This is the Mount Sinai Division of Plastic and Reconstructive Surgery presenting our CME articles associated video series for the reconstructive management of amniotic band syndrome. In this second video, we will specifically discuss upper and lower extremity defects associated with amniotic band syndrome. Additionally, we will go over different surgical techniques and their markings for the management of the most common extremity manifestation, the amniotic band constricting ring. Amniotic band syndrome of the extremities is classified by the Patterson classification system with one referring to a simple ring constriction, two referring to a ring constriction with distal deformities or lymphedema, three referring to a constricting ring with any syndactyly present, and four referring to the presence of any amputation. Timing for the preoperative management of amniotic band syndrome ring should be individualized to the tailored needs and comorbidities of the specific patient. In an otherwise healthy child, most surgeons recommend waiting until the child is three to six months of age. This allows for minimization of risk associated with unnecessary anesthesia at a young age, but also ensures that treatment is complete at a young enough age to minimize any associated psychological trauma caused by either the presence of the band itself or the surgical intervention. Indications for earlier intervention include severe lymphedema, vascular compromise, or signs of nerve compression. There are a variety of operative techniques and associated preoperative markings that have been described in the literature for the management of the classic amniotic band constricting ring. We will review them next. Historically, plastic surgeons have performed the amniotic band release in two separate stages with a six to 12 week window of time in between each stage. This was thought to preserve vascular supply to the distal portion of the extremity. However, single stage excision has become increasingly popular in the recent years and has been demonstrated to be safe without any increased risk for ischemia or congestion of the extremity. When marking the patient preoperatively, regardless of incision technique, it is important to note that both the adherent constrictive band of connective tissue, as well as the surrounding subcutaneous tissue and skin that start to invest into the band should be resected. This allows for the best chance to prevent remnant divoting of the area of the band and proper re-approximation of the surrounding skin and soft tissues during closure. In terms of incision design, different surgeons have advocated for the use of z-plasties, triangular flaps, or rectangular flaps. Shown on the left is the traditional z-plasty technique used at our own institution, but in the center and on the right, you can see the triangular and rectangular flaps presented in the literature. Regardless of which technique is used, the importance of using these incisions rather than a linear pattern is that the band is resected and closed in a way that avoids any linear contracture. Of note, there have also been reports of perpendicular transcutaneous subcision of the band in order to break up its attachments with or without fat grafting into the space as an alternative to constriction band excision. These images represent the typical preoperative markings created at our own institution. We create two z-plasties on opposite sides of the constriction band to break up the linear incision. The dots shown proximal to the band show the donor site for the subcutaneous turnover flaps, which are used to fill the dead space created by the resection of the constriction band. This will be described in more detail in the next video in this series.

amniotic band syndrome

surgical management

Patterson classification

extremity defects

surgical techniques