Microsurgery

Background: The M1As are located in the main trunk (M1) of the MCA, between the bifurcation of the ICA and the main bifurcation of M1. Proximal MCA aneurysms are often small and thin-walled, which makes their proper clipping tedious. There are few reports on their microsurgery. Methods: This review, and the whole series on intracranial aneurysms, is mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve, without selection, the catchment area in the southern and eastern Finland. Results: These 2 centers have treated more than 10 000 patients with aneurysm since 1953. We review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of M1As which form 7.4% of all intracranial and 14% of all MCA aneurysms in our patients. Conclusions: Proximal MCA aneurysms are often wide-necked and intimately connected to an M1 branch at its origin on M1, features that favor exosurgery rather than endosurgery. The direction and course of the parent and branching arteries and the orientation of the fundus are the most important factors affecting the efficacy and safety of clipping. D

RESUMO Introdução: Atualmente, existe uma carência de exposição à cirurgia plástica durante a graduação. A maioria dos currículos univer-sitários não possui uma forma específica de ensino em cirurgia plástica. Para reverter essa situação, algumas universidades fomentam o contato precoce com a cirurgia plástica através de cursos extracurriculares. Método: Foi desenvolvido um Curso Básico de Mi-crocirurgia para acadêmicos de Medicina com uma aula teórica e uma prática, anualmente e ao longo de 3 anos; na última edição, foi aplicado um questionário sobre o interesse na área e a importância no ensino durante a graduação. Resultados: Dentre os alunos, 65% apresentaram grande interesse pela microcirurgia, 95% relataram um aumento de interesse. Todos os alunos concordaram que os acadêmicos de Medicina devem ser mais envolvidos e treinados na área microcirúrgica durante a graduação. Conclusões: O de-senvolvimento de um curso de treinamento básico de microcirurgia para acadêmicos de Medicina é benéfico para o aprendizado dos alunos, para obtenção de informações acerca da disciplina e para o aprimoramento de habilidades. ABSTRACT Introduction: Currently there is a lack of exposure to plastic surgery during medical graduation. Most college curricula do not have a specific form of education in plastic surgery. To reverse this situation, some universities encourage early contact with plastic surgery through extracurricular courses. Methods: We developed a basic course of microsurgery for medical students with a lecture and a practical class, annually and over 3 years; in the last edition, a questionnaire on the interest in the area and the importance in education during graduation was applied. Results: Among the students, 65% showed great interest in microsurgery, and 95% reported an increase of interest. All students agreed that medical students should be more involved and trained in the microsurgical area during graduation. Conclusions: The development of a basic training course of microsurgery for medical students is beneficial for student learning, obtaining information about the discipline, and improving skills.

Background: We report our experience with the minimally invasive supraorbital approach to aneurysms of the ipsilateral anterior cerebral circulation. Methods: A prospective review of all patients who underwent operations to clip aneurysms in Newcastle between 1993 and 2002. Results: Fifty-six aneurysms were clipped via minicraniotomy in 47 patients. Six patients presented with acute subarachnoid hemorrhage (SAH), 40 patients were admitted for elective clipping, and 1 patient presented with an SAH, had the responsible aneurysm clipped and was readmitted later for elective clipping of a further aneurysm. Bilateral supraorbital craniotomies were performed in 3 patients. In 6 patients, multiple aneurysms were clipped via a single craniotomy. All aneurysms were well visualized with the microscope. Endoscopic assistance was not found necessary. All were successfully clipped. Two aneurysms ruptured while being clipped. There was no direct mortality from surgery. One patient died later from a separate posterior circulation aneurysm. One patient had a significant long-term deficit but remained independent, and 1 had 3 seizures over the 12 months after surgery. This represents a 4% morbidity at 1 year. Conclusion: Selected anterior cerebral circulation aneurysms can be clipped with low morbidity, using an ipsilateral minicraniotomy preserving the orbital rim, and without using an endoscope. The types of aneurysm selection criteria and operative equipment used are described. D

Subglottic hemangioma is a rare condition that can be potentially life threatening because of airway obstruction. It is common for subglottic hemangioma to be misdiagnosed as croup initially. Infants with a subglottic hemangioma and cutaneous facial hemangiomas in a "beard" distribution should be evaluated for PHACE syndrome. Endoscopic laser resection is effective for subglottic hemangioma but carries a chance of subglottic stenosis, up to 25%. Open excision of subglottic hemangioma is an excellent option, particularly in patients with bilateral or circumferential subglottic hemangioma. It is a more extensive surgery when compared with endoscopic laser resection. Surgeons who do not have access to a pediatric intensive care unit staffed by experienced pediatric intensivists should not use this procedure.

Low back pain remains a costly quality-of-life-related health problem. Microdiscectomy is often the surgical procedure of choice for a symptomatic, single-level, lumbar disc herniation in younger and middle-aged adults. The question of whether a post-microdiscectomy exercise program enhances function, quality of life, and disability status has not been systematically explored. Thus, the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program, developed at University of Southern California (USC), targeting the trunk and lower extremities (USC Spine Exercise Program) for persons who have undergone a single-level microdiscectomy for the first time. One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study. Subjects will be randomly assigned to one of two groups: 1) one session of back care education, or 2) a back care education session followed by the 12-w...

Treatment of osteoarthritis in young and middle-aged patients, in whom joint replacement is usually not appropriate, is a challenge to orthopaedic surgeons. Arthroscopic techniques can help control patients' symptoms. In particular, the microfracture procedure combined with management of the joint volume and a specific rehabilitation protocol shows good results in patients with osteoarthritis and cartilage defects by resurfacing the defect with a combination of types I and II cartilaginous tissue. Microfracture is a single-staged arthroscopic procedure that can be combined with any other arthroscopic treatment for osteoarthritis of the knee. With an appropriate rehabilitation protocol and techniques for controlling the joint volume, these treatments are very effective for pain relief and functional improvement. The described technique is our choice for initial surgical treatment of osteoarthritis of the knee.

Endodontic surgery is an alternative therapeutic approach to endodontic treatment. The outcome of the technique is affected by several factors, some of which can be eliminated by the use of a dental operating microscope. The microscope was used during the performance of 50 apicoectomies, with or without retrograde fillings. For clinical evaluation cases treated with the dental operating microscope were compared to cases treated without it. The postoperative evaluation showed a reduced incidence of symptoms in the cases treated with the dental operating microscope. More important, the dental operating microscope enhanced and facilitated each phase of endodontic surgery. Its use is highly recommended.

We sought to investigate the three-dimensional structure of the white matter of the brain by means of the fiber-dissection technique and diffusion-tensor magnetic resonance imaging to assess the usefulness of the combination of both techniques, compare their results, and review the potential functional role of fiber tracts. METHODS: Fifteen formalin-fixed human hemispheres were dissected according to Klingler's fiber-dissection technique with the aid of ϫ6 to ϫ40 magnification. Threedimensional anatomic images were created with the use of specific software. Two hundred patients with neurological symptoms and five healthy volunteers were studied with diffusion-tensor magnetic resonance imaging (3 T) and tractographic reconstruction.

Introduction: The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a metaanalysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated. Methods: A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups. Results: One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715). Conclusions: The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice. (J Endod 2012;38:1-10)

Background: Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. Patients and methods: We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio-venous malformation, Paget's disease, squamous cell carcinoma, and Fournier's gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. Results: All the flaps had 100% viability without partial loss. Mean follow-up was of 7.4 months (range 4 2 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. Conclusion: The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals.