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Video-Productions with special permission) 46 Tissue Surgery ^cXgZVhZh ^cYjXZ ^cigVkVXjdaVg ]neZgegZhhjgZ l^i]ÑWg^aaVgY^aVXZgVi^dc!XgZVi^c\hbVaabZ\V" kVXjdaV VcY XdbeaZiZan eZgijgW^c\ bdkZbZci# I]ZgZ[dgZ!i^hhjZ^hYZhigdnZY!VcYi]ZgZhi^iji^dc VY^ciZ\gjbl^aacZkZgWZdWiV^cZY#;jcXi^dcVa hZfjZaVZl^aaWZi]ZXdchZfjZcXZ# 6\^c\^hVkZgnY^[[ZgZcibZX]Vc^hb#>i^hcdi hjYYZcX]Vc\ZWjigVi]ZghadlVcYegd\gZhh^kZ X]Vc\Z ^c i]Z e]nh^XVa WVaVcXZ d[ [dgXZh ^ch^YZ ]jbVc i^hhjZ# 6\Z^c\! WZXVjhZ d[ i]Z adhh d[ ^ciZgcVa WVh^X fjVa^i^Zh d[ i]Z B8K6H! ^h i]Z bVc^[ZhiVi^dc d[ i]Z \gVk^iVi^dcVaÅgZkZc\ZÆ dc i]ZBK86H^ciZgcVaegZ"iZch^dc# I]^h^hcdii]ZXVhZ[dgdWZh^in!l]^X]XVcWZ V XVhjVaX^gXjbhiVcXZ# >i ^h ZVhn id jcYZghiVcY i]Vii]ZkVXjdaV^hÑaaZYWnVY^edXniZhgZeaVX^c\ \anXda^XVch#6ii]ZWZ\^cc^c\!kVXjdaVVcYÑWZgh VgZ^cY^hiZch^dc!bdkZbZci^hhadlZY!VcY\gVk^" iVi^dc WZXdbZh bdgZ ^bedgiVci# 7ji i]^h Ñghi hiV\Z^hgZkZgh^WaZ!i]Vc`hidVegd\gZhh^kZadhhd[ lZ^\]i!l]^X]bjhicdiWZiddfj^X`# >ci]ZhZXdcYhiV\Z!lZ^\]i^h^cXgZVh^c\!VcY kVXjdaV VgZ ^c ZmigZbZ Y^aViVi^dc# I]Zc! ÑWZgh VgZ cdi dcan ^c Y^hiZch^dc Wji WZXVjhZ d[ i]Z Z[[ZXih d[ \gVk^iVi^dc! i]Zn VgZ ^c Y^aVXZgVi^dc VcY^chZVgX]d[VbZ\VkVXjdaVigVch[dgbVi^dc! l]^X] ^c ijgc l^aa WZ ÑaaZY Wn VY^edXniZh# Hd! WdYn[dgbX]Vc\Zhl^i]dWZh^in#6ii]^hhiV\Z!V gZijgcidi]Zdg^\^cVabdge]dad\n^h^bedhh^WaZ! VcYdcanhjg\Zgnl^aagZXgZViZi^hhjZiZch^dcWn gZhZXi^c\ZmXZhhh`^cVcY[Vi# 6cVidb^XVa8dcXajh^dch I]^hcZlXdcXZeid[ BK86HZcVWaZhjhidY^hXjhh hdbZ WVh^X VcY igVY^i^dcVa Vhhjbei^dch VWdji i]Z cVijgZ d[ i^hhjZ VcY! eVgi^XjaVgan ^c ]VcY VcVidbn!idY^hXjhhe]nh^dad\nVcYgZXdchigjX" i^kZhjg\Zgn# HdbZ igVY^i^dcVaan ]ZaY XdcXZeih VgZ Vi kVg^VcXZ l^i] VcVidb^XVa gZVa^in VcY h]djaY WZX]Vc\ZY#I]Zi^bZ]VhXdbZidXdcÑgbhdbZ VcVidb^XVa igji]h VcY id Y^hXVgY YZÑc^i^kZan XZgiV^c egZXdcXZ^kZY^YZVhVWdjii]Z]VcY# ;dg ZmVbeaZ!i]Zi^bZ"]dcdjgZYaVndjid[i]Zh]ZVi]h ^c i]Z ]VcY bjhi WZ XdbeaZiZan gZXdch^YZgZY# I]Zcdi^dcd[V]^hidad\^XVaY^[[ZgZcXZWZilZZc i]Z eVgViZcYdc VcY i]Z XVgeVa h]ZVi]! VcY i]Z igVY^i^dcVaanVXXZeiZYcdi^dcd[Ve^hidcbVX]^cZ bZX]Vc^hb [dg ha^Y^c\ e]ZcdbZcdc bjhi Vahd WZgZXdch^YZgZY# L]Zc i]^h egZhhjgZ ^cXgZVhZh! i]Z WVaVcXZ ^h Y^hijgWZY!VcYi]ZhnhiZbgZhedchZ^hVX]Vc\Z ^cVW^\kVXjdaVl^i]YZhigjXi^dcdgadXVaY^hiZc" h^dc d[ i]^h XdaaV\Zc^X [gVbZ! l]^X] ^h jcVWaZ idgZh^hii]ZegZhhjgZ#L]Zci]^h]neZgegZhhjgZ ^h XVjhZY Wn Vc ^ciZgcVa h^ijVi^dc! hjX] Vh V Figure 4-4. MVCAS and physiopatholo- gies. (A.D.F. 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(A.D.F. 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The transfer of a sliding flexion unit composed of a flexor tendon and its surrounding sheaths in a reverse island pedicled manner. 1st stage: Mesotendon identification. 2nd stage: Section of FSIVth flexor sublimis of the ring finger and ulnar pedicle. Island ulnar tendon transfer iso- lated. 3rd stage: Insertion of the island trans- fer into digital zone. 4th stage: Tendon sutures outside of the No Man’s Land and pulley reconstruction. (A.D.F. 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Flexor superficia- lis section at the tendinomuscular junction and at the level of decussation. 2nd stage: The flexion sliding unit after revasculariza- tion. 3rd stage: Forward translation of the sliding unit transfer. 4th stage: Before inserting and pulley reconstruction. (A.D.F. Video-Productions with special permission) Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery 51 6XXdgY^c\idi]ZhVbZeg^cX^eaZ!VcYjh^c\i]Z hVbZ hjg\^XVa iZX]c^fjZ! ^i ^h edhh^WaZ id XVggn djicdi dcanejgZ iZcY^cdjh kVhXjaVgigVch[Zgh bdhid[iZcl^i]i]ZhjeZgÑX^VaÒZmdgiZcYdcd[ i]Z g^c\ Ñc\Zg! Wji Vahd V XjiVcZd"iZcY^cdjh igVch[Zg! VcY ZkZc i]Z ig^eaZ igVch[Zg d[ h`^c! iZcYdc!VcYWdcZ# (# =dll^aai]^hha^Y^c\jc^iWZeaVXZY^cidÅCd BVcÈhAVcYÆ4 CdlVYVnh!i]ZiZX]c^fjZd[^haVcYgZigd\gVYZ [dgZVgbigVch[Zg^hjhZYidigVch[ZgV[dgZVgbdg lg^hi higjXijgZ i]Vi ^h eZY^XaZY dc Vc VgiZg^Va Vm^h# ;dggZigd\gVYZ kVhXjaVg^oZYiZcYdcigVch" [Zg! dcan i]Z jacVg"WVhZY eZY^XaZ ^h hj^iVWaZ! dl^c\id^ihY^hiVaanWVhZYeVabVged^cid[gdiV" i^dcVcYid^ihWgVcX]igVchb^hh^dcViVcZmXaj" h^kZaniZcY^cdjhaZkZa# 8dbW^cZY;aZmdgIZcYdcVcYH`^c>haVcY;dgZVgb IgVch[Zg# >chdbZXVhZh!l]Zci]ZdkZgan^c\h`^c ^hZmigZbZanhXVggZYVcYd[eddgfjVa^in!eVgi^Xj" aVganVii]ZWVhZd[egdm^bVadgb^YYaZe]VaVcm! ^i^h^bedhh^WaZidgZeaVXZi]Z[>ZmdgiZcYdcVcY VX]^ZkZZVganbdi^dc#H`^cd[i]^hhdgi^cZk^iVWan WgZV`hYdlcdgY^Zh!Xdbegdb^h^c\i]Z[jcXi^dcVa gZhjai0i]ZgZ[dgZ!^ih]djaYWZgZeaVXZY# >c i]Z Y^hiVa i]^gY d[ i]Z [dgZVgb! i]Z jacVg eZY^XaZ cdi dcan hZcYh WgVcX]Zh id i]Z ÒZmdg hjeZgÑX^Va^hiZcYdchWjiVahdidi]Zh`^c#I]ZhZ WgVcX]Zh VgZ ZVh^an ^YZci^ÑZY! WZ^c\ XadhZ id i]Z bZhdiZcYdc WgVcX]Zh VcY d[ hj^iVWaZ Y^VbZiZg! Vaadl^c\ h^bjaiVcZdjhan Xdbedh^iZ igVch[Zgd[h`^cVcYiZcYdc#<ZcZgVaani]Zh`^c ^haVcYa^Zhegdm^bVaidi]ZbZhdiZcYdcedh^i^dc# =dlZkZg!i]Vc`hidi]Zea^VW^a^inVcYÒZm^W^a^in d[ i]ZhZ XjiVcZdjh WgVcX]Zh! i]Z igVch[Zg XVc WZgdiViZYVcYedh^i^dcZYdci]ZY^\^iVahjg[VXZ l^i]dji X]Vc\^c\ i]Z e]nh^dad\^X Y^gZXi^dc d[iZcYdcÑWZgh#I]^h^hd[[jcYVbZciVa^bedg" iVcXZ ^c VX]^Zk^c\ V \ddY [jcXi^dcVa gZhjai ;^\jgZ)".# I]^hcZliZX]c^fjZ!l]^X]^hcdldjghiVcY" VgYegdXZYjgZ[dg7dnZhXaVhh>>>dg>KXVhZh!jhZh V bZhdkVhXjaVg iZcYdc ^haVcY! VcY i]Z iZcYdc XVc WZ gZXdchigjXiZY ^c dcZ deZgVi^dc# 8db" eVgZYl^i]Vaadi]ZgiZcYdc\gV[iiZX]c^fjZh!i]Z VYkVciV\Zhd[i]^hiZX]c^fjZVgZVh[daadlh/  >ibV`ZhjhZd[Va^k^c\iZcYdc^haVcYÄi]Vid[ V i]^c bZhdiZcYdc l^i] kVhXjaVg WgVcX]Zh! egdk^Y^c\VeZg[ZXiWaddYhjeeanidVaaVgZVh! Wdi] Zmig^ch^X VcY ^cig^ch^X# >i i]jh Vkd^Yh VY]Zh^dchVcY^begdkZhi]ZkVhXjaVg^ind[i]Z hjggdjcY^c\i^hhjZh#7ZXVjhZi]ZigVch[Zg^hV gZVaÒZmdgiZcYdcVcYcdiVh^beaZbndiZcY^" cdjhhigjXijgZ! ^igZiV^chÒZm^W^a^in!ea^VW^a^in! VcYgZh^hiVcXZVcYVaadlhi]ZXdggZXiiZch^dc abc d feg Figure 4-9. a) Diagram of the different vascular branches emerging from the ulnar artery before Guyon’s canal entrance. Bone, skin, flexor tendons. b) Ulnar artery dissec- tion before Guyon’s canal entrance. c) A bayonet-shaped incision including an outline of the skin flap is traced on the medial side of the forearm. d) Raising of the composite flexor tendon and skin flap island transfer for tendon repair and digital palmar resurfacing. Before and after tourniquet release. e) Other multiple combinations: combined island flexor superficialis tendon and palmaris longus transfer for flexor and pulley reconstruction. f) The double flexor tendons and double skin flaps transfer. g) The composite skin, flexor tendon, and bone transfer. (A.D.F. 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ineZd[gZXdchigjXi^dc^c]VcYhjg\Zgn#>iXVcWZ jhZYcdidcan[dgi]ZÒZmdghnhiZb!WjiVahd[dg WdcZ VcY _d^cih# ;dg i]Z bdbZci! bZY^XdaZ\Va XdchigV^cihVgZhZkZgZ!VcYZmVXi^c\Xg^iZg^Vbjhi WZbZiWZ[dgZVcnigVcheaVciXVcWZeZg[dgbZY# HjX] XdchigV^cih bVn Y^b^c^h] dkZg i^bZ! VcY iZX]c^fjZhd[gZeV^gVcYgZXdchigjXi^dc!hjX]Vh i]dhZYZhXg^WZY]ZgZ!l^aaYZkZade[gZZan[dgjhZ ^c hZaZXiZYeVi^Zcih# 9Zhe^iZ i]Z hjXXZhhd[i]^h iZX]c^fjZ! ^i h]djaY WZ gZhZgkZY [dg XdbeaZm XVhZh^cl]^X]XdckZci^dcVaiZX]c^fjZhVgZcdi edhh^WaZ# [...]... 2000, Aszmann15 16 12 NA 69 16 2001, Tambwekr 10 10 80 70 2003, Wood17 33 33 90 70 20 04, Biddinger18 15 22 86 80 20 04, Valdivia19 60 60 85 85 29 20 04, Lee 46 46 92 92 2005, Steck32 25 25 84 72 49 49 90 72 2005, Rader89 Total 376 351 88 78 NA not available Tissue Surgery Innovations in Peripheral Nerve Surgery Figure 5-1 Decompression of the four medial ankle tunnels a) The medial ankle region contains... Table 5-2 Results of Studies Treating Neuropathy of Unknown Cause with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 20 04, Valdivia19 40 40 90 80 20 04, Lee21 40 40 80 80 2005, Steck32 26 26 88 68 Total 106 106 85 72 Tissue Surgery Nerve Reconstruction Nerve Allografts Innovations in Peripheral Nerve Surgery 59 Nerve Conduits Figure 5-2 Use... the forearm of a 37-year-old man Previous primary repair was unsuccessful a) Resection of the neuroma showing the 3-cm gap in the median nerve The tourniquet is inflated b) Interfascicular reconstruction of the defect with four, 2.3-mm-diameter Neurotubes, each 4 cm long Figure 5 -4 Reconstruction of the median and ulnar nerve at the level of the brachium 18 months ago in a 51-year-old man Note the recovered... Table 5-3 Reports of Clinical Applications of the Neurotube Peripheral Nerve Reconstructed Report Sensory Nerve: Arm Digital and Median at the Wrist47 Digital45 Digital49 Sensory Nerve: Foot50 Cranial Nerves: Sensory V (inferior alveoloar)51 Cranail Nerve: Motor VII (facial)52 XI (spinal accessory)53 Tissue Surgery Date of 1990 2000 2003 2001 1992 2005 2005 Figure 5-3 Reconstruction of the neuroma-in-continuity... 54 Tissue Surgery a b c d References Figure 4- 1 0 Flexor tendon unit allotransplantation program a) A monoflexor superficialis allotransplant after tourniquet release b) A bi flexor superficialis and profundus allotransplant after milking and washing, to be placed in a sterile refrigerated container c) Layout of the allotransplant before inserting d) Insertion and anastomoses (A.D.F Video-Productions... Innovations in Peripheral Nerve Surgery Christopher T Maloney, Jr and A Lee Dellon Introduction Decompressing Nerves to Treat Symptomatic Neuropathy 55 56 Table 5-1 Results of Studies Treating Diabetic Neuropathy with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 1992, Dellon12 31 32 85 72 1995, Wieman13 33 26 92 72 2000, Caffee 14 58 36 86 50 2000, Aszmann15... of reinnervation of the flexor carpi radialis, flexor profundus, flexor superficialis, pronator, and flexor carpi ulnaris was obtained Sensation was recovered in the fingertips with two-point discrimination and good localization 24 months after the Neurotube reconstruction Two tubes were placed for the ulnar nerve and three for the median nerve (Courtesy of A L Dellon, MD.) ... The abductor hallucis brevis muscle is retracted (not divided) after incising its superficial fascia In 50% of patients, a 57 small branch from the medial plantar nerve innervating the skin of the heel-arch region is present and is preserved When the muscle is retracted, the thick fascia providing the roof of the medial and lateral plantar tunnels is identified c) The roof of the medial plantar tunnel . V Figure 4- 4 . MVCAS and physiopatholo- gies. (A.D.F. Video-Productions with special permission) Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery. defect with four, 2.3-mm-diameter Neurotubes, each 4cm long.   Figure 5 -4 . Reconstruction of the median and ulnar nerve at the level of the brachium 18 months ago in a 51-year-old man. Note the. Pain Sensibility 20 04, Valdivia 19 40 40 90 80 20 04, Lee 21 40 40 80 80 2005, Steck 32 26 26 88 68 Total 106 106 85 72 Innovations in Peripheral Nerve Surgery 59 hZchdgn dg bdidg [jcXi^dc