Abstracts-Part I

Second Congress, Heidelberg, Germany

June 11-14, 2003

ree Fasciocutaneous Temporalis Flaps. Verhelle, Heymans; Liege, Belgium.

Coverage of the weight-bearing area of the heel in chronic wounds remains a difficult problem for plastic surgeons. Although certain defects can be covered by different local flaps, radiodermatitis is a contraindication for these flaps. Thin free flaps are usually the only correct solution for this particular problem. However, additional to specific microvascular problems, heel coverage by grafted fascial or muscle flaps is complicated by specific events that will have an impact on the final result of the reconstruction. These include the shearing phenomenon, ulceration, hypertrophic scar, and hyperkeratosis. Based on anatomic concepts and confirmed by a small number of cases, the fasciocutaneous temporal free flap seems to be an excellent alternative for small heel reconstructions.

Between 1996 and 2001, the authors performed six heel reconstructions with fasciocutaneous temporalis free flaps in the weight-bearing area. All patients presented with chronic ulcers, previously treated by radiation therapy. The mean patient age was 40 years (range: 27 to 52 years), and those with vascular diseases were not included. The size of defects varied between 15 and 30 cm² (mean: 20 cm²); all defects were closed primarily. All microsurgical arterial anastomoses were performed end-to-side on the posterior tibial artery.

The mean follow-up was 32 months (range: 15 months to 7 years) and during follow-up, the volume and appearance of the flap, sensibility, scars, and hyperkeratosis were noted. The shearing phenomenon and gait were studied both subjectively and objectively. There was no partial or total flap loss. One revision of the venous microsuture was performed, and one debulking after 20 months. No ulcers developed, and there were normal scars with one transient hyperkeratosis. There was no shearing phenomenon demonstrated, and an almost normal gait pattern. The presence of hair caused no functional disability, but it was always removed for aesthetic reasons.

Although muscle flaps remain the workhorse for heel coverage in osteomyelitis and acute large surface defects, the fasciocutaneous temporalis free flap appears to have several advantages in specific conditions such as small, chronic, irradiated wounds.

Venoneuroadipofascial and Venoadipofascial Flaps for Skin Coverage of the Leg and Ankle. Kanaya, Taira, Asato, Futenma; Okinawa.

The venoneuroadipofascial (V-NAF) flap and venoadipofascial (VAF) flap, first presented by Nakajima, are flaps that receive arterial blood supply from accompanying arteries of the cutaneous vein and/or cutaneous nerve. These flaps permit skin flap coverage of the extremities. The authors reported the surgical results of V-NAF and VAF flaps used to cover leg and ankle defects.

Since 1996, the authors have performed 11 V-NAF and one VAF flap in 12 patients. The mean patient age of 9 men and 3 women was 42 years (range: 3 to 71 years). There were 8 V-NAF flaps containing the small saphenous vein and the sural nerve in the pedicle, 2 V-NAF flaps containing the greater saphenous vein and the saphenous nerve, and 1 VAF flap containing the greater saphenous vein. Flap size ranged from 5×4 cm to 17×6 cm. The etiology of the skin defects was a traumatic defect in 6 (4 of them combined with osteomyelitis), intractable ulcer and a skin defect after contracture release in 2 each, wound dehiscence after total knee arthroplasty and resection of malignant tumor in 1 case each. Ten of the 12 patients demonstrated skin defects exposing bone. The remaining 2 patients had an intractable ulcer resistant to conservative treatment for 2 years and 27 years, respectively. All patients with osteomyelitis were treated simultaneouslsy with a flap and antibiotic-impregnated bone cement beads after meticulous debridement. Five proximally-based flaps were used to cover skin defects as proximal as the popliteal fossa and the prepatellar region. Seven distally-based flaps were used to cover skin defects as distal as the stump of Chopart amputation. Follow-up ranged from 5 months to 4 years (mean: 1 year and 7 months).

All flaps survived completely. The donor sites of these flaps were closed primarily in 3, and with a skin graft in 9 cases. All osteomyelitis cases healed without any problems.

Skin defects exposing bone and intractable ulcers in the leg and and ankle are difficult to treat. Free vascularized flaps have been required in many cases; however, free-flap transfer may be difficult in elderly patients or in patients with damage to major arteries of the leg. Advantages of the V-NAF and VAF flaps over free-flap transfer include a safe pedicled flap, relative ease of dissection, and no need to sacrifice the major arteries of the leg.

These are useful flaps to cover skin defects of the leg and ankle.

Microsurgical Reconstruction and Prosthetics in the Treatment of Severe Foot Injuries. Gritsuk; Moscow.

During movement, the foot is under relatively great mechanical loads. Resistance to this loading is provided by the plantar tissue surface that mitigates the mechanical load. In 1518 patients with foot diseases and injuries (during an 18-year period), inflammatory foot disease appeared in 37.9%, traumas in 25.2%, foot static deformations in 7.6%, gunshot injuries in 6.1%, burns and frostbite in 6.3%, and foot neurodystrophic and ischemic diseases in 16.7%. Extensive defects of foot tissue appeared in 109 patients who required 149 complex surgical interventions using plastic surgery techniques. The main types of interventions included: local tissue reconstruction (36 patients), autodermoplasty with split-thickness and other skin grafts (49 patients), dermatotension (11 patients), Italian plasty (8 patients), and microsurgical angioplasty with vascularized tissue complexes (36 patients). After wound healing, orthopedic footwear and prostheses were fabricated.

Good (41.3%) and satisfactory (32.2%) results were obtained; in 29 patients (26.5%), the results were considered unsatisfactory and reoperation was proposed. Long-term results were obtained in 93 cases: 56 patients were followed-up from 1-3 years, and 37 patients during 3-10 years or more. Ulcerated trophic alterations on the foot surface were observed in 17 patients and, in 10 of them, were of constant character. In the late periods during restoration of plantar surface tissue, 15 patients had stable trophic changes and osteomyelitis of the foot bones that required reamputation at a higher level with formation of a functional stump. In the late period after amputation in the upper and middle third of the shin, 56% of the patients used a prosthesis constantly, and 32% used it periodically because of the trophic and inflammatory changes. Twelve percent of the patients could not use a prosthesis and required reoperation.

The introduction of microsurgical transfer of tissue complexes in cases of severe and extensive defects of foot tissue provides the maximal number of good anatomic and functional results; however, adequate restoration of the supporting tissue remains a significant problem.

Bone Hardware or Articular Exposure: Is Muscle Coverage Mandatory or Can Fascial Coverage Do the Job? Verhell, Heymans; Liege.

Soft-tissue defects in the lower extremity remain real challenges for the reconstructive surgeon, particularly when located in the distal lower leg. Several loco-regional flaps have already been described, but they are not always feasible. A free flap is often the only solution that is possible. The authors presented two series of 22 flaps each, in order to compare the advantages of fascial and muscle tissue in covering bone tissue. In the first series, 22 free muscle flaps were done, while in the second series, 22 pedicled anteromedial adipofascial flaps were performed as coverage procedures.

A series of 120 free muscle flaps for lower leg reconstruction were reviewed, to obtain a series of patients in whom the anteromedial adipofascial flap could have been used as a reconstructive solution. The authors excluded all defects larger than 40 cm²; all patients with peripheral vascular disease; all patients with deep defects in which extensive dead space had to be filled; and osteomyelitis patients. The result was 20 patients (22 flaps); these were compared with 22 patients with a comparable medical history, age, gender, origin, and size of defect, and the use of free muscle flaps. All flaps were performed between 1999 and 2002, and the mean patient age was about 58 years. There was a mean follow-up of 28 months.

In the muscle series, the mean operative time was 4 hr 20 min, while in the pedicle series, it was about 1 hr 35 min. There was one complete flap necrosis in both groups. Recurrence of the initial problem also occurred once in both groups. However, for defect coverage, another free flap was required in the muscle series, while readvancement of the pedicled fascial flap solved the problem in the fascial series. Donor-site morbidity was lower in the pedicled flap group, as well as medical complications and length of hospital stay. A good mean overall aesthetic result was evaluated in 17/20 in the pedicled group, and in 14/20 in the muscle group.

In selected cases of exposure of bone hardware or articular exposure, the final functional outcome after muscle or fascial coverage was identical. Although free-flap surgery has become a versatile procedure, it remains more demanding and risky than the use of pedicled flaps. Moreover, the anteromedial adipofascial flap of the leg can provide a better alternative to free-flap coverage, with fewer surgical and medical complications, a shorter hospital stay, and better aesthetic results.

Extensive Skin and Soft-Tissue Defect Reconstruction in the Lower Leg with Free Thin Flaps. Fujimoto, Hyakusoku, Aoki, Ishimaru, Ogawa, Kawahara; Tokyo.

The authors presented two cases of extensive skin and soft-tissue defects in the lower leg, reconstructed with free thin flaps. The first case was that of a 26-year-old woman who had an extensive skin and soft-tissue defect of the lower leg after a traffic accident. First, free split-thickness skin grafts were used for defect coverage in another hospital; however, the patient wanted a reconstruction of the depressed region. As a large thin flap was required for coverage of the soft-tissue defect, the authors chose a free reduced thinned TRAM flap. The flap design was for a larger than usual flap, but the flap survived completely. The donor site was closed primarily. The result was satisfactory and an excellent cosmetic result was obtained.

The second case was that of a 29-year-old woman who also had an extensive skin and soft-tissue defect of the lower leg due to a traffic accident. Free split-thickness skin grafts were also used for defect coverage previously, but the patient wanted reconstruction of the depressed region. The defect was very extensive, and release of scar contracture in the foot joint region was required; a free reduced TRAM flap was used initially. Postoperatively, the patient requested reconstruction of the upper area in the foot joint region. A free groin flap was used. The patient then wanted the depressed area reconstructed. An expanded scapular flap was used for this reconstruction. The recipient artery was the anterior tibial artery, which was utilized for all three operative procedures. The flaps survived perfectly, and the extensive skin and soft-tissue defects were reconstructed very well with these three free thin flaps.

Reconstruction of the Lower Extremity with Microvascular Free Flaps: Experience with 140 Consecutive Cases. Fasano, Montanari; Bologna.

One hundred and forty cases of microvascular free flaps to the lower extremity were performed by the senior author between 1994 and 2002. The etiology of cases was recent trauma in 69 cases; osteomyeelitis, ulcers, unstable scars in 55 cases; and neoplasms in 16 cases. Muscle flaps were used more frequently (120 cases), compared to skin flaps (19) and omentum (1 case). The latissimus dorsi, serratus anterior, and rectus abdominis were the muscle flaps of choice, and were utilized with consideration of the size and topography of the defects. The lateral arm, DIEP, and IMECS (inframammary extended circumflex scapular) flaps have become preferred skin flaps over time. Recipient vessels were chosen on the basis of Doppler investigation and, if in doubt, arteriography. The anastomoses were also placed proximally to the defect in cases of thigh, knee, and foot defect, and were distal to the defect in 25% of cases. In 15 cases, there was flap failure, but with only two failures in the last 70 cases. Actual indications based on these experiences were discussed.

Role of Microsurgery in the Treatment of Type IIIB andd IIIC Tibial Open Fractures. Kaplan, Ozerkan, Ademoglu, Ada, Kayalar; Izmir.

Lower extremity injuries, especially open fractures of Gustillo types IIIB and IIIC, are caused by high-energy trauma, and there are neurovascular problems accompanying some bone and soft-tissue defects. Treatment in these types of injuries includes: radical debridement; rigid bone fixation; use of antibiotics; and closing the defects with free flaps for bone defects smaller than 6 cm and with vascularized bone grafts for larger defects, after the healing of soft-tissue injuries.

Between 1993 and 2000, the authors treated 26 patients, four females and 22 males. The patient age range was 4 to 72 years (mean age: 28 years). Types of fractures were classified as follows: type IIIA (1), IIIB (13), IIIC (12). Ten amputations were necessary (38%), and local and regional flaps were applied in 14 patients. All free flaps were carried out between 0 and 18 days. Four free flaps were lost (21%); there was infection in 6 patients in the acute stage, and they were treated with debridement and antibiotics. Chronic osteomyelitis was seen in one patient (31%). All fractures healed between 4 and 43 months (average time: 12 months).

For common problems of lower limb injury with extensive loss of skin and bone, microsurgical free flaps are useful in a number of selected cases.

Clinical Results of Microsurgical Foot Reconstruction. Kazuhiko, Moroe, Hiroyuki, Saburo, Juli; Kawasaki City.

The authors reported a study to examine the clinical results of microsurgical foot reconstruction. Nineteen reconstructive cases were performed with 21 flaps. Seventeen males and two females, whose average age at injury was 36 years, were followed-up. Causes of injury were trauma (16), burn (2), and tumor (1). The sole was reconstructed in 12 cases with 14 flaps (heel - 8 cases, 9 flaps; sole without heel - 4 cases, 5 flaps). The dorsum of the foot and the lateral malleolus of the ankle were reconstructed in 7 cases with 7 flaps. The former 14 flaps included 5 latissimus dorsi (LD) flaps, 4 saphenous, 3 medial plantar, and 2 peroneal flaps. The latter 7 flaps included 3 each of LD and peroneal flaps, and 1 saphenous flap. The average follow-up for the 21 flaps was 9 years and 6 months. Nineteen flaps (90%) of the 21 flaps survived. One reverse peroneal flap was replaced with an LD flap because of necrosis. Another medial plantar flap showed signs of superficial necrosis; a free skin graft was used instead. Two LD flaps for heel reconstruction required removal of the subcutaneous fat tissue because of flap thickness. However, saphenous and medial plantar flaps for heel reconstruction did not require this type of reoperation, and the sensory recovery was good. Ten flaps of the surviving 19 flaps required arch support. There were no skin ulcers or callosity in any of the cases.

Both sensory saphenous and medial plantar flaps are ideal for heel reconstruction, but other flaps used did not cause skin ulceration or callosity with arch support.

Free-Tissue Transfer for Coverage of Amputation Stumps in the Upper and Lower Extremities. Vlastou, Lykoudis, Kintos; Athens.

The authors presented their experience with the use of microsurgical free-tissue transfers for coverage of amputation stumps. The goal of the transfers was preservation of length, functional joints, restoration of contour, and to aid in prosthetic rehabilitation.

During the last 15 years, 20 free flaps were transferred, 7 in the upper and 13 in the lower extremity. Nine of them were used during the acute post-injury phase, and 11 at a later stage. The flaps used included: two partial toe transfers; 10 muscle flaps (5 gracilis and 5 latissimus dorsi); 5 myocutaneous flaps; and 3 innervated fasciocutaneous flaps (1 dorsalis pedis, 1 deltoid, and 1 lateral arm). The vessels in the flaps were anastomosed to regional vessels in 17 cases, while in 3 with below-knee amputations, a temporary AV loop was used.

All flaps survived. Two of the upper extremity amputees (1 upper arm, 1 below elbow) were fitted with prostheses, and the functional status was improved. Nine of the lower extremity amputees (4 below knee, 5 foot) were also fitted with prostheses and resumed ambulation. The rest of the patients who did not require prosthetic devices showed improved function.

Emergency or elective microvascular reconstruction of amputation stumps with free-tissue transfers, in an effort to avoid further shortening of the limb, succeeds in preserving length and functional joints, thus contributing to a more rapid and superior rehabilitation of patients.

Salvage of the Lower Limb with the Serratus Anterior Muscle Flap. Corcella, Belfkira, Bozonnet, Martinet, Moutel; Grenoble.

The purpose of this study was to investigate the reliability and versatility of free transfer of the serratus anterior muscle for soft-tissue defects and contour reconstruction of the lower limb. The authors reported their experience with 26 consecutive cases.

Twenty-six serratus free flaps were harvested during the period 1997-2001. The series included 26 patients, 19 males and 7 females, with a mean patient age of 40.7 years (range: 19 to 63 years). In the majority of cases, the flap was used after high-velocity wounds of the leg or ankle due to car accidents. In two cases, a composite muscle and rib bone flap was used for osteomyelitis of the distal part of the tibia. The two or three lower slips of the muscle were harvested, carefully sparing the long thoracic nerve distribution for the six upper slips. The mean duration for flap dissection was less than 1 hr.

Overall transfer success was 92%. One of the two failures was due to an incorrect decision on a heel chronic wound recipient site. For all patients, no major upper extremity dysfunction was noted, especially with scapular winging. In three cases, a seroma at the donor site was evacuated with needle puncture. The reliability of flap coverage and the cosmetic appearance at both recipient and donor sites were judged to be good or very good.

The serratus flap is a remarkably consistent and reliable muscle flap with minimal donor-site morbidity. The long (12 to 18 cm) and large-caliber pedicle allows microsurgical anastomoses well outside the zone of injury. Dissection of the muscle and pedicle is relatively easy and is not time-consuming. The malleability of the flap includes isolation of the slips, allowing for coverage of complex and tri-dimensional soft-tissue defects. These authors believe that the free serratus anterior muscle flap is the gold standard for small-to-moderate defect coverage of the extremities, especially the distal third of the leg.

Reconstruction of Soft-Tissue Defects in the Lower Extremity with Free Flaps. Taniguchi, Iwata, Honda, Yoshida; Wakayama.

The treatment of patients with skin defects of the lower extremity associated with severe soft-tissue defects is very difficult. The authors reported the results of treatment by free flap transfers.

Twenty-nine free flaps were transferred to lower extremities with skin defects; there were 21 male and 8 female patients whose ages ranged from 5 to 74 years. Free flaps included 15 scapular flaps, 10 latissimus dorsi myocutaneous flaps, 3 plantar flaps, and 1 peroneal flap. It was not possible to anastomose the feeding vessels of the flap to the vessels of the affected extremity in 4 patients, whose recipient vessels were in poor condition; thus, cross-leg free flap transfer, a method in which the feeding vessels are anastomosed to the posterior tibial artery and vein of the opposite lower leg, was performed.

Free scapular flap transfer was useful for treatment of soft-tissue defects in the lower extremity. Latissimus dorsi myocutaneous flap transfer was indicated for patients with skin soft-tissue defects extending from the lower leg to the foot. Such flaps were useful also for filling the dead spaces generated by defects at the knee joint. The vascularized cross-leg free-flap procedure was a significant and urgent procedure for the salvage of complicated and massively traumatized extremities. Indication for these methods is extensive soft-tissue injury with lack of adequate recipient vessels or failure of a previous free flap in which anastomoses to the recipient leg were carried out.

Experience in Ankle and Heel Reconstruction with Perforator Flaps. Kepenekidis; Kifissia-Athens.

The aim of this study was to delineate the indications for the use of perforator flaps for coverage of soft-tissue defects of the ankle and heel.

With advanced anatomic studies, a number of fasciocutaneous or fasciosubcutaneous flaps, based on septocutaneous or musculocutaneous perforators, were found suitable for reconstruction of soft-tissue defects of the posterior heel or the ankle, thus delimiting the indications for microsurgical transfer. Inclusion of the deep fascia in the flaps, as proposed by Ponten, and atraumatic dissection with inclusion of as many perforators as possible, are factors to enhance flap survival.

In the last 10 years, 35 patients presenting with soft-tissue defects of the heel and ankle were surgically treated with perforator flaps. Twenty-seven patients were males (77.14%) and 8 were females (22.86%), with ages ranging from 4 to 84 years (mean age: 45 years). The flap was proximally based in 5 patients (14.28%) and distally based in 30 patients (85.72%). A skin island was used in most of the cases to cover a shoe-wearing area.

In the majority of cases, the operative and postoperative periods were uneventful (30/35, 81.75%), and patients began walking a week later. One total and 4 partial necroses of the flap were encountered, due to postoperative venous congestion, leading to prolongation of hospitalization time, and with healing achieved in a second stage. Leeches were used in one patient to improve the congested flap.

The advantages of using perforator flaps for coverage of ankle and heel soft-tissue defects are conservation of the main vascular axes of the leg; no microsurgical risk; easy dissection; and acceptable aesthetic results. Defects presenting signs of infection are better treated with a muscle flap after extensive debridement.

Perforator flaps offer a reliable alternative in the surgical treatment of soft-tissue defects of the ankle and heel, with good quality skin and an acceptable aesthetic result.

Advanced Breast Cancer and Autologous Reconstruction: Is It Safe? Behnam, Moran, Nguyen, Serletti; Rochester, NY.

TRAM breast reconstruction in patients with advanced breast cancer is controversial. Management of these patients is often complex, and consists of surgical extirpation, postoperative radiation, chemotherapy, and in some cases, bone marrow transplantation. Few studies have attempted to examine patient long-term survival and overall satisfaction with the surgical procedure. This study examined one center's experience with patients undergoing breast reconstruction for stages III and IV breast cancer. Surviving patients and family members were contacted for follow-up. Patients were asked to grade their satisfaction with the reconstructive procedure on a five-point scale (5=extremely satisfied and 1=extremely dissatisfied). Postoperative complications and time to return to work were also recorded.

Over a 10-year period (1991-2001), 21 women underwent TRAM reconstruction for advanced breast cancer. Twenty had stage III disease and 1 had stage IV disease. The patient mean age was 49 years. A total of 26 TRAM flaps were performed; five patients had bilateral procedures. Of the 26 TRAMs, 17 were immediate and 9 were delayed, while 20 were free and 6 were pedicled. Follow-up averaged 6.5 years (range: 2-10 years).

Postoperative complications occurred in 7 patients and included fat necrosis (3), hematoma (2), cellulitis (1), delayed donor-site healing (2), and seroma (1). There were no flap losses. Patients were able to return to normal activities or work at an average of 10.6 weeks. Eleven patients developed recurrent disease; 9 patients (43%) succumbed to their disease during the follow-up period; the average interval between TRAM reconstruction and death was 3.7 years (range: 11-6.5 years). Eleven patients or surviving family members participated in the patient satisfaction survey. The average satisfaction grade was 4.6. All patients would repeat the TRAM reconstruction again.

Patients with advanced breast cancer can be considered appropriate candidates for TRAM reconstruction. The results of this study indicated that patients with advanced breast cancer do not have an increased rate of postoperative complications and recover within a reasonable time from their surgical procedures, despite adjuvant radiation and chemotherapy.

600 Consecutive Free TRAM Flaps for Breast Reconstruction: A Single Surgeon's Experience. Jiang, Vega, Sbitany, Behnam; Rochester, NY.

Free TRAM flaps have been shown to provide a soft, naturally textured, warm, and ptotic breast that changes minimally with time. The TRAM flap can be performed as a pedicled or as a free flap. Proponents of the free TRAM flap cite better vascularity of the flap and broader patient selection. Proponents of the pedicled TRAM flap cite predictable results with appropriate patient selection, and the avoidance of the technical considerations of the free flap.

The study population consisted of patients who underwent free TRAM breast reconstruction between 1991 and 2002 at the six teaching hospitals of the authors' medical center, performed by a single microsurgeon. Hospital records and office charts were reviewed for patient demographics, defects, timing of reconstruction, vessels used, OR time, and postoperative complications.

Currently, 302 patients have been reviewed and 600 will be reviewed at the end of the study. The mean patient age was 50.6 years. The ethnic background of patients was 98% Caucasian, 1% African American, and 1% other. Preoperative comorbidites were HTN (18.80%), DM (2.60%), Obesity (14.50%), Heart Dis. (7.90%), Preop Chemo (5.60%), Preop Rad (5.00%), and Smoking (15.80%). Thirty-three percent (98) of flaps were performed at the university hospital and 67% (203) at five community hospitals. Two hundred eighty-three (93.7%) patients had modified radical mastectomy and 19 (6.3%) had simple mastectomies; 263 (87.1%) had unilateral defect, while 39 (12.9%) had bilateral defects; 60 (19.9%) had delayed breast reconstruction, while 242 (80.1%) had immediate reconstruction. Operating room times were: all unilat. 5.9 hr; all bilat. 7.8 hr; imm. unilat. 5.8 hr; delayed unilat. 6.1 hr; imm. bilat 7.8 hr; delayed bilat. 8.0 hr. There were no statistically significant differences in operating time between the immediate and delayed TRAM flaps, and there was no difference between OR time at the university hospital and community hospitals. Two hundred sixty (86.1%) flaps used the thoracodorsal system, 32 (10.6%) the internal mammary system, and 10 (3.3%) used others. There were 12 (4%) intraoperative arterial thromboses and 8 (2.6%) intraoperative venous thromboses identified and repaired, without flap compromise or subsequent thromboses.

Bilateral Deep Inferior Epigastric Perforator/ Fascial-Sparing TRAM Flaps for Reconstruction of Large Defects. Gottlieb, Su, Buscher; Chicago, IL.

There are many disadvantages of double pedicle TRAM flaps, including decreased abdominal-wall strength, upper abdominal midline bulge, and the use of mesh to close the abdominal-wall defect. The authors have used the bilateral deep inferior epigastric perforator/fascial-sparing (DIEP/FS) free TRAM flap to overcome the disadvantages of the conventional bilateral TRAM flap.

Between June, 1996 and September, 1999, 11 bilateral DIEP/FS free flaps were performed in 11 patients for either breast reconstruction, head and neck, or lower extremity reconstruction. The indication for bilateral DIEP/FS free flaps was the need for coverage of a large area or volume of tissue. Evaluation of results was conducted through a retrospective chart review and questionnaire. Of the 8 breast reconstructions, the bilateral DIEP/FS free flap was chosen because either the patient was large-breasted or had little abdominal-wall fat. Three were immediate and five were delayed cases. The average patient age was 45 years (range: 31-53 years). Four patients had had radiation therapy prior to their reconstruction. Three patients were obese, defined by IBW >25%. The harvesting of the TRAM flap included the DIEP on one side and a DIEP or fascial and muscle-sparing DIEA on the other side. The donor recipient vessels were most commonly the thoracodorsal and internal mammary vessels. The abdominal wall was closed without mesh in all cases. The average hospital stay was 5.75 days. Follow-up ranged from 3 to 5 years.

There was no flap loss, and there were no hernias, although one obese patient had lower abdominal-wall bulging. A questionnaire was returned by 6 patients with an average rating of 4 (1-5), and with all but one who would recommend the procedure to others. Five of six had no abdominal pain, back pain, or loss of ability to perform regular activities and sports. All patients who had worked preoperatively returned to work postoperatively. The other three patients had large defects as a result of recurrence of tumor and radiation necrosis. A bilateral DIEP/FS TRAM flap was used to cover these defects.

The bilateral DIEP/FS free TRAM flap is useful for the reconstruction of large defects, both in area and volume. In the series reported, although the dissection was more time-consuming, there was no flap loss, mesh was not required for closure, and there was no reduction in abdominal wall strength.

Long-Term Results in the Salvage of Silicone or Hydrocarbon-Implanted Breasts Using Bilaterally Divided Free Reduced TRAM Flaps. Kawahara, Hyakusoku, Aoki, Hirakawa; Tokyo.

After World War II, many injectable breast augmentations were performed in Japan. Between 1950 and 1960, hydrocarbon material was used, and between 1960 and 1970, silicone gel or fluid was used for injectable breast augmentation. After 1970, silicone bag prostheses were mainly used. Many of the patients have suffered from various late complications, including intramammary induration due to foreign body granuloma; oily infiltration of the foreign material into the skin; breast deformity; asymmetry of the breasts; anxiety about breast cancer which cannot be discriminated from granuloma; and human adjuvant disease (HAD), which is denied epidemiologically in the United States (with data apparently based on silicone bag prostheses implantation patients). For these reasons, many patients want the foreign material and granuloma removed. Since 1994, these authors have performed many salvage operations, and now have long-term follow-ups in 27 cases in which augmentation materials and/or foreign body granulomas have been removed.

Forty-six of 50 breasts were re-implanted with free bilaterally denuded TRAM flaps; 2 of 50 breasts had supercharged pedicled flaps; 23 of the 27 cases were reconstructed immediately after removal of material. Endoscopy was used in 3 cases to avoid inframammary scar formation. Mastopexy was performed simultaneously in one case. Gore-tex was used to prevent pseudo hernia in 3 cases which were reconstructed in the authors' early experience; however, it is no longer used, as the sacrifice of the rectus abdominis muscle is minimal. Not all of the patients wanted to be re-augmented. Three of 50 flaps were lost due to vascular thrombosis.

Re-implantation with the free bilaterally denuded TRAM seems to be one of the best reconstructive methods for patients who need or want the removal of augmentation foreign material and granulomas, and subsequent reconstruction.

Outcomes Following 170 Consecutive Deep Inferior Epigastric Perforator Free Flap Breast Reconstructions. Chang, Fabian; Baltimore, MD.

Breast reconstruction using autologous tissue and muscle-sparing techniques has become increasingly popular. The deep inferior epigastric perforator (DIEP) free flap is one of the latest refinements in the use of abdominal soft tissue to reconstruct the breast, while preserving the rectus abdominis muscle. Free-flap breast reconstruction has been shown to have many advantages over conventional pedicle TRAM flap surgery; however, controversy has arisen regarding the complication rates of DIEP flaps vs. the use of free TRAM flaps.

This reported study evaluated the outcomes of 170 consecutive DIEP flaps performed in 132 patients in a community hospital setting. Thirty-eight patients had bilateral procedures. Immediate reconstruction was performed in 95 cases (56%) and 75 cases (44%) were delayed reconstructions. The mean age of patients was 50 years (range: 26 to 74 years). The mean hospital stay was 3.36 days. Risk factors were present: smoking, 25%; previous radiotherapy, 22%; and obesity, 30%. The thoracodorsal vessels were the preferred inflow for the DIEP flaps, which were based on one (41%), two (28%), three (25%), four (4%), or five (0.6%) perforators. The mean postoperative follow-up period was 15.9 months (range: 3 to 34 months).

Total flap necrosis occurred in 7 patients (4.1%), while partial flap loss occurred in 10 patients (5.9%). Fat necrosis occurred in 18 patients (11.1%). No abdominal hernias were noted, but two patients (1.1%) had slight unilateral abdominal-wall bulges. All patients were able to resume their normal daily activities. One hundred sixty-one patients (95%) had a mean of 1.3 secondary procedures for breast-mound shaping, scar revision, and/or nipple reconstruction, including 36 patients (21%) who had mastopexy or reduction surgery on the contralateral breast for symmetry.

DIEP flap reconstruction offers the advantages of reducing abdominal-wall morbidity, allowing short hospital stays and a return to normal daily activity. These data indicated that while performing the DIEP flap may be more technically demanding, this procedure can be safely carried out in a community setting with complication rates no higher than those reported for free TRAM flaps.

Reliability of the Deep Inferior Epigastric Perforator Flap. How Much Tissue Can Be Used Safely? Cheng, Robles, Wei, Chen, Chuang; Keelung.

From March, 2000 to September, 2002, 110 breast reconstructions were performed at Chang Gung Memorial Hospital, mainly for breast cancer. The deep inferior epigastric perforator flap (DIEP) was the most common procedure (81 cases). Two flaps were revised for venous congestion, one of which was successfully saved. In the 80 successful DIEP flaps, zones I, II (ipsilateral) and III, IV (contralateral) were included, harvesting flaps with a mean weight of 589 g. After shaping the new breast mound, the mean tissue volume used was 522 g, which corresponds to 88.6% of the total volume harvested.

During follow-up, both physical examination and mammography showed a 13% rate of fat necrosis, ranging from 2×2 cm to 4×5 cm, which was noted 3 to 6 months postoperatively. Although this fat necrosis was excised in some patients, none of them needed another flap to preserve adequate shape and volume of the reconstructed breast mound.

Observations suggested that the DIEP flap is very reliable, and that the entire flap may be safely used when required. This includes the farthest tissue beyond the midline (zone IV), even when the blood supply is limited to only one perforator.

Selection and Dissection of Muscle Perforators and Superficial Epigastric Veins: Keys to Success in DIEP Flaps for Breast Reconstruction. Holle, Peek, Kaisers, Exner; Frankfurt.

The use of perforator flaps, and especially the DIEP flap, has been a milestone in microsurgery to reduce donor-site morbidity and to improve flap perfusion in breast reconstruction. However, a review of the literature discloses a wide range of complications, but results are scarcely comparable because of differences in dissection techniques, number of perforators, and observation of motor nerves. This has led to controversy about DIEP flap superiority over the free TRAM flap.

In the course of 228 DIEP breast reconstructions (207 unilateral and 21 bilateral) over the last 7 years, the authors have standardized the technique of flap dissection and selection of blood supply by the muscle perforators and superficial epigastric system. All major perforators and the superficial epigastric veins on both sides are routinely identified - the perforators as they come through the fascia and the superficial epigastric veins in the groin. By observing the size and number of perforators and temporarily clamping the vessel groups, the dominant side is identified on whose deep epigastric vessels the flap is raised. In case of equal sides, the one leading to less muscle and nerve damage is chosen. One segmental motor branch will generally be sacrificed, but immediately resutured (83% of cases), to allow for at least two perforators in the flap. With the chosen perforators open and the contralateral ones divided, the flap is then checked for venous stasis, easily identified by a capillary refill time under 1 sec. If such is not the case (noted 18% of times), opening the contralateral superficial epigastric vein has immediately decongested the flap. It is dissected for a second venous anastomosis. Anastomosis of the deep epigastric pedicle is always performed end-to-end with the divided internal thoracic vessels. The additional vein is usually connected to the upleading leg of the internal thoracic vein. Retrograde drainage is guaranteed by the intercostals and diaphragmatic veins. In four cases, the cephalic vein was mobilized for this purpose, and in one case, the superficial jugular vein.

Follow-up examination of at least 3 months (6 years to 3 months) was done. The function of the rectus muscle was tested by dynamic ultrasound investigation. Five of 228 patients (2.1%) developed cardiac or pulmonary problems postoperatively, which resolved with ICU care.

DIEP Flaps: Are We Reaching the Goal? Lantieri, Alamdari, Petit, Kouroch, Paraskevas; Creteil.

The goals of an ideal breast reconstruction are a natural ptotic breast, using the patient's own tissue, and as reliable as possible. Also, in failed or relapsed cases, it should be possible to revert to a standard reconstruction with the latissimus. The evolution from the TRAM to the DIEP flap raises the question of whether the DIEP should replace the conventional or free TRAM.

These authors have evaluated their own series of 123 DIEP flaps performed between 1995 and 2003, and tried to answer questions about reliability, reproducibility, effectiveness, and morbidity. Their failure rate was 4.87%. Their complication rate (hematomas, reoperations, fat necroses) was relatively high at 20.3%; however, it was higher in the earlier period from 1995 to 1999 (25%). Venous drainage is still a problem, but better knowledge of the perforators makes the dissection less traumatic and helps to choose the best drainage. In the earlier procedures, operating time was an average of 6.5 hr but since 2001, the time for the senior author is now 4 hr; done by fellows, as it is now, the average time for the procedure is 5 hr. The DIEP has been the authors' main choice for immediate reconstruction (52 flaps). The use of the flap is especially rewarding in skin-sparing mastectomy (38 cases).

To establish the extent of donor-site morbidity, EMGs have been done on the lower part of the abdomen in 25 patients with a 1-year follow-up. At 3 months, the strength of the operated side was 50% of the contralateral (control) side. At 1 year, it was 80% of the control side. This can be compared with the free or pedicle TRAM flap, where the loss is much more extensive. In cases of double reconstruction (5 cases), patients had no abdominal problem and could easily carry out all daily life tasks. At the recipient site, the authors advocate the use of the circumflex scapular vessels; they are easily reached, especially in immediate reconstruction, and in cases of failure or relapse, the use of the latissimus is possible.

The DIEP flap for these authors is an efficient tool for breast reconstruction, reaching the goals of effectiveness, reproducibility, and low morbidity. It has been perfectly integrated into a breast surgery center that performs lumpectomy, mastectomy, and breast reconstruction. Although not a solution for all reconstructive cases, the DIEP should replace the conventional or free TRAM flap whenever possible.

Breast Reconstruction with the Superficial Inferior Epigastric Artery Free Flap. Spiegel, Klebuc; Houston, TX.

The prospect of harvesting tissue for breast reconstruction without disrupting the fascia, muscle, and innervation of the anterior abdominal wall, in conjunction with technical refinements in microsurgical technique, have led to a renewed interest in the superficial inferior epigastric artery (SIEA) flap. A limited number of clinical series are available outlining indications for this flap. The authors have reviewed their initial experience with SIEA breast reconstructions, in order to determine what vessel size constitutes a reliable pedicle, the flap size that can be dependably transferred, and the complications associated with the procedure.

Twenty-five SIEA flaps were performed on 22 women over a 10-month period. Six reconstructions were bilateral and 16 were unilateral. Of the bilateral reconstructions, three patients had a bilateral SIEA and three patients had a unilateral SIEA and a contralateral DIEP. Vessel diameters of the superficial inferior epigastric artery ranged from 1.3 mm to 3.0 mm, with an average of 1.8 mm. If the artery was less than 1.3 mm in diameter, the SIEA was abandoned in favor of the DIEP flap. Superficial inferior epigastric vein diameter ranged from 1.8 mm to 3.0 mm, with an average diameter of 2.6 mm. Flap weights ranged from 1127 gm to 368 gm, with a mean of 582 gm. On average, 67% of the flap was utilized for creation of the breast mound. Patients were evaluated by a blinded, independent clinician, who was asked to score the presence of fatty necrosis as absent, mild, moderate, or severe. Additionally, a retrospective chart review was performed to evaluate immediate and late postoperative complications.

Of the 25 flaps that were performed, there were three re-explorations and one flap loss. There was one partial flap loss due to a hematoma. There were two wound infections. Fat necrosis was evaluated as mild in 8% of patients. There were no patients with complaints of abdominal bulge, weakness, or hernia.

The superficial epigastric artery flap is the most recent step in the evolution of breast reconstruction. The authors have found that the SIEA flap can be performed safely and reliably, if an arterial vessel larger than 1.3 mm is present. Due to the donor-site advantages, they have adopted the SIEA flap as their first choice in breast reconstruction.

Is the SIEA Flap a Valuable Alternative for Breast Reconstruction? Vandevoort, Fabre; Leuven.

The gold standards for breast reconstruction in the authors' unit are the DIEP and the S-GAP flaps, the latter especially in cases with insufficient abdominal excess, or more specifically, bilateral breast reconstruction in thin patients.

Between January, 1998 and October, 2002, 300 breasts were reconstructed, of which 256 were with DIEP flaps, 33 with S-GAP flaps, and 11 with SIEA flaps. The first SIEA flap performed was in July, 2001. In a period of 14 months, 11 breasts were reconstructed using this flap. An SIEA flap was harvested every time when dissection in the lower abdomen revealed a large superficial epigastric artery, and the artery in this flap is the limiting factor that decides whether harvesting is possible or not. Zone 4 was used in only 1 flap, zone 3 in 4 flaps, and in the remaining flaps, only zones 1 and 2 were used for free tissue transfer. No SIEA flaps were lost, and all flaps healed without skin necrosis or clinically significant fat necrosis.

The superficial inferior epigastric pedicle length averaged approximately 7 cm. The internal mammary vessels were used as recipients in 9 flaps and the internal mammary perforators in 2 flaps. The contralateral pedicle was always harvested to reconstruct the breast, and the flap was turned 90 degrees prior to insetting in order to allow easy approximation for microanastomosis and modeling of the flap at the recipient site.

The free SIEA flap is an attractive option for autologous breast reconstruction but, due to the shorter pedicle, needs careful preoperative planning. The incidence of a pedicle diameter of the superficial inferior epigastric artery, sufficient enough to carry a large adipocutaneous flap, was rather small in this series. The advantages of the SIEA flap are ease of pedicle dissection and absence of injury to the underlying anterior rectus fascia.

Choice of Recipient Vessels for Free Flap Breast Reconstruction. Hamdi, Blondeel, Van Landuyt, Monstrey; Gent.

The internal mammary (IM) vessels are the authors' first choice for free flap breast reconstruction, although this may result in pain and thoracic deformity. Efforts in reducing morbidity led to the adoption of an algorithm in free flap breast reconstruction, and also to the salvage of compromised free flaps.

The IM perforators are searched out during the undermining of breast skin. If no suitable perforator is found, the pectoralis major (PM) muscle is split at the level of the 4^th rib. The PM muscle is dissected cranially to find a good-sized perforator. The IM vessels are considered for microanastomosis if the perforator is small. The IM perforator can also be used as an additional recipient vein in cases of congested free flaps or venous thrombosis. The thoracodorsal (TD) vessels are used as an additional blood supply or drainage in case a large flap is indicated. The TD vessels are spared, if a latissimus dorsi flap is required in a secondary procedure. Thoracoacromial vessels are considered in salvage of a flap with late venous thrombosis.

This protocol was used in patients between June, 1999 and December, 2001. Breast reconstruction with free flaps was done in 218 patients with perforator flaps. IM, TD, and thoracoacromial vessels were used in 180 patients (82%), in 10 (4.5%), and in one case (0.5%), respectively. IM perforators were successfully used in 27 cases (12.5%), but a revision of arterial thrombosis occurred in one case, resulting in partial flap necrosis. Operating time was decreased by 60 min by limiting the dissection of recipient vessels and of the main pedicle of the flap.

Using IM perforators as recipient vessels spared the IM vessels for eventual cardiac bypass surgery, avoiding recipient-site morbidity, and decreasing postoperative discomfort.

Autologous Free Tissue Breast Reconstruction Using the Internal Mammary Perforators as Recipient Vessels. Sassoon, Haywood, Logan, Raurell, Perks, O'Neill; Norwich.

Donor-site morbidity has steadily been reduced in autologous breast reconstruction with the evolution from pedicled transverse rectus abdominis myocutaneous (TRAM) flaps to free TRAM flaps, to free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric perforator (SIEP) flaps. The recipient vessels for these free flaps are usually either branches of the thoracodorsal axis or the internal mammary vessels. Access to the internal mammary vessels requires the removal of a section of costal cartilage. This may cause pain and there is a risk of pneumothorax; contour defects may be created, and using the internal mammary vessels removes a potential donor vessel for future coronary artery bypass surgery. During dissection to expose the internal mammary vessels, the perforators of these vessels are often seen in the 2^nd or 3^rd intercostal spaces.

These authors presented their experience with 21 cases in which the perforators of the internal mammary vessels were used as recipient vessels for DIEP, SIEA, or S-GAP flaps in breast reconstruction. Eleven of the cases were delayed reconstructions, and four patients had received radiotherapy after mastectomy. There were no partial or complete flap losses. Five flaps underwent successful re-exploration. The authors described the lessons learned, and discussed the place of these flaps in the armamentarium.

Complications in 40 Consecutive DIEP Flaps for Breast Reconstruction. Roche, Hofer; Rotterdam.

The TRAM flap offers the best option for autologous breast reconstruction in women with adequate abdominal tissue. Transferring the flap as a free flap greatly improves vascularity. The DIEP flap has further improved outcomes, as it reduces donor-site morbidity. The aim of this presentation was to evaluate the recipient and donor site complications in 40 consecutive DIEP flaps performed by one surgical team, and to comment on solutions to problems that arise.

Between January, 2002 and February, 2003, 40 DIEP flaps were performed in 31 patients. Recipient and donor-site complications were evaluated, and risk factors in all patients were correlated with complications. All breast reconstructions were successful. Eight flaps showed a marginal venous congestion in the zone II area during the early postoperative course. These were treated with excision and primary closure. One patient with a large skin requirement due to an irradiated skin-grafted chest required a local transposition flap to replace the excised area. One patient with a bilateral reconstruction demonstrated venous congestion in one flap. Six patients had minor abdominal skin-healing problems. Two patients had major healing problems which resulted in abdominal skin loss requiring skin grafting. In all cases of abdominal wound-healing problems, patients had a combination of two or more of these risk factors: diabetes, smoking, or obesity. All patients were satisfied with their early aesthetic and functional outcomes. Refinements were presented that improved results.

Autologous breast reconstruction with the DIEP flap has proven to be a safe procedure in the authors' hands. A high number of minor recipient-site complications early in the series could have been improved after better planning during breast shaping. Donor-site complications were correlated with the known risk factors associated with impaired wound healing.

Use of Internal Mammary Vessel Perforators as Recipient Vessels for Free TRAM Breast Reconstruction. Park, Lee; Korea.

Breast reconstruction is a cosmetically critical procedure for women, and it must be undertaken to balance the shape, size, and position of one breast with the other. Since the introduction of the free abdominoplasty flap in 1979, the transverse rectus abdominis musculocutaneous (TRAM) flap has been a widely accepted method of breast reconstruction after mastectomy. In breast reconstruction with a free flap, the selection of suitable recipient vessels is an important decision to be made by the surgeon. The most common recipient vessels for free flap breast reconstruction are in the axillary system. However, when used as a recipient, the axillary system may limit flap movement and flexibility in breast shaping. The use of the internal mammary vessels as recipients attains ideal breast symmetry; however, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft requiring the internal mammary artery. The authors have performed breast reconstructions with the TRAM flap anastomosed to the internal mammary perforator vessels, and have concluded that these perforators can be useful as recipient vessels, especially in the case of immediate breast reconstruction with free TRAM flaps.

Free TRAM Flap for Breast Reconstruction in Patients with Midline Scarring in the Lower Abdomen. Santamaria; Mexico City.

Lower abdominal midline scar after a C-section is not uncommon in Mexico. Pedicled or free TRAM flaps for breast reconstruction have been contraindicated in these patients, due to a decreased blood supply from zone I to zone II and increased risk of flap necrosis. Instead, a bipedicled TRAM or unipedicled TRAM/supercharged flap on the opposite half has been recommended. To determine if it was safe to use a free TRAM flap for breast reconstruction in this group of patients, the authors did angiographic studies in 7 women with an abdominal midline scar, who underwent an aesthetic abdominoplasty. A TRAM flap with a 2×2-cm muscle segment including one or two perforators was harvested. Using an infusion bomb with a continuous pressure of 120 mmHg, 20 cc of diluted non-ionic contrast media solution was injected through the deep inferior epigastric artery. Two to 5 min later, x-ray films were obtained to assess the vascular supply within the flap zones. After closing the anterior rectus fascia, the abdominal lipectomy was completed.

A free TRAM flap was used for breast reconstruction in 9 patients with a midline scar in the lower abdomen. Flap bleeding was evaluated prior to pedicle division, zone IV was always discarded, and zone II was always included in the flap to create the breast mound. Vascular anastomoses were to the internal mammary artery and vein. The mean age of all 16 patients (angiography group and surgery patients) was 36±+5.1 years. The number of C-sections was 3 in 2 patients, 2 in 3 patients, and 1 in 11 patients. The average time elapsed between the last C-section and the angiography study/surgery was 7.3±+4.7 years (range: 4.5 to 18 years). Assessment of angiographic studies demonstrated excellent blood perfusion of the flap in zones I and III, reduced vascular supply in zone II, and no arterial vessels stained in zone IV. Flap survival in the 9 patients who underwent breast reconstruction with the free TRAM flap was 100%. Wound dehiscence in the breast mound was observed in 1/9 patients. Fat necrosis (less than 20%) developed in 2/9 patients in the zone III flap area. However, no correlation could be established between the number of C-sections, patient age, or time elapsed after the abdominal surgery, and blood perfusion findings at the time of the angiography study or surgery outcomes.

The free TRAM flap was found to be a safe procedure for breast reconstruction in patients who underwent previous abdominal surgery through the midline. Further studies are pending to determine how soon after abdominal surgery vascular connections between zones I and II of the skin paddle/fat tissue are safely established.

Vascularized Bone Grafts - Free or Pedicled Flaps? Molski; Warsaw.

Free vascularized bone grafts (FVBGs) have become a routine procedure in cases of extensive defects of long bone shafts. They are possible only in highly specialized medical centers with significant experiencee in microsurgery. FVBGs are an ideal treatment with very good late results. Application of this method is restricted because of various reasons. Pedicled flaps (PF) including elements of the vascularized bone (e.g., fibula, radius) are a simpler procedure which can be performed in any orthopaedic center. The results of treatment are as good as with FVBGs. Indications for PF are still controversial because of possible additional restrictions in the function of the impaired extremity at the donor site. Yet, in some cases, pedicled flaps are the only procedure possible to save the extremity (e.g., cross-leg pedicled fibular graft). In such cases, the extremity must be immobilized in an uncomfortable position, and the patient must stay in the hospital for several weeks.

The author discussed actual possibilities for the application of bone vascularized grafts in the extremities on the basis of his own experience treating 90 cases. He presented his criteria for procedures in relation to the extensiveness of bone and soft-tissue damage and the condition of the axial vessels in the impaired lower limb.

Vascularized Free Fibular Grafts in Spinal Reconstruction. Rishavy, Khan, Shin, Bishop, Wilden, Moran; Rochester, MN.

Vascularized free fibular grafts have been previously described for use in spinal reconstruction in cases of osteoporosis, tumor, kyphosis, and spondylolisthesis. While most of the literature involves case reports, there are a few small series documenting the benefits of this type of reconstruction. The benefits of vascularized bone grafts include more rapid rates of fusion, resistance to fracture and resorption, and maintenance of structural integrity.

The authors retrospectively reviewed a 9-year period at their institution in which seven patients received a vascularized free fibular graft to augment spinal reconstruction after infection, trauma, or tumor. A thorough chart review was performed, looking specifically at presentation, work-up, graft length, levels spanned, and postoperative time to fusion, as well as complications.

Seven patients underwent surgery during 1993- 2002. The grafts spanned from 1 to 6 (mean: 2) vertebral levels in the thoracolumbosacral region. Follow-up ranged from 4 to 85 months (mean: 50 months). Fusion and viability of all grafts was confirmed via standard radiographs or computed tomography. Patient ages ranged from 14 to 58 years (mean: 45 years). Six of the seven patients presented with lower back pain. The majority of patients (6/7, 85%) were referred from outside institutions after undergoing previous spinal operations. The harvested fibular length ranged from 15 to 25 cm (mean: 21 cm). All grafts were utilized to provide vertebral support after resection of tumor or infection. There were no microvascular failures in any of the grafts although, in one case, the graft had to be exchanged for a contralateral free fibula secondary to the development of an arteriovenous malformation. Graft fusion was confirmed in 4 patients radiographically from 12 to 49 months (mean: 22.5 months). There were no donor-site complications.

Vascularized free fibular transfer for spinal fusion may provide a means of improving union rates in difficult reconstructive settings. A thorough review of the literature has verified this to be the largest series to date, as well as the only series to involve the use of these grafts in the presence of infection. The results confirm the notion that vascularized free fibular grafts are a safe and successful choice in the armamentarium of spine surgery.

Limb Salvage in Pediatric Orthopedic Oncology: Experience with Free Flap Reconstruction in 19 Children. Gur, Zaritski, Leshsem, Barnea, Kolander; Tel-Aviv.

Soft-tissue and bone sarcoma represents 1% of adult malignancies, but 15% in children. In the past, the surgeon had to decide the level of limb amputation for sarcoma, but current interest is in the preservation of functional limbs. At surgery, large bone and soft-tissue defects are created, and microsurgery plays a role in the reconstruction of these defects.

Between July, 1998 and July, 2003, 19 patients were operated on, 7 males and 12 females, with a mean patient age of 13 years. The diagnoses were osteosarcoma (8), Ewing sarcoma (7), high-grade soft-tissue sarcoma (3), and giant cell tumor (1). The anatomic distribution was femur (7), tibia (5), fibula (1), radius (4), forearm (1), and arm (1). In 14 patients, the fibula was transferred to provide bone reconstruction: in 4, for femur reconstruction; in 4, for the tibia; in 1, for knee arthrodesis; in 4, for the distal radius; and in the last, for femoral head reconstruction. Five patients had soft-tissue reconstructions; in 2, the latissimus dorsi flap was used; the scapular flap, DIEP, and gracilis muscle were used once each.

The flap transfer success rate was 95%. Bone viability was assessed clinically, radiologically, and by radioisotope scanning. There were 3 postoperative major complications: one total flap loss, a femoral artery thrombosis, and loosening of a plating system.

Special reconstructive considerations relating to the pediatric population are: growth potential, the need for long-term and durable results, reduction of the number of procedures, and aesthetic results. The authors presented several patients with various reconstructive needs, detailing the problems and demonstrating the microsurgical solutions for pediatric orthopedic oncology.

Fracture of the Vascularized Fibular Graft: Risk Factors and Prevention. Ihara, Shigetomi, Muramatsu, Sakamoto, Ohno, Kawai; Ube, Yamaguchi Prefecture.

Fracture of the vascularized fibular graft is often encountered until the graft obtains sufficient mechanical strength. In 1992, these authors reported the results in a small series; in the present report, their series included 63 patients who received vascularized fibula grafts for extremity reconstruction.

Patients with avascular necrosis of the femoral and humeral head were excluded; thus, 63 patients (43 males, 20 females), with a mean age of 41 years (range: 3 to 78 years), were included. There were 43 traumatic defects or non-unions, 12 tumors, 5 osteomyelitis, and 3 others. The recipient sites were the tibia (32), femur (18), and upper extremity (13). The mean follow-up period was 37 months (range: 6 to 125 months). Statistical analysis was performed using the Mann-Whitney U test.

The mean length of the grafts was 15 cm (range: 6 to 27 cm). Fracture of the grafts occurred in 18 patients (29%). There were 10 stress and 8 traumatic fractures. Stress fractures occurred at the mean of 9.5 months after surgery. Six of 8 traumatic fractures occurred at an osteosynthetic site of the graft in an early stage after surgery. All but one patient with stress fractures in the lower extremity did not require surgery. On the other hand, three-quarters of patients with upper extremity involvement required operative treatment. The risk factors for stress fractures were large bony defects longer than 10 cm, and malalignment of the graft with greater than 5 degrees.

Stress fracture usually promotes hypertrophy of the graft, but should be avoided because of adverse effects on functional recovery. Results showed that good alignment of the graft is very important for prevention of stress fracture. Technical augmentation, such as dual grafting, should be considered in cases with extensive defects longer than 10 cm.

Long-Term Follow-Up of Patients with Large Extremity Bone Defects Treated with Free Vascularized Bone Transfer. Hankiss, Gal, Renner, Szendroi; Hannover.

Management of large extremity bone defects is a major challenge for the reconstructive surgeon. Extensive injury or damage to different types of tissue are common. Salvage of the extremity should consider whether useful function can be preserved or not. In well-selected cases, a successful free vascularized bone transfer offers the most rapid recovery and best stability and function. This study evaluated long-term results in the authors' patients.

Between 1992 and 1996, 8 patients underwent free vascularized bone transfer for large extremity bone defects of various origins, including post-traumatic and septic cases, and primary bone tumors. The upper extremity was affected in 3 cases, the lower extremity in 5 cases. The follow-up was 6 to 10 years. Physical examination and x-ray imaging were performed, and patient satisfaction was evaluated by using a standardized protocol.

All transplanted bones were viable. All limbs had more useful function, compared to usual conditions after amputation and prostheses. The majority of patients had returned to work, although some patients had moderate gait difficulties. In these cases, the procedure was beneficial for function of the extremity, general well-being, and quality of life. Most of the affected extremities would not have been salvageable with conventional methods.

Problems Encountered in Free Fibular Transfer. Yadav; Mumbai.

1. Osteotomies at the time of fibula contouring. 2. Disparity of vessels, mainly veins to be anastomosed. 3. Reliability of the skin paddle for judgment of underlying fibular graft. 4. Excision of part of the graft. 5. Short height for permanent dental implant.

Vascularized Bone Transfer for Reconstruction of Defects after Trauma and Osteomyelitis. Fromberg, Conz, Schmidt; Murnau.

Distraction osteogenesis has revolutionized the treatment of long and circumferential bone defects of the femur and tibia, and has reduced the number of microsurgical bone transfers. However, microsurgical bone flaps have not become obsolete. Bony defects after trauma and/or infection are frequently associated with soft-tissue defects or scar tissue with recurrent ulceration. The patients face numerous operations, long periods of hospitalization, and even longer immobilization. In many cases, microvascular soft-tissue transfer is essential for stable, long-term results.

From 1997 to 2003, 52 free vascularized bone grafts were performed at the BG-trauma center, Murnau. The main donor region was the lateral border of the scapula. This offers a safe and versatile length of pedicle, with a choice of three pedicles, using either the thoracodorsal or the circumflex scapular vessels and their respective soft tissue. Defects were most frequently located in the lower leg; other recipient areas were the femur, forearm, metacarpal, or metatarsal/tarsal bones. In 3 cases, the bulk of soft-tissue transferred with the bone was lost due to vascular complications, but the pedicle to the segment of scapula survived, allowing consequent skin grafting of the remaining defect.

Patients with bony defects, who require soft-tissue reconstruction of the same region, should be offered the benefit of simultaneous vascularized bone grafts. This applies to non-circumferential defects of the femur and tibia of less than 8 cm, as well as loss of the metatarsal or metacarpal bones, or of bone segments of the tarsal or carpal region. Microsurgical reconstruction of these cases seems to be superior to callus distraction procedures.

Indications for Vascularized Fibular Grafting for Osteonecrosis of the Femoral Head. Shigematsu, Yajima, Kawate, Kobata, Kawamura; Kashihara.

Since 1992, 46 patients with osteonecrosis of the femoral head have been treated using vascularized fibular grafting. The authors reported the clinical results and indications for the procedure.

Thirty-eight consecutive patients, involving 44 hips, who were followed for at least 1 year postoperative, were investigated. Twenty-nine patients (34 hips) were males and 9 (10 hips) were females. The average patient age at surgery was 36 years (range: 15 to 56 years). The etiology of osteonecrosis of the femoral head included idiopathic (3), use of steroids (21), consumption of alcohol (8), and post-traumatic lesion (6). According to the modified Marcus criteria, 3 hips were in stage I, 24 in stage II, 9 in stage III, 7 in stage IV, and 1 in stage V at the time of operation. Classification of the osteonecrosis of the femoral head (Japanese Ministry of Health and Welfare) before surgery was B in 1 hip, C1 in 14, and C2 in 29. The Japanese Orthopedic Association (JOA) score was 60 points in the unilateral cases and 54 points in the bilateral cases. The average follow-up was 50 months (range: 14 to 114 months).

All patients improved in the JOA score; the average score improved to 79 points in unilateral cases and 74 points in bilateral cases at the latest follow-up. The stage of 14 hips deteriorated, and 6 patients were converted to a total hip arthroplasty because of progressive coxalgia after 5 years post surgery. A Kaplan-Meier survivor analysis demonstrated the probability of conversion to total hip arthroplasty. The survival rate was 100% at 2 years, 91% at 3 years, and 78% at 5 years post surgery. All patients converted to a total hip arthroplasty had used steroids and were bilaterally involved and type C2 as well.

Osteonecrosis of the femoral head induced by idiopathic etiology and consumption of alcohol obtained better results with the use of vascularized fibular grafting. However, strongest indications are in bilateral cases with previous steroid use.

Actual Hypertrophy of Vascularized Fibular Grafts in Tibial Bone Loss. Moroe, Kazuhiko, Sasuo, Koh, Kajime; Kawasaki City, Japan.

Vascularized bone grafts have made it possible to reconstruct previously incurable large bone defects, and the clinical results are constantly improving. The purpose of this study was to measure by CT scanning, the true amount of hypertrophy of vascularized fibular grafts used for tibial bone loss.

The study consisted of 8 cases of vascularized fibular graft used for bone loss in the tibia. Patient age at injury ranged from 17 to 52 years (average: 38.4 years), and the mean duration of follow-up was 11 years and 6 months. The mean length of bone loss was 9.9 cm and the mean length of the fibular grafts was 16.8 cm. Bone union was attained 6 to 8 months after surgery. The percent hypertrophy of grafted bone was measured radiographically by the method described by Boer and Wood. Measurement was performed at a point which was not influenced by callus formation from the recipient bone or the fracture of the grafted fibula. The true amount of hypertrophy of cortical bone volume was measured by CT scan (Toshiba X Vigor CT) at 5-mm intervals using 5-mm sections. The volume of the fibula and medullary cavity was each calculated by using software on the scanner; the difference between the two equals cortical bone volume. Bone mineral volume in the vascularized fibula was measured by DEXA.

The mean percent hypertrophy was 44.0 A}28.5%. The cortical bone volume in the grafted fibula was 2.8 times greater than in the recipient fibula and 86% of the healthy tibia. Bone mineral volume of the grafted fibula was 4.2 A}1.06 times greater than in the recipient fibula, and 1.11 A}0.26 times greater than the healthy tibia. The percent hypertrophy of the grafted bone was measured radiographically by the method described by Boer and Wood, as mentioned; however, this method is two-dimensional. Cortical bone hypertrophied in both the outer and medullary directions, and the medullary cavity was narrower from the AP view. Measurement of percent hypertrophy was not accurate enough to evaluate hypertrophy in the grafted fibula. The authors therefore developed a method to measure cortical bone volume by computerized tomography scan.

Results of Pedicled Vascularized Rib Grafts in Complicated Segmental Spine Fusion Surgery. Shin, Moran, Dekutoski, Wilden, Bishop; Rochester.

The results of vascularized pedicled rib grafts in patients with complicated segmental spine fusion have not been adequately reported. A retrospective review over a 20-year period at a single academic institution identified 16 patients who underwent vascularized pedicled rib grafts for complicated segmental spine fusions. The average patient age was 47.4 years (range: 19 to 74 years), with 8 female and 8 male patients. Diagnoses included 9 with either recurrent/metastatic or primary spine tumors; 3 with multiply failed scoliosis surgery; 2 with multilevel osteomyelitis; and 2 with traumatic spine injuries with failed multiple previous surgeries. Three patients had no prior surgery, while the remainder had an average of 3.2 procedures prior to presentation.

During the spine fusion, which was performed anteriorly in 9 patients, posteriorly in 1, and combined anterior/posterior in 6, a pedicled vascularized rib was used to augment the fusion, along with allograft and autograft bone. The average spine levels fused was 4.25 levels, and instrumentation was used in 7 of the 16 patients. Right-sided ribs were used in 7 and left ribs in 9 cases. Ribs between the 4^th and 11^th were used. The average length of vascularized rib was 14.1 cm. The average follow-up was 3.76 years in 14 patients; 2 patients died within 4 months of surgery; and 2 died approximately 1 year after surgery. Perioperative complications included 1 wound infection, 1 fractured rib, 1 pulmonary embolism, 1 deep vein thrombosis, and 2 deaths. There were 12 subsequent surgeries performed in 10 patients, often relating to hardware failures or nonunions. Viability of the vascularized rib graft was confirmed by bone scans. The average time to union of the vascularized rib graft was 8.25 months. There was one nonunion of the vascularized rib graft at the proximal junction; all others incorporated into the fusion mass.

The use of vascularized pedicled rib grafts is a relatively simple technique that introduces living and viable bone, which can aid in the arthrodesis of difficult segmental spinal fusions that often have had multiple previous procedures. Its use was recommended in cases of previously failed arthrodesis or in large segmental defects in which allograft and autograft bone is often used.

Vascularized Fibular Grafting in the Treatment of MRSA Osteomyelitis and Infected Nonunion. Tamai, Kobata, Shigematsu, Kawamura, Tamai; Kashihara.

Between 1976 and 2000, vascularized fibular grafting was performed in 78 patients with osteomyelitis or infected nonunion. Twenty of these patients with MRSA infection were analyzed.

Sixteen patients were men and four were women, with ages at operation ranging from 17 to 73 years (mean: 37 years). They were followed-up for an average of 5 years and 4 months. Nine of the lesions affected the femur, 8 the tibia, 1 the clavicle, 1 the radius, and 1 the ulna. The average time between initial injury and vascularized fibular grafting was 17 months. All of the patients were treated by extensive debridement and additional local antibiotic therapy. Continuous local irrigation was applied in two patients, antibiotic-formulated bone cement in 5, and both in 10 patients. The average length of the bone defect was 9.6 cm, and the mean length of the donated fibula was 18.2 cm.

Postoperative circulatory disturbance necessitated revision surgery in 6 patients, and salvage occurred in 4 patients. Recurrence of local infection was encountered in 6 patients, including one failed graft. Eventually, 18 of the 20 cases attained successful subsidence of inflammation. The mean period required for radiographic bone union was 7 months in the femoral reconstructions (range: 4 to 18 months), 6.1 months in the tibial reconstructions (range: 4 to 11 months), and 6 months in the remaining patients (range: 4 to 8 months).

In the authors' opinion, vascularized fibular grafting is the most reliable procedure in the treatment of MRSA osteomyelitis and infected nonunion.

Comparison of Free Fibula Transfer and the Ilizarov Method for Reconstruction of Congenital Pseudarthrosis of the Tibia. Venkatramani, Sabapathy, Rajasekaran; Coimbatore.

Congenital pseudarthrosis of the tibia is a rare and difficult condition to treat and, in the past, a large number of patients have undergone amputation. The advent of the Ilizarov technique and microsurgical bone transfer have radically changed the situation. The authors presented a comparison of experience with both techniques.

Five patients with congenital pseudarthrosis were treated by the Ilizarov technique; two patients with non-union, and an additional two children were treated by microsurgical free fibula transfer. The ages of patients ranged from 1.5 to 5 years. The longest follow-up in the Ilizarov group was 8 years and in the free fibula group, 4 years.

Results Ilizarov Group Free Fibula Group

Bony union 3/5 4/4

Failure 2/5 none

Average #

Surg. Procedures 6-8 1

Time to bony 10-14 weeks 22-26 weeks

union

Duration of 16-20 weeks 24-36 weeks

fixator

Microsurgical free fibula transfer was currently presented by the authors as their preferred technique for the management of congenital pseudarthrosis. It provides reliable bone union, and is a single-stage procedure with less time to bony union, compared with the Ilizarov technique. Patient compliance was also better. The limitation is the inability to simultaneously correct leg length and additional deformities of the foot.

Hemi-Resection of the Knee Joint and Reconstruction Using Pedicled Patella and Free Vascularized Fibular Graft. El-Gammal, El-Sayed, Kotb; Asssiut, Egypt.

A new technique was described for mobile biologic reconstruction of the knee joint following resection of bone tumors involving one condyle of the distal femur or proximal tibia. The patella is used for joint resurfacing after being mobilized on the infra- or suprapatellar fat pad. The central portion of the quadriceps or patellar tendon is used for collateral ligament reconstruction. A free vascularized fibular graft is used to reconstruct the metaphysis and to support the patella. The procedure was used in four patients, in three following resection of the medial femoral condyle, and in one following resection of the medial tibial condyle. Follow-up averaged 2 years. None of the patients had pain or axial malalignment. One patient had anteromedial instability that required support bracing. The resulting arc of motion averaged 20/100. The technique provides an alternative in mobile knee reconstruction following excision of a single compartment of the knee joint.

Combined Procedure of Transtrochanteric Osteotomy and Vascularized Iliac Bone Graft for Advanced Osteonecrosis of the Femoral Head. Nakamura, Toh, Mistui, Kumazawa, Katano; Hirosaki, Aomori.

Since 1984, these authors have performed a combined operation of transtrochanteric rotational osteotomy and vascularized ilic bone grafting for advanced osteonecrosis of the femoral head. They reported the rationale, surgical technique, and results of this combined procedure.

The criteria for the procedure were an age of less than 45 years, a specific Ficat stage, and a determined stage of osteonecrosis of the femoral head. It is indicated for the patient with an extensive necrotic lesion involving more than two-thirds of the femoral head, with collapse of the femoral head at the weight-bearing portion in lateral x-ray. The adaptation of the hip joint is restored by transtrochanteric osteotomy, and the vascularization and strength of the new weight-bearing portion are maintained by vascularized strut bone grafting.

This procedure was performed in 12 patients with advanced osteonecrosis. At a mean of 81 months after operation, eight patients had clinically satisfactory results, and 10 hips were protected from further collapse of the femoral head. In these cases of advanced and extensive osteonecrosis, the combined procedure was successful in restoring congruity of the femoral head. This combination was recommended for advanced and extensive osteonecrosis of the femoral head, especially in young patients.

Long-Term Effects of Lymph Vessel Transfer in the Treatment of Lymphedemas. Baumeister, Frick; Munich.

Lymphatic vessels are one of the most interesting vascular challenges for microsurgery, because they require advanced microsurgical skills to anastomose them and utilize them as grafts. Local interruptions of the lymphatic system, e.g., in the axilla and groin, can be bridged by lymphatic bypasses. The grafts are harvested from the thigh to a length up to 30 cm. In cases of arm edema, the grafts are interposed between the ascending lymphatics at the upper arm and those at the neck. In unilateral edemas of the lower extremities, the grafts are transposed via the symphysis and anastomosed with ascending lymphatics in the affected leg. Penile and scrotal lymphedemas, as well as primary lymphedemas due to a regional atresia, and peripheral lymphedemas after a local interruption of the lymphatics, can be treated with lymphatic grafts.

The authors reported on 240 patients treated by lymphatic grafting; 130 of them had edemas of the upper extremities, 103 of the lower extremities, 7 had penile and scrotal lymphedemas. In arm edemas, the mean preoperative volume was decreased from 3368 cm³ to 2507 cm³. After a mean follow-up of 2.6 years, the volume was 2625 cm³. A group of patients with a minimal follow-up of 10 years had a volume of 2273 cm³. In the lower extremities of adults, the preoperative volume was decreased from 13098 cm³ to 11074 cm³ after a mean follow-up of 1.7 years, and to 10692 cm³ after 4 years. All differences were statistically significant, p<0.001.

Microsurgery opens the possibility of a causal therapy in lymphedemas due to localized blockade. After initial conservative treatment one should not hesitate to offer the patient the chance for a reconstructive microsurgical procedure.

Pre-Expanded Arterialized Venous Free Flaps for Burn Contracture of the Cervicofacial Region. Woo; Taegu.

Despite the fact that arterialized venous flaps can provide thin, good quality tissue for defects of the head and neck, their clinical applications have been limited by an unstable postoperative course and flap necrosis. The author applied tissue expansion techniques to the arterialized venous flap before flap transfer. Three cases of pre-expanded arterialized venous free flaps for post-burn scar contracture of the cervicofacial region were presented. The donor site was confined to the forearm. A rectangular expander was usually placed over the fascia of the flexor muscles on the proximal two-thirds of the forearm. The mean expansion period, volume, and flap size were 44 days, 420 cc, and 147 cm², respectively. There were no complications caused by insertion and expansion. The cervicofacial region could be successfully reconstructed after excision of the post-burn contractures with the pre-expanded arterialized venous flaps, with no marginal necrosis or unstable postoperative flap course. The thin and large arterialized venous flaps were well-matched with the recipient defect in the cervicofacial area, since the color and texture match obtained with forearm tissue produced an aesthetically favorable result. These pre-expanded arterialized venous flaps are another option for free-flap reconstruction in the face and neck.

Neck Scar Contracture Reconstruction with Bipedicled Free Super-Thin Flaps. Ogawa, Hyakusoku, Aoki, Ishimaru, Kawahara, Koike; Tokyo.

Since 1994, these authors have reconstructed scar contractures with “super-thin” flaps. Such flaps (sometimes called “subdermal vascular network,” SVN, flaps) are useful for reconstruction of contour-sensitive areas, such as the face, neck, and hand. The flaps are primarily thinned to the level of the subdermal plexus. The original flaps had a narrow skin pedicle, and microvascular augmentation (super-charging) was useful for very long or large examples of these flaps. Previous studies have demonstrated the safety and efficacy of the flaps, and the authors have more recently used bipeddicled free super-thin flaps (a completely free type).

Bipedicled free super-thin flaps employed have included an internal thoracic perforator - lateral thoracic vessels type and a dorsal intercostal perforator (latissimus dorsi paraspinal perforator) - circumflex scapular vessel type. The vessels were anastomosed with the bilateral facial vessels at the recipient site. All flaps survived completely, and excellent functional and cosmetic results were obtained. Bipedicled free super-thin flaps can be considered as combined free perforator flaps. However, the super-thin flaps reported have a particular type of thinning: the flap is primarily thinned to a layer such that the subdermal plexus can be seen through a minimal fat layer. The flap is very thin and useful for the reconstruction of contour-sensitive areas. The newer type of bipedicled free super-thin flap is much freer to transfer than the original pedicled type of flap. Additionally, much longer and large flaps can be harvested, depending on the selection of perforators.

Lymphaticovenular Anastomosis under Local Anesthesia for Leg Lymphedema. Koshima, Tsutsui, Sugiyama; Okayama.

Fifty-two patients (ages 15 to 78 years; 8 males and 44 females) were treated with lymphaticovenular anastomoses under local anesthesia, as well as postoperative compression using elastic stockings. The average duration of edema in these patients before treatment was 5.3 years. The average number of anastomoses in each patient was 2.1 (range: 1 to 5). Patients were followed for an average of 14.5 months, and the results were effective (82.5%), even for patients with stages 4 and 5 (fibrotic leg with repeated phlegmones); others showed no improvement. Seventeen patients showed reduction in edema of over 4 cm in the circumference of the lower leg. The average decrease in the circumference, excluding edema in bilateral legs, was 41.8% of preoperative excess. The results indicated that minimally invasive lymphaticovenular anastomosis under a local anesthesia, instead of general anesthesia, is valuable.

Innovative Sensory Scapular Free Flap. Chung; Seoul.

Ten cadaveric and 15 clinical dissections were performed on nerves to the scapular free flap. The upper six dorsal rami of the thoracic nerves have medial branches that pierce the longissimus thoracis and multifidus muscles, which have small cutaneous twigs that pierce the latissimus dorsi and the trapezius muscles. Among these cutaneous twigs, several distribute to the skin of the back from the midline to the lateral aspect, which is identical to the area of the scapular free flap.

Etiologies of soft-tissue defects included 7 industrial injuries, 2 traffic accidents, 2 electric burns, and 3 severe frostbites. All the patients were male, with an average age of 29 years. The average follow-up period was 3.5 years. The location of the cutaneous nerve was observed, as well as the length of its neural pedicle and number of nerve fascicles. Sensibility was evaluated every month. Analysis of clinical experiences with the sensory scapular free flap and its anatomy was done after 1-year follow-up studies. Objective deep touch sensation commenced from 2 months postoperatively in 3 cases, between 3 and 6 months in 10 cases. Two-point discrimination tests were carried out at last follow-up in 5 cases. Two patients reported sweating on the transferred flap in warm conditions, but this could not be confirmed.

Two to three cutaneous twigs pierce the trapezius muscle over the scapular free-flap region. Each twig has two to four nerve fascicles with a small artery. The nerves that distribute to the ordinary scapular free flap have a large enough pedicle and length for neurorrhaphy with various recipient-site nerves. The scapular free flap can be utilized as a sensory flap through the medial cutaneous branches of the thoracic nerve. The nerve has at least two fascicles. Protective sensation was recovered in 11 of 15 cases. The author recommended the sensory free scapular flap as a useful method for treating hands and feet with large soft-tissue defects.

Free Flap Transfers with a Y-Branch Anastomosis. Yajima, Kobata, Shigematsu, Kawamura, Takakura; Kashihara.

This was a report of the usefulness of free flap transfers with Y-branch anastomoses and indications for their use. Eight free flaps with a Y-branch were used in seven patients, four males and three females, with ages at the time of surgery ranging from 26 to 73 years (average: 53 years). Preoperative conditions included an open fracture in three patients, an ulcer in three, and traumatic skin necrosis in one patient. The causes of ulcer formation were polyarteritis nodosa, venostasis, and Werner syndrome. In the case of traumatic skin necrosis, the patient had diabetes mellitus as a complication, and necrosis occurred due to subcutaneous hematoma.

A latissimus dorsi musculocutaneous flap was transferred in 6 cases, and a scapular flap in 2 cases. In the former cases, a latissimus dorsi musculocutaneous flap was harvested with a Y-branch of the subscapular and circumflex scapular arteries in 3 cases, and with a Y-branch of the thoracodorsal artery and branch to the serratus anterior muscle in 3 cases. In the latter cases, the scapular flap was harvested with a Y-branch of the subscapular and thoracodorsal arteries in 1 case, and the circumflex scapular artery and the descending branch in the other. These procedures were performed for single-artery extremities in 2 cases.

One patient developed arterial thrombosis at the branch to the foot; circulation to the flap was not disturbed, and removal of the thrombus and reanastomosis resulted in preservation of the peripheral blood circulation. Eventually, all flaps survived completely, and there was no patient with peripheral circulatory disorder. Recurrence of ulcer formation on the flap was encountered in the 1 case with Werner syndrome. In this case, a skin graft was carried out on the muscle flap. In another case, there was recurrence of ulcer around the flap; a part of the flap was transposed after debridement of the ulcers.

Free flap transfer with a Y-branch anastomosis was recommended in patients with lower leg reconstruction, especially with arteriosclerosis.

Hindquarter Composite Tissue Transplantation: Case Report. Zuker, Alman, Redett, Coles, Timoney, Ein; Toronto.

Composite tissue transplantation has emerged as a viable alternative to the utilization of prosthetics and complex reconstructive surgery. Thus far, it has been reserved for situations that cannot be effectively reconstructed, and in which it offers some benefits over prostheses. It has been used in the upper extremity with encouraging results. This report outlined what the authors believe is the first such use in the lower extremity.

A useless, non-innervated, non-vascularized hindquarter and lower limb of a 3-month-old ischiopagus twin that was not going to survive, was transplanted to the appropriate pelvic position, revascularized, and reinnervated in an otherwise healthy sister. The limb survived and, because of immune compatibility, did not require immune suppressive therapy.

As drug therapy improves, the boundaries of composite tissue allotransplantation will become endless, and a new era in reconstructive surgery will begin. This reported case and others like it will form the cornerstone on which an entire new subspecialty will arise.

Significant Angiogenic Potential is Present in the Microenvironment of Muscle Flaps in Humans. Muehlberger, Topsakal, Schneider, Vogt; Hannover.

The purpose of this study was to determine the presence of growth factors and the quality of angiogenic potential in the wound microenvironment in different types of flaps in humans. In 23 patients, soft-tissue defects of the trunk and lower extremities were covered by various free or pedicled flaps. The wound exudate was processed for analysis of activated transforming growth factor b1, epidermal growth factor, interleukin 1a, platelet-derived growth factor AB, vascular endothelial growth factor, and insulin-like growth factor, by ELISA or RIA. Angiogenic activity was determined by thymidine incorporation in porcine microendothelial cells exposed to various concentrations of wound fluid and control media.

Significant concentrations of growth factors were detected in all patients. The highest levels were found for IGF-1 (80000 to 200000 pg/mL), the lowest for Il-1a (6 to 194 pg/mL). Angiogenic and matrix growth factors increased in a linear fashion during the wound-healing process. Significantly lower concentrations of VEGF were found in free vs. pedicled latissimus dorsi flaps on days 2, 3, and 4 following transplantation. Growth of in vitro endothelial cells was stimulated most by 10% wound fluid, compared to any of the individual recombinant angiogenic factors or combinations of these factors. Individual temporal profiles of 6 different growth factors were established in the wound fluid of defects covered by flaps. The microenvironment in the microendothelial in vitro assay contained a significant angiogenic potential that was higher than that of individual recombinant angiogenic growth factors.

The data suggested that vascularized tissue flaps will promote wound healing in reconstructive surgery by providing sufficient sources of growth factors in the wound environment. The particular type of flap, i.e., muscle or fasciocutaneous, did not seem to have an impact on growth factor expression.

Role of Remote Ischemic Preconditioning in Inducing Tolerance in Skeletal Muscle. Addison, Lipa, Neligan, Pang; Toronto.

It has been shown that skeletal muscle can be rendered tolerant to ischemia, either mechanically by direct pedicle clamping or pharmacologically. This phenomenon is called ischemic preconditioning (IPC). Clamping is potentially damaging to pedicle vessels and is unlikely to gain wide acceptance by practicing surgeons. Pharmacologic preconditioning can be achieved with adenosine; however, it is hypotensive, and this is equally unlikely to be adopted clinically. The authors reported a simple, drug-free, and non-invasive alternative.

Latissimus dorsi (LD), gracilis, and rectus abdominis flaps were raised in pigs. Remote IPC was achieved with 3 cycles of 10-min ischemia/reperfusion of the hindlimb by tourniquet. All flaps were subjected to 4 hr ischemia, either immediately following remote IPC (acute) or 24 hr later (late). Blood flow and viability were assessed. Muscles were biopsied to study energy metabolism. The potential pathway of remote IPC was investigated using pharmacologic probes.

Remote IPC significantly attenuated LD muscle infarction in acute and late ischemia, compared to controls. Similar results were seen in gracilis and rectus abdominis flaps. Adenosine receptor blockers (SPT or DPCPX) did not block this protective effect, but the mitochondrial Katp blocker, 5-hydroxydecanoate, did block the effect. Remote IPC preserved ATP levels and reduced lactate accumulation in the flaps. Blood flow was increased by 110% at 2 hr reperfusion.

Remote IPC provided effective global protection of skeletal muscle flaps against ischemic necrosis. This may have important implications for both vascular and microvascular surgeons.

Technique of Computer-Designed Neoclavicle from Osteotomized Free Fibula. Kalbermatten, Wolfinger, Bucher, Messmer, Regazzoni; Basel, Switzerland.

The clavicle as an anterior connection of the shoulder grid is essential for stability. Pain, weakness, instability, or plexus irritation can follow resection of the clavicle. These authors presented the anatomic neogenesis of a shaped clavicle from a microvascularly transferred fibula. In their opinion, this was the first report of a total construct (acromioclavicular-sternoclavicular) of the clavicle with a vascularized osteotomized fibula bone.

They described a 23-year-old patient after complete clavicle resection due to desmoid tumor, with progressive symptoms of pain and sensation of instability. A reconstruction of the ventral shoulder grid was performed. With a 3-D DICOM representation of the present clavicle, a neoclavicle was calculated. The data were used with a thermojet procedure to form model slices of thermoplastic wax. Consecutively, a double titanic osteotomy template with correct angulation was constructed.

During the operative procedure, the dissection, double osteotomy, microvascular end-to-end anastomoses to the a. mamaria interna, and AC-SC fixation validated that the computer-assisted planning was useful. The patient recovered appropriately.

Computer-supported DICOM-CT planning with construction of a wax model and an osteotomy template aided in an anatomic and cosmetically acceptable reconstruction. The computer-asssisted, anatomic, osteotomized fibula construct fulfills the criteria for generating a neoclavicle and is thereby an excellent option for treatment.

Transosseous Routing of Vascular Pedicles in Microsurgical Tissue Transfer. Druecke, Hauser, Lehnhardt, Steinstraesser, Steinau; Bochum.

Free microsurgical tissue transfer is indicated when distant composite tissue is required for wound coverage after major trauma of the lower leg. In the case of combined soft-tissue and large bone defects, the free transfer of musculocutaneous flaps and free bone grafts is required. If the recipient vasculature is unsuitable for microvascular anastomosis close to the wound bed, primary vessel loops of the greater saphenous vein are performed. An alternative procedure is the transosseous routing of length-limited pedicles.

Two patients with direct trauma of the lower leg, in one case with a large soft-tissue defect and in the other case with combined soft-tissue and bone defect, were treated with a free latissimus dorsi flap and a free fibula graft. In both cases, the vascular pedicle length was insufficient for direct anastomosis to the undamaged artery. Via transosseous pedicle routing, a two-stage surgical intervention with vessel-loop interposition was avoided. In both cases, there were excellent surviving transplants, and early bone union was achieved. Long-term follow-up showed an integrated pedicle in the trans-tibial canal.

With transosseous routing of the vascular pedicles in free tissue transfer, it is possible to reach an undamaged site in a damaged leg, thus avoiding vascular interposition. The concepts and operative techniques, and the indications and advantages of transosseous pedicle routing were discussed, and a literature review was presented.

Intraarterial Chemotherapy: Effects on Free Tissue Transfer. Niederbichler, Sadrian, Robb, Steinau, Vogt, Evans; Ann Arbor, MI.

Multimodal therapy is recognized as state-of-the-art therapy for malignanat soft-tissue tumors. The various treatment options include intraarterial limb perfusion with chemotherapeutic agents. A retrospective chart review of 52 patients, who had undergone limb perfusion between 1988 and 1998 at the University of Texas M.D. Anderson Cancer Center and the Division of Plastic and Reconstructive Surgery of the University Hospital Bergmannsheil, Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion followed by surgical resection and free flap reconstruction.

All patients received adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor-recipient anastomosis had been previously perfused. A vein graft was used in one case, and split-thickness skin grafting was necessary in four cases. Average length of hospitalization was 21.75 days, with an average follow-up of 20 months.

No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis; three patients developed partial skin graft loss; one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation, on the basis of patient self-evaluation and physical therapy evaluation.

The results of this study indicated that preoperative intraarterial chemotherapy did not increase the risk of immediate free-flap complications. Although the numbers are small, there is no clinical evidence justifying hesitation or refusal of free-flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be carried out to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free-flap reconstruction.

Basic Research and Clinical Application of Free-Flap Transfer Bridged by Antegrade and Retrograde Posterior Tibial Vessel Flaps Borrowed from the Healthy Leg. Guoxian, Shizhzen; Guangzhou.

It has been demonstrated that the posterior tibial vessels communicate with the anterior tibial vessels and fibular vessels in a compensatory fashion. The mechanism for venous drainage of a free flap through a retrograde vascular bridge flap is through higher intravenous pressure in the distal part of the posterior tibial veins and collateral venous circulation via communicating tributaries, and the segmental efficacy of venous valves.

The pathway of blood circulation in two free flaps carried by an antegrade and retrograde vascular bridge flap is established by anastomosing the arteries and veins of the flaps directly with the proximal and distal posterior tibial vessels. Hemodynamic studies were carried out in animal experiments. These studies showed that there is postoperative reduction of average arterial pressure and pulse pressure in the retrograde vascular bridge flap and the carried free flap. But this reduction was fully compensated for in a short time. There was no difference in blood flow between the free flap and vascular bridge flap at each time point, both in antegrade and retrograde cases. The parasitic free flap under these conditions is dependent on a vascularly compromised extremity, following division of the vascular pedicles, but under relatively normal hemodynamic circumstances.

The bridge flap is designed on the medial side of the healthy leg along the posterior tibial vessels, and is dissected underneath the deeper fascia, to expose the posterior tibial vessels. After evaluating the blood supply, the bridge flap is resected transversely at its mid portion, to wrap the posterior tibial vessels which are also cut in the same region, to form two vascular bridge flaps - an antegrade vascular bridge flap based on the proximal part of the posterior tibial vessels, and a retrograde vascular bridge flap based on the distal part of the posterior tibial vessels. The donor site is covered by a full-thickness skin graft under compression. Two free flaps that anastomose with the antegrade and the retrograde posterior tibial vessel bridges are transferred to cover two defects in the compromised leg. Blood circulation in the antegrade flap is in a physiologic condition, but that in the retrograde flap is not because of its lower arterial pressure and reversed venous drainage.

Sensory Innervated Anterolateral Thigh Flap in the Head and Neck Region. Suominen, Vuola; Hus.

The free anterolateral thigh flap (ALT) is a versatile flap, fasciocutaneous or musculocutaneous, thick or thin, according to the requirements at the recipient site. Donor-site morbidity is minimal and, as cancer patients tend to be thin, the flap is usually of suitable thickness to be molded into a new tongue or tonsillar bed. However, in heavier patients, it can also be thinned to 3 to 5 mm of subcutaneous tissue, if a cuff of tissue is spared around the perforator. There is a learning curve, as perforator anatomy varies, but the benefits outweigh the disadvantages of the tedious dissection.

From January, 2001 to January 2003, the free anterolateral thigh flap was used for reconstruction in 36 patients in the head and neck region. Most had been operated on for T3-T4 oropharyngeal cancers: 2 pharyngolaryngectomies, 2 total glossectomies, 14 hemiglossectomies, and 13 tonsillar or retromolar tumors. One patient had an extensive squamous-cell carcinoma requiring enucleation, and 3 had gunshot injuries of the face. One chimeric flap with two skin islands was used to cover a defect from recurrent sarcomas of the mandible. A sensory nerve was coapted in all cases, and a part of the vastus lateralis muscle with motor innervation was included for the total glossectomy cases.

One flap failed due to insufficiency of the perforators, and two developed major edge necrosis requiring revision. Three others were re-explored but salvaged. During follow-up, one patient died from the disease, and one was permanently hospitalized. All others were available for follow-up; 12 have reached 1 year. Three have required minor revisions, debulking, or intraoral scar release. All have resumed a normal or soft diet. The donor site was closed directly in all but one case, which was skin-grafted. One patient developed a seroma. None complained of donor-site pain or functional problems, but most had some dog-ear formation.

The anterolateral thigh flap is especially suitable for intraoral reconstruction because of its thinness and pliability. Donor-site morbidity is minimal. During the authors' experience over the last 2 years, the ALT has mostly replaced the radial forearm flap in reconstructions in the head and neck region.

Clinical Application of the Retrograde Arterialized Venous Flap. Koch, Moshammer, Schwarzl, Scharnagl; Graz, Austria.

Although there have been several reports on the clinical use of arterialized venous flaps (AVF), this procedure has not found wide acceptance, possibly due to reported problems, including prolonged healing following partial flap necrosis, and a long clinical learning curve.

Based on the results of an experimental study with cadaver specimens, revealing that the perfusion of venous flaps can be enhanced by retrograde arterialization, retrograde AVFs were clinically applied in 13 patients with skin and soft-tissue defects. There were 9 males and 4 females, with an average age of 34.4 years. In 10 cases, the defect was located on the hand and in 3 cases, on the lower leg. Trauma was the etiology in all cases; in one case, this was a thermal trauma. All flaps (2×1 to 11×7 cm) were harvested from the flexor aspect of the forearm. Retrograde arterialization was established by perfusing the flaps against the original direction of blood flow in the venous system.

Six of the flaps showed marked venous congestion with superficial epidermolysis over a period of up to 14 days. In 7 cases, there were no signs of venous congestion. No vascular complication occurred, and there was no complete flap loss; however, in two flaps applied to defects in the lower leg, there was partial full-thickness skin loss requiring skin grafts.

A 100% survival rate was achieved with retrograde AVFs in the upper extremity, with a rapid and straightforward single-stage procedure requiring only two microanastomoses. Although the data should be interpreted cautiously because of the limited number of cases, they would suggest that retrograde perfusion enhances blood flow in the periphery of the AVF and yields good results in terms of flap survival, especially in the upper extremity.

Perforator Flaps for Repair of Intractable Lower Leg Ulcers. Tsutsui, Yamashita, Koshima; Okayama.

Intractable ulcers in the lower leg are avascular skin defects exposing bone and osteomyelitis that cannot be repaired even with skin grafting. A total of 151 patients with such ulcers were treated with perforator flaps: 60 cases of traumatized avascular defects; 20 diabetic ulcers; 17 cases of osteomyelitis; 14 malignant tumors; 5 arterial obstructions; and 5 arteriovenous malformations, as well as others. A total of 61 island perforator flaps were used: 20 posterior tibial perforator flaps; 7 saphenous flaps; 7 peroneal flaps; 4 anterior tibial flaps; 4 malleolar perforator flaps; 4 medialis pedis flaps, and others. In addition, a total of 82 free perforator flaps using microvascular anastomoses were used: 24 flow-through anterior thigh flaps; 13 flow-through thoracodorsal artery perforator flaps (or latissimus dorsi MC flaps); 8 paraumbilical (or deep inferior epigastric artery) perforator flaps; 6 saphenous venous flaps; 7 combined flaps; and 24 others.

Small ulcers were repaired with a minimally invasive method, including local perforator flaps and small muscle flaps, under local anesthesia. Free flow-through flaps and free bypass flaps (for diabetic gangrene with ASO), and combined osteocutaneous flaps (for massive segmental defects after resecting advanced carcinoma) are indicated for large ischemic defects.

Loupes for Magnification of Free-Tissue Transfer: One Center's Experience with 1100 Cases. Vega, Jiang, Sbitany, Serletti; Rochester, NY.

Free-tissue transfer has become a standard method for the reconstruction of a broad spectrum of defects in many academic centers. The operating microscope has been used most often for anastomotic magnification. Surgical loupes provide an alternative, with more ease and a greater degree of freedom.

In the authors' institution, 1200 free-tissue transfers (FTT) were performed. Approximately 100 of these were done using the operating microscope, and the remaining 1100 using ×3.5 loupe magnification. For this report, the authors reviewed 638 loupe-only free flaps.

In this preliminary study group, 638 free flaps were performed on 598 patients, 72% female (429), 28% male (169). FTTs were performed for breast reconstruction in 61.3% of cases (391), lower extremity reconstruction, 20.7% (132), head and neck reconstruction, 16.3% (104), upper extremity reconstruction, 1.4% (9), gender reassignment, 0.2% (1), trunk, abdomen-perineal reconstruction, 0.2% (1). Free flaps included the TRAM , 58.5% (373), the radial forearm flap, 144.3% (91), the rectus abdominis muscle, 13.8% (88), the fibula, 3.9% (25), the latissimus dorsi muscle, 3.6% (23), the gluteal myocutaneous flap, 1.7% (11), the SGAP flap, 1.3% (8), the omentum, 0.9% (6), the DIEP flap, 0.6% (4), the lateral arm flap, 0.5% (3), the VRAM flap, 0.3% (2), the serratus muscle, 0.2% (1), the scapular flap, 0.2% (1), the jejunum, 0.2% (1), the gracilis, 0.2% (1). Ninety-five percent of the FTTs were performed or supervised by the senior author. Ninety-nine percent of venous anastomoses and 89% of arterial anastomoses were performed with interrupted 9-0 nylon. The remainder were sewn with interrupted 8-0 nylon.

The intraoperative arterial thrombosis rate was 3.4% (n=22), and the intraoperative venous thrombosis rate was 1.3% (n=8). The postoperative arterial thrombosis rate was 0.9% (6), and the postoperative venous thrombosis rate was 1.7% (11). Of the postoperative arterial thromboses (n=6), all occurred within 24 hr, and flap salvage was obtained with a vein graft (n=5) 83% of the time. Of the postoperative venous thromboses (n=11), there were 4 total flap losses (0.6%).

The use of ×3.5 loupes for anastomotic magnification was an effective method of magnification, with intraoperative and postoperative thromboses and flap success rates comparable to those reported using the operating microscope. Intraoperative vascular thrombosis was not associated with an increased risk of postoperative thrombosis and flap failure.

Primary Revascularization, Vacuum-Assisted Closure, and Microsurgical Reconstruction: A Borderline Case of Limb Salvage. Shintler, Spendel, Schramayer, Clement, Hellbom, Scharnagl; Graz.

Twenty-five years ago, open fractures were already classified into groups, according to the extent of soft-tissue damage and the presence of additional neurologic and vascular damage. The significance of limb salvage vs. primary amputation was objectivized for the first time, using developed scoring systems. Since then, the chances of limb salvage have increased due to improved surgical techniques, including free microsurgical tissue transfer and osteosynthesis, as well as application of the vacuum-assisted closure method.

A 26-year-old warehouse worker had an accident on the job and suffered severe lower leg trauma (extensive soft-tissue damage, multiple-tiered compound fracture with periosteal loss and accompanying vascular damage). After initial emergency treatment and stabilization, exploration, repositioning of the fracture, and fixating were performed in the operating room. Primary amputation was initially considered. Due to the relatively isolated injury, maintained continuity of the tibial nerve, and successful vascularization, primary limb salvage was undertaken. Although interdisciplinary deliberations decided for secondary upper leg amputation, the patient absolutely refused. Thus, VAC TM-ATS was applied and, 3 weeks later, final soft-tissue coverage was performed with a free latissimus flap.

Although surgery was successful, late complications resulting from the accident and salvage, such as missing consolidation of bone, secondary osteomyelitis, loss of sensibility and function, could not be assessed. From a rational and economic viewpoint, amputation with quick rehabilitation would definitely have been the best solution. However, the personal and psychological effects of limb loss on a young patient should not be neglected. Vacuum-assisted closure was a conditio sine qua non in this case of severe and extreme soft-tissue trauma for the subsequent free tissue transfer. Despite reassessment and development of improved scoring systems (Hannover Fracture Scale, 1998), the decision for limb salvage or amputation still remains the responsibility of the surgeon. The possibility of free microvascular tissue transfer after preparation with vacuum-assisted closure should also be considered in extreme cases of type IIIC fractures, with the knowledge that salvage may yield a functionally unsatisfactory bioprosthesis. Scoring should be used only as a support in decision-making.

Negative Pressure Therapy (VAC) as an Adjunct to or Replacement of Free-Tissue Transfer in Lower Extremity Reconstruction. Lee, Song, Lohman; Chicago, IL.

The authors presented a retrospective review of six patients who underwent successful VAC therapy as an adjunct to failed free-tissue transfer, or as a replacement of free-tissue transfer in lower extremity salvage.

Between March, 2002 and November, 2002, six patients were identified who met the above criteria. Age, indications for free tissue transfer, wound type, time on VAC therapy to successful soft tissue coverage, time to ambulatory activities, and complications were the parameters analyzed.

Patient ages ranged from 6 to 65 years. Indications for free-tissue transfer included exposed tendon, bone, or neurovascular structures secondary to trauma, tumor ablation, infection, and burn. The average time on VAC therapy was 27 days, and the average time to ambulation was 17 days. No patient died or underwent amputation as a result of therapy.

VAC therapy and skin grafting can serve as adjuncts to failed free-tissue transfer in lower extremity reconstruction, and can also serve as replacements for free-tissue transfers in those patients who are not candidates. This may force reconsideration of the classic indications for free-tissue transfer.

Temporary A-V Loops Facilitate Microvascular Free-Tissue Flap Transfer in Areas Lacking Recipient Vessels. Vogt, Lahoda, Spies, Muehlberger, Steinau; Hannover.

Successful microvascular tissue transfer requires sufficient donor size and length and, most important, patent recipient vessels of adequate size and tissue quality. However, trauma, irradiation, infection, and previous surgery may result in the destruction of major local vessels. Irradiated defects of the head and neck area, open comminuted fractures of the lower leg with vascular damage, and extended defects of the pelvic area, are common examples of zones of problematic microvascular tissue transfer. In these cases, a temporary arteriovenous loop may provide sufficient local recipient vessels for subsequent microvascular free-tissue transfer.

Between 1991 and 2002, 21 patients received 17 free latissimus dorsi myocutaneous flaps, 1 combined rectus-tensor fasciae latae myofasciocutaneous flap (“mutton-chop” flap), 1 combined osteomyofasciocutaneous flap based on the scapular and parascapular system (four-in-one flap), 1 radial forearm flap, and 1 free jejunal graft. Due to a lack of patent local recipient vessels, an arteriovenous loop was constructed by pedicled or free vein grafts, allowing for placement of the dome of the loop into the area of prospective microanastomosis. Vessel patency was controlled by Doppler. A-V loops were constructed in the head and neck from brachiocephalic veins or saphenous grafts (6; latissimus flaps to scalp, jejunal graft for esophagus reconstruction), by saphenous grafts in the trunk (5; groin, pelvis, sacrum), and by saphenous or brachiocephalic vein loops in the lower leg and foot (10).

In three patients, thrombosis of the loops required revision and construction of a new loop. Microvascular tissue transfer was performed after 4 to 17 days. All 21 patients underwent successful free-flap transfer. No flap was lost.

Temporary A-V loops facilitate microvascular free-tissue flap transfer in areas lacking adequate recipient vessels and in which no other reconstructive options exist. Primary loop construction and subsequent flap transfer in the reported series allowed for successful transfer of required flaps into problematic defects.

Versatility of the Lateral Arm Flap in Tumor Reconstruction. Prandl, Haas, Koch, Hubmer, Scharnagl, Hellbom; Graz.

The free lateral arm flap has become a workhorse in reconstructive surgery, with its potential for supplying vascularized skin, fascia, tendon, and bone. It provides soft and pliable tissue with low donor-site morbidity.

The versatility of the lateral arm flap was outlined in a small series of 5 reconstructive procedures. Defects were situated in the face (n=2), intraorally (n=1), on the dorsum of the hand, and on the anterolateral aspect of the distal lower leg and proximal part of the foot (n=1). All were combined defects. An osteoseptocutaneous flap was used to reconstruct an osteocutaneous defect of the lateral orbital wall. A folded flap was employed in a perforating defect of the upper lip, necessitating reconstruction of skin and oral mucosa. A combined defect of the tongue and floor of the mouth was covered with a conventional septocutaneous flap. Tendoseptocutaneous flaps were used to cover a combined skin and extensor tendon defect of the dorsum of the hand and a defect on the lower leg and foot, including the extensor tendon retinaculum. There was no vascular complication, and the postoperative clinical course was uneventful in all cases.

Due to its versatility, the free lateral arm flap is the authors' first choice in reconstruction of combined defects in areas that require soft and pliable tissue.

Salvage of Critically Ischemic Limbs by Microsurgical Omental Transfer. Khazanchi, Saha, Aggarwal; New Delhi.

In India, thromboangitis obliterans (TAO), also known as Buerger's disease, is an important cause of chronic arterial occlusion of the limbs. Current modalities of treatment, which include lumbar sympathectomy, pedicled omental transfer, and vascular reconstruction, do not provide relief in a large number of patients. These authors have used microsurgical omental transfer to the leg in 20 patients as a limb salvage procedure.

All patients (n&=20) who underwent free omental transfer to the leg were diagnosed as having TAO, based on clinical and radiologic evaluation. They were suffering from critical limb ischemia, as evidenced by the presence of rest pain (n&=17), non-healing ulcers (n&=10), and pregangrenous changes (n&=4). Nine patients had undergone lumbar sympathectomy, with temporary or no relief. The possibility of any direct vascular reconstruction was ruled out after angiography. The omentum was harvested from the abdomen, using a right gastroepiploic pedicle. It was transferred to the leg and draped in a subfascial plane extending from knee to ankle. The pedicle was passed into the thigh through a subcutaneous tunnel. The gastroepiploic artery was anastomosed to the superficial femoral artery in the thigh in an end-to-side fashion. The vein was anastomosed end-to-end with an appropriate vein.

Patients have been followed-up for a period of 1 to 3 years. Seventeen are fully relieved of their symptoms and have an increase in claudication distance. One patient was lost to follow-up, and two patients got worse; these latter had continued to smoke, and one of them required an amputation.

Microsurgical omental transfer to the leg in patients with TAO and critical limb ischemia has helped salvage limbs which otherwise were likely to end up in amputation.

Free Rectus Abdominis Muscle Transfer in Upper and Lower Extremity Reconstruction. Bannasch, Sultan, Andree, Stark; Freiburg.

Upper and lower extremity defects following injury or tumor resection commonly require free-tissue transfer. In cases requiring muscle tissue, the transfer of the rectus abdominis muscle represents a safe, rapid, and reliable method because of the constant vascular anatomy (inferior epigastric vessels). As preparation is relatively simple and possible in a supine position, the rectus muscle flap is an excellent emergency flap.

Between 1998 and 2002, 45 rectus abdominis muscle transfers for extremity reconstruction were performed. There were 3 intraoperative complications requiring revision and resulting in two total flap losses (4.4%). All other flaps healed well and showed good atrophy to normal skin level, with excellent functional and aesthetic results. Donor-site morbidity was minimal.

Free transfer of the rectus abdominis muscle represents a relatively safe and reproducible method for both upper and lower extremity soft-tissue reconstruction.

Lymphatic Reconstructive Microsurgery: Over 25 Years of Clinical Outcomes. Campisi, Boccardo, Zilli, Maccio, Gariglio, Schenone; Genoa.

One of the main problems in microsurgery for lymphedema is the discrepancy between the excellent technical possibilities and the insufficient reduction of lymphedematous tissue fibrosis and sclerosis. Appropriate treatment based on pathologic evaluation and surgical outcomes is adequately documented.

The authors now have over 25 years of clinical experience in the microsurgical treatment of more than 1000 patients with peripheral lymphedema. Among derivative lymphovenous shunts, lymphatic-venous multiple anastomoses (LVA) are used most. For those patients in whom venous disorders are associated with lymphedema, it is possible either to repair the venous insufficiency and use LVA, to perform reconstructive techniques using vein grafts interposed between the lymphatics above and below the obstacle to lymph flow, or to use lymphatic-venous-lymphatic anastomoses (LVLA). Most patients (66%) were available for long-term follow-up. Objective assessment was undertaken by water volumetry and lymphoscintigraphy.

Subjective improvement was noted in 87% of patients. Objectively, volume changes showed a significant improvement in 83%, with an average reduction of 67% of the excess volume. Of those patients followed-up, 85% have been able to discontinue the use of conservative measures, with an average reduction in excess volume of 69%. There was an 87% reduction in the incidence of cellulitis after microsurgery.

Microsurgical procedures have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonsurgical treatment. Improved results can be expected with procedures performed early, at the very first stages of lymphedema.

Using the Extensor Digitorum Brevis Muscle to Improve Donor-Site Morbidity of the Dorsalis Pedis Flap. Ghareeb.

Much has been reported about donor-site morbidity using the dorsalis pedis flap, which may occur early as delayed wound healing, soft-tissue infection, osteomyelitis, wound breakdown, and gangrene of the big toe, or late as late wound breakdown, pain after prolonged walking, paresthesia, and hypersensitivity to touch. On the other hand, easy harvesting of the flap, reliability of vascularity, thinness, and proximity to the recipient site have encouraged surgeons to adopt the flap in reconstruction of foot and distal lower leg defects, and also in hand reconstruction.

Success has been achieved in satisfactory donor-site healing by concomitant use of the extensor digitorum brevis muscle based on its lateral blood supply, to cover the extensor tendons and tarsal bones before application of the graft. The donor site showed delayed healing (incomplete in more than 1 month) in only two patients, but these healed eventually in 2 months without additional grafts. Pain after prolonged walking occurred in one patient, while paresthesia occurred in another patient. Hypertrophic scars were observed in six patients and responded to conservative treatment. The technique was applied in 14 patients in whom the dorsalis pedis flap was used as a proximally-based fasciocutaneous flap in reconstruction of defects over the medial malleolus (5), defects over the Achilles tendon (4), and over the lateral malleolus (2). The flap was also used as a reverse flow adipofascial flap in big-toe reconstruction (1), and as a free revascularized flap in hand reconstruction (2). With this modification, overall benefits have out-weighed problems at the donor site, and patient compliance has been excellent.

Perforator Flap of the First Interdigital Space of the Foot. Garofalo, De Nuntiis, Ferri, Guerra, Pagliarini; Rome.

The perforator flap of the first interdigital space of the foot is an extremely useful flap in reconstructions of the hand or foot, especially regarding the thin skin, wealth of innervation, and skin quality which aid in reconstructing tissue and sensibility. The presence of a constant perforator ramus in the interdigital region allows harvesting of the flap without sacrificing the principal arterial axis (dorsal artery of the foot). It is possible to use only the perforator ramus and the intermetatarsal artery, unless there is a requirement for a much longer pedicle (greater than 2.5 cm). Sacrifice of the network can be contained, and other immediate reconstruction is possible using the same pedicle.

The authors described 10 cases using the perforator flap of the first interdigital space of the foot, showing its versatility and the optimal aesthetic results in the donor and recipient areas. Compared with the traditional dorsal flap of the foot, there is less scarring, and the subsequent pain reported with the dorsal flap of the foot on using footware, is minimized.

Outcome of Salvage Procedures in Head and Neck Microsurgery. Ikuo, Bin, Yasuhisa, Satohoro, Tetsuya, Shuhei; Nagoya.

Between 1993 and 2002, the authors performed 404 procedures of microsurgical reconstruction in the head and neck. There were 15 thromboses postoperatively. One flap failed due to arterial thrombosis, 9 failures were due to venous thrombosis, 3 were due to infection, and 2 flap failures were due to anatomic variations and dissection errors. Four cases (26.7%) could be salvaged with one free flap, and 11 cases (73.3%) required subsequent flaps. Four successful two-flap salvages were in cases of venous thrombosis. The median time interval from first operation to salvage procedure was 1.5 days (range: 1 to 3 days). This median interval was shorter than 4.1 days in the unsuccessful cases of salvage (range: 1 to 8 days). Results have shown that in thrombosis cases involving the head and neck, a first free flap will be unsuccessful, especially in cases involving infection. When the patency of the vessels is in question, a second flap should be chosen as soon as possible.

Subjective Patient Satisfaction in Microsurgical Breast Reconstruction. Gohritz, Schmiedl, Geishauser, Biemer; Munich - Neusstadt/Saale.

The aesthetic results and donor-site morbidity in microsurgical breast reconstruction have been reported, based mostly only on technical criteria and the view of surgeons. This study documented subjective evaluation of long-term outcomes of breast reconstruction with free TRAM flaps by a large and homogeneous group of affected women themselves.

A total of 331 patients who had received breast reconstruction using free TRAM flaps between 1987 and 1999 received a list of 80 questions focusing on their personal motivation, evaluation of aesthetic results, flap reinnervatiion, postoperative pain, abdominal weakening, psychosocial effects, and overall satisfaction. All patient charts were reviewed in order to correlate the responses of patients with objective criteria.

Of the returned questionnaires, 209 (63%) were eligible for analysis. The aesthetic appearance of the breast was rated good to excellent by 74% of the patients, fair by 18%, and sufficient or poor by 8% of the patients. The sensitivity of the reconstructed breast was rated good or very good by 55%, moderate by 20%, and absent by 22%. Forty-nine percent of the patients rated the donor site in the lower abdomen good to excellent, 32% fair, and 19% sufficient or poor. Seventy-one percent of the women were completely pain-free, 21% noted pain during strain, and 8% sometimes also at rest. Severe impairment of daily life activities caused by the donor defects was rare, but 32% experienced an increase of their activities, above all due to improved body image and self-confidence. Ninety percent judged the overall outcome as excellent, good, or fair. The best results were seen in the unilateral split-muscle group, with 41% excellent and 37% good overall results. Total avoidance of alloplastic material (76%) and a good aesthetic result (57%) were seen as the main advantages, and the large abdominal scars and high effort as the main disadvantages. Ninety-four percent felt a positive change in their body image, 84% a better quality of life, and 40% a positive impact on their partnership. Eighty-nine percent of the women would undergo the same operation again, and 91% would recommend it to others.

Comparing the subjective view of patients and objective information gained through chart review, microsurgical breast reconstruction using TRAM flaps offers a safe and permanent solution for women after mastectomy, yielding high patient satisfaction.

Cosmetic Outcome in 85 Breast Reconstructions: Ranking by Physicians and Non-Physicians Based on Photographs. Niemi, Peltoniemi, Suominen, Asko-Seljavaara; Turku, Finland.

The goal of breast reconstruction is to achieve body symmetry and to restore a positive body image. The outcome is usually analyzed by patient satisfaction studies. Reconstruction of the nipple-areola complex is the final step in reconstructive breast surgery and it is believed to correlate strongly with patient satisfaction.

The authors evaluated photographs taken of patients who had had breast reconstruction in Helsinki University Hospital between 1999 and 2000. In an earlier study, patient satisfaction was measured prospectively with the same patient material, and 93% were very satisfied or satisfied with the final result.. Breast reconstruction was performed in 76 patients with free TRAM flaps, and in 9 with latissimus dorsi flaps. Three groups of photographs were analyzed: complete reconstruction with pre- and postoperative photographs, unfinished reconstruction without nipple-areola complex, and postoperative photographs of completel reconstruction only. The group that judged the photographs were 3 men and 3 women; there were 3 non-physicians and 3 physicians (not plastic surgeons). The results in the photographs were graded from 1 (poor) to 4 (excellent).

The overall means score of breast reconstruction was 2.8. The complete reconstructions had a mean value of 2.9 and, without nipple-areola complex, 2.7. Without preoperative photographs, the evaluation was 2.6. Men, in general, gave poorer scores than women; the latter were more satisfied with general outcome than with the reconstructed breasts. Postoperative results were considered better when preoperative comparison was available. The lack of nipple-areola complex disturbed more men and physicians than women and non-physicians. Postoperative appearance of the abdomen was judged good after free TRAM flaps.

The study showed, compared to the earlier study of this material, that women themselves are more satisfied with their breast reconstructions than are outsiders. However, this is probably because women in their late forties are seldom undressed in public, and outsiders have no view of what a breast reconstruction really looks like.

Efficacy of Preoperative Color Doppler Ultrasonography for Planning Flaps. Inou, Ichioka, Nakagawa, Nakatsuka, Nanri; Shizuoka.

Preoperative evaluation of blood vessels is very important for either free or pedicled flaps. Preoperative color Doppler ultrasonography helps to find the precise location of flap blood vessels during surgery; however, it is not a routine procedure in planning standard flaps, and many microsurgeons still depend on simple palpation or Doppler flowmetry. The purpose of this report was to describe the efficacy of preoperative ultrasonography for planning standard free myocutaneous or pedicled flaps.

Twelve patients underwent flap reconstruction with various parameters: anatomic anomalies, history of prior surgery, injury, and infection. The location, diameter, and blood flow of the pedicle vessels were evaluated preoperatively by color Doppler ultrasonography. Flaps utilized included the rectus abdominis myocutaneous flap, latissimus dorsi myocutaneous flap, groin flap, and others.

Preoperative data on the location and size of the pedicle vessels with color Doppler ultrasonography were consistent with the intraoperative findings, and the data enabled surgeons to more safely elevate the flaps. All flaps survived except for one that was lost due to venous thrombosis.

Surgeons may hesitate to undertake flap procedures, when encountering difficult cases involving vessel incompetence or secondary damage of soft tissue at the recipient or donor sites due to individual anatomic variations, previous surgical damage, or trauma. The most problematic challenge is to secure good vessels to provide an adequate blood supply to the flaps. The authors concluded that preoperative color Doppler ultrasonography is a great help in planning flaps.

Sutureless Anastomosis of Vein Grafts Using Magnets. Heitmann, Khan, Levin, Klitzman; Durham, NC.

Performing vascular anastomoses requires complete circumferential access, is time-consuming, and technically challenging. The purpose of this study was to assess the efficacy of sutureless vascular anastomoses utilizing a magnetic device.

Oval magnets with a lumen were placed in six male foxhounds. The femoral artery was ligated, and an 8-cm length of femoral vein was harvested and reversed. After a 4-mm venotomy or arteriotomy, one magnet was inserted into each vessel lumen, and a second magnet was placed outside the vessel but aligned directly over the intraluminal magnet, forming a magnetic port in each vessel. The graft and target vessels were then allowed to self-align and seal, creating a side-to-side anastomosis.

Patency was confirmed with duplex Doppler ultrasound scans after 6 and 13 weeks and during explantation after 14 weeks. At that time, the contralateral femoral vein was harvested and an acute graft was created as a control. Macroscopically, there was no sign of stenoses or aneurysms. After explant, saline was perfused through all grafts, and hydrodynamic resistance was quantified. There was no statistically significant difference in resistance indicating stenosis between the acute and 14-week grafts. Microscopic examination of 14-week anastomoses showed that all blood-contacting surfaces were well-endothelialized.

The magnetic vascular coupler allowed sutureless anastomoses between vascular arteries and veins. This device might prove useful for anastomosis of large and small vessels, as well as for anastomosis or approximation of non-vascular structures, such as peripheral nerves, Fallopian tubes, or ureters.

Robotic Internal Mammary Harvest for TRAM, SIEA, and Gluteal Flaps. Boyd, Stahl, Samson, Boyd; Weston, FL.

Internal mammary artery harvesting via minimally invasive techniques aided by robotic devices has been previously reported from the authors' center. Their current method of choice is use of the “Aesop” voice-activated robotic arm (Computer Motion, Inc., Santa Barbara, CA). With small modifications to the standard technique used in cardiac surgery, it has been possible to harvest the internal mammary artery, and to pass the pedicle containing the artery and vein through the chest wall for use in post-mastectomy free-flap breast reconstruction. The principal modification involves port placement through the mastectomy incision into the thoracic cavity, which allows for a more acceptable cosmetic result. The remainder of pedicle mobilization is done as has been reported in the cardiac surgery literature. The entire internal mammary pedicle is mobilized as far inferiorly as its bifurcation into the superior epigastric and musculophrenic vessels. A 6 to 10-cm pedicle is brought out through the second interspace without the need to resect ribs or even costal cartilage. This pedicle has abundant length to accommodate any free flap with ease. The diameter of the artery ranged from 1.5 to 2.5 mm, and of the vein, a little smaller. The size of the artery was fairly consistent along the length of the pedicle, but the diameter of the vein varied significantly from place to place. The long pedicle permits the surgeon to select the optimal vein diameter for anastomosis. A chest tube is placed perioperatively and removed on postoperative day 1. The authors have now performed this procedure in 18 cases and have found it particularly useful for gluteal and SIEA flaps. Direct DIEA perforator flaps would also benefit from its use.

Implantabale Doppler Probe for Continuous Monitoring of Hepatic Artery and Portal Vein Blood Flow in Pediatric Liver Transplantation. Liza, Lohman, Schecter, Cronin; Chicago, IL.

Acute vascular thrombosis is a potentially fatal complication in solid organ transplantation. Pediatric liver transplantation is associated with a high incidence of hepatic artery thrombosis. Current methods of surveillance for vascular thrombosis are indirect and cannot provide early detection. The authors have adopted the use of the 20-MHz implantable Doppler probe, to assess hepatic artery and portal vein blood flow in the immediate postoperative period after pediatric liver transplantation.

Six consecutive pediatric liver transplants were performed between July, 2001 and November, 2002. All six patients had the hepatic artery anastomosis constructed using microvascular techniques with the aid of the operating microscope. The portal vein anastomosis was constructed under 2.5 to 3.5 loupe magnification. The implantable Doppler probe was attached to the hepatic artery and portal vein distal to the anastomosis, using topical fibrin sealant. During the postoperative period, the presence, quality, and character of the Doppler signal from the hepatic artery and portal vein were assessed.

In all six patients, the implantable Doppler probe was successfully placed. One patient developed hepatic artery thrombosis, and one patient developed portal vein thrombosis. Both were accurately detected by the implantable Doppler probe. Both patients were re-explored, and the grafts salvaged. All patients had their probes removed without complication, and were discharged.

The implantable Doppler probe provides direct, real-time monitoring of hepatic artery and portal vein blood flow. Signal quality and character were easily assessed by physician and staff, and reliably reflected intravascular flow. This allows for early detection and intervention in microvascular complications in pediatric liver transplantation.

The Pig is the Ideal Animal Model for Conventional and Minimally Invasive Free- Flap Harvesting and Research. Ionac, Avram, Lykoudis; Timisoara.

The majority of data regarding free-flap physiology are obtained from rat, rodent, or canine models. The skin component in all these loose-skinned animals is irrigated by direct cutaneous arteries emerging from paniculus muscle, rather than by the musculocutaneous vessels prevalent in the human and pig. There are additional aspects of both infant and adult anatomy and physiology in which pigs and humans are similar. The present study defined the range of free flaps that may be harvested by both conventional and endoscopic-assisted techniques, and that are simple, reproducible, and applicable as models in free-flap research.

Twenty-four standard white adult pigs, weighing 30 to 35 kg, were used. Gross dissections and radiographic studies were used to define the specific vascular territories in the following flaps: cutaneous and fasciocutaneous: saphenous, buttock, epigastric, radial forelimb; muscular and musculocutaneous: biceps femoris, gracilis, latissimus dorsi, pectoralis, rectus abdominis, tensor fasciae latae, trapezius; osseous flaps: fibula; intraabdominal flaps: jejunum, omentum. Endoscopic-assisted techniques were used for dissection and harvesting of the gracilis, latissimus dorsi, rectus abdominis, jejunum, and omentum.

No animal suffered intra- or postoperative complications. All models demonstrated consistent and easily identifiable anatomic landmarks for flaps and their pedicles. The vascular ± nerve pedicle systems were constant and reliably supplied all flaps dissected. All flaps survived in their entirety.

Swine are large enough to permit multiple flap types, and the skin color allows subjective observations of tissue circulation. The pig serves as an excellent model for conventional and endoscopic training in free-flap harvesting.

Use of Mini-Endoscopic Features for the Control of Anastomosis in Microsurgical Training. Schoeffl, Hager, Hinterdorfer, Kwasny; Linz.

In microsurgical training at MAZ (Microsurgical Training and Research Center), the authors use cadaveric coronary arteries of pigs, because they are excellent for sophisticated microsurgical preparation and anastomosis due to their “near-reality” biologic status. Carrying out training in this fashion, there is a significant reduction in the use of living animals (rats). The trainee is qualified for continuing microsurgical work on rats in advanced courses, since a certain level of skill has been reached. For anastomotic control, mini-endoscopy is used.

Freshly harvested pig hearts are used. First, the coronary artery is identified far distally; then, various anastomoses are performed several times (end-to-end, end-to-side, vein interposition, etc.) For transluminal verification, a 1.2-mm mini-endoscope (Aesculap) approaches the coronary artery from the ostium and is brought into the vessel lumen, to observe the quality of each single suture.

For beginners, as well as for advanced microsurgeons, this method has proved to be a very reliable and easy procedure for evaluation of anastomoses. More than a year ago, MAZ introduced this procedure in its beginner, intermediate, and advanced courses. There are advantages in using mini-endoscopy in microsurgical training: there is no necessity of cutting the vessel open, anastomoses can be precisely controlled transluminally, and sutured vessels can be critically observed from the inside, while they are pulsatile and perfused.

Effect of Hyperbaric Oxygen in Ischemia-Reperfusion Injury: Experimental Study in Rat Musculocutaneous Flaps. Hong, Chung; Seoul.

The purpose of this study was to evaluate the effect of hyperbaric oxygen on musculocutaneous flaps in a rat model and its effect in ischemia-reperfusion injury. The focus was on the mechanism involving the expression of adhesion molecules, such as the intercellular adhesion molecule-1 (ICAM-1) of endothelial cells and CD18 of neutrophils.

A TRAM flap supplied by a single superior epigastric pedicle was elevated in 70 Sprague-Dawley rats. The animals were divided into 4 groups: Group 0 - sham (n&=10); Group 1 - 4-hr ischemia followed by reperfusion (n&=20); Group 2 - 4-hr ischemia and hyperbaric oxygen (100% oxygen, 2.5 atm, last 90 min of ischemia before reperfusion), followed by reperfusion, n&=20); and Group 3 - 4-hr ischemia followed by reperfusion and hyperbaric oxygen (100% oxygen, 2.5 atm, 90 min after reperfusion, n&=20). The study consisted of gross examination for flap survival, histology, myeloperoxidase (MPO) assay, flow cytometric study of CD18, and Northern blot analysis on ICAM-1 mRNA expression. The gross measurement of the flaps showed increased survival in Groups 2 and 3, compared to Group 1 (p<0.05). Regarding the leukocytes adherent to the endothelium at 24 hr and on the 5th day: in Group 1 they were significantly increased, compared to Groups 2 and 3 (p<0.05). The MPO assay of TRAM flaps at 24 hr revealed significant increase in Group 1, compared to Groups 2 and 3 (p<0.05). The expression of CD18 was similar in all groups. The staining for ICAM-1 and Northern blot analysis on ICAM-1 mRNA showed decreased expression in Groups 2 and 3, compared to Group 1. Throughout the analysis, Groups 2 and 3 did not show any significant differences.

These results suggested: 1) hyperbaric oxygen reduced the introduction of leukocytes in the TRAM flap, but not enough to prevent adhesion of neutrophils on endothelial cells; 2) ischemia-reperfusion injury increased the expression of CD18 and ICAM-1 and caused increased adhesion of leukocytes on endothelium; 3) hyperbaric oxygen did not alter the expression of CD18, but decreased the expression of ICAM-1; 4) the point of application for hyperbaric oxygen, whether applied before or after reperfusion, did not show any difference in outcome. The application of hyperbaric oxygen against ischemia-reperfusion injury increased flap survival, and the beneficial effect may be explained by a protective mechanism involving down-regulation of ICAM-1 on endothelial cells.

Intravital Fluorescence Microscopy: A New Instrument for Measuring Tissue Perfusion. Stuetz, Messmer, Nolte; Bad Neustadt/Saale.

Intravital fluorescence microscopy (IVM) is a new method for quantifying microvascular perfusion by measuring the microcirculatory parameters of leukocyte-endothelium interaction (LE-1), red blood cell (RBC) velocity, macromolecular leakage (extravasation), and functional capillary density (FCD). The purpose of this study was to investigate the effects of endotoxin on the microcirculation of striated skin muscle, using IVM as a valuable tool for quantitative analysis in an experimental mouse model using microsurgery.

The experimental model used was the transparent dorsal skin-fold chamber in awake BALB/c mice, permitting chronic intravital microscopic analysis of the microcirculation over several days. The effects of endotoxin (1.25 mg/kg) on FCD, LE-1, RBC velocity, and macromolecular leakage, as indicators of endothelial integrity, were analyzed in striated skin muscle. Control animals received equivalent volumes of 0.9% saline. Measurements were made at 10 min, 1 hr, 3 hr, 5 hr, 8 hr, and 24 hr after i.v. injection of endotoxin. For visualization of the plasma, fluorescein isothiocyanate-dextran (FITC-dextran 150 kd), and for visualization of intravascular leukocytes, the in vivo fluorescent marker, rhodamine 6G, were used. FCD, defined as the length of red cell-perfused capillaries per observation area (cm -1), was used as an indicator of tissue perfusion. Quantitative analysis of FCD in randomly selected regions of the tissue was performed with a computer-assisted video analysis system which allows calculation of the length of RBC-perfused capillaries.

Eight hours after injection, endotoxin elicited a significant increase in venular and arteriolar leukocyte sticking, which was accompanied by leakage of FITC-dextran into the perivascular tissue. Extravasation of FITC-dextran was found significantly increased, while FCD was found decreased, which was associated with a reduction of RBC velocity in postcapillary venules (p<0.05 vs. control, n&=6 in each group).

The use of IVM for measuring intravital microcirculatory parameters, using a double fluorescence technique of rhodamin 6G and FITC-dextran, was highly effective in assessing microcirculatory disturbances. FCD as an indicator for tissue perfusion was reduced as a consequence of an endotoxin-induced microvascular failure. This technique may be a helpful tool for early detection of microvascular failure, and may elucidate the underlying pathomechanisms in experimental microsurgery.

A Microsurgeon's Hawkeye: Potential Risks Following Successful Free-Tissue Transfer. Steinau, Lehnhardt, Steinstraessser, Langer, Druecke; Bochum.

In microsurgical free-tissue transfer, numerous follow-up studies have been done to analyze the factors for flap loss. In lower extremity trauma, timing plays a pivotal role, while smoking habits, arteriosclerosis, thrombosis, bleeding disorders, and, rarely, an insufficient anastomosis, may lead to perfusion disturbances.

During the past 24 years, a variety of partial or complete flap necroses were collected. In every case, the disaster was not caused by the primary treating microsurgeon. Despite clear orders, well-meaning nurses and colleagues not familiar with risk parameters played a central role in the complication cascade, e.g., compression bandages, casts and stockings, suprapubic urine routing through venous interposition grafts, hemostatic sutures including the pedicle, i.v. nutrition into the draining vein in the neck, Steinmann pins and screws through the supplying vessels, ischemic distension with the Ilizarov fixator, alcohol intoxication, thinning procedures without the microsurgeon's help, burn injuries from heating lamps - all led to severe problems, secondary revisions, or loss of the flap. Only a minor number of these complications could have been avoided by introducing clinical pathways for microsurgical procedures.

Aspirin Improves Tissue Microcirculation and Protects Arterial and Venous Microanastomoses. Peter, Steinau, Barker; Berlin.

Free flap/replant failure is caused by anastomotic thrombosis and/or impaired tissue microcirculation. These authors hypothesized that aspirin would reduce anastomotic thrombosis and improve tissue microcirculation.

In part I of the reported study on tissue microcirculation, 16 Wistar rats were assigned to two groups: aspirin (5 mg/kg), and control. Free-flap transfer was simulated with the isolated cremaster muscle and a thrombogenic upstream anastomosis. Capillary density at 27 sites and diameters of A2 and A3 vessels were measured for 6 hr. In part II of the reported study on anastomotic thrombosis, 40 Wistar rats were assigned to four groups: arterial anastomosis + aspirin; arterial anastomosis + vehicle; venous anastomosis + aspirin; and venous anastomosis + vehicle. Thrombogenic anastomoses were performed at the femoral artery or vein. Using vessel transillumination, the authors measured maximum thrombus size, thrombus size at the end of the experiment, and time until maximum size was reached.

In part I, capillary density was significantly increased in the aspirin group (p&=.002). A2 and A3 vessel diameters tended to be greater in the aspirin-treated animals. In part II, significant differences favoring the aspirin-treated group were found for the artery, thrombus size at the end (p&=.49), the vein, maximum thrombus size (p&=.0013), and thrombus size at the end (p&=.0003).

Aspirin protected both risk zones with microvascular surgery: capillary tissue perfusion and arterial and venous anastomoses.

Mammary DIEP Flap Reconstruction: Postoperative Surveillance with Neurotrend and Microdialysis. Fogdestam, Hokland, Dahl, Tonnesen, Bjerke; Oslo, Norway.

For mammary reconstruction with the DIEP flap, small vessels are anastomosed, and it is important to monitor the condition of the flap postoperatively. Clinical evaluation is often difficult, and a failing blood supply may be detected too late. The authors undertook a prospective study to investigate whether postoperative monitoring with Neurotrend and microdialysis probes would provide more accurate and sensitive information on the circulatory and metabolic conditions in transplanted tissue.

Over the last 20 months, they performed 20 consecutive DIEP flap breast reconstructions. All patients had had one breast removed due to cancer. The flaps were based on one or two perforator vessels. Zone 4 was cut and discarded. For left-sided breast reconstructions, the thoracodorsal vessels were used as recipients, and for right-sided reconstructions, the internal mammary vessels. At the end of the procedure, Neurotrend and microdialysis catheters were introduced subcutaneously into the flap and into reference intact fat tissue. Microdialysis catheters were placed both in zones 1 and 3. The dialysate was analyzed in a CMA 600 analyzer, with measurements of glucose, pyruvate, lactate, and glycerol. During the first 3 hr, the dialysate was analyzed every 30 min or until stabilization of the values; thereafter, every 60 min. The Neurotrend probe measured pO2, pCO2, pH, and temperature by fiberoptical technique. Monitoring was aborted after 3 days.

In this series of 20 patients, there were two cases with arterial failure. The flaps became pale, with rapidly deteriorating metabolic values, e.g., an increase in the lactate/pyruvate ratio. In one of these patients, intima separation was noted at the initial operation. At re-operation, an arterial thrombus was found with extensive intima separation, and the flap could not be salvaged. In the other patient with arterial failure, the thrombosed arterial anastomosis was removed and reanastomosed, after rerouting of the vessel. There was one patient with venous congestion, in whom re-operation disclosed clogging of the vein; after removal of the thrombus and reanastomosis, this flap was also saved.

Postoperative monitoring of free flaps with Neurotrend and microdialysis probes is a useful supplement to clinical evaluation of DIEP flaps and may contribute to the early detection of ischemia, so that irreversible tissue damage can be avoided.

Evaluation of Flap Perfusion with Indocyanine Green Laser Fluoroscopy - First Clinical Experiences. Giunta, Holzbach, Taskov, Biemer; Munich.

Evaluation of flap perfusion relies mainly on clinical parameters such as time to recapillarization, flap temperature, color, and bleeding after puncture. Various devices are used for continuous postoperative monitoring of free-flap perfusion. Indocyanine green fluoroscopy, which is well-established in ophthalmology, allows a topographical evaluation of flap perfusion in a semi-quantitative manner. The aim of this study was to report the first clinical experiences with application of this new technique.

A total of 16 flaps in 14 patients, whose mean age was 54 years, underwent postoperative indocyanine green fluoroscopy. Two flaps were free flaps, and 14 were pedicled flaps, of which one relied on reverse flow and two were perforator flaps. This method was applied after a mean of 7 (1 to 24) days after surgery. Three flaps had critical perfusion in terms of arterial insufficiency.

Fourteen flaps healed without complication. In two flaps, operative revision was necessary. Total flap loss occurred in one patient and partial flap loss in three more patients. Maximum flap signal intensity was 68% (6 to 150%) of local reference skin. Semi-quantitative perfusion index evaluation revealed a mean of 70% of surrounding skin. Four patients had a perfusion index of less than 25%, in three of whom partial flap loss occurred. Perforator flaps showed neither a reduced maximum intensity or a reduced perfusion index. No side effects were observed.

Indocyanine green fluoroscopy allows a semi-quantitative topographical evaluation of flap perfusion and provides additional information, mainly on arterial inflow. With this technique, continuous flap monitoring is not possible and it is an invasive method. However, critically perfused flaps can be evaluated topographically. Especially with partial perfusion insufficiency, critically perfused skin areas appear to be detected more easily than with other tools.

Monitoring Flap for Buried Free-Tissue Transfer: Importance and Reliability. Cho, Park, Chung, Baik; Taegu, Korea.

To improve the success rate of microsurgical flap transfers into buried areas, it is important to monitor flap circulation during the early stage. A monitoring flap includes such advantages as simplicity, reliability, non-invasiveness, and the ability to continuously monitor the vascular status of various buried flaps.

Between 1990 and 199, a total of 109 flaps in 99 patients were treated with buried free flaps, including a monitoring flap. Forty-nine patients received a tubed free radial forearm flap with a skin-monitoring flap, and six received a free jejunal flap with a jejunal segment monitoring flap for the reconstruction of the esophagus. Vascularized fibular grafts with a skin-monitoring flap or peroneus longus muscle monitoring flap were used for reconstructing the mandible in six patients, and for treating osteonecrosis of the femoral head in 48 flaps in 38 patients. Monitoring-flap abnormalities were demonstrated in 14 flaps; therefore, immediate revisions were performed on the pedicle of the monitoring flap and microanastomosis site. Among these flaps, nine showed true thrombosis and five showed false-positive thrombosis. Among the nine flaps that showed true thrombosis, five were salvaged and four were finally lost. The false-positive thrombosis in the five flaps was attributed to torsion or tension of the perforator of the monitoring flap, an unclear determination in one flap because the monitoring flap size was too small, and damage to the perforator in the last flap. The total thrombosis rate was 8.3% (9/109), and the failure rate of free-tissue transfer was 3.7% (4/109). The overall sensitivity of the monitoring flap was 100%, the predictive value of a positive test was 64% (9/14), and false-positive results occurred in 36% (5/14). The salvage rate was 55.6%.

To improve the reliability of a monitoring flap, it was recommended that the size of the flap be larger than 1×2 cm to assess arterial status, and that a perforator with the appropriate caliber be selected. When a monitoring flap is fixed to a previous incision line or a newly created wound, any torsion or tension on the perforator should be avoided. The current results suggested that a monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of a buried free flap.

Durability of Free Flaps on the Sole of the Foot. Kuokkanen, Helsinki.

A consecutive clinical series of 36 microvascular reconstructions on the sole of the foot in 34 patients was analyzed. In 25 cases, the indication for the reconstruction was a chronic soft-tissue instability, and in 11 cases, an open defect after an acute injury. In 23 patients, the soft-tissue injury was associated with a skeletal injury of the foot. Several flaps were used for reconstruction: scapular - 18, radial forearm - 5, dorsalis pedis - 3, LD musculocutaneous - 22, LD with split-thickness skin graft - 2, rectus abdominis - 2, tensor fasciae latae musculocutaneous - 1, gracilis with split-thickness skin graft - 1, gluteal thigh flap - 1, iliac crest osteomusculocutaneous flap - 1. Three flaps were transferred as neurovascular flaps; in the remaining flaps, no sensory nerve reconstruction was done.

The best fit and contour were achieved with the thin dorsalis pedis and radial forearm flaps, followed by muscle flaps with split-thickness skin coverage. Scapular flaps were in the intermediate category, with most flaps giving only fair contour. The scapular donor-site thickness varied between 5 and 16 mm. The optimal thickness was less than 6 mm. Walking ability was closely related to the skeletal injury of the foot. The flaps varied greatly in sensibility: good sensibility was found in 10 flaps, intermediate sensibility in 13, poor sensibility in 9 flaps. Soft-tissue stability of the reconstruction was not associated with flap sensibility.

Good stability was achieved in 25 of 33 flaps. Intermittent superficial breakdown occurred in 7 flaps and chronic ulceration in 1 flap. The scapular flap was prone to develop abrasions, while most of the thin skin flaps and muscle flaps covered with split-thickness skin grafts were very resistant to breakdown.

Peroneal Flap as a Sensory Flap for Reconstruction of Heel Lesions. Kudoh, Shinji, Miura, Toh; Hirosaki, Aomori.

From January, 1984 to December, 2000, the authors performed 80 peroneal flaps (43 island, 37 free) to cover skin defects. Of the 80 cases, 19 flaps were taken with the lateral sural cutaneous nerve for sensory flaps. To date, this flap has been used to reconstruct the heel region after resection of malignant melanoma in 4 cases, other foot regions in 4 cases, and other areas in another 8 cases. During surgery, the nerve is found at the proximal and lateral level of the peroneal flap and the flap, including the nerve, is meticulously dissected. After transferring the flap to the recipient site, the nerve is anastomosed to a suitable sensory branch. Of the 19 cases, 15 sensory flaps were evaluated with Semmes-Weinstein tests. One tested normal, one had diminished light touch, 7 had diminished protective sensation, and 6 had loss of protective sensation. In the 4 cases of reconstruction after resection of malignant melanoma in the heel that were followed for more than 3 years (38 to 123 months), there was no flap ulceration. The sensory peroneal flap was therefore proposed as a useful method for reconstruction of the heel.

Pediatric Facial Parlysis: Etiology, Strategies, and Outcomes of Reconstruction in 80 Cases. Terzis, Deally; Norfolk, VA.

The purpose of this study was to evaluate the authors' experience with facial paralysis in children, to review the etiologies, to present strategies for reconstruction, and to analyze the results of facial reanimation procedures.

A retrospective review was carried out of all cases of pediatric facial paralysis patients who presented for treatment at the authors' center over the last 20 years. An outcome analysis was performed in those patients who underwent microsurgical intervention. A total of 133 patients were assessed. Patient ages ranged from 6 months to 18 years, <2 years 13%, 2-10 years 40%, 11-18 years 21%. Sixty-three percent were females. Denervation times ranged from 6 months to 17 years. Etiologies included developmental (Dev), 41%, Moebius syndrome (Mo), 26%, tumor extirpation (tumor), 18%, trauma, 8%, Bell's palsy, 3%, and infection, 2%. Other systemic abnormalities were found in 52% of Dev, 94% of Mo, and in none of the other groups.

Eighty (62%) underwent surgery. Of these, 12 (9%) had previously undergone facial reanimation procedures elsewhere. The maximum number of surgeries for any patient was six. The most common procedure for stage 1 was CFNG for all patient groups. Free muscle transfer, either gracilis (44%) or pectoralis minor (56%), with micro-coaptations of the CFNG, was performed in 80% of patients in stages 2 or 3. Later stages were individualized according to the needs of each patient. Inclusion criteria were established on the basis of whether reconstruction was completed, and whether adequate follow-up was present (1 year after CFNG and/or free muscle transfer, 3 months after revisional microsurgery). Outcome assessment by clinical exam and needle EMG demonstrated an overall improvement, with no patients being downgraded by surgery.

The management of pediatric facial paralysis presents unique challenges for the reconstructive microsurgeon. These patients are complex, both in terms of the etiology of their paralysis and in their management. Cross-facial nerve grafting, combined with free muscle transplantation and subsequent revisions, have been effective strategies in achieving rewarding functional and aesthetic results. It is imperative that afflicted children complete their reconstruction prior to entering school, when social pressures can have a significant impact on their self-esteem.

Functional Restoration of Total Avulsion of the Brachial Plexus with Subclavian Artery Injury (Scapulothoracic Dissociation) Using Functioning Free Muscle Transfer. Hattori, Kazuteru; Yamaguchi Prefecture.

The usefulness of functioning free muscle transfer (FFMT) for brachial plexus reconstruction is well-described. These authors reported the double free muscle technique in which two gracilis muscles were transferred to restore the prehensile function following total avulsion of the brachial plexus. For successful FFMT, the use of recipient vessels with adequate blood flow is one of the most important prerequisites. Total avulsion of the brachial plexus with subclavian artery injury (so-called scapulothoracic dissociation, SD) is not uncommon. Although an absent radial pulse is frequent in such injuries, acute limb-threatening ischemia is unusual. The prognosis for functional recovery of the limb in SD is very poor. In this devastating injury, early above-elbow amputation may be recommended. However, the authors have attempted FFMT following repair of the subclavian artery, to reconstruct the prehensile function. In this report, they described the preliminary results of four cases.

All patients were male, and their mean age was 21.7 years (range: 19 to 26 years). They were referred at an average of 2.8 months after injury. All patients had total avulsion of the brachial plexus with subclavian artery injury. However, despite the lack of a radial pulse, they had no limb-threatening ischemia of the affected upper extremity. FFMT was attempted to restore elbow flexion and finger extension (so-called first stage of double free muscle technique), following simultaneous subclavian artery repair.

Repair of the subclavian artery succeeded in all cases. In 3 cases, simultaneous FFMT succeeded with no vascular complication. In 1 case, the use of FFMT was abandoned because of lack of proper recipient vessels at a deltopectoral lesion, despite the success of arterial repair. In 2 of 3 successful cases, the second stage of the double muscle technique to restore finger flexion has already been done with no vascular complication.

Although the functional results of these cases are still to be determined, the recovery from FFMT is not different from cases without subclavian artery injury. The procedure is the only useful one to restore finger function following total avulsion of the brachial plexus. Repair of the subclavian artery is mandatory for use of FFMT in patients with SD. Although very skillful technique is necessary, FFMT following repair of the subclavian artery is a worthwhile procedure.

Reconstruction of Muscle Function to the Paralyzed Face: A Long-Term Clinical and Immunohistochemical Study. Kauhanen, Yla-Kotola, Leivo, Asko-Seljavaara; Helsinki, Finland.

The purpose of this study was to use morphometry and immunohistochemistry to characterize changes in microneurovascular muscle transplants up to 10 years after transfer, and to relate histology to long-term functional outcome.

The study included 15 patients (9 females and 6 males) with complete long-lasting facial paralysis, operated on by Harii's two-stage procedure between 1986 and 2001. The gracilis, LD, and serratus muscles were used in 4, 7, and 4 cases, respectively. Sixteen biopsies from the microvascular muscle grafts were obtained during secondary refinement procedures. The mean follow-up time was 32 months (range: 12 to 120 months). Immunohistochemistry evaluation included skeletal myosin fast for muscle fiber type distribution, Ki-67 for cell proliferation including satellite cells, and S-100 and PGP 9.5 for reinnervation. Muscle atrophy was assessed histomorphometrically. Hospital charts were reviewed, and 13 of 15 patients were available for interview and video recording of mimic muscle function, graded on the House scale from 1 to 6 (mean follow-up: 8.8 years). Histology and functional outcomes for each patient were compared.

In muscle biopsies taken from 1 to 10 years after the second-stage operative procedure, the mean muscle fiber diameter was 38 mm (range: 14 to 70 mm), indicating a 40% decrease, compared to control values. Muscle atrophy was not type-specific, and the mean percentage of type 2 fibers was not altered; however, individual variation was considerable. Proliferative activity of the satellite cells was seen in 60% of the samples, and it tended to decline with increased follow-up. Intramuscular expression of PGP 9.5 and S-100 protein indicative of reinnervation was seen in all samples. In the late clinical evaluation, 8 patients displayed only mild or moderate dysfunction of the facial muscles. In 5 cases, dysfunction was graded as moderately severe. In statistical analyses, flap atrophy correlated with prolonged intraoperative ischemia (p&=0.03). The serratus tended to atrophy more than other muscles, and it showed less satellite cell proliferation and reinnervation (ns).

Muscle morphology was not fully restored, despite muscle innervation. Ischemia time affected muscle morphology. Adaption of the graft to fast-twitch muscle activity favored mimic function. Ultimately, the serratus muscle did not seem like a good choice.

Functioning Free Muscle Transfer in the Reconstruction of the Quadriceps Muscle after Oncologic Resection. Innocenti, Delcroix, Beltrami, Capanna; Florence, Italy.

The surgical ablation of the entire quadriceps muscle is not frequently demanded in tumor surgery. However, in some instances, when a soft-tissue sarcoma is particularly aggressive and diagnosis has been delayed, the whole muscle must be sacrificed. In cases of total or subtotal resection, none of the traditional procedures is able to restore good function; functioning free muscle transfer can be an alternative.

The authors reported their experience with latissimus dorsi transfer in a series of 10 patients, who underwent total or subtotal resection of the quadriceps muscle between 1994 and 2002. All the patients had been affected by high-grade soft-tissue sarcomas. A motor nerve was identified at the recipient site and anastomosed to the thoracodorsal nerve, with the aim of restoring function in the transferred latissimus.

The mean follow-up was 33 months (range: 6 to 96 months). One patient died of the disease, and a second one has too short a follow-up. Thus, the results reported refer to a series of 8 patients. In 7 cases, the active contraction of the muscle has been restored. In one case, the latissimus was involved in a local infection and then removed. Although all patients found the procedure advantageous, in some cases knee extension was partially reduced because of insufficient strength and excursion of the transferred muscle. Nevertheless, in the authors' opinion, such a procedure resulted in quite an effective option, particularly in young patients in whom an acceptable range of motion was restored.

Functional Muscle Transfer in the Upper and Lower Extremity. Berger; Hannover.

Over the last 20 years, more than 42 functional muscle transfers were performed in patients with muscle and nerve losses in the upper arm and leg. Free muscle transfers with connections to nerves were done as an additional procedure after partial nerve regeneration. They were also used for functional support when the regenerated muscles were too weak, or in the lower leg when skin and muscle were lost, along with function. Even in patients with amputation and replantation, microsurgical functional muscle transfer offered a better result. The procedure plays an interesting role in the concept of rehabilitation in severe functional losses in the extremities. Technical problems and complications were discussed.

Limits of Muscle-to-Nerve Ratio in Functional Muscle Transplantation. Giovanoli, Kamolz, Frey; Vienna.

The aim of the present study was to investigate the functional limits of over-dimensioning a free functioning muscle transplant for neuromuscular reconstruction. A portion of the rectus femoris muscle, two and three times bigger than a scutuloauricularis muscle, was used to functionally replace loss of the latter muscle. The major finding was that both double- and triple-sized portions of the rectus femoris muscle developed maximal tetanic tension during isometric contractions, which were up to 175% of the control scutuloauricularis muscle on the unoperated, contralateral side, although the same branch of the facial nerve was used for reinnervation of the grafted muscle. This implied that the supplying branch of the facial nerve has the potential to innervate a muscle much larger than the originally supplied muscle, with optimal efficiency. These results emphasized the usefulness of over-dimensioning during functional muscle transplantation, and also in limited neural capacity situations.

Reconstruction of Hand Function with Various Types of Free Functional Muscle Transplantation. Krimmer, Engelhardt, Kitzinger, Woo; Bad Neustadt.

Free muscle transplantation with motor innervation represents the only way to restore hand function in cases of extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture).

Twenty-seven patients were treated by 31 muscle transplantations. Although considerably weaker than the finger flexors, the gracilis muscle was the preferred donor muscle for reconstruction of finger flexion in 22 cases. The latissimus dorsi muscle was used in 4 cases with extensive loss of soft tissue at the forearm. Three patients in whom the extensor compartment was additionally destroyed, were reconstructed by an additional gracilis muscle in 2 cases, and by tensor fasciae latae muscle transplantation in 1 case after failure of the gracilis. For reconstruction of thumb opposition and resurfacing of a thenar defect, an abductor hallucis muscle with medial plantar flap was transferred in 1 case. The mean age of the patients was 26 years. Sequelae of Volkmann's contracture were seen in 13 patients, loss of musculature by direct trauma in 11, and burn injuries in 3 patients. For motor innervation, the interosseus anterior nerve was present in 22 cases, the motor portion of the proximal ulnaris in 1 case, the interosseus posterior nerve in 3 cases, and the motor branch of the median nerve in 1 case.

The mean follow-up was 7.5 years (range: 1 to 18 years). Reinnervated functioning muscle was obtained in 24 patients, 3 patients achieved no function despite muscle survival, and 2 muscles failed because of one arterial and one venous thrombosis. Both patients demonstrated extensive scarring from long-standing ischemia in avulsion injuries. All 24 patients regained useful function and were satisfied with the final result. Additional procedures were necessary, with wrist fusion in 5 patients and tenolysis in 6 patients. On average, total active motion demonstrated 110 degrees, and grip strength reached 28% of the opposite side.

Free functional muscle transplantation represents a reliable procedure for reconstruction of finger flexion or extension. In cases of extensive loss of soft-tissue coverage, the latissimus dorsi proved to be preferable to the gracillis. Complete excision of all necrosed and fibrosed musculature and neurolysis are prerequisites for good functional outcomes. The abductor hallucis muscle and medial plantar flap can be useful for covering wide thenar defects and restoring thumb opposition.

Brachial Plexus Palsy at Birth: Surgical Treatment of Shoulder Deformity in Young Children. Gabriel, Bishop, Shaughnessy, Shin, Wood; Rochester, MN.

Internal rotation contractures, and weakness/loss of shoulder abduction and external rotation are common sequelae of upper trunk injury, and multiple surgical procedures are performed for limited shoulder motion in young children. Release of the internal rotation contracture is frequently recommended at age 2 years, and tendon transfers at age 3 years, if a functional deficit remains. The authors have routinely combined a subscapularis release with transfers of the conjoined latissimus dorsi and teres major tendon to the supraspinatus tendon, in children as young as 18 months. This paper summarized the results.

All tendon transfers performed at the authors' institution for residual deformity of the shoulder in patients with birth brachial palsy were reviewed. Range of motion and shoulder strength were measured before and after the procedures. Twenty patients underwent a subscapularis origin release combined with a latissimus dorsi and teres major transfer. These procedures were performed in children with a mean age of 1.96 years (range: 1 to 4 years). The indication for surgery was a fixed internal rotation contracture associated with limited active shoulder abduction and external rotation that had been unresponsive to physiotherapy. All children had palpable contraction of the latissimus dorsi muscle. Patients were followed-up for 2.4 years postoperatively. There were 11 males and 9 females. The right upper extremity was involved in 16 patients. Passive external rotation with elbow at side was from -40 to 40 degrees (average: 8 degrees) preoperatively, and improved to a mean of 60 degrees. Active abduction improved from a mean of 84 to 133 degrees after the tendon transfer. Two complications were observed.

Impairment of shoulder abduction and external rotation is the most common long-term problem following birth-related injury of the brachial plexus. Most authors recommend an early release of tight internal rotators and/or shoulder joint capsule, to be followed at a later date with tendon transfer when motor strength can be reliably tested. The authors' experience suggests that tendon transfers can be combined with a subscapularis release in very young children, thus avoiding the morbidity and expense of two surgical procedures and postoperative casting. Improved strength and range of motion were uniformly observed. Patients with relatively less improvement than the mean tended to have more severe initial injury, including significant weakness of the hand and wrist.

Double Free Functioning Muscle Transfer for the Reconstruction of Brachial Plexus Injury. Tu, Chou, Ueng; Keelung.

Brachial plexus injury (BPI) is a devastating injury for trauma patients, especially when presenting with a total trunk avulsion type, “nothing over the injured limb.” The authors presented their double free-flap experience in 8 patients who had no function of the upper extremity after BPI.

From 1997 to 1999, 18 free functional gracilis muscle flap transfers were performed for BPI reconstruction in 8 patients (7 males and 1 female). All of them were victims of motorcycle accidents, and all had total trunk avulsion supra-clavicle lesions. The average patient age was 31 years (range: 18 to 45 years). Free functioning gracilis muscle transfer with neurotization of spinal accessory/intercostal nerves was performed as first stage surgery for elbow flexion; second-stage surgery was done with free functioning gracilis muscle transfer for hand function, with nerve graft at the same time. The surgical technique was demonstrated. Postoperative evaluation was evaluated by muscle power assessment. The average follow-up was 4 years.

The flap success rate was 93.7%, with 1 case requiring a reopen surgery due to venous thrombosis. Seventy-five percent (6/8) achieved M3 elbow flexion, and 50% obtained an M3 hand grip (4/8) at a 2-year follow-up. At a 4-year follow-up, 87.5% (7/8) had an M4 elbow function, and only 50% (4/8) had an M4 hand grip.

Double functioning free muscle flap transfer for the reconstruction of total avulsion type BPI is a worthwhile technique. Elbow function can be effectively restored. However, hand function was not satisfactorily recovered.

Restoration of Elbow Flexion by Tsu-Min Tsai's Method in Brachial Plexus Palsy. Miura, Toh, Nishikawa, Kudoh, Vallejo, Tsubo; Hirosaki City, Aomori Prefecture.

Many varieties of surgical procedures to restore elbow flexion by transferring muscles have been described. In this paper, the authors reported the functional results in patients who underwent elbow flexorplasty by complete pectoralis major and pectoralis minor muscle transposition.

From 1984 to 2001, the authors treated 7 patients with flexor paralysis of the elbow by transplantation of the entire pectoralis major and pectoralis minor muscles, a method first reported by Tsu-Min Tsai in 1983. All of the patients had sustained traumatic traction injuries of the upper brachial plexus. All were males, with an average age at operation of 37 years (range: 19 to 63 years). The right arm was affected in 3 patients and the left arm in 4 patients. The mean interval between injury and operation was 14.7 months (range: 4 to 30 months). The mean length of follow-up was 38.3 months (range: 17 to 124 months).

The mean arc of active flexion following flexorplasty was 95.7 degrees (range: 20 to 130 degrees), and the mean postoperative active supination was 51.0 degrees (range: 10 to 90 degrees). The postoperative strength of elbow flexion was good in 3 patients, fair in 3 patients, and poor in 1 patient. When the results were evaluated according to the criteria of Mayer and Green (1954), the results were excellent in 1 patient, good in 2, fair in 3, and poor in 1 patient. In 1 patient, the procedure could not provide a satisfactory result, apparently due to severe bone damage of the arm and forearm sustained simultaneously.

In recent years, either the latissimus dorsi or the pectoralis major muscles have been used as bipolar transfers for the reconstruction of elbow flexion. The dissection of the pectoralis major and minor muscles as a single functional unit protects the medial pectoral nerve, and the muscles can provide adequate elbow flexion.

Latissimus Dorsi Pedicled Flap for Restoration of Elbow Flexion after Major Upper Limb Replantation. Wechselberger, Schoeller, Hussl, Piza; Innsbruck.

Major upper limb amputations are often accompanied by different levels of soft-tissue division involving crushing, traction, and avulsion injuries to various structures. In these cases, the goal is not only the reestablishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft-tissue coverage with the pedicled latissimus dorsi flap.

From August, 1998 to April, 2002, five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper limb replantation. Latissimus transfer was bipolar in 4 patients and unipolar in 1 patient. Patient ages ranged from 7 to 55 years. The time period between replantation and latissimus transfer ranged from 2 weeks to 12 months.

All flaps healed well, and donor-site morbidity was minimal. At a mean 25-month follow-up (range: 7 to 40 months), functional results were good (muscle manual test of the limb indicated M4 in 3 patients for elbow flexion and M3 in 2 patients). All patients were satisfied with their outcome.

The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and to cover soft-tissue defects after severe upper limb replantation.

Improved Functional Recovery in Diabetic Rats Following Crush Injury. Siemionow, Zielinski, Meirer, Nair; Cleveland, OH.

The vascular endothelial growth factor, 165 (VEGF 165), has demonstrated angiogenic as well as neurogenic activity. An experimental study was conducted to investigate the potential of VEGF to stimulate peripheral nerve tissue regeneration after crush injury in diabetic rats.

Eighteen male type II diabetic rats were divided into three groups of 6 animals each. The right sciatic nerve was crushed using a standard technique (60 sec compression with 17.4 N force). Group 1 (control): following crush injury, rats received no treatment. Group 2 (GFP control): after crush, 0.3 ml of GFP (108 pfu of Ad-GFP) was injected subepineurially. In Group 3 (VEGF treatment): following crush, the sciatic nerve was injected subepineurially with 0.3 ml of 108 pfu of Ad-VEGF. Functional nerve recovery evaluation included: pin-prick test, toe-spread test, and somatosensory evoked potentials (SEP) analysis of N1, P1, and N2 latencies in a triphasic wave.

At 3 weeks after crush injury, SEPs showed a significant prolongation of N2 latencies in the control groups: Groups 1 (N2:33:63 ms) and 2 (N2:32:32 ms), compared to the VEGF treatment group (N2:27.59 ms) (p<0.05). The pin-prick test demonstrated an improved sensory regeneration in the VEGF treatment group, in which sensory recovery was detected at the ankle level (grade 2), compared to the knee level (grade 1). At 6 weeks, SEP evaluation showed significant prolongation of the N2 latencies in the control groups: Groups 1 (N2:31:23 ms) and 3 (N2:31:64 ms), compared to shorter N2 latencies in the VEGF treatment group (N2:24:73 ms) (p<0.05). Significant improvement in SEP latencies was found in VEGF-treated nerves at 12 weeks after crush: Group 3 (N2:26:13 ms) vs. Groups 1 (N2:29:70 ms) and 2 (N2:32:01 ms).

In this study, adenovirus-mediated VEGF gene therapy improved the functional recovery of crushed sciatic nerves at 3, 6, and 12 weeks, compared to the controls. This was confirmed by more rapid recovery of sciatic nerve function by the somatosensory-evoked potential test.

Functional Electrophysiologic and Morphometric Evaluation of Nerve Regeneration in Coaptation of Regenerated Nerve Fibers - An Experimental Study in the Rabbit. Beer, Burg, Zehnder, Seifert, Steurer, Meyer; Zurich, Switzerland.

The importance of a sufficient number of nerve fibers at a proximal coaptation site is vital for the successful repair of nerves; however, the quality of the nerve fibers required at this site has yet to be defined. The present study dealt with the question of whether it is necessary to trim nerves back to unaffected neuronal tissue, or whether the coaptation of recently regenerated nerve fibers, commonly believed to produce a poor quality of repair can, in fact, produce adequate nerve regeneration.

Twenty New Zealand White rabbits received a standard crush lesion on the peroneal nerves of both hind legs, 45 mm proximal to the muscle entrance on the left and 35 mm on the right side. Four weeks later, the nerves of the left hind legs (n&=20) were transected 10 mm distal to the previous crush lesion and coapted to the freshly regenerated nerve fibers. For comparison, on 10 right hind legs, the nerves were transected at the site of previous crushing (Group 1, superimposition) or 10 mm proximal to the site of crushing on unscathed nerve fibers (Group 2). Eleven weeks later, the quality of nerve regeneration was assessed by functional, electrophysiologic, and histologic evaluation.

In the animals in Group 1, none of the examined parameters of nerve regeneration differed significantly between the two sides. Also, in Group 2, neither the amplitude and conduction velocity (CV) across the suture or at an equivalent site distal to the suture, were significantly different between left and right sides. However, due to the 10-mm difference in the transection sites in favor of the left hind leg, the compound muscle action potential (cMAP) was significantly higher (p&=.038) and the CV across the lesion significantly more rapid (p&=.015), calculated from the cMAP on the left peroneal nerves. Correspondingly, the toe-spreading reflex was positive on the left hind legs in all animals, but not yet positive on the right side. The weight of the peroneal nerve-innervated muscles was significantly higher on the left sides. Histology revealed no significant differences between the left and right hind legs.

With this coaptation model in the peroneal nerve of rabbits, it could be demonstrated that coaptation to recently regenerated nerve fibers led to an evident functional regeneration. Under these experimental conditions, there was no obvious disadvantage to using previously damaged nerve fibers over using unscathed fibers to regenerate nerve tissue.

Neuroma Prevention by End-to-Side Neurorrhaphy: Experimental Study in Rats. Aszmann, Korak, Rab, Frey; Vienna, Austria.

The successful treatment of painful neuroma remains a difficult goal to obtain. In this reported study, the authors explored the feasibility of neuroma prevention by inserting the proximal end of a nerve through an end-to-side neurorrhaphy into an adjacent mixed nerve, to provide a pathway and target for axons deprived of their end organs.

Experiments were performed on a total of 20 Sprague-Dawley rats weighing 250 g. Two groups of 10 animals were prepared. Group 1 served as an anatomic control. In Group 2, the right saphenous nerve was transected and implanted end-to-side through an epineurial window into the tibial nerve distal to the trifurcation of the sciatic nerve. After 12 weeks, the corresponding sensory neurons were identified by retrograde labeling techniques, and histomorphometric analyses of the proximal and distal tibial nerve segments were done.

The results of retrograde labeling of the corresponding sensory neuron pool of the saphenous nerve showed massive labeling of the L1-L3 spinal ganglions after intracutaneous tracer application to the plantar pedis. The morphology of the end-to-side coaptation site and histomorphologic analysis validated that sensory neurons penetrate the perineurial sheath, and axons obviously regenerate along the tibial Schwann-cell tubes toward either muscle or skin.

Whether these regenerating axons will lead to disturbing sensations, such as par- or dysesthesia in the newly found environment or will remain silent co-dwellers, the experiment cannot answer. Long-term results of future clinical work will have to decide whether the prevention of neuroma through end-to-side coaptation will be the appropriate therapy for this difficult problem.

Hematopoietic Stem-Cell Mobilization and Immune Response in Tumor-Bearing Mice. Isenberg, Ojelfo.

It has been accepted that the immune system undergoes changes in its ability to respond to immune challenge, both with advancing age and in the presence of tumor. The clinical observations of increased infection rates and wound-healing complications in elderly and cancer-bearing patients is often attributed to this immune system defect. Some reports have documented T-cell functional defects in tumor-bearing mice, and also in humans. However, the exact nature of the defect has not been fully elucidated. The purpose of this study was specifically to quantify the effect of advancing age and tumor burden on hematopoietic stem-cell mobilization and the immune system response.

Female BALB/c mice of specific ages were treated with 4 T1 mammary cancer cells (1×105) injected to the mammary fat pad. Control mice received no injections. Animals were matched for age and tumor-bearing interval at the time of sacrifice when blood and spleens were collected. Low-density mononuclear cells (LD MNCs) were separated via gradient centrifugation and used immediately. Assays performed included colony-forming unit count, INF-output, mitogenic response, and cytotoxicity. Cells were also stained and percentage distributions determined via FACS analysis.

Tumor-bearing mice showed a progressive increase in their splenic-to-body weight ratios with lengthening tumor interval. The corresponding increase in their splenic weight and size paralleled the increased numbers of LD MNCs recovered from each organ. Control mice did not show changes in splenic-to-body weight ratios with advancing age, although modest increases in total recovered LD MNCs were noted. INF-output, a general measure of inflammatory activity, was markedly increased in LD MNC from blood and splenic cells of tumor-bearing animals, although a dropoff in INF-output occurred after the fourth week in blood LD MNC. Mitogenic response was also markedly increased in cells from tumor-bearing animals, compared to controls. This effect was found in cells from the blood and spleen. Even at 5 weeks of tumor-bearing interval, the mitogenic response was still elevated above control. However cell-killing activity against 4 T1 cells was increased in only LD MNCs of splenic origin. As a measure of hematopoietic stem-cell mobilization, the CFU-C assay demonstrated a significant increase in blood cells. FACS analysis demonstrated a decrease in all cell lines, except those positive for Gr 1.

A New Model to Induce Angiogenesis by Ex Vivo Transfected Isogenic Fibroblasts Based on Gene Transfer. Machens, Spanholtz, Maichle, Niedworok, Lindenmaier, Krueger; Luebeck.

These authors have developed a new model for temporary production of angiogenic proteins by using adenovirally transfected isogenic fibroblasts as carriers.

Isogenic fat fibroblasts were produced, harvested, and cultured for three cell passages. Adenoviral gene transfer was performed using a padcos46 RESeGFP vector. The vector was charged with the gene sequence for PDGF-BB (Group 1), bFGF (Group 2), VEGF165 (Group 3), and GFP (Group 4, mock infected). Non-modified fibroblasts served as controls (Group 5). In vitro examination of successful gene transfer and protein production was performed. For in vivo experiments, 26 isogenic healthy animals were selected for each group. In each animal, 5 x 106 cells from Groups 1-5 were injected into the animals' panniculus carnosus 24 hr after transfection. Histologic, immunohistochemical, and proteoanalytic examination of the target tissue was performed in one animal of each group up to 182 days after cell transplantation. Quantification of small blood vessels was performed using microangiography in 28 isogenic animals/group up to 4 weeks after treatment.

All animals in Groups 1-3 developed micro- and macroscopic signs of angiogenesis, quantified by microangiography during 3 weeks after cell transplantation. During this time, protein production was detectable in Groups 1-3, both directly by Western blot and indirectly by Northern blot. In contrast to all other subgroups, all animals in Group 1 developed transient pseudotumors within 4 weeks after cell transplantation. Histologically, pseudotumors consisted mainly of macrophages and neutrophils. No relevant histomorphologic changes were found in all tissue samples of Groups 4 and 5.

In the described model, adenoviral gene transfer created isogenic transfected cells, which were able to act as carriers for transient production of significant amounts of protein, both in vitro and in vivo. In vivo, both VEGF165 and bFGF induced transient angiogenesis in the target tissue, while PDGF-BB acted mainly by recruitment of polymorphonuclear cells. The model will be tested to induce therapeutic angiogenesis in various ischemic situations in vivo.

Distribution of NGF and BDNF and their Receptors, p75 and trkA, in Experimental End-to-Side Neurorrhaphy. Risitano, Papalia, Cavallaro, Stagno d'Alcontres; Messina.

Neurotrophins and their receptors have a definite role in nerve regeneration, other than in nerve development during fetal life. The biologic and molecular bases of nerve regeneration after end-to-side neurorrhaphy are still unknown. The aim of this study was to investigate the distribution of neurotrophins and their receptors after end-to-side anastomosis of the median nerve to an intact ulnar nerve in a rat experimental model.

The authors utilized two groups of 10 Wistar rats. In Group 1, an end-to-side neurorrhaphy was performed bridging a cut median nerve to an ulnar nerve. In Group 2, the donor ulnar nerve was cut distally to the neurorrhaphy. In both groups, functional tests were performed (grasping test and electrostimulation). Immunohistochemical analysis of specimens obtained from the two groups was done by using anti-NGF, anti-BDNF, anti-p75, and anti-trkA antibodies. The immunofluorescence of the same antibodies was observed by confocal microscope. Detection of mRNA for NGF was performed by in situ hybridation techniques.

As in autogenous vein grafts used to bridge nerve gaps, the neurotrophins and their receptors can be detected in the target nerve and in the donor nerve, and can also have a definite role in different phases of the regeneration process.

Regrowth of Functional Lymphatic Vessels in Skin Flaps Stimulated by VEGF-C Growth Factor Gene Therapy. Saaristo, Tammela, Tukianen, Asko-Seljavaara, Alitalo; Helsinki, Finland.

Tissue edema and secondary lymphedema are common problems in surgery, especially in reconstructive surgery. While the blood vessels of free flaps can be reconstructed, lymphatic vessel function is generally lost after surgical incision of the skin. Discovery of the first lymphangiogenic growth factors now allows the development of new targeted therapies for lymphedema. The vascular endothelial growth factor-C is the first known growth factor that is capable of inducing growth of new lymphatic vessels, and mutations of its target receptor, VEGFR-3 gene, are associated with hereditary lymphedema. The authors have recently shown that VEGF-C gene transfer to the skin of mice with primary lymphedema can induce regeneration of the cutaneous lymphatic vessel network. Yet another potential use for VEGF-C therapy in reconstructive surgery was described.

The authors used pro-lymphangiogenic gene therapy in an epigastric flap model, in order to restore the lymphatic vessel network after surgical incision. The results showed that VEGF-C gene transfer is able to induce growth of new lymphatic vessels, and that fluorescent macromolecules are taken up by these vessels and transported across the flap margin to the axillary lymph nodes only in VEGF-C-treated tissue.

In reconstructive surgery, necrosis is partly caused by elevated interstitial fluid pressure that impairs flap perfusion. The authors envision that VEGF-C therapy might be used in human reconstructive surgery to improve the perfusion in tissues subjected to surgery, and thereby reduce swelling in the flaps utilized.

Pulsed Magnetic Energy Affects Survival of Groin Composite Grafts. Strauch, Yu, Weber; Bronx, NY.

Pulsed magnetic energy (PME) has been shown to stimulate neovascularization in the authors' laboratory. The groin composite flap was used to create a prospective randomized trial to test the effectiveness of PME. The skin paddle to this flap is highly consistent, and it was proposed to use this flap in order to study how PME affects composite flap survival, when the dominant vessel to the flap is divided and flap survival becomes dependent on a transferred vessel loop.

Each rat had its tail artery microsurgically anastomosed to the femoral artery and placed between the groin musculature and the abdominal skin. Pulsed magnetic energy of 1 gauss was applied for 8 or 12 weeks to the experimental groups (n&=5-16/group). After 8 or 12 weeks, all groups had an 8x4-cm skin flap raised, and the superficial epigastric artery, the main feeding vessel, was ligated.

The experimental animals in the 8-week group treated with PME had highly statistically significant flap survival over the control animals. The study continued to provide evidence that PME stimulates angiogenesis, and suggested a possible use of this modality to create island vascular flaps in otherwise random areas.

Prevention of Neuroma Formation by Selectively Inhibiting Nerve Regeneration with Intraneural Injection of OX7-Saporin. Zhang, Belzberg, Meyer, Griffin; Baltimore, MD.

The authors investigated whether axonal transport of a kind of neuron-specific toxin (OX7-saporin) would lead to selective loss of neurons in DRG and ventral horn of the spinal cord.

Thirty adult Sprague-Dawley rats, weighing 200- 250 g at the beginning of the experiment, were randomly divided into three groups. Group A (GA, n&=10): the left common peroneal nerve and posterior tibial nerve were severed to allow neuroma formation; Group B (GB, n&=10): the nerves were cut as in GA and then 2 mL OX7-saporin was injected into the posterior tibial nerve. In Group C (GC, n&=10), 2 mL of Dulbecco's PBS was injected into the posterior tibial nerve. After 3 and 6 weeks, the animals were sacrificed by transcardial perfusion. The common peroneal nerve, tibial nerve, sciatic nerve dorsal and ventral roots were harvested and routinely processed for light and electron microscopy evaluations.

There was typical neuroma formation by gross observation in GA. The same findings were found in GC. However, there was a tapered tip instead of a neuromatous bulb in GB. Microscopically, the neuroma was composed of an entangled mass of nerve fibers with a large number of regenerating axons. In marked contrast, there was an extensive degenerating change of nerve fibers in the OX7-saporin-treated rats. The degeneration was in a well-defined portion of the sciatic nerve, corresponding to the fascicles that form the posterior tibial nerve. The degeneration was also found in the dorsal and ventral roots in GB.

The study demonstrated that intraneural injection of OX7-saporin could effectively prevent neuroma formation by wiping out and/or inhibiting the regeneration of injured nerve fibers in rats. This kind of neuron-specific neurotoxin could be used as a potential molecular neurosurgical approach for preventing neuroma formation in the future. The study validated that intraneural injection of OX7-saporin could effectively prevent neuroma formation.

L-Arginine Improves Skeletal Muscle Function after Ischemia. Benditte-Klepetko, Koller, Fuegl, Mittlboeck, Huk, Frey; Vienna, Austria.

L-arginine is the natural precursor for nitric oxide (NO). It has a plethora of physiologic effects and plays an important role in ischemia/reperfusion injury in different tissues. This study was designed to investigate the influence of L-arginine application on the contractility of skeletal muscle after ischemia.

In 15 rabbits, the rectus femoris muscle was dissected, and a 3-hr ischemia was induced. The animals were randomly divided into two experimental groups: Group 1 received L-arginine treatment (4 mg/kg/min) during 1 hr before ischemia; in Group 2, ischemia of the rectus femoris muscle was induced without application of L-arginine. Three weeks after ischemia, muscle function was tested by an established model. The muscle was isolated and isometric tetanic contractions were measured at supramaximal stimulation of the femoral nerve. In each animal, the operated side was compared to the non-operated contralateral side.

L-arginine plasma concentrations measured at the onset of ischemia were 2.5-fold higher in the L-arginine-treated animals, compared to the control group. In the L-arginine-treated group, the muscle force measurements of the rectus femoris muscle 3 weeks after ischemia were 104%, compared to the non-operated contralateral side. In the control group, muscle force was reduced to 54% on the operated side vs. 100% on the contralateral non-operated side (p&=0.0001). In addition, less interstitial edema and less vasoconstriction of the microvessels were observed in the L-arginine-treated group, compared to the control group.

This study suggested that intravenous application of L-arginine prior to onset of ischemia of skeletal muscle has a beneficial effect on prevention of loss of muscle function.

Effect of Torsion on Microvenous Anastomotic Patency in a Rat Model. Bilgin, Topalan, Ip, Chow; Ankara, Turkey.

Torsion at the microanastomosis site is a basic fault and should be avoided. The situation may be less favorable in microvenous anastomosis than in microarterial anastomosis, as veins are expected to collapse with torsion. The study reported set out to examine the effect of torsion on microvenous anastomotic patency.

One hundred anastomoses were performed at different degrees of torsion, using the femoral vessels of Sprague-Dawley rats. Patency was assessed immediately, at 1 hr, and at 1 week with the refill test. Histopathologic and scanning electron microscopy evaluations were performed. On detecting a peculiar phenomenon of early recanalization of the thrombosed vessels, 20 further vessels were explored at POD 1 and 3. The data demonstrated that torsion at 1800 units significantly impaired patency, compared with 0, 450, and 900 U (p<0.005). In a subsequent study of the 20 veins that thrombosed on the first day, the vast majority of them became patent on the third day, and remained so.

Rotation of the microvenous anastomosis began to affect patency rate at 90 degrees of torsion, and the rate diminished to 25% at 180 degrees. Thrombosis of rat femoral veins without chronic obstruction resulted in rapid lysis of the thrombus and transient proliferative changes. In clinical microsurgery, such a scenario seldom occurs. However, in the light of this study, minor torsion of less than 45 degrees seems to be acceptable.

Plasma Levels of Endothelin-1 after Myocutaneous Latissimus Dorsi Transfer. Jokuszies, Muehlberger, Spies, Lahoda, Vogt; Hannover.

ET-1, an endothelium-derived peptide, is the most potent endogenous vasoconstrictor, and therefore may be associated with the failure of myocutaneous free flaps. The goal of this study was to evaluate whether ET-1 is involved in reperfusion injury after prolonged ischemia due to tourniquet and flap transfer.

Fourteen patients underwent a free-flap reconstruction of the lower leg, with controlled ischemia due to tourniquet and flap transfer. The control group included 25 healthy volunteers. The interval from trauma to muscle transfer varied from 1 week up to 26 years. Plasma levels of ET-1 in venous blood samples were measured with ELISA. The samples were drawn at pre-, peri-, and postoperative intervals via central vein catheter and also directly from the vein after reperfusion. The following time table was chosen: T1 - preoperative (systemic); T2 - pre-perfusion (syst.); T3 - post-reperfusion (local); T4 - 10 min post-reperfusion (syst.); T5 - 15 min post-reperfusion (syst.); and T6 - 1 hr post-reperfusion (syst.)

A distinct increase in ET-1 plasma level was measured in the flap vein after reperfusion (flap ischemia ranged from 87 to 203 min; mean: 145.86 min/SD 34.08 min), compared with plasma levels in preoperative general circulation (mean: 1.85 pg/ml ± 3.64 pg/ml vs. mean: 0.51 pg/ml ± 0.08 pg/ml). No increase was measured systemically pre- and post-reperfusion. In the tourniquet group (ischemia ranged from 22 min to 210 min; mean: 76.58 min/SD 40.91 min), plasma levels of ET-1 also increased directly after reperfusion (mean: 0.95 pg/ml ± 0.79 pg/ml). The high standard deviation was probably due to hemolysis.

In this study, the authors investigated for the first time plasma levels of ET-1 in humans, regarding the duration and type of ischemia. It was shown that ET-1 is present in the general circulation, as well as in the flap vein after recharging the flap. It was also shown that plasma levels of ET-1 were increased at the local site immediately after flap, as well as extremity, reperfusion due to declamping and tourniquet release. The interval from trauma to muscle transfer, as well as the extent of tissue damage, had no influence on endothelin plasma level in the general circulation. Further investigation should demonstrate the local effect of ET-1 immediately after reperfusion with avoidance of hemolysis.

Generation of Three-Dimensional Vascularized Constructs in Tissue Engineering - A Prelude to Soft-Tissue Defect Correction. Dolderer, Kelly, Cooper-White, Penington, Thompson, Morrison; Melbourne-Fitzroy, Australia.

The correction of soft-tissue defects presents a challenge in plastic and reconstructive surgery. Three-dimensional tissue-engineered structures involving matrix scaffolds require vascularization for their survival and, if required, for transfer to other sites.

The authors created a method of producing a vascular network in vivo in the rat, using a microsurgically-created arteriovenous loop implanted inside a plastic chamber containing a poly DL-lactic-glycolic acid (PLGA) scaffold. This loop has the capacity to spontaneously proliferate and fill the chamber with angiogenic tissue. The effects of modification of the vascular structure, as well as the chamber, have been examined. The more simple ligated arteriovenous pedicle has been compared to the more complex arteriovenous (AV) shunt loop, and the effects of perforations in the chamber have also been assessed. Tissue and PLGA weight and volume, as well as the histologic characteristics and quantification of the newly formed tissue were assessed at 2, 4, and 6 weeks.

Tissue weight and volume showed a strong linear correlation with time. The matrix was progressively replaced with vascularized tissue, and overall shape and dimensions were maintained. The amount of tissue formed around the ligated pedicle was almost the same as with the AV shunt loop. The inclusion of perforations in the chamber lid resulted in significantly increased tissue outgrowth seen in both the AV shunt loop and the ligated pedicle groups.

The simplicity of the ligated pedicle vascular design, compared to the AV shunt loop, makes it the preferred option from a clinical perspective. The perforated chamber shell allowed vascular invasion from the periphery, as well as from the implanted vessel, and the two systems linked to maximize angiogenesis and tissue proliferation. Future reconstruction of three-dimensional defects will be possible using stable vascular matrices, such as the one described. The fact that new tissue has its inbuilt blood supply has many advantages for tissue engineering and transplantation in the in vivo situation. These experiments demonstrated increased tissue production as a prelude to advancing to larger size, longevity, and transplantation studies in the pig, and eventually to human studies. Characterization and manipulation of outgrowth hold further promise for differentiation and end products.

Spinal-Cord Gap Repair with Newborn Sciatic Nerve Graft, Compared with Lumbar L2-L3 Spinal-Cord Gap Repair: A Study in the Wistar Rat. Almeida, Mousinho, Silvestre, Mafra, Medeiros; Lisbon.

The aim of this study was to test the regeneration capacity of the thoracic T9-T10 spinal cord, following repair of a 5-mm gap with a peripheral nerve graft. The authors evaluated functional muscle recovery in the posterior limbs of Wistar rats following repair of 5-mm thoracic spinal cord gaps grafted with newborn rat sciatic nerve, compared with results obtained at levels L2-L3.

Fifteen female Wistar female rats, weighing 300 g, were utilized. The animals were anesthetized with intraperitoneal ketamine/xylasine injection. All surgical procedures were performed by the same three surgeons. In 12 rats, a 5-mm gap of the thoracic spinal cord was created and repaired with six to eight cables of newborn sciatic nerve. In the three other animals, the gap created was not repaired. The animals were divided into three groups, and observed at 4, 8, and 12 weeks after surgery. In all animals, evaluation of regeneration was made by electrophysiologic and histologic analyses. Their walking patterns were registered on videotape.

The authors found it was possible to produce thoracic spinal cord regeneration in this rat model, following repair with newborn peripheral nerve grafts, and improving the ability to walk in the experimental animals.

Analysis of Epigallocatechin Gallate Treatment on Oxygen Derived Free Radicals in the Ischemic Rat Limb Using a New Biosensor. Philipp, Mall, Schlenzka, Schceller, Lisdat, Buettemeyer; Berlin.

There is experimental evidence that oxygen derived free radicals (superoxide O2-) play a key role in tissue damage in ischemia/reperfusion injury. Among the various antioxidants tested in vitro, natural polyphenols like epigallocatechine gallate (EGCG) show a 164-fold higher scavenging activity for O2- than ascorbic acid. A recently developed cytochrome c-based biosensor facilitates on-line in vivo monitoring of O2- concentrations in muscle tissue. The authors therefore conducted an animal study in order to investigate the impact of EGCG on O2- production during reperfusion after defined periods of ischemia in the muscle tissue of the rat.

Arteria and vena femoralis were dissected below the inguinal ligament in male Wistar rats. The cytochrome c-based biosensor was placed in the m. gastrocnemius. Ischemia was induced by clamping the femoral vessels. Ischemia times were either 60 (n&=14) or 120 (n&=14) min. Six animals in each group received 4 mg/kg body weight EGCG intravenously at the time of reperfusion; another six animals in each group served as controls (no treatment). Additionally, two animals in each group received the same volume of saline instead of EGCG. The current response of the biosensor corresponding to the O2- concentrations in vivo was recorded on a PC. The gastrocnemius muscles were harvested for histologic evaluation.

Median maximum O2- concentration after 60 min ischemia was 188.18 nM (23 pA), compared to 90 NM (11 pA) (p<0.01), with EGCG application. Median value of O2- after 120 min was 220 nM (27 pA) and 135 nM (16.5 pA) (p<0.01) with EGCG, respectively. Histologic analysis showed advanced muscle cell injury and neutrophil infiltration in the group without EGCG. No O2- reduction could be verified administering saline instead of EGCG.

For the first time, the scavenging activity of an antioxidant could be verified in vivo on-line. EGCG significantly diminished O2- tissue concentrations after 60- and 120-min ischemia by nearly 50% on average, emphasizing its potential.

Qualitative Assessment of Adult Mouse NSC Survival and Differentiation in an In Vivo Model of Angiogenesis with Application in Tissue Engineering. Bedogni, Keramidaris, Young, Bartlett, Morrison, Messina; Melbourne.

Adult mammalian CNS-derived NSCs have been shown to generate multipotent neurospheres that, under experimental culture conditions, are able to develop both neural and non-neural progenies. Neurospheres have also been demonstrated to survive after transplantation in the CNS of the mouse. To date, there have not been any studies that describe the fate of these cells in peripheral tissues. The aim of this study was to determine the capacity of NSCs derived from adult mammalian CNS to survive and differentiate in an in vivo mouse model of angiogenesis with an application in tissue engineering.

NSCs were isolated from the sub-ventricular zone (SVZ) of adult BU5X transgeneic mice, which express both lacZ and enhanced GFP, and subsequently expanded in vitro by neurosphere formation. Five hundred neurospheres were seeded into 10 microl of a medium containing growth factor-reduced matrigel and neural basal media. This media-cell mixture was then injected into a silicone chamber, which incorporated the superficial epigastric vessels and nerves in the groins of 28 syngeneic mice (C57BI/6 males). The vehicle without cells was injected into an identical construct on the contralateral side of each mouse. Animals were sacrificed at 6 days, 2, 3, 4, and 6 weeks, and the contents of the chambers assessed for neurosphere-derived cells by histologic and immunohistochemical analyses.

The results indicated that in vitro-expanded neurosphere cells derived from adult mammalian SVZ are able to survive, once transplanted in an in vivo model of angiogenesis.

Solitary Flexor Pollicis Longus Palsy - An Anatomic Study. Dolderer, Jones, Briggs, Morrison; Melbourne-Fitzroy.

The variability of the origin of the flexor pollicis longus (FPL) and its tendon has been described in the anatomy literature. Several variations of the FPL muscle have been implicated as causes of anterior interosseous nerve compression in the forearm. These variations and their relation to the median nerve and anterior interosseous nerve are important when decompressing these nerves in the proximal forearm and when doing nerve and tendon repairs in this region. The anterior interosseous nerve is a pure motor nerve supplying the flexor pollicis longus, flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus (PQ). A relatively uncommon solitary neuropathy of the branch of the anterior interosseous nerve to the FPL muscle occurs from unusual etiologies.

The authors have treated four patients who presented with an isolated palsy of the FPL muscle after attempted venepuncture of the median cubital vein. Cadaver dissections were undertaken to see if there might be any anatomic explanation which would predispose to such an injury.

On embalmed cadaver dissections, the anatomy and the relation of the cubital veins to the median and anterior interosseous nerves were demonstrated. The nerve branch to the FPL, when traced retrogradely from its muscle insertion, was notable for the fact that, although it joined the anterior interosseous nerve proper at the level of the proximal third of the forearm, it continued proximally as an easily separable fascicular group without intraneural cross connections well up to the median nerve trunk at the cubital fossa. It was oriented to the superficial radial side of the median nerve and could easily be teased away from it.

In this study, a direct relation of the superficial cubital vein to the solitary nerve branch to the FPL could be shown. Injury to this branch would therefore be potentially significant, because of the absence of any interfascicular cross-over from other territories within the anterior interosseous nerve. Second, the relative separation of the FPL fascicular bundle within the median nerve at the level of the cubital fossa, as well as its radial position, might render it more prone to injury than if it were clustered more securely within the dominant bulk of the median nerve trunk.

Experience with Obstetrical Palsy in the Last 15 Years. Berger, Hierner; Hannover.

Concepts and techniques relating to treatment of obstetrical palsy were based on experience with more than 250 patients. An algorithm for indications of different treatment programs was presented. An integrated treatment program including conservative nerve surgery, muscle and tendon transfers, and the treatment of co-contractions, was demonstrated, as well as long-term follow-ups. Comparison with the results and programs of other groups demonstrated the best possible microsurgical choices for the reconstruction of these severe lesions.

Clinical Comparison of Vascularized and Non-Vascularized Full-Length Phrenic Nerve Transfer in Treatment of Brachial Plexus Avulsion Injury. Xu, Xu, Gu; Shanghai.

Since 1999, 15 cases of brachial plexus avulsion injury were treated by means of full-length phrenic nerve transfer via video-assisted thoracic surgery. Two methods were used in harvesting these nerves, non-vascularized and vascularized. In order to understand whether or not vascularization has clinical value in nerve transfer and grafting, the authors compared both types of full-length phrenic nerve transfers. They found that there was no significant difference in the functional outcome between the two. They concluded that vascularization had little clinical value, not only in the phrenic nerve transfer, but also in nerve grafting, regardless of the length of the gap. They believe that a nerve bed with normal vascularity is more important in nerve grafting.

Muscle Transfers Combined with Biceps Neurotization for Restoration of Elbow Flexion in Brachial Plexus Palsy. Stamate, Burdurca, Stamate; Iasi.

None of the currently used techniques for recovery of elbow flexion in brachial plexus treatment offers enough strength for normal daily activities. The association of several different methods grants a better result, compared to each method used separately. These authors have initiated an association between muscle transfers (pectoralis major, latissimus dorsi, triceps) and neurotization, either neuro-neuronal or direct neuromuscular.

Of 42 cases of reconstruction in brachial plexus palsy, in 17 cases the authors performed neuro-neuronal neurotizations associated with direct neuromuscular neurotization of the biceps, and in 14 cases, a muscle transfer: 5 latissimus dorsi transfers (3 monopolar and 2 bipolar), 3 pectoralis major, and 6 triceps transfers. Direct neuromuscular neurotization of the biceps, EMG efficient, was associated with a muscle transfer in 6 cases: in 3 of the 5 latissimus dorsi transfers, in 2 cases of triceps transfer, and in 1 case of pectoralis major transfer. The association of the three methods - direct neuromuscular neurotization, neuro-neuronal neurotization, and muscle transfer - had a better effect than using one method alone in flexion restoration of the elbow, a major problem in brachial plexus palsy. Although too few to produce statistical significance, the overall results of these cases justify the operative effort.

Use of Intercostal Nerve Neurotization for Elbow Flexion in Brachial Plexus Injury Reconstruction - Comparison between the Use of Two and Three Nerves. Tu, Chou, Ueng; Keelung.

This study was undertaken to compare the clinical outcomes of two types of commonly used methods - using two intercostal nerves (2 ICN) and three intercostal nerves (3 ICN) for neurotization in brachial plexus injury (BPI) reconstruction.

From 1996 to 1999, the authors conducted a prospective randomized study on 20 patients (18 males, 2 females) with BPI. They divided their cases into two groups: Group 1 (n&=10) - transfer of 2 ICN (T3, T4) for elbow flexion, and Group 2 (n&=10) - transfer of 3 ICN (T3, T4, T5). The neurotization procedure was carried out with 10-0 nylon suture anastomosis with the musculocutaneous nerve. Elbow flexion was evaluated by the Medical Research Council grading system.

The average follow-up was 2.5 years. In Group 1, the elbow flexion was M3 in 70% of the cases, and M4 in 60% of the cases. In Group 2, the elbow flexion was M3 in 80% and M4 in 60% of cases. It took 5 to 15 months (average: 8 months) to obtain M3, and 11 to 30 months (average: 17 months) to obtain M4 gradings. There was no significant difference in the muscle power and time for recovery of elbow function, in comparison of 2 ICN with 3 ICN neurotization methods.

Intercostal nerve neurotization is an acceptable method in the reconstruction of BPI elbow function. Flexion can be recovered in 70 to 80% of patients within 3 years after microsurgery. There was no difference in the use of both methods for neurotization.

Musculocutaneous Neurotization to Restore Elbow Flexion in Brachial Plexus Paralysis: Preliminary Results. Vekris, Beris, Afendras, Korobilias, Soucacos; Ioannina, Greece.

In brachial plexus palsy patients, neurotization of the musculocutaneous nerve is one of the primary goals in the reconstruction of the injured plexus, since the return of elbow flexion is of paramount importance.

Over the last 4 years (March, 1998 to March, 2002), 51 adult patients with post-traumatic brachial plexus palsy were treated in the authors' clinic. Patient mean age was 24.6 years, and the most common cause of injury was motor vehicle accident. Exploration of the brachial plexus was performed in 39 patients, while 12 were late cases (> 2 years) and only secondary procedures were done, i.e., muscle transfers. The mean denervation time was 6 months (range: 1 to 14 months). Seven patients had an extended infraclavicular lesion, while in the 32 suspraclavicular lesions, 21 had an element of avulsion (4 global, 10 with four-root avulsions, and 7 with three roots avulsed). Neurotization of the musculocutaneous nerve was performed in the majority of cases via nerve grafts from intraplexus donors (C5, C6, C7). Extraplexus donors were utilized in 14 patients. In 7 patients, the phrenic nerve was used alone or with intraplexus donor (5), the accessory nerve in 3 cases, and the accessory and cervical plexus motor branches in 1 patient; in 3 patients, 3 intercostals were used.

All patients with intraplexus neurotization of the musculocutaneous nerve (excepting two) regained useful function of the biceps (M3+ to M4+). With extraplexus neurotization, the phrenic nerve as a conjunctant donor yielded useful functional results (when used alone, M3 and M3-); accessory neurotization yielded M3+ evaluation in combination with cervical motors, and M3- when used alone. Intercostal neurotizations yielded M2+ and M3- evaluations.

In brachial plexus paralysis, when an element of avulsion is present, reconstruction is often based on extraplexus donors. The return of biceps function is greater and more rapid when intraplexus donors are used. Extraplexus neurotizations can yield more satisfactory results when used in combinations.

Triangular Chitosan Tubes Coated with HAp and Coupled with Laminin Peptides Enhance Nerve Regeneration In Vivo. Itoh, Yamaguchi, Kobayashi, Shinomiya, Tanaka.

These authors have developed chitosan tubes derived from crab tendons and having a circular cross section. The mechanical strength of the tube is low for pressure applied from the side, and the tube wall swells to reduce the inner space in vivo. Therefore, the tubes were thermally annealed at 120 degrees C and formed into a triangular shape. Hydroxyl apatite (HAp) was reacted with the chitosan tubes to enhance the mechanical strength. The relationship between strain (deformed distance/ original length) and the added force perpendicular to the tube axis were measured, using chitosan tubes having either a circular or triangular cross section, as well as those with and without HAp coating (n&=10 in each group).

Chitosan tubes with triangular cross sections, as well as those containing covalently bound intact lamin and laminin peptides, were prepared. Bridge graft implantation (15 mm) into the sciatic nerve of Sprague-Dawley rats was carried out using these tubes (n&=20 in each group). The effectiveness of HAp/intact laminin coating to enhance the mechanical strength of the tubes and to preserve the inner space, and that of laminin peptides coupled to the tubular walls was examined in nerve regeneration in vivo. As a control, isografting (n&=5) was also carried out. Three rats in each experimental group were sacrificed for histologic observations at 1, 2, 4, 6, and 8 weeks. The total area in the grafted tube was measured at the middle third in transverse sections stained with toluidine blue. In 5 rats from each experimental and control group, the latency quotient between the implanted and non-treated site was determined 12 weeks after implantation. The percentage of the myelinated axon area was measured at a 10-mm distance from the distal anastomosed site.

The mechanical strength of the triangular tube was greater than that of the circular tube, and was enhanced by HAp coating. The inner spaces were well preserved. According to the percentages of neural tissue found and evoked action potentials, sequential treatments with laminin peptides correlated with the effectiveness of intact laminin in enhancing nerve regeneration.

Ultrastructural Changes after Denervation of Different Muscles. Hu, Xu, Gu, Li; Shanghai.

In clinical practice, the authors found that after long-term denervation, human skeletal muscles are typically not restored to full function, even if regenerating nerve fibers grow into them. This is especially true for the hand intrinsic muscles. The reasons are still not clearly identified. Recently, the changes in satellite cells after denervation have attracted more attention, since these cells represent a source of new nuclear material for reversing the atrophy of denervated muscles. The satellite cells can provide myonuclei during skeletal muscle development and regeneration.

In the reported study, the authors observed changes in ultrastructure and the number of satellite cells in two different muscles (abductor digiti minimi, biceps brachii) with different denervation intervals (1, 2, 3, 6, 12, and 18 months), and attempted to investigate the mechanisms of denervation atrophy. Ultrastructures of samples were observed under transmission electron microscope. The number of nuclei and satellite cells were counted to calculate the percent content of the satellite cells.

In the early stage of denervation, ultrastructure was similar to normal. There was no obvious proliferation of collagen fiber around the myofibers. The satellite cells were enlarged and had more cytoplasm. After denervation of half a year, rupture and disorientation of myofilament were seen. The nucleus became smaller and dark-stained. Condensation of some nuclei was seen. There was proliferation of fibroblasts, adipose cells, and collagen fibers around the myofibers. One year after denervation, the motor end plate was not recognized. The satellite cells had shrunk and had less cytoplasm.

In the early stage of denervation, the percentage of satellite cells of the muscles was relatively high; it then declined with time. One year after denervation, the satellite cells could scarcely be detected. Comparison of the curves for satellite cell declination in the two muscles revealed that the declination of the abductor digiti minimi was more rapid than that of the biceps brachii. Decreases in the former began 3 months after denervation, while it started after 6 months in the latter.

Nerve Regeneration by In Situ Tissue Engineering - Polyglycolic Acid-Collagen Tubes. Inada, Nakamura, Shimizu, Morimoto, Yamashina, Okuchi; Nara.

These authors have developed a new type of bioabsorbable nerve tube, and began an experimental study on the feasibility of artificial nerve conduits in the repair of peripheral nerve gaps. After a 10-year study, they achieved successful functional recovery in canines with 80-mm peroneal nerve gaps. The aim of the presented paper was to confirm the objective effectiveness of the polyglycolic acid-collagen (PGAC) tube in humans.

The clinical application of the tube began in April, 2002 in Japan. One hundred three nerve gaps in 63 patients were operated on between April, 2002 and January, 2003. Of the 103 gaps in 63 cases, 23 gaps in 14 cases (10 men and 4 women) had a 6-month follow-up and were evaluated in the study. Patient ages ranged from 13 to 65 years. Affected nerves were calcaneal branches of the sural and posterior tibial nerve in the heel pad, 17 common digital nerves in 13 fingers, a median nerve, a sciatic nerve, and a frontal branch of the facial nerve. The length of the PGAC tube ranged from 10 to 80 mm. The time period between the initial injury and treatment with the tube ranged from 1 to 98 months. No patient had surgical complications.

In the common digital nerve, the result was excellent in 9/17 nerves (53%), good in 6/17 (35%), and poor in 2/17 (12%). Electrophysiologically, the compound sensory nerve action potential was evoked in 82% of cases, and vasomotor reaction recovered in 76% at 6 months after PGAC tube reconstruction. In a patient who was reconstructed for an 80-mm median nerve gap at elbow level, preoperative ADL scoring dramatically improved from 44 to 96 points (Carroll test) by 3 months, and an electrophysiologic response of the repaired median nerve was observed at 6-month follow-up. In the cases involving the facial and sciatic nerves, improvement was demonstrated on both physical examination and also in electrophysiologic results at a few months after reconstruction.

This presentation was the first precise clinical evaluation done not only with physical examination, but also with objective methods such as thermography and/or electrophysiologic assessment. Nerve regeneration and patient recovery were observed with the PGAC tube used as a conduit across a human peripheral nerve gap.

Reverse End-to-Side Neurotization in an Intact Recipient Nerve. Isaacs, Allen, Chen, Nunley; Richmond, VA.

End-to-side nerve repair, in which an epineurial window is created in a donor nerve to allow axonal sprouting into a recipient nerve, has been studied by multiple investigators. A reverse end-to-side repair, in which the end of a donor nerve is sutured to an epineurial window in the side of a recipient nerve, has not received as much attention, but would have useful applications in nerve reconstructive surgery. The purpose of this study was to evaluate the effectiveness of this repair technique.

Female Sprague-Dawley rats were divided into three groups (n&=9). In Group 1, the peroneal nerve was transected and immediately directly repaired in standard end-to-end fashion. In Group 2, the tibial nerve was transected and the proximal end was sutured to the side of the intact peroneal nerve through an epineurial window. In Group 3, the tibial nerve was also transected and the proximal end sutured to the side of the intact peroneal nerve; the peroneal nerve was then cut proximally. At 12 weeks, contractile forces of the extensor digitorum communis were measured, following stimulation of the proximal sciatic nerve, on all experimental limbs, as well as non-operated contralateral control limbs. In Group 2, the peroneal nerve was transected proximal to the repair site, just prior to stimulation. Measurements were obtained at voltage settings of 1V, 5V, 10V, and 15V and at stimulation frequencies of 40 Hz, 70 Hz, and 100 Hz.

Group 2 had no measurable contractions. Groups 1 and 3 were compared, based on percentages of experimental side contractions to control side contractions. Although muscles in Group 3 generated slightly more contractile force than in Group 1, the difference was not statistically significant. There was a strong statistical difference between control and experimental limbs. This demonstrated that donor axons entering the epineurial space of a recipient nerve can functionally reinnervate denervated muscle.

Full-Length Phrenic Nerve Transfer via Video-Assisted Thoracic Surgery in the Treatment of Brachial Plexus Avulsion Injury. Xu, Xu, Gu; Shanghai.

Phrenic nerve (PN) transfer has been widely used in treating brachial plexus avulsion injury. The authors were interested in modifying the procedure, especially regarding the thoracic portion of PN transfer and the requirement for a nerve graft, which lead to a long duration of regeneration and some irreversible muscle atrophy. They presented their early experience with video-assisted thoracic surgery (VATS) to harvest a full length of PN for transfer.

Fifteen patients (mean age: 28 years) were treated. The thoracic portion of the PN was freed via VATS and removed from the thoracic cavity; the full length of the PN was transferred to the musculocutaneous nerve to recover elbow flexion. Patients were followed-up. Another 29 patients with long-term follow-up, who underwent a traditional cervical PN transfer to the musculocutaneous nerve between 1994 and 1997, were selected. Comparisons were carried out between the two groups on the duration of biceps regeneration and the time necessary for the biceps to attain an M3 grading.

The procedure was safe and no complications occurred. The additional length of the PN was 12.3±4.5 cm. Eleven patients had a sufficient follow-up; eight had biceps recovery to M3 (elbow flexion against gravity); the mean time was 198.8±36.0 days, much earlier than in results of the traditional method (p<0.01). Pulmonary function recovered to preoperative levels 9 months postoperatively.

The new method is safe and minimally invasive. The results of full-length PN transfer are much better than those of the traditional method. Time to nerve reinnervation is shorter. The modified procedure is promising for patients with a long interval between injury and surgery, and for forearm muscle reconstruction by PN transferred to the median nerve or combined with a free muscle transfer.

Aberrant Reinnervation in Obstetric Brachial Plexus Palsy. Chuang; Taipei, Taiwan.

Aberrant reinnervation is a misdirection of regenerated axons. The phenomenon is more frequently seen in the shoulder and elbow, and less in the forearm and hand in obstetric brachial plexus palsy (OBPP). Among the main reasons for aberrant reinnervation are a dominant rupture of the upper trunk with a short gap, and natural conduits produced in ruptured scalene muscle fibers.

Between 1989 and 2000, 100 pediatric palsies were surveyed, based on intraoperative findings, injury of C5 and C6 spinal nerves, and the quality of scar tissue. The authors sought to find the relationship between initial (or infantile) OBPP injury and late (or sequelae) OBPP shoulder function. There were 8 types of lesions encountered: type 1, C5 major + C6 major contributions, with evenly acceptable scars; type 2a, C5 major + C6 minor contributions with poorer scar on C6 components; type 2b, C5 major + C6 minor contributions with C5 rupture and C6 avulsion/rupture; type 2c, C5 major + C6 major contributions with C5 avulsion/rupture; type 3a, C5 minor + C6 major contributions with poorer scar on C5; type 3b, C5 minor + C6 major contributions with C5 avulsion/rupture; type 3c, C5 minor + C6 major contribution with C5 true avulsion; type 4, C5, C6 minor contributions with avulsion in both.

There were 47 (47%) cases of type 1; 26 cases (26%) of type 2a; 3 cases (3%) of type 2b; 16 cases (16%) of type 2c; 1 case (1%) of type 3a; no cases of type 3b; 2 cases (2%) of type 3c; and 5 cases (5%) of type 4. Clinically, in the sequelae of OBPP, there were two major signs: the “umbrella” sign in which the elbow will flex spontaneously, like holding an umbrella, during shoulder elevation; and a “trumpet” sign in which the shoulder will elevate spontaneously, during hand-to-mouth movements. There are various degrees of both signs, characterized as mild, moderate, and severe.

The relationship between initial and late OBPP was then estimated: more than 90% (92%) of OBPP patients had recovered shoulder function with aberrant reinnervation, half from C5 and C6 major contributions, and half from C5 major and C6 minor contributions. Only 5% of patients had a paralytic type of shoulder function.

Nerve Regeneration after End-to-Side Neurorrhaphy Is Enhanced by Postoperative Low-Power Laser Biostimulation: Experimental Study. Geuna, Benato, Tos, Fornaro, Battiston, Robecchi; Orbassano.

The aim of this study was to investigate the effects of postoperative low-power laser biostimulation on peripheral nerves repaired by means of end-to-side neurorrhaphy.

After complete transection, the left median nerve of Wistar female rats was repaired by end-to-side neurorrhaphy on the ulnar donor nerve. The animals were then divided into four groups: one untreated control group and three experimental groups that received laser therapy 3 times a week for 3 weeks, starting from POD 1. Three different types of laser biostimulation were used: continuous, pulsate, and a combination of the two. Motor function recovery was assessed every 2 weeks after surgery by means of the grasping test. The animals were sacrificed 16 weeks after surgery. Recovery of muscle trophism was assessed by weighing the mass of muscles innervated by the repaired nerves. The median nerves were withdrawn, embedded in resin, and analyzed by light and electron microscopy.

In untreated animals, any signs of motor function recovery in the repaired median were still not detectable at the time of nerve withdrawal. In laser-treated animals, motor function recovery at the time of nerve withdrawal was, on average, 8.8% of normal in the pulsate group, 35.3% of normal in the continuous group, and 61.6% of normal in the pulsate-continuous combined group. Muscle trophism recovery was, on average, 71.4% of normal in the pulsate laser-treated group, 80.1% of normal in the continuous group, and 100% of normal in the pulsate-continuous combined group. Finally, morphologic analysis of the repaired nerves demonstrated that laser biostimulation accelerates the regeneration process in nerve fibers.

Early postoperative physiotherapy with low-power laser biostimulation can significantly improve the repair process in peripheral nerves with end-to-side neurorrhaphy. The best results can be obtained using pulsate-continuous combined laser biostimulation.

(Financial support for this research was provided by the Italian Ministry of Education, University and Research [MIUR] and ASA Medical Devices s.r.l., Arcugnano [VI], Italy).

Peripheral Nerve Repair Using Alginate Sponge. Suzuki, Kataoka, Tadashi, Suzuki, Suzuki; Kyoto.

A novel material for nerve regeneration, alginate, was utilized in both tubulation and non-tubulation repair of long peripheral nerve defects.

Twelve cats underwent severing of the right sciatic nerve to generate a 50-mm gap, which was treated by tubulation repair (n&=6) or non-tubulation repair (n&=6). In the tubulation group, a nerve conduit consisting of polyglycolic acid mesh tube filled with alginate sponge was implanted into the gap, and the tube was sutured to both nerve stumps. In the non-tubulation group, the nerve defect was repaired by a simple interposition of two pieces of alginate sponge without any suture.

Three months postoperatively, successful axonal elongation and reinnervation in both afferent and efferent systems were detected by electrophysiologic examination. Eight months after the operation, many regenerated myelinated axons with fascicular organization by perineurial cells were observed within the gap, peroneal and tibial branches in both groups, while no alginate residue was found within the regenerated nerves. In morphometric analyses of the axon density and diameter, there were no significant differences between the two groups. It was concluded that non-tubulation is also a possible repair approach for peripheral nerve defects.

A further study using rats analyzed nerve regeneration through alginate gel in the early stage (within 2 weeks) and late stage (up to 21 months) after implantation. Four days after surgery, regenerating axons grew without Schwann cell investment through the partially degraded alginate gel, in direct contact with the alginate without a basal lamina covering. Numerous mast cells infiltrated into the alginate. One to 2 weeks after surgery, regenerating axons were surrounded by common Schwann cells to form small bundles, with some axons at the periphery partly in direct contact with the alginate. At the distal stump, numerous Schwann cells had migrated into the alginate 8 to 14 days after surgery; they had no basal laminae.

The results indicated that alginate gel has good biocompatibility for regenerating axon outgrowth and Schwann cell migration, and that regenerated fibers can have diameters as thick as those of normal fibers over the long term. Alginate gel is a promising material for use as an implant for peripheral nerve regeneration. The authors presented two clinical cases as well.

Outcomes of Suprascapular Nerve Neurotization in 125 Patients with Brachial Plexus Injuries. Terzis, Kostas; Norfolk, VA.

Shoulder stabilization is of utmost importance in upper extremity reanimation. This paper presented the authors' experience of suprascapular nerve reconstruction in 125 cases of obstetrical and adult brachial plexus lesions. Outcomes were analyzed in relation to various factors, including patient age, denervation time, donor nerve used, and achievement of functional restoration in the supraspinatus vs. the infraspinatus muscles.

The medical records of 165 patients who had suprascapular nerve reconstruction were reviewed. One hundred twenty-five (125) patients operated on by a single surgeon between 1978 and 2000 had adequate follow-up. Eighty-five (85) patients were adults, and 40 patients suffered from obstetrical brachial plexus palsy (OBPP). Direct neurotization of the suprascapular nerve was done in 59 patients while in 26, interposition nerve grafts were used. In 93 patients, the distal spinal accessory was used as the motor donor nerve for suprascapular nerve neurotization, while in 25 cases, intraplexus donors were used. In 7 cases, cervical plexus donors were used.

The overall results in adult plexopathies were good or excellent in 75% of the patients for the supraspinatus muscle, and in 55% for the infraspinatus muscle. In the OBPP cases, the results were good or excellent in 82% for the supraspinatus muscle, and in 65% for the infraspinatus muscle. The mean postoperative muscle grading for the distal accessory to suprascapular nerve neurotization was 3.31; for intraplexus to suprascapular neurotization was 3.37; and for cervical plexus to suprascapular neurotization was 3.19. There was a statistically significant difference between direct accessory to suprascapular neurotization vs. accessory to suprascapular via a nerve graft. Early surgery (less than 6 months) yielded significantly better results than late surgery (more than 12 months).

Suprascapular nerve reconstruction is a worthwhile procedure that stabilizes the glenohumeral joint, avoids shoulder arthrodesis, as well as restoring shoulder abduction from 20 to 80 degrees. The best results are seen in OBPP patients, when direct neurotization of the suprascapular nerve is carried out soon after injury (6 months or less).

Free-Flap Surgery for Infected Diabetic Foot Ulcers. Song, Kim, Kim; Gwangju.

Diabetic foot ulcer is a serious complication which results from long-standing diabetes. Severe infected diabetic foot ulcer in particular results in lower extremity amputation. The diabetic patient is considered a relative contraindication for microsurgery because of severe peripheral vascular disease. Recently, microvascular free-tissue transfer techniques have been applied to diabetic foot ulcers. It is well-known that free tissue transfer provides immediate soft-tissssue coverage and control of infection. Preservation of the lower extremity through free tissue transfer is therefore possible.

A retrospective study of diabetic patients with infected foot ulcer, seen between 1999 and 2001, was carried out. The defects reconstructed with free-tissue transfer were reviewed. Twenty-two patients were studied, with a mean follow-up of 20.8 months. There were two deaths during the follow-up period, and two failures after free-flap surgery. One patient required amputation above the ankle joint. The other 20 survived, and all patients were ambulatory. There were three recurrences of ulcer.

The authors found that free-tissue transfer for infected diabetic foot ulcers is an effective surgical technique. Careful patient selection and regular follow-up are important.

The Diabetic Foot: A Vasculo-Plastic Approach. Heymans, Lemaire, Vandamme, Verhelle; Liege.

Ulcers frequently occur during the evolution of diabetic patients. These lesions can be ischemic or neuropathic. They are frequently treated by a vascular bypass, resulting in spontaneous healing. In some cases, bone or tendinous exposure remains problematic, even after revascularization. In order to lower the amputation rate, the authors adopted a combined approach: revascularization and free-flap coverage.

Between 1999 and 2001, 19 patients presenting with foot ulcerations in a diabetic and arteritic context, were treated with a vascular bypass followed by free flap coverage. The mean patient age was 59 years, with a male/female ratio of 4:1. Revascularization was accomplished by an infra-inguinal bypass in all cases. Defects were located at the heel in 13 cases, while the forefoot was affected in 6 cases. The latissimus dorsi, serratus anterior, rectus, or radial forearm flap were used. Follow-up ranged between 8 and 40 months.

The procedures were simultaneous in 3 cases. Microvascular success, as well as bypass patency, was 100%. Immediate complications included 1 death (myocardial infarction), 1 abdominal-wall infection, and 2 delays in healing. There were 1 superficial ulceration and 2 osteitis recurrences, but these were treated successfully. Gait rehabilitation was achieved in all cases.

This combined approach seems to be a valuable alternative to amputation in selected cases. Flap and recipient vessel selection can differ from other types of limb reconstruction, because a reliable result has to be achieved in a compromised patient. Mortality and morbidity appear to be acceptable, compared to patient benefits.

Free Muscle Flap Reconstruction of Chronic Ulcers of the Foot in High-Risk Diabetic Patients. Calcagni, Pivato, Pegoli, Pajardi; Sesto San Giovanni, Italy.

Diabetic patients have a prevalence of critical chronic ischemia four times higher than the normal population, with an expectation of a major amputation as high as 22% within 1 year. An aggressive approach to this pathology with endovascular procedures (PTA) or distal revascularization allows for limb salvage in 89% of cases. In the great majority of these patients, the success of vascular procedures leads to healing or at least to substantial reduction of distal trophic lesions, which can be treated with minor amputation. Still, in some cases, the preservation of lower limb length and of ambulation is possible only with free-tissue transfers.

The authors reported their experience in reconstruction of chronic ulcer of the weight-bearing area of the foot with free muscle flaps in 6 high-risk diabetic patients with extensive occlusive arterial disease. Between 2001 and 2002, 6 diabetic and arteriopathic patients were selected for free-flap (1 serratus anterior, 5 latissimus dorsi muscle) reconstruction of chronic ulcers of the sole. All patients were affected with occlusive coronary and peripheral arterial disease treated by means of PTA and/or bypass before the reconstructive procedures. In all patients, indication for free-tissue transfer was the presence of a large and chronic soft-tissue loss of the sole, a strong desire to preserve limb length, contralateral above-knee amputation, and a good peripheral flow.

All free-tissue transfers were successful. No revision of vascular anastomosis was necessary. Minor complications were two local infections. There were no major complications in the postoperative period. Length of hospitalization averaged 7 days (range: 5 to 12 days), and ambulation was recovered in 30 to 40 days. At a mean follow-up of 12 months, all flaps were viable and all patients were ambulating.

Diabetic patients are often high-risk patients with many contraindications to free-tissue transfer. In this small series, the authors demonstrated that accurate patient selection and a multidisciplinary approach with staged procedures may lead to a high success rate without major complications. Functional results with salvage of lower-limb length permitted recovery of unassisted ambulation in 5 patients (the sixth has a contralateral above-knee amputation).

Microsurgical Reconstruction for Osteomyelitis - 12 Years of Experience. Tu, Ueng; Keelung.

Osteomyelitis remains a challenge for orthopedic surgeons. The importance of microsurgical treatment is obvious, when dealing with a long bone or soft-tissue defect after debridement. This study evaluated the results in osteomyelitis patients after microsurgical reconstruction.

From 1989 to 2000, the authors undertook a prospective study on 145 osteomyelitis patients, who received microsurgical treatment for either bone or soft-tissue reconstruction. One hundred nine were male, and 36 were female, with an average patient age of 52.7 years. The mean history with the disease was 2.6 years. Microsurgical procedures included free soft-tissue transfers and free bone transfers. The average follow-up was 7 years.

One hundred thirty-three (91.7%) cases obtained successful free-tissue transfers; however, one patient received below-knee amputation due to a change of lesion to malignancy. Ten patients (6.9%) required a re-open procedure due to venous thrombosis, and salvage procedures were successful. Two patients (1.4%) had failed surgery that resulted in the same osteomyelitic situation as previously, but also without plans for amputation. The recurrent infection rate was 18.6%, including 18 cases of cellulitis and 9 cases of recurrent osteomyelitis. All but 2 of these patients recovered after antibiotics and adequate debridement. The free bone grafts had satisfactory union and hypertrophy. Five fractures occurred in the vascularized bone grafts and were treated by plating. Functional outcomes demonstrated 81.4% with good results.

Microsurgical reconstruction is effective in solving the clinical difficulties of osteomyelitis. Excellent soft-tissue coverage and hypertrophy of vascularized bone transfers were observed in this series. The functional outcomes were satisfactory.

Abdominal-Wall Reconstruction after Clostridial Myonecrosis with an Expanded Scapular and Parascapular Flap and Prolene Mesh: Case Report. Spendel, Schintler, Wittgruber, Pinter, Hellbom, Scharnagl; Graz.

Clostridial myonecrosis of the abdominal wall is a devasting and highly lethal postoperative complication that requires wide surgical debridement of all involved layers of the abdominal wall. The authors reported a 20-year-old woman with a defect of the anterior abdominal wall following surgical debridement for clostridial myonecrosis after appendectomy. In the first stage of reconstruction, closure of the abdominal wall was performed with Prolene mesh and a split-thickness skin graft applied on the granulation tissue arising from the visceral peritoneum of the underlying organs. After 2 months, the abdomen was closed, but the aesthetic result was unacceptable. One year later, a second stage of reconstruction of the anterior abdominal soft tissue was carried out, after complete removal of the split-thickness skin graft and utilization of a scapular and parascapular free flap, which was prefabricated with an expander. This expanded flap is considered to be useful in reconstructing the anterior abdominal soft tissue, when there is no opportunity for complete closure with tissue expansion alone.

Reconstruction of a Complex Thoracic Defect by Free Musculocutaneous Latissimus Dorsi Flap: Case Report. Molski, Lembas; Warsaw.

Broncho-pleural fistula with subsequent emphyema occurs in 0.5 to 10% of patients after pulmonectomy. Transposition of local pedicle flaps is a commonly used method of fistula closure and dead space management. When local flaps fail or are not available, microvascular transfer of free muscle flaps is the only alternative for recovery.

The authors presented a 51-year-old male patient who had a right pneumonectomy for bronchial cancer. The postoperative period was complicated with broncho-pleural fistula and emphyema. Due to these complications, the patient underwent six surgical procedures. The broncho-pleural fistula was finally closed after the second transpotition of a pedicled muscle flap. Extensive scars and deformities of the right side of the thorax made it impossible to close the dead space and to close the “window” in the chest wall by local flaps. Microvascular techniques were employed to transfer a free musculocutaneous latissimus dorsi flap from the contralateral side. The procedure was performed in the Department of Plastic Surgery in Warsaw with a thoracosurgeon's assistance. The muscular part of the flap filled the dead space of the right pleural cavity, and the island achieved closure of the window in the chest wall. The microsurgical part of the procedure consisted of end-to-end anastomoses of both thoracodorsal vessels using Ethilon 10-0, 28-30 sutures, with good blood inflow and rapid stabilization of circulation. The postoperative period was uneventful, and during 14 months of follow-up, there was no fistula recurrence.

Applying Microsurgical Dissection to Pedicled Flaps: Indications and Limitations of the Pedicled Anterolateral Thigh Flap. Lipa, Beausang, Neligan; Toronto, Canada.

The anterolateral thigh free flap has gained popularity in microsurgical head and neck reconstruction as a reliable, versatile flap with minimal donor-site morbidity. The vascular pedicle of this skin or fasciocutaneous flap, a perforator from the descending branch of the lateral circumflex femoral artery (LCFA) and its venae comitantes, can be dissected to achieve pedicle lengths of up to 15 cm. Instead of harvesting this as a free flap, it can be kept pedicled to the LCFA and passed under the rectus femoris muscle. The arc of rotation from this point will then allow for coverage of complex lower abdominal and pelvic defects without the need for prosthetic mesh or sacrifice of a functioning regional muscle.

In the past year, the authors have used the pedicled anterolateral thigh flap for 6 reconstructions in 5 patients: 2 perineal defects, 3 groin wounds with exposed femoral vessels, and 1 lower abdominal-wall defect. The skin paddle was combined with random fascial extensions in 2 cases and with the tensor fasciae latae in another case, in order to avoid prosthetic mesh at the recipient site. Donor sites were closed primarily in 4 cases; 2 of these had minor delayed wound healing. No functional deficit resulted from flap elevation. There were no partial or complete flap losses.

The pedicled anterolateral thigh flap cannot reach reliably superior to the umbilicus; this region requires conversion to a free flap. Similarly, in perineal reconstruction, the flap cannot reach further posterior than the coccyx, so that an alternate or additional flap is required. However, the authors have found that the pedicled anterolateral thigh flap is a useful alternative to pedicled muscle or myocutaneous flaps for lower abdominal, groin, and perineal coverage.

Right Atrium as Venous Recipient in Free Flap Transfer: Case Report. Krag, Herlev; Copenhagen.

A male patient in his eighth decade was admitted to the Department of Internal Medicine for palliative care, with a long-established (>20 years) ulceration in the pectoral region. He had had repeated episodes of infection and was exhausted. The plastic surgeons were contacted to give advice on wound care. A biopsy showed the ulcer to be a basocellular carcinoma. CT scans showed the process to be localized. As the ulceration penetrated the thoracic wall, but not the mediastinal structures, the patient was offered a potentially life-saving resection and reconstruction. The large locally invasive rodent ulcer on the anterior thoracic wall was resected, creating a through-and-through defect. This was covered with a combined TFL and RF flap anastomosed to the two IMAs and via a saphenous vein graft, to the right atrium, as the IMVs were unsuitable for microsurgical anastomosis. The patient regained his joie de vivre and has survived without recurrence for 3 years so far.

Safety, Efficacy, and Reconstructive Arena for Radical Ablation in Patients with Locally Advanced Breast Cancer. Beahm, Salibian, Kuerer, Walton; Houston, TX.

Historically, locoregional recurrence and chest-wall involvement in breast cancer have been considered harbingers of distant metastasis and poor prognosis. The use of neoadjuvant chemotherapy has resulted in selected patients with advanced disease, previously deemed inoperable, to be referred for radical resection requiring reconstruction. The aim of this study was to define the safety, efficacy, and reconstructive arena of radical ablation in advanced breast cancer.

Treatment outcomes and survival of patients with advanced breast cancer, treated by resection and reconstruction from 1988 to 2000, were reviewed retrospectively. Study inclusion criteria were tumor size 5 cm or greater, with chest-wall invasion requiring flap reconstruction, and a minimum 6-month follow-up. Ninety-two patients were evaluated: 55 had primary locally advanced cancer (LABC), 37 had recurrent cancer (RC). All patients were female with T4 tumors: stages IIIb (80) and IV (12). The mean patient age was 53 years (range: 28 to 86 years); the mean follow-up was 28 months (range: 6 to 144 months). All patients received adjuvant/neoadjuvant chemotherapy; two-thirds of patients underwent radiation therapy. The mean survival was 40 months, and the median disease-free survival, 18 months. Survival of LABC was not statistically different from RC (28 vs. 22 months, p&=.318). The mean tumor size was 6.9 cm (range: 5 to 8.5 cm). The mean defect size was 264 cm² (range: 70 to 900 cm²).

One hundred sixteen flaps were used in 92 patients; 20 patients required more than one flap. The latissimus dorsi and rectus abdominis myocutaneous flaps were the primary flaps, and pedicled (88) more common than free (28) flaps. Prosthetic materials were used in 33 patients, with one infection. There were no perioperative deaths. Hospital stay averaged 7 days (range: 2 to 34 days). Complications included flap loss (total&=4, partial&=6), cellulitis/infection (10), seroma (13), respiratory compromise (29).

In the largest series to date, the authors have demonstrated that radical ablation and reconstruction in large locally advanced or recurrent breast cancers can be safely carried out with an acceptable risk, even if multiple flaps are required. Overall survival with this regimen is favorable to historic controls. Some patients may experience a long disease-free interval and a few, long-term survival. While rarely curative, this surgery appears to decrease morbidity by palliation in the final stages of terminal disease, and it appears to be warranted in selected cases.

Hemifacial Resurfacing after Post-Burn Scarring with Prefabricated Vascularized Supraclavicular Flaps. Topolan, Ermys, Guven, Erer; Istanbul.

Extensive post-burn scars of the face, scalp, and neck regions produce social and psychological morbidities. Many techniques have been used to resurface the whole face or parts of it, but the results have been discouraging in terms of color matching, contour restoration, and residual visible scars. In the last two decades, prefabrication has been developed to obtain specific tissue to cover specific areas. This two-stage procedure creates, after skin expansion, cutaneous arterialized flaps longer than the local anatomy would usually provide.

A 35-year-old man was referred to the authors' clinic for facial contour correction. His left face, including the temporal region, the forehead, upper and lower lid, and cheek, were extensively involved in post-burn scarring. Resurfacing was planned with a prefabricated vascularized supraclavicular flap. In the first stage, the antebrachial fascia with the radial artery was transferred below the supraclavicular skin, and the pedicle was anastomosed to the neck vessels. A skin expander was inserted below the fascial flap. Following skin expansion for 3 months, a second operative stage took place. The scarred hemi-facial tissue was excised, and the prefabricated supraclacivular axial flap was dissected and then rotated to cover the skin defect. There was transient venous congestion in the first postoperative week. The transferred prefabricated flap provided a uniform surface and a good color match between the flap and adjacent area. Of interest, the patient's facial movements, such as smiling and lid movement, have improved with time.

In this paper, the authors demonstrated a successful hemifacial resurfacing after post-burn scarring, using a prefabricated vascularized suspraclavicular flap.

Short Pedicle DIEP Adiposal Flap for Facial Contour Deformities. Yamashita, Koshima, Sugiyama; Okayama.

Free vascularized dermal fat flaps have been used for facial contouring in the treatment of congenital anomalies of the face (first and second brachial arch syndrome and hemifacial microsomia) and traumatized facial atrophy. The major disadvantage of these flaps is wide postoperative donor scars at unacceptable sites. With the recent development of perforator flaps and supermicrosurgery with anastomosis of 0.5-mm caliber vessels, a free paraumbilical perforator (PUP) flap has been developed for coverage of deep skin defects in the scalp and extremities.

Between 1987 and 2002, free vascularized DIEP or PUP adiposal flaps with short pedicles were used in 20 patients with facial deformities, including hemifacial microsomia and atrophy. The advantages of this method are a one-stage augmentation without secondary defatting, flap transfer through an intraoral approach resulting in minimal invasive surgery with a short scar, and little deformity over a long follow-up.

Breast Reconstruction Using the Free Superficial Epigastric Perforator Artery Flap (SIEA): A Good Alternative? Mithoff, Garusi, MacKay, Webster: Glasgow.

Breast reconstruction with abdominal tissue has progressed from the pedicled TRAM flap to the deep inferior epigastric perforator flap (DIEP) with complete preservation of the rectus muscle. The dissection of the myocutaneous perforators can be tedious and time-consuming. However, it is worthwhile to assess the presence and diameter of the superficial inferior epigastric vessels (SIEA), which can now be used to transfer the abdominal apron as a true “free abdominoplasty” flap, and which are often correlated with the small DIE perforator.

Since 1997, 19 patients received a total of 22 free SIEA flaps for immediate and delayed breast reconstruction. Three patients had bilateral breast reconstruction with SIEA flaps, and 3 patients had bilateral reconstruction with a combination of SIEA and DIEP flaps.

The authors presented their learning curve and discussed modifications of the harvesting technique to improve the safety of the SIEA flap. The flap can be very useful, especially in bilateral breast reconstruction.