buncke, MD 

Jeffrey Friedman, MD 

Howard Langstein, MD 


Guenter Germann, MD, Chairperson 

Michael R. Zenn, MD, Ex-Officio 

Rudolf Buntic, MD 

R. Jobe Fix, MD 

James Higgins, MD 

Neil Jones, MD 

Howard Langstein, MD 

Charles Lee, MD 

TECHNICAL EXHIBITS COMMITTEE 

Peter C. Neligan, MD, Chairperson 

L. Scott Levin, MD, FACS 

William Lineaweaver, MD 

TIME & PLACE COMMITTEE 


William Pederson, MD 

Robert Walton, MD, FACS 

ASPS REPRESENTATIVE 

Robert Walton, MD 

PSEF REPRESENTATIVE 

Gregory R.D. Evans, MD

ASRM HISTORICAL INFORMATION 

1983 FOUNDING COUNCIL 

James B. Steichen, MD, Berish Strauch, MD, Julia K. Terzis, MD, PhD, James R. Urbaniak, MD, Allen L. Van Beek, MD 

YEAR PRESIDENT ANNUAL MEETING SITE FOUNDERS/GODINA/BUNCKE LECTURERS 

1985 Berish Strauch, MD Las Vegas, NV Henry J. Buncke, MD Founders’ Lecturer 

1986 James R. Urbaniak, MD New Orleans, LA Harold E. Kleinert, MD Founders’ Lecturer 

1987 Joseph E. Kutz, MD San Antonio, TX Robert D. Acland, MD Founders’ Lecturer 

1988 H. Bruce Williams, MD Baltimore, MD Berish Strauch, MD Founders’ Lecturer 

1989 James B. Steichen, MD Seattle, WA G. Ian Taylor, FRCS, FRACS Founders’ Lecturer 

1990 Allen L. Van Beek, MD Toronto, Ontario, Canada Andrew Lightbody Founders’ Lecturer 

1991 Michael B. Wood, MD Orlando, FL Alain Gilbert, MD Founders’ Lecturer 

1992 Andrew J. Weiland, MD Scottsdale, AZ Edgar Biemer, MD Founders’ Lecturer 

1993 Graham Lister, MD Kansas City, MO Algimantas Narakas Founders’ Lecturer 

Lawrence B. Colen, MD Godina Lecturer 

1994-95 Robert C. Russell, MD Marco Island, FL Nguyen Huy Phan, MD Founders’ Lecturer 

Mark A. Schusterman, MD Godina Lecturer 

1995-96 Ralph T. Manktelow, MD Tucson, AZ Fu Chan Wei, MD Founders’ Lecturer 

Randy Sherman, MD Godina Lecturer 

1996-97 James A. Nunley, MD Boca Raton, FL James R. Urbaniak, MD Founders’ Lecturer 

Zoran M. Arnez, MD Godina Lecturer 

1997-98 William M. Swartz, MD Scottsdale, AZ H. Bruce Williams, MD Founders’ Lecturer 

L. Scott Levin, MD Godina Lecturer 

1998-99 David T. W. Chiu, MD Waikoloa, HI Julia K. Terzis, MD Founders’ Lecturer 

Phillip Blondeel, MD Godina Lecturer 

1999-2000 Daniel Nagle, MD Miami, FL Allen Van Beek, MD Founders’ Lecturer 

Gregory R. D. Evans, MD Godina Lecturer 

2000-2001 Saleh M. Shenaq, MD San Diego, CA Wayne Morrision, MD, FRACS Founders’ Lecturer 

Roger Khouri, MD Godina Lecturer 

2001-2002 Randy Sherman, MD Cancun, Mexico Robert Russell, MD Founders’ Lecturer 

William Zamboni, MD Godina Lecturer 

2002-2003 Julia K. Terzis, MD, PhD Kauai, HI Panayotis Soucacos, MD Founders’ Lecturer 

Raymond Dunn, MD Godina Lecturer 

2003-2004 Ronald M. Zuker, MD Palm Springs, CA Ralph Manktelow, MD Founders’ Lecturer 

Milomir Ninkovic, MD, PhD Godina Lecturer 

2004-2005 Robert L. Walton, MD, FACS Fajardo, Puerto Rico Isao Koshima, MD Founders’ Lecturer 

Michael Neumeister, MD, FRCSC, FACS Godina Lecturer 

G. Ian Taylor, MD, FACS Buncke Lecturer 

2005-2006 William C. Pederson, MD Tucson, AZ David Chang, MD, FACS Godina Lecturer 

Fu Chan Wei, MD, FACS Buncke Lecturer 

2006-2007 L. Scott Levin, MD, FACS Rio Grande, Puerto Rico Ming Huei Cheng, MD, MHA Godina Lecturer 

9 

James Urbaniak, MD Buncke Lecturer

MESSAGES FROM THE PROGRAM CHAIRS 

AAHS 

Welcome to Hollywood. As Ed Sullivan would say, “We have a really big Shoooo” for you in tinsel town. The 2008 Annual Meeting of the AAHS promises 

to be a colorful combination of science and entertainment meshed together with interactive dialogue designed to stimulate the minds of the old and new. 

Christine Novak and Dr. Craig Johnson have worked diligently to arrange a captivating opening session on Wednesday with a focus on the management of 

our arthritic conditions of the hand. A forum of lectures, discussions, and panel experts will update participants on medical, surgical and rehabilitation management 

of rheumatoid arthritis. Instructional courses in the afternoon will provide an opportunity for attendees to learn the current practices on various topics 

in hand surgery. 

The opening ceremonies will be held on Thursday morning followed immediately by a panel on one of the latest advancements in hand surgery “Wide Awake 

Approach to Hand Surgery” moderated by Dr. Brad Meland. The keynote speaker Ramez Naam will discuss his latest book in a lecture entitled “More Than 

Human”. Dr. Joe Slade will end the days’ scientific session with an update panel on the current issues of the Management of Scaphoid Fractures. 

On Friday, following early bird instructional courses, a controversial panel chaired by Dr. Susan Mackinnon entitled “Cubital Tunnel: Defend Your Operation” 

promises to provide an interesting debate from the panelists and the audience. Our president Dr. Brad Meland, has scripted a riveting presidential address 

to enlighten us on his views of the future of hand surgery. The consummate enthusiast, Dr. Allen Van Beek, is this year’s Joseph Danyo Presidential Lecturer. 

The conjoint session on Saturday with the ASRM and ASPN is highlighted by presentation of the top papers from each society as well as two panels. 

The combination of exciting speakers, panels and scientific paper presentations shall truly make this years’ AAHS a very memorable experience. Thank you 

to all of the participants and attendees and in the words of one of Hollywoods finest stars, Edward G. Robinson “Look you mugs….. It’s going to be swell 

see…. swell”. 

Michael Neumeister, MD 

AAHS Program Chairman 

It is my distinct pleasure to welcome you to the 17th annual meeting of the American Society for Peripheral Nerve. The meeting will be held on Friday, Saturday 

and Sunday January 11, 12th and 13th, 2008 at the Hyatt Regency Century Plaza Hotel & Spa in Beverly Hills, California. The scientific program will offer both 

clinical and basic science advances in the field of peripheral nerve surgery in an exciting venue located in the heart of Century City, convenient to the many 

attractions of the magnificent City of Los Angeles. 

The program will start mid-day on Friday to allow for a longer program than in past meetings. The first invited speaker, Professor Andrew Schwartz, PhD of the 

University of Pittsburgh, will give an address entitled “Useful Signals from Motor Cortex“ on the exciting field of cortical neural prosthetics. As in the past, 

Saturday morning will consist of a shared session with the American Association for Hand Surgery and American Society for Reconstructive Microsurgery meetings. 

Two combined panels on “Treatment of Scleroderma with Sympathectomy” and “Tendon and Nerve Transfers for Common Upper Extremity Palsies: 

Consensus and Controversies” will be given. The Presidents Invited Lecture, Arthur Vinik, MD, will also give an address on Neurovascular Dysfunction in 

Diabetes. Outstanding papers selected by the 3 groups will then be presented. 

The ASPN will meet Saturday afternoon and Sunday. Professor Jeff Lichtman, MD, PhD will begin the ASPN program after lunch with a scientific lecture on the 

rapidly evolving topic of “Peripheral Nerve Growth Branching and Retraction: Studies in Fluorescent Mice.” Instructional courses Sunday morning will cover 

intraoperative monitoring, obstetrical brachial plexus palsy, peripheral nerve tumors, reinnervating muscle, and brain-body interfacing. A combined 

ASRM/ASPN panel on the treatment of the mangled hand will be held Sunday morning. Scientific and clinical papers will be given throughout the three day 

program. The final invited speaker for the meeting, Professor Neville Hogan, PhD, an expert on contact robotics, will give a fascinating lecture on “Robotics 

for Neurorecovery.” The ASPN welcome reception will be held in conjunction with the ASRM on Saturday evening. 

I encourage you to attend and participate in this meeting. It promises to be an exciting, rewarding and enjoyable experience, and I am looking forward to seeing 

you there. 

Jonathan M. Winograd, MD 

ASPN Program Chairman 

The annual meeting is here, although the great days of Puerto Rico are still in our minds. For the first time, the remoteness and tranquility of a resort have been 

changed to a congress venue in the heart of a vibrant city. The newly remodeled hotel with its excellent facilities should provide precisely the atmosphere for 

a meeting that guarantees familiarity, an excellent scientific program, many fun things to do and enough time to meet old and new friends. 

The goal of the program is to combine basic science, which has always been the basis for clinical progress, with very interesting topics for the practicing clinical 

micro-surgeon. Highlights from last year’s program such as the “Best Case” and the “Best Save” have been kept and several new features have been added. 

The “Big Debate” focuses on the question: Do we still need flaps to salvage a lower extremity or does the VAC do the job for us? “Grill the experts” will test 

the various strategic solutions of acknowledged experts in identical cases. “Voodoo in Micro” will address questions that have been discussed since the early 

age of Microsurgery: When can an extremity be mobilized? When can an extremity with a flap reconstruction be trained by lowering the extremity? How do 

we immobilize after flap reconstruction? When can a flap be debulked? When is it randomized, if so at all? 

These new features will be embraced by several interesting panels, some of them in cooperation with AAHS, ASPN and concurrent scientific sessions. Excellent 

lectures will be other highlights of the meeting; some sessions will be opened by “state of the art” introductions. The instructional courses feature topics that 

are both clinically relevant and future oriented at the same time. As it is almost custom, a CTA update will be included in our time table with as little as possible 

overlapping of sessions. 

In the movie city, a little “Voodoo” and some “magic” by the presenters should create a great program that is as exciting as the city itself. So come to LA to 

be part of the experience. 

We are glad you are here. 


ASRM Program Chairman 

10 

ASPN 

ASRM

GENERAL ANNOUNCEMENTS 

Meeting Service Hours (subject to change) 

Wednesday, January 9 6:30am – 2:30pm; 5:00pm – 7:00pm 

Thursday, January 10 6:30am – 3:00pm 

Friday, January 11 6:30am – 7:00pm 

Saturday, January 12 6:30am – 6:30pm 

Sunday, January 13 6:30am – 4:00pm 

Monday, January 14 6:30am – 3:00pm; 6:30pm – 8:00pm 

Tuesday, January 15 6:30am – 9:30am 

AAHS POSTER PRESENTATION VIEWING HOURS 

The AAHS Poster Presentations will be placed in the California Showroom. Posters will be available for viewing Wednesday - Friday. If you are a presenter, 

please have your poster set up prior to 12:00pm on Wednesday and taken down prior to 11:00am on Friday. The American Association for 

Hand Surgery will not be responsible for any poster that is not removed within the time allotted. 

ASPN POSTER PRESENTATION VIEWING HOURS 

The ASPN Poster Presentations will be placed in the California Showroom. Posters will be available for viewing Friday - Sunday. If you are a presenter, 

please have your poster set up prior to 1:00pm on Friday and taken down prior to 5:00pm on Sunday. The American Society for Peripheral Nerve 

will not be responsible for any poster that is not removed within the time allotted. 

ASRM POSTER PRESENTATION VIEWING HOURS 

The ASRM Poster Presentations will be placed in the California Showroom. Posters will be presented digitally on a continuous loop in the California 

Showroom on Sunday, January 13th and Monday, January 14th. 

COMMERCIAL EXHIBITS 

The commercial exhibits will be located in California Showroom. A variety of commercial exhibits are featured at the meeting, enabling the attendees 

to learn about the technological advances pertaining to upper extremity surgery, neurosurgery and reconstructive microsurgery, and to meet 

key suppliers. Please refer to the Exhibit Listing in this book. 

EXHIBIT HOURS 





Monday, January 14 7:00am – 4:30pm 

SPEAKER READY ROOM HOURS 

The Speaker Ready Room will be located in the California Showroom. 

Wednesday, January 9 6:00am – 5:00pm 





Monday, January 14 6:00am – 3:30pm 

Tuesday, January 15 6:00am – 11:30am 

DRESS CODE 

We encourage meeting attendees to dress casually and comfortably. Jackets and ties are not required for any business or networking events. If you 

plan to be outdoors in the evening, a jacket may be preferred. 

MESSAGE BOARD 

A message board will be set up near Meeting Services. Please refer to the message board for meeting notices and general announcements. 

11

NETWORKING EVENTS 

Networking events are offered to promote collaboration in a social environment, and to enhance your meeting experience. Many of the events are 

included in your registration fee, and we encourage you to purchase tickets for your guests for all networking events. We recommend that you purchase 

guest tickets in advance, as they will be available on a very limited basis at the meeting. Name badges will be required to attend all social events. 

AAHS Welcome Reception 

Wednesday, January 9 – 6:00pm – 8:00pm 

Cost: One admission included in AAHS registration. Additional tickets available @ $50 each. 

Reconnect with fellow meeting-goers at the Hyatt’s fabulous new X Bar. So trendy, you may want to come dressed Hollywood-Hip, and don’t forget to 

bring your Bling. This event is indoor and outdoor. Tickets include beverages and light hors d’oeuvres. Not recommended for guests under age 21. 

AAHS Salsa Sensation Awards Dinner and Dance 

Friday, January 11 – 7:00pm – 10:00pm 

Cost: One admission included in AAHS registration. 

Additional adult tickets available @ $100 each; tickets for children and young adults ages 5 - 20 available @ 

$50 each. 

Can you Rumba, Samba, Salsa, Mambo, Merengue? You will if you attend our sizzling hot Salsa Sensation party. 

After a brief awards presentation, move to the beat of Latin rhythms with the pros and discover what the dance 

craze is about. A Latin inspired casual dinner buffet, refreshments and entertainment are all included in your ticket. 

Dress casual or Latin chic and prepare yourself for an electro-charged, scintillating night to remember. Cha cha cha. 

ASPN-ASRM Welcome Reception 

Saturday, January 12 – 6:30pm – 8:00pm 

Cost: One admission included in ASPN and ASRM registration. Additional tickets available @ $50 each. 

Reconnect with fellow meeting-goers at the Hyatt’s fabulous new X Bar. This event is indoor and outdoor. Tickets include beverages and light hors d’oeuvres. 

We thank ASSI for their generous sponsorship of this reception. 

ASRM Cocktail Reception and Dinner – Theater of the Imagination 

Monday, January 14 – 7:00pm – 10:30pm 

Cost: One admission included in ASRM registration. Additional tickets available @ $100 each; tickets for children and young adults ages 5 - 20 @ $50 each. 

Journey beyond the depths of your imagination during this elegant and entertaining evening. From the sparkling flutes of champagne, to delectable 

gourmet dining, each one of your senses will be stirred. Your perception of the abilities of the human body will be forever changed. Through a fusion 

of strength, flexibility and technical skill, a cast of Cirque Du Soleil-inspired performances will dazzle, as suspenseful aerial acrobatics and ground level 

feats of dexterity are performed before your very eyes. Adult admission includes a reception with beverages and hors d’oeuvres, 3 course dinner, wine 

and Cirque Du Soleil performances throughout dinner. 

The ASRM would like to thank ASSI for their generous sponsorship of the cocktail reception. 

ASRM Day At The Links 

Monday, January 14 - 12:30pm shotgun (depart hotel at 11:15am) 

Cost: $225 per player. Tickets are non-refundable. 

The ASRM day at the links will take place at the private Mountain Gate Country Club. By special privilege, ASRM has been granted an opportunity to 

play this exclusive Ted Robinson designed course that boasts a challenging play that’s as inviting as the scenery. Gorgeous views of the Santa Monica 

Mountains and rolling elevation changes makes for a truly unique golf outing. (Prizes will be awarded) Tournament registration will officially close on 

Sunday, January 13 at 12:00pm. If you prefer to be paired with specific players, requests must be submitted to our Meeting Services staff by this time. 

Tournament costs include transportation, lunch at the course, hosted beverage cart during play, greens fees, cart, tournament coordination, prizes and 

range balls. Limited club rentals are available to rent with advance reservation at $45 per set. 

ASRM Guest Fee 

Have your guest or spouse join you for ASRM social events, breakfasts and lunches Saturday – Tuesday at a reduced price. Please see ASRM daily 

schedules for details. These individuals will not receive CME credit. Any attendee that intends to attend general sessions and receive CME credit 

must register as a regular attendee. 

The All Inclusive Registration Packages 

Receive the following benefits for the meeting or meetings that you are registering for. 

AAHS, ASRM or ASPN: Admission to all instructional courses ● Access to speaker presentations ● Admission for each evening 

networking event Breakfast & lunch served per the agenda ● Refreshment breaks ● Access to the Exhibit Hall 

Free internet access in Exhibit Hall ● Self-Guided computerized CME courses (ASRM only) 

Valuable CME Hours ● 2008 Program Book complete with abstracts ● Discounted hotel rates. 

The AAHS Comprehensive Review Course and the ASRM Master Series require an additional admission purchase. Additional 

evening network event admission is available for your guests at an additional cost. 

12

2008 EXHIBITOR LISTING 

AMERICAN SOCIETY OF 

PLASTIC SURGEONS 

Booth: 50 

Emily Matzelle 

American Society of Plastic Surgery 

444 East Algonquian Road 

Arlington Heights, IL 60005 

phone: 847-228-9900 

fax: 847-981-5482 

email: ejm@plasticsurgery.org 

www.plasticsurgery.org 

The American Society of Plastic Surgeons is the largest organization of board-certified 

plastic surgeons in the world. With 6,000 members, the society is recognized as 

a leading authority and information source on cosmetic and reconstructive plastic 

surgery. The society represents physicians certified by The American Board of 

Plastic Surgery or The Royal College of Physicians and Surgeons of Canada. 

AM SURGICAL 

Booth: 47 

Marc Binnick 

290 East Main Street, Ste. 200 

Smithtown, NY 11787 

phone: 800-437-9653 

fax: 631-980-4369 

email: mbinnick@amsurgical.com 

www.amsurgical.com 

Visit A.M. Surgical at booth # 47 to learn about our single-incision, scope-assisted 

carpal and cubital tunnel release procedures. We will also be hosting sawbones 

demonstrations at our booth for our novel, non-spanning fixator (The CPX) for distal 

radius fractures. The CPX provides multiplanar fixation through an external, unilateral 

frame resulting in early mobilization and return to ADL. 

APTIS MEDICAL LLC. 

Booth: 45 

Bill Sandbach 

5 River Hill Road 

Louisville, KY 40207 

phone: 502.500.7000 

fax: 502.897.9007 

email: bills@aptismedical.com 

www.aptistmedical.com 

Aptis Medical has invented and developed upper extremity prosthesis including 

the Scheker Distal Radio-Ulnar Joint. The Scheker DRUJ Prosthesis has none of 

the widely known weaknesses associated with alternative procedures: 

1) Soft Tissue Arthroplasty: short-lived 

2) Single Bone Forearm: innobility 

3) Salvage procedures: impingement 

4) Allograft procedures: high cost of anti-rejection drugs/steriod risk 

5) Other prosthetic devices: replace only one of the three primary 

components of the DRUJ. 

ASCENSION ORTHOPEDICS 

Booth: 7 

Leigh Lovato 

8700 Cameron Road 

Suite 100 

Austin, TX 78754 

phone: 512-836-5001 

fax: 512-836-5145 

email: llovato@ascensionortho.com 

www.ascensionortho.com 

Ascension Orthopedics is dedicated to combining advanced materials with innovative 

designs, focusing on extremity surgery, and leading the field in surgeon 

education. Our founders are pioneers in using advanced materials to combat the 

debilitating effects of arthritis. Our goal is to provide solutions for all areas of surgery 

– reconstruction, trauma and tissue regeneration. 

13 

ASSI - ACCURATE SURGICAL 

Booth: 14 

Marie Bonazinga 

300 Shames Drive 

Westbury, NY 11590 

phone: 800-645-3569 

fax: 516-997-4948 

email: assi@accuratesurgical.com 

www.accuratesurgical.com 

ASSI will feature the Engler Breast Retractor, the Stanger C Breast Retractors and 

the new Lalonde Breast Sizers, the Lalonde Percutaneous Bone Clamp with K-wire 

guide, Face Lift Retractors, Campbell Lip Awl, Matarasso Lipo Roller and 

SuperCut Face Lift Scissors, ASSI’s Bipolar Scissors, Micro Monopolar Forceps, 

the Surex Sural Nerve Extractor and Nerve Holding/Cutting Forceps. ASSI’s Hand 

Crafted Microsurgical Instruments and Clinical Microvascular Clamps. 

AXOGEN, INC. 

Booth: 20 

Douglas Silber 

13859 Progress Boulevard 

Suite 100 

Alachua, FL 32615 

phone: 386-462-6816 

fax: 386-462-6801 

email: dsilber@axogeninc.com 

www.axogeninc.com 

AxoGen Nerve Regeneration provides surgeons with solutions to repair and 

regenerate peripheral nerves, bringing relief and restoring function to patients 

who suffer peripheral nerve injuries. AxoGen is a leader in the advancement of 

peripheral nerve repair – creating a unique combination of patented technologies 

and a rich pipeline of new products. 

BIOMET TRAUMA 

Booth: 23 

Steven Rassner 

100 Interpace Parkway 

Parsippany, NJ 07054 

phone: 973-299-9300 

fax: 973-316-2452 

email: steven.rassner@ebimed.com 

www.biomedtrauma.com 

Biomet Trauma develops and markets a full range of internal/external orthopedic 

devices used for upper extremity fracture fixation. This includes the OptiLockâ 

Distal Radius Plating System with SphereLockTM technology, UNIFLEXâ Humeral 

Nails, Variable Pitch Compression Screws, OptiROMâ Elbow Fixators and a variety 

of distal radius fixators. 

BIO PRO, INCORPORATED 

Booth: 40 

Jason Schneider 

17 Seventeenth Street 

Port Huron, MI 48060 

phone: 810-982-7777 

fax: 810-982-7794 

email: jschneider@bioproimplants.com 

www.bioproimplants.com 

BioPro manufactures the Modular Thumb Implant for the CMC joint, Nitinol 

Memory Staples for arthrodesis and fracture fixation, and the Digital Compression 

Screw for digital IP joint fusion.

BME 

Booth: 8 

Lisa May 

14785 Omicon Drive 

Suite 205 

San Antonio, TX 78245 

phone: 800-880-6528 

fax: 210-677-0355 

email: lisamay@bme-tx.com 

www.bme-tx.com 

The BME OSStaple and OSSPlate are changing the way surgeons manage 

fractures, fusions and osteotomies. The OSSforce offers controlled compression 

of Nitinol implants, which provide continual compression throughout the 

healing process. This controllable residual compression is what sets the 

OSStaple and OSSplate fixation system in a category of its own. 

COOK MEDICAL 

Booth: 17 

750 Daniels Way 

Bloomington, IN 47404 

Fax: 800-554-8335 

phone: 800-468-1379 

email: info@cookmedical.com 

www.cookmedical.com 

Cook ® Medical presents two unique products: The Cook-Swartz implantable 

Doppler Blood Flow probe with new DP-M250 Monitor offers the latest technology 

for continuous confirmation of vascular patency. Surgisis ® , a resorbable 

porcine small intestinal submucosa biomaterial provides a scaffold for host tissue 

remodeling, creating natural, cost-effective alternative to surgical repair. 

DEPUY ORTHOPEDICS, 

INCORPORATED 

Booth: 36 

Lynn Best 

700 Orthopaedic Drive 

Warsaw, IN 46580 

phone: 574-371-4979 

fax: 574-372-7382 

email: dpyus@.jnj.com 

DePuy Orthopaedics Inc., a Johnson and Johnson Company, is the world’s oldest 

and largest orthopaedic company and is a leading designer, manufacturer and distributor 

of orthopaedic devices and supplies. DePuy products are used in both surgical 

and non-surgical therapies to treat patients with musculoskeletal conditions 

resulting from degenerative diseases, deformities, trauma and sports related injuries. 

ELESVIER/SAUNDERS/MOSBY 

Booth: 9 

Matt Fee 

11363 Dulcet Avenue 

Northridge, CA 91326 

phone: 818-831-6717 

fax: 818-360-5903 

email: m.fee@elsevier.com 

www.elsevier.com 

Elsevier-Saunders-Mosby- is the world’s largest medical book publisher. The latest 

hand therapy and surgery textbooks will be available for viewing. 

HAND REHABILITATION FOUNDATION 

Booth: 19 

Leslie Ristine 

834 Chestnut Street, G114 

Philadelphia, PA 19107 

phone: 215-925-4579 

fax: 215-925-2386 

email: lristine@handfoundation.org 

The Hand Rehabilitation Foundation, established in 1975, is a 501(c)3 non profit 

corporation formed to promote research and education, and disseminate information 

to physicians and therapists who work with children and adults with hand 

disorders caused by injury, disease or present at birth. 

14 

HOLOGIC, INCORPORATED 

Booth: 15 

Laura L. DiGangi 

35 Cosby Drive 

Bedford, MA 01730 

phone: 781-999-7667 

fax: 781-280-0668 

email: ldigangi@hologic.com 

www.hologic.com 

Fluoroscan ® mini C-arm X-ray systems from Hologic are designed for orthopedic 

surgeons performing minimally invasive surgical procedures of the extremities, as 

well as for low-dose, in-office imaging. 

HOODMAN CORPORATION 

Booth: 2 

Lou Schmidt 

20445 Gramercy Place #201 

Torrance, CA 90501 

phone: 310-222-8608 

fax: 310-222-8623 

email: lou@hoodmanusa.com 

www.hoodmanusa.com 

Introduces its United States Ergonomics Certified ThermalRest ® ThermalRest ® is a 

Heated Computer Keyboard Wrist Pad which relieves wrist and hand pain associated 

with keyboard operating. CSA Safety Certified. 

INNOMED, INC. 

Booth 43 

Shannon Willhite 

HR Manager 

103 Estus Drive 

Savannah, GA 31404 

phone: 913-236-0000/109 

fax: 912-236-7766 

email: shannon@innomed.net 

www.innomed.net 

Innomed, Inc., a developer of instruments for orthopedic surgery, continues to 

introduce new and innovative products. We offer an array of unique instruments 

and patient positioning devices, designed by or in conjunction with orthopedic 

surgeons and surgical professionals. 

INTEGRA 

Booth: 12 

Jon Trout 

311 Enterprise Drive 

Plainsboro, NJ 08536 

phone: 609-275-0500 

fax: 609-799-3297 

email: jtrout@integra-ls.com 

www.integra-ls.com 

Integra develops, manufactures, and markets medical devices for neuro-trauma 

and neurosurgery, plastic and reconstructive surgery and general surgery. Integra’s 

peripheral nerve surgery products include NeuraGen for completely severed 

nerves and NeuraWrap for compressed, scarred or partially injured nerves

LIPPINCOTT, WILLIAMS & WILKINS 

Booth: 39 

Sean Fee 

11636 Andasol Avenue 

Granda Hills, CA 91344-2203 

phone: 818-363-0477 

fax: 603-372-0007 

email: sean.fee@woltersklower.com 

www.lww.com 

Lippincott Williams & Wilkins (LWW) is a leading international publisher of professional 

health information for physicians, nurses, specialized clinicians and students. 

The latest Hand surgery books from Lippincott, Thieme, and Springer will 

be on display. 

MAST BIOSURGERY 

Booth: 46 

David Goodman 

6749 Top Gun St., Suite 108 

San Diego, CA 92121 

phone: 858-550-8050 

fax: 858-550-8060 

email: dgoodman@mastbio.com 

www.mastbio.com 

The OrthoWrap Bioresorbable Protective Sheet is designed to protect tendons and 

minimize soft tissue attachments (STAs) to the device. MAST Biosurgery is a leader 

in the design, development, and production of bioresorbable polymer implants, 

and emerging new technologies for use in a variety of surgical applications. 

MEDARTIS, INC. 

Booth: 18 

Norman Eckley 

127 W. Street Road 

Suite 203 

Kennett Square, PA 19348 

phone: 610-961-6101 

fax: 610-961-6108 

email: Norman.eckley@medartis.com 

www.medartis.com 

Medartis is recognized around the world as an innovator in the use of Polyaxial screw 

fixation for the treatment of Distal Radius and Hand fractures. Since 2001, MEDAR- 

TIS has continued to develop exceptional implants and elegant instrumentation, 

finely crafted in the Swiss tradition of Orthopaedics. 

MEDICAL COMMUNICATIONS MEDIA 

Booth: 4 

Linda Hopkins 

54 Friends Lane, Suite 125 

Newtown, PA 18940 

phone: 267-364-0556 

fax: 267-364-0567 

www.cmecorner.com 

The CME Corner center is a unique service of Medical Communications Media, 

Incorporated and is intended to provide AAHS members with access to a free CME 

monograph on the topic of Dupuytren’s Contracture. Free copies of the monograph 

will be available at the exhibit. 

MEDLINK USA, INC. 

Booth: 5 

Tod Kellen 

PO BOX 42483 

Des Moines, IA 50323 

phone: 800-762-7921 

fax: 800-329-5990 

email: tkellen@medlinkusa.com 

www.medlinkusa.com 

15 

MEDTRONIC ENT 

Booth: 22 

6743 Southpoint Drive North 

Jacksonville, FL 32216 

phone: 904-296-9600 

fax: 904-281-0966 

Medtronic ENT is a leading developer, manufacturer and marketer of surgical products 

for use by ENT specialists. Medtronic ENT markets over 5,000 surgical products 

worldwide addressing the major ENT subspecialties – Sinus, Rhinology, 

Laryngology, Otology, Pediatric ENT. and Image Guided Surgery. 

MICRINS SURGICAL, INC. 

Booth: 11 

Bern Teitz 

28438 Ballard Drive 

Lake Forest, IL 60048 

phone: 847-549-1410 

fax: 847-549-1510 

email: bern@micrins.com 

www.micrins.com 

MICRINS is featuring some of our most popular instruments and accessories for 

Hand surgery, Micro-reconstructive surgery and Aesthetic surgery. With over 3500 

different patterns we are certain that we will have just the right instrument that you 

are looking for. Make a point to reserve some time and stop by the MICRINS booth. 

MICROSURGERY INSTRUMENTS, INC. 

Booth: 6 

Nancy Kang 

7211 Regency Sq. Blvd, #223 

Houston, TX 77036 

phone: 713-664-4707 

MICROSURGERY INSTRUMENTS, INC. 

fax: 713-664-8873 

email: microusa@microsurgeryusa.com 

Microsurgery Instruments, Inc. is one of the leading suppliers of instruments and surgical 

loupes in the United States. We are well known in a large number of surgical 

fields. Apart from high-quality loupes (from 2.5x to 11x), we also have super-cut scissors, 

titanium instruments, vascular clamps, headlights, sutures, microscopes and 

other surgical instruments 

MMI 

Booth: 33 

Melissa Rattle 

6000 Poplar Avenue 

Memphis, TN 38119 

phone: 901-685-7557 

fax: 901-683-7077 

email: mrattle@mmi-usa.com 

www.mmi-usa.com 

MMI is the U.S. Subsidiary of Memometal Technologies. Founded in 1992, 

Memometal Technologies is one of the only fully integrated manufacturers of 

Nitinol (NiTi) in the world. Memometal produces their Nitinol products from raw 

material (melting) to the final sterile implant. In 2002, Memometal Technologies 

began a strategic effort to concentrate its core technology and efforts in the 

extremity market (hand/wrist/elbow and foot/ankle). 

NEUROMETRIX 

Booth 44 

Leli Ng 

Marketing Specialist 

62 Fourth Ave 

Waltham, MA 02451 

phone: 981-890-9989 

fax: 981-890-1556 

email: info@neurometrix.com 

www.neurometrix.com 

The NC-stat® Nerve Conduction System enables all physicians to measure neuropathies 

related to diabetes and common conditions such as radiculopathy, 

spinal stenosis, sciatica, and carpal tunnel syndrome. Physicians order tests & staff 

administers under guidance. NC-stat has been clinically validated in 45 peerreviewed 

journal articles and abstracts.

NORTH COAST MEDICAL 

Booth: 1 

Roy Beckham 

18305 Sutter Boulevard 

Morgan Hill, CA 95037 

phone: 408-776-5000 

fax: 408-776-5087 

email: rbeckham@ncmedical.com 

www.ncmedical.com 

North Coast Medical specializes in the manufacture and wholesale distribution of 

occupational, physical and hand therapy products. For over 30 years, North Coast 

has established itself as the premier supplier of clinical supplies by providing outstanding 

customer service, exceptional quality products and competitive pricing. 

NOVADAQ TECHNOLOGIES 

INCORPORATED 

Booth: 41 

Mary Kay Baggs 

6473 Saddlewood Lane 

Fairhope, AL 36532 

phone: 772-559-9902 

fax: 772-929-0992 

email: mbaggs@novadaq.com 

www.novadaq.com 

Novadaq commercializes medical imaging systems and real-time image guided therapies 

for use in the operating room. Novadaq's proprietary imaging systems can be 

used to visualize blood vessels, nerves and the lymphatic system during a variety of surgical 

procedures. Novadaq's SPY ® Imaging System enables surgeons to visually assess 

blood flow and tissue perfusion during the course of plastic reconstructive surgery. 

NUTEK 

Booth: 38 

Jim Tyson 

301 SW 7th Street 

Fort Lauderdale, FL 33315 

phone: 954-779-1400 

fax: 954-779-1900 

email: jim@nutekortho.com 

www.nutekortho.com 

Nutek Orthopaedics, INC, was formed in Sep. 2006. Its first products are the NBX 

non-bridging external fixator and the First Assistant wrist fracture reduction 

device. Used in tandem these two products provide the surgeon with a combined 

MIS surgical and rehab. solution for distal radius fractures. 

ORFIT ® INDUSTRIES AMERICA 

Booth: Hall – Wednesday Only 

Debby Schwartz 

350 Jericho Turnpike, Suite 101 

Jericho, NY 11753 

phone: 516-935-8500 

fax: 516-935-8505 

email: debby.schwartz@orfit.com 

www.orfit.com 

Orfit ® Industries America is a world leader in the formulation, development and manufacture 

of low temperature thermoplastic materials for over 20 years. There is a wide 

range of Orfit ® splinting materials available to meet all therapy requirements and personal 

preferences. Orfit ® splinting materials are available in an unmatched number of 

thicknesses and perforation styles. Orfit ® offers innovative splinting materials that 

enable you to create elegant solutions for all of your splinting challenges. 

ORTHOSCAN, INC. 

Booth: 27 

Tiffany Townsend 

8212 E. Evans Road 

Scottsdale, AZ 85260 

phone: 480-503-8010 

fax: 480-503-8011 

email: tiffany.townsend@orthoscan.com 

www.orthoscan.com 

OrthoScan re-invented the Mini C-Arm with the goal of bringing “Mini” back to 

Mini C-arms, with a light weight, easy to use, high definition image. In addition to 

this improved resolution, we have the largest image on the market and the most 

contrasted image. OrthoScan is 100% dedicated to the orthopedic surgeon and 

100% dedicated to the Mini C-Arm. 

16 

ROBBINS INSTRUMENTS 

Booth: 16 

William Sabella 

2 North Passiac Avenue 

Chatham, NJ 07928 

phone: 800-206-8649 

fax: 973-635-8732 

email: williamsabella@cox.net 

www.robbinsinstruments.com 

Robbins Instruments will have on display our “High Torque” Micromotor Surgical 

System with surgical hand pieces for K-Wire placement, cutting and contouring 

bone and skin grafting. 

SMALL BONE INNOVATIONS 

Booth: 10 

Caralyn Foster 

1380 South Pennsylvania Avenue 

Morrisville, PA 19067 

phone: 215-428-1791 

fax: 215-428-1805 

email: cfoster@totalsmallbone.com 

www.totalsmallbone.com 

Small Bone Innovations, Inc. (SBi), is a single-source provider of products, technology 

and education for the small bone and joint sector of the orthopedic market. Please 

come visit us at Booth #10 at the 2008 AAHS Meeting. 

SPRINGER 

Booth: 26 

Acasia Dalmau 

233 Spring Street 

New York, NY 10013 

phone: 212-460-1600 

fax: 201-272-1832 

email: exhibits-ny@springer.com 

www.springer.com 

Stop by and browse Springer’s selection of Hand Surgery publications, and pick 

up your free sample copy of HAND, the new official journal of the American 

Association for Hand Surgery. 

STRYKER ORTHOPAEDICS 

Booth: 13 

Peter Valente 

325 Corporate Drive 

Mahwah, NJ 07430 

phone: 201-831-5276 

fax: 201-831-6453 

email: peter.valente@stryker.com 

www.stryker.com 

Stryker range of Upper Extremities and Hand Products offers a full range of options 

from Intramedullary nails, external fixation devices, screws, pins, plates and new 

orthobiologic solutions for fracture treatment. Industry recognized product lines 

such as T2 ® , Hoffmann, Asnis III, Variax and Profyle Hand Products. 

SYNOVIS MCA 

Booth: 30 

Terry Harrell 

739 Industrial Lane 

Birmingham, AL 35211 

phone: 205-941-0111 

fax: 205-941-1522 

email: terry.harrell@synovis.com 

www.synovis.com 

Synovis MCA, “the microsurgeon’s most trusted resource, provides innovative 

advanced technologies for microsurgeons. Come see our products: The 

Micorvascular Anastomotic COUPLER, GEM Neurotube ® - the proven choice in 

nerve conduits, S&T ® Collagen Matrix – for soft tissue repair, Biover disposable 

microvascular clamps, and the Life optics Varioscope ® - the world’s smallest headmounted 

operating microscope.

SYNTHES CMF 

Booth: 21 

Angela Obzud 

1301 Goshen Parkway 

West Chester, PA 19380 

phone: 610-719-6552 

fax: 610-719-6533 

email: obzud.angela@synthes.com 

www.synthes.com 

Synthes CMF is the sole authorized North American manufacturer and distributor 

of AO ASIF instruments and implants for internal fixation of craniomaxillofacial and 

mandibular trauma and reconstruction. Our product offering includes distraction 

osteogenesis devices, resorbable plating, and bone graft substitutes. Synthes 

CMF also supports North American AO ASIF Continuing Education courses. 

THE GUATEMALA HEALING 

HANDS FOUNDATION 

Booth: 52 

Mona Lipson 

290 6th Avenue 

Brooklyn, NY 11215 

phone: 718-768-5927 

email: monalipson@hotmail.com 

www.guatemalahands.org 

GHHF is a nonprofit organization dedicated to improving the quality and availability 

of hand care in Guatemala through education, surgery, and therapy. 

Specializing in the treatment of congenital and hand injuries, we aim to reach the 

Guatemalan population through medical missions led by a volunteer team of 

specialized and skilled surgeons, therapists, and dedicated volunteers. 

TORNIER 

Booth: 37 

Caroline Muigai 

10750 Cash Road 

Stafford, TX 77477 

phone: 281-494-7900 

fax: 281-494-0206 

email: cmuigai@tornier.com 

www.tornier-us.com 

The TORNIER Company is a global orthopaedic medical device company specializing 

in the design, manufacture and marketing of reconstructive joint devices. 

Please visit our booth and see our comprehensive portfolio of innovative products 

for upper extremity applications including the CoverLoc Volar Plate. 

TRIMED, INC. 

Booth: 3 

Jim Fassett 

25864 Tournament Road 

Valencia, CA 91355 

phone: 508-668-0988 

fax: 508-668-0212 

email: Tania@trimedortho.com 

www.trimedortho.com 

Founded in 1995, TriMed revolutionized the treatment of distal radius fractures. 

TriMed® is one of the most dynamic companies in the field of orthopaedics with 

its Advanced Fixation Technologies. The company specializes in small fragment 

and peri-articular fractures fixation and holds numerous patents on its innovative 

fracture fixation products 

17 

TRUEVISION SYSTEMS, INC. 

Booth: 29 

Latifa McQuiggan 

114 East Haley Street, Suite L 

Santa Barbara, CA 93101 

phone: 805-963-9700 

fax: 805-963-9719 

email: latifa@truevisionsys.com 

www.truevisionsys.com 

TrueVision is a revolutionary 3HDH vision system for microsurgery. The True 

Vision System converts the optical 3D image viewed through the microscope to 

a digital 3D high-definition image displayed to a projection screen or monitor in 

real time. It’s an ideal tool in surgery, teaching and collaboration. 

UPEX 

Booth: 24 

Dipak Rajhansa 

1300 Minnesota Avenue #101 

Winter Park, FL 32789 

phone: 407-539-2704 

fax: 407-539-2765 

email: info@upexco.com 

www.upexco.com 

VIOPTIX, INC. 

Booth: 28 

Denise Yarmlak 

44061-B Old Warm Springs Blvd. 

Fremont, CA 94538 

phone: 510-226-5806 x 217 

fax: 510-226-5864 

email: yarmlakd@vioptix.com 

www.vioptix.com 

The ViOptix Tissue Oximeter provides continuous, non-invasive, direct, real-time 

measurements of local tissue oxygen saturation. It is used for post-operative monitoring 

of flaps and digit replants to assess and monitor tissue, thereby improving 

medical outcomes and decreasing cost. The system consists of a monitor and sterile 

single-use optical sensors.

AAHS CONTINUING MEDICAL EDUCATION 

AAHS MEETING OBJECTIVES: 

1. To arrange clinical and basic science panels, special speakers, instructional courses and skill workshops on a variety of hand and upper extremity problems including 

therapy issues. 

2. To assemble a specialty day with experts in the field reviewing all aspects of the current medical treatments of arthritis, as well as new techniques in joint replacement, 

fusion and therapy techniques for the complete care of the arthritic hand patient, both osteo and rheumatoid. 

3. To contrast and compare the intellectual discourses of the annual meeting through an integrated program with the ASRM and ASPN. 

4. To learn and apply new skills during courses on hands for the replacement of new joints, plates, fracture management, hand soft tissue reconstruction for the 

upper extremity patient. 

5. Debate panel presentations on the following topics: the wide awake approach to hand surgery in an office setting with local anesthesia, the problem of ulnar 

nerve compression, neuropathies of the elbow, cubital tunnel syndrome, scaphoid fractures and management both non-operative and operative with newer techniques 

and compression screws. 

6. To appraise a presidential guest speaker, who is a Micorsoft engineer, will discuss new techniques in genetic engineering and implantable computer chips in the 

brain to help patients with paralysis, stroke, blindness and hearing deficits. 

7. To define current practices in wrist and hand fracture management. 

8. To demonstrate new surgical techniques in tendon, nerve and soft tissue repair. 

9. To acquire evidence based knowledge of current trends in the management of arthritis of the hand and wrist. 

10. To critique and appraise the latest basic science research in tissue engineering, composite tissue allografts and joint replacements. 

11. To discuss challenges and management issues in peripheral nerve surgery. 

METHODS TO ACHIEVE THESE OBJECTIVES WILL BE: 

1. Original research papers will be presented and discussed throughout the meeting. 

2. Poster presentations that were not selected for podium presentation will be presented and available for all members to review. 

3. All of the panelists are recognized experts and published in the international literature, in regards to those topics of nerve, out patient, local anesthetic surgery, 

patient safety issues ands- scaphoid and wrist fractures with problems discussed completely including therapy. 

4. Specialty day will include hand therapists as well as expert surgeons discussing an entire day on the treatment of the patient with osteo and rheumatoid arthritis, 

including a medical rheumatologist discussing current treatment protocols, as well as an entire review of all the new arthropplasty’s, fusions and a therapist will be 

included in every topic to discuss patient outcome, rapid recovery and patient safety issues in regards to therapy. 

5. Skills courses will be presented using cadaver related techniques to improve the hand surgeon and therapist understanding of newer techniques in joint arthroplasty, 

plating for fractures and soft tissue related issues for coverage of wounds. 

6. All attendees will have the opportunity to take a board review course which covers the entire aspect of board examination for the upper extremity surgeon, presented by a series 

of experts. 

7. Instructional courses will be offered throughout the program and will avail attendees with information related to all aspects of hand surgery. 

ACCREDITATION/CME 

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education 

through the joint sponsorship of the American Society of Plastic Surgeons and American Society for Peripheral Nerve. The American Society of Plastic Surgeons is accredited 

by the ACCME to provide continuing medical education for physicians. 

The American Society of Plastic Surgeons designates this educational activity for a maximum of 13.75 AMA PRA Category 1 credits. Physicians should only claim credit 

commensurate with the extent of their participation in the activity. (Credit hours subject to change): 

AAHS ANNUAL MEETING 

January 9-12, 2008 13.75 hours 

COMPREHENSIVE HAND SURGERY REVIEW COURSE 

January 11, 2008 4.5 hours 

AAHS/ASPN/ASRM COMBINED DAY 


Additional CME hours are available for Instructional/Bioskills Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows: 

COURSE # CME COURSE # CME 

101-104 1.0 hours 112-116 1.0 hours 

105 2.0 hours 117-122 1.0 hours 

106 1.5 hours 

107-111 1.0 hour 

Credit hours are subject to program changes. 

COPYRIGHT 

All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American 

Association for Hand Surgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation 

is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or 

to the American Association for Hand Surgery. Any sound reproduction, transcript, or other use of material presented at the meeting without the permission of the speaker 

or the American Association for Hand Surgery is prohibited to thef ull extent of common law copyright in such material. 

THE USE OF CAMERAS OR PHOTOGRAPHIC EQUIPMENT IS NOT PERMITTED DURING THE PRESENTATION OF SCIENTIFIC PAPERS. 

18

ASPN CONTINUING MEDICAL EDUCATION 

ASPN MEETING OBJECTIVES: 

ASPN's commitment to research and education has encouraged the organization to add an additional day of programming to the regular two day schedule. New for 2008, 

ASPN attendees will meet on Friday, Saturday and Sunday to enhance their educational experience. 

1. Describe and discuss experimental techniques in nerve research. 

2. Identify emerging technologies in the management of nerve and extremity injuries. 

3. To explain electrodiagnostic evaluation of acute and chronic nerve injuries. 

4. To identify and describe the management of nerve injury and nerve tumors. 

5. To describe and discuss evolving management of nerve injury causing pain. 

6. To explain the physiology of the neuromuscular junction and muscle reinnervation. 


1. Scientific presentations on current and recent advances in research on nerve injury and repair. 

2. Seminars from invited experts on specialized topics related to reinnervation, reconstruction and nerve tumors. 

3. Invited lectures from clinical scientists and researchers in nerve biology, pathophysiology and injury. 


This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education 

through the joint sponsorship of the American Society of Plastic Surgeons and American Society for Peripheral Nerve. The American Society of Plastic Surgeons is accredited 


The American Society of Plastic Surgeons designates this educational activity for a maximum of 12.75 AMA PRA Category 1 credits. Physicians should only claim credit 

commensurate with the extent of their participation in the activity. (Credit hours subject to change) 

ASPN ANNUAL MEETING 

January 11 – 13, 2008 12.75 hours 

AAHS/ASPN/ASRM COMBINED DAY 


Additional CME hours are available for Instructional Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows: 

COURSE # CME 

Instructional Courses 301 – 305 1.00 hour each 


COPYRIGHT 


Society for Peripheral Nerve. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation 

is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or 

to the American Society for Peripheral Nerve. Any sound reproduction, transcript, or other use of material presented at the meeting without the permission of the speaker 

or the American Society for Peripheral Nerve is prohibited to the full extent of common law copyright in such material. 

DISCLAIMER 

The views expressed and the subject material presented in the course of any activities sponsored by the American Society for Peripheral Nerve including lectures, seminars, 

instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the American Society for Peripheral 

Nerve. The Society assumes no responsibility for such views or materials, or implied, for the content of any Society sponsored presentations. Further, the Society hereby 

acknowledges that while its broad purpose is to promote the development and exchange of knowledge pertaining to the practice of microsurgery; it does so only in 

the context of a private forum without making any representation to the public whatsoever. Accordingly, the Society declares that its primary purpose is to benefit only 

its members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed. 


19

ASRM CONTINUING MEDICAL EDUCATION 

ASRM MEETING OBJECTIVES: 

1. To recognize and express updates on the state of the art techniques for microsurgical and complex reconstruction via peer reviewed scientific presentations 

on clinical and basic science research. 

2. To assemble scientific and academic interaction and foster collaboration amongst the American Association for Hand Surgery, the American Society for Peripheral 

Nerve and the American Society for Reconstructive Microsurgery. 

3. To arrange education opportunities for practicing surgeons, residents and fellows. 

4. To define and provide the attendees a focused update on specific topics in the form of expert panel presentations. 

5. To integrate participation by colleagues from around the world. 


1. Free papers to be presented in the open forum that allows audience discussion. 

2. National and international experts will provide different instructional courses on each day of the meeting. 

3. Panels by national and international experts will discuss conventional, new and controversial aspects of microsurgery and complex reconstruction. 

4. Patient Safety CME will be available by meeting participation and specialized computer modules available throughout the program. 

5. Specific mailing and invitations will increase participation of colleagues from around the world. 

6. Daily social events will provide interaction amongst colleagues, societies, and trainees. 

7. A conjoint scientific session including panels, instructional courses will be maintained on Saturday with the AAHS and on Sunday with the ASPN. 


This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through 

the joint sponsorship of the American Society of Plastic Surgeons and American Society for Reconstructive Microsurgery. The American Society of Plastic Surgeons is accredited 


The American Society of Plastic Surgeons designates this educational activity for a maximum of 26 AMA PRA Category 1 credits. Physicians should only claim credit 

commensurate with the extent of their participation in the activity. (Credit hours subject to change): 

AAHS/ASRM/ASPN Combined Day 


ASRM Master Series in Microsurgery 


ASRM Annual Meeting 

January 12 – 15, 2008 22 hours 

Additional CME hours are available for Instructional Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows: 

Course # CME 


Instructional Coruses 205 – 208 1.00 hour each 



Patient Safety Modules 

January 12 – 15, 2008 1.00 hour each 


COPYRIGHT 


Society for Reconstructive Microsurgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or 

presentation is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to 

the speaker or to the American Society for Reconstructive Microsurgery. Any sound reproduction, transcript, or other use of material presented at the meeting without 

the permission of the speaker or the American Society for Reconstructive Microsurgery is prohibited to the full extent of common law copyright in such material. 

DISCLAIMER 

The views expressed and the subject material presented in the course of any activities sponsored by the American Society for Reconstructive Microsurgery including lectures, 

seminars, instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the American Society 

for Reconstructive Microsurgery. The Society assumes no responsibility for such views or materials, or implied, for the content of any Society sponsored presentations. 

Further, the Society hereby acknowledges that while its broad purpose is to promote the development and exchange of knowledge pertaining to the practice of microsurgery; 

it does so only in the context of a private forum without making any representation to the public whatsoever. Accordingly, the Society declares that its primary 

purpose is to benefit only its members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed. 


20

Association for Hand Surgery 

American Society for Peripheral Nerve 

American Society for Reconstructive Microsurgery 

2008 Annual Meeting 

PRESENTERS’ DISCLOSURES 

THE FOLLOWING ANNUAL MEETING PRESENTERS HAVE INDICATED THE FOLLOWING DISCLOSURES: 

Brian Adams, MD, serves as a consultant to Ascension Orthopedics. 

Chris Attinger, MD, is on the speaker bureau for KCI, J&J, Novadsig, Insigon, and Smith &Nephew. He is also on the advisory panel of RCI and Smith & Nephew. 

Marie Badalamente, PhD, is a consultant for Auxilium Pharmaceuticals Inc. 

Robert Beckenbaugh, MD, receives royalties and travel assistance for laboratory from Ascension Orthopedics. 

Allan J. Belzberg, MD, receives grant support from DOD. 

Randy R. Bindra, MD, receives research support, non income support, and serves as consultant for DVO Tornier. 

Brandon M. Boyce, MD, receives WVU Dept of Orthopaedics. 

Charles Butler, MD, speaks for and receives clinical & research grant support from Life Cell Inc. 

Edward I. Chang, MD, receives stock support from Synvascular INC. 

Constance M. Chen, MD, receives research support from Allergan Corporation. 

Tyson Cobb, MD, receives research support from Wright Medical. He has also served as a consultant for SBI. 

William Cooney, MD, serves as a consultant to Small Bone Innovations. 

Vishal Didwania, BA, receives research and non income support from Integra Neurosciences. 

Haluk Duman, receives research support from Gulhane Military Medical Academy & Medical School. 

Gregory A. Dumanian, receives research support and non income support from Defense Department Research (DARPA), and DEKA Engineering. 

Michael Charles Edwards, MD, PhD, receives research support from the Michael Charles Edwards center, non income support from Medtronic, Inc., 

and stock support from Human Electric, Inc. 

Neville Hogan, PhD, holds equity in Interactive Motion Tech., Inc., which manufactures robots for physiotherapy. 

Wei-Chao Huang, receives research support from Chang Gung Memorial Hospital. 

Jeffery M. Jacobson, MD, receives stock support for Allergan, Inc. 

Phillip Johnston, MA, MRCS, receives research support from Action Arthritis. 

Alex Keller, MD, is a consultant for ViOptix. 

Tosca Kinchelow, MD, receives research support, royalties, and is a consultant for Wright Medical. 

Lukasz Krokowicz, MD, receives research support and is a consultant for SanuWave. 

Amy L. Ladd, MD, receives research support from Packard Children’s Foundation grant, and OREF grant. 

Donald, Lalonde, MD, serves as a consultant to ASSI instruments. 

Wyndell Merritt, MD, serves as a consultant to Micro Aire, and receives royalties for their Epicut Knife. 

Ather Mirza, MD, holds stock with AM Surgical. 

Jose Monsivais, MD, receives research support from the University of Texas at El Paso. 

Wong Moon, MD, receives research support and non income support from Cleveland Clinic 

Arash Moradzadeh, MD, receives non income support from Axogen, Inc. 

Afshin Mosabebi, receives research support for Allergan Corporation 

Tanya M. Oswald, MD, receives research support from the University of Mississippi Medical Center. 

Jeff Rodgers, MD, receives research support from Integra Life Sciences. 

Laura Rummler, MS, receives research support from NIH and ASSH. She also is a consultant for the University of California, Irvine. 

Michel C. Samson, MD, is a consultant for Novadaq. 

Robert Spinner, MD, receive royalties for work licensed through Mayo Clinic to a privately held company for contributions related to the use of nerve signal modulation 

to treat central, autonomic, and peripheral nervous system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does 

not currently license or manufacture any drug or device in the medical field. 

Mario G. Solari, MD, received research support from AAHS, NIH, and PSEF. 

William Swartz, MD, receives royalties from Cook Vascular for his patent of the Cook Doppler Monitor. 

Shian Chao Tay, MBBS, FRCS, FAMS, receives research support from Siemens Medical Solutions, National Medical Research Council, and Mayo Foundation. 

Charles Y. Tseng, MD, receives non income support from ViOptix, Inc. 

Sami H. Tuffah, BA, receives research support from AxoGen, Inc. 

Robert Whitfield, MD, receives research support from Life Cell and Integra, and receives non income support from Alloderm. 

The following presenters will include a discussion of an “off-label” or other non-FDA-approved, investigational use of medical devices or pharmaceutical products during 

their presentation. They will disclose that the product is not labeled for use under discussion or that the product is still investigational. 

Peter B. Arnold, MD, PhD Candice O. McDaniel, MD 

Marie Badalamente, PhD Wong Moon, MD 

Rachel Bluebond-Langner, MD Peirong Yu, MD 

Alex Keller, MD 

All other faculty members responded to PSEF that they did not have a conflict of interest. 

21

FUTURE ANNUAL MEETING LOCATIONS 

AAHS 

2009 ANNUAL MEETING 

January 7 – 10, 2009 

Grand Wailea Resort Hotel and Spa 

Maui, Hawaii 


January 6 – 9, 2010 

Boca Raton Resort and Club 

Boca Raton, Florida 


January 12 – 15, 2011 

Ritz Carlton Cancun 

Cancun, Mexico 


January 11 – 14, 2012 

Red Rock Casino Resort & Spa 

Las Vegas, Nevada 

ASPN 


January 9 – 11, 2009 

Grand Wailea Resort Hotel and Club 

Maui, Hawaii 


January 9 – 10, 2010 

Boca Raton Resort and Spa 



January 15 – 16, 2011 




January 14 – 15, 2012 


Las Vegas, Nevada 

22 

ASRM 


January 10 – 13, 2009 

Grand Wailea Resort Hotel and Spa 

Maui, Hawaii 


January 9 – 12, 2010 

Boca Raton Resort and Club 



January 15 – 18, 2011 




January 14 – 17, 2012 


Las Vegas, Nevada

AAHS 

DAY-AT-A-GLANCE 

Wednesday, January 9, 2008 

6:30am – 5:00pm Speaker Ready Room California Showroom 

6:30am – 2:00pm Meeting Services California Lounge 

6:30am – 7:30am Continental Breakfast Los Angeles 

7:00am – 4:30pm Specialty Day Program: Arthritis Los Angeles 

9:05am – 9:25am Break California Showroom 

12:34pm – 12:55pm Lunch California Showroom 

2:30pm – 3:30pm Hand Surgery Endowment Board of Governors Meeting Director’s Boardroom 

2:00pm – 3:00pm AAHS Instructional Courses 

101 Distal Radius Fracture Encino 

102 DRUJ Pacific 

103 Flexor Tendon Repair Palisades 

104 Extensor Tendon Injuries Brentwood 

2:00pm – 4:00pm 105 Treatment of Thumb CMC Arthritis Sherman Oaks 

3:00pm – 4:30pm 106 Splinting Challenges – Practical Pearls Westwood 

5:00pm – 7:00pm Meeting Services California Lounge 

5:00pm – 6:00pm Therapists’ Reception Meland Suite 

6:00pm – 8:00pm AAHS Welcome Reception X Bar 

23

MEETING AGENDAS 

AAHS 

Wednesday, January 9, 2008 

6:30am – 7:30am Continental Breakfast 

7:00am – 7:15am President/Program Chair Welcome 

N. Bradley Meland, MD, President 

Michael Neumeister, MD, Program Chair 

Craig Johnson, MD, Program Chair 

Christine Novak, PT, MS, Program Chair 

7:15am – 9:05am MEDICAL/SURGICAL MANAGEMENT 

Craig Johnson, MD, Moderator 

7:15am Pathogenesis & Medical Management 

Steven Ytterberg, MD 

DIP/PIP 

7:40am PIP Arthroplasty 

Robert Beckenbaugh, MD 

8:05am Post Op Management Following PIP Arthroplasty 

Ann Lund, OTR, CHT 

MP 

8:20am MP Arthroplasty 

Steve Moran, MD 

8:40am Post Op Management Following MP Arthroplasty 


8:55am Discussion & Questions 

9:05am BREAK 

9:25am – 10:45am SOFT TISSUE RECONSTRUCTION 

Christine Novak, PT, MS, Moderator 

9:25am Tendon Reconstruction 

James Chang, MD 

9:45am Post Op Management Following Tendon Reconstruction 


10:00am Surgical Management of Raynaud’s Phenomenon 


10:20am Post Op Management 

Julianne Howell, PT, MS, CHT 

10:35am Discussion and Questions 

10:45am PANEL: Wrist Reconstruction 

Mark Baratz, MD, Moderator 


A. Bobby Chhabra, MD 

Bill Cooney, MD 

11:30am – 1:00pm Past President’s Lunch 

11:40am PANEL: Thumb Arthritis: Challenges & Management 

Peter Murray, MD, Moderator 

James Chang, MD 

Peter Jebson, MD 

Matthew Tomaino, MD 

12:35pm LUNCH 

24 

12:55pm PANEL: When Bad Things Happen to Good People 

Nicholas Vedder, MD, Moderator 

Peter Amadio, MD 

Daniel Nagle, MD 

A. Lee Osterman, MD 

William Swartz, MD 

2:30pm – 3:30pm Hand Surgery Endowment Board of 

Governors Meeting 

2:00pm – 3:00pm Instructional Courses 

2:00pm – 4:00pm 

3:00pm – 4:30pm 

101 Distal Radius Fracture 

Current techniques for operative treatment and postoperative 

rehabilitation will be presented through a 

case-based format. Indications for volar plating, including 

comminuted fractures and elderly patients will be 

discussed. Associated injuries to the distal radioulnar 

joint and treatment options will also be included. 

Brian Adams, MD, Moderator 

William Geissler, MD 


Ann Kammien, PT, CHT 

102 DRUJ 

Mark Baratz, MD, Moderator 


Maureen Hardy, PT, MS, CHT 

103 Flexor Tendon Repair 

This course will focus on the current issues of flexor tendon 

repair including anatomy, pathophysiology, type of 

repair, and recent advances in rehabilitation. Material 

will represent evidence-based practice. 

Michael Neumeister, MD, Moderator 


Donald Lalonde, MD 

Aviva Wolff, BSc, OTR/L, CHT 

104 Extensor Tendon Injuries 

Surgical and non-surgical management of acute and 

chronic common extensor injuries are reviewed with 

emphasis on newer methods that permit immediate 

active motion and function, including long extensor 

laceration’s boutonniere deformity, sagittal band rupture 

and mallet deformity. 

Wyndell Merritt, MD, Moderator 

Julianne Howell, PT, MS, CHT 

105 Treatment of Thumb CMC Arthritis 

A number of different methods can be successfully used 

for treatment of osteoarthritis of the CMC joint. This 

workshop will focus on strategies for the use of a less 

invasive approach to treat earlier stage OA utilizing a 

degradable resurfacing implant. The faculty will discuss 

implantation using an open surgical approach as well as a 

minimally invasive, arthroscopic approach. 

Alejandro Badia, MD 

Randy Bindra, MD 

Sponsored by: 

Tyson Cobb, MD 


106 Splinting Challenges – Practical Pearls 

In this course, practical splinting pearls, techniques and 

demonstrations will be presented. The course will 

include immediate controlled active motion program 

for extensor tendon repairs, intra-articular dynamic traction 

splint for phalangeal fractures and unique splinting 

for flexor tendon repairs. 

Julianne Howell, PT, MS, CHT, Moderator 

James Gyovai, PT, CHT 


5:00pm – 6:00pm Therapists’ Reception 

6:00pm – 8:00pm Welcome Reception

AAHS 


Thursday, January 10, 2008 



7:00am – 8:00am Continental Breakfast with Exhibitors California Showroom 

7:00am – 8:00am Instructional Courses 

107 Fractures of the Hand Pacific 

108 PIP Joint Stiffness Palisades 

109 Vascularized Bone Grafts Westwood 

110 Scapho-Lunate Injuries Sherman Oaks 

111 Cost-Effective and Tax-Efficient Managed Money Encino 

for Physicians 

8:10am – 8:45am President/Program Chair Welcome Los Angeles 

AAHS Presidential Welcome 

Program Chair Welcome 

ASSH Presidential Welcome 

ASPS Preidential Welcome 

Vargas Recipient Welcome 

8:45am – 10:15am PANEL: Wide Awake Hand Surgery Los Angeles 

10:15am – 10:45am Break with Exhibitors California Showroom 

10:30am – 11:30am Hand Journal – Editorial Board Meeting Bel Air 

10:45am – 12:35pm Concurrent Scientific Paper Session A Los Angeles 

10:45am – 12:35pm Concurrent Scientific Paper Session B Beverly Hills 

12:35pm – 1:00pm Lunch with Exhibitors California Showroom 

1:10pm – 1:40pm Keynote Speaker: Ramez Naam Los Angeles 

1:45pm – 2:15pm PANEL: Scaphoid Fractures Los Angeles 

2:30pm – 3:30pm AAHS Instructional Courses 

112 Complex Hand Trauma Pacific 

113 Tumors of the Upper Extremity Palisades 

114 Nerve and Tendon Transfer Westwood 

115 The Assessment and Treatment of Peripheral Brentwood 

Nerve Injuries in Children 

116 Anatomy and Care of the Perionychium Sherman Oaks 

116A Partial Ulnar Head Replacement Arthroplasty: Encino 

Why Resect the Entire Head? 

25

AAHS 

Thursday, January 10, 2008 

7:00am – 8:00am Continental Breakfast with Exhibitors 


107 Fractures of the Hand 

This course will review treatment options to get the best 

results for the various common finger and metacarpal 

fractures, with emphasis on the difficult ones. New concepts 

in early protected movement in finger fractures 

will be explored. 


Stephen Trigg, MD 

Mary Burns, OT 

108 PIP Joint Stiffness 

This course will review the treatment options for the stiff 

finger. Therapy measures, soft tissue surgical and manipulation 

treatment, and mobilization techniques for the 

stiff PIP after arthroplasty will be discussed. 

Robert Beckenbaugh, MD, Moderator 

Ann Lund, OTR, CHT 

Joseph Slade, MD 

109 Vascularized Bone Grafts 


Michael Saurbier, MD 

110 Scapho-Lunate Injuries 

This course will review current concepts on the diagnosis, 

evaluation and management of acute and chronic 

scapholunate injuries. Indications, technical pearls and 

outcomes of surgical procedures for repair or reconstruction 

of radial-sided wrist instability will be discussed. 

Randy Bindra, MD, Moderator 

Michael Hayton, MD 

Jai Ryu, MD 

111 Cost Effective and Tax 

Efficient Managed Money 

for Physicians 

Physicians are busy individuals that require specialized services 

for their wealth management needs. This discussion 

will focus on managed money for physicians—the most 

cost-effective and tax-efficient way to manage money for 

high income earning individuals. We will discuss current 

investment opportunities and markets, maximizing the use 

of tax-free investments. This year’s talk features special 

guests the Nexus Group of portfolio managers. The Nexus 

Group seeks to achieve higher returns but with significantly 

lower risk. The portfolio managers employ a disciplined 

and balanced strategy; they have a goal of producing consistent 

above market returns. Come learn valuable insights 

into how to maximize your returns. 

Patrick Donnelly- Smith Barney Consulting Group 

Jeff Palmer- Smith Barney Consulting Group 

Bimal Sheth- Smith Barney Nexus Group 

Sanjeev Arora- Smith Barney Nexus Group 

Aziz Ihani- Smith Barney Nexus Group 

8:10am – 8:45am Welcome 

N. Bradly Meland, MD, President 

Michael Neumeister, MD, Program Chair 

Craig Johnson, MD, Program Chair 

Christine Novak, PT, MS, Program Chair 

Steven Glickel, MD, ASSH President 

Richard D’Amico, MD, ASPS President 

Roberta Finley Morris, OTR/L, 2007 Vargas Recipient 

8:45am – 10:15am PANEL: Wide Awake Hand Surgery 

N. Bradly Meland, MD, Moderator 


Wyndell Merritt, MD 

Matthew Concannon, MD 

10:15am – 10:45am Break with Exhibitors 

10:30am – 11:30am Hand Journal – Editorial Board Meeting 

Sponsored by Springer 

26 

10:45am – 12:45pm Concurrent Scientific Paper Session A 

*Designates resident/fellow paper presentations 

Moderators: Keith E. Brandt, MD 


10:45am – 10:51am 

Long Term Outcome Following Scaphoidectomy and Four-Corner Fusion 

Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA 

David Dennison, MD; Coen Wijdicks; Justin Strickland; Steven Moran; 

Alexander Shin 

10:51am – 10:57am 

Reconstruction of the TFCC using ECU Half-Slip and Interference Screw 

Institution where the work was prepared: Department of Orthopaedic Surgery, 

Keio University, Tokyo, Japan 

Toshiyasu Nakamura, MD, PhD; Kazuki Sato; Noriaki Nakamichi; Yoshiaki Toyama; 

Hiroyasu Ikegami 

10:57am – 11:03am 

*Expression of TGF beta and IL-10 in Rat Hindlimb Composite Tissue Allografts 

Institution where the work was prepared: Plastic Surgery, Southern Illniois University 

School of Medicine, P.O. Box 19653, Sprignfield, IL, USA 

Damon Cooney MD, PhD; Chris Chambers; Michael Neumeister 

11:03am – 11:09am 

*Is There More Translational Motion after Proximal Row Carpectomy? 

Institution where the work was prepared: University of Pittsburgh Medical Center, 

Pittsburgh, PA, USA 

Peter Tang, MD, MPH; Jean Gauvin, PhD; Muturi Muriuki, PhD; Jamie Pfaeffle, 

MD, PhD; Joseph Imbriglia, MD; Robert Goitz, MD 

11:09am – 11:15am 

A Novel Approach for Treating Fractures of the Distal Radius 

Institution where the work was prepared: Dr Ather Mirza, Smithtown, NY, USA 

M. Ather Mirza, MD; Mary Kate Reinhart, CNP 

11:15am – 11:21am 

Discussion 

Moderators: Allen T. Bishop, MD 


11:21am – 11:27am 

*Radiographic Evaluation of the Distal Radius Using Two Novel Biplanar 

"Pitch-And-Roll" Views: A Cadaveric Study 

Institution where the work was prepared: West Virginia University Department of 

Orthopaedics, Morgantown, WV, USA, Brandon M. Boyce, MD; Jaiyoung Ryu 

11:27am – 11:33am 

*Repair of Distal Radial Malunions with Intramedullary Fixation 

Institution where the work was prepared: UMDNJ- NJ Medical School, Newark, 

NJ, USA 

John Capo; Damon Ng, MD; Tosca Kinchelow, MD; Virak Tan, MD 

11:33am – 11:39am 

Transosseous Repair of the Triangular Fibrocartilage Complex in Ulnar Sided 

Lesions; Cadaver Model and Clinical Series 

Institution where the work was prepared: Miami Hand Center, Miami, FL, USA 

Eduardo Gonzalez-Hernandez, MD; Ignacio Garcia-Cepeda, MD 

11:39am – 11:45am 

*Wrist Arthrodesis as a Salvage Operation for Failed Wrist Implant Arthroplasty 


Duncan B. Ackerman, MD; Marco Rizzo; Robert Rodrigues; Robert D. 

Beckenbaugh 

11:45am – 11:51am 

*Osteochondral Resurfacing of Capitate Chondrosis in Proximal Row Carpectomy 

Institution where the work was prepared: Western Pennsylvania Hand and 

UpperEx Center, Wexford, PA, USA 

Peter Tang, MD, MPH; Joseph E. Imbriglia, MD 

11:51am – 11:57am 

Discussion 

Moderators: James Chang, MD 


11:57am – 12:03am 

*Post-Operative Complications Of Arthroscopic TFCC Repair 

Institution where the work was prepared: University of Toledo, Toledo, OH, USA 

Ian Rodway, MD; Martin C Skie; Despina E Ciocanel 

12:03am – 12:09pm 

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-wire and 

Circular Plate Fixation 

Institution where the work was prepared: Des Moines Orthopaedic Surgeons, 

West DesMoines, IA, USA 

Jeff Rodgers, MD; Gary Holt, MD; Edward Finnerty, PhD; Blake Miller, BS

12:09pm -12:15pm 

*The Volar Approach for Fractures of the Distal Radius: 100 Patients Analysis 

Institution where the work was prepared: Faculdade de Medicina do ABC, Santo 

Andre, Brazil 

Marcio A. Aita, MD; Gustavo M. Ruggiero, MD; Alvaro B. Cho, MD; Walter Y. 

Fukushima, MD; W. Lino Jr, MD; Fabiano N. Faria, MD 

12:15pm – 12:21pm 

Mechanical Effect of Metaphyseal Plate Stand-off in Radius Volar Plates 

Institution where the work was prepared: University of Arkansas, Little Rock, AR, USA 

Randy R. Bindra, MD, FRCS; Sivathan Kumar; William R Hogue 

12:21pm – 12:27pm 

*Surgical Management of Post-traumatic Elbow Contractures in the Adolescent 

Patient Population: Principles and Outcome 

Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, 

USA 

Alexander H. Payatakes, MD; Nickolaos A Darlis; Robert W Kaufmann; Dean G 

Sotereanos 

12:27pm – 12:42pm 

Discussion 

10:45am – 12:45pm Concurrent Scientific Paper Session B 


Moderators: Loree K. Kalliainen, MD, FACS 

Steven L. Moran, MD 

10:45am – 10:51am 

Injectable Collagenase Enzyme (AA4500) in Dupuytren's Contracture: Clinical 

Success in Patients with Concomitant Diabetes 

Institution where the work was prepared: SUNY at Stony Brook, Stony Brook, NY, USA 

Marie Badalamente, PhD; Lawrence C. Hurst 

10:51am – 10:57am 

*Clinical Outcome in Dupuytren's Disease Correlates with Proteinase Gene 

Expression 

Institution where the work was prepared: University of East Anglia and Norfolk & 

Norwich Hospital, Norwich, United Kingdom 

Phillip Johnston, MA, MRCS; Debbie Larson; Adrian J. Chojnowski, MA, FRCS, 

(Orth); Ian M. Clark, PhD 

10:57am – 11:03am 

Amputation Versus Reconstruction in Severe Crush Injuries of the Upper Limb 

Institution where the work was prepared: UMF Iuliu Hatieganu, Plastic and 

Reconstructive Microsurgery Clinic, Cluj Napoca, Romania 

Alexandru Georgescu, Prof, MD, PhD; Filip Ardelean MD; Ileana Matei; Irina 

Capota MD 

11:03am – 11:09am 

A Comparison Study of Preliminary Soft Tissue Distraction vs. Check Rein 

Ligament Release in the Treatment of Dupuytren's PIP Joint Contracture 

Institution where the work was prepared: Mayo Clinic Hospital Arizona, Phoenix, AZ, USA 

Aaron Klomp, MD; Grant Fankhauser; Anthony Smith; Alanna Rebecca; Scott Duncan 

11:09am – 11:15am 

*The Spiral Flap for Fingertip Resurfacing: Short- and Long-Term Results 

Institution where the work was prepared: Singapore General Hospital, Singapore, 

Singapore 

Gale Lim, MBBS, MRCS, MMed; Andrew Yam, MBBS, MRCSEd, MM; Jonthan YL 

Lee, MBBS, MRCSEd, MM; Lc Teoh, MBBS, FRCS, FAMS 

11:15am – 11:21am 

Discussion 

Moderators: Matthew Concannon, MD 

Jaiyoung Ryu, MD, FACS 

11:21am – 11:27am 

*Analysis of Limited Wyndell Merritt Splint for Extensor Tendon Injuries to 

Hand Immobilization 

Institution where the work was prepared: SIU School of Medicine, Springfield, IL, USA 

Nada Berry, MD; Michael Neumeister 

11:27am – 11:33am 

*Comparison of FiberLoop and Supramid in Zone II Flexor Tendon Repair 

Using a Cyclic Protocol 

Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA 

Aaron Anderson, MD; S. Chase Donnelly; Richard Drake, PhD; Kathleen Derwin, 

PhD; Jeff Lawton, MD 

27 

11:33am – 11:39am 

Graft-on flap Method for Fingertip Nail Reconstruction 

Institution where the work was prepared: Yuichi Hirase, Saitama, Japan 

Yuichi Hirase, MD 

11:39am – 11:45am 

Deep Inferior Epigastric Artery Graft for Raynaud's Disease 

Institution where the work was prepared: Hee Chang Ahn, Seoul, South Korea 

Hee-Chang Ahn, MD; Steven Bates, MD; Scott L. Hansen; Neil F. Jones 

11:45am – 11:51am 

The Use of Dermal Substitutes in Burn Scar Contracture Releases to the Hand 

and Upper Extremity 

Institution where the work was prepared: Indiana University, Indianapolis, IN, USA 

Madeline Zieger, PA; David Roggy, RN; Rajiv Sood, MD, FACS 

11:51am – 11:57am 

Discussion 

Moderators: Nash Naam, MD 

Michel Saint-Cyr, MD 

11:57am – 12:03pm 

Treatment of Distal Biceps Ruptures Using a One-Incision Technique and 

Biotenodesis Screw Fixation: A Preliminary Report on Patient-Oriented 

Outcomes 

Institution where the work was prepared: UMass Memorial Medical Center, 

Worcester, MA, USA 

Mark Eskander, MD; Jonathan Eskander; Douglass Weiss; Nicola DeAngelis 

12:03pm – 12:09pm 

*Flexor Tendon Repair with Barbed Suture 

Institution where the work was prepared: UT SouthWestern Medical center, 

Dallas, TX, USA 

Fatemeh Abtahi, MD; Michel Saint-Cyr; Spencer A. Brown; Debby Noble, BS; 

Dan Hatef, MD; Jordan Farkas, MD 

12:09pm – 12:15pm 

*Management of the Central Extensor Tendon on the Surgical Approach for 

Exposure of the Proximal Interphalangeal Joint: A Biomechanical Study 

Institution where the work was prepared: University of New Mexico, Department 

of Orthopaedics, Albuquerque, NM, USA 

Deana Mercer; Keikhosrow Firoozbakhsh; Alex Carvalho; Moheb S. Moneim 

12:15pm – 12:21pm 

Treatment of Chronic Digital Ischemia with Direct Microsurgical Revascularization 

Institution where the work was prepared: Northwestern University, Chicago, IL, USA 

Zol Kryger, MD; Vinay Rawlani; Gregory A. Dumanian 

12:21pm – 12:27pm 

*Modified Allen's Test Using Near Infrared Spectroscopy: Clincal and Anatomic 

Study 

Institution where the work was prepared: University of Texas Southwestern 

Medical Center, Dallas, TX, USA 

Daniel A. Hatef, MD; Dallas Alvey; Li Ngov; Michel Saint-Cyr; Spencer A. Brown; 

Rod J. Rohrich 

12:27pm – 12:35pm 

Discussion 

12:35pm – 1:00pm Lunch With Exhibitors 

1:10pm – 1:40pm Keynote Speaker 

Ramez Naam 

“More Than Human: From Therapy to Enhancement” 

At the edge of medicine, researchers are demonstration that 

it’s possible to enhance human abilities beyond the health 

norm. Should we? Ramez Naam is an author and professional 

technologist who has spent his career seeking ways to 

empower people through software. He helped develop 

two of the most widely used pieces of software in the 

world – Microsoft Internet Explorer and Microsoft Nano 

Technologies, developing software for nanotechnology 

researchers. He is currently the Group Program Manager for 

Windows Live Search, where he leads efforts to develop new 

and smarter technologies for searching the internet. Naam is 

also the author of More than Human: How Technology Wil 

l Transform Us and Why We Should Embrace It

(Broadway Books, 2004). In the book, Naam explores how 

new technologies can serve as powerful tools in humans’ 

quest to improve themselves. Naam is regularly invited to 

speak at software and nanotechnology conferences. He 

is a fellow of the Institute for Ethics and Emerging 

Technologies and the recipient of the 2005 H.G. Wells Award 

for Contributions to Transhumanism. Naam recently 

appeared in the PBS television show “The 22nd Century” 

and has been profiled or reviewed in the New York Times, 

Scientific American, Fast Company, Discover Magazine, 

Business Week and numerous other publications. 

He is a graduate of the University of Illinois at 

Champaign-Urbana. 

1:45pm – 2:15pm PANEL: Scaphoid Fractures 

Joseph Slade, MD, Moderator 


112 Complex Hand Trauma 

This course will focus on the treatment of complex hand 

trauma, including assessment and planning, initial treatment, 

and delayed reconstruction and rehabilitation. 

Treatment algorithms for managing vascular, nerve, skeletal, 

and soft tissue injuries will be presented and discussed. 

Nicholas Vedder, MD, Moderator 


W. P. Andrew Lee, MD 

113 Tumors of the Upper Extremity 

Gene Deune, MD 

114 Nerve and Tendon Transfer 

This course will review nerve and tendon transfer options 

for isolated and complex upper extremity injuries. Pre- 

Operative evaluation, timing and planning, operative 

technique and motor and sensory re-education will be 

reviewed. 

Susan Mackinnon, MD, Moderator 

Neil Ford Jones, MD 

Christine Novak, PT, MS 

115 The Assessment and Treatment 

of Peripheral Nerve Injuries in Children 

This course will cover the gamut of peripheral nerve injuries 

in children. The principles of diagnosis and assessment of 

nerve injuries in children will be discussed. Subsequently, 

the treatment of both acute nerve trauma and of late presentations 

of nerve injuries will be highlighted. Importantly, 

the role of the therapist on the evaluation process and during 

the time of nerve recovery will be reviewed. Case 

presentations will conclude the course with audience participation. 

Scott Kozin, MD, Moderator 

Howard Clarke, MD 

Lynn Bassini, OTR, CHT 

116 Anatomy and Care of the Perionychium 

A summary of the anatomy of the perionychium and the 

care of injury, reconstruction, and other conditions of the nail. 

Elvin Zook, MD, Moderator 

116-A Partial Ulnar Head Replacement 

Arthroplasty: Why Resect the Entire Head? 

This course will introduce a new Partial Ulnar Head replacement, 

designed to allow preservation of the native ulnar styloid 

and keep the critical soft tissue structures intact. This 

workshop will provide a comprehensive overview of DRUJ 

disorders, design rationale, patient selection, surgical technique 

and post-op therapy. Cadaveric models will be used 

to demonstrate the Ascension® First Choice® Partial Ulnar 

Head Replacement surgical technique. 


Sponsored by Ascension Orthopedics 

28

AAHS 


Friday, January 11, 2008 


6:30am – 7:00am Meeting Services California Lounge 

7:00am – 7:30am Annual Business Meeting Breakfast Encino 

7:00am – 8:30am Continental Breakfast w/Exhibitors California Showroom 


117 Thumb Reconstruction Palisades 

118 Outcomes of Nerve Decompression Pacific 

119 NCS Nerve Electrophysiology Brentwood 

120 Basilar Joint Arthritis Westwood 

121 Periarticular Elbow Fracture Dislocations: Will My Sherman Oaks 

Elbow Bend Again? 

122 Financial Planning for the Newly Established Surgeon Director’s Dining Room 

8:35am – 9:35am PANEL: Cubital Tunnel: Defend Your Operation Los Angeles 

9:35am – 10:00am Presidential Address Los Angeles 

10:00am – 10:30am Joseph Danyo Presidential Invited Lecturer: Allen Van Beek Los Angeles 


11:00am – 12:45pm Concurrent Scientific Paper Session C Los Angeles 

11:00am – 12:45pm Concurrent Scientific Paper Session D Palisades/Pacific 

12:00pm – 2:30pm AAHS Board of Directors Luncheon/Meeting Governor’s Boardroom 

12:45pm– 6:10pm Comprehensive Hand Surgery Review Course Beverly Hills 

7:00pm – 10:00pm AAHS Salsa Sensation Awards Dinner & Dance Plaza Pavilion 

29

AAHS 


7:00am – 7:30am Annual Business Meeting 

(Attendance is limited to AAHS members only) 

7:00am – 8:30am Continental Breakfast 


117 Thumb Reconstruction 

This case-oriented panel will review simple to complex 

methods of thumb reconstruction for congenital and 

post-traumatic thumb absence. The cases presented 

will illustrate key principles in thumb reconstruction. 

Algorithms for optimal thumb reconstruction will be 

presented. 

James Chang, MD, Moderator 

Rudy Buntic, MD 

Neil Ford Jones, MD 

118 Outcomes of Neve Decompression 

This course will combine a review of outcomes 

measurements for nerve decompression surgery and an evidence 

based review of the outcomes that are achieved. It 

will be of interest to the surgeon, therapists, others providing 

care, and to the clinical researcher. 

Steven McCabe, MD, Moderator 


119 NCS Nerve Electrophysiology 

This course’s objective is to teach participants 

understanding of NCS and the clinical use of intraoperative 

use of Nerve Stimulation and Recording 

techniques during complex reconstructive surgery. 

Allen Van Beek, MD, Moderator 

120 Basilar Joint Arthritis 

This course deals with the etiology, diagnosis and 

treatment of degenerative arthritis of the basal joint of 

the thumb. Treatment modalities will be discussed 

including arthroscopy, metacarpal osteotomy, arthrodesis, 

interposition arthroplasty and total joint replacement. 

Nash Naam, MD, Moderator 

Miguel Saldana, MD 

Jennifer Thompson, PT 

121 Periarticular Elbow Fracture Dislocations: 

Will My Elbow Bend Again? 

This course will review surgical and therapeutic 

treatment principles related to periarticular elbow 

fractures and dislocations. Emphasis will be placed on 

factors that ultimately lead to optimal outcome and 

patient satisfaction. 

Robert Goitz, MD, Moderator 

Paul Brach, PT, MS, CHT 


122 Financial Planning for the 

Newly Established Surgeon 

As a physician, you have worked hard for your wealth. 

However, accumulating wealth is just one aspect of 

managing your assets. If you are like most busy physicians, 

you may lack the time needed to select the right 

investments that best meet your specific financial needs. 

This discussion will focus on the basic things residents or 

new physicians need to do in order to begin investing 

for themselves and their practices, and how to select the 

right investment program. This year’s talk features special 

guests the Nexus Group of professional portfolio managers, 

who seek to achieve higher returns with significantly 

lower risk. Come ask your investment and 

market related questions and gain wisdom for 

the future. 

Patrick Donnelly- Smith Barney Consulting Group 

Jeff Palmer- Smith Barney Consulting Group 

Bimal Sheth- Smith Barney Nexus Group 

Sanjeev Arora- Smith Barney Nexus Group 

Aziz Ihani- Smith Barney Nexus Group 

8:35am – 9:35am PANEL: Cubital Tunnel: Defend Your Operation 

This panel will cover z plasty/submuscular, learmonth 

submuscular, medial epicondylectomy and endoscopic 

operations. 

Susan Mackinnon, MD, Moderator 




Tyson Cobb, MD 

30 

9:35am – 10:00am Presidential Address 

N. Bradly Meland, MD 

10:00am – 10:30am Joseph Danyo Presidential Invited Lecturer 


“Handing Back Options” 

The surgical outreach to help children in third world 

countries provides children with new options for their 

futures. It provides inspiration, challenges and meaning 

for the Hand Surgeon. 

Dr. Van Beek has served as President of the AAHS, 

ASPN, ASRM and PSEF. He has traveled to numerous 

countries and locations performing Hand and 

Reconstructive Plastic Surgery in under served areas or 

teaching centers. His experience serves as an impetus 

for him to encourage others to help provide care for 

children whose futures are altered because of their 

hands. His challenge is for health care providers to go 

beyond their “comfort zone” something he considers 

the “danger zone”. 


11:00am – 12:45pm Concurrent Scientific Paper Session C 


Moderators: Peter Murray, MD 

Christine Novak, PT MS 

11:00am – 11:06am 

*Evaluating the Efficacy of Combining Clinical Signs of Scaphoid Fracture to 

Decrease Unnecessary Immobilization: A Prospective Multi-Institutional Study 

Supporting the Early Use of Advanced Imaging 

Institution where the work was prepared: Naval Medical Center San Diego, San 

Diego, CA, USA 

Joseph R. Carney, MD; Eric Hofmeister; John Paul Rhue; Brian Fitzgerald; 

Michael Thompson 

11:06am – 11:12am 

*Long-term Outcomes of Dorsal Intercarpal Ligament Capsulodesis for 

Chronic Scapholunate Dissociation 

Institution where the work was prepared: University of California, Davis, 

Sacramento, CA, USA 

Varun Gajendran, MS; Brett Peterson, MD; Robert R. Slater, MD, FACS; Robert 

Szabo, MD, MPH 

11:12am – 11:18am 

*Treatment of Scaphoid Fractures and Nonunions with a Cannulated AO 

Screw and Threaded Washer: Report of 99 Cases 

Institution where the work was prepared: University of California San Diego, San 

Diego, CA, USA WITHDRAW 

Andrew Pennock, MD; Todd Horton, MD; William Tontz, MD; Reid Abrams, MD 

11:18am – 11:24am 

*Outcome Assessment after Treatment of Scaphoid Nonunion in the Middle 

Third (Herbert Type D2) with Conventional Bone Grafting and Screw Fixation 

from a Palmar Approach 

Institution where the work was prepared: Department of Hand, Plastic and 

Reconstructive Surgery, Ludwigshafen, Germany 

Miriam Mueller, MD; Andre Otto; Christiane Hitzigrath; Rainer Simon; Günter 

Germann; Michael Sauerbier 

11:24am – 11:30am 

*Open Reduction for Perilunate Injuries - Long Term Results and Patients Content 

Institution where the work was prepared: BG Trauma Center Ludwigshafen, 

Ludwigshafen, Germany 

Thomas Kremer, MD; Michael Wendt; Michael Sauerbier; Guenter Germann 

11:30am – 11:35am 

Discussion 

Moderators: Daniel Nagle, MD 

Michael Sauerbier, MD

11:35am – 11:41am 

Thumb Metacarpal Phalangeal Joint Capsulodesis at the Time of Basal Joint 

Arthroplasty: a Surgical Technique Utilizing Suture Anchors 

Institution where the work was prepared: Mayo Clinic, Phoenix, AZ, USA 

Scott F.M. Duncan, MD, MPH; Smith Anthony, MD; Merritt Marianne, RNFA; Ivy 

Cindy, OT, CHT; Renfree Kevin, MD; Kousuke Iba, MD 

11:41am – 11:47am 

Biotenodesis Screw in Basilar Thumb Arthritis: A Biomechanical Study 

Institution where the work was prepared: Tripler Army Medical Center, Honolulu, HI, USA 

John Faillace, MD; Shawn Hermenau, MD 

11:47am – 11:53am 

*Partial Ulnar Head Resurfacing Implant Arthroplasty 

Institution where the work was prepared: University of Iowa, Iowa City, IA, USA 

Danielle A. Conaway, MD; Brian D Adams 

11:53am – 11:59am 

*Dynamic (4D) Computed Tomography of the Wrist : Proof of Feasibility in a 

Cadaveric Model 

Institution where the work was prepared: Mayo Clinic College of Medicine, 

Rochester, MN, USA 

Shian Chao Tay, MBBS, FRCS, FAMS; Andrew N. Primak, PhD; Joel G. Fletcher, 

MD; Bernhard Schmidt, PhD; Kimberly K.amrami, MD; Cynthia H. McCollough, 

PhD; Richard A. Berger, MD, PhD 

11:59am – 12:05pm 

Preliminary Experience with Fat Grafting of Dupuytren's Contracture 

Following Complete Percutaneous Release 


Roger K. Khouri, MD; Jorge L. Orbay, MD; Steven E.R. Hovius 

12:05pm – 12:10pm 

Discussion 

Moderators: Donald H. Lalonde, MD 

Thomas Tung, MD 

12:10pm – 12:16pm 

Ulnohumeral Arthroplasty in the Management of the Arthritic Elbow 

Institution where the work was prepared: Wrightington Hospital Centre For 

Upper Limb Surgery, Wigan, United Kingdom 

M. J. Hayton; Sumedh C Talwalkar; Ian A Trail; Niloy Roy; John K Stanley 

12:16pm – 12:22pm 

Isolated Proximal Pole Hamate Arthritis 

Institution where the work was prepared: Thomas Jefferson University, 

Philadelphia, PA, USA 

A. Lee Osterman, MD; Randall Culp 

12:22pm – 12:28pm 

*In-Vivo Kinematic Analysis of the Forearm 

Institution where the work was prepared: Mayo Clinic College of Medicine, 


Shian Chao Tay, MD, MS; Kazunari Tomita, MD; Roger P. Van Riet, MD; Kimberly 

K.amrami; Kai-Nan An, PhD; Richard Berger, MD, PhD 

12:28pm – 12:34pm 

Mesh Implant Arthroplasty for Treatment of Basilar Joint Arthritis 

Institution where the work was prepared: Methodist Hospital, Houston, TX, USA 

Evan Collins, MD; Kimberly Staines; John Thornby 

12:34pm – 12:40pm 

*Combining a Clinical Software Program, Research Databases, and Novel 

Teaching Software with the Use of Medical Informatics in a Resource Limited 

Environment 

Institution where the work was prepared: Baylor College of Medicine, Houston, TX, 

USA 

Brian A. Janz, MD; Anthony Echo; Morgan E. Norris, MD, DDS; Nicholas A. Fiore II 

12:40pm – 12:45pm 

Discussion 

11:00am – 12:45pm Concurrent Scientific Paper Session D 


Moderators: Miguel Saldana, MD 

Patrick Stewart, MD, FACS 

11:00am – 11:06am 

*Chimerism Induction and Maintenance in Composite Tissue Allograft 

Transplants after Augmentation with Donor Specific BMT 


Wioleta Luszczek, PhD; Aleksandra Klimczak, PhD; Maria Siemionow, MD, PhD 

31 

11:06am – 11:12am 

Fifteen Year Follow-up of the Distal Single Scope Assisted Carpal Tunnel 

Release 


M. Ather Mirza, MD; Mary Kate Reinhart, CNP 

11:12am – 11:18am 

*A Simple Method to Demonstrate Collateral Sprouting of An Intact Axon at 

End-to-side Neurorrhaphy Site 

Institution where the work was prepared: The First Affilated Hospital of Sun Yat- 

Sen University, Guangzhou, China 

Qing Tang Zhu, MD, PhD; Jia Kai Zhu, MD; Zhen Guo Lao, MD; Xiao Lin Liu, MD, 

PhD; Gary Chen, MD 

11:18am – 11:24am 

*Real Time in Vivo Imaging of Neural Microarchitecture with Coherent Antistokes 

Raman Scattering (CARS) Microscopy 

Institution where the work was prepared: Massachusetts General Hospital, 

Harvard Medical School, Boston, MA, USA 

Francis Patrick Henry, MD; Daniel Cote, PhD; M.A. Randolph, MAS; Irene E. 

Kochevar, PhD; Charles P. Lin, PhD; Jonathan M. Winograd, MD 

11:24am – 11:30am 

Innervations of the Medial Head of the Triceps by the Ulnar Nerve 

Institution where the work was prepared: Department of Orthopaedic Surgery 

Columbia Uni. Medical Cen., New York, NY, USA 

Halil I. Bekler, MD; Joy Christiane Vroemen; Jason M. McKean; Melvin P 

Rosenwasser 

11:30am – 11:35am 

Discussion 

Moderators: Rocco Barbier, MD 

David Netscher, MD 

11:35am – 11:41am 

*Endoscopic Revision of Carpal Tunnel Release 

Institution where the work was prepared: University of Washington, Seattle, WA, 

USA 

Shai Luria, MD; Thanapong Waitayawinyu; Thomas E. Trumble 

11:41am – 11:47am 

Practical Clinical Guide for the Management of Chronic Pain Secondary to 

Neuropathic Conditions 

Institution where the work was prepared: Hand and Microsurgery Center of El 

Paso and UTEP, El Paso, TX, USA 

Jose Monsivais, MD; Kris Robinson, PhD, FNP 

11:47am – 11:53am 

An Upper Limb Reach and Grasp Cycle for Children 

Institution where the work was prepared: Stanford University, Stanford, CA, USA 

Amy L. Ladd, MD; Erin Butler; Stephanie Louie; Wendy Wong; Andrew Rogers; 

Jessica Rose 

11:53am – 11:59am 

*Anticoagulation in Digital Revascularization and Reimplantation Surgery: a 

Complete Analysis of Beneficial and Detrimental Effects 

Institution where the work was prepared: Montreal University Health Care Center, 

Montreal, Canada 

Youssef Tahiri, medical, student; Patrick Harris, MD; Genevieve Landes, MD; 

Valerie Lemaine, MD; Andreas Nikolis, MD 

11:59am – 12:04pm 

Discussion 

Moderators: William Dzwierzynski, MD 

A. Lee Osterman, MD FACS 

12:04pm – 12:10pm 

*Local Immunotherapy Inhibits Skin Rejection in Composite Tissue Allotransplantation 

Institution where the work was prepared: University of Pittsburgh, Pittsburgh, PA, 

USA 

Mario G. Solari, MD; Kia M. McLean; Justin M. Sacks; Theresa Hautz; Jignesh V. 

Unadkat; Elaine K. Horibe; Vijay S. Gorantla; Stefan Schneeberger; Angus W. 

Thomson; W.P. Andrew Lee 

12:10pm – 12:16pm 

*Rate of Reoperation Following Digital Replantation and Revascularization 

Surgery in a Designated Provincial University Replantation Program 

Institution where the work was prepared: Centre hospitalier de l'Universite de 

Montreal, Montreal, QC, Canada 

Valerie Lemaine, MD; Geneviève Landes; Patrick Harris; André Chollet; Youssef 

Tahiri; Andreas Nikolis

12:16pm – 12:22pm 

Survey of The Current State of Upper Extremity Replantation in Northamerica 

Institution where the work was prepared: University of Texas Southwestern, 

Dallas, TX, USA 

David W. Mathes, MD; Dan Hatef; Michel Saint-Cyr 

12:22pm – 12:28pm 

*The Effect of Donor Presensitization on the Immunotolerance in Composite 

Tissue Transplantation in Rat Groin Flap Model 


Mehmet Bozkurt, MD; Serdar Nasir; Aleksandra Klimczak; Lukasz Krokowicz; 

Wioleta Luszczek; Maria Siemionow 

12:28pm – 12:34pm 

Pedicled radial artery removal does not compromise palmar microcirculationamong 

arteriosclerotic patients 

Institution where the work was prepared: Hannover Medical School, Hannover, 

Germany 

Karsten Knobloch, MD, PhD; Sandra Tomaszek; Marcus Spies; Kay H. Busch; 

Peter M. Vogt 

12:34pm – 12:40pm 

Discussion 

12:00pm – 2:30pm AAHS Board of Directors Luncheon/Meeting 

12:45pm – 6:10pm Comprehensive Hand Surgery Review Course 

Randy Bindra, MD, Chairman 

The expert faculty of this Comprehensive Hand Surgery Review Course will address the 

important principles of common topics covered on board examinations, the hand surgery 

certification examination and resident in-training examinations. The exciting new 

format will be more interactive using an “audience response system”. From infection 

to arthritis, nerve to bone, the child to the adult, this course will truly cover it all and you 

will consider it an afternoon well spent. 

Additional registration required. 

Sponsored by: 

12:45pm – 1:00pm Vascular Disorders of the Hand/Reimplantation 


Vascular disorders of the hand are uncommon and the 

indications for reimplantation narrow. This presentation 

will discuss the various diagnostic and treatment challenges 

encountered in vascular disorders of the hand. 

Techniques and indication for implantation will be 

reviewed. 

1:00pm – 1:20pm Compressive Neuropathies & CRPS 


In this lecture carpal tunnel syndrome and cubital tunnel 

syndrome will be reviewed. Physical examination and 

diagnostic modalities will be emphasized. The last portion 

of the presentation will review the diagnosis, treatment 

and long-term sequelae of complex regional pain 

syndrome. 

1:20pm – 1:40pm Thumb Basal Joint Arthritis and Wrist Arthritis 

Alejandro Badia, MD 

This lecture will address the fundamentals of diagnosis 

and treatment for thumb basal joint arthritis, SLAC/SNAC 

degeneration of the wrist. Critical success factors necessary 

to obtain favorable outcomes will be emphasized. 

1:40pm – 2:00pm Inflammatory Arthritis of the Hand and Wrist 

Matt Tomaino, MD 

Indications and various reconstructive options for hand 

and wrist deformities secondary to rheumatoid arthritis 

and other inflammatory conditions will be discussed. 

Indications and techniques for synovectomy, arthroplasty 

of the MCP and wrist and small joint fusions will be 

reviewed. 

2:00pm – 2:15pm Distal Radius Fractures 

Peter J. L. Jebson, MD 

A review of adult distal radius fractures including the clinical 

evaluation, diagnostic imaging options and interpretation, 

indications for operative versus non-operative 

treatment and the current strategies and indications for 

the various operative treatment techniques. 

32 

2:15pm – 2:30pm Distal Radioulnar Joint 


Anatomy, biomechanics and patterns of injury will be discussed. 

Bone and soft tissue salvage reconstructive 

options will be illustrated. 

2:30pm – 2:45pm Scaphoid Fractures and Non-Unions 

Mike Hayton, FRCS 

A review of the clinical features, diagnostic challenges, 

operative and non-operative treatment options, and a 

contemporary approach to the patient with an acute 

scaphoid fracture or established non-union. 

2:45pm – 3:00pm Brachial Plexus Injuries 


A simplification of this complex injury focusing on principles 

of acute management to include clinical assessment, 

investigations and indications for surgery. 

3:00pm – 3:15pm Carpal Instability 


A review of the anatomy and mechanics of the wrist as it 

relates to carpal instability, including a review of the diagnostics 

and treatment of common patterns of instability. 

3:15pm – 3:35pm Fractures of the Metacarpals and Phalanges 

David Dennison, MD 

Metacarpal and phalangeal fractures are among the 

most common injuries seen in the hand. A thorough 

review of the anatomy and biomechanics of these 

injuries will be provided. The treatment choices of 

closed management, percutaneous pinning and plate 

fixation will be reviewed along with surgical approaches. 

3:35pm – 3:55pm Flexor Tendon Injuries 

Kevin J. Renfree, MD 

This presentation will review the basic science of tendon 

healing, physical examination and techniques of exposure 

and of flexor tendon injuries. The biomechanical 

rationale behind the development of current post op 

rehab protocols will be discussed. 

3:55pm – 4:10pm Infections of the Hand 

Kevin D. Plancher, MD, MS, FACS, FAAOS 

Comprehensive review of infections of the hand with up 

to date information on antibiotics to allow the participant 

to feel comfortable treating patients with these maladies. 

4:10pm – 4:30pm Congenital Hand Differences 

Scott H. Kozin, MD 

Discuss congenital anomalies of the upper extremity 

including embryology, diagnosis, and treatment. Focus 

on associated syndromes that require accurate diagnosis 

and management. Review surgical techniques, outcomes, 

and complications of selected conditions. 

4:30pm – 4:50pm Tumors of the Hand and Wrist 

Michael Bednar, MD 

Discussion of the pathology, radiology and treatment of 

benign and malignant bone and soft tissue tumors affecting 

the hand and wrist. 

4:50pm – 5:10pm Soft Tissue Coverage in the Hands 

Loree Kallianen, MD 

A variety of pedicled flaps and free flaps of are available 

for coverage of the soft tissue defects of the hand. These 

flaps will be reviewed and technical tips provided. A spectrum 

of cases will be reviewed to illustrate the utility of 

each soft tissue coverage procedure. 

5:10pm – 5:30pm Tendon Transfers for the Hand 


Palsy of the median, ulnar or radial nerves can be devastating 

to hand and wrist function. Tendon transfers can 

provide predictable restoration of function. The more 

commonly chosen tendon transfers will be discussed 

along with the technical challenges unique to each set of transfers. 

5:30pm – 5:50pm Tendonopathies and Dupuytren’s Contracture 


Tendonopathies of the hand and wrist and Dupuytrens 

Contracture are among the most common problems 

seen in hand surgery. An overview of the pathophysiology 

of these conditions will be provided as well as specific 

treatment recommendations. 

5:50pm – 6:10pm Questions/Adjourn 

7:00pm AAHS Salsa Sensation Awards Dinner & Dance

AAHS/ASPN/ASRM 


Saturday, January 12, 2008 



6:30am – 7:00am AAHS/ASRM/ASPN Coffee Break California Lounge 

7:00am – 6:00pm ASRM Patient Safety Computerized Presentations California Showroom 

7:00am – 7:15am AAHS/ASRM/ASPN Presidents’ Welcome Los Angeles 

7:15am – 8:15am PANEL: Treatment of the Ischemic Limb Los Angeles 

8:15am – 8:45am AAHS/ASRM/ASPN Breakfast with Exhibitors California Showroom 

8:45am – 9:45am PANEL: Tendon and Nerve Transfers for Common Los Angeles 

Upper Extremity Palsies: Consensus and Controversies 

9:45am – 10:45am AAHS/ASPN/ASRM Presidents Invited Lecturer: Aaron Vinik, MD Los Angeles 

10:45am – 11:30am AAHS/ASPN/ASRM Outstanding Paper Presentations Los Angeles 

11:30am – 12:30pm ASRM/ASPN Lunch with Exhibitors California Showroom 

12:30pm – 3:00pm ASPN Programming Santa Monica 

12:30pm – 6:00pm ASRM Programming Los Angeles 

33

AAHS-ASPN-ASRM 


6:30am – 7:00am Coffee 

7:00am – 6:00pm ASRM Patient Safety Computerized Presentations 

7:00am – 7:15am Presidents’ Welcome 

N. Bradly Meland, MD, AAHS President 

Gregory R. D. Evans, MD, ASPN President 

Lawrence B. Colen, MD, ASRM President 

7:15am – 8:15am Panel: Treatment of the 

Ischemic Limb 

This panel will cover treatment of ischemic feet hypothenar 

hammer syndrome and treatment with botox. 

William C. Pederson, MD, Moderator 

Chris Attinger, MD 

Craig Johnson, MD 


8:15am – 8:45am Breakfast with Exhibitors 

8:45am – 9:45am Panel: Tendon and Nerve Transfers for Common 

Upper Extremity Palsies: Consensus and Controversies 

Nerve transfers and tendon transfers for radial nerve palsy 

will be discussed. 

Jonathan Winograd, MD, Moderator 

Allen T. Bishop, MD 


Thomas Tung, MD 

9:45am – 10:45am AAHS/ASPN/ASRM Presidents Invited Lecture 

Aaron Vinik, MD 

Neurovascular Dysfunction in Diabetes 

Dr. Aaron I. Vinik will present the information on the role 

of the microvasculature in providing nutritive support for 

the nervous system, to illustrate the functional as well as 

the organic causes of microvascular insufficiency, to show 

the mechanistic aspects thereof and highlight potential for 

medical intervention to improve function. 

Dr. Vinik is one of the leading diabetes researchers in 

the world and leads the quest for a cure to diabetes at 

the Strelitz Diabetes Institute at Eastern Virginia Medical 

School. Dr. Vinik went to EVMS from the University of 

Michigan where he was a professor of both Internal 

Medicine and Surgery. He is a leader in research 

on the diagnosis and treatment of diabetic neuropathy 

and has particular expertise in the area of autonomic 

diabetic neuropathy. Dr. Vinik has been a leader in 

research on new approaches to generate islet cell tissue 

from pancreatic duct tissue. 

34 

10:45am – 11:30am AAHS/ASPN/ASRM Outstanding 

Paper Presentations 


Moderator: Michael Neumeister, MD 

10:45am – 10:50am 

*Aberrant Anatomy Does Not Preclude Safe Carpal Tunnel Release Via a 

Limited-Open Approach 

Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, 

USA 

Caitlin Gannon, BS; Mark E. Baratz 

10:50am – 10:55am 

Efficacy of Endoscopic Cubital Tunnel Release 

Institution where the work was prepared: Orthopaedic Specialists, PC, 

Davenport, IA, USA 

Tyson Cobb, MD; Jon Lemke, PhD; Jennifer Tyler, PA; Patrick Sterbank, PA 

10:45am – 11:00am 

Discussion 

Moderator: Jonathan Winograd, MD 

11:00am – 11:05am 

Rodent Facial Nerve: A Model for the Study of Synkinesis 

Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, 

Boston, MA, USA 

Tessa A. Hadlock, MD; Jeffrey Kowaleski; David Lo; Susan Mackinnon; James T. 

Heaton, PhD 

11:05am – 11:10am 

*Enhancement of Regeneration of Peripheral Nerve Defects by Application of 

Epineural Tubes Filled with Donor Derived Bone Marrow Stromal Cells 


Mehmet Bozkurt; Christopher Grykien; Lukasz Krokowicz; Aleksandra Klimczak; 

Jill Froimson; Dileep Nair; Maria Siemionow 

11:10am – 11:15am 

Discussion 

Moderator: Guenter Germann, MD 

11:15am – 11:20am 

*Extended Applications of Vascularized Preauricular and Helical Rim Flaps in 

Reconstruction of Nasal Defects 

Institution where the work was prepared: Duke University Medical Center, 

Durham, NC, USA 

Yi Xin Zhang, MD; Keith E. Follmar; Danru Wang, MD; Yee Siang Ong, MRCS, 

(Edin); Yunliang Qian, MD; Detlev Erdmann; Michael R. Zenn; L. Scott Levin 

11:20am – 11:25am 

*Microvascular Free Flaps: A Novel Delivery Vehicle for Local Immunotherapy 

with Minimal Systemic Toxicity 


Marlese P. Dempsey, MD; Cynthia Hamou, MD; Leila Jazayeri, BS, BA; Edward I. 

Chang, MD; Hariharan Thangarajah, MD; Shadi Ghali, MD; Raymon Grogan, MD; 

Geoffrey C. Gurtner, MD 

11:25am – 11:30am 

Discussion 

11:30am – 12:30pm 

ASRM/ASPN Lunch with Exhibitors

ASPN 





9:00am – 11:00am ASPN Council Meeting Governor’s Boardroom 

12:00pm – 12:10pm Presidents/ Program Chair Welcome Santa Monica 

Gregory R.D. Evans, MD, ASPN President 

Jonathan Winograd, MD, ASPN Program Chair 

12:10pm – 1:30pm Scientific Paper Session A Santa Monica 

1:30pm – 3:00pm ASPN Invited Speaker: Prof. Andrew Schwartz, PhD Santa Monica 

3:00pm – 3:30pm Break with Exhibitors California Showroom 

3:30pm – 5:00pm Scientific Paper Session B Santa Monica 

35

ASPN 


9:00am – 11:00am ASPN Council Meeting 

12:00pm – 12:10pm Presidents/Program Chair Welcome 

Gregory R.D. Evans, MD, ASPN President 

Jonathan Winograd, MD, ASPN Program Chair 

12:10pm – 1:30pm Scientific Paper Session A 


Moderators: Joseph M. Rosen, MD 

Jonathan M. Winograd, MD 

12:10pm – 12:15pm 

Maintainance of Neuronal Differentiated Adipose-derived Stem Cells in Long 

Term Culture 

Institution where the work was prepared: University of California, Irvine Medical 

Center, Orange, CA, USA 

Suraj Kachgal, MS; Sanjay Dhar, PhD; Eul Sik Yoon, MD; Gregory R.D. Evans, MD 

12:15pm – 12:18pm 

Discussion 

12:18pm – 12:25pm 

*Repair of Partial Nerve Injury by Bypass Nerve Grafting with End-to-side 

Neurorrhaphy 

Institution where the work was prepared: University of Mississippi Medical Center, 

Jackson, MS, USA 

Tanya M. Oswald, MD; Feng Zhang; William C Lineaweaver 

12:23pm – 12:26pm 

Discussion 

12:26pm – 12:31pm 

*The Effect of In Vivo Delivery of Nerve Growth Factor (NGF) Through a Novel 

T-tube Chamber on Behavioural Recovery in a Rat Model of Peripheral Nerve 

Injury 

Institution where the work was prepared: University of Calgary, Calgary, AB, Canada 

Stephen W.P. Kemp, BSc(Hons), MSc; Aubrey A. Webb; Rajiv Midha 

12:31pm – 12:34pm 

Discussion 

12:34pm – 12:39pm 

Nerve Repair with Introduction of a MEMS-Based Neural Electrode is Not 

Detrimental to Muscle Reinnervation 

Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA 

Melanie G. Urbanchek, MS, PhD; Antonio P. Peramo, PhD; Daryl R. Kipke, PhD; 

William M. Kuzon Jr, MD, PhD; Paul S. Cederna, PhD 

12:39pm – 12:42pm 

Discussion 

12:42pm – 12:47pm 

Nerve Regeneration through Nerve Autografts after Local Administration of 

Brain Derived Neurotrophic Factor (Bdnf) with Osmotic Pumps 

Institution where the work was prepared: Clinica Universitaria. Universidad de 

Navarra, Pamplona, Spain 

Bernardo Hontanilla, MD, PhD; Cristina Aubá; Oscar Gorria 

36 

12:47pm – 12:50pm 

Discussion 

12:50pm – 12:55pm 

Peripheral Nerve Surgery: Pre-operative Variables Associated With Outcome 

Failures 

Institution where the work was prepared: Georgetwon University Hospital, 

Washington, DC, USA 

Ivica Ducic, MD, PhD; Emily Hartmann 

12:55pm – 12:58pm 

Discussion 

12:58pm – 1:03pm 

The Dynamic Phases of Peroneal and Tibial Intraneural Ganglion Formation: A 

New Dimension Added to the Unifying Articular Theory 


Robert J. Spinner, MD; Huan Wang; Kimberly K. Amrami 

1:03pm – 1:06pm 

Discussion 

1:06pm – 1:11pm 

*Delay of Denervation Atrophy by Sensory Protection in an End-to-Side 

Neurorrhaphy Model 

Institution where the work was prepared: Erasmus MC, Rotterdam, Netherlands 

H.M. Zuijdendorp; W. Tra; J. van Neck; J.H. Coert 

1:11pm – 1:14pm 

Discussion 

1:14pm – 1:19pm 

Insulin-Like-Growth Factor 1 Improves Nerve Regeneration in Aged Rats 

Institution where the work was prepared: Wake Forest University, Winston-Salem, 

NC, USA 

Peter Apel, MD; Timothy Alton, BS; Jianjun Ma, MD, PhD; Zhongyu Li, MD, PhD 

1:19pm – 1:22pm 

Discussion 

1:30pm – 3:00pm ASPN Invited Speaker 

Sponsored by: 

Prof. Andrew Schwartz, PhD 

Useful Signals from Motor Cortex 

Recent scientific progress has led to a better understanding 

of the representation of arm movement in 

the motor cortex. This knowledge has been used to 

build neural prosthetic devices capable of operating 

a prosthetic arm and gripper in a self-feeding task. 

Dr. Schwartz received his Ph.D. from the University of 

Minnesota in 1984 with a thesis entitled “Activity in the 

Deep Cerebellar Nuclei During Normal and Perturbed 

Locomotion.” He then went on to a postdoctoral 

fellowship at the Johns Hopkins School of Medicine 

where he worked with Dr. Apostolos Georgopoulos, 

who was developing the concept of directional tuning 

and popuation-based movement representation in the 

motor cortex While there, Dr. Schwartz was instrumental 

in developing the basis for three-dimensional trajectory 

representation in the motor cortex. 

In 1988, Dr. Schwartz began his independent research 

career at the Barrow Neurological Institute in Phoenix. 

There, he developed a paradigm to explore the continuous 

cortical signals generated throughout volitional 

arm-movements. This was done using monkeys 

trained to draw shapes while recording single-cell 

activity from their motor cortices. After developing the 

ability to capture a high fidelity representation of 

movement intention from the motor cortex, Dr. 

Schwartz teamed up with engineering colleagues at 

Arizona State University to develop cortical neural prosthetics. 

The work has progressed to the point that 

monkeys can now use these recorded signals to 

control motorized arm prostheses to reach out grasp a 

piece of food and return it to the mouth.

Dr. Schwartz moved from the Barrow Neurological 

Institute to the Neurosciences Institute in San Diego in 

1995 and then to the University of Pittsburgh in 2002. 

In addition to the prosthetics work, he has continued 

to utilize the neural trajectory representation to better 

understand the transformation from intended to actual 

movement using motor illusions in a virtual reality 

environment. 

3:00pm – 3:30pm Break with Exhibitors 

3:30pm – 5:00pm Scientific Paper Session B 


Moderators: Ranjan Gupta, MD 


3:30pm – 3:35pm 

*In Vivo Microscopy of the Peripheral Nerve, a Quantitative Analysis Following 

Injury using Optical Coherence Tomography (OCT) 

Institution where the work was prepared: Massachusetts General Hospital, 


Francis Patrick Henry, MD; Hyle Boris Park, PhD; Esther A. Z. Rust; M.A. 

Randolph, MAS; Johannes F. DeBoer, PhD; Jonathan M. Winograd, MD 

3:35pm – 3:38pm 

Discussion 

3:38pm – 3:43pm 

*Comparative Analysis of Holding Strength of Available “Nerve Glues” 

Institution where the work was prepared: Candice McDaniel, Richmond, VA, USA 

Jonathan Isaacs, MD; Candice O. McDaniel, MD; John R. Owen, PE; Jennifer S. 

Wayne 

3:43pm – 3:46pm 

Discussion 

3:46pm – 3:51pm 

Sensory Protection of Rat Muscle Spindles Following Peripheral Nerve Injury 

and Reinnervation 

Institution where the work was prepared: McMaster University, Hamilton, ON, Canada 

Margaret Fahnestock, PhD; Amal S. Elsohemy, BSc; Richard G. Butler, PhD; 

James R. Bain, MSc, MD 

3:51pm – 3:54pm 

Discussion 

3:54pm – 3:59pm 

*The Efficacy of Subcutaneous Transposition of the Ulnar Nerve in Surgical 

Treatment of Cubital Tunnel Syndrome 

Institution where the work was prepared: Dept. of Plastic Surgery,University of 

Tuebingen, Tuebingen, Germany 

Armin Kraus, MD; Nektarios Sinis; Frank Werdin; Hans-Eberhard Schaller 

3:59pm – 4:02pm 

Discussion 

4:02pm – 4:07pm 

Health Related Quality of Life and Disability in Patients Following Peripheral 

Nerve Injury 

Institution where the work was prepared: University Health Network, Toronto, 

ON, Canada 

Christine B. Novak, PT, MS, PhD(c); Dimitri J. Anastakis 

4:07pm – 4:10pm 

Discussion 

4:10pm – 4:15pm 

The Mechanisms of Axonal Sprouting With End-to-Side Neurorrhaphy 

Institution where the work was prepared: Washington University in St Louis, St 

Louis, MO, USA 

Ayato Hayashi, MD, PhD; Daniel A. Hunter, RA; Alice Y. Tong, MS; David H. 

Kawamura, MD; Arash Moradzadeh, MD; Sami H. Tuffaha, BA; Christina B. 

Kenney, MD; Janina Luciano, BS; Thomas H. Tung, MD; Susan E. Mackinnon, 

MD; Terence M. Myckatyn, MD 

4:15pm – 4:18pm 

Discussion 

37 

4:18pm – 4:23pm 

Comparison of Psychosocial Outcomes of Patients with Neuropathic 

Conditions Treated With and Without Surgery 

Institution where the work was prepared: Hand and Microsurgery Center of El 

Paso, El Paso, TX, USA 

Jose Monsivais, MD; Kris Robinson, PhD, FNP 

4:23pm – 4:26pm 

Discussion 

4:26pm – 4:31pm 

*Delivery Strategy Significantly Affects the Number and Phenotype of 

Schwann Cells in Seeded Decellularized Allografts 

Institution where the work was prepared: Washington University School of 

Medicine, Saint Louis, MO, USA 

Arash Moradzadeh, MD; Sami H. Tuffaha, BA; Ryan D. Luginbuhl; Jason Gustin; 

Gregory H. Borschel; Alice Y. Tong; Jeffery Milbrandt, MD, PhD; Susan E. 

Mackinnon, MD; Terence M. Myckatyn, MD 

4:31pm – 4:34pm 

Discussion 

4:34pm – 4:39pm 

*Saphenous Nerve Neuropathy: Treatment Options and Outcomes 

Institution where the work was prepared: Georgetwon University Hospital, 


Ethan Larson, MD; Ivica Ducic, MD, PhD 

4:39pm – 4:42pm 

Discussion 

4:42pm – 4:47pm 

Caspase 3 Knockout Mice Show Partial Protection of Skeletal Muscle Atrophy 

following Denervation 

Institution where the work was prepared: McMaster University, Hamilton, ON, 

Canada 

James Bain, MD, MSc; Jane AE Batt, MD, PhD, FRCPC; Pam Plant; Minna Woo 

4:47pm – 4:50pm 

Discussion

ASPN 





6:30am – 7:00am AAHS/ASPN/ASRM Coffee Break California Lounge 

7:00am – 11:30am AAHS/ASPN/ASRM Combined Programming Los Angeles 

11:30am – 12:30pm ASPN/ASRM Lunch with Exhibitors California Showroom 

12:30pm – 1:30pm ASPN Invited Speaker: Prof. Jeff Lichtman, MD, PhD Santa Monica 

1:30pm – 3:00pm Scientific Paper Session C Santa Monica 

6:30pm – 8:00pm ASPN/ASRM Welcome Reception X Bar 

38

ASPN 


11:30am – 12:30pm Lunch with Exhibitors 


Prof. Jeff Lichtman, MD, PhD 

Peripheral Nerve Growth Branching and 

Retraction: Studies in Fluorescent Mice 

Description: Mice in which axons express a variety of 

different colored fluorescent proteins allow in vivo 

studies of peripheral nerve development and reorganization 

in trauma and aging. 

Jeff Lichtman, MD, PhD is Professor of Molecular and 

Cellular Biology at Harvard University. He received his 

MD and PhD in Neurobiology at Washington University 

in St. Louis. Dr. Lichtman currently serves as Advisory 

Editor for Anatomy and Embryology and is on the 

Editorial Board for the Journal of Neuroscience, Journal 

of Neurobiology, Molecular and Cellular Neuroscience 

and Cells and Systems. 

1:30pm – 3:00pm Scientific Paper Session C 


Moderator: Gregory R. D. Evans, MD, FACS 

David T. J. Netscher, MD 

1:30pm – 1:35pm 

Grip Strength and CMAP Amplitude in Median Nerve Injury of the Rats 


Huan Wang, MD, PhD; Eric J. Sorenson; Robert J. Spinner; Anthony J. 

Windebank 

1:35pm – 1:38pm 

Discussion 

1:38pm – 1:42pm 

Nerve Transfers For Paralysis Of The Tibialis Anterior Muscle (Foot-Drop)—A 

Cadaveric Feasibility Study 

Institution where the work was prepared: Teaxs Tech University Health Science 

Center, El Paso, TX, USA 

Miguel Pirela-Cruz, MD; D.A. Terreros; U.D. Hansen, MD; P. West, MD; A.D. 

Rossum, MD 

1:43pm – 1:46pm 

Discussion 

1:46pm – 1:51pm 

*Soleus Arch as Compression Site for Proximal Tibial Nerve: Cadaver Study 

Institution where the work was prepared: Union Memorial Hospital, Baltimore, 

MD, USA 

Eric H. Williams, MD; Gedge D. Rosson, MD; A. Lee Dellon, MD 

1:51pm – 1:54pm 

Discussion 

1:54pm – 1:59pm 

*Anatomical Landmarks for the Nerve Branch to the Masseter Muscle in Facial 

Reanimation 


Nada Berry, MD; Margo Herron; Rebuen Bueno; Ronald Zuker, MD; Michael W. 

Neumeister 

1:59pm – 2:02pm 

Discussion 

Sponsored by: 

2:02pm – 2:07pm 

*Novel Model for End-Neuroma Formation in the Amputated Rabbit Forelimb 

Institution where the work was prepared: Northwestern University, Feinberg 

School of Medicine, Chicago, IL, USA 

Peter S. Kim, MD; Kristina O'Shaughnessy, MD; Todd A. Kuiken, MD, PhD; 

Gregory A. Dumanian 

39 

2:07pm – 2:10pm 

Discussion 

2:10pm – 2:15pm 

*Antibodies to Galactocerebroside Enhance Nerve Regeneration after Acute 

Contusion and Transection Injuries in the Adult Rat Sciatic Nerve 

Institution where the work was prepared: University of California, Irvine, Orange, 

CA, USA 

Aaron M. Kosins, MD, MBA; Charles Mendoza; Michael P. McConnell, MD; 

Brandon Shepard; Sanjay Dhar, PhD; Gregory RD Evans, MD, FACS; Hans S. 

Keirstead, PhD 

2:15pm – 2:18pm 

Discussion 

2:18pm – 2:23pm 

*Sympathetic Nerves in the Tarsal Tunnel: Implications for Blood Flow in the 

Diabetic Foot 

Institution where the work was prepared: University of Arizona School of 

Medicine, Tucson, AZ, USA 

Andrew Blount, BS; Erika Dexter; Raymond Nagle; Christopher Maloney; Lee 

Dellon; Ziv Peled 

2:23pm – 2:26pm 

Discussion 

2:26pm – 2:31pm 

*A Study of Modality Specific Nerve Regeneration in the Rat Femoral Nerve 

Institution where the work was prepared: Washington University, St. Louis, MO, 

USA 

David H. Kawamura, MD; Gregory H Borschel; Daniel A Hunter; Susan E 

Mackinnon; Thomas HH Tung 

2:31pm – 2:34pm 

Discussion 

2:34pm – 2:39pm 

Limb Length Discrepancy in Obstetrical Brachial Plexus Injury 

Institution where the work was prepared: McMaster Children's Hospital, 

Hamilton, ON, Canada 

James Bain, MD, MSc; Carol DeMatteo; Deborah Agro 

2:39pm – 2:42pm 

Discussion 

2:42pm – 2:47pm 

*Regeneration in an Enzyme-Treated Decellularized Nerve Allograft 

Institution where the work was prepared: Washington University School of 

Medicine, St. Louis, MO, USA 

Sami H. Tuffaha, BA; Daniel A. Hunter; Ying Yan; Janina P. Luciano; Susan E. 

Mackinnon; Gregory H. Borschel 

2:47pm – 2:50pm 

Discussion 

2:50pm – 2:55pm 

*Increase of Neuronal Camp by Electrical Stimulation or Rolipram Administration 

and/or Local Application of Chonodrioitinase 

ABC Accelerates Motor Axon Outgrowth Across the Surgical Repair Site of 

Sectioned Rat Peripheral Nerve 

Institution where the work was prepared: University of Alberta, Edmonton, AB, 

Canada 

T. Gordon; M Furey; N Tyreman; E Udina 

2:55pm – 2:58pm 

Discussion 

6:30pm – 8:00pm ASPN/ASRM Welcome Reception 

The ASPN & ASRM would like to thank ASSI 

for their generous sponsorship of this reception.

ASPN 


Sunday, January 13, 2008 


6:30am – 7:30am ASPN Breakfast with Exhibitors California Showroom 


7:00am – 8:00am ASPN Instructional Courses 

301 Interoperative Monitoring Palisades 

302 Obstetrical Brachial Plexus Palsy Pacific 

303 Peripheral Nerve Tumors Sherman Oaks 

304 Peinnervating Muscle Westwood 

305 Working Toward a Brain-Body Interface: Brentwood 

Intelligent Functional Electrical Stimulations 

For The Upper Extremity 

8:15am – 9:15am ASRM/ASPN Panel: Treatment of the Mangled Hand: Los Angeles 

A Multidisciplinary Approach 


9:45am – 11:30am Scientific Paper Presentations D Santa Monica 

11:30am – 12:00pm ASPN Poster Presentations California Showroom 


1:00pm – 2:15pm Scientific Paper Presentations E Santa Monica 

2:15pm – 3:15pm ASPN Invited Speaker: Prof. Neville Hogan Santa Monica 

3:15pm – 3:30pm Closing Remarks & Presentation of Awards Santa Monica 

3:30pm – 4:00pm ASPN Business Meeting Santa Monica 

4:00pm – 4:30pm ASPN Council Meeting Santa Monica 

40

ASPN 




301 Intraoperative Monitoring 

Intraoperative neurophysiological techniques help guide 

decision making during nerve surgery so that outcome 

may be optimized. Background to these techniques, and 

their usefulness, will be explored by classical and case 

studies. Practical applications will also be emphasized. 

David Houlden, PhD 

Robert Tiel, MD 


302 Obstetrical Brachial Plexus Palsy 

Current thinking concerning timing of surgery versus 

natural history will be explored. Techniques of nerve transfers 

will be described. 

Allan Belzberg, MD 

Howard M. Clarke, MD, PhD 

Scott Kozin, MD 

303 Peripheral Nerve Tumors 

Diagnosis and treatment of benign and malignant peripheral 

nerve tumors. 

Ab Guha, MD 



304 Reinnervating Muscle 

The course will focus on the consequence of muscle denervation, 

physiologic responses during reinnervation, and 

the potential techniques to optimize the recovery of function. 


Tessa Gordon, PhD 

William Kuzon, Jr, MD 

305 Working Toward a Brain-Body Interface: 

Intelligent Functional Electrical Stimulation 

For The Upper Extremity 

The course will focus on the development of a brain-body 

interface, including implementation of existing technologies 

to link functional electrical stimulation of the upper 

extremity to cortical movement inention. 

Robert Ajemian, PhD 

Jonathan Winograd, MD 

8:15am – 9:15am ASRM/ASPN Panel: Treatment of the Mangled 

Hand: A Multidisciplinary Approach 

This panel will focus on the surgical approach to the 

complex wounds of the upper extremity. Aspects of discussion 

will include acute management of soft tissue, 

nerve loss, bony instability and revascularization. The 

multidisciplinary approach should captivate peripheral 

nerve surgeons, microsurgeons and hand surgeons. 

Michael W. Neumeister, MD; Moderator 

David Chwei-Chin Chuang, MD 

L. Scott Levin, MD 

Michael Sauerbier, MD, PhD 


9:45am – 11:30am Scientific Paper Session D 


Moderators: Gregory M. Buncke, MD 


9:45am – 9:50am 

*Brachial Plexus Surgery in a German Center for Peripheral Nerve Surgery 

Institution where the work was prepared: University of Tuebingen, Tuebingen, 

Germany 

Nektarios Sinis, MD; Tatjana Lanaras; Hans-Eberhard Schaller, MD 

41 

9:50am – 9:53am 

Discussion 

9:53am – 9:58am 

*Effect Of Nerve Growth Factor (NGF) Releasing Polylactic-Co-Glycolic Acid 

(PLGA) Microspheres On Peripheral Nerve Regeneration 


Ralph De Boer, MD; Huan Wang, MD, PhD; Andrew M. Knight, PhD; Robert J. 

Spinner; M.J.A. Malessy; Michael J. Yaszemski, MD, PhD; Anthony J. Windebank, 

MD 

9:58am – 10:01am 

Discussion 

10:01am – 10:06am 

Nerve Transfers to Reanimate Elbow Flexion in Obstetric Brachial Plexus 

Lesions 

Institution where the work was prepared: Leiden University Medical Center, 

Leiden, Netherlands 

Willem Pondaag, MD; Martijn J.A. Malessy 

10:06am – 10:09am 

Discussion 

10:09am – 10:14am 

Specialty of the Phrenic Nerve for Modified End-to-Side Nerve Repair - 

Experiment and Clinical Implications 

Institution where the work was prepared: Medical College of Wisconsin, 

Milwaukee, WI, USA 

ji-Geng Yan, MD; Lin-Ling Zhang; Hani S Matloub; James R Sanger; Yu-Hui Yan 

10:14am – 10:17am 

Discussion 

10:17am – 10:22am 

Spontaneous Gait Recovery in Denervated Rats May Impair the Evaluation of 

Artificial Nerve Guides 

Institution where the work was prepared: The Catholic University, Rome, Italy 

Antonio Merolli, MD; Lorenzo Rocchi; Maria Silvia Spinelli; Rocco De Vitis; 

Francesco Catalano 

10:22am – 10:25am 

Discussion 

10:25am – 10:30am 

*Suppression of Fibrous Scar Improves Peripheral Nerve Regeneration After 

Primary Nerve Suture 

Institution where the work was prepared: University of Tuebingen and University 

of Duesseldorf, Tuebingen and Duesseldorf, Germany 

Nektarios Sinis, MD; Philip Schoenle; Tatjana Lanaras; Frank Werdin, MD; Armin 

Kraus, MD; Max Haerle, MD; Timm Danker, PhD; Elke Guenther, Phd; Federica Di 

Scipio, Phd; Stefano Geuna, MD; Hans-Werner Mueller, PhD; Daniela Mueller; 

Carmen Masannek; Susanne Hermanns, Phd; Hans-Eberhard Schaller, MD 

10:30am – 10:33am 

Discussion 

10:33am – 10:38am 

*Extending the Indications for Primary Nerve Surgery in Obstetrical Brachial 

Plexus Palsy 

Institution where the work was prepared: The Hospital for Sick Children, 

University of Toronto, Toronto, ON, Canada 

Jenny C. Lin, MD, PhD; Christine G. Curtis, BScPT; Howard M. Clarke, MD, PhD, 

FRCS(C) 

10:38am – 10:41am 

Discussion 

10:41am – 10:46am 

*The Effects of Inflammation on GFAP Expression in Satellite Cells of the 

Dorsal Root Ganglion 


Krzysztof Siemionow, MD; Alexandra Klimczak, PhD; Maria Siemionow, MD, PhD; 

Robert F. McLain, MD 

10:46am – 10:49am 

Discussion

10:49am – 10:54am 

Actual Delivery Location of Carpal Tunnel Injections: A Cadaveric Study 

Institution where the work was prepared: The Cleveland Clinic, Cleveland, OH, USA 

Joseph E. Robison, MD; Peter J. Evans, MD, PhD; Jeffrey N. Lawton, MD 

10:54am – 10:57am 

Discussion 

10:57am – 11:02am 

Understanding Pain Associated with Chronic Nerve Compression Injuries 

Institution where the work was prepared: University of California Irvine, Irvine, CA, USA 

Laura Rummler, BS; Winnie Palispis; Ranjan Gupta 

11:02am – 11:05am 

Discussion 

11:05am – 11:10am 

Surgical Treatment of Post-operative or Post-traumatic Chronic Headaches: 

Indications and Outcome 

Institution where the work was prepared: Georgetown University Hospital, 


Ivica Ducic, MD, PhD 

11:10am – 11:13am 

Discussion 

11:13am – 11:18am 

*Morphological Analysis of the Carpal Tunnel and Median Nerve Following 

Endoscopic and Open Carpal Tunnel Release 

Institution where the work was prepared: University of Manitoba, Winnipeg, MB, Canada 

Avinash Islur, MD, FRCSC; Kenneth A. Murray, MD, FRCPS(C) 

11:18am – 11:21am 

Discussion 

11:21am – 11:26am 

*Does Mode of Minocycline Delivery Affect Recovery From Partial Nerve Injury? 

Institution where the work was prepared: Rush University Medical Center, 

Chicago, IL, USA 

Vishal Didwania, BA; Mark Gonzalez, MD; Jeffrey S. Kroin, PhD; Susan Shott, 

PhD; Sara Beddow, BA; James M. Kerns, PhD 

11:26am – 11:29am 

Discussion 

11:30am – 12:00pm Poster Presentations 

12:00pm – 1:00pm Lunch with Exhibitors 

1:00pm – 2:15pm Scientific Paper Session E 


Moderator: Nancy H. McKee, MD, FRCSC 

Thomas H. H. Tung, MD 

1:00pm – 1:05pm 

Nonviral HVJ (Hemagglutinating Virus of Japan) Liposome Mediated 

Retrograde Gene Transfer of Human Hepatocyte Growth Factor Improves 

Neuropathic Pain-Related Phenomena in Rats 

Institution where the work was prepared: National Defense Medical College, 

Tokorozawa, Japan 

Toyokazu Tsuchihara; Koichi Nemoto; Hiroshi Arino; Masatoshi Amako; Kuniaki 

Nakanishi; Morishita Ryuichi 

1:05pm – 1:08pm 

Discussion 

1:08pm – 1:13pm 

*Repairing Peripheral Nerve Injuries Using Skin-Derived Precursor Cells 

Institution where the work was prepared: University of Calgary, Hotchkiss Brain 

Institute, Calgary, AB, Canada 

Sarah K. Walsh, BSc; Raj Midha, MD, MSc 

1:13pm – 1:16pm 

Discussion 

1:16pm – 1:21pm 

DASH as a Measurement of Outcome in Adult Brachial Plexus Reconstruction 


Keith A. Bengtson; Alexander Shin; Robert Spinner; Allen Bishop; Michelle Kircher 

1:21pm – 1:24pm 

Discussion 

1:24pm – 1:29pm 

Reversal of Distal Symmetric Polyneuropathy by Microsurgical Decompression 

of Localized Nerve Entrapments 

Institution where the work was prepared: International Neuropathy Microsurgery 

Institute, Sonora, CA, USA 

Michael Charles Edwards, MD/PhD; Joseph Paul Day, PhD 

1:29pm – 1:32pm 

Discussion 

42 

1:32pm – 1:37pm 

*Evaluation of Function of Composite Osseomusculocutaneous Nose, Lower Lip 

and Premaxilla Allograft Transplants via Somatosensory Evoked Potentials 


Mehmet Bozkurt; Erhan Sonmez; Christopher Grykien; Lukasz Krokowicz; Serdar 

Nasir; Klimczak Aleksandra; Jill Froimson; Dileep Nair; Maria Siemionow 

1:37pm – 1:40pm 

Discussion 

1:40pm – 1:45pm 

Pressure Changes in the Medial and Lateral Plantar and Tarsal Tunnels Related to 

Ankle Position: a Prospective Intra-Operative Study in Patients with Underlying 

Neuropathy 

Institution where the work was prepared: Johns Hopkins University School of Medicine, 

Baltimore, MD, USA 

Gedge D. Rosson, MD; Eric H. Williams, MD; Allison R. Barker, BA; A. Lee Dellon, MD 

1:45pm – 1:48pm 

Discussion 

1:48pm – 1:53pm 

Inducible Nerve Growth Factor Delivery by HEK-293 Cells for Peripheral Nerve 

Regeneration in Vivo 

Institution where the work was prepared: University of California, Irvine, CA, USA 

Thomas Scholz, MD; James M. Rogers; Alisa Krichev; Sanjay Dhar; Gregory R. D. Evans 

1:53pm – 1:56pm 

Discussion 

1:56pm – 2:01pm 

Restoration of Elbow Function Using Inverse End-to-Side Anastomosis between 

Ulnar Fascicles and Musculocutaneous Nerve in Late Incomplete Obstetrical 

Erb's Palsy 

Institution where the work was prepared: Tel Aviv Medical Center, Tel Aviv University, 

Tel Aviv, Israel 

Shimon Rochkind, MD; Mohamed Shafi; Malvina Alon; Hagar Patish 

2:01pm – 2:04pm 

Discussion 

2:04pm – 2:09pm 

*The Feasibility of Using Side-to-Side Nerve Grafts to “Protect” Nerve Pathways 

during Axon Regeneration from Surgically Repaired Proximal Nerve Injuries 

Institution where the work was prepared: University of Alberta, Edmonton, AB, Canada 

P. Schembri, BSc, MD; A Ladak; N. Tyreman; J Olson; T. Gordon 

2:09pm – 2:12pm 

Discussion 


Sponsored by: 

Professor Neville Hogan, PhD 

Robotics for Neurorecovery 

Robots are well on their way to becoming commonplace 

domestic appliances but to realize their full potential 

requires the perfection of contact robotics, machines that 

physically cooperate with humans. Robots capable of safe 

physical cooperation with humans enable entirely new 

ways for technology to help people. One pioneering 

application of contact robotics is the delivery of physiotherapy 

to facilitate recovery after neurological injury. I will 

review recent success with interactive robotic treatment of 

upper-extremity motor disorders. It has proven to afford 

lasting benefits, both an increase of motor ability and a 

reduction of paretic arm pain, for persons in both the 

acute phase and the chronic phase of recovery after stroke. 

Neville Hogan is Professor of Mechanical Engineering 

and Professor of Brain and Cognitive Sciences at the 

Massachusetts Institute of Technology. He is Director of 

the Newman Laboratory for Biomechanics and Human 

rehabilitation and a founder and director of Interactive 

Motion Technologies, Inc., a company offering innovative 

robotic tools to study and treat neuro-motor impairments. 

Born in Dublin, Ireland, he obtained a Dip. Eng. 

(with distinction) from Dublin Institute of Technology and 

M.S., M.E. and Ph.D. degrees from the Massachusetts 

Institute of Technology. Following industrial experience in 

engineering design, he joined MIT’s school of 

Engineering faculty in 1979 and has served as Head and 

Associate Head of the MIT Mechanical Engineering 

Department’s System Dynamics and Control Division. He 

has been awarded Honorary Doctorates from the Delft 

University of Technology and the Dublin Institute of 

Technology and the Silver Medal of the Royal Academy 

of Medicine in Ireland. 

3:15pm – 3:30pm Closing Remarks & Presentation of Awards 

3:30pm – 4:00pm ASPN Business Meeting (attendance is limited to ASPN members only) 

4:00pm – 4:30pm ASPN Council Meeting

ASRM 





6:30am – 7:00am AAHS/ASPN/ASRM Coffee Break California Lounge 

7:00am – 11:30am AAHS/ASPN/ASRM Combined Programming Los Angeles 

11:30am – 12:30pm Lunch with Exhibitors California Showroom 

12:30pm – 1:30pm Scientific Paper Presentations: Research II Los Angeles 

1:30pm – 2:30pm ASRM Instructional Courses 

201 Pedicle and Microsurgical Perforator 

Flaps in Upper Extremity Reconstruction 

Palisades 

202 Venous Flow Through Flaps Pacific 

203 Microsurgical Salvage of the Chronic Wound Sherman Oaks 

204 Breast Reconstruction – What has evolved 

as the Clinical Standard? 

Westwood 

2:30 – 3:00pm Coffee Break with Exhibitors California Showroom 

3:00pm – 4:00pm PANEL: Grill the Expert Los Angeles 

4:00pm – 6:00pm Best Microsurgical Case/Best Microsurgical 

Save Presentations 

Los Angeles 

6:30pm – 8:00pm ASPN/ASRM Welcome Reception X Bar 

43

ASRM 



12:30pm – 1:30pm Scientific Paper Presentations: Research II 


Moderator: Paul Cederna, MD 

12:30pm – 12:34pm 

*Changes in the Nitric Oxide Pathway During Free Flap Failure 

Institution where the work was prepared: R Adams Cowley Shock Trauma Center, 


Suhail K. Mithani, MD; Rachel Bluebond-Langner, MD; Hunter C. Champion, MD, 

PhD; Eduardo D. Rodriguez 

12:34pm – 12:38pm 

Regenerative Acellular Collagen Tube Matrix as a Microvascular Conduit 

Institution where the work was prepared: Cleveland Clinic Foundation, 

Cleveland, OH, USA 

Wong Moon, MD 

12:38pm – 12:41pm 

Discussion 

12:41pm – 12:45pm 

*Thermoreversible Poloxamers and Applications for Vascular Biology 


Edward I. Chang, MD; Cynthia D. Hamou; Michael G. Galvez; Michael T. 

Longaker; Geoffrey C. Gurtner 

12:45pm – 12:49pm 

*Brain Plasticity after Facial Reanimation Imaged by fMRI 

Institution where the work was prepared: Dep of Plastic Surgery, Helsinki 

University Hospital, Helsinki, Finland 

Tuija M. Ylä-Kotola, MD; Antti Korvenoja, MD, PhD; M Susanna C Kauhanen; 

Sinikka Suominen; Erkki Tukiainen; Sirpa Asko-Seljavaara 

12:49pm – 12:53pm 

Postoperative Changes in Blood Velocity Following Microvascular Free Tissue 

Transfer 

Institution where the work was prepared: University of Texas M. D. Anderson 

Cancer Center, Houston, TX, USA 

Olubunmi Ogunleye, MD; Michael J. Miller, MD; Craig J. Hartley, PhD; Matthew 

M. Hanasono, MD 

12:53pm – 12:56pm 

Discussion 

12:56pm – 1:00pm 

*Correlation of Chimerism with Size of Vascularized and Non Vascularized 

Allograft Transplants 


Serdar Nasir; Mehmet Bozkurt; Lukasz Krokowicz; Aleksandra Klimczak; Maria Siemionow 

1:00pm – 1:04pm 

*Supportive Therapy with Donor Bone Marrow Transplantation and Role of 

Regulatory T-cell for Allograft Survival in Facial Allograft Model 


Aleksandra Klimczak, PhD; Mehmet Bekir Unal; Yavuz Demir; Maria Siemionow 

1:04pm – 1:08pm 

*Involvement of Notch1 Signals in Osteoinduction and Proliferation of Adipose 

Derived Adult Stem Cells 

Institution where the work was prepared: SIU SOM, springfield, IL, USA 

Damon Cooney, MD, PhD; Chris Chambers; Minh-Doan Nguyen; Michael Neumeister 

1:08pm – 1:11pm 

Discussion 

1:11pm – 1:15pm 

*The Use of Thrombolytics in Microvascular Free Flaps 

Institution where the work was prepared: NYU Medical Center, New York, NY, USA 

Otway Louie; Pierre Saadeh; Jamie Levine 

44 

1:15pm – 1:19pm 

Ischemia/reperfusion-induced Apoptotic Endothelial Cells Isolated from Rat 

Skeletal Muscle 

Institution where the work was prepared: University of Nevada School of Medicine, Las 

Vegas, NV, USA 

Wei Z. Wang, MD; Xin-Hua Fang, MT; Linda L. Stephenson, MT; Kayvan T. Khiabani, 

MD; William A. Zamboni, MD 

1:19pm – 1:23pm 

*A Prefabricated Neo-Endocrine Pancreas Using a Muscle Flap to Maximize‚-cell Mass 

in Pancreatic Transplants – Pilot Study in a Rat Model 

Institution where the work was prepared: Singapore General Hospital, Singapore, Singapore 

Eky Woo, MBBS, MRCSEd; Bien-Keem Tan, FRCS; Kok Chai Tan, FRCS; Pk Chow, 

FRCS, PHD 

1:23pm – 1:26pm 

Discussion 


201 Pedicle and Microsurgical Perforator Flaps in 

Upper Extremity Reconstruction 

This course will cover the anatomy, dissection technique 

and applications in pedicle and microsurgical 

perforator flaps in upper extremity reconstruction. 

Alexandru Georgescu, MD 

Ming Huei-Cheng, MD 

Yixin Zhang, MD 

202 Venous Flow Through Flaps 

Venous flow through flaps are defined as composite 

flaps of skin and subcutaneous vein that uses the subcutaneous 

venous system for the nutrient support. The 

inflow can be arterial blood or venous blood. The outflow 

can be artery or vein. 

Rudolf Buntic, MD 

Tsu Min Tsai, MD 

203 Microsurgical Salvage of the Chronic Wound 

Chronic venous ulcer disease remains a highly prevalent 

condition for which no medical or surgical solution 

has resulted in definitive cure without a high prevalence 

for recurrence. The purpose of this instructional course 

is to review our experience in the rationale, technical 

performance and the results of microvascular flap 

treatment of chronic venous ulcer disease and lower 

extremity chronic osteomyelitis. Details of wide subfascial 

excision of ulcer, or wounds, bony debridement 

resection and grafting and details of post-operative 

care, patient and flap selection for surgery will be discussed 

in detail. 

Raymond Dunn, MD 

Koenraad Landuyt, MD 

204 Breast Reconstruction – What has 

evolved as the Clinical Standard? 

This instructional course will cover the current strategies 

in autogenous breast reconstruction and when to use 

Free Tram, DIEP and SIEA flaps for reliable results. The 

use of internal mammary vessels and patient selection 

will be covered as well. 


Michael Zenn, MD 

David Chang, MD 

2:30pm – 3:00pm Coffee Break with Exhibitors 

3:00pm – 4:00pm Panel: Grill the Expert 

Experts grilled on the management of complex reconstructive 

problems including complications and salvage 

procedures. 

Julian Pribaz, MD, Co-Moderator 

Robert Walton, MD, Co-Moderator 



Julia K. Terzis, MD, PhD 

Randy Sherman, MD 

4:00pm – 6:00pm Best Microsurgical Case/ Best Microsurgical 

Save Presentations 

The Best Microsurgical Save of the Year Award and the Best 

Microsurgical Case of the Year Award will be presented, based 

on submissions from the membership of microsurgical salvage 

cases performed during the last year. A panel of experts will 

critique submitted cases and the attendees will vote for the best 

case and the best save 

Michael Zenn, MD, Co-Moderator 

Robert Russell, MD, Co-Moderator 

The ASRM would like to thank Synovis MCA 

for their generous sponsorship of this event. 

6:30pm – 8:00pm ASPN/ASRM Welcome Reception

ASRM 



6:30am – 7:30am Breakfast with Exhibitors California Showroom 



7:00am – 5:00pm Patient Safety Computerized Presentations California Showroom 

7:00am – 7:15am Welcome: Los Angeles 

Lawrence B. Colen, MD 


7:15am – 8:15am Scientific Paper Presentations: Breast Los Angeles 

8:15am – 9:15am ASRM/ASPN PANEL: Treatment of the Mangled Hand: Los Angeles 



9:45am – 10:45am PANEL: Basic Science for Clinical Microsurgeons Los Angeles 

Current Status and Clinical Relevance 

9:45am – 10:45am PANEL: GU Reconstruction Beverly Hills 

10:45am – 11:45am PANEL: Voodoo in Microsurgery? Los Angeles 

11:45am – 12:15pm Presidents Address: Lawrence B. Colen, MD Los Angeles 


12:15pm – 1:00pm Mentor Luncheon (Invitation Only) Director’s Dining 

1:00pm – 2:00pm ASRM Instructional Courses 

205 Reconstruction of a Weight Bearing Sole Palisades 

206 Pedicled and Microsurgical Flaps in Pacific 

Lower Extremity Reconstruction – What has 

Evolved as the Routine State of the Art? 

207 Monitoring Free Flaps – What should be Sherman Oaks 

the standard of care? 

208 Head and Neck Reconstruction - Westwood 

What’s new in hard and soft tissue transfer? 

2:00pm – 3:00pm Concurrent Scientific Paper Presentations: Other Beverly Hills 

2:00pm - 3:00pm Concurrent Scientific Paper Presentations: Upper Extremity Los Angeles 

3:00pm – 3:30pm Break with Exhibitors California Showroom 

3:30pm – 4:30pm Presidents Invited Lecturer: Luis Vasconez, MD Los Angeles 

4:30pm – 5:30pm Godina Lecture: Peirong Yu, MD Los Angeles 

45

ASRM 



7:00am – 5:00pm Patient Safety Computerized Presentations 

7:00am -7:15am Welcome 



7:15am – 8:15am Scientific Paper Presentations: Breast 


Moderator: Michael Zenn, MD 

7:15am – 7:19am 

Redesigned Gluteal Artery Perforator Flap for Breast Reconstruction 

Institution where the work was prepared: Univ. of Texas, M.D. Anderson Cancer 

Center, Houston, TX, USA 

Steven J. Kronowitz, MD 

7:19am – 7:23am 

*DIEP Flaps in Patients with Abdominal Scars: Are Complication Rates Affected? 

Institution where the work was prepared: Beth Israel Deaconess Medical Center, 


Brian M. Parrett, MD; Stephanie A. Caterson, MD; Adam M. Tobias; Bernard T. Lee 

7:23am – 7:27am 

Laser-Assisted ICG Angiography; Applications in Perforator Flap Surgery 

Institution where the work was prepared: Cleveland Clinic Florida, Weston, FL, 

USA 

Michel C. Samson, MD; Martin I. Newman, MD 

7:27am – 7:30am 

Discussion 

7:30am – 7:34am 

*Comparison Of Superior Gluteal Artery Perforator Flaps and Myocutaneous 

Flaps For Breast Reconstruction 

Institution where the work was prepared: University of California at Los Angeles, 

Los Angeles, CA, USA 

Mark Gelfand, MD; Brian Boyd, MD; William Shaw, MD; James Watson, MD; 

Andrew Da Lio, MD 

7:34am – 7:38am 

*Advanced Age as a Risk Factor for Free Tissue Transfer Breast Reconstructions: 

A Review of 372 Operations 

Institution where the work was prepared: UCLA (University of California, Los 

Angeles), Los Angeles, CA, USA 

Maura Reinblatt, MD; Luis Vaca; Jaco Festekjian, MD; James Watson, MD; 

Andrew Da Lio, MD; Christopher Crisera, MD 

7:38am – 7:42am 

Late Venous Thrombosis in Free Flap Breast Reconstruction 

Institution where the work was prepared: Hospital of the University of Pennsylvania, 

Philadelphia, PA, USA 

Elizabeth M. Kim, MD; Liza C. Wu; Joseph M. Serletti 

7:42am – 7:45am 

Discussion 

7:45am – 7:49am 

Chimeric Stacked Deep Inferior Epigastric Perforator Flap Breast 

Reconstruction: A New Solution to an Old Problem 

Institution where the work was prepared: The Center for Restorative Breast 

Surgery, New Orleans, LA, USA 

Frank J. DellaCroce, MD; Scott Keith Sullivan, MD, FACS 

46 

7:49am – 7:53am 

*Outcome of Microvascular Complications after Free Flap Breast Reconstruction 

Institution where the work was prepared: UCLA Medical Center/David Geffen 

School of Medicine at UCLA, Los Angeles, CA, USA 

Brian Carlsen, MD; Peter Ashjian, MD; Brian P. Dickinson, MD; Jaco Festekjian, 

MD; Andrew L. Da Lio; James P. Watson, MD; Christopher A. Crisera, MD 

7:53am – 7:57am 

*Simultaneous Bilateral Breast Reconstruction with In-the-Crease Inferior 

Gluteal Artery 

Institution where the work was prepared: Louisiana State University Department 

of Plastic Surgery, New Orleans, LA, USA 

Quintessa Miller, MD; Robert J. Allen; M. Whitten Wise; Joshua Levine 

7:57am – 8:00am 

Discussion 

8:00am – 8:04am 

*Functional MRI to Evaluate “Sense of Self” Following Deep Inferior Epigastric 

Perforator Flap Breast Reconstruction 



Stephanie A. Caterson, MD; Sharon Fox, BS; Adam M. Tobias; Bernard T. Lee, MD 

8:04am – 8:08am 

Utilization of the Internal Mammary Intercostal Perforator Instead of the True 

Internal Mammary Vessels as the Recipient Vessels for Breast Reconstruction 

Institution where the work was prepared: Johns Hopkins University, Baltimore, 

MD, USA 

Gedge D. Rosson, MD; Eduardo D. Rodriguez; Jaime I. Flores; Michele A. 

Manahan; Nia D. Banks; Navin K. Singh 

8:08am – 8:12am 

*Microvascular Free Tissue Transfer for Breast Reconstruction in the Elderly: A 

Safe and Effective Option 



Jeffrey M. Jacobson, MD; Maurice Y. Nahabedian, MD 

8:12am – 8:15am 

Discussion 

8:15am – 9:15am ASRM/ASPN Panel: Treatment of the Mangled Hand: 


Michael W. Neumeister, MD, Moderator 


Michael Sauerbier, MD, PhD 


9:45am – 10:45am Panel: Basic Science for Clinical Microsurgeons 

Current Status and Clinical Relevance 

This panel will cover stem cells, gene therapy, tissue engineering 

and transplant. 

William Zamboni, MD, Moderator 

Gregory R. D. Evans, MD 

Geoffrey Gurtner, MD 

Wayne Morrison, MD, PhD 

Maria Siemionow, MD, PhD 

9:45am – 10:45am Panel: GU Reconstruction 

Lawrence Gottlieb, MD, Moderator 


David Gilbert, MD 

Milomir Ninkovic, MD 


10:45am – 11:45am Panel: Voodoo in Microsurgery? 

This panel will discuss anti coagulation - do's and don'ts, 

the HIT phenomenon, flap training and flap protection 

and upper and lower extremity flaps. 

Michael Neumeister, MD, Co-Moderator 

Peter Neligan, MD, Co-Moderator 



Alexander Shin, MD

11:45am – 12:15pm Presidents Address 

12:15pm – 1:00pm 


Lunch with Exhibitors 

12:15pm – 1:00pm Mentor Luncheon (Invitation Only) 


205 Reconstruction of a Weight Bearing Sole 

Sole defect may arise from trauma, tumor excision or neurotrophic 

ulcer. Regarding to the caveat of weight bearing, 

the reconstruction had better provide stable post with 

adequate soft tissue and protective sensation. 

B. Battiston, MD 

Marco Innocenti, MD 

Chi-Hung Lin, MD 

206 Pedicled and Microsurgical Flaps in Lower 

Extremity Reconstruction – What has Evolved 

as the Routine State of the Art 

Chris Attinger, MD 

Detlev Erdmann, MD 

Steve Moran, MD 

207 Monitoring Free Flaps - What should be the 

standard of care? 

During this instructional course discussion will cover the 

outline of techniques available, pros, con’s and limitations 

of monitoring free flaps as well as survey results of practice 

patterns. 

William Swartz, MD 

Joan Lipa, MD 

208 Head and Neck Reconstruction-What’s New 

in Hard and Soft Tissue Transfer? 

This course will cover refinements and tailoring of the free 

and pedicled flaps, including prelaminated and pre-fabricated 

flaps to maximize the aesthetic outcome in complex 

head and neck reconstruction. In addition this course 

will present technical refinements to optimize aesthetic 

and functional results in jaw reconstruction. 

Giorgio de Santis, MD 

Julian Pribaz, MD 

E. Rodriguez, MD 

2:00pm – 3:00pm Concurrent Scientific Paper Presentations: 

Other 


Moderator: Charles Lee, MD 

2:00pm – 2:04pm 

An Anatomical Study of the Superficial Peroneal Nerve Accessory Artery and 

Its Perforators, and Clinical Application of Superficial Peroneal Nerve 

Accessory Artery Perforator Flaps 

Institution where the work was prepared: Gyeongsang National University 

Hospital, Jinju, South Korea 

Tae Hyun Choi, MD, PhD; Jun Sik Kim; Nam Gyun Kim; Kyung Suk Lee 

2:04pm – 2:08pm 

Tissue Oximetry, A Reliable Technique for Non-Invasive Free Flap Monitoring 

Institution where the work was prepared: Long Island Jewish Medical Center, 

New Hyde Park, NY, USA 

Alex Keller, MD 

2:08pm – 2:12pm 

20 Years Experience In Pediatric Microsurgery 

Institution where the work was prepared: Sheba Medical Center, Tel Hashomer, Israel 

Batia Yaffe, MD; Eyal Winkler; Haim Kalpan 

2:12pm – 2:15pm 

Discussion 

2:15pm – 2:19pm 

A Reconstruction Algorithm to Encounter No Sizable Skin Perforator during 

Anterolateral Thigh Flap Dissection 

Institution where the work was prepared: Chang Gung Memorial Hospital - 

Kaohsiung Medical Center, Kaohsiung, Taiwan 

Ching-Hua Hsieh, MD; Seng -Feng Jeng, MD; Yur-Ren Kuo, MD, PhD, FACS; 

Pao-Yuan Lin, MD; Johnson C. Yang, MD 

47 

2:19pm – 2:23pm 

*Early Results of a Prospective, Randomized Cost and Outcome Analysis of 

ICU vs. Surgical Floor Monitoring in Free Flap Breast Reconstruction 

Institution where the work was prepared: University of Chicago Medical Center, 


Charles Y. Tseng, MD; David H. Song, MD 

2:23pm – 2:27pm 

Partial Muscle Transplantation: Strategy for Preservation of Form and Function 

at the Donor Site 

Institution where the work was prepared: California Pacific Medical Center, San 

Francisco, CA, USA 

Darrell Brooks; Rudolf F. Buntic 

2:27pm – 2:30pm 

Discussion 

2:30pm – 2:34pm 

*Microvascular Venous Coupler Reduces the Rate of Venous Anastomosis Failure 

Institution where the work was prepared: University of Manitoba, Winnipeg, MB, 

Canada 

Matthew Choi, MD; Edward Wayne Buchel; Thomas E.J. Hayakawa 

2:34pm – 2:38pm 

Strategic Approaches to Salvage the Venous Compromised Deep Inferior 

Epigastric Perforator Flap 

Institution where the work was prepared: Chang Gung Memorial Hospital, 

Taipeh, Taiwan 

Rozina Ali, MD; Ming-Huei Cheng, MD, MHA; Christina Bernier, MD; Yt Lin; 

Alexander Cardenas-Mejia, MD; Rachel Bluebond-Cangner, MD; Eduardo P. 

Rodriguez, MD; We-Chen Ching, MD 

2:38pm – 2:42pm 

13 Years Experience with Free Fibula Flap Phalloplasty 

Institution where the work was prepared: Gulhane Military Medical Academy, 

Ankara, Turkey 

Mustafa Sengezer; Serdar Ozturk; Mustafa Deveci; Fatih Zor 

2:42pm – 2:45pm 

Discussion 

2:45pm – 2:49pm 

Outcomes of Immediate VRAM Flap Reconstruction versus Primary Closure in 

Patients Undergoing Chemoradiation and Abdominoperineal Resection for 

Anorectal Cancer 

Institution where the work was prepared: The University of Texas M. D. Anderson 


Charles E. Butler, MD; Õzlem Gûndeslioglu, MD; Miguel A. Rodriguez-Bigas, MD 

2:49pm – 2:53pm 

*Comparison of Surgical Outcomes Using VRAM Flaps vs. Thigh-based Flaps for 

Reconstruction of Abdominoperineal Resection and Pelvic Exenteration Defects 

Institution where the work was prepared: The University of Texas M. D. Anderson 


Rebecca A. Nelson, MD; Charles E. Butler, MD 

2:53pm – 2:57pm 

*Microangiosomes: a New Concept 

Institution where the work was prepared: University of Chicago Hospitals, 


Eric A. Odessey, MD; Charles Y. Tseng, MD; Amir H. Dorafshar, MD; Lisa Spiguel, 

MD; Lawrence J. Gottlieb, MD, FACS 

2:57pm – 3:00pm 

Discussion 

2:00pm – 3:00pm Concurrent Scientific Paper Presentations: 

Upper Extremity 


Moderator: James Higgins, MD 

2:00pm – 2:04pm 

Total and Subtotal Amputations with Destruction of the Proximal Interphalangeal 

and Metacarpal Phalangeal Joint: a Paradigm Shit Towards Salvage 

Institution where the work was prepared: California Pacific Medical Center, San 

Francisco, CA, USA 

Darrell Brooks, MD; Rudolf F. Buntic, MD

2:04pm – 2:08pm 

*Single-Stage Reconstruction of the Mutilated Hand Using Bilobed and Trilobed 

Free Flaps Based on the Anterior Tibial Artery 

Institution where the work was prepared: Duke University, Durham, NC, USA 

Keith E. Follmar; Yi Xin Zhang; Danru Wang; Detlev Erdmann; L. Scott Levin 

2:08pm – 2:12pm 

Complications Associated With Specific Types of Intrinsic Pedicle Flaps Used 

to Reconstruct Digital Trauma Defects 

Institution where the work was prepared: Hand & Wrist Center of Houston, 

Houston, TX, USA 

Mark Henry, MD 

2:12pm – 2:15pm 

Discussion 

2:15pm – 2:19pm 

Refinement of Arterialized Venous Flaps in Finger Reconstructions 

Institution where the work was prepared: Chang Gung Memorial Hospital, Tao- 

Yuan, Taiwan 

Yu-Te Lin, MD, MS; Chih-Hung Lin; Cheng-Hung Lin; Fc Wei, MD, FACS 

2:19pm – 2:23pm 

*Arterialized Venous Instep Flap: A New Alternative for Reconstruction of 

Palmar Contracture Release 



Fatih Zor; Selçuk Isik; Muhidtin Eski; Serdar Ozturk 

2:23pm – 2:27pm 

*Long-Term Functional Outcome of the Upper Extremity following 

Osteocutaneous Radial Forearm Free Flap Harvest 

Institution where the work was prepared: University of Pittsburgh Medical Center, 

Pittsburgh, PA, USA 

Justin M. Sacks, MD; Kia M. McLean, MD; Ernest K. Manders, MD; James M. 

Russavage, MD, DMD; Frederic W.-B. Deleyiannis, MD, MPhil, MPH 

2:27pm – 2:30pm 

Discussion 

2:30pm – 2:34pm 

*Vascularized Scapular Grafts: An Excellent Option for Humeral Nonunions 

Institution where the work was prepared: Denver Clinic for Extremities at Risk, 

Denver, CO, USA 

Jerrod Keith, MD; David P. Schnur, MD; William Brown; Ross Wilkins; Ronald 

Hugate, MD; Cynthia Kelly 

2:34pm – 2:38pm 

The Aesthetic Mini Wrap - around Technique for Thumb Reconstruction 

Institution where the work was prepared: Department of Orthopaedics University 

of Modena, Modena, Italy 

Roberto Adani, MD 

2:38pm – 2:42pm 

*Radical Reduction of Upper Extremity Lymphedema with Preservation of 

Perforators: A Preliminary Report 

Institution where the work was prepared: E-DA Hospital, I-Shou University, 

Kaohsiung, Taiwan 

Paolo Sassu, MD; Christopher Salgado; Samir Mardini, MD; Hung-Chi Chen, MD, 

FACS 

2:42pm – 2:45pm 

Discussion 

2:45pm – 2:49pm 

Vascularized Groin Lymph Node Transfer for Postmastectomy Upper Extremity 

Lymphedema 

Institution where the work was prepared: Cheng-Hung Lin, Taipei, Taiwan 

Cheng-Hung Lin; Rozina Ali; Chris Wallace; Hung-Chi Chen; Ming-Huei Cheng 

2:49pm – 2:53pm 

*Use of Nerve Conduits as an Adjunct to Brachial Plexus Micro-Neurorraphy 

Institution where the work was prepared: Hospital for Special Surgery, New York, 

NY, USA 

Helene L. Strauss, BA; Richard Cheng, BS; Scott Wolfe, MD; Joseph Feinberg, MD 

48 

2:53pm – 2:57pm 

The Extended Lower Trapezius Flap for the Reconstruction of Shoulder Tip 

Defects 

Institution where the work was prepared: Singapore General Hospital, Singapore, 

Singapore 

Kok-Chai Tan, MBBS, FRCS; Bien-Keem Tan, MBBS, FRCS, (Ed); Mohamed Z. 

Rasheed, MBBS, MRCS(Ed) 

2:57pm – 3:00pm 

Discussion 

3:00pm – 3:30pm Break with Exhibitors 

3:30pm – 4:30pm Presidents Invited Lecture 

4:30pm – 5:30pm Godina Lecture 

Luis Vasconez, MD 

“Complex Reconstructive Surgery: 

An Increasing Need” 

The presentation will illustrate one medical center’s 

approach to complex reconstruction involving multiple 

specialties, and where a plastic surgeon plays a key role. 

Dr. Luis O. Vasconez currently is the Chief of the Division 

of Plastic Surgery at the University of Alabama in 

Birmingham. Prior to taking his position in Alabama, Dr. 

Vasconez was the Chief of the Division of Plastic Surgery 

at the University of California in San Francisco. As a 

Captain in the United States Air Force, Dr. Vasconez 

served as the Chief of Surgery at the James Connally 

AFB Hospital in Waco, Texas from 1964–1966. Dr. 

Vasconez has been involved in the resurrection of reconstructive 

surgery, including microsurgery, from the very 

beginning. 

Peirong Yu, MD 

“Marko Godina was distinguished by his tireless energy, 

his impeccable logic, his boundless optimism, and his 

constant good humor and courtesy” – G. Lister 

It is these qualities that are sought after in choosing the 

ASRM Godina Lecturer, honoring Dr. Marko Godina, an 

unrivaled leader and innovator in reconstructive microsurgery 

whose life was tragically cut short at the young 

age of 43. Established by the trustees of the Marko 

Godina Fund, this distinguished lectureship highlights a 

young, upcoming microsurgeon who has demonstrated 

leadership, innovation and ongoing commitment to our 

field in the best traditions of Dr. Godina. It is a pleasure to 

introduce Peirong Yu, MD as the 2007 Godina Traveling 

Fellow. 

MY JOURNEY, THE LAND OF OPPORTUNITIES 

America is known as the land of opportunities. Born in a 

small village and received medical education in China, I 

came to the United States in 1989 to search for the 

opportunities for my career development. I will share 

with you my journey to the world of microsurgery and 

my contributions in this field, particularly in head and 

neck, and tracheal esophageal reconstruction. 

Dr. Peirong Yu is currently an Associate Professor in the 

Department of Plastic Surgery at the University of Texas, 

MD Anderson Cancer Center. Dr. Yu received a degree 

in medicine from Suzhou Medical College in Suzhou, 

China and a degree in Immunology from the Peking 

Union Medical College in Beijing, China. His post graduate 

training was done at Peking Union Medical College, 

Massachusetts General Hospital (Harvard Medical 

School), Brown University and the Medical College of 

Wisconsin.

ASRM 


Monday, January 14, 2008 



6:30am – 7:00am Coffee California Lounge 


7:00am – 8:00am ASRM Instructional Courses 

209 Innovative Nerve Transfers/Conduits Palisades 

210 Concept of A-V Loops in Critical Pacific 

Reconstructive Situations 

211 Free Flaps in Seriously Ill Patients Sherman Oaks 

212 Transfer of Engineered Tissue – Research Westwood 

Status and Clinical Applicability 

8:00am – 8:30am Past Presidents Breakfast (Invitation Only) Encino 

8:00am – 8:30am Continental Breakfast in Exhibit Hall California Showroom 

8:30am – 9:30am Buncke Lecture: Berish Strauch, MD Los Angeles 

9:30am – 10:15pm PANEL: The Big Debate – Is there still a Place Los Angeles 

for Flaps in Lower Leg Reconstruction? 

10:15am – 11:15am Concurrent Scientific Paper Presentations: Lower Extremity Los Angeles 

10:15am - 11:40am Concurrent Scientific Paper Presentations: Research Beverly Hills 

11:15am – 12:00pm Lunch with Exhibitors California Showroom 

11:15am Departure for Golf Tournament: Mountain Gate CC 

Mountain Gate Country Club 

12:00pm – 4:30pm Master Series in Microsurgery Los Angeles 

12:30pm – 5:00pm ASRM Composite Tissue Allotransplantation Update Session Beverly Hills Room 

6:30pm – 8:00pm Meeting Services California Lounge 

7:00pm – 10:30pm ASRM Cocktail Reception & Dinner-Theater California Lounge / Los Angeles 

of the Imagination 

49

ASRM 

Monday, January 14, 2008 




209 Innovative Nerve Transfers / Conduits 

During this course the instructors will discuss past, present 

and future biologic, alloplastic and bioartificial peripheral 

nerve conduits 


Alexander Shin, MD 

Michael Klebuc, MD 

210 Concept of A-V Loops in Critical 

Reconstructive Situations 


M. Pelzer, MD 

211 Free Flaps in Seriously Ill Patients 

Koenraad Landuyt, MD 


Michael Sauerbier, MD 

212 Transfer of Engineered Tissue – Research Status 

and Clinical Applicability 


Gregory R. D. Evans, MD 

8:00am – 8:30am Past Presidents Breakfast (invitation only) 

8:00am – 8:30am Continental Breakfast in Exhibit Hall 

8:30am – 9:30am Buncke Lecture 

Berish Strauch, MD 

The Harry Buncke Lectureship has been created with the 

support of the California Pacific Medical Center to honor 

Dr. Buncke’s remarkable contributions to the field of 

microsurgery. Dr. Harry Buncke has played a major role 

in the development of our specialty and has helped 

develop several microsurgical laboratories across the 

globe. He has influenced countless residents and fellows 

as well as numerous department chairs throughout 

the world. It is with great appreciation that we are able 

to honor Dr. Harry Buncke with this lectureship due to the 

sponsorship of the California Pacific Medical Center. It is 

our pleasure to introduce Berish Strauch, MD as the 2008 

Harry Buncke Lecturer. 

“Reflection of Microsurgery” 

During this lecture Dr. Strauch will reflect on microsurgery 

from the early beginnings to current time both in the 

USA and around the world. 

Dr. Berish Strauch recently retired as the chairman of the 

Department of Plastic and Reconstructive Surgery and 

Professor of Plastic Surgery at the Albert Einstein College 

of Medicine and Montefiore Medical Center. Dr. Strauch 

is Board-certified in both general and plastic surgery, and 

holds a certificate of added qualification in hand surgery 

from the American Board of Plastic Surgery. 

In 1984, Dr. Strauch founded the Journal of Reconstructive 

Microsurgery and has been Editor In Chief since that time. 

His bibliography contains over 90 items, including the 

three-volume Grabb’s Encyclopedia of Flaps (with Drs. 

Vasconez and Hall-Findley), the Atlas of Microvascular 

Surgery: Anatomy and Operative Approaches (with Dr. Yu), 

and the Textbook on Microsurgery (with Dr. Daniller). 

Dr. Strauch is a founding president of the American 

Society for Reconstructive Microsurgery, International 

Society of Reconstructive Microsurgery and the American 

Society for the Peripheral Nerve, and served as president 

of the New York Society for Surgery of the Hand. 

9:30am – 10:15am Panel: The Big Debate – Is there still a Place 

for Flaps in Lower Leg Reconstruction? 

Allen Van Beek, MD, Moderator 

Dennis Orgill, MD 


50 

10:15am – 11:15am Concurrent Scientific Paper Presentations 

Lower Extremity 


Moderator: Rudy Buntic, MD 

10:15am – 10:19am 

Vascularized Fibula Flap Onlay for Salvage of Pathologic Long-Bone Fracture 


Jeffrey B. Friedrich, MD; Steven L. Moran; Allen T. Bishop; Christina M. Wood; 

Alexander Y. Shin 

10:19am – 10:23am 

*Microvascular Bone Flap Prefabrication: Preliminary Results in an Animal 

Experimental Model 

Institution where the work was prepared: Div of Plastic Surgery - University of 

Modena and Reggio Emilia, Modena, Italy 

Alessio Baccarani; Giovanna Petrella; Pietro Loschi; Massimo Pinelli; Giorgio De Santis 

10:23am – 10:27am 

The Use of Corticoperiosteal Flaps in Recalcitrant Distal Tibial Nonunions 

Institution where the work was prepared: Fundación Pedro Cavadas, Valencia, Spain 

Pedro C. Cavadas, MD, PhD; Luis Landin 

10:27am – 10:30am 

Discussion 

10:30am – 10:34am 

How Do Free Muscle Flap Reconstruction Effect Gait Analysis in Landmine 

Injury Patients? 



Serdar Ozturk; Mustafa Sengezer; Haydar Mohur; Fatih Zor 

10:34am – 10:38am 

*Complex Perineal and Groin Wound Reconstruction Using the Extended 

Dissection Technique of the Gracilis Flap 



Joseph H. Dayan, MD; Patrick Curry; Chris E. Attinger, MD; Ivica Ducic, MD, PhD 

10:38am – 10:42am 

*Vascularization of the Flexor Hallucis Longus Muscle and Its Implication in 

Free Fibula Flap Transfer 

Institution where the work was prepared: KleinertKutz Institute, louisville, KY, USA 

Paolo Sassu, MD; Samir Mardini, MD; Tuna Ozyurekoglu, MD; J. Christopher 

Salgado, MD; Steven Moran; Robert D. Acland, MD 

10:42am – 10:45am 

Discussion 

10:45am – 10:49am 

*The Distal Superficial Femoral Arterial (SFA) Branch to the Sartorius Muscle 

as Recipient Vessels for Peri-Knee Soft Tissue Reconstruction: Anatomic Study 

and Clinical Applications 

Institution where the work was prepared: University of California, San Francisco, 

San Francisco, CA, USA 

Fernando Herrera, MD; Charles K. Lee, MD; Mark W. Kiehn, MD; Scott Lee 

Hansen, MD 

10:49am – 10:53am 

Trends in the Treatment of Severe Open Tibial Fractures 

Institution where the work was prepared: BG Trauma Center Ludwigshafen, 


Christoph Czermak; Emilios Nalbantis; Guenter Germann; Christoph Heitmann 

10:53am – 10:57am 

Free Tissue Transfer for Complex Extremity War Injuries 

Institution where the work was prepared: The Microsurgery Unit, The Department 

of Plastic Surgery, Tel-Av, Tel-Aviv, Israel 

Arik Zaretski, MD; A. Amir; E. Arad; Y. Barnea; E. Miller; D. Leshem; J. Weiss; E. Gur 

10:57am – 11:00am 

Discussion 

11:00am – 11:04am 

Pedicled Perforator Flaps of the Lower Leg: Cluster Analysis of Perforator 

Locations and Clinical Application 

Institution where the work was prepared: UT Southwestern Medical Center at 

Dallas, Dallas, TX, USA 

M. Saint-Cyr, MD; Mark Schaverien; Gary Arbique; Spencer A Brown; Rod J Rohrich

11:04am – 11:08am 

Aesthetic Perforator Free Flap for Soft Tissue Restoration 

Institution where the work was prepared: Samsung Medical Center, Seoul, South 

Korea 

Goo-Hyun Mun, MD; Jai-Kyung Pyon 

11:08am – 11:12am 

Reconstruction of Segmental Femoral Defects with Living Bone Allografts 

Combined with Host-derived Neoangiogenesis: Mechanical, Histologic and 

Radiographic Analysis 

Institution where the work was prepared: Dept. of Orthopedic Surg., Microvasc. 

Research Lab., Mayo Clinic, Rochester, MN, USA 

Goetz A. Giessler, MD; Patricia F. Friedrich; Allen T. Bishop, MD 

11:12am – 11:15am 

Discussion 


Research 


Moderator: William Zamboni, MD 

10:15am – 10:19am 

*Reduction of the Immunological Rejection in Composite Tissue 

Allotransplantation by Heat Stress Preconditioning 

Institution where the work was prepared: Hand-, Plastic and Reconstructive 

Surgery, BG Trauma Center, Ludwigshafen, Germany 

Nina Ofer, resident; Michael Sauerbier; Guenter Germann 

10:19am – 10:23am 

*Investigation of Allograft Tolerance in Non-Human Primate Composite Facial 

Transplantation Model 

Institution where the work was prepared: University of Maryland School of 

Medicine, Baltimore, MD, USA 

Rachel Bluebond-Langner, MD; Rolf Barth, MD; Eduardo D. Rodriguez, DDS, 

MD; Stephen Shipley; Stephen T. Bartlett 

10:23am – 10:27am 

Swine Hemi-facial Composite Tissue Transplantation: A Preclinical Large 

Animal Model 

Institution where the work was prepared: Chang Gung Memorial Hospital 

–Kaohsiung Medical Center, Kaohsiung, Taiwan 

Yur-Ren Kuo, MD, PhD, FACS; Nai-Siong Kueh, MD; Wen-Sheng Wu; Chien-Chih 

Lin; Chong-Wei Huang; Yuan-Cheng Chiang 

10:27am – 10:30am 

Discussion 

10:30am – 10:34am 

Comparison between Cyclosporine A and Tacrolimus in Vascularized Bone 

Marrow Transplantation for Inducing Composite Tissue Allotransplantation 

Tolerance with Non-Myeloablative Conditioning 

Institution where the work was prepared: Wei-Chao Huang, Taoyuan, Taiwan 

Wai-Chao Huang; Nai-Jen Chang, yes; Jeng-Yee Lin, MD; Christopher Glenn 

Wallace, MD; Fu-Chan Wei 

10:34am – 10:38am 

*In Vivo and In Vitro Evidence that Intrajejunal Administration of Fresh Donor 

Splenocytes Delays the Onset of Rejection of Hindlimb Composite Tissue 

Allotransplants by Regulating Th1/Th2 Cytokines in Rats 

Institution where the work was prepared: Chang Gung Memorial Hospital and 

Chang Gung University, Taipei, Taiwan 

Christopher Glenn Wallace, MB, ChB, MRCS; Chia-Hung Yen, PhD; Hsiang-Chen 

Yang, MSc; Chun-Yen Lin, MD, PhD; Wei-Chao Huang; Jeng-Yee Lin; Fu-Chan 

Wei, MD, FACS 

10:38am – 10:42am 

*The Gene Expression Profiling of Ischemia-Reperfusion Injury in Rat Kidney, 

Small Intestine, and Cremasteric Muscle Model by DNA Microarray 

Institution where the work was prepared: Chang Nai-Jen, Taoyuan, Taiwan 

Nai-Jen Chang, yes; See-Tong Pang; Fu-Chan Wei 

10:42am – 10:45am 

Discussion 

10:45am – 10:49am 

Aged Donor Bone Marrow Influcences Mixed Chimerism and Donor-specific 

Tolerance to Composite Tissue Allotransplantation with Nonmyeloablative 

Conditioning 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Taiwan 

Jeng-Yee Lin, MD; Wei-Chao Huang; David C.C. Chuang; Fu-Chan Wei 

51 

10:49am – 10:53am 

*Quantitative Evaluation of the Dilation of Rat Femoral Vessels Following 

Application of Topical Botulinum Toxin 

Institution where the work was prepared: University of Virginia, Charlottesville, VA, USA 

Peter B. Arnold, MD, PhD; Christopher A. Campbell; David B. Drake; Wyndell H. 

Merritt, MD; George T. Rodeheaver; Raymond F. Morgan 

10:53am – 10:57am 

*A Modification of Neural-Island Flap: “Split Neural-Island Flap” 

Institution where the work was prepared: Hacettepe University Hospital, Plastic 

and Reconst Surg Dept, Ankara, Turkey 

Erhan Sonmez, MD; Hakan Ozdemir; Tunc Safak; Abdullah Kecik 

10:57am – 11:00am 

Discussion 

11:00am – 11:04am 

*Impact of Hypertonic and Hyperoncotic Saline Solutions on Ischemia- 

Reperfusion Injury in Free Flaps in Rats 

Institution where the work was prepared: Aesthetic and Plastic Surgery Institute, 

UCI, Orange, CA, USA 

Thomas Scholz, MD; Gregory R. D. Evans 

11:04am – 11:08am 

*The Effect of Ischaemia Time on Acute Rejection of Composite Tissue 

Allotransplantation in Rat Model 

Institution where the work was prepared: Duke University Medical Center, 

Durham, NC, USA 

Yee Siang Ong, MRCS, (Edin); Yi Xin Zhang; Alessio Baccarani; Keith E. Follmar; 

Caroline Messmer; Bruce Klitzmann; Detlev Erdmann; L. Scott Levin 

11:08am – 11:12am 

*Targeted Motor Reinnervation of the Rabbit Rectus Abdominis: a Single 

Muscle Can Receive and Distinguish Three Independent Nerve Inputs 

Institution where the work was prepared: Northwestern University, Feinberg 

School of Medicine, Chicago, IL, USA 

Peter S. Kim, MD; Kristina O'Shaughnessy, MD; Todd A. Kuiken, MD, PhD; 

Gregory A. Dumanian 

11:12am – 11:15am 

Discussion 

11:15am – 11:19am 

*Donor-Recipient Bone Marrow Cells Fusion as a Novel Therapy for CTA Transplants 


Maria Siemionow, MD, PhD; Earl Poptic; Serdar Nasir; Aleksandra Klimczak; 

Lukasz Krokowicz; Wioleta Luszczek, PhD 

11:19am – 11:23am 

Tissue Expression of The Beta-Chemokine, RANTES (CCL5), is Upregulated in 

Acutely Rejecting, Fully MHC-Mismatched Vascularized Skin Allotransplants in 

Rats 

Institution where the work was prepared: From the Department of Plastic and 

Reconstructive Surgery1 and t, Taipei, Taiwan 

Arik Zaretski, MD; Chia-Hung Yen; Christopher Glenn Wallace; Ren-Chin Wu; Fu- 

Chan Wei 

11:23am – 11:27am 

*The Role of Thymus in Chimerism Induction on Composite Osseomusculocutaneous 

Sternum, Ribs, Thymus, Pectoralis Muscles, Skin Allotransplantation Model 


Mehmet Bozkurt, MD; Serdar Nasir; Aleksandra Klimczak; Lukasz Krokowicz; 

Christopher Grykien; Maria Siemionow 

11:27am – 11:30am 

Discussion 

11:30am – 11:34am 

*Acute and Delayed Effects of Pulsed Acoustic Cellular Therapy (PACE) on 

Capillary Perfusion and Microcirculatory Hemodynamics of Muscle Flaps 


Lukasz Krokowicz; Christopher Grykien; Mariusz Mielniczuk; Aleksandra Klimczak; 

Maria Siemionow 

11:34am – 11:38am 

Three-and Four-Dimensional Arterial and Venous Anatomies of the 

Thoracodorsal Artery Perforator Flap 

Institution where the work was prepared: UT Southwestern Medical Center at 

Dallas, Dallas, TX, USA 

Michel Saint-Cyr, MD; Mark Schaverien; Gary Arbique; Spencer A Brown; Rod J Rohrich 

11:38am – 11:40am 

Discussion


11:15am Departure for Golf Tournament: 

Mountain Gate Country Club 

12:00pm – 4:30pm Master Series in Microsurgery 

Milan Stevanovic, MD, Chairperson 

Pre-registration is required. 

12:00pm – 12:05pm Introductory Remarks 

Milan V. Stevanovic, MD, Chair 

12:06pm – 12:21pm Vascularized Bone Pedicle Flaps in the 

Upper Extremity 

Allen T. Bishop, MD 

12:22pm – 12:37pm Vascularized Bone Grafts for Long Bone Defects 


12:38pm – 12:53pm Mandibular Reconstruction 

Giorgio DeSantis, MD 

12:54pm – 1:09pm Free Vascularized Fibular Graft for the Treatment 

of Osteonecrosis of the Femoral Head 

James Urbaniak, MD 

1:10pm – 1:30pm Discussion 

1:31pm – 1:46pm Nerve Transfer 


1:47pm – 2:02pm The Best Flaps for Small Defects of the Hand 

Roberto Adani, MD 

2:03pm – 2:18pm The Best Flaps for Small Defects of the Foot 



2:35pm – 2:50pm Break 

2:50pm – 3:05pm Prefabricated Flaps for Head And Neck 

Reconstruction 

Julian Pribaz, MD 

3:06pm – 3:21pm Best Free Flaps in Pediatrics 

Joseph Upton, MD 

3:22pm – 3:37pm Microsurgical Reconstruction of the Pediatric Thumb 

Neil F. Jones, MD 

3:38pm – 3:53pm Single and Double Functional Muscle Transfer 

Alexander Shin, MD 


4:15pm – 4:30pm Closing Remarks and Adjournment 

Milan Stevanovic, MD 

52 

12:30pm – 4:30pm ASRM Composite Tissue Allotransplantation 

Update Session 

Course is complimentary to ASRM registrants, 

but pre-registration is required. 

12:30pm – 12:40pm Welcome and Introduction 

Warren C. Breidenbach III, MD and Sue McDiarmod, MD 

12:40pm – 12:50pm A Historical Perspective of CTA Over the 

Last 50 Years 

Gordon R. Tobin, MD 

12:50pm – 1:05pm Status of Clinical CTA 

W.P. Andrew Lee, MD 

1:05pm – 1:20pm Chronic Rejection 

Anthony J. Demetrius, MD 

1:20pm – 2:20pm Immunological Risks of CTA 

Moderator: Warren C. Breidenbach III, MD 

Presenters: Mark A. Hardy, MD 

Neil F. Jones, MD 

Gerhard Opelz, MD 

Thomas H. Tung, MD 

2:20pm – 2:35pm Break 

2:35pm – 3:35pm T Regulatory Cells and CTA 

Moderator: Suzanne T. Ildstad, MD 

Presenters: Carla C. Baan, MD 

Haval Shirwan, MD 

Assia Eljaafari, MD 

Flavio G. Vincenti, MD 

3:35pm – 5:00pm Presentation of Abstracts 

Moderator: Linda C. Cendales, MD 

7:00pm – 10:30pm ASRM Cocktail Reception & Dinner 

Theater of the Imagination 

The ASRM would like to thank ASSI for their 

sponsorship of this evenings cocktail reception.

ASRM 


Tuesday, January 15, 2008 

6:30am – 7:30am Coffee California Lounge 

6:30am – 11:30am Speaker Ready Room California Showroom 



7:00am – 8:00am ASRM Instructional Courses 

213 Innovative Concepts in Vascularized Bone Transfer Palisades 

214 Functional Muscle Transfer Pacific 

215 Complex Chest and Trunk Reconstructions Sherman Oaks 

216 Microsurgical Reconstructions of Burn Injuries Westwood 

7:30am – 8:30am Breakfast California Lounge 

8:15am – 9:00am Business Meeting (members only) Encino 

9:00am – 10:30am Concurrent Scientific Paper Presentations: Head and Neck Los Angeles 

9:00am - 10:35am Concurrent Scientific Paper Presentations: Miscellaneous Beverly Hills 

10:30am – 10:45am Coffee Break California Lounge 

10:45am – 12:30pm Scientific Paper Presentations and Lecture: Hans Steinau, MD Los Angeles 

12:30pm Adjourn 

1:00pm – 2:00pm ASRM Council Meeting Encino 

53

ASRM 

Tuesday, January 15, 2008 




213 Innovative Concepts in Vascularized Bone Transfer 


M. Pelzer, MD 

P. Pinal, MD 

214 Functional Muscle Transfer 

Allen Bishop, MD 

K. Doi, MD 

215 Complex Chest and Trunk Reconstructions 

Milomir Ninkovic, MD - Bladder 

Charles Butler, MD - Abdomen 

Michael Sauerbier, MD – Complex Chest Reconstruction 

Lawrence Gottlieb, MD 

216 Microsurgical Reconstructions of Burn Injuries 

During this course the instructors will cover indications, 

timing and choices for microsurgical reconstruction in 

pediatric and adult burn injuries 

P.Vogt, MD 

Kevin Yakuboff, MD 

Elliott Rose, MD 

7:30am – 8:30am Breakfast 

8:15am – 9:00am Business Meeting (members only) 

9:00am – 10:30am Concurrent Scientific Paper Presentations: 

Head and Neck 


Moderator: R. Jobe Fix, MD 

9:00am – 9:04am 

*The Incidence of Venous Thromboembolism in Head and Neck Reconstruction 

Institution where the work was prepared: Memorial Sloan-Kettering Cancer 

Center, New York, NY, USA 

Constance M. Chen, MD, MPH; Joseph J. Disa; Babak J. Mehrara 

9:04am – 9:08am 

Microsurgical Correction of Craniofacial Malformations: A Fifteen-Year 

Experience 

Institution where the work was prepared: New York University School of 

Medicine, New York, NY, USA 

Pierre Saadeh; Chris Chang, BA; Evan Garfein; Otway Louie; John Siebert 

9:08am – 9:12am 

Rehabilitation after Mandibular Reconstruction with Fibula Free Flap: Clinical 

(Outcome) and Quality of Life Assessment 

Institution where the work was prepared: Erasmus University Medical Center, 

Rotterdam, Netherlands 

Stefan O.P. Hofer; Alessandra C. Hundepool; Antoine G. Dumans; Nico Fokkens; 

Sukh S. Rayatt; Erik H. van der Meij; Kees P. Schepman 

9:12am – 9:15am 

Discussion 

9:15am – 9:19am 

*Evaluation of Cortical Reorganization in Facial Transplantation 

Institution where the work was prepared: University of Pittsburgh, Pittsburgh, PA, USA 

Kia M. McLean, MD; Mario G. Solari; Justin M. Sacks; Anjey Su; Vijay S. Gorantla; 

Jignesh V. Unadkat; Stefan Schneeberger; George E. Carvell; Daniel J. Simons; 

W.P. Andrew Lee 

9:19am – 9:23am 

*Le Fort I Osteotomy with Interpositional Free Fibula Flap for Maxillary 

Augmentation 

Institution where the work was prepared: R Adams Cowley Shock Trauma Center, 


Rachel Bluebond-Langner, MD; Lisa Witkin; Eduardo D. Rodriguez 

9:23am – 9:27am 

*Maxilla Transplantation 

Institution where the work was prepared: Cleveland Clinic Foundation Plastic 

Surgery Department, Cleveland, OH, USA 

Ilker Yazici; Kevin Carnevale, MD; Ayhan Comert, MD; Tarik Cavusoglu, MD; 

Aleksandra Klimczak, PhD; Ibrahim Vargel, MD, PhD; Ibrahim Tekdemir, MD; 

Maria Z. Siemionow 

54 

9:27am – 9:30am 

Discussion 

9:30am – 9:34am 

Microvascular Free Appendix Transfer For Reconstruction Of Various Purposes 

Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan 

Hung-Chi Chen, MD, FACS; Samir Mardini, MD; Yueh-Bih Tang, MD, PhD; 

Christopher Salgado; Guan-Ming Feng, MD 

9:34am – 9:38am 

*Does the Ischemia Time Affect the Outcome of Free Fibula Flaps for Head 

and Neck Reconstruction? A Review of 117 Fibular Flaps 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan, 

Taipeh, Taiwan 

Shu-ying Chang, MD; Huang-Kai Kao, MD; Jung-Ju Huang, MD; Holger Engel, 

MD; Betul Ulusal; Ming-Huei Cheng, MD, PhD 

9:38am – 9:42am 

*Harnessing the Potential of the Free Fibula Osteoseptocutaneous Flap in 

Mandible Reconstruction: How to Attain Adequate Functional and Esthetic 

Height for the Reconstructed Segment 


Christopher Glenn Wallace, MB, ChB, MRCS; Yang-Ming Chang; Chi-Ying Tsai; 

Ming-Huei Cheng; Chung-Kan Tsao; Fu-Chan Wei, MD, FACS 

9:42am – 9:45am 

Discussion 

9:45am – 9:49am 

*Autolgous Fat as an Alternative to Microvascular Free Tissue Transfer for the 

Treatment of Severe Facial Soft Tissue Deformities 

Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA 

Suhail Kanchwala, MD; Louis P. Bucky 

9:49am – 9:53am 

*Radial Forearm Free Flap Pre-lamination with Acellular Dermal Matrix for 

Repair of Subtotal Glossectomy Defects 

Institution where the work was prepared: Fox Chase Cancer Center, Philadelphia, PA, USA 

Fernando Cordera, MD; Neal S. Topham, MD 

9:53am – 9:57am 

*Management of Life Threatening Tracheaesophageal Fistulae, Leaks, and Defects 

Institution where the work was prepared: MD Anderson cancer Center, Houston, 

TX, USA 

John Nigriny, MD, DMD; Peirong Yu 

9:57am – 10:00am 

Discussion 

10:00am – 10:04am 

*Chronic Deep Venous Thrombosis in the Peroneal Veins of a Fibula Flap: 

Strategies for Salvage and Avoidance 

Institution where the work was prepared: Brigham and Women's Hospital, 


Amir Taghinia, MD; Julian J. Pribaz, MD; Lifei Guo, MD, PhD 

10:04am – 10:08am 

Go for the Jugular – A 10-year Experience with End-to-Side Anastomosis to 

the Internal Jugular Vein in 320 Head and Neck Free Flaps 

Institution where the work was prepared: Memorial Sloan-Kettering Cancer 

Center, New York, NY, USA 

Eric Halvorson, MD; Peter G. Cordeiro 

10:08am – 10:10am 

Discussion 


Miscellaneous 


Moderator: Neil F. Jones, MD 

9:00am – 9:04am 

*Using Stereolithographic Models to Plan Mandibular Reconstruction for 

Advanced Oral Cavity Cancer 


Eric Y. Ro, MD; John A. Ridge, MD, PhD, FACS; Neal S. Topham, MD

9:04am – 9:08am 

*Timing of Microsurgical Reconstruction of Lower Extremity: Is It Really 

Important In Flap Failure 



Fatih Zor; Mustafa Sengezer; Murat Turegun; Selcuk ˘sik; Mustafa Nisanci; 

Muhidtin Eski 

9:08am – 9:12am 

*Buried Flap Monitoring Using a Novel Non-Invasive Simultaneous 

Microcirculatory Perfusion, Oxygenation and Venous Outflow Monitor 

Institution where the work was prepared: Hannover Medical School, Hannover, 

Germany 

Karsten Knobloch, MD, PhD; Andreas Gohritz; Niels C. Gellrich; Peter M. Vogt 

9:12am – 9:15am 

Discussion 

9:15am – 9:19am 

Local Perforator Flaps Around the Elbow 

Institution where the work was prepared: Recovery Hospital, Cluj-Napoca, 

Romania 

Alexandru Georgescu, Prof, MD, PhD; Ileana Matei; Filip Ardelean, MD 

9:19am – 9:23am 

The Use of Free Medial Pedis Perforator Flap in The Treatment of Chron˘c 

Postburn Palmar Contractures 

Institution where the work was prepared: GATA Haydarpa?a E?itim Hastanesi 

dept. of Plastic Surgery, Istanbul, Turkey 

Haluk Duman, Assoc, Prof, MD; Fatih Uygur; Ersin ülkür; Sinan öksüz; Bahattin 

çeliköz 

9:23am – 9:27am 

The Effect of Preoperative Radiotherapy on the Free Jejunum Flap Transfer 

Institution where the work was prepared: E-Da Hospital, Kao-hsiung, Taiwan 

Hung-Chi Chen, MD, FACS; Yueh-Bih Tang, MD, PhD; Samir Mardini, MD; 

Christopher Salgado; Chung-chen Hsu, MD 

9:27am – 9:30am 

Discussion 

9:30am – 9:34am 

*Further Esthetic Refinement for Great Toe Transfers in Pursuit of an Ideal Thumb 


Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, 

Taiwan 

Christopher Glenn Wallace, MB, ChB, MRCS; Chih-Hung Lin; Yu-Te Lin; Fu-Chan Wei 

9:34am – 9:38am 

V-Y Advancement Adductor Magnus Perforator Flap for Reconstruction of 

Scrotal/Perineal Defects 

Institution where the work was prepared: UMass Plastic Surgery, Worcester, MA, USA 

Mustafa Akyurek, MD; Marjorie R. Chelly, MD; Raymond M. Dunn, MD 

9:38am – 9:42am 

*Resurfacing of a Complex Upper Extremity Injury: An Excellent Indication for 

the Dorsal Thoracic Fascial Flap 

Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA 

Ron Hazani, MD; Darrell Brooks, MD; Rudolf F. Buntic, MD 

9:42am – 9:45am 

Discussion 

9:45am – 9:49am 

The Pedicled FHL Flap: A Good Option When Options Aren't Good 



Otway Louie; Evan Garfein; Jamie P. Levine; Pierre Saadeh 

55 

9:49am – 9:53am 

Achieving Aesthetic Results in Facial Reconstructive Microsurgery: Planning 

and Executing Secondary Refinements 



Pierre Saadeh; Otway Louie; Evan Garfein; Jamie P. Levine; John W. Siebert 

9:53am – 9:57am 

*Immediate Nipple-Areolar Complex Reconstruction with Inner Thigh (TUG) 

Flap Microvascular Breast Reconstruction 

Institution where the work was prepared: California Pacific Medical Center, Ralph 

K. Davies Campus, San Francisco, CA, USA 

Matthew J. Trovato, MD; Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, 

MD, FACS; Darrell Brooks, MD 

9:57am – 10:00am 

Discussion 

10:00am – 10:04am 

Using Free Style Proximal Radial Forearm Free Flaps while Preserving Radial 

Artery for Reconstructions of Burn hand and Head and Neck Defects 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, 

Taiwan 

Jeng-Yee Lin, MD; Wei-Chao Huang; David C.C. Chuang; Fu-Chan Wei 

10:04am – 10:08am 

Voice Reconstruction Utilizing the Free Ileo-Ileocecal Valve Free Flap with a 

Patch of Cecum 

Institution where the work was prepared: E-Da Hospital/I-Shou University, 

Kaohsiung, Taiwan 

Samir Mardini, MD; Hung-Chi Chen, MD, FACS; Christopher J. Salgado, MD 

10:08am – 10:12am 

*Modified Tibial Turn-up Fillet flap for Repair of Extensive Composite Defects 

of the Thigh 

Institution where the work was prepared: The University of Texas, M. D. Anderson 

Cancer, Houston, TX, USA 

Yoav Barnea; Patrick Lin, MD; Gregory Reece, MD 

10:12am – 10:15am 

Discussion 

10:15am – 10:19am 

Partial Breast Reconstruction with Free Autologous Tissue Transfers 

Institution where the work was prepared: university of Manitoba, winnipeg, 

Canada 

Edward Wayne Buchel; Thomas E.J. Hayakawa 

10:19am – 10:23am 

Imaging Techniques in Preoperative Planning of the Abdominal Perforator 

Flaps: Our Experience Using the MRI 

Institution where the work was prepared: Hospital de la Santa Creu i Sant Pau, 

Barcelona, Spain 

Jaume Masia, MD, PhD; Jm Monill; Ja Clavero; G. Pons; J. Larrañaga; L. Vives 

10:23am – 10:27am 

*Innervation Improves Patient-rated Quality of Life in free TRAM Breast 


Institution where the work was prepared: University of Western Ontario, London, 

ON, Canada 

Claire LF Temple, MD, FRCSC; Sharon Kim, MD, FRCSC; Douglas C. Ross, MD, 

FRCSC; Raymond Tse, BSc, MD; Margo Bettger-Hahn, BScN, MScN; Bing Siang 

Gan, MD, PhD, FRCSC; Joy MacDermid, PhD, PT 

10:27am – 10:31am 

*End-to-Side Anastomosis to the Internal Mammary Artery in Free Flap Breast 

Reconstruction: Preserving the Internal Mammary Artery for Coronary Artery 

Bypass Grafting 

Institution where the work was prepared: Union Memorial Hospital, Baltimore, 

MD, USA 

Amani Hemphill, MD; Ramon De Jesus, MD; Nathaniel McElhaney; Jonathan 

Ferrari 

10:31am – 10:35am 

Discussion 

10:30am – 10:45am Coffee Break

10:45am – 11:15am Scientific Paper Presentations and Lecture 

Hans Steinau, MD – Introductional Lecture 

11:15am – 12:45pm Scientific Paper Presentation 

Tumor Reconstruction 


Moderator: Howard Langstein, MD 

11:15am – 11:19am 

Free Vascularized Fibula Graft Salvage of Complications of Long-Bone 

Allograft Post-Tumor Reconstruction 


Jeffrey B. Friedrich, MD; Steven L. Moran; Allen T. Bishop; Christina M. Wood; 

Alexander Y. Shin 

11:19am – 11:23am 

*Vascularized Bone Grafts – An Effective Tool for Limb Salvage in Long Bone 

Malignancies and Non-unions 

Institution where the work was prepared: Devner Clinic for Extremities at Risk, 

Devner, CO, USA 

Alex Colque, MD; David P. Schnur, MD; William C Brown; Ross M Wilkins; Ronald 

R. Hugate; Cynthia Kelly 

11:23am – 11:27am 

Limiting Complications and Complexity of the Transverse Upper Gracilis Flap 

in Breast Reconstruction 

Institution where the work was prepared: University of Manitoba, Winnipeg, Canada 

Edward Wayne Buchel; Thomas E.J. Hayakawa 

11:27am – 11:30am 

Discussion 

11:30am – 11:34am 

*Outcome of Radical Excision and Microsurgical Reconstruction in Patients 

with Recurrent Oromucosal Cancer and Secondary Primary Cancer 

Institution where the work was prepared: Chang Gung Memorial Hospital, Tao- 

Yuan, Taiwan 

Emre Gazyakan, MD, MSc; Holger Engel, MD; Jung-Ju Huang, MD; Huang-Kai 

Kao, MD; Ming-Huei Cheng, MD, PhD 

11:34am – 11:38am 

The Use of Thromboelastography as a Guide to Tailor the Anticoagulation 

Management in the Microvascular Surgical Patient 

Institution where the work was prepared: The Methodist Hospital, Institute for 

Reconstructive Surgery, Houston, TX, USA 

Aldona J. Spiegel, MD; Hector Salazar-Reyes, MD 

11:38am – 11:42am 

Free-style Proximal Lateral Leg Perforator Flaps for Head and Neck 


Institution where the work was prepared: Chang Gung Memorial Hospital, 

Taoyuan, Taiwan 

Wei-Chao Huang; Christopher Glenn Wallace; Robert EH Ferguson, MD; Fu- 

Chan Wei; Jeng-Yee Lin 

11:42am – 11:45am 

Discussion 

11:45am – 11:49am 

*The SIEA, DIEP and Free TRAM flaps: A Comparison of Abdominal Wall and 

Flap Complications and a Surgical Algorithm 

Institution where the work was prepared: University of Pennsylvania, Philadelphia, 

PA, USA 

Jesse Creed Selber, MD, MPH; Fares Samra, BA; Lauren Hill, BA; Mirar Bristol; 

Seema Sonnad; Joseph Serletti 

11:49am – 11:53am 

A New Composite Flap: Rectus Abdominis Muscle Flap Harvested with Pubic 

Bone Segment (Anatomic Considerations) 



Serdar Ozturk; Mustafa Sengezer; Unsal Coskun; Fatih Zor 

56 

11:53am – 11:57am 

*Extended Anterolateral Thigh Flap in Oncological Reconstruction 

Institution where the work was prepared: Memorial Sloan Kettering, New York, 

NY, USA 

Afshin Mosahebi; Martin Jugenburg, MD; Pravin Reddy; Andrea L. Pusic; Joseph 

J. Disa; Peter G. Cordeiro; Babak J. Mehrara 

11:57am – 12:00pm 

Discussion 

12:00pm – 12:04pm 

*Fat Necrosis in Microvascular Breast Reconstruction: An Assessment and 

Comparison of SIEA, DIEP and Muscle-Sparing Free TRAM Methods 

Institution where the work was prepared: University of Pennsylvania, Philadelphia, 

PA, USA 

Alison E. Kaye, MD; Liza C. Wu; Joseph M. Serletti 

12:04pm – 12:08pm 

*A Ten-Year Experience of Free Flaps in Head and Neck Surgery. How Necessary 

is a Second Venous Anastomosis? 

Institution where the work was prepared: University of Toronto, Toronto, ON, 

Canada 

Gary L. Ross, MD, FRCS(plast); Erik Ang; Declan Lannon; Patrick Addison; Alex 

Golger; Christine Novak; Joan Lipa; Patrick Gullane; Peter Neligan 

(Laura Snell presenting) 

12:08pm – 12:12pm 

The Longitudinal Gracilis Myocutaneous Flap: Another Option in Breast 


Institution where the work was prepared: California Pacific Medical Center and 

UCSF Medical Center, San Francisco, CA, USA 

Gabriel M. Kind, MD; Robert D. Foster, MD 

12:12pm – 12:16pm 

*Ultrasound-Assisted Liposuction as a Novel Treatment for Fat Necrosis after 

Autologous Breast Reconstruction 



Stephanie A. Caterson, MD; Adam M. Tobias; Bernard Lee 

12:16pm – 12:20pm 

Discussion 

12:30pm Adjourn 

1:00pm ASRM Council Meeting

ABSTRACT TABLE OF CONTENTS 

AAHS/ASPN/ASRM Abstract Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-59 

AAHS Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60-97 

AAHS Outstanding Nerve Paper Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98-99 

AAHS Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100-102 

AAHS/ASRM/ASPN Outstanding Nerve Paper Presentations . . . . . . . . . . . . . . . . . . . . . . 103-104 

ASPN Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105-131 

ASPN Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132-135 

ASRM Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136-206 

ASRM Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207-214 

57

ABSTRACT AUTHOR INDEX 

58 

A 

Abrams, Reid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 

Abtahi, Fatemeh . . . . . . . . . . . . . . . . . . . . . . . . . 76 

Ackerman, Duncan B.. . . . . . . . . . . . . . . . . . . . . 65 

Acland, Robert D. . . . . . . . . . . . . . . . . . . . . . . . 166 

Adams, Brian D.. . . . . . . . . . . . . . . . . . . . . . . . . . 84 

Adani, Roberto . . . . . . . . . . . . . . . . . . . . . 161, 211 

Addison, Patrick. . . . . . . . . . . . . . . . . . . . . . . . . 205 

Agro, Deborah. . . . . . . . . . . . . . . . . . . . . . . . . . 119 

Ahn, Hee-Chang . . . . . . . . . . . . . . . . . . . . . . . . . 75 

Aita, Marcio A. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 

Akyurek, Mustafa. . . . . . . . . . . . . . . . . . . . . . . . 193 

Ali, Rozina. . . . . . . . . . . . . . . . . . . . . . . . . . 154, 162 

Allen, Robert J. . . . . . . . . . . . . . . . . . . . . . . . . . 147 

Alon, Malvina . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 

Alton, Timothy . . . . . . . . . . . . . . . . . . . . . . . . . . 109 

Alvey, Dallas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 

Amako, Masatoshi. . . . . . . . . . . . . . . . . . . . . . . 126 

Amir, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 

Amrami, Kimberly K. . . . . . . . . . . . . . . 84, 86, 108 

An, Kai-Nan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 

Anastakis, Dimitri J.. . . . . . . . . . . . . . . . . . . . . . 112 

Anderson, Aaron . . . . . . . . . . . . . . . . . . . . . . . . . 74 

Ang, Erik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 

Anthony, Smith. . . . . . . . . . . . . . . . . . . . . . . . . . . 83 

Arad, E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 

Arbique, Gary . . . . . . . . . . . . . . . . . . . . . . 169, 181 

Ardelean, Filip. . . . . . . . . . . . . . . . . . . 71, 191, 209 

Arino, Hiroshi . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 

Arnold, Peter B. . . . . . . . . . . . . . . . . . . . . . . . . . 175 

Ashjian, Peter. . . . . . . . . . . . . . . . . . . . . . . . . . . 147 

Asko-Seljavaara, Sirpa . . . . . . . . . . . . . . . . . . . 138 

Attinger, Chris E. . . . . . . . . . . . . . . . . . . . . . . . . 166 

Aubá, Cristina . . . . . . . . . . . . . . . . . . . . . . . . . . 107 

B 

Baccarani, Alessio . . . . . . . . . . . . . . . . . . . 164, 176 

Badalamente, Marie . . . . . . . . . . . . . . . . . . . . . . 70 

Bain, James R.. . . . . . . . . . . . . . . . . . 111, 115, 119 

Banks, Nia D. . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 

Baratz, Mark E.. . . . . . . . . . . . . . . . . . . . . . . . . . . 98 

Barker, Allison R. . . . . . . . . . . . . . . . . . . . . . . . . 129 

Barnea, Yoav . . . . . . . . . . . . . . . . . . . . . . . 168, 197 

Barth, Rolf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 

Bartlett, Stephen T. . . . . . . . . . . . . . . . . . . . . . . 171 

Bates, Steven . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 

Batt, Jane AE . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

Beckenbaugh, Robert D. . . . . . . . . . . . . . . . . . . 65 

Bekler, Halil I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 

Bengtson, Keith A. . . . . . . . . . . . . . . . . . . . . . . 127 

Berger, Richard A. . . . . . . . . . . . . . . . . . . . . . 84, 86 

Bernier, Christina . . . . . . . . . . . . . . . . . . . . . . . . 154 

Berry, Nada . . . . . . . . . . . . . . . . . . . . . . . . . 73, 117 

Bettger-Hahn, Margo . . . . . . . . . . . . . . . . . . . . 198 

Bindra, Randy R. . . . . . . . . . . . . . . . . . . . . . . . . . 68 

Bishop, Allen T.. . . . . . . . . . . . . 127, 164, 170, 200 

Blount, Andrew . . . . . . . . . . . . . . . . . . . . . . . . . 118 

Bluebond-Langner, Rachel . . . 136, 171, 184, 207 

Borschel, Gregory H. . . . . . . . . 114, 119, 120, 133 

Boyce, Brandon M. . . . . . . . . . . . . . . . . . . . . . . . 63 

Boyd, Brian 145 

Bozkurt, Mehmet . . . . . . . . 97, 104, 128, 139, 179 

Bristol, Mirar. . . . . . . . . . . . . . . . . . . . . . . . 203, 211 

Brooks, Darrell . . . . . . . . . . . . . 153, 157, 194, 195 

Brown, Spencer A. . . . . . . . . . . . . . . . . . . . . 77, 79 

Brown, William C. . . . . . . . . . . . . . . . . . . . . . . . 160 

Buchel, Edward Wayne . . . . . . . . . . 153, 197, 201 

Bucky, Louis P. . . . . . . . . . . . . . . . . . . . . . . . . . . 187 

Bueno, Rebuen . . . . . . . . . . . . . . . . . . . . . . . . . 117 

Buntic, Rudolf F. . . . . . . . . . . . . 153, 157, 194, 195 

Busch, Kay H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 

Butler, Charles E. . . . . . . . . . . . . . . . . . . . . . . . . 155 

Butler, Erin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 

Butler, Richard G.. . . . . . . . . . . . . . . . . . . . . . . . 111 

C 

Campbell, Christopher A. . . . . . . . . . . . . . . . . 175 

Capo, John. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 

Capota, Irina . . . . . . . . . . . . . . . . . . . . . . . . 71, 209 

Cardenas-Mejia, Alexander . . . . . . . . . . . . . . . 154 

Carlsen, Brian. . . . . . . . . . . . . . . . . . . . . . . . . . . 147 

Carnevale, Kevin . . . . . . . . . . . . . . . . . . . . . . . . 185 

Carney, Joseph R. . . . . . . . . . . . . . . . . . . . . . . . . 80 

Carvalho, Alex . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 

Carvell, George E.. . . . . . . . . . . . . . . . . . . . . . . 184 

Catalano, Francesco . . . . . . . . . . . . . . . . . . . . . 125 

Caterson, Stephanie A. . . . . . . . . . . 144, 148, 206 

Cavadas, Pedro C.. . . . . . . . . . . . . . . . . . . . . . . 165 

Cavusoglu, Tarik . . . . . . . . . . . . . . . . . . . . . . . . 185 

Cederna, Paul S. . . . . . . . . . . . . . . . . 101, 106, 134 

Chambers, Chris . . . . . . . . . . . . . . . . . . . . . 61, 140 

Champion, Hunter C. . . . . . . . . . . . . . . . . . . . . 136 

Chang, Chris . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Chang, Edward I.. . . . . . . . . . . . . . . . . . . . . . . . 137 

Chang, Nai-Jen . . . . . . . . . . . . . . . . . . . . . 172, 174 

Chang, Shu-ying . . . . . . . . . . . . . . . . . . . . . . . . 186 

Chang, Yang-Ming . . . . . . . . . . . . . . . . . . . . . . 187 

Chelly, Marjorie R. . . . . . . . . . . . . . . . . . . . . . . . 193 

Chen, Constance M.. . . . . . . . . . . . . . . . . . . . . 182 

Chen, Gary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 

Chen, Hung-Chi. . . . . . . . 161, 162, 185, 192, 196 

Cheng, Ming-Huei . 154, 162, 186, 187, 201, 212 

Cheng, Richard . . . . . . . . . . . . . . . . . . . . . . . . . . 162 

Chiang, Yuan-Cheng. . . . . . . . . . . . . . . . . . . . . . 172 

Ching, We-Chen . . . . . . . . . . . . . . . . . . . . . . . . . 154 

Cho, Alvaro B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 

Choi, Matthew . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 

Choi, Tae Hyun. . . . . . . . . . . . . . . . . . . . . . . . . . . 150 

Chojnowski, Adrian J. . . . . . . . . . . . . . . . . . . . . . . 71 

Chollet, André . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 

Chow, Pk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 

Chuang, David C.C. . . . . . . . . . . . . . . . . . . . . . . 174 

Cindy, Ivy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 

Ciocanel, Despina E.. . . . . . . . . . . . . . . . . . . . . . . 67 

Clark, Ian M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 

Clarke, Howard M. . . . . . . . . . . . . . . . . . . . . . . . 100 

Clavero, Ja . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 

Cobb, Tyson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 

Coert, J.H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 

Collins, Evan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 

Colque, Alex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 

Comert, Ayhan. . . . . . . . . . . . . . . . . . . . . . . . . . . 185 

Conaway, Danielle A. . . . . . . . . . . . . . . . . . . . . . . 84 

Cooney, Damon . . . . . . . . . . . . . . . . . . . . . . 61, 140 

Cordeiro, Peter G.. . . . . . . . . . . . . . . . . . . . 189, 204 

Cordera, Fernando . . . . . . . . . . . . . . . . . . . . . . . 188 

Coskun, Unsal . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 

Cote, Daniel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 

Crisera, Christopher A.. . . . . . . . . . . . . . . . 145, 147 

Culp, Randall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 

Curry, Patrick. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 

Czermak, Christoph . . . . . . . . . . . . . . . . . . . . . . 167 

D 

Da Lio, Andrew L. . . . . . . . . . . . . . . . . . . . . 145, 147 

Danker, Timm. . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 

Darlis, Nickolaos A. . . . . . . . . . . . . . . . . . . . . . . . 69 

Day, Joseph Paul . . . . . . . . . . . . . . . . . . . . . . . . . 128 

Dayan, Joseph H. . . . . . . . . . . . . . . . . . . . . . . . . 166 

De Boer, Ralph. . . . . . . . . . . . . . . . . . . . . . . . . . . 123 

De Jesus, Ramon . . . . . . . . . . . . . . . . . . . . 133, 199 

De Santis, Giorgio . . . . . . . . . . . . . . . . . . . . . . . . 164 

De Vitis, Rocco. . . . . . . . . . . . . . . . . . . . . . . . . . . 125 

DeAngelis, Nicola . . . . . . . . . . . . . . . . . . . . . . . . . 76 

DeBoer, Johannes F. . . . . . . . . . . . . . . . . . . . . . . 110 

Deleyiannis, Frederic W. B. . . . . . . . . . . . . . . . . 160 

DellaCroce, Frank J. . . . . . . . . . . . . . . . . . . . . . . 146 

DeMatteo, Carol . . . . . . . . . . . . . . . . . . . . . . . . . 119 

Demir, Yavuz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 

Dennison, David . . . . . . . . . . . . . . . . . . . . . . . . . . 60 

Derwin, Kathleen . . . . . . . . . . . . . . . . . . . . . . . . . . 74 

Deveci, Mustafa . . . . . . . . . . . . . . . . . . . . . . . . . . 154 

Dexter, Erika . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 

Dhar, Sanjay. . . . . . . . . . . . . . . . . . . . . 105, 118, 130 

Di Scipio, Federica . . . . . . . . . . . . . . . . . . . . . . . 122 

Dickinson, Brian P. . . . . . . . . . . . . . . . . . . . . . . . . 147 

Disa, Joseph J. . . . . . . . . . . . . . . . . . . . . . . 182, 204 

Donnelly, S. Chase. . . . . . . . . . . . . . . . . . . . . . . . . 74 

Dorafshar, Amir H.. . . . . . . . . . . . . . . . . . . . 156, 213 

Drake, David B. . . . . . . . . . . . . . . . . . . . . . . . . . . 175 

Drake, Richard . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 

Ducic, Ivica. . . . . . . . . . . . . . . . . . . . . . 107, 114, 166 

Duman, Haluk . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 

Dumanian, Gregory A . . . . . . . . . . . . . 78, 117, 177 

Dumans, Antoine G. . . . . . . . . . . . . . . . . . . . . . . 183 

Duncan, Scott F. M. . . . . . . . . . . . . . . . . . . . . . . . . 72 

Dunn, Raymond M. . . . . . . . . . . . . . . . . . . . . . . . 193 

E 

Echo, Anthony . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 

Edwards, Michael Charles . . . . . . . . . . . . . . . . . 128 

Elsohemy, Amal S.. . . . . . . . . . . . . . . . . . . . . . . . 111 

Engel, Holger. . . . . . . . . . . . . . . . . . . . . . . . 186, 201 

Erdmann, Detlev . . . . . . . . . . . . . . . . . . . . . 158, 176 

Eskander, Jonathan . . . . . . . . . . . . . . . . . . . . . . . . 76 

Eskander, Mark. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 

Eski, Muhidtin . . . . . . . . . . . . . . . . . . . . . . . 159, 190 

Evans, Gregory R. D.. . . . . . . . . . . . . . . . . . 130, 176 

F 

Fahnestock, Margaret. . . . . . . . . . . . . . . . . . . . . 111 

Faillace, John . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 

Fang, Xin-Hua . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 

Fankhauser, Grant . . . . . . . . . . . . . . . . . . . . . . . . . 72 

Faria, Fabiano N. . . . . . . . . . . . . . . . . . . . . . . . . . . 68 

Farkas, Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 

Feinberg, Joseph . . . . . . . . . . . . . . . . . . . . 117, 162 

Feng, Guan-Ming . . . . . . . . . . . . . . . . . . . . . . . . 185 

Ferguson, Robert E.H. . . . . . . . . . . . . . . . . . . . . 202 

Ferrari, Jonathan . . . . . . . . . . . . . . . . . . . . . 133, 199 

Festekjian, Jaco. . . . . . . . . . . . . . . . . . . . . . 145, 147 

Finnerty, Edward . . . . . . . . . . . . . . . . . . . . . . . . . . 67 

Fiore II, Nicholas A. . . . . . . . . . . . . . . . . . . . . . . . . 88 

Firoozbakhsh, Keikhosrow . . . . . . . . . . . . . . . . . . 78 

Fitzgerald, Brian. . . . . . . . . . . . . . . . . . . . . . . . . . . 80 

Fletcher, Joel G.. . . . . . . . . . . . . . . . . . . . . . . . . . . 84 

Flores, Jaime I.. . . . . . . . . . . . . . . . . . . . . . . . . . . 149 

Fokkens, Nico . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Follmar, Keith E. . . . . . . . . . . . . . . . . . . . . . 158, 176 

Foster, Robert D. . . . . . . . . . . . . . . . . . . . . . . . . . 205 

Fox, Sharon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 

Friedrich, Jeffrey B. . . . . . . . . . . . . . . . . . . . 164, 200 

Friedrich, Patricia F. . . . . . . . . . . . . . . . . . . . . . .170 

Froimson, Jill . . . . . . . . . . . . . . . . . . . . . . .104, 128 

Fukushima, Walter Y . . . . . . . . . . . . . . . . . . . . . .68 

Furey, M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 

G 

Gajendran, Varun . . . . . . . . . . . . . . . . . . . . . . . .81 

Galvez, Michael G. . . . . . . . . . . . . . . . . . . . . . .137 

Gan, Bing Siang . . . . . . . . . . . . . . . . . . . . . . . .198 

Gannon, Caitlin . . . . . . . . . . . . . . . . . . . . . . . . . .98 

Garcia-Cepeda, Ignacio . . . . . . . . . . . . . . . . . . .64 

Garfein, Evan . . . . . . . . . . . . . . . . . . .183, 194, 195 

Gauvin, Jean . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 

Gazyakan, Emre . . . . . . . . . . . . . . . . . . . . . . . . .201 

Gelfand, Mark . . . . . . . . . . . . . . . . . . . . . . . . . .145 

Gellrich, Niels C. . . . . . . . . . . . . . . . . . . . . . . . .191 

Georgescu, Alexandru . . . . . . . . . . . .71, 191, 209 

Germann, Güenter . . . . . . . . . . . . . . .82, 167, 171 

Geuna, Stefano . . . . . . . . . . . . . . . . . . . . . . . . .122 

Giessler, Goetz A. . . . . . . . . . . . . . . . . . . . . . . .170 

Glenn Wallace, Christopher . .172, 173, 178, 187, 193, 202 

Gohritz, Andreas . . . . . . . . . . . . . . . . . . . . . . . .191 

Goitz, Robert . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 

Golger, Alex . . . . . . . . . . . . . . . . . . . . . . . . . . . .205 

Gonzalez-Hernandez, Eduardo . . . . . . . . . . . . .64 

Gorantla, Vijay S. . . . . . . . . . . . . . . . . . . . . .95, 184 

Gordon, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 

Gorria, Oscar . . . . . . . . . . . . . . . . . . . . . . . . . . .107 

Gottlieb, Lawrence J. . . . . . . . . . . . . . . . . . . . .156 

Grykien, Christopher . . . . . . . .104, 128, 179, 180 

Guenther, Elke . . . . . . . . . . . . . . . . . . . . . . . . . .122 

Gullane, Patrick . . . . . . . . . . . . . . . . . . . . . . . . .205 

Guo, Lifei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 

Gur, E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 

Gurtner, Geoffrey C. . . . . . . . . . . . . . . . . . . . . .137 

Gustin, Jason . . . . . . . . . . . . . . . . . . . . . . . . . . .114 

Gûndeslioglu, Õzlem . . . . . . . . . . . . . . . . . . . .155 

H 

Hadlock, Tessa A. . . . . . . . . . . . . . . . . . . . . . . .103 

Haerle, Max . . . . . . . . . . . . . . . . . . . . . . . . . . . .122 

Halvorson, Eric . . . . . . . . . . . . . . . . . . . . . . . . . .189 

Hamou, Cynthia D. . . . . . . . . . . . . . . . . . . . . . .137 

Hanasono, Matthew M. . . . . . . . . . . . . . . . . . .139 

Hansen, Scott L. . . . . . . . . . . . . . . . . . . . . . . . . . .75 

Hansen, U. D. . . . . . . . . . . . . . . . . . . . . . . . . . . .116 

Harris, Patrick . . . . . . . . . . . . . . . . . . . . . . . . .94, 96 

Hartley, Craig J. . . . . . . . . . . . . . . . . . . . . . . . . .139 

Hartmann, Emily . . . . . . . . . . . . . . . . . . . . . . . .107 

Hatef, Daniel A. . . . . . . . . . . . . . . . . . . . .77, 79, 96 

Hautz, Theresa . . . . . . . . . . . . . . . . . . . . . . . . . . .95 

Hayakawa, Thomas E.J. . . . . . . . . . .153, 197, 201 

Hayashi, Ayato . . . . . . . . . . . . . . . . . . . . . . . . . .113 

Hayton, M. J. . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 

Hazani, Ron . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 

Heaton, James T. . . . . . . . . . . . . . . . . . . . . . . . .103 

Heitmann, Christoph . . . . . . . . . . . . . . . . . . . .167 

Hemphill, Amani . . . . . . . . . . . . . . . . . . . . . . . .199 

Henry, Francis Patrick . . . . . . . . . . . . . . . . .90, 110 

Henry, Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . .158 

Hermanns, Susanne . . . . . . . . . . . . . . . . . . . . .122 

Hermenau, Shawn . . . . . . . . . . . . . . . . . . . . . . . .83 

Herrera, Fernando . . . . . . . . . . . . . . . . . . . . . . .167 

Herron, Margo . . . . . . . . . . . . . . . . . . . . . . . . . .117 

Hill, Lauren . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 

Hirase, Yuichi . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 

Hitzigrath, Christiane . . . . . . . . . . . . . . . . . . . . .82 

Hofer, Stefan O. P . . . . . . . . . . . . . . . . . . . . . . .183 

Hofmeister, Eric . . . . . . . . . . . . . . . . . . . . . .80, 100 

Hogue, William R. . . . . . . . . . . . . . . . . . . . . . . . .68 

Holt, Gary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 

Hontanilla, Bernardo . . . . . . . . . . . . . . . . . . . . .107 

Horibe, Elaine K. . . . . . . . . . . . . . . . . . . . . . . . . .95 

Horton, Karen M. . . . . . . . . . . . . . . . . . . . . . . . .195 

Horton, Todd . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 

Hovius, Steven E. R. . . . . . . . . . . . . . . . . . . . . . .85 

Hsieh, Ching-Hua . . . . . . . . . . . . . . . . . . . . . . .152 

Hsu, Chung-Chen . . . . . . . . . . . . . . . . . . . . . . .192 

Huang, Chong-Wei . . . . . . . . . . . . . . . . . . . . . .172 

Huang, Jung-Ju . . . . . . . . . . . . . . . .186, 201, 212 

Huang, Wai-Chao . . . . . . . . . . . . . . . . . . . . . . .172 

Huang, Wei-Chao . . . . . . . . . . . . . . . . . . .173, 174 

Hugate, Ronald R. . . . . . . . . . . . . . . . . . . .160, 200 

Hundepool, Alessandra C. . . . . . . . . . . . . . . .183 

Hunter, Daniel A. . . . . . . . . . . .113, 120, 132, 133 

Hurst, Lawrence C. . . . . . . . . . . . . . . . . . . . . . . .70 

I 

Iba, Kousuke . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 

Ikegami, Hiroyasu . . . . . . . . . . . . . . . . . . . . . . . .60 

Imbriglia, Joseph E. . . . . . . . . . . . . . . . . . . .62, 66 

Isaacs, Jonathan . . . . . . . . . . . . . . . . . . . . . . . .111 

Isik, Selçuk . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159 

J 

Jacobson, Jeffrey M. . . . . . . . . . . . . . . . . . . . . .149 

Janz, Brian A. . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 

Jeng, Seng - Feng . . . . . . . . . . . . . . . . . . . . . .152 

Johnston, Phillip . . . . . . . . . . . . . . . . . . . . . . . . .71 

Jones, Neil F. . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 

Jugenburg, Martin . . . . . . . . . . . . . . . . . . . . . . 204 

K 

Kalpan, Haim . . . . . . . . . . . . . . . . . . . . . . . . . . .151 

Kanchwala, Suhail . . . . . . . . . . . . . . . . . . . . . . .187 

Kao, Huang-Kai . . . . . . . . . . . . . . . . .186, 201, 212 

Kaufmann, Robert W. . . . . . . . . . . . . . . . . . . . . .69 

Kauhanen, M Susanna C. . . . . . . . . . . . . . . . . .138 

Kawamura, David H. . . . . . . . . . . . . . . . . .113, 119 

Kaye, Alison E. . . . . . . . . . . . . . . . . . . . . . . . . . .204 

Kecik, Abdullah . . . . . . . . . . . . . . . . . . . . . . . . .175 

Keirstead, Hans S. . . . . . . . . . . . . . . . . . . . . . . .118 

Keith, Jerrod . . . . . . . . . . . . . . . . . . . . . . . . . . .160 

Keller, Alex . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 

Kelly, Cynthia . . . . . . . . . . . . . . . . . . . . . . .160, 200 

Kemp, Stephen W. P. . . . . . . . . . . . . . . . . . . . .106 

Kenney, Christina B. . . . . . . . . . . . . . . . . . . . . .113 

Kevin, Renfree . . . . . . . . . . . . . . . . . . . . . . . . . . .83 

Khiabani, Kayvan T. . . . . . . . . . . . . . . . . . . . . . .141 

Khouri, Roger K. . . . . . . . . . . . . . . . . . . . . . . . . .85 

Kiehn, Mark W. . . . . . . . . . . . . . . . . . . . . . . . . .167 

Kim, Elizabeth M. . . . . . . . . . . . . . . . . . . . . . . .146 

Kim, Jun Sik . . . . . . . . . . . . . . . . . . . . . . . . . . . .150 

Kim, Nam Gyun . . . . . . . . . . . . . . . . . . . . . . . . .150 

Kim, Peter S. . . . . . . . . . . . . . . . . . . . . . . .117, 177 

Kim, Sharon . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Kinchelow, Tosca . . . . . . . . . . . . . . . . . . . . . . . . .64 

Kind, Gabriel M. . . . . . . . . . . . . . . . . . . . . . . . .205 

Kipke, Daryl R. . . . . . . . . . . . . . . . . . . . . . .106, 134 

Kircher, Michelle . . . . . . . . . . . . . . . . . . . . . . . .127 

Aleksandra, Klimczak . . . .97, 104, 128, 139, 140, 177, 179, 185 

Klitzmann, Bruce . . . . . . . . . . . . . . . . . . . . . . . .176 

Klomp, Aaron . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 

Knight, Andrew M. . . . . . . . . . . . . . . . . . . . . . .123 

Knobloch, Karsten . . . . . . . . . . . . . . .97, 101, 191 

Kochevar, Irene E. . . . . . . . . . . . . . . . . . . . . . . . .90 

Korvenoja, Antti . . . . . . . . . . . . . . . . . . . . . . . . .138 

Kosins, Aaron M. . . . . . . . . . . . . . . . . . . . . . . . .118 

Kowaleski, Jeffrey . . . . . . . . . . . . . . . . . . . . . . .103 

Kraus, Armin . . . . . . . . . . . . . . . . . . . . . . .112, 122 

Kremer, Thomas . . . . . . . . . . . . . . . . . . . . . . . . .82 

Krichev, Alisa . . . . . . . . . . . . . . . . . . . . . . . . . . .130 

Krokowicz, Lukasz . . . . . . . . . . . 97, 104, 128, 139, 177, 179, 180 

Kronowitz, Steven J. . . . . . . . . . . . . . . . . . . . . .143 

Kryger, Zol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78 

Kueh, Nai-Siong . . . . . . . . . . . . . . . . . . . . . . . .172 

Kuiken, Todd A. . . . . . . . . . . . . . . . . . . . . .117, 177 

Kumar, Sivathan . . . . . . . . . . . . . . . . . . . . . . . . . .68 

Kuo, Yur-Ren . . . . . . . . . . . . . . . . . . .152, 172, 212 

Kuzon Jr, William M. . . . . . . . . . . . . . . . . . . . . .106 

L 

Ladak, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 

Ladd, Amy L. . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 

Lanaras, Tatjana . . . . . . . . . . . . . . . . . . . . . . . . .122 

Landes, Geneviève . . . . . . . . . . . . . . . . . . . .94, 96 

Landin, Luis . . . . . . . . . . . . . . . . . . . . . . . . . . . .165 

Lannon, Declan . . . . . . . . . . . . . . . . . . . . . . . . .205 

Lao, Zhen Guo . . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Larrañaga, J. . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Larson, Debbie . . . . . . . . . . . . . . . . . . . . . . . . . .71 

Larson, Ethan . . . . . . . . . . . . . . . . . . . . . . . . . . .114 

Lawton, Jeffrey N. . . . . . . . . . . . . . . . . . . . . . . . .74 

Lee, Bernard T. . . . . . . . . . . . . . . . . . . . . .144, 148 

Lee, Charles K. . . . . . . . . . . . . . . . . . . . . . . . . . .167 

Lee, Kyung Suk . . . . . . . . . . . . . . . . . . . . . . . . .150 

Lee, W.P. Andrew . . . . . . . . . . . . . . . . . . . . . . . .184 

Lemaine, Valerie . . . . . . . . . . . . . . . . . . . . . .94, 96 

Lemke, Jon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 

Leshem, D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 

Levin, L. Scott . . . . . . . . . . . . . . . . . . . . . .158, 176 

Levine, Jamie . . . . . . . . . . . . . . . . . . . . . . .141 214 

Levine, Jamie P. . . . . . . . . . . . . . . . . . . . . .194, 195 

Levine, Joshua . . . . . . . . . . . . . . . . . . . . . . . . . .147 

Li, Zhongyu . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 

Lim, Gale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 

Lin, Charles P. . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Lin, Cheng-Hung . . . . . . . . . . . . . . . . . . .159, 162 

Lin, Chien-Chih . . . . . . . . . . . . . . . . . . . . . . . . .172 

Lin, Chih-Hung . . . . . . . . . . . . . . . . . . . . .159, 193 

Lin, Chun-Yen . . . . . . . . . . . . . . . . . . . . . . . . . . .173 

Lin, Jeng-Yee . . . . . . . . . .172, 173, 174, 196, 202 

Lin, Pao-Yuan . . . . . . . . . . . . . . . . . . . . . . . . . . .152 

Lin, Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 

Lin, Yt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154 

Lin, Yu-Te . . . . . . . . . . . . . . . . . . . . . .159, 193, 212 

Lineaweaver, William C. . . . . . . . . . . . . . . . . . .105 

Lino Jr, W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 

Lipa, Joan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .205 

Liu, Xiao Lin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Lo, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 

Longaker, Michael T. . . . . . . . . . . . . . . . . . . . . .137 

Loschi, Pietro . . . . . . . . . . . . . . . . . . . . . . . . . . .164 

Louie, Otway . . . . . . . . . .141, 183, 194, 195, 214 

Louie, Stephanie . . . . . . . . . . . . . . . . . . . . . . . . .93

59 

ABSTRACT AUTHOR INDEX 

Luciano, Janina P. . . . . . . . . . . . . . . .113, 120, 133 

Luginbuhl, Ryan D. . . . . . . . . . . . . . . . . . . . . . .114 

Luria, Shai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 

Luszczek, Wioleta . . . . . . . . . . . . . . . . .89, 97, 177 

M 

MacDermid, Joy . . . . . . . . . . . . . . . . . . . . . . . .198 

Mackinnon, Susan . . . . . . . . . . . . . . . . . . .103, 133 

Malessy, Martijn J.A. . . . . . . . . . . . . . . . . . . . . .124 

Manahan, Michele A. . . . . . . . . . . . . . . . . . . . .149 

Manders, Ernest K. . . . . . . . . . . . . . . . . . . . . . .160 

Mardini, Samir . . . . . . . . .161, 166, 185, 192, 196 

Marianne, Merritt . . . . . . . . . . . . . . . . . . . . . . . .83 

Masannek, Carmen . . . . . . . . . . . . . . . . . . . . . .122 

Masia, Jaume . . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Matei, Ileana . . . . . . . . . . . . . . . . . . . .71, 191, 209 

Mathes, David W. . . . . . . . . . . . . . . . . . . . . . . . .96. 

Matloub, Hani S. . . . . . . . . . . . . . . . . . . . . . . . .124 

McCollough, Cynthia H. . . . . . . . . . . . . . . . . . . .84 

McConnell, Michael P. . . . . . . . . . . . . . . . . . . .118 

McDaniel, Candice O. . . . . . . . . . . . . . . . . . . .111 

McElhaney, Nathaniel . . . . . . . . . . . . . . . . . . . .199 

McKean, Jason M. . . . . . . . . . . . . . . . . . . . . . . .91 

McLean, Kia M. . . . . . . . . . . . . . . . . . .95, 160, 184 

Mehrara, Babak J. . . . . . . . . . . . . . . . . . . .182, 204 

Mendoza, Charles . . . . . . . . . . . . . . . . . . . . . . .118 

Mercer, Deana . . . . . . . . . . . . . . . . . . . . . . . . . . .78 

Merolli, Antonio . . . . . . . . . . . . . . . . . . . . . . . . .125 

Merritt, Wyndell H. . . . . . . . . . . . . . . . . . . . . . .175 

Messmer, Caroline . . . . . . . . . . . . . . . . . . . . . .177 

Midha, Raj . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 

Midha, Rajiv . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 

Mielniczuk, Mariusz . . . . . . . . . . . . . . . . . . . . . .180 

Milbrandt, Jeffery . . . . . . . . . . . . . . . . . . . . . . .114 

Miller, Blake . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 

Miller, E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 

Miller, Michael J. . . . . . . . . . . . . . . . . . . . . . . . .139 

Miller, Quintessa . . . . . . . . . . . . . . . . . . . .147, 214 

Mirza, M. Ather . . . . . . . . . . . . . . . . . . . . . . .63, 89 

Mithani, Suhail K. . . . . . . . . . . . . . . . . . . .136, 207 

Mohur, Haydar . . . . . . . . . . . . . . . . . . . . . . . . . .165 

Moneim, Moheb S. . . . . . . . . . . . . . . . . . . . . . . .78 

Monill, JM . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Monsivais, Jose . . . . . . . . . . . . . . . . . . . . . .92, 113 

Moon, Wong . . . . . . . . . . . . . . . . . . . . . . . . . . .137 

Moradzadeh, Arash . . . . . . . . .113, 114, 132, 133 

Moran, Steven L. . . . . . . . . . . . .60, 164, 166, 200 

Morgan, Raymond F. . . . . . . . . . . . . . . . . . . . .175 

Mosahebi, Afshin . . . . . . . . . . . . . . . . . . . . . . .204 

Mueller, Daniela . . . . . . . . . . . . . . . . . . . . . . . .122 

Mueller, Hans-Werner . . . . . . . . . . . . . . . . . . . .122 

Mueller, Miriam . . . . . . . . . . . . . . . . . . . . . . . . . .82 

Mun, Goo-Hyun . . . . . . . . . . . . . . . . . . . . . . . .170 

Muriuki, Muturi . . . . . . . . . . . . . . . . . . . . . . . . . .62 

Myckatyn, Terence M. . . . . . . . . . . .113, 114, 133 

N 

Nagle, Raymond . . . . . . . . . . . . . . . . . . . . . . . .118 

Nahabedian, Maurice Y . . . . . . . . . . . . . . . . .149. 

Nair, Dileep . . . . . . . . . . . . . . . . . . . . . . . .104, 128 

Nakamichi, Noriaki . . . . . . . . . . . . . . . . . . . . . . .60 

Nakamura, Toshiyasu . . . . . . . . . . . . . . . . . . . . .60 

Nakanishi, Kuniaki . . . . . . . . . . . . . . . . . . . . . . .126 

Nalbantis, Emilios . . . . . . . . . . . . . . . . . . . . . . .167 

Nasir, Serdar . . . . . . . . . . . .97, 128, 139, 177, 179 

Neligan, Peter . . . . . . . . . . . . . . . . . . . . . . . . . .205 

Nelson, Rebecca A. . . . . . . . . . . . . . . . . . . . . .155 

Nemoto, Koichi . . . . . . . . . . . . . . . . . . . . . . . . .126 

Neumeister, Michael W. . . . . . . .61, 73, 117, 140 

Newman, Martin I. . . . . . . . . . . . . . . . . . . . . . .144 

Ng, Damon . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 

Ngov, Li . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 

Nguyen, Minh-Doan . . . . . . . . . . . . . . . . . . . . .140 

Nigriny, John . . . . . . . . . . . . . . . . . . . . . . . . . . .188 

Nikolis, Andreas . . . . . . . . . . . . . . . . . . . . . .94, 96 

Nisanci, Mustafa . . . . . . . . . . . . . . . . . . . . . . . .190 

Noble, Debby . . . . . . . . . . . . . . . . . . . . . . . . . . .77 

Norris, Morgan E. . . . . . . . . . . . . . . . . . . . . . . . .88 

Novak, Christine B. . . . . . . . . . . . . . . . . . .112, 205 

O 

O’Shaughnessy, Kristina . . . . . . . . . . . . . .117, 177 

Odessey, Eric A. . . . . . . . . . . . . . . . . . . . . . . . .156 

Ofer, Nina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171 

Ogunleye, Olubunmi . . . . . . . . . . . . . . . . . . . .139 

Olson, J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 

Ong, Yee Siang . . . . . . . . . . . . . . . . . . . . . . . . .176 

Orbay, Jorge L. . . . . . . . . . . . . . . . . . . . . . . . . . .85 

Osterman, A. Lee . . . . . . . . . . . . . . . . . . . . . . . .86 

Oswald, Tanya M. . . . . . . . . . . . . . . . . . . . . . . .105 

Otto, Andre . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 

Owen, John R. . . . . . . . . . . . . . . . . . . . . . . . . . .111 

Ozdemir, Hakan . . . . . . . . . . . . . . . . . . . . . . . . .175 

Ozturk, Serdar . . . . . . . . . . . . . .154, 159, 165, 203 

Ozyurekoglu, Tuna . . . . . . . . . . . . . . . . . . . . . .166 

P 

Pang, See-Tong . . . . . . . . . . . . . . . . . . . . . . . . .174 

Park, Hyle Boris . . . . . . . . . . . . . . . . . . . . . . . . .110 

Parrett, Brian M. . . . . . . . . . . . . . . . . . . . . . . . . 144 

Patish, Hagar . . . . . . . . . . . . . . . . . . . . . . . . . . 130 

Payatakes, Alexander H. . . . . . . . . . . . . . . . . . . 69 

Peled, Ziv. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 

Pennock, Andrew. . . . . . . . . . . . . . . . . . . . . . . . 81 

Peramo, Antonio P. . . . . . . . . . . . . . . . . . 106, 134 

Peterson, Brett . . . . . . . . . . . . . . . . . . . . . . . . . . 81 

Petrella, Giovanna . . . . . . . . . . . . . . . . . . . . . . 164 

Pfaeffle, Jamie . . . . . . . . . . . . . . . . . . . . . . . . . . 62 

Pinelli, Massimo . . . . . . . . . . . . . . . . . . . . . . . . 164 

Pirela-Cruz, Miguel . . . . . . . . . . . . . . . . . . . . . 116 

Plant, Pam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

Pondaag, Willem . . . . . . . . . . . . . . . . . . . . . . . 124 

Pons, G.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 

Poptic, Earl . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 

Pribaz, Julian J.. . . . . . . . . . . . . . . . . . . . . . . . . 189 

Primak, Andrew N.. . . . . . . . . . . . . . . . . . . . . . . 84 

Pusic, Andrea L. . . . . . . . . . . . . . . . . . . . . . . . . 204 

Pyon, Jai-Kyung . . . . . . . . . . . . . . . . . . . . . . . . 170 

R 

Randolph, M. A.. . . . . . . . . . . . . . . . . . . . . 90, 110 

Rasheed, Mohamed Z. . . . . . . . . . . . . . . . . . . 163 

Rawlani, Vinay. . . . . . . . . . . . . . . . . . . . . . . . . . . 78 

Rayatt, Sukh S. . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Rebecca, Alanna . . . . . . . . . . . . . . . . . . . . . . . . 72 

Reddy, Pravin . . . . . . . . . . . . . . . . . . . . . . . . . . 204 

Reece, Gregory . . . . . . . . . . . . . . . . . . . . . . . . 197 

Reinblatt, Maura. . . . . . . . . . . . . . . . . . . . . . . . 145 

Reinhart, Mary Kate. . . . . . . . . . . . . . . . . . . 63, 89 

Rhue, John Paul . . . . . . . . . . . . . . . . . . . . . . . . . 80 

Rizzo, Marco . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 

Ro, Eric Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 

Robinson, Kris . . . . . . . . . . . . . . . . . . . . . . 92, 113 

Rocchi, Lorenzo . . . . . . . . . . . . . . . . . . . . . . . . 125 

Rochkind, Shimon . . . . . . . . . . . . . . . . . . 130, 132 

Rodeheaver, George T.. . . . . . . . . . . . . . . . . . 175 

Rodgers, Jeff. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 

Rodrigues, Robert . . . . . . . . . . . . . . . . . . . . . . . 65 

Rodriguez, Eduardo D. . . . . . . . . . . 136, 149, 171, 184, 207 

Rodriguez, Eduardo P.. . . . . . . . . . . . . . . . . . . 154 

Rodriguez-Bigas, Miguel A. . . . . . . . . . . . . . . 155 

Rodway, Ian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 

Rogers, Andrew . . . . . . . . . . . . . . . . . . . . . . . . . 93 

Rogers, James M. . . . . . . . . . . . . . . . . . . . . . . 130 

Roggy, David . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 

Rohrich, Rod J. . . . . . . . . . . . . . . . . . 79, 169, 181 

Rose, Jessica. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 

Rosenwasser, Melvin P. . . . . . . . . . . . . . . . . . . . 91 

Ross, Douglas C. . . . . . . . . . . . . . . . . . . . . . . . 198 

Ross, Gary L. . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 

Rosson, Gedge D. . . . . . . . . . . . . . . . . . . . . . . 117 

Rossum, A. D.. . . . . . . . . . . . . . . . . . . . . . . . . . 116 

Roy, Niloy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 

Ruggiero, Gustavo M.. . . . . . . . . . . . . . . . . . . . 68 

Russavage, James M. . . . . . . . . . . . . . . . . . . . 160 

Rust, Esther A. Z. . . . . . . . . . . . . . . . . . . . . . . . 110 

Ryu, Jaiyoung . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 

Ryuichi, Morishita. . . . . . . . . . . . . . . . . . . . . . . 126 

S 

Saadeh, Pierre . . . . . . . . . . . . . 141, 183, 194, 195 

Sacks, Justin M. . . . . . . . . . . . . . . . . . 95, 160, 184 

Safak, Tunc . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 

Saint-Cyr, Michel. . . . . . . . . . 77, 79, 96, 169, 181 

Salazar-Reyes, Hector . . . . . . . . . . . . . . . . . . . 202 

Salgado, Christopher J.. . . . . . . . . . 161, 166, 185, 192, 196 

Samra, Fares . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 

Samson, Michel C.. . . . . . . . . . . . . . . . . . . . . . 144 

Sanger, James R. . . . . . . . . . . . . . . . . . . . . . . . 124 

Sassu, Paolo . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 

Sato, Kazuki. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 

Sauerbier, Michael. . . . . . . . . . . . . . . . . . . 82, 171 

Schaller, Hans-Eberhard. . . . . . . . . 112, 122, 123 

Schaverien, Mark . . . . . . . . . . . . . . . . . . . 169, 181 

Schembri, P. . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 

Schepman, Kees P. . . . . . . . . . . . . . . . . . . . . . 183 

Schmidt, Bernhard. . . . . . . . . . . . . . . . . . . . . . . 84 

Schneeberger, Stefan . . . . . . . . . . . . . . . . 95, 184 

Schnur, David P. . . . . . . . . . . . . . . . . . . . . 160, 200 

Schoenle, Philip . . . . . . . . . . . . . . . . . . . . . . . . 122 

Scholz, Thomas . . . . . . . . . . . . . . . . . . . . 130, 176 

Selber, Jesse Creed . . . . . . . . . . . . . . . . 203, 211 

Sengezer, Mustafa . . . . . . . . . 154, 165, 190, 203 

Serletti, Joseph M. . . . . . . . . . 146, 203, 204, 211 

Shafi, Mohamed. . . . . . . . . . . . . . . . . . . . . . . . 130 

Shaw, William . . . . . . . . . . . . . . . . . . . . . . . . . . 145 

Shepard, Brandon . . . . . . . . . . . . . . . . . . . . . . 118 

Shin, Alexander Y. . . . . . . 60, 101, 127, 164, 200. 

Shipley, Stephen . . . . . . . . . . . . . . . . . . . . . . . 171 

Siebert, John W. . . . . . . . . . . . . . . . . . . . 183, 195 

Siemionow, Maria Z. . . . 89, 97, 104, 128, 139, 140, 177, 179, 180 

Simon, Rainer . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 

Simons, Daniel J. . . . . . . . . . . . . . . . . . . . . . . . 184 

Singh, Navin K. . . . . . . . . . . . . . . . . . . . . . . . . .149 

Sinis, Nektarios . . . . . . . . . . . . . . . .112, 122, 123 

Skie, Martin C. . . . . . . . . . . . . . . . . . . . . . . . . . .67 

Slater, Robert R. . . . . . . . . . . . . . . . . . . . . . . . . .81 

Smith, Anthony . . . . . . . . . . . . . . . . . . . . . . .72, 83 

Solari, Mario G. . . . . . . . . . . . . . . . . . . . . .95, 184 

Song, David H. . . . . . . . . . . . . . . . . . . . . .152, 213 

Sonmez, Erhan . . . . . . . . . . . . . . . . . . . . .128, 175 

Sonnad, Seema . . . . . . . . . . . . . . . . . . . .203, 211 

Sood, Rajiv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 

Sorenson, Eric J. . . . . . . . . . . . . . . . . . . . . . . . .116 

Sotereanos, Dean G. . . . . . . . . . . . . . . . . . . . . .69 

Spiegel, Aldona J. . . . . . . . . . . . . . . . . . . . . . .202 

Spies, Marcus . . . . . . . . . . . . . . . . . . . . . . . . . . .97 

Spiguel, Lisa . . . . . . . . . . . . . . . . . . . . . . . . . . .156 

Spinelli, Maria Silvia . . . . . . . . . . . . . . . . . . . . .125 

Spinner, Robert J. . . . . . . . . . .108, 116, 123, 127 

Staines, Kimberly . . . . . . . . . . . . . . . . . . . . . . . .87 

Stanley, John K. . . . . . . . . . . . . . . . . . . . . . . . . .85 

Stephenson, Linda L. . . . . . . . . . . . . . . . . . . . .141 

Sterbank, Patrick . . . . . . . . . . . . . . . . . . . . . . . . .99 

Strauss, Helene L. . . . . . . . . . . . . . . . . . . . . . . .162 

Strickland, Justin . . . . . . . . . . . . . . . . . . . . . . . . .60 

Su, Anjey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 

Sullivan, Scott Keith . . . . . . . . . . . . . . . . . . . . .146 

Suominen, Sinikka . . . . . . . . . . . . . . . . . . . . . .138 

Szabo, Robert . . . . . . . . . . . . . . . . . . . . . . . . . . .81 

T 

Taghinia, Amir . . . . . . . . . . . . . . . . . . . . . . . . . .189 

Tahiri, Youssef . . . . . . . . . . . . . . . . . . . . . . . .94, 96 

Talwalkar, Sumedh C. . . . . . . . . . . . . . . . . . . . . .85 

Tan, Bien-Keem . . . . . . . . . . . . . . . . . . . .142, 163 

Tan, Kok-Chai . . . . . . . . . . . . . . . . . . . . . . . . . .163 

Tan, Virak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 

Tang, Peter . . . . . . . . . . . . . . . . . . . . . . . . . .62, 66 

Tang, Yueh-Bih . . . . . . . . . . . . . . . . . . . . .185, 192 

Tay, Shian Chao . . . . . . . . . . . . . . . . . . . . . .84, 86 

Tekdemir, Ibrahim . . . . . . . . . . . . . . . . . . . . . . .185 

Temple, Claire L. F. . . . . . . . . . . . . . . . . . . . . . . .98 

Teoh, Lam Chuan . . . . . . . . . . . . . . . . . . . .73, 101 

Terreros, D. A. . . . . . . . . . . . . . . . . . . . . . . . . . .116 

Thompson, Michael . . . . . . . . . . . . . . . . . . . . . .80 

Thomson, Angus W. . . . . . . . . . . . . . . . . . . . . .95 

Thornby, John . . . . . . . . . . . . . . . . . . . . . . . . . . .87 

Tobias, Adam M. . . . . . . . . . . . . . . .144, 148, 206 

Tomaszek, Sandra . . . . . . . . . . . . . . . . . . . . . . .97 

Tomita, Kazunari . . . . . . . . . . . . . . . . . . . . . . . . .86 

Tong, Alice Y. . . . . . . . . . . . . . . . . . .113, 114, 133 

Tontz, William . . . . . . . . . . . . . . . . . . . . . . . . . . .81 

Topham, Neal S. . . . . . . . . . . . . . . . . . . .188, 190 

Toyama, Yoshiaki . . . . . . . . . . . . . . . . . . . . . . . .60 

Tra, W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 

Trail, Ian A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 

Trovato, Matthew J. . . . . . . . . . . . . . . . . . . . . .195 

Trumble, Thomas E. . . . . . . . . . . . . . . . . . . . . . .91 

Tsai, Chi-Ying . . . . . . . . . . . . . . . . . . . . . . . . . .187 

Tsao, Chung-Kan . . . . . . . . . . . . . . . . . . . . . . .187 

Tse, Raymond . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Tseng, Charles Y. . . . . . . . . . . . . . . .152, 156, 213 

Tsuchihara, Toyokazu . . . . . . . . . . . . . . . . . . . .126 

Tuffaha, Sami H. . . . . . . . . . . .113, 114, 120, 133 

Tukiainen, Erkki . . . . . . . . . . . . . . . . . . . . . . . . .138 

Tung, Thomas H. . . . . . . . . . . . . . . .113, 119, 133 

Turegun, Murat . . . . . . . . . . . . . . . . . . . . . . . . .190 

Tyler, Jennifer . . . . . . . . . . . . . . . . . . . . . . . . . . .99 

Tyreman, N. . . . . . . . . . . . . . . . . . . . . . . . .121, 131 

U 

Udina, E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 

Ulusal, Betul . . . . . . . . . . . . . . . . . . . . . . . . . . .186 

Unadkat, Jignesh V. . . . . . . . . . . . . . . . . . .95, 184 

Unal, Mehmet Bekir . . . . . . . . . . . . . . . . . . . . .140 

Urbanchek, Melanie G. . . . . . . . . . . . . . .106, 134 

Uygur, Fatih . . . . . . . . . . . . . . . . . . . . . . . . . . . .192 

V 

Vaca, Luis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 

van der Meij, Erik H. . . . . . . . . . . . . . . . . . . . .183 

Van Neck, J. . . . . . . . . . . . . . . . . . . . . . . . . . . .108 

Van Riet, Roger P. . . . . . . . . . . . . . . . . . . . . . . . .86 

Vargel, Ibrahim . . . . . . . . . . . . . . . . . . . . . . . . .185 

Vives, L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198 

Vogt, Peter M. . . . . . . . . . . . . . . . . . .97, 101, 191 

Vroemen, Joy Christiane . . . . . . . . . . . . . . . . . .91 

W 

Waitayawinyu, Thanapong . . . . . . . . . . . . . . . .91 

Wallace, Chris . . . . . . . . . . . . . . . . . . . . . . . . . .162 

Wallace, Christopher Glenn . . . . . .172, 173, 178 

Walsh, Sarah K. . . . . . . . . . . . . . . . . . . . . . . . . .127 

Wang, Danru . . . . . . . . . . . . . . . . . . . . . . . . . . .158 

Wang, Huan . . . . . . . . . . . . . . . . . . .108, 116, 123 

Wang, Wei Z. . . . . . . . . . . . . . . . . . . . . . . . . . .141 

Watson, James P. . . . . . . . . . . . . . . . . . . .145, 147 

Wayne, Jennifer S. . . . . . . . . . . . . . . . . . . . . . .111 

Webb, Aubrey A. . . . . . . . . . . . . . . . . . . . . . . .106 

Wei, Fu-Chan . . . . . . . . .159, 172, 173, 174, 178 

Weiss, Douglass . . . . . . . . . . . . . . . . . . . . . . . . .76 

Weiss, J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 

Wendt, Michael . . . . . . . . . . . . . . . . . . . . . . . . .82 

Werdin, Frank . . . . . . . . . . . . . . . . . . . . . .112, 122 

West, P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116 

Wijdicks, Coen . . . . . . . . . . . . . . . . . . . . . . . . . .60 

Wilkins, Ross . . . . . . . . . . . . . . . . . . . . . . . . . . .160 

Williams Eric H. . . . . . . . . . . . . . . . . . . . . . . . . .117 

Windebank, Anthony J. . . . . . . . . . . . . . .116, 123 

Winkler, Eyal . . . . . . . . . . . . . . . . . . . . . . . . . . .151 

Winograd, Jonathan M. . . . . . . . . . . . . . .90, 110 

Wise, M. Whitten . . . . . . . . . . . . . . . . . . .147, 214 

Witkin, Lisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 

Wolfe, Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 

Wong, Wendy . . . . . . . . . . . . . . . . . . . . . . . . . . .93 

Woo, Eky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 

Woo, Minna . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 

Wood, Christina M. . . . . . . . . . . . . . . . . .164, 200 

Wu, Liza C. . . . . . . . . . . . . . . . . . . . . . . . . .146, 204 

Wu, Ren-Chin . . . . . . . . . . . . . . . . . . . . . . . . . .178 

Wu, Wen-Sheng . . . . . . . . . . . . . . . . . . . . . . . .172 

Y 

Yaffe, Batia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 

Yam, Andrew . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 

Yan, Ying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 

Yan, Yu-Hui . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 

Yan, Ji-Geng . . . . . . . . . . . . . . . . . . . . . . . . . . .124 

Yang, Hsiang-Chen . . . . . . . . . . . . . . . . . . . . . .173 

Yang, Johnson C. . . . . . . . . . . . . . . . . . . . . . . .152 

Yaszemski, Michael J. . . . . . . . . . . . . . . . . . . . .123 

Yazici, Ilker . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 

Yen, Chia-Hung . . . . . . . . . . . . . . . . . . . . .173, 178 

Ylä-Kotola, Tuija M. . . . . . . . . . . . . . . . . . . . . . .138 

Z 

Zamboni, William A. . . . . . . . . . . . . . . . . . . . . .141 

Zaretski, Arik . . . . . . . . . . . . . . . . . . . . . . .168, 178 

Zhang, Feng . . . . . . . . . . . . . . . . . . . . . . . . . . .105 

Zhang, Lin-Ling . . . . . . . . . . . . . . . . . . . . . . . . .124 

Zhang, Yi Xin . . . . . . . . . . . . . . . . . . . . . . . . . . .176 

Zhu, Jia Kai . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Zhu, Qing Tang . . . . . . . . . . . . . . . . . . . . . . . . . .90 

Zieger, Madeline . . . . . . . . . . . . . . . . . . . . . . . . .75 

Zor, Fatih . . . . . . . . . . . . . .154, 159, 165, 190, 203 

Zuijdendorp, H. M. . . . . . . . . . . . . . . . . . . . . . .108 

Zuker, Ronald . . . . . . . . . . . . . . . . . . . . . . . . . . .117 

çeliköz, Bahattin . . . . . . . . . . . . . . . . . . . . . . . .192 

öksüz, Sinan . . . . . . . . . . . . . . . . . . . . . . . . . . . .192 

ülkür, Ersin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192

AAHS Concurrent Scientific Paper Session A 

Long Term Outcome Following Scaphoidectomy and Four-Corner Fusion 


David Dennison, MD; Coen Wijdicks; Justin Strickland; Steven Moran; Alexander Shin; Mayo Clinic 

INTRODUCTION: 

The long term outcome following scaphoidectomy and four-corner fusion (FCF) has received limited investigation and few studies have 

included patient rated outcome measures. The purpose of this study was to examine the long-term outcome following FCF with respect 

to patient rated outcome measures and to investigate the effect that the method of fixation, age, follow-up period, and radiographic 

parameters, have upon outcome measures. 

METHODS: 

A retrospective review identified patients that underwent a scaphoidectomy and FCF between February 1976 and August 2003. The 

Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and a pain survey were completed by 84 patients. 

The mean outcome measure follow-up was 9.6 ± 5.7 years. Outcome measures were compared to method of fixation, age, follow-up period, 

and postoperative capitolunate angle. The correlation between outcome scores was examined. Union rates were evaluated and compared 

based upon fixation type. Statistical analysis was performed with significance set at alpha less than or equal to 0.05 

RESULTS: 

The mean DASH score was 23 (SD 19) and the mean PRWE score was 27 (SD 22). Eighty-four per cent of patients reported decreased 

pain while 62% still had some degree of pain. There was a significantly higher PRWE score (more impairment) associated with dorsal 

circular plate fixation compared to non-plate fixation. There was also a significant decrease in PRWE score with longer follow-up time. 

The DASH and PRWE scores correlated well. There were no significant differences in nonunion rates with respect to type of fixation. 

CONCLUSION: 

Although higher PRWE scores were significantly associated with circular plate fixation, we were not able to detect a difference in union 

rates between circular plate fixation and other methods of fixation. The PRWE was able to detect significant findings compared to the 

DASH, and should be considered when evaluating patients with isolated wrist dysfunction. 

Reconstruction of the TFCC Using ECU Half-Slip and Interference Screw 

Institution where the work was prepared: Department of Orthopaedic Surgery, Keio University, Tokyo, Japan 

Toshiyasu Nakamura, MD, PhD; Kazuki Sato; Noriaki Nakamichi; Yoshiaki Toyama; Hiroyasu Ikegami; Keio University 

PURPOSE: 

Since 1998, we treated 33 wrists of ulnar detachment of the TFCC by reconstruction technique using half-slip of the extensor carpi 

ulnaris (ECU) tendon with the very small interference screw. We described the technique of the reconstruction and examined our clinical 

results of the procedure. 

TECHNIQUE: 

This technique was indicated to the severe DRUJ instability cases with the avulsion of the TFCC from the ulnar fovea. The ECU half-slip 

was harvested and was induced inside the TFCC from the dorsodistal artificial slit of the TFCC to the fovea area. The half-slip was tightly 

sutured to the remnant TFCC, then pulled out through the bone tunnel that was made at the center of the fovea by 2.5 mm diameter 

drill. The ECU half-slip was subsequently anchored to the ulnar fovea with the small interference screw (Figure). Two weeks long arm 

cast was occurred, followed by three weeks of short arm cast. 

PATIENTS AND METHODS: 

There were 21 right, 10 left and 1 bilateral wrist with an average age of 35.8 years (range 13-68). All complained ulnar sided wrist pain 

and severe distal radioulnar joint (DRUJ) instability. The neutral ulnar variance was indicated in 26 wrists and positive in 7. In the positive 

variance wrists, the ulnar shortening equalized the abutment before the reconstruction. Periods from initial injury were 1 month to 48 

years. Diagnosis of the TFCC avulsion was done by arthrogram and MRI. Radiocarpal arthroscopy could demonstrate loss of trampoline 

effect in all wrists. DRUJ arthroscopy revealed detachment of the radioulnar ligament origin at the fovea in recent 13 cases. Clinical 

results were evaluated by pain, range of rotation and DRUJ instability. 

RESULTS: 

At final follow-up (average 21.5months), 26 wrists indicated no pain and slight pain remained in 7 wrists. Complete re-stabilization of 

the DRUJ was noted in 30 wrists, however there remained moderate DRUJ instability in 2 wrists. Severe DRUJ instability remained in 1 

wrist. There were 21 excellent, 8 good, 2 fair and 2 poor results. CONCLUSION: This reconstruction technique represented real anatomical 

reattachment of the TFCC to the ulnar fovea, which induced excellent DRUJ stability and clinical result. When the TFCC was 

detached from the fovea completely and condition of the distal remnant TFCC was relatively secured, this technique is promising. 

60

Expression of TGF beta and IL-10 in Rat Hindlimb Composite Tissue Allografts 

Institution where the work was prepared: Plastic Surgery, Southern Illniois University School of Medicine, P.O. Box 

19653, Sprignfield, IL, USA 

Damon Cooney MD, PhD; Chris Chambers; Michael Neumeister 

Composite-tissue allografting is in many ways an ideal solution to many of the problems of reconstructive surgery. The major drawback 

of this technique is the need for immunosuppression and the possibility of rejection. The induction of immunological tolerance has 

been seen as critical step in the protection of allogenic tissue from rejection. We propose a novel approach to the induction of allograft 

tolerance by modifying the allograft itself. In vitro experiments have demonstrated the ability of cytokines including IL-10 and TGF beta 

to produce CD4+, CD25+, foxp3 expressing cells T “regulatory” cells (Treg). These cells may be able to reduce or stop the rejection of 

the transplanted material. By expressing these molecules in the composite tissue allograft we will promote the production of Treg cells 

specific to the allograft without disturbing the function of the immune system in the rest of the host animal. 

The long term goal of this project is to determine the effect of the over-expression of the cytokines TGF beta and IL-10 on the rejection 

of hind limb transplantation in rats. The first step necessary to achieve this goal is the generation of adenoviral expression vectors 

and expression in a composite tissue allograft model. We have created vectors containing GFP alone, TGF beta, IL-10, and TGF beta 

and IL-10 combined using the AdEasy adenoviral expression system. The transfection conditions are optimized by establishing a timecourse 

of GFP expression. Conditions which yield optimal GFP expression are utilized for the remainder of the experiments. Using these 

conditions the viral vectors containing the TGF beta and IL-10 genes are expressed and expression verified with immuno-histochemical 

staining of biopsies taken from the transduced limbs. We demonstrate the expression levels and location of GFP, TGF beta and IL- 

10 using immuno-histochemistry. This demonstrates the ability to over express cytokines of interest within the transplanted hindlimb 

and describes the tissue distribution of expression. 

With the ability to express our target cytokines within the transplanted hind limb future studies will determine the effect they have on 

allograft rejection. Transplants will involve transplantation of a limb from a donor Lewis rat onto a Brown Norway recipient rat. The effect 

of over-expression of TGF beta and IL-10 on tolerance and rejection will be investigated. The ultimate goal of these studies is the development 

of a means of inducing composite tissue allograft tolerance in humans. 

61

Is There More Translational Motion after Proximal Row Carpectomy? 

Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA 

Peter Tang, MD, MPH1; Jean Gauvin, PhD2; Muturi Muriuki, PhD2; Jamie Pfaeffle, MD, PhD2; Joseph Imbriglia, MD2; 

Robert Goitz, MD2; (1)Columbia University Medical Center, (2)University of Pittsburgh Medical Center 

HYPOTHESIS: 

After proximal row carpectomy (PRC) contact pressure increases, contact area decreases and translational motion increases. 

METHOD: 

• N=6 cadaveric wrists 

• Sealed UltraSuperLow Fuji Contact Film was inserted in the radiocarpal joint of the intact wrist and a total force of 200 N was applied 

for 60 seconds 

• The specimens were tested in neutral, flexion (45 deg) and extension (45 deg) 

• The specimens then underwent PRC and the experiment was repeated with SuperLow and Low Fuji film 

• The film was scanned and analyzed with a customized MATLAB program to determine contact pressure, area and location 

• Multivariable ANOVA with multiple contrast testing as well as t-tests were performed 

RESULTS: 

• Average pressure significantly increased 320 to 400% after PRC. (p

A Novel Approach for Treating Fractures of the Distal Radius 


M. Ather Mirza, MD; M. Ather Mirza, MD, PC; Mary Kate Reinhart, CNP; M. Ather Mirza, MD 

INTRODUCTION: 

This study reports the outcome of distal radius fractures (DRF) treated with cross pin fixation and a non-bridging external fixator; the CPX System. 

METHODS: 

Thirty-eight patients (27 females, 11 males) with 40 displaced DRF were treated with the CPX System. Average age was 57 years (range 

22-87y). There were 32 intra- and 8 extra-articular fractures. A removable custom splint was applied two to five days post-op. Grip and 

pinch strengths and radiologic measurements; radial height, radial inclination, and palmar tilt, were recorded post-operatively at designated 

intervals. The Patient Rated Wrist Hand Evaluation (PRWHE) and DASH were used for subjective outcome analysis. 

RESULTS: 

Radiologic measurements were maintained throughout healing. Mean wrist ROM at four weeks post-op revealed dorsiflexion 53%, 

volarflexion 41%, pronation 85%, supination 55% and at one year; dorsiflexion 95%, volarflexion 87%, pronation 97% and supination 

96% compared to the contralateral side. Mean grip strength at six months was 79% of the contralateral side and 100% at one year. 

Lateral and precision strengths were 87.5% and 80% at 6 months and 100% and 89% at one year respectfully compared to the contralateral 

side. DASH scores revealed a clinically significant improvement in physical function at 4 weeks, 12 weeks, and 1 year. Mean PRWHE 

was 21 at 6 months and 10.8 at one year. 

CONCLUSION: 

The CPX System is a minimally invasive surgical technique for stabilization of extra- and intra-articular displaced reducible or non-displaced 

DRF. This technique affords the patient a removable splint for early wrist ROM and ADL with maintenance of radiologic measurements. 

Radiographic Evaluation of the Distal Radius Using Two Novel Biplanar "Pitch-And-Roll" Views: 

A Cadaveric Study 

Institution where the work was prepared: West Virginia University Department of Orthopaedics, Morgantown, WV, USA 

Brandon M. Boyce, MD; Jaiyoung Ryu; West Virginia University 

PURPOSE: 

To compare the use of two biplanar angled radiographs versus standard posterioanterior (PA) and lateral radiographs in determining 

preservation of the articular space with regard to pin placement in the distal radius. 

METHODS: 

A series of five cadaveric forearms were evaluated radiographically at various combinations of inclination (pitch) and clockwise/counterclockwise 

rotation (roll) to determine which provided the best view of the distal radius articular surface. Then, smooth k-wires were placed 

into the distal radii, stopping proximally to penetrating the subchondral bone, and the radiographic series was repeated. Optimum visualization 

of the articular surface presented at 12? inclination plus 15? counterclockwise rotation for the PA view and 22? inclination and 15? 

counterclockwise rotation for the lateral view. Finally, ten cadaveric forearms were dissected and ten k-wires were placed at specific surfaces 

of the distal radius. The articular surface was penetrated, then each k-wire was countersunk 2mm below the chondral surface so all 

k-wires resided within the subchondral bone. Each forearm was radiographed in four views; PA, lateral, pitch-and-roll PA (PR-PA), and pitchand-roll 

lateral (PR-lateral). Four blinded reviewers evaluated these radiographs; a board certified orthopaedic hand surgeon, a board certified 

orthopaedic surgeon, and a fifth year and a third year orthopaedic resident. For each radiograph, reviewers marked whether they 

were certain (value=1), relatively certain (value=2), or uncertain (value=3) that the k-wires did not penetrate into the articular space. The data 

were then analyzed using logistic fit of uncertainty for each view and intraobserver reliability was calculated using contingency Chi-square. 

RESULTS: 

Reviewers demonstrated significantly less uncertainty about intraarticular penetration (p

Repair of Distal Radial Malunions with Intramedullary Fixation 

Institution where the work was prepared: UMDNJ- NJ Medical School, Newark, NJ, USA 

John Capo; Damon Ng, MD; Tosca Kinchelow, MD; Virak Tan, MD; UMDNJ- NJ Medical School 

PURPOSE: 

To evaluate the effectiveness of using an intramedullary implant combined with osteotomy and grafting for treatment of distal radial malunions. 

METHODS: 

Eleven patients with healed distal radial malunions had surgical correction of their wrist deformities at an average of 7.6 months after 

the date of the original fracture. They were all treated with osteotomy, grafting, and fixation with an intramedullary implant. The implant 

is available in varying sizes, contains three fixed angle screws distally and two locking bolts proximally. Bone graft was taken from the 

iliac crest in six patients, locally from the distal radius callous in four patients, and was an injectable calcium-sulfate paste in one. There 

were ten dorsal malunions and one volar malunion. Radiographic exam before the osteotomy revealed an average radial inclination of 

20 degrees and an ulnar length of + 3.5mm. The volar tilt for the dorsal malunions averaged -13.1 degrees (apex volar), while the volar 

malunion measured +28 degrees (apex dorsal). Post-procedure the patients were immobilized with a short arm cast or splint for an average 

of 4 weeks and then range-of-motion exercises were begun. 

RESULTS: 

All eleven of the patients healed their osteotomies at an average time period of 7.8 weeks following surgery. Physical exam, at an average 

follow-up of 6.1 months, showed wrist flexion of 46 degrees, extension of 59 degrees, forearm supination of 75 degrees, and pronation 

of 80 degrees. Radiographs post-procedure showed a correction of alignment to the following average values: volar tilt of 2.2 

degrees, radial inclination of 22.6 degrees and an ulnar length of 0.4 mm ulnar positive. There were no cases of nerve injury or tendon 

irritation, and grip strength averaged 67 % of the contralateral side. 

CONCLUSION: 

Treatment of distal radial malunions with an intramedullary implant combined with osteotomy and bone grafting is a viable treatment option. 

The intramedullary position of the implant aids in realigning the anatomy and appears to minimize tendon and hardware problems. 

Transosseous Repair of the Triangular Fibrocartilage Complex in Ulnar Sided Lesions; Cadaver 

Model and Clinical Series 


Eduardo Gonzalez-Hernandez, MD; Miami Hand Center; Ignacio Garcia-Cepeda, MD; Universidad de Salamanca 

INTRODUCTION: 

The purpose of this study is to evaluate a technique for surgical repair of ulnar sided triangular fibrocartilage complex tears. We produce 

a cadaver model for complete tears of the TFCC at its insertion into the distal ulna. 

MATERIALS/ METHODS: 

Our model includes a complete detachment of the triangular fibrocartilage complex from the fovea and the ulnar styloid. The lesion is 

repaired using two different techniques: standard arthroscopic technique for repair of peripheral TFCC tear and transosseous pull-out 

technique for reattachment of the TFCC into the fovea and the base of the ulnar styloid. Biomechanical testing consists of measuring 

the AP translation of the radius with respect to the ulna when a load of 10 lb. is applied to the specimen reproducing the well known 

piano-key test. Testing is done in the intact specimen, and is repeated in the same specimen after the TFCC has been released entirely 

from its ulnar insertion. Mechanical testing is then repeated following standard arthroscopically assisted repair and finally in the specimen 

following a transosseous repair. Translation of the radius with respect to the ulna was measured in three positions of forearm rotation: 

neutral, full pronation and full supination. A stability index is developed to reflect the amount of AP translation of the radius with 

respect to the ulna. The clinical series consists of 12 patients followed prospectively for a minimum of 12 months post operatively. There 

is no comparison made to a similarly matched group undergoing a standard repair. All patients had an MRI diagnosis of ulnar sided 

avulsion of the TFCC confirmed on arthroscopic evaluation. 

RESULTS: 

In all instances of our laboratory testing, the stability index was higher following the transosseous repair. The stability index was 10 to 

30% higher following transosseous repair than standard repair. In our clinical series, all patients, except one, were asymptomatic and 

had returned to their pre-morbid activity. There was one failure in a college athlete who developed recurrent symptoms four months 

after returning to competitive swimming. This particular patient has a very significant ulnar minus variant (-4mm) and that anatomic variant 

may limit our ability to repair the TFCC. 

CONCLUSION: 

In the cadaver model we were able to demonstrate significantly improved stability with a transosseous repair and our clinical series show 

consistently good outcomes sufficient to warrant further investigation. 

64

Wrist Arthrodesis as a Salvage Operation for Failed Wrist Implant Arthroplasty 


Duncan B. Ackerman, MD; Marco Rizzo; Robert Rodrigues; Robert D. Beckenbaugh; Mayo Clinic 

INTRODUCTION: 

The purpose of this study was to evaluate the clinical utility of wrist arthrodesis as a salvage procedure for failed total wrist arthroplasty 

(TWA). Arthrodesis can be a successful salvage procedure for failed wrist implant arthroplasty. 

METHODS: 

Between 1980 and 2006, twenty patients were identified as having undergone wrist arthrodesis for salvage of a failed TWA. Data collected 

included: implant type, mode of implant failure, revisions prior to arthrodesis, method of fusion, the use of allograft or autograft 

bone at the time of fusion, rate of union, clinical outcome, and patient satisfaction. 

RESULTS: 

Twenty wrists in twelve females (80%) and 4 males (20%) underwent TWA at an average age of 56 years (range, 40-78). The average time from 

the index arthroplasty to wrist arthrodesis was 8.4 years (range, 7 months-20 years). The average follow-up was 4.1 years (range, 2 months- 

21 years). The mode of failure in the majority of wrists were loosening, migration, or instability (n=12, 70%). Three patients (15%) underwent 

removal of the components due to infection. Three wrists had undergone a total of 4 revisions prior to the index salvage procedure. The 

method of fixation for arthrodesis included: Steinmann pins in 10 (50%) wrists, plates and screws in 6 (30%), staples in 2 (10%), external fixation 

in one (5%), Steinmann pins and staples in one (5%). Allograft bone was utilized in 11 (55%) wrists and autogenous bone in 9 (45%). 

Overall 10 (50%) wrists achieved radiographic union, 7 (35%) had a pseudarthrosis with minimal to no pain, and 3 (15%) had a nonunion. 

DISCUSSION: 

Bony union was achieved in only 50% of patients who underwent attempted arthrodesis as a salvage procedure for a failed wrist arthroplasty. 

Despite a relatively low union rate, most patients had clinical improvement with little/no pain at last followup. 

65

Osteochondral Resurfacing of Capitate Chondrosis in Proximal Row Carpectomy 

Institution where the work was prepared: Western Pennsylvania Hand and UpperEx Center, Wexford, PA, USA 

Peter Tang, MD, MPH; Columbia University Medical Center; Joseph E. Imbriglia, MD; Western Pennsylvania Hand and 

UpperEx Center 

HYPOTHESIS: 

Osteochondral resurfacing of capitate chondrosis in proximal row carpectomy (PRC) can give equal results to standard PRC.† 

METHODS: 

Patients undergoing PRC who had grade 2 and higher capitate chondrosis, underwent osteochondral resurfacing of the capitate with 

grafts harvested from normal cartilage from resected carpal bones.(Fig. 1-3)† Demographic information, pre- and post-operative pain, 

employment status, ROM, grip strength and modified Mayo wrist scores were assessed.† MRI's were done to evaluate graft incorporation.† 

Student's t-test was utilized to detect statistical significant between the pre- and post-operative state. 

RESULTS: 

N = 8 patients, average age 53.1 years, follow-up 17.7 mos 

Pain ñ Pre-op - 87.5% moderate to severe; Post-op - 87.5% mild to no pain (p=0.0005) 

Employment - Pre-op - 62.5% regular employment; Post-op - 75.0% regular employment (p>0.05) 

ROM ñ Pre-op - 84 degrees (74.0% of the contralateral); Post-op - 75 degrees (66% of the contralateral) (p>0.05) 

ROM in previous studies ñ DiDonna 72 deg, Imbriglia 84 deg, Jebson 77 deg, Tomaino 74 deg (1,2,3,4) 

Grip Strength ñ Pre-op - 65 lbs or 62% of the contralateral; Post-op - 74 lbs or 71% of the contralateral (p>0.05) 

Grip Strength in previous studies ñ DiDonna 91%, Imbriglia 80%,† Jebson 83%, Tomaino 79%. (1,2,3,4) 

Mayo wrist score ñ Pre-op ñ 51 = poor result; Post-op - 68 = fair result (p=0.01) 

Radiographic degeneration - 75% of patients had mild to no degeneration. 

MRI's showed graft incorporation (Fig. 4) 

SUMMARY: 

Our results compare favorably to the literature on PRC, showing that osteochondral grafting in PRC performs as well as standard PRC 

in terms of pain relief, employment status, ROM and grip strength.† Autogenous osteochondrondral grafting is a proven technique 

which we have applied to the PRC wrist for the first time.† If this procedure proves effective, the hand surgeon will have another option 

to treat wrist arthritis, specifically PRC when there is capitate chondrosis. 

REFERENCES: 

1. DiDonna ML. J Bone Joint† Surg 2004;86A:2359-2365. 

2. Imbriglia JE. J Hand Surg 1990;15A:426-430. 

3. Jebson PJL. J Hand Surg 2003;28A:561-569. 

4. Tomaino MM. J Hand Surg 1994;19A:694-703. 

Fig. 1 Capitate chondrosis found on capitate after PRC. 

Fig. 2 Graft pictured next to lunate. 

Fig. 4 Post-operative MRI at 21.3 mos from surgery reveals 

graft incorporation. Arrow indicates graft. 

Fig. 7 Capitate after osteochondral graft placement. 

66

Post-Operative Complications Of Arthroscopic TFCC Repair 

Institution where the work was prepared: University of Toledo, Toledo, OH, USA 

Ian Rodway, MD; Martin C Skie; Despina E Ciocanel; University of Toledo 

PURPOSE: 

Wrist arthroscopy is frequently used in the diagnosis and treatment of traumatic injuries to the wrist, including repair of the triangular 

fibrocartilage complex (TFCC) tears. Our purpose was to determine the incidence of complications after arthroscopic repair of Palmer 

1B TFCC tears and to compare the results with data from the literature. 

METHODS: 

In order to determine the incidence of complications after arthroscopic repair for Palmer 1 B TFCC tears, we retrospectively reviewed 

the records of 67 consecutive patients, 35 males and 32 females. All patients underwent arthroscopic repair using zone specific cannula 

and the inside-out repair method. The mean patient age was 34 years, with a range of 14 to 59 years. The mean follow-up for these 

67 patients was 17 months. 

RESULTS: 

The results of arthroscopic repair were compared and analyzed based on their complications. Transient paresthesis within the distribution 

of the dorsal sensory branch of the ulnar nerve was the most frequent complication (49 %). Six patients (9%) were complicated with 

ulnar nerve irritation (3 sensory paresthesia involving the ring and small fingers, 2 mild cubital tunnel syndromes and 1 ulnar motor neuropathy). 

9 patients had residual instability of DRUJ ( distal radio-ulnar joint) and one patient had infection. 12 patients (18%) underwent 

ulnar shortening following arthroscopic TFCC repair for treatment of continued pain, one of them having bilateral ulnar shortening. 

CONCLUSION: 

82% of our reported complications following TFCC tears arthroscopic repair were minor or transient. No previous study described transient 

paresthesia as a complication of arthroscopic TFCC repairs. This complication was related to the suture knots near dorsal branches 

of the sensory branch of ulnar nerve. Our results confirm similar findings (Hulsizer et al) that recommend an ulnar-shortening osteotomy 

for unsuccessful arthroscopic debridement in eliminating ulnar-sided wrist pain. Overall the success rate of arthroscopic repair in our 

study was similar with previous studies. 

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-wire and Circular Plate Fixation 

Institution where the work was prepared: Des Moines Orthopaedic Surgeons, West DesMoines, IA, USA 

Jeff Rodgers, MD1; Gary Holt, MD2; Edward Finnerty, PhD3; Blake Miller, BS3; (1)Des Moines Orthopaedic Surgeons, 

(2)Iowa Radiology, (3)Des Moines University 

HYPOTHESIS: 

Recent reports suggest that circular plate fixation for Scaphoid excision and limited wrist fusion is inferior to traditional methods. While 

implicating the circular plate implant as the major cause of complications and failure, these studies failed to control for important variables 

including the source of bone graft, surgical technique of multiple surgeons and patient factors that may have influenced the selection 

of the implant. 

The purpose of this study is to compare the clinical outcome, union rate and complications of Scaphoid excision and limited wrist 

arthrodesis performed by a single surgeon using distal radius bone graft and k-wires or distal radius bone graft and circular plate fixation. 

METHODS: 

A sequential series of 12 wrists (eleven patients) that were stabilized with temporary k-wires were compared to 12 patients who were stabilized 

with a circular plate. Minimum follow up was 1 year. One patient in the K-wire group was converted to a wrist fusion. 6 of the remaining 

10 patients in the K-wire fixation group and 8 of the 12 patients in the Circular Plate fixation group returned for the following blinded 

evaluations: Quick DASH, Analog Pain Scale, Range of Motion, Strength measurement, plain x-ray and Multi Detector CT evaluation. 

RESULTS/STATISTICS: 

Data was analyzed using SPSSÆ 14.0. The independent measures t-test was used for functional tests, two-factor ANOVA procedure for 

ROM and Strength parameters and Pearson correlation was used to assess the CL-angle with ROM. Power and appropriate measures 

of size effect were determined where indicated. 

One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in 

any of remaining measures or rate of complications. 

Cost analysis assuming a return to the OR for k-wire removal reveals an overall cost of care savings of $1975 using circular plate fixation. 

SUMMARY POINT: 

Based on this Sequential Cohort with careful control of non-implant related variables, the use of a Circular Plate Device is equivalent in 

efficacy and more cost effective than K-wires for Scaphoid excision and limited wrist fusion. 

67

The volar aproach for fractures of the distal radius: 100 patients analysis 

Institution where the work was prepared: Faculdade de Medicina do ABC, Santo Andre, Brazil 

Marcio A. Aita, MD1; Gustavo M. Ruggiero, MD1; Alvaro B. Cho, MD1; Walter Y. Fukushima, MD1; W. Lino Jr, MD2; 

Fabiano N. Faria, MD2; (1)Faculdade de Medicina do ABC, (2)Beneficencia Portuguesa Hospital 

ABSTRACT 

We review the results of 100 patients with distal radius fractures treated surgically by the volar aproach and fixation with fixed-angle volar 

plate, since march 2002 to december 2005. The indications were: instability only (17%), instability and articular displacement (72%), articular 

displacement only (5%) , contralateral upper limb fracture (3%) and refusal of non-operative treatment by the patient (3%). There was 

58% female and 42% male, age was 46,8 years (11 to 81 years). Radiographic averages results after surgery shows Dorsal Tilt of ñ 8o (2o 

to -18o), Radial Inclination of 19o (-8o to 24o), Radial Shortening of 0,5mm (0mm to 6mm) and articular surface displacement of 0,13mm 

(0mm to 1mm). Compared to the contralateral wrist we found the Dorsal Tilt correction of 97% (70% to 100%) and Radial Inclination correction 

of 95% (65% to 100%). The flexion-extension range of motion was 144o again 147o of oppositive side (98% of normal ROM), pronation-supination 

ROM was 176o again 177o of contralateral limb (99% of normal ROM) and radial-ulnar deviation of 41o again 45o of other 

wrist (91% of normal ROM). According Gartland score we found 86% of excellent, 10% good and 4% fair results. There were 2 infections, 

and 2 patients with loosening of reduction. Fracture healing occurs at an average 8 weeks time in all patients. We consider the volar 

aproach and fixation with volar fixed-angle plates the best treatment choice for fractures of the distal radius when surgical treatment is 

indicated. This can lead to lower rates of complications and improved functional and radiographic results compared to other techniques. 

Mechanical Effect of Metaphyseal Plate Stand-off in Radius Volar Plates 

Institution where the work was prepared: University of Arkansas, Little Rock, AR, USA 

Randy R. Bindra, MD, FRCS; Sivathan Kumar; William R Hogue; University of Arkansas for Medical Sciences 

PURPOSE: 

Volar fixation with a locking plate has become the standard of care for operative management of dorsally unstable distal radius fractures. 

Traditional locking plates are based on screws locking into the plate upon tightening ñ the plate is not compressed against the 

metaphysis and may stand off. The purpose of this study was to examine the mechanical effect of plate stand-off from the radius metaphysis 

in an unstable radius fracture model. To our knowledge, this has not been previously examined. 

METHODS: 

An unstable extra-articular distal radial fracture was simulated using a Sawbones foam model by excising a 5mm dorsal wedge 2 cm 

from the distal articular surface. Group 1 specimens (n=5) were fixed with a locking volar plate (DVO, IN) with the plate flush against the 

specimen. In Group 2 (n=5),the plate was fixed with a 4mm standoff from the distal metaphysis. The specimens were vertically loaded 

to failure at the rate of 0.1 mm/s using a servo-hydraulic machine (MTS Systems MN) and the stiffness, yield point and load to ultimate 

failure were recorded. 

RESULTS: 

Axial loading resulted in fracture collapse followed by fixation failure at the most proximalscrew hole. The point of initial yield was similar 

in both groups(group 1: 562 (+26) N; group 2: 549 (+48) N). The specimens in group I failed at a higher ultimate load of 1337 (+162) 

N compared to 1179 (+246) N in group II but this difference did not reach statistical significance. The specimens in group 1 were significantly 

stiffer at 485 (+79) N/mm versus 366 (+55) N/mm in group 2 where the plate had a 4 mm standoff (p=0.026). 

SUMMARY: 

Failure to seat a volar plate flush against the radius metaphysis reduces stiffness and may clinically result in fracture collapse with early 

mobilization. Newer plate designs that utilize alternative locking technology instead of threaded plate holes such as the "CoverLoc" 

plate may be advantageous as they allow plate compression against the metaphysis during screw insertion. 

68

Surgical Management of Post-traumatic Elbow Contractures in the Adolescent Patient 

Population: Principles and Outcome 

Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA 

Alexander H. Payatakes, MD; Nickolaos A Darlis; Robert W Kaufmann; Dean G Sotereanos; Allegheny General Hospital 

INTRODUCTION: 

Contracture is a common sequela of elbow trauma which often responds poorly to conservative management, even in the pediatric 

and adolescent patient population. The literature concerning results of surgical management in this group is limited and has suggested 

a less favorable outcome compared to adults. 

PURPOSE: 

To present our experience with surgical treatment of post-traumatic elbow contractures in adolescents using a consistent management 

protocol. 


Our records were retrospectively reviewed to identify adolescent patients that underwent open release of post-traumatic elbow contractures. 

Charts were reviewed for data concerning age, initial injury, prior management, and surgical procedure performed. A modified 

lateral column approach was utilized in all cases to perform an anterior joint release, as well as additional posterior release if necessary. 

Medial-sided pathology was addressed through a separate medial approach. Supervised therapy was initiated within the first 

postoperative week. Prophylaxis for heterotopic ossification was not routinely administered. Preoperative and postoperative evaluation 

included range of motion, pain, other associated symptoms, radiographic findings, and complications. 

RESULTS: 

Twelve adolescent patients (mean age 16.7 years, range 13-21) with open release of elbow contractures secondary to fracture and/or 

dislocation were evaluated. Mean preoperative flexion and extension was 113? and -51? respectively, with severely limited rotation in 4 

cases. Anterior release was performed in all cases, with supplemental posterior release in four. Radial head excision was performed in 

three cases to improve forearm rotation. An additional medial approach was necessary in three patients. Mean follow-up was 25.8 

months (range 18-42 months). All patients obtained a functional arc of at least 100? (mean 114?), with a mean gain of 56? in the flexionextension 

arc (p

AAHS Concurrent Scientific Paper Session B 

Injectable Collagenase Enzyme (AA4500) in Dupuytren's Contracture: Clinical Success in 

Patients with Concomitant Diabetes 

Institution where the work was prepared: SUNY at Stony Brook, Stony Brook, NY, USA 

Marie Badalamente, PhD; Lawrence C. Hurst; SUNY-Stony Brook 

INTRODUCTION: 

In phase II and III controlled clinical trials, injectable collagenase enzyme (AA4500, Auxilium Pharmaceuticals, Inc.) has been shown to 

be an effective nonsurgical treatment for improving finger joint function in patients with Dupuytren's contracture (DC), a progressive 

fixed flexion deformity associated with abnormal collagen synthesis. The prevalence of DC is 3 to 4 times greater in diabetic patients 

than in nondiabetic patients. In the US, diabetes occurs in almost 10% of people aged 20 years and older, and increases to nearly 21% 

after age 60. 

METHODS: 

A post hoc analysis was performed to compare efficacy and safety of AA4500 in the treatment of DC in diabetic (n=17) and nondiabetic 

(n=108) patients in one phase II trial and one phase III clinical trial. Clinical success was defined as correction of metacarpophalangeal 

(MP) and/or proximal interphalangeal (PIP) joint contractures to 0 to 5 degrees extension (normal=0 degrees) following treatment with 

1 to 3 injections of 0.58 mg AA4500 into the cords affecting MP or PIP joints. Tolerability was evaluated from adverse events (AEs) recorded 

for diabetic and nondiabetic patients with DC receiving AA4500 or placebo injections. 

RESULTS: 

Overall clinical success rates were 58.3% for 24 joints treated in 17 diabetic patients with DC, and 74.7% for 146 joints treated in 108 

nondiabetic patients with DC. Success rates were lower for diabetic patients than for nondiabetic patients (64.3% vs 87.3% for the MP 

joint; 50% vs 62.7% for the PIP joint). In diabetic patients, success rates were 33.3% (n=3), 61.5% (n=13), and 62.5% (n=8) for middle, ring 

and little finger joints, respectively, and 87.5% (n=16), 75% (n=44), and 70.4% (n=81) for middle, ring and little finger joints, respectively, 

in nondiabetic patients. Treatment-related AEs were similar for diabetic and nondiabetic patients who received at least 1 injection of 

AA4500. The 5 most common AEs were hand edema (76.5% vs 84.3%), ecchymosis (58.8% vs 62%), tenderness (58.8% vs 50%), injection 

site pain (35.3% vs 31.5%), and elbow and/or axillary lymphadenopathy (23.5% vs 25.9%) for diabetic and nondiabetic patients, 

respectively. 

DISCUSSION: 

Marked improvements in correction of joint contractures and joint function were achieved for diabetic and nondiabetic patients with 

DC following treatment with AA4500. Although the clinical success rate was lower for diabetic than nondiabetic patients, this nonsurgical 

approach provides an important alternative in a population more prone to surgical complications. AA4500 had the same tolerability 

profile in both groups in this study. 

70

Clinical Outcome in Dupuytren's Disease Correlates with Proteinase Gene Expression 

Institution where the work was prepared: University of East Anglia and Norfolk & Norwich Hospital, Norwich, United Kingdom 

Phillip Johnston, MA, MRCS1; Debbie Larson2; Adrian J. Chojnowski, MA, FRCS, (Orth)2; Ian M. Clark, PhD3; 

(1)Addenbrooke's Hospital, (2)Norfolk & Norwich University Hospital, (3)University of East Anglia 

INTRODUCTION: 

We have previously demonstrated that gene expression levels of matrix metalloproteinases (MMPs), related metalloproteinases 

ADAMTSs and tissue inhibitors of metalloproteinases (TIMPs) differ when comparing palmar fascia from 20 patients with Dupuytren's 

Disease (DD) to 20 disease-free controls (carpal tunnel syndrome) [1]. 

MATERIALS/METHODS: 

All of the patients with DD were followed up for at least 12 months from their primary fasciectomy. Clinical outcome was scored by 

measuring range of movement to assess total extension deficit (fixed flexion deformity of the affected digit), total further flexion and 

grip strength. Three validated outcome scores, the DASH (disability of arm, shoulder and hand), MHQ (Michigan Hand Questionnaire) 

and the Vancouver Scar Scale were also used. 

RESULTS: 

There was a significant correlation between levels of gene expression of several of the MMPs and ADAMTSs and the change in total extension 

deficit. Interestingly, all of these genes were up-regulated in DD samples compared with controls. In particular, greater expression levels 

of MMP-13 (Collagenase 3), MMP-14 and ADAMTS-14 (procollagen N-propeptidase) were correlated with greater extent of recurrence. 

CONCLUSION:/ CLINICAL RELEVANCE: 

These findings suggest that gene expression levels of certain key MMPs and ADAMTSs could be used to predict the recurrence of fixed 

flexion deformity of the affected finger following fasciectomy for DD at one-year follow-up. This study therefore provides further evidence 

to support the link between metalloproteinase activity and DD progression. 

REFERENCE: 

1. Johnston P, Chojnowski AJ, Davidson RK, Riley GP, Donell ST, Clark IM. A complete expression profile of matrix-degrading metalloproteinases 

in Dupuytren's disease. J Hand Surg [Am]. 2007; 32 (3): 343 - 51 

Amputation Versus Reconstruction in Severe Crush Injuries of the Upper Limb 

Institution where the work was prepared: UMF Iuliu Hatieganu, Plastic and Reconstructive Microsurgery Clinic, Cluj 

Napoca, Romania 

Alexandru Georgescu, Prof, MD, PhD; Filip Ardelean MD; Ileana Matei; Irina Capota MD 

INTRODUCTION: 

Severe crush traumas, unfortunately still happening very frequently, are in many cases accompanied by great tissue defects. The question 

that naturally rises is: when and how can we decide to conserve a completely destroyed limb segment? Certainly, there are cases 

in which the amputation per primam is much more profitable from economical point of view. The problem is whether a patient will benefit 

more in the future from a more or less performing prosthesis or from conserving a segment, even with the price of a reduction in 

functionality. Because the majority of patients choose the second possibility, in our service we established a protocol concerning the 

when we should try to preserve the crushed segment. The study in this paper is based on our experience on more then 450 cases. 

MATERIAL AND METHOD: 

In the last 10 years we treated in our service more then 450 cases with severe crush injuries of the upper limb, including complete and 

incomplete amputations, large soft tissue destructions and extensive bone defects. We performed amputation from the beginning in 

only 5 cases. In the remaining cases we tried to preserve the crushed segments. In more then half of them we proceeded to emergency 

all-in-one reconstruction, and in the remaining cases we reconstructed and covered the tissue defects after 24-48 hours. In covering the 

tissue defects we used different types of free or local flaps, mostly perforator flaps. 

RESULTS: 

The post-surgery evolution of the 5 cases when we amputated per primam was without incidents. We lost only 2 replanted segments, 

the rest being fully integrated; the sooner we performed the reconstruction, the better the results were and the lower the degree of 

bacterial contamination. 

CONCLUSIONS: 

Although there are still many discussions regarding the abandonment or the preservation of the severely crushed limbs, considering 

the modern techniques of reconstruction and covering with flaps, we think that even when we are dealing with highly destroyed segments, 

we should try first to preserve them. 

71

A Comparison Study of Preliminary Soft Tissue Distraction vs. Check Rein Ligament Release 

in the Treatment of Dupuytren's PIP Joint Contracture 

Institution where the work was prepared: Mayo Clinic Hospital Arizona, Phoenix, AZ, USA 

Aaron Klomp, MD; Grant Fankhauser; Anthony Smith; Alanna Rebecca; Scott Duncan; Mayo Clinic Arizona 

HYPOTHESIS: 

Check rein ligament release (CRLR), the standard treatment for PIP joint contracture in Dupuytren's disease, does not address: 1) the 

shortened neurovascular bundle, and 2) the insufficient skin envelope, particularly in re-operated cases. The Digit-WidgetÆ (DW) uses 

soft-tissue distraction to overcome these problems. The purpose of this study is to compare our operative experience in treating 

Dupuytren's PIP joint contractures with a CRLR to treating Dupuytren's PIP joint contractures with preliminary placement of the Digit- 

WidgetÆ followed by operative release. 

METHODS: 

Twenty-three patients (29 digits) were treated. There were 19 men and 4 women. Age ranged from 45 to 81 years. Twenty digits underwent 

CRLR for flexion contractures from 10-80 degrees (mean=52.4). Six (30%) were re-operations. Five of these six required full thickness 

skin grafts (FTSG). Nine digits were treated with DW distraction for flexion contractures from 30-90 degrees (mean=66.7). Three 

(33%) were re-operations 

RESULTS: 

Twenty CRLR digits had an average of 27.7 (range -48 to 70) degrees of improvement in active PIP joint extension. Digits treated with 

DW distraction and release had an average of 44.1 (range 12-73) degrees of improvement in active PIP joint extension. Two DW-treated 

digits improved to full PIP extension without residual contracture and were not released. Mean improvements for re-operated digits 

treated by CRLR or DW distraction were 32 and 52 degrees respectively. Two of the CRLR re-operated digits had partial loss of the 

FTSG. Primarily treated digits with CRLR or DW distraction improved PIP extension by means of 16 and 34 degrees. For contractures 

under 30 degrees, CRLR worsened the contracture by a mean of 13 degrees while DW distraction improved the contracture by a mean 

of 12 degrees. Contractures between 30 and 60 degrees treated by CRLR or Digit-Widget distraction improved by means of 30 and 28 

degrees, respectively. Contractures over 60 degrees treated by CRLR or DW distraction improved extension by means of 30 and 55 

degrees respectively. 

SUMMARY: 

Digit-WidgetÆ soft tissue distraction followed by operative release showed greater correction of the contractures than CRLR for both 

primarily treated and re-operated groups. ï Preliminary soft tissue distraction is particularly effective in contractures greater than 60 

degrees. ï In re-operated digits the CRLR technique is more likely to worsen than improve the PIP joint contracture. ï Use of the Digit 

WidgetÆ obviated the need for a FTSG for wound closure in re-operated digits. 

72

The Spiral Flap for Fingertip Resurfacing: Short- and Long-Term Results 


Gale Lim, MBBS, MRCS, MMed; Andrew Yam, MBBS, MRCSEd, MM; Jonthan YL Lee, MBBS, MRCSEd, MM; Lc Teoh, 

MBBS, FRCS, FAMS; Singapore General Hospital 

PURPOSE: 

We describe a new homodigital neurovascular island flap for reconstructing large pulp defects of the fingertips and review the shortand 

long-term appearance and function of the reconstructed fingertips. 

METHODS: 

The ìspiral flapî is a homodigital neurovascular island flap with a unique spiral advancement and transposition design that allows pulp reconstruction 

using sensate glabrous skin while restricting donor morbidity to the injured digit. 32 fingertips were resurfaced using this flap. All 

had large volar unfavourable pulp defects averaging 1.2 cm wide x 2.0 cm long (1.0 to 2.0 by 1.5 to 2.5cm). Short-term results for all patients 

at a minimum of 6 months and long-term results for 10 patients with a follow-up of 13.4 years were reviewed. Objective outcome measures 

included static two-point discrimination, degree of nail deformity (beaking), total active motion and hypersensitivity or cold intolerance. 

Subjective outcome measures included patient satisfaction with function and aesthetics, using a visual analog scale. 

RESULTS: 

All flaps achieved primary healing with no complications. There was initially mild extension deficit in the PIP and DIP joints, which 

improved to full range of motion in the long term. Sensory recovery was excellent with an average 2-point discrimination of 5 mm initially, 

improving to 3.7mm in the long term. Nail beaking was minimal initially, but increased significantly in the long-term. These results 

may be explained by soft tissue remodeling. All patients on long-term follow up were highly satisfied with both aesthetic and functional 

outcome. There was no hypersensitivity or cold intolerance at either the short term or long term follow up assessments. 

CONCLUSION: 

The spiral advancement-transposition flap is suitable for resurfacing large pulp defects with excellent short- and long-term functional 

and aesthetic results, and high patient satisfaction. 

Analysis of Limited Wyndell Merritt Splint for Extensor Tendon Injuries to Hand Immobilization 


Nada Berry, MD; Michael Neumeister; SIU School of Medicine 

INTRODUCTION: 

The Wyndell-Merritt (relative motion) splint has been used effectively for extensor tendon lacerations. We have been treating extensor 

tendon injuries with the yoke splint without wrist immobilization with good clinical results. This study compares range of motion (ROM) 

of the injured finger to previously published results, as well as ROM for the digits treated with a traditional Wyndell-Merritt splint 

METHODS: 

A retrospective chart review was performed for two groups of patients treated over the last six years for complete extensor lacerations. 

Group A was treated with a relative motion hand splint only, while group B was immobilized at the wrist. Both groups of patients were 

treated with the same method of tendon repair, and were initially placed in a static splint. On follow-up, a controlled relative motion 

splint was fabricated and hand therapy commenced. The ROM figures were collected and analyzed. Two patients in group A were 

excluded and one patient was excluded from group B 

RESULTS: 

Fourteen patients were included in group A and 7 patients in group B. The average duration of treatment for both groups was 45 days. 

The average time of motion splint application for group A was 8.8 days post-operatively and 9.8 days for group B. Group A had 5 index, 

7 long, 1 ring, and 2 small finger injuries that included 1 zone IV, 11 zone V, and 2 zone VI injuries. Group B had 3 index, 3 long, and 1 

ring finger that included 2 zone IV, 3 zone V and 2 zone VI tendon lacerations. The ROM at conclusion of hand therapy was 230.4 and 

230.7 degrees of flexion for groups A and B respectively. The average extensor lag for group A was 7.5 and 10.7 degrees for group B. 

One patient in each group required tenolysis for the complaint of skin adhesion. 

CONCLUSION: 

Limiting the Wyndell-Merritt splint to the hand and not immobilizing the wrist has produced good clinical results for patients with complete 

EDC injuries in zones IV through VI. ROM for the patients treated with yoke splint only is the same as those treated with wrist 

splinting, and is comparable to previous studies with a traditional Wyndell-Merritt splint. The extensor lag is better for patients with a 

mobile wrist. These results support the use of a hand-based relative motion splint for treatment of zone IV, V, and VI extensor tendon 

lacerations. 

73

Comparison of FiberLoop and Supramid in Zone II Flexor Tendon Repair Using a Cyclic Protocol 


Aaron Anderson, MD; S. Chase Donnelly; Richard Drake, PhD; Kathleen Derwin, PhD; Jeff Lawton, MD; Cleveland Clinic 

INTRODUCTION: 

Many suture methods and materials are used for zone II flexor tendon repairs. The ideal repair should be strong enough to allow early 

range of motion while facilitating tendon glide through the pulley system. The purpose of this study was to investigate the differences 

in gap formation and failure load between FiberLoop (Arthrex Inc., Naples, FL) and Supramid (S. Jackson Inc., Alexandria, VA) sutures 

in zone II flexor tendon repairs using a human cadaveric model under cyclic loading. 

METHODS: 

Twenty paired flexor tendons from human, cadaveric hands were used to test the repair strength of FiberLoop versus Supramid suture. 

FDP Tendons were obtained from the ring, middle, and index fingers, transected in zone II, and repaired with either 4-0 FiberLoop or 

4-0 looped Supramid suture using a standard 8-strand cruciate repair technique followed by a running epitendinous 6-0 prolene suture. 

The repaired tendons were then clamped and mounted on a material testing system (MTS, Eden Prairie MN) preloaded to 2N and 

cycled 8000 times between 2N and 25N at a frequency of 1 Hz. Specimens were then pulled at a rate of 12mm/min until failure, defined 

as either the maximum load or a point corresponding to a drop in load of 10% or more of maximum during the failure test. Suture markers 

were placed on both sides of the repair site to analyze gap formation across the repair during testing with an optical system. 

Outcome measures included gap formation at 8000 cycles and failure load. Statistical differences were analyzed using a paired t-test 

(p

Deep Inferior Epigastric Artery Graft for Raynaud's Disease 

Institution where the work was prepared: Hee Chang Ahn, Seoul, South Korea 

Hee-Chang Ahn, MD1; Steven Bates, MD2; Scott L. Hansen2; Neil F. Jones2; (1)Hanyang University Hospital, (2)UCLA 

HYPOTHESIS: 

To examine the use of the deep inferior epigastric artery (DIEA) graft for reconstruction of occluded ulnar or radial arteries in patients 

with Raynaud¢ÆØs disease. 

METHODS: 

We evaluated eight patients (6 female, 2 male) who had undergone digital sympathectomy and interposition of a DIEA graft for ulnar 

or radial artery occlusion from August 2004 to July 2006.† The mean age was 39.2 y.o. (range 31 to 58). Three patients underwent arterial 

grafts on bilateral hands (11 grafts).† 10 grafts were for ulnar artery and 1 for radial artery reconstruction. 

We evaluated subjective symptom improvement such as ischemic pain and Raynaud¢ÆØs phenomena, and objective measures such 

as angiograms, pre- and postoperative color Doppler vascular flow, thermoscan and ulceration on the finger tips.† All patients received 

periarterial sympathectomy.† The DIEA graft was harvested through a 10 cm transverse incision on the lower abdomen. Vascular anastomosis 

was performed with 10-0 ethilon sutures. 

RESULTS: 

Following arterial reconstruction, immediate perfusion of the digits was obvious. Patients were evaluated at 6 and 12 months for symptom 

relief and vascular flow using a Doppler.† All patients showed the improvement in the subjective symptoms and wound healing.† Doppler 

evaluation revealed excellent vascular reflow through grafted artery in 7 cases, moderate flow in 2 cases, and scant flow in 2 cases. 

SUMMARY: 

Vascular reconstruction with a DIEA graft provided vascular reflow and improved wound healing. Two of 11 (18%) arterial grafts seemed 

to be narrowed or occluded in post operative follow-up, although subjective symptoms were improved with rapid wound healing in all 

cases. We suggest that the DIEA graft has several advantages in donor site morbidity including scar location, good match in size for 

arterial reconstruction at wrist (proximal) and common digital arteries at the palmar arch (distal), and good long-term patency rates. 

Fig. 1. Deep inferior epigastric artery with several braches 

that can be used for palmar arch and common digital artery 

The Use of Dermal Substitutes in Burn Scar Contracture Releases to the Hand and Upper Extremity 

Institution where the work was prepared: Indiana University, Indianapolis, IN, USA 

Madeline Zieger, PA1; David Roggy, RN2; Rajiv Sood, MD, FACS1; (1)Indiana University, (2)Richard M. Fairbanks Burn Center 

Numerous options exist for soft tissue coverage of the upper extremity following contracture release. Recently, a number of dermal substitutes 

have become available for coverage of wounds in the upper extremity obviating the need for more complex reconstruction. 

We report our experience, with the use of AlloDerm and Integra dermal substitutes, in 40 patients (32 adults and 8 children) from 1998 

to the present. AlloDerm is freeze-dried dermal homograft, which provides an acellular matrix of dermal elements (collagen and GAGs). 

Integra is bilaminar structure with cross-link bovine collagen with an overlying silicone epidermis. Thick AlloDerm is applied to the soft 

tissue release site and simultaneously covered with a thin autograft (.006-.008 inches). Integra is applied directly to the wound bed and 

the patient is returned to the operating room for delayed autografting. Both dermal substitutes are covered with a VAC device. Forty 

patients had AlloDerm (55 sites) and Integra (19 sites) applied following hand and upper extremity contracture release (see table 1). 

Thirty-five of the forty patients had successful wound healing with increased active range of motion to the contracture release site (see 

table 1). Four patients required additional surgical procedures due to re-contracture caused by non-compliance with physical and occupational 

therapy (2 axillas, 1 elbow, and 1 wrist) and one patient required additional skin grafting due to a non-healing wound to an 

elbow release site. The use of dermal substitutes provides a useful reconstructive option for coverage of the hand and upper extremity 

and prevents the use of other potentially useful donor sites for future reconstructive needs. The use of dermal substitutes also allows 

an excisional approach to be used, and is also useful for coverage of denuded muscle, tendon, or bone. 

75 

Fig. 2. Deep inferior artery graft from the ulnar 

artery to common digital artery

Treatment of Distal Biceps Ruptures Using a One-Incision Technique and Biotenodesis Screw 

Fixation: A Preliminary Report on Patient-Oriented Outcomes 

Institution where the work was prepared: UMass Memorial Medical Center, Worcester, MA, USA 

Mark Eskander, MD; Jonathan Eskander; Douglass Weiss; Nicola DeAngelis; UMass Medical School 

OBJECTIVES: 

Complete distal biceps brachii tendon ruptures are uncommon injuries. This type of injury can be approached by either a one or twoincision 

method. Unfortunately, both have associated risks. Moreover, there are a variety of fixation techniques to choose from including 

biotenodesis screws. The purpose of this study is to evaluate the patient outcomes of a one-incision technique coupled with biotenodesis 

screws for treatment of distal biceps tendon ruptures. 

METHODS: 

We prospectively followed all patients who underwent surgery with this technique. Data from ten surgeries on nine patients coupled 

with postoperative questionnaires (DASH and SF-12) were collected and analyzed. The surgeries took place from 2005-2006 by the 

same surgeon. The cohort group consisted of employed males at an average age of 44 ranging from 31 to 56 years old. Eight out of 

the nine patients were right-hand dominant, six were manual laborers, and four out of the ten ruptures were on the right side and the 

other six were on the left. There were no intra-operative complications during the ten surgeries. 

RESULTS: 

The patients were all seen back at regular postoperative intervals and our DASH and SF-12 scores were collected at one year after surgery. 

All patients demonstrated a normal range of motion (ROM) with flexion, extension, pronation, and supination except for one. The 

postoperative mean flexion and supination strength were 5.0±0 and 4.9±0.21 respectively. The postoperative mean DASH, SF-12 

Physical Component (PC), and SF-12 Mental Component (MC) scores were 9.91±13.88, 50.65±9.21, and 51.26±9.38 respectively. These 

values are similar to the normative DASH (10.10±14.68) as well as SF-12 PC and MC (51.22±8.80, and 50.72±9.31) values for the US male 

population. One patient in our group has additional medical problems affecting overall outcomes. If this patient is excluded, the DASH, 

SF-12 PC, and MC are 7.68±12.68, 53.36±3.62, and 50.57±9.67 respectively. We noted an overall complication rate of 30% (three of the 

ten surgeries). The complications included calcific tendonitis with decreased ROM after a partial re-rupture, decreased strength, and 

numbness along the distribution of the radial sensory nerve. 

CONCLUSION: 

There is no consensus in the literature on the best way to treat distal biceps tendon ruptures. Our DASH and SF-12 scores imply the oneincision 

approach and biotenodesis screw fixation provide excellent outcomes. Our complications are similar to those reported by other 

authors and thus demonstrate the safety and effectiveness of this technique for patients who present with distal biceps tendon ruptures. 

76

Flexor Tendon Repair with Barbed Suture 

Institution where the work was prepared: UT SouthWestern Medical center, Dallas, TX, USA 

Fatemeh Abtahi, MD1; Michel Saint-Cyr2; Spencer A. Brown2; Debby Noble, BS3; Dan Hatef, MD4; Jordan Farkas, 

MD3; (1)UT SouthWestern Medical Center, (2)University of Texas Southwestern Medical Center, (3)UTSW medical center, 

(4)UT Southwestern 

PURPOSE: 

This study evaluated the tensile strength properties (maximum tensile load, gapping at the repair site, and the pattern of failure) of flexor 

tendon repaired with barbed sutures. 

INTRODUCTION: 

According to Strickland an ideal tendon repair should permit easy placement of sutures in the tendon, would allow smooth gliding, 

have secure suture knots with a smooth junction of tendon ends without gapping at the repair site, create minimal interference with 

tendon vascular, and have sufficient strength throughout healing to permit early motion of the tendon. The difficulty in satisfying all 

these criteria by any repair technique is probably reflected in the multitude of repairs described and currently utilized by practitioners. 

There are many variations in the suture technique of placing core sutures. The described technique include Bunnel, Strikland, Kessler, 

modified Kessler, Becker, modified Becker, repair. Tendon repair ruptures usually occur at the suture knots. Adhesion formation remains 

the most common complication after flexor tendon repair, despite the widespread use of early-motion protocols. With these factors 

related to tendon repair failure considered, our department performed a pilot study using barbed sutures to repair lacerated flexor digit 

rum tendons. Barbed sutures (self-anchoring)have been developed by Quill Medical, in which bidirectional barbs are introduced into a 

suture that eliminates the need for tying a knot to obtain suture closure. The barbs are designed to grip tissue and obviate the need 

for tying a knot during tissue approximation. They can pass easily through tissue in one direction, but can not be reversed, therefore 

providing knot security. 


160 cadaveric and porcine flexor tendons were harvested and cut. Repairs were performed using 0 or 2-0 barbed Nylons and same sizes 

standard Nylon. Modified Bunnell and Modified Kessler techniques were used.All repairs have been done without epitendonous 

suture.The repaired tendons were then tested for Maximum Load, Gap Strength, and Initial Gap, using a Tensiometer. Result:Overall 

mean Maximum Load for barbed sutures was 41.12 N. Mean Maximum Load for 0 barbed Nylon was 55.90 N. Mean Maximum Load 

for 2-0 barbed Nylon was 37.46 N,and mean Maximum Load for 2-0 Nylon was 53.76. Mean Maximum Load for conventional 3-0 

Ethibond was 31.25 N. These data are fairly consistent with what has been seen previously in the literature. 

SUMMARY: 

Overall,barbed sutures gave a stronger repair, especially when 0 barbed Nylons were used. Conventional 0 barbed Nylons would be 

clinically unfeasible,as the knots would be far too bulky.The ability to use this size of suture without the need for knot tying gives hand 

surgeons this option in repair of flexor tendon injuries. 

77

Management of the Central Extensor Tendon on the Surgical Approach for Exposure of the 

Proximal Interphalangeal Joint: A Biomechanical Study 

Institution where the work was prepared: University of New Mexico, Department of Orthopaedics, Albuquerque, 

NM, USA 

Deana Mercer; Keikhosrow Firoozbakhsh; Alex Carvalho; Moheb S. Moneim; University of New Mexico 

PURPOSE: 

Since 1966 silicone implant arthroplasty has been used to treat arthritis of the PIP joint as an alternative to fusion. The volar approach 

to expose this joint spares the extensor mechanism at the cost of increased risk to neurovascular structures. In the dorsal approach, the 

extensor mechanism must be carefully handled, reattached and then protected during rehabilitation. Several surgical techniques have 

been used to handle the extensor mechanism. Swanson et al. recommended midline incision of the central tendon followed by release 

of the lateral insertion on the middle phalanx and then reattachment to the base of the middle phalanx. Our clinical experience led us 

to a new surgical technique; splitting then repairing the extensor mechanism without bone reattachment as recommended by Swanson. 

The purpose of this study was to biomechanically compare strength and function of this technique with that of Swanson. 

METHODS: 

Four pairs of fresh-frozen cadaveric hands were used. The index, long and ring finger were harvested for testing. Twelve digits (3 digits 

x 4 hands) were designated as control and were used to measure the fixation strength of Swanson's procedure. The other 12 digits of 

the paired hands were designated as experimental and were used to measure the fixation strength of the proposed new technique. 

RESULTS: 

The fixation strength mean ± SD were 4.74 ± 0.46 N/mm for the control group and 4.62 ± 0.30 for the experimental group. The results 

were not statistically different, p=0.45. 

DISCUSSION: 

The simple repair of the central slip without the bone reattachment preserves the function of the extensor mechanism on the PIP joint. 

In our clinical cases we haven't noticed any increase in the incidence of extensor lag or boutonniËre deformity as a result of that. This 

technique can also be applied for fracture fixation in the area. 

Treatment of Chronic Digital Ischemia with Direct Microsurgical Revascularization 

Institution where the work was prepared: Northwestern University, Chicago, IL, USA 

Zol Kryger, MD; Vinay Rawlani; Gregory A. Dumanian; Northwestern University 

INTRODUCTION: 

Chronic digital ischemia of the fingers is a painful debilitating condition that untreated can progress to functional loss and even amputation. 

Direct revascularization techniques require microsurgery, however, these procedures are quite distinct from free tissue transfer and replantation. 

The literature is lacking an adequate description of how best to perform this uncommon procedure. The authors present their technique 

for treating digital ischemia using a radial to digital artery bypass graft performed in a bloodless field under tourniquet and microscope. 

METHODS: 

This procedure was performed in six consecutive patients (four with occlusive collagen vascular disease, one with diabetic peripheral 

vascular disease, one with hypercoagulable state), all of whom had ischemic digits with ulceration, pain, and dry gangrene and who 

were unmanageable under conservative medical or surgical therapy. The outcomes were resolution of fingertip ulcers, avoidance of 

more proximal amputations, and elimination of ischemic pain. 

RESULTS: 

Successful outcomes were obtained in all six patients, and the grafts have remained patent with an average follow up 17 months as 

confirmed by a hand-held Doppler examination. All patients had salvage of the revascularized finger, and resolution of the ulcers and 

rest pain. The mean tourniquet time was 100 minutes. 

CONCLUSION: 

Digital revascularization using a radial to digital artery bypass is a straightforward, reproducible technique for the treatment of patients 

suffering from refractory chronic digital ischemia. 

78

Modified Allen's Test Using Near Infrared Spectroscopy: Clincal and Anatomic Study 

Institution where the work was prepared: University of Texas Southwestern Medical Center, Dallas, TX, USA 

Daniel A. Hatef, MD; Dallas Alvey; Li Ngov; Michel Saint-Cyr; Spencer A. Brown; Rod J. Rohrich; University of Texas 

Southwestern Medical Center 

INTRODUCTION: 

A dogma of hand surgery instructs that the dominant arterial supply to the hand is the ulnar artery. This has some serious clinical implications, 

as reconstructive surgeons use the radial forearm flap to repair defects all over the body, and cardiac surgeons often harvest 

the radial artery for use as a graft in coronary bypass surgery. 

METHODS: 

Near Infrared Spectroscopy was used to assess tissue oxygen saturation (St02) in the second and fifth digit, while performing the modified 

Allen's test, in 30 hands of 15 subjects. Measurements were recorded and statistically analyzed. A cadaveric study was undertaken 

using 6 upper extremities, to confirm the findings of this and previous studies. Radiopaque barium was injected into the brachial 

artery to demonstrate the vasculature of the forearm and hand. The arms were then scanned using a CT scanner, and the images were 

reconstructed and analyzed using TeraRecon Æ imaging software. 

RESULTS: 

Baseline St02 readings were variable (range 39 to 90; Mean = 64.43; St. Dev. = 13.07). Two hands, of the same patient, demonstrated 

clear ulnar dominance; one hand demonstrated radial dominance. Of note, two hands had normal Allen's tests, but appeared to have 

radial dominance to the index. The results of the cadaveric investigation demonstrate that 2 of the 10 upper extremities had incomplete 

filling of the superficial arch. The ulnar digital artery was seen to be dominant in every index digit; this was a branch of the palmar 

metacarpal artery off of the superficial palmar arch in 8 specimens, and the terminal branch of the radial artery in 2 specimens. 

DISCUSSION: 

This study shows that there is no one dominant blood supply to the hand. This study demonstrates the importance of diligent use of 

the Allen's test preoperatively, and in any patient with questionable result, it is recommended that the radial artery not be sacrificed. 

Some hands may have radial dominance to the index, but an anatomical reason for this was not confirmed through cadaveric investigation. 

Near infrared spectroscopy demonstrated extremely variable St02 readings. It cannot be concluded that use of near infrared 

spectroscopy aids in improving the sensitivity of the Allen's test. 

79

AAHS Concurrent Scientific Paper Session C 

Evaluating the Efficacy of Combining Clinical Signs of Scaphoid Fracture to Decrease 

Unnecessary Immobilization: A Prospective Multi-Institutional Study Supporting the 

Early Use of Advanced Imaging 

Institution where the work was prepared: Naval Medical Center San Diego, San Diego, CA, USA 

Joseph R. Carney, MD; Eric Hofmeister; John Paul Rhue; Brian Fitzgerald; Michael Thompson; Naval Medical Center 

San Diego 

BACKGROUND: 

The initial clinical examination for scaphoid fracture is inaccurate leading to unnecessary immobilization in a large percentage of 

patients suspected of occult fracture. An exam with improved accuracy in patients suspected of scaphoid fracture can potentially lead 

to the cost effective use of advanced diagnostic imaging modalities to further guide treatment and decrease unnecessary immobilization. 

METHODS: 

An IRB approved, prospective, multi-institutional study was performed in adults with suspected scaphoid fractures. An initial examination 

documenting the presence or absence of seven described clinical signs of scaphoid fracture was performed and patients followed 

until a scaphoid fracture was determined to be present or absent. Initial exam findings, initial and final diagnosis, diagnostic studies 

used to exact a final diagnosis, number of follow up visits needed to exact a final diagnosis, and length of immobilization were determined. 

Statistical measures of test validity for the seven clinical signs used in multiple combinations were determined. The mean number 

of positive signs in patients with a final diagnosis of scaphoid fracture was compared to patients with a final diagnosis of scaphoid 

nonfracture in an effort to further evaluate the accuracy of the initial clinical examination when using multiple signs of fracture. A cost 

analysis for patients unnecessarily immobilized was compared to a proposed model utilizing early use of bone scintigraphy to decrease 

periods of over treatment. 

RESULTS: 

From June 2004 to June 2006 eighty-three patients were enrolled. Four were lost to follow up (95% retained). Clinical examination accuracy 

did not improve when clinical signs were combined (p>0.05). Furthermore, suspected occult fracture patients found to be without 

fracture possessed a significantly higher number of positive signs than patients found to have fractures (p

Long-term Outcomes of Dorsal Intercarpal Ligament Capsulodesis for Chronic Scapholunate 

Dissociation 

Institution where the work was prepared: University of California, Davis, Sacramento, CA, USA 

Varun Gajendran, MS1; Brett Peterson, MD1; Robert R. Slater, MD, FACS2; Robert Szabo, MD, MPH1; (1)University of 

California, Davis, (2)The Permanente Medical Group 

PURPOSE: 

Chronic scapholunate dissociation is a common cause of symptomatic wrist instability. In an attempt to restore normal carpal mechanics 

and prevent wrist arthrosis, we developed and tested biomechanically the dorsal intercarpal ligament capsulodesis (DILC). Previously, 

we reported good early clinical results for this procedure. Here, we report on the functional and radiographic outcomes of these 

patients at long-term follow-up. 

METHODS: 

After IRB approval, records of patients undergoing the DILC for chronic (greater than 6 weeks), flexible, static scapholunate dissociation 

were reviewed. Only patients with follow-ups of greater than 60 months were included. Physical examination, radiographs, and validated 

outcome instruments were used to evaluate the patients. 

RESULTS: 

Twenty-one patients (22 wrists) met the inclusion criteria. Fifteen of these 21 patients (16 wrists) were available for follow-up. After an average 

follow-up period of 86 months, physical examination revealed an average wrist flexion and extension of 50Ña and 55Ña respectively, 

radial and ulnar deviation of 17Ña and 36Ña respectively, and grip strength of 61 kgf. DASH, SF-12, and Mayo wrist scores averaged 

19, 78, and 78 respectively. Radiographs revealed an average scapholunate angle and gap of 62Ña and 3.5 mm respectively. Eight of the 

16 wrists in our study demonstrated arthritic changes on radiograph, including one patient who developed Stage IV arthritis of the wrist. 

CONCLUSION: 

Our results show that the DILC does not prevent radiographic deterioration and the development of arthrosis in the long term. 

However, the level of functionality and patient satisfaction remained high in the majority of our patients, suggesting a lack of correlation 

between the radiographic findings and development of arthritis on one hand and functional outcomes and patient satisfaction on 

the other hand. Based on these findings, we believe that the DILC is still a good choice for treating flexible static scapholunate dissociation 

in carefully selected patients. Prevention of radiographic deterioration and arthrosis, however, remains an unsolved problem. 

Treatment of Scaphoid Fractures and Nonunions with a Cannulated AO Screw and Threaded 

Washer: Report of 99 Cases 

Institution where the work was prepared: University of California San Diego, San Diego, CA, USA 

Andrew Pennock, MD1; Todd Horton, MD2; William Tontz, MD1; Reid Abrams, MD3; (1)University of California San 

Diego, (2)Naval Medical Center, (3)University of California, San Diego 

PURPOSE: 

Several implant designs have been utilized for the rigid internal fixation of scaphoid fractures. To date, no study in the literature has 

reported surgical outcomes using the 3.0 mm cannulated AO screw lagged through a threaded washer. The purpose of this study was 

to evaluate union rates in a consecutive series of patients who had internal fixation of a scaphoid fracture or nonunion using this device. 

WITHDRAW 

METHODS: 

From September 1996 to September 2006, 68 consecutive scaphoid waist fractures requiring surgical stabilization were treated with a 

3.0 mm cannulated AO screw and threaded washer by a single surgeon. Nondisplaced fractures were treated through a mini-volar 

approach while displaced fractures and nonunions were treated with an open volar approach. At the time of surgery, if nonunions were 

unstable, bone graft from the iliac crest or distal radius was harvested, but if stable, graft was not utilized. Charts and radiographs were 

reviewed from all patients and pertinent demographic and clinical data were recorded. Postoperative radiographs were reviewed to 

assess fracture union and screw position. 

RESULTS: 

The union rate for the 21 nondisplaced fractures was 100% with an average time to union of 15.5 weeks. The union rate for the 23 displaced 

fractures was 96% with an average time to union of 17.1 weeks. In none of the acute fractures was it necessary to remove symptomatic 

hardware. The union rate for the 24 nonunions was 92% with an average time to union of 22 weeks. In two instances, symptomatic 

hardware had to be removed which had migrated into the scapho-trapezio-scaphoid joint. 

CONCLUSION: 

The 3.0 mm AO cannulated screw and threaded washer can be used reliably and safely to treat both scaphoid waist fractures and 

nonunions. A theoretic advantage of this device is that it enables the controlled compression of the scaphoid if resorption occurs across 

the fracture site, increasing the probability of successful union. This benefit is not without risk of distal screw migration, which was 

observed in two cases in this study. We therefore recommend close radiographic follow-up in all cases until bony union is achieved. 

81

Outcome Assessment after Treatment of Scaphoid Nonunion in the Middle Third (Herbert 

Type D2) with Conventional Bone Grafting and Screw Fixation from a Palmar Approach 

Institution where the work was prepared: Department of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany 

Miriam Mueller, MD; Andre Otto; Christiane Hitzigrath; Rainer Simon; Guenter Germann; Michael Sauerbier; 

Heidelberg University 

OBJECTIVES: 

This study was designed to assess the clinical and radiological outcomes after treatment of scaphoid nonunion of the middle third 

(Herbert D2) with bone graft and screw fixation. 


Eighty patients were treated for scaphoid nonunions in the middle third between 05/98 and 10/05 and were retrospectively reviewed. 

Average follow-up time was 41.5 months. 73 patients were male, 7 female with a mean age of 32 years. The right hand was affected in 

55 %, the left in 45 % of the cases. Mean delay to surgery was 9,7 months. All patients were treated by resection of the nonunion from 

a palmar approach, interposition of a nonvascularized bone graft from the radius or iliac crest, stabilization by screw fixation and immobilization. 

All patients received pre- and postoperative CT-scans to assess osseous union. Apart from demographic data range of 

motion, grip strength, pain relief (VAS score) and DASH-score were obtained. 

RESULTS: 

Average time of immobiliazation was 8,7 weeks. Osseous union could be achieved in 73 (91 %) patients at this time. The average DASHscore 

(range 0-100 points) was 11,8 points (range 0-53). The average range of motion were: Ext./Flexion 116.4?, Ulnaabd./Radialadd. 

65.4?, Pronation/Supination 164.4? and grip strength was 40.7 kg. The pain relief (VAS range 0-100) was 4.3 at rest and 21.4 during stress 

activities in average. Complications occurred in 5 patients (6,25 %) and consisted of necessary further operation like four corner fusion 

(2), proximal row carpectomy (1) or re-operation with iliac crest bone graft (2) 

DISCUSSION: 

Our study demonstrates that excellent union rates can be achieved with using a conventional bone graft and screw fixation for scaphoid 

nonunion in the middle third. For reliable assessment of bony union CT-scans are necessary; radiological osseous union is highly predictive 

for patientxs satisfaction and functional outcome. 

Open Reduction for Perilunate Injuries - Long Term Results and Patients Content 

Institution where the work was prepared: BG Trauma Center Ludwigshafen, Ludwigshafen, Germany 

Thomas Kremer, MD; Michael Wendt; Michael Sauerbier; Guenter Germann; BG Trauma Center Ludwigshafen 

INTRODUCTION: 

Perilunate injuries lead to severe destruction of the carpal integrity. Optimal treatment is mandatory to avoid poor results in terms of 

pain and function. However, the patientsx outcome is still unsatisfying in a subset of patients. Moreover, these injuries are frequently 

overlooked. This study evaluates the long term results after open reduction and treatment with K-wires. 

PATIENTS/METHODS: 

Patients, who were treated for perilunate dislocations / fractures (Mayfield 3/4) in our institutiuon (1995-2004) were included in this retrospective 

analysis. The evaluation focussed on postoperative radiologic results and on development of arthrosis, range of motion, 

pain, sensitivity, grip strength, Mayo - and Krimmer wrist scores and the patients content (DASH-score). 

RESULTS: 

72 patients were treated at our institution for perilunate injuries from 1995-2004. 54% (n=39 [2 females/37 males]) were evaluated for 

functional results and patientsx satisfaction (median follow-up 65, 5 months). Blue collar workers dominated (n=26). Two thirds (61%) of 

the patients suffered from perilunate fracture dislocations and the dominant hand was affected in one third. Postoperative reduction 

was successful in the majority of patients (89.7% normal scapholunate angles, normal Gilula arcs in 64.1%). At follow-up, pain was rated 

1.8 at rest and 4.8 under stress conditions (visual analogoue scale). Average extension/flexion was 76.7? (62.3% of the opposite side) 

and radial-/ulnarabduction was reduced to 60% of the unaffected side. Sensitivity was normal in all patients. Average grip strength was 

36.6 kg (51.6 kg opposite side). 17 patients were diagnosed with significant radiocarpal arthrosis at follow-up, a pathologic scapholunate 

angle was found in 14 patients, whereas 6 patients developed an ulnar shift of the carpus. 69.2% of the patients worked in their 

former occupation. Average Mayo- and Krimmer wrist scores were 70.4 and 70.3, respectively. The average DASH-score was 23.2, which 

is low with respect to the severe injury pattern. 

DISCUSSION: 

Open reduction is the treatment of choice for perilunate injuries. However, long term results show significant functional impairment and 

arthrosis even after ideal treatment course. Furthermore, radiologic changes and functional results demonstrate no correlation. The 

high patientsx individual satisfaction shows, that treatment in specialized hand surgery units is mandatory. 

82

Thumb Metacarpal Phalangeal Joint Capsulodesis at the Time of Basal Joint Arthroplasty: 

a Surgical Technique Utilizing Suture Anchors 

Institution where the work was prepared: Mayo Clinic, Phoenix, AZ, USA 

Scott F.M. Duncan, MD, MPH1; Smith Anthony, MD1; Merritt Marianne, RNFA1; Ivy Cindy, OT, CHT1; Renfree Kevin, 

MD1; Kousuke Iba, MD2; (1)Mayo Clinic - Scottsdale, (2)Sapporo University 

PURPOSE: 

Metacarpal-phalangeal joint capsulodesis is considered a technically demanding procedure with a recognized risk of digital nerve injury 

and tendon adhesions. Additionally, there is no uniform surgical approach for the procedure or agreed upon method of volar plate fixation 

to allow the procedure to be considered routine. The use of capsulodesis for the treatment of the hyperextended MPC joint at 

the time of basal joint arthroplasty is well established. The purpose of this study was to examine the results of a unique surgical approach 

to MCP joint capsulodesis that utilizes suture anchors. 

METHODS: 

This was a retrospective chart review examining the results consecutive patients undergoing thumb MCP joint capsulodesis between 

2003 and 2006. Indications for surgery were thumb MCP joint hyperextension deformity of at least 30 degrees with radiographic evidence 

of stage III basal joint arthritis. Variables examined included pre/post operative range of motion and complications. The surgical 

technique involves making a Bruner incision on the volar aspect of the MPJ. Both digital nerves are identified and protected. The A1 

pulley is released and the FPL retracted. The volar plate is released proximally and the joint is placed in 30 degrees of flexion. A Kirshner 

wire is then directed obliquely across the joint. A mini-mitek suture anchor is placed in the distal metacarpal. The volar plate is then 

mobilized and secured with the mitek sutures. The K-wire is pulled at 6 weeks. Hand therapy was initiated at the first post operative visit 

and a strict 16 week protocol followed. 

RESULTS: 

The average patient age was 62.4 years (55-79). Twenty-one thumbs in 19 patients were treated with the above technique. The average 

range of motion at the thumb MPJ after capsulodesis was 0 degrees of extension (range -5 to 5) and 40 degrees of flexion (range 20 

to 70). There were no cases of residual hyperextension at the last follow up (6-38 months). There were 4 complications: two superficial 

pin tract infection treated with oral antibiotics and two cases of complex regional pain syndrome. One patient complained of pain at 

the thumb MCP joint post operatively, and was considering arthrodesis. 

CONCLUSION: 

Thumb metacarpal phalangeal joint capsulodesis at the time of CMC arthroplasty can easily and effectively be performed utilizing this 

technique of suture anchors, joint pinning for 6 weeks, and a strict hand therapy protocol. 

Biotenodesis Screw in Basilar Thumb Arthritis: A Biomechanical Study 

Institution where the work was prepared: Tripler Army Medical Center, Honolulu, HI, USA 

John Faillace, MD; Hillcrest Baptist Medical Center; Shawn Hermenau, MD; Tripler Army Medical Center 

A number of procedures have been developed to reconstruct incompetent volar ligaments and to relieve pain in patients with CMC 

arthritis. Volar beak ligament reconstruction with local tendon grafts, tendon interpositions, and resection arthroplasties have all been 

described with success in the literature. More recent literature has shown that ligament reconstruction without tendon interposition provides 

reproducible relief to patients with CMC arthritis without loss of range of motion, pinch strength, or the ability to perform ADLs. 

Biotenodesis screws have been used with marked success in the knee and sports literature as well as the foot and ankle literature to 

aide in the reconstruction of ligaments. We have applied these principles to the reconstruction of the thumb volar beak ligament. The 

purpose of this cadaver study is to test load to failure and method of failure of volar beak ligament reconstruction with biotenodesis 

screw reconstruction compared to the standard tendon to tendon technique i.e. the modified ligament reconstruction of Eaton and 

Littler. 

Ten matched pairs of cadaveric hands of average age 60 years had ligament reconstruction with biotenodesis screw randomized to 

right or left and suture on the other. The specimens were tested first with 10 cycles of load for preconditioning then loaded to failure. 

The data was tabulated and analyzed with a One-Way ANOVA. 

The load at failure for both groups surpassed that expected for light pinch. The Biotenodesis screw was stiffer but did not reach statistical 

significance. The suture repair had a statistically significant higher load to failure (p=0.007). 

83

Partial Ulnar Head Resurfacing Implant Arthroplasty 

Institution where the work was prepared: University of Iowa, Iowa City, IA, USA 

Danielle A. Conaway, MD; Brian D. Adams; University of Iowa 

Although complete implant replacement of the distal ulna has become a popular and accepted procedure, in many cases it sacrifices 

normal portions of a distal ulna and important soft tissue attachments. Consequences of resecting unaffected portions of the distal ulna 

include a higher risk of distal radioulnar joint instability, implant prominence, soft tissue irritation, and ulnocarpal instability. To minimize 

the resection and to optimize the functional result of implant arthroplasty of the distal ulna for the treatment of distal radioulnar arthritis, 

a partial ulnar head replacement was developed, which only replaces the articular surfaces. The implant allows retention of the ulnar 

neck, ulnar styloid, extensor carpi ulnaris grove, ulnocarpal ligament attachments, extensor carpi ulnaris sheath, and the triangular fibrocartilage 

complex attachments to the ulnar styloid. It is intended for patients who have good skeletal alignment and functioning soft 

tissue stabilizers surrounding the distal ulna. To assess the design's replication of the natural anatomy, a study was performed on 10 

cadavers. A number of radiographic parameters were compared between the natural state of the distal ulna and the state after implantation. 

In addition, the results of the first 10 patients treated by 3 surgeons were reviewed to assess its clinical efficacy. Plain radiographs 

demonstrated a good match (within 7%) between the size and shape of the natural ulna and the implant, as well as ulnar variance, ulnar 

offset, and ulnar height at the distal radioulnar joint. Distal radioulnar joint stability was maintained by subjective assessment, and there 

was no loss of forearm rotation. Of the 10 clinical patients, 7 were treated for osteoarthritis and 3 for posttraumatic arthritis. In a retrospective 

chart review at an average 6 month follow up, there were no intraoperative or postoperative complications. Pain relief was satisfactory 

in all, though none were pain free. Motion was improved in all, with all patients achieving at least 75 degrees of pronation and 

65 degrees of supination. Wrist flexion and extension was unaffected. There were no cases of distal radioulnar joint instability. In conclusion, 

this preliminary report suggests that surface, ìconservativeî, implant replacement of the distal ulna may offer advantages over 

complete distal ulna replacement in selected patients. 

Dynamic (4D) Computed Tomography of the Wrist : Proof of Feasibility in a Cadaveric Model 

Institution where the work was prepared: Mayo Clinic College of Medicine, Rochester, MN, USA 

Shian Chao Tay, MBBS, FRCS, FAMS1; Andrew N. Primak, PhD2; Joel G. Fletcher, MD2; Bernhard Schmidt, PhD3; 

Kimberly K. Amrami, MD1; Cynthia H. McCollough, PhD1; Richard A. Berger, MD, PhD4; (1)Mayo Clinic, (2)Mayo Clinic 

College of Medicine, (3)Siemens Medical Solutions, (4)Mayo Clinic Foundation 

PURPOSE: 

High resolution real-time 3D imaging of the moving wrist may provide novel insights into the pathophysiology of dynamic joint instability. 

The purpose of this work was to assess the feasibility of using retrospectively-gated spiral computed tomography to perform 

dynamic (4D) imaging of the moving wrist joint. 

METHODS: 

A cadaver forearm from below the elbow was mounted on a motion simulator which performed periodic radioulnar deviation of the 

wrist at 30 cycles per minute. An electronic trigger from the simulator provided the "electrocardiogram" (ECG) signal required for gated 

reconstructions. The wrist was scanned on a 64-slice CT scanner (Sensation 64, Siemens Medical Solutions) using a retrospectively-gated 

CT protocol with a special low pitch of 0.1 provided by the manufacturer. Scanning was performed from the distal radius and ulna to 

the proximal metacarpals to ensure adequate coverage of the carpal bones. The first condition scanned was during periodic radioulnar 

deviation and was designated the 4D condition. The second scan served as a control where the wrist was precisely moved to four 

designated static positions and scanned. This control scan was designated the 3D condition. Both the 4D and 3D images were then 

compared by two blinded observers for image quality and presence of artifacts. The displacement of the distal pole of the scaphoid 

during radioulnar deviation was also calculated from the dynamic 4D phase after appropriate image segmentation and thresholding. 

RESULTS: 

Image quality of 4D images was rated by both observers to be excellent at the extremes of radial and ulnar deviation (end-motion phases). 

Mid-motion phases were rated by both observers to be fair due to the presence of motion and band artifacts. However, in all phases, 

carpal joint spaces remain well resolved. The centroid of the distal pole of the scaphoid was found to undergo a displacement magnitude 

of 12.4 mm. 

CONCLUSION: 

In conclusion, a method using retrospectively-gated CT for dynamic 4D imaging in the wrist is feasible. In the near future, this may provide 

hand surgeons a new diagnostic tool in which dynamic carpal instabilities can be assessed. 

84

Preliminary Experience with Fat Grafting of Dupuytren's Contracture Following Complete 

Percutaneous Release 


Roger K. Khouri, MD1; Jorge L. Orbay, MD1; Steven E.R. Hovius2; (1)Miami Hand Center, (2)Erasmus University 

Medical Center Rotterdam 

INTRODUCTION: 

Fat atrophy is inherent to the pathology of Dupuytren's contracture. Graft interposition after simple fasciotomy is widely believed to 

change the biology of the disease and to prevent recurrences. We hereby report our preliminary experience with lipografting 

Dupuytren's contracture following a novel minimally invasive release technique that safely cuts up the diseased cord and separates it 

from the dermis. 

PURPOSE: 

A strong steady extension force is applied on the digit using a lead hand retractor. Then progressing in an orderly fashion from proximal 

to distal, we make a series of palmar puncture wounds with a sharp tipped 1mm blade equipped with a T-bar stop which prevents 

from penetrating more than 3mm proximal to the transverse palmar crease, 2 mm over the distal palm, and 1 mm over the digits. 

Working along a wide area around the contracture, the cords are progressively and extensively severed through transverse oscillations 

at each puncture point. Skin wrinkles or pits are released with another dissecting instrument that severs dermal attachments of the cord. 

Following full contracture release, full skin separation from the cord, and full morcelization of the nodules, we fill the surgical site with 

lipoaspirate harvested from the flanks. An extension splint is incorporated in the dressing. 

CLINICAL RESULTS: 

We performed this incision-less minimally invasive procedure in 12 hands, four had four digital rays released and six had three. Three 

had recurrent disease, four had 90? PIP contractures and six had 60?MP contractures. Full complete extension was achieved in 9 and 

the remaining had less than 15? lag at the completion of the procedure. There were no complications and no morbidity. One week post 

op the patients were allowed to use the hand and wear an extension splint at night. At 2 weeks, all patients recovered full use of the 

hand. At one month, most striking findings were softness of the hand and absence of scarring. All patients were satisfied with the result 

and had no evidence of recurrence at an average of 6 months follow-up. 

CONCLUSION: 

We hereby describe a safe and minimally invasive approach to the treatment of Dupuytren's contracture that departs from the standard 

of cord excision and adds padding to the already fat-deficient hand. Fat grafting after extensive percutaneous superficial fasciotomy 

seems to prevent the flare reaction and to change the biology of the disease. 

Ulnohumeral Arthroplasty in the Management of the Arthritic Elbow 

Institution where the work was prepared: Wrightington Hospital Centre For Upper Limb Surgery, Wigan, United Kingdom 

M. J. Hayton; Sumedh C Talwalkar; Ian A Trail; Niloy Roy; John K Stanley; Wrightington Hospital 

Purpose: 

To present the long term follow-up of patients who underwent Ulohumeral arthroplasty for symptomatic elbow arthritis. 

METHODS: 

81patients were who underwent ulnohumeral arthroplasty between 1994 and 2002 were included in the study. All patients were sent a 

questionnaire with a request to attend a clinical evaluation. 40 patients replied and 34 attended for clinical examination. There were 6 

females and 34 males with an average age of 63 years (32-80) and a mean follow-up of 6years (2-10). There were 22(55%) patients with 

primary osteoarthritis, 14(35%) with osteoarthritis secondary to trauma, two patients with rheumatoid arthritis and one patient each with 

arthrogryphosis multiplex congenital and post-septic arthritis of the elbow. 

RESULTS: 

Using the VAS(0-10), the pain score was seen to improve from a mean pre-operative score of 8(6-10) to 4(0- 9). 21 patients (50%) were 

on minimal or no analgesia and 31(75%) patients felt they would have the surgery again for the same problem. The arc of motion as 

regards flexion/extension was found to increase by 19% while prono-supination was found to increase by 30%.There was one patient 

each with superficial infection, anterior interosseous nerve neuropathy and myositic ossificans while two patients had triceps rupture. 

Radiological examination showed that in 12 cases the trephine hole was partially obliterated while in 4 cases it was completely obliterated. 

This could not be correlated clinically. Patients with loose bodies seemed to do better in the post-operative phase. 

CONCLUSION: 

Ulnohumeral arthroplasty has a role in the management of the arthritic elbow as it provides pain relief in the post-operative period; 

however the improvement in the range of movement is limited particularly as regards the arc of extension. 

85

Isolated Proximal Pole Hamate Arthritis 

Institution where the work was prepared: Thomas Jefferson University, Philadelphia, PA, USA 

A. Lee Osterman, MD; Randall Culp; Thomas Jefferson University 

Proximal pole hamate arthritis is a common cause of ulnar wrist pain. Anatomic studies have shown increased lunato-hamate load forces 

and a consequent high association of proximal hamate arthritis with Type II lunates.Burgess first defined the association of lunato-triquetral 

instability and proximal pole arthritis. Palmer noted an incidence of 91% and defined the syndrome HALT,hamate arthrosis lunato-triquetral 

ligament tear. This study introduces a new entity-isolated hamate impaction --and its treatment. Between 1997-2000 we 

arthroscopically identified 57 consecutive patients with proximal pole hamate arthritis, of which 18 were isolated as defined by Grade 

II-IV Outerbridge changes and the absence of LT instability. 18 consecutive pts (19 wrists) 13 ?â 5 ?ä; 48yrs (27-66) Dominant wrist 50%; 

Acute injury event 50%; Work related 5, 2 WC. The onset of symptoms was often related to sports, especially those with ulnar loading 

such as golf (55%).Average symptom duration 11 months. All pts activity related pain. 74% had grip strength weakness in UD. Xray findings: 

All had Type II Lunate Facets averaging 2.7mm (1-5);Prox Pole Erosions in 37% Ulnar variance: 5+ avg 1.4mm; 10 neutral; 5- avg 

1.6mm.MRI findings: Proximal Pole changes 53%; 7 TFC tears (only 5 @ arthro)1 Hook Hamate Nonunion. Arthroscopic findings:Prox 

Pole Hamate Arthritis 100%; Midcarpal Synovitis 100%; TFC Tear IA---2 IIC---3; Pisotriquetral Arthritis 1 LT Instability none . Treatment 

was arthroscopic proximal pole hamate excision in all. An avg of2.6 mm Hamate resected (1-4mm). Concommitant surgery: Midcarpal 

synovectomy 100%; TFC debridement 5; Open Hook Hamate excision 1. Follow-up 7.0 years (3.1-9.3).1 lost to Fu @ 3.1 yrs 1 died, Last 

FU @ 5.1yrs. 94% very satisfied and would repeat surgery :RTW 15 days (2-84); RT Sports 3 months No radiographic evidence of progressive 

arthritis or collapse deformity. Wrist evaluation scores: Preop 73.1(Fair) to Postop 94.7 (Excellent). No Complications. In summary,Isolated 

proximal pole hamate arthritis does occur, and is another cause of ulnar wrist pain. It has an association with type II Lunates 

and a high incidence in golfers. Arthroscopic Proximal pole resection of 2.5 mm provides a reasonable solution with excellent results @ 

moderate FU interval. 

In-vivo Kinematic Analysis of the Forearm 

Institution where the work was prepared: Mayo Clinic College of Medicine, Rochester, MN, USA 

Shian Chao Tay, MD, MS1; Kazunari Tomita, MD1; Roger P. Van Riet, MD2; Kimberly K. Amrami2; Kai-Nan An, PhD3; 

Richard Berger, MD, PhD4; (1)Mayo Clinic College of Medicine, (2)Mayo Clinic, (3)Orthopedic Biomechanics 

Laboratory, (4)Mayo Clinic/Mayo Foundation 

PURPOSE: 

Controversy still exists regarding the location and nature (static or dynamic) of the forearm joint axis. This might be due to inconsistent 

results from in-vitro data and less precise methods of analysis. We present the first in-vivo kinematic analysis of normal forearm joint 

rotation described by helical axis analysis. 

METHODS: 

Data obtained from computed tomography images of both forearms of five healthy volunteers was used to calculate finite helical axis 

(FHA) parameters from transformation matrices. Four positions were analyzed: maximum pronation, maximum supination, 60? pronation, 

60? supination. Registration of the image data were performed using Analyze 7.0. Kinematic analysis focused on the motion of the 

radius around the ulna. 

RESULTS: 

FHAs were located near the center of the radial head biased towards the proximal radioulnar joint (PRUJ), extending towards the ulnar 

head just dorsal to its center at the distal radioulnar joint (DRUJ), moving in a linear motion at the radial and ulnar heads during forearm 

rotation. Magnitude of FHA rotation during pronation was larger than in supination. Proximo-distal translation of the radius during 

forearm rotation was a mean of 0.98 mm. A significant linear relationship was found between translation and rotation. 

CONCLUSION: 

The in-vivo forearm joint axis was precisely located. This new information of the forearm joint axis defined by FHA analysis, may be useful 

in implant design, and in guiding surgeons in their reconstruction of instabilities of the DRUJ or PRUJ. 

86

Mesh Implant Arthroplasty for Treatment of Basilar Joint Arthritis 

Institution where the work was prepared: Methodist Hospital, Houston, TX, USA 

Evan Collins, MD; Kimberly Staines; John Thornby; The Methodist Hospital 

PURPOSE: 

Multiple surgical approaches have been performed for advanced stage thumb basilar joint osteoarthritis (OA). This study assesses initial 

results of a new surgical approach utilizing a biodegradable polycaprolactone-based mesh implant as a spacer following a trapezium 

and base metacarpal resurfacing osteotomy. 

METHODS: 

A prospective convenience design was used to assess 15 patients between the ages of 42 and 66, who suffered from OA limited to the 

carpometacarpal (CMC), or basilar, joint of the thumb nonresponsive to conservative treatment over a 4 to 6 month period. Data collection 

included x-rays of the hand and thumb, posterior anterior, oblique, lateral and basil joint stress views, along with DASH and VAS 

scores and ROM ñ bilateral evaluation. The same surgeon treated all subjects and performed a surgical technique utilizing an approach 

to the capsule as described by Eaton. A biodegradable mesh T-shaped spacer of woven construction was used as implant. The outpatient 

procedure was performed using an intrascalene block. The surgeon began by dividing the capsule as a metacarpal based tongue 

flap, exposing the CMC joint. An osteotome and rasp resurfaced the joint, creating a parallel space. The implant was inserted and 

affixed to the metacarpal or trapezium ñ depending on the quality of bone stock ñ and secured with a Mitek suture anchor. 

Intraoperative imaging confirmed results. The capsule was closed with a running double loop supramid suture and the metacarpophalangeal 

(MP) joint was then assessed for laxity. Following 4-week immobilization, the same CHT performed postoperative follow-up at 

10 days, 4, 6, 8, 12 and 24 weeks. Pre and postoperative data was recorded. 


Mean data normalized as percentage change from pre to postoperative measures and compared to uninvolved side revealed significant 

improvement of 39% for Disability Assessment for Shoulder/Hand (DASH), p=0.0194(54.17 ± 24 preoperative; 32.96 ± 25 postoperative) 

and 54% improvement in Visual Analogue Scale for Pain (VAS), p=0.0212 (8.51 ± 2.6 preoperative; 3.38 ± 2.5 postoperative). 

Total Active Motion(TAM) in the involved thumb increased by 9% postoperative and was 96% of values in the uninvolved thumb. Tripod 

Pinch strength was 68% of uninvolved side preoperatively and improved to 81% postoperatively. Grip strength improved by 22% postoperatively 

and was 77% of values in the uninvolved thumb. 

CONCLUSION: 

Mean values and early results reflected improvement and indicate that this procedure leads to high patient satisfaction with low complications 

and should be considered for CMC basilar joint OA. 

87

Combining a Clinical Software Program, Research Databases, and Novel Teaching Software 

with the Use of Medical Informatics in a Resource Limited Environment 

Institution where the work was prepared: Baylor College of Medicine, Houston, TX, USA 

Brian A. Janz, MD; Anthony Echo; Morgan E. Norris, MD, DDS; Nicholas A. Fiore II; Baylor College of Medicine 

Combining a clinical software program and research databases in a resource limited environment can be advantageous to clinicians 

because of the ability to efficiently store patient information for both patient caring and later retrieval for research studies. The same 

user-interface, if linked to a repository of medical information can assist with streamlining teaching while caring for patients (Figure 1). 

The goals of the project included capturing patient data that was readily available at the point of care and utilize it for both tracking 

patients within the hospital and storing the data for research purposes; while at the same time linking the user-interface to a database 

of medical information for teaching purposes. 

SETTING: 

The software was designed to be utilized on a plastic surgery hand service at a major level one trauma center. 

METHODS: 

To accomplish this goal, a software program was designed to track hand surgery patients and serve as a large repository for key information 

that can be utilized to assist with retrospective research projects. The user-interface was also designed to allow information to 

be stored for prospective studies. A database of high yield upper extremity information was compiled by topic which could be linked 

to patient diagnoses. The clinical-user interface and research tools were both designed using the Visual Studio.NET © environment 

coupled with a relational database to store information. The standard demographic information along with major diagnoses for each 

patient was linked to both DRG and ICD-9 codes to allow for efficient access when evaluating and querying the databases. Patient data 

was recorded during the time period from March 2006 until April 2007 for this study. 

RESULTS: 

The database currently stores information for 184 patients. 64.2 % (n = 118) of the patients who underwent an operation were male. The 

major injury was related to trauma in 71.1 % (n = 131) of the cases. 48% of the trauma cases involved multiple injuries. Four-hundred 

and eighty three high yield clinical information summaries were compiled and separated into twenty-one categories. 

CONCLUSION: 

The software program allows for the entry of data to assist with the tracking of patients on a hand surgery service. Concurrently, the software 

program allows for retrieval of stored data to assist with clinical research projects either prospectively or retrospectively. The quick 

links between diagnoses and medical information summaries allows for a teaching module to assimilate with clinical and research userinterfaces. 

88

AAHS Concurrent Scientific Paper Session D 

Chimerism Induction and Maintenance in Composite Tissue Allograft Transplants after 

Augmentation with Donor Specific BMT 


Wioleta Luszczek, PhD; Aleksandra Klimczak, PhD; Maria Siemionow, MD, PhD; Cleveland Clinic 

INTRODUCTION: 

Impact of donor bone marrow transplantation (BMT) on chimerism induction in different composite tissue allograft (CTA) models was 

investigated. Methods: Four CTA models were studied: (1) limb allograft (n=36), (2) composite hemiface transplant (n=26), (3) vascularized 

bone (n=10) and (4) composite vascularized skin allograft (n=10) transplants. Transplants were performed across MHC barrier 

between ACI(RT1a, LBN(RT1l+n) or BN(RT1n) donors and LEW(RT1l) recipients under 7-day protocol of ??-TCR/CsA. All CTA allografts 

(except limb allografts) were augmented with donor BMT (70x106). Flow cytometry evaluated donor specific chimerism for MHC class 

I antigens in peripheral blood. Chimerism was evaluated as a contribution of donor T-(CD4, CD8) and B-lymphocytes (CD45RA). 

Immunohistochemistry determined engraftment of donor cells into lymphoid organs. 

RESULTS: 

In long-term survivals (over 100 days) chimerism levels were as follows: (1) limb allograft for T-cells 7.6% of CD4/RT1n, 1.3% of CD8/RT1n 

and 16.5% of CD45RA/RT1n for B-cells. (2) hemiface allograft transplants T-cells chimerism revealed 2.8% for CD4/RT1n and 1.9% for 

CD8/RT1n and 6.8% for CD45RA/RT1n B-cells population (3) vascularized bone allografts T-cells chimerism was assessed at 5.1% for 

CD4/RT1n and 1.9% for CD8/RT1n and at 5.2% for CD45RA/RT1n B-cells. (4) In vascularized skin allografts T-cell chimerism was: 8.0% 

for CD4/RT1a, 2.6% for CD8/RT1a and 0.4% for CD45RA/RT1a for B-cells linage. In all CTA models immunochemistry confirmed presence 

of donor-origin cells in the lymphoid organs of recipients. 

CONCLUSION: 

The best engraftment of donor cells was achieved in limb allograft transplant model as confirmed by stable chimerism level in T-cells 

population at early post-transplant and was maintained by B-cells lineage. The lowest level of chimerism was found in vascularized skin 

allografts confirming importance of bone marrow compartment as an integral part of the graft. This data indicate that constant source 

of BM delivery in limb allograft model is permissive for chimerism induction and its maintenance at stable level. This mechanism would 

apply and be permissive in acceptance of hand allograft transplants. 

Fifteen Year Follow-up of the Distal Single Scope Assisted Carpal Tunnel Release 


M. Ather Mirza, MD; Mary Kate Reinhart, CNP; M. Ather Mirza, MD, PC 

TITLE: 

Fifteen Year Follow-up of the Distal Single Scope Assisted Carpal Tunnel Release 

INTRODUCTION: 

This study reports the fifteen-year follow-up (1855 cases) of the distal single incision scope assisted carpal tunnel release technique. 

METHODS: 

A 1.5 cm longitudinal distal single incision in the palm allows direct visualization of the distal edge of the transverse carpal ligament, 

median nerve, the superficial palmar arch, and any abnormal structures. A specially designed knife/sleeve unit mounted on a standard 

4mm endoscope allows division of the transverse carpal ligament with a distal-to-proximal pass. 

RESULTS: 

Among those in whom the interthenar fascia is preserved, high lateral pinch strength was reported. Postoperative pinch and grip 

strength were near or greater than preoperative levels by eight weeks. The mean overall return to work time was 21 days. Among the 

patients reporting analgesic usage, 27% required no postoperative analgesics. Patients reported minimal scar, ulnar and radial pillar 

tenderness. There were no permanent injuries to the median nerve or superficial palmar arch. 

CONCLUSION: 

This technique allows for a small cosmetically appealing scar, direct identification of key anatomy, higher strength and function in early 

postoperative periods, and an overall early return to work and activities of daily living. This technique has shown excellent long- and 

short-term results. 

89

A Simple Method to Demonstrate Collateral Sprouting of An Intact Axon at End-to-side Neurorrhaphy Site 

Institution where the work was prepared: The First Affilated Hospital of Sun Yat-Sen University, Guangzhou, China 

Qing Tang Zhu, MD, PhD1; Jia Kai Zhu, MD2; Zhen Guo Lao, MD2; Xiao Lin Liu, MD, PhD2; Gary Chen, MD1; 

(1)California Hospital Medical Center, (2)The First Affilicated Hospital of Sun Yat-Sen University 

Recent experimental studies had suggested the successful nerve regeneration of an injured nerve repaired with end-to-side neurorrhaphy 

technique. However, the origin of the regenerating axons is still controversial. Some studies demonstrated that regenerating axons 

emerged at sites far proximal to the coaptation site. Some studies indicated nerve damage was a prerequisite for axonal regeneration 

through end-to-side neurorrhaphy, the regenerating axons originated from terminal sprouting of the proximal stump of the injured 

donor nerve. Most studies supported that the regenerating axons sprouted collaterally from the donor nerve at the neurorrhaphy site. 

Considering retrograde tracing or electrophysiological study only provided indirect evidences of collateral sprouting from the donor 

nerve, we presented a simple method to directly demonstrate collateral sprouting of an intact axon at end-to-side neurorrhaphy site. 

5 Wistar adult rats were used in this study. The common peroneal nerves at one side were sectioned and their distal ends were sutured 

laterally to the tibial nerves after removal of a 1-mm-diameter window in the epineurium. 3 months postoperatively, the nerve segments 

at neurorrhaphy site and the contralateral normal tibial nerves were harvested. The specimens were fixed in 10% formaldehyde and 

postfixed in 1% osmium tetroxide, then macerated in glycerol. Single nerve fiber was teased out with microsurgical instruments in pure 

glycerol under an operative microscope, then transferred to a slide and observed under light microscope. We found that small nerve 

fibers sprouted collaterally from a donor nerve fiber near nodes of Ranvier (Fig 1). However, such phenomena could not be found in 

normal tibial nerve without end-to-side neurorraphy. This study provided a direct evidence of collateral sprouting of an intact axon at 

end-to-side neurorraphy site. Nerve fiber micro-tease technique is a simple method to demonstrate such a phenomenon. 

Real Time in Vivo Imaging of Neural Microarchitecture with Coherent Anti-stokes Raman 

Scattering (CARS) Microscopy 

Institution where the work was prepared: Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 

Francis Patrick Henry, MD; Daniel Cote, PhD; M.A. Randolph, MAS; Irene E. Kochevar, PhD; Charles P. Lin, PhD; 

Jonathan M. Winograd, MD; Massachusetts General Hospital, Harvard Medical School 

INTRODUCTION: 

Current analysis of nerve injury and repair relies largely on electrophysiological and ex vivo histological techniques. In vivo architectural 

assessment of a nerve without removal or destruction of the tissue would greatly assist in the grading of nerve injury and in the monitoring 

of nerve regeneration over time. CARS Microscopy is a nonlinear optical process using ultrashort laser pulses to probe molecular 

vibrational structures and conformations in tissue with a particular sensitivity for high lipid containing molecules such as myelin. This 

minimally invasive, non-thermal technique offers high resolution images of neural microarchitecture, which we aim to evaluate in both 

normal and injured nerve. 

METHODS: 

A standard demyelinating crush injury was reproduced in the sciatic nerves of male Sprague Dawley rats. Animals were randomized into 

groups and CARS microscopy was undertaken at Day 1 and weeks 2, 3 and 4 following injury. The uninjured nerve was used as a control. 

Functional analysis was undertaken weekly with standardized walking track analysis. Histomorphometry of both control and injured 

nerve was undertaken following imaging to allow verification of our findings. 

RESULTS: 

All animals demonstrated loss of sciatic nerve function following nerve injury. Recovery was documented with sciatic functional index 

data approaching normal at three weeks. Demyelination was confirmed in nerves up to three weeks post injury. Remyelination was 

observed in the three week group and beyond (fig. 1). Imaging of the control nerves revealed structured myelin bundles as shown in 

fig. 2. These results were consistent with histological findings. 

CONCLUSION: 

We conclude that CARS Microscopy has the ability to image the peripheral nerve following demyelinating crush injury. This technology 

which permits in vivo, real time microscopy of nerves at a resolution of 5-10 microns could provide invaluable diagnostic and prognostic 

information about intraneural preservation and recovery following injury. 

90

Innervations of the Medial Head of the Triceps by the Ulnar Nerve 

Institution where the work was prepared: Department of Orthopaedic Surgery Columbia Uni. Medical Cen., New York, NY, USA 

Halil I. Bekler, MD; Joy Christiane Vroemen; Jason M. McKean; Melvin P Rosenwasser; Columbia University Medical 

Center 

INTRODUCTION: 

Surgical observations suggested that ulnar nerve give some motor branches to medial head just proximal to Cubital tunnel. Material 

and Methods: Seventeen fresh frozen human cadaver upper limbs from eleven cadavers were used. Nine of cadavers used were male, 

two female with an average age of 61.9 years. The medial head of the triceps (MHT) and ulnar nerve were exposed by a long medial 

incision over the upper arm and the soft tissue was dissected under 3.5 loupe magnification. For each dissection we measured how far 

the origin of the motor branch of the MHT was from the Cubital tunnel. Specimens of nerve branches from the ulnar nerve innervating 

the medial head of the triceps were taken, fixed in formalin, embedded in paraffin, sectioned at nerve-muscle connection and impregnated 

with silver nitrate to visualize axons and end-plates. 

RESULTS: 

Nerve branches from ulnar nerve were observed proximal to the cubital tunnel. These branches entered in the medial head of triceps 

muscle. The branches from the ulnar nerve comprised two or three separated fascicle that usually accompanied by vascular tissues. 

Discussion: A consistent presence of the motor branch to MHT arising from the ulnar nerve was observed. Branches are from the ulnar 

collateral branches of radial nerve having anatomical integrity with ulnar nerve. 

CONCLUSION: 

On the basis of cadaver specimen dissection and in vivo motor nerve stimulation, the ulnar nerve gives motor branches to the MHT. 

Figure 1: Ulnar nerve motor branch to the medial head of the triceps. 

Endoscopic Revision of Carpal Tunnel Release 

Institution where the work was prepared: University of Washington, Seattle, WA, USA 

Shai Luria, MD; Thanapong Waitayawinyu; Thomas E. Trumble; University of Washington 

BACKGROUND: 

Open revision with or without internal neurolysis has been the standard approach for treatment of recurrent carpal tunnel syndrome 

(CTS). Our hypothesis was that endoscopic revision without neurolysis will result in comparable results to open revision. 

METHODS: 

Forty-one patients with unilateral recurrence were prospective analyzed before and after endoscopic revision for a period of one year. 

All had clinical signs or symptoms, a positive response to a steroid injection and electrodiagnostic findings consistent with CTS after 

primary open release and had failed to improve after an average of 16 months. Follow-up evaluations were performed with validated 

outcome instruments and quantitative measurements of strength and sensation. Results - Thirty-seven of the 41 patients reported 

improvement after the endoscopic revision. Significant improvement was seen at 3 and 12 months after the procedure in the CTS 

Symptom Severity Scores (SSS), the CTS Functional Status Scores (FSS), the UW satisfaction score, pinch strength and sensation and a 

decrease in scar sensitivity. An improvement in grip strength was measured after 12 months. The satisfaction score was found to be significantly 

correlated to the SSS and FSS. 

CONCLUSION: 

Endoscopic release of recurrent CTS may be performed safely using standard technique with good results without the performance of 

neurolysis. The advantage of the procedure is the ability to approach the tunnel while avoiding the scaring related to the previous open 

approach. This technique is not adequate for cases after several open revisions, suspected nerve injury or extension of the previous 

open approach proximal to the wrist crease. 

91

Practical Clinical Guide for the Management of Chronic Pain Secondary to Neuropathic 

Conditions 

Institution where the work was prepared: Hand and Microsurgery Center of El Paso and UTEP, El Paso, TX, USA 

Jose Monsivais, MD; Hand & Microsurgery Center; Kris Robinson, PhD, FNP; University of Texas at El Paso 

INTRODUCTION: 

Chronic pain secondary to peripheral neuropathic conditions is frequently seen in clinical practice. However, precipitous surgical treatment 

in the presence of undiagnosed psychosocial dysfunction will end up in frustration for both the surgeon and the patient. 

MATERIALS/METHOD: 

Psychosocial dysfunction was recognized through clinical acumen and the use of multidimensional assessment of pain (VAS, Wong- 

Baker, and BPI). The clinical diagnosis of neuropathy was determined using standard sensory-motor evaluations and electrodiagnostic 

and imaging studies (MRI). An archival review of records from 91 patients treated for neuropathic pain over a ten-year period in a specialty 

clinic were included. Inclusion criteria were individuals with proven nerve dysfunction experiencing pain > 3 months. Surgical candidates 

were determined by the severity of sensory-motor abnormalities and showed evidence of improved psychosocial functioning 

as measured by the Brief Pain Inventory (BPI). Surgical procedures included nerve decompressions, reconstruction, neurolysis, and excision 

of neuromas. Medical treatment included analgesics, adjuvants, and neuroleptic medications. Psychosocial treatment included a 

prescription to remain or return to work on a predetermined date and daily exercise. Patient progress was monitored by pain diary, BMI, 

pulse, and biological markers when applicable. Participants received periodic clinical evaluation of sensory and motor function, and 

assessment of pain. 

RESULTS: 

Over 93% (85/91) of patients returned to work and reported lower levels of pain up to 5 years after onset of nerve injury/ condition. In 

addition, no differences were noted between individuals treated medically or surgically on a variety of psychosocial measures after treatment 

including pain level (p=.2), litigation status (p > .5), and return to work (p>.05). The majority of individuals expected total relief of 

pain with surgical treatment. This issue needs to be addressed to insure that patients have a realistic expectation of the treatment, 

whether surgical or medical. 

CONCLUSION: 

With psychosocial assessment, support, and adequate pain treatment, there seems to be no difference in functional outcomes on several 

levels between those patients receiving surgical and non-surgical treatment. Patients' expectations of total pain relief with surgery 

are unrealistic and must be addressed prior to treatment. In summary, early recognition and treatment of psychosocial dysfunction leads 

to improved outcomes as measured by improvement in pain, neurological signs/symptoms, and functionality. 

92

An Upper Limb Reach and Grasp Cycle for Children 


Amy L. Ladd, MD; Erin Butler; Stephanie Louie; Wendy Wong; Andrew Rogers; Jessica Rose; Stanford University 

Medical Center 

SUMMARY: 

We developed a ìReach and Graspî Cycle to evaluate upper limb motor performance in children, with consistent kinematic patterns 

emerging among control subjects for seven specified joint motions. The low coefficient of variation (CV) for elbow flexion/extension in 

each of the five phases of the Reach and Grasp cycle suggests a repeatable upper limb cycle for object evaluation of functional motor 

performance. 

INTRODUCTION: 

While a normative protocol exists for evaluating lower limb gait deficits [Schutte], kinematic analysis of the upper limb is more challenging 

and only recently examined [Mosqueda, Fitoussi]. We propose a ìReach and Graspî Cycle that is defined by upper limb kinematics 

and is consistent among children and adolescents. 


Three-dimensional kinematic data were recorded from 17 children (9 males and 8 females, ages 5-18 years) during a single Reach and 

Grasp cycle. We divided the upper limb ìReach and Graspî Cycle into five phases: 1) initial position, 2) reach and grasp an object placed 

at 75% total reach, 3) retract arm, bring object toward self, 4) reach and replace object, and 5) return arm to initial position (Figure 1). 

Light-reflective markers were placed on the children's torso and upper limbs, and a 3-D motion analysis system captured and processed 

upper limb kinematics for seven primary joint motions of the dominant arm and trunk (Motion Analysis Corportation, Santa Rosa, CA). 

We calculated the mean ± 1 standard deviation (SD) for every 2% increment of the cycle, and determined the coefficient of variation 

(CV) for elbow flexion/extension. We also evaluated upper limb kinematics for one child, age 6.5 years, with mild hemiplegic cerebral 

palsy (CP). 

RESULTS: 

Consistent normal kinematic patterns emerged for each of the seven motions: trunk flexion/ extension; shoulder elevation/ extension; 

shoulder rotation; elbow flexion/ extension; Forearm pronation/ supination; wrist flexion/ extension; and ulnar/ radial deviation. The 

mean ± 1 SD (CV) for peak elbow flexion/ extension in each of the five phases were: 82±13 (16%), 53±12 (22%), 127±6 (5%), 54±12 (22%), 

and 82± 14 (18%). The child with mild CP demonstrated decreased shoulder elevation, increased shoulder internal rotation, and 

reduced elbow extension, compared to the normative data. DISCUSSION The defined Reach and Grasp cycle has potential to provide 

an effective classification system for upper limb kinematics based on 3-D motion analysis. Such a system is necessary to advance our 

understanding of upper limb motor disorders and improve therapeutic modalities for the upper limb. 

93

Anticoagulation in Digital Revascularization and Reimplantation Surgery: a Complete Analysis 

of Beneficial and Detrimental Effects 

Institution where the work was prepared: Montreal University Health Care Center, Montreal, Canada 

Youssef Tahiri, medical, student; Patrick Harris, MD; Genevieve Landes, MD; Valerie Lemaine, MD; Andreas Nikolis, 

MD; UniversitÈ de MontrÈal, HÙpital Notre-Dame 

INTRODUCTION: 

Anticoagulation administration in digital replantation microsurgery is not without serious consequences. Furthermore, no consensus exists 

among microsurgeons regarding indications, timing and duration of medication administration. The aim of the study is to better establish 

the efficacy and risks associated with three different thromboprophylaxis regimens commonly used in digital replantation microsurgery. 


All patients consecutively treated at a specialized microsurgical replantation center from April 2004 to April 2006 were evaluated. All 

traumatically severed digits revascularized or reimplanted over the study period were included. Demographic data, injury characteristics, 

as well as type, dosage, duration and timing of medication administration for thromboprophylaxis were assessed. Primary endpoints 

with respect of thromboprophylaxis regimens efficacy and risks were i) the proportion of successfully replanted digits at the 

moment of patient discharge and ii) the incidence of complications in the immediate and short term post-operative periods. 

Proportions were compared by using X≤ tests and multivariate analyses were conducted with logistic regression. 

RESULTS: 

Over a 2-year period, 151 digits were treated: 91 revascularization and 60 reimplantation procedures. Sixty-five percent of digits received 

pre-operative aspirin at dosing of 325 mg. Overall, 98.0% of the digits received post-operative thromboprophylaxis regimens: 51,0% 

received aspirin 80 mg once daily plus subcutaneous heparin 5000 U twice daily (group A; n=77) for a mean duration of 4.8 days (±1.4 

days), 33.1% received aspirin 80 mg once daily plus IV heparin (group B; n=50) for a mean duration of 5.3 days (±1.9 days), and 13.9% 

received two weeks of aspirin 80 mg once daily (group C; n=21). Success rates at discharge were as following: group A 96.1%, group B 

90.0%, and group C 85.7% (p=0.191). Short term complication rates in groups A, B, and C were similar at 24.7%, 42.0%, and 33.3% 

respectively (p=0.121). Controlling for age, smoking status and the intervention performed, the type of anticoagulation regimen was 

not significantly related to success rates, whereas digits on IV heparin had a 2.4 times greater risk of complication than digits on subcutaneous 

heparin (95% CI, 1.5-5.4). 

CONCLUSION: 

Important discrepancies were outlined in the administration of anticoagulation regimens in digital replantation surgery. When considering 

short-term outcomes following microsurgical digital reimplantation and revascularization interventions, no significant survival differences 

were identified based on the type of regimen used. Digits receiving IV heparin had a significantly greater risk of post-operative 

complications than those receiving subcutaneous heparin. 

94

Local Immunotherapy Inhibits Skin Rejection in Composite Tissue Allotransplantation 


Mario G. Solari, MD; Kia M. McLean; Justin M. Sacks; Theresa Hautz; Jignesh V. Unadkat; Elaine K. Horibe; Vijay S. 

Gorantla; Stefan Schneeberger; Angus W. Thomson; W.P. Andrew Lee; University of Pittsburgh 

INTRODUCTION: 

Skin is the most immunogenic component of a composite tissue allograft (CTA). Clinically this has manifested as multiple acute skin 

rejection episodes in most of the human CTA performed to date. Intravenous steroids and increased systemic immunosuppression have 

been used to mitigate these rejection episodes. These drugs cause direct organ toxicity and are associated with metabolic dysfunction, 

opportunistic infection, and malignancy. Topical immunotherapy is an attractive and practical therapeutic option to provide local 

immunosuppression with minimal systemic toxicity. Topical tacrolimus is known to reduce the stimulatory activity of antigen presenting 

cells (APC) toward autologous T cells in atopic dermatitis. The present study applies these properties to CTA. It investigates the potential 

of topical tacrolimus to maintain a CTA after total withdrawal of a short course of systemic therapy. 

METHOD: 

Wistar Furth to Lewis (full MHC mismatch) orthotopic hind limb transplants were performed. Groups included: I- topical tacrolimus 

alone, II- anti-lymphocyte serum (ALS) (0.5mL x2 doses) + 21 days cyclosporine (CsA) (10/mg/kg/day), III- ALS (2 doses) + 21 days CsA 

+ topical tacrolimus once daily. The endpoint of the study is grade 3 rejection, defined by epidermolysis, or 100 days (long term survival). 

Biopsies of skin, muscle, and bone were taken for immunohistochemistry and H&E. 

RESULTS: 

All animals in Group I (n=7) developed grade 3 clinical rejection by postoperative day (POD) 9, similar to controls without treatment. The 

mean onset of grade 3 rejection was POD 40 with a range of 34-44 in Group II (n=7). In Group III (n=6), two animals developed grade 3 

rejection on POD 35 and 56. The remaining 4 experimental animals reached the 100 day endpoint without grade 3 rejection (Fig 1). 

CONCLUSION: 

This study demonstrates the feasibility of maintaining a CTA on topical tacrolimus therapy alone after induction therapy. The induction 

protocol in this model mirrors what is currently performed clinically where recipients undergo lymphoid depletion before organ transplantation, 

followed by systemic immunosuppression. Preoperative depletion of T cells with ALS, along with a short course of systemic 

immunosuppression, prevents acute rejection, while topical tacrolimus may inhibit immune cell activation and multiplication in the skin 

component of the CTA. This novel regimen could reduce or eliminate the morbidity associated with systemic immunosuppression in 

clinical CTA. 

95

Rate of reoperation following digital replantation and revascularization surgery in a designated 

Provincial University Replantation Program 

Institution where the work was prepared: Centre hospitalier de l'Universite de Montreal, Montreal, QC, Canada 

Valerie Lemaine, MD; GeneviËve Landes; Patrick Harris; André Chollet; Youssef Tahiri; Andreas Nikolis; UniversitÈ de 

MontrÈal, HÙpital Notre-Dame 

PURPOSE: 

The Quebec Provincial Replantation Program (QPRP) is comprised of a core group of twelve microsurgeons who cover the entire 

province of Quebec, Canada for all microsurgical emergencies (n=120 patients/year). The impetus for creation of the program included 

centralizing surgeon expertise to one designated center, increasing the surgeons' exposure to infrequent surgical traumas, and 

developing and refining protocols for this trauma population. As our outcomes for successful replantation or revascularization have 

reached approximately 90%, our next step in the evolution of the program is the evaluation of secondary procedures. Further surgery 

following digital replantation or revascularization is frequently necessary in improving function, this in conjunction with a tailored rehabilitation 

program. The goals of this study were first, to determine the rate of reoperation in a unique patient population; second, to identify the 

type and frequency of procedures performed; and finally, to establish which factors predisposed patients to reoperation. 

METHOD: 

An observational study was conducted from April 2004 to March 2005. Patients who underwent successful digital microsurgery were 

included. Data was abstracted from hospital and office charts, as well as through patient interviews conducted in the follow-up period. 

Informed consent was obtained from all study participants. 

RESULTS: 

A total of 68 patients who suffered hand trauma requiring digital microsurgery were included. The combined digital survival rate in these 

patients was 88.9%. Twenty-five of these patients (41.7%) had one or more secondary procedures. Secondary procedures in patients 

who had successful digital microsurgery were divided into an early group (< 2 months after the initial surgery) and a late group (> 2 

months after the initial surgery). In the early group, approximately half of the procedures were performed for anastomotic problems (all 

within 10 days). In the late group, 37.5% of procedures were bone-related surgeries for functional improvement, followed by joint-related 

procedures (25%). Avulsion injury, multiple-digit trauma and zone II injuries were significantly associated with a higher rate of reoperation. 

No significant association was found between the incidence of secondary procedures and smoking, alcohol consumption, 

patient age, or the digit traumatized. 

CONCLUSION: 

This study reports a rate of reoperation of 41.7% within 24 months following successful digital microsurgery, which is comparable to 

published data. Early procedures were predominantly emergency surgeries for anastomotic problems while late procedures were mainly 

bone grafts and arthrodesis for functional improvement. 

Survey of The Current State of Upper Extremity Replantation in North America 

Institution where the work was prepared: University of Texas Southwestern, Dallas, TX, USA 

David W. Mathes, MD1; Dan Hatef2; Michel Saint-Cyr2; (1)University of Washington, (2)University of Texas Southwestern 


INTRODUCTION: 

Replantation is the standard of care for treatment of selected upper extremity amputations. While many technical steps central to successful 

replantation have been standardized, significant variations in their management exist. We sought to examine the frequency, success, 

and the technical variations in digital replantation performed at replant centers in North America. 

METHODS: 

In 2006, a 3-page survey on the current management of upper extremity replants was sent to 58 centers that have an active Hand surgery 

training program. Surveys were mailed to each program and results were evaluated in a blinded fashion. The survey examined the 

pre-operative, intra-operative and post-operative management of the upper extremity replants. 

RESULTS: 

Of the 58 surveys sent out, we received 31 responses (55.4% response rate). The majority of programs perform 1 to 10 replants per 

month (84.6) while one program reported 31 to 40 replants per month. The success rate of these replants was high in all programs with 

32% of them reporting 100% success rate. Sixty percent of the program surveyed stated that they were performing single digit replants 

(excluding thumb) with 17 of the programs replanting single digits amputated in zone 1. Most hand surgeons employed intra-operative 

heparin (96.2%) but the dosage varied. However, only 57.6% of the programs used post-operative heparin while and even smaller 

group (36%) use Dextran. The most common method of post-operative monitoring was oxygen saturation monitoring (50%). Hand held 

Doppler was used in only 26.9% of the programs. The majorities of the centers keep their patients hospitalized for an average of 5 days 

(42.3%) and begin post-operative mobilization at 2 weeks (44.4%). 

CONCLUSION: 

This survey indicates that variations in replant management mostly involve post-operative medical care. The liberal use of aspirin, vein 

grafts, and K wire fixation were found in most training programs. The survey provides a cross sectional assessment of digital replantation 

practices in North America and could provide the basis for further multi-institutional examination of what constitutes the best management 

of the digital replant. 

96

The Effect of Donor Presensitization on the Immunotolerance in Composite Tissue 

Transplantation in Rat Groin Flap Model 


Mehmet Bozkurt, MD; Serdar Nasir; Aleksandra Klimczak; Lukasz Krokowicz; Wioleta Luszczek; Maria Siemionow; 

Cleveland Clinic 

INTRODUCTION: 

New protocols are needed for tolerance induction in composite tissue allograft (CTA) such as human hand. It is well documented that 

bone marrow transplantation induces donorñspecific immune-tolerance through the creation of mixed chimerism. Donor sensitization 

with the recipient bone marrow before transplantation is a new approach to induce immuntolerance. We demonstrated the effect of 

donor sensitization on the immune response to vascularized skin allografts. 

METHODS: 

Fourty transplantations were performed in 8 experimental groups of 5 animals each. Allograft transplants were performed between presentisized 

ACI donors and Lewis recipients. In each experimental group ACI (RT1a) donor rats were presentisized with Lewis (RT1l) bone 

marrow (80x106 cells) 24 hours (group I, III, V, VII) or 72 hours (group II, IV, VI, VIII) before transplantation. In groups I, II, V, VI donors 

received ??-TCR and cyclosporine (CSA) treatment therapy before transplantation. Animals in groups III, IV, VII, and VIII did not receive 

??-TCR. After groin flap transplantation Lewis (RT1l) recipients in groups V, VI, VII, VIII were under 7 day protocol of ??-TCR and CSA. 

Recipients in groups I, II, III, IV did not receive any kind of immunosupression. Before transplantation bone morrow cells (BMC) were 

stained with PKH dye to evaluate migratory process of donor BMC. Assessment included flap viability, flow cytometry for donor 

chimerism, and immunohistochemistry. 

RESULTS: 

In the control groups VSA were acutely rejected within 5 to 9 days. The mean survival of VSA was 82 days in Group V, 73 days in group 

VI, 75 day in Group VII and 54 day in group VIII. Donor specific chimerism in peripheral blood was estimated by presence of T and B 

cells. Total chimerism levels for Group V at day 7, 21, 35 and 63 were 4.93%, 1.75%, 2.46%, 1.45% respectively and Group VI 3.6%, 2.37%, 

1, 87%, and 0.48% respectively. Chimerism level for Group VI (24 hour after bone marrow transplantation) were at 7th 21st 35th 63rd are 

3.92%, 1.26%, 1.64%, 1.42% respectively and for group VIII were 4.82%,2.29%, 2.37%, 2.25% at respective days. 

CONCLUSION: 

Donor sensitization with recipient BM modified the recipient's responsiveness to VSA. This study proved that immunomodulation is not 

required for donor presensitization however is mandatory during allograft transplantation. Significant extension of skin allograft survival 

is encouraging and in future boosting dosage of BM may facilitate tolerance induction in composite allograft allotransplantation. 

Pedicled Radial Artery Removal Does Not Compromise Palmar Microcirculation Among 

Arteriosclerotic Patients 

Institution where the work was prepared: Hannover Medical School, Hannover, Germany 

Karsten Knobloch, MD, PhD; Sandra Tomaszek; Marcus Spies; Kay H. Busch; Peter M. Vogt; Hannover Medical School 

BACKGROUND: 

Radial artery forearm flaps are used for reconstruction of soft tissue defects. However, the functional consequences of removal of the 

radial artery for hand perfusion remain unclear. Therefore, we determined palmar microcirculation in a long-term follow-up among arteriosclerotic 

patients following removal of the radial artery for revascularisation. 

METHODS: 

A total number of 114 patients (100 males, 61.7±6.7 years) were included undergoing elective coronary revascularization using the radial 

artery of the non-dominant forearm with non-pathological Allen-Test. Palmar microcirculatory mapping was applied regarding capillary 

flow, finger tip oxygenation as well as postcapillary venous filling pressures throughout both hands at a mean 25±5months following 

removal of the radial artery using combined non-invasive real-time Laser-Doppler flowmetry & spectrophotometry (Oxygen-to-see, 

LEA Medizintechnik, Giessen, Germany). 

RESULTS: 

25±5months following radial artery removal only 2/56 positions revealed a difference beyond a 5% threshold. Superficial capillary blood 

flow decreased by 13% at the hypothenar eminence (242.0±153.6 vs. 275.6±169.2, p=0.009). Deep postcapillary venous filling pressure 

(8mm) was significantly increased by 9% only at the fingertip of the fifth finger (112.4±49.7 vs. 103.0±25.0, p=0.033). No clinical signs of 

malperfusion were found following radial artery removal and no patient was impaired in his daily palmar motor activity. 

CONCLUSION: 

Pedicled removal of the radial artery does not compromise superficial or deep palmar capillary blood flow, finger tip oxygenation or 

postcapillary venous filling pressures in a long-term perspective in arteriosclerotic patients. No clinical relevant signs of malperfusion or 

any deterioration of palmar motor function was encountered. The blood flow via the ulnar artery and the interosseal artery compensates 

palmar perfusion without microcirculatory deterioration even more than two years following removal of the radial artery. 

97

AAHS Outstanding Nerve Paper Presentations 

Aberrant Anatomy Does Not Preclude Safe Carpal Tunnel Release Via a Limited-Open 

Approach 

Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA 

Caitlin Gannon, BS; Mark E. Baratz; Allegheny General Hospital 

HYPOTHESIS: 

The presence of aberrant anatomy during a limited-open carpal tunnel release does not require conversion to an open procedure. 

Patients with aberrant anatomy who undergo a limited-open approach can have successful and safe outcomes. 


One thousand three hundred sixty-nine patients underwent carpal tunnel release (CTR) between January 2000 and April 2007 were 

identified and 1,091 patients were included in the study. Patients were excluded if their surgical record could not be found. There were 

709 women and 381 men. Anomalies were categorized by those involving the median nerve, anomalous muscles or tendons, and aberrant 

arteries or veins. Anomalous nerves were often seen in the presence of anomalous fibers of thenar muscle that crossed the midline 

of the palm. In each case the nerve was dissected back to the main trunk of the median nerve. When the nerve could be traced to 

the median nerve in the distal 25% of the carpal canal, limited open release using a knife and guide proceeded in a typical fashion. 

Otherwise, we performed a formal open carpal tunnel release tracing the motor branch until it rejoined the median. 

RESULTS: 

Of the 1,091 carpal tunnel releases, 66 (6%) showed aberrant anatomy of the motor branches, muscle, or a combination of motor 

branches and muscle. The anomalies included thirty-five (54%) transligamentous aberrant motor branches of the median nerve, 1 (2%) 

subligamentous aberrant motor branch, 1 (2%) intraligamentous anomalous nerve branch, and 1 (2%) median nerve was aberrant to the 

radial leaflet. Of the other anomalies found 34 patients (52%) had anomalous muscles, 8 (12%) hands contained an aberrant motor 

branch and anomalous muscle, 1 had a palmaris longus tendon within the carpal canal and 1 patient (2%) had an aberrant median artery 

and vein passing superficial to the transverse carpal ligament. Sixty-five of the procedures were able to proceed safely through a limited-open 

approach using a knife and guide designed to facilitate limited open release. One procedure, where the aberrant motor 

branch was intra-ligamentous, required conversion to an open release. 

SUMMARY: 

In our experience, most aberrant branches of the median nerve split the distal fibers of the transverse carpal ligament on the ulnar side 

of the median nerve and cross the field to enter the thenar musculature. In all but one instance the nerve could be safely dissected 

through the small distal incision, allowing the release to proceed via a limited-open approach. 

98

Efficacy of Endoscopic Cubital Tunnel Release 

Institution where the work was prepared: Orthopaedic Specialists, PC, Davenport, IA, USA 

Tyson Cobb, MD1; Jon Lemke, PhD2; Jennifer Tyler, PA1; Patrick Sterbank, PA1; (1)Orthopaedic Specialists, PC, (2)Genesis 


HYPOTHESIS: 

Endoscopic cubital tunnel release is as efficacious as open release based on resolution of preoperative paresthesias in the ulnar nerve 

distribution. 

METHODS: 

Records from 113 consecutive cases of endoscopic cubital tunnel releases performed in 99 patients were retrospectively reviewed.† 

Patients were queried as to the presence or absence of numbness and tingling in the ulnar nerve distribution.† There were 104 of the 

113 cases of endoscopic cubital tunnel release who had preoperative paresthesia.† The 9 who did not have preoperative paresthesia 

underwent the endoscopic cubital tunnel release as a prophylactic measure due to the nature of concomitant surgery.† Preoperative 

severity was classified using Dellon's classification.† Two control groups (submuscular transposition and simple decompression) were 

formulated from a meta-analysis of published reports.† Logistic regression was used to compare resolution rates of paresthesia following 

endoscopic versus open cubital tunnel release while controlling for Dellon's scores. 

RESULTS: 

Of the 104 cases, 42 (40.4%) received endoscopic cubital tunnel release only.† Concomitant surgeries included 49 (47.1%) endoscopic 

carpal tunnel releases and the other 13 surgeries included trigger finger releases, elbow arthroscopy, and mass excision.† Evaluation 

based on Dellon's classification revealed 5 cases of mild, 41 cases of moderate, and 58 cases of severe cubital tunnel syndrome.† There 

was resolution following endoscopic cubital tunnel release in 100.0% of mild, 80.5% of moderate, and 65.5% of the severe cases.† In 

the simple decompression control group, paresthesias resolved in 91.1% of mild, 60.8% of moderate, and 33.8% of severe cases. 

Controlling for Dellon's scores, the odds ratio was 3.38 (p

AAHS Poster Presentations 

Management of Open Wounds with Exposed Vital Structures 

Institution where the work was prepared: UMDNJ - New Jersey Medical School, Newark, NJ, USA 

Ulysses Scarpidis, MD, MPA; Ramazi O. Datiashvili, MD, PhD; UMDNJ - New Jersey Medical School 

Primary wound closure in extremity replantation is frequently impossible due to significant post ischemic and post traumatic edema 

and/or tissue loss. In many instances, despite local tissue rearrangement, there remain open wounds with exposed vital structures such 

as repaired vessels, nerves, and tendons at the site of replantation. This threatens the survival of replanted segments as well as the functional 

outcome of the surgery. Immediate skin grafting of these wounds risks thrombosis of the vessels, creation of neuromas, and tendon 

adhesions. We report our experience in managing post-replantation open wounds with exposed vital structures using a biosynthetic 

skin substitute (Biobrane, Bertek Pharmaceuticals, NC) and subsequent skin grafting of the wound. This experience is based on 

two cases of forearm replantations and one case of thumb replantation. All replanted segments survived, and patients have good long 

term functional results. 

Our experience shows that temporary wound closure with biobrane provides reliable protection of vital structures, prevents thrombosis 

of the vessels and prevents tendon adhesions. It facilitates in the formation of a fine granulation tissue envelope around these structures 

providing optimal conditions for subsequent skin grafting of the wounds without interfering with vital structure function. 

Large Fragment Coronal Split Fractures of the Hamate 

Institution where the work was prepared: Naval Medical Center San Diego, San Diego, CA, USA 

Eric Hofmeister; Leo T. Kroonen; Michael G. Clarke; Naval Medical Center San Diego 

INTRODUCTION: 

Coronal split fractures of the hamate are rare injuries caused by axial loads, often as a result of a clenched fist striking a solid object. 

Only case reports and small case series are found in the literature. The purpose of this study was to examine the methods of diagnosis, 

treatment, and outcomes of a cohort of seven patients with this rare injury. 

METHODS: 

From December 2004 to June 2005, all patients with large coronal split fractures of the hamate were treated at our institution. A retrospective 

review of the clinical data and radiographs was conducted. Demographics, radiographic studies, associated injuries, time to 

definitive treatment, treatment methods, and rate and time to return to full activities were reviewed. 

RESULTS: 

Seven cases of this injury were indentified and five elected operative fixation. Four of the cases were initially misdiagnosed. Computed 

tomography was used for injury characterization in six of seven cases, and revealed a significant articular ìdie-punchî fragment in three 

cases. Average diastasis of major fragments in the sagittal plan was 7.5mm (range 5.2-10.7mm). Associated injuries included 4th 

metacarpal fractures in six cases, capitate fractures in two cases, and 3rd and 5th metacarpal fractures in two cases each. Five of seven 

patients returned to full active duty status in an average of 58 days and 2 cases were lost to followup. 

DISCUSSION: 

In the largest series of coronal fractures of the hamate, only 4/17 were Type III injuries (described as coronal split fractures of the hamate 

described here) and other case reports describe the rarity of this injury. Injuries to the body of the hamate should be suspected any time 

a patient presents with significant ulnar sided hand or wrist pain after a closed fist injury as in our series four of seven injuries were initially 

misdiagnosed. Computed tomography is useful in characterizing the intraarticular component of this injury, as die-punch fragments 

and significant diastasis can be associated with these fractures. Two of our cases were successfully treated with closed reduction 

and casting, but the majority required surgical fixation. While closed reduction and casting of these injuries can be attempted, often 

adequate reduction cannot be achieved. In these cases, surgical stabilization should be performed in order to prevent early arthrosis, 

muscle imbalance, loss of grip strength and chronic pain. With appropriate treatment, these injuries heal well, and patients are usually 

able to return to full duty in 6-12 weeks. 

100

Wrist Arthroscopy: Correlation of Clinical Findings, Imaging with Arthroscopic Findings and 

Outcome Results 


Siau Woon Jacqueline Tan, MBBS, MRCS, MMED; Lam Chuan Teoh; Soo Heong Tan; Siew Weng Ng; Singapore General 

Hospital 

This is a retrospective review of 70 consecutive wrist arthroscopies performed at our institution between January 2000 and July 2005. All 

the patients complained of wrist pain, which often interfered with their daily activities, work or sports. The mean duration of symptoms 

was 8 months. Preoperative arthrograms and MRIs were performed in 50 and 15 patients, respectively. A standard arthroscopic technique 

was employed in all. Any triangular fibrocartilage complex (TFCC), scapholunate (SL) or lunotriquetral (LT) tears found were debrided. 

There were 42 patients with TFCC tears, 62 with SL tears and 51 with LT tears. Clinical findings were found to correlate well with arthroscopic 

findings. Using wrist arthroscopy as a standard reference, arthrography was found to have high sensitivities for the detection of 

TFCC tears (0.96), SL tears (1.00) and LT tears (0.94) but low specificities of 0.63, 0.14 and 0.27, respectively. MRI was neither sensitive nor 

specific. At follow-up examination at an average of 16.2 months, 85.8% reported an improvement in symptoms and 20% had improved 

range of motion. Grip strength improved by 11%. On the average, the patients rested for 2.6 months before returning to work. Outcome 

following arthroscopic debridement was determined using the Mayo Modified Wrist Score. Based on the postoperative wrist scores of 

50 patients, 23 patients (46%) were rated excellent, 20 (40%) good, 5 (10%) fair and 2 (4%) poor. By comparing preoperative and postoperative 

wrist scores of 37 patients, we were able to demonstrate significant improvement in patients who underwent wrist arthroscopies. 

Outcomes for Limb-Salvage Surgery for Osteosarcoma of the Distal Radius: 

Institution where the work was prepared: University of Michigan Hospitals, Ann Arbor, MI, USA 

Asheesh Bedi, MD1; Peter J. L. Jebson1; Peter M. Murray, MD2; Edward A. Athanasian, MD3; Alexander Y. Shin, MD4; 

Paul S. Cederna, MD1; (1)University of Michigan, (2)The Mayo Clinic, (3)Hospital for Special Surgery & Memorial Sloan 

Kettering Cancer Center, (4)Mayo Clinic; J. Erickson, MD 

Osteosarcoma of the distal radius is an extremely rare lesion, accounting for less than 1% of all primary osteosarcomas. Limited information 

on the outcome of different treatment strategies is available in the literature. The purpose of our study is to present the diagnostic 

challenges, imaging features, and treatment principles of limb salvage surgery for these rare lesions through illustrative case examples. 

A multi-center case series of patients treated with limb-salvage surgery for osteosarcoma of the distal radius is presented. All patients 

were treated using a multidisciplinary approach and underwent preoperative, neo-adjuvant chemotherapy. Surgical management 

included wide resection and vascularized or non-vascularized fibular autograft reconstruction with fibulo-capitate fusion. Serial radiographs 

and adjunct imaging studies were reviewed for tumor staging, progression to union, and hardware complications. Chart review 

was performed to define patient demographics, preoperative chemotherapy regimen, tumor response, surgical margins, postoperative 

complications, tumor recurrence, metastatic disease, and patient satisfaction. 

We determined that an osteosarcoma of the distal radius is rare and that misdiagnosis is common. A successful outcome defined by a 

functional limb, patient life expectancy, and high patient satisfaction is feasible with a multidisciplinary treatment strategy of neoadjuvant 

chemotherapy and wide resection with fibula autograft reconstruction. 

Sclerosing Therapy and Eccentric Training in Flexor Carpi Radialis Tendinopathy in a Tennis Player 


Karsten Knobloch, MD, PhD; Peter M. Vogt; Hannover Medical School 

Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. Recent research revealed the role of a neurovascular ingrowth at the point 

of pain in various tendinopathic locations, such as at the Achilles and patellar tendon, in plantar fasciitis as well as in supraspinatus and 

tennis elbow tendinopathy. However, beyond the elbow no such neovascularisation has been reported yet. We present a 35-year old tennis 

player suffering tremendous pain (VAS 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform 

bone. Laser-Doppler flowmetry incorporated in the Oxygen-to-see system (LEA Medizintechnik, Giessen, Germany) revealed an 

increased capillary blood flow in 8mm tissue depths at three distinct positions at the distal flexor carpi radialis tendon in 1cm distances 

in contrast to the healthy contralateral side (from distal to proximal: 146/240/232rU at the symptomatic side vs. 93/74/70rU at the asymptomatic 

side). Tendon oxygen saturation was slightly elevated at the corresponding three symptomatic vs. the asymptomatic positions 

(81%/79%/88% vs. 66%/65%/67%). However, postcapillary venous filling pressures at the FCU tendon were within the same range 

(46/39/50rU vs. 38/55/41rU). Using combined Power and Laser-Doppler spectrophotometry a targeted sclerosing therapy was performed 

using 0.25% polidocanol in 0.1ml titration volumes at the area of neovascularisation until resolution of the flow signal using the Power- 

Doppler, which was achieved with 1.5ml of polidocanol. Capillary blood flow using the Oxygen-to-see system declined immediately at 

all three positions in the flexor carpi radialis tendon (113rU vs. 146rU (distal), 219rU vs. 240rU (middle), and 175rU vs. 232rU (proximal). 

Tendon oxygenation was slightly elevated following sclerosing from 81%/79%/88% to 97%/99%/91% associated with slightly elevated 

postcapillary venous filling pressures by 20%. Pain immediately following the initial sclerosing was decreased to 4/10 with further resolution 

of pain following a 12 week interval of daily eccentric training of the forearm muscles using the Thera-BandÆ Flex-BarÆ for eccentric 

training with 6x15 repetitions per day to VAS 0/10. Neovascularisation is evident beyond the elbow at the wrist level such as in flexor 

carpi ulnaris tendinopathy. Power-Doppler ultrasound associated with quantitative combined Laser-Doppler & spectrophotometry are 

capable to detect the area of neovascularisation in flexor carpi ulnaris tendinopathy, where selective sclerosing therapy using polidocanol 

was performed. Immediately following sclerosing therapy the patient's pain level was reduced by 50% with further reduction within the 

next 2 weeks. Painful eccentric forearm training was initiated for a substantial and sustained modification of the wrist tendons. 

101

“A Well-Structured Induction Program in Plastic Surgery”: A Strategy to Effective Integration 

of Surgical Trainees into a Plastic Surgery Unit for the Benefits of Patients' Care 

Institution where the work was prepared: University College Hospital, Galway, Galway, Ireland 

Fuan Chiang Chan, AFRCSI, MD; C. O'Boyle, MD; J. Kelly; University College Hospital Galway 

INTRODUCTION: 

High quality patient care and smooth integration of junior trainees into a plastic surgery department is an issue during the changeover 

periods of plastic surgical trainees. This study aims to address both of the above issues with a well-structured, clinically orientated induction 

program in plastic surgery. 


A half-day induction program which includes history taking and clinical examination, management of common plastic surgical emergencies, 

and consultants' preferences of dressings and suture materials was held at week 2 of starting of job in our department. Surgical 

trainees (n=10) were asked to answer a set of clinical and non-clinical questionnaires before and after the induction program. 

RESULTS: 

It was clinically useful and essential to include clinical components in the induction program (p < 0.05). There was a significant improvement 

in term of approach and management of common plastic surgical emergencies before and after the induction program (p < 0.02). 

CONCLUSION: 

A well-structured and clinically orientated induction program ensures not only effective integration of surgical trainees into a surgical 

unit but also improves the effectiveness of the management of plastic surgical patients. 

Crystal Deposition Disease Masquerading as Stenosing Tenosynovitis and its Associated Sequelae 

Institution where the work was prepared: Baylor College of Medicine, Houston, TX, USA 

Cara R. Downey, MD; Jamal M. Bullocks, MD; David Dice, MD; David T. Netscher, MD; Baylor College of Medicine 

Extra-articular crystalline deposition secondary to gout, and less commonly, pseudogout is a well known phenomenon. Tophacious 

deposits into the soft tissues are the manifestation of biochemical metabolic derangements. Despite this well documented entity of 

extra-articular deposition, there have been few reports of infiltration of the flexor tendon sheath of the hand. Here we present a case 

series of this unique occurrence, including surgical techniques, pathology and the clinical outcomes of 5 patients treated at the affiliated 

hospitals of the Texas Medical Center at Baylor College of Medicine in Houston, Texas. Between the years 2002 and 2007 we encountered 

2 cases of calcium pyrophosphate, and 3 cases of uric acid deposition into the flexor tendon sheath masquerading as common 

tendonopathies. These include cases of carpal tunnel syndrome, non-suppurative flexor tenosynovitis, trigger finger and attrition rupture 

of the flexor tendons. While most patients presented with a known history of metabolic disease undergoing standard medical therapy, 

one case marked the initial presenting symptom of the disease. Although, medical therapy is the cornerstone of treatment for diseases 

that result in crystal deposition, these cases emphasize the potential need for surgical therapy in the armamentarium of their management. 

This case series demonstrates the importance of inclusion of crystal deposition into the flexor tendon sheath in the differential 

diagnosis in patients that present with uncharacteristic symptomatology of common flexor tendonopathies. 

102

AAHS/ASPN/ASRM OUTSTANDING 

NERVE PAPER PRESENTATIONS 

Rodent Facial Nerve: a Model for the Study of Synkinesis 

Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, Boston, MA, USA 

Tessa A. Hadlock, MD1; Jeffrey Kowaleski1; David Lo1; Susan Mackinnon2; James T. Heaton, PhD3; (1)Massachusetts 

Eye and Ear Infirmary and Harvard Medical School, (2)Washington University in St. Louis, (3)Massachusetts General 

Hospital 

INTRODUCTION: 

Rodent whisker movement has been measured after facial nerve manipulation, in an attempt to quantify functional recovery. We have 

recently established a method of simultaneously monitoring both whisking movement and induced ocular closure, for the purpose of 

studying aberrant regeneration. Herein we describe normal bilateral whisking movement and air puff-induced eye closure, and the relationship 

between these two distinct facial movements, in a group of normal rats. 

MATERIALS / METHODS: 

80 female Wistar rats underwent implantation of a head fixation device, followed by quantitative facial movement testing in an apparatus 

designed to measure vibrissial movement and ocular closure for each side independently. Animals were handled daily, and then 

conditioned to the apparatus. On the day of testing, each animal underwent a 300 second recording session, in which right and left C- 

1 whisker positions were continuously recorded, and infrared (IR) emitter/detectors positioned in front of each eye recorded changes 

in the IR detection corresponding to eye closure were continuously recorded. An olfactory stimulus was delivered in 10 second pulses 

three times at random during the run, and three separate 20 millisecond air puffs were delivered to each eye at random to elicit a blink. 

All whisks greater than 15 degrees were analyzed via the method of Bermejo et al, and all eye closures with greater than a 100mV 

change in IR detection were counted as blinks. 

RESULTS: 

Animals tolerated the testing apparatus well. Average whisking amplitude was 35 degrees (sd = 7), consistent with literature values, and 

there was no significant difference between whisking frequency, amplitude, velocity, or acceleration between the right and left sides. 

Air puff delivery elicited an ipsilateral blink 97% of the time, and a contralateral blink 34% of the time. Olfactory stimulus delivery prompted 

a distinct change in whisking behavior 69% of the time, and prompted at least one meaningful eye closure 20% of the time. Air puff 

delivery to the eye produced a bilateral whisking burst 85% of the time, indicating that most often air puff delivery elicits whisking as 

well as eye closure. 

CONCLUSION: 

Our study establishes normative data for assessing cranial nerve VII-controlled facial movement in four separate facial regions. We 

demonstrate the capability of animals to move their orbicularis oculi muscles independently of and simultaneously with their midfacial 

muscles. This model provides an excellent tool for the study of aberrant regeneration following facial nerve injury in the rodent. 

103

Enhancement of Regeneration of Peripheral Nerve Defects by Application of Epineural Tubes 

Filled with Donor Derived Bone Marrow Stromal Cells 


Mehmet Bozkurt; Christopher Grykien; Lukasz Krokowicz; Aleksandra Klimczak; Jill Froimson; Dileep Nair; Maria 

Siemionow; Cleveland Clinic 

INTRODUCTION: 

Supportive therapy with bone marrow stromal cells (BMSCs) has shown enhancement of nerve regeneration. This study was performed 

to asses the effect of BMSCs in nerve gaps repaired with isogenic epineural tubes filled with isogenic and allogenic BMSCs. 

METHODS: 

Total of 54 isogenic epineural tubes were transplanted in 3 experimental groups (18 animals each). Group 1 control saline, Group 2 isogenic 

BMSCs (Lewis (RT1l)) and Group 3 allogenic BMSCs (ACI (RT1a)). Transplantation in Group 2 and 3 was supported with BMSCs 

therapy (2x106) delivered directly into transplanted epineural tube. Before transplantation BMSCs were stained with PKH-dye to assess 

migratory potential and ability for neural differentiation. Evaluation at 6, 12 and 24 weeks post-transplant included Gastrocnemius 

Muscle Index (GMI), sensory and motor recovery was evaluated by pinprick, toe-spread and Somato-Sensory Evoked Potentials (SSEP). 

Toluidin blue staining determined number of regenerated axons. Immunostaining with NGF and Laminin B2 assessed the migration 

and presence of BMSCs in regenerating epineural tubes. 

RESULTS: 

Functional assessment by pin prick test, 6 weeks after transplantation, showed in all groups score 3. Toe spread for groups 1, 2 and 3 

was respectively 1.7; 2; 1. SSEP in groups 1, 2 and 3 (P1, N2-latencies; P1, N2 % of normal values) was respectively (20.2; 23.6; 113; 95), 

(17.5; 18.1; 98; 73) and (15.7; 21.65; 88; 87). GMI in groups 1,2 and 3 respectively (0.45; 0.48; 0.47). Histology revealed first signs of axonal 

regeneration in all groups at 6 weeks. Group 2 showed higher number per measured field of regenerated axons (90.6 ± 26.9) compared 

to Group 1 (71.4 ± 3.0) and 3 (76.4 ± 5.4). In group 2 and 3 (with BMSCs) PKH positive cells were found in proximal part of transplanted 

tube. Immunostaining with NGF confirmed upregulation of NGF in proximal segment of tube compared to middle and distal 

parts. Moreover, NGF-staining in combination with PKH-staining confirmed that BMSCs differentiated into neural tissue. Differentiation 

efficacy was greater after transplantation in isogenic (Lewis) BMSCs compared to allogenic (ACI) BMSCs. NGF upregulation in groups 

2 and 3 correlated with upregulation of Laminin B2 in both groups, indicating active nerve regeneration. 

CONCLUSION: 

In this study co-transplantation of BMSCs with epineural tube enhanced regeneration of peripheral nerve defects, confirmed by 

increased expression of NGF and Laminin B2. Better functional recovery and axonal regeneration was seen in BMSCs supported 

epineural tube grafts. Finally we have proven differentiation of BMSCs into neural tissue. 

104

ASPN SCIENTIFIC PAPER SESSION A 

Maintainance of Neuronal Differentiated Adipose-derived Stem Cells in Long Term Culture 

Institution where the work was prepared: University of California, Irvine Medical Center, Orange, CA, USA 

Suraj Kachgal, MS; Sanjay Dhar, PhD; Eul Sik Yoon, MD; Gregory R.D. Evans, MD; University of California, Irvine 

INTRODUCTION: 

Adipose-derived stem cells (AdSCs) have documented great potential to differentiate into cells of a neural phenotype. These cells provide 

a great source for autologus transplantation into in vivo models of peripheral nervous system disorders. The present study investigates 

the efficacy of a new neuronal induction media and whether it can maintain human AdSCs in a differentiated state in vitro for a 

period of time that would correspond with nerve regeneration in vivo. 

METHODS: 

Human lipoaspirate was processed by standard methodologies and AdSCs from the product were extracted into culture. AdSCs were 

briefly expanded in control medium and then subjected to culture in our neural induction media (DE-1) for periods of 1 day, 1, 2, 4, 6, 

and 8 weeks. Cultures were probed for expression of neural-specific markers: NeuN, nestin, GFAP, vimentin, NSE, trk-A, and MAP2 via 

immunocytochemistry, RT-PCR, and Western blot. 

RESULTS: 

Immunocytochemical staining of the neural-induced cells was positive for the markers GFAP, trk-A, nestin, and NeuN. Western blot 

analysis revealed expression of early neural markers NSE and NeuN was found in control AdSCs and showed decreasing expression in 

our neural-induced AdSCs, suggestive of a developing neural phenotype. Expression of the early glial marker vimentin was not present 

in the control blot but was expressed in neural-induced AdSCs at day one. Vimentin expression tapered off to zero by week eight 

while expression of the mature astrocyte marker GFAP expressed from day one to week eight. RT-PCR results indicate that all markers 

except trk-A are transcribed in control and experimental groups, but Western blot analysis shows not all are transcribed. 

CONCLUSION: 

We have successfully established a medium which promotes neural differentiation of AdSCs and holds them in the differentiated state 

for a period of time longer than previously reported. The media was successful in promoting the development of cells of a glial phenotype 

as shown by expression profiles of vimentin and GFAP. 

Repair of Partial Nerve Injury by Bypass Nerve Grafting with End-to-side Neurorrhaphy 

Institution where the work was prepared: University of Mississippi Medical Center, Jackson, MS, USA 

Tanya M. Oswald, MD; Feng Zhang; William C Lineaweaver; University of Mississippi Medical Center 

BACKGROUND: 

The peripheral nerve injury without disruption of the anatomic continuity of the nerve often results in formation of neuromas-in-continuity. 

Management of this partial nerve injury is notoriously difficult. The purpose of this study was to determine the efficacy of bypass 

nerve grafting with end-to-side neurorrhaphy in repair of partial nerve injury in a rabbit model. 

METHODS: 

Thirty-six adult male New Zealand rabbits were divided into three groups. The partial nerve injury was created by removal of a segment 

of the lateral fascicle of the left peroneal nerve. In Group one, the injured nerve was repaired with a nerve graft bypassing the injury site 

in an end-to-side fashion 4 weeks after injury. In Group two, the injured nerve was repaired with an end-to-end interposition nerve grafting 

6 weeks after injury. The injured nerve without repair was used as the control. At the 16th week after nerve repair in groups one and 

two, and 20 weeks after the initial nerve injury in the control group, the nerves were dissected for electrophysiological examination and 

biopsied for histology and molecular marker expressions. 

RESULTS: 

The nerve repair with interposition nerve grafting achieved maximal functional recovery. However, the motor nerve conduction velocity 

(MCV) and compound motor action potential (CMAP) in nerve repair with the bypass nerve grafting were significantly higher than 

that in the nerve injury without repair. Histologically, the regenerated myelinated axons and unmyelinated axons were present in the 

distal peroneal nerves in the bypass nerve grafts. The axon counts in nerve repair with bypass nerve grafting were also significantly higher 

than that in the nerve injury without repair. The comparisons of the ciliary neurotrophic factor (CNTF) and the calcitonin gene related 

peptide (CGRP) gene expressions between nerves with and without repair were significantly different. 

CONCLUSION: 

End-to-side bypass nerve grafting can significantly improve the functional recovery in the nerve with partial injury and may be a useful 

repair strategy in neuroma-in-continuity. 

105

The Effect of In Vivo Delivery of Nerve Growth Factor (NGF) Through a Novel T-tube 

Chamber on Behavioural Recovery in a Rat Model of Peripheral Nerve Injury 

Institution where the work was prepared: University of Calgary, Calgary, AB, Canada 

Stephen W.P. Kemp, BSc(Hons), MSc; Aubrey A. Webb; Rajiv Midha; University of Calgary 

Various behavioural measurements have traditionally been used to assess recovery following peripheral nerve transection, including the 

sciatic functional index (SFI), video gait analysis and ankle rotation measures. However, direct measures that objectively and sensitively 

assess the return of sensorimotor function in peripheral nerve injured animals are currently lacking. We sought to assess the extent of 

behavioural recovery in both skilled and unskilled sensorimotor tasks, especially locomotion, in normal rats both before and after unilateral 

injury to the right sciatic nerve. In addition to traditional methods of sciatic nerve repair, the effect of in vivo delivery of nerve growth 

factor (NGF) was evaluated using a novel T-tube chamber nerve conduit. Animals were randomly assigned to one of five treatment 

groups: nerve crush (Group 1); direct suture repair (Group 2); transection and T-tube repair with saline administration (Group 3); transection 

and T-tube repair with NGF (800 pg/day) administration (Group 4), and; sham-operated controls (Group 5). Locomotor measurements 

consisted of (1) ladder rung; (2) tapered beam with crutch; (3) quantitative kinematics, and; (4) ground reaction force determination. 

Ground reaction force determination, in particular, provides a sensitive assessment of behavioural recovery by allowing the analysis 

of each limb's contribution to vertical (body weight support), fore-aft (braking and propulsion), and mediolateral forces during locomotion. 

Sensory testing consisted of two parts: (1) a traditional measure of tactile allodynia was assessed via von Frey filament testing, and; 

(2) thermal nociception was evaluated using a modified thermal plantar test. Following serial and final endpoint behavioural measures (3 

months), EMG measurements assessed both nerve and muscle conduction velocities. Animals were subsequently sacrificed and final outcome 

measures consisted of (1) gastrocnemius muscle weights, and; (2) morphometry (axon/myelination) of EPON embedded section 

tissue. Preliminary results indicate that our battery of locomotor tests provide a sensitive, comprehensive, and objective means by which 

to evaluate peripheral nerve regeneration. Ongoing evaluation aims to further determine whether animals directly administered NGF 

within a T-tube environment show improved sensorimotor behavioural recovery compared to animals administered saline. 

Nerve Repair with Introduction of a MEMS-Based Neural Electrode is Not Detrimental to 

Muscle Reinnervation 


Melanie G. Urbanchek, MS, PhD; Antonio P. Peramo, PhD; Daryl R. Kipke, PhD; William M. Kuzon Jr, MD, PhD; Paul S. 

Cederna, PhD; University of Michigan 

Bioengineers are constructing Micro-Electro-Mechanical Systems (MEMS) that contain integrated sensors, actuators, and electronics on 

a common silicon microelectrode substrate. MEMS devices can perform complex functions in small areas such as peripheral nerves. 

MEMS could be implanted within a severed peripheral nerve to detect efferent signals for powering prostheses or providing afferent 

signals for sensory feedback. This closed-loop neural control of a prosthesis would provide a dramatic increase in functionality for upper 

extremity amputees. To achieve this goal, we designed a series of experiments testing the compatibility of MEMS electrodes on axonal 

sprouting, regeneration and subsequent muscle reinnervation following neurorrhaphy. 

We studied F344 rat peroneal nerve reinnervation of the extensor digitorum longus (EDL) muscle. Our 3 experimental groups received 

either no peroneal nerve surgery (Normal), division and repair surgery (Repair), or division and repair with a MEMS electrode introduced 

into the distal end of the neurorrhaphy (Repair+Electrode). Each silicon electrode was 10mm X .4mm X 15um with 16 shanks and 

embedded inactive wiring. Operated rats recovered for 58-87 days which is early in the postoperative recovery prior to achievement of 

maximal reinnervation. EDL maximum tetanic isometric force (Fo) was measured in situ by supramaximal stimulation of the peroneal 

nerve proximal to the nerve repair. Peroneal nerve conduction velocity was measured. The EDL muscle was then harvested, weighed, 

and the specific force (sFo) was calculated based upon the muscle cross sectional area. 

The EDL muscles of the Repair (-43%) and the Repair+Electrode (-33%) groups produced less maximal force when compared with the 

Normal group but did not differ from each other. There were no significant differences between the Repair and Repair+Electrode 

groups in muscle mass, Fo, sFo, or nerve conduction velocity indicating that the presence of the MEMS probe did not adversely effect 

nerve regeneration or muscle reinnervation based upon these outcome measurements. 

This study demonstrates that decreased maximal forces early in the reinnervation process discriminate repaired nerve/muscle from normal 

for both nerve repair groups. Most importantly the lack of a significant difference between repair groups indicates that intraneural 

placement of a MEMS silicon electrode within the peroneal nerve did not adversely effect muscle reinnervation early in recovery. 

106

Nerve Regeneration through Nerve Autografts after Local Administration of Brain Derived 

Neurotrophic Factor (Bdnf) with Osmotic Pumps 

Institution where the work was prepared: Clinica Universitaria. Universidad de Navarra, Pamplona, Spain 

Bernardo Hontanilla, MD, PhD; Cristina Aubá; Oscar Gorria; Clínica Universitaria, Universidad de Navarra 

OBJECTIVE: 

To determine if administration of brain-derived neurotrophic factor (BDNF) with osmotic pumps at the site of the proximal stump of a 

peripheral nerve autograft can improve the peripheral nerve regeneration. 

METHODS: 

Tibialis branch of sciatic nerves were transected and grafted with a 20 mm nerve autografts. Wistar rats (n=70) were divided into four 

groups: a non-grafted control group (group I, n=10), a grafted but non-treated control group (group II, n=20), a grafted saline-treated 

group (group III, n=20), and finally a grafted and BDNF-treated group (group IV, n=20). BDNF was delivered at a rate of 6 µg/day for 2 

weeks after nerve repair, using osmotic pumps subcutaneously implanted with a connecting tube, the distal end of which faced the 

proximal stump of the nerve graft. The animals were sacrificed at 6 weeks. Spinal motoneurons were quantified as well as axons at the 

tibialis branch 5 mm distal to the distal nerve repair site. Neuron size was categorised as large (>25 µm) or small (0.1). Finally, there were no statistically significant differences between groups II, III and IV regarding the number of 

distal axons. 

CONCLUSION: 

BDNF delivered through osmotic pumps demonstrates a significant capacity for improving the presence of motoneurons in the ventral 

spinal horn and then the capacity to improve nerve regeneration thorough nerve autografts. However, in this study BDNF does not specially 

protect from injury to motoneurons depending of the soma size. 

Peripheral Nerve Surgery: Pre-Operative Variables Associated with Outcome Failures 

Institution where the work was prepared: Georgetwon University Hospital, Washington, DC, USA 

Ivica Ducic, MD, PhD; Emily Hartmann; Georgetown University Hospital 

A wide range of outcomes in peripheral nerve surgery are reported and are linked to the type of nerve injury or neuropathy and the 

type of surgery designed to address the cause. Even with proper meta-analysis of available data, it is still not possible to normalize 

specifics to each reported outcome, so rather false conclusions about variables associated with post-operative failures are commonly 

encountered. In order to address these issues, controlling the patient selection criteria, type of surgeries and follow-up, a single surgeon 

outcome failures were analyzed identifiying what is common had patients that failed the same type of the surgery when compared 

to the one with success. 

Fifteen hundred consecutive patients that underwent peripheral nerve surgery by a single surgeon were identified. Patients were sent 

a survey asking them about their outcome (reduction in pain, return to pre-injury daily function – sensory/motor improvement, quality 

of life improvement). Only patients who had less then 50% of improvement with surgery were then analyzed (n = 425; 28.3%). Outcomes 

were measured with minimum of one year follow up (range 1-3 years). 

Out of 425 patients, 41 (9.6%) were on methadone, 350 (82%) had pain longer then 3 years pre-op, 429 (88.2%) had depression, 330 

(77%) had workmen's compensation, 220 (52%) had surgery on more then 3 nerves at the same time. Each of 425 patients had one variable 

present, 69% had two and 31% three or more variables. Complete failure of surgery for patients with three of more variables (131) 

was the outcome. 

Although we often present our best results, it is important to consider these findings when evaluating and consenting patients for 

peripheral nerve surgery. 

107

The Dynamic Phases of Peroneal and Tibial Intraneural Ganglion Formation: A New 

Dimension Added to the Unifying Articular Theory 


Robert J. Spinner, MD; Huan Wang; Kimberly K. Amrami; Mayo Clinic 

OBJECT: 

The pathogenesis of intraneural ganglia has been controversial for more than a century. Recently we have identified a stereotypic pattern 

of occurrence of peroneal and tibial intraneural ganglia and based on an understanding of their pathogenesis, provided a unifying explanation. 

Atypical features occasionally observed have offered an opportunity to further verify and expand upon our proposed theory. 

METHODS: 

Ten unusual cases are reviewed to introduce the dynamic features of peroneal and tibial intraneural ganglia. In part I, we analyzed 2 of 

our own patients who shared the essential principles common to peroneal intraneural ganglia: namely a) connections to the anterior 

portion of the superior tibiofibular joint, and b) intraepineurial dissection of the cyst along the articular branch of the peroneal nerve 

and proximally. These patients also demonstrated unusual MRI findings: a) the presence of a cyst within the tibial and sural nerves in 

the popliteal fossa region, and b) spontaneous regression of the cysts on serial examinations performed weeks apart. We then identified 

a clinical outlier that could not be understood in terms of our previously reported unified theory. Reported 32 years ago, this patient 

had a tibial neuropathy and was found to have tibial, peroneal and sciatic intraneural cysts without a joint connection at operation. Our 

hypothesis, based on our initial experience was that this reported patient had a primary tibial intraneural ganglion with proximal extension, 

sciatic cross-over and then distal descent, and that a joint connection to the posterior aspect of the superior tibiofibular joint with 

remnant cyst within the articular branch would be present, a finding that would help us explain the formation of the different cysts by a 

single mechanism. We proved this by careful inspection of a recently obtained postoperative MRI. In part II, we retrospectively reviewed 

20 additional cases of our own and identified 7 examples with subtle unrecognized MRI features of sciatic cross-over (as well as several 

examples in the literature). 

CONCLUSION: 

These cases provide firm evidence for mechanisms underlying intraneural ganglia formation and allow us to expand our unified articular 

theory to elucidate unusual presentations of intraneural cysts. Whereas an articular connection and fluid following the path of least 

resistance was pivotal, we now incorporate dynamic aspects of cyst formation due to pressure fluxes. These principles explain new patterns 

of primary ascent, sciatic cross-over and terminal branch descent when cyst fills the sciatic nerve's common epineurial sheath. 

Delay of Denervation Atrophy by Sensory Protection in an End-to-Side Neurorrhaphy Model 

Institution where the work was prepared: Erasmus MC, Rotterdam, Netherlands 

H.M. Zuijdendorp; W. Tra; J. van Neck; J.H. Coert; Erasmus MC 

OBJECT: 

Temporary sensory innervation delays the atrophy process. A major disadvantage of most experimental models is that sensory protected 

muscles must be denervated a second time to allow reinnervation by the affected nerve. The aim of this study was to assess the 

effect of sensory protection on denervated gastrocnemius muscle in an end-to-side neurorrhaphy model, in which denervated muscles 

may be preserved until axons of the native nerve reach their target without the necessity for a second operation. 

METHODS: 

The tibial nerve of 24 female Lewis rats was transected. Twelve animals acted as the controls. In the other 12 animals, the end of the 

sural nerve was connected to the side of the distal tibial nerve stump (sensory protection group). At 5 and 10 weeks, wet gastrocnemius 

muscle weight was reported as a ratio of the operated to the unoperated side. For histological analysis, muscle samples were rapidly 

frozen and sections were stained with hematoxylin and eosin, Oil Red O stain and modified Gomori Trichrome stain. 

RESULTS: 

The difference between the sensory protection group and the control group was statistically significant at 5 (0.36 ± 0.01 and 0.29 ± 0.01 

respectively; p < 0.001) and 10 weeks postoperatively (0.28 ± 0.01 and 0.19 ± 0.00 respectively; p < 0.001). Histological observations 

revealed that sensory protected muscles underwent less atrophy. 

CONCLUSION: 

Sensory protection delays atrophy in an end-to-side neurorrhaphy model. 

108

Insulin-Like-Growth Factor 1 Improves Nerve Regeneration in Aged Rats 

Institution where the work was prepared: Wake Forest University, Winston-Salem, NC, USA 

Peter Apel, MD; Timothy Alton, BS; Jianjun Ma, MD, PhD; Zhongyu Li, MD, PhD; Wake Forest Univeristy 

INTRODUCTION: 

Increasing age significantly impairs neuromuscular recovery following injury via an unknown etiology. Previous studies indicate a 

decrease in circulating trophic and anabolic factors with age, such as insulin-like growth factor-1(IGF-1), which may contribute to agerelated 

impairments. HYPOTHESIS: Locally delivered IGF-1 will improve the quality of nerve regeneration and in aged rats. 


Twenty-four rats were divided into two groups: Young adult (8 months) and Aged (24 months). The tibial nerve was transected, nerve 

stumps were placed in opposing ends of a T-tube, and the middle arm was attached to a mini-pump. In half of the animals, 0.10Ìg/ÌL 

IGF-1 in saline was delivered at 0.25 Ìl/hr. Control animals received saline. After 3 months, compound motor action potential (CMAP) of 

the gastrocnemius was recorded. The regenerated nerve was examined by both light and electron microscopy. Axon number, density, 

average diameter, nerve area and myelin thickness were measured. The gastrocnemius muscle was harvested and gene expression 

of GAP-43, myogenin, MyoD, MYF5, MYF6 (MRF4) and the ·, ‚, Á, ‰, and Â-subunits of the nicotinic acetlycholinergic receptor(nAChR) 

were examined. 

RESULTS: 

For control animals, 83% of Young showed evidence of regeneration vs. 50% of Aged. For IGF-1 treated animals, 100% of Young and 

75% of Aged showed evidence of regeneration. Of regenerated animals, there was no difference in conduction delay or amplitude. In 

aged animals, IGF-1 significantly increased a) axons per nerve (13025 vs. 3062; p

ASPN SCIENTIFIC PAPER SESSION B 

In Vivo Microscopy of the Peripheral Nerve, a Quantitative Analysis Following Injury using 

Optical Coherence Tomography (OCT) 

Institution where the work was prepared: Massachusetts General Hospital, Harvard Medical School, Boston, MA, 

USA 

Francis Patrick Henry, MD; Hyle Boris Park, PhD; Esther A. Z. Rust; M.A. Randolph, MAS; Johannes F. DeBoer, PhD; 

Jonathan M. Winograd, MD; Massachusetts General Hospital, Harvard Medical School 

INTRODUCTION: 

Electrophysiological and invasive ex vivo histological techniques remain the current gold standard method for assessing nerve injury 

and regeneration. In vivo assessment of a nerve without destruction of the tissue would greatly advance both grading and monitoring 

following neural injury. Optical Coherence Tomography (OCT) is a minimally-invasive optical tomographic imaging technique which 

uses coherent light to offer good penetration with micrometer axial and lateral resolution in tissues. Using a multifunctional OCT system 

we plan to quantitatively and qualitatively assess changes in optical density and birefringence of nerve following injury. 

METHODS: 

A standard demyelinating crush injury was reproduced in the sciatic nerves of male Sprague Dawley rats. Animals were randomized into 

groups (n=8) and nerve exposure with OCT imaging was undertaken at day 1 and weeks 1, 2, 3 and 4 following injury. The uninjured 

nerve was used as a control. Functional analysis was undertaken weekly with standardized walking track analysis. Histomorphometry of 

both control and injured nerve was undertaken following imaging to allow verification of our findings. 

RESULTS: 

All animals demonstrated loss of sciatic nerve function following nerve injury. Recovery was documented with sciatic functional index 

data approaching normal at four weeks. OCT imaging revealed a quantifiable change in birefringence of the nerve (as measured by 

phase retardation graphs) following a simple crush injury. These changes can be characterized both visually and in graph form to indicate 

definitive injury and recovery in a longitudinal pattern. Figures below are examples of a normal nerve and samples 2 and 3 weeks 

following injury. Regeneration can be assessed with the recovery of phase retardation versus depth over time as characterized by a 

change in the slope of the graph (red line). The initial decrease and subsequent increase following injury represents recovery and reorganization 

of the nerve fibers. 

CONCLUSION: 

We conclude that OCT has the ability to image the peripheral nerve revealing quantitative and qualitative changes in composition 

which may be used to grade injury and regeneration over time. This technology which permits in vivo, real time imaging of nerves could 

provide invaluable diagnostic and prognostic information following neural injury. 

110

Comparative Analysis of Holding Strength of Available ìNerve Gluesî 

Institution where the work was prepared: Candice McDaniel, Richmond, VA, USA 

Jonathan Isaacs, MD1; Candice O. McDaniel, MD2; John R. Owen, PE3; Jennifer S. Wayne3; (1)VCU Medical Center, 

(2)Medical College of Virginia at VCUHS, (3)Virginia Commonwealth University 

HYPOTHESIS: 

A variety of potentially useful artificial and biological sealants applied to a sutured nerve decrease gapping at the repair site. 

METHODS: 

Fifty-seven cadaveric nerve specimens were transected and repaired with two 8-0 nylon epineural sutures placed 180 degrees apart. 

The specimens were divided into five groups. Four groups received augmentation of the repair with application of either autologous 

fibrin glue, Tisseel fibrin glue (Baxter Healthcare Corporation), Evicel fibrin glue (Ethicon, Inc.), or DuraSeal polyethylene glycol based 

hydrogel sealant (Confluent Surgical, Inc.). Each nerve construct was mounted in a servohydraulic materials testing machine (Instron 

Corporation; MTS Systems Corporation) and stretched at a constant 5mm/min displacement rate until failure. A noncontact video analysis 

permitted normalization of stretch within the repair region. Statistical analysis was performed via ANOVA followed by Tukey-Kramer 

post-hoc pairwise comparison, if indicated. 

RESULTS: 

There was no statistical difference for the peak load at failure between any of the groups (p>0.4, Fig. 1). Resistance to gapping as measured 

through normalized stiffness (N/mm/mm) was greater for the Tisseel group (p

The Efficacy of Subcutaneous Transposition of the Ulnar Nerve in Surgical Treatment of 

Cubital Tunnel Syndrome 

Institution where the work was prepared: Dept. of Plastic Surgery,University of Tuebingen, Tuebingen, Germany 

Armin Kraus, MD; Nektarios Sinis; Frank Werdin; Hans-Eberhard Schaller; University of Tuebingen 

PURPOSE: 

In surgical treatment of cubital tunnel syndrome, subcutaneous transposition of the ulnar nerve is controversial. It is aim of this study to evaluate 

the efficacy of subcutaneous transposition of the ulnar nerve in cubital tunnel syndrome in comparison to nerve decompression alone. 


54 patients undergoing surgery for neurologically proven cubital tunnel syndrome between 2000 and 2006 at our institution were scheduled 

for a postoperative examination with standardized history taking, examination and grip strength measurement with Jamar 

dynamometer and pinchmeter. Patients undergoing ulnar nerve decompression alone were assigned to group 1, patients undergoing 

additional subcutaneous transposition of the nerve were assigned to group 2. 

RESULTS: 

12 patients were operated with decompression alone, 42 patients underwent additional subcutaneous nerve transposition. There were 

no differences between the groups concerning age, sex, preoperative nerve conduction velocitiy and the presence of Froment`s sign. 

Postoperatively, there was no significant difference between group 1 and group 2 concerning overall amelioration of symptoms (83% 

ìyesî vs 81% ìyesî, p=0.33), subjective usage property of the operated hand rated on a scale 1 to 10 (mean 8.1 vs 7.9, p=0.81), presence 

of paresthesia (50% ìyesî vs 52% ìyesî, p=0.79) and duration of disability (24 vs 26 days, p=0.77). Comparison of grip strength between 

groups showed no significant difference for both the right hand and the left hand measured with the Jamar dynamometer (p=0.91 and 

p=0.62, respectively). Pinchmeter measurement of finger force revealed no significant difference between groups for the right and the 

left hand either (p=0.90, p=0.73, respectively). 2-point discrimination ability of the 8th, 9th and 10th finger nerve was not significantly 

different between group 1 and 2 (p=0.36, p=0.14, p=0.66 respectively). 

CONCLUSION: 

In our patient collective, subcutaneous transposition of the ulnar nerve revealed no advantages concering symptom amelioration, duration 

of disability, improvement of grip strength and improvement of 2-point discrimination ability. 

Health Related Quality of Life and Disability in Patients Following Peripheral Nerve Injury 

Institution where the work was prepared: University Health Network, Toronto, ON, Canada 

Christine B. Novak, PT, MS, PhD(c); Dimitri J. Anastakis; University Health Network 

BACKGROUND: 

Most outcome studies following peripheral nerve lesions of the upper extremity have focused on functional recovery. There have been 

few studies examining long-term outcomes related to health related quality of life and disability. A quantitative examination of these 

factors would provide a valuable and comprehensive understanding of upper extremity impairments due to nerve lesions. 

PURPOSE: 

The objective of this study was to determine the relative level of disability, pain and health related quality of life in patients following 

peripheral nerve injury in the upper extremity. 

METHODS: 

Following Research Ethics Board approval, prospectively collected data from patients with nerve injury were reviewed from a larger 

database. There were 187 patients who had sustained a traumatic nerve injury and were at least 6 months following nerve injury/repair. 

At the final office visit, patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Medical 

Outcomes Study 36-Item Short-Form Health Survey (SF-36). Independent variables assessed included nerve injured, dominant arm 

affected, gender and workers' compensation involvement. Data were analyzed using SPSS. For the SF-36, comparisons were made 

between the Canadian norms and the nerve injured patients. Patients were grouped as having increased pain if they exceeded 2 standard 

deviations from the normative data and the DASH scores were compared to patients who had pain versus no pain. 

RESULTS: 

There were 187 patients (134 men, 53 women) with a mean age of 43 years (sd 15 years). The mean time from injury to final assessment 

was 4 years (sd 5 years). As reported on the SF-36, the mean bodily pain was 45 (sd 26) and indicated significantly more pain than the 

reported SF-36 normative data (p < 0.001). Similarly, patients with nerve injury had significantly decreased physical function, vitality, social 

function, general health and mental health (p< 0.001). The mean DASH score was 39 (sd 24), which indicated a high level of impairment 

in these patients. Significantly more impairment as indicated by a lower score on the DASH was found in patients with abnormal bodily 

pain (p = 0.016) and with brachial plexus nerve injuries (p = 0.047). 

CONCLUSION: 

Peripheral nerve injuries are associated with increased chronic neuropathic pain and impairment as reported on the SF-36 and the 

DASH. Recognition of chronic pain and the associated factors may permit more efficacious treatment and better health related quality 

of life in these patients. 

112

The Mechanisms of Axonal Sprouting With End-to-Side Neurorrhaphy 

Institution where the work was prepared: Washington University in St Louis, St Louis, MO, USA 

Ayato Hayashi, MD, PhD; Daniel A. Hunter, RA; Alice Y. Tong, MS; David H. Kawamura, MD; Arash Moradzadeh, MD; 

Sami H. Tuffaha, BA; Christina B. Kenney, MD; Janina Luciano, BS; Thomas H. Tung, MD; Susan E. Mackinnon, MD; 

Terence M. Myckatyn, MD; Washington University in St. Louis 

BACKGROUND: 

Nerve injuries are usually reconstructed by end-to-end neurorrhaphy. However, end-to-side neurorrhaphy is an alternative procedure 

that may be used in certain situations. Since the reintroduction of this technique in 1992, significant controversy remains regarding how 

end-to-side neurorrhaphy results in axonal sprouting and whether it provides any functional benefit. To investigate these issues, we used 

transgenic mice with fluorescently-labeled axons to visualize this process. 

METHODS: 

We used transgenic mice in which a few motor axons (Thy1-GFPS) or all axons, including sensory, (Thy1-YFP16) were labeled with GFP 

or YFP. Animals were randomized into three groups: 1) end-to-side neurorrhaphy was performed by opening an epineurial window with 

partial neurectomy, 2) the nerve graft was wrapped around the donor nerve to keep the donor nerve completely uninjured while endto-side 

coaptation was achieved, and 3) chronic compression to the donor nerve was applied by wrapping the proximal donor nerve 

with a tight fitting silicon tube. All animals were evaluated using a fluorescent live imaging system at multiple time points to monitor 

for regenerating axons. At a 3 or 5 month endpoint, the site of anastomosis was harvested and evaluated with immunohistochemistry, 

confocal whole mount imaging, histomorphometry, and western blot. In addition, the functional connections of the regenerating axons 

were characterized with muscle end plate staining and an evaluation of cutaneous innervation. 

RESULTS: 

With partial neurectomy, abundant regenerating axons were seen projecting from the stump of the injured donor nerve into the graft at 

early time points. The non-injury model using thy1-GFPS mice showed no motor axonal regeneration throughout the experiment. 

However, YFP16 mice showed new axons projecting into the graft at late time points. The compression injury group using thy1-GFPS mice 

also showed regenerating motor axons at late time points, appearently due to induction of collateral sprouting from the donor nerve. 

CONCLUSION: 

Our results demonstrate that some type of injury, such as compression or epineurotomy, is required to trigger motor axonal regeneration 

through an end-to-side neurorrhaphy. In contrast, sensory axonal regeneration can take place with end-to-side neurorrhaphy without 

any injury to the donor nerve as evidenced by the different results seen with the YFP16 and thy1-GFPS mice. This study represents 

a novel model for studying end-to-side neurorrhaphy over time and provides further insights into the mechanism by which axonal 

regeneration occurs in this setting. 

Comparison of Psychosocial Outcomes of Patients with Neuropathic Conditions Treated With 

and Without Surgery 

Institution where the work was prepared: Hand and Microsurgery Center of El Paso, El Paso, TX, USA 

Jose Monsivais, MD; Hand & Microsurgery Center; Kris Robinson, PhD, FNP; University of Texas at El Paso 

PURPOSE: 

To evaluate psychosocial outcome after surgical and non-surgical treatment of neuropathies and nerve injuries in chronic pain patients. 

METHODS: 

Archival review of records from 91 patients (1995-2005). Inclusion criteria included nerve dysfunction and pain >3 months. Diagnosis was 

established by history, P/ E, sensory/motor evaluation, electrodiagnostics and imaging. Surgical candidates were determined by severity 

of sensory -motor abnormalities and had no evidence of uncontrolled depression/psychological distress. Pain was not used as an 

indicator for any form of treatment. Surgical procedures included nerve decompressions, reconstruction, neurolysis, and excision of 

neuromas. Medical treatment included analgesics, adjuvants, and neuroleptic medications. Psychological reports included psychological 

diagnosis, results of Oswestry Pain Questionnaire, GAF, and PSS. Statistician conducted correlational analysis using SAS statistical 

program. A sample size of 85 is required to detect a medium effect size with alpha set at .05 and power of .80. 

RESULTS: 

The majority of patients returned to work and reported lower levels of pain ~5 years after onset of nerve injury/ condition. No differences 

were noted between groups on a variety of measures including pain level (p=.2), litigation status (p>.5), and return to work 

(p>.05). The majority of individuals expected total relief of pain with surgical treatment. 

CONCLUSION: 

With psychosocial assessment, support, and adequate pain treatment, no difference was detected in psychosocial outcomes between those 

patients receiving surgical and non ñsurgical treatment. Patients' expectations of surgery are unrealistic and must be addressed prior to treatment. 

113

Delivery Strategy Significantly Affects the Number and Phenotype of Schwann Cells in 

Seeded Decellularized Allografts 

Institution where the work was prepared: Washington University School of Medicine, Saint Louis, MO, USA 

Arash Moradzadeh, MD; Sami H. Tu faha, BA; Ryan D. Luginbuhl; Jason Gustin; Gregory H. Borschel; Alice Y. Tong; Je fery 

Milbrandt, MD, PhD; Susan E. Mackinnon, MD; Terence M. Myckatyn, MD; Washington University School of Medicine 

BACKGROUND/PURPOSE: 

Nerve regeneration is impaired when non-native constructs are used to bridge long nerve gaps. Efforts have been made to improve 

regeneration through decellularized nerve grafts by adding stem cells, Schwann cells (SC) and/or growth factors. The goal of the current 

study is to compare the commonly used SC injection technique to a SC co-culture delivery mechanism in 2 different types of decellularized 

nerve grafts. 

METHODS: 

Adult Brown-Norway rat sciatic nerves were harvested and decellularized using either 7 weeks of cold-preservation with University of 

Wisconsin solution or using a proprietary graft processing method from AxoGen Inc. This method removes antigens and degrades molecules 

that inhibit neuroregeneration while leaving laminin intact. Nerves from each group were treated with either (1) injection of 1 X 

105/20 µl fluorescent labeled SCs (GFP) or (2) nerves were co-cultured with 1 X 105 GFP-labeled SCs in growth media. Nerves were sectioned 

and labeled with S100 (marker for mature SCs), DAPI (nuclear stain), and p75 (marker for immature SCs). Confocal microscopy 

was used to evaluate the quantity and maturity of viable SCs delivered into the grafts. For the SC injection group, evaluation was conducted 

immediately after injection and at a 3 day time-point (for this group nerves were injected and then incubated in growth media 

for 3 days). In the co-culture group evaluation was done following 3 days of incubation. 

RESULTS: 

SC injection and co-culture are both effective for delivering SCs into nerve grafts. A greater number of cells are found in grafts using 

the injection technique, with the location of SCs closer to the middle of the graft. Nerves decellularized using the AxoGen Inc. method 

appear to be more receptive to SC delivery by the co-culture technique and demonstrate a greater number of mature SCs as demonstrated 

by immunolabeling and confocal microscopic quantification of SC processes. 

CONCLUSION: 

SC co-culture is a possible alternative to SC injection for the delivery of SCs into decellularized nerve grafts. Both grafts support the 

adherence of SCs, however, AxoGen Inc. processed nerve grafts appear to be more receptive to the co-culture delivery technique and 

demonstrate a greater number of mature SCs. We are now staining the laminin and extracellular matrix of AxoGen Inc. and cold-preserved 

nerve grafts, to identify possible differences. Decellularized nerve grafts supplemented with SCs via the injection or co-culture 

are also being evaluated in vivo to study the impact of SC delivery technique on nerve regeneration. 

Saphenous Nerve Neuropathy: Treatment Options and Outcomes 

Institution where the work was prepared: Georgetwon University Hospital, Washington, DC, USA 

Ethan Larson, MD; Ivica Ducic, MD, PhD; Georgetown University Hospital 

PURPOSE: 

There is not much reported about leg pain and paresthesia related to saphenous nerve neuropathy. Extending from the groin area to 

the dorso-medial foot, the saphenous nerve is exposed to a number of possible danger zones. It can be compressed, due to trauma 

or other conditions, at the adductor canal causing mid-thigh pain and distal paresthesia, or can be damaged as a result of previous surgeries 

(vascular surgery saphenous vein harvest, orthopaedic knee surgery or foot and ankle surgery). Despite the number of opportunities 

to cause saphenous nerve neuropathy, its involvement remains under diagnosed primarily due to lack of recognition of the problem 

by other specialties. We reviewed 20 consecutive patients and present their outcomes. 

METHODS: 

Common to all 20 patients is that their pain was present for at least 9 months (9m-2.7y) and that all conservative pain modalities failed 

to provide relief. Three patients had nerve compression at the adductor canal (one idiopathic, two following blunt trauma). Two patients 

had nerve exposed in open wound (sickle cell), five patients had pain due to orthopaedic procedures in the lower extremity and foot, 

while ten had pain following knee surgery. All patients had moderate to major quality of life issues due to the pain. Patients who had 

nerve compression at the adductor canal were decompressed, while patients with post-op neuroma along the course of the nerve had 

excision of the nerve proximal to the site of the injury and implantation to the muscle. 

RESULTS: 

Patient's had an average 2-year follow up (range 1.4-2.9 years). Pre-operative average VAS pain level was 7.4 (with ten on direct stimulation 

of the neuroma site), while post-operatively it dropped to an average of 2.3 (p

Caspase 3 Knockout Mice Show Partial Protection of Skeletal Muscle Atrophy following 

Denervation 

Institution where the work was prepared: McMaster University, Hamilton, ON, Canada 

James Bain, MD, MSc1; Jane AE Batt, MD, PhD, FRCPC2; Pam Plant2; Minna Woo2; (1)Hamilton Health Sciences and 

McMaster University, (2)University Health Network, University ofToronto 

Early functional reinnervation is the goal following peripheral nerve injury and denervation. However, profound and eventually irreversible 

muscle denervation atrophy is a barrier to this goal. The ubiquitin proteasomal pathway is the predominant protein degradation 

pathway activated following denervation that results in denervation muscle atrophy. However, the proteasome is not able to 

degrade intact actinomyosin myofibrils. Capsase-3 has been purported to be a key enzyme that degrades intact actinomyosin complexes, 

into substrates upon which the ubiquitin proteasome subsequently acts. 

HYPOTHESIS: 

The absence of the caspase-3 protein will protect muscle from denervation atrophy. 

PURPOSE: 

To explore the muscle denervation atrophy in caspase-3 knockout mice and evaluate both the downstream ubiquitination pathways, 

and apoptotic pathways in this animal model. 

METHODS/MATERIALS: 

Caspase-3 knockout mice and heterozygote and wild type controls were anesthetized and had the sciatic nerve transected under institutionally 

guided ethics approval. Animals were sacrificed after 2 or 4 weeks of denervation. Animal and wet Gastrocnemius muscle 

weights were recorded for experimental and contralateral sides. Muscle was then either snap frozen in liquid nitrogen and maintained 

at ñ80, or fixed in paraformaldehyde for subsequent histological analysis. RNA and protein were isolated. Real time RT PCR and western 

blotting determine mRNA and protein expression levels respectively of key mediators of the ubiquitin proteasome pathways. 

RESULTS: 

Although experimental and control animals demonstrated muscle atrophy, significantly less muscle loss was observed in the homozygous 

animals at both 2 weeks and 4 weeks (p

ASPN SCIENTIFIC PAPER SESSION C 

Grip Strength and CMAP Amplitude in Median Nerve Injury of the Rats 


Huan Wang, MD, PhD; Eric J. Sorenson; Robert J. Spinner; Anthony J. Windebank; Mayo Clinic 

INTRODUCTION: 

Grip strength is a measurement of finger flexor power and therefore reflects motor function of the median nerve which innervates finger 

flexors in rats. The aim of the study is to develop atraumatic recording of compound muscle action potential (CMAP) of median 

nerve and validate its reliability by correlating CMAP amplitude with grip strength. 

METHODS: 

12 Sprague Dawley rats were used. In one group median nerve transection and repair was done. Transection and direct coaptation of 

both median and ulnar nerves was done in the other group. CMAP was recorded by placing a subcutaneous needle electrode at the 

thenar muscle while the median nerve was percutaneously stimulated at the cubital fossa. A grasping task was carried out to measure 

grip strength. These measurements were conducted preoperatively and postoperatively after 1, 3, 4, 6, 8, 10, 12, and 16 weeks. 

Relationship between recovery of CMAP amplitude and recovery of grip strength was assessed by plotting grip strength against CMAP 

amplitude. To further determine if there is any correlation between this pair of variables, correlation coefficient was examined by nonlinear 

regression curve fit of these two sets of data. 

RESULTS: 

Reproducible median nerve CMAP was recorded in both groups. Following nerve transection CMAP disappeared and did not return 

until 4 weeks after nerve repair. CMAP dispersion, amplitude deterioration, area deterioration and prolonged onset latency were seen 

during early regeneration period. The amplitude gradually increased as post-operative time passed and did not reach pre-operative 

level until 16 weeks. Following median nerve transection, flexion of forepaw digits was lost and grip strength was not measurable. Digit 

flexion was observed 3 weeks postoperatively and grip strength gradually recovered and returned to pre-operative level 12 weeks postoperatively. 

Visual correlation between grip strength and median nerve CMAP amplitude in both groups showed similar pattern of 

recovery with time. Recovery of CMAP amplitude lagged behind recovery of grip strength. Nonlinear regression of CMAP amplitudegrip 

strength curve followed a hyperbolic shape. R squared of the curve fit in median nerve injury group was 0.91 while r squared of the 

curve fit in combined median and ulnar nerve injury group was 0.93. This demonstrated a strong correlation between grip strength and 

median nerve CMAP amplitude. 

CONCLUSION: 

CMAP is a valid parameter that shows typical time course of nerve regeneration and motor function recovery. To our knowledge it is 

the first report of conducting CMAP measurement in rat forelimb. 

Nerve Transfers For Paralysis Of The Tibialis Anterior Muscle (Foot-Drop)óA Cadaveric 

Feasibility Study 

Institution where the work was prepared: Teaxs Tech University Health Science Center, El Paso, TX, USA 

Miguel Pirela-Cruz, MD; D.A. Terreros; U.D. Hansen, MD; P. West, MD; A.D. Rossum, MD; Texas Tech University HSC, El Paso 

INTRODUCTION: 

Nerve transfers for upper extremity neurological problems is now an accepted treatment option for addressing some motor and sensory 

deficits. However this treatment option for reconstructing peripheral lesions of the lower extremity is limited. This study is an 

attempt to explore the possibility of restoring motor function of the tibialis anterior (TA) muscle following an irreparable traumatic injury 

to the common peroneal nerve that results in a foot-drop. 


Eight caderveric legs, disarticulated at the hip, were studied. Specimens included 4 male and 4 female with an average age 51 and 47 

years respectively. Three nerves were evaluated as possible donors; the branch to the soleus muscle, branch to the medial and to the 

lateral gastrocnemius muscle. 

RESULTS: 

Nerve transfer using the interosseous route could be accomplished for each of the donor nerves. The average working length of the 

branch to the tibialis anterior (BTA) was 96 mm +/- 8.9. All nerve transfers with the exception of one could be performed without an 

interpositional nerve graft. The average repair site to TA was 73.5 mm, 66.6 mm, 46.6 mm for the medial gastrocnemius, lateral gastrcnemius 

and soleus respectively. 

CONCLUSION: 

Successful mobilization of the BTA can be accomplished through a fibula and interosseus windows to reach to potential donor nerves. 

These finding may have significant clinical benefits pertaining treatment for traumatic foot drop. 

116

Soleus Arch as Compression Site for Proximal Tibial Nerve: Cadaver Study 

Institution where the work was prepared: Union Memorial Hospital, Baltimore, MD, USA 

Eric H. Williams, MD; Dellon Institute for Peripheral Nerve Surgery: Baltimore. Clinical Instructor; Johns Hopkins 

University School of Medicine; Gedge D. Rosson, MD; Johns Hopkins School of Medicine; A. Lee Dellon, MD; Dellon 

Institute for Peripheral Nerve Surgery: Baltimore. Professor; Johns Hopkins University School of Medicine 

TITLE: 

Soleus Arch as Compression Site for Proximal Tibial Nerve: Cadaver Study 

PURPOSE: 

As the Pronator Syndrome represents a site of proximal compression of the median nerve that can be symptomatic by itself or be the 

etiology of ìfailed carpal tunnel syndromeî, so too may a site of proximal compression of the tibial nerve beneath the aponeurotic arch 

of the origin of the soleus muscle be a source of symptoms for patients with pain in the calf or who complain of pain or numbness in 

their toes. The setting for the syndrome of proximal compression of the tibial nerve may be in patients with previous lumbosacral spine 

surgery, ìfailed tarsal tunnel syndromeî, compartment syndrome, of it may exist on its own. 

METHOD: 

25 limbs from 18 embalmed cadavers were dissected using 3.5X loupe magnification. There were 12 right and 13 left cadaver limbs; the 

sex was unknown. The distance from the medial femoral epicondyle to the soleus arch and the length of the leg was measured. The 

ratio of limb length to location of the soleus arch was calculated. The thickness of the fibrous soleus arch, its relationship to the tibial 

nerve, and any narrowing of the tibial nerve in this location were noted. 

RESULTS: 

The average limb length was 46.8 cm (40-55 cm). The tibial nerve traveled under the soleus arch 9.4 cm (7-13 cm) below the medial 

femoral epicondyle. This location measured approximately 1/5 the total length of the leg. The soleus arch demonstrated a thick deep 

layer of fascia in 64% of the specimens. The tibial nerve was narrowed in 52% of the specimens; 48% demonstrated slight narrowing 

over several centimeters, but 4% demonstrated a tight focal constriction across the nerve at the level of the soleus arch. 

CONCLUSION: 

The soleus arch represents an anatomic site of potential compression of the proximal tibial nerve. 

Anatomical Landmarks for the Nerve Branch to the Masseter Muscle in Facial Reanimation 


Nada Berry, MD1; Margo Herron1; Rebuen Bueno1; Ronald Zuker, MD2; Michael W. Neumeister3; (1)SIU School of 

Medicine, (2)The Hospital for Sick Children, (3)Southern Illniois University School of Medicine 

The nerve branch to the masseter muscle has been used as the donor nerve in facial reanimation surgery for the Moebius syndrome 

patient. It is located on the undersurface of the masseter usually coursing downward at the posterior margin of the muscle below the 

zygomatic arch. As the nerve enters the muscle, it divides into smaller branches. An anatomical study has not been done to map out 

the location and course of the nerve as in enters the muscle. This study defines the course of the nerve in relation to anatomical landmarks 

and measures the length of the nerve before branching. Total of 15 nerves were dissected and examined. The following landmarks 

were selected: superior pole of the tragus, point A at superior border of the zygoma, oral commisure, and the first branch emerging 

from the muscle. The average length from the tragus to point A is 29.4mm (STD 3.4), and the average distance to the first branch 

is 18mm (STD 2.1). When using the nerve branch to the masseter muscle as the donor nerve for reanimation with a reinnervated gracilis 

muscle, the results from this study will help identify the nerve during the reanimation procedure. 

Novel Model for End-Neuroma Formation in the Amputated Rabbit Forelimb 

Institution where the work was prepared: Northwestern University, Feinberg School of Medicine, Chicago, IL, USA 

Peter S. Kim, MD1; Kristina O'Shaughnessy, MD1; Todd A. Kuiken, MD, PhD2; Gregory A. Dumanian1; (1)Northwestern 

University, Feinberg School of Medicine, (2)Rehabilitation Institute of Chicago 

The forelimb amputee poses many reconstructive challenges in the clinical setting, and there is a paucity of established surgical models 

for study. To further elucidate the pathogenic process in amputation neuroma formation, we created a reproducible, well-tolerated 

rabbit forelimb amputation model. Upon approval from the institutional Animal Care and Use Committee, 5 New Zealand white rabbits 

underwent left forelimb disarticulation. During this initial surgery the median, radial and ulnar nerves were transected 1.6-2.5 (mean 

2.0) cm distal to the brachial plexus, transposed onto the anterior chest wall and preserved at length. Six weeks subsequent to the 

amputation, the distal 5 mm of each neuroma was excised and the remaining stump underwent histomorphometric analysis. The nerve 

cross sectional areas increased by factors of 1.99, 3.17, and 2.59 in the median (p=0.059), radial (p=0.001) and the ulnar (p=0.012) nerves 

respectively. At the axonal level, the number and cross sectional area of axons demonstrated an inverse relationship whereby the number 

of axons in the median, radial and ulnar nerves increased by factors of 5.13 (p=0.096), 5.25 (p=0.037) and 5.59 (p=0.046) and the 

cross sectional areas of the axons decreased by factors of 4.62 (p

Antibodies to Galactocerebroside Enhance Nerve Regeneration after Acute Contusion and Transection Injuries 

in the Adult Rat Sciatic Nerve 

Institution where the work was prepared: University of California, Irvine, Orange, CA, USA 

Aaron M. Kosins, MD, MBA; Charles Mendoza; Michael P. McConnell, MD; Brandon Shepard; Sanjay Dhar, PhD; 

Gregory RD Evans, MD, FACS; Hans S. Keirstead, PhD; University of California, Irvine 

INTRODUCTION: 

To improve the regenerative potential of PNS axons in vivo, we utilize a novel therapy in the adult rat sciatic nerve in which nerve regeneration 

is enhanced following contusion and transection injuries. We demonstrate that 1) Axon regeneration within a region of injury 

increases in the presence of immunological demyelination, and 2) Regenerated axons are derived from the proximal motor axons. 

METHODS: 

Adult female Sprague-Dawley sciatic nerves were contused and injected with the demyelinating agent. The sciatic nerves were harvested 

14 and 28 days following the onset of demyelination. The lesion containing length of nerve was cut into 1mm transverse blocks and 

processed to preserve the cranio-caudal orientation. In a second group, the sciatic nerves were exposed, transected, repaired, and 

injected with the demyelinating agent. These animals were similarly euthanized at 1 and 2 months and processed to examine the extent 

of axon regeneration. Specimens were fixed and evaluated using structural and immunohistochemical analysis. A Mini-Ruby Tracer was 

included to determine the source and direction of axonal re-growth. 

RESULTS: 

A single epineural injection of complement proteins plus antibodies to galactocerebroside (the major myelin sphingolipid) resulted in 

demyelination followed by Schwann cell remyelination that enhanced nerve regeneration in the injured (contusion and transection) animals. 

At each time point for both contused and transected animals, nerve regeneration was enhanced following demyelination therapy. 

Tracers demonstrated that nerve regeneration arose from proximal motor axons, and not the distal branching of sensory axons. 

CONCLUSION: 

These studies demonstrate a new method to enhance nerve regeneration in the PNS using experimental immunological demyelination. 

Our findings indicate that peripheral nerve regeneration within a region of contusion or transection injury in the adult rat sciatic 

nerve can be enhanced using a demyelinating agent. This data can be applied in the creation of tissue-engineered constructs, cellbased 

therapy systems, and even nerve transfers to improve the outcome of critical nerve injuries in the PNS. 

Sympathetic Nerves in the Tarsal Tunnel: Implications for Blood Flow in the Diabetic Foot 

Institution where the work was prepared: University of Arizona School of Medicine, Tucson, AZ, USA 

Andrew Blount, BS; Erika Dexter; Raymond Nagle; Christopher Maloney; Lee Dellon; Ziv Peled; University of Arizona 

BACKGROUND: 

Peripheral nerve decompression has been shown to alter the natural history of lower extremity peripheral neuropathy by reducing the 

incidence of ulceration and amputation. One method by which this occurs is an increase in protective sensation in the decompressed 

foot. Another possible method, which has yet to be evaluated, is an improvement in blood flow resulting from sympathectomy of the 

tibial vasculature which takes place during tarsal tunnel decompression surgery. 

METHODS: 

Seven consecutive patients evaluated at our clinic were enrolled in this pilot study which was approved by the Institutional Review Board 

of our university. All patients had neuropathy as documented by their clinical history, physical exam, and by neurosensory testing using 

the Pressure Specified Sensory Device (PSSD) (Sensory Management Services L.L.C., Baltimore, MD). During tarsal tunnel decompression, 

all patients had a partial epineurectomy of the tibial nerve, a portion of which was sent as a specimen. Connective tissue bridging 

the tibial nerve and vessels was also harvested and sent for evaluation. Specimens were analyzed by immunohistochemistry using an 

anti-tyrosine hydroxylase antibody, which is specific for sympathetic nerves. 

RESULTS: 

Five of seven tibial epineurial specimens stained positively with TH. Six of seven connective tissue specimens stained positively with TH. 

In those specimens that were negative, no nerve tissue of any type was identified. Staining was especially apparent surrounding the 

microvasculature in each specimen (Fig 1). 

CONCLUSION: 

Sympathetic nerves are present adjacent to the tibial vessels and microvasculature within the tarsal tunnel. Sympathectomy occurring 

during tarsal tunnel decompression may account for increased blood flow to the foot, a concept supported by our identification of sympathetic 

nerve fibers along the local microvasculature in our specimens. This mechanism has several implications. One, it may help 

explain how tarsal tunnel decompression functions in preventing future ulceration and amputation. Furthermore, if blood flow is 

improved after decompression and epineurectomy, perhaps our tarsal tunnel release procedure could be considered an adjunct to 

bypass surgery in patients with lower extremity peripheral vascular disease. In the future, we plan to perform more direct blood flow 

measurements and correlate these data with similar immunohistochemical findings. 

118

A Study of Modality Specific Nerve Regeneration in the Rat Femoral Nerve 

Institution where the work was prepared: Washington University, St. Louis, MO, USA 

David H. Kawamura, MD; Gregory H Borschel; Daniel A Hunter; Susan E Mackinnon; Thomas HH Tung; Washington 

University in St. Louis 

BACKGROUND/HYPOTHESIS: 

Today, autologous sensory nerve grafting is the standard of care for the repair of peripheral nerve gaps. Motor nerve defects are frequently 

reconstructed with grafts harvested from superficial sensory nerves due to the morbidity associated with motor nerve harvest. 

However, some investigators have suggested that modality matching, i.e. repairing motor nerves with motor grafts and sensory nerves 

with sensory grafts, may improve nerve regeneration. The aim of this study is to compare nerve regeneration between modality 

matched and modality mismatched grafts in a clinically-representative scenario utilizing unifascicular nerve grafts in a rodent model. 

MATERIALS AND METHODS: 

Isogeneic nerve grafts were harvested from the quadriceps branch of the femoral nerve (motor), femoral cutaneous branch (sensory), 

and peroneal nerve (mixed). Grafts were 10mm in length and were used to reconstruct a 5mm defect in the quadriceps branch or cutaneous 

branch of a recipient rat. A total of 48 Sprague-Dawley rats were randomized to six groups of eight animals each. The groups 

represented six different combinations of donor and recipient nerves, as follows: 1) motor/motor, 2) sensory/motor, 3) mixed/motor, 4) 

sensory/sensory, 5) motor/sensory, 6) mixed/sensory. Animals were sacrificed after 7 weeks and nerves were harvested for analysis. The 

recipient nerve distal to the graft was fixed, stained, and sectioned for histomorphometry. 

RESULTS: 

Histologic sections revealed robust regeneration through the graft and into the distal nerve in all groups. Histomorphometric analysis 

of nerve sections distal to the graft revealed no significant difference between any of the six experimental groups with regard to nerve 

fiber count, fiber density, fiber width, nerve area, or percent nerve. Assessment of fiber size revealed that sensory and motor grafts supported 

regeneration of a similar number of large-diameter axons when grafted into motor nerve. 

CONCLUSION: 

Our data demonstrate that injured peripheral axons do not regenerate in a manner specific to motor or sensory modality. On the contrary, 

motor and sensory nerve regeneration occurs to an equal degree in motor, sensory, and mixed nerve grafts. In addition, equal 

numbers of large-diameter fibers regenerated through sensory and motor grafts in the quadriceps branch. This indicates that sensory 

grafts are equal to motor in their ability to support regenerating motor axons. Our findings support the continued use of nerve grafts 

derived from sensory nerves when reconstructing motor nerve defects in human patients. Further studies will be undertaken to compare 

end organ reinnervation and functional recovery between modality matched and mismatched grafts. 

Limb Length Discrepancy in Obstetrical Brachial Plexus Injury 

Institution where the work was prepared: McMaster Children's Hospital, Hamilton, ON, Canada 

James Bain, MD, MSc; Carol DeMatteo; Deborah Agro; Hamilton Health Sciences and McMaster University 

Obstetrical brachial plexus injury (OBPI) has a variable natural history depending upon severity of nerve trauma. Approximately 50 % of 

children will completely recover, many will be left with a functional but short, impaired arm. 

PURPOSE: 

To determine if OBPI results in differences in limb length comparing the affected to unaffected limbs. 

METHODS: 

A prospective database of OBPI patients from 1998-2007 has been reviewed. Limb lengths were manually measured by the same investigator 

at standard times in new patients and at 3 and 12 month follow-up. Arm length was measured from the acromion to the olecranon 

and forearm length from the olecranon to the ulnar styloid. Inclusion criteria included those with full records and early presentation 

to our clinic. Comparisons were made between affected and unaffected limbs, and results correlated with total active motion scale 

scores (AMS) using SAS statistical software. 

RESULTS: 

Twenty-four children had complete scores at 3 months and there was a significant reduction in the limb length of the affected side 

(p

Regeneration in an Enzyme-Treated Decellularized Nerve Allograft 

Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA 

Sami H. Tuffaha, BA; Daniel A. Hunter; Ying Yan; Janina P. Luciano; Susan E. Mackinnon; Gregory H. Borschel; 

Washington University in St. Louis 

INTRODUCTION: 

Peripheral nerve injuries are currently reconstructed using nerve autografts. The very limited supply of autologous nerve grafting material 

combined with the morbidity associated with nerve autograft harvest, such as sensory loss and painful neuroma formation, necessitate 

a suitable substitute to autografting. AxoGenô nerve allografts are manufactured by decellularizing human nerves with a process 

that removes antigens and degrades molecules that inhibit neuroregeneration while leaving laminin intact. We designed a study to 

compare the neuroregenerative capacities of the AxoGenô nerve graft to those of an autograft and the NeuraGenô conduit (the leading 

hollow tube nerve conduit). 

METHODS: 

To obtain processed nerve grafts, sciatic nerves from Brown Norway rats were harvested and sent to AxoGenô for proprietary processing. 

Three groups (Avanceô, NeuraGenô and isograft) were implanted into the sciatic nerve of Lewis rats at two different lengths (14mm 

and 28mm). Grafts were harvested at either a 6 or 12 week endpoint and evaluated for neuroregeneration using histomorphometry. 

Retrograde labeling, motor endplate staining, walking track analysis, and wet muscle mass were used to analyze functional recovery. 

RESULTS: 

Midgraft histomorphometric data of the 14mm grafts at 6 weeks showed significantly greater regeneration in AxoGenô processed 

grafts, as compared to NeuraGenô conduits.† Fiber distribution patterns resembled those of an isograft as demonstrated by electron 

micrographs of midgraft sections. 

CONCLUSION: 

The AxoGenô grafts were well-tolerated by all animals. The 6 week histomorphometric data suggest that the neuroregenerative capacities 

of AxoGenô processed grafts are comparable to those of an isograft and significantly better than those of the leading biosynthetic 

conduit. Pending functional outcome measures and data from the 12 week endpoint, it appears that AxoGenô grafts could provide 

a much needed substitute for autografts. 

Graft Type 

Total fiber number ± 

std dev 

Percent Nerve 

± std dev 

* or †: significant difference between groups; p < 0.05 by ANOVA. 

Fiber width (µm) 

± std dev 

120 

Nerve density 

(fibers/mm 2 ) 

± std dev 

Isograft 13649 ± 4967*† 23.5 ± 11.0* 3.0 ± 0.2* 23191 ± 9616* 

AxoGen TM 

Processed 

Nerve Graft 

6041 ± 1515† 16.5 ± 3.4† 3.3 ± 0.2† 14749 ± 3512† 

NeuraGen TM 1427 ± 2018* 1.3 ± 1.8*† 1.6 ± 2.2*† 1278 ± 1821*†

Increase of Neuronal Camp by Electrical Stimulation or Rolipram Administration and/or 

Local Application of Chonodrioitinase ABC Accelerates Motor Axon Outgrowth Across the 

Surgical Repair Site of Sectioned Rat Peripheral Nerve 


T. Gordon; M Furey; N Tyreman; E Udina; University of Alberta 

Inhibitory proteins associated with myelin and the proteoglycans of the extracellular matrix play a major role in the failure of the central 

axons to regenerate after injury. Although also present in the peripheral nervous system (PNS), these molecules do not block PNS 

regeneration mainly due to the effective Wallerian degeneration after a nerve lesion. Nevertheless, these molecules could play an 

important role in the delay in the onset of axonal regeneration observed after the repair of a transected peripheral nerve. By accelerating 

the onset of axonal regeneration the detrimental consequences of long periods of chronic axotomy and Schwann cell denervation 

would be diminished and the functional recovery would be improved. In this study we wanted to elucidate the role of cAMP in PNS 

regeneration, since its elevation in neurons can overcome inhibition of myelin associated proteins. Electrical stimulation (ES) of the 

peripheral nerve accelerates the onset of regeneration and its effect has been linked to increased levels of cAMP in the neuron, therefore 

we also wanted to compare the similarities between ES with systemic administration of an agent that increase cellular cAMP levels 

in PNS regeneration. We repaired the transected common peroneal (CP) nerve in rats and increased levels of cAMP in the axotomized 

neurons with subcutaneous administration of rolipram, a specific inhibitor of the phosphodiesterase, the enzyme that degrades 

cAMP. Moreover, we investigated if combination of rolipram treatment with local degradation of the proteoglycans by application of 

chondroitinase ABC (cABC) in the distal stump, would elicit an additive enhancement in nerve regeneration. Rolipram treatment significantly 

increased the mean (± SE) number of motor (but not sensory) neurons that regenerated their axons across the repair site at 1w 

and 2w with 194±14 of a total of 336±19 CP motoneurons regenerating their axons a 10mm distance into the distal nerve stump at 2w 

as compared to 109±20 motoneurons that regenerated their axons after saline treatment. This effect mimicked the effect of 1h of ES 

(at 20Hz) applied to the proximal stump of the transected and repaired femoral nerve in accelerating axon outgrowth. Both rolipram 

and ES significantly increased the number of motor axons crossing the lesion site at earlier time points by ~3-fold when compared to 

the control groups. Local application of cABC also accelerated axonal outgrowth but the effect was not additive when combined with 

rolipram. We conclude that pharmacological elevation of cAMP accelerates PNS axonal outgrowth similar to ES. 

121

Suppression of Fibrous Scar Improves Peripheral Nerve Regeneration After Primary Nerve Suture 

Institution where the work was prepared: University of Tuebingen and University of Duesseldorf, Tuebingen and 

Duesseldorf, Germany 

Nektarios Sinis, MD1; Philip Schoenle1; Tatjana Lanaras1; Frank Werdin, MD1; Armin Kraus, MD1; Max Haerle, MD2; 

Timm Danker, PhD1; Elke Guenther, Phd1; Federica Di Scipio, Phd3; Stefano Geuna, MD3; Hans-Werner Mueller, 

PhD4; Daniela Mueller5; Carmen Masannek5; Susanne Hermanns, Phd5; Hans-Eberhard Schaller, MD1; (1)University of 

Tuebingen, (2)Orthopaedische Klinik Markgroeningen, (3)University de Torino, (4)Heinrich-Heine-University of 

Duesseldorf, (5)Neuraxo Biopharmaceuticals GmbH 

BACKGROUND: 

Despite the progress of microsurgical techniques the outcome of repaired nerves after primary nerve suture remains incomplete in a 

lot of cases. One reason that explains these results is the development of a fibrous collagen scar at the site of coaptation with expression 

of different growth inhibiting substances. This collagen scar prevents axons from passing the lesion and reaching the end organ. 

The aim of this study was to analyze the impact of a scar inhibiting substance, namely a potent iron chelator on peripheral nerves after 

transection and primary nerve suture. 

MATERIAL/ METHODS: 

In a rat median nerve model four experimental groups were operated. Group I ñ transection of the median nerve and primary nerve 

suture (N = 12). Group II ñ transection and venous ensheatment of the median nerve at the coaptation site (external jugular vein) (N = 

12). Group III ñ transection of the nerve, venous ensheatment and filling the vein with a lipid carrier (N = 12). Group IV ñ transection, 

venous ensheatment, filling of the vein with the iron chelator combined with the lipid carrier (N = 12). The observation† Axon number, 

density, average diameter, nerve area and myelin thickness were measured. The gastrocnemius muscle was harvested and gene expression 

of GAP-43, myogenin, MyoD, MYF5, MYF6 (MRF4) and the ?, ?, ?, ?, and ?-subunits of the nicotinic acetlycholinergic 

receptor(nAChR) were examined. 

RESULTS: 

For control animals, 83% of Young showed evidence of regeneration vs. 50% of Aged. For IGF-1 treated animals, 100% of Young and 

75% of Aged showed evidence of regeneration. Of regenerated animals, there was no difference in conduction delay or amplitude. In 

aged animals, IGF-1 significantly increased a) axons per nerve (13025 vs. 3062; p

ASPN SCIENTIFIC PAPER SESSION D 

Brachial Plexus Surgery in a German Center for Peripheral Nerve Surgery 

Institution where the work was prepared: University of Tuebingen, Tuebingen, Germany 

Nektarios Sinis, MD; Tatjana Lanaras; Hans-Eberhard Schaller, MD; University of Tuebingen 

Brachial plexus lesions are still associated with complete or partial plegia of affected muscles even though the microsurgical concepts 

and treatment options were improved during the past twenty years. This work should provide an overview of strategies and outcomes 

of 42 patients operated in a center for peripheral nerve surgery in the southwest of Germany. The patients were followed after surgery 

and examined for muscle strength of different muscle groups following the classification introduced by Loved et al. (M0 ñ no function 

to M5 ñ full function) and sensitivity (differentiation of blunt and sharp touch in different dermatomes). They were asked with a short 

questionnaire about their experiences and daily life after surgery. The longest follow-up was 96 months while the shortest was four. 

Mean time past between trauma and operation was 7.1 months. 93% of the patients received a grafting procedure using the sural nerve. 

Different procedures were applied referring to the underlying pathology: Intercostal nerve transfer, end-to-side coaptation of donor and 

recipient nerves (one case of phrenic nerve to axillary nerve), direct grafting between roots, cords and trunks to different recipient 

nerves. At the time of examination 27 patients had a follow-up time of at least 36 months. Only these patients presented a measurable 

function in the affected extremity. In general the results for reconstruction of proximal muscle groups were more satisfactory than those 

in distally located muscles (e. g. short muscles of the hand, exception the deltoid muscle). Elbow ñ flexion was restored in 56 % of cases 

(i. e. muscle strength of at least M3). Triceps function was successfully reconstructed in 26 % of cases. Hand function was in contrast poor 

except of one case with full regeneration after neurolyisis. Nevertheless, some developed an acceptable force of the forearm muscle 

groups with the ability to flex the wrist in 37 % and for wrist extension in 17 %. Results were estimated as acceptable for biceps reconstruction 

but poor for the other muscle groups. Some treatment strategies which are today under frequent discussion (contralateral C7transfer, 

banked autografts, Oberlin procedure) were not applied. However, some of these techniques may provide a key to improve 

the results, therefore frequent exchange in form of specialist meetings for different concepts and surgical techniques should be performed 

by centers operating brachial plexus lesions in order to share their experiences with the others. 

Effect Of Nerve Growth Factor (NGF) Releasing Polylactic-Co-Glycolic Acid (PLGA) 

Microspheres On Peripheral Nerve Regeneration 


Ralph De Boer, MD1; Huan Wang, MD, PhD1; Andrew M. Knight, PhD1; Robert J. Spinner1; M.J.A. Malessy2; Michael 

J. Yaszemski, MD, PhD1; Anthony J. Windebank, MD1; (1)Mayo Clinic, (2)Leiden University Medical Center 

INTRODUCTION: 

Autologous nerve grafting is the standard method for repair of a peripheral nerve when direct coaptation is not feasible. Optimization 

of artificial nerve conduits by incorporation of trophic factors may enhance nerve regeneration and improve outcomes for patients. 

Consistent delivery of trophic factors for a prolonged period of time is therefore required. We have characterized the long term release 

of nerve growth factor, using a microsphere delivery system and evaluated the effect on functional regeneration in a rat sciatic nerve 

injury model. 

METHODS: 

In vitro: 125I-NGF was incorporated into PLGA microspheres with lactic to glycolic acid ratios of 50:50 (1A - inherent viscosity 0.1 dL/g); 

50:50 (4A - inherent viscosity 0.4 dL/g); 50:50 (7A - inherent viscosity 0.7 dL/g); 75:25 and 85:15. Microspheres were placed in a transwell 

and continuously shaken at 37'C for 10 weeks. Release of radioactivity into the medium was measured weekly by ?-counting. Biological 

activity of released NGF was established using the E15 rat dorsal root ganglion (DRG) assay In vivo: An animal study has been initiated 

with PLGA nerve conduits loaded with NGF releasing microspheres bridging a 10 mm gap in the rat sciatic nerve. An autologous nerve 

graft and a conduit filled with saline were used as the positive and negative control respectively. Electrophysiological (CMAP, SEP), sensory 

(Hargreaves) and motor testing (motion analysis) were carried out at baseline and at two week intervals after surgery. Retrograde 

tracing will be performed before sacrificing the rats at 17 weeks. Sciatic nerves, along with appropriate spinal cord segments and dorsal 

root ganglia will be harvested and analyzed for cell counting and nerve morphometric measurements. 

RESULTS: 

In vitro: Microspheres could be designed to gradually release NGF at a rate of 0.2-2.5% of total per day. There was a small (

Nerve Transfers to Reanimate Elbow Flexion in Obstetric Brachial Plexus Lesions 

Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands 

Willem Pondaag, MD; Martijn J.A. Malessy; Leiden University Medical Center 

INTRODUCTION: 

In obstetric brachial plexus lesions with avulsion injury, nerve grafting is not possible due to the lack of a proximal stump as lead-out. In 

such cases, intercostal nerves (ICN) and pectoral (PEC) nerves can serve as donor for a nerve transfer to the musculocutaneous nerve 

(MCN) to restore elbow flexion. Reports are scarce on the results of ICN-MCN and PEC-MCN transfers. In the present study the results 

of both techniques are reported from a single institution. 

METHODS: 

Patients We analyzed 30 consecutive patients (1995-2005) in whom nerve transfers for biceps reanimation had been applied. From 1995- 

2000 only ICN-MCN transfers were performed, from 2001-2005 both techniques were applied. 8 of the 16 patients with ICN-MCN transfer 

had a flail arm. The PEC-MCN was applied in 10 cases of avulsion injury to both C5 and C6, which had often resulted from breech 

delivery. Alternatively, the PEC-MCN transfer was applied in 4 patients because shoulder innervation had recovered spontaneously but 

recovery of the biceps muscle had not taken place. 

RESULTS: 

Surgical Technique In all but one ICN-MCN patients three intercostal nerves were coaptated directly to the musculocutaneous nerve; in 

one patient a 1 cm graft proved necessary. In the patients with PEC-MCN transfer, in half of the patients the musculocutaneous was significantly 

bigger in diameter than the pectoral nerves. In these cases the MCN was sectioned only partially, leaving half of the nerve intact. 

Results Elbow flexion > MRC 3 was achieved in 26/30 patients (87%) after a mean follow-up of 40 months. The results in the PEC-MCN 

group were somewhat better than in the ICN-MCN group (93% vs. 81%). In the ICN-MCN group once secondary surgery was performed 

(Steindler flexor-plasty). No adverse effects were noted in both groups, especially no rib cage deformity. 

DISCUSSION: 

The overall success rate was satisfying. The observed difference in results between the PEC-MCN and ICN-MCN transfers may be 

explained by the more severe brachial plexus lesions that were included in the ICN-MCN group. 

Specialty of the Phrenic Nerve for Modified End-to-Side Nerve Repair - Experiment and 

Clinical Implications 

Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA 

ji-Geng Yan, MD; Lin-Ling Zhang; Hani S Matloub; James R Sanger; Yu-Hui Yan; Medical College of Wisconsin 

INTRODUCTION: 

End-to-side neurorrhaphy has had limited use clinically due to its few and small donor side sprouts. Phrenic nerve possesses a continuous 

firing rhythm that enhances side sprouting. 

METHODS: 

Laboratory phase: 18 SD rats were divided into 3 groups of 6. Group I: Phrenic side with wide oblique window was sutured with 1.5-cm 

saphenous nerve graft, then musculocutaneous nerve; Group II: Phrenic nerve was transected, its proximal end sutured to1.5-cm saphenous 

nerve graft, then to musculocutaneous nerve; Group III: Musculocutaneous nerve was transected without any repair. Clinical phase: 

From 1999 to 2007, a total 46 patients (15 adults, 32 children) with brachial plexus injury underwent modified end-to-side neurorrhaphy 

in which the phrenic side was widely opened, one or two nerve grafts were interpositioned and sutured between the phrenic nerve side 

and the recipient nerve end, which included various recipient ends on different nerve injuries (musculocutaneous nerve, anterior or posterior 

division of the upper trunk, axillary nerve, suprascapular nerve, etc.) 34 patients have been followed postoperatively from 3 months 

to 69 months (mean:25.5). 

RESULTS: 

Laboratory phase: Group I was superior to Groups II and III. by histology and electrophysiologic study. Side sprouting behavior was 

studied by various histology and molecular methods that showed that sprouting growth of the phrenic nerve was easy and extensive. 

Clinical phase: 17/34 (50%) patients had muscle grade 4; 10/34 (30%) patients had muscle grade 3; 4/34 (11%) patients had muscle grade 

2; 3/34 (9%) patients had muscle grade 1. 

CONCLUSION: 

1. Both laboratory and clinical surgery showed excellent results can be obtained if the phrenic nerve side is widely opened to allow one 

or more nerve grafts by oblique repair methods. 2. The special suitability of the phrenic nerve for this type of repair is evidenced by 

easy, fast and intense side sprouting, probably due to its continuous firing rhythm. 

124

Spontaneous gait recovery in denervated rats may impair the evaluation of artificial nerve guides 

Institution where the work was prepared: The Catholic University, Rome, ItalyAntonio Merolli, MD; Lorenzo Rocchi; 

Maria Silvia Spinelli; Rocco De Vitis; Francesco Catalano; The Catholic University 

PURPOSE: 

The study of the morphology of the in-vivo regeneration of a nerve, made by purely histological methods, may require such a high number 

of animals to pose serious problems of technique, ethics and funding and, then, a cheaper analysis like the evaluation of gait recovery 

is viewed with favour. The purpose of this study is to evaluate the reliability of this approach with the future perspective of studying 

artificial nerve guides implantation. 

METHODOLOGY: 

The study of peripheral nerve regeneration makes a widespread use of the rat sciatic nerve model where an artificial nerve guide may be 

implanted to bridge the gap in the eventually ablated segment of the nerve. In this work, 4 mm of the left sciatic nerve were ablated in 

inbred male Wistar rats; the retraction of the stumps led to a final gap of about 8 mm; nothing was interposed to bridge the gap. Twice a 

week the animals where individually taken out of their cage and let walk freely on a 0,5*2,0 m board for about 4 minutes; their walking was 

video-recorded. After 8 weeks the animal were sacrificed and a macroscopic examination of the operated site was performed. 

RESULTS: 

Two rats exhibited a partial recovery in gait within the first week after surgery; additional three exhibited it within the second week. Only 

one rat dragged the opertated limb during the first two weeks, mostly because of a deficit in extension of the foot, but afterwards a 

partial gait recovery ensued. As time passed, improving in gait recovery was documented; at the same time the operated limb 

appeared more hypotrophic and abducted. 

CONCLUSION: 

A cheaper analysis performed on the same animal along the duration of the experiment is seeked with favour and several studies in 

the literature contemplate the evaluation of gait pattern, and its eventual recovery after trauma, to avoid the use of more animals. The 

present study highlights that in the male Wistar rat sciatic model a spontaneous recovery in gait pattern occurs very early. This will impair 

any possible subtle discrimination, by qualitative visually-based analysis alone, about a possible benefit derived from the use of an artificial 

nerve guide since a recovery in gait is likely to ensue even without a device. 

125

ASPN SCIENTIFIC PAPER SESSION E 

Nonviral HVJ (Hemagglutinating Virus of Japan) Liposome Mediated Retrograde Gene 

Transfer of Human Hepatocyte Growth Factor Improves Neuropathic Pain-Related 

Phenomena in Rats 

Institution where the work was prepared: National Defense Medical College, Tokorozawa, Japan 

Toyokazu Tsuchihara1; Koichi Nemoto1; Hiroshi Arino1; Masatoshi Amako1; Kuniaki Nakanishi1; Morishita Ryuichi2; 

(1)National Defense Medical College, (2)Osaka University Medical School 

INTRODUCTION: 

Peripheral nerve injury is relatively common and sometimes may cause chronic neuropathic pain characterized by hyperalgesia and allodynia. 

However, neuropathic pain is extremely difficult to treat because of poor understanding of the underlying mechanisms. The purpose 

of this study is to investigate the therapeutic effect of Human hepatocyte growth factor (HGF) delivered into the nervous system 

by retrograde axonal transport using liposomes containing the hemagglutinating virus of Japan (HVJ). 

MATERIAL/METHODS: 

Male Wistar rats, approximately 6 weeks old were used (n=228). Chronic constriction injury (CCI) model in rats was made as an experimental 

neuropathic pain model. HGF gene was delivered into the nervous system by retrograde axonal transport following its repeated 

intramuscular transfer, using liposomes containing the HVJ. Evaluation methods were as follows: (a) the withdrawal threshold of the 

hind paw in response to non-noxious mechanical stimuli; (b) the thermal threshold in response to noxious heat applied to the plantar 

surface of the hind paw; (c) the blood flow of the sciatic nerve and the hind paw; (d) mRNA levels for P2X and P2Y receptors. P2X and 

P2Y receptors, which are activated by extracellular ATP, may play important roles as nociceptive purinoceptors on sensory nerve terminals, 

and (e) imaging study using light- and electron-micrographs. 

RESULTS: 

CCI (control) rats exhibited marked mechanical allodynia and thermal hyperalgesia, and decreased blood flow in sciatic nerve and hind 

paw. All these changes were significantly reversed by HGF-gene transfer. In the sciatic nerve in HGF-transferred rats, the histgram of the 

axons showed rightward shifts, the number of myelinated axons more than 5ìm in diameter was significantly increased, and the mean 

diameter of unmyelinated axons was significantly increased (versus CCI rats). Levels of P2X3, P2X4, and P2Y1 receptor mRNAs were elevated 

in the ipsilateral dorsal root ganglia and/or sciatic nerves by CCI, and these levels were decreased by HGF-gene transfer. 

CONCLUSION: 

We have demonstrated that transfer the human HGF gene into the nervous system via repeated intramuscular injection of nonviral 

HGF-HVJ liposomes is an efficient way of preventing or limiting sensory nerve degeneration in a rat model of neuropathic pain. On this 

basis, HGF gene transfer via retrograde transport may become a novel useful therapeutic tool for the treatment of neuropathic pain. 

126

Repairing Peripheral Nerve Injuries Using Skin-Derived Precursor Cells 

Institution where the work was prepared: University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada 

Sarah K. Walsh, BSc; Raj Midha, MD, MSc; University of Calgary 

Previous work has shown that clones of progenitor cells isolated from the dermis of the neonatal and adult murine skin have the ability 

to differentiate in vitro into neural crest cell types, including peripheral neurons and glia. These cells, termed skin-derived precursors 

(SKPs), also respond to the milieu of the regenerating nerve in vivo and are able to differentiate into GFAP/S-100‚ positive Schwann cells 

when transplanted distal to a nerve injury. In our ongoing study, we are exploring the viability and differentiation of SKPs in various nerve 

injury models to ascertain their role in promoting nerve regeneration. To this end, the sciatic nerves of CD-1 mice were transected and 

chronically denervated. SKPs or SKP-SCs were injected into the subepineurium distal to the transection either immediately following 

injury or after 8 weeks of denervation. Immunohistochemical analysis 2-8 weeks following transplantation revealed survival and differentiation 

of both naïve and pre-differentiated SKPs, with 73% of the surviving cells injected after established chronic denervation 

expressing Schwann cell markers. Eight weeks following SKP transplant, survival of pre-differentiated SKPs was significantly higher than 

that of the naïve preparation. This study also examined the potential for SKPs to improve nerve regeneration across a gap bridged by 

a freeze-thawed nerve graft. Donor sciatic nerves were collected from adult Lewis rats and decellularized by repeated cycles of freezing 

in liquid nitrogen and thawing in warm water bath. These syngeneic grafts were then used to bridge a 12 mm nerve injury gap in 

Lewis rat recipients and SKPs-SCs or cultured Schwann cells were injected into the grafted area. Immunohistology after 4 weeks showed 

survival of both cell types and early regeneration in SKP seeded grafts (as deemed by NF-stained axon counts) was comparable to those 

seeded with Schwann cells. We expect that morphometrical and electrophysiological measurements of cell-treated nerve segments 

after 8 weeks survival will show a similar contribution to regeneration. We therefore conclude that SKPs represent an accessible, autologous 

source of Schwann cells for transplantation therapies that have the potential to survive over long time periods and improve 

regeneration outcomes. 

DASH as a Measurement of Outcome in Adult Brachial Plexus Reconstruction 


Keith A. Bengtson; Alexander Shin; Robert Spinner; Allen Bishop; Michelle Kircher; Mayo Clinic 

No clear consensus exists on how to measure outcomes after adult brachial plexus reconstruction. The BMRC muscle strength scale is 

the most popular measuring tool used to date. Unfortunately, this method has many shortcomings including its imprecision, lack of 

inter-rater reliability, as well as the wide range of strength that is covered by the grade of 4/5. The DASH, however, “is the most validated 

measure of upper extremity function in upper extremity disorders. The instrument's ease of use in a heterogeneous sample is possibly 

its greatest advantage.” (Dowrick 2005). No studies have been published that measure DASH scores both before and after brachial 

plexus reconstruction. The purpose of this study is to illustrate the usefulness of the DASH as an outcome measure in adult brachial 

plexus reconstruction. Between the dates of November 2004 and October 2006, 34 patients underwent reconstruction of brachial 

plexus injuries and completed both pre-operative and post-operative DASH questionnaires. Time of follow-up questionnaire ranged 

from 5 months to 26 months (average of 15.4 months) depending on type of surgery and expected time period for neurologic recovery. 

Improvement in DASH scores ranged from -27.5 (greater disability) to +29.2 with an average improvement of 11.2. Five different 

patient groups were included based on type of neurologic injury. Each group showed a significant change in DASH score before and 

after surgical intervention. Such responsiveness to change would indicate that the DASH is a sensitive outcome tool for the study of 

adult brachial plexus reconstruction. 

REFERENCE: 

Dowrick AS. Gabbe BJ. Williamson OD. Cameron PA. Outcome instruments for the assessment of the upper extremity following trauma: 

a review. Injury. 36(4):468-76, 2005 Apr. 

127

Reversal of Distal Symmetric Polyneuropathy by Microsurgical Decompression of Localized 

Nerve Entrapments 

Institution where the work was prepared: International Neuropathy Microsurgery Institute, Sonora, CA, USA 

Michael Charles Edwards, MD/PhD; Joseph Paul Day, PhD; International Neuropathy Microsurgery Institute 

BACKGROUND: 

Current medical guidelines recommend non-surgical care of distal symmetric polyneuropathy (Chaudhry, Stevens et al. 2006). We 

hypothesize that intra-operative electromyography to identify localized nerve entrapments will validate nerve decompression surgery 

(Dellon 2006; Dyck 2007). The increasing population of neuropathy patients need effective treatments (Papanas, Maltezos et al. 2006). 

Lost productivity costs the United States $61 billion annually (Henig, Ephron et al. 2007). 

METHODS: 

Our 1.5 year study integrated intra-operative electromyography with standard nerve decompression techniques of the lower extremity 

treating a wide population of patients with well defined distal symmetric polyneuropathy (England, Gronseth et al. 2005). Placebo surgeries 

were considered unethical with 17 years of empirical data (Chaudhry, Stevens et al. 2006) (Siemionow, Alghoul et al. 2006). Nerve 

entrapments were objectively identified; in contrast to human studies and on-going clinical application (Dellon 2006; Dyck 2007). 

RESULTS: 

Distal symmetric polyneuropathy was reversed by nerve decompression surgery at the tarsal tunnel, fibular tunnel, and pedal dorsum. 

Intra-operative electromyography objectively identified local entrapments. 433 lower extremity muscle groups in 111 patients were tested 

intra-operatively. High post nerve decompression increase in motor unit action potential correlated with an improved post-operative 

sensibility (P

Pressure Changes in the Medial and Lateral Plantar and Tarsal Tunnels Related to Ankle 

Position: a Prospective Intra-Operative Study in Patients with Underlying Neuropathy 

Institution where the work was prepared: Johns Hopkins University School of Medicine, Baltimore, MD, USA 

Gedge D. Rosson, MD1; Eric H. Williams, MD2; Allison R. Barker, BA1; A. Lee Dellon, MD3; (1)Johns Hopkins 

University School of Medicine, (2)Dellon Institute for Peripheral Nerve Surgery: Baltimore. Clinical Instructor; Johns 

Hopkins University School of Medicine, (3)Dellon Institute for Peripheral Nerve Surgery: Baltimore. Professor; Johns 

Hopkins University School of Medicine 

BACKGROUND: 

Pressure in the tarsal tunnel has been shown to be elevated in pronation. We hypothesized that this result would hold for the medial 

and lateral plantar tunnels since they are also potential sites of nerve compression. Additionally we hypothesized that decompression 

surgery would decrease these pressures. We have previously presented that these pressures are decreased by surgery in a cadaver 

model. We further hypothesized that the pressures in symptomatic patients would be higher than in our cadaver study. Thus, we sought 

to study the pressure changes in the medial and lateral plantar and tarsal tunnels in actual symptomatic patients with co-existing peripheral 

neuropathy and evidence of superimposed nerve compressions. 

METHODS: 

10 patients were enrolled. Intra-operative pressure measurements were made in the medial and lateral plantar and tarsal tunnels before 

and after decompression surgery, including excision of the septum between the medial and lateral plantar tunnels, in a variety of foot 

positions. Approval for this prospective study was obtained from The Johns Hopkins Medicine IRB. 

RESULTS: 

Pronation and pronation with plantar flexion gave significantly higher pressures than the other foot positions in the medial and lateral 

plantar tunnels. This was the same as seen in the cadaver study. Surgery significantly decreased the pressures in the three tunnels in all 

foot positions except pronation in the tarsal tunnel and supination in the lateral plantar tunnel. Significant decreases in pressure were 

seen with simple roof incision in all tunnels in all positions except the two mentioned above. Septum excision gave further significant 

decreases in pressure in the medial and lateral plantar tunnels when compared with roof incision alone. These patients did have significantly 

higher pressures in several foot positions in the medial and lateral plantar tunnels than the cadaver study limbs. 

CONCLUSION: 

Pressures within the medial and lateral plantar tunnels, and the tarsal tunnel, increase significantly with changes in ankle position. These 

pressure changes are significantly decreased by surgical release of these three tunnels, including excision of the septum between the 

medial and lateral plantar tunnels. Pressures within the medial and lateral plantar tunnels are significantly higher in living symptomatic 

patients versus presumably asymptomatic cadaver limbs. 

CLINICAL RELEVANCE: 

Symptoms related to chronic compression of the tibial nerve and its branches may potentially be relieved by custom orthotics and proper 

gait mechanics, and, when necessary, by a surgical strategy targeting release of multiple anatomic regions rather than focusing upon 

the tarsal tunnel alone. 

129

Inducible Nerve Growth Factor Delivery by HEK-293 Cells for Peripheral Nerve Regeneration 

in Vivo 

Institution where the work was prepared: University of California, Irvine, CA, USA 

Thomas Scholz, MD; James M. Rogers; Alisa Krichev; Sanjay Dhar; Gregory R. D. Evans; University of California, Irvine 

INTRODUCTION: 

Autologous nerve grafts are currently the treatment of choice for peripheral nerve injury, but are limited by availability and related morbidity. 

Tissue engineered nerve constructs have the potential to improve peripheral nerve regeneration following nerve injury. We have 

previously demonstrated that HEK-293 cells can be genetically tripel transfected to release and regulate nerve growth factor (NGF) in 

vitro. The aim of this study was to evaluate the efficacy of the NGF delivery system in vivo and its impact on nerve regeneration and 

functional recovery. 


HEK-293 cells were tripel transfected with a regulatory vector, NGF cDNA, and HSV-TK. The NGF production by this stable cell line is 

induced by Ponasterone A (Pon A) and stopped by ganciclovir (GCV). A total of 120 nude rats were used to create a 15mm sciatic nerve 

gap with both nerve ends sutured into a silastic conduit. Conduits were filled with the transfected HEK-293 cells diluted in culture media 

and assigned to one of the following treatment groups (n=20): A) non-induced, B) induced with Pon A, C) non-induced and treated with 

GCV at day 7, 14, 21, D) induced with Pon A and boostered with Pon A at day 7, 14, 21, E) induced with Pon A and treated with GCV at day 

7, 14, 21. An additional group was implemented using transplanted nerve isografts from donor animals as a control. Animals were harvested 

at day 7, 14, 21, 60, and 120. Macroscopic nerve growth was measured during the first month. Functional assessment was performed by 

walking track analysis, extensor postural thrust, gastrocnemius and soleus muscle weight, and sensory evaluation. Nerves were fixed for histomorphology 

and media was harvested from conduits for analysis of NGF expression by ELISA and its bioactivity by PC-12 differentiation. 

RESULTS: 

The induction of the cell line by Pon A and additional booster (Group D) demonstrated significantly the highest levels of bioactive NGF 

(ELISA and PC-12 differentiation), enhanced nerve growth, improved functional recovery as well as histological regeneration when compared 

to control groups. The treatment with GCV resulted in suppression of the NGF production and decreased functional and histological 

outcome. 

CONCLUSION: 

Transfected HEK-293 cells can be regulated to inducibly produce bioactive NGF in vivo over prolonged periods of time. This tissue 

engineered nerve construct including the NGF delivery system is able to improve peripheral nerve regeneration and functional recovery 

and is superior to nerve isografts. 

Restoration of Elbow Function Using Inverse End-to-Side Anastomosis between Ulnar 

Fascicles and Musculocutaneous Nerve in Late Incomplete Obstetrical Erb's Palsy 

Institution where the work was prepared: Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel 

Shimon Rochkind, MD; Mohamed Shafi; Malvina Alon; Hagar Patish; Tel-Aviv Sourasky Medical Center, Tel-Aviv 

University 

PURPOSE: 

Improvement of elbow flexion using inverse end-to-side anastomosis, where intact fascicles of the ulnar nerve are implanted into a barely 

functional musculocutaneous nerve, has been clinically investigated in cases of late obstetrical Erb's palsy. 

METHODS: 

The study was conducted on 2 patients suffering from severe elbow flexion disability resulting from late obstetrical Erb's palsy (operated 

on at the ages of 5 and 14.5 years old). Clinical and electrophysiological motor function data were compared before and after surgery. 

Using intraoperative electrophysiological monitoring 2 intact fascicles of the ulnar nerve were implanted (end-to-side) into a barely 

functional musculocutaneous nerve (at the connection point between musculocutaneous nerve and its branch to the biceps) through 

an epineural window, using 10-0 sutures. Follow up periods after the operation were 1 year and 6 months respectively. 

RESULTS: 

Prior to the surgery, the first patient's strength of elbow flexors (using MRC grading system) was M2 and improved 1 year after surgery 

to M4-. The second patient's strength of elbow flexor improved from M1 (prior to the surgery) to M3 six months after surgery. 

Postoperative electrophysiological analysis showed improvement in amplitude of compound muscle action potentials and recruitment 

compared to before surgery. 

CONCLUSION: 

The study suggests that inverse end-to-side anastomosis can be considered as a viable microsurgical technique for patients suffering 

from incomplete long-term brachial plexus injuries. 

130

The Feasibility of Using Side-to-Side Nerve Grafts to “Protect” Nerve Pathways during Axon 

Regeneration from Surgically Repaired Proximal Nerve Injuries 


P. Schembri, BSc, MD; A Ladak; N. Tyreman; J Olson; T. Gordon; University of Alberta 

The goal in the surgical repair of peripheral nerve injuries is the precise union of the proximal and distal stumps of the transected nerve 

such that optimal nerve function is achieved. It has been established that there is a narrow window of opportunity for axonal regeneration 

so that with high ulnar nerve lacerations for example, long-term neuronal axotomy and chronic denervation of distal nerve stumps 

will progressively reduce regenerative potential to almost zero. In this study we used side-to-side nerve bridges on the distal nerve 

stump as a means to “protect” the distal nerve stumps and counted the number of motoneurons that regenerated their axons through 

the bridge(s). Sprague Dawley rats (n=43) were divided into 4 groups, all of which were subjected to unilateral excision of a 6mm segment 

of the common peroneal (CP) nerve to use as a side-to-side nerve bridge in Groups II and III. In the Group I, an 18mm contralateral 

CP nerve graft (cCPgraft) was harvested to bridge between the ipsilataral CP nerve stumps using end-to-end anastomoses. In 

Group II, a cCPgraft was again inserted between the ipsilateral CP nerve stumps AND a side-to-side ipsilateral CP nerve graft joined 

the tibial and CP distal nerve stumps. In Groups III and IV, the CP nerve was transected and NOT bridged end-to-end by the cCP graft; 

one (Group III) or 3 (Group IV) side-to-side nerve CP graft(s) joined the tibial (TIB) and CP distal nerve stumps. All anastomoses were 

performed using Tisseel fibrin glue and rats convalesced prior to backlabelling of TIB and CP regenerated axons 4 months later with 

fluorescent retrograde dyes. Axonal regeneration through the contralateral CP nerve graft in Groups I and II showed exceptional recovery: 

~90% of CP motoneurons regenerated axons through the cCP graft. In Group III, there was minimal TIB axon regeneration with 

8±3 (mean ± SE) labeled motoneurons in 8 out of 15 rats in contrast to the significantly better regeneration of 76±30 backlabelled 

motoneurons in 7 out of 7 rats in Group IV. There was only one case of sprouting in 32 rats in Groups II, III and IV. Our data demonstrate 

the feasibility of using multiple rather than single side-to-side nerve bridges to “protect” the distal nerve stump after surgical repair of 

proximal nerve injuries. 

131

ASPN POSTER PRESENTATIONS 

Increase of Neuronal Sprouting and Migration Using 780mn Laser Phototherapy 

Institution where the work was prepared: Tel Aviv Medical Center, Tel Aviv University and NVR Lab., Tel Aviv, Ness 

Ziona, Israel 

Shimon Rochkind, MD1; Dalia El-Ani, PhD2; Tami Hayun, MA2; Zvi Nevo, PhD3; Abraham Shahar, PhD2; (1)Tel-Aviv 

Medical Center, Tel-Aviv University, (2)NVR Labs, (3)Tel Aviv University 

PURPOSE: 

The present study focuses on the effect of 780 nm laser irradiation on the growth of embryonic rat brain cultures embedded in neurogel 

(cross-linked hyaluronic acid with adhesive molecule laminin). Neuronal cells attached to microcarriers (MCs) were laser treated, and 

their growth in stationary cultures was detected. 

METHODS: 

Whole brains were dissected from rat embryos. Cells were seeded directly in neurogel on DE-53 positively charged cylindrical MCs. After 14 days 

of suspension, the formed floating cell-MC aggregates were sub-cultured in neurogel. Single cell-MC aggregates were either irradiated with nearinfrared 

780 nm laser beam for 1, 3, 4 or 7 min, or cultured without irradiation. Laser powers were 10, 30, 50, 110, 160, 200 and 250 mW. 

RESULTS: 

780 nm laser irradiation accelerated migration and fiber sprouting of neuronal cells aggregates. The irradiated cultures contained a 

higher number of large neurons than the controls. Significant differences in cell size were obtained following 1 min irradiation of 50mW. 

Neurons in the irradiated cultures developed a dense branched interconnected network of neuronal fibers. 

CONCLUSION: 

780 nm laser treatment of embryonic rat brain cultures embedded in neurogel and attached to positively charged cylindrical MCs, stimulated 

migration and fiber sprouting of neuronal cells aggregates and, therefore, can be considered as potential therapy for neuronal injury. 

Ropivacaine-Induced Nerve Injection Injury in the Rodent Model 

Institution where the work was prepared: Washington University School of Medicine, St Louis, MO, USA 

Elizabeth L. Whitlock, BA; Arash Moradzadeh, MD; Michael J. Brenner; Daniel A. Hunter; Susan E. Mackinnon; 

Washington University School of Medicine 

BACKGROUND/HYPOTHESIS: 

Ropivacaine is a long-acting local anesthetic which has gained recognition for its reduced potential for CNS and cardiac toxicity as compared 

to racemic bupivacaine. Because of its milder toxicity profile, ropivacaine is indicated when a large quantity of local anesthetic is 

given, such as in major peripheral nerve block. Iatrogenic intraneural administration of certain local anesthetics has been associated 

with severe nerve damage. Because ropivacaine is injected in high concentrations for peripheral nerve blockade, we undertook the 

present study to investigate histologic changes induced by ropivacaine injection into rat sciatic nerve. 

METHODS: 

Forty-five adult male Lewis rats were randomly distributed to 9 groups, 5 animals per group. Fifty microliters of normal saline, 10% phenol 

or 0.75% ropivacaine was administered by intrafascicular injection, extrafascicular injection, or as a drip in close proximity to the sciatic 

nerve. At a two-week endpoint, animals were sacrificed and the sciatic nerve at the injection site was evaluated with light 

microscopy, histomorphometry and electron microscopy. 

RESULTS: 

Injection with saline was associated with mild intraneural edema and no significant damage to nerve fibers. Injection with phenol resulted 

in severe demyelination and axonal degeneration. Intrafascicular injection of ropivacaine resulted in a wedge-shaped region of 

demyelination with relative sparing of axons, bordered by a region of normally-myelinated axons in a background of edematous 

endoneurium. The area most distant from the administration site was uninjured. Extrafascicular injection and ropivacaine drip were both 

associated with damage to the perineurium, with an area of local demyelination surrounded by edematous endoneurium. Nerve tissue 

distant to the site of ropivacaine contact was uninjured. Extrafascicular injection resulted in more significant damage than ropivacaine 

drip, but less than intrafascicular injection as shown with quantitative histomorphometry. 

CONCLUSION: 

Unlike bupivacaine, from which it is derived, ropivacaine is associated with marked nerve damage when injected into or dripped in close 

proximity to a nerve. Because extrafascicular and drip injury were associated with similar, although milder, histological damage than 

intrafascicular injection, we suggest that extrafascicular injection or extraneural drip of ropivacaine is associated first with disruption of 

the perineurium, permitting the anesthetic to enter and damage the nerve fibers themselves. These results suggest that great care 

should be taken when administering large volumes of concentrated ropivacaine near a nerve, since injury may occur even without 

mechanical damage to the nerve itself. 

132

Subperiosteal Approach: A New, Safe Technique for Suprascapular Nerve Decompression 


Jie Xu, HBSc1; Ramon De Jesus, MD2; Jonathan Ferrari, BS1; (1)Union Memorial Hospital, (2)Johns Hopkins 

Decompression of the suprascapular nerve by excision of the superior transverse scapular ligament (STSL) can be a curative approach 

for suprascapular neuropathy. Current methods of suprascapular nerve release include the superior, anterior, and posterior approach. 

We suggest a new variation of the more commonly used posterior approach. Subperiosteal dissection of the supraspinatus enables 

easier and safer access to the STSL to decompress the suprascapular nerve. Advantages of the subperiosteal approach includes minimization 

of intraoperative muscle injury, early rehabilitation, increased safety, and an unobstructed view of the STSL as compared to the 

conventional posterior approach. This case report describes the technique performed on a 62-year-old mechanic with a history of extensive 

overhead work for thirty years. Presenting symptoms included chronic right shoulder pain with difficulty abducting and flexing the 

right shoulder for nine months. 

Effects of Bipolar Electrocautery on Regeneration of Rat Sciatic Nerve 

Institution where the work was prepared: Washington University School of Medicine, St Louis, MO, USA 

Arash Moradzadeh, MD; Michael J. Brenner; Vinay K. Puppula; Alice Y. Tong; Thomas T. Tung; Terence M. Myckatyn; 

Daniel A. Hunter; Susan E. Mackinnon; Washington University School of Medicine 

While bipolar electrocautery was developed to decrease the risk of iatrogenic nerve injury, bipolar nerve damage remains a potential 

source for significant functional impairment. Although a rare injury, the prognosis is difficult to predict, partly because of the lack of experimental 

data comparing cautery injuries against better studied nerve injury models. For example, the nerve crush model reliably produces 

a Sunderland III axonotmetic nerve injury. The present study investigates the morphologic, immunohistochemical, and functional outcomes 

following bipolar nerve injury. Sixteen Lewis rats were randomized to sciatic nerve injury from bipolar electrocautery or nerve crush. 

Assessment at 21 days shows greater disruption of myelin and neurofilament architecture at the bipolar versus crush injury sites. Distal 

nerve histomorphometry demonstrates significantly decreased total nerve fiber count, nerve density, and percent neural tissue (all p 

Compatibility of Myoblast Growth with Bio, Synthetic, and Biosynthetic Materials Used as 

Components for an Endoprosthetic Nerve Interface 


Melanie G. Urbanchek, MS, PhD; Michael S Wellington; Lisa M Larkin; Antonio P Peramo; Cynthia L Marcelo; Daryl R 

Kipke; David C Martin; William M Kuzon, Jr; Paul S Cederna; University of Michigan 

Tissue engineers are growing functional miniature tissue constructs in vitro from adult derived mammalian donor cells with the goal to 

ultimately implant the constructs in vivo during limb reconstruction or prosthetic rehabilitative surgery. Neural prostheses could incorporate 

engineered muscle as an intermediary between native nerve and myoelectric micro-electro-mechanical systems (MEMS). An 

endoprosthesis with nerve interface would contain engineered muscle where transected nerve stumps could quickly sprout and innervate 

unoccupied neuromuscular junctions, perhaps permanently halting neuroma formation while powering the muscle. Additional biocompatible 

materials are needed to support, stabilize, contain and perhaps enhance signaling along components of the endoprosthesis. 

We tested compatibility of myocyte growth in the presence of materials being considered for incorporation into the endoprosthesis 

design. The groups tested were cells alone or cells plus: conductive polymer poly (3,4-ethylenedioxythiophene) (PEDOT); smooth 

or rough silicone; Biobrane, a bilayer biosynthetic skin substitute; acellular muscle; acellular nerve, acellular muscle coated with iron 

chloride (FeCl3), an oxidizer in the polymerization of PEDOT; silicon MEMS electrodes with PEDOT coated recording sites; and PEDOT 

covered acellular muscle. Robust myoblast growth of mononuclear progenitor satellite cells in the presence of these materials would 

confirm compatibility. A primary culture of myoblasts and fibroblasts was grown from adult rat soleus muscles. Each culture plate was 

prepared with a silicone elastomer layer. A test material was pinned to the elastomer. The plate was sterilized, coated with laminin, dried, 

rinsed, filled with growth medium, and UV treated. Cells were then plated and grown in growth medium until proliferation achieved 

confluence and then were switched to differentiation medium. Myoblast growth was observed daily to determine compatibility with the 

materials. Myoblast proliferation rates were compared for cells grown in the presence of select materials. Small undifferentiated cells 

developed into multinucleated myocytes and fibroblasts with cells becoming confluent on all plates regardless of material. By day 14 

for each material, multinucleated myocytes fused into myotubes, as confirmed by desmin staining. Many myotubes contracted spontaneously. 

Proliferation presently shows no significant difference for the groups (Table 1). Myoblast compatibility was confirmed by 

myotube formation for all plates tested: bio (myoblasts alone), synthetic (Silicone and PEDOT), and biosynthetic (Acellular muscle, acellular 

nerve, PEDOT coated acellular muscle, FeCl3 coated acellular muscle, Silicon electrode with PEDOT and Biobrane). Primary 

myoblasts grown in the presence of bio, synthetic, and biosynthetic materials were also successfully passaged indicating the ability to 

keep myocytes alive and growing for extended periods. 

Cord Encasing Lipoma of the Brachial Plexus: A Case Report with One Year Follow-Up 

Institution where the work was prepared: Albany Medical Center, Albany, NY, USA 

Benjamin J. Schalet, MD, MS, Joseph A. Wolf, MD and Jerome D. Chao, MD, Albany Medical Center 

Brachial plexus region tumors are relatively rare, comprising less than 5% of tumors of the hand and upper extremity. Both intrinsically 

derived tumors and tumors extrinsic to the peripheral nervous system (PNS) can affect the brachial plexus. Tumors that originate from 

the PNS include schwannoma, neurofibroma and malignant peripheral nerve sheath tumor (MPNST). Tumors of non-neural origin 

include sarcoma and lipoma among others. These tumors may affect the brachial plexus and peripheral nerves by direct extension or 

compression. There are reports of lipomas affecting peripheral nerves of the brachial plexus and portions of the proximal plexus, causing 

selective neuropathy. We present a case of a lipoma encasing the entire brachial plexus at the cord level. This 56 year old patient 

initially presented with dysesthesia in her hand, forearm, chest, and back. The lipoma surrounding the brachial plexus was resected 

using standard incisions for brachial plexus exploration without disrupting neural tissue. At her two week postoperative visit she was 

noted to have a median neuropathy with loss of sensation to the radial thumb, index, and middle finger as well as loss of flexor pollicis 

longus and flexor digitorum profundus to the index finger. By one year postoperatively, the patient has had improvement of motor 

and sensory function both clinically and by electromyographic studies. 

134

The Use of Ultrasound to Identify the Position of the Digital Nerves of the Thumb 

Institution where the work prepared: Henry Ford Hospital, Detroit, MI, USA 

Kanye Willis, MD; Henry Ford Hospital; Donald Ditmars; Henry Ford Hospital 

Purpose: 

Trigger finger, also known as stenosing tenosynovitis, occurs when a digital flexor tendon sheath becomes constricted at the A-1 pulley. 

The constriction is usually due to scar tissue or a nodule of the tendon sheath and results in pain, clicking of the finger with movement 

and a digit that becomes locked in the flexed position. Surgical treatment consisting of dividing the A-1 pulley has a significantly 

lower recurrence rate than medical treatment. Surgical treatment consists of a traditional open technique and a percutaneous 

approach. The percutaneous approach employs the use of an 18 gauge needle guided anatomic landmarks to divide the A-1 pulley. 

Several authors have discouraged performing percutaneous trigger finger release in the thumb due to the increased risk of injuring the 

digital nerves. Our study uses ultrasound to identify the in vivo position of the digital nerves of the thumb in both flexed and extended 

positions. We hypothesized that extending the thumb causes the digital nerves to move more laterally decreasing the risk of injuring 

them during percutaneous trigger finger release. 

Methods: 

The study included 15 healthy subjects (7 male, 8 female) with a mean age of 29.5 years. An 8-megahertz frequency ultrasound probe 

was used to identify the digital nerves of the right thumb. The distance between the digital nerves was measured with the thumb in 

both flexed and extended positions. A single operator performed all ultrasound examinations using the same ultrasound equipment. 

A comparison of the distance between the digital nerves with the thumb in flexion and extension was made. 

Results: 

On average there was a 1.4mm increase in the distance between the digital nerves when the thumb was placed in extension. This represents 

a 12.6% increase in overall distance and reached statistical significance with a p-value of 0.01 using a T-test. Two subjects had a 

decrease in the distance between the digital nerves when the thumb was extended, however the nerves appeared to be located more 

inferiorly. 

Conclusions: 

Placing the thumb in extension results in lateral movement of the digital nerves in most patients, which may protect them during percutaneous 

trigger finger release. Because individual variability exists, ultrasound may be a useful guide in identifying and protecting the 

digital nerves when performing trigger finger release percutaneously. Future investigations may include using ultrasound to identify the 

position of the digital nerve in multiple dimensions and in patients with comorbidities such as connective tissue disorders. 

Peroneal Nerve Regeneration after End-to-Side Repair in Rat 

Institution where the work was prepared: Poznan University of Medical Sciences, Poznaƒ, Poland 

Piotr Czarnecki, MD; Aleksandr Astapov; Leszek Romanowski; Hand Surgery, Poznan University of Medical Sciences 

Background: 

En-to-side neuroraphy can be a solution for injuries with nerve gap when en-to-end or grafting techniques are not applicable. Current 

experiences leave a lot of questions to this method of treatment. 

Aim: 

The aim of research is to evaluate: - effectiveness of end-to-side nerve repair, - the need of epineural window, - possible donor nerve damage. 

Material and Method: 

45 Wistar rats were divided into 3 equal groups: • end-to-side repair without epineural window, • end-to-side repair with epineural window, 

• nerve graft reconstruction Right peroneal nerve were cut and then repaired according to the group investigated. Follow-up period 

was 24 weeks and the regeneration was checked by: • footprint analysis after 1, 2, 4, 6, 8, 10, 12, 24 weeks, • electroneurography 

after 24 weeks months using direct sciatic stimulation, magnetic field stimulation and both tibial and peroneal direct probing. Both 

sides: operated and nonoperated were tested, • microscopic evaluation of tibial and peroneal nerve specimens after 24 weeks. 

Results: 

Footprint analysis Calculated factors prove on regeneration in every group investigated: SFI (A – -18,37, B – -15,15, C – -14,75); PFI (A - 

-20,95, B - -21,17, C - -20,8); TSI (A – 0,08, B – 0,06, C – 0,06) after 3 months, values has decreased after 6 months. The highest values 

were in graft repair group, the lowest in the group without epineural window. Electroneurography In both direct and magnetic stimulation 

amplitude, latency and conduction velocity were in normal range in every group investigated. Amplitude and latency of peroneal 

nerve were higher on operated side. 

135

ASRM SCIENTIFIC PAPER PRESENTATION: RESEARCH II 

Changes in the Nitric Oxide Pathway During Free Flap Failure 

Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA 

Rachel Bluebond-Langner, MD1; Suhail K. Mithani, MD1; Hunter C. Champion, MD, PhD2; Eduardo D. Rodriguez1; 

(1)R Adams Cowley Shock Trauma Center, (2)Johns Hopkins School of Medicine 

INTRODUCTION: 

Despite advances in microsurgery, free flap failure or flap salvage re-exploration range from 5-20%. Nitric Oxide (NO) has been shown 

to play a role in free flap failure and up-regulation of NO has been targeted with varying success. The purpose of this study was to look 

at changes in the NO pathway, specifically the downstream effector of NO and cyclic guanosine monophosphate (cGMP). 

MATERIALS AND METHODS 

Twenty Sprague-Dawley rats underwent harvest of a free flap based on the inferior epigastric vessels. In ten rats (group 1) the flap was 

havested, stored sterile for 20 minutes to simulate warm ischemia time and then anastomosed to the femoral vessels under the microscope 

using 10-0 nylon. To simulate flap failure, in ten rats (group 2) the flap was raised, arterial anastomosis performed and the vein was occluded 

with 10-0 nylon for 12 hours and then released. Rats were euthanized at three days. Serum, flap tissue and vascular pedicle were collected. 

cGMP levels were measured in the serum and tissue. eNOS, iNOS, arginase and PDE-5 activity was measured in the flap tissue. 

RESULTS: 

All flaps in group 1 survived and 85% of flaps in group 2 survived. PDE5 activity in flaps that survived increased by 17% compared to 

controls, while flaps that failed had 59%* increased activity. eNOS activity was halved in free flap tissue compared with controls, and 

reduced an additional 2 fold* in free flap failure. iNOS activity was comparable in free flaps compared to controls, but doubled in free 

flap failure*. Arginase activity increased modestly in flaps which survived compared to controls; however, activity increased almost 2 fold 

in flaps which failed. cGMP levels were 20%* higher in the vascular pedicles and plasma of free flaps that survived compared with those 

that failed. (*=p

Regenerative Acellular Collagen Tube Matrix as a Microvascular Conduit 

Institution where the work was prepared: Cleveland Clinic Foundation, Cleveland, OH, USA 

Wong Moon, MD; Cleveland Clinic Foundation 

INTRODUCTION: 

Autogenous vein is the only biologic graft available for vascular reconstruction. However, autogenous vein is limited by its quality, quantity, 

diameter, and length. The purpose of this study is to determine if a human derived Acellular Collagen Matrix (ACM) tube graft can 

be used as a microvascular conduit. 

METHODS: 

In 10 Sprague-Dawley 500g rats, 7mm long segment of aorta was excised. 1.75 to 2.0mm in diameter vascular conduits were created 

from human derived ACM. These grafts were interpositioned between the two cut ends of the aorta and anastomosed in an end-toend 

fashion using 12-30x magnifying surgical microscope. Animals were given heparin 100IU/kg before surgery and received daily 

LMWH 1.5mg/kg for 7 days. Rats were observed daily to detect possible complications. Graft patency was check at 3 and 6 months. 

Grafts were sent for histological examination. 

RESULTS: 

Post-operatively, all 10 rats appeared healthy and were active. Their limbs were viable. At the time of harvest, all rats had patent grafts 

at 3 and 6 months. There was well incorporation of the graft material into the native aorta. No infections or aneurysms were present 

during the follow-up period. The H & E stained graft tissue showed an intact collagen matrix with in-growth of endothelial and smooth 

muscle cells. 

CONCLUSIONS: 

We report the first study that human derived Acellular Collagen Matrix (ACM) tube can be used as a vascular graft preparation. This 

material can tolerate the high shear stresses of the aorta, can regenerate into a native artery, and has successful long-term patency. 

Thermoreversible Poloxamers and Applications for Vascular Biology 


Edward I. Chang, MD; Cynthia D. Hamou; Michael G. Galvez; Michael T. Longaker; Geo frey C. Gurtner; Stanford University 

INTRODUCTION: 

Conventional suture techniques for vascular anastomoses are time consuming and prone to thrombosis and restenosis due to intimal 

damage and inflammation. We propose a novel sutureless technique using thermoreversible poloxamers. 

METHODS: 

Rheological studies determined the formulation of P407/P188 to obtain a phase transition temperature at 42°C. Anastomoses were performed 

on Fisher rat aortas using P407/P188 and bioadhesives (n=30) and 10-0 nylon sutures (n=30). CT angiograms, burst strength 

assays, histology, and scanning electron microscopy (SEM) were performed at designated timepoints. Tissue factor pathway inhibitor 

(TFPI) ELISA was performed on media harvested from HUVECs exposed to heparin and heparinized P407/P188. 

RESULTS: 

A formulation of 17% P407 and 6% P188 achieved a phase transition temperature of 42°C which was used for all future experiments. 

The average diameter of the rat aorta used for the end-to-end anastomoses in this study was 2.8mm, and the average diameter of the 

iliac vessels used in the end-to-side anastomoses was 1.9mm. End-to-end anastomoses performed using P407/P188 were completed 

more efficiently than the hand-sewn technique (10.0 ± 4.2min vs. 47.3 ± 5.0 min, p1500mm Hg, 

p>0.05). Angiograms demonstrated equivalent patency, and flow through native aorta, hand-sewn anastomoses, and sutureless anastomoses 

were not significantly different (26mL/sec vs. 27mL/sec vs. 29mL/sec respectively). Histology and SEM demonstrated less fibrosis 

in the sutureless group compared with the traditional technique. End-to-side anastomoses performed with the hand-sewn technique 

had 100% failure rate; however, end-to-side sutureless anastomoses were successful in 33% of operations performed (p

Brain Plasticity after Facial Reanimation Imaged by fMRI 

Institution where the work was prepared: Dep of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland 

Tuija M. Ylä-Kotola, MD; Antti Korvenoja, MD, PhD; M Susanna C Kauhanen; Sinikka Suominen; Erkki Tukiainen; Sirpa 

Asko-Seljavaara; Helsinki University Hospital 

PURPOSE/INTRODUCTION 

The purpose of the study was to investigate cerebral reorganization in patients treated for total facial paralysis with cross-facial nerve grafting 

and microneurovascular muscle transfer. Long-lasting unilateral facial paralysis is often treated with cross-facial nerve grafting and 

microneurovascular muscle transfer. To date, it is not known where in brain the cerebral activation due to the new mimic muscle function in 

the transplant innervated by the contralateral facial nerve occurs. Functional Magnetic Resonance Imaging (fMRI) localizes an increased neuronal 

activity in a particular area of the brain in response to voluntary tasks like muscle activity through changes in the blood oxygen. 

MATERIALS/METHODS 

Four consecutive female patients with unilateral facial paralysis were included in the prospective study. Three imaging sessions were 

scheduled. Preoperative fMRI was done to every patient before the cross-over nerve grafting. The patients were instructed to attempt 

a smile as visual cues to smile appeared at approximately 15 s intervals. During the session time series of 730 gradient-echo echo-planar 

images were acquired with a Siemens Sonata 1.5 T scanner. Analysis was carried out using FEAT (FMRI Expert Analysis Tool) Version 

5.43. The second session followed six to eight months after the first operation before the microneurovascular muscle transfer. Two 

patients went through the second session. The third session was done approximately one year after microneurovascular muscle transfer. 

Three patients have completed the study schedule so far. 

RESULTS: 

FMRI offers a statistical parametric map showing changes in brain activity seen during smiling. We compared the activation maps taken 

before the operations, between the operations and one year after the operation. Before surgery, multiple areas of the brain were activated 

by the task. After cross facial nerve grafting, activation pattern was not changed. The transferred muscle was clinically functioning 

one year after facial reanimation. At this timepoint, brain activity was increased in parietal areas on both sides, and in frontal areas 

on the contralateral to the original paralyzed side. Activation was also increased in anterior cingulate cortical areas in all the patients. 

CONCLUSION: 

We have found changes in brain activity in fMRI after facial reanimation, suggesting that brain plasticity plays a role in the adaption of 

microneurovascularly transferred muscle to the face. Increased knowledge of brain plasticity offered by research combining neuroscience 

and plastic surgery will benefit patients undergoing various forms of reconstruction. 

138

Postoperative Changes in Blood Velocity Following Microvascular Free Tissue Transfer 

Institution where the work was prepared: University of Texas M. D. Anderson Cancer Center, Houston, TX, USA 

Olubunmi Ogunleye, MD1; Michael J. Miller, MD2; Craig J. Hartley, PhD3; Matthew M. Hanasono, MD1; (1)University 

of Texas M. D. Anderson Cancer Center, (2)Ohio State University, (3)Baylor College of Medicine 

BACKGROUND: 

Microvascular free flap surgery is routine today, but little is known about its physiology. Quantifying blood velocity during the postoperative 

period would help inform the surgeon as to when microvascular thrombosis, which is associated with low velocity states, is most likely to occur. 

OBJECTIVES: 

1. To quantify arterial and venous blood velocity in microvascular free flaps prior to pedicle division and after anastomosis to understand 

how free tissue transfer affects blood flow through the flap. 2. To understand how arterial and venous blood velocity change during the 

early postoperative period. 

METHODS: 

Thirty-two free flaps were performed for reconstruction of head and neck defects. During surgery, a 20 MHz needle-type Doppler was 

held at a 45 degree angle to the flap artery or vein to measure blood velocity prior to pedicle division and 20 minutes after anastomosis. 

A Cook-Schwartz (Cook Vascular Incorporated, Vandergrift, PA) implantable Doppler probe was then used to measure arterial 

and/or venous blood velocity daily for 5 days. 

RESULTS: 

Free flaps included: 14 anterolateral thigh free flaps, 10 radial forearm free flaps, and 8 fibula osteocutaneous free flaps. The arterial blood 

velocity was 30.3±16.2 cm/s prior to pedicle division and increased to 36.5±14.7 cm/s 20 minutes after anastomosis (p

Supportive Therapy with Donor Bone Marrow Transplantation and Role of Regulatory T-cell 

for Allograft Survival in Facial Allograft Model 


Aleksandra Klimczak, PhD; Mehmet Bekir Unal; Yavuz Demir; Maria Siemionow; Cleveland Clinic 

PURPOSE: 

We have formerly achieved functional tolerance in fully MHC mismatched rat hemifacial allotransplantation model under Cyclosporine- 

A (CsA) monotheraphy. In this study we have evaluated the effect of supportive therapy with donor bone marrow transplantation (DBMT) 

under short-term ·‚-TCRmAb and CsA 7-day protocol, on chimerism induction in hemifacial allograft model across MHC barrier. 

METHODS: 

Thirty six hemiface allotransplantation were performed between LBN(RT1l+n) donors and LEW(RT1l) recipients in 6 groups of 6 rats 

each. Controls: Group 1 isograft and Group 2 allograft recipients without treatment, Group 3 received intraosseous DBMT only. Groups 

4, 5 and 6 received ·‚-TCRmAb/CsA 7-day therapy. Additionally Groups 5 and 6 were augmented with intraosseous DBMT of 35x106, 

and 100x106 bone marrow cells (BMC) respectively. Before transplantation BMC were stained with PKH dye to evaluate migratory 

process of donor BMC. Flow cytometry assessed immunodepletion of T–lymphocytes, donor-specific chimerism for MHC class I-RT1n 

antigens and presence of regulatory T-cells (Treg) CD4/CD25. Histological grading of graft rejection was assessed by H+E staining. 

RESULTS: 

Isograft controls survived indefinitely, whereas controls without immunosuppression rejected transplanted allograft within 5 to 8 days. 

Group 3 treated with only DBMT accepted transplant up to 13 days. Median survival time (MST) of facial allograft (Group 4) under ·‚- 

TCRmAb/CsA therapy was 35 days. In both Groups 5 and 6 augmented with donor BMC MST was 48 days. However, the longest survival 

time in Groups receiving 35x106 or 100x106 BMC was 465 and 498 days respectively. In long-term survaivals split tolerance was 

assessed because these animals lose the hair but skin was pliable. PKH-positive cells of donor origin were present within lymphoid 

organs and skin of recipients. In rejected allografts T-cell chimerism declined

The Use of Thrombolytics in Microvascular Free Flaps 


Otway Louie; Pierre Saadeh; Jamie Levine; NYU Medical Center 

BACKGROUND: 

Microvascular reconstruction has emerged as a highly reliable method of reconstruction, with free flap success rates well over 90%. However, 

flap failures do occur, often secondary to venous or arterial thrombosis. The use of thombolytics has been proposed by some to aid in salvage 

of compromised flaps. The purpose of this study was to review our experience with thrombolytics in the salvage of microvascular free 

flaps. 

METHODS: 

A retrospective review of all microvascular free flaps performed at NYU Medical Center from 2001 to 2007 was performed. Patients 

requiring emergent re-exploration for impending flap failure were identified. The findings upon re-exploration were analyzed, as well 

as the methods of management and final outcome. 

RESULTS: 

Over the course of 5 years, 418 microvascular free flaps were performed in 388 patients. Overall flap survival was 96.2%. There were 53 

cases (12.7%) where emergent re-exploration was performed. Re-exploration was for hematoma in 19 patients, venous congestion or 

thrombus in 25 patients, and arterial thrombus in 5 patients. Thrombolytics were used in 14 patients; 10 of these flaps had successful 

salvage (71%), whereas 4 resulted in flap failure. Of the 24 patients with pedicle thrombosis treated without thrombolytics, 13 flaps were 

salvaged (54%). The majority of flaps salvaged were re-explored in the zero to seven day post-operative interval. 

CONCLUSIONS: 

Microvascular free flap reconstruction can be performed with high success rates. The use of thrombolytics may offer a slight advantage in 

the salvage of thrombosed flaps. Close post-operative monitoring and expeditious re-exploration are essential for successful flap salvage. 

Ischemia/reperfusion-induced Apoptotic Endothelial Cells Isolated from Rat Skeletal Muscle 

Institution where the work was prepared: University of Nevada School of Medicine, Las Vegas, NV, USA 

Wei Z. Wang, MD; Xin-Hua Fang, MT; Linda L. Stephenson, MT; Kayvan T. Khiabani, MD; William A. Zamboni, MD; 

University of Nevada School of Medicine 

BACKGROUND: 

Necrosis was considered to be the solo mechanism for ischemia/reperfusion (I/R)-induced cell death. Our previous study has demonstrated 

that ischemia followed by reperfusion not only causes cell necrosis, but also accelerates cell apoptosis in the cells isolated from 

rat skeletal muscle. However, the cell types of these apoptotic cells from skeletal muscle still need to be identified. The purpose for the 

present study was to investigate I/R-induced apoptotic endothelial cells isolated from rat skeletal muscle. 


A vascular pedicle isolated rat gracilis muscle model was used. After surgical preparation, clamps were applied on vascular pedicle to 

create 4h of ischemia and released for reperfusion (I/R, n=10). Clamping was omitted in sham I/R rats (sham I/R, n=10). The muscle sample 

was harvested after 24h of reperfusion and incubated with collagenase IA followed by EDTA and rat's own serum. Cells were filtered 

through a sieve and collected by sedimentation. One million cells from each sample were stained by monoclonal anti-CD146- 

Fluorescein (a principal marker for endothelial cells) and Annexin-V-Phycoerythrin to detect and quantify apoptotic endothelial cells. 

Twenty thousand cells from each sample were scanned and analyzed by flow cytometry. 

RESULTS: 

The average percentage (±SEM) of CD146-Fuorescein-positive cells was 21.0±2.9% suggesting these cells are endothelial cell. In total 

isolated cells, the average percentage of apoptotic cells was 18.3±1.8% in I/R group vs. 5.5±0.3% in the sham I/R group that suggesting 

there was a statistically significant apoptosis (P=0.001) in the post-I/R cells. In CD146-negative cells, the average percentage of apoptotic 

cells was 1.4±0.4% in I/R group vs. 1.3±0.1% in the sham I/R group that suggesting there was no significant apoptosis either in 

sham I/R or after I/R in non-endothelial cells. However, in CD146-positive cells, the average percentage of apoptotic cells was 38.6±1.0% 

in I/R group vs. 19.4±0.3% in the sham I/R group that suggesting there was a statistically significant apoptosis (P

A Prefabricated Neo-Endocrine Pancreas using a Muscle Flap to Maximize Cell Mass in 

Pancreatic Transplants – Pilot Study in a Rat Model 


Eky Woo, MBBS, MRCSEd; Bien-Keem Tan, FRCS; Kok Chai Tan, FRCS; Pk Chow, FRCS, PHD; Singapore General 

Hospital 

AIMS: 

Pancreatic transplant is the treatment of choice in a special subset of diabetic patients e.g type 1 diabetes with worsening complications. 

Presently, whole organ pancreatic transplantation is the procedure of choice. However, the pancreas has a low tolerance for surgical 

manipulation which makes surgery challenging. Islet cell transplantation is an emerging technique that suffers from poor yield and 

engraftment. This novel technique creates a transplantable muscle-pancreas composite flap which can potentially overcome the above 

problems. We aim to demonstrate the viability of this flap. 

METHODS: 

Using a rat model, a neo-endocrine pancreas was created using a muscle flap to vascularize a segment of pancreas. The experiment 

was carried out in 3 phases: Phase 1: Pancreatic vascularization A rectus flap was raised and juxtaposed to the tail of the pancreas Phase 

2: Separation of neo-pancreas Once the segment was vascularized by the muscle carrier, it was separated from the rest of the gland 

and was thus be available for transplant as a neo pancreas. Phase 3: Assessment of viability The viability of the neo-endocrine organ 

was demonstrated through histological examination. 

RESULTS: 

Histological examination was performed using H&E and immuno-chemical stains specific for insulin and vascular endothelium. More 

than 75% of specimens showed viable islet cells that stained positive for insulin specific stains. The remaining 25% showed poor take 

probably attributable to evolving surgical technique. 

CONCLUSIONS: 

This study proves that a viable prefabricated neo-pancreas can be fashioned. At present, our islet cell yield already compares favourably 

to that of free islet cell transplants. We anticipate that with further refinement of technique, results can be improved. Ongoing preclinical 

studies in diabetic animal models are evaluating its feasibility as a transplantable organ. We hope to showcase these results in your 

coming meeting 

142

ASRM SCIENTIFIC PAPER PRESENTATIONS: BREAST 

Redesigned Gluteal Artery Perforator Flap for Breast Reconstruction 

Institution where the work was prepared: Univ. of Texas, M.D. Anderson Cancer Center, Houston, TX, USA 

Steven J. Kronowitz, MD; M. D. Anderson Cancer Center 

BACKGROUND: 

The standard elliptical gluteal artery perforator (SE-GAP) flap is an alternative to an autologous tissue flap from the lower abdomen in 

patients undergoing breast reconstruction. However, many experienced microsurgeons find use of the SE-GAP flap technically difficult, 

and the complication rate with this flap is high. 

PURPOSE: 

The purpose of this study was to redesign the SE-GAP flap to become a more reliable option for breast reconstruction and to improve 

the cosmetic outcomes, especially in large-breasted patients. A secondary objective was to compare the outcomes of the R-GAP flap 

with those of the SE-GAP flap. 

METHODS: 

We retrospectively reviewed the records of 12 patients. Four underwent unilateral SE-GAP flap reconstruction; one, bilateral SE-GAP 

flap reconstruction; and seven, unilateral R-GAP flap reconstruction. Thus, the study included 13 reconstructed breasts. Differences 

between the two breast reconstruction options were assessed using a two-sided Fisher's exact test. 

RESULTS: 

Indications for use of GAP flap included; prior abdominoplasty (R-GAP, 14%; SE-GAP, 17%), prior contralateral breast reconstruction with 

a lower abdominal flap (R-GAP, 29%; SE-GAP, 33%), prior ipsilateral breast reconstruction with loss of lower abdominal flap (R-GAP, 14%; 

SE-GAP, 0%) or insufficient abdominal adipose tissue (R-GAP, 43%; SE-GAP, 50%). Eighty-six percent of the R-GAP versus only 17% of 

the SE-GAP reconstructions had received prior PMRT (p = 0.0291). Seventy-one percent of the R-GAP flaps were based on the superior 

gluteal vessels as opposed to 50% of the SE-GAP flaps. Whereas the inferior gluteal vessels were used in 50% of the SE-GAP flaps 

and in only 30% of the R-GAP flaps. The complication rate was higher with SE-GAP flaps (67%) than R-GAP flaps (29%). Recipient site 

complication rates were 50% with SE-GAP and 14% with R-GAP flaps; donor site complication rates were 17% with SE-GAP and 14% 

with R-GAP flaps. Cosmetic outcomes were worse with SE-GAP flaps: in 83% of SE-GAP versus no R-GAP reconstructions there was 

insufficient volume to achieve the desired breast size (p = 0.0047); in 67% of SE-GAP versus no R-GAP reconstructions the reconstructed 

breast had an irregular contour (p = 0.0210). In 50% of SE-GAP but no R-GAP reconstructions, a major revision of the reconstructed 

breast was required (p = 0.0699). In 75% of SE-GAP versus 14% R-GAP reconstructions a contralateral breast symmetry procedure was 

required (p = 0.0879). 

CONCLUSIONS: 

The R-GAP flap is more reliable than the SE-GAP flap and permits successful reconstruction of larger breasts. 

143

DIEP Flaps in Patients with Abdominal Scars: Are Complication Rates Affected? 

Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, 

MA, USA 

Brian M. Parrett, MD1; Stephanie A. Caterson, MD2; Adam M. Tobias2; Bernard T. Lee2; (1)Harvard Medical School, 

(2)Beth Israel Deaconess Medical Center, Harvard Medical School 

Previous abdominal surgery in breast cancer patients is common and may affect perforator anatomy and complication rates in deep 

inferior epigastric perforator (DIEP) breast reconstruction patients. The purpose of this study is to determine if preexisting abdominal 

scars have an effect on flap and donor site complications in DIEP flap breast reconstruction. Over a 3 year period, DIEP flap patients 

were divided into a control group with no preexisting abdominal scars, and a scar group with previous abdominal procedures. Postoperative 

flap and donor site complications were retrospectively compared between the two groups with statistical analysis performed 

with the chi-square test. Of 168 consecutive DIEP flap patients, 90 patients (54%) underwent 114 DIEP flaps in the control group and 78 

patients (46%) underwent 104 flaps in the scar group. The most common previous incisions were the Pfannenstiel, the McBurney's 

appendectomy incision, and the midline incision. The mean age was 48 years in both groups. There was no significant difference in BMI 

(mean 27 kg/m2 in both groups), smoking history, and radiation status between the two groups. There were no significant differences 

in flap loss (1.8% in control vs. 2.9% in scar group), partial flap loss (1.8% vs. 1.0%), or fat necrosis (14.9% vs. 14.4%). However, the scar 

group had a significantly higher overall rate of abdominal donor site complications (24.4%) when compared to the control group (6.7%; 

p = 0.005). The most common complications in the scar group were abdominal wound breakdown (11.5%), seroma requiring operative 

drainage (6.4%), and abdominal laxity or bulge (5.1%). With minor technical modifications, DIEP flaps can be performed successfully 

without increased flap complications in patients with preexisting abdominal incisions. However, patients should be informed of an 

increased risk for donor site complications. 

Laser-Assisted ICG Angiography; Applications in Perforator Flap Surgery 

Institution where the work was prepared: Cleveland Clinic Florida, Weston, FL, USA 

Michel C. Samson, MD; Martin I. Newman, MD; Cleveland Clinic Florida 

BACKGROUND: 

The ability to confirm perforator flap perfusion, before harvest and following microsurgical anastomosis, is a key factor in intraoperative 

decision-making. Previously, clinical assessment combined with adjuncts such as Doppler ultrasound, temperature probes, and other 

modalities have served to provide microsurgeons with clues to perforator flow and flap perfusion. Laser-assisted intraoperative indocyanine 

green fluorescent-dye angiography (LA-ICGA) has been used for decades in the diagnosis and treatment of retinal disorders. 

Recently, LA-ICGA has been successfully adopted by cardiac, urologic and liver transplant surgeons for its ability to provide unparalleled, 

real time vascular images. We report here the initial experience with the application of this technology in perforator flap surgery. 

METHODS: 

Following IRB approval, LA-ICGA technology was introduced into our perforator flap protocol. In our practice, deep inferior epigastric 

perforator flaps are performed for breast reconstruction in breast cancer patients using standard technique. In a prospective fashion, 

LA-ICGA was performed prior to harvest and following microsurgical anastomosis. Examined and imaged prior to harvest were the arterial 

and venous pedicles as well as the subdermal plexus. Examined and imaged following inset were the arterial and venous anastomoses, 

the vascular pedicles and the perfusion of the flaps through both adipose tissue and skin. 

RESULTS: 

Ten (10) DIEP flaps were performed on eight (8) female breast cancer patients. Flap survival was 100% and one flap (10%) required return 

to operating room for venous congestion. LA-ICGA imaging helped to identify intraoperatively: one flap (10%) with inadequate subdermal 

plexus perfusion leading us to débride the distal portion of the flap prior to harvest; one flap (10%) with inadequate venous 

return leading us to seek additional perforators prior to harvest; and, one flap (10%) in which inadequate perfusion of a mastectomy 

flap was identified leading us to débride the marginal tissue prior to final inset. 

CONCLUSION: 

LA-ICGA appears to be a valuable adjunct in perforator flap surgery. It can be used to evaluate arterial, venous and subdermal plexus 

perfusion prior to harvest and following anastomosis. As additional data is collected and analyzed, the ability to interpret findings will 

develop. A multicenter trial is recommended to evaluate the effect of this new technology on clinical outcome. 

144

Comparison Of Superior Gluteal Artery Perforator Flaps and Myocutaneous Flaps For Breast 


Institution where the work was prepared: University of California at Los Angeles, Los Angeles, CA, USA 

Mark Gelfand, MD; Brian Boyd, MD; William Shaw, MD; James Watson, MD; Andrew Da Lio, MD; University California 

Los Angeles 

Use of the Superior Gluteal Artery (SGA) myocutaneous flap for breast reconstruction was popularized in the US by Shaw in 1983. At 

UCLA it was initially the main backup in patients who were not candidates for autologous lower abdominal tissue flaps. Later it was 

replaced by Superior Gluteal Artery Perforator flap (SGAP). This flap, first introduced by Allen and Tucker in 1995, allowed for a much 

longer pedicle, leading to a simpler microvascular anastomosis, and obviated the need for vein grafts to access the internal mammary 

vessels. However, so far there has been no head to head comparison of these two flaps. We performed retrospective chart review of 

102 operations in 80 patients. A total of 70 SGA and 32 SGAP flaps were performed over a ten year period. Patients in SGAP group 

tended to lose significantly less blood (241 vs. 375 cc) and were less likely to require transfusion (9% vs. 11.4 %). There was no significant 

difference in length of surgery (505 min vs. 496 min) or hospital stay (4.4 vs. 4.7 days). Although the overall complication rate was 

higher in SGAP group (28% vs. 20%), it failed to achieve statistical significance. Even though the difference in the rate of anastomotic 

thrombosis (6 % in SGAP group vs 10 % in SGA group) was not statistically significant, patients in SGA group were prone to thrombosis 

at venous site. They were also more likely to require vein grafting and require take-back for anastomotic problems, specifically venous 

thrombosis. In this group, venous access proved a problem in number of cases even when a vein graft was not required: the external 

jugular vein was utilized in 13 cases and the cephalic in 3. Overall, patients in SGAP group had higher rate of utilization of internal mammary 

vessels for recipient site (100 % vs 66%), a statistically significant difference. To analyze requirements for second stage reconstruction 

separate analysis was carried out for staged bilateral or unilateral breast reconstruction. There was no difference between two 

groups with regards to a number of second stage operations, as well as number of procedures required to achieve optimal outcome 

at donor site or breast. We believe that our report highlights that SGAP and SGA flaps are very similar. However, SGAP flap appears to 

be superior in allowing utilization of internal mammary vessels for as recipients, allowing for better planned, smoother and more predictable 

operative course. 

Advanced Age as a Risk Factor for Free Tissue Transfer Breast Reconstructions: A Review of 

372 Operations 

Institution where the work was prepared: UCLA (University of California, Los Angeles), Los Angeles, CA, USA 

Maura Reinblatt, MD; Luis Vaca; Jaco Festekjian, MD; James Watson, MD; Andrew Da Lio, MD; Christopher Crisera, 

MD; University of California, Los Angeles 

BACKGROUND: 

Aging is an important risk factor for developing breast cancer. As the population ages, surgeons will encounter a growing proportion 

of elderly women requiring breast reconstruction after mastectomy. Because free tissue transfer breast reconstruction generally results 

in longer operative times and recovery periods, the applicability of microsurgical reconstruction in the aging patient needs further study. 

We set out to assess the risks of microvascular breast reconstruction with advancing age. 

METHODS: 

A prospectively maintained database was utilized to identify microvascular breast reconstructions performed between 2002 and 2006. 

Patients were divided into four age groups: less than 50 years of age (Group 1), between 50 and 59 (Group 2), between 60 and 69 (Group 

3), and 70 years of age and above (Group 4). Comorbidities (hypothyroidism, diabetes, smoking, hypertension, hypercholesterolemia, 

surgical history, body mass index), American Society of Anesthesiology (ASA) status, and length of hospital stay (LOS) were examined. 

Surgical complications including flap loss, thrombosis, hematoma, abdominal hernia, and fat necrosis were analyzed. 

RESULTS: 

A total of 372 free flaps were performed on 295 patients, ranging from 24 to 75 (mean 51) years of age. The flap success rate was 99.2%, 

with 3 flap losses. 60% of the flaps performed were free transverse rectus abdominis musculocutaneous (TRAM) and muscle-sparing 

free TRAM, 34% were deep inferior epigastric artery perforator (DIEP), and 5% were superior gluteal artery perforator (SGAP). The overall 

rate of surgical complications was 33%. The most common complication was fat necrosis (21%), followed by abdominal laxity or hernia 

(6%). Age was not predictive of any surgical complication. There was no significant difference in the risk of overall surgical complications, 

or each individual complication, among the various age groups. ASA designation was the only significant predictor of overall 

surgical morbidity (p=0.02), specifically associated with fat necrosis (p=0.001) and hematoma (p

Late Venous Thrombosis in Free Flap Breast Reconstruction 

Institution where the work was prepared: Hospital of the University of Pennsylvania, Philadelphia, PA, USA 

Elizabeth M. Kim, MD; Liza C. Wu; Joseph M. Serletti; University of Pennsylvania 

PURPOSE: 

Identify the phenomenon and management of late postoperative venous thrombosis after free flap breast reconstruction. 

PATIENTS/ METHODS: 

Most venous thromboses occur within 48 hours following free flap surgery. It has been the senior author's experience that in free flap 

breast reconstruction, there is a group of patients who develop late venous thrombosis, frequently following discharge. A retrospective 

chart review of this surgeon's experience was performed to determine the incidence, management, and outcome of late venous thrombosis. 

All patients undergoing free flap breast reconstruction were monitored post-operatively by following a surface arterial Doppler 

signal every hour in an ICU for a minimum of 48 hours and then every 4 hours until discharge. The skin paddle was examined for signs 

of congestion; venous flow was not directly monitored. Late venous thrombosis was defined as venous occlusion that occurred 72 hours 

or more post-operatively. 

RESULTS: 

More than 1000 free flap breast reconstructions were performed by the senior surgeon between 1992 and 2007. Ten free flaps in ten 

patients were identified with late venous thrombosis. The thromboses occurred on post op day 3 in two patients, day 4 in three patients, 

day 5 in one patient, day 6 in two patients, day 8 in one patient, and day 12 in one patient. Two cases were identified on the day of 

planned discharge and three came from home. Eight of these ten patients were urgently taken to the operating room where thrombectomy 

and repeat venous anastamosis was performed. In 6 patients, a thrombolytic was infused into the recipient artery following repeat 

venous anastomosis. The remaining two patients received heparin infusion only. 7 of these 10 flaps survived. Two patients were not 

taken to the OR because the flap changes appeared to be very late. One of these flaps was lost and the other did survive but has developed 

significant fat necrosis. Mean follow-up was 21 months. 

CONCLUSION: 

With only one per cent of our free flap breast reconstruction series suffering a late venous thrombosis, it would appear that this is a rare 

entity. The late timing of this thrombosis in free flap breast reconstruction has, for us, been the rule and not the exception. Surgeons 

who perform free flap breast reconstruction should be made aware of this potential event and instruct patients on the signs of venous 

thrombosis. Prompt diagnosis and surgical treatment including thrombolytics increases the likelihood of total flap salvage. 

Chimeric Stacked Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A New 

Solution to an Old Problem 

Institution where the work was prepared: The Center for Restorative Breast Surgery, New Orleans, LA, USA 

Frank J. DellaCroce, MD; Scott Keith Sullivan, MD, FACS; The Center for Restorative Breast Surgery 

Breast reconstruction continues to evolve. Autogenous breast reconstruction has proven to provide the most natural and lasting result 

over time. The Deep Inferior Epigastric Perforator flap is a well described and increasingly accepted means of providing natural tissue 

reconstruction with minimum associated morbidity. For patients with insufficient abdominal fat for DIEP breast reconstruction, secondary 

options such as GAP flap or implant reconstruction are usually considered. For patients with need for autogenous reconstruction of 

a single breast and heretofore insufficient abdominal fatty volume, we present a new option that allows for incorporation of the entire 

abdominal fatty composite with chimeric linkage and stacked inset of two individual abdominal flaps. The ability to take advantage of 

the entirety of the abdominal donor volume allows those with relatively thin body habitus to enjoy candidacy for DIEP reconstruction. 

Sophisticated microsurgical technique transcends procedures with similar goals such as the bipedicled TRAM flap by avoiding muscle 

sacrifice and allowing precise, independent flap inset. We describe our experience with this technique in 50 patients with 100 flaps over 

2 years. 

146

Outcome of Microvascular Complications after Free Flap Breast Reconstruction 

Institution where the work was prepared: UCLA Medical Center/David Geffen School of Medicine at UCLA, Los 

Angeles, CA, USA 

Brian Carlsen, MD; Peter Ashjian, MD; Brian P. Dickinson, MD; Jaco Festekjian, MD; Andrew L. Da Lio; James P. 

Watson, MD; Christopher A. Crisera, MD; University of California, Los Angeles 

BACKGROUND: 

Microvascular complications after free flap reconstruction can be devastating, increasing patient morbidity and leading to flap loss. Little 

is known about rates of salvage of free flaps after recurrent thrombosis or vascular compromise. 

METHODS: 

A retrospective review of all patients at a major university medical center undergoing microvascular breast reconstruction from January 

1992 to December 2006 was conducted. The incidence of thrombotic and hemorrhagic complications was determined. Rates of flap 

salvage and complications were analyzed after a single microvascular revision (Single Event), two revisions (Plural Event), three or more 

revisions (Multiple Event), and after a delayed presentation (i.e. > 3days) and attempted salvage (Delayed Event). Fisher's exact test was 

used to determine statistical difference among the groups. 

RESULTS: 

1704 free flaps were performed for breast reconstruction between January 1992 and December 2006. Fifty-three flaps (3.1%) suffered a 

microvascular complication. Thirteen flaps (0.8%) were lost. The overall salvage rate after any microvascular complication was 75% 

(40/53). Salvage rates were determined for each of the four groups. Single Events (less than 3 days postoperative) had a salvage rate of 

94% (31/33). Plural Events had a salvage rate of 80% (4/5). Multiple Events had a salvage rate of 40% (4/10). Delayed Events (greater than 

3 days postoperative) had a salvage rate of 20% (1/5). The salvage rate decreased with repeated microvascular events (p

Functional MRI to Evaluate “Sense of Self” Following Deep Inferior Epigastric Perforator Flap 

Breast Reconstruction 

Institution where the work was prepared: Beth Israel Deaconess Medical Center, Boston, MA, USA 

Stephanie A. Caterson, MD; Sharon Fox, BS; Adam M. Tobias; Bernard T. Lee, MD; Beth Israel Deaconess Medical 

Center, Harvard Medical School 

INTRODUCTION: 

Patient satisfaction following breast reconstruction is an integral component in assessing surgical outcomes. In the past, patient questionnaires 

have been the mainstay of satisfaction analysis but are limited by patient bias and subjective answers. In this study, we use 

functional MRI (fMRI) to identify changes in patterns of brain activation following deep inferior epigastric perforator flap breast reconstructions. 

This method objectively evaluates self-recognition, or “sense of self” in a reconstructed breast compared to a natural breast. 

METHODS: 

Two patient groups were identified. The first group consisted of four patients scheduled for delayed DIEP flap breast reconstruction, 

who had undergone a unilateral mastectomy at least two years prior. The second group included four patients who had undergone a 

unilateral immediate DIEP breast reconstruction, at least two years prior. Each patient had one unaffected breast, allowing for an internal 

control of self-recognition. In a block-design fMRI experiment, patients were cued to alternately touch their natural breast, operative 

site, or silicone gel models. Regions of interest (ROIs) defined in the literature as being associated with self-recognition (as opposed 

to "other") were mapped to averaged patient data using normalized spatial coordinates. A general linear model examining activity in 

each ROI was applied to average data from each patient group. In addition, analyses of variance between the two patient populations 

were performed. A questionnaire was administered to all patients at the time of the fMRI. 

RESULTS: 

ROIs in the right superior frontal gyrus, inferior parietal, and medial frontal lobes were identified as breast self-recognition areas. In the 

pre-operative group, the self-recognition ROIs had minimal activity when the mastectomy site was stimulated. In contrast, the normal 

breast showed increased activity in these areas, as compared to the mastectomy site. In the post-operative group, DIEP flap stimulation 

was associated with increased activity in the self-recognition ROIs, and was remarkably similar to the natural breast fMRI signals. 

Questionnaire results were examined and found to be consistent with favorable patient satisfaction. 

CONCLUSIONS: 

Two years following unilateral breast reconstruction with DIEP flap, patients demonstrate an association of the reconstructed breast with 

self-recognition regions that are also active upon stimulation of the natural breast. These same areas are not active when the pre-operative 

mastectomy site was stimulated. This study provides objective evidence that supports an association of DIEP flap breast reconstruction 

with "self". Autologous reconstructions can improve patient satisfaction when compared to no reconstruction. 

148

Utilization of the Internal Mammary Intercostal Perforator Instead of the True Internal 

Mammary Vessels as the Recipient Vessels for Breast Reconstruction 

Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA 

Gedge D. Rosson, MD; Eduardo D. Rodriguez; Jaime I. Flores; Michele A. Manahan; Nia D. Banks; Navin K. Singh; 

Johns Hopkins School of Medicine 

OBJECTIVE: 

Although autologous free tissue transfer has become a mainstay in breast reconstruction, there exist inherent controversies regarding 

the procedure, including choice of recipient vessels. For the past few years, our institution has preferred the routine use of the internal 

mammary artery and vein for DIEP and SGAP flap reconstruction. In an effort to decrease any potential morbidity at the recipient site 

by preserving the internal mammary artery for potential use as a coronary artery bypass conduit in the future, we aim to use the internal 

mammary intercostals perforator as a recipient vessel if suitable. We have implemented the following protocol: preoperative mapping 

of the perforators along the sternal border with a hand-held Doppler, intraoperative exploration to find a suitable perforator, and 

costal cartilage resection if necessary to expose the true internal mammary vessels. Our previous cadaver studies showed that the 

largest internal mammary intercostal perforator is usually located in the 2nd or 3rd intercostal space. In this study we sought to evaluate 

the utility of the internal mammary intercostal perforator for microsurgical breast reconstruction. 

METHODS: 

We retrospectively reviewed a single surgeon's first 101 DIEP flap breast reconstructions, performed during a 1 ? year period from July 

2005 through January 2007. Recipient vessel selection, flap failure, and development of fat necrosis were critically analyzed. 

RESULTS: 

Of these 101 flaps reviewed, 22 DIEP flaps were anastomosed to an internal mammary intercostal perforator in the 2nd or 3rd interspace. 

When broken down into groups of 20 flaps, a statistically significant pattern of increasing frequency of usage emerges. In the 

first 20 flaps an IM perforator was used for only one flap (5%), while in the final 20 flaps an IM perforator was used for 9 flaps (45%). 

Overall, four flaps had partial flap fat necrosis of less than 5% of the flap volume and one patient had total failure of the flap due to 

venous congestion; however none of these were in the flaps using the IM intercostal perforator. 

CONCLUSIONS: 

The probable need for use of the internal mammary artery for future coronary artery bypass graft is rare in our breast cancer reconstruction 

patients. However, we have implemented an approach to utilize the IM intercostal perforating vessels as the recipient vessels when 

suitable. Although the learning curve is steep, use of these vessels can be performed safely without increased fat necrosis and preserve 

the internal mammary artery for potential future life-saving surgery. 

Microvascular Free Tissue Transfer for Breast Reconstruction in the Elderly: A Safe and 

Effective Option 

Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA 

Jeffrey M. Jacobson, MD; Maurice Y. Nahabedian, MD; Georgetown University Hospital 

While nearly half of breast cancer cases involve women 65 years of age or older, there is a paucity of literature reviewing microvascular 

free tissue transfer for breast reconstruction in this age group. The objective of this study was to evaluate the safety and efficacy of 

microvascular free tissue transfer for breast reconstruction in women 65 years of age and over. Between 1997 and 2007, 890 women 

underwent immediate or delayed microvascular breast reconstruction by a single surgeon. Of these, 21 (2.4%) were performed on 

women 65 years of age or older (mean age 68, range 65-82). Women were assessed for candidacy, evaluated for medical co-morbidities, 

and cleared for surgery by their primary care physician. Reconstructions were unilateral in 18 women and bilateral in 3, immediate 

in 17 cases and delayed in 7, and the specific flaps included the DIEP (16), free TRAM (7), and SGAP (1). 14 DIEP flaps were based off 

of a single perforator (87.5%) and 2 DIEP flaps were based off of 2 perforators (12.5%). The free TRAM flaps were MS-0 in 1 case (14%), 

MS-1 in 2 cases (29%), and MS-2 in 4 cases (57%). Recipient artery and vein included the internal mammary in 14 women (67%) and the 

thoracodorsal in 7 women (33%). Co-morbidities included diabetes mellitus (4.8%), tobacco use (4.8%), hypertension (33%), and preoperative 

XRT (9.5%). Cancer stage ranged from 0 to 2B. Mean follow-up was 26.6 months (range, 5-84 months). Complete success 

without morbidity was achieved in 17 women (81%). Surgical complications occurred in 4 women including failure of 1 DIEP flap secondary 

to venous thrombosis, 2 abdominal bulges following unilateral and bilateral DIEP flaps, and fat necrosis (

ASRM SCIENTIFIC PAPER PRESENTATIONS: OTHER 

An Anatomical Study of the Superficial Peroneal Nerve Accessory Artery and Its Perforators, 

and Clinical Application of Superficial Peroneal Nerve Accessory Artery Perforator Flaps 

Institution where the work was prepared: Gyeongsang National University Hospital, Jinju, South Korea 

Tae Hyun Choi, MD, PhD; Jun Sik Kim; Nam Gyun Kim; Kyung Suk Lee; Gyeongsang National University 

BACKGROUND: 

In the 1990s, skin island flaps supplied by the vascular axis of sensitive superficial nerves, like the sural and saphenous nerves, were introduced. 

Flaps supplied by the superficial peroneal nerve accessory artery (SPNAA), however, are still not commonly used. The aim of this 

study is to understand the anatomical structure of the SPNAA and its perforators, and to utilize SPNAA perforator flaps in the clinic. 

METHODS: 

We dissected sixteen cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous perforators 

originating from the anterior tibial artery. The largest diameter of the SPNAA was also measured. A SPNAA perforator flap was 

applied to twelve patients, the free flap was applied to eleven patients, and the pedicled flap was applied to one patient. 

RESULTS: 

The origin of the SPNAA was 4 to 8 cm (average 5.5 cm) away from the fibular head. The SPNAA was 7 to 16 cm in length (average 

12.33 cm), originating from the superior lateral peroneal artery and gradually disappearing between 15 and 22 cm (average 17.06 cm) 

from the fibular head. The largest diameter of the SPNAA was between 0.6 and 1.2 mm (average 0.85 mm). The number of perforators 

in SPNAA examined ranged from zero to eight (average 4.5). Of these, the number of septocutaneous perforators ranged from zero to 

six (average 3.19), and the number of musculocutaneous perforators ranged from zero to three (average 1.31). The size of the flap 

ranged from 3.5 x 6 cm to 9 x 12 cm (mean 65.5 cm2). The complete follow-up period ranged from three to 20 months (mean 7.6 

months). Although one flap was lost due to arterial thrombosis, the procedure was successful in the remaining eleven patients. The flap 

was very thin, comparable in thickness to the recipient site (i.e. foot, ankle, pretibia, knee or hand), and thus, aesthetically appealing. 

CONCLUSION: 

SPNAA perforator flaps could be an excellent alternative to perforator flaps that use the lower leg as a donor site. Legends Fig. 1. 

(Above, left) Preoperative view. (Above, right) Preoperative design of the SPNAA perforator flap. (Below, left) The septocutaneous perforator 

of the SPNAA (yellow arrow) is the pedicle of this flap. Black arrow indicates the SPN. EDL: extensor digitorum longus. PL: 

Peroneus longus. (Below, right) Post-operative observation six months after surgery. 

150

Tissue Oximetry, A Reliable Technique for Non-Invasive Free Flap Monitoring 

Institution where the work was prepared: Long Island Jewish Medical Center, New Hyde Park, NY, USA 

Alex Keller, MD; North Shore Long Island Jewish Health System 

INTRODUCTION: 

Despite improvements in anastomotic techniques in free tissue transfer or replantation, anastomotic failure can still plague the microsurgeon. 

Clinical evaluation including flap color, capillary refill and bleeding can be hard to interpret and are most valuable when 

assessed by an experienced surgeon. Even in specialized units a nurse is usually responsible for flap monitoring. It is for these reasons 

that more objective and reliable flap monitoring techniques have been sought. Range of techniques currently utilized include external 

and internal temperature probes, laser Doppler monitoring, intravenous fluorescein, pulse oximetry, transcutaneous oxygen, and surface 

and implantable Doppler. An ideal monitor should provide continuous non-invasive monitoring of perfusion or flap metabolism 

with rapid detection of arterial or venous occlusion. Tissue oximetry is the only way to measure end organ perfusion. A new device, the 

ViOptix Tissue Oximeter (ODISsey) was evaluated. The ODISsey uses an optical tissue characterization based on measuring the scattering 

and absorption of near infrared light which is related to the oxygen content of the hemoglobin in that particular tissue. 

METHODS & DATA: 

133 clinical free flap transfers (either DIEP, SIEA or SGAP) for breast reconstruction in 98 patients were monitored continuously during 

elevation, transfer, and in the postoperative period both clinically and with the ViOptix Tissue Oximeter. While there were no flap failures, 

6 patients were reoperated upon acutely. Early in the series, reoperation occurred only when there was clear evidence of ischemia 

and flap compromise. Later in the study, with increased confidence in the ViOptix monitor, a low or falling oxygen saturation reading 

was the trigger for reoperation. In these instances, reoperation was undertaken before there was clear clinical evidence of flap compromise. 

One patient was reoperated upon for hematoma without flap compromise or outflow problems. The findings were consistent 

with the monitor prediction of a healthy flap. False negative readings (low or falling tissue oxygen saturation) was related to movement 

of the probe. Experience with the monitor and the fixation of the surface probe increased the confidence in the device to pick up early 

flap compromise. Most importantly, the ability to follow a flap was now less dependent upon the observer. 

CONCLUSION: 

The use of the ViOptix Tissue Oximeter is a reliable, noninvasive technique to monitor a cutaneous free flap. Flap compromise can be 

identified before clinically evident. Routine flap monitoring can be performed by individuals less skilled in the clinical evaluation of the 

flap. 

20 Years Experience In Pediatric Microsurgery 

Institution where the work was prepared: Sheba Medical Center, Tel Hashomer, Israel 

Batia Yaffe, MD; Eyal Winkler; Haim Kalpan; Sheba Medical Center 

Elective microvascular surgery is a routine method of reconstruction of a variety of defects in adults. In pediatric patients this method is 

used less frequently. The aim of this presentation is to review our 20 years experience with elective microvascular surgery in children, 

addressing the special considerations pertinent to this patient population and stressing both the similarities and differences of microsurgery 

in children as opposed to adults. In the last 20 years we performed 96 free tissue transfer procedures in 87 children aged 4 

month – 17 years, (mean age 10.5 years) with 97% success rate (93 out of 96 flaps). The most common etiologies were motor vehicleaccident 

(31 children), and congenital deformities (19 patients). Other etiologies were post burns deformity, iatrogenic injury, deformities 

created by disease or tumor surgery, and firearms injury. In adults during the same period the most common etiology was oncological 

resection. The most common recipient area was the lower extremity (44 children). In 35 children the flap was transferred to the upper 

extremity and in 15 to the head and neck region. For reconstruction of soft tissue defects latissimus dorsi muscle covered with skin graft 

was the most frequently used flap (29 flaps) followed by the scapular free flap (19 flaps). Other less frequently used flaps were radial 

artery forearm flap (7 flaps), lateral arm free flap (6 flaps), groin flap based on SCIA (5 flaps), posterior interosseous free flap (2), 1 anterolateral 

thigh flap and 1 gracilis muscle with skin graft. For restoration of muscle function we used gracilis neurovascular free flap 5 times 

and latissimus dorsi neurovascular free flap twice. For bony defects osteocutaneous or osseous fibula flap was used in 8 children and 

vascularized iliac crest in 5. For replacement of missing digits 5 toes were transferred. The operative time and recovery time in children 

was shorter than in same flaps in adults. Heparin was used in 2 cases only. The post operative regime included axillary block in surgery 

on the upper extremity, keeping the room temperature and blood pressure stable, and good pain management. Although we use 

aspirin routinely in microsurgery in adults, it was not used in children. Follow up period ranged between 1 - 20 years (mean – 10 years). 

In conclusion, although often technically challenging, free flaps in children are safe and usually provide the best possible reconstruction 

in a variety of conditions. 

151

A Reconstruction Algorithm to Encounter No Sizable Skin Perforator during Anterolateral 

Thigh Flap Dissection 

Institution where the work was prepared: Chang Gung Memorial Hospital - Kaohsiung Medical Center, Kaohsiung, Taiwan 

Ching-Hua Hsieh, MD1; Seng -Feng Jeng, MD2; Yur-Ren Kuo, MD, PhD, FACS3; Pao-Yuan Lin, MD1; Johnson C. Yang, 

MD4; (1)Chang Gung Memorial Hospital in Kaohsiung, (2)Chang Gung Memorial Hospital - Kaohsiung Medical Center, 

Chang Gung University, (3)Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University, 

(4)Chang Gung Memorial Hospital at Kaohsiung 

PURPOSE: 

The free anterolateral thigh (ALT) flap is becoming the preferred option for soft-tissue reconstruction in most clinical situations. If no sizable 

skin perforators are found or if they are inadvertently divided during flap dissection in the ALT region, we propose a reconstruction 

algorithm with modified options to facilitate a successful reconstruction. 

MATERIALS & METHODS: 

A Doppler flowmeter was used preoperatively to detect the location of the perforator. After incision being made down to the deep fascia, 

the perforator to the skin was visualized first to determine which perforator was preferred for skin perfusion. If there was no sizable 

skin perforator at all, the reconstruction algorithm was followed in this order: 1. More proximal exposure of the lateral circumflex femoral 

artery system to harvest a tensor fascia lata flap. 2. Detection of a promising skin vessel medial to the incision with audible Doppler, and 

proceeded dissection in a medial direction to elevate an anteromedial thigh flap. 3. Elevation of a free vastus lateralis muscle with coverage 

of full-thickness skin graft (FTSG) harvested from ALT skin portion. 4. Abandon the donor site and sought for another donor region. 

RESULTS: 

Between August of 1995 and December of 2006, 923 patients received ALT flaps elevation at Chang Gung Memorial Hospital in 

Kaohsiung. There were ten patients had no any adequate skin perforator in the ALT region during the initial dissection. There were three 

patients, who had no perforator in one thigh, received dissection in contralateral thigh but still had no any sizable perforator for reconstruction. 

In total, four patients received reconstruction with a free tensor fascia lata flap, three with an anteromedial thigh flap, two with 

a free muscle flap and FTSG, and one with a radial forearm flap. There was one postoperative venous thrombosis in a tensor fascia lata 

flap which was finally salvaged. 

DISCUSSION: 

With sizable perforator in 99% of the designed area, ALT flap is a very reliable flap for reconstruction. If there is no adequate skin perforator 

in one thigh, dissection performed in another thigh is not suggested, because similarity of the vascular condition would be 

encountered. When there is no sizable skin perforator in ALT dissection, an acceptable successful rate to complete the reconstruction 

could be achieved by following the above algorithm according to our experience, which might be the largest series in dealing with such 

kind of problem. 

Early Results of a Prospective, Randomized Cost and Outcome Analysis of ICU vs. Surgical 

Floor Monitoring in Free Flap Breast Reconstruction 

Institution where the work was prepared: University of Chicago Medical Center, Chicago, IL, USA 

Charles Y. Tseng, MD; David H. Song, MD; University of Chicago Medical Center 

PURPOSE: 

At present, it is standard practice to admit all patients who undergo free flap reconstruction to the ICU or an equivalent flap recovery 

unit for monitoring on an hourly basis. The ICU remains a large user of hospital resources, accounting for 25% to 30% of total hospital 

costs, despite the fact that these beds represent only 5 to 10% of total hospital beds. To date, there have been no studies documenting 

an improvement in free flap outcomes or cost-savings based solely on ICU level flap monitoring. The purpose of this study is to perform 

a cost comparison of free flap monitoring in the ICU versus surgical floor using standard clinical criterion, external Doppler probe, 

and Near Infrared Spectroscopy (NIRS) in patients who have undergone free flap breast reconstruction. 

METHODS: 

Since August 2006, 14 patients underwent free flap breast reconstruction using MS-TRAM, DIEP, or SIEA free flaps. 8 patients (10 flaps) 

were randomized to the ICU and 6 patients (7 flaps) to the standard surgical floor for post-operative monitoring using standard clinical 

criteria, external Doppler probe, and continuous NIRS monitoring. Patient demographics, procedure type, diagnosis, adjuvant treatment, 

and complications were recorded. 

RESULTS: 

6 MS-TRAM, 6 DIEP, and 5 SIEA free flaps breast reconstructions were performed. There was no difference in flap loss, fat necrosis, or 

venous congestion. Average total length of stay (LoS) and cost of stay (CoS) in patients randomized to recover in the ICU was 4.25 days 

and $18,122. Average LoS and CoS in patients recovering on the surgical floor was 4 days and $7,564. 

CONCLUSION: 

This randomized, prospective study compares the cost and early (30-day) results of post-operative recovery and free-flap breast reconstruction 

monitoring in an ICU versus surgical floor setting at a single institution using external doppler probe and near-infrared spectroscopy 

(NIRS) as adjunctive monitoring devices. Current monitoring devices fall short of the ideal and none have gained widespread 

acceptance. A monitoring tool that could detect disturbances in vascular flow early, reliably, and independent of level of care and experience 

of nursing staff could potentially generate tremendous cost savings to both the institution and to the patient. Easy to use and 

accurate, NIRS technology has the potential to lower hospital costs by allowing patients to recover on a standard surgical floor while 

receiving continuous free flap monitoring. Long term outcomes data are needed to corroborate our early findings. 

152

Partial Muscle Transplantation: Strategy for Preservation of Form and Function at the Donor Site 

Institution where the work was prepared: California Pacific Medical Center, San Francisco, CA, USA 

Darrell Brooks; Rudolf F. Buntic; Buncke Clinic 

INTRODUCTION: 

Selection of the best tissue transplant requires striking a balance between the potential benefit for the recipient site and risk to the 

donor site. There has been a recent trend towards transplantation of perforator flaps and away from muscle flaps given the attendant 

loss of function with muscle harvest. Although we acknowledge the attributes of the perforator flap, we continue to recognize significant 

advantages of muscle transplantation in selected patients. 

PURPOSE: 

The purpose of this study is to describe the design and transplantation of the partial superior latissimus dorsi(PSL) and partial medial 

rectus abdominis(PMR) muscle flaps while preserving form and function at the donor sites. 

METHODS: 

A retrospective review of partial muscle flaps transplanted between 2003-2006 was conducted. Charts were reviewed to define indications 

for tissue transplantation, characteristics of transplanted tissue, outcome analysis, maintenance of donor site form/function, as well 

as, patient satisfaction. The PSL flap is designed along the superior edge of the latissimus dorsi muscle, medial or lateral depending 

on recipient site requirements such as pedicle length and flap dimension. The descending branch of the thoracodorsal nerve is preserved 

maintaining function in the residual latissimus. The majority (>70%) of the latissimus muscle is left intact with adequate blood 

supply and persistent innervation from the descending branch of the thoracodorsal nerve. Depending on the required pedicle length 

and flap dimension, the PMR flap is designed up or down the medial edge of the muscle. Care is taken to protect the arcade of intercostal 

nerves and arteries. Branches from the deep inferior epigastric vessels (DIEVs) going to the medial aspect of the rectus muscle 

are identified and followed back to the DIEVs. The majority (>50%) of the rectus width is preserved with adequate blood supply and 

innervation by intercostals arteries and nerves. 

RESULTS: 

Thirty-seven PSL muscle flaps were performed for arm/hand(12), leg/foot(16), and head/neck(9) defects. Twenty-five PMR muscle flaps 

have been performed for chest wall(1), arm/hand(11), and leg/foot(13) defects. All flaps survived. Examination revealed preservation of 

function of the residual muscle without associated hernia after PMR or early arm fatigue or changes in strength related to activities 

involving arm extension after PSL harvest. The lateral thoracic silhouette was maintained in all PSL cases. 

CONCLUSION: 

The partial latissimus dorsi and rectus abdominis muscle flaps are reliable techniques for muscle transplantation. The minimal donor 

site morbidity and versatility in flap design make them excellent options in reconstructing a range of defects. 

Microvascular Venous Coupler Reduces the Rate of Venous Anastomosis Failure 

Institution where the work was prepared: University of Manitoba, Winnipeg, MB, Canada 

Matthew Choi, MD; Edward Wayne Buchel; Thomas E.J. Hayakawa; University of Manitoba 

PURPOSE: 

To compare venous anastomosis complication rates between hand sewn anastomoses and those using a venous coupler device. 

METHODS: 

We retrospectively reviewed a single surgeon experience using Deep Inferior Epigastric Perforator (DIEP) flaps and Superficial Inferior 

Epigastric Artery (SIEA) free flaps for breast reconstruction. The surgeon performed hand-sewn venous anastomoses exclusively in his 

practice before changing his technique to using a venous coupler exclusively (Synovis coupling device). The consecutive series of handsewn 

cases was then compared to the consecutive series where the venous coupling device was used. Only DIEP and SIEA free flaps 

were considered for this analysis. In all cases, end-to-end anastomosis were performed to internal mammary vessels, with one exception 

where these recipient vessels were matted down by diseased lymph nodes and the thoracodorsal vessels were used instead. 

Outcomes measured were takebacks to the operating room for venous insufficiency or venous occlusion. 

RESULTS: 

A total of 141 cases of DIEP and SIEA free flaps were performed with the hand-sewn technique. Bilateral surgeries were performed in 

60 cases totaling 201 flaps. Fifteen (7.4%) patients were taken back to the operating room for venous congestion or venous occlusion. 

A total of 81 cases of DIEP and SIEA free flaps were performed using a venous coupler. Bilateral surgeries were performed in 29 cases 

totaling 110 flaps. One (0.9%) patient was taken back to the operating room for venous occlusion. This significant difference in anastomosis 

complication rate (p = 0.036) represents an absolute risk reduction of 6.5% and a relative risk reduction of 88%. 

DISCUSSION: 

Published series of coupler experiences to date have reviewed cases where the authors have selected cases as appropriate for coupler 

use. This exposes results to a bias which may reflect the use of the coupler in ideal circumstances. Furthermore, reported series do not 

have direct comparison of failure rates to hand-sewn controls. Our study addresses these shortcomings by reporting large consecutive 

cohorts where the same operative technique is used repeatedly without a decision to abandon the coupler in favor of hand-sewing, or 

vice versa. By reviewing a single surgeon experience performing a single operative procedure, we also achieve reasonable comparison 

to a hand-sewn control group. 

CONCLUSION: 

The use of a venous coupler reduces the complication rate associated with the venous anastomosis. 

DISCLOSURE: 

The authors have no conflicts of interest. 

153

Strategic Approaches to Salvage the Venous Compromised Deep Inferior Epigastric 

Perforator Flap 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taipeh, Taiwan 

Rozina Ali, MD; Ming-Huei Cheng, MD, MHA; Christina Bernier, MD; Yt Lin; Alexander Cardenas-Mejia, MD; Rachel 

Bluebond-Cangner, MD; Eduardo P. Rodriguez, MD; We-Chen Ching, MD; Chang Gung Memorial Hospital 

INTRODUCTION: 

Venous congestion in deep inferior epigastric perforator (DIEP) flap is not infrequent and is the major cause of flap loss and fat necrosis. 

The conservative managements of venous congestion include the use of leech, anticoagulants, vasodilators, arteriovenous shunt, keeping 

bleeding, and release wound tension. The congested flap may need re-exploration and sometimes require another venous anastomosis 

for augmentation of venous drainage. The objective of the study was to find the strategic approaches to salvage the venous compromised 

DIEP flap. 


Between March 2000 and December, there were 158 DIEP flaps performed for breast reconstruction at Chang Gung Memorial Hospital. 

Twenty-nine DIEP flap developed venous congestion. Mean age was 48.5 years. Right breast was in 15 cases, and left breast in 14 cases. 

Risk factors including pre-op radiation in 5 cases, and longitudinal abdominal scar in 4 cases, transverse cesarean scar in 1 case. The managements 

include conservative treatment in 10 cases, post-operative re-exploration in 7 cases and intra-operative salvage in 12 cases. 

RESULTS: 

There were two total flap failures, giving a success rate of 98.7%. Partial flap loss developed in 3 flaps, and fat necrosis in 4 flaps. The 

venous congestion rate was 18.3% (29/158) in this series. The complication rate was 31% (9/29) in the venous congestion group. The 

complication rate was statistically significant in post-operative group compared to the conservative and intra-operative groups. The 

complication rate was also higher in one-perforator than 2- or 3-perfortors groups. There were more than 10 methods in this study to 

augment the superficial venous system to the deep venous system for salvaging the congested DIEP flap. 

DISCUSSION: 

Preservation of the superficial inferior epigastric vein, both ipsilateral and contralateral during the flap harvest will provide a helpful tool 

to salvage the flap in case of venous congestion. The timing for salvage of venous congested DIEP flap may be shifted from post-operative 

re-exploration to intra-operative salvage to decrease the possible complications. In conclusion, strategic approaches for the management 

of venous congested DIEP flaps may salvage the flap and minimize the complication rate. 

13 Years Experience with Free Fibula Flap Phalloplasty 

Institution where the work was prepared: Gulhane Military Medical Academy, Ankara, Turkey 

Mustafa Sengezer; Serdar Ozturk; Mustafa Deveci; Fatih Zor; Gülhane Military Medical Academy 

PURPOSE: 

Surgical reconstruction of the is challenging because of the many cosmetic and functional requirements such as ual and voiding. 


Since 1994, 25 patients were treated with free sensate osteocutaneous fibula flaps. Of the patients, 23 were biological males and the 

remaining 2 were operated for transsexuals. The ages of the patients ranged between 20 and 27 years (mean, 23,5 years). The average 

follow-up period was 7 years (range, 1 to 12 years). Patient satisfaction was evaluated by a questionnaire regarding ual , and daily activities. 

Conventional radiographic imaging, magnetic resonance imaging, and bone mineral densitometry were performed to evaluate 

the fate of the bony component. Sensibility was evaluated by bulbocavernous reflex and penile somatosensory evoked potentials. 

RESULTS: 

Eight patients married, and six of them had eight children. Most patients and their parents reported pleasurable ual and . Conventional 

radiographs of the fibular bone in neophallus showed robust, calcified bone structure without any evidence of bone resorption or fracture. 

The magnetic resonance imaging showed the cortical substance and spongiosum of the bone marrow, which are characteristic 

signs of bone viability. Viability of neophallus bone was shown even at 12-year follow-up (the longest in the literature). Dual energy xray 

absorbtiometry measurements of the penile bone grafts showed that fibular components in the had bone mineral density values 

that were close to the normal subjects. These results were considered as evidence of viability of bone grafts. Neural integrity was found 

between the nerves of the neophallus and the residual penile bodies. 

CONCLUSION: 

Free sensate fibula flap phalloplasty provides cosmetic and functional requirements that an ideal should have. All results put an end to 

the discussion that the fibular component of the neophallus could resorb. Constitution of neural integrity is important in terms of pleasurable 

ual . 

154

Outcomes of Immediate VRAM Flap Reconstruction versus Primary Closure in Patients 

Undergoing Chemoradiation and Abdominoperineal Resection for Anorectal Cancer 

Institution where the work was prepared: The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA 

Charles E. Butler, MD; Õzlem Gûndeslioglu, MD; Miguel A. Rodriguez-Bigas, MD; The University of Texas M.D. 

Anderson Cancer Center 

BACKGROUND & PURPOSE: 

Perineal wound complications occur in up to 60% of patients who undergo chemoradiotherapy and abdominoperineal resection (APR) 

for anorectal cancer. The most common and problematic wound complications are perineal abscess and wound dehiscence owing to 

the poor vascularity of surrounding tissues, a large, non-collapsible pelvic dead space, and bacterial contamination. Vertical rectus 

abdominis myocutaneous (VRAM) flaps, transferred from the abdomen to the perineum, have been used in an attempt to minimize 

these complications by obliterating the dead space and closing the perineal skin defect with non-irradiated, vascularized tissue. The 

purpose of this study was to compare the surgical outcomes of anorectal cancer patients who underwent chemoradiotherapy and APR 

with immediate VRAM flap reconstruction or primary closure. 

METHODS: 

We retrospectively reviewed the records of all patients who underwent chemoradiotherapy and APR for anorectal cancer from 1993 to 2005 

at a major cancer center. Patient, tumor, and treatment characteristics and surgical outcomes in patients who underwent VRAM flap reconstruction 

(flap group, n = 35) were compared with those in patients who had primary closure (control group, n = 76) of the perineal wound. 

RESULTS: 

There were no differences in radiation dose, patient age, medical comorbidities, body mass index, or tumor stage between the groups. 

Overall, there was no significant difference in the incidence of perineal wound complications between the groups; however, severe complications 

were less frequent in the flap group. The flap group had a significantly lower incidence of perineal abscess (9% vs. 37%, p = 

0.002), major wound dehiscence (3% vs. 30%, p = 0.014), and need for drainage procedures for perineal/pelvic fluid collections (3% vs. 

25%, p = 0.003) than the control group. Despite flap harvest and donor site closure in the flap group, there was no difference in the incidence 

of abdominal wall complications between the groups during the study's mean patient follow-up of 3.8 years. 

CONCLUSIONS: 

VRAM flap reconstruction of irradiated APR tissue defects reduces the incidence of severe perineal wound complications without 

increasing the incidence of postoperative abdominal wall complications. Strong consideration should be given to immediate VRAM 

flap reconstruction following chemoradiotherapy and APR for anorectal cancer. Prospective studies may help identify preoperative 

and/or intraoperative factors that affect the risk of perineal complications and thus identify patients who would benefit the most from 

VRAM flap reconstruction. 

Comparison of Surgical Outcomes Using VRAM Flaps vs. Thigh-based Flaps for 

Reconstruction of Abdominoperineal Resection and Pelvic Exenteration Defects 

Institution where the work was prepared: The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA 

Rebecca A. Nelson, MD; Charles E. Butler, MD; The University of Texas M.D. Anderson Cancer Center 

BACKGROUND & PURPOSE: 

Pelvic/perineal defects following abdominoperineal resection (APR) and pelvic exenteration (PE) are commonly repaired with regional 

flaps from the thigh or abdomen. Previous studies have described the use of these flaps but have not compared outcomes between 

flaps from the two donor sites. This study compared the surgical outcomes with vertical rectus abdominis musculocutaneous (VRAM) 

flaps and thigh-based flaps used for immediate reconstruction of APR and PE defects. 

METHODS: 

The study included all consecutive patients with a primary colorectal or urogynecologic malignancy who underwent APR or PE and 

immediate reconstruction with a VRAM or thigh-based (gracilis, anterolateral thigh, or posterior thigh) flap at a major cancer center from 

1993 to 2007. Data were obtained from a prospectively maintained database, and surgical outcomes were retrospectively compared 

between patients in the VRAM and thigh flap groups. Patient, tumor, and treatment characteristics were entered into a stepwise logistic 

regression model to identify predictors of donor and recipient site complications. 

RESULTS: 

A total of 133 patients (114 VRAM, 19 thigh) were included. The mean follow-up was 23 months. There were no significant differences 

in patient demographics, tumor pathology or stage, adjuvant therapy, or co-morbid conditions between the groups. Patients in the 

thigh group had a significantly greater incidence of superficial donor site infection (26% vs. 6% in the VRAM group) and recipient site 

complications (cellulitis, 21% vs. 4%; pelvic abscess formation, 32% vs. 6%; and major wound dehiscence, 21% vs. 5%). There were no 

differences in abdominal wall complications (including dehiscence, incisional or parastomal hernia, seroma, and infection), despite flap 

harvest from the abdominal wall in the VRAM group. Patients in the thigh group had a significantly greater incidence of prolonged (>2 

weeks) donor site wound healing (37% vs. 16% in the VRAM group), had a longer mean hospital stay (20 days vs. 12.4 days), and required 

more time for healing of donor and recipient site wounds (79% and 61% longer, respectively). Obesity (body mass index ? 30) was an 

independent predictor of major donor site complications (odds ratio (OR), 3.3), and previous abdominal surgery (OR, 3.5) and tobacco 

use (OR, 1.7) were predictors of major recipient site complications. 

CONCLUSIONS: 

Reconstruction of APR and PE defects with VRAM flaps results in fewer donor and recipient site complications than reconstruction 

using thigh-based flaps, without increased abdominal wall morbidity. If available, abdominal flaps should be considered the primary 

flap choice to repair these defects. 

155

Microangiosomes: a New Concept 

Institution where the work was prepared: University of Chicago Hospitals, Chicago, IL, USA 

Eric A. Odessey, MD; Charles Y. Tseng, MD; Amir H. Dorafshar, MD; Lisa Spiguel, MD; Lawrence J. Gottlieb, MD, 

FACS; University of Chicago Hospitals 

BACKGROUND: 

The concept of angiosomes has been monumental to the furthering of reconstructive surgery. Such detailed, 3-dimensional knowledge 

of soft tissue vascularity has helped shape reconstruction of nearly every part of the human body. The advent of perforator-based flaps 

has created a new degree of freedom to reconstructive design. Whereas named vessels supply angiosomes, these perforators supply 

what may be called microangiosomes. In search of a consistent source of reliable cutaneous perforators, we have discovered some commonalities. 

METHODS: 

Corroborated by our literature's description of various individual perforator flaps, we present here a case series designed to further 

three hypotheses: 1) There are reliable perforators both proximal and distal to all extremity joints; 2) In general, the direction of blood 

flow within these microangiosomes extends away from the joint; and 3) Predictions of flap size can be anticipated depending on the 

location of adjacent perforators (and by definition, adjacent microangiosomes). 

RESULTS: 

Each microangiosome has a self contained circulation with reliable arterial flow and venous drainage. Many flaps previously considered 

“distally based” are actually proximally based (from a blood flow point of view) although the base of the pedicle might be distal on the 

extremity. 

CONCLUSION: 

A new concept of microangiosomes has been developed by combining the principles and knowledge of macroangiosomes and perforator 

flaps. Using this microangiosome concept, free style pedicled and free perforator flaps can be reliably designed and transferred 

for a variety of defects. Further defining the soft tissue extent of perforator-based microangiosomes will greatly broaden the spectrum 

of reconstructive surgery. 

156

ASRM SCIENTIFIC PAPER PRESENTATIONS: 

UPPER EXTREMITY 

Total and Subtotal Amputations with Destruction of the Proximal Interphalangeal and 

Metacarpal Phalangeal Joint: a Paradigm Shit Towards Salvage 

Institution where the work was prepared: California Pacific Medical Center, San Francisco, CA, USA 

Darrell Brooks, MD; Rudolf F. Buntic; Buncke Clinic 

INTRODUCTION: 

Beneficial function can be obtained utilizing a staged approach for salvage of digital amputations through the proximal interphalangeal 

(PIP) and metacarpal phalangeal (MCP) joints. Completion amputation is currently recommended for these injuries. 1,2 

METHODS: 

Between 2002 and 2006 we treated 14 patients for total and subtotal amputations characterized by destruction of their PIP (12) and 

MCP (4) joints in a staged approach. In the initial stage, patients underwent restoration of joint height, reconstruction of joint supporting 

joint structures, as well as repair of tendons, vessels and nerves. Tissue was transferred or transplanted as needed for soft tissue coverage. 

In a subsequent stage, pyrolytic carbon two-piece arthroplasty (Ascension Austin, Texas) was performed through a dorsal 

approach. Outcome evaluation involved range of motion (ROM), grip strength, pain, and analysis of the joint characteristics such as lateral 

stability, stem loosening, and subsidence. 

RESULTS: 

All patients completed 18 months follow-up evaluation. Mechanisms of injury included crush, ring avulsion, and saw. An average of 2.8 

(PIP group) and 2.0 digits (MCP group) were injured per hand. Range was 1-4 and 2-3 digits per hand respectively. All digits undergoing 

staged reconstruction survived. Outcome analysis is illustrated in table 1. Video documentation of function will be provided at presentation. 

CONCLUSION: 

In selected patients rewarding function can be obtained in cases previously thought to be a contraindication for salvage. 

Table 1. 

Patients Joint ROM (degrees) 

11 

3 

PIP (12) 

MCP (4) 

60-95 

65-90 

ROM 

(% of nl) 

60-95 

70-100 

157 

Avg. % 

Reference 1: Soucacous PN. Indications and selection for digital amputation and 

replantation. J Hand Surg [Br]. 2001 Dec;26(6):572-81. 

Reference 2: Allen DM, Levin LS. Tech Hand Up Exterm Surg. 2002 

79 

86.2 

Grip 

(% of nl) 

39-70 

12-66 

Avg. injured 

digits/hand 

2.8 

2.0

Single-Stage Reconstruction of the Mutilated Hand Using Bilobed and Trilobed Free Flaps 

Based on the Anterior Tibial Artery 

Institution where the work was prepared: Duke University, Durham, NC, USA 

Keith E. Follmar; Yi Xin Zhang; Danru Wang; Detlev Erdmann; L. Scott Levin; Duke University 

BACKGROUND: 

Reconstruction of the mutilated hand remains a challenging clinical problem. Due to the complex shape of the hand, multiple flaps or 

staged procedures are often necessary to resurface the hand with an acceptable outcome. Furthermore, involvement of the thumb or 

other fingers often complicates reconstruction. The authors describe our experience with bilobed and trilobed free flaps based on the 

anterior tibial artery system for single-stage reconstruction of the mutilated hand. 

METHODS: 

Five patients with mutilated hands (two traumatic injuries, three burn injuries) underwent soft tissue coverage with a bilobed (N=2) or 

trilobed (N=3) free flap based on the anterior tibial vessel system, including the anterior tibial, dorsalis pedis, and, in the trilobed cases, 

the first dorsal metatarsal vessels. The flaps consisted of a lateral leg lobe, a dorsalis pedis lobe, and the great toe as the third lobe. 

The sensatory nerve was also anastomosed in all cases. All donor sites were resurfaced by thick-split skin grafts. 

RESULTS: 

All flaps survived. Functional and aesthetic outcome was acceptable at 3 to 12 months of follow up. Some recovery of protective thermal 

sensation was observed in all patients. In the three cases where a great toe was included in the flap, this allowed the reconstructed 

thumb to act as an opposable post and provide some pinching action. All donor sites were free from major disability. 

CONCLUSION: 

Bilobed and trilobed free flaps based on the anterior tibial artery are a robust reconstructive option for resurfacing of the mutilated hand, 

especially in cases where the thumb or another digit has been lost. It allows for excellent results in a single stage. Figure Legend: A 36year-old 

female presented with severe burn contractures three years after a burn to her right hand. (A) Preoperative view showing severe 

contractures involving the wrist, dorsum, and thenar regions. Also note partial loss of the thumb. (B) Preoperative flap design showing the 

three lobes of the flap. (C) Intraoperative view after raising the three lobes of the flap, prior to pedicle division. (D) Postoperative view, 

showing the three lobes of the flap used to reconstruct the first web and palm area, the thenar area, and the thumb respectively. 

Complications Associated With Specific Types of Intrinsic Pedicle Flaps Used to Reconstruct 

Digital Trauma Defects 

Institution where the work was prepared: Hand & Wrist Center of Houston, Houston, TX, USA 

Mark Henry, MD; University of Texas 

One hundred and seventy-five consecutive pedicle flaps of the hand and wrist performed over a 4 year period were reviewed, eliminating 

5 cases for inadequate patient follow-up and 61 cases for recipient sites proximal to the metacarpophalangeal joints. The remaining 

108 intrinsic hand vessel based pedicle flaps were performed in 98 males and 10 females averaging 36 years of age for digit level 

trauma in 19 thumbs, 27 index fingers, 50 long fingers, 8 ring fingers, and 4 small fingers. Specific flaps employed were 79 antegrade 

flow homodigital proper digital artery, 10 reverse flow homodigital proper digital artery, 3 reverse flow second dorsal metacarpal artery, 

5 antegrade flow first dorsal metacarpal artery, 6 reverse flow dorsal ulnar artery of thumb, and 2 dorsal middle phalangeal flaps based 

on a dorsal branch of the proper digital artery. The final average total active motion in the fingers was 235 degrees. Complications 

occurred in 42 cases in which 39% of the patients were actively smoking post-operatively. Complications included 10 partial flap losses, 

13 cases of superficial epidermolysis, 4 cases of venous congestion, 4 superficial infections, 3 deep infections, and 8 cases of delayed 

healing at the wound margin. Second surgeries were required to manage these complications in 15 cases: 3 debridements of deep 

wound infections, 3 revisions of the distal fingertip amputation profile for partial flap loss, 5 full-thickness skin grafts for partial flap loss, 

and 4 full-thickness skin grafts for wound breakdown at the flap margin. Specific associations of complications with flap type were that 

the antegrade homodigital proper digital artery flaps used to preserve length in digital amputations experienced partial flap loss, epidermolysis, 

delayed wound healing, and infections involving the portion of the flap bordering the amputation margin in a secondary 

zone of crush but no cases of venous congestion. Reverse flow proper digital artery flaps of the finger and reverse flow dorsal ulnar 

artery flaps of the thumb experienced venous congestion and epidermolysis but no partial flap losses or infection. Whether the skin 

taken as part of the flap has experienced direct trauma itself and the direction of flow in the pedicle may play a role in determining what 

type of complications can be expected when using pedicle flaps intrinsic to the hand in the reconstruction of digital trauma defects. 

158

Refinement of Arterialized Venous Flaps in Finger Reconstructions 

Institution where the work was prepared: Chang Gung Memorial Hospital, Tao-Yuan, Taiwan 

Yu-Te Lin, MD, MS; Chih-Hung Lin; Cheng-Hung Lin; Fc Wei, MD, FACS; Chang Gung Memorial Hospital 

INTRODUCTION: 

Venous flaps had been broadly applied in hand/finger reconstruction and been classified according to different afferent vessels. Though 

arterialized venous flap was proposed superior to other styles of venous flaps in the literatures, venous congestion seemed to be predestinated 

in most observations. Partial loss of the flap was considered a “normal” finding during the first few days after arterialization. 

The unfavorable results may not affect the general outcomes of wound healing. Nevertheless, scarring and fibrosis does affect the functional 

outcomes of reconstructed fingers/hands. Refinement of the arterialized venous flaps was intended. 


From May 2005 to Apr 2006, seven arterialized venous flaps were used for six acutely traumatized fingers and one reconstruction after 

release of a finger contracture. All venous flaps were arterialized in an orthodromic pattern. One to two veins were repaired according 

to the veins included in the flaps. Technique of refinement was to decrease intravascular pressure of the drainage vein by interfering 

arterial flow-through with a hemoclip. Clipping the communicating branch of H-shaped veins was performed in 3 patients; Clipping a 

limb ofë-shaped vein at the bifurcation or clipping at the midway of a flow-through arterialized vein were done in 4 patients. Flaps were 

monitored in the Microsurgical Intensive Care Unit for 5 to 7 days. The patients received hand therapies and were followed in the clinics 

for 6 months. 

RESULTS: 

No venous congestion of the flap was detected during the early postoperative course. Flaps were observed mimicking conventional 

arterial flaps in color and texture. Scarce congestion was noted in one case during postoperative 3rd to 7th day, and subsided without 

any loss. One vasospasm with arterial insufficiency was detected in one case and re-do arterial anastomosis was done. Mild to moderate 

venous congestion was relieved in 10 days with superficial loss on the margin. No contraction of flap was observed and adequate 

hand function was obtained in all cases. 

DISCUSSION: 

A vein with diversion of arterial blood provided a venous blood pressure for venous drainage, which decreased the venous congestion 

of the flaps. Expression of scarce venous congestion starting at 3rd postoperative day may be due to dilatation of choke vessels after 

arterialization. Flap survival mimicking an arterial flap makes the refined flaps reliable in hand and finger reconstructions. 

Arterialized Venous Instep Flap: A New Alternative for Reconstruction of Palmar Contracture 

Release 


Fatih Zor; Selçuk Isik; Muhidtin Eski; Serdar Ozturk; Gülhane Military Medical Academy 

Palmar contractures cause great difficulty in performing the tasks required in daily life. A wide variety of flaps have been used for hand 

reconstruction and each has its own advantages and disadvantages. As a general rule of plastic surgery, all losses must be replaced by 

kind. So plantar region seems to be a good alternative. Medial plantar flap has been used in the literature but, it is a bulk flap and sacrifices 

a major artery. In this study, arterialized venous instep flap is described, and used in a clinical series. The amount of tissue loss is 

first determined, and the appropriate dimensions of the skin island of the flap are designed on the non-weight bearing area of the foot. 

The skin island of the flap resembles medial plantar flap. The thin skin flap is then elevated by preserving the subdermal plexus. At the 

distal edge of the skin island, 2or3 subcutaneous veins are preserved and harvested. At the proximal edge of the flap, saphenous vein 

is preserved and included in the flap. Following subcutaneous dissection the skin island is transferred to the defect. Following preparation 

of the digital arteries, one of the veins at the distal edge of the flap is anastomosed to the digital arteries and the vein at the proximal 

edge is anastomosed to the dorsal veins of the hand. Between January 2006-June 2007, 5 arterialized venous instep flaps were 

performed. The flap dimensions were averagely 3x 5 cm. All flaps survived without any significant problem. The mean follow-up period 

was 6 months. Functional results were satisfactory in all cased. Protective sensation was recognized about 3-6 months postoperatively. 

None of the flaps required defatting in follow-up period. Arterialized venous instep flap is very thin as it lacks fascia, it is easily 

harvested and no major artery is sacrificed. Moreover characteristics of plantar skin is very similar to palmar skin which causes a great 

advantage to this flap. Although further studies are required, we think that the use of arterialized venous instep flap is a very useful 

method for reconstruction of the palm. 

159

Long-Term Functional Outcome of the Upper Extremity following Osteocutaneous Radial 

Forearm Free Flap Harvest 

Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA 

Justin M. Sacks, MD1; Kia M. McLean, MD1; Ernest K. Manders, MD2; James M. Russavage, MD, DMD1; Frederic W.- 

B. Deleyiannis, MD, MPhil, MPH2; (1)University of Pittsburgh Medical Center, (2)University of Pittsburgh 

BACKGROUND/INTRODUCTION: 

The osteocutaneous radial forearm free flap (ORFFF) represents a versatile modality in the reconstruction of composite tissue defects of 

the head and neck. Poor cosmetic outcomes and the possibility of pathologic fractures have been cited as the primary disadvantages. 

The purpose of this study was to determine any long-term functional morbidity of the donor upper extremity following flap harvest. 

METHODS: 

A prospective cross-sectional analysis was performed on twelve patients who were at least one-year post-operative. Patient, injury and 

tumor variables were obtained. Clinical outcomes included donor site appearance, size and any history of wound complications. 

Functional capacity was quantified by comparing range of motion (ROM) of the thumbs, digits and wrists along with pronation and 

supination of bilateral forearms. Pinch and grip strengths were obtained. Neurovascular assessment using two-point discrimination in 

the median, ulnar and radial nerve distribution along with digital plethysmography of the thumb and index fingers was assessed. 

Disability of the Arm, Shoulder and Hand (DASH) questionnaires were elicited at long-term post-operative evaluation. Radiographs of 

bilateral forearms were utilized to evaluate for deformity and occult fracture. 

RESULTS: 

All radial forearm donor sites were healed with no evidence of tendon exposure. The mean ROM of full active wrist flexion, wrist extension, 

and thumb flexion measured respectively 83% (p =0.01), 82% (p=0.01), and 89% (p=0.03) of the non-flap arm. Forearm supination 

was reduced 83% (p=.03). Three of the patients (25%) were unable to fully oppose their thumb to their little finger (p=0.08). No significant 

differences were found between forearm pronation, full composite grip, pinch or grip strength, digital plethysmography, or twopoint 

discrimination. Five of the 12 patients (41.6%) reported a DASH score greater than 10, and 3 (25%) patients indicated that harvest 

of the ORFFF created a disability. Radiographs revealed one malunion secondary to post-operative pathological fracture. 

CONCLUSION: 

Harvest of the ORFFF is associated with a significant reduction in ROM of the wrist, forearm, and thumb. Patients frequently reported 

upper extremity limitations. The ORFFF, although versatile and reliable, is associated with long-term functional morbidity of the upper 

extremity. Surgeons should pre-operatively counsel their patients about these possible risks. 

Vascularized Scapular Grafts: An Excellent Option for Humeral Nonunions 

Institution where the work was prepared: Denver Clinic for Extremities at Risk, Denver, CO, USA 

Jerrod Keith, MD1; David P. Schnur, MD2; William Brown2; Ross Wilkins2; Ronald Hugate, MD2; Cynthia Kelly2; 

(1)University of Colorado Health Science Center, (2)Denver Clinic for Extremities at Risk 

Posttraumatic humeral nonunions are uncommon, ranging from 0% to 13% in published series, yet this is a problematic complication, 

challenging to surgeons and debilitating to patients. A variety of conventional techniques have been described to treat nonunions, 

including intramedullary nailing, plating with and without bone grafting, and external fixation. These methods can be successful, as 

reports of bony union range from 22 % to 95%. An attractive alternative to these traditional methods for humeral reconstruction is the 

addition of vascularized bone grafts, which are especially advantageous in patients with local devascularization and infection. Most 

microvascular surgeons utilize the free fibula graft to treat humeral nonunions. Only a few case reports and small case series, the largest 

being 3 patients, describe the use of lateral boarder of scapula bone grafts to treat this problem. We retrospectively reviewed 23 

patients from a single institution treated with vascularized bone graft for humeral nonunion using the lateral border of the scapula. Our 

mean population age was 59, and patients underwent an average of 3 prior operations. The length of time from injury to grafting averaged 

33.4 months. Healing occurred in 21/23 patients (91.3%), with an average time of 18 weeks to bony union. 19/23 grafts were pedicled, 

and the remaining 4 were free grafts. Three of the four free grafts included skin paddles. Fracture locations involved the entire 

length of the humerus, although the majority was in the middle third (61%). There were three distal nonunions that were successfully 

treated with osteocutaneous free grafts. Three complications occurred in only 2 patients. One patient developed an infection and ulnar 

nerve entrapment, while the other formed thrombosis in the graft vein. Both complications resolved after operative revisions and these 

patients achieved union of their fractures. Throughout follow-up, patients completed a modified MSTS upper extremity functional evaluation 

score. The average length of follow up was 30 months and the average MSTS functional score was 80%. Based on these results, 

we believe that the lateral border of the scapula as a vascularized bone graft is an excellent option for humeral nonunions. The majority 

of grafts can be performed on a pedicle, obviating the need for lengthy operations and complications associated with vascular anastamoses. 

Additionally, the operative field is limited to one region of the body, which may aid in patient comfort and hasten recovery. 

160

The Aesthetic Mini Wrap - Around Technique for Thumb Reconstruction 

Institution where the work was prepared: Department of Orthopaedics University of Modena, Modena, Italy 

Roberto Adani, MD; University of Modena and Reggio Emilia 

INTRODUCTION: 

Free flaps from the great toe are an established method for reconstruction of absent or partially amputated thumbs. However, opinions 

differs as to which technique represents the ideal solution for each level of amputation. In addition, there may be some controversy 

for distal thumb reconstruction, i.e. distal to the IP joint. This work reflects our experience in using the great toe mini wrap-around 

flap for distal thumb reconstruction. 


In the period between 1990-2005 we have used a great toe mini wrap-around for reconstruction of the thumb in 19 patients with traumatic 

amputations localized at the distal phalanx of the thumb. A flap including the entire nail and most of the distal phalanx of the 

great toe was used. The patients included 15 men and 4 women with a mean age of 25 years (range 17-52 years).The mean interval 

between injury and surgery was 98 days (range 7days-13months) with the exception of one patient in whom reconstruction was performed 

13 years after injury. In 6 cases ,the amputation was through the base of the distal phalanx, in 11cases it was at the level of the 

IP joint and finally in two cases it was at the MP joint (in these cases the bone was initially lengthened with an external fixator and later 

reconstruction was performed using a mini wrap around flap). 

RESULTS: 

18 of the grafts survived. Four of the 6 patients with amputation distal to the IP joint had a functional IP joint with a mean range of motion 

of 30° (range 25-°-45°); the other cases had a non functional IP joint.Arthrodesis at the IP level was performed in the remaining cases 

.The mean 2sPD was 10 mm (range, 5-15) and there were no complaints of cold intolerance. There was minimal morbidity of the donor 

foot and only 3 patients complained of mild foot discomfort when walking without shoes. 

CONCLUSION: 

The mini wrap-around flap has several advantages: it restores adequate thumb length, achieves good pulp reconstruction and the cosmetic 

appearance of the nail is very similar to the contra lateral thumb. The disadvantages are complete loss of the nail at the donor 

site and loss of the “nail-to-nail pinch” if the IP joint of the thumb cannot be salvaged The great toe mini wrap-around flap is an excellent 

reconstruction technique in selected patients. 

Radical Reduction of Upper Extremity Lymphedema with Preservation of Perforators: A 

Preliminary Report 

Institution where the work was prepared: E-DA Hospital, I-Shou University, Kaohsiung, Taiwan 

Paolo Sassu, MD1; Christopher Salgado2; Samir Mardini, MD3; Hung-Chi Chen, MD, FACS2; (1)KleinertKutz Institute, 

(2)E-da/I-I Shou University Hospital, (3)Mayo clinic Rochester 

HYPOTHESIS: 

Excisional procedures have been successfully utilized by different authors in multi-stage treatment of upper extremity lymphedema. In 

the last five years we have combined microsurgical principles of perforator flap surgery in order to develop a one-stage procedure that 

enables a radical reduction of the lymphedematous tissue with preservation of the vascular supply to the overlying skin. 

METHODS: 

Between March 2000 and November 2005 seven patients were treated by Radical Reduction of the subcutaneous tissue with 

Preservation of Perforators (RRPP). Perforator vessels from the radial and posterior interosseous arteries were identified with a doppler 

probe and marked. Through medial and lateral forearm incisions, skin flaps as thin as 5 mm were raised off the underlying lymphedematous 

tissue and the affected tissue was removed off the deep fascia. During the dissection, 3 cm of soft tissue was preserved around 

the perforators in order to avoid their injury and guarantee adequate perfusion of the skin flaps. Medial and lateral antebrachial cutaneous 

nerves were preserved during the dissection. 

RESULTS: 

At a mean follow-up of 9.1 months all patients showed a significant reduction of the entire extremity and satisfaction from our evaluation. 

Measurements were evaluated from above and below the elbow joint, at the wrist and the hand. At each of these regions the average 

percentage reduction was 11.7%, 21.5%, 3.4%, and 5.4% respectively. There were no cases of wound breakdown, skin necrosis or 

cellulitis in the postoperative period. 

CONCLUSION: 

Even though further evaluations will be necessary, microvascular principles applied to the radical excision of the subcutaneous tissue 

seems to offer a new promising one-stage surgical procedure in patients affected by upper extremity lymphedema 

161

Vascularized Groin Lymph Node Transfer for Postmastectomy Upper Extremity Lymphedema 

Institution where the work was prepared: Cheng-Hung Lin, Taipei, Taiwan 

Cheng-Hung Lin1; Rozina Ali1; Chris Wallace1; Hung-Chi Chen2; Ming-Huei Cheng1; (1)Chang Gung Memorial 

Hospital, Chang Gung University, (2)E-Da Hospital, I-Shou University 

OBJECTIVE: 

The objective of this study was to evaluate the outcome of vascularized groin lymph node (VGLN) transfer in patients with postmastectomy 

upper extremity lymphedema (PMUEL). 

SUMMARY BACKGROUND DATA: 

Microlymphatic surgery for obstructive lymphedema was introduced in 1977. Based on results observed in an experimental canine 

model, VGLN transfer has been performed in place of microlymphatic surgery in our hospital as the first-line treatment for PMUEL 

refractory to non-operative therapies. This shift has been fueled by the drive for less technically demanding and more physiological procedures. 

METHODS: 

Between January 1997 and June 2005, 13 consecutive patients with refractory PMUEL underwent VGLN transfer. Superficial inguinal 

nodes supplied by the superficial circumflex iliac vessels, were harvested within a lympho-cutaneous flap measuring 10 cm by 5 cm and 

transferred to the dorsal wrist of the lymphedematous limb. The superficial branch of the radial artery at the anatomical snuffbox and 

the cephalic vein were used as recipient vessels. Outcome was assessed by reduction in upper limb girth, increased functional usage, 

decrease in infection rate and improved lymphatic drainage on lymphoscintigraphy. 

RESULTS: 

All flaps survived although one flap required early re-exploration. No donor site morbidity was encountered. A postoperative reduction 

in arm circumference was documented in eleven (84.6%) patients, with a mean percentage reduction in arm circumference of 53.2%. A 

marked postoperative reduction in the incidence of cellulitis was noted in eleven patients. Postoperative technetium-labeled sulfur colloid 

lymphoscintigraphy indicated improved lymph drainage of the affected arm, revealing decreased lymph stasis and more rapid lymphatic 

clearance. 

CONCLUSION: 

VGLN transfer is a technically simple, reliable and safe procedure that significantly improves refractory PMUEL as assessed by objective 

measures and clinical parameters. 

Use of Nerve Conduits as an Adjunct to Brachial Plexus Micro-Neurorraphy 

Institution where the work was prepared: Hospital for Special Surgery, New York, NY, USA 

Helene L. Strauss, BA1; Richard Cheng, BS2; Scott Wolfe, MD3; Joseph Feinberg, MD3; (1)UMDNJ, (2)Dartmouth 

Medical School, (3)Hospital for Special Surgery 

HYPOTHESIS: 

The use of nerve conduits in level I clinical trials shows improvement in sensory recovery when compared with direct repair. While primate 

studies on major mixed motor-sensory nerves have also documented significant improvements over direct repair with nerve conduits, 

no clinical data analyzing motor recovery following nerve conduit repair has been reported. We hypothesize that the recovery of 

nerves repaired with conduits surpasses that of nerves repaired with end-to-end neurorraphy. 

METHODS: 

17 patients had one or multiple nerve-to-nerve transfers for adult traumatic brachial plexus palsy using the operative microscope, with 

some patients undergoing multiple procedures. 7 transfers were performed by advancing the nerve ends into a semi-permeable Type I 

cross-linked collagen conduit and 24 nerve transfers were performed utilizing standard end-to-end neurorraphy. No repairs involved interposition 

grafts. Postoperative rehabilitation and follow-up were identical between groups. The following three criteria were analyzed: clinical 

evaluation using the Medical Research Council grading scheme of muscle function at one year, at two years, and postoperative EMG. 

31 and 21 transfers were available for one- and two-year follow-up testing, respectively. Two-tailed unpaired t-tests were completed. 


For all three evaluation criteria, no significant differences existed between the conduit and standard end-to-end neurorraphy. Notably, 

all transfers performed with nerve conduits demonstrated clinical and electromyographic reinnervation at one year and all 6 muscles 

with two year follow-up data demonstrated M3 or M4 clinical function. 

CONCLUSION: 

Functional muscle recovery is equivalent for nerve transfers performed with collagen nerve conduits and by traditional micro-neurroraphy. 

Successful conduit usage for motor neuron repair in humans as documented here and previous studies of conduit usage in animals 

and sensory neurons warrant continued investigation into conduit repair efficacy and potential improvements in operative time, 

precision of repair, and speed of nerve recovery. 

162

The Extended Lower Trapezius Flap for the Reconstruction of Shoulder Tip Defects 


Kok-Chai Tan, MBBS, FRCS; Bien-Keem Tan, MBBS, FRCS, (Ed); Mohamed Z. Rasheed, MBBS, MRCS(Ed); Singapore 

General Hospital 

BACKGROUND: 

Defects of the shoulder tip expose the glenohumeral and acromioclavicular joints and lead to scarring and contractures. Well vascularised 

cover is required to restore function and appearance, yet few pedicled flaps are able to reach the shoulder tip. The latissimus 

dorsi flap is commonly employed, but its sacrifice affects glenohumeral function, which is undesirable in a patient with a shoulder weak 

from an underlying pathological condition. 

METHODS: 

We describe the extended lower trapezius flap for reconstructing the shoulder tip defects of three patients. This pedicled flap is based 

on the dorsal scapular artery and includes the lower trapezius muscle and a long inferior fasciocutaneous extension. 

RESULTS: 

All flaps healed without complications and all patients regained good shoulder function with full range of motion. One patient who 

developed tumor recurrence was treated with re-excision and latissimus dorsi flap reconstruction. 

CONCLUSION: 

The extended lower trapezius flap is well suited for reconstructing shoulder defects. Based on the dorsal scapular artery, the flap has a 

long inferior fasciocutaneous extension that is able to reach the shoulder tip. Shoulder morbidity is low as only the lower trapezius is 

released minimizing disruption to scapulothoracic function. And as the latissimus dorsi is spared, glenohumeral function is not affected 

and the option of the latissimus dorsi flap remains available for future use. 

Figure 1a: 

Figure 1b: 

Tz – Trapezius, RM – Rhomboid Major, Rm – Rhomboid Minor, LD – Latissimus Dorsi, DSA – Dorsal Scapular Artery, Arrow – Protraction 

of Scapula. 

Figure 2: 

Post-operative appearance at one month. 

163


LOWER EXTREMITY 

Vascularized Fibula Flap Onlay for Salvage of Pathologic Long-Bone Fracture 


Jeffrey B. Friedrich, MD; Steven L. Moran; Allen T. Bishop; Christina M. Wood; Alexander Y. Shin; Mayo Clinic 

INTRODUCTION: 

Long bone pathologic fractures, especially when radiation-induced, represent a significant and difficult entity to treat. The ultimate goal 

of treatment is limb salvage, however, there are no treatment methods that guarantee bony healing. Frequently, immobilization or open 

reduction and fixation are unsuccessful. In recent decades, the vascularized fibula flap has revolutionized skeletal reconstruction, including 

that of the long bones. One treatment option for long-bone pathologic fracture is an onlay free vascularized fibula flap spanning 

the fracture site. The purpose of this study is to report the results of onlay vascularized fibula flaps for pathologic long bone fractures, 

and to determine the clinical outcomes, postoperative functional status, and complications of this method of reconstruction. 


A tumor registry review was conducted to search for patients who underwent long bone pathologic fracture reconstruction with the 

onlay vascularized fibula flap. These patients' records were analyzed for details of reconstruction; time to bony union; subsequent surgeries; 

clinical and functional outcomes; and complications associated with flap harvest and reconstruction. 

RESULTS: 

Twenty-five patients met criteria for this study. Twenty-one patients demonstrated bony fracture union at an average of 11 months following 

fibula flap onlay reconstruction. All 4 of the patients whose fibular flap failed to demonstrate bony healing later obtained limb salvage 

following subsequent procedures. Two patients who had experienced bony union ultimately required amputations for reasons unrelated 

to the fibular reconstruction. Overall limb salvage was possible in 23 patients (92%). Twelve of 25 patients achieved a good or excellent 

functional outcome as judged by a common oncologic reconstruction functional outcome scale. Thirteen patients had a fair or fail outcome. 

Post-surgical complications were common in this group of patients, with a total of 22 distinct complications (88% incidence). 

CONCLUSION: 

This study demonstrates that pathologic long bone fracture salvage with an onlay vascularized fibula flap enables limb salvage in a majority 

of patients. The incidence of postoperative complications is high, and must be weighed against the potential morbidity of limb loss. 

Microvascular Bone Flap Prefabrication: Preliminary Results in an Animal Experimental Model 

Institution where the work was prepared: Div of Plastic Surgery - University of Modena and Reggio Emilia, Modena, 

Italy 

Alessio Baccarani; Giovanna Petrella; Pietro Loschi; Massimo Pinelli; Giorgio De Santis; University of Modena and 

Reggio Emilia 

INTRODUCTION: 

Bone defects still represent a significant challenge to the reconstructive surgeon. Despite major advancements in the field of biomaterials, 

autologous bone grafts are to be considered the gold standard for reconstructing extended bony defects. Our study was designed 

to develop a pre-fabricated bone flap in an animal model, starting from a predetermined-shape biocompatible scaffold (BS), a vascular 

pedicle and different types of autologous stem cells. 

METHODS: 

Thirty New Zealand rabbits (male, weight range from 1.8 to 2.4 kg) were used and divided in three groups (10 rabbits each). In group 1 

(control group) a 7 mm diameter biocompatible scaffold (xenogenic decellularized and deproteinized bone) was inset across the rabbit's 

femoral pedicle and then wrapped into a silicon sheet. In group 2 the same BS was inset and 0.5 cc of autologous bone marrow 

(BM) were added. In group 3 the same BS system was added with 1.5*106 autologous rabbit adipose-derived stem cells (ASCs) in 0.5 

cc hyaluronic acid matrix suspension. After 16 weeks all implants were harvested as micro-flaps and then analized with microradiograms 

(Micro X-Ray, Italstructure, Como, Italy) and by histology (5 mm sections, Toluidine Blue and Gomori staining). 

RESULTS: 

At microradiographic analysis all the inset scaffolds showed decreased density with respect to the same pre-operatory non-implanted 

scaffolds. Group 2 implants showed additionally a significant change in the finest trabecular morphology. Histological analysis showed 

in group 1 implants an abundant connective tissue deposition with angiogenesis, and frequent bone resorption sites. In group 2 

implants, osteogenesis was found. Active osteoblasts were assessed together with vital osteocytes. Group 3 implants did not differ 

much histologically from the control group, but were characterized by a more intense granulocytic inflammatory reaction. 

CONCLUSIONS: 

Bone marrow derived stem cells are able to promote a faster osteogenesis process in this microsurgical experimental model. Adipose 

derived stem cells (ASCs) may promote the same process with longer latency. Microsurgical bone prefabrication may represent a possibile 

reconstructive option in the future. 

164

The Use of Corticoperiosteal Flaps in Recalcitrant Distal Tibial Nonunions 

Institution where the work was prepared: Fundación Pedro Cavadas, Valencia, Spain 

Pedro C. Cavadas, MD, PhD; Luis Landin; Fundación Pedro Cavadas 

Recalcitrant nonunions of the distal tibia without bone defect are severe problems difficult to treat. Vascularized corticoperiosteum can 

provide osteogenesis The thin corticoperiosteal flap based on the descending genicular artery has been previously described to treat 

nonunions in the upper extremity without bone defect. The use of this flap to treat distal tibial nonunions is reported. Twentyone 

patients with recalcitrant nonunion of the distal tibial metaphysis without segmental bone defect or evidence of infection were treated 

with revision of the internal fixation and a corticoperiosteal free flap from the medial condyle of the femur. The number of previous surgical 

procedures was 2-5. The flaps were compound, including muscle or fat, for wound coverage in seven cases. All compound flaps 

survived. Bony union was achieved in all cases, with substantial bone formation at the nonunion site by the fourth month in all cases but 

one. In this case bone union took seven months. Donor morbidity was negligible. Two tibiotalar arthrodeses were performed secondarily 

for posttraumatic osteoarthritis. Treatment of recalcitrant distal tibial nonunions without bone defect with removal of previous hardware, 

stable internal fixation and free corticoperiosteal flap transfer is safe and effective in noninfected cases. 

How Do Free Muscle Flap Reconstruction Effect Gait Analysis in Landmine Injury Patients? 


Serdar Ozturk; Mustafa Sengezer; Haydar Mohur; Fatih Zor; Gülhane Military Medical Academy 

INTRODUCTION: 

Landmine explosion results in severe composite soft tissue and bone defects especially on the heel area. Such injuries bring a formidable 

challenge to both patients and reconstructive surgeons. Here, we present gait analysis of the patients in one of the largest series in 

the literature. We discuss our experience and give important points in gait analyses of these patients. 

MATERIAL AND METHODS: 

Eighty four patients who had heel defects treated with muscle flaps in Department of Plastic and Reconstructive Surgery at GMMA were 

examined objectively. Type of injury, localization of the wounds, tissue defects and timing of the definitive treatment were included in 

the study. Treatment modalities according to the severity and localization of the wounds were defined. Our preference for reconstruction 

of large complex defects was free muscle flaps covered by split-thickness skin grafts. Among these, we used free latissimus dorsi 

muscle flaps in 48 patients, and rectus abdominis muscle flaps in 36 patients. Outcomes of free muscle flap surgery were evaluated 

mainly by use of three dimensional gait analysis as well as dynamic podography and dynamic EMGs. The mean follow-up of these 

patients was 7.2 years ranging from 1 to 13 years. The values were compared with both the results of the intact foot of the patient and 

with the ones obtained from 20 healthy volunteer men (control group).Statistical analysis were performed by Mann-Whitney U and 

Wilcoxon (non-parametric) tests. 

RESULTS: 

Most of the patients declared their satisfaction of having their own feet instead of prosthesis. 41 patients are still working without any 

difficulty for a mean of 3.4 years (range, 1 to 8 years). Chronic and repetitive ulcerations (24patients, 33%) and chronic discharge through 

the ulcer (20 patients, 27.8%) were found. The mean time of standing or walking per day was 2.85 hours for the rest of the patients. 

Dynamic pressure distribution tests revealed significantly higher pressure and load values on the injured feet of the patients than the 

control group(p

Complex Perineal and Groin Wound Reconstruction Using the Extended Dissection 

Technique of the Gracilis Flap 

Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA 

Joseph H. Dayan, MD; Patrick Curry; Chris E. Attinger, MD; Ivica Ducic, MD, PhD; Georgetown University Hospital 

BACKGROUND: 

The purpose of this paper is to review the applications of the extended dissection technique of the gracilis flap in a high risk patient 

population with complex wounds requiring more coverage than a standard gracilis flap may provide. To our knowledge, this is the first 

study applying the extended dissection technique as described by Hasen, et al, to pedicled gracilis flaps. 

METHODS: 

A chart review conducted from 2003 to 2006 identified 19 consecutive patients as having undergone an extended gracilis dissection. 

The technical details of this procedure are described. 

RESULTS: 

All reconstructions were successful. There was one complication presenting as a late infection at the donor site. Mean patient age was 

66 years old and nearly all patients had multiple significant comorbidities including diabetes, peripheral vascular disease, and/or radiation 

therapy. 

CONCLUSIONS: 

The extended-dissection technique for gracilis harvest has significant benefits for use in pedicled flaps including greater arc of rotation 

and no restriction on post-op ambulation or thigh abduction. These factors are particularly important in the challenging patient population 

represented in this study and add to the reliability and versatility of the gracilis flap. Anatomic illustrations for technical guidance 

in this procedure are also provided. 

Vascularization of the Flexor Hallucis Longus Muscle and Its Implication in Free Fibula Flap 

Transfer 

Institution where the work was prepared: KleinertKutz Institute, Louisville, KY, USA 

Paolo Sassu, MD1; Samir Mardini, MD2; Tuna Ozyurekoglu, MD1; J. Christopher Salgado, MD3; Steven Moran4; 

Robert D. Acland, MD5; (1)KleinertKutz Institute, (2)Mayo clinic Rochester, (3)Cooper University Hospital / U.M.D.N.J, 

(4)Mayo Clinic, (5)University of Louisville 

INTRODUCTION: 

Contracture as well as weakness of the flexor hallucis longus (FHL) are possible complications following harvest of the fibula flap. 

Clinically significant contracture when it occurs represents a major problem. Possible causes have been related to fibrotic change of the 

muscle either due to devascularization or compartment-like syndrome after a tight wound closure. Blood supply to the FHL is partially 

disturbed during harvest of the fibula flap. To what degree this occurs is not clear. The purpose of this study is to study the anatomy, 

vascularization, and nerve supply of the FHL muscle after fibula flap harvest in a fresh cadaver model. 


A vascularized fibula bone flap was harvested through a lateral approach in twenty fresh limbs. The popliteal artery was isolated and 

injected with 40cc of silicone injection compound. . Twenty-four hours later the FHL muscle was isolated and marked into four sections 

(one quarter of the entire length) using a marking pen. The vessels supplying the FHL and the nerve to the muscle were studied under 

microscopic visualization. 

RESULTS: 

The distal third and fourth part of the FHL muscle was always found to be located in a tight deep compartment.. The distal part of the 

peroneal artery was refilled by the silicone compound in 19 legs. In all specimens at least one branch was found to supply the distal 

fourth of the FHL. In all legs the posterior tibialis artery was refilled and an average of two branches were found to supply the muscle. 

In all dissections the nerve supplying the FHL originated from the tibialis nerve and its course was strictly close to the tibialis nerve with 

an average of three branches perforating the muscle.. No branches of the nerves were injured during the dissection. 

CONCLUSIONS: 

After harvest of a fibula flap, the FHL muscle maintains adequate vascular supply through the distal portion of the peroneal artery and 

the posterior tibialis artery. Since there was no injury to the nerves supplying the FHL, this is unlikely to be a cause of any problems in 

clinical cases. The FHL is enclosed in a tight compartment and this may explain the occasional contracture seen in clinical cases. The 

results of this study require clinical correlation and lead us to believe that if contracture does occur it is most likely to be related to an 

increase in compartment pressure causing some ischemia of the muscle. 

166

The Distal Superficial Femoral Arterial (SFA) Branch to the Sartorius Muscle as Recipient 

Vessels for Peri-Knee Soft Tissue Reconstruction: Anatomic Study and Clinical Applications 

Institution where the work was prepared: University of California, San Francisco, San Francisco, CA, USA 

Fernando Herrera, MD; University of California, San Diego; Charles K. Lee, MD; University of California, San Francisco 

(UCSF); Mark W. Kiehn, MD; University of Wisconsin; Scott Lee Hansen, MD; University of California at San Francisco 

(UCSF) 

BACKGROUND: 

Soft tissue defects around the peri-knee and upper-third open tibial wounds present a significant challenge, particularly for large defects 

which frequently require free tissue transfer. Recipient vessels for this region include the femoral, popliteal, and other distal branches. 

Often times, these vessels are not optimal because of location or zone of injury. We describe a consistent recipient vessel choice for 

microsurgical anastomosis, the distal SFA branch to the sartorius muscle (saphenous artery). 


4 fresh cadaver legs were dissected to identify the SFA branch to the sartorius muscle. Anatomic landmarks and measurements were 

taken to identify the takeoff point of the distal sartorius branch and caliber of vessel. A case series of peri-knee reconstruction is 

described to demonstrate its clinical utility 

RESULTS: 

The distal SFA branch was identified in all 4 cadaver specimens. The vessel takes off at 13cm (mean) proximal to the medial epicondyle 

of the femur. Mean diameter was 1.5mm. The vessel can be found through an incision over the adductor hiatus. Dissection is taken 

down to the superior border of the sartorius muscle and then posterior to the muscle. The branch to the muscle can be seen originating 

from the SFA and enters the muscle from its deep side, accompanying the saphenous nerve. 3 cases of successful lower extremity 

reconstruction with free tissue transfer and use of the distal SFA branch to the sartorius as recipient vessels are described. Venous outflow 

was established with the sartorius branch or saphenous vein. 

DISCUSSION: 

Vessel choices for free tissue transfer around the knee include the popliteal, the descending geniculate artery, the superior medial 

geniculate artery, the superficial femoral artery, and others. Recently, we have preferentially used the descending genicular vessels. In a 

number of cases these vessels were absent or inadequate and compelled us to search for another vessel option which gave similar 

advantages: consistent anatomy, good caliber vessels (>1.5mm diameter), proximal to the zone of injury, and a nearby saphenous vein 

for outflow. The distal SFA branch to the sartorius gives these advantages and appears to be more consistent. 

Trends in the Treatment of Severe Open Tibial Fractures 

Institution where the work was prepared: BG Trauma Center Ludwigshafen, Ludwigshafen, Germany 

Christoph Czermak; Emilios Nalbantis; Guenter Germann; Christoph Heitmann; University of Heidelberg 

INTRODUCTION: 

Treatment of severe open tibial fractures (Gustilo IIIb, IIIc) represent the classic interface between orthopedic and plastic surgery. This 

“orthoplastic” approach is currently considered the Standard of Care. “Fix and flap” within the first 72-96 hours has been postulated 

as “golden window“ in the treatment of these type of injuries. This retrospective study addresses the following questions: 1. Is the postulated 

“golden window” practicable in a Level III Trauma Center? 2. How does the interval between trauma and reconstruction influence 

the final outcome with respect to limb salvage? 3. Is limb salvage correlated to the type of flap employed? 4. Patient satisfaction 

with the functional and aesthetic result. 5. Options of secondary othopedic correction in correlation to the flap type. 


During a five year period, 92 patients with severe open tibial fractures underwent reconstruction using different types of free flaps. 

Twenty-five patients were primarily treated in our institution, 67 were secondary referrals after bone-reconstruction on outlying orthopedic 

units. There were 72 men and 20 women, mean age 46 years (10-79). Study parameters were: Interval between trauma and reconstruction, 

type of free flap, Hannover Functional Ability Questionaire, patient satisfaction, VAS, complications, limb salvage, secondary 

orthopedic approach, Cybex. 

RESULTS: 

The following free flaps were used for reconstruction: Latissimus dorsi (39), Gracilis muscle (16), Rectus abdominis muscle (2), ALT (32), 

Parascapular (2), Radial forearm (1), Lateral arm (1). 66 patients could be evaluated postoperative (71%). Flap survival rate was 91,4%. 5 

of 8 patients with total flap loss underwent reconstruction with a second free flap, three patients had lower leg amputation. Average 

interval between trauma and definitive wound closure was 18,6 (4-59) days. Mean score of FFbH was 72 (0-100), meaning a normal result. 

Regarding the functional results there were no significant differences between musculocutaneous and cutaneous free flaps. Aesthetical 

results of cutaneous flaps were superior compared to myocutaneous flaps. 

DISCUSSION: 

In none of our cases we could stay within the “golden window”. However, our data show that this had no significant influence on the 

rate of limb salvage. Complication rate in comparison to the literature is not significantly increased. This may partly due to the fact that 

the use of A-V loops to perform the vascular anastomosis remote from the zone of injuy is liberal in our department. Cutaneous perforator 

flaps proved to be superior with respect to aesthetics and simplification of secondary orthopedic procedures than myocutaneous 

flaps. 

167

Free Tissue Transfer for Complex Extremity War Injuries 

Institution where the work was prepared: The Microsurgery Unit, The Department of Plastic Surgery, Tel-Av, Tel- 

Aviv, Israel 

Arik Zaretski, MD; A. Amir; E. Arad; Y. Barnea; E. Miller; D. Leshem; J. Weiss; E. Gur; Sackler Faculty of Medicine, Tel- 

Aviv University 

BACKGROUND: 

War injury to the extremities due to blast or gunshot injuries are characterized by severe damage to both bony structures and soft tissue. 

The common finding is grade III - IV open fractures where concomitant vascular or neural injuries are frequent. The management 

of such complicated injuries remains a multi-disciplinary challenge to the orthopedic, vascular and plastic surgeon. If reconstruction is 

delayed for more than 48-72 hours, the risk of serious complications rises dramatically. We present a unique group of patients, transferred 

from The Palestinian Authority in Gaza Strip to Israel following failed initial treatment in Gaza, with highly complicated and infected 

open fractures of the limbs that where treated with free tissue transfer. 


Records were reviewed of patients transferred to our institution from Gaza from February 2006 until April 2007, for treatment of war 

injuries grade III open fractures of limbs. Included in this study were all patients that underwent limb salvage procedures using free tissue 

transfer. 

RESULTS: 

A total of ten patients were included. The etiology was blast injury in 5 patients (50%), gunshot injury in 4 patients (40%) and one patient 

was hit by a bulldozer (10%). Six patients presented with open tibial fractures (60%), Two had sever foot injury with exposed bones (20%), 

one (10%) had open fractures of the humerus, and 1 (10%) had palmar soft tissue defect. All patients had been initially treated in hospitals 

in Gaza, and were transferred to our hospital 3 days on average (range, 0.5-4 days) following trauma. Delayed reconstruction was 

achieved by microsurgical flaps in all patients included in the current study group. The flaps used where Gracilis muscle free flap (4), 

fibula osteo-septo-cutaneous flap (2), Latissimus dorsi muscle flap (2), tensor fascia lata muscle with iliac crest bone (1), tensor fascia lata 

myo-cutaneous flap (1) and vascularized fascia lata flap covered with full thickness skin graft (1). There where 3 re-explorations during 

the first 24 hours after surgery and one flap was lost. No mortalities were recorded. 

CONCLUSIONS: 

Limb preserving procedures should be considered for war injuries and grade III open fractures of limbs, even in cases that present late, 

with serious wound complications and osteomyelitis. A multidisciplinary approach focusing on proper revascularization, external skeletal 

fixation, debridement and control of infection, can achieve good conditions for delayed reconstruction. Microsurgical flaps play a 

pivotal role in delayed reconstruction of such complex injuries. 

168

Pedicled Perforator Flaps of the Lower Leg: Cluster Analysis of Perforator Locations and 

Clinical Application 

Institution where the work was prepared: UT Southwestern Medical Center at Dallas, Dallas, TX, USA 

M. Saint-Cyr, MD; Mark Schaverien; Gary Arbique; Spencer A Brown; Rod J Rohrich; UT Southwestern Medical Center 

at Dallas 

BACKGROUND: 

Pedicled perforator flaps of the lower leg offer local reconstruction options with minimal donor site morbidity. This study maps all of the 

perforators of the lower leg in order to determine predictable perforator locations for reconstructive options in this region as well as 

further defining the venous drainage and contribution of the fascia to flap vascularity. 

METHODS: 

Twenty lower limbs harvested from fresh cadavers were used in the study. The popliteal artery was cannulated and injected with red 

latex, and dissection was performed in a suprafascial plane and the location of perforators of diameter greater than 0.5mm was recorded. 

The location of the anterior tibial, posterior tibial, and peroneal arteries were recorded from the intermalleolar line. Sural artery perforators 

were recorded as grid locations from the intersection of the popliteal crease with the septum between the heads of gastrocnemius. 

Perforators were followed back to their source arteries, the perforator length was measured. Cluster analysis of the perforator 

location was performed. 

RESULTS: 

Cluster analysis revealed that reliable perforators locations from the posterior tibial, anterior tibial, and peroneal arteries could be found 

within 5cm intervals. At 4 to 8cm from the intermalleolar line perforators from the anterior tibial and posterior tibial arteries could be 

found. In the 13 to 17cm interval a reliable peroneal artery perforator and posterior tibial artery perforator could be found, and at the 

21 to 25cm interval reliable perforators could be found from the anterior tibial and posterior tibial arteries. The posterior tibial artery 

perforators were found to be the largest and easiest to dissect. 44 percent of perforators from the medial sural artery were found in a 

cluster 7 to 9cm distal to the popliteal crease within 2.5cm of the intermuscular septum. Injection of perforators from each source artery 

with dye pre- and post-fascial harvest revealed that the fascia plays a significant role in the perfusion of perforator flaps in the lower leg. 

CONCLUSIONS: 

The perforators of the arteries of the lower leg can be found in predictable locations, aiding in the design of pedicled perforator flaps. 

Of these the posterior tibial artery perforators were found to be the largest and easiest to dissect. Studies of the contribution of the fascia 

to vascularity suggest that the fascia is important in the vascularity of perforator flaps of the lower leg. 

Figure 1. Latex injection of the posterior tibial artery perforators and venae comitantes. 

169

Aesthetic Perforator Free Flap for Soft Tissue Restoration 

Institution where the work was prepared: Samsung Medical Center, Seoul, South Korea 

Goo-Hyun Mun, MD; Jai-Kyung Pyon; Samsung Medical Center 

PURPOSE: 

By the increased capability of customized flap tailoring and markedly reduced donor site morbidity with the introduction of perforator 

flaps, it is now able to fulfill both functional and aesthetical requirements more so than in the past. As previous approaches with this 

concept were mostly limited to the reconstruction of the face or the breast, we are now to introduce authors' cases of elective surgery 

for soft tissue restoration in the non-facial region using the concept of aesthetic free flaps. 

METHODS: 

From March 2006 to May 2007, 10 free flap transfers were performed in 10 patients for aesthetic purposes of the restoration of soft tissue 

and/or skin. Reconstruction of the lower extremity was in 6 cases, the upper extremity in 2 cases, the neck and buttock each in 1 

case. The patient group was composed of 7 females and 3 males, and age ranged from 14 to 59 years (mean: 31.9 years). After the 

utmost important step of recreation of the actual soft tissue defect, precise designing and elevation of the flap was followed by microsurgical 

vascular anastomosis and elaborate flap insetting with thickness control. 

RESULTS: 

Among the 10 cases, the deep inferior epigastric artery perforator (DIEP) free flap was transferred in 6 cases and the thoracodorsal artery 

perforator (TDAP) free flap in the 4 cases. Flap sizes ranged from 34 x 20 cm to 18 x 5 cm. All 10 flaps were successfully transferred without 

any flap loss. The operative results were able to meet the aesthetic demands of the patients. Further corrections such as debulking 

were needed in a patient. 

CONCLUSIONS: 

With the continuing refinements in perforator flap surgery, microsurgical tissue transfer has become more readily considered armamentarium 

in expanded application. Established soft tissue deficit in the non-facial regions developed by the trauma, infection or previous 

surgery could be restored to meet the high cosmetic demands of the patients. Aesthetic perforator free flap would be a valuable option 

in restoration of soft tissue in various parts of body. 

Reconstruction of Segmental Femoral Defects with Living Bone Allografts Combined with 

Host-derived Neoangiogenesis: Mechanical, Histologic and Radiographic Analysis 

Institution where the work was prepared: Dept. of Orthopedic Surg., Microvasc. Research Lab., Mayo Clinic, 


Goetz A. Giessler, MD; Patricia F. Friedrich; Allen T. Bishop, MD; Department of Orthopedic Surgery, Mayo Clinic 

Living musculoskeletal allografts currently require long-term immunosuppression to maintain viability, impractical due to associated 

risks for non-life-critical tissue transplantation. We have previously demonstrated an alternative method using implanted host-derived 

vessels to replace the allogeneic nutrient circulation. These vessels maintain measurable blood flow, generate extensive neoangiogeneic 

capillaries and form new bone when combined with short-term immunosuppression. In this study, we have used this method to reconstruct 

large segmental femoral defects. A segmental femoral defect was created in Dutch-Belted rabbits. Reconstruction was performed 

using a free vascularized allogeneic femoral diaphyseal transplant from a New Zealand White rabbit. Rigid fixation allowing 

immediate full weight-bearing was performed. In addition to microvascular repair of the nutrient artery circulation, a pedicled inferior 

epigastric fascial flap was placed within the medullary canal. Survival time was 16 weeks. Five groups of 10 Dutch-Belted rabbits each 

included a pedicled autograft control group, and four allograft groups which varied in fascial flap patency (patent or ligated) and 

immunosuppression with 0.08 mg/kg Tacrolimus (+ or -). Healing was quantified by X-ray. Microangiography and Spalteholz bone clearing 

allowed quantification of neoangiogenesis. Mechanical properties were evaluated using 4-point bending. Quantitative histomorphometry 

assessed bone remodeling. X-ray analysis using a grading schema demonstrated an equivalent healing response when autograft 

controls were compared to immunosuppressed allografts with patent fascial flaps. The latter group demonstrated 

roentgenograms of faster healing as well as the lowest relative ultimate strength and elastic modulus values of all groups. This is an indication 

of biologic activity, including a greater blood supply and a higher rate of bone remodeling than other groups. It correlated with 

findings from microangiography (the highest amount of neoangiogenesis among all groups) and histomorphometric analysis of bone 

turnover. Not surprisingly, the lowest angiogenesis and bone remodeling values were found in the non-immunosuppressed allograft 

femurs with a ligated intramedullary flap. Surgical angiogenesis from host-derived fascial flaps can provide greater blood flow and 

improved rates/grading of healing in immunosuppressed allogeneic bone transplants than other groups. Material properties of this 

group were also less than the other groups. Thus, while the vascularized tissue allotransplants treated with immunosuppression and fascial 

flap implantation maintained flow and viability at levels higher than other groups, we found this to weaken the graft more as well. 

As the demonstrated active bone turnover ultimately replaces the graft with host-derived cells, this process in the long-term may result 

in a more stable graft with minor rejection. 

170

ASRM SCIENTIFIC PAPER PRESENTATIONS: RESEARCH 

Reduction of the Immunological Rejection in Composite Tissue Allotransplantation by Heat 

Stress Preconditioning 

Institution where the work was prepared: Hand-, Plastic and Reconstructive Surgery, BG Trauma Center, 


Nina Ofer, resident; Michael Sauerbier; Guenter Germann; BG Trauma Center 

The outcome of composite tissue allotransplantations can be improved by reduction of ischemia reperfusion injury and graft rejection. 

Heat shock proteins are produced as a reaction of the body during a stress situation. Once elevated they protect against a second stress 

event. The purpose of the study was to examine the immunological rejection in a rat model of composite tissue allotransplantation and 

to evaluate the effect of preconditioning by heat stress exposure prior to limb transplantation. Brown Norway rats were systemically 

heated to a body temperature of 43°C in order to upregulate heat shock protein 70 (HSP70). The expression of HSP70 - measured by 

western blot analysis - showed a peak after 24 hrs. Hindlimb transplantations were performed between Brown Norway rats and Lewis 

rats. Group 1 (n=10) was exposed to heat stress 24 hrs prior to transplantation. In group 2 (n=10) the transplantation was performed 

without heat shock pre-conditioning. Postoperatively, the transplanted hindlimb was evaluated clinically every twelve hours. The beginning 

of the immunological rejection was defined when erythema, foot edema and hardening of the hindlimb could be observed at the 

same time. At this time the rat was sacrificed and hindlimb muscle samples were taken for an histological assessment. The rejection in 

group 1 occured after five days on average, whereas the graft rejection in group 2 was observed after four days. The difference was significant 

(Whitney-Mann-U-Test: p

Swine Hemi-facial Composite Tissue Transplantation: A Preclinical Large Animal Model 

Institution where the work was prepared: Chang Gung Memorial Hospital –Kaohsiung Medical Center, Kaohsiung, 

Taiwan 

Yur-Ren Kuo, MD, PhD, FACS; Nai-Siong Kueh, MD; Wen-Sheng Wu; Chien-Chih Lin; Chong-Wei Huang; Yuan-Cheng 

Chiang; Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University 

BACKGROUND: 

Partial face composite tissue allo-transplantation (CTA) was recently achieved in a human subject. However, application of CTA is limited 

by the risk of side effects caused by long-term high-dose immunosuppression. This preliminary study investigated the reproducibility 

of swine hemi-facial transplantation for pre-clinical studies. 

METHODS: 

Twelve out-bred miniature swine underwent hemi-facial transplant. The hemi-facial orthotopic transplant consisted of ear cartilage, 

muscle with surrounding hemi-facial skin paddle supplied by the carotid artery and external jugular vein transplanted to recipient swine. 

Two different experimental designs were studied. Group I: autologous hemi-facial transplantation as a normal control; group II: hemifacial 

allo-transplantation without treatment. Swine viability and rejection signs of allograft were monitored postoperatively. 

RESULTS: 

The recipient swine were ambulatory immediately following surgery. Survival following autologous hemi-facial transplant was 100 percent 

and indefinite until sacrifice. The allo-transplants showed swelling but no visible signs of rejection over the first four days of observation. 

The allo-skin paddle appeared blue–purple and edematous on postoperative days 5 to 7 and progressed to tissue necrosis and 

rejection at postoperative days 8 to 14. 

CONCLUSION: 

The experimental results revealed this swine hemi-facial transplantation model is reproducible and suitable for pre-clinical training and 

offers a new immuno-suppression strategy toward human facial allo-transplantation. 

Comparison between Cyclosporine A and Tacrolimus in Vascularized Bone Marrow 

Transplantation for Inducing Composite Tissue Allotransplantation Tolerance with Non- 

Myeloablative Conditioning 

Institution where the work was prepared: Wei-Chao Huang, Taoyuan, Taiwan 

Wai-Chao Huang1; Nai-Jen Chang, yes2; Jeng-Yee Lin, MD1; Christopher Glenn Wallace, MD3; Fu-Chan Wei2; 

(1)Chang Gung Memorial Hospital, (2)Chang-Gung Memorial Hospital, (3)Chang Gung Memorial Hospital, Chang 

Gung University and Medical College 

INTRODUCTION: 

Cyclosporine A (CsA) and tacrolimus, both calcineurin inhibitors, are immunosuppressant commonly used for transplantations. Previous 

studies showed that tacrolimus combined with anti-lymphocyte serum (ALS) could induce mixed chimerism (MC) and tolerance to composite 

tissue allotransplantation (CTA) with non-myeloablative conditioning. Here we compare the efficiency of CsA and tacrolimus for 

tolerance induction in rat CTA. 

METHODS: 

Male 8-12 week-old donor Brown Norway rats (RT1An) and recipient Lewis rats (RT1A1l) were divided into 6 Groups. Group I: CsA treatment 

but no total body irradiation (TBI); Group II: CsA treatment and 200 cGy TBI; Group III: CsA and 400 cGy TBI; Group IV: tacrolimus 

treatment but no TBI; Group V: tacrolimus and 200 cGy TBI; Group VI: tacrolimus and 400 cGy TBI. Groups I, II and III received 16 mg/kg 

CsA (Days 0-10; 11 doses) and 5 mg ALS on Days 1 and 10. Groups IV, V and VI received 1mg/kg tacrolimus (Days 0-10; 11 doses) and 

5 mg ALS on Days 1 and 10. Groups II, III, V and VI received TBI the day before CTA. Recipients were transplanted with heterotopic 

hindlimb osteomyocutaneous (HHOMC) CTA on Day 0. Body weight and CTA rejection were assessed postoperatively. Chimerism levels 

and multi-lineage cells were determined by flow cytometry, 14, 30, 60, 90, 120 and 150 days post-CTA. 

RESULTS: 

Graft versus Host disease did not occur. CTA survival in recipients treated with CsA was significantly prolonged compared to receipients 

treated with tacrolimus. CTA acceptance rates were: 0% in Group I, 28 % in Group III, 80 % in Group III, 0 % in Group IV, 0 % in 

Group V and 16 % in Group VI. Chimerism levels after CTA were proportional to the TBI dose. Hematopoietic stem cells from HHOMC 

CTA created MC averaging 2.6 % in Group I, 4.2 % in Group II, 15.9 % in Group III, 1.4 % in Group IV, 3.7 % in Group V and 13.1 % in 

Group VI. 

CONCLUSIONS: 

CsA or tacrolimus with non-myeloablative conditioning created MC without significant difference, but recipients treated with CsA displayed 

a higher percentage of CTA acceptance than those treated with tacrolimus. Although tacrolimus is used to prevent CTA rejection, 

these findings suggest that CsA is more likely to induce CTA tolerance than tacrolimus. 

172

In Vivo and In Vitro Evidence that Intrajejunal Administration of Fresh Donor Splenocytes 

Delays the Onset of Rejection of Hindlimb Composite Tissue Allotransplants by Regulating 

Th1/Th2 Cytokines in Rats 

Institution where the work was prepared: Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan 

Christopher Glenn Wallace, MB, ChB, MRCS1; Chia-Hung Yen, PhD2; Hsiang-Chen Yang, MSc1; Chun-Yen Lin, MD, 

PhD1; Wei-Chao Huang1; Jeng-Yee Lin1; Fu-Chan Wei, MD, FACS1; (1)Chang Gung Memorial Hospital, Chang Gung 

University and Medical College, (2)National Pingtung University of Science and Technology 

INTRODUCTION: 

Jejunal mucosal tolerance was superior to oral tolerance in generating donor-specific hyporesponsiveness to cardiac allotransplants in 

rats. We previously demonstrated that intrajejunal administration of fresh donor splenocytes (FDS) delayed onset of rejection of semiallogeneic 

hindlimb composite tissue allotransplants (CTA) in rats, even without concurrent immunosuppressive drug therapy. We now 

report our investigations into the underlying mechanism. 

METHODOLOGY: 

Adult (8-10 weeks) male recipient Lewis (RT1l) and donor Lewis-Brown-Norway (LBN; RT1l+n) rats were used in this study. Percutaneous 

gastro-duodeno-jejunostomies were sited in all Lewis rats on Day -12. Lewis rats received either intrajejunal-FDS from LBN donors 

(5x107 cells; TREATED Group; n=12) or vehicle alone (HBSS only; SHAM Group; n=11) everyday on Days -9 through -3 (7 doses) and 

were sacrificed on Day 0 for one-way mixed lymphocyte reaction (MLR). Other Lewis rats received heterotopic LBN hindlimb CTAs on 

Day 0, and received intrajejunal-FDS from LBN donors (5x107 cells; TREATED/CTA Group; n=8) or vehicle alone (HBSS only; SHAM/CTA 

Group; n=5) everyday from Day -9 until completion of CTA rejection. Immunosuppressive drugs were never administered. Cytokine levels 

were determined by ELISA (TGF-beta) or flow cytometric bead arrays (IL4, IL10, IFN-Gamma, TNF-alpha) in one-way MLR supernatants 

(obtained after 72 hours co-culture) and in sera obtained from CTA recipients on Day +7 post-transplant. 

RESULTS: 

IL10 (p

The Gene Expression Profiling of Ischemia-Reperfusion injury in Rat Kidney, Small Intestine, 

and Cremasteric Muscle Model by DNA Microarray 

Institution where the work was prepared: Chang Nai-Jen, Taoyuan, Taiwan 

Nai-Jen Chang, yes; See-Tong Pang; Fu-Chan Wei; Chang-Gung Memorial Hospital 

BACKGROUND: 

Ischemia-reperfusion (I/R) injury is inevitable to cause tissue damage and leading to graft failure. Although susceptibility of various tissues 

to I/R injury has been demonstrated, the detailed mechanism is not fully elucidated. DNA microarray is a powerful tool to detect 

whole genome of the molecular changes during I/R injury. Here we compared the gene expression profile of I/R injury using kidney, 

intestine, and cremasteric muscle model in rats. 

METHODS: 

45 male Lewis rats ranging from 270 to 330 gw were randomly assigned to one of 9 groups with an equal number in each group (n=5) 

and prepared for the study. Left kidney, small intestine, and cremasteric muscle were prepared for I/R pedicle. In each model, the group 

I is the time controlled group without ischemic insult. The group II had ischemic for 60 minutes. The group III had ischemic for 60 minutes 

plus 60 minutes reperfusion. Extracted total RNA was used to probe the whole rat genome oligo array and the novel genes were 

confirmed by real-time PCR. 

RESULTS: 

Gene expression profiling of the kidney, small intestine, and cremasteric muscle during I/R injury were performed. 23465 genes included 

in our studies. After 60 minutes ischemia plus 60 minutes reperfusion, 654, 162, 776 genes were 2-folds up-regulated whereas 129, 

518, 4837 genes 2-folds down-regulated in kidney, small intestine, and cremasteric muscle individually. There were no common gene 

2-folds up-regulated in all three models during the reperfusion stage. Among the genes, we further identified activating protein-1(AP- 

1), an important transcription factor. We found the expression of the AP-1 subunits were extremely high in renal and intestinal but downregulated 

in muscle model, such as Fra-2 (18.75/17.33/0.24 folds), activating transcription factor 3 (ATF3) (13.26/5.77/0.26 folds). 

CONCLUSION: 

AP-1 expresses during cell stress and mediated in many biological pathways. The activation of AP-1 bases on the shifting conjugation 

from [Jun]-[Jun] homodimer to [Jun]-[Fos] and [Jun]-[ATF3] heterodimers and activate the JNK and p38 ERK pathways (belong to MAPK 

kinase pathway) individually. The dynamic balance of the two pathways may be important in determining whether a cell survives or 

undergoes apoptosis. Ap-1 presented with up-regulation in kidney and intestine whereas down regulation after I/R insult may due to 

the longer ischemic-tolerance of skeletal muscle. The specific role and the related pathway related to the I/R injury between these three 

organs will be further analyzed. 

Aged Donor Bone Marrow Influcences Mixed Chimerism and Donor-specific Tolerance to 

Composite Tissue Allotransplantation with Nonmyeloablative Conditioning 


Jeng-Yee Lin, MD; Wei-Chao Huang; David C.C. Chuang; Fu-Chan Wei; Chang Gung Memorial Hospital 

BACKGROUND: 

Allogeneic transplantation with aged donor organ or tissue is associated with a higher acute rejection rate or delayed organ dysfunction. 

The purpose of this study is to investigate if composite tissue allotransplantation (CTA) through mixed chimerism with aged donor 

bone marrow transplantation faces a lower engraftment rate, lower mixed chimerism or higher CTA rejection rate. 


Twelve male (6-to-10-week old) and Lewis (LEW) rats (RTA1l) were equally categorized into two groups as recipients. Male Brown Norway 

rats (RTA1c) were the donors. Group I recipients were transplanted with100 x 106 · ‚ -TCR+ and Á &delta-TCR+ T-cell depleted bone 

marrow (BM) cells from 8-to-10-week-old Brown Norway (BN) rats. Group II recipients were transplanted with same number of T-cell 

depleted BM cells from 14-to-16-month-old BN rats. Recipient rats were irradiated with 400cGy total body irradiation one day before 

BMT and treated with one dose of 5 mg antilymphocyte serum (ALS) intraperitoneally (IP) one day before BMT, cyclosporine 16 mg/kg/d 

from days 0 to 10 and one dose of 5 mg ALS, IP ten days after BMT. In both groups, the hindlimb osteomyocutaneous flap allotransplantation 

(BN„? mixed chimera rat) was done 28 days after bone marrow transplantation (BN„?LEW). Chimerism level and multilineage 

were assessed by flowcytometry 15, 30, 60, 120, and 150 days following BMT. The percentage of the facilitating cells (CD8+, · ‚- 

TCR-, Á &delta -TCR-), and hemopoietic stem cells (SSClow, ALDFlourbright) in lymphoid gate were checked in donor BM cells. 

RESULTS: 

Recipients in both groups were 100 % engrafted with donor BM. The chimerism level in each group 28 days after BMT were as follows: 

Group I: 50 %. Group II: 7%. The graft tolerance rate in Group I (80%) was significantly higher than in Group II (0%). The percentage of 

facilitating cells in lymphoid gate were found to be higher in 6-to-10-week-old donor BM cells than in 12-to-16-month-old BM cells while 

the percentage of hemopoietic stem cells were the same in two different age donor BM cells. 

CONCLUSION: 

Significantly lower mixed chimerism level and allograft tolerance rate were found in CTA through BMT with aged donor BM cells. Lower 

mixed chiemrism level is probably associated with a lower percentage of facilitating cells rather than stem cells in the aged donor BM 

cells. 

174

Quantitative Evaluation of the Dilation of Rat Femoral Vessels Following Application of 

Topical Botulinum Toxin 

Institution where the work was prepared: University of Virginia, Charlottesville, VA, USA 

Peter B. Arnold, MD, PhD1; Christopher A. Campbell1; David B. Drake1; Wyndell H. Merritt, MD2; George T. 

Rodeheaver1; Raymond F. Morgan1; (1)University of Virginia, (2)Wyndell H. Merritt, M.D 

INTRODUCTION: 

The topical application of Botulinum Toxin-A (BTX) to digital blood vessels has been described as a useful, non-surgical adjunct for the 

treatment of digital pain and ulceration resulting from peripheral vasospastic disease. However, quantitative results of this application 

with respect to blood flow or vessel dimensions have not been documented. Our study attempts to demonstrate that topically applied 

BTX increases the diameter of blood vessels, potentially increasing flow through the dilated segments. 

METHODS: 

Bilateral femoral artery and vein cutdowns were performed on six adult Sprague-Dawley rats under inhalational anesthesia. The femoral 

artery and vein were identified and individually dissected free from surrounding tissue under the operating microscope. A background 

micrometer was placed behind the vessels and two marking sutures were placed to identify the area of treatment. Ten units of BTX, 

reconstituted with sterile saline, were then applied to the external surface of the vessels. An equivalent volume of sterile saline was 

applied to the contralateral side. Digital images of the vessels were obtained before and immediately after application of the topical 

agents, and again on postoperative days (POD) one and fourteen. The overlying skin was closed with interrupted nonabsorbable suture 

and the animals recovered after each anesthetic. Average vessel diameter was measured with an image analysis software package following 

calibration to the micrometer in each image. Multivariate analysis of variance was performed for average BTX treated vessel 

diameter compared to control at individual time points, and for each study group over time, with Bonferroni post hoc analysis. 

RESULTS: 

Average vein and artery diameters were equivalent at baseline and immediately after application of BTX and saline. The BTX treated 

artery was visibly larger than the control artery on POD 1, and reached significance by POD 14, (p

Impact of Hypertonic and Hyperoncotic Saline Solutions on Ischemia-Reperfusion Injury in 

Free Flaps in Rats 

Institution where the work was prepared: Aesthetic and Plastic Surgery Institute, UCI, Orange, CA, USA 

Thomas Scholz, MD; Gregory R. D. Evans; University of California, Irvine 

BACKGROUND: 

The purpose of this study was to evaluate the influence of hypertonic and hyperoncotic saline solutions on the ischemia/reperfusion 

injury after free tissue transfer. 


Twenty eight Sprage Dawley rats were divided into four groups (n = 7). An inferior epigastric flap was designed in the left groin region. 

Directly after skin incision microcirculation was investigated using the orthogonal polarization spectral imaging technique. A free tissue 

transfer of the inferior epigastric flap was performed to the right groin region. In group A 1ml of 7.5% hypertonic saline solution (HS) 

was administered to the flap via the inferior epigastric artery at reperfusion. Group B, C, and D received 6% Dextran-70 (DS), a HS and 

DS mixture, and isotonic saline solution respectively. Evaluation of the flap microcirculation was again performed at reperfusion, 10, 20, 

and 40 minutes later. Flap survival was determined by measurement of viable area of the flap divided by total flap area at day 2. The 

results were analysed with a two tailed Rank Sum Test (Mann-Whitney). 

RESULTS: 

The control group (group D) showed a decline in blood cell velocity (BCV) to 30 +/- 10% of baseline values within the first 40 minutes 

of flap reperfusion. Furthermore, arterial vessel diameter (AVD), venous vessel diameter (VVD), and functional capillary density (FCD) 

was decreased in this group by 65 +/- 5%, 71 +/- 9%, and 56 +/- 7% respectively. Group A, B and C demonstrated a BCV of 100 +/- 

15%, 67 +/- 22%, and 119 +/- 9%, an AVD of 91 +/- 7%, 51 +/- 5%, and 103 +/- 5%, and a FCD of 91 +/- 6%, 46 +/- 7%, and 97 +/- 4% 

respectively when compared to baseline values. At day 2 flap survival was decreased in group A by 12.7 +/- 9.2%, in group B by 32.8 

+/- 14.2%, in group C by 3.9 +/- 8.9%, and in group D by 41 +/- 12.2%. Group A and C showed statistically significant differences when 

compared to group D for BCV, AVD, VVD,FCD, and flap survival. 

CONCLUSION: 

We assume that local administration of soft tissues with HS combined with DS improves microcirculatory disturbances upon reperfusion 

and increases overall flap survival. These data demonstrate that a positive influence on no-reflow mechanisms is possible by extensive fluid 

shifts on the level of microcirculation. This procedure is easily applicable in a clinical setting and may hold a high cost effectiveness. 

The Effect of Ischaemia Time on Acute Rejection of Composite Tissue Allotransplantation in 

Rat Model 

Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA 

Yee Siang Ong, MRCS, (Edin); Yi Xin Zhang; Alessio Baccarani; Keith E. Follmar; Caroline Messmer; Bruce Klitzmann; 

Detlev Erdmann; L. Scott Levin; Duke University 

OBJECTIVE: 

Composite tissue allotransplantation (CTA) has now become a clinical reality but several questions about its immunology remain unanswered. 

Ischaemia time is an important determinant of survival of transplanted tissues. Our study aime to evaluate the effect of 

ischaemia time on severity of acute rejection in composite tissue allotransplants. 


Vascularised epigastric flaps consistiing of skin, subcutaneous tissue and muscle were transplanted from male WKY rats to female F344 

rats. To keep ischaemia time as the only variable in the study, no immunosupressive theray was given. A total of 10 rats were divided 

into 2 groups. Group A (n=5) had ischaemia time of 1 hour while the Group B had ischaemia time of 3 hours. All the flaps were biopsied 

at 6 days and 13 days post- transplantation. They were then stained with hematoxylin and eosin and the severity of the acute rejection 

graded using criteria like perivascular lympocytic infiltrates, epidermal infiltrates, stromal infiltrates, eosinophils, spongiosis and 

endothelial plumping. 

RESULTS: 

Gross signs of early rejection like erythema, macular rash and edema were observed as early as 6 days and the flap was completely 

rejected by 13 days post- transplant. Histologically, a moderate acute rejection was seen in both groups at day 6. Greater than 50% of 

the vessels showed perovascular infiltrates that were accompanied by epidermal infiltrates and stromal inflammation. There was no 

spongiosis, endothelial plumping, eosinophils and large lymphocytes. More lymphocytes were seen at the epidermal and dermal junction 

in Group B compared to Group A but the difference was not statistically significant (p>0.05). All the other criteria were similar in 

both groups. At day 13, severe acute rejection was seen in both groups and no difference in histological examination. 

CONCLUSION: 

There is very little correlation between gross signs and histological grade of acute rejection. Based on analysis of these two parameters, 

there was no significant difference in severity of acute rejection with 1 and 3 hour ischaemia time in a rat model. 

176

Targeted Motor Reinnervation of the Rabbit Rectus Abdominis: a Single Muscle Can Receive 

and Distinguish Three Independent Nerve Inputs 

Institution where the work was prepared: Northwestern University, Feinberg School of Medicine, Chicago, IL, USA 

Peter S. Kim, MD1; Kristina O'Shaughnessy, MD1; Todd A. Kuiken, MD, PhD2; Gregory A. Dumanian1; (1)Northwestern 

University, Feinberg School of Medicine, (2)Rehabilitation Institute of Chicago 

BACKGROUND: 

Current myoelectric prostheses are limited at the patient-prosthetic interface, lacking means for intuitive, rapid simultaneous prosthetic 

joint movements. Targeted motor reinnervation (TMR) is a new method of rerouting the signals in existing amputated nerves to surrounding 

musculature which thereby amplifies these signals. Until now, nerve transfers for the improved control of myoelectric prostheses 

have only been performed in humans. This study investigates the feasibility of TMR of the rabbit rectus abdominis (RA) as a means 

to better study this surgical technique and to investigate areas for technical advances. 

METHOD: 

After approval by our institutional Animal Care and Use Committee, 3 New Zealand white rabbits underwent a forelimb amputation 

with preservation of the proximal median, radial and ulnar nerves. In a second stage operation, an inferiorly based rectus abdominis 

flap was created and transposed onto the ventral chest wall. A neurorrhaphy was made between the median, radial, ulnar nerves and 

three motor nerves innervating 3 distinct muscle bellies of the RA. After 10 weeks, the electrophysiologic properties of the reinnervated 

flap were investigated prior to harvest. Specific muscle bellies also underwent glycogen depletion to further demonstrate discrete, 

segmental innervation of the RA muscle bellies. 

RESULTS: 

Of the 9 total TMRs performed in 3 rabbits, 7 were grossly successful. Except in one rabbit, each single muscle flap was able to be reinnervated 

by three different nerves that previously had served the forelimb. Muscle surface electromyographic data demonstrate that 

the innervation of the RA retains its segmental nature after TMR. A logarithmic loss of electromyographic amplitude was noted in signals 

crossing into adjacent muscle outside the area of the active contraction. These results are similar to those observed in the uninjured 

rabbit RA controls. Similarly, prolonged stimulation of a nerve reinnervating the RA results in the loss of glycogen isolated to the 

territory of the muscle stimulated by that nerve. 

CONCLUSION: 

This study demonstrates that the RA can safely and reliably undergo TMR in the rabbit and that the reinnervated muscle bellies are 

electrically discrete entities. Therefore, by using a clinically proven muscle flap, several myoneurosomes may be created to help drive 

increasingly complex myoelectric prostheses and to further improve the patient-prosthetic interface. 

Donor-Recipient Bone Marrow Cells Fusion as a Novel Therapy for CTA Transplants 


Wioleta Luszczek, PhD; Earl Poptic; Serdar Nasir; Aleksandra Klimczak; Lukasz Krokowicz; Maria Siemionow; Cleveland Clinic 

INTRODUCTION: 

The aim of this study was to create ex vivo, a new generation of chimeric cells by donor-recipient cell fusion. 

METHODS: 

Bone marrow cells (BMC) were isolated from ACI (RT1a) donors and LEW (RT1l) recipients. Following harvesting, donor and recipients 

BMC were stained respectively with green PKH67-GL and red PKH26-GL dye. ACI (RT1a) and LEW (RT1l) stained BMC were fused by 

standard Poly-(ethylene-glycol) method. Ex vivo fused chimeric cells (RT1a/RT1l) were purified by FACS-sorting sorting using doublefluorescent 

dye. Efficacy of purification was evaluated by immunofluorescence microscopy. PCR-SSP (polymerase chain reactionsequence 

specific primers) method was used to confirm chimerism. Colony-forming-units (CFU) assessed clonogenic potential. 

Kariotype analysis was performed to confirm polyploidy of the fused chimertic cells. Purified chimeric cells (1.3x106– 2.0x106) were transplanted 

by direct intraosseous injection to five naïve LEW recipients to assess engraftment and migratory potential. 

RESULTS: 

Chimerism in peripheral blood was evaluated by flow cytometry. Immunofluorescence proved the presence of fused donor-recipient 

chimeric cells characterized by RT1a/RT1l phenotype which morphologicaly resembled heterokaryon and synkaryon. Kariotype confirmed 

polyploidy of fused cells and CFU assay established clonogenic capacity. PCR study allowed for detection of MHC class I genes 

characteristics for both the donor and the recipient in genetic material isolated from fused RT1a/RT1l cells. 7 day after transplantation 

of fused chimeric cells total chimerism in blood ranged between 1.2-4.58% and at day 21, between 2.54-4.57%. Engraftment and migratory 

potential of fused chimeric cells was confirmed by their presence in a bone marrow compartment of the recipients at day 21 posttransplant. 

CONCLUSION: 

Our study confirmed the feasibility of ex vivo creation of chimeric cells. This study reports for the first time successful engraftment of ex 

vivo fused chimeric cells from fully MHC mismatch donors into naïve recipients. Moreover efficacy of cell fusion was confirmed by cells 

engraftment followed by chimerism induction. This approach may be applied as a novel cell-based supportive therapy in solid organ 

and CTA transplants. 

177

Tissue Expression of The Beta-Chemokine, RANTES (CCL5), is Upregulated in Acutely 

Rejecting, Fully MHC-Mismatched Vascularized Skin Allotransplants in Rats 

Institution where the work was prepared: From the Department of Plastic and Reconstructive Surgery1 and t, Taipei, 

Taiwan 

Arik Zaretski, MD; Chia-Hung Yen; Christopher Glenn Wallace; Ren-Chin Wu; Fu-Chan Wei; Chang Gung Memorial 

Hospital, Chang Gung University and Medical College 

INTRODUCTION: 

Chemokines are homologous small proteins (8-10 kD) that are critical to the overall control of immune cell trafficking. RANTES 

(Regulated upon Activation Normal T cell Expressed and Secreted; also known as CCL5), a beta-chemokine, exerts its principle 

chemoattractant effects on T lymphocytes that are vital to acute allotransplant rejection. RANTES levels become significantly elevated 

5 days following solid organ allotransplantation. Monoclonal antibody blockade of RANTES significantly prolonged allograft survival in 

several models. 

AIM: 

To define the tissue-specific expression patterns of RANTES in vascularized skin allotransplants during acute rejection. Methodology: 

Adult (10-14 weeks) male donor Brown-Norway (BN; RT1n) and recipient Lewis (LEW; RT1l) rats were used throughout. Eight allogeneic 

(BN to LEW) and 8 isogeneic (LEW to LEW) groin flaps were performed and graded for signs of rejection. Four allogeneic and four 

isogeneic flap recipients were sacrificed on Day 4, and the rest were sacrificed on Day 6, for standard histology as well as immunohistochemical 

staining for RANTES to be assessed in a single-blinded fashion by a pathologist. 

RESULTS: 

Transplant Rejection (Table 1): Allotransplant rejection started on mean Day 3.6; rejection became moderately severe by Day 6. 

Isogeneic transplants never showed signs of rejection. 2) Histology (Figure 1): Isogeneic transplants showed moderate edema and a 

low density of inflammatory cells only. Allotransplants showed severe oedema, focal epidermal/myocytic necrosis and a high density of 

inflammatory cells (including macrophages, neutrophils, lymphocytes), each feature of which was more severe on Day 6 than Day 4. 3) 

Immunohistochemistry to RANTES (Figure 1): The negative control showed no non-specific staining. Isogeneic transplants showed minimal 

staining in inflammatory cells in Day 4 and Day 6 tissues. Allotransplants showed moderate intensity staining in inflammatory cells 

in Day 4 tissue, and Day 6 tissue showed a four-fold increased density of staining in inflammatory cells, particularly of lymphocytes, compared 

to that observed on Day 4. 

CONCLUSION: 

Tissue expression of the beta-chemokine, RANTES (CCL5), is upregulated in acutely rejecting vascularized skin allotransplants in rats, 

correlating with the clinical and histological severity of rejection. RANTES may therefore also be a useful therapeutic target for blockade 

in the control of vascularized skin allotransplant rejection. This is, to our knowledge, the first study of chemokine expression in acutely 

rejecting vascularized skin allotransplants. 

178

The Role of Thymus in Chimerism Induction on Composite Osseomusculocutaneous Sternum, 

Ribs, Thymus, Pectoralis Muscles, Skin Allotransplantation Model 


Mehmet Bozkurt, MD; Serdar Nasir; Aleksandra Klimczak; Lukasz Krokowicz; Christopher Grykien; Maria Siemionow; 

Cleveland Clinic 

INTRODUCTION: 

Cellular and vascularized bone marrow may supply donor derived hematopoietic cells, and both have been used to induce donor-specific 

chimerism in various models of vascularized bone marrow transplants. We are introducing a new composite vascularized sternal bone marrow 

transplant model which can be applied for augmentation of hematopoietic activity for chimerism induction after transplantation. 

METHODS: 

Ten allograft transplantation were performed between Lewis-Brown Norway (LBN,RT11+n) donors and Lewis (RT1l) recipients. Group I 

consisted of 5 allograft transplantation via osseomusculocutaneous sternum, ribs, thymus, pectoralis muscles, skin. In Group II 5 allografts 

transplantation were performed using osseomusculocutaneous sternum, ribs, pectoralis muscles, skin without the thymus (Fig 1). 

Sternum and the costal ribs were harvested based on the common carotid artery and internal jugular vein. In the recipient Lewis (RT1 

l), harvested isograft transplants were transferred into the inguinal region and anastomosis was performed between carotid, jugular and 

femoral pedicles (Fig 2). All animals received tapered dose of CsA therapy. Presence of donor orgin cells in the peripheral blood of 

recipients was evaluated by flow cytometry using monoclonal antibodies specific for donor MHC class I. 

RESULTS: 

Longest survival is 120 days post transplanted and are still under observation (Fig 3-4 early/long survival view). All sternal grafts have 

survived and flap viability was observed daily via inspection of skin island. This composite graft carried 5x106 of hemoetopeotic cells. 

Donor specific chimerism was detected during follow up period and introduced as a sum of donor T cell, B cells and monocyte/ 

macrophage/ dendiric cells. At day 7 post transplant total level of chimerism was assessed at 3.8% of RTIn positive cells and increased 

to 13.2% at day 63 post transplant. In contrast in group II (without thymus) initial chimerism at day 7 was evaluated at 0.3% and increased 

to 2.4% at day 21 post-transplant (still under observation). Donor orgin cells were also detected in the bone morrow compartment of 

recipient at 4.21% of RTIn positive cell cells. Chimerism will be monitored during follow-up period. 

CONCLUSIONS: 

We have introduced a new model of composite vascularized bone marrow transplantation by sternal allograft which does not require 

laparotomy for the placement of the bone. This graft carries significant amount of bone marrow within intact microanotomical compartment. 

In this model long term survival correlated directly with chimerism level. Furthermore long term survival of the composite allograft 

via thymus is imperative for induction of high level of donor specific chimerism. 

179

Acute and Delayed Effects of Pulsed Acoustic Cellular Therapy (PACE) on Capillary Perfusion 

and Microcirculatory Hemodynamics of Muscle Flaps 


Lukasz Krokowicz; Christopher Grykien; Mariusz Mielniczuk; Aleksandra Klimczak; Maria Siemionow; Cleveland Clinic 

PURPOSE: 

Despite practical indications of Pulsed Acoustic Cellular Therapy (PACE), its effect on inflammation and flap healing at microcirculatory 

level remains unknown. Aim of study was to asses effect of PACE on muscle flap microcirculatory hemodynamics, neovascularization 

and improvement of blood-supply and muscle flap healing. 

METHODS: 

Cremaster muscles were dissected in 34 Lewis rats divided into 5 groups: 1) Non-ischemic baseline controls (n=10); 2) PACE with 500 

impulses (n=6) and 3) 200 impulses (n=6) immediately before dissection; 4) PACE with 500 impulses (n=6) and 5) 200 impulses (n=6) 24h 

before dissection (n=6). Microcirculatory hemodynamics (number of rolling, sticking and transmigrating leukocytes in postcapillary 

venule, functional capillary index and RBC velocity) were recorded at 1,2,3,4 hours after dissection. Tissue oxygenation (Licox probe) 

and H+E histological evaluation were performed. Mechanism of microcirculatory responses was evaluated by immunostaining with 

monoclonal antibodies characteristic for cell adhesion molecules such as ELAM-1, and their ligand CD15s and ICAM-1. 

RESULTS: 

After PACE treatment increase in capillary activation was seen in group 2 compared to groups 4 and 1 immediately after flap dissection 

(14.11 ± 3.85 vs. 12.59 ± 3.7 vs. 13.46 ± 3.2 respectively). Average amount of rolling leukocytes during observations was decreased in 

groups 2 and 4 comparing to control group (6.68 and 7.0 vs. 9.29 respectively).At same time average number of sticking and transmigrating 

leukocytes in groups 2 and 4 was increased comparing to control group (4.49 and 2.49 in group 2 and 4.40 and 2.25 in group 4 

vs. 3.1 and 2.16 in group 1). Licox probe showed no significant difference between control group and groups 2, 3, 4 and 5 (18-20 mmHg 

vs. 18.03 ± 1.8 mmHg). Histology demonstrated no damage to small vessels and capillaries. We observed increased level of leukocytes 

adhering to vessels endothelium. Vessel endothelium showed increased level ELAM-1 in acute phase and significant upregulation in 

group 4 compare to control group. In addition we determined significant upregulation of CD15s on rolling leukocytes in group 4. This 

phenomenon was not observed in group 2 and control group. In contrast upregulation of ICAM-1 was detected in group 2 compare 

to group 4 and control group. 

CONCLUSIONS: 

This study confirmed that PACE therapy increased capillary perfusion in group 2 and presented stable capillary perfusion over 24h 

observations comparable with normal controls. Increased level of transmigrated leukocytes in group 4 correlated with upregulation of 

ELAM-1 on vessel endothelium and CD15s on transmigrated leukocytes. 

180

Three-and Four-Dimensional Arterial and Venous Anatomies of the Thoracodorsal Artery 

Perforator Flap 

Institution where the work was prepared: UT Southwestern Medical Center at Dallas, Dallas, TX, USA 

Michel Saint-Cyr, MD; Mark Schaverien; Gary Arbique; Spencer A Brown; Rod J Rohrich; UT Southwestern Medical 

Center at Dallas 

BACKGROUND: 

The vascular anatomy of the thoracodorsal artery perforator flap, which has not been previously elucidated, was examined using threeand 

four-dimensional computed tomographic angiography and venography. 

METHODS: 

Twenty-five thoracodorsal artery perforator flaps were harvested from fresh cadavers from the Western population. Dynamic static CT 

angiography using iodinated contrast media was performed following cannulation of the largest perforator from the descending branch 

of the thoracodorsal artery and its vena comitans in ten flaps. Imaging was repeated subsequent to flap thinning between the deep 

and superficial adipose layers. Coloured latex injections and flap dissections were performed in a further fifteen flaps to establish the 

location, calibre, and intramuscular length of the perforators from the thoracodorsal artery. 

RESULTS: 

Two distinct perforator complex types were described. Flap thinning can be safely performed between the deep and superficial adipose 

layers without significantly affecting flap vascularity, provided that a safety zone about the perforator is respected. The superficial 

venous system consisted of large veins arranged in a polygonal pattern situated at the subdermal level, and was connected to the deep 

system by the venae comitantes of the perforators of the thoracodorsal artery. Perforators from the descending branch of the thoracodorsal 

artery were found in reliable locations. 

CONCLUSIONS: 

Using a novel dynamic three-dimensional imaging technique, perfusion of the arterial and venous system of the throracodorsal artery 

perforator flap have been elucidated. Although the flap is inherently thin, it can be safely thinned between the superficial and deep adipose 

layers. This study has identified important advantages of the thoracodorsal artery perforator flap for use in reconstruction. Figure 

1. 3D static image following cannulation of the most proximal perforator from the descending branch and injection with a barium sulphate/gelatin 

mixture, with illustration. Note the filling of the adjacent dorsal intercostal artery perforators via recurrent flow through the 

subdermal plexus, with an absence of a suprafascial plexus. This enables the flap to be thinned without disrupting its vascular supply. 

181


HEAD AND NECK 

The Incidence of Venous Thromboembolism in Head and Neck Reconstruction 

Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, New York, NY, USA 

Constance M. Chen, MD, MPH; Joseph J. Disa; Babak J. Mehrara; Memorial Sloan-Kettering Cancer Center 

BACKGROUND: 

Cancer patients undergoing head and neck reconstruction are at high risk for venous thromboembolism (VTE). Such patients often 

exhibit major risk factors including advanced age, immobility due to a prolonged surgical procedure, malignant disease, and hypercoagulability. 

Currently, no published data exist regarding the incidence of VTE in patients undergoing oncologic head and neck reconstruction. 

This study evaluates the incidence of symptomatic pulmonary embolism (PE) and deep venous thrombosis (DVT) after head 

and neck reconstruction at a single tertiary-care cancer center. 

METHODS: 

A retrospective review was done of 6759 surgical procedures performed between 1997 and 2006 at Memorial Sloan-Kettering Cancer 

Center (MSKCC). Data from a prospectively maintained surgical database was reviewed to identify procedures that resulted in postoperative 

PE or DVT. 

RESULTS: 

From 1997-2006, there were 6759 procedures performed by two surgeons at MSKCC. There were 1583 head and neck operations 

(n=1583) and 5176 non-head and neck procedures (n=5176). Non-head and neck procedures included surgeries of the breast, upper 

extremity, lower extremity, trunk, and back. When compared to patients undergoing procedures in other parts of the body, patients 

undergoing oncologic head and neck reconstruction were older, spent more days in the hospital, and underwent longer anesthesia 

times. While the incidence of VTE was less than 1% in both patient populations, there was a six-fold greater incidence of VTE among 

patients undergoing head and neck surgery (0.57%) than non-head and neck surgeries (0.09%). The difference between the two groups 

was statistically significant (p = 0.001). 

CONCLUSIONS: 

The incidence of pulmonary embolism was significantly higher in cancer patients undergoing head and neck reconstructions than in all 

other types of procedures. Possible reasons include advanced age and prolonged immobility. When possible, anticoagulant therapy 

for prophylaxis against VTE in cancer patients undergoing head and neck reconstruction is strongly recommended. 

182

Microsurgical Correction of Craniofacial Malformations: A Fifteen-Year Experience 

Institution where the work was prepared: New York University School of Medicine, New York, NY, USA 

Pierre Saadeh1; Chris Chang, BA2; Evan Garfein1; Otway Louie1; John Siebert1; (1)NYU Medical Center, (2)New York 

University School of Medicine 

PURPOSE: 

Since our initial description of microsurgical correction of facial contour in 19 patients with craniofacial malformations, we have expanded 

our experience by 76 additional patients. We reviewed our experience with staged craniofacial, soft tissue, and microsurgical procedures 

to effect both functional and cosmetic improvement in this diverse patient population. We sought to provide a comprehensive 

summary of the operative results, complications, and refinements in techniques. A treatment algorithm is also presented. 

METHODS: 

The medical records of 95 patients (1989 to 2004) were reviewed and included 73 craniofacial microsomia patients, 8 Treacher Collins 

syndrome patients, 12 severe orbitofacial cleft patients, and 2 severe micrognathia patients. All underwent microsurgical correction 

(superficial inferior epigastric, groin, circumflex scapular flaps with/without bone or muscle, fibula) of facial contour deformities. Flap 

revisions, complications, and non-free flap related surgery were tabulated. The patients were followed for a minimum of 1 year and post 

operative evaluation included physical examination and medical photography. 

RESULTS: 

63/73 patients with craniofacial malformations underwent non-free flap-related surgery, usually mandibular/ear reconstruction, whereas 

7/8 Treacher Collins syndrome patients, 12/12 severe orbitofacial cleft patients, and 2/2 severe micrognathia patients underwent 

additional procedures. 17 patients underwent bilateral flaps (1/17 immediate). The flap of choice was a circumflex scapular variant (105). 

Mean age at flap operation was 11 (range 4-27). A two team approach was employed with simultaneous ipsilateral flap harvest and facial 

dissection. Complications included 1 flap failure, 1 flap salvage, 1 partial flap loss, 5 cellulitis, 5 hematomas requiring bedside drainage. 

All patients had improved facial contour and symmetry. Overlying skin tone and color similarly improved. Short and long-term followup 

revealed improvement. 

CONCLUSION: 

Soft tissue augmentation is a welcome byproduct of distraction osteogenesis. However, long-term midfacial reconstruction with nonvascularized 

bone and soft tissue graft may be unpredictable introducing a self-perpetuating cycle of devascularization, scar, and 

relapse. The adjunctive use of microsurgical techniques has greatly enhanced our ability to improve craniofacial recontouring. These 

techniques have proven safe, well-tolerated, and durable. Refinements of these techniques include the identification of the parascapular 

flap as our “workhorse flap”, removal of the flap skin entirely, and redefining the position of microsurgery in the reconstructive 

sequence. Microsurgical reconstruction was initially employed late, often as an attempt at salvage. Success with this approach lead to 

earlier interventions and, in selected patients, primary augmentation with free vascularized soft tissue can play a major role in midfacial 

reconstruction of these craniofacial malformations. 

Rehabilitation after Mandibular Reconstruction with Fibula Free Flap: Clinical (Outcome) and 

Quality of Life Assessment 

Institution where the work was prepared: Erasmus University Medical Center, Rotterdam, Netherlands 

Stefan O.P. Hofer; Alessandra C. Hundepool; Antoine G. Dumans; Nico Fokkens; Sukh S. Rayatt; Erik H. van der Meij; 

Kees P. Schepman; Erasmus University Medical Center Rotterdam 

BACKGROUND: 

Tumors (benign or malignant), osteoradionecrosis, or osteomyelitis sometimes lead to large segmental resections of the mandible. 

Osteo(cutaneous) fibula free flaps (OFFF) are used to reconstruct these defects. New anatomical relationships as well as possible irradiation 

of oral tissues make dental rehabilitation complicated. The aim was to determine the rate of dental rehabilitation with an 

implant-retained lower denture or fixed appliances, after segmental resection and reconstruction of the mandible with an OFFF. 

METHODS: 

Data were obtained from 70 patients, who underwent segmental mandibular resection due to various causes followed by reconstruction 

of the defect with an OFFF over a 10-year period (1995-2005). Dental rehabilitation was defined as, a patient, who after segmental 

mandibular resection and reconstruction with an OFFF, received an implant-retained lower denture or fixed appliances. Clinical and 

functional assessments, as well as quality of life and denture satisfaction were evaluated. 

RESULTS: 

Twenty-four out of 70 patients received dental implants. Eighteen patients received complete dental rehabilitation. Functional assessment 

and denture satisfaction were 5.8 and 7.7, respectively on a 10-point visual analogue scale. 

CONCLUSIONS: 

A relatively small percentage of patients with segmental mandibular reconstructions with an OFFF received complete dental rehabilitation. 

Main reason was due to poor survival after treatment of malignant tumors of the oral cavity. The beneficial effects of dental rehabilitation 

with an implant-retained denture or fixed appliances, mainly favored cosmetic aspects, rather than oral function. 

183

Evaluation of Cortical Reorganization in Facial Transplantation 


Kia M. McLean, MD; Mario G. Solari; Justin M. Sacks; Anjey Su; Vijay S. Gorantla; Jignesh V. Unadkat; Stefan 

Schneeberger; George E. Carvell; Daniel J. Simons; W.P. Andrew Lee; University of Pittsburgh Medical Center 

INTRODUCTION: 

Facial transplantation must provide effective functional outcome in order to be widely accepted as a reconstructive option. 

Understanding cortical reorganization, the brain's functional compensation for injury, could be the key to optimizing functional outcome 

in facial transplantation. The specific aims of this study were to establish a functional face transplant model in the rat and perform a 

comprehensive analysis of functional recovery and cortical reorganization. 

METHODS: 

We performed 5 syngeneic and 5 allogeneic functional hemifacial transplants with appositions of donor and recipient infraorbital nerves 

and facial nerve branches. Allogeneic transplants were given 15 mg/kg/day of cyclosporine for immunosuppression. As a control 5 syngeneic 

hemifacial transplants without nerve appositions were performed. Electromyography (EMG) was completed 12 weeks 

post–transplant. Sensory regeneration, cortical reintegration and reorganization were studied at 20 weeks post-transplant through stimulation 

of the whiskers and microelectrode output recording from the somatosensory cortex. 

RESULTS: 

All experimental transplants showed clinical evidence of motor recovery by movement of the whiskers at 24 days (syngeneic) and 32 

days (allogeneic) post-transplant respectively, while control animals did not exhibit return of whisker movement. All experimental animals 

showed presence of conduction potentials on EMG 12 weeks post-transplant, while no electrical activity was elicited in control animals 

(p < .001). Stimulation of whiskers elicited a specific regional response and directional sensitivity of cells in the somatosensory cortex. 

Histology of the somatosensory cortex with cytochrome oxidase and horseradish peroxidase staining confirmed cortical reorganization. 

CONCLUSION: 

We have established a functional model for face transplantation in the rat. This is the first model for cortical reorganization in composite 

tissue transplantation. Motor nerve recovery was confirmed clinically and physiologically. The sensory pathway in each whisker was 

traced to the corresponding region of the somatosensory cortex, quantified, and visualized by histology. This is the first electrophysiological 

and histological evidence of cortical reorganization in face transplantation. 

Le Fort I Osteotomy with Interpositional Free Fibula Flap for Maxillary Augmentation 


Rachel Bluebond-Langner, MD; Lisa Witkin; Eduardo D. Rodriguez; R Adams Cowley Shock Trauma Center 

INTRODUCTION: 

Severe maxillary deficiency results in functional compromise including altered mastication, speech abnormalities, as well as cosmetic 

deformities. Historically this has been treated in one of three ways: augmentation with non-vascularized bone grafts, Le Fort I osteotomy 

with interpositional bone graft or LeFort I osteotomy with distraction osteogenesis. We present a novel technique, Lefort I osteotomy 

with interpostional vascularized bone flap, which is particularly useful in patients who have failed augmentation with conventional 

techniques. 


Six patients with maxillary hypoplasia underwent Le Fort I osteotomy with interpositional osteoseptocutaneous fibula flaps. 

Osteotomies were made to contour the fibula which was then secured between the down-fractured maxilla and the stable zygomaticomaxillary, 

pterygomaxillary and nasomaxillary buttresses. Data collected included age, gender, mechanism of injury, maxillary 

advancement operative procedures. 

RESULTS: 

Maxillary retrusion was due to trauma (n=3), cancer (n=1), chronic maxillary atrophy (n=1) and Crouzon's (n=1). There were 3 females 

and 4 males with an average age of 40. Four patients had prior attempts at maxillary advancement or augmentation including onlay 

bone grafts, Lefort III advancement without bone grafting and distraction osteogenesis. The average skin flap area was 33.7 cm2 and 

average bone flap length was 13.7 cm. All flaps survived with no donor site complications. Simultaneous vestibuloplasty was performed 

in 3 patients using the fibula skin paddle. Average maxillary advancement was 3mm. One has had complete dental restoration including 

endosseous implants and a fixed prosthesis. The remaining five are in the process. Average follow up was 9 months. 

DISCUSSION: 

Classically, non vascularized bone graft is used to bridge the gap between the osteotomized maxilla and stable bone. The advantages 

of vascularized bone flaps over non-vascularized bone grafts include transfer of viable bone with significantly less resorption over time 

and long term osseous integration of implants. Augmentation with a fibula flap has been performed however to our knowledge there 

are no reports of the use of the fibula osteoseptocutaneous flap as an interpositional material following LeFort I osteotomy for treatment 

of severely atrophic maxillas. This technique allows simultaneous repositioning of the maxillary alveolus between stable skeletal 

buttresses, augmentation of the midface and creation of a vestibule. Furthermore, the maxillary muscosa is left intact obviating the need 

for debulking and skin grafting when endosseous implants are placed. 

184

Maxilla Transplantation 

Institution where the work was prepared: Cleveland Clinic Foundation Plastic Surgery Department, Cleveland, OH, USA 

Ilker Yazici1; Kevin Carnevale, MD2; Ayhan Comert, MD3; Tarik Cavusoglu, MD4; Aleksandra Klimczak, PhD5; Ibrahim 

Vargel, MD, PhD4; Ibrahim Tekdemir, MD3; Maria Z. Siemionow5; (1)Cleveland Clinic, (2)Cleveland Clinic Foundation, 

(3)Ankara University Medical Faculty, (4)Kirikkale University Medical Faculty, (5)The Cleveland Clinic Foundation 

INTRODUCTION: 

The aim of this paper is to provide and discuss biological and anatomical parameters in order to present the allograft maxilla transplantation 

concept for midface reconstruction based on our studies. 


10 rats and 6 human cadavers were used to develope maxilla transplant model. In the rat study allograft maxilla transplantations were 

performed across the major histocompatibility barrier between 10 Lewis-Brown-Norway (RT1nl) and 10 Lewis (RT1l) rats under 

cyclosporin A monotherapy. Maxilla grafts (Le-Fort II resembling) were dissected based on the common carotid artery and external 

jugular vein and transplanted to the anterior abdominal wall via microvascular anastomosis. Allografts were examined by tomography, 

flow cytometry, angiography, and histology. Grafts were transplanted to the abdominal region of recipient rats via microvascular anastomosis 

to femoral artery and vein. In the anatomical study 6 human cadavers were used for dissection of hemimaxilla grafts (Larger Le- 

Fort II) and anatomical data were collected based on graft harvest. 

RESULTS: 

In the rat study three of the allografts survived up to 105 days without any signs of rejection with high level of donor specific chimerism. 

The incisors continued to grow; teeth buds, bone, cartilage, and mucosa remained intact with moderate inflammation of the nasal, oral 

mucosa and keratinous metaplasia of the oral mucosa. In the anatomical study, arterial and venous pedicles of the hemimaxilla graft, 

the graft dissection algorithm and dissection planes were established. We have found that maxillary venous pedicle can be dissected 

by using planes surrounding deep buccal fat pad and masticatory space soft tissue boundaries. 

CONCLUSIONS: 

Our experience with heterotopic maxilla allotransplantation in rat model with long term survival and our series of cadaver dissections 

bring us closer to human practice of maxilla allograft transplantation. To justify this approach we are further testing tolerance inducing 

and minimal immunosupression protocols for maxilla allotransplantation. 

Microvascular Free Appendix Transfer For Reconstruction Of Various Purposes 

Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan 

Hung-Chi Chen, MD, FACS1; Samir Mardini, MD2; Yueh-Bih Tang, MD, PhD3; Christopher Salgado1; Guan-Ming 

Feng, MD4; (1)E-da/I-I Shou University Hospital, (2)E-da Hospital, (3)National Taiwan University Hospital, (4)Army 

General Hospital 

BACKGROUND: 

Appendix can provide a small lumen with motility of its mucosa as well as secretion, which can prevent obstruction when it is used as a 

conduit with two ends open. In this institute it has been applied for the reconstruction of voice tube, urethra and cervix which connects 

the uterus and vagina. PATIENTS AND 

METHODS: 

There were 7 patients, among them 4 had appendix for voice tube reconstruction, 2 for urethra, and one had colon with appendix for 

cervico-vaginal reconstruction. The pedicle was the appendiceal artery in 3 patients, and ileocolic artery in 4 patients. In two of them 

mini-incisions were used for harvesting. 

RESULTS: 

(1) voice reconstruction as a biological substitute of voice prosthesis: no food reflux to the trachea. One of them had excellent voice, 

two had good-fair results. (2)urethra reconstruction: The passage of urine was smooth, but in one patient the appendix was the limit of 

penile length. (3) The patient having colon and appendix for cervicovaginal reconstruction had excellent long-term result at 3 years follow-up. 

She had congenital vaginal dysgenesis, atretic cervix and a functional endometrium. The menstral bleeding commenced at 8 

weeks after surgery and the uterovaginal fistula was patent at 3 years follow-up. 

CONCLUSION: 

Although the appendix is small, it can maintain patency due to its nature as a part of the intestine. It is useful for various types of reconstructions. 

185

Does the Ischemia Time Affect the Outcome of Free Fibula Flaps for Head and Neck 

Reconstruction? A Review of 117 Fibular Flaps 

Institution where the work was prepared: Chang Gung Memorial Hospital, Tao-yuan, Taipeh, Taiwan 

Shu-ying Chang, MD; Huang-Kai Kao, MD; Jung-Ju Huang, MD; Holger Engel, MD; Betul Ulusal; Ming-Huei Cheng, 

MD, PhD; Chang Gung Memorial Hospital 

INTRODUCTION: 

Fibula osteocutaneous flap is a good option for reconstruction of segmental mandibular defect. The ischemia time of fibula flap for 

mandibular reconstruction is variable according to surgeon's experiences, osteotomies of fibula and fixation of fibula before vs. after 

division of the pedicle, anastomosis before vs. after inset of the flap, and artery vs. vein anastomosis first. The purposes of this study 

were to investigate the relations between the ischemia time and the outcome of fibula flap including bone and skin paddle, and to 

establish the upper limit of ischemia time for fibula flap. 


Between February of 2003 and March of 2005, 117 fibula flaps were used for mandibular reconstructions. The outcome was compared 

in the success rate and the complication rate among different ischemia time, 1~3 (n=29), 3~4 (n=51), 4~5 (n=23), 5~7(n=14) hours 

groups. The complications were defined as three categories: acute complications (within a week postoperatively); subacute complications 

(between a week and one month postoperatively); and chronic complications (one month after operation). 

RESULTS: 

The mean ischemia time was 3.6 hours (ranged from 1 to 6.6 hours). The patient's risk factors including smoking, diabetes, pre-operative 

radiotherapy, and cancer stage were not statistically different between each group. The re-exploration rate was 7.7%. Mean flap success 

rate was 98.3%. Mean partial flap loss rate was 17.1% (ranged from 7.8 to 100 %). There was statistical difference between the ischemia 

time shorter and longer than 5 hours groups (P=0.035). There was no statistically significant difference among the 4 groups in success 

rate and complication rates in different stages. The number of osteotomies (0~3) of fibula bone did not significantly affect the success 

rate, complication (acute, subacute, chronic and overall complications ) rates, partial flap loss rate, and bone loss rate in this series. 

DISCUSSION: 

Although the ischemia time of fibula flap is critical for the microsurgical mandibular reconstruction, surgeons may spend a little more 

time for shaping the fibula to mandible or even adding the osseointegrated dental implants if the longer ischemia time does not compromise 

the outcome of this procedure. In conclusion, the longer ischemia time of fibula flap for mandibular reconstruction does not 

affect the success and complication rates. We suggest the ischemia time of fibula osteocutaneous flap for mandibular reconstruction 

is better limited to 5 hours to reduce the partial flap loss. 

186

Harnessing the Potential of the Free Fibula Osteoseptocutaneous Flap in Mandible 

Reconstruction: How to Attain Adequate Functional and Esthetic Height for the 

Reconstructed Segment 


Christopher Glenn Wallace, MB, ChB, MRCS; Yang-Ming Chang; Chi-Ying Tsai; Ming-Huei Cheng; Chung-Kan Tsao; 

Fu-Chan Wei, MD, FACS; Chang Gung Memorial Hospital, Chang Gung University and Medical College 

INTRODUCTION: 

The free fibula osteoseptocutaneous flap remains the first choice for segmental mandible and contiguous soft tissue defect reconstructions 

in most situations. We present our techniques and results for restoring adequate height for the reconstructed segment, both 

esthetically and functionally, including the incorporation of primary or secondary osseointegration of dental implants. 

METHODS: 

Three recent advancements that we have found useful when addressing difficulties in height contouring, particularly at the anterior segment, 

are as follows: (1) Place an additional reconstruction plate inferior to the fibula-implant construct and use primary osseointegration of dental 

implants [11 patients; total 34 fibula-borne implants]; (2) Use a double-barrelled fibula construct with primary osseointegration [8 patients; total 

19 fibula-borne implants]; (3) Use vertical distraction osteogenesis and secondary osseointegration [4 cases; total 13 fibula-borne implants]. 

RESULTS: 

All free tissue transfers were successful. Few complications were encountered, as follows: Methods (1) and (2) – no major complications, 

all patients have good esthetic results and have completed prosthodontic rehabilitation, one patient from the Method 1 group is mildly 

bothered by palpability of the second reconstruction plate; Method (3) – difficulty controlling the distraction direction caused mild 

implant malpositioning, notably in the second premolar region, no other complications. Several important principles that should be 

respected when using these three methods will be highlighted as well as patient selection criteria when choosing between them. In 

particular, technical tips identified when using vertical distraction of the fibula flap will be a further focus. 

CONCLUSION: 

When applied appropriately, each of the presented methods can be useful for increasing the height of the reconstructed mandibular 

segment to provide an optimal mandibular reconstruction that restores mechanical functions, facial esthetics and complete dental competence 

with minimal complications. Specific technical steps are critical to each, if optimal outcomes are to be expected. Maintaining 

control over the vector of vertical distraction remains a challenge. 

Autolgous Fat as an Alternative to Microvascular Free Tissue Transfer for the Treatment of 

Severe Facial Soft Tissue Deformities 


Suhail Kanchwala, MD; Louis P. Bucky; University of Pennsylvania 

PURPOSE: 

The management of acquired and congenital facial soft tissue deformities poses many challenges to the facial reconstructive surgeon. 

The use of free tissue transfer to restore soft tissue contour in patients suffering from severe soft tissue deformities has been the “gold 

standard”. We have had extensive experience with the use of autologous facial fat grafting in aesthetic surgery and have applied similar 

techniques for facial reconstruction. The purpose of our study is to describe the use of autologous facial fat grafting as the primary 

treatment for patients with severe facial soft tissue deformities. 

METHODS: 

We performed a retrospective review of all patients who underwent autologous facial fat grafting as the primary method of facial soft 

tissue reconstruction between 1995 and 2005. We utilized a modified Coleman technique for fat harvest and injection. The number or 

fat grafting sessions and volume of fat injected was subsequently recorded. In addition, all complications including infection, fat necrosis, 

palpable nodules were recorded. 

RESULTS: 

Reconstructive facial fat grafting was performed in 36 patients. The conditions treated included Hemifacial Atrophy (12 patients), Hemifacial 

Microsomia (6 patients), Treacher-Collins syndrome (7 patients), HIV associated lipodistrophy (5 patients), and post-traumatic deformities (6 

patients). The median patient age in our series was 34 yrs. Our average follow-up was 4.2 years (range 2.7-10 years). The overall incidence of 

complications was low. There were no infections, two patients suffered prolonged bruising, and palpable nodularity was noted in one patient. 

CONCLUSION: 

Autologous facial fat grafting can be extremely effective in treating patients with severe facial soft tissue defects. Fat grafting has significantly 

decreased morbidity when compared with alternative treatment modalities such as free tissue transfer. Improved techniques 

for fat harvest and injection have enhanced the reliability of fat grafting. Autologous facial fat grafting is a safe and effective technique 

for the management of severe soft tissue deformities of the face. 

187

Radial Forearm Free Flap Pre-lamination with Acellular Dermal Matrix for Repair of Subtotal 

Glossectomy Defects 


Fernando Cordera, MD; Neal S. Topham, MD; Fox Chase Cancer Center 

BACKGROUND: 

The mainstay of treatment for advanced resectable squamous cell carcinomas (SCCs) of the tongue is surgery and postoperative radiation 

therapy. Free-tissue transfer has become the standard technique for tongue reconstruction after hemiglossectomies because of 

superior functional results when compared to local flaps. We present a novel technique for reconstruction of the tongue that uses a 

prelaminated radial forearm free flap that can be transferred to reconstruct the tongue and oral cavity. 


After obtaining Institutional Review Board approval, eight patients requiring subtotal glossectomies for tongue malignancy underwent 

a two stage procedure to reconstruct the tongue using a pre-laminated radial forearm free flap between April 2006 and February 2007. 

Using the RRC-149-06 head and neck questionnaire, the results of this group of patients were compared to those of four other patients 

with the same diagnosis who underwent similar resections but had their reconstruction performed with a standard radial forearm free 

flap. 

RESULTS: 

All patients underwent a successful reconstruction. All patients are alive and with no evidence of disease. The novel technique achieved 

comparable results to the control in terms of range of motion, pain strength, speech, swallowing, and appearance with the added 

advantages of minimizing donor site morbidity and eliminating the potential transfer of radial forearm hair to the tongue. 

CONCLUSIONS: 

Radial forearm free flap pre-lamination with acellular dermal matrix for repair of subtotal glossectomy defects is feasible and safe. This 

technique improves the appearance of the radial forearm donor site, eliminates the need for skin grafting, and eliminates the transfer 

of hair to the mouth while achieving excellent functional outcomes. 

Management of Life Threatening Tracheaesophageal Fistulae, Leaks, and Defects 

Institution where the work was prepared: MD Anderson cancer Center, Houston, TX, USA 

John Nigriny, MD, DMD; Peirong Yu; MD Anderson Cancer Center 

BACKGROUND: 

Tracheal and esophageal fistulae, leaks, and defects are life threatening complex reconstructive dilemmas. Contributing factors include prior 

surgical procedures or dilation, esophageal stenting, radiation therapy, caustic substance ingestion, medical comorbidity, and malignancy. 


We present our experience with these problems at a tertiary care cancer hospital over a two year period (10/22/04-9/26/06) in 14 

patients. Age ranged from 34-78 yrs (mean 62 yrs) and 3/14 were female. Before reconstructive plastic surgery 86% had prior surgery of 

the trachea and/or esophagus, 57% had received chemotherapy, and 64% were treated with external beam radiation (range 45-66 Gy). 

64% had two or more medical comorbidities and were previous or current smokers. Ten patients had cancer of the esophagus (squamous 

cell carcinoma-5, adenocarcinoma-4, Non Hodgkin's Lymphoma-1). Two patients had cancers adjacent to the esophagus 

(parathyroid carcinoma-1, malignant mesothelioma of bronchus-1). Two patients were cancer free (esophageal duplication cyst-1, complications 

from Nissen fundoplication-1). Life threatening sequelae included: tracheoesophageal fistula (5), esophageal perforation (2), 

esophageal anastomotic leak after Ivor Lewis Esophagectomy (3), acquired esophageal defect (3), tracheobronchial stump leak (1). 

RESULTS: 

Reconstructive intervention included a free and or pedicled flap. 21% of patients required a secondary flap intervention for salvage. 

One patient died secondary to ARDS associated with the initial tracheoesophageal fistula. Esophageal leaks, perforations or stumps, 

and tracheobronchial fistulae, were covered with pedicled flaps (latissimus (7), serratus (5), pectoralis (1), intercostal (1), and omentum 

(1). The esophagus in tracheoesophageal fistulae and large esophageal defects were reconstructed with supercharged jejunal flaps (5). 

Two of three patients who required a second operation for salvage of a failed pedicled muscle flap received a supercharged jejunal flap 

as well. The third patient required a total laryngectomy and subsequent reconstruction with an anterolateral thigh flap due to a severe 

neck infection with tracheal necrosis. In total seven patients received supercharged jejunal flap reconstruction of the esophagus, all 

except the reported death ultimately tolerated a regular diet. 

CONCLUSIONS: 

The hostile surgical environment created by an esophageal fistula necessitates the use of a staged reconstruction. Our algorithm for reconstruction 

of life threatening tracheal and esophageal disasters can be divided into two stages. Stage one is debridement, diversion, and 

cover of the tracheal esophageal bed with muscle flaps. In stage two several months later, a supercharged jejunal flap is used to provide 

alimentary continuity. This algorithm has resulted in a stable and effective salvage template for catastrophic tracheoesophageal disasters. 

188

Chronic deep venous thrombosis in the peroneal veins of a fibula flap: strategies for salvage 

and avoidance 

Institution where the work was prepared: Brigham and Women's Hospital, Boston, MA, USA 

Amir Taghinia, MD; Harvard Plastic Surgery; Julian J. Pribaz, MD; Brigham and Women's Hospital, Harvard Medical 

School; Lifei Guo, MD, PhD; Brigham and Women's Hospital 

Thrombosis of free flap vessels is usually a significant concern after micro-anastomosis; however, reports of chronic thrombotic venous 

occlusion prior to free flap transfer are rare. We present a case of chronic occlusion of the peroneal veins of a free fibula osteocutaneous 

flap and a successful salvage attempt. Prolonged bedrest from a contralateral ankle fracture led to deep venous thrombosis and chronic 

occlusion in these veins. Successful flap transfer was possible by using a venous branch from the soleus muscle for microanastomosis. 

An extensive literature search of 773 cases yielded only one similar example. Discussion with multiple experienced microsurgeons 

yielded another anecdotal case. In both of these other cases, flap transfers had to be aborted. Based on our experience, we recommend 

early intra-operative identification and preservation of the soleus vein branch in case of similar venous difficulties during free fibula 

harvest. The use of pre-operative ultrasound to assess these veins in selected patients with history of lower extremity trauma is also 

recommended prior to flap harvest. 

Go for the Jugular – A 10-year Experience with End-to-Side Anastomosis to the Internal 

Jugular Vein in 320 Head and Neck Free Flaps 

Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, New York, NY, USA 

Eric Halvorson, MD; University of North Carolina; Peter G. Cordeiro; Memorial Sloan-Kettering Cancer Center 

INTRODUCTION: 

Venous patency is critical for successful free tissue transfer in head and neck reconstruction. Although multiple suitable arteries are often 

found, venous recipients are usually limited to the internal jugular vein, stumps of its branches, and/or the external jugular vein. We have 

found that preferential use of end-to-side anastomosis to the internal jugular vein whenever possible offers distinct advantages, and 

has consistently yielded excellent outcomes. A 10-year experience with 320 cases is presented. 

METHODS: 

A prospectively maintained database was queried for patients who underwent free flap reconstruction of head and neck oncologic 

defects from 1996 to 2006 by the senior author. Intravenous heparin was given prior to flap harvest, and aspirin was administered for 5 

days post-operatively. End-to-side venous anastomosis was performed with 9-0 nylon continuous suture. Patient demographics, donor 

and recipient sites, and complications were noted for all patients who underwent end-to-side anastomosis to the internal jugular vein. 

RESULTS: 

Over a 10-year period, a total of 470 patients underwent head and neck reconstruction with free tissue transfer, of which 320 (70%) 

underwent end-to-side anastomosis to the internal jugular vein. Mean patient age in this group was 56 years (range 7-88). The most 

common flaps employed were the rectus (33%), forearm (28%), and fibula (21%) flaps. The most common recipient sites were the 

mandible with or without floor of mouth (27%), pharyngoesophagus (25%), and tongue or cheek (17% each). Minor wound healing problems, 

infection, hematoma, and death were noted in 5% or less. Partial flap loss was seen in 2%. Total flap loss, arterial thrombosis, and 

venous thrombosis all occurred in less than 1% of patients. 

CONCLUSION: 

Presented is a large series of consecutive cases by a single surgeon at one institution over a 10-year period, with preferential use of endto-side 

anastomosis to the internal jugular vein for head and neck free flap reconstruction. Excellent outcomes were noted, which compare 

favorably with other described techniques. The size, constant anatomy, availability, patency, and possibility for multiple anastomoses 

of any size at any site along its course in the neck make use of the IJV very advantageous. End-to-side anastomosis to the IJV in 

this situation results in high patency rates, and kinking is not observed when the neck is rotated. Theoretical advantages include 

increased flow in the IJV (which may promote venous outflow and wash away microthrombi) due to its size and the respiratory venous 

pump. 

189


MISCELLANEOUS 

Using Stereolithographic Models to Plan Mandibular Reconstruction for Advanced Oral 

Cavity Cancer 


Eric Y. Ro, MD1; John A. Ridge, MD, PhD, FACS2; Neal S. Topham, MD2; (1)Fox Chase Cancer Center/Temple 

University, (2)Fox Chase Cancer Center 

INTRODUCTION: 

Use of the fibula osteocutaneous free flap in mandibular reconstruction has allowed patients to recover essential aspects of mandibular 

function, including oral competence, mastication, and aesthetic appearance. To improve the efficiency, accuracy and outcomes of 

such procedures, we present our use of stereo lithographic modeling in fifteen patients with oral cancer that require mandibular reconstruction. 

This technique is especially beneficial for patients where tumor bulk extends laterally from the mandible. 

METHODS: 

Fifteen patients underwent computed tomography (CT) scan of the mandible using specific parameters (20 cm FOV, pitch 1.0, 1 mm 

slice, 120-280 mA) and the data was sent to ProtoMed (Arvada, CO). A 3-D anatomic epoxy model was returned to the reconstructive 

surgeon. A 2.4 mm or 3.0 mm locking reconstruction plate (Synthes, Inc., West Chester, PA) was bent and pre-cut to the patient's model 

and then sterilized prior to the procedure. Intra-operatively, the pre-bent titanium plate was used to drill holes needed to secure the 

plate to the native mandible prior to performing the osteotomies. The plate was then sterilized and used as a three-dimensional template 

to create an accurate neo-mandible using the fibula flap. If tumor extension inhibited plate alignment, holes were drilled after the 

osteotomies were performed. In this scenario, accurate alignment was achieved using landmarks on the mandibular model and plate. 

RESULTS: 

This technique was especially useful with neoplasms that extend laterally from the mandible because the bulk of the lesion prevented 

contouring of the titanium reconstruction plate at the time of surgical resection. Alignment of the pre-bent plate eliminated operating 

time typically dedicated to plate contouring. There were no complications attributable to this technique. There were no flap failures. 

One patient developed a local recurrence. 

CONCLUSIONS: 

Use of stereo lithographic models in mandibular reconstruction allows for accurate contouring of the plate to the mandible, reduces 

operative time, and provides a method to reconstruct patients whose tumors extend laterally to the buccal soft tissues. 

Timing of Microsurgical Reconstruction of Lower Extremity: Is It Really Important In Flap 

Failure 


Fatih Zor; Mustafa Sengezer; Murat Turegun; Selcuk ˘sik; Mustafa Nisanci; Muhidtin Eski; Gülhane Military Medical 

Academy 

Landmine injuries of the lower extremity constitute a challenging problem to the reconstructive surgeon. These injuries create composite 

tissue defects which are always contaminated. The transfer of the patient to a well established center generally takes time. All these 

factors yield a delay at the definitive treatment of the patient. Here, we want to present patients injured by landmine explosions and 

treated at different times and to discuss the effect of timing of the microvascular tissue transfer on success of the procedure. Between 

1995-2006, 109 patients were treated by microvascular tissue transfers at Gulhane Military Medical Academy in Department of Plastic 

and Reconstructive Surgery. All patients were injured due to landmine explosion and reconstructed with microvascular tissue transfer. 

The flap success rate and postoperative complications were evaluated. The average follow-up period was 19 months. Of the 109 

patients, 12 were operated between 0-7 days (group I-at the acute period). Forty-two of them were operated at the subacute period 

(group II, between 7-14 days) and the remaining 55 were operated at the chronic period (group III, more than 14 days). There was no 

flap loss in group I patients. Flap failure rate was 16.7 % and 14.5 % for group II and group III, respectively and the difference was not 

significant. No postoperative infection was observed at the acute period. Postoperative infection rate was 16.7 % and 7.3 % at subacute 

and chronic period respectively, and the difference was statistically significant. Microvascular reconstruction of the lower extremity 

at the acute period is preferred but landmine injuries are not always possible to operate at the acute period. Posttraumatic vessel 

disease is known to be the most important reason of the flap failure. Although, Godina et al. advocates that the acute period is the first 

2 days, we agree with Byrd et al as it is the first 7 days. So we think that the critical period for the microvascular surgery should be considered 

as the first 7 days. When the surgery is performed according to microvascular principles subacute period does not differs from 

chronic period when the flap failure is concerned. Subacute period is associated with a higher infection rate. 

190

Buried flap monitoring using a novel non-invasive simultaneous microcirculatory perfusion, 

oxygenation and venous outflow monitor 


Karsten Knobloch, MD, PhD; Andreas Gohritz; Niels C. Gellrich; Peter M. Vogt; Hannover Medical School 

INTRODUCTION: 

Buried microsurgical flaps into the local skin provide an excellent soft tissue augmentation in facial reconstruction, but is hampered by 

the fact that methods of flap monitoring are pending. A method for early identification of microcirculatory perfusion complications in 

these tissue transplants seems indispensable for a successful long-term outcome. 

OBJECTIVE: 

To present the feasibility of real-time microcirculatory mapping for capillary flow, tissue oxygen saturation and postcapillary venous filling 

pressures using a quantitative non-invasive Laser-Doppler-Spectrophotometry (Oxygen-to-see, 02C) of free flaps . 

METHODS: 

We report the use of this system in a 24-year-old patient who required complex facial reconstruction following orbital evisceration and 

hemifacial atophy caused by radiation therapy during childhood due to retinoblastoma. For soft tissue augementation a split latissimus 

dorsi muscle flap was transplanted to the frontal zygomatic region subcutaneously and anastomosed to the facial vessels. 

Microcirculatory parameters of blood flow, flow velocity, postcapillary venous filling pressures (AU, Arbitrary Units) and oxygen saturation 

(S02%) were assessed prospectively at five positions around both orbitae. 

RESULTS: 

Capillary blood flow was increased superficially at all five positions up to the 40-fold preoperative value (3AU/120AU). Deep capillary 

blood flow was increased in all five positions more than 4-fold (85AU/354AU). Baseline periorbital microcirculation markedly differed 

preoperatively with reduced S02% and capillary blood flow and increased postcapillary venous filling pressures. S02% at a superficial 

and deep level was increased up to fivefold level at the 6th day postoperatively (16%/82%). Postcapillary venous filling pressures were 

increased in 3/5 positions superficially up to 40% (37AU/61AU) and 3/5 positions at 8mm up to 13% following flap transfer 

(162AU/184AU). The flap survival was 100%. 

CONCLUSION: 

Free flap monitoring using the Oxygen-to-see Laser-Doppler-Spectrophotometry offers quantitative microcirculatory values for intraand 

postoperative perfusion control. Tissue oxygenation is increased following buried flap transfer with transient increase of postcapillary 

venous filling pressure without clinical deterioration of the buried flap. 

Local Perforator Flaps Around the Elbow 

Institution where the work was prepared: Recovery Hospital, Cluj-Napoca, Romania 

Alexandru Georgescu, Prof, MD, PhD; Ileana Matei; Filip Ardelean, MD; UMF Iuliu Hatieganu 

INTRODUCTION: 

The advancements in knowledge about the blood supply of tissues induced the surgeons to imagine new types of flaps, the last one 

described being the perforator flaps. This paper will try to demonstrate that around the elbow it is better to harvest flaps based on brachioradial 

musculocutaneous perforators or on the inferior cubital artery. The advantage of using these flaps is the possibility for early 

post-surgery mobilization. 


In this paper we will present 7 cases of perforator flaps around the elbow, from which 2 harvested on the posterior aspect, one on the 

distal third of the forearm and the rest on the anterior aspect (on the elbow’s flexion fold and the proximal third of the forearm). The 

patients were aged between 2 and 35 years. Three flaps were based on musculocutaneous perforators from the brachioradialis muscle, 

three were based on the inferior cubital artery (the most important perforator vessel emerging from the radial artery) and one on 

the recurrent radial artery. In the absence of the Doppler pre-surgery investigations, the harvesting technique consisted of: - initial incision 

on two thirds of the flap’s circumference - subfascial undermining until the perforator is detected - completion of the flap’s incision 

and deep dissection - the flap’s pedicle is undermined inside the muscle or septum The flap’s length is 2 cm larger then the defect’s 

length. In 5 of the 7 cases the donor site was directly sutured, in 2 cases we used split skin grafts. 

RESULTS: 

The post-surgery mobilization was early, without affecting the flap’s viability. All the flaps survived without any suffering. 

CONCLUSIONS: 

The perforators emerging from the proximal third of the forearm, especially the musculocutaneous ones and the inferior cubital artery 

are able to sustain the blood supply for flaps as wide as 100 cmÇ, used to cover anterior and posterior defects in the elbow area. 

191

The Use of Free Medial Pedis Perforator Flap in The Treatment of Chron˘c Postburn Palmar 

Contractures 

Institution where the work was prepared: GATA Haydarpa?a E?itim Hastanesi dept. of Plastic Surgery, ?stanbul, Turkey 

Haluk Duman, Assoc, Prof, MD; Fatih Uygur; Ersin ülkür; Sinan öksüz; Bahattin çeliköz; GATA Haydarpa?a E?itim hastanesi 

INTRODUCTION: 

Hand burns are quite important since functional recovery is an obligation. However, inadequate treatment at the very beginning causes 

severe functional deficiencies which can be difficult to correct. The unique anatomic characteristics of the hand which are thick, sensate 

and glabrous skin provide a cushioning and durability effect. In the present study, we introduce the free medialis pedis perforator 

flap in the coverage of palmar defects resulting from radical release of chronic postburn contractures. 

METHOD: 

Eight patients with palmar contractures were treated with free medialis pedis perforator flap between May 2005 and November 2007. 

The flaps were planned on the medial aspect of the foot and elevated as fasciocutaneous perforator flap. The flap sizes ranging from 

1.5 x 3.0 cm to 3.0 x 6.5 cm. The flaps were transferred to the palmar defects resulting from radical release of chronic postburn contractures. 

Arterial anastomosis were performed with flap artery and proper digital arteries in all but two cases. Venous anastomosis was 

done between superficial vein which included in the flap and the recipient superficial vein.The flap donor sites were closed with splitthickness 

skin graft in all patients. The mean follow-up period was 10,5 months. 

RESULTS: 

The transplanted flaps survived with satisfactory recovery in function. Grasp function of the hand was dramatically improved. Deep sensation 

appeared by the end of the second month, and superficial sensation returned in all cases, as assessed by monofilament testing 

(Semmes-Weinstein). In two cases transient venous insufficiency was encountered and resolved with elevation. 

CONCLUSION: 

We believe that the medialis pedis flaps were a remarkable alternative for palmar reconstruction of the hand and digits due to burn 

because of its glabrous skin, which is very similar to palmar skin and with low donor site morbidity. Although the main disadvantage of 

this flap is non sansate, protective sensation was regained in all cases. 

The Effect of Preoperative Radiotherapy on the Free Jejunum Flap Transfer 

Institution where the work was prepared: E-Da Hospital, Kao-hsiung, Taiwan 

Hung-Chi Chen, MD, FACS1; Yueh-Bih Tang, MD, PhD2; Samir Mardini, MD1; Christopher Salgado1; Chung-chen Hsu, 

MD3; (1)E-da/I-I Shou University Hospital, (2)National Taiwan University Hospital, (3)Chang Gung Memorial Hospital 

BACKGROUND: 

Microvascular free jejunum flap transfer has been widely employed for reconstruction of defects following ablation of malignant tumors 

in the pharynx and larynx. Preoperative radiation therapy has two effects: (1) tissue fibrosis in the neck, which may interfere with wound 

healing, and (2) damage to vascular intima which induced a higher rate of thrombosis after microvascular anastomoses in the animal 

studies. However, in the clinical situation it is still not clear whether preoperative irradiation causes more complications including survival 

of the flap. 


From 1998 to 2006, 67 patients with cancers in the pharynx and larynx had been reconstructed with free jejunum flap transfer after wide 

excision. Among them 31 cases had preoperative radiation (group I )and 36 (group II) did not have radiation. A retrospective study was 

performed with a focus on survival, re-exploration and other complications including leakage, dysphagia and later stricture. 

RESULTS: 

Reexploration was performed in 2 patients in group I and 3 patients in group II. Among them all flaps were salvaged except for one 

patient in group II. The other complications were found in 20 % of patients in group I and 22 % in group II. There was no statistically significant 

difference in the two groups. 

CONCLUSION: 

Theoretically, preoperative radiation therapy should pose more problems in microsurgical reconstruction. In this series it did not affect 

the results of free jejunum flap transfer. Technical pearls in dealing with this difficult situation are presented. 

192

Further Esthetic Refinement for Great Toe Transfers in Pursuit of an Ideal Thumb Reconstruction 


Christopher Glenn Wallace, MB, ChB, MRCS; Chih-Hung Lin; Yu-Te Lin; Fu-Chan Wei; Chang Gung Memorial Hospital, 

Chang Gung University and Medical College 

INTRODUCTION: 

The trimmed-great-toe-transfer and the modified Morrison's wrap-around technique are useful methods for thumb reconstruction, but 

each leaves a prominent tubercle (on the fibular side of the distal phalangeal base) with overlying soft tissue that occasionally bothers 

patients. We introduce a simple, effective secondary esthetic refinement that addresses this problem. 

METHODS: 

Key points of technique that should be adhered to for optimal esthetic outcome will be described. Furthermore, necessary technical 

modifications required for great-toe-transfers that incorporate the interphalangeal joint will be demonstrated. Case selection criteria 

will be discussed. 

RESULTS: 

Patient satisfaction has been high and the improved cosmesis has encouraged each to use the reconstructed thumb more openly in 

daily life. Thumb vascularity, stability and nail growth were not affected by the operation. 

CONCLUSION: 

Self-consciousness regarding the esthetics of a reconstructed thumb, causing concealment and disuse, is an unfortunate and frustrating 

outcome. We introduce a straightforward, effective outpatient technique that cosmetically refines the thumb reconstructed by a 

trimmed-great-toe or modified wrap-around great toe transfer. 

V-Y Advancement Adductor Magnus Perforator Flap for Reconstruction of Scrotal/Perineal 

Defects 

Institution where the work was prepared: UMass Plastic Surgery, Worcester, MA, USA 

Mustafa Akyurek, MD1; Marjorie R. Chelly, MD2; Raymond M. Dunn, MD2; (1)University of Massachusetts, (2)University 

of Massachusetts Medical School 

BACKGROUND: 

The gracilis myocutaneous flap has been traditionally used to carry skin from the medial thigh region. However, the survival of the skin 

paddle is unpredictable and often associated with partial flap necrosis. Adductor magnus perforator flap was described in 2001 as a 

safer method of flap transfer in posteromedial thigh area, yet with skin grafting of the donor site in almost all of the cases. Purpose: This 

presentation describes the anatomic basis and clinical technique of V-Y advancement flap design for the adductor magnus perforator 

flap in reconstruction of scrotal and perineal defects. 


A total of 6 fresh cadavers were dissected to identify the musculocutaneous perforators from the adductor magnus muscle that supplies 

the posteromedial thigh skin. Pedicle characteristics and possible flap advancement were noted. Technique: The flap was 

designed in the medial thigh region as a V-Y advancement flap centered around the perforating vessels. It was raised as a complete 

island with 2 or 3 perforator vessels carefully preserved. The flap was advanced toward the defect in V-Y fashion. In one patient, the 

adductor magnus perforator flap was raised as a combined flap with the gracilis muscle flap included. A total of 5 flaps were used in 3 

patients for reconstruction of scrotal (n=1) and perineal (n=2) defects. 

RESULTS: 

Anatomic studies demonstrated that at least two consistent perforating vessels were noted, originating from the medial branches of 

the profunda femoris artery and coursing through the adductor magnus muscle, finally supplying the posteomedial thigh skin about 2 

cm posterior to the posterior border of the gracilis muscle and 10 and 14 cm inferior to the inguinal crease, respectively. The length of 

the perforator vessels ranged from 6 to 8 cm without major intramuscular dissection. Clinical experience proved that the flaps provided 

adequate coverage of the defects. All of the flaps survived completely without any complications. None of the patients required skin 

grafting of the flap donor sites. 

CONCLUSION: 

The V-Y advancement adductor magnus perforator flap has been found to be very simple and effective for reconstruction of perineal 

defects, offering the following advantages: (a) vascular anatomy is consistent, (b) musculocutaneous perforators have large diameter, (c) 

the perforators have ample pedicle length allowing for significant flap advancement, (d) a large size skin paddle can be harvested reliably, 

(e) flap dissection is easy, and (f) there is no need for skin grafting of the donor site. 

193

Resurfacing of a Complex Upper Extremity Injury: An Excellent Indication for the Dorsal 

Thoracic Fascial Flap 

Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA 

Ron Hazani, MD; Darrell Brooks, MD; Rudolf F. Buntic, MD; The Buncke Clinic 

INTRODUCTION: 

Resurfacing of complex injuries of the upper extremity can pose a challenge to the reconstructive surgeon. Injuries characterized by 

skeletonization of structures such as bone or tendon can require circumferential wrap by the transplanted tissue. Skin graft and fasciocutaneous 

flaps are not appropriate and muscle flaps can be excessively bulky. Fascial flaps are an ideal solution but most are small. 

We present a case in which the dorsal thoracic fascia was harvested, transplanted for forearm coverage, and its distal extent wrapped 

around skeletonized extensor tendons. 

CASE REPORT: 

A 35 year-old right-hand-dominant man sustained a left forearm crush injury in an all-terrain-vehicle rollover accident. The patient had 

open radius and ulna fractures, with significant muscle loss at the muscle-tendon junction. The resultant defect involved a large circumferential 

wound with skeletonized extensor tendons. After serial debridement, ORIF of the comminuted radius and ulna, and cable graft 

reconstruction of the ulnar nerve, the contralateral dorsal thoracic fascia was harvested. The flap was thin and well vascularized measuring 

8X15 cm in dimension. It was successfully transplanted to provide vascular cover of the ulnar nerve reconstruction, flexor tendons, 

plated fracture sites, and its distal extent was wrapped around the extensor tendons. There were no complications. 

CONCLUSION: 

The dorsal thoracic fascial flap is an excellent option for reconstructing large complex wounds requiring thin, supple, vascular tissue, 

which is completely or partially buried. It can be utilized for many applications, but is especially suited for circumferential wrap of tendons 

and/or obliteration of complex dead space. It is one of the largest sources of vascular fascia, its harvest is associated with little 

morbidity and its transplantation does not result in a bulky reconstruction. 

The Pedicled FHL Flap: A Good Option When Options Aren't Good 


Otway Louie1; Evan Garfein1; Jamie P. Levine2; Pierre Saadeh1; (1)NYU Medical Center, (2)New York University School 

of Medicine 

INTRODUCTION: 

Lower extremity wounds remain challenging problems for even the most experienced reconstructive surgeon. Wounds of the distal 

third of the tibia and ankle, in particular, frequently require free flap reconstruction, given the paucity of described local flap options. 

Additionally, free flaps around the knee are represent difficulty with regard to recipient vessels. We present an anatomical study of the 

pedicled flexor hallicus longus (FHL) flap (proximally or distally based) and clinical examples of its use. 

METHODS: 

The anatomic approach and arc of rotation of the FHL flap was defined in 8 cadavers. The distally and proximally based FHL flaps were 

used in lower extremity reconstruction. 

RESULTS: 

Optimal approach to the FHL was prone, through an incision over the fibula with dissection between the lateral and posterior compartments. 

The FHL was dissected off the fibula with its peroneal artery to the tibioperonal bifurcation. Distally, flap dissection proceeded 

to just below maleolar level. The flap could be proximally or distally based allowing for coverage of defects up to 8x12cm of the distal 

tibia and ankle. Anterior defects could be directly accessed via a local opening in the interosseous septum. A distally based FHL flap 

was used to reconstruct a 6x8cm distal posterior tibial/calcaneal sarcoma resection defect. The patient had 3 vessel runoff into the foot 

and adequate foot /retrograde flap perfusion (tested by peroneal artery occlusion). There was no flap loss and the patient went on to 

receive XRT at 6wks post op. A patient with injuries including a posterior knee dislocation required coverage of an open knee wound 

for which local flap options were precluded due to disruption of local vasculature. A proximally based FHL flap was used to provide a 

covered vascular leash with excellent vessel size match for reconstruction with a free rectus flap. 

CONCLUSIONS: 

The pedicled FHL flap is a useful option in lower extremity reconstruction. Caveats for its use include the need for adequate leg inflow 

and foot outflow. Additionally, the distally based flap requires adequate collateral circulation from the posterior/anterior tibial systems. 

Supercharging to these vessels may extend the use of this flap in situations of compromised vasculature. Additionally, the flap may be 

proximally based effectively allowing for an "insulated extension cord" to which donor vessels may be attached. 

194

Achieving Aesthetic Results in Facial Reconstructive Microsurgery: Planning and Executing 

Secondary Refinements 


Pierre Saadeh1; Otway Louie1; Evan Garfein1; Jamie P. Levine2; John W. Siebert1; (1)NYU Medical Center, (2)New York 

University School of Medicine 

INTRODUCTION: 

The use of free tissue transfer to provide bulk and contour in facial deformities including malformations, trauma, radiation, and iatrogenic 

injuries is extensively documented. The reconstructive challenges implicit in these complex abnormalities are almost always 

addressed in multiple surgical stages. The refinements which turn an acceptable result into an excellent result are essential to reconstruction, 

yet have not been comprehensively elaborated. We reviewed our experience and described these refinements. 

METHODS: 

The charts of 322 free tissue transfer cases (1989-2006) by the senior author were reviewed. Free tissue transfer of a circumflex scapular 

variant flap (97%) was performed for the treatment deformities arising from hemifacial atrophy (106), hemifacial microsomia (73), radiation 

therapy (39), bilateral malformations including HIV lipodystophy (24 patients; 44 flaps), other congenital anomalies (22), facial palsy 

(16), and burns and trauma (22). Lessons learned and standardization of surgical approaches were identified and outlined. 

RESULTS: 

The following techniques optimize aesthetic outcomes. Revisional surgery planning begins at initial flap operation where, prior to inset, 

the flap is stretched to maximal dimensions. The dermis is almost always discarded and this must be complete. Qualitatively, more tissue 

is required in the malar region, less elsewhere. The borders of the flap must be interdigitated with recipient tissue. Revision is indicated 

in all cases but only after 6 months post-operatively. Flap revisions involve liposuction, sharp debulking, and re-elevation with strict 

attention to release of tethering or contracture. A frequent trouble spot is the jawline which requires relatively more debulking and elimination 

of overhang. Elevation is followed by advancement, rotation, transposition, and/or turnover. Readvancements need to be overcorrected 

and re-inderdigitated, especially into the alar-facial junction, oral commisure, lateral and medial canthus, ear, and eyebrow. 

Periorbital reconstruction is always combined with lower lid support. The flap is suspended high on the lateral orbit and a lower lid/infraorbital 

sling is created. The lateral or medial canthus may require repositioning. Conventional facelift techniques can augment the result 

wherein the flap is treated as a SMAS equivalent. Autologous fat injection is useful after stable results have been achieved, particularly 

for perioral and nasal/alar subtleties; it remains our technique of choice for lip augmentation. Severe lip deficiencies are addressed with 

a variety of flaps (tongue, lip switch, FAMM, and Abbe [rare]). 

CONCLUSIONS: 

Often lessons learned the “hard way” were the most instructive. The keys to improving results were continual critical reassessment, 

open-mindedness to new approaches, and maintaining aggressive expectations. 

Immediate Nipple-Areolar Complex Reconstruction with Inner Thigh (TUG) Flap Microvascular 


Institution where the work was prepared: California Pacific Medical Center, Ralph K. Davies Campus, San Francisco, CA, 

USA 

Matthew J. Trovato, MD; Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD, FACS; Darrell Brooks, MD; 

California Pacific Medical Center 

INTRODUCTION: 

Creation of the nipple-areolar complex (NAC) is the final step in surgical restoration of the breast. Often considered as a complement 

to breast reconstruction, NAC reconstruction is usually completed after an interval of several months, making use of local flaps or composite 

graft techniques involving the opposite nipple. Because the position of the NAC is defined from the outset in skin-sparing mastectomy, 

immediate reconstruction is possible using the skin paddle of the inner thigh flap. The authors report their experience with 

immediate NAC reconstruction using the transverse upper gracilis (TUG) inner thigh flap microvascular transplant. 

METHODS: 

Once the inner thigh flap has been harvested, the crescentic skin paddle is folded back onto itself to form a standing cone, which is fitted 

in the skin-sparing mastectomy pocket. The standing cone is subsequently exaggerated using absorbable horizontal mattress 

sutures to create an immediate nipple reconstruction. The upper inner thigh skin naturally has somewhat darker pigmentation than the 

skin of the breast. This regularly obviates the need for areolar tattoo, and enables immediate areolar reconstruction with the inner thigh 

flap. Patients were surveyed by questionnaire, and measurements and photographic documentation was carried out. 

RESULTS: 

Twelve flaps in 6 patients (mean age 52 years; range 42 to 59 years) were used for immediate breast and NAC reconstruction between 

2005 and 2007. Retrospective review with a mean follow-up of 6.5 months (range, 3 to 15 months) revealed patient satisfaction by means 

of questionnaire and physical examination. One hundred percent of patients were pleased with their breast reconstruction. Eighty-three 

percent were satisfied with breast symmetry, 83% with size, 100% with shape, and 100% with softness/quality of the reconstructed breast. 

Every patient would recommend this type of breast reconstruction to a friend. Seventy-five percent of patients were pleased with their 

nipple and areolar reconstruction. Clinical examples and projection measurements of reconstructed nipples at a minimum of 6 months 

postoperatively will be presented. 

CONCLUSIONS: 

Immediate NAC reconstruction with the inner thigh (TUG) flap produces reliable and aesthetically superior results. Shape and projection 

make this flap an excellent choice in selected patients requiring breast reconstruction. NAC reconstruction with the inner thigh flap 

offers an additional potential advantage for breast reconstruction: completion of the entire reconstruction in a single procedure. 

195

Using Free Style Proximal Radial Forearm Free Flaps while Preserving Radial Artery for 

Reconstructions of Burn hand and Head and Neck Defects 


Jeng-Yee Lin, MD; Wei-Chao Huang; David C.C. Chuang; Fu-Chan Wei; Chang Gung Memorial Hospital 

PURPOSE: 

Although radial forearm free flaps are commonly used for a variety of reconstructions, the associated morbidity remains a concern. The 

most notable problems are related to the conspicuousness of a distal forearm skin graft and radial artery sacrifice. In this study, we 

describe harvesting a proximal radial forearm free flap while preserving radial artery and describe its indications and limitations. 

Materials and 

METHODS: 

From November, 2002 through October, 2006, 4 patients had burn related injuries of the hand and 3 patients had the oral defect after 

head and neck surgery that were reconstructed using proximal radial forearm free flaps (6 males, 1 female) in the free style fashion. The 

perforator pedicle of the flap was confirmed and chosen intraoperatively. The radial artery was preserved in all cases. Either the septocutaneous 

or myocutaneous perforator that nourished the flap was chosen for microsurgical anastomosis to the recipient vessels. The 

average dimension of the flap was 4cm x 8.5 cm. All but one donor site was closed primarily. One patient had intentionally delayed 

wound closure 10 days after reconstruction. 

RESULTS: 

Six flaps survived with good functional and aesthetic outcomes. One flap used for buccal reconstruction failed due to arterial thrombosis. 

There were only minor complaints regarding the proximal forearm donor site. 

CONCLUSION: 

Proximal radial forearm free flaps are suitable for reconstruction of both hand and head and neck defects. In highly selected situations, 

use of free style proximal radial forearm free flap allows preservation of the radial artery and primary donor site wound closure. 

Voice Reconstruction Utilizing the Free Ileo-Ileocecal Valve Free Flap with a Patch of Cecum 

Institution where the work was prepared: E-Da Hospital/I-Shou University, Kaohsiung, Taiwan 

Samir Mardini, MD1; Hung-Chi Chen, MD, FACS2; Christopher J. Salgado, MD2; (1)Mayo Clinic, (2)E-da/I-I Shou 

University Hospital 

PURPOSE: 

Voice reconstruction following laryngectomy has been performed with a variety of methods, many of which divert air from the trachea 

to the esophagus or neo-esophagus and subsequently to the mouth where articulation takes place. Intestinal flaps including jejunum, 

ileocolon and skin flaps have been utilized for this purpose with reasonable outcomes. A newly designed flap from the ileocecal region 

has been used for the purpose of reconstructing voice with or without reconstruction of a partial esophageal defect. 

METHODS: 

19 patients between July 2004 and May 2006 with a previous history of laryngectomy underwent voice reconstruction with the ileo-ileocecal 

valve flap with a patch of cecum and were included in this study. The ileum was used for creation of a voice tube, the ileocecal 

valve prevented the occurrence of regurgitation and the patch of cecum was used to reconstruct the esophageal defect. Clinical evaluation, 

a chart review and questionnaires were conducted. Voice evaluation was based on a modified version of the 5-point Likert scale, 

where 1 indicated the patient could not produce any voice and 5 indicated a very good outcome. Swallowing function was evaluated 

using a 7-point Likert like scale, where 1 indicated severe complaints and an inability to swallow, and 7 indicated satisfactory swallowing 

without any complaints. 

RESULTS: 

All flaps survived. One patient developed an esophagocutaneous fistula. Two patients had prolapse of ileal mucosa at the voice tube 

trachea junction, and two patients had regurgitation of liquid into the voice tube. All patients were able to produce voice (Mean 3.5; 

based on the modified Likert scale). All patients were able to eat a solid diet (Mean 6; based on the modified Likert scale) 

CONCLUSIONS: 

Utilizing intestinal flaps for the reconstruction of voice following laryngectomy is a method that can achieve good outcomes. The ileoileocecal 

valve flap with a patch of cecum has the advantages that intestinal flaps have to offer with minimal complications at the donor 

site and good results of voice and swallow function. 

196

Modified Tibial Turn-up Fillet flap for Repair of Extensive Composite Defects of the Thigh 

Institution where the work was prepared: The University of Texas, M. D. Anderson Cancer, Houston, TX, USA 

Yoav Barnea; Sackler Faculty of Medicine, Tel-Aviv University; Patrick Lin, MD; The University of Texas, M. D. Anderson 

Cancer; Gregory Reece, MD; MD Anderson Cancer Center 

INTRODUCTION: 

Management of sarcomas in the proximal, posterior thigh region can be quite challenging, especially for recurrent disease and tissues compromised 

by previous treatment. Conventional treatment for massive soft tissue loss is hemipelvectomy or hip disarticulation with an anterior 

flap. The modified tibial turn-up fillet flap offers an alternative to high amputation and is a novel means for reconstructing the lower limb. 

PATIENT & METHODS: 

We present a case report of a 58-year-old male who previously underwent numerous wide excisions and flap reconstructions for multiple 

recurrences of malignant fibrous histiocytoma of his left posterior upper thigh. He had received extensive radiation therapy. The current 

tumor recurrence required a radical composite resection of the femur, sciatic nerve, and the soft tissues of the posterior upper thigh 

and inferior gluteal area (total area, 1000 cm2). Instead of performing a hip disarticulation, the lower limb was reconstructed using a 

modified tibial turn-up fillet flap. The leg and foot of the affected extremity were filleted from the popliteal fossa to the metatarsal-digital 

joints and only the tibia with all the soft tissue attached was preserved. The flap was vascularized by the popliteal vessels. After trimming 

the ends, the distal tibia was turned up to the hip, converting the medial malleolus to a neo-greater trochanter. The gluteal tendons 

were sewn to the deltoid ligament of the medial malleolus laterally and the Achilles tendon posteriorly. The iliopsoas tendon was 

reattached to the fibular periosteum anteriorly. A total hip joint prosthesis with a constrained acetabular liner was used to reconstruct 

the hip. The skin of the sole of foot was inset to cover the inferior gluteal and the ischial areas. The proximal tibia became the distal end 

of the stump and the leg skin covered the posterior side of the thigh. 

RESULTS: 

Ten months postoperatively, he had a well-healed stump with durable sensate skin covering the ischium. He could actively flex and 

abduct the left hip 30 degrees but relied on gravity for hip extension. An above-knee-amputation prosthesis with microprocessor-controlled 

knee joint (C-Leg, Otto Bock) provided stable ambulation. 

CONCLUSION: 

The modified tibial turn-up fillet flap is a novel reconstructive option for patients who require composite resection of the proximal thigh 

that is too extensive for free flap coverage. The method offers distinct advantages over hip disarticulation, i.e., better cosmesis and 

patient self-image and the technique provides a sensate, functional stump permitting ambulation with a prosthetic leg. 

Partial Breast Reconstruction with Free Autologous Tissue Transfers 

Institution where the work was prepared: University of Manitoba, Winnipeg, Canada 

Edward Wayne Buchel; Thomas E.J. Hayakawa; University of Manitoba 

PURPOSE: 

Lumpectomy and radiation therapy is the standard of care for treatment of early stage breast cancer. Cosmetic results vary significantly 

depending on the lumpectomy size, location and the development of a significant seroma pre-radiation. Cosmetic results on many of these 

patients are suboptimal resulting in the patient requesting reconstruction surgery to obtain better symmetry and individual breast shape. 

We present our initial experience with perforator flap reconstruction of partial breast defects post lumpectomy and radiation treatment. 

METHODS: 

A retrospective chart review was completed on all patients undergoing a partial breast reconstruction using autologous tissue transfers. 

RESULTS: 

The review of the University of Manitoba Micorsurgical Data base revealed 48??? Free perforator flap breast reconstructions. Twelve 

patient underwent partial breast reconstruction. Eight even were completed using the Deep Inferior Epigastric artery Perforator flap 

while the remaining four were completed using the Superficial Inferior Epigastric Artery flap. There were no flap failures. Three patients 

required secondary revisions for flap debulking and one patient need revision of the nipple and areola complex. 

CONCLUSIONS: 

Partial breast defects are common problems facing patients post lumpectomy and radiation therapy. Typically, symmetry is obtained by 

reducing the contralateral breast, tissue rearrangements of the affected breast or an combination of both. Implant reconstructions have 

also been completed with varying degrees of success. Pedicled flaps form the lateral chest and back have been advocated for laterally 

placed lumpectomy defects. The use of free perforator flap transfers allows the reconstructive surgeon to replace lost or scarred skin, 

while filling the irradiated lumpectomy defects in any position on the chest wall. The long pedicle allows easy access to the IMA vessels 

for the anastomosis and the perforator anatomy allow the flap to be thinned and shaped to fit the lumpectomy defect. Abdominal 

donor morbidity is limited and cosmetics can be excellent. Our patients are now offered the option of breast volume and shape restoration 

in addition to the option for only breast symmetry. 

Learning Objectives: 

Review the reconstructive option for partial breast reconstruction. Highlight the technique of autologous tissue transfer for partial breast 

defects. 

197

Imaging Techniques in Preoperative Planning of the Abdominal Perforator Flaps: Our 

Experience Using the MRI 

Institution where the work was prepared: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain 

Jaume Masia, MD, PhD1; Jm Monill1; Ja Clavero2; G. Pons1; J. Larrañaga1; L. Vives1; (1)Sant Pau University Hospital 

(Universitat Autonoma de Barcelona), (2)Clinica Creu Blanca 

INTRODUCTION: 

The key to predict the viability for any muscle perforator flap is an adequate circulation of the chosen perforator. Therefore, a reliable 

method for the precise identification of the dominant perforator with regard to its position, course and calibre would be extremely valuable. 

During the last 4 years we have been using the multidetector-row CT (MDCT) for the preoperative planning in DIEP flaps with an 

excellent results, it helps us in reducing the operating time and the complication rates. Unfortunately, even being less than a conventional 

abdominal CT scan, the main drawback for the patient still is the radiation. . 

METHOD: 

Between January 2006 and January 2007 we performed 86 DIEAP flaps for breast reconstruction in 76 female patients. The mean age 

was 46.7 (range 24-70 years). An preoperative multi-dectector row CT and a MRI were done in the first 36 cases, comparing the results 

with the preoperative doppler sonography findings and the intraoperative clinical findings. After the comparative study we have been 

using only the MRI as the preoperative planning method. 

RESULTS: 

Comparing the MDCT and the MRI with the intraoperative findings, no false positive and no false negative results were found. We can 

get the same information with both techniques but the MRI gives better 3D reconstruction images of the perforator branching inside 

the flap. Therefore MRI seems to have the same advantages of the MDCT but no radiation. 

CONCLUSION: 

In conclusion we find that the MRI is a very useful tool which provides a reliable method for studying the inferior epigastric artery perforators 

of the lower abdomen. MDCT allows an anatomic study of the donor area, very ease of interpretation not only by the radiologist 

even by the plastic surgeon. It gives us the possibility to do a virtual anatomy dissection of the patient by the computer because 

the pictures obtained are 3 dimensional anatomy reconstructions. Therefore it help us in reducing the operating time and the complication 

rates. 

Innervation Improves Patient-Rated Quality of Life in Free TRAM Breast Reconstruction 

Institution where the work was prepared: University of Western Ontario, London, ON, Canada 

Sharon Kim, MD, FRCSC1; Claire LF Temple, MD, FRCSC2; Douglas C. Ross, MD, FRCSC3; Raymond Tse, BSc, MD4; 

Margo Bettger-Hahn, BScN, MScN3; Bing Siang Gan, MD, PhD, FRCSC4; Joy MacDermid, PhD, PT4; (1)Mayo Clinic, 

(2)University of Western Ontario, (3)St. Joseph's Health Centre, (4)Hand and Upper Limb Centre 

BACKGROUND: 

Restoring sensory innervation has proven to be a useful adjunct in free flap head and neck reconstruction but as yet, has not been shown 

to improve outcomes of breast reconstruction. Our previous study demonstrated objectively improved sensation in a group of innervated 

transverse rectus abdominus myocutaneous (TRAM) flap breast reconstruction patients relative to non-innervated flaps. The purpose 

of this study is to compare patient-rated outcomes of free TRAM breast reconstruction in innervated versus non-innervated flaps. 

METHODS: 

Twenty-six women were prospectively randomized to receive either an innervated or a non-innervated free TRAM breast reconstruction. 

For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the 

recipient site. Three validated outcome tools were administered pre- and post-surgery. These included the SF-36 Health Survey, the 

Breast Cancer Therapy Quality of Life Instrument and the Body Image after Breast Cancer Questionnaire. Results of these outcomes 

were correlated with previously reported objective sensibility outcomes. 

RESULTS: 

Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy and nipple-areola reconstruction 

between randomized patient groups. Time to average follow-up was 28 months. There was a statistically significant improvement 

in all three measures (SF-36, BIBCQ and FACT-B) in patients who were randomized to receiving innervated free TRAM flaps compared 

to those receiving non-innervated flaps. 

CONCLUSIONS: 

This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a 

positive effect upon patient-rated quality of life. 

198

End-to-Side Anastomosis to the Internal Mammary Artery in Free Flap Breast Reconstruction: 

Preserving the Internal Mammary Artery for Coronary Artery Bypass Grafting 


Amani Hemphill, MD1; Ramon De Jesus, MD2; Nathaniel McElhaney1; Jonathan Ferrari1; (1)Union Memorial Hospital, 

(2)Johns Hopkins 

Myocardial revascularization has become an indispensable tool in the management of ischemic heart disease over the last four 

decades. Because of its long-term patency as compared to venous grafts, the left internal mammary artery (LIMA) graft to left anterior 

descending artery has been the gold standard in bypass surgery since the mid 1980s. Additionally, the IMA's location, patency, and 

favorable diameter have also lead to its routine use by plastic surgeons as the recipient vessel in microvascular breast reconstruction. 

Unfortunately, when the vascular pedicles of breast flaps used for reconstruction are anastomosed to the internal mammary vessels in 

an end-to-end fashion, they are rendered too short to reach the coronary artery making them unavailable for future myocardial revascularization. 

By anastomosing the flap's vascular pedicle to its internal mammary recipient vessels in an end-to-side fashion, we can preserve 

the IMA in its distal course for future myocardial revascularization. We have performed five deep inferior epigastric perforator 

(DIEP) flap reconstructions to date using an end-to-side arterial anastomosis without morbidity or mortality. We know cutaneous perforator 

flaps develop rich collateral blood supplies which sustain them after their vascular pedicles are disrupted in the setting of debulking 

and recontouring. Considering this, should the need arise for coronary artery revascularization in one of our patients, the deep inferior 

epigastric pedicle can be safely divided without compromising the viability of the reconstructed breast (DIEP flap). It is foreseeable 

that patients who have undergone standard DIEP flap reconstructions may require future coronary artery revascularizations. Because of 

this, the preservation of the IMA as a bypass conduit in the manner described is an option that should be widely considered in the context 

of free flap breast reconstruction. 

199


TUMOR-RECONSTRUCTION 

Free Vascularized Fibula Graft Salvage of Complications of Long-Bone Allograft Post-Tumor 



Jeffrey B. Friedrich, MD; Steven L. Moran; Allen T. Bishop; Christina M. Wood; Alexander Y. Shin; Mayo Clinic 

INTRODUCTION: 

The surgical reconstruction of long-bone tumors achieved a significant milestone when the practice of intercalary allograft insertion 

became common. This method allowed for limb salvage in a majority of cases. Unfortunately, allograft reconstruction is not a panacea, 

and achieves success rates of 70-80% in large series. The complications that are most common are host-allograft junction nonunion, 

allograft fractures, and allograft infection. An onlay free vascularized fibula bone graft can be employed to span the host-allograft junction 

in cases of host-allograft nonunion or fracture. The purpose of this study is to describe this reconstruction modality for the treatment 

of complications arising from long-bone allograft reconstruction, and to assess the complications, clinical outcomes, and functional 

status following allograft reconstruction salvage with onlay vascularized fibula bone grafting. 

MATERIAL/METHODS 

A tumor registry review was conducted for all patients who had undergone reconstruction with a vascularized fibula graft for allograft 

reconstruction complications within the last 19 years. These patients' records were analyzed for details regarding their neoplasms and 

the treatment thereof, details of free vascularized fibula graft reconstruction, time to host-allograft bony union, functional outcome, and 

clinical outcome. 

RESULTS: 

Thirty-three patients met criteria for this study. The involved bones were femur (18), tibia (8), and humerus (7). All patients in the series 

achieved host-allograft bony union at a mean of 7.7 months. Average followup was 72 months. Twenty-three patients achieved a good 

or excellent functional outcome, and 10 had a fair or fail outcome. Ultimately 7 patients had failure of allograft reconstruction due to 

subsequent complications, 5 of which resulted in limb loss. Postoperative complications were relatively common in this series, with an 

overall complication rate over 50%. 

CONCLUSION: 

While it is not a perfect limb-salvage modality, onlay vascularized fibula grafting is a procedure that affords an opportunity for limb salvage 

in patients who have had host-allograft complications following long-bone allograft reconstruction. When compared to the morbidity 

of limb loss following allograft reconstruction failure, the complication rate associated with allograft salvage using onlay vascularized 

fibula grafting is acceptable. 

Vascularized Bone Grafts – An Effective Tool for Limb Salvage in Long Bone Malignancies and 

Non-unions 

Institution where the work was prepared: Devner Clinic for Extremities at Risk, Devner, CO, USA 

Alex Colque, MD1; David P. Schnur, MD2; William C Brown2; Ross M Wilkins2; Ronald R. Hugate2; Cynthia Kelly2; 

(1)University of Colorado Health Science Center, (2)Devner Clinic for Extremities at Risk 

Long bone reconstruction for malignancies and nonunions are complex and difficult procedures. Vascularized bone grafts are often used 

when significant bone loss is encountered or when local tissues prove hostile for bone healing. We retrospectively reviewed the results of 

vascularized bone grafts from the fibula and scapula to reconstruct long bone defects for long bone malignancies and non-unions. All 

microsurgical long bone reconstructions were performed in a single institution between May 1987 and March 2006 were reviewed. A total 

of 62 patients underwent microvascular bone graft transfer. Thirty-five were free fibular grafts and 27 were lateral boarder of scapula grafts. 

The indications were nonunion, tumor resection and bone loss. The patients were analyzed for comorbid conditions, complications, rate 

of union, need for secondary operations and failure requiring amputation. Of the 62 patients, 31 (50.0%) were male and 31 (50.0%) were 

female. Fifty (80.6%) patients were treated for nonunion or malunion, 11 (17.7%) were treated for tumor, and 1 (1.6%) for bone loss. 

Receipient sites were: tibia 10 (16.1%), ulna 1 (1.6%), femur 13 (21.0%), humerus 31 (50.0%), and radius 7 (11.3%). Nineteen (30.6%) had a 

history of previous infection. Mean follow up was 39.9 months. Of the 62 grafts, 23 (36.5%) had complications. 9 (14.5%) had infection, 6 

(9.7%) had delayed unions or nonunion, 3 (4.8%) had painful hardware, 2 (3.2%) had fractures, 2 (3.2%) had fixation failure, 1 (1.6%) had recurrence 

of tumor, 1 (1.6%) had ulnar neuropathy, 1 (1.6%) had graft thrombosis, and 1 (1.6%) had large hematoma formation. All 23 of the 

patients with complications required re-operation. Four (6.5%) patients required subsequent conversion to a total joint arthroplasty and 2 

(3.2%) patients required amputation. Of the 4 patients requiring total joint arthroplasties, 2 fibula grafts to the humerus were due to 

nonunion, 1 fibula graft to the humerus was due to fracture and 1 scapula graft to the humerus required amputation for fracture. Of the 

amputations, 1 fibula graft to the tibia was due to nonunion and 1 fibula graft to the femur was due to infection. Overall, 56 (90.3%) patients 

achieved union. Our data suggests that vascularized fibula and scapula grafts for the reconstruction of long bone defects is a valuable form 

of limb salvage with an excellent rate of union and a low rate of subsequent amputation. 

200

Limiting Complications and Complexity of the Transverse Upper Gracilis Flap in Breast 


Institution where the work was prepared: University of Manitoba, winnipeg, Canada 

Edward Wayne Buchel; Thomas E.J. Hayakawa; University of Manitoba 

PURPOSE: 

The Transverse Upper Gracilis (TUG) flap has become a reliable second choice for autologous breast reconstruction. Complications 

associated with the TUG flap still limit it's routine use. Our institution has evolved it's technique over the past several months in an 

attempt tp decrease these complications. The purpose is to highlight the complications associated with the Transverse Upper Gracilis 

(TUG ) flap in breast reconstruction and suggest changes in technique to limit the complications and complexity of the operation. 

METHODS: 

A retrospective review of the microsurgical data base over the past 24 months was completed on all patients having a TUG flap for 

breast reconstruction. Complications related to the donor site and reconstruction site were quantified. Video documentation of the harvesting 

technique and patient positioning was also completed. 

RESULTS: 

31 Free TUG flaps in 25 patients were performed for immediate and delayed breast reconstruction. All patients did not have abdominal 

tissue available for autologous tissue transfer. One complete failure occurred secondary to a harvesting error. All other flaps survived. 

Fat necrosis was noted in 11 flaps (35.4%) of whom 3 underwent secondary revision of small superior contour irregularities. Donor 

site complications occurred in 8 donor sites ( 25.8%) with 1 requiring a return to the operating room for closure her wounds. 

CONCLUSION: 

The TUG flap is quickly becoming an excellent second choice for autologous tissue breast reconstruction. While fat necrosis and donor 

occurred frequently early on in our experience, changes in technique have limited these complications while decreasing the complexity 

of the operation. 

LEARNING OBJECTIVES: 

Review the harvesting techniques of the TUG flap. Highlight complications specific to the TUG flap and technique changes to decrease 

these complications. 

Outcome of Radical Excision and Microsurgical Reconstruction in Patients with Recurrent 

Oromucosal Cancer and Secondary Primary Cancer 

Institution where the work was prepared: Chang Gung Memorial Hospital, Tao-Yuan, Taiwan 

Emre Gazyakan, MD, MSc; Holger Engel, MD; Jung-Ju Huang, MD; Huang-Kai Kao, MD; Ming-Huei Cheng, MD, PhD; 

Chang Gung Memorial Hospital 

INTRODUCTION: 

Recurrent oromucosal cancer and secondary primary cancer are predominant destructive cancers with significant morbidity and mortality. 

In most cases it leads to major midface- and mandibular-defects. Although the extensive defects are posing a challenge to the 

microsurgeon the possibilities for reconstruction should outweigh the fear of radical tumor resection to minimize recurrence. In the case 

of recurrence most patients are still treated with chemo- and/or radiotherapy alone. This study was to investigate the outcome of radical 

excision with microsurgical free tissue coverage for recurrent oromucosal cancers. 


Between 1999 and 2005, 45 men and 1 woman with a median age of 49.4 years with oromucosal cancer underwent radical excision with 

106 microsurgical free tissue transfers. Indications were recurrence, osteoradionecrosis and plate exposure. Patients with recurrence 

who received a second or third radical excision with microsurgical free tissue coverage were included in this study. The outcome was 

compared in the rate of recurrence, the overall survival rate and the operative complication rate. A comprehensive follow up was available 

for a minimum of 48 months. 

RESULTS: 

The initial TNM staging showed T1 in 7, T2 in 13, T3 in 12 and T4 in 14 cases. N0 was shown in 22, N1 in 13 and N2 in 11 patients respectively. 

13 Patients received postoperative radiation. Twenty-nine out of 46 patients (63%) were recurrent. Of these, 18 (39%) had disease 

recurrence at primary site and 11 (24%) developed a secondary primary tumor. No patient had distant metastasis in the mean 48 months 

of follow up. Most recurrences occurred within the first 12 months. These patients underwent the same surgical approach for the second 

time (20 anterior lateral thigh flaps (ALT) and 9 radial forearm flaps). Of these 29 patients, 3 (10%) developed for the second time 

recurrence. Two patients had a third tumor and one had local recurrence. In all cases an ALT-flap was performed. 5 patients (17%) were 

lost to follow up due to disease related death. The rest of the 24 patients (83%) are currently without recurrence. Surgical complications 

included flap failure (3.8%) and anastomosis insufficiency (1.9%) among others. 

DISCUSSION: 

Microsurgical free tissue transfer for recurrent oromucosal cancer and secondary primary cancer had a high success rate, minimal complications 

and a survival rate of 83% in 48 months. Aggressive wide tumor excision followed by microsurgical reconstruction after recurrence 

is a good option. 

201

The Use of Thromboelastography as a Guide to Tailor the Anticoagulation Management in 

the Microvascular Surgical Patient 

Institution where the work was prepared: The Methodist Hospital, Institute for Reconstructive Surgery, Houston, TX, USA 

Aldona J. Spiegel, MD; The Methodist Hospital; Hector Salazar-Reyes, MD; Baylor College of Medicine / The 

Methodist Hospital, Institute for Reconstructive Surgery 

PURPOSE: 

Thrombo-embolic events are among the most feared complications in plastic surgery. Deep venous thrombosis (DVT) and pulmonary 

embolism (PE) remain a small (Incidence: 0.35%-1.4%; 0.02%-1.4%, respectively) but real life-threatening risk in plastic surgery. In 

microvascular breast reconstruction DVT incidence ranges from 0.87% -5%. Additionally, flap loss incidence due to local thrombosis 

varies from 1%-10%. Microvascular surgeons have to balance thrombo-embolic events and flap losses on one side, and postoperative 

bleeding complications on the other. Currently employed tests for assessing patients' coagulation status do not reflect the dynamic 

process of hemostasis and offer a limited perspective. Assessing patients' hemostasis globally, allows the microsurgeon to promptly 

implement preventive measures. Thromboelastography (TEG) monitors hemostasis as well as platelet interaction by measuring the viscoelastic 

properties of blood, by assessing the clotting cascade and by evaluating the strength and stability of the newly formed clot. 

In the last nine months, we have routinely used in our microsurgical practice the TEG as tool to manage the anticoagulation therapy 

and to monitor patients' overall coagulation status. Additionally, an algorithm for patient management based on the TEG results has 

been developed. The purpose of this work is to retrospectively review the outcome in our microsurgical practice, following the proposed 

algorithm and to evaluate the impact that TEG had in complication rates. 

METHODS: 

A retrospective chart review was performed in all patients who underwent autologous breast reconstruction (DIEaP and SIEA flaps) by the 

senior author (AJS). Special attention was placed on patients' risk factors for developing thrombo-embolic and hemorrhagic events, type 

and timing of reconstruction, outcome, complications and their correlation with the TEG values obtained before, during and after surgery. 

RESULTS: 

Forty-seven DIEaP and 9 SIEA flaps were performed in 34 patients. Age ranged from 34 to 64 years. The data analysis will be presented 

and shows encouraging results in the treatment of these patients. Since TEG has been implemented on routine basis, no thromboembolic 

events have occurred; flap loss index has been reduced to zero and hematoma formation has been present only in one case; 

drainage of the hematoma was not necessary. 

CONCLUSION: 

A thorough coagulation evaluation must be performed to avoid complications and guarantee surgical success. In the quest for the ideal 

test to evaluate the coagulation status in microvascular patients, TEG has demonstrated to be a valuable element, and may have the 

potential to become the cornerstone to assess these patients' coagulation status. 

Free-style Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstruction 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan, Taiwan 

Wei-Chao Huang1; Christopher Glenn Wallace1; Robert EH Ferguson, MD2; Fu-Chan Wei1; Jeng-Yee Lin1; (1)Chang 

Gung Memorial Hospital, (2)University of Kentucky 

INTRODUCTION: 

Free-style perforator flap surgery represents a relatively new concept in reconstructive microsurgery that brings potential benefits of 

reduced donor site morbidity and improved flexibility in customization of, for example, flap orientation, dimensions and composition. 

We report harvesting techniques, anatomic variations encountered and clinical applications of free-style proximal lateral leg perforator 

(PLLP) flaps in head and neck reconstruction. 

MATERIAL: 

From January 2000 through May 2007, 17 patients (15 males, 2 females; age range: 32 to 80 years) underwent head and neck reconstruction 

with free-style PLLP flaps. Dimensions of skin islands ranged between 4x7 cm and 6.5x18 cm. Three flaps included a small portion of 

soleus muscle to provide bulk for reconstructing tongue or through-and-through cheek defects. Mean follow-up was 13.6 months. 

RESULTS: 

Vascular origins of free-style PLLP flaps were noted as follows: 11.7 % from the posterior tibial system, 11.7 % from the common popliteal 

system, 76.6 % from the peroneal system. Five flaps were re-explored for compromised circulation, of which four required venous reanastomosis 

for venous thrombosis. Three of these flaps recovered with no sequelae, but one failed completely and required replacement 

with a radial forearm free flap. The fifth flap suffered arterial pedicle disruption due to accidental forceful hyperextension of the 

neck 5 days postoperatively. Revascularization with a 1.5 cm vein graft was performed, but the flap still underwent partial necrosis which 

required resection and reconstruction with a pedicled deltopectoral flap. Overall, 15 flaps survived completely, one flap had partial 

necrosis and one flap failed completely. 

CONCLUSIONS: 

When applying the concept of free-style harvest, we were able to exercise considerable flexibility intraoperatively, such as when changing 

flap design and when incorporating intraoperatively identified and more substantial perforators to supply the PLLP flap, allowing us 

to overcome potential problems of limited pedicle length, vascular variations and small diameter pedicle vessels. Free-style PLLP flaps 

offer many advantages, such as versatility in design, appropriate tissue volume, superior texture, diverse tissue types available on one 

pedicle, feasibility for a two-team approach and negligible donor site morbidity, and we recommend it as a useful addition to the Plastic 

Surgeon's armamentarium for head and neck reconstruction. 

202

The SIEA, DIEP and Free TRAM flaps: A Comparison of Abdominal Wall and Flap 

Complications and a Surgical Algorithm 


Jesse Creed Selber, MD, MPH; Fares Samra, BA; Lauren Hill, BA; Mirar Bristol; Seema Sonnad; Joseph Serletti; 

University of Pennsylvania 

PURPOSE: 

Attempts to limit the impact of autogenous breast reconstruction on the abdominal wall have lead to the use of the muscle sparing 

free TRAM, the DIEP and more recently, the SIEA flap. These procedures differ in complication profile, particularly with respect to the 

abdominal wall, and flap related complications such as fat necrosis and flap loss. The purpose of this study is to compare these three 

methods across a spectrum of such clinical outcomes to weigh the relative risks and benefits of each, and better refine their respective 

roles in autogenous breast reconstruction. 

METHODS: 

A retrospective cohort study of 72 SIEA flaps, 50 DIEP flaps, and 569 free TRAM flaps was performed. Outcome variables included 

wound infection, hematoma, seroma, fat necrosis, abdominal flap necrosis, mastectomy flap necrosis, abdominal hernia or bulge, vessel 

thrombosis, partial flap loss and total flap loss. Chi square and Fisher's Exact tests were used to determine significant differences in 

patient population characteristics as well as complication rates among groups. 

RESULTS: 

There was no difference in age, past medical history, length of follow-up or recipient vessels in the 3 groups. In the SIEA and DIEP 

groups, there were higher percentages of obese patients (p = 0.0001), bilateral cases (p = 0.0001), and immediate reconstructions (p = 

0.001), and in the DIEP group, there was a higher percentage of smokers (p = 0.0001). The rate of flap loss was 3.0% in the SIEA group, 

2% in the DIEP group, and 0.2% in the free TRAM group (p = 0.05). The rate of vessel thrombosis was 17% in the SIEA group, 10% in 

the DIEP group, and 6% in the free TRAM group (p < .05). The hernia rate was 0% in both the SIEA and DIEP groups, and 2% in the 

free TRAM group. 

CONCLUSION: 

The SIEA has the highest rate of flap loss and vessel thrombosis, followed by the DIEP, followed by the free TRAM. The SIEA and DIEP 

both enjoy less donor site morbidity than the free TRAM. These results are consistent with theoretical risks and benefits in which donor 

site morbidity is decreased at the expense of reliability. Because of this relationship, the authors recommend that muscle preserving 

techniques be undertaken judiciously by microsurgeons experienced in the successful management of vessel thrombosis. The authors 

present a surgical algorithm that leads to consistently successful results in autogenous breast reconstruction. 

A New Composite Flap: Rectus Abdominis Muscle Flap Harvested with Pubic Bone Segment 

(Anatomic Considerations) 


Serdar Ozturk; Mustafa Sengezer; Unsal Coskun; Fatih Zor; Gulhane Military Medical Academy 

The aim of this study is to incorporate a segment of pubic bone to rectus abdominis muscle(RAM). Eight RAM flaps from four fresh 

cadavers were used. During surgical dissection utmost care was paid to enclose the areolar tissue between the main DIE vessels and 

the pubic bone. A bone segment, 1.5x5cm in dimension, with an intact periosteum was included in RAM. Surgical dissections revealed 

two major vascular branches.The first branch arising from the DIEA at a distance of 5.2±1.4 cm from the origin gave rise to two consistent 

sub-branches. The second major branch originated from DIEA at a distance of 8.4±1.8 cm from the origin. The first branch gave 

off two sub-branches. The second sub-branch coursed antero-medially and nourished the periosteum of the pubic bone. 

Microangiographies showed a similar branching pattern of the vessels that create two significant networks. The x-rays confirmed a rich 

vascular network around the periosteum of the pubic bone. This wealthy nourishment of the pubic periosteum comes mainly from the 

perpendicular descending branches. In conclusion, a vascularized part of pubic bone can be incorporated to the RAM flap by preserving 

the delicate vascular network between the DIE vessels and the pubic periosteum. 

203

Extended Anterolateral Thigh Flap in Oncological Reconstruction 

Institution where the work was prepared: Memorial Sloan Kettering, New York, NY, USA 

Afshin Mosahebi1; Martin Jugenburg, MD2; Pravin Reddy3; Andrea L. Pusic1; Joseph J. Disa1; Peter G. Cordeiro1; 

Babak J. Mehrara1; (1)Memorial Sloan-Kettering Cancer Center, (2)University of Manitoba, (3)Memorial Sloan Kettering 

INTRODUCTION: 

Reconstruction of large cutaneous defects is a challenging problem. Skin grafted muscle flaps have been traditionally used. However, 

skin grafted muscle flaps have distinct disadvantages such as contracture, poor aesthetic outcome, and failure after radiation therapy 

for oncologic management. Although the anterolateral thigh (ALT) flap has been used extensively in reconstruction, the use of large or 

extended skin paddles (ie. >240 cm2) is in general thought to be associated with increased risk of partial flap necrosis. This trepidation 

is based on cadaver perfusion studies of isolated ALT flaps. The purpose of this report was, therefore, to evaluate our experience with 

the extended ALT flap for reconstruction of oncologic defects. 

METHODS: 

All consecutive patients who had undergone reconstruction of oncological defects using free ALT flap at a single institution between 

2002 and 2006 were identified. The subset of patients in whom extended ALT flaps were used (flap size of at least 240 cm2) were then 

evaluated using our prospectively maintained database and chart review. Patient characteristics, number of perforators, flap survival, 

and outcome data were analyzed. 

RESULTS: 

Thirty six patients underwent oncologic reconstruction using the ALT flap during the study period. Of these, 13 patients fitted the minimum 

size required of 240 cm2. The average age of the patients was 63 years old & majority male (2:1). The majority of the defects were 

for head & neck soft tissue reconstruction. The average size of the flap was 322 cm2 (240-480 cm2). All flaps were perforator flaps and 

the vast majority had one perforator. In 2 patients, ALT as well as tensor fascia lata (TFL) based perforators were used. There was one 

total flap loss on postoperative day 7 due to recipient vessel spasm. Three of the patients had delayed donor site wound healing. One 

patient had partial necrosis of the distal portion of the flap, however this healed uneventfully with dressing changes. 

CONCLUSIONS: 

The ALT flap is an excellent choice for large or massive defects requiring skin and soft tissue coverage. The flap can be safely extended 

beyond the limit of 240 cm2 as suggested by cadaver perfusion studies. Inclusion of TFL perforators may increase the blood supply 

of the flap proximally; however, in general a single perforator is capable of supplying a large area of the lateral thigh. 

Fat Necrosis in Microvascular Breast Reconstruction: An Assessment and Comparison of SIEA, 

DIEP and Muscle-Sparing Free TRAM Methods 


Alison E. Kaye, MD; Liza C. Wu; Joseph M. Serletti; University of Pennsylvania 

PURPOSE: 

Free flap options for autologous breast reconstruction using abdominal tissue includes the superficial inferior epigastric artery (SIEA) 

flap, deep inferior epigastric perforator (DIEP) flap, or muscle-sparing transverse rectus abdominus myocutaneous (ms-TRAM) flap. 

Controversy remains as to which of these flaps provides a superior reconstruction in terms of vascular support of the transferred tissue. 

One clinical marker for the quality of free tissue transfer is the presence or absence of fat necrosis in the reconstructed breast flap. The 

purpose of this study is to compare outcomes of SIEA, DIEP, and ms-TRAM free flap breast reconstruction with regard to fat necrosis 

and the ability of the donor vessels to perfuse the tissue and provide an adequate and stable breast reconstruction. 

METHODS: 

34 patients with 53 free tissue autologous breast reconstructions performed by a single surgeon from March 2005 to June 2006 were 

enrolled and evaluated for clinically evident fat necrosis in the reconstructed breasts. Of the 53 flaps, (15 unilateral and 19 bilateral) there 

were 16 SIEA, 16 DIEP, and 21 ms-TRAM flaps. Each of the patients in these groups was variable-matched for age, BMI, volume of reconstruction, 

tobacco use, post-operative radiation, co-morbidities, and length of follow-up. Each patient was evaluated by an independent 

plastic surgeon blinded to the type of flap used for each reconstructed breast. Any patient with a palpable mass in the reconstructed 

breast received an ultrasound or MRI to confirm the diagnosis of fat necrosis. 

RESULTS: 

Study patients averaged 49.5 years of age (range 29-67 years) with an average BMI of 28.1 (range 21.3-49.4) and 11 months of postoperative 

follow-up (range 4-20 months). Of the 53 flaps evaluated, only 6 flaps (11.3%) demonstrated fat necrosis, all in different 

patients. These flaps included 3 SIEA, 1 DIEP, and 2 ms-TRAM flaps. Those with fat necrosis averaged 42.7 years old (range 29-52 years) 

with an average BMI of 30.05 (range 22.3-41.9). Two of the SIEA flaps with fat necrosis belonged to tobacco-users and one of these also 

received post-operative radiation. The remaining patients were neither radiated nor tobacco users and were without significant co-morbidities. 

CONCLUSION: 

This data indicates no overwhelming trends towards a higher incidence of fat necrosis in one particular type of autologous free tissue 

breast reconstruction. We can deduce that there are no significant differences in vascular stability of the SIEA, DIEP and ms-TRAM flaps 

with regard to development of fat necrosis. 

204

A Ten-Year Experience of Free Flaps in Head and Neck Surgery. How Necessary is a Second 

Venous Anastomosis? 

Institution where the work was prepared: University of Toronto, Toronto, ON, Canada 

Gary L. Ross, MD, FRCS(plast); Erik Ang; Declan Lannon; Patrick Addison; Alex Golger; Christine Novak; Joan Lipa; 

Patrick Gullane; Peter Neligan; University of Toronto 

INTRODUCTION: 

Successful free flap surgery in the head and neck is dependent on the successful anastomosis of both artery and vein. The success of 

all free flaps was analysed to determine the necessity for performing two venous anastomoses. 


We retrospectively analysed a single surgeons ten-year experience (August 1993 - August 2003) in free flap reconstruction for malignant 

tumors of the head and neck. 492 free flaps were primary reconstructions that did not require a vein graft, vein loop or cephalic 

turnover procedure. 345 flaps had one venous anastomosis and 147 had two venous anastomoses. 

RESULTS: 

Overall flap success was 468/492 (95%). Successful flap reconstruction in patients undergoing two venous anastomoses was 145/147 

(99%) compared to patients undergoing one anastomosis 323/345 (94%) (P

Ultrasound-Assisted Liposuction as a Novel Treatment for Fat Necrosis after Autologous 


Institution where the work was prepared: Beth Israel Deaconess Medical Center, Boston, MA, USA 

Stephanie A. Caterson, MD; Adam M. Tobias; Bernard Lee; Beth Israel Deaconess Medical Center, Harvard Medical 

School 

INTRODUCTION: 

Fat necrosis is a common complication following all types of autologous breast reconstruction. While the incidence of fat necrosis has 

been broadly reported, treatment options beyond direct excision are limited. Here, we describe a novel utilization of ultrasound-assisted 

liposuction (UAL) to address fat necrosis after deep inferior epigastric perforator (DIEP) breast reconstruction. Historically, UAL has 

been successfully used in areas with high fibroadipose content such as gynecomastia. In breast reconstruction, this minimally invasive 

technique is safe and efficacious, while minimizing contour deformities like those seen after direct excision. 

METHODS: 

A retrospective review of 250 consecutive perforator flaps performed over a three year period revealed 13 DIEP flaps in which UAL was 

performed to treat flap associated fat necrosis. Fat necrosis was diagnosed at three months post reconstruction. A thorough history was 

obtained and reports of pain associated with the firm areas were recorded. On physical exam areas of fat necrosis were measured along 

the largest diameter. The fat necrosis was then categorized dependant on symptoms and size. All patients underwent UAL using the 

Byron LySonix 3000 machine with a 4 mm x 20 cm hollow golf tip cannula on settings of 4 and 70%. Clinical results were assessed on 

post operative office visit documentation. 

RESULTS: 

Data reviewed for the 13 patients with fat necrosis treated with UAL revealed an average DIEP flap weight of 635 grams. Three of the 

patients underwent preoperative radiation therapy (23%). No patients underwent post-reconstruction radiation therapy. Six of the DIEP 

flaps were based on one perforator (46%), three DIEPs were based on two perforators (23%), and the remaining four flaps relied on three 

perforators (31%). All post-UAL results were examined in the office by the attending surgeon. All areas of fat necrosis were improved, with 

increased suppleness. Most patients had near to complete resolution of firmness. Three patients had some residual rigidity, although 

much decreased in size. One patient underwent repeat UAL of the same area previously treated at a third stage operation. 

CONCLUSIONS: 

Currently there is a paucity of treatment options described for fat necrosis. Direct excision is often a major intervention that can result 

in aesthetic compromise. In our institution, we have used UAL to successfully soften areas of fat necrosis in DIEP flaps while maintaining 

a desirable contour. UAL offers a minimally invasive, effective, and reliable alternative to direct excision. 

206

ASRM POSTERS PRESENTATIONS 

Concentration of NO in the Postischemic Muscle under Different Levels of Oxygen Free 

Radicals 

Institution where the work was prepared: Plastic Surgery Charité Campus Mitte Humboldt University, Berlin, 

Germany 

Rolf Buettemeyer, MD, PhD1; Felix Stoffels1; Moritz Beisenhirtz2; Fred Lisdat, PhD3; (1)Charité, Humboldt University, 

(2)University of Potsdam, (3)Wildau University of Applied Sciences 

Reperfusion of ischemic skeletal muscle is associated with an alteration of the concentrations of 02- and N0. In this study, the influence 

of EGCG, a known radical scavenger, on the balance of 02- and NO has been measured on-line in the skeletal muscle of wistar rats. 

The hind limb of 14 male rats had been exposed to ischemic stress for 2 h. 7 rats received an infusion of 1,5 µmol EGCG/kg 5 min. 

before reperfusion. 02-, NO and temperature were measured during reperfusion. The concentration of 02- declined under the influence 

of EGCG from 156.5 nmol/l to 72.2 nmol/l (p=0.01). The level of NO was found to decrease; this decrease was not significantly 

changed by EGCG (-175 nmol/l vs. – 227 nmol/l; p=0.33). Thus the different superoxide concentrations did not correspond to different 

levels of NO and the interaction of both radicals is not the only reason for the concentration decrease of NO in the reperfusion period. 

We conclude that EGCG protects skeletal muscle from I/R-injury without influencing the NO concentration profile to a large extent. 

Gene Expression Analysis and Biomarker Discovery in a Rat Model of Free Flap Failure 


Suhail Mithani; Rachel Bluebond-Langner; Eduardo D. Rodriguez; Johns Hopkins School of Medicine 

BACKGROUND: 

Free tissue transfer is a potent tool in reconstructive surgery, but has a failure rate of up to 10%. Identification of failure relies on clinical 

assessment of flap viability which lacks sensitivity for early failure. Flap failure is likely preceded by altered gene expression; however, 

use of a broad based genome wide approach to identify potential biomarkers and therapeutic targets has not been described. In this 

study, an RNA expression microarray identified genes whose expression is altered in a rat model of free flap failure. 

METHODS: 

A well described rat model of free tissue transfer, with a pedicle based upon the inferior epigastric artery and microvascular anastomosis 

of the femoral vessels, was utilized. To model early failure, the venous pedicle was occluded with a vessel loop after anastomosis to 

simulate the most common cause of flap failure. After 6 hours a portion of the flap was excised from both early failure and control groups 

and RNA extracted. Gene expression of 3 samples in each of the experimental groups was assessed with the Affymetrix GeneChip Rat 

230 v2.0 microarray, yielding expression data for over 28,000 genes. Quantitative reverse transcription polymerase chain reaction (qRT- 

PCR) was performed on genes identified by microarray analysis on RNA extracted from all harvested tissue. 

RESULTS: 

890 genes had greater than twofold expression differences between the early failure and control groups. Student's t-test and ANOVA 

filtering identified 53 genes with statistically significant expression differences. Hierarchical clustering by gene ontology identified 4 

genes with likely involvement in the pathogenesis of flap failure. These are RT1 class II, locus Bb (RT2Bb,58.64 fold upregulation), secreted 

frizzled-related protein 1 (SFRP1, 2.06 fold upregulation), platelet/endothelial cell adhesion molecule (PECAM, 2.67 fold downregulation), 

Claudin 5 (CLDN5, 3.42 fold downregulation). Validation was performed by qRT-PCR on separate control and early failure animals 

(n=7 in each arm). RT2Bb, PECAM, CLDN5 had statistically significant alterations of expression in the early failure group. Utilizing 

expression thresholds for test positivity of these genes, venous occlusion was predicted with 100% sensitivity and 86% specificity. 

CONCLUSIONS: 

Using a genome wide expression tool, 3 novel genes were identified with altered expression in an animal model of early free flap failure. 

Expression levels of these genes predict early flap failure with high sensitivity and specificity. This pilot study validates this method, 

and identifies 3 genes which warrant further study as potential diagnostic and therapeutic targets in free flap failure. 

207

Understanding the Physiologic Process Behind VAC®: Comparison of Wound Healing 

Markers with Non-VAC® Treated Wounds 

Institution where the work was prepared: Penn State College of Medicine, Hershey, PA, USA 

Rachel H. Noone, BA; Robert Grunfeld, MA; Sprague W. Hazard, MD; Noel B. Natoli, MD; Justin Zelones, BS; Brad Morrow, 

BS; Jason Hancey, MD; Paul Ehrlich, PhD; Donald R. Mackay, MD; Reza Miraliakbari, MD; Penn State College of Medicine 

INTRODUCTION: 

The success of Vacuum Assisted Closure (VAC®) in treatment of wounds is evidenced by its popularity and wide spectrum of clinical 

application. Recent studies have examined the effect of VAC® on the biochemical composition of wound fluids by cytokine assay. No 

direct data exist as how these findings are different from the non-VAC treated fluid. We propose to study the effect of VAC by comparing 

physiologic assays (fibroblast migration and proliferation) as well as the cytokine profiles of wound fluid from patients treated with 

VAC®, to closed wounds treated with closed suction JP (Jackson-Pratt) systems. 

METHODS: 

Wound fluid was collected from 34 VAC® treated patients, and 11 patients with JP drains. Diabetic patients were purposely excluded. 

Wound fluid was collected from VAC® canisters and JP bulbs roughly every two days for a period of 7 days (at least three collections). 

VEGF, IL-1, MMP-13, collagen type I and EDA-Fibronectin levels were analyzed. Also, effects of wound fluid on cultured fibroblast migration 

and proliferation were tested on all samples. 

RESULTS: 

VAC® treated wound fluid showed a significant increase in IL-1 (p = 0.0027). and VEGF (p = 0.016) levels at all time points compared 

to JP drained wounds There were no significances detected when comparing the two wound fluids with respect to collagen, fibronectin, 

MMP13, or cultures fibroblast migration or proliferation. 

CONCLUSIONS: 

The mechanism for VAC® treatment's success is undefined. This study reports significant elevation of IL-1 and VEGF in VAC treated 

wounds compared to non treated wounds. These findings, viewed in isolation, may speak to VAC®'s success. However, once the larger 

picture (wound fluid effects on cultured cells) is taken into account, more questions will be raised, regarding the mechanism for 

VAC®'s success. Non- VAC® treated wounds did not differ from VAC® treated wounds in regard to: cell migration, proliferation, collagen 

and fibronectin production, as well as MMP13 levels. Further wound fluid analysis is underway to clarify the physiological processes 

underlying VAC®'s effectiveness in promoting wound closure. 

Cold Ischemia Facilitates Free TRAM and DIEP Flap Breast Reconstruction 

Institution where the work was prepared: Stanford University, Palo Alto, CA, USA 

Ali Salim, MD; Gordon K. Lee; Stanford University 

INTRODUCTION: 

The free TRAM flap is a well-established method of autologous tissue breast reconstruction. A drawback to this and other microvascular-based 

approaches is the length of operation, which may be 6 hours for unilateral and 8 hours for bilateral breast reconstruction. 

Longer operative times have been reported for perforator-based reconstructions, including the DIEP flap. As this may take a significant 

physical toll on the surgical team, we have adopted a two-surgeon protocol in which flaps are placed under cold ischemia immediately 

after harvest. We believe this (a) reduces surgeon fatigue by facilitating performance of the operation and (b) is a safe modification 

which does not increase operative time or compromise flap viability. 

METHODS: 

We performed 84 consecutive breast reconstructions (free TRAM, muscle-sparing TRAM, and DIEP flaps) over 36 months. All flaps were 

exposed to post-harvest cold ischemia as follows: immediately after harvest, each flap was wrapped in a moist sponge, sealed in a 

bowel bag, and placed in an ice slush bath. With the flap(s) on ice, one member of the team proceeds with closure of the abdominal 

fascia while the other member takes a break. The surgeons then alternate roles, such that by the time the microvascular anastomosis is 

performed, both surgeons are refreshed mentally and physically for this delicate part of the operation. A second assistant can close the 

skin layer of the abdomen and perform the umbilicoplasty at the same as the microsurgery. We then retrospectively reviewed flap 

ischemia times, operative times, and the rate of complications including flap loss, microvascular thrombosis, and fat necrosis evident 

upon physical exam. 

RESULTS: 

Average cold ischemia time for unilateral reconstruction was 1 hour 45 minutes, and for bilateral reconstruction was 2 hours 5 minutes 

for the first flap and 3 hours 35 minutes for the second flap. There was 1 flap loss (1.2%) which was due to vascular thrombosis; this complication 

was not associated with a statistically significant increase in ischemia time. Fat necrosis rate was 3% and average patient follow-up 

was 22 months. 

CONCLUSION: 

As our operative times and complication rates compare to other large published series, we believe that cold ischemia is well-tolerated 

by the free TRAM flap, and in fact facilitates the operation significantly by contributing to decreased surgeon fatigue. 

208

Microsurgical Treatment of Chronic Osteomyelitis 

Institution where the work was prepared: Careggi University Hospital, Florence, Italy 

Marco Innocenti, MD; Luca Delcroix; Amerigo Balatri; A.U.O. Careggi 

BACKGROUND: 

Long standing osteomyelitis are a difficult challenge in orthopaedics. Neither the conventional surgical procedure nor the pharmacological 

treatment are likely to be successful when there is a long lasting massive invasion of the affected bone and surrounding soft tissue. 

Aggressive debridment, resection at wide margins of contaminated tissue and coverage by free tissue transfer may be effective in 

eradicating the infection and providing optimal tissue reconstruction 

METHODS: 

Seventeen patients ranging in age between 15 and 68 years affected by chronic osteomyelitis lasting from 5 to 45 years, underwent 

microsurgical reconstruction in the past 10 years. Tibia was involved in 12 cases, the foot in 5. All the patients had had previous multiple 

operations and several pharmacological attempts without success. The operation consisted of radical debridment of contaminated 

tissues including large portions of cortical bone , muscle and skin according to principles similar to the ones adopted in tumor surgery. 

The following cavity has been repaired by free vascularized muscle transfer in all cases. 

RESULTS: 

Fifteen patients are free of disease and two underwent amputation after microsurgical failure and recurrence of the infection. The functional 

results depend on the elapsed time from the inset of the infection, on the location of the osteomyelitis and on the amount of 

joints involved. In all the fifteen patients , however, the limb was salvaged and acceptable function recovered. 

CONCLUSIONS: 

The advantages related to the described microsurgical approach may be listed as follows: 1. The microvascular transfer of large amount 

of healthy tissue allows for wide margin excision of infected and necrotic tissues improving the possibility to sterilize the bone and surrounding 

soft tissue . 2. The vascularized muscle can be used to fill the medullary canal in order to eradicate possible residual infection 

with a vascularized carrier of antibiotics. 3. In the vast majority of patients no further surgery was needed. 

Microsurgical non Microvascular Flaps in Diabetic Lower Limb Reconstruction 

Institution where the work was prepared: Recovery Hospital, Cluj-Napoca, Romania 

Alexandru Georgescu, Prof, MD, PhD; Irina Capota, MD; Filip Ardelean, MD; Ileana Matei; UMF Iuliu Hatieganu 

INTRODUCTION: 

Pressure sores and post-traumatic lesions in the diabetic lower limb are extremely challenging from reconstructive point of view, 

because of the arterial deficit caused by the diabetic artheriopathy. Generally, these cases are treated through long by-pass loops, needed 

to revascularize the limb and vascularize the free flaps. This paper will try to demonstrate that even in diabetic lesions in advanced 

stages we can still use local or regional means of reconstruction for these defects. That is because the diabetic foot has until very late 

in evolution a more or less adequate blood supply through the peroneal artery. Based on it, we can harvest various flaps, with good viability 

and very useful in reconstructing the diabetic foot. 

MATERIAL/METHODS 

We performed 11 reconstructions in patients with diabetic foot. In 5 cases the lesions were trophic ulcers induced by diabetes, and in 

6 cases we had chronic post-traumatic lesions on foot and shank, generally accompanied by osteitis or osteomyelitis. For all these 

patients we performed peroneal artery perforator flaps, used as transposition or propeller flaps, with dimensions between 75 and 200 

cmÇ. The flaps used were 8 fasciocutaneous and 3 adipofascial (2 of them including a muscular segment from the lateral gastrocnemius 

muscle). 

RESULTS: 

We lost one flap, but the rest were successful, even the one with open fracture osteitis and bone defect, resulting also the bone consolidation. 

The patients were followed for 6 to 24 months and we did not notice any relapse in the operated limb. 

CONCLUSIONS: 

A very successful alternative to the by-pass loops – free flaps treatment for the diabetic foot lesions is using peroneal artery perforator 

flaps, method that is not as complicated and achieves comparable results. 

209

Buried DIEP Flaps For Complex Head and Neck Contour Defects 

Institution where the work was prepared: Georgetown University Medical Center, Washington, DC, USA 

Mark W. Clemens, MD; Steven Paul Davison, MD, DDS, FACS; Georgetown University Hospital 

BACKGROUND: 

As the art of microsurgery advances, the demands are changing. No longer is the emphasis on anastamosis, but rather the focus has 

turned to the donor site and the final functional result without aesthetic compromise. A prime example of this is head and neck reconstruction. 

The expectation is now for a result that no longer fills a hole, but restores shape, dimension, and patient confidence; John 

Winston Siebert's longitudinal work with facial atrophy exemplifies this philosophy. The DIEP flap has been presented as a potential 

source of tissue for head and neck reconstruction. It has been sparingly reported for pharyngeal reconstruction and to provide a large 

bulk of skin, but is not previously described for buried contour defects. 

METHODS: 

We present a retrospective study of a consecutive series of six buried DIEP flaps, performed between 2005 and 2006 with a review of 

their indications, results, and complications. Three patient defects had previous radiation. The DIEP flaps were used for both functional 

scar repair, bulk fill, and for soft tissue fill of contour defects. Five flaps were used in the delay setting, as secondary reconstructions 

and one flap was designed with a monitor paddle of skin. Despite buried nature of flaps, postoperative monitoring was possible in all 

cases by directed Doppler evaluation of anastamotic vessels. 

RESULTS: 

Soft tissue defects addressed in this study were the result of a variety of different pathologies including temporal fossa meningioma, 

fibrous dysplasia of the skull and orbit, nasopharyngeal carcinoma, neck scar repair, sinus cancer, and osteomyelitis. We report a one 

hundred percent success rate with primary flap survival, secondary contouring, minimal donor site, provision of moldable bulk soft tissue 

fill, and ability to fillet and redistribute. Patient reported satisfaction at six months and one year was good to excellent in all cases. 

CONCLUSIONS: 

In select cases, we report the functional and aesthetic advantages of the DIEP flap for head and neck reconstruction of soft tissue defects 

as superior to implants, fillers, and non-vascularized fat grafts. Donor site defects are minimized with no muscle loss. The subcutaneous fat 

of the DIEP flap has resilience which tends to last and retain its shape. We observe maintenance of residual volume over muscle flaps. 

During revisions, these flaps are amendable to liposuction as a contouring tool with portions that can be redistributed on pedicles. 

210

Aesthetic Outcomes in the Free TRAM, DIEP and SIEA: Does Muscle Improve Projection 


Jesse Creed Selber, MD, MPH; Mirar Bristol; Seema Sonnad; Joseph Serletti; University of Pennsylvania 

BACKGROUND: 

The free TRAM flap differs from the DIEP and SIEA flaps in that it retains a portion of the rectus abdominus muscle in the flap. This muscle 

adds bulk in the antero-posterior vector, and some speculate that this bulk improves the projection and overall aesthetic appearance 

of the reconstructed breast. This is the first study aimed at comparing the aesthetic characteristics of the TRAM, the DIEP and the 

SIEA. 

METHODS: 

The authors performed a prospective, blinded, cohort study in which consecutive patients having undergone either bilateral or unilateral 

autogenous breast reconstruction, were photographed in standard three view fashion. Ninety-two free TRAM flaps, thirty-two DIEP 

flaps and sixteen SIEAs were compared. The photographs, devoid of patient identifiers, were evaluated by 2 plastic surgeons, and a 

lay person, based on a validated, standardized rating sheet for aesthetic attributes. Patients also evaluated their own reconstructions. 

Results were compared using Kruskal -Wallis tests for significance. 

RESULTS: 

Areas evaluated included vertical and horizontal positioning, projection, naturalness, quality of the infra-mammary fold, medial fullness 

and overall appearance. The results demonstrate no significant difference in aesthetic outcomes among the three techniques based 

on patient or physician ratings. The lay person, who was also the only person to see all the reconstructed breasts in person, rated the 

free TRAM flap as having more projection (p = 0.02), less of the defect visible (p = 0.05) and better overall appearance (p = 0.08). 

CONCLUSIONS: 

The aesthetics of the reconstructed breast may be affected by multiple factors. The authors believe that projection is improved by the 

muscle included in a free TRAM flap, a benefit not enjoyed by the DIEP and SIEA reconstructions. Out of four blinded evaluators, only 

one found this to be the case. Interestingly, it was the only person to evaluate the breasts in three dimensions. Results of this study 

demonstrate that the free TRAM flaps may have better projection than muscle sparing procedures. A larger series would help clarify 

this question. 

Free Fibular Graft for Post-Traumatic Upper Extremity Reconstruction :Report on 31 Cases 

Institution where the work was prepared: Department of Orthopaedics University of Modena and CTO Florence, 

Modena and Florence, Italy 

Roberto Adani, MD1; Luca Delcroix, MD2; Luigi Tarallo1; Marco Innocenti, MD2; (1)University of Modena and Reggio 

Emilia, (2)CTO Florence 

PURPOSE: 

Vascularized bone graft is most commonly applied for lower extremity reconstruction. However, indications for its use in the reconstruction 

of the upper extremity have expanded in recent years, as the technique as become increasingly appreciated. The aim of this paper 

is to review our experience with the use of vascularized fibular graft(VFG) in the treatment of large bone defects, after trauma or 

osteomyelitis, located in the upper extremity. 

METHOD: 

Between 1993-2005, 31 patients with segmental bone defects following upper extremity trauma were managed with VFG. There were 

22 males and 9 females, aged 39 years on average (range,16 to 65 years). The reconstructed site was clavicle(1 case), humerus (13 cases), 

radius (11 cases) and ulna (6 cases). The length of bone defect ranged from 6 to 16 cm; in five cases the fibular graft was harvested and 

used as a vascularized fibula osteoseptocutaneous flap. 

RESULTS: 

29 grafts were successful. The mean period to obtain radiographic bone union was 5.4 months(mean time in the humerus 6 months 

and in the forearm 4.8 months). Three patients required additional bone grafts and two cases showed fractures of the grafted bone. 

DISCUSSION: 

The results obtained suggest that the use of the VFG to the arm is more complex than application to the forearm with a higher rate of 

complications. A vascularized fibular graft is indicated in cases were conventional treatment has failed, and for reconstruction of bone 

defects larger than 6-7 cm in the humerus or forearm bones. It is also indicated in cases involving osteomyelitis and infected nonunion. 

CONCLUSIONS: 

Fibular graft allow the use of a segmental of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length 

to reconstruct skeletal defects of the arm. 

211

Prevention of Distal End Pharyngoesophageal Stricture Using Z-pasty of Tubed Skin Flap and 

Cervical Esophagus for Lower Anastomosed site 

Institution where the work was prepared: Chang Gung Memorial Hospital- Kaohsiung Medical Center, Kaohsiung, 

Taiwan 

Yur-Ren Kuo, MD, PhD, FACS; Seng-Feng Jeng; Johnson Chia-Shen Yang; Chih-Yen Chien; Chih-Ying Su; Chang Gung 

Memorial Hospital- Kaohsiung Medical Center, Chang Gung University 

BACKGROUND: 

Various attempts at reconstruction of pharyngo-esophageal defect after ablative cancer surgery have been made. Skin tubing flap was 

the common used to reconstruct the defect. However, distal end circular contracture is a big complication. Herein, we presented a triangular-Z-pasty 

suture technique to prevent distal end circular contracture. 


Seven patients who had undergone esophagus reconstruction due to circumferential pharyngo-esophageal defect had been applied 

this technique. All patients were stage III to IV. All patients were male. Their age ranged from 39 to 63 year-old with a mean of 51 yearold. 

Four received free radial forearm flap and three received anterolateral thigh perforator flap. The distal end of tubed flap size was 

designed at least 2 cm radius. The distal skin tube and cervical esophagus parts were incised at three lower tri-angular parts, respectively. 

A Z- plasty triangular suture to increase the diameter of anastomosis site was designed. All patients received modality adjuvant 

radiotherapy postoperatively. The follow-up ranged from 10 to 36 months. 

RESULTS: 

All the flaps were survived except one failed due to venous thrombosis. He redid another tubed radial forearm flap uneventfully. There 

was no leakage in the cervical esophagus and tubed skin flap anastomosis junction. The barium swallowing study revealed a wide 

patent anastomosis postoperatively without stricture after adjuvant radiotherapy. All patients tolerated regular diet smoothly after adjuvant 

radiotherapy. 

CONCLUSION: 

With this modification, there is no apparent stricture in distal-anastomosis site of tubed skin flap. This is a useful technique to prevent 

tubed contracture in pharygo-esophageal reconstruction. 

Comparisons of Donor Site Morbidity Between Free Fibula Osteocutaneous Flap and 

Osteomyocutaneous Peroneal Artery Perforator Flap 

Institution where the work was prepared: Chang Gung Memorial Hospital, Taiyuan, Taiwan 

Jing-Song Guo; Yu-Te Lin; Huang-Kai Kao; Jung-Ju Huang; Ming-Huei Cheng; Chang Gung Memorial Hospital 

BACKGROUND: 

Previously published studies have shown that there is only minimal donor site morbidity associated with free fibular osteocutaneous 

flaps. A modification of the traditional free osteocutaneous fibula (fibula) flap, the osteomyocutaneous peroneal artery perforator (PAP) 

flap includes a segment of soleus muscle to give it greater tissue volume. The PAP flap's versatility and extra volume makes it a good 

flap for composite mandibular and maxillary reconstructions where there is great tissue loss. The purpose of this study is to compare 

donor site morbidities between the PAP and o-fibula groups by performing functional soleus muscle evaluations. 


Between December 1999 and May 2006, eight patients underwent PAP flap and thirteen patients underwent an fibula flap reconstructions 

of either composite mandibular or maxillary defects at Chang Gung Memorial Hospital. Subjective evaluations were performed 

by interviewing patients for donor leg symptoms, such as pain, paresthesia, problems walking, activity restrictions, gait alterations, and 

donor site aesthetics. Objective assessments were performed by measuring ankle and big toe range of motion and power. 

RESULTS: 

The Mann-Whitney Test comparing the subjective questionnaire scores between the two study groups showed no significant differences 

(p=0.447). The unpaired t-test comparing ankle and big toe range of motion in the PAP flap group and the fibula flap group also 

showed no significant functional impairment from segmental soleus muscle harvesting (p>0.05). Muscle power evaluations also failed 

to show any significant differences (p>0.05).However,either fibula or PAP flap dose compromise the donor leg ankle and big toe range 

of motion comparing to normal leg(84.78% in fibula and 82.08% in PAP for ankle dorsiflexion as example). 

CONCLUSION: 

Although previous study claimed the donor site morbidity of fibula flap is minimal,the range of motion of ankle and big toe do decrease 

after the surgery.Long-term follow up of PAP flap patients showed that donor site morbidity is similar to that of the fibula group. Due 

to its greater flap volume, the PAP flap is a good reconstructive option for extensive mandibular or maxillary composite tissue which 

might otherwise require double free-flaps. 

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The Incorporation of Biologics and Free Flaps in My First One Hundred Lower Extremity 

Procedures 

Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA 

Robert Whitfield, MD; Medical College of Wisconsin 

Lower extremity reconstruction involves in many instances multiple methods to gain a stable soft tissue envelope. This may involve local 

tissue rearrangement, skin grafting, rotational muscle flaps with or without skin grafting and free muscle flap with skin graft. One hundred 

lower extremity procedures were performed on 49 patients, 34 males and 15 females. Evaluation of the first 100 lower extremity 

procedures in my practice showed that this was not entirely true. Of those patients, eighteen, who required free tissue transfer, 57% 

(15/26) of the flaps utilized were perforator flaps, 3 Deep Inferior Epigastric Artery Perforator (DIEAP) flaps and 12 Anterolateral Thigh 

(ALT) flaps. There was one complete flap loss due to damage of the perforator during the dissection. Also there were two cases of 

venous congestion requiring reoperation and in one case vein grafting. Both of these flaps suffered partial flap necrosis of approximately 

25% and 33% respectively. In those patients where muscle flaps were used, 43% (11/26), there were two complete flap failures secondary 

to venous thromboses. In both instances the flaps that failed were latissimus dorsi muscle free flaps. In one case the contralateral 

latissimus was used for salvage. In the other case a free Transverse Rectus Abdominus Myocutaneous (TRAM) flap ultimately was 

chosen secondary to the patient's difficulty dealing with the donor site of the initial latissimus flap harvest. In addition the use of biologics, 

both Integra and Alloderm, have been usefull in the management of these patients. In 50% (6/12) ALT flaps Integra was used to 

cover exposed blood vessels or to use as coverage for partially debrided flaps. In 16% (2/12) alloderm was used in addition to an ALT 

flap to reconstruct the lower extremity over an orthopedic prosthesis. Integra was used in 45% (5/11) as temporary coverage of muscle 

flaps. Based on this early experience perforator flaps and biologics are reliable and can be a useful adjuncts in the algorithm of treating 

lower extremity injuries. 

Navigating the DIEP SIEA: A Perforator Progression Algorithm for Microsurgical Breast 


Institution where the work was prepared: University of Chicago Medical Center, Chicago, IL, USA 

Charles Y. Tseng, MD; Amir H. Dorafshar, MD; David H. Song, MD; University of Chicago Medical Center 

BACKGROUND: 

An increasing number of women are undergoing breast reconstruction due to increased awareness, screening, and improved surgical 

technique. SIEA, DIEP, and MS-TRAM free flaps reliably replace and closely approximate the look and feel of lost breast tissue. Among 

the alternatives for autologous breast reconstruction, the SIEA flap provides the least donor-site morbidity, as dissection of the rectus 

abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the SIE artery, its use is 

limited. In previous reports, free flap breast reconstruction using the SIEA flap is about 30-40% 

PURPOSE: 

To perform a prospective study of the reliability and outcomes of SIEA, DIEP, and MS-TRAM free flap reconstruction and develop an 

algorithm for flap selection in autologous breast reconstruction that the developing reconstructive microsurgeon will find useful. 

METHODS: 

From January 2005 - 2007, 61 consecutive patients underwent SIEA, DIEP, or MS-TRAM free flap breast reconstruction utilizing a specific 

algorithm. 66 flaps were used in 56 unilateral and 5 bilateral breast reconstructions. Patient demographics, procedure type, diagnosis, 

adjuvant treatment, and complications were recorded. 

RESULTS: 

22 SIEA (33%), 35 DIEP (53%), and 9 MS-TRAM (13%) free flap breast reconstructions were performed. Fat necrosis was observed in 2 

SIEA (9%), 3 DIEP (8.5%), and 1 MS-TRAM (11%) flap. Other complications included 4 intraoperative anastomotic avulsions in the SIEA 

group, 1 complete flap loss in the DIEP group, and 1 hematoma in the MS-TRAM group. 

CONCLUSION: 

This prospective study compares the reliability and outcomes of SIEA, DIEP, and MS-TRAM free flaps in breast reconstruction. Similar 

to previous reports, we find that the SIEA flap can be employed in about 30% of cases to achieve breast reconstruction equal in aesthetic 

quality to that achieved with DIEP and MS-TRAM flaps while decreasing abdominal donor-site morbidity. Based on the experience 

gained from this study and the data collected, we present an algorithm for flap selection in autologous breast reconstruction incorporating 

the MS-Free TRAM, DIEP, and SIEA flaps. It is our hope that this algorithm will be useful to the developing microsurgeon. 

213

The Versatility of Perforator Flaps in the Reconstruction of Upper Extremity Defects 

Institution where the work was prepared: Louisiana State University Health Sciences Center, New Orleans, LA, USA 

Jules A. Walters III, MD; Quintessa Miller, MD; Jonathan Boraski, MD, DMD; Charles Louis Dupin, MD; M. Whitten 

Wise, MD; Louisiana State University Health Sciences Center 

BACKGROUND: 

Upper extremity wounds present unique reconstructive challenges. They often require thin covering with pliable tissue over joint surfaces 

and necessitate reconstruction of a variety of tissues. Regional flaps are frequently available; however, they are often unreliable in 

the face of extensive trauma and carry increased donor site morbidity. Free muscle flaps are alternatives, but fibrosis can often lead to 

joint contractures. Perforator flaps provide the ideal solution. They allow long vascular pedicles, carry reduced donor site morbidity, and 

can carry specialized structures for tendon reconstruction. The purpose of this study was to outline the versatility of perforator flaps to 

upper extremity wounds resulting from trauma, malignancy, and burns. 


The authors present a retrospective study of 13 free perforator flaps in 12 patients between June 2002 and March 2007. The authors 

applied 10 ALT flaps and 3 DIEP flaps for reconstruction of a variety of complex soft tissue defects. The recipient site was the hand in 5 

patients, elbow in 3 patients, arm in 2 patients, and forearm in 2 patients. One patient had reconstruction of his triceps tendon with vascularized 

fascia lata as part of his ALT flap. 

RESULTS: 

Patient follow-up averaged 16 months and ranged from 3 to 62 months. All perforator flaps survived. Complications included venous insufficiency 

in one flap treated successfully with leech therapy, distal hand ischemia in another patient requiring a partial finger amputation, 

and a periumbilical abscess in one patient. Four patients required flap revisions consisting of liposuction, debridement, and skin grafting. 

CONCLUSIONS: 

Perforator flaps are indicated in a variety of clinical situations. Their size can easily be shaped to fit the spectrum of three-dimensional 

wounds encountered during reconstruction. Due to flap versatility, reduced donor site morbidity, and the ease of revision, perforator 

flaps provide safe and effective soft tissue coverage to upper extremity wounds. 

Multi-digit Replantation in Patients with Cardiac Stents 


Otway Louie; Joe Michaels; Sheel Sharma; Jamie Levine; NYU Medical Center 

BACKGROUND: 

Multi-digit amputation is an indication for digital replantation. Contraindications to replantation include amputations in patients with 

other severe injuries or medical comorbidities. The number of patients receiving cardiac stents is rising. In those patients receiving P2Yreceptor 

antagonists with aspirin, the incidence of stent thrombosis is as low as 1%. Most of these events occur within 10 days after 

implantation. To date, no study have documented multi-digit replantation in patients with pre-existing cardiac stents. 

METHOD: 

We present our experience performing multi-digit replantation in patients with cardiac stents. The hospital course, management, and 

outcome of these patients were reviewed. 

RESULTS: 

Two patients undergoing multi-digit replantation had pre-existing cardiac stents. Both developed cardiac stent occlusion requiring 

emergent angioplasty. One patient with a 6 month old coronary stent had sustained a severe crush injury to his right 2nd-5th digits and 

underwent replantation. He developed angina POD1 and emergent catheterization revealed occluded LAD and RCA stents. All 

replanted digits eventually failed, likely secondary to inadequate perfusion. The second patient underwent successful replantation of 

his 1st-4th digits but developed complete occlusion of his drug eluting stent POD5. Both patients underwent angioplasty with successful 

opening of their occluded stents. 

CONCLUSION: 

Despite antiplatelet agents, patients with pre-existing cardiac stents are at high risk for stent thrombosis when undergoing multi-digit 

replantation. Preoperative discussion regarding the possibility of stent occlusion should be held at length with the patient when considering 

proceeding with multi-digit replantation. Emergent cardiac catheterization should be available for stent salvage. 

214

Floor plan - 2013 Annual Meeting - American Association for Hand ...

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