Abstracts-Part I

Inaugural Congress

October 31-November 3, 2001 Taipei, Taiwan

Applied Anatomy in Surgery: The Anatomic Renaissance. G. Ian Taylor. Royal Melbourne Hospital, University of Melbourne, Australia.

Over the last 25 years, there has been an anatomic renaissance that has had a major impact on reconstructive plastic surgery and tissue transfer. The introduction of the free flap, the revival of the musculocutaneous flap, and the development of the fasciocutaneous flap, have all required a reappraisal of the blood supply of the various body tissues in a search for suitable donor sites for transplantation.

In 1987, we introduced the concept of the angiosome, after analyzing a series of total body lead oxide injection and dissection studies. Based on the results, the body was mapped anatomically into three-dimensional vascular territories. Each territory spanned between skin and bone, supplied by a named segmental or distributing artery, with adjacent angiosomes linked together in each tissue layer by either true anastomotic arteries without change in caliber or, more commonly, by reduced caliber ``choke'' vessels. In 1990, a similar anatomic study of the venous network of the body revealed composite venous territories that matched their arterial counterparts. The adjacent venous territories were found to be linked usually by avalvular ``oscillating'' veins, which allowed bi-directional flow between territories. Thus, each angiosome could be subdivided anatomically into matching arterial (arteriosome) and venous (venosome) territories.

Subsequently, our anatomic studies were expanded to evaluate the neurovascular relationships in the skin and the underlying muscles, and our findings were published in 1994. This allowed us to develop new donor sites for sensate skin flaps, and to provide refined functioning muscle transfers. Other studies have focused on Doppler flowmetry to plan the base and axis of the flap and a re-evaluation of the delay phenomenon to enhance flap survival. Illustrative procedures were demonstrated.

Aesthetic Nasal Reconstruction with Free Microvascular Subunits. Robert L. Walton and Gary C. Burget. Section of Plastic Surgery, University of Chicago, Illinois, U.S.A.

In cases of subtotal and total nasal loss, traditional methods for reconstruction have fallen short in achieving ideal function and aesthetics. A common link to these shortcomings has been the inadequacy of nasal lining. The introduction of microsurgical techniques for nasal reconstruction initially offered great promise by delivering to the operative site ample volumes of unsullied, well-vascularized tissue for reconstruction. However, these expectations were short-lived, because the tradition of sculpting large, bulky flaps could not be applied to the small dimensions and reconstructive demands imposed by the thin, delicate, three-dimensional nasal lining. Over the past four years, we have had the unique opportunity of collaborating on a number of total and sub-total nasal reconstructions. We have meshed our collective experiences in aesthetic nasal reconstruction and reconstructive microsurgery to forge a unique reconstructive pathway that has led to a new and exciting approach to management.

We presented our first seven sequential microsurgical reconstructions for major nasal deformity. The patients included four males and three females, with patient ages averaging 47 years (range: 5 to 75 years). The etiology of the nasal deformities was post-cancer extirpation (5 patients), post-cancer extirpation + radiation therapy (4 patients), meningococcal infection (1 patient), and congenital hamartoma (1 patient). Follow-up averaged 12 months (range: 5 to 29 months).

Our approach to management proceeded according to the following plan. The reconstruction was performed in stages with the soft-tissue lining and associated components provided first and braced with lamina of cartilage or bone to maintain shape and to resist contraction. Microvascular islands (1 to 3) of tissue were designed on the palmar forearm, anterior leg, chest, or groin to restore the various subunits of the surface of the face (cheek, nasal lining, nasal floor, columella), to restore nasal volume, or to provide vascularized structural support. Nasal support and external cover were provided during a second procedure. For this purpose, we employed various combinations of cantilevered bone or cartilage grafts stabilized by a mortised vertical strut, septal pivotal flaps, carved bony or cartilagenous side walls, and nasal tip grafts usually from the ear.

Our preferred method was the construction of a light tripod of bone and cartilage resting on the frontal bone, bilateral maxillae, and nasal spine, which supports the nose, while preserving a wide-open airway. A vertical paramedian forehead flap is used for nasal cover. Following the application of the paramedian forehead flap, one to three subsequent interventions are required for precision sculpting, and inset of the flap pedicle.

Seven reconstructions utilizing this approach have been concluded and were presented in detail. There were no flap losses. Our experience has involved four basic priciples for microvacular reconstruction of the nose, that we believe are crucial for achieving an aesthetic/functional reconstruction: 1) avoid large, bulky flaps; 2) reconstruct unit by unit and layer by layer with separate precise microvascular islands assembled to create an artistic whole; 3) brace free flaps with lamina of cartilage or bone to maintain shape and size; and 4) restore surface of the nasal unit with a forehead flap.

Current Role of Microsurgery in the Treatment of Hemifacial Microsomia. Eric Santamaria. Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico.

Distraction osteogenesis (DOG) has become the current treatment for the vast majority of patients with hemifacial microsomia (HMS). However, a large group of patients still require microsurgical procedures to correct different anomalies that cannot be improved using other surgical techniques.

Twenty-eight patients with HMS were operated on during the last 3 years, using 31 microsurgical procedures. HMS deformity was classified as Pruzansky I in 1 patient (3.5%), Pruzansky IIa in 4 patients (14.2%), Pruzansky IIb in 12 patients (42.8%) and Pruzansky III in 11 patients (39.2%). All patients but one had undergone DOG previously, and non-vascularized bone grafts had been used in 12 patients. Soft-tissue free flaps were used to improve facial contour and symmetry in 21 patients (67.7%). A wax template of the defect was obtained from an acrylic mask in each patient. This template was used to design the free flap and to determine the amount of required tissue in a 3-D fashion. Soft-tissue free flaps included scapular/parascapular (19), latissimus dorsi (1), and lateral arm (1). The fibula osteocutaneous free flap was used in 8 patients (25.8%), who had complete resorption of previous costal and/or iliac non-vascularized bone graft, for the ascending ramus. Cross-nerve grafts and functional muscle transfer (anterior serratus) were used in 2 patients (6.45%) with complete facial palsy.

Free flap survival was 100%, despite reexploration due to venous thrombosis in 2 patients. Facial symmetry was considered excellent in 17 patients (60.7%), good in 8 patients (28.5%), and poor in 3 patients (10.7%). A posterior open bite was created in 7/8 patients with reconstruction of the ascending ramus, using the fibula free flap. This was corrected orthodontically after an average of 8 months. Functional recovery and symmetry were partially improved in the 2 patients with facial palsy, due to severe craniofacial deformity.

Although DOG has proved to be very useful to correct skeletal and soft-tissue alterations in HMS patients, microsurgical techniques are still very valuable for severe deformities (Pruzansky IIb and III). The deepithelialized scapular free flap is the best option to improve facial contour, and the fibula free flap is used to reconstruct the ascending ramus and to provide soft-tissue volume in one stage.

Esthetic and Functional Reconstruction for Burn Deformities of the Lower Face and Neck with the Free Radial Forearm Flap. Jong-Wook Leee, Young-Chul Jang, and Suk-Joon Oh. Plastic Surgery, Hangang Sacred Heart Hospital, Seoul, Korea.

Often, burn injuries produce deformities both of facial contour and facial cover. Hypertrophic burn scar contracture of the lower face and neck is problematic, because it distresses patients, both functionally and aesthetically. In planning the correction of lower face and neck deformities, the aim should be not only to reestablish normal form and function, but also to achieve, if possible, an aesthetic appearance.

When there was no available skin adjacent to the area of deformity, the authors have used the free radial forearm flap for reconstruction, in order to restore a normal facial shape and position, and homogeneity of the quality of facial skin coverage. There were no noteworthy complications after reconstruction of six patients.

For better outcomes, the authors recommended the following: 1) release and resurfacing of neck contracture should be carried out in advance; 2) the lower margin of the flap should be limited to at least one finger-breadth above the hyoid bone, because a low setting of the flap compromises the cervicomental angle; 3) adhesion between the flap dermis and wound bed may be necessary for reconstruction of a dumbbell-shaped lower lip subunit.

Burn deformities of the lower face and neck were resurfaced with the free radial forearm flap. Results did not appear completely normal, but were compatible with the adjacent skin. The authors achieved adequate functional resurfacing and optimal aesthetic outcomes, while minimizing recurrent contractures.

Evaluation of Volume Ratio between Defect and Flap in Reconstructive Surgery for Head and Neck Cancer. K. Ueda, A. Kajikawa, Y. Suzuki, B. Satake, and M. Nakagawa. Plastic Surgery, Fukushima Medical University, Fukushima, Japan.

Flap selection after tumor resection has been widely discussed, but little has been said about the relationship between the size of the defect and the volume of the transplanted tissue. The authors believe that the volume of transplanted tissue has a greater influence on the final result than the type of flap utilized. They therefore investigated the results of free tissue transfer on the basis of flap volume.

Thirty-six patients who underwent free tissue transfers for head and neck cancers were analyzed. There were 22 cases of tongue cancer, 10 cases of middle phalanx cancer, 3 cases of oral floor cancer, and 1 case of buccal mucosal cancer. The rectus abdominis MC flap was used in the greatest number of cases (24), followed by the radial forearm flap and thigh flap.

Defect and flap volumes were calculated by measuring the volume of saline displaced from a container of saline when the tissue was submerged. The difference in volume between the defect and the transplanted flap (volume ratio) was investigated, regarding the incidence of complications and the functional results. The latter, including the ability to communicate and to accept food, was evaluated by quantitative classification of patients' replies to questioning.

There was no relationship between volume ratio and the incidence of abscess or fistula formation. With respect to its relationship to functional results, the volume ratio had little influence with tongue cancer patients, but did have a relationship with middle pharynx cancer patients.

The increased volume of transferred tissue did not prevent the occurrence of leaks, although it appeared to have obliterated dead space. For tongue cancer patients, other thicker flaps can be substituted for the thin forearm flap, when the latter is not desirable for cosmetic reasons. In middle pharynx cancer patients, a lack or an excess of flap volume may result in the disturbance of food acceptance.

The Anterolateral Thigh Flap as the Preferred Method for Hypopharyngeal Reconstruction. E.H.M. Hartman, G. de Jongh, and H.A.M. Marres. University Medical Centre, Nijmegen, The Netherlands.

The authors illustrated their choice of the anterolateral thigh flap in hypopharyngeal reconstruction. From 1998 until 2001, eight patients had hypopharyngeal reconstructions with anterolateral thigh flaps. In two patients, a large skin island was required to reconstruct irradiated skin in the neck. In one patient, there was no success in elevating an anterolateral flap, and an anteromedial flap was used. The fascia lata was included in all but one flap. Flap survival was 100%, and donor-site morbidity was negligible.

From 1996 to 1998, seven patients in the authors' hospital underwent hypopharyngeal reconstruction with radial forearm flaps, which was their preferred method at that time. The functional results of both the radial forearm flap and anterolateral thigh flap are comparable. But, if donor-site morbidity of the radial forearm flap and the anterolateral thigh flap is evaluated, the latter is superior both cosmetically and functionally; it has become the standard in hypopharyngeal reconstruction for these authors.

Double-Barreled Free Vascularized Fibula in Mandibular Reconstruction with Dental Restoration. Sobhi Hweidi, Gaber Ali, Emad Tolba, Tarek Alnemr, and Wail Ayad. Department of Plastic Surgery and Microsurgery, Zagazig University, Egypt.

The aim of this study was to demonstrate the authors' experience with the double-barreled free vascularized fibula in mandibular reconstruction. This technique increases the bone height of the graft and allows for better conditions for dental restoration.

The procedure was used in 26 patients. A fibular graft corresponding to at least double the length of the mandibular defect was harvested. Eleven patients were primarily reconstructed, and the rest secondarily. The average length of the fibular graft harvested was 23 cm, and the number of fibular osteotomy sites ranged from one to four. To produce a double-barreled design, the resulting struts are folded on top of each other, and fixed with miniplates and screws. Six months after healing of the graft, osseointegrated implants are applied. Usually, three implants were used for a hemi-mandibular defect.

All patients demonstrated rapid healing at the osteotomy sites, and smooth attachment from the graft to the native bone radiographically. The postoperative facial appearance and symmetry were judged to be good-to-excellent in all patients. When compared with the conventional single-barreled fibula transplant, the double-barreled graft achieved greater bone height and markedly reduced the vertical distance to the occlusion plane.

The use of the double-barreled fibula increases the available bone height for implant placement, which increases the survival rate of the osseointegrated implants. Increasing bone height also creates better conditions for prosthetic rehabilitation by bringing the bone level nearer to the plane of occlusion.

Cosmetic and Functional Reconstruction Combined with Fibular Flap and Dental Implant. Mataga Izumi, Kaneko Takashi, Ishihara Osamu, Fumihiko Watanabe, and Yorio Suzuki. Departments of Oral and Maxillofacial Surgery II, and Crown and Bridge, School of Dentistry at Niigata, Nippon Dental University; and Division of Orthopedics, Rinkou General Hospital, Niigata, Japan.

Recently, not only cosmetic, but also functional rehabilitation, has been required for oral and maxillofacial reconstruction following cancer ablation. Revascularized osteocutaneous flaps have been considered the best indications for poor recipient conditions, such as high-dose irradiation, previous multiple surgeries, and large bony defects remaining after oncologic surgery. For these reconstructions, the fibular osteoseptocutaneous flap is one with several advantages, and also allows the use of dental implants into grafted fibula for rehabilitation of oral function.The authors have used this flap since 1992 (n=17 fibular flaps), with endosseous implants in the grafted fibula in 8 patients. In this reported series, results of the reconstructions and utilization as pre-prosthetic procedures were discussed.

Reconstructed locations included 7 mandibles and 1 maxilla. Tumors were dissected by 5 segmental mandibulectomies, 1 subtotal mandibulectomy, 1 hemi-mandibulectomy, and 1 partial maxillectomy at primary surgery. These defects were reformed by fibula with from one to four osteotomies, and fixation by titanium mini-plates. Harvested fibulas were 6 to 20 cm in length, and cutaneous flaps were used for additional soft-tissue adaptation or flap monitoring. All implants could be installed in the position designed before installation, with attention taken to prosthetic considerations. As to the timing of the placement of endosseous implants, 2 were installed at the same time as reconstruction, and others were delayed for at least 6 months. A total number of 41 endosseous implants were placed in fibula. Three of five implants in 1 of 2 patients placed at the time of reconstruction did not obtain osseointegration. For these patients, implants were placed again 1 year later. The cumulative survival rate of implants was 92.7% in this series.

The authors confirmed that the fibular osteocutaneous flap is useful for mandibular reconstruction, especially for wide-range defects, and also that the fibula is an adequate bone for the placement of endosseous implants.

Chimeric Genicular Flap for Salvage of Primary Mandibular Reconstruction. Vivek Jain, H.C. Chen, F.C. Wei, D.C.C. Chuang, and Mortem Kildal. Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Osteoradionecrosis of the reconstructed mandible constitutes one of the most serious complications of postoperative radiotherapy for head and neck tumors, and its management poses a challenge to the reconstructive surgeon. These authors reported their experience in managing these cases with chimeric genicular flaps based on a descending genicular axis. This flap can include an osteoperiosteal component or coritocancellous chunk and fasciocutaneous paddle (with sartorius muscle), depending on recipient site requirements.

Six patients had buccal cancer excised with segmental mandibulectomy and the mandible reconstructed with free osteoseptocutaneous fibular grafts. Following postoperative radiotherapy, they developed soft-tissue, as well as bone, defect with exposed plate. The size of the soft-tissue defect averaged 6 x 10 cm, and the defect in the mandible averaged from 4 to 8 cm. The indications for using the chimeric genicular flap were 1) the bone defect was too small to justify the use of another fibular osteoseptocutaneous flap, and 2) the anxiety of the patient about sacrificing another fibula. Bone was placed in the gap, bone grafts from the same donor site placed around the defect, and a plate was applied. The donor sites were all closed primarily.

All the flaps survived. There was necrosis of the tip of one flap, which was debrided and which healed with skin grafting.

Osteoradionecrosis of the reconstructed mandible constitutes one of the most serious complications of postoperative radiotherapy for head and neck tumors, and its management poses a challenge to the reconstructive surgeon. Salvage procedures are more complicated and challenging, as there could be associated bone or soft-tissue infection, and patients may be debilitated by multiple surgical procedures, chronic wounds, and malnutrition. Also, because of irradiation, the local area becomes scarred, with diminished vascularity. The descending genicular flap has multiple advantages, as no major artery needs to be sacrificed, the skin is hairless and can be made neurosensory, the skin flap is of large size, and there is minimal donor-site deformity. The main disadvantages are variation in saphenous artery anatomy in 5 to 15% of cases, a short pedicle, and that scarring may be undesirable in female patients.

The chimeric osteoperiosteal fasciocutaneous/ myocutaneous descending genicular flap has proved useful in one-stage secondary salvage of osteoradionecrosis of primary mandibular reconstructions.

Mirosurgical Reconstruction for Mandibular Defects. Ashok K. Gupta. Bombay Hospital and Medical Research Centre, Bombay, India.

Advances in reconstructive microsurgery and the ability to reconstruct large bone defects, using a living bone graft, have created new opportunities in the reconstructive surgery of mandibular reconstruction. Congenital or post-traumatic hypoplasia, post-infective, and post-traumatic or post-excision defects with large bone defects of the mandible, are best treated with microvascular reconstitution, using either osteotomized fibula. The possibility of shaping the bone graft by serial osteotomies, without compromising the strength of the graft, and adaptability to different needs, have made these grafts choices over other autogenous or alloplastic materials for such reconstruction.

The fibula is supplied by the anterior tibial and peroneal vessels, and the head of the fibula with an un-united epiphysis or about 30 CMS of diaphyseal shaft, can be harvested on these vessels singly or in conjunction with both the vessels. The fibula provides a strong cortical bone, with no functional deficit at the donor site.

This author presented a series of 48 cases of using vascularized fibula for congenital hypoplaasia, hemi-facial microsomia, and/or TMJ ankylosis in childreen, and post-infective, post-traumatic, or post-excision mandibular reconstruction in adults. Patients ranged in age from 3 to 55 years, and have been followed-up for a period ranging between 2 and 5 years. Repeated x-rays, radioisotope bone scan, and 3-D CT scan have been used for pre- and postoperative assessment and for follow-up studies. In all cases, there has been excellent osteointegration and consolidation of the osteotomized fibular bone graft as a neo-mandible.

First Dorsal Metacarpal Free Flap for Nasal Lining. Elisabeth K. Beahm.

Despite the reliability and consistent anatomy of the first dorsal metacarpal artery (DMA), utilization of it as a free flap has not been previously described, and only a single case of a free second DMA flap has been reported. The majority of the applications of this flap have been as fascial, fasciocutaneous, or even reverse flaps for reconstruction of local (thumb or first web space) defects. The authors presented a case utilizing microsurgical free tissue transfer of a double island free first DMA flap for reconstruction of a nasal septal and vestibular defect.

The patient was a 72-year-old former cigarette smoker, who underwent near total nasal resection, including portions of the left cheek and left upper lip, followed by radiation therapy as treatment of a basal cell carcinoma. The nasal lining was restored utilizing a radial forearm free flap, with subsequent placement of rib cartilage grafts for support, and a paramedian forehead flap for nasal skin cover. The composite nasal reconstruction was surgically thinned to refine it in a number of additional procedures. This resulted in necrosis of the membranous septal portion of the nasal lining flap, with exposure of the underlying cartilage support.

To salvage the reconstruction, restoration of the bilateral membranous septal lining was required. Ideally, this demanded that the flap be small, thin, and could be inset with minimal trauma to the reconstructed nose, without distorting it or causing nasal airway obstruction. The first DMA was selected for this purpose. The course of the first DMA was identified via percutaneous Doppler, and the flap was designed with double skin islands (1.5 x 2 cm) to duplicate each side of the membranous septum. The first DMA and its accompanying venae comitantes were anastomosed end-to-side to the pedicle of the previous radial forearm free flap. The donor site was closed with a full-thickness skin graft. The patient had an uneventful postoperative course and went on to successfully complete her nasal reconstruction.

This case is the first to report the use of a first DMA free flap, and it was successful in fulfilling the special requirements of an intranasal reconstruction without compromising the aesthetic result or the mechanical airway. Clearly, the DMA flap has very specific indications, and has its limitations. The vascular pedicle is very reliable, and its course is easily traced utilizing the hand-held Doppler. The donor site confers no functional deformity, but is highly visible. If closed meticulously with a full-thickness skin graft, however, it is quite acceptable, especially in the older patient. While the flap size is small, the long vascular pedicle makes it quite useful in nasal reconstruction, or in other reconstructions in which a small amount of thin tissue is required. Color match in the face, as in all remote flaps, may be problematic, if required for skin cover in this area. The pedicle vessels may be small, and this may pose potential technical problems in transfer. Finally, patients who are obese may have relatively thick flaps that may be unsuitable for use in special areas such as the nose.

Burned Neck Reconstruction Using Various Versions of the Microvascular Augmented Subdermal Vascular Network Flaps in the Dorsal Area. Hiko Hyakusoku, Ritsu Aoki, Jian-Hau Gao, David G. Pennington, and V.Q. Vinh. Departments of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan; Nan-fan Hospital, Guangzhou, China; Royal Prince Alfred Hospital, Sydney, Australia; and National Institute of Burns, Hanoi, Vietnam.

The microvascular augmented subdermal vascular network flap was presented by the authors as a microvascular augmented occipito-cervical-dorsal (OCD) super-thin flap in 1994. The original flap had an augmentation of the circumflex scapular vessels. Following this report, over 20 flaps were successfully performed. Another new choice of the pedicle is a vascular or muscular pedicle of the superficial artery (SCA) and veins. A skin island subdermal vascular network (SVN) flap can be elevated with this pedicle. In addition, we selected the dorsal intercostal perforator(s) (DICP) for an augmentation, when a flap had to be designed in another course or of an extremely large size.

In the authors' study, the sixth or seventh dorsal intercostal perforators were useful for vascular augmentation. They were used for augmenting OCD of SCA subdermal vascular network flaps. Moreover, free or pedicled scapular flaps with these augmentation vessels have been used successfully for reconstructing the neck and axilla. The flaps demonstrated were the DICP augmented OCD SVN flap, the DICP augmented SCA SVN flap, and the DICP augmented scapular SVN flap. In some cases, only the dorsal intercostal perforator veins were anastomosed for venous drainage. When the flap size is long or wide, or beyond the central line of the body, augmentation of an artery and vein is needed for safer transposition. Several successful cases with long-term results and modifications were presented.

Computer-Simulated Occlusion-Adjusted Prefabricated 3-D Mirror Image Templates in Difficult Cases of Head and Neck Reconstruction. Sophia C.N. Chang, C.T. Liao, H.C Chen, and C.S. Tseng. Departments of Plastic Surgery and ENT, Chang Gung Memorial Hospital, Taipei, Taiwan; and Department of Mechanical Engineering, Central University.

In reviewing the experience of one otolaryngologist during a 5-year period (January 1996 to December 2000) in performing radical neck dissection (n=464), combined with vascularized bone-containing free fibula flaps (n=44), used for oromandibular reconstruction, the minor complication rate was over 30%. The majority of complications involved malocclusion which prevents a coordinated dental arch from osseointegrating tooth insertion. A prefabricated 3-D mirror image template based on computer-simulated surgery aids in adjusting occlusion, and assists in microvascular flap insertion during reconstructive surgery.

Three patients underwent the microvascular transfer of vascularized fibula flaps and suffered from severe malocclusion, causing headache, TMJ pain, unsymmetrical faces, and inability to undergo further osseointegrating tooth insertion. 3-D CT examination was carried out, and the nonprocessed raw data were sent for computer simulation surgery; a subsequent mirror image template was fabricated for microsurgical flap guidance.

The authors demonstrated a video presentation, that was developed to do the computer-simulating surgery on the screen. Ultimate occlusion was acceptable and facial symmetry was obtained. The success of computer-simulated occlusion-adjusted 3-D mirror image templates supports the use of vascularized bone free flaps in restoring continuity to the mandible in this series. A coordinated arch is of use in further osseointegrating tooth insertion.

Vascularized Toe Joint Transfer for Hand Joint Replacement. Michael Wong and Tsu-Min Tsai. Christine M. Kleinert Institute, Louisville, Kentucky, U.S.A.

Finger joint reconstruction using a vascularized toe joint transfer is a well-established treatment. In 1967, Buncke and colleagues reported their successful transfer of a vascularized MCP joint of a severely traumatized index finger to the PIP joint of the adjacent long finger. These authors' clinical experience with vascularized joint transfers began in 1978, and has evolved to include double-joint transfers on one pedicle. Vascularized joint transfer is indicated in either joint or epiphyseal destruction not amenable to arthroplasty. In children, the best indication is MCP and IP or PIP joint injury with epiphyseal damage.

The most commonly performed vascularized joint transfer to the hand uses the second toe PIP joint as donor. The surgery was well-described. For double-joint transfer of the MTP and PIP joints on a single vascular pedicle, the second toe is dissected with its pedicle attached to the distal phalanx, preserving the distal commissural vessels, maintaining MTP joint vascularity through tibial branches of the first dorsal metatarsal artery, while PIP joint vascularity is maintained through retrograde flow through fibular digital artery branches. This technique may be used to replace two adjacent MCP joints or two nonadjacent MCP joints. Another double-joint transfer that has been performed uses two adjacent PIP joints supplied by the second plantar artery. Tibial and fibular vessels from the second plantar metatarsal artery are delineated and ligated at the DIP joint , while preserving branches to each PIP joint.

Although these authors have limited experience with the latter technique of double-joint transfer, it is their preferred method for several reasons. Despite additional morbidity in using a second donor toe, the patient will still have 5 toes. More important, the vascular pedicle length to each PIP joint from the second plantar metatarsal artery enables a combination of joints to be replaced: two adjacent PIP joints, an adjacent PIP and MCP joint, or two MCP joints, whether adjacent or separated, by one normal, non-thumb metacarpal.

If the recipient extensor mechanism was preserved, gentle range of motion (ROM) exercises for the PIP joint are started on postoperative day 2, protected by a dynamic dorsal block splint. After 2 to 3 weeks, when graft survival is assured, the patient is placed in a brace and encouraged to move more aggressively under physical therapy guidance, performing both active and passive ROM exercises.

Compiling results of almost 20 reports, 79 patients have undergone 89 joint transfers: 51 adults (54 joints), 28 children (35 joints); 74 patients-single joints, 5 patients-double joints. The second toe MTP or PIP joint was the most common donor, and trauma was the surgical indication in 75% of patients. Total active ROM averaged 32 degrees in adult patients and 37 degrees in children. Necrosis was reported in 5 to 10% of cases. Forty-eight of the patients required tenolysis or capsulotomy for extensor tendon adhesions. Infections occurred in 13%, and Foucher and colleagues reported cold intolerance in injured hands (61%) and donor feet (31%).

Free vascularized joint transfer can provide patients with a useful ROM and good lateral stability. Dynamic splinting and good postoperative physical therapy can improve the transferred joint ROM. Moreover, it may be useful in maintaining growth in children whose joint injury involves the growth plate. In epiphyseal transfer, the authors prefer the MTP joint over the PIP joint for its larger growth plate. Thus, free vascularized single- and double-joint transfers are viable options for treating traumatized finger joints in the growing child and mature adult.

Joint Reconstruction with Free Vascularized Osteochondral Transplantation in the Upper Extremity. Duke Whan Chung and Ki Bong Kim. Department of Orthopaedic Surgery, Kyung Hee University, Seoul, Korea.

The purpose of this study was to introduce a reconstructive method for major joint defects of the upper extremity using free vascularized bone and joint transplantation. The authors had experience of 16 cases of joint reconstruction with free vascularized fibular head or metatarsal joints. The affected joints were 12 wrists, 3 shoulders, and 1 elbow joint. The average age of the patients was 12.3 years (range: 3 to 34 years). The average follow-up period was 6.3 years (range: 1 to 16 years). The etiologies of the joint defect were 7 traumatic, 3 infection sequelae, 3 congenital, and 3 tumorous conditions. Donor bone and cartilage of this transplantation surgery included 15 fibular heads with metaphysis and one case of double metatarsal joints transplanted to the elbow joint. The authors evaluated the joint conditions and fate of the transplanted osteochondral parts during the follow-up period with serial radiographic study and functional joint evaluation.

Transplanted bony portions united to recipient bone within 5 months in all cases (average: 4.8 months; range: 3.2 to 8.3 months). The articular cartilage of the donor bone survived with expectable outcome in 13 cases; maintained continuous growth potential was observed in children in both volume and length of the bone and cartilage. Adoptive changes of the transplanted osteochondral part were observed in 13 cases. In the case of elbow reconstruction with double metatarsal joint transplantation, there was persistent lateral instability and weakness of joint power.

Free vascularized osteochondral transplantation to the defective joint portion in major joints of the upper extremity can be utilized as one of the most challenging methods in profound joint lesions that present no other effective solutions with conventional modalities. The proximal osteochondral part of the fibula can serve as a very effective donor in this procedure. Free vascularized metatarsal joint transplantation to the elbow joint could not provide sufficient stability, even though double metatarsal joints were transplanted.

Reconstruction of the Elbow Joint by Metatarsophalangeal Joint Transfer from the Second and Third Toes. Hitoshi Miura, Satoshi Toh, Kenji Tsubo, Satoru Kudoh, and G. Ivan Vallejo. Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki City, Aomori Prefecture, Japan.

The authors performed vascularized metatarsophalangeal joint (MTP joint) transfer from the second and third toes for two cases of severe open injury of the elbow joint. The patients were an 18-year-old man and a 20-year-old man; both had been injured in traffic accidents. There were large bone and cartilage defects in the elbow joints.

After harvesting of the second and third MTP joints, the joints were transferred into each elbow joint and fixed. One artery and two veins were anastomosed. Donor sites were covered with free peroneal flaps. Three weeks after surgery, range of motion exercises were begun with the assistance of a Compass universal hinge.

In each case, the transferred joints survived completely. In one case, the transferred MTP joints were gradually dislocated, because the patient did not maintain application of the brace, but he has no current complaints of pain. In the other case, no dislocation of the transferred joints occurred, but the peroneal flap at the donor site became necrotic, and the second and third toes were amputated due to ischemia.

The procedure was recommended to patients with complete defects of the elbow joint, who are young and who do not desire an arthrodesis procedure.

New Concept of Digital Nail Reconstruction. Wen-Ming Hsu and Chen Yang. Chi-Mei Foundation H, Taiwan.

Considering size discrepancy and short nail deformity, a new concept was proposed for microsurgical reconstruction of the digital nail and its surrounding tissue. Ten patients with 11 digits were injured, involving the dorsum of the digits and total nail germinal matrix loss, along with some skin necrosis.

They received a microsurgical second toe nail transfer to resurface the defect. Six of them were treated by conventional microsurgical nail transfer, four were treated combined with nail bed elongation, by preserving some residual distal nail bed and eponychium, if present. The last case received only partial nail matrix, nail bed, and fold transfer. A split-thickness skin graft from the instep was used to cover the donor defect. All procedures were successful and the patients were satisfied at the final result. In comparing appearance, those digits receiving elongation of the nail bed were more like a hand nail than a toe nail. Details of the techniques were reported.

Microsurgical Indications for Aesthetic and Functional Nail Reconstruction. Yuichi Hirase, Tadao Kojima, Keizou Fukumoto, and Toshihito Yamaguchi. Saitama Hand Surgery Institute, Saitama Seikeikai Hospital, Higashi-matsuyama, Japan.

The hand is usually naked and exposed, and is an essential organ in daily life. If a portion of a finger is lacking, this creates a great functional disadvantage. In such cases, an adequate method should be selected, considering the condition of the portion of the finger remaining. In order to select an appropriate reconstructive method, the authors have used a classification of amputation level to determine the operative method.

• Type A: the nail matrix is not injured, and more than two-thirds of the distal phalangeal bone remains.

• Type B-1: The nail matrix is not damaged, but more than half the distal phalangeal bone remains.

• Type B-2: The nail matrix is not damaged, but less than half the distal phalangeal bone remains.

• Type C: The nail matrix is lost or severely damaged, but PIP joint functiion remains.

• Type D: PIP joint function is lost.

Surgical procedures are selected based on the amputation classification

• Type A: A combined method of finger island arterial flap and split-thickness nail bed graft from the toe.

• Type B-1: Procedure as for type A and bone graft to the fingertip.

• Type B-2: Vascularized nail bed graft from the big toe.

• Type C: Vascularized nail graft, combined with finger arterial island flap

• Type D: Whole toe transfer.

For aesthetic reconstruction of both the donor and recipient sites, minimum harvesting from the toe should be performed, by considering combination with a finger flap at the recipient site. Thus, microsurgical transfer is indicated in cases of amputation proximal to type B-2.

Pedicled Perforator Flaps in Upper Limb Reconstruction. M. Innocenti and L. Delcroix. Hand Surgery and Reconstructive Microsurgery, Az. Careggi, Florence, Italy.

Over the past 30 years, many varieties of soft-tissue flaps have been described and successfully adopted into clinical practice. Random flaps can be considered as the ancestors of more sophisticated flaps, in which a named pedicle was related to the blood supply of a defined area of skin, allowing a more reliable outline of the flap and improving the arc of rotation. The possibility of harvesting a proximal flap based on a reverse flow pedicle further enlarged the reconstructive boundaries in the upper limb in soft-tissue repair. Flaps based on perforator vessels are one of the most recent families and offer several advantages: they provide skin of good quality without the sacrifice of a major vessel; they can be harvested almost anywhere a perforator vessel can be detected; they do not need fascia, since they are based on the subdermal plexus; and they are relatively easy to dissect.

Over the past year, nine flaps based on the perforator arterial system have been raised, in order to cover soft-tissue defects in the upper limb. Four of them were supplied by small unnamed arteries available in the proximity of the skin defect. The remaining five flaps were based on an adipofascial strip containing the perforator networks arising from the radial artery and from the posterior interosseous artery.

All the transferred flaps survived and successfully accomplished their purpose. However, two flaps based on the adipofascial pedicle from the radial artery suffered skin necrosis and required secondary coverage of the exposed subcutaneous tissue with a skin graft.

The upper limb, particularly the forearm, is a very versatile donor site, and many local and locoregional flaps have been described for the coverage of small and medium soft-tissue defects. The Chinese flap and the posterior interosseous flap are probably the most popular procedures, and they have been continuously refined over the last years. The former provides a significant amount of skin of good quality, but needs the preservation of the palmar arches and the sacrifice of the radial artery. The donor scar is usually quite unaesthetic. The posterior interosseous flap is based on a secondary artery, but the dissection is difficult and time-consuming. Both of them can be complicated by venous problems related to reverse flow drainage.

Perforator flaps are based on very small direct arteries which arise from the deep vascular networks and supply the subdermal plexus perforating the fascia. The feeding pedicle must be included in the outlined flap, but can be quite eccentric, allowing rotation of the flap up to 180 degrees. This type of perforator flap should be harvested in the proximity of the defect. When more distant skin is required, a radial flap or an interosseous flap based on an adipofascial perforator pedicle may be preferred. The preliminary results of the clinical application of such procedures convinced the authors that perforator flaps are less invasive than traditional flaps, can be raised more quickly, present a lower complication rate, and are therefore useful tools in the hands of the reconstructive microsurgeon.

Osteomuscular Free Serratus Anterior Flaps in the Repair of Bone Defects. A. Georgescu, Ivan Ovidiu, C. Melincovici, Serbu Simona, and L. Fodor. Plastic Surgery Clinic, University of Medicine, Cluj-Napoca, Romania.

The relative ease of harvesting, the possibility of using different varieties and numbers of muscular components, and the relatively long pedicle make the free serratus anterior flap an important competitor to the latissimus dorsi flap in the coverage of complex osteocutaneous defects.

Between 1998 and 2001, the authors used this flap in 21 consecutive cases, 16 males and 5 females aged between 4 and 54 years. The etiology of the defects was post-traumatic, and the cases involved the arm (2), forearm (4), hand (9), leg (4), and foot (2). The flap was used predominantly in complex defects, either infected or with a high risk of infection. The flaps were harvested with a bony component, including one or two segments of rib. In five cases, the flap was part of a double simultaneous or consecutive free transfer associated with the latissimus dorsi (4) or the Chinese flap (1).

A single flap was lost due to an irreversible arterial thrombosis, but the bony component survived and was covered with another flap. Minor superficial or distal necroses were observed in 5 cases, and usually resolved spontaneously. In all cases, the bony fragment consolidated, and radiographs at 12 months demonstrated very good integration. The flaps were monitored for a period of 6 to 24 months, and only minor volume readjustments were necessary in 4 cases. No infection developed in these cases.

Compared with other free muscle flaps, and especially with the latissimus dorsi flap, the serratus anterior flap has further qualities that make it extremely useful in limb trauma: a large surface for reduced volume; a flat belly muscle useful in hand reconstruction; the possibility of partial harvesting of 1 to 3 digitations, essential for small bone defects in which the flap serves as a bone carrier; ease of harvesting with bone fragments; a long pedicle; and reduced functional deficit in the donor area. In addition, the possibility of associating it with the latissimus dorsi on the same pedicle makes the flap useful in the coverage of large, complex defects.

Free Flaps in Finger Reconstruction. Bartolome J. Ferreira. Barcelona, Spain.

In finger injuries with wide skin loss, the treatment of trauma depends on the direction of amputation. In oblique injuries with palmar skin loss, microvascular procedures offer different types of procedures for wound closure. The author has used free flaps from the toes, first web, wrap-around, and conventional cutaneous free flaps. The type, amount of skin loss, and number of fingers affected suggest the surgical procedure. In many of the cases presented, the proximal interphalangeal joint was affected, with preservation of the flexor tendon. In these cases, good restoration of PIP flexion was achieved. Cosmetic and functional results were satisfactory, with a good range of motion of the proximal interphalangeal joint. The remaining donor scar in the foot was acceptable.

Arterialized Venous Free Flaps for Reconstruction of Composite Defects of the Hand. Joo Sung Kim. Department of Orthopedic Surgery, Hyundea Hospital, Taegu, Korea.

Since Nakayama's first report on the venous flap, many experimental and clinical studies have been done on this type of flap. Currently, due to its various benefits, applications as arterialized venous free flaps have increased. In this study, the author reported reconstruction of various kinds of hand defects with new modifications of arterialized venous free flaps, and simultaneously reconstructed skin, nerve, and tendon successfully.

From 1994 to 1999, defects in the hands of 35 patients were reconstructed with various modifications of arterialized venous free flaps. The patient age range was from 19 to 55 years, and flap size ranged from 1×2 cm to 14×9 cm. Among them, 12 cases with flaps over 20 cm in size were included. Indications for the flaps were: resurfacing of skin defects (9), simultaneous reconstruction of extensor, skin, and digital nerve (2), reconstruction of the skin with extensor (5), flap-through type vascular reconstruction (6), digital nerve reconstruction (2), contracture release (3), and fingertip reconstruction (9). All the cases but one were successful, with marginal skin necrosis less than 10%. Relatively large flaps over 20 cm in size survived successfully with no delay procedure. Composite reconstructions, including those of tendon and nerve, adapted well to flap modifications.

The arterialized venous free flap is a useful procedure in hand reconstruction because it has several advantages: lack of bulk; variable length of pedicle; preservation of a major vascular pedicle; less operative time required; a single operative field; and the possibility of various modifications to suit the particular case.

Rope Avulsion of the Thumb: Review of 73 Cases. Darrell Brooks, Karin Schott, Rudolf F. Buntic, Gabriel M. Kind, Gregory M. Buncke, and Harry J. Buncke. Department of Microsurgery, Buncke Clinic, San Francisco, California, U.S.A.

Rope avulsion carries a particularly poor prognosis for digit salvage, given that traction energy is transmitted through the soft tissues far proximal and distal to the level of initial insult. It is considered a relative contraindication for finger replantation. However, few hand surgeons would not attempt replantation of the avulsed thumb. The authors presented their experience with revascularization and replantation of 73 such injuries to the thumb-to their knowledge, the largest extant series.

A retrospective review of their clinical database identified 391 traumatic amputations of the thumb between 1983 and 1998. Seventy-three met their inclusion criteria, which included complete rope avulsion (45) or incomplete rope avulsion with both arterial and venous insufficiency and bony trauma (38). Eleven thumbs underwent immediate revision amputation. Of these, two distally amputated thumbs underwent pedicle flap coverage to preserve functional length; one was not available for replant evaluation; 7 had no vascular target; and one patient refused replantation. The 62 thumbs which underwent replantation were grouped as avulsion or crush/avulsion, as to the level of bony amputation, and whether the FPL was avulsed, transected, or intact.

Most revascularizations and replantations were treated with bony shortening. All were treated with aggressive vessel debridement to healthy-appearing intima. Interpositional vein grafts were used in a majority of cases. All replants were treated with dextran 40 after replantation; some additionally were treated with aspirin or heparin. Functional assessment included a measurement of the average total active motion (TAM) for the IP and MCP joints, and a percent comparison of grip and pinch strength against the uninjured hand.

The overall success rate for the replanted thumbs was 82%. Complete amputations showed 75% (21/28) survival, while incomplete amputations showed 91.2% (31/34) survival. If there was a crush component to the avulsion injury, only 77% (10/13) survived. The TAM for complete amputations in which the FPL was avulsed from the muscle belly was 28 degrees. The TAM for amputations in which the FPL was intact or repaired was 73 degrees. Similar trends were found with pinch and grip strength.

Rope avulsion injuries of the thumb can be successfully managed with aggressive removal of all involved vasculature and replacement with healthy interpositional vein grafts. Incomplete rope avulsions are associated with a higher survival rate. An intact or primarily repaired flexor pollicis longus is associated with higher functional return.

Neural Lesions in Volkmann's Contracture in the Upper Limb. A. Landi, A. Leti Acciaro, and N. Della Rosa. S.C. Chirurgia della Mano e M. Azienda Ospedaliera, Policlinico, Modena, Italy.

The authors reported their experience of the assessment (clinical, TC, and MRI evaluations) and surgical treatment of Volkmann's contracture in the upper limbs, with specific emphasis on neural lesions. Forty-seven patients were treated between 1975 and 2001.

Five patients belonged to the perinatal group (1 intrauterine upper limb ischemia and 4 post-natal vascular or septic lesions). Eighteen belonged to the adolescent group in which the various problems linked to the growing phase were recorded. Twenty-four patients belonged to the adult group (21 following traumatic events, 1 as a consequence of thrombophlebitis, and 2 as a result of drug extravasation). In relation to etiology, severity, and associated joint stiffness, the surgical treatment ranged from simple external or internal neurolysis to nerve grafting, the staged St. Clair Strange procedure, vascularized pedicled or free nerve grafting in association with infarct removal ± muscle sliding (mainly in the adult group), or early and late free muscle transfer (mainly in the perinatal and adolescent groups).

All patients underwent long-term follow-up ranging from 2 to 20 years (average: 6 years). The following factors were considered to be relevant: the extreme variability in etiology, with new factors being added; the favorable outcomes of early exploration (within 3 months) on overall nerve function, compared to late exploration (over 6 months) as first indicated; the still unrivalled role of the staged Strange procedure in the most severe cases; the limited and personalized indications for vascularized pedicled or free nerve grafting, leading constantly to excellent outcomes; and the new adjuvant role of end-to-side nerve suture, mainly in the perinatal and adolescent groups presenting with a severe Volkmann contracture, in which simultaneous or staged free muscle transfers were carried out.

Ring Avulsion Injuries: Treatment Outcome with Microsurgical Techniques. Darrell Brooks, K. Schott, R.F. Buntic, G.M. Kind, G.M. Buncke, and H.J. Buncke. Department of Microsurgery, Buncke Clinic, San Francisco, California, U.S.A.

The treatment of ring avulsion amputations is challenging, given the diffuse longitudinal injury to the skin envelope, arteries, veins, and nerves. The authors reported the treatment outcome, utilizing microsurgical techniques in such cases, between 1977 and 2000.

This was a retrospective review. Eighty-four patients presented to the Buncke Clinic between 1977 and 2000 with ring avulsion injuries. All hospital/clinic records were reviewed to obtain patient demographics and to define injury patterns. All patients were then classified, based on the system described by Urbaniak, and modifications of that system, such as Kay's and Adnai's. Twenty-three digits were deemed ``non-replantable'' (digits without a distal vascular target) and underwent immediate complete amputation. Sixty-one patients had their digits replanted. Outcome parameters included survival, and functional assessment included total active motion (TAM), grip strength, and pinch strength. Average follow-up was 10 months.

The study demonstrated excellent survival and good functional outcome after microsurgical treatment of selected ring avulsion injuries. The majority of digits survived, regardless of Urbaniak classification. Modifications of this system based on anatomic injury were more predictive of functional outcome. Microsurgical treatment of some type III avulsions resulted in useful function. All ring avulsion injuries should therefore be evaluated for replantation.

Vascularized Bone Grafts for the Reconstruction of Congenital Pseudarthrosis and Bone Defects. Musa Mateev, Peter Pokrovsky, Bakyt Omurzakov, and Arstan Imanaliev. Department of Plastic and Reconstructive Microsurgery and Hand Surgery, National Hospital of Kyrgyzstan.

The aim of this study was to show the advantage of treatment of bone defects and congenital pseudarthrosis by free vascularized bone grafts, in combination with the Ilizarov device.

Reconstruction of bone defects was done in two stages. In the first stage, they applied the Ilizarov device to the tibia for lengthening and elimination of deformation. In the second stage, the bone defects were repaired by free vascularized bone grafts. The authors' clinic has experience with 68 cases of reconstruction of congenital pseudarthrosis and extensive bone defects by free transplantation of vascularized bone grafts. Bone defects occurred as results of pseudarthrosis (14), wide tumor resection (19), traumatic injuries (27), and total osteomyelitis (8).

The maximum lengthening of the extremity is 1 mm per day. This process can be very lengthy and painful. However, it is necessary for both legs not to be of discrepant length. They lengthen the extremity by 5 cm; after this, there is a 2-week hiatus because of the pain the patient endures. During the lengthening process, it is necessary to have active movements of the extremity as a preventive against contracture.

The authors prefer to use an osteoseptocutaneous fibula graft. The cutaneous component of the osteoseptocutaneous VFG is responsible for the blood supply of the flap; also, it is useful in maintaining the pressure in the flap vessels. Seven patients had bone defects after wide tumor resection of the distal radial bone portion and proximal shoulder portion, with defects of the radiocarpal and shoulder joints. For these patients, reconstruction was done with fibula epiphysial bone grafts for new radiocarpal and shoulder joint formation.

The Ilizarov device does not always allow for the optimal placing of microvascular anastomoses. In order to create workable conditions, it was necessary to open the operative area in which the anastomoses were to be done. The authors worked out a technique (sliding) of remounting the device during the operative procedure, as follows. The operative field is determined. Remounting of the device involves transposing the longitudinal steel wires, in order to widen the field; the number of wires should not be less than three. When the anastomoses have been placed, the device should be restored to its initial position. If properly carried out, the whole process should take no more than 10 to 15 min.

Three patients among the 68 cases had resultant necrosis of the transplanted bone graft. Sixty-five patients had complete survival of the grafts. Bone consolidation was observed in 6 to 8 months after the reconstruction. In the authors' opinion, application of free vascularized bone grafts, in combination with the Ilizarov device, is a very efficient method of treatment for congenital pseudarthrosis and extensive bone defects.

Donor Site Reconstructioin after Free Vascular Fibular Transfer in Children with Congenital Pseudarthrosis of the Tibia. Bertil Romanus and Ingemar Fogdestam. Department of Orthopedics, Goteborg, Sweden, and Departments of Plastic Surgery, Goteborg, Sweden and Oslo, Norway.

Free vascular fibular transfer has been a very successful method of bridging various defects of the long bones. The authors have used this technique in the treatment of congenital pseudarthrosis of the tibia (CPT). However, in children, progressive valgus deformities, both at the knee and the ankle at the donor site, have been a major concern. This was a report on preventing knee and ankle valgus deformity in growing children by careful reconstruction of the fibular donor-site defect.

Since 1981, they have used contralateral free fibular transfer in 10 cases to fill the defect after resection of the CPT. The ages of patients ranged from 6 months to 15 years at the time of operation. All except three patients have been followed until skeletal maturity, and the results were presented in a separate paper. The defect at the donor site (6 to 12 cm long) has been filled with an osteoperiosteal strip, which was removed from the medial aspect of the tibia at the donor site and shaped into a tube. The tube was sutured to the resected upper and lower ends of the fibula. The fibular ends were transfixed to the tibia with screws or pins, to prevent proximal and distal migration. After re-forming of a fibular diaphysis, the fixation was removed.

The tubular strip filled the defect with bone in all cases. Minor defects in the continuity of the new fibula were seen in the earliest two cases, and in the two oldest patients at the time of the procedure. None of the patients had any symptoms at the knee or valgus deformity at the latest follow-up. None had any symptoms at the ankle. All but two had 10 degrees of valgus of the ankle on radiographic examination. Two patients had defects in fibular regeneration and had too much remaining growth at the time of the surgery. Another two with defects were females and the oldest ones at surgery, with almost no remaining growth; they did not develop any deformity at the ankle.

Development of progressive valgus deformities of the knee and ankle of the donor side in children, after resection for free vascular fibular transfer, can be prevented by interposing an osteoperiosteal tube from the medial aspect of the tibia into the diaphyseal defect. This appears to be important, especially in children with several years of remaining growth. Temporary fixation of the fibular ends to the tibia during remodeling of the fibula appears to be beneficial.

Free Vascularized Fibular Grafts for the Treatment of Osteonecrosis of the Femoral Head. Binka Popova, P. Tivtchev, E. Mateva, S. Georgiev, and A. Peshev. Clinic of Traumatology, Queen Giovanna Hospital, Sofia, Bulgaria.

Non-traumatic osteonecrosis of the femoral head (ONFH) is a disabling condition with a poor prognosis in relation to total hip arthroplasty. The aim of this study was to assess the effectiveness of free vascularized fibular grafting, according to the authors' experience.

Since 1994, 50 patients (53 joints) have been operated on; their ages were between 23 and 54 years. Preoperatively, the stage of the disease was classified after Ficat: stage I-3 joints; stage II-29 joints; stage III-20 joints; and stage IV-1 joint. The operative technique was extraarticular. After trimming, the length of the grafts was 8 cm on average. Revascularization was accomplished by microanastomoses with the lateral circumflex femoral artery. Blood flow was normal in 20 grafts and reversed in 33. There were two complications in the early postoperative period-septic arthritis, and penetration of the graft into the joint. Because of clawing of the big and second toes, the tendons were lengthened behind the medial malleolus in two cases.

Forty-four patients (46 joints) were followed-up for a period from 8 months to 7 years. The spherical contour of the head was preserved in 25 joints: in the group of stage I-2 joints; in those with stage II-18 joints; in those with stage III-5 joints. The contour was altered in 15 joints: in stage I-1 joint; in stage II-6 joints; in stage III-7 joints; and in stage IV-1 joint. Three joints were converted, and three others are candidates for total hip arthroplasty (10.8%). The range of motion in the sagittal and frontal planes did not improve significantly. Twenty-four patients were free of pain, while 14 described the pain as mild-to-moderate. Most of the patients were satisfied with the treatment in terms of daily activities and ability to work.

Free vascularized fibular grafting decreases the necessity for total hip arthroplasty in young adults with ONFH, especially when the diagnosis determines that the patient is in the early stages of the disease.

Experience with Free Fibula Transfer to the Distal Tibia. William C. Pederson, Michael Pannunzio, Lorenzo Pacelli, and Marvin Brown. University of Texas, San Antonio, Texas, U.S.A.

Fractures of the distal tibia present difficult management problems. They often involve the joint surface of the ankle and are frequently open, leading to a relatively high rate of infection and nonunion. While transfer of a free fibula is an accepted procedure for tibial-shaft nonunions, there is little in the literature regarding free fibula transfer in the management of tibial plafond fractures.

Over a 6-year period, 13 patients underwent free vascularized fibular transfer for bone loss and/or nonunion after tibial plafond fracture. All patients had been considered for below-the-knee amputation prior to fibular transfer. The average age at the time of fibular transfer was 39 years, with an average time from injury to the index procedure of 8 months. Three of the initial fractures were closed, with the remaining 10 being open. There were infected nonunions in 5/13 patients; however, all were culture negative at the time of fibula transfer. The average number of prior operations was 3.8. Seven patients had tibiotalar arthrodesis, while the remaining ones had the fibula placed into the tibial plafond without crossing the joint.

Three patients required early return to the operating room for vascular compromise, but all had vascular salvage. One patient required free muscle transfer due to venous compromise of the skin paddle (with patent vessels to the bone). Ten of 13 patients (77%) went on to ``primary'' union of the fibula and tibia, with three patients developing a nonunion of one end. One patient opted for secondary cancellous bone graft of the distal site, with eventual healing, while the other two patients (15%) opted for below-the-knee amputation. One patient developed a draining sinus at 13 months (despite healing), which resolved after debridement and hardware removal. Of the 11 patients with eventual union, partial weight-bearing was begun at an average of 4 months, and weight-bearing without assistive devices by 8 months. The presence of prior infection did not significantly increase the time to full weight-bearing. Donor-site morbidity was low, 2/13 (15%).

Management of nonunion and infected nonunion of distal tibial fractures remains a challenging problem. This small series showed that free fibula transfer offers a relatively high union rate (85%) in these complex cases, with an acceptable rate of complications. In properly selected patients, the procedure can offer a functional alternative to below-the-knee amputation.

Vascularized Bone Graft for the Treatment of Avascular Necrosis of the Talus. Mitsunori Shigetomi, Koichiro Ihara, Keiichi Muramatsu, Shinya Kawai, and Kazuteru Doi. Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Japan.

The reported study was undertaken to evaluate the usefulness of vascularized bone grafts for the treatment of avascular necrosis of the talus.

Vascularized bone grafts harvested from the medial supracondylar region of the femur were used to treat 6 patients with avascular necrosis of the talus. These grafts can be trimmed to any shape without compromising vascularity, as the graft is nourished by the periosteal blood supply. The vascularized bone graft was inset into the core of the avascular talar body to promote healing. Three patients had developed partial collapse of the tarsal dome, and one had osteoarthritic changes of the ankle joint preoperatively. The average follow-up was 66 months (range: 32 to 96 months).

The necrotic talar body was prevented from progressive collapse in four patients in early stages of avascular necrosis. One patient with osteoarthritic changes of the ankle preoperatively had a moderately painful gait; however, she requires no cane for activities of daily living. Two patients had a mildly painful gait. Results in 5 of the 6 cases were rated as good or excellent by the criteria of Hawkins. A vascularized small periosteal bone graft from the medial supracondylar region of the femur can thus be used to promote revascularization of the subchondral bone in the treatment of avascular necrosis of the talus.

Emergency Debridement, Reconstruction, and Free-Tissue Transfer in Acute Lower Extremity Injuries: The Ljubljana Experience. Z.M. Arnez, S. Wilson, N. Satj, U. Khan, D. Pogorelec, and F. Planinsek. Ljubljana University Medical Center, Slovenia.

Between 1984 and 1997, 54 patients with complex lower extremity injuries were treated by emergency free tissue transfer at the authors' institution. There were 31 lower leg injuries and 23 injuries of the ankle/foot. Forty-six injuries were open fractures (32 Gustilo IIIb, 14 Gustilo IIIc); eight injuries were soft-tissue defects, which were large in 36 patients, medium in 9, and small in 9 patients. Fractures were reduced by external fixation in 19 patients, by Kirschner wires in 12 patients, and by AO/ ASIF plating in 8 patients. Nine patients required major vessel repair for limb ischemia. In 6 of them, postoperative vascular thrombosis was observed. The limb salvage rate in the revascularized limbs following thrombosis of the repaired vessels was 50%, and the flap salvage rate was 83.3%. Microvascular anastomosis was end-to-end in 29 patients and end-to-side in 25 patients. The posterior tibial vessels were the recipient in 29 patients (53.7%). The latissimus was the most frequently used free flap in this series (34 flaps, 1 failure, 97% success rate). The free flap success rate was 94.4%. There were three failures (5.5%), two in the ankle/foot injuries and one in a lower leg injury. Primary healing was observed in 35 patients (64.8%). Wound cover and reconstruction were provided with one operative procedure in 23 patients (42.5%) and in two procedures in 43 patients. (79.5%).

Definitive cover and comprehensive reconstruction of selected complex lower limb injuries is possible in a one-only, first operation within 24 hr of injury, without increasing the postoperative complication rate, and is the authors' recommended treatment. It requires a multidisciplinary team approach (plastic, orthopaedic/ trauma, vascular surgery), and organization of a continuous mirovascular service possible only in major hospitals.

Temporary Placement of Defatted Plantar Heel Skin and Subsequent Transfer to the Heel Using Carrier Flaps: Two Case Reports. Tsan-Shiun Lin, Seng-Feng Jeng, and Fu-Chan Wei. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Heel pad avulsion with devascularization ideally should be revascularized microsurgically. However, when revascularization is not feasible because of the extensiveness of the injury, the reconstructive goal should then be to achieve a durable and sensate padding. Although there are reconstructive options available, most of them are far from ideal. The authors presented a new approach for a two-staged reconstruction of unreplantable heel pad avulsions.

The first patient reported received temporary placement of defatted plantar heel skin in the calf, and subsequent transfer to the heel, using a distally-based sural artery flap as a carrier. The second patient received temporary placement of defatted plantar heel skin in the thigh, and subsequent transfer to the heel, using an anterolateral thigh flap as a carrier. The second procedures were performed 2 weeks after placement of the defatted heel skin. The grafted heel skin and carrier flaps survived well. There was no ulceration of the heel after a 2-year follow-up. The new heel skin behaves as glabrous skin with a thick, keratinized layer.

As there is no such glabrous skin available for reconstruction of the plantar heel, the original skin of the injured heel should be preserved whenever possible during initial surgery. The distally based sural artery flap and anterolateral thigh flap are good choices as carriers of grafted heel skin. The preliminary results of this method appear to reveal superior outcomes to other methods.

Problems after Lower Limb Replantation Surgery: Possibilities of Treatment by External Fixation. Bruno Battiston, Pierluigi Tos, Italo Pontini, Antonio Biasibetti, and Domenico Aloj. Interdivisional Group of Microsurgery, C.T.O. Hospital, Torino, Italy.

In lower limb replantations, late complications are frequent (partial necrosis, limb shortening, non-unions, etc.) In the case series reported (1992 to 1999, 14 cases in 12 patients, two bilateral), there were always limb length discrepancies; in the two bilateral cases, there was a need of shortening, to allow for the possibility of good replantation. All replanted segments survived, but the authors had to secondarily amputate in 5 cases for severe general complications. In the remaining cases, 4 had minimal bone loss (2 to 3 cm) or symmetrical bone loss (bilateral cases). Two replanted segments presented delayed union. In 5 patients, a large bone loss was present (max: 14 cm, min: 4 cm, mean: 5.4 cm), requiring bone lengthening.

The two delayed unions were treated by means of fibular osteotomy and bone compression with the Ilizarov device. In 5 cases, a significant limb shortening was solved or reduced about 1 year later by limb lengthening with external fixation devices (in one case, a double lengthening at two separate times was necessary, due to a long bone loss of 14 cm). A proximal metaphyseal tibial osteotomy was always used.

Even if emergency external fixation can create some problems in replantation (excess bulk, the need for very rapid fixation), in the subsequent period it allows for the solution of two of the main problems in this surgery, i.e., non-union and limb shortening. In the patients reported, different external devices were used (e.g., Orthofix, Ilizarov, etc.), according to the particular case and the process of healing. At times, two different types of devices were used in the same patient, according to the problem presenting. Limb lengthening caused no further problems, and did not interfere with the biologic processes and healing.

On average, social reintegration of the patients was obtained 8 months after trauma. However, the mean time for the overall treatment (including secondary procedures) and a return to normal living was 1.5 years. Secondary limb lengthening allows replantation, even in the presence of extensive bone loss, but the authors believe that a loss of substance greater than 10 cm is a contraindication to replantation, as reconstruction will have a poor functional outcome.

Ankle and Foot Reconstruction: A Systematic Approach. C. Vlastou and E. Lykoudis.

The difficulties encountered in reconstructing the ankle and foot include the lack of regional large muscle bellies available for transfer, and the need for reconstruction of a durable weight-bearing surface. The authors presented a systematic approach to these reconstructions.

During the last 10 years, 72 flaps were performed on 64 patients, ranging in age from 2 to 75 years (mean: 37 years). The choice of the flap was based on the size, nature, and location of the defect and the vascular status of the limb. Regional flaps were avoided on severely traumatized extremities, on diabetic limbs, or in patients with vascular impairment. If vascular impairment was present, a bypass graft to restore limb circulation preceded flap transfer, or an AV loop was used to provide circulation to the flap. Twenty regional and 52 free flaps were used. Regional flaps included the extensor digitorum brevis (4), dorsalis pedis (2), lateral calcaneal (9), medial plantar (4), and flexor digitorum brevis (1). Free flaps included fasciocutaneous (8)-deltoid (4), scapular (1) radial forearm (1), lateral arm (1), groin (1); myocutaneous (3); and skin grafted muscle (41)-latissimus dorsi (26), rectus abdominis (4), and gracilis (11). Fifteen regional and 6 free flaps were sensory. Nine regional and 20 free flaps were used on plantar defects. Nine limbs with vascular impairment, four of which had arterial bypass grafts, were successfully reconstructed with free flaps.

Complications included a partial loss of a regional flap and one free flap failure. One free flap was aborted, due to recipient vessel fibrosis, because of an extended zone of injury. On long-term follow-up, ulceration developed on two skin-grafted muscle free flaps covering heel defects. These were resolved by refashioning the flap and using special footwear. In addition, one extremity was amputated, despite successful free flap coverage, because of persistent osteomyelitis and destruction of the ankle joint.

The authors presented a graphic algorithm for various situations and choices to cover defects of the ankle, posterior heel, and plantar heel. They commented that sensory flaps are preferable for plantar surface reconstruction, although skin-grafted muscle may be adequate. Customized footwear is frequently necessary in cases of plantar defects.

Microvascular Reconstruction of Unusual Upper Limb Injuries. Samir Kumta, Sudhir Warrier, and Shrirang Purohit. Lilavati Hospital, Mumbai, India.

A series of 20 cases of unusual upper limb injuries, treated by a combination of microvascular free tissue transfer followed by other reconstructive procedures, was presented. The mechanism and pattern of injuries seen in this series is unusual, but not uncommon at the authors' institution. Their complete reconstruction is a challenge and requires multiple modalities of treatment; however, good results can be obtained in the majority of cases.

Over a period of 6 years, the authors treated 20 cases with complex injuries of the upper extremity. Mechanisms of injury ranged from extensive electric burns in a child who attempted to catch a kite, using a metal rod which connected with an overhead high tension wire, to extensive dorsal hand and forearm injuries in people traveling with their upper limbs hanging out of car windows, to injuries from plastic moulding machinery, to close-range gunshot wounds (gangland warfare).

All acute cases, on arrival, required debridement and bony stabilization, which was performed in all cases with an indigenously developed external fixator device. This was usually followed in a few days by a microvascular free flap which, in most cases, was the latissimus dorsi muscle, with or without skin. Once the flap was well-settled, between 6 weeks and 3 months, bone grafting (when required) and extensor tendon reconstruction, using a combination of tendon transfers and plantaris tendon grafts, were performed. In the patient with electric burns, flexor tendon grafting and median and ulnar nerve grafting were performed. The circumferential wrist injuries had simultaneous nerve grafting as well. In both cases with large bone gaps, a microvascular fibular osteocutaneous flap was used.

All flaps except one did well. A latissimus dorsi flap for the child with electrical burns of the forearm failed, and had to be replaced by an abdominal flap. The vascularized fibular graft in the patient with non-union united within 6 months, providing a stable forearm. The patient with loss of the distal half of the radius and ulna, in whom a vascularized fibular graft was placed, developed non-union at the upper end, requiring subsequent bone grafting. Extensor tendon grafting yielded the most gratifying results, even though the graft was tunneled through or under the latissimus dorsi muscle. After nerve grafting, sensory recovery was good, with a 2PD less than 10 mm in all patients, but poor motor recovery.

These cases were presented because of the unusual mechanisms and patterns of injury. A combination of microvascular surgery and conventional tendon reconstruction provided gratifying results. Most of the patients did well because microvascular techniques were used in preference to conventional flaps. Also, the authors emphasized the great advantages of external fixation in the upper limb, a practice that is still not widely acceptable by many hand surgeons (although widely used in India). Some questions that still need to be answered: are microvascular flaps safe for use in electrical burn injuries? what is the ideal time to perform one? Also, aesthetic reconstruction of extensive defects is still not always achievable, and this subject needs to be pursued.

Microsurgical Reconstruction for Combined Achilles Tendon Defect with Soft-Tissue Loss: Comparison between Free Flap and Free Functional Muscle Transfer. Yuan-Kun Tu and Steve Wen-Neng Ueng. Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan.

Post-traumatic Achilles tendon defect, combined with chronic soft-tissue loss, is difficult to manage by traditional suturing techniques, especially when severe infection also presents at the heel cord. The options for local soft-tissue flap transfer around the ankle and foot are limited; therefore, microsurgical free-tissue transfers are always indicated. In this study, the authors presented their experience of challenging cases, using microsurgical reconstruction, and compared functional outcomes between innervated and non-innervated free gracilis muscle in reconstructing combined Achilles tendon and soft-tissue defects.

Between 1995 and 1998, there were 18 patients with Achilles tendon disruption and soft-tissue infection due to the failure of previous surgery. Twelve patients were males, and 6 were females; the average age was 37.5 years (range: 27 to 69 years). The average number of previous operations on the Achilles tendon was 5.2 (range: 4 to 7). Common problems were soft-tissue defect with chronic wound infection, pus discharge, absence of heel cord, and weakness of plantar flexion. For Group 1 (n=9), surgical reconstruction was carried out with debridement, innnervated free gracilis muscle transfer, and skin graft for the combined soft-tissue infection and Achilles tendon defect. For Group 2 (n=9), similar surgery was done, as in Group 1, except for an innervated procedure. Rehabilitation programs were begun 3 weeks after flap transfer, and continued for 2 years. Postoperative evaluation involved isometric muscle testing (Cybex II dynomometer) at 3, 6, 9, 12, 24, and 36 months after microsurgery. MRI imaging was performed both pre- and postoperatively. In the follow-up, EMG evaluations were also carried out. The clinical outcome was assessed according to the criteria of Percy and Conochie. The average follow-up was 4 years (range: 3 to 5 years).

All reconstructions were successful, with no vascular or infection complications. Postoperative MRIs showed good healing of the bridging muscle flaps in all patients. All those in Group 1 could walk without assistance 6 months after surgery, and functional outcomes were excellent in 8/9 patients. Isometric ankle muscle studies demonstrated no difference in plantar flexion muscle torque over both ankles at 9, 12, 24, and 36 months. However, in Group 2 patients, only 5/9 could walk without assistance at 6 months, and functional outcomes were excellent in 2/9 and good in 3/9 patients. The isometric muscle power in Group 2 patients showed that the differences still existed even at 24 months postoperatively.

The authors' report is the first to compare using non-innervated vs. innervated functional gracilis muscle for Achilles tendon reconstruction. Microsurgically innervated functional gracilis muscle flaps were found to have more satisfactory results than non-innervated transfers for reconstructing Achilles tendon defects combined with soft-tissue loss and infection. The recovery of ankle muscle power and function was significantly better in the innervated muscle transfer group. The rationale for the procedure is that the use of the posterior tibial nerve for functional innervation facilitates the recovery of muscle power.

Microvascular Surgery in the Abdomen. Yuan-Cheng Chiang, Tsan-Shiun Lin, Chao-Long Chen, Yao-Sen Chen, and Chih-Chi Wang. Departments of Plastic Surgery and General Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Microvascular surgery in the human abdomen has rarely been addressed in the literature; however, this is an important subject when confronted with repair of delicate and indispensable vessels. The purpose of this report was to elucidate surgical results and technical pitfalls in this special location.

From July 1989 to June 2000, 69 intraabdominal microvascular procedures were done at the authors' institution (Kaohsiung Medical Center). Most of these were hepatic artery reconstructions (67), while the other two were renal artery reconstructions. Ages of patients ranged from 2.5 months to 56 years. Surgical indications included liver transplantation, kidney autotransplantation, and revascularization of the kidney following tumor excision. Postoperative assessments were performed with the color Doppler imaging system or renal scan.

All of the viscera survived. Minimal arterial complications were encountered during the perioperative period. The results suggested that microvascular surgery in the abdomen can be a safe and reliable procedure, if possible technical pitfalls are carefully managed. The procedure is especially important in reconstructing delicate and indispensable vessels.

How Many Major Flaps or Microsurgical Procedures are Safe in One Person? Life through Plastic Surgery: In Pursuit of Excellence. Ashok K. Gupta. Bombay Hospital and Medical Research Centre, Bombay India.

The author reported the successful rehabilitation of a patient following extensive, traumatic, life-threatening loss of the anterior abdominal wall, anterior wall of the urinary bladder, pubic symphysis and ramus, phallus, scrotum, testes, and upper half of thigh soft tissue (both right and left sides). The total number of major flaps used in this patient was 7: radial artery forearm flap, extracorporeal transfer (2); vascularized fibula as symbiotic flap (2); island gracilis muscle flap (2), and inferiorly based supercharged latissimus dorsi flap (1).

The extracorporeal radial artery forearm flap was used in the perineal and pubic region to provide stable and water-resistant skin cover. The urinary bladder was closed, a bladder neck was created, and the gracilis muscle flaps were used to reinforce the bladder wall. Prefabricated phallus reconstruction was undertaken, using the radial forearm flap and vascularized fibula. Due to the absence of any recipient vessel, an extracorporeal transfer of the prefabricated flap was undertaken. Dynamic, innervated motor muscle latissimus dorsi flap transfer, along with osteotomized vascularized fibula and gracilis muscle flaps were used for the abdomino-perineal wall.

All the flaps, either alone or in combination, were carried out under regional anesthesia (e.g., brachial block + continuous epidural block). These combinations allowed positioning of the patient, while undertaking extracorporeal tissue transfer. The latissimus muscle flap could also be dissected under thoracic epidural block, along with infiltration of local anesthesia in the axilla for dissection of the neurovascular pedicle.

The patient was ultimately discharged from the hospital, after extensive and total physical, functional, and emotional rehabilitation, including abdominal wall and phalloplasties. He has gone back into society with some self-confidence. He is an example of surgical perseverance and the judicious use of surgical techniques and skills in a situation which, at the beginning, was definitely considered close to death.

Microvascular Autotransplantation of the Testis: 60 Cases Using the ``Refluo'' Technique. M. Lima, M. Domini, G. Ruggeri, M. Libri, M. Bertozzi, C. Antonellini, and G. Pelusi. Department of Pediatric Surgery, Bologna University, Bologna, Italy.

Many surgical techniques have been proposed for the treatment of high intraabdominal testis. The one most applied is the Fowler-Stephens technique, with section of the short testicular vessels, and reliance on the deferential ones for testicular survival. This procedure frequently causes testicular congestion resulting from inadequate venous drainage, with high testicular atrophy rates (35 to 50%). Silber has proposed microvascular anastomosis of the testicular vessels to the inferior epigastric vessels. The gonadal survival rate is over 90%, but mismatch between the vessels (especially the artery) in the pediatric age group, makes the anastomosis very difficult (end-to-oblique) and too long (risk of thrombosis).

Beginning with these previous procedures, these authors used rabbits as their experimental models, and evaluated the damage caused by partial or total ischemia of the testis. It was shown that the lesions were secondary to damage caused by insufficient venous outflow (confirming the inadequacy of the deferential blood drainage), rather than by an insufficient arterial supply. They then modified Silber's original technique, using a so-called ``refluo'' technique, performing only the venous microsurgical anastomosis between the internal spermatic and the inferior epigastric veins.

Their technique, which has been recently published (1995) has two essential steps. The first is directed toward identification of the intraabdominal testis, preparation of the pathway through which the gonad will be placed into the scrotum, and the mobilization of the vas deferens, spermatic, and epigastric vessels. The second step is the performing of the microvascular anastomosis (between the spermatic and the epigastric vein) under X15-20 magnification with the operating microscope, and with 6 to 8 interrupted monofilament sutures (10-0 nylon), to achieve a perfect ``blood-proof'' anastomosis. At the end of microvascular suturing, the gonad is placed into the scrotum.

From 1981 to the present, this technique has been performed 60 times in 51 patients with high intraabdominal testis (9 bilateral). Patient ages ranged from 18 months to 13 years. Diagnosis of the condition is now obtained by laparoscopy, in order to obtain more accurate information on existence, location, volume, and consistency. Follow-up has consisted of clinical controls at 1, 6, and 12 months postoperatively. During the second control, ultrasonography is performed. In the 60 testes treated, 6 atrophic conditions were found.

The authors maintained that their technique improves the success rate, compared with other procedures.

Scrotal Free Flap. Arthi Kruavlt and Pongsakorn Eamtanaporn. Division of Plastic and Maxillofacial Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

The aim of this reported study was to develop a new free flap from the scrotum. Dissection studies were performed in 10 Thai male fresh cadavers, and dye injection studies were carried out in four specimens. It was revealed that the mean surface area of the unilateral scrotal flap supplied by the vascular pedicle from the external pudendal artery and vein was 44.3 cm³. The mean pedicle length was 8.95 cm, the mean diameter of the artery at its origin from the femoral artery was 1 mm, and the mean diameter of the vein at its origin from the long saphenous vein was 1.68 mm. The fasciocutaneous areas supplied by this unilateral vascular pedicle were three-fourths of the suprapubic area, three-fourths of the penile skin, all of the prepuce skin, and the ipsilateral half of the anterior portion of the scrotum. The contralateral scrotal skin was not included in the scrotal flap.

Subsequently, the scrotal fasciocutaneous free flap was developed for clinical application in two patients. The first flap was used to cover a wound at the distal leg with exposed tibia, while the second flap was used to cover a wound with exposed tendons on the dorsum of the hand. Both cases validated that the scrotal free flap could be successfully used in clinical practice. The thinness and pliability of the flap, the long vascular pedicle, the minimal donor-site morbidity, and the possibility of raising the flap simultaneously with recipient site dissection, were major advantages. The small caliber of the flap vessels, the small size of the flap, and the unsightly appearance of the scrotal skin were among the disadvantages. The possibility of combining suprapubic skin, penile skin, prepuce skin, and scrotal skin, to enlarge flap size, is being studied.

The authors concluded that the scrotal fasciocutaneous free flap should be considered as an additional option in the reconstructive surgeon's armamentarium.

Urethral Reconstruction with a Jejunal Free Tissue Transfer. Lawrence J. Gottlieb, Dimitri P. Kuznetsov, Kaveh Alizadeh, and Gregory T. Bales. University of Chicago, Chicago, Illinois, U.S.A.

Urethral reconstruction has undergone significant evolution since Russell described the first modern approach to surgery of the urethra in 1914. Currently, a broader understanding of penile blood supply and the application of tissue transfer techniques have improved the overall success in treating urethral strictures. Despite these advances, there remains a select group of patients with extensive urethral disease or urethral loss, in whom traditionally available reconstructive options are inadequate. Many of these patients have had previous procedures that failed and/or are otherwise poor candidates for skin or mucosal grafts; they are also not well suited for local or regional vascularized tissue transfers.

A case report introduced a new dimension in urethral reconstruction previously not available. The authors successfully used a tailored jejunal free tissue transfer to reconstruct the proximal 16 cm of a severely diseased urethra in a 32-year-old patient. The report detailed the technical considerations involved, demonstrated that the procedure is a unique approach to urethral reconstruction, and emphasized that it should find ready applications for patients compromised by urethral strictures and others with extensive urethral loss.

Gluteal Fold Flap for Reconstruction of Vulvo-Vaginal and Perineal Defects. N.S. Niranjan. Plastic Surgery, St. Andrew's Centre, Broomfield Hospital, Chelmsford, United Kingdom.

The perineum is an area of rich blood supply, with multiple arterial anastomoses involving arteries arising from the internal and external iliac systems. Flaps raised on perforators around the perineum resemble the petals of a lotus flower. A cutaneous flap from the gluteal fold corresponds to the lower-most petal of the flower. From this area, large cutaneous flaps can be raised, based on a branch from the internal pudendal system, and this flap can be used unilaterally or bilaterally, following radical vulvectomy. It can also be used for vaginal reconstruction and peri-anal skin defects. The gluteal fold is an excellent donor site, as scarring in this area still gives excellent cosmetic results. Fifty such flaps have been used successfully in 32 patients.

Autologous Sural Nerve Grafting to Preserve Potency Following Non-Nerve-Sparing Radical Prostatectomy. David W. Chang, Christopher G. Wood, Richard J. Babaian, and Stephan S. Kroll. M.D. Anderson Cancer Center, Houston, Texas, U.S.A.

Erectile dysfunction following radical surgery for clinically localized prostate cancer remains a problem that deters many men from seeking surgical treatment. Cavernous nerve-sparing has been popularized as a method for preserving potency, but men with locally advanced disease may be at increased risk for a positive margin with this technique. In this study, the authors examined sural nerve grafting of the cavernous nerve bundles to preserve postoperative potency, while potentially maximizing cancer control.

Thirty men were enrolled in this prospective phase I study and underwent non-nerve-sparing radical prostatectomy by one of two protocol surgeons. Preoperative erectile function was assessed objectively, using a Rigiscan^TM and subjectively, using a set of validated sexual questionnaires prior to surgery. The cavernous nerves were identified and resected at the time of surgery, using an intraoperative mapping device (Cavermap^TM). Bilateral autologous sural nerve grafting to the cavernous nerve stumps was performed by one of two protocol plastic surgeons. Postoperative erectile dysfunction therapy, with intracorporeal injection, vacuum pump, and/or oral sildenafil, was instituted at 6 weeks postoperatively. Subjective and objective spontaneous erectile activity was measured postoperatively every 3 months.

Of the 30 men enrolled in the study, 25 have had at least 12 months of follow-up. The authors predicted the return of spontaneous erectile activity due to cavernous nerve regeneration at 12 to 18 months postoperatively in these patients, based on published data on known nerve regeneration rates and the nerve graft length. Of these 25, 14 (56%) have both objective and subjective evidence of spontaneous erectile activity. Of these 14 patients, 10 (71%) are able to have intercourse. In comparison, historical controls who undergo non-nerve-sparing radical prostatectomy have a spontaneous erectile activity rate of less than 5%.

Autologous sural nerve grafting after non-nerve-sparing radical prostatectomy is an effective means of preserving spontaneous erectile activity in some patients, while maximizing cancer control.

Cross Jump Expanded Scapular Free Flap. Ahmad Maghari, and K.S. Forootan.

There are rare instances when only one free flap can be transferred for both legs or knees, such as when there is only one single recipient vessel, or only one single free flap available. In such difficult cases, the authors recommended free flap transfer to cover both legs or knees, such as a cross-leg flap, and joining the donor and recipient vessels.

A 14-year-old girl with severe soft-tissue loss of both knees and legs was treated by controlled expansion of a scapular flap over an 8-month period. The patient was then assigned for a microvascular procedure using the expanded scapular free flap. Unfortunately, the recipient vessels (L) femoral artery and vein, were so badly damaged during the previous operation, that anastomosing the free flap was impossible. The authors then fixed the right forearm to the right knee through an external fixator, anastomosing the donor vessels to the right radial vessels, crossing the flap from the right knees and legs to the left, and also covering some portion of the left popliteal area. After 4 to 6 weeks, the flap was divided. The techniques were discussed in detail, and slides were presented.

Critical Experiences with the Thoracodorsal Artery Perforator Flap. A.H. Schwabegger, G. Bodner, M. Ninkovic, and H. Piza-Katzer. Universitaetsklinik fuer Plastische und Wiederherstellungschirurgie, Ludwig-Boltzmann Instit fuer Qualitaetssicherung in der Plastischen Chirurgie. University of Innsbruck, Innsbruck, Austria.

In this report, the authors' experiences with the thoracodorsal artery perforator (TAP) flap were presented. Its uses and pitfalls were critically highlighted, especially the application of this flap as an island flap. There are few publications on this recently described flap, perhaps because there is an absolute need for expertise in preparation, with inherent problems.

Eleven patients received 10 free and 2 pedicled TAP flaps for reconstructive procedures in the neck and extremities. Preoperatively, localization of the perforators was performed, using power Doppler imaging, whereby it could be demonstrated that the location and course are dependent on the arm's position. Complications relating to the location and course arise because of differences observed during surgery, compared to preoperative markings.

In the series described, this flap was used twice as a pedicled flap (resulting in two failures), and 10 times as a free flap (with one failure). Transfer as a free flap is a delicate procedure, especially as concerns vessel preparation; transposition as an island flap is limited in range.

Based on the authors' limited experience, they recommended this flap only with very selected indications. The procedure must be performed by very experienced microsurgeons, after training on cadavers, and precise clinical determination of the main perforators by color Doppler imaging. The use of this perforator flap is limited to cases in which a long vascular pedicle for an appropriate free tissue transfer is necessary, and when aesthetic appearance and minimizing donor-site morbidity are of dominant importance over a potentially higher failure rate. In addition, application as a pedicled flap may be prone to failure because of the extremely fragile perforator veins.

Reconstruction of the Thoracic Esophagus with Skin Flap Transplantation Combined with Placement of a Temporary Fistula. Y. Suzuki, K. Ueda, and A. Kajikawa. Plastic Surgery, Fukushima Medical University, Fukushima, Japan.

Despite the high value placed on the bowel as reconstructive material for the thoracic esophagus, the bowel is often unavailable due to severe adhesions in the intraperitoneal cavity. In such cases, a skin flap has been used instead. However, skin flap transplantation often may be accompanied by suture insufficiency caused by poor healing of the wound between the flap and the recipient site. Accidental suture insufficiency can result in compromise of the reconstructed area and the risk of flap necrosis. To avoid such a result, the authors temporarily place a fistula between the skin surface and the reconstructed esophagus to attenuate internal pressure in the esophagus.

Three patients underwent the described procedure. Defects of the thoracic esophagus were reconstructed with a forearm flap, and the surface was covered with another skin flap: a thigh flap for one patient, the tensor fasciae latae MC flap for another, and a pectoralis major MC flap for the third patient. The forearm flap was sutured to the intestinal tract at the recipient site, leaving an open area 2 cm in length. The margin of the open section was sutured to the margin of the overlying skin flap and the chest skin. The orifice thus formed was covered with a pouch, representing an artificial anus, which was closed after all operative wounds had healed completely.

All the flaps survived and the fistulas closed uneventfully 2 to 3 months later. Patients achieved smooth passage of food through the reconstructed esophagus. The authors stated that the temporary formation of a fistula may be a good supplementary procedure for uneventful esophageal reconstruction using skin flaps.

Intra-Arterial Chemotherapy: Effects on Free Tissue Transfer. R. Sadrian, A.D. Niederbichler, J. Friedman, P.M. Vogt, H.U. Steinau, D. Chang, S.S. Kroll, H. Langstein, M.U.J. Miller, G. Reece, G. Robb, and G.R.D. Evans. University of California, Irvine, California, U.S.A.

Multimodal therapy, including intra-arterial chemotherapy, is recognized as state-of-the-art therapy for soft-tissue cancer. This reported study was performed in an effort to evaluate the potential of free flap reconstruction following intra-arterial therapy.

A retrospective chart review of 52 patients, who had undergone limb perfusion between 1988 and 1998, identified 16 patients who also had had intra-arterial limb perfusion that was followed by surgical resection and free flap reconstruction. There were 7 women and 9 men, with an average age of 37.9 years. All 16 patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels utilized for donor/recipient anastomosis had been previously perfused.

The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection were observed. Two flaps demonstrated partial edge necrosis. The overall flap success rate was 100%, with no flap failures. The overall surgical outcome was considered to be good in 12 patients, based on improved function and ambulation, and fair in 4 who had limitation in function and/or ambulation, based on both the patient and on physical therapy evaluations. Seven patients had recurrence of their disease. The overall mean survival time following surgery was 20.6 months.

The results of this study indicated that preoperative intra-arterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although the series is small, the authors believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intra-arterial chemotherapy. Routine care in vessel selection and microsurgical technique should be taken to maximize favorable outcomes. Vessels should be inspected for their suitability prior to attempting any free flap reconstruction.

Varicocele in Children: 304 Cases Treated with Microsurgical Technique. M. Lima, G. Ruggeri, M. Domini, M. Libri, M. Bertozzi, C. Antonellini, and G. Pelusi. Department of Pediatric Surgery, Bologna University, Bologna, Italy.

Varicocele is not a rare anomaly. After a proper physical examination, it is possible to observe scrotal varices in 18% of school-age boys. The interest that the pediatric surgeon directs toward diagnosis and research of the best treatment for this pathology, is due mainly to the higher and tighter correlation between varicocele and adult hypofertility. In fact, 30% of sterility cases result from this affliction. The peculiar progression of varicocele sometimes results in testicular hypotrophy, together with cytoarchitectural alterations of the seminiferous tubule, leading up to the frequent subfertility of adulthood. The most common surgical therapy is Ivanissevich's technique (interruption of blood reflux by dissection of the incompetent spermatic vein), which results in a high rate of local failures (persisting or recurrent varicocele, rising of hydrocele, and testicular atrophy). In addition, most of the time, the technique does not lead to an improvement in the quality of the seminal fluid. It is important to guarantee an outflow to the gonad, using microvascular anastomosis. The authors consider this as the best technique for treating varicocele in the pediatric age group, because of the chances for reversing damage before puberty.

They use Belgrano's spermatico-epigastric venous anastomosis as their surgical technique. The inguinal skin is incised for a few centimeters. Once the inguinal canal is opened, the spermatic cord is located, and the spermatic vein is isolated within all its collaterals. Then, with the aid of loupes, the epigastric vein with the more adequate caliber (to be anastomosed to the spermatic vein) is freed. The spermatic vein is ligated as distally as possible and, once positioned, is divided at its distal end. Then, the chosen epigastric vein is sectioned and placed on the other branch of the microclamp. The procedudre is performed under X16-20 magnification under the operating microscope. The microvascular spermatico-epigastric anastomosis is carried out using interrupted stitches and 10-0 nylon. On completion, the anastomosis is checked for leakage, and intradermal sutures are used for the skin.

From 1984 to the present, 304 children have been treated in the pediatric surgical unit of the authors' institution. Their ages range from 8 to 16 years. According to Horner's classification, 138 had a grade II varicocele, while the remaining 160 had a grade III varicocele. Follow-up can be performed with Doppler ultrasonography, and the recurrence is 3%, much lower than with Ivanissevich's technique (nearly 15%, according to reports). Clinical results are optimal, with disappearance of varices in the majority of cases. This technique enables establishment of an immediate and physiologic testicular venous outflow, essential for testicular growth and development.

Surgical Treatment of Lesions of the Lumbosacral Plexus. H. Millesi, Dagmar Millesi, W. Korak, and T. Basar. Vienna, Austria.

During the past 10 years, these authors have treated 19 cases of lumbosacral plexus lesions. In the majority of the cases, the cause was a fracture of the pelvis with dislocations. Types of lesions can be divided into three groups: 1) lesions of the lumbar plexus alone-these are treated via a retroperitoneal approach; 2) lesions of S1 to S3-these cases are explored via a transgluteal approach. The sciatic nerve is followed in a central direction and the roots are identified dorsally; 3) lesions of the whole lumbosacral plexus, especially those of the lumbosacral trunk (L4 and L5).

These patients are operated on in the lateral position. The lumbar portion is explored by dissection in the retroperitoneum. The lumbosacral trunk can be followed by disinsertion of the iliac muscle, to visualize the superior and inferior nerve, and the sciatic nerve by disinsertion of the gluteus muscles. Sometimes, it is necessary to create a window across the iliac bone, in order to obtain sufficient access to the lumbosacral trunk.

The progress of lesions of the lumbar plexus alone is good, on average. As far as the sacral portion is concerned, regeneration usually occurs in the tibialis innervated muscles. In some cases, a tibialis posterior transfer should be performed, in order to replace failure of regeneration of the tibialis anterior. The key to success is the regeneration of the gluteal muscles, especially the gluteus medius. If this muscle regenerates well and becomes strong enough, the patient can walk without support, because the pelvis is stabilized when standing on the involved leg.

However, if the gluteus medius does not regenerate, the patient is not able to stabilize the pelvis, and must use support when walking. In cases of paralysis of the sacral plexus, with failure of regeneration of the gluteus medius, but good function of the quadriceps femoris, the authors have successfully transferred the vastus lateralis muscle, to replace the gluteus medius.

The surgical technique was presented in detail, and results were reported.

Management of Neuromas in Continuity of the Median Nerve with the Pronator Quadratus Muscle Flap. R. Adani, L. Tarallo, and B. Battiston. Department of Orthopaedic Surgery, University of Modena, Modena, Italy.

Treatment of median nerve neuromas in continuity still poses many problems. Total or partial neurorrhaphy to the median nerve after cut injuries may be associated with painful tumefaction at the wrist and a markedly positive Tinel's sign, even when accurately performed by means of microsurgical technique. The purpose of such treatment is to minimize pain and to preserve residual function of the median nerve. The purpose of this reported study was to review the results obtained, when covering neuromas in continuity of the median nerve with pronator quadratus muscle flaps.

From January 1995 to January 2000, the pronator quadratus muscle flap was used in 9 patients, with ages ranging from 26 to 50 years (average: 40 years). The initial injury to the median nerve was total in 5 cases and partial in the remaining 4. In 8 patients, the nerve was repaired by neurorrhaphy, and sural nerve grafts were used in only one case. The time interval between the initial trauma and subsequent coverage with the pronator quadratus muscle flap ranged from 12 to 84 months (average: 27 months). Clinically, all the patients presented with wrist pain, associated with a positive Tinel's sign always observed at the site of the median nerve: 5 patients achieved a Highet scale rating of S3, and 4 of S3+. Motor function of the thenar muscles was preserved in all the subjects, totally (M5) in 4 cases, and almost totally (M4) in the remaining 5 cases. Prior to susrgical coverage of the median nerve neuroma, neurolysis was performed in 7 patients using microsurgical technique.

All of the patients were reviewwed at a mean follow-up of 23 months after surgery. Clinical evaluation demonstrated pain relief in all of the patients, except for one case. Tinel's sign had regressed in 6 cases, while a more modest sign occasionally persisted in 3 cases. A recovery of sensory function was achieved after surgery in 2 cases, in which it improved from S3 to S3+, according to the Highet score. Postoperative motor function of the thenar muscles was unchanged.

The major inconvenience of such a technique is represented by the limited distal excursion of the pronator quadratus, which prevents its application in cases of injuries to the median nerve at a level with the wrist flexion fold and beyond. Under these circumstances, the techniques used for the treatment of recurrent carpal tunnel syndromes should be employed, in order to avoid useless and harmful traction on the vascular pedicle. The possible pronation deficit due to the use of the pronator quadratus muscle was never observed, since patients showed maintenance of physiologic pronation with the elbow in flexion and extension, therefore supported by pronator teres muscle activity.

Gynecologic Microsurgery. W.D. Boeckx. Department of Plastic Surgery, University Hospital, Maastricht, The Netherlands.

Gynecologic microsurgery currently has only limited applications. This is due mainly to the fact that modern in vitro fertilization technologies and subsequent success have taken over the surgical treatment of the infertile patient. However, in 1974, the conventional surgical treatment of infertility was still complicated, with numerous postoperative adhesions. Now this has changed. The efforts of Robert Winston have led to the development of microsurgical salpingostomies.

The authors has developed the microsurgical treatment of ovarian endometriosis, both for peritubal and peritoneal endometrial implants, even including large endometriomas, large cystic endometriomas, or even frozen pelvis. More than 5000 patients have been treated in this fashion. Reconstruction of the ovary could be achieved, using microsurgical techniques, after complete removal of the endometriomas. Microsurgical adhesiolysis also resulted in a much improved fertility outcome. This was especially true for microsurgical neo-salpingostomy for the treatment of distally occluded tubes, with especially good results in thin-walled hydrosalpinges.

The major effect of microsurgical gynecology was found in the reversal of tubal sterilization. Microsurgical resection of the occluded tubal segment, and end-to-end extra mucosal micro anastomosis resulted in more than 90% term pregnancy rates. This is in great contrast to the conventional techniques, in which only 25% pregnancy could be achieved. However, gynecologists have not adopted the skills required for microsurgery and, in the early 1980's, in vitro fertilization techniques and assisted fertility techniques have taken over, although the results of microsurgical tubal reconstruction in selected cases are far superior to the in vitro results. Now that sufficient data are available to make the proper patient selection, coupled with the expansion of experience, the author's method of choice is still microsurgical salpingostomy.

Free Vascular Fibular Transfer in Children with Congenital Pseudarthrosis of the Tibia. Ingemar Fogdestam and Bertil Romanus. Departments of Plastic Surgery, Goteborg, Sweden/Oslo, Norway, and Department of Orthopedics, Goteborg, Sweden.

The reported work was planned to save the authors' original patients from further disappointing surgical trials and, by a thorough follow-up protocol, to draw and apply conclusions for the benefit of future generations with this unusual but serious malformation. The ultimate aim was finally to show that ultra-early reconstruction would prevent retardation of ipsilateral leg and foot growth at functionally inconsiderable or no cost at all in the contralateral donor leg.

Between 1981 and 2001, 10 patients were treated, 2 females and 8 males. All the patients had unilateral malformations. Ages at operation varied between 15 years and 6 months. The two girls in this series were 12 and 15 years of age. Thus being young women, they were much more skeletally mature than the 8 boys, whose ages ranged from 6 months to 13 years. Follow-up time for 7 of the 10 patients ranged between 14 and 20 years. At the time of report, follow-up was only 6 months for the latest patient, who was 13 years old at operation, and for two infants (18 and 6 months old respectively, at the time of surgery), follow-up time is 4 and 3 years, respectively. All, excepting the 2 infants, had been previously operated on with several various procedures, and had considerable leg length and foot size discrepancies. All but the three latest cases have reached skeletal maturity.

With consistency, the authors performed a ruthless excision of the diseased tissue after clinical judgement. The resulting defect was repaired with a free vascular bone transfer of a segment centered somewhat proximal to the middle of the contralateral healthy fibula. (Donor-site reconstruction was reported in another paper.) The fibular segment was taken 4 cm longer than the resection defect, allowing for trimming for exact pegging into the tibial bone marrow canal. External osteosynthesis material was always used, usually freely placed screws connected by bone cement bridges. Microvascular connections followed standard principles. The slit formed skin defect was covered with split-thickness skin graft. There was monitoring by ultrasound Doppler and later Tc⁹⁹ scan, and early mobilization.

All reconstructions healed primarily. The very first patient broke his distal femur shaft on the diseased side over the transverse part of the fixator bridge, which was then redesigned. Another boy broke his transferred fibula at an early stage. Both these fractures have healed well. Two patients have successfully undergone Ilizarov lengthening. Corrective osteotomies were performed in two males after skeletal maturity; delayed union was experienced in one of them. Retarded foot growth has not been found to significantly catch up with the size of the healthy side in those 7 patients operated on at ages 4 to 15 years. On the other hand, thus far, there are no signs of major growth disturbance of the corresponding legs or feet in the two infants.

The method described seems to be compatible with CPT treatment at all ages but, even more important, it is indispensable when applied at early infancy, preferably before the patient is walking.

Complex Facial Reconstruction with the Use of Prelaminated Free Flaps. George Psaras. Division of Plastic and Reconstructive Surgery, University of the Witwatersrand, South Africa.

Complex central facial defects are often difficult to manage, due to the extent of the injury and the multi-planar nature of the deficit. The aim of this presentation was to show that such complex defects can be managed effectively with prelaminated free flaps, such as the radial forearm and fibula.

From September 1999 to June 2001, four patients with severe and complex facial defects were treated. The causes of injury were gunshot (2), electrocution, and burns. The facial structures damaged included the mandible, nose, upper and lower lip, floor of the mouth, hard palate, forehead, and cheeks. Reconstruction was achieved with the use of prelaminated free flaps, mainly the radial forearm and fibula. The tissues used for the prelamination were skin graft and conchal cartilage, where appropriate.

All the flaps survived, and the patients achieved a satisfactory aesthetic result, considering the extent of their injuries. Reconstruction of structures like the nose and upper and lower lips requires bilaminar flaps (lining and cover). Prelaminating flaps such as the radial forearm and fibula (skin paddle) enables one to create ``thin'' bilaminar flaps, ideal for such reconstructions. The need for a further flap, free or local, is thus eliminated.

The techniques used in each case were illustrated and explained. Experiences derived from prelaminating the fibula flap were discussed and illustrated.

Free Anterior Lateral Thigh Flap in Burn Reconstruction: Functional and Aesthetic Considerations. Jui-Yung Yang, Shiow-Shuh Chuang, and Sung-Yuan Chang. Linkou Burn Center, Department of Plastic Surgery, Chang Gung Medical College and Memorial Hospital, Taipei, Taiwan.

Many types of free flaps can be used for reconstruction of deep burn injuries in the acute stage or scar contracture in the chronic stage. Traditional cutaneous flaps, such as the groin flap, may be too bulky to achieve both functional and aesthetic results. The anterior lateral thigh (ALT) flap may be thinned and divided into two or three segments, according to the distribution of its perforators. This flap has the advantages of both the traditional cutaneous flap and full-thickness skin graft, and can be used for either acute or chronic burn reconstruction. This report evaluated the outcome of the ALT flap in burn reconstruction, based on function and aesthetic considerations.

From September 2000 to May 2001, a total of 23 burn patients underwent 24 thin ALT flap reconstructions. In the acute stage, there were 9 patients, including 7 males with an average age of 40 years, and 2 females with an average age of 24 years. In the chronic stage, there were 14 patients, including 8 males with an average age of 24.3 years, and 6 females with an average age of 30.7 years. The reconstructed areas were the foot (4), face-neck (2), hand (2), breast (2), foot (1), and thigh (1). Among the chronic stage reconstruction group, there were 5 chimeric ALT flaps.

All the flaps survived well, except for one in which tip necrosis was noted. All the donor sites were closed primarily with no problem. The follow-up period ranged from 5 to 18 months (average: 10.9 months). Postoperative function included neck extension-rotation, hand flexion-extension, and foot movements; appearance, including breast shape, chin contour, and hand web curve, were all satisfactory.

The free thin ALT flap was proven to be a good flap for burn reconstruction, both in acute and chronic stages, based on functional and aesthetic considerations.

Value of Microsurgical Reconstruction in Orthopedic Oncology. Koichiro Ihara, Mitsunori Shigetomi, Keiichi Muramatsu, Yoshinari Goto, and Shinya Kawai. Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Japan.

Several effective adjuvant therapies have been developed in orthopedic oncology. However, surgical resection with an adequate margin is still a mainstay of treatment. Thereby, extensive defects of bone and soft tissue are created after oncologic resection. Vascularized tissue has been applied to reconstruct these defects by the authors since 1986. The reported study was undertaken to evaluate the usefulness of microsurgical reconstruction in orthopedic oncology.

The study included 85 patients with musuloskeletal neoplasms, who received vascularized tissue transfer for reconstruction after oncologic defects. Of these, 4 patients received double tissue transfers, and thus a total of 89 tissue procedures were used. The mean patient age was 44 years (range: 5 to 81 years). The involved sites were the lower extremity in 54 patients, upper extremity in 19, and trunk in 12. Included were 49 soft tissue tumors, 33 bone tumors, and 3 skin cancers. Microsurgical, oncologic, and functional results were evaluated in these patients. The mean follow-up period was 57 months (range: 12 to 125 months).

Transplanted tissue included 60 muscle or musulocutaneous flaps, 21 fibulas, and 8 skin flaps; 85 tissues were transferred immediately after tumor resection. Free transfer involved 59 tissues, and the other 30 were pedicle transfers. In 59 free transfers, venous thromboi were encountered in 6 (10%); 5 tissues were successfully revised by early thrombectomy. Except for a patient who had necrosis of the flap and infection, primary wound healing was obtained. Vascularized fibula achieved primary bone union at a mean of 4.7 months postoperatively. Thirty free and 3 pedicle muscles provided useful contraction, which improved lower and upper extremity function. Chemotherapy had no adverse effect on either bony union or muscle reinnervation. Local recurrence occurred in 7 patients, 4 of whom also suffered systemic recurrence. In 73 patients with extremity involvement, the mean functional score using criteria of the Musculoskeletal Tumor Society was 88%.

Vascularized tissue transfer provided early and predictable recovery after oncologic surgery. Microsurgical reconstruction improved the functional results, and also extended the indications for limb-salvage surgery.

Experience of Nodo-Venous Shunt in Endemic Lymphedema. F.M. Tripathi. Institute of Medical Sciences, Bauaras Hivdu University, Varanasi, India.

Lymphedema is very common in the author's part of the world, the primary etiology being filarial. Various treatment modalities, both medical and surgical, have been described for its management. The micro-nodo-venous shunt is a procedure commonly employed for all grades of lymphedema, especially for grades III and IV.

Over a period of 10 years, 189 cases of endemic lymphedema were treated, with the most common etiology being filariasis. The duration of the disease varied from 1 to 18 years. The majority of patients (114 of 189) were males, and the most common age group was 21 to 30 years. Forty percent of cases were lymphedema grade II, 32% grade IV, 21% grade III, and 7% grade I. The lower extremities were involved more commonly, and the right side was involved in 40% of cases, the left, in 42%. The genitals were involved in 10% of cases.

Patients were subjected to combined surgical and medical treatment. Surgical treatment was in the form of microsurgical nodo-venous shunt in 37% of cases, and it was combined with an excisional procedure in 33% of cases. Pre- and postoperative extremity pumping and pressure garments were supplementary. Special emphasis was given to foot hygiene. All the patients were regularly followed in the lymphedema clinic, the maximum follow-up being 10 years. All patients showed definite clinical improvement in the form of reduction of swelling in the limb. The results of nodo-venous microlymphatic surgery were compared with other results in the literature and were discussed.

Effect of Single Intrapedicle Administration of Vascular Endothelial Growth Factor on Necrosis and Pedicle Dependence of the Rat Island Flap. Ewa Komorowska-Timek, T. Timek, L. Brevetti, F. Zhang, W.C. Lineaweaver, R.A. Hardesty, and H.J. Buncke. Transplantation-Replantation Department, San Francisco, California, U.S.A.

Vascular endothelial growth factor (VEGF) induces angiogenesis, and has been shown to improve the survival of surgical flaps. The authors used the rat epigastric skin flap to study the effect of a single intra-arterial dose of VEGF on flap regional necrosis, and pedicle dependence on flap perfusion.

In 20 Sprague-Dawley rats, an 8x8-cm skin flap, consisting of four vertical zones (2x8 cm each), marked A through D (right to left), based on the proximal right inferior epigastric vesssels (zone MB), was raised. Subsequently, 1 ml of either saline (control, n=10) or 5 ng VEGF (n=10) were injected into the right arterial pedicle by cannulating the right saphenous artery. The flap was then resutured in place. After 8 days, the VEGF animals were re-anesthetized, and perfused systemically through a microcannula placed in the left ventricle with 15 nm colored fluorescent microspheres, before (blue) and after (yellow-green) ligation of the right inferior epigastric vascular pedicle. All animals were sacrificed at POD 8, the area of flap necrosis was measured in each zone by templates and weight-to-surface ratio and, in the VEGF group, the flap zones were harvested and processed for determination of fluorescence. Flap shrinkage was calculated as the percent decrease in flap area after 8 days.

A single intrapedicle administration of VEGF decreased necrosis of the epigastric skin flap at 8 days postoperatively, but flap shrinkage also increased in the zone with the greatest degree of necrosis. In VEGF-treated animals, flap perfusion did not change after ligation of the vascular pedicle.

Late Preconditioning Attenuates Vascular Endothelium Dysfunction after Prolonged Ischemia/ Reperfusion in Skeletal Muscle. Wei Z. Wang and William A. Zamboni. Division of Plastic Surgery, Department of Surgery, University of Nevada School of Medicine, Las Vegas, Nevada, U.S.A.

The authors' hypothesis was that microvascular protection induced by late preconditioning (IPC) in skeletal muscle is initiated by adenosine (ADO) and dependent on protein kinase C (PKC).

Vascular isolated cremaster muscle of SD rats underwent 2 hr or 4 hr of warm (30 to 32 degrees C) ischemia and then 60 min of reperfusion. IPC consisted of 45 min of ischemia, but was done 24 hr before the prolonged ischemia. To mimic the effects of IPC in the late phase, ADO (adenosine receptors activator) or 4-phorbol 12-myristate 13-acetate (PMA, a PKC activator) was given 24 hr before prolonged ischemia via local intra-arterial infusion. To block the effects of IPC in the late phase, 8-sulfophenyl-theophylline (SPT, a non-specific adenosine receptor blocker) or Chelerythrine (CHE, a PKC inhibitor) were given 30 min before prolonged ischemia via local intra-arterial infusion. There was a total of eight groups (8 rats/group). Arteriole diameters (including feeding and terminal arterioles) and capillary perfusion were measured using intravital microscopy. Vascular endothelium function was tested by acetylcholine chloride (Ach).

Defined by the reduction of endothelium-dependent vasodilation to Ach, vascular endothelium dysfunction was found in the terminal arterioles of cremaster muscle in 4-hr ischemia, but not in 2-hr ischemia. Local inter-arterial infusion of sodium nitroprusside (a donor of nitric oxide) 2 min prior to reperfusion attenuated prolonged ischemic/reperfusion-induced vasospasm. IPC on day 1 produced significant microvascular protection against prolonged ischemia on day 2. Administration of ADO, or PMA without IPC, produced a similar protection on day 2, as that induced by IPC alone. In contrast, blocking adenosine receptors or PKC enzymes eliminated the IPC-induced microvascular protection seen on day 2.

The results indicated that 4 hr, but not 2 hr, of warm ischemia, followed by reperfusion, created significant vascular endothelium dysfunction in skeletal muscle. The reduction in endothelium-dependent vassodilatation did not take place, if ischemia/reperfusion was preceded by preconditioning. IPC-induced microvascular protection in the late phase was initiated by adenosine and dependent on PKC.

Reactive Thrombocytosis Alone Does Not Affect the Patency of Microvascular Anastomosis: Animal Experiment Using Splenectomized Rat. Yur-Ren Kuo, Kuender D. Yang, Mong-Na Lo Huang, Fu-Chan Wei, and Seng-Feng Jeng. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Vascular thrombosis is a prerequisite of failure in microsurgery. However, there is still controversy about the correlation of thrombocytosis and thrombosis complications. Some evidence indicates that patients with elevated platelet counts tend to have a higher flap failure rate. Nevertheless, the authors have experienced successful free-tissue transfer in 7 patients with thrombocytosis due to traumatic splenectomy or multiple trauma. Based on clinical observations, they decided to investigate whether reactive thrombocytosis contributes to the patency of a microvascular anastomosis.

Forty Lewis rats were splenectomized. Stable reactive thrombocytosis occurred after the 5^th to 10^th postoperative days, with a peak on the 7^th postoperative day. Femoral artery division and re-anastomosis were performed in rats with or without splenectomy-induced thrombocytosis. Vascular patency was assessed by laser Doppler. They investigated the p-selectin (CD62P) expression of activated plaatelets between splenectomy-induced thrombocytosis and sham-operated groups, using flow cytometry. Platelet counts and platelet activation were studied in correlation to microvascular patency.

Platelet activation, as demonstrated by CD62P expression on platelets, was not significantly different between rats with and without thrombocytosis (6.41±0.95% vs. 4.51±0.55%, p=0.089). Since immature platelets with RNA staining were not increased (2.86±0.33% vs. 1.99±0.32%, p=0.074), it appeared that the splenectomy-induced thrombocytosis was due to redistribution of platelets, instead of an increase in bone marrow production. There were no differences in the patency rates or perfusion units of the femoral artery after arterial re-anastomosis between rats with and without thrombocytosis, 90% vs. 95% (p=0.561).

The study suggested that reactive thrombocytosis without platelet activation may not be a contraindication for microvascular anastomosis.

Effect of Prostaglandin E1 against Ischemia/Reperfusion Injury in the Rat TRAM Flap. Joon Pio Hong and Yoon Kyu Chung. Department of Plastic and Reconstructive Surgery, Wonju, Korea.

The purpose of this study was twofold: to evaluate whether prostaglandin E1 can increase the survival of the flap, and its function against ischemia/reperfusion injury in musculocutaneous flaps.

Thirty-five Sprague-Dawley rats, weighing 250 to 350 g, were analyzed. The transverse rectus abdominis musculocutaneous (TRAM) flap was used in all animals. The rats were divided into three groups: Group 1 (n=15), controls with 4-hr ischemia injury and intra-flap injection of normal saline, followed by reperfusion; Group 2 (n=15), prostaglandin E1 intra-flap injection of 1 ug immediately after ischemic injury and reperfused 4 hr later; Group 3 (n=5), the sham-operated group. Analysis consisted of flap skin survival area measurements, immunohistochemical studies using ICAM-1 monoclonal antibody, and histologic evaluation, including endothelium-adhering leukocytes at 24 hr and 5 days after reperfusion.

The group treated with prostaglandin E1 showed immunohistochemical findings with decreased expression of intercellular adhesion molecule (ICAM-1) on the surface of the endothelium and histologically, with statistically significant reduction of leukocyte adhesion at 24 hr and 5 days after reperfusion. These two factors were considered to play a role against ischemia/reperfusion injury, leading to improved survival of the flap.

The results suggested that prostaglandin E1 may increase flap survival and may have a protective effect against ischemia/reperfusion injury, by decreasing leukocyte-endothelial cell adhesion through decreased expression of ICAM-1.

Novel Platelet-Rich Arterial Thrombosis Model in Rabbits: Simple, Reproducible, and Dynamic Real-Time Measurement by Using Double-Opposing Inverted-Suture Model. Shyh-Jou Shieh, Haw-Yen Chiu, Guey-Yueh Shi, Ching-Ming Wu, and Hua-Lin Wu. Departments of Plastic Surgery and Biochemistry, National Cheng Kung University, Tainan, Taiwan.

Although numerous animal thrombosis models have been introduced, an easy, reliable, and reproducible arterial thrombosis model remains a continuing challenge prior to a thrombolytic study. In an effort to evaluate the efficiency of various recombinant thrombolytic agents with specific affinity to activated platelets in vivo, the authors developed a novel double-opposing inverted-suture model to create a platelet-rich thrombus in the femoral artery of rabbits.

The arteriotomy was done semicircumferentially, and variously sized microsurgical sutures were introduced intraluminally in a double-opposing inverted manner. The animals were divided into three groups, according to the double-opposing inverted sutures used: Group 1 with 10-0 nylon (n=6), Group 2 with 9-0 nylon (n=6), and Group 3 with 8-0 nylon (n=22). The superficial epigastric branch was cannulated with a thin polyethylene tube for intra-arterial administration of the studied thrombolytic agent. Blood flow was continuously measured with a real-time ultrasonic flowmeter. Histologic evaluation of thrombus formation and its components was performed via H&E stain and transmission electron microscopy. To confirm that the double-opposing inverted-suture model would be useful for a study of thrombolytic agents, they evaluated the effects of recombinant tissue-type plasminogen activator (rt-PA) and streptokinase-human plasminogen (SK-HPlg).

Within 2 hr of installation of the sutures, there was no thrombus formation in either Groups 1 or 2. In Group 3, the thombosis rate was 91% (20 of 22) under a steady baseline flow (with an average of 12.23±2.40 ml/min). It was highly statistically significant, with a p value of 0.0000743, using Fisher's exact test. The average time to thrombosis was 21.8±9.8 min. The ultrasonic flowmeter to record the dynamic real-time measurement of blood flow was a guideline for thrombus formation or dissolution, which was correlated with the morphologic findings of stenotic status of the vessel, detected by Doppler sonography. The components of the thrombus were proven to be platelet-rich, predominantly by H&E stain and transmission electron microscopy. The average time to thrombolysis post re-PA infusion was 16.2±2 min, and that of SK-HPlg was 79.6±23.1, which were similar to previous reports.

The novel double-opposing inverted-suture (8-0 nylon) model provided a simple, reliable, and reproducible platelet-rich arterial thrombosis model, non-invasive and with dynamic real-time measurement. It may be applied in assessing the efficiency of the recombinant thrombolytic agents, and it offers many of the advantages of an arterial platelet-rich in vivo thrombosis model.

Ischemia/Reperfusion Injury of the Skeletal Muscle: Combined Use of WEB 2170 and/or HBO Therapy. M. Riccio, P.P. Pangrazi, A. Campodonico, A. Bertani, and W.A. Morrison. Hand Surgery and Microsurgery Unit, Department of Plastic Surgery, Umberto I Teaching Hospital, Ancona, Italy, and O'Brien Institute of Microsurgery, Melbourne, Australia.

I/R injury represents a negative prognostic factor in flap transfer and all reimplants of limbs, due to the high incidence of retraction (Volkmann's syndrome) with the so-called no-reflow phenomenon. Many biochemical studies have demonstrated that the physiopathologic moment responsible for the injury is when free radicals are produced on reperfusion, causing cell lysis through the peroxidation of the membrane lipids and the circulation of new free radicals. The oxyradicals most implicated in I/R injury come from two important sources: xanthine oxidase and neutrophils. The therapeutic instruments that have proven to be effective in protecting the skeletal muscle from ischemia are WEB 2170, a PAF-antagonist, and hyperbaric oxygen.

In an experimental study, 40 New Zealand white rabbits were used. Using vascular clamps, after the dissection of the rectus femoris muscle, a condition of warm ischemia was produced for a period of 3 hr and 30 min (clamping both the artery and vein of the pedicle). The animals tested were divided into four groups. In the control Group A, the rectus femoris muscle of each rabbit was exclusively injected with a saline solution. In Group B animals, a solution of 60 mg/ml of WEB 2170 diluted in saline solution was injected for the same period of time. In Group C, the saline solution was injected as in Group A, but at the end of the injection, HBO was administered at 2.5 ATA (atmospheric absolute tension). In Group D, the WEB 2170 was injected, as in Group B and, at the end of the injection, HBO was administered at 2.5 ATA, as in Group C.

Biochemical tests confirmed that treatment with both WEB 2170 and oxygen at 2.5 ATA decreases myeloperoxidasis activity and the production of hydroperoxides, thereby diminishing muscle injury caused by free radicals. This effect is not produced by the injection of saline solution only. Myeloperoxidase, an enzyme present in the secreting compartment of neutrophils and in monocytes and its activity, should be assayed, as it reveals the degree of infiltration. These results have been confirmed also by histologic assessment of the rectus femoris muscle, using the NBT test to define the quantity of viable portion of muscle present in each group.

Effect of Cigarette Smoking on Tibial Microcirculation. Yuan-Kun Tu, and Steve Wen-Neng Ueng. Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Keelung, Taiwan.

Cigarette smoking has been proven to delay bone healing. However, no previous study has demonstrated the effect of smoking on bony microcirculation. The authors used bone chambers to investigate the effect of cigarette smoking on tibial microcirculation.

Eighteen New Zealand rabbit were divided into three groups: Group 1, control; Group 2, 1-week smoking; and Group 3, 6-week smoking. All rabbits were anesthetized, and their tibias put into bone chambers after cannulation, perfused with Krebs-Ringer solution (phase 1), and then comparisons were carried out of the effect of vasospasm by norepinephrine dose-response curve (NEDRC). Acetylcholine (phase 2) and L-NMMA (phase 3) were perfused after phase 1, and NEDRC recorded. Data analysis was performed by ANOVA.

The NEDRC data in Group 1 (control) was set to be 100%. In phase 1, 1 week of cigarette smoking significantly increased NEDRC in Group 2 (142.5%, p<0.01), and 6 weeks of smoking strikingly boosted NEDRC in Group 3 (226.5%, p<0.01). In phase 2, NEDRC of Group 2 tibias showed no difference, in comparison with Group 1 (p>0.05) under acetylcholine perfusion. However, Group 3 tibias showed significant vasospasm, even under acetylcholine perfusion. In phase 3, L-NMMA perfused data revealed that Group 3 tibias had the highest NEDRC, i.e., the most severe vasospasm.

Both short-term and long-term cigarette smoking were hazardous to the bony vascular endothelium. Nitric oxide production significantly attenuated in Groups 2 and 3 tibias. However, the adverse effect of smoking seems reversible over the short-term (Group 2). Long-term smoking caused irreversible damage to the vascular endothelium.

Postoperative TC-99m-HDP Pinhole Bone Scintigraphy in Avascular Necrosis of the Femoral Head Treated with Vascularized Fibular Grafts. Hyoung-Min Kim, Chang-Hoon Jeong, Kee-Haeng Lee, and Youn-Soo Kim. Department of Orthopaedic Surgery, Holy Family Hospital, College of Medicine, Catholic University of Korea.

Vascular fibular graft (VFG) is one of the treatment options for avascular necrosis of the femoral head (ANFH), and has been known to provide revascularization and mechanical support. It is important to evaluate the healing process in the femoral head after vascularization procedures. Bone scan scintigraphy, used with a pinhole collimeter which is simple and not expensive, is used for very high resolution images of small organs, such as the thyroid and in certain skeletal regions. The purpose of this study was to assess the changes of pattern of pinhole bone scintigraphy in ANFH after VFG.

The authors analyzed chronologic changes of postoperative Tc-99m-HDP pinhole bone scintigraphy in the 22 cases of ANFH which were treated with VFG, and showed satisfactory results at least 2 years following surgery, that is, the Harris Hip Score was 90 or more, and femoral head collapse was less than 2 mm radiologically. At 1 week after surgery, the pinhole image showed no significant change in cold defect areas, but parallel linear RI uptake corresponding to the fibular graft was noted in all cases. At 3 months after surgery, localized hot uptake just above the tip of the fibular graft was observed in 17 cases (77.2%), and diffuse increased uptake surrounding the cold area was observed in all cases. At 6 months after surgery, localized hot uptake was increased in size, replaced the cold area, and delineated the shape of the superolateral aspect of the femoral head. At 1 year after surgery, increased RI uptake at the superolateral aspect of the femoral head expanded medially and gradually in all cases. After 2 years postoperatively, the cold area faded away in 18 cases (81.8%).

TC-99m-HDP pinhole bone scintigraphy provided high resolution bone scintigraphy imaging, and was also able to represent the bone remodeling process in ANFH after VFG.

Assessment of Microcirculation after Graner Procedure in Patients with Kienbock Disease. D. Kamburov, A. Klisarova, and D. Raikov. Department of Orthopaedics and Traumatology, Varna University of Medicine, Bulgaria.

The Graner procedure is a surgical method used in patients with second and third stage Kienbock disease. The aim of this study was to establish the microcirculatory changes in the carpal bones in the early (2 weeks) and late (6 weeks to 1 year) stages after surgery.

The Graner procedure was applied in 25 patients. It consists of capitate osteotomy, translocating the capitate head in a proximal direction, to replace the collapsed lunate bone. The developed defect is filled with a bone graft. In 9 of the patients, the microcirculation was followed, using Tc-99-MDP three-phase bone scintigraphy on day 15 and in the sixth month after the procedure. The scintigraphy assessed the perfusion and metabolism as criteria of the microcirculation.

Asymmetric perfusion curves and a decreased bone metabolism index were established in 8 patients, 2 weeks postoperatively. This validated a decreased microcirculation level. A symmetric curve of perfusion was established in only one patient in the early postoperative period, and also found 6 months after the operation. The disturbed microcirculation was restored in 7 of the patients in the sixth month. In one patient, there was no restoration of microcirculation.

The Graner intercarpal fusion procedure is a reliable method for use in patients with second and third stage Kienbock disease. This study validated the temporary break in microcirculation in the early postoperative period, and its restoration in the later stages, in 82% of the subjects.

Influence of Host Vesssels on Neovascularization in Flap Prefabrication. S.S. Makkar, Gautam Biswas, P. Bapuraj, and P.S. Chari. Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

The sprouting of new vessels from an isolated, surgically implanted vessel, has generated keen interest. It has been reported that neovascularization from the implanted vessel takes place as early as 3 days, and progresses rapidly. Communication with already present dermal vessels occurs as early as 5 days. Venous outflow is delayed, and flaps isolated on these implanted vessels have reduced venous outflow, resulting in congestion, unless the interval for transfer is increased or a venous outflow channel is already present. The influence of the host vessel on neovascularization from implanted vessels has not yet been documented.

The authors therefore conducted a study using 18 Wistar rats, divided into two groups. In Group 1, femoral vessels distal to the profunda femoris were isolated, preserving the superficial inferior epigastric (SIE) vessels, and implanted into a subcutaneous tunnel of the lower abdomen. Rats were sacrificed at 1, 2, and 4-week intervals (3 subgroups of 3 rats each, n=9). The skin of the lower abdomen was isolated on inferior vascular pedicles (femoral/SIE). The vascular system was visualized using a microangiographic technique. In Group 2 (n=9), the procedure was similar to Group 1, except that the SIE vessels supplying the lower abdomen, were ligated on one side. The opposite half of the lower abdomen acted as control in both the groups.

Results in a total of 18 rats showed that both vascular pedicles were clearly visualized, and neovascularization was observed in the animals as early as 1 week post implantation. Linkups between implanted and SIE vesssels were visualized by the second week. In the group in which SIE vessels were ligated (Group 2), even at the end of 4 weeks post implantation, absent/minimal neovascularization was observed. This emphasized that the host vessels appear to play an important role in influencing neovascularization. A discussion of such influence was presented, and conclusions were outlined.

Technique and Strategy in Anterolateral Thigh Perforator Flap Surgery: Analysis of 15 Complete and Partial Failures in 439 Cases. Naci Celik, Fu-Chan Wei, Hung-Chi Chen, Chih-Hung Lin, Ming-Huei Cheng, and Yi-Chieh Chen. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.

The authors attempted to analyze the causes of flap failure, and presented their techniques and strategies regarding anterolateral thigh (ALT) perforator flap surgery.

Between June 1996 and August 2000, 672 ALT flaps were used in 660 patients. Patient ages at the time of surgery ranged from 3 to 94 years (mean: 49.7 years). In order to analyze the perforator flap failures only, flaps based on the septocutaneous vessels, musculocutaneous ALT flaps, and chimeric ALT flaps, were excluded from the study. There was a total of 439 flaps that were based on musculocutaneous perforators.

Of the 439 flaps, 424 survived completely, providing a success rate of 96.58%. Of the 15 failed cases, 8 were complete failures and 7 were partial (10% to 60%) failures. Thirty-four flaps were re-explored after surgery; 19 of these (55.89%) were totally salvaged.

Some of the reasons for flap failure, unique to ALT perforator flaps, were identified. They included relative inexperience with perforator flap elevation, fragility of the musculocutaneous perforators, and easy twisting of the pedicle. Technical suggestions for the harvesting of ALT perforator flaps include the following: mapping the skin vessels with a hand-held Doppler probe before the operation; meticulous harvesting of the flap under the surgical loupe or even the microscope with lower magnification, especially for the inexperienced surgeon; and intermittent topical use of 2% xylocaine during the intramuscular dissection of the perforators, in order to prevent vasospasm. During re-exploration of an ALT perforator flap, one must search for twisting of the pedicle or skin vessels and small bleeders from the intramuscular perforators.

The ALT flap is reliable, with a constant anatomy, long and large pedicle, large area of available skin, and little donor-site morbidity. Knowledge of the common causes of failure, unique to the ALT perforator flap, should guide the surgeon for prevention of failure and the salvage of flaps in jeopardy.

Expression of Schwann Cell-Specific Proteins and Low-Molecular-Weight Neurofilament Protein during Regeneration of the Sciatic Nerve Treated with Neurotrophin-4. Yin Qi, Simon P. Frostick, Graham Kemp, Lu-Gang Yu, and Simon Wagstaff. Department of Musuloskeletal Science, Royal Liverpool University Hospital, Liverpool, UK.

The aim of this study was to evaluate the effects of neurotrophin-4 (NT-4), a member of the recently identified neurotrophin family, in promoting peripheral nerve regeneration and regulating the Schwann cell-specific proteins and one of the axonal proteins during regeneration of the sciatic nerve.

Forty-eight adult male Sprague-Dawley rats were divided into NT-4-treated and control groups. The treated group received NT-4 mixed in a fibrin glue, while PBS was incorporated for the controls. The left sciatic nerve was transected and immediately repaired, and the fibrin glue was injected around the nerve repair site. Six rats from each group were sacrificed at 5, 15, 30, and 60 days postoperatively. A 5-mm segment of sciatic nerve located 5 mm distal to the repair site, together with a 5-mm nerve segment from the unoperated contralateral nerve at the same level, were collected for analysis. Immunoblotting was used to assess the levels of these molecules in all groups, and immunohistochemistry was used to investigate the Schwann cells.

In all the control groups, the distal nerve segment levels of myelin-basic protein (MBP), myelin-associated glycoprotein (MAG), and neurofilament-70 declined at 5 and 15 days following nerve transection/ repair, and then steadily increased between 30 to 60 days. However, in the NT-4-treated group, there was a significant increase in the synthesis of MBP and MAG at both 5 and 15 days after nerve repair (p<0.01), between NT-4-treated and time-paired control groups. Following this, the concentration of MAG and MBP slightly declined, but still remained high until 60 days.

In the NT-4-treated group, a significant difference was also seen in the increase of neurofilament-70 at 15 days after nerve repair, compared with the control groups, and the concentration of neurofilament-70 then increased very slowly until 60 days in both groups. There was no significant difference in the concentration of neurofilament-70 between NT-4-treated and control groups after 30 days following nerve repair.

The number of Schwann cells increased by 3% and 7% at 5 and 15 days, respectively after surgery in the NT-4 group.

NT-4 is a potent factor regulating the levels of MAG, MBP, and neurofilament-70 in the distal sciatic nerve, following nerve transection and repair. The individual Schwann cells produced more MAG and MBP, than the increased number of cells did.

Schwann-Cell Proliferation into Muscle-Vein Combined Grafts Used to Repair Rat Sciatic Nerves. P. Tos, S. Geuna, S. Raimondo, I. Perroteau, and B. Battiston. Gruppo Interdivisionale di Microchirurgia, Ospedale C.T.O.; Dipartmento di Scienze Cliniche e Biologiche; Dipartimento di Biologia Animale e dell' Uomo, University of Turin, Italy.

Considering the fundamental importance of vital Schwann cells within non-nerve grafts, the authors investigated the proliferation of migrating Schwann cells along a non-nervous tube used to bridge a sciatic nerve defect in the rat. For nerve tubulization, they used muscle-vein combined conduits, a grafting method that proved to be particularly effective both experimentally and clinically.

In 24 Wistar adult male rats, severed sciatic nerves were repaired, using a 1-cm graft made with an autologous vein filled with fresh skeletal muscle. The grafted sciatic nerves were withdrawn at different times after surgery (from 6 hr to 7 days), fixed in paraformaldehyde, and embedded in paraffin. Sections were then immunostained with antibodies directed against glial fibrillar acid protein (GFAP), a protein that is specifically expressed in glial cells, and proliferating cell nuclear antigen (PCNA), a protein that is expressed by cells during DNA synthesis. Finally, the sections were analyzed by means of a Zeiss LSM 510 laser confocal microscopy system.

At 6 hr postoperatively, long chains of small GFAP-positive Schwann cells, many of which were immunopositive for PCNA, were detected in the proximal part of the distal nerve stump. At later postoperative times, the graft was progressively invaded, from both the proximal and distal sciatic nerve stumps, by a number of GFAP immunopositive Schwann cells that were often in close contact with the grafted skeletal muscle fibers. At all postoperative times investigated, many of the migrating Schwann cells were found to be immunopositive for the PCNA protein also, thus showing that Schwann-cell proliferation continued to occur inside the muscle-vein combined graft.

According to previous studies, the results of the present study showed that active Schwann-cell proliferation occurs early in severed nerves. In addition to what was already known, these authors have shown that the potential to proliferate is retained by Schwann cells that have migrated inside the muscle-vein combined graft. Since the adequate presence of Schwann cells is a key factor for the successful employment of a non-nervous graft conduit, the results provided a further point in favor of employing muscle-vein combined grafting techniques for the repair of peripheral nerve lesions.

Ischemia/Reperfusion Regulates NOS Expression in Peripheral Nerve. W.N. Qi, Long-En Chen, A.V. Seaber, and J.M. Urbaniak. Department of Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A.

Nitric oxide (NO) is thought to be an important messenger molecule in the nervous system. The purpose of this study was to characterize the distribution of NOS isoenzymes, and to observe any changes in their transcriptional and transnational levels in peripheral nerve subjected to ischemia/reperfusion (I/R) injury.

The sciatic nerves of 66 male adult rats were divided into two groups. Nerves in the ischemia group underwent 2 hr of ischemia. In nerves in the I/R group, a 5-mm segment of each nerve was subjected to a 100-g crush load for 2 hr, to simulate ischemia, followed by 3 hr of reperfusion, after which the nerves were harvested. In each group, the opposite sciatic nerve of each rat was used as a normal control.

Following 2 hr of ischemia, mRNA expressions measured by RT-PCR remained at normal level, but iNOS mRNA showed a 6-fold increase from the normal. Following 2 hr/3 hr (I/R), n- and e-NOS mRNA expression diminished to 91±30% and 62±25% of normal, respectively. In contrast, i-NOS mRNA further up-regulated to 14-fold of normal. Western blots showed that nNOS protein level decreased slightly from normal in the nerve, following 2 hr of ischemia, but further decreased to 63.9% following 2 hr/3 hr (I/R). eNOS protein decreased in response to ischemia (80.9%) and I/R (81.0%). iNOS protein expression was not identified in any group. Immunohistochemistry showed nNOS-positive staining in the Schwann cells and axons of nerves and eNOS in vascular endothelia, but no iNOS-positive staining in any group.

To the best of the authors' knowledge, this was the first study to examine altered expressions of NOS genes and proteins in the somatic nerve, following I/R. The results revealed the dynamic expression of individual NOS isoforms during the course of I/R injury. The findings that decreased constitutive NOS expression and increased iNOS expression during I/R, indicated that NO plays an important role in the physiologic or pathologic processes involved in reperfusion injury of peripheral nerve. NO may be beneficial or detrimental, depending on the stage of evolution of the event (such as ischemia and I/R) and on the cellular compartment producing NO. It is conceivable that an understanding of the modulation on a cellular and molecular level may lead to an understanding of reperfusion injury observed in vivo,, and improvement of clinical outcomes in peripheral nerve injury.

Voluntary Motor Control Recovery after End-to-Side Neurorrhaphy: Experimental Research. I. Papalia, P. Tos, S. Coppolino, S. Geuna, and B. Battiston. Discipline Chirurgiche, University of Messina, Italy; Clin. Jouvenet, Paris France; G.I.M. Ospedale C.T.O.; Scienze Cliniche e Biologiche, University of Turin, Italy.

Many experimental studies have recently shown that termino-lateral sutures (end-to-side neurorrhaphy) lead to functional motor reinnervation of the peripheral territories belonging to the severed nerve. However, data about voluntary control of the motor function restored by end-to-side neurorrhaphy are still lacking. To fill this gap, this study aimed at experimentally investigating the end-to-side neurorrhaphy in rats, and especially at assessing voluntary motor control recovery.

In 24 adult Wistar female rats, the median nerve was cut midway, and then repaired by end-to-side neurorrhaphy on the ulnar nerve, in order to recover flexion of the fingers through neurotization of the median nerve by axons originating from the ulnar nerve. Functional recovery was assessed after 2, 4, and 6 months postoperatively, by means of the grasping test, a procedure that allows the evaluation of voluntary flexion of the upper limb fingers in the rat. In addition, electro-stimulation was used prior to sacrifice, to further assess the recovery of median nerve function. In all animals, the repaired median nerve, the donor ulnar nerve, and the flexor muscles of the fingers were withdrawn and processed for light and electron microscopy analysis.

Grasping test analysis showed that, at 6 months postoperatively, most rats recovered up to 20% of the normal strength of the flexor muscles of the fingers. Morphologic and morphometric analysis showed that satisfactory nerve fiber regeneration occurred in all repaired median nerves, and allowed the description of some of the structural and ultrastructural features of the reinnervation process, as well as some of the modifications that occur in the donor nerve following end-to-side neurorrhaphy.

The results of the reported study suggested that voluntary motor control can be recovered by end-to-side neurorrhaphy, and thus provided further experimental evidence on the effectiveness of this technique for the repair of peripheral nerve lesions with substance loss, or when it is not possible to use the proximal stump of the severed nerve.

Sensory Restoration of a Skin Graft on a Free Muscle Flap: Experimental Rabbit Study. Yasunori Hattori, David C.C. Chuang, and Chyn-Tair Lan. Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan, and Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.

Transplantation of a muscle flap with skin graft for wound coverage is a common procedure in reconstructive microsurgery. However, the grafted skin has little or no sensation. Restoration of sensibility to the grafted skin on the transferred muscle is critically important, especially for reconstruction of the palmar area of the hand, plantar area of the foot, the heel, and oral cavity. The purpose of this study was to investigate the possibility of sensory restoration to grafted skin on a trimmed muscle surface that was sensory neurotized after coaptation of a sensory nerve to motor nerve, using the rabbit gracilis muscle as an animal model.

The ipsilateral saphenous nerve (sensory) was transferred to the motor nerve of the gracilis for muscle sensory neurotization. A 4x4 cm² area of skin island over the midportion of the gracilis was harvested as a full-thickness skin graft. The upper half of the gracilis muscle was trimmed. The skin graft was then reapplied over the trimmed raw area of the muscle. After 6 months, horseradish peroxidase (HRP) retrograde and antegrade labeling studies were performed through skin graft, muscle, and saphenous nerve injection. A control group with a skin graft on an intact muscle surface of the gracilis was also assessed. By muscle injection, HRP-labeled neurons could be constantly identified in the dorsal root ganglion in both the trimmed muscle surface group and the intact muscle surface group. However, in skin graft injection, HRP-labeled neurons could be constantly identified only in the dorsal root ganglion in the trimmed muscle surface group. With antegrade labeling evaluations of saphenous nerve injection, regenerated fibers with HRP reaction products were found only in the skin graft in the trimmed muscle surface group.

The study showed that sensory nerves can regenerate and penetrate into the trimmed muscle surface and grow into the overlying skin. If the muscle surface is intact in the control group, sensory restoration of the grafted skin is then not possible. Sensory neurotization of a trimmed muscle flap with an overlying skin graft has a good potential for obtaining improved sensory recovery.

Plasticity of Motor Neurons Contributing to C7 Spinal Nerves. Robert W.H. Pho, Yang Yunhai, Leong Seng Kee, and Barry Pereira. Department of Orthopaedic Surgery, National University of Singapore, Singapore.

Cross-C7 spinal nerve transfer has been used as a donor in complete brachial plexus injury. Many authors have demonstrated recovery of functional status of the donor limbs after transection of the C7 nerve. Explanations of functional recovery include lateral sprouting and compensatory hypertrophy of adjacent muscles. In this report, the authors have examined the activation of adjacent motor neurons in C6 and/or C8 spinal segments as potential contributing axons to C7 nerves.

To clarify whether motor neurons in C6 and C8 cord segments could possibly contribute fibers to C7 spinal nerves, 18 male adult Sprague-Dawley rats (weighing 200 to 250 g) were used for C7 intraspinal or extraspinal avulsion. Ten rats were used for intra- and extraspinal and C8 avulsion, followed with C7 avulsion 28 days later. The spinal cords were subjected to immuno-histochemical studies. Four antibodies were used to detect changes in the motor neurons at the spinal cord level. The antibodies used were neuronal nitric oxide synthase (nNOS), endothelial nitric oxide synthase (XO), inducible nitric oxide synthase (iNOS), and xanthis oxidase (XO). Observations demonstrated that believing that the C7 nerve root is formed by the axons of the motor neurons in the C7 spinal segment is only an assumption. Current technology cannot prove beyond doubt that this assumption is correct, and that adjacent segments of C6 and C8 do not contribute to the C7 spinal nerve, as supported by the following: 1) after avulsion of the C7 nerve, stainings with nNOS, iNOS, and XO antibodies were observed bilaterally and also in the C6 and C8 segments; 2) avulsion of C6 and C8 nerves prior to C7 avulsion did not show much difference in results, compared to those without prior avulsion of C6 and C8 nerves; 3) following C7 avulsion, there was not only a bilateral reaction of the motor neurons forming the C7 nerve root, but also evoked reaction in C6 and C8 spinal motor neurons.

Most likely, a compensatory response of adjacent motor neurons may partially account for the functional recovery observed as early as 3 months after transection of C7 nerve roots.

Neurotization of the Ulnar Nerve at the Wrist by Phrenic Nerve Harvested at the Diaphragm: Rat Model for Distal Neurotization in Reconstruction of Brachial Plexus Injury. Eduardo Gonzalez Hernandez, S. Suominen, David C.C. Chuang, C.T. Lan, and H.L. Hsu. Chang Gung Memorial Hospital, Taipei, Taiwan, and Miami Hand Center, Miami, Florida, U.S.A.

Currently, there is no method of reanimating the intrinsic musculature of the hand in brachial plexus injury (BPI ) following trauma. In addition, it is not possible to reinnervate the forearm musculature, because there is no readily available source of distal axons. These authors addressed the problem of neurotization of the forearm and possibly hand intrinsics in reconstruction of BPI.

In China and Taiwan, different clinicians (especially Gu and Chuang) have utilized the phrenic nerve extensively for brachial plexus reconstruction. Donor morbidity has been studied and is acceptable, with normalization of pulmonary function tests at 2 years. In the rat, the phrenic nerve has been evaluated as a source of neurons for various muscles, using different techniques including direct neurorrhaphy, nerve grafts, and direct neurotization into a target muscle. There is a lack of description in the literature about harvesting the phrenic distal to its course on the anterior scalene muscle at the base of the neck. The authors designed a rat model in which the phrenic nerve is harvested at the level of the diaphragm and delivered to the distal forearm for coaptation with the ulnar nerve which has been severed.

The study group included 10 rats. An additional 10 animals served as controls. Intraperitoneal injection of ketamine was used for general anesthesia. Mechanical ventilation was delivered via a tracheotomy tube. The phrenic nerve is exposed at the level of the brachial plexus. Since the nerve arises from C5, C6 is located and dissected as distal as possible. The blood supply of the nerve at the proximal dissection site is preserved. A thoracotomy is developed, and the heart and lung are protected as the nerve is exposed along the pericardium traversing on the surface of the superior vena cava, the atrium, and onto the diaphragm, where it is cut. The nerve is retrieved from the dissection site at the brachial plexus. The chest is closed, and a chest tube for wall suction is applied. A 15-mm segment of ulnar and median nerves over the mid and distal forearm is excised to prevent regeneration. The phrenic nerve is delivered via a subcutaneous tunnel to the distal forearm, where it is sutured to the ulnar nerve.

Controls underwent identical surgery, with the additional step of transection of the phrenic nerve at its origin and immediate primary repair. The authors' intentions were to compare the benefits of harvesting an intact phrenic nerve for distal neurotization vs. using the phrenic itself as a long interpositional graft.

The animals were sacrificed at 4 months. Evaluation of nerve regeneration was done by electrophysiologic studies, as well as anatomic studies by retrograde neuron tagging with horseradish peroxidase (HRP). At the time of sacrifice, the animals were anesthetized to measure the amplitude of the compound muscle action potential (MAP) in the intrinsic hand musculature with direct stimulation of the phrenic nerve. Distal latencies and nerve conduction velocity (NCV) across the nerve repair site were measured. Insertional intrinsic muscle activity was evaluated. HRP was injected into the ulnar nerve distal to the repair site. The animal was sacrificed 24 to 48 hr later. The spinal cord in the cervical region was harvested for analysis.

All rats in which technically flawless surgery was performed demonstrated excellent MNCV. In contrast, those rats in which excessive traction on the nerve was recorded at the time of surgery, performed poorly on MNCV evaluation. HRP retrograde labeling was challenging to perform, and only a few animals underwent the procedure successfully, given the high mortality at the time of HRP labeling. It was possible to demonstrate the uptake of HRP in the phrenic motoneurons in the middle portion of the ventral horn throughout C4 and C5 spinal segments.

Four months postoperatively was enough time to allow nerve regeneration for the rats in the control group. A significant difference in outcomes would probably have been seen, if the evaluation was done at 1.5 months, which would be enough time for nerve regeneration in the study group, but not sufficient for the control animals. In the rat model, the actual distances involved are rather small, and it is difficult to fully investigate the benefits of having such a long nerve available for distant transfer. In the study, the authors attempted to harvest the nerve, leaving its proximal blood supply intact, but this is hardly critical in the rat, where the nerve is very small in diameter, and its blood supply can be re-established readily from the surrounding tissue.

The results of this study were very encouraging, and the authors are prepared to develop an animal model in which the sizes more closely match those of human subjects.

Effect of CNTF and BDNF in Nerve Regeneration after Nerve Root Avulsion of the Brachial Plexus. Eva Lang, E. Asan, N. Plenila, G.D. Hofmann, and M. Sendtner. University of Freiburg, University of Wuerzburg, University of Munich, 4 B-G Trauma Center, Murnau.

Currently, the operative therapy of nerve root avulsions in brachial plexus injuries is still unsatisfying. By administration of CNTF and BDNF, in combination with nerve root replantation into the spinal cord, progress in regeneration is possible. This point was the object of the reported investigation.

Ventral nerve root avulsion was induced in the spinal cord segment C7 in rabbits. In the first part of the experiment, tissue glue with CNTF or BDNF were applied to the lesion (n=21). After a survival time of 1 to 3 weeks, the number of viable motoneurons was determined and compared with that of the healthy side. In the second part of the experiment, the nerve roots were replanted in the spinal cord, and also tissue glued with CNTF and BDNF, or a combination of both was locally applied (n=28). After a survival time of 6 months, the number of sprouting axons was counted and the axon-myelin relationship was determined at the level of the spinal ganglion and the nervus radialis.

More than 80% of the motoneurons were lost in the C7 segment, while 55% were lost in segments C6-C8 after root avulsion between 1 and 3 weeks after trauma. Local application of CNTF or BDNF with fibrin glue at the lesion site afforded an attenuation of the loss of motoneurons to 17.1% (CNTF) and 25.3% (BDNF) after 1 week. Nearly the same situation could be seen after 3 weeks. There was axon sprouting into the replanted nerve roots. The regenerating axons were smaller and the myelin thinner than those of the healthy side.

Local administration of CNTF and BDNF may enhance survival of the affected motoneurons after nerve-root avulsion. Nerve-root replantation profits from the new cell potential.

Intramuscular Innervation of Skeletal Muscles: Study of the Human Upper Limb. Amerio Y.T. Lim, Barry P. Pereire, Jessie Tan, and V. Prem Kumar. Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore.

The Sihler staining technique, which renders muscles translucent and stains the myelinated nerve fibers within dark blue, was applied to all muscles in 8 fresh human upper limbs and to 5 latissimus dorsi muscles. The intramuscular innervation was thus revealed to a very fine level of detail, filling gaps in the understanding of the intramuscular anatomy of muscles between what is revealed by surgical dissection and histologic sections. A primary factor determining innervation is the point of entry of the nerve into the muscle. A nerve entering the muscle at its proximal end does not need to give off a recurrent branch, unlike one entering the proximal or middle third of the muscle belly. The nerve seldom crosses an intramuscular tendon of insertion that extends proximally within the muscle belly, and this anatomic fact may be made use of in splitting skeletal muscles into two or more independent functional units.

This study identified the flexor carpi ulnaris, flxor carpi radialis, abductor pollicis longus, extensor carpi radialis brevis, latisssimue dorsi, biceps brachii, and brachialis as muscles that have the potential for being split for use in reconstructions of limbs deficient in muscle. The three-dimensional study of the nerve within the muscle belly raises the possibility of intramuscular nerve repair in lacerated skeletal muscle bellies of functionally important upper limb muscles.

Repair of Rat Sciatic Nerve Gaps with Human Amniotic Membrane Tube, Using Interposition of Autologous Vein Conduits. Maira Angelica Almeida, M. Manuel Mouzinho, Joao Anacleto, Teresa Ramos, and Laura Silva. Department of Plastic Surgery, S. Jose Hospital, Lisbon, Portugal.

The aim of this study was to find an immunologically inert tissue to use in peripheral nerve repair. The interposition of vein conduits to repair sciatic nerve gaps has been previously studied by these authors. A similar type of experiment was performed using human amniotic membrane treated to become immunologically inert.

In 30 Wistar rats, 15 animals were repaired by means of the interposition of 1 cm of autologous jugular, and 15 repaired by 1 cm of human amniotic membrane tube. The animals were divided into three groups and observed at 4, 8, and 12 weeks after surgery. Evaluations of outcomes of nerve regeneration, morphologically and functionally, were made by electrophysiologic and histologic analysis in all animals.

The results obtained so far indicated that human amniotic membrane, when made immunologically inert, can promote the regeneration of neurons, can stimulate new vascularization, and can successfully replace autologous vessels, with subsequent functional recovery. Since the supply of immunologically inert human amniotic membrane is practically unlimited, the use of this tissue will undoubtedly become more favored.

Intraoperative Diagnosis of Brachial Plexus Injury Using Evoked Spinal Cord Potentials and Choline Acetyltransferase Activity. Yasunori Hattori and Kazuteru Doi. Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan.

The most reliable method of distinguishing between postganglionic lesions (reparable root) and preganglionic lesions (unreparable root) in brachial plexus injury (BPI) is by surgical exploration, together with intraoperative electrophysiologic study (somatosensory evoked potentials or evoked spinal cord potentials [ESCPs]). However, these tests mainly record the nerve potentials belonging to the afferent sensory pathway. They are based on the assumption that the anterior and posterior roots are usually damaged together. The authors measured choline acetyltransferase (ACT) activity to assess the motor function of the injured root directly and quantitatively in combination with ESCPs. The purpose of this study was to investigate the diagnostic value of ESCPs and CAT activity during brachial plexus exploration.

The study included 26 spinal roots (C5-19, C6-7) in 19 patients with traumatic BPI. ESCPs following root stump stimulation were recorded from a catheter electrode in the posterior cervical epidural space. Based on the amplitudes of the ESCPs, responses were classified as poor (less than 5 uV) and good (more than 5 uV). According to the criteria used, the injured root with good response indicated a reparable root that can be a donor motor source of nerve graft. Seven roots had good response on ESCPs and could be repaired. The CAT activity of these roots was more than 2000 cpm. The donor roots were coapted via the nerve graft to the suprascapular nerves in 5 cases and to the musculocutaneous nerve in 2 cases. Five roots with poor response had CAT results less than 2000 cpm and were not repaired. However, 5 roots with poor response had results of more than 2000 cpm and were coapted to the suprascapular nerve. Reinnervation of the target muscle was obtained within 4 to 6 months in all cases.

Assessment by ESCPs is easy and rapid. They mainly reflect the sensory function of the injured roots. On the other hand, CAT activity directly reflects the motor function; however, it requires a nerve specimen and a special technique. The strategy for intraoperative diagnosis of BPI was based on the use of both the ESCPs and CAT activity. These two techniques are complementary, so that a more accurate diagnosis of BPI can be achieved.

Spinal Cord Gap Repair Using Newborn Sciatic Nerve Graft. Maira Angelica Almeida, M. Manuel Mouzinho, Joao Anaccleto, Manuela Mafra, and Luisa Medeiros. Department of Plastic Surgery, S. Jose Hospital, Lisbon, Portugal.

The aim of this reported study was to test the regeneration capacity of the spinal cord following repair of a 1-cm gap with peripheral nerve graft. The authors studied the functional muscle recovery of the posterior limbs of Wistar rats, following repair of a 1-cm spinal cord gap grafted with newborn sciatic nerve.

The authors used 12 Wistar female rats weighing 300 g. The animals were anesthetized with intraperitonal ketamine-xylasine injection. All nerve graft procedures were performed by the same three surgeons. In the 12 rats, they created a 1-cm gap in the spinal cord and repaired it with 8-10 cables of newborn sciatic nerves. In three other animals, the gap created was not repaired. The animals were divided into three groups, and observed at 4, 8, and 12 weeks postoperatively. In all animals, evaluation of the regeneration process was carried out by electrophysiologic and histologic analysis, and the condition of walking was registered on video.

In this rat model, it was found that spinal cord regeneration following repair with newborn sciatic nerve made walking possible.

Robotic Harvest of the Internal Mammary Vessels in Breast Reconstruction. J. Brian Boyd, K. Stahl, and M. Samson. Cleveland Clinic Florida, Weston, Florida, U.S.A.

Internal mammary artery harvesting via minimally invasive techniques is becoming more common in the modern era of cardiac surgery, for use as a bypass conduit in coronary bypass surgery. Over the last 24 months, port access endoscopic LIMA and RIMA harvesting, aided by robotic devices, has been advanced in several centers. The authors' current method of choice is the use of the ``Aesop'' voice-activated robotic arm manufactured by Computer Motion, Inc. of Santa Barbara, California.

With small modifications of the standard techniques in cardiac surgery, it has been possible to harvest the internal mammary artery, and pass the pedicle containing the artery and vein through the chest wall for use in TRAM flap reconstruction after mastectomy. The principal modification involves port placement through the mastectomy incision into the thoracic cavity, which allows for a more appealing final cosmetic result. The remainder of pedicle mobilization is done, as has been reported in the cardiac surgery literature. The entire internal mammary artery is mobilized, and a 3 to 4 inch long pedicle is brought out through the second interspace, without the need to resect ribs or even costal cartilage. The pedicle has abundant length to accommodate any free flap with ease. Six illustrative cases were reported.

Intraoperative Electroneurodiagnostics with Transcutaneous Electrical Stimulation of the Spinal Roots in Routine Peripheral Nerve Surgery: Results of a Prospective Study. E. Turkof, M. Reichel, W. Mayr, E. Unger, and M. Frey. Department of Plastic and Reconstructive Surgery, and Department of Biomedical Engineering and Physics, University of Vienna, Austria.

Frequently, plastic surgeons must face controversial NCV studies, and often, exposed nerves do not show any pathologic aspect. In November, 1996, the authors initiated a prospective study to investigate the possible benefit of routine application of intraoperative electroneurodiagnostics (IOE) in peripheral nerve surgery. The aim of the study was to clarify the following questions: 1) how frequently does the intraoperative determination of the site and proximal extent of nerve lesions provide the information leading to a change of the initial surgical concept? and 2) is it beneficial, hence to be recommended, to routinely apply IOE?

Ninety-five peripheral nerves in 89 patients suffering from common various types of nerve lesions were measured during surgery. Following exposure of the nerves, the surgical concept was decided without implementation of IOE. Subsequently, patients were fully relaxed, and the spinal roots of the damaged nerve were transcutaneously stimulated with surface electrodes placed paravertebrally on the ipsilateral side over the respective nerve segments (Digitimer D185, monophasic square wave pulse, 50 usec duration, 300-1000 volts). The evoked efferent nerve compound action potentials were recorded with a bipolar electrode moved proximally and distally along the surface of the nerve. Decreased amplitude was regarded as an indication of nerve damage, and elevated amplitude as a sign of a healthy segment.

IOE was performed on 45 ulnar, 23 median, 10 radial, 5 peroneal, 5 tibial, 5 common sciatic, and 2 intercostal nerves. In all but four patients (=4.2%, misplacement of the stimulating electrode, obesity), recordings were successful. In 23 patients (25.8%), the obtained recordings led to a more or less important change of the initial surgical concept. In 7 cases, the measurements confirmed the solely clinically-based surgical indication, despite controversial preoperative NCV studies.

The described technique represents an alternative to David Kline's technique (nerve-to-nerve stimulation and recording). The main differences are: 1) Kline's technique requires a minimum distance between stimulation and recording site (approximately 10 cm)-the authors' technique stimulates the nerve from the most proximal site, its spinal roots. 2) The described technique insures stimulation of the nerve from a healthy site, while Kline's technique might be performed from partially damaged sites. On the other hand, the described technique requires full anesthesia and full relaxation, which may confound the measurement.

IOE is a valid, simple, reliable, and effective tool to detect the exact site and proximal extent of nerve lesions. The authors recommend the routine implementation of IOE.

Systemic Microchimerism Following Vascularized Bone Allotransplantation: Detection by Polymerase Chain Reaction. Keiichi Muramatsu and Allen T. Bishop. Department of Orthopaedic and Microvascular Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.

Systemic microchimerism following allogeneic organ transplantation may be a mechanism for induction of donor-specific graft acceptance. However, little is known about graft cell migration following vascularized bone allograft. Systemic microchimerism was studied following vascularized bone allograft in a rat model.

A vascularized tibiofibular graft was transplanted from male DA rats (allograft) or PVG rats (isografts) to female PVG rats. Tacrolimus (FK 506) was administered after transplantation for immunosuppression. Microchimerism was assessed by semi-quantitative polymerase chain reaction (PCR) for the Y chromosome.

All PVG rats immunosuppressed recipients of PVG bone grafts showed a high level of microchimerism (1%) in the thymus, spleen, liver, and cervical lymph nodes at 18 weeks post-transplant. Donor cells were also detected in the contralateral tibia and humerus. In non-immunosuppressed PVG rat recipients of DA bone grafts, donor cells were detected in the spleen within 2 weeks post-transplant. In these animals, the bone grafts were severely rejected. In immunosuppresssed PVG rat recipients of DA bone grafts, two of 5, four of 8, and eight of 10 rats showed low-level microchimerism (0.1%) in peripheral blood at 1, 12, and 18 weeks post-transplant. Six rats showed a high level of microchimerism in spleen and thymus. Histologic studies revealed no rejection findings through 18 weeks post-transplant.

PCR for the Y chromosome is a useful tool for differentiating between donor and recipient cell populations experimentally, using sex-mismatched tissues in this rat model. The results indicated that microchimerism, or the presence of graft cells in host tissue, is not always associated with acceptance of vascularized bone grafts. Microchimerism likely reflects the immunosuppressive state of the recipient and may be a consequence, rather than a cause, of tolerance.

Functional Detrusor Reconstruction Using Innervated Free Latissimus Dorsi Muscle in Patients with Acontractile Bladder. M. Ninkovic, A. Schwabegger, G. Bartsch, and A. Stenzl. Department of Plastic and Reconstructive Surgery, University of Innsbruck, Austria.

Bladder acontractility may be the result of spinal cord injury, pelvic or spinal surgery, congenital malformation, chronic disease, or of unknown idiopathic origin. Many of these patients are young and have a life expectancy of several decades. Until now, the best mode of treatment for the paralyzed bladder was lifelong, clean, intermittent catheterization. Little can be gained from treatment of a bladder presenting with flaccidity secondary to lower motor neuropathy or impaired detrusor contractility by electrical stimulation of the spinal cord, sacral roots, or the detrusor itself. In these patients, bladder myoplasty would therefore represent the only alternative for the restoration of voluntary voiding without catheterization. On the basis of the results of the authors' animal experiments, a clinical protocol was initiated, using free neurovascular latissimus dorsi muscle (LD) transfer to restore voluntary voiding in patients with long-standing bladder acontractility, for whom there was no treatment alternative.

Latissimus dorsi detrusor myoplasty (LDDM) was used in 18 patients with bladder acontractility due to spinal cord injury, congenital malformation, detrusor myopathy, and idiopathic causes, who had required catheterization for bladder emptying for a minimum of 2 years. Voluntary contraction of the latissimus dorsi muscle (LD) wrapped around the bladder, was achieved by using the lowest motor branch of the rectus abdominis muscle as a recipient nerve, and the vascular pedicle of the LD was anasomosed to the deep inferior epigastric artery and vein.

There were no technical difficulties during the operative procedure. No free flap failure occurred. Biannual Doppler ultrasonography and annual dynamic computerized tomography revealed vascularization and contractility in all 18 patients. After a postoperative catheterization period of 2 to 3 months, 14 of the 18 patients were able to void spontaneously, with postvoid residuals of less than 100 cc. Four patients, two of them 60 years of age and older, who had a bladder acontractility due to unknown etiology, still need to catheterize themselves; one of them once every 2 to 3 days, two of them once every day, and the fourth noted no improvement with 4 to 5 daily catheterizations.

The voluntary voiding of the urinary bladder can be induced through the contractility of a reinnervated free LD that has been wrapped around the bladder. LDDM has proven to be a viable option for the treatment of patients with an acontractile bladder due to traumatic or congenital lower motor neuropathy. Since these patients are able to void again, they have notably regained self-confidence, and have resumed their professional and daily activities.

Functional Sphincter Ani Externus Substitute Using a Free Innervated Latissimus Dorsi Muscle Flap: Experimental Study in Dogs. A.H. Schwabegger, P. Kronberger, P. Obrist, E. Brath, and I. Miko. Department of Plastic and Reconstructive Surgery, Ludwig Boltzmann Institut fuer Qualitaettssicherungg in der Plastischen Chirurgie, University of Innsbruck, Austria.

This experimental study was designed to investigate the ability of the free latissimus dorsi muscle (LDM) flap to serve as a functional substitute for the external anal sphincter in mongrel dogs. The indication for this reconstructive option was repair of the voluntary external anal sphincter muscle for treatment of stress incontinence, resulting from any kind of muscular tissue defects of only the external sphincter muscle.

Eight dogs underwent total resection of the external and internal anal sphincter apparatus. The internal sphincter muscle additionally was resected to circumvent false positive results. The neosphincter was created by transfer of a tailored neuromicrovascular LDM with adjacent serratus muscle fascia, sutured around the anal canal in a circular fashion, and the thoracodorsal neurovascular bundle was anastomosed to the internal pudendal vessels and nerves.

Five dogs survived the primary surgery, and four of them were subjects of functional investigation 6 and 8 months thereafter. Investigation consisted of sphinctermanometry electromyogram and video under stimulation before, and sphincter resection as well, 6 to 8 months after the reconstruction, with immunohistochemical examination of the transplanted tissue.

All four dogs showed reinnervation of the transplanted LDM with visible contraction, and pressure ranges from 10 to 45 mmHg at sphinctermanometry, as well as positive waves on electromyogram during stimulation of the coapted nerve. Standard histologic immunohistochemic examination and video documentation confirmed the viability of the transferred muscle.

Because of these promising results, external (voluntary) anal sphincter repair may be indicated in humans, but should be carried out only with carefully selected indications.

Expanded Free Flaps: Design Influence on Venous Congestion. W. Boeckx, R. Van der Hulst, and F. de Lorenzi. Department of Plastic Surgery, University Hospital, Maastricht, The Netherlands.

In head and neck reconstructions, large or very large (fascio) cutaneous free flaps are often required. Neck burn scar corrections often require large cutaneous flaps. The scapular free flap can be expanded prior to its microsurgical transfer. However, postoperative problems often occur. Venous congestion is one of the most frequent problems, especially in the most distal portion. As a consequence of expansion, venous return toward the vascular pedicle is progressively occluded, and venous blood drains away from the main arteriovenous axis of the free flap. In order to overcome this problem, the authors have used a horseshoe type of expansion to avoid venous congestion in the distal half of the free flap. Thereby, venous drainage in the flap is progressively obstructed on the periphery, while axial drainage is enhanced prior to flap transfer.

In 11 patients, a scapular free flap was selected for burn contracture release or knee or sternal burns. Six free flaps were expanded; three flaps had a horseshoe type of expansion, which was described. Three months prior to flap transfer, two banana-shaped expanders were inserted around the free flap, except for its vascular pedicle. The flap itself was not expanded. The average diameter of the flap was 23x20 cm. The area around the flap was expanded to such a volume that the donor site could be closed primarily. A 5 cm diameter area of non-expanded skin was preserved overlying the pedicle in the triangular axillary space. The free flaps were transferred to the facial vessels.

All flaps had a successful microvascular anastomosis. The three expanded flaps presented venous congestion, two resulting in partial flap loss. The three horseshoe expanded free flaps had no venous congestion.

Expansion of a free flap is a method for increasing flap size and to thin the flap. However, compression of venous return due to a pressure higher than the venous pressure, decreases the drainage of venous blood. This is most pronounced across the point of maximal expansion (the equator of the expander). This problem can be avoided when a circumferential barrier (the horseshoe type expander) is placed around the free flap.

Endoscopic-Assisted Microsurgery May Be the Microsurgery of the New Millennium: Comparative Experimental Study. M. El-Shazly, A. Kamel, M. El-Sonbaty, M. Zaki, and R. Baumeister. Institute of Surgical Research, Munich University, Munich, Germany.

The long hours of intensive work looking through the operating microscope have been accepted as the price to be paid for working in microsurgery. With the introduction of endoscopy to surgery, it has become apparent that magnification similar to that provided by the operating microscope can be achieved. The significantly less expensive endoscopic unit provides both magnification and the ability to operate at a distance. The authors extensively investigated the possibilities of microsurgical performance with the visual assistance of the endoscope, and compared them with the conventional operating microscrope regarding technical and clinical aspects.

Six group classification of 120 Sprague-Dawley rats, weighing 250 to 350 g, was as follows. In the first two groups, the femoral vessels and nerves were sectioned and anastomosed with the operating microscope in 20 animals, and by the application of an endoscopic unit in the other 20. In the next two groups, groin flaps based on femoral pedicles were elevated as free flaps to be anastomosed in the neck with the common carotid and internal jugular vessels by the operating microscope in 20 animals, and by the endoscope in another 20 animals. The thoracic ducts of the third two groups were divided and anastomosed by the microscope in 20 animals, and by application of the endoscope in 20 other animals.

Technical and clinical data on the 240 vascular, neural, and lymphatic anastomoses in the 120 animals were collected and assessed. There was no technically significant difference between the microscope and endoscope, as regards the depth of focus, diameter of the field, or image quality. Also, there was no clinically significant difference, as regards the patency rate and free flap viability. In this series, mean times of 27, 19.6, and 27.4 min for the vascular, neural, and lymphatic endoscopic anastomoses were recorded, respectively. These results were significantly shorter than those of the microscopic anastomoses (p<0.0005), which had mean times of 36.5, 25.7, and 331.9 min for the vascular, neural, and lymphatic anastomoses, respectively. Furthermore, there were recordings in the endoscopically-assisted groups of a significant reduction in the total operating time by more than 50 min, and in vessel preparation time by more than 20 min (p<0.0005).

The endoscope seems to be a promising device in performing microsurgery with much better technical aspects concerning magnification and visualization, significantly shorter anastomotic time, better handling, and more physical comfort for the surgeon. It is reliable, time-efficient, and cost-effective. According to the feasibilities and difficulties of the project, the authors have established some technical modifications, making the endoscope more compatible, perhaps to be a world-wide clinically accepted operating microsurgical device in the near future.

Concept of End-to-Side Neurorrhaphy for Treatment of Painful Neuroma: Experimental Study. Toru Yamauchi, Manabu Maeda, Susumu Tamai, Yasunori Kobate, Takeo Sempuku, Takashi Yoshii, Hiroshi Yajima, and Yoshinori Takakura. Orthopaedic Surgery, Saiscikai Chyuwa Hospital, Nara, Japan

This presentation reported the utilization of an end-to-side neurorrhaphy concept for the prevention and treatment of painful neuromas.

A total of 30 rats were divided into three groups (10 per group). In Group 1, the peroneal nerve was divided and left lying in the subcutaneous tissue. In Group 2, the cut ends of the peroneal nerves were folded back on themselves, placed into epineurial sheath window defects, and sutured in an end-to-side fashion. In Group 3, the cut ends of the peroneal nerves were folded back on themselves, placed into epineurial sheaths without defects, and sutured in an end-to-side fashion. Histologic examination was performed 90 days after nerve injury.

In Group 1, the proximal end of the peroneal nerve formed a neuroma. Grossly, the nerve ends formed bulges with dense masses embedded in the surrounding soft tissue. Microscopically, the bulges showed relatively disorganized axons invaded by fibrous tissue. In Groups 2 and 3, the proximal ends of the peroneal nerves did not infiltrate the surrounding soft tisssue, and healed instead into the intact peroneal nerves. Microscopically, in these two groups, the proximal ends of the peroneal nerves healed into the peroneal nerves. However, in Group 2, there was no continuity between the distal stumps of axons and the trunks of axons. In Group 3, there was no continuity between the distal stumps of axons and the epineurial sheaths.

The findings suggested that end-to-side neurorrhaphy might be an alternative treatment for painful neuromas under certain clinical situations.

Experimental Limb Transplantation Indefinite Survival. E.R. Owen, M. Lanzetta, C. Ayrout, A Gal, and Z. Dereli. Microsearch Foundation of Australia, Sydney, Australia.

In this study, the three components of an immunosuppressive combination therapy were gradually withdrawn in a rat limb transplantation model, to evaluate the effects on long-term survival of the grafted limbs, rejection rate, and functional recovery.

The procedure was performed in 8 rats, using a strong Brown Norway to Fischer 344 histocompatibility barrier. The animals were given a tapered 20% of the dosage every week; by week 7, the animals were on FK506 only. FK506 was then tapered at the same rate (20% every week) until a maintenance dose of 0.6 kg/day was reached by week 12. At 6 months, the immunosuppression was stopped.

Four of the 8 animals did not reject throughout the study up to the 1-year endpoint. At this stage, they showed an excellent functional outcome, evaluated by clinical tests and walking-track analysis. The other 4 rats developed rejection at an average of 267 days postoperatively (range: 224 to 302 days), corresponding to an average of 87 days (range: 44 to 122 days), without any immunosuppression. They were then sacrificed for histologic examinations of the various tissues, without further treatment.

This study demonstrated that a low-dose triple combination therapy could provide an excellent long-term functional outcome in the transplanted limbs, with no rejection episodes and no side effects or complications for at least 6 months after withdrawal of all single components. It noted that the authors have already shown that if rejection commences (even 6 months after stopping all drugs in a supposedly tolerant animal), this can be readily reversed by a gentle return of the immunosuppressants.

Short Extremity Ischemia Prior to Flap Ischemia Improves Flap Survival in a Rat Model. Markus V. Kuentscher, Eva U. Schirmbeck, C. Heitmann, Martha Maria Gebhard, and Guenter Germann. Department of Plastic and Hand Surgery, Burn Center BG-Trauma Center Ludwigshafan, University of Heidelberg; and Department of Experimental Surgery, University of Heidelberg, Germany.

Ischemic preconditioning (IP) is a protective endogenous mechanism to reduce ischemia reperfusion injury, and is defined as a brief period of ischemia that the authors term ``preclamping.'' This is followed by tissue reperfusion, and is believed to increase the ischemic tolerance. Murray was the first to describe this phenomenon for the heart in 1986. The first study dealing with preconditioning in a muscle flap model was published by Mounsey in 1992. The objective of this reported study was to determine if ischemic preconditioning and enhancement of flap survival can be achieved not only by preclamping of the flap pedicle, but also by induction of an ischemia/reperfusion phenomenon in a body area distant from the flap, prior to flap harvest.

Forty male Wistar rats were divided into four experimental groups. An extended epigastric adipocutaneous flap (6×10 cm) was raised, based on the left superficial epigastric artery and vein. In the control group, a 3-hr flap ischemia was induced. In the preclamping group, a brief ischemia of 10 min was induced by clamping the flap pedicle, followed by 30 min of reperfusion. Ischemia of the right hindlimb was induced in Group 3 by clamping the femoral artery and vein for 10 min after flap elevation. The limb was then reperfused for 30 min. Thereafter, flap ischemia was induced as in the control group. A similar protocol was used in Group 4. A tourniquet was used to induce hindlimb ischemia. The experiment then proceded as in Group 3. Mean flap necrosis area was assessed for all groups on the fifth postoperative day using planimetry software.

Average flap necrosis area was 68.2% (±18.1%) in the control group, 11±8.38% in the preclamping group, 12.5±5.83% in the femoral ischemia group, and 24±11.75% in the tourniquet group. All preconditioned animals demonstrated a significantly lesser area of flap necrosis than the control group (p<0.0001, Student's t test).

The data showed that ischemic preconditioning and enhancement of flap survival can be achieved not only by preclamping of the flap pedicle, but also by induction of an ischemia/reperfusion event in a body area distant from the flap prior to harvest. These findings indicated that IP is a systemic phenomenon, and not just a local reaction in the flap. The exact mechanism is not yet completely understood. The data also suggested that remote IP could be performed simultaneously with flap harvest in the clinical setting, for improved flap survivval without prolonging the operative procedure. This may decrease the rate of partial flap loss or flap necrosis, especially in high-risk groups such as smokers, those with irradiated tissue, and obese patients.

Osteoblast Survival, Differentiation, and VEGF Release in a Hypoxic Environment. Ming-Huei Cheng, Wei-Chao Huang, Eric Brey, Fu-Chan Wei, Hung-Chi Chen, and Ken-Yuan Chang. Department of Plastic Surgery, Chang Gung Memorial Hospital; Institute of Biosciences and Bioengineering, Rice University; Department of Plastic Surgery, University of Texas, M.D. Anderson Cancer Center; and Biomaterial Engineering Center, Industrial Technology Research Institute.

Tissue engineering, fracture healing, surgical flap transfer, ischemic osteonecrosis, and tooth extraction are all situations in which osteoblasts may encounter hypoxic environments. All of these situations require angiogenesis to increase the oxygen levels. The authors investigated the influence of hypoxic conditions on primary rat osteoblast survival, differentiation, and vascular endothelial growth factor (VEGF) release.

Primary cells were isolated from the bone marrow of rat tibias and femurs. Cells at the third through fifth passage were subjected to an anoxic environment (5% CO₂, 95% N2) for 2, 4, 8, 12, 16, 20, and 24 hr. Cell counts, lactate dehydrogenase activity, alkaline phosphatase production, VEGF release, and calcium levels were evaluated. Cellular injury was seen at 8 hr, and cell number also began to decrease at 8 hr. The LD₅₀ was determined to be 20 hr. VEGF production increased rapidly at 4 hr and gradually increased throughout the anoxic episode. Osteoblasts showed a low tolerance for anoxia; they responded rapidly to the anoxic episode, released VEGF, and increased osteogenic activity.

De Novo Adipogenesis in a Vascularized Biodegradable Construct. Elisabeth K. Beahm.

Tissue engineering of fat has tremendous appeal for soft-tissue deformities, yet has only recently received significant investigation. Strategies for in vivo engineering of fat are generally divided into two groups: those in which cultured adipose cells are transferred to tissue sites, and those in which de novo fat formation is induced by altering the tissue microenvironment. Previous studies have demonstrated in vivo adipogenesis from endogenous connective tissue stem cells with infiltration of reconstituted basement membrane (Matrigel) and basic fibroblast growth factor (bFGF), but resultant fat growth appeared limited by the forces of the surrounding tissue. In this reported pilot study, Matrigel and bFGF were injected on a vascularized 3-D biodegradable scaffold isolated with a silicone housing, in order to determine the feasibility of engineering an adipocyte construct to a defined vascular pedicle, its stability over time, as well as the influence of construct dimension on resultant fat accumulation.

Eighteen vascularized constructs in 9 athymic semi nude rats, aged 6 to 16 weeks, were used for the study. The vascular construct was engineered, based on the bilateral superficial inferior epigastric vessels, which served as the vascular pedicle. A standardized weight of teased polyglycolic acid suture fibers served as the biodegradable scaffold placed overlying the vessels, and then isolated from surrounding tissue ingrowth with an inert silicone housing. In 3 rats, the vascular pedicle and scaffold were sandwiched between two 1.2×1.2-cm flat pieces of silicone sheeting coated with small surgical clips; in 6 rats, a 1.7×1.7-cm firm silicone dome was used to house the pedicle and polyglycolic acid matrix. Control animals received no further treatment. In the experimental group, Matrigel alone or in combination with bFGF at a ratio of 1:10 was injected onto the scaffold. The animals were re-explored, and the constructs qualitatively assessed at 4, 8, 12, 16, and 20-week intervals. Selected specimens obtained at each interval were submitted for histologic analysis, with H&E and Oil red O histologic staining.

All early specimens revealed some fibrovascular ingrowth, which was far greater in the Matrigel/bFGF constructs. No fat growth was observed in the control and only minimal fat proliferation in the Matrigel only constructs. Adipocyte growth was noted in all Matrigel/bFGF preparations, regardless of the age of the animal. The fat tissue qualitatively remained stable for up to 5 months (life of the animal), was well-vascularized, and assumed a mature histomorphology. The dome-shaped silicone constructs resulted in qualitatively larger 3-D fat constructs, suggesting that fat volume related directly to the configuration of the housing.

The author has demonstrated the ability to induce liponeogenesis in a vascularized, pedicled, biodegradable scaffold. This growth appeared to be qualitatively stable over time. The adipocyte induction was possible in rats of all ages. The pedicled nature of these constructs suggested their applicability for microsurgical transfer. Further investigation incorporating a quantitative assessment of fat growth and the long-term stability and durability of these engineered constructs is ongoing. Future studies will need to focus on the safety and efficacy of the control mechanisms on in vivo adipogenesis.

Simultaneous Transcutaneous PO2 and PCO2 Monitoring for Various Flap Viability. Ichiro Hashimoto and Hideki Nakanishi. Department of Plastic Surgery, Tokushima University, Japan.

Relatively recently, it has become possible to safely transplant skin flaps from various parts of the body. However, the possibility of ischemic or congestive circulatory failure always exists. Thus, a monitoring method that can successfully detect circulatory failure before the development of clinical signs is needed for treatment of the flap. Transcutaneous carbon dioxide pressure (TcPCO2), which has not been given much attention for flap monitoring, shows less change than does TcPO2 at various body sites. The purpose of this presented study was to clinically examine simultaneous TcPO2 and TcPCO2 values in various transplanted flaps.

Fifteen patients in whom TcPO2 and TcPCO2 could be monitored, were selected among cases of skin flap transfer performed at the authors' institution between 1996 and 2000. On the first day after surgery, simultaneous monitoring of TcPO2 and TcPCO2 was performed in each patient via a cutaneous PO2/PCO2 Monitor 9000 (Kohken Medical).

Twelve of the 15 flaps survived completely without incident. Circulatory failure of the skin flaps could be detected in the other three; two of these survived with minimal treatment, and one was salvaged surgically. TcPO2 values in 6 of the 12 surviving flaps remained at 0 mmHg. The TcPCO2 values of the surviving flaps ranged from 42 to 83 mmHg. In the troubled flaps, TcPO2 values remained at 0 mmHg. TcPCO2 values were greater in these troubled flaps than in most of the surviving flaps.

TcPO2 has been used since 1980 for determination of flap viability. In addition to the differences in TcPO2 found at various body sites, it has been controversial whether TcPO2 values do indeed correlate with flap survival. One of the problems has been the interpretation of TcPO2 values that remain around 0 mmHg in surviving flaps. The authors concluded that simultaneous measurement of TcPO2 and TcPCO2 in skin flaps offers more useful information than measurement of TcPO2 alone for predicting flap viability.

Microsurgery in the Treatment of War Wounds. J. Kozarski, L.J. Panajotovic, M. Gacevic, S. Vesanovic, G. Stankovic, and B. Stanojevic. Clinic for Plastic Surgery and Burns, MMA, Belgrade, Slovenia.

Experiences from the civil war in former Yugoslavia showed that there were clear indications for application of free flaps in the treatment of war wounds with extensive tissue defects. War wounds caused by modern infantry weapons or explosive devices are very often followed by defects of various tissues. Such defects can include skin and soft-tissue defects with no exposure of deep structures; skin and soft-tissue defects with exposed deep structures; skin and soft-tissue, tendon, and nerve defect; skin and soft-tissue, tendon, nerve, and bone defects.

At the authors' clinic, they used free flaps in treating 120 wounded with vast tissue defects. With the aim of closing wounds, covering deep structures, or encouraging the possibility for later reconstruction of deep structures, they applied free flaps primarily, delayed, or secondarily. The main criteria for treatment and use of free flaps were the general condition of the wounded patient, and the extent, location, and structure of the tissue defects.

They analyzed both the simple and complex 123 free flaps that were applied. For the extensive defects of tissue and intensively contaminated wounds, they used latissimus dorsi free flaps. For tissue defects of the distal portions of the lower extremities, they used scapular free flaps. While using free tissue transfer for compensation of the bone defects, they applied free vascularized fibular grafts, and in skin and bone defects, they used complex free osteoseptocutaneous fibular, free osteoseptocutaneous radial forearm, and free skin-bone scapular flaps. After free flap transfer, they performed 20 (16.6%) revisions and after 11 (9.2%) unsuccessful revisions, they applied another free flaps in three patients (2.5%), local skin flap (1, 0.8%), cross-leg flaps in 5 (4.2%), or performed below-knee amputation in 2 patients (1.6%).

Treatment of war wounds with extensive tissue defects by application of free flaps provided a shorter wound-closure period, an earlier beginning of physical therapy, and the possibility of treating a great number of patients with extensive defects, considering the influx of wounded patients.

Benefit of Early Microsurgical Reconstruction of High-Energy War Wounds. M. Bumbasirevic, C. Vucetic, A. Lesic, R. Manojlovic, and N. Jovanovic. Institute for Orthopedic Surgery and Traumatology, University Clinical Center, Belgrade, Slovenia.

Eighty-three patients with severe tissue destruction underwent microsurgical reconstruction of war injuries. The sites were the face (12), upper extremity (28), and lower extremity (43). Despite the well-established opinion that closure of war wounds should be delayed because of the possibility of serious infection, the authors performed early microsurgical wound cover in the first group of 52 patients. The second group had wounds in a subacute and chronic biologic phase. A uniform treatment protocol, involving antibiotic prevention, wound irrigation, thorough debridement, fracture stabilization, combined with a free flap, was used in both groups of patients. Complex reconstruction was performed with the goal of immediate restoration of all damaged structures. The latissimus dorsi was the flap of choice in the lower extremity, and fasciocutaneous flaps in hand and facial reconstruction. Bone loss was treated with microvascular free fibula graft or Ilizarov bone transport, combined with free flap coverage. Integrity of the extremity was preserved in all patients but one. Deep infection occurred in 5 patients, and flap necrosis in 2. Within the group of primary or early wound coverage, the results were better in many aspects. Early microsurgical reconstruction of complex high-energy war wounds is the authors' treatment of choice, and was validated as a limb-salvage procedure.

External Decompression and Internal Neurolysis of Leprous Nerves Monitored by Intraoperative Electroneurodiagnostics are Effective and Support Surgical Procedures. E. Turkof, E. Knolle, B. Richard, and S. Tambwekar. Departments of Plastic and Reconstructive Surgery, and Anesthesia B, Vienna University Clinic, Austria; Green Pasture Hospital, Pokhara, Nepal; and K.E.M. Hospital, Bombay, India.

Leprous nerves are affected in various ways, according to the type of the disease, duration of illness, and characteristics of the nerves. If surgery is to be performed for leprous neuropathy, it is crucial to release all the affected segments, to insure effective intervention. The surgical procedure, therefore, should include the option of internal neurolysis, if necessary. The variety of the disease does not lead to uniform pathologic changes in the affected nerves, thus showing various aspects ranging from large localized neuromas to macroscopically inconspicuous, long-distance internal fibrosis.

During several international pilot studies (Bombay, 1992, 1994; Cairo, 1995, Nepal, 1996, 1997), intraoperative electroneurodiagnostics (IOE) have been performed during surgery on leprous nerves to insure effectiveness. In limb nerves, the spinal root was electrically stimulated with surface electrodes; in facial nerves, their exit at the pontal region was stimulated with needle electrodes. Efferent nerve compound action potentials (NCAPs) were registered from the nerve surface with bipolar wire electrodes moved proximally and distally along the exposed segments. Patients were fully relaxed to avoid volume conduction. If the amplitudes of the NCAPs showed significant depletion on macroscopically inconspicuous segments, epineuriotomy was performed and completed by interfascicular neurolysis, if fibrosis of the interfascicular epineurium was observed.

The implementation of IOE revealed that nerve lesions reach far more proximally than the expected sites, and that leprous nerves are often affected in a scattered way (median, tibial, and facial nerves). Surgery, even though performed invasively, did not further deteriorate nerve function.

Conventional nerve conduction velocity studies (NCV) are commonly performed preoperatively to determine the site of lesion. However, the technique is limited in two ways: the proximal extent of the lesion cannot be detected, and a second affected site in cases of scattered lesions (median nerves, tibial nerves, facial nerves) would not be identified. Furthermore, measurements are impaired, if the common stimulation sites are affected as well, which is frequently the case (distal upper arm/ulnar nerve, cubital region, median nerve, fibular head/peroneal nerve, popliteal region/tibial nerve, stylomastoid foramen/ facial nerve). In contrast, with IOE, the nerves are stimulated at the most proximal possible site.

Leprous patients in whom the bacteria have been eradicated, often suffer from devastating neuropathies which cannot be cured without surgery. IOE is a safe tool to insure effective interventions.

Microsurgical Reconstructions as Long-Distance Visiting Microsurgeons: Personal Experiences. Barbara S. Lutz and Jan B. Wieslander. Department of Plastic Surgery, Medical Centre Orebro, Sweden.

During a period of 7 months, 17 free flap reconstructions were performed by either one of the authors as long-distance visiting microsurgeons. Free flap transplantations were performed for head and neck reconstruction in 16 patients, and for soft-tissue reconstruction in the lower leg in 1 patient. There were 13 males and 4 females, 62 years old on average. Free flaps included fibula with (6) and without skin paddle (1), radial forearm flap (4), anterolateral thigh flap (4), crista iliaca (1), and myocutaneous latissimus dorsi flap (1). Nine patients underwent resection of a primary head and neck tumor. Four patients were operated on for tumor recurrences, one for radionecrosis, two for fistulas after previous mandible reconstruction with free fibula, and one for coverage of a traumatic soft-tissue defect in the lower leg. Seven patients were irradiated before free flap reconstruction, and three patients received a second free flap after previous mandible reconstruction with a free fibula 1 to 3 years preoperatively.

No acute re-exploration was necessary, and there was no complete flap loss. One partial skin loss after free osteomyocutaneous fibula transplantation healed spontaneously in one case without further sequelae. In a second patient a pedicled trapezius flap and hyperbaric oxygen therapy healed a persistent orocutaneous fistula in a severely irradiated patient. A small oronasal fistula after maxilla reconstruction healed uneventfully.

The microsurgeon arrived 1 day before reconstructions and stayed 1 to 3 days postoperatively. Preoperative investigations and postoperative care was provided by the local plastic surgeons (who had no microsurgical experience), the ENT surgeons, and the nurses, following the regimen given by the respective microsurgeon. Although preoperative investigations and postoperative treatment varied between the two microsurgeons, individual guidelines were followed meticulously. Contact via e-mail or telephone was always possible.

Microvascular reconstructions, performed by a long-distance visiting microsurgeon, have been shown to be a reliable and safe option. This may be of advantage in remote areas with no available microsurgeon, thus avoiding long transports of patients and the accompanying high costs.

Reconstructive Lymphatic Microsurgery: Techniques and Long-Term Results. C. Campisi. Department of Special Surgery Sciences, Anesthesia, and Organ Transplants, Emergency Surgery Lymphology and Microsurgery Center, S. Martino Hospital, University School of Genoa, Italy.

This author reported the modern surgical management of peripheral lymphedema. For an adequate selection of patient candidates for lymphatic microsurgery, proper diagnostic investigations are indispensable. Diagnostics include lymphoscintigraphy, an accurate study of venous circulation and, in cases of complex angiodysplastic syndromes, also the arterial system. Based on the author's 30 years or so of clinical experience (more than 1000 patients), the role of lymphatic microsurgery was particularly emphasized. Among derivative lymphovenous shunts, lymphatic-venous multiple anastomoses (LVA) have been used extensively. For those patients in whom venous disorders are associated with the lymphedema, it is possible either to repair the venous insufficiency and use LVA, or to perform reconstructive techniques, using vein grafts interposed between the lymphatics above and below the obstacle to lymph flow, i.e., lymphatic-venous-lymphatic anastomoses (LVLA).

With follow-up from 5 to 15 years after microsurgical procedures, positive results were achieved in more than 80% of the cases, with better results among patients operated on at the earlier stages (II or III) of lymphedema. Long-term clinical outcomes showed that lymphatic derivative and reconstructive microsurgical techniques can be advantageously used to treat not only secondary, but also primary, lymphedemas, even in childhood.

Adductor Magnus ``Back-Up'' Free Flaps. Emmanuel G. Melissinos, Timothy Leung, and Donald H Parks. Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Texas, U.S.A.

The use of the adductor magnus muscle as a free flap in cases in which the gracilis is unsuitable for transfer was introduced.

The gracilis muscle has been reliably utilized as a free flap for different types of reconstruction by these authors. During a 22-year experience, 168 gracilis free flap transfers were attempted. The size of the branches of the medial circumflex femoral vessels supplying the gracilis was found to vary considerably, but in most cases (163) was judged adequate for transfer. On five occasions (2.98%), it was detected intraoperatively that the main blood supply to the gracilis originated from multiple branches of the superficial femoral vessels. The caliber of the division of the medial circumflex femoral artery to the gracilis muscle was found to be extremely small (less than 1 mm in diameter), rendering the gracilis unsuitable for use as a free flap. Lack of a better donor site in these 5 cases, due to a combination of spinal, intraabdominal, and upper extremity injuries, prompted further dissection of the local vascular distribution, revealing that the caliber of the vascular pedicle to the adjacent adductor magnus was much larger than that of the gracilis muscle, varying between 2.5 and 3.5 mm in diameter. Subsequent dissections indicated that such sized vessels to the adductor magnus were observed only in the presence of extremely small branches to the gracilis.

The medial muscle fibers of the adductor magnus were harvested and transplanted successfully for reconstruction of lower extremity soft-tissue defects. Follow-up of 6 months to 18 years demonstrated no detectable morbidity from the procedure. Advantages of utilizing the adductor magnus free flap when the gracilis is found to be unsuitable for transfer include: 1) ease of harvest via the same incision, averting the need to abandon the procedure for a new harvest site; 2) large size of muscle available for reconstruction; 3) minimal additional operating time; and 4) minimal donor-site morbidity.

Based on the authors' experience, it was recommended that, in rare cases where the main vascular pedicle of the gracilis muscle is found to be small and not useful for free flap reconstruction, the vascular distribution to the adjacent adductor magnus muscle should be examined. If suitable, the adductor magnus can be used safely and reliably as a free flap, substituting for the gracilis muscle.

Formation of Independently Revascularized Bowel Segments Using the Rectus Abdominis Muscle Flap: Rat Model for Jejunal Prefabrication. B.K. Tan, H.C. Chen, F.C. Wei, S.F. Ma, C.T. Lan, L.C See, and Y.L Wan. Plastic Surgery, Singapore General Hospital and Chang Gung Memorial Hospital, Taiwan.

Reconstruction of the pharyngoesophagus with free jejunal transfer is a major challenge, when recipient neck vessels are absent because of previous surgery or irradiation. In such instances, jejunal transfer using a muscle flap as a ``vascular carrier'' may be a problem-solving alternative. Pretransfer vascularization of the jejunum is achieved by wrapping the muscle flap around the small bowel segment. After a short staging period, the mesenteric pedicle is divided, and the bowel segment transferred up to the neck based on its new blood supply. The objectives of this reported study were to develop an animal model for prefabricating independently revascularized jejunal segments, using the rectus abdominis muscle flap, and to determine the minimal time required for independent bowel survival.

Twenty-four mature (500 to 700 g) rats were divided into 6 experimental groups of 4 animals each. In each animal, a 1.5-cm segment of proximal jejunum was isolated on two jejunal arteries and wrapped around with a superior pedicled rectus abdominis muscle flap. To determine the time of neovascular takeover, the mesenteric pedicles were ligated on postoperative day 2 (Group 1), day 3 (Group 2), day 4 (Group 3), day 5 (Group 4), day 6 (Group 5), and day 7 (Group 6). At the time of pedicle ligation, the composite flap was transposed to a new subcutaneous position. Viability of bowel was assessed according to gross appearance and histology 48 hr after transfer.

Complete survival of revascularized jejunum in 11 of 12 animals was obtained after pedicle ligation on postoperative day 5 and beyond (p<0.0001, Fisher's exact test). These bowel segments demonstrated luminal patency, intact pink mucosa, mucous production, and visible peristalsis. Histologic evaluation showed healthy intestinal epithelium and tissue integration along the serosa-muscle interphase. In contrast, pedicle ligation on day 4 and earlier resulted in varying degrees of bowel necrosis characterized by flattening or ulceration of mucosa (day 4), mucosal sloughing and necrosis of mural musculature (day 3), and complete loss of bowel architecture with lumen obliteration (day 2). These findings suggested that jejunal segments may be independently revascularized with the rectus abdominis muscle flap in the rat model. Complete survival and gross normal bowel function may be obtained without mesenteric perfusion after a minimal time of 5 days.

One-Stage Reconstruction of Soft Tissue and Neurovascular Defects of the Hand with the Free Neurocutaneous Venous Flap. Tai-Ju Cheng and Hung-Chi Chen. Plastic Surgery, En-Chu-Kong Hospital, Taipei, Taiwan.

The purpose of this study was to evaluate the 4-year clinical result of using neurocutaneous free venous flaps for repairing digital soft tissue and neurovascular defects in one stage. Following crush injury, combined soft-tissue and segmental neurovascular defects are sometimes encountered. One-stage reconstruction of such complex defects requires a supply of soft tissue, a vascular conduit, and a nerve conduit simultaneously. A venous flap harvested from the distal palmar forearm can incorporate a segment of antebrachial cutaneous nerve. The venous pedicle of the flap can bridge the vascular defect, and the nerve graft repairs the nerve defect, with the flap per se covering the soft-tissue defect.

From 1994, 8 cases of digital crush injury with soft-tissue and segmental neurovascular defect were repaired with arterialized neurocutaneous free venous flaps in one-stage reconstruction. Two flaps with marginal loss were treated conservatively and the wounds healed uneventfully. The arterialized flap provided stable wound coverage and protection of the venous and neural pedicle contained within it. At 6-month follow-up, sensory return was demonstrated for every case, with a range of two-point discrimination from approximately 6 to 10 mm.

Using the neurocutaneous free venous flap, complex digital defects with soft-tissue and neurovascular involvement can be reconstructed in a one-stage and one-procedure modality. The authors believe this is a versatile option in managing such problems.

Role of Th1 Cytokines in Tolerance Revisited: Effect of T Cell Clone Size. Koji Kishimoto, Isao Koshima, and Mohamed H. Sayegh. Department of Plastic and Reconstructive Surgery, Laboratory of Immunogenetics and Transplantation, Okayama University Medical School, Japan; and Harvard Medical School, Boston, Massachusetts, U.S.A.

Transplantation of limb tissue allografts would greatly expand the realm of reconstructive surgery. Recent studies have demonstrated that limb tissue allograft tolerance was achieved between MHC-matched swine, using a limited course of immunosuppression. It is known that the Th1 cytokine, IFN-gamma or IL-2, is necessary for tolerance induction by T cell costimulatory blockade in MHC-mismatched donor/recipient combinations. However, it is not known whether this is true for tolerance across minor histocompatibility barriers.

The authors hypothesized that, while reduction of donor-reactive clone size by IFN-gamma or IL-2 may be necessary for induction of tolerance in conditions of high alloreactive T cell clone size (MHC mismatched combination), these cytokines may not be necessary for tolerance, when the alloreactive T cell clone size is relatively small (minor mismatched combination). In vitro data showed that the estimated T cell clone size of C57BL/6 mice against minor-mismatched 129 mice was approximately 10-fold smaller than against MHC-mismatched BALB/c mice.

To test this hypothesis, IFN-gamma-/-, IL-2 -/- or wild type C57BL/6 mice were used as recipients of BALB/c (MHC mismatch) or 129 (minor mismatch) cardiac allografts. In the MHC-mismatched combination, CD28-B7 blockade by CTLA4Ig induced long-term allograft survival in IFN-gamma -/-, IL-2 -/-, and wild-type recipients. Moreover, in the minor-mismatched combination, CD154 blockade by MR1 was not as effective as CD28 to blockade by CTLA4Ig in IFN-gamma -/- recipients.

These studies indicated that the requirement of Th1 cytokines for tolerance induction is not universal; both the alloreactive T cell clone size, as well as the tolerance strategy itself, are important determinants of this requirement. This has implications for the design and implementation of clinical strategies to induce transplant tolerance.

VEGF Expression in Pig Latissimus Dorsi Myocutaneous Flaps after Ischemia/Reperfusion Injury. D. Erdmann, K.C. Olbrich, R. Sweis, C.E. Eyler, M.S. Wong, L.E. Niklason, T.V. DuLaney, L.S. Levin, and B. Klitzman. Kenan Plastic Surgery Research Laboratories, Division of Plastic Surgery and Department of Biomedical Engineering, Duke University Medical Center, Durham, North Carolina, U.S.A.

Vascular endothelial growth factor (VEGF), a potent angiogenic, mitogenic, and vascular permeability-enhancing glycoprotein, has been recently reported to significantly improve survival of ischemic flaps, independent of the route of (exogenous) administration. The purpose of this reported study was to determine endogenous VEGF expression in myocutaneous latissimus dorsi flaps after ischemia/reperfusion injury, which has not previously been reported.

Twelve latissimus dorsi myocutaneous flaps (15×10 cm) were elevated bilaterally in six Yorkshire male pigs (26 kg). After isolation of the vascular pedicle, one flap was randomly assigned to 4 hr of ischemia by occluding the axial pattern blood flow, following by 2 hr of reperfusion. The contralateral flap served as a control. Skin blood flow in each of three zones (5×10 cm - zone 1, base; zone 2, middle; zone 3, tip) was evaluated as baseline after flap elevation, after 4 hr of ischemia, and after 1 and 2 hr of reperfusion with laser Doppler flowmetry. Microvascular length density was monitored using orthogonal polarization spectral imaging (OPSI). Skin and muscle biopsies were taken at the end of the protocol, and VEGF protein levels determined for each flap zone, as well as for tissue adjacent to the flap, using the human VEGF Quantikine^R immunoassay.

Laser Doppler flowmetry quantitatively differentiated perfusion in different musculocutaneous flap zones during ischemia and reperfusion. Skin blood flow was similar among flap zones 1, 2, and 3 prior to surgery. Flow fell similarly in both flaps immediately following flap elevation. After 4 hr of ischemia, blood flow fell to 1.1±0.5, 0.8±0.3, 0.5±0.2 LDF units in zones 1, 2, and 3, respectively, compared to control flaps (2.1±0.5, 1.8±0.4, 1.1±0.4; p≤0.05, ANOVA). After 2 hr of reperfusion, flow in ischemic flap skin recovered to levels in control flaps. OPSI showed microvascular density and architecture in muscle before, during, and after occlusion. No significant differences were found in linear vascular density (LVD) in ischemic flaps vs. control flaps. VEGF levels (pg/mg protein; mean ± SEM) were given.

VEGF protein levels in muscle tissue exceeded levels in skin, and decreased from zone 1 to 3 in control, as well as ischemic flaps. Differences in ischemic flap muscle zones, compared to control flap muscle zones, were not statistically significant. However, both flaps had significantly higher VEGF levels, compared to muscle tissue adjacent to the flap (p≤0.05, ANOVA). VEGF levels in skin zones 1 and 2 were significantly higher in ischemic flaps, compared to control flaps (p≤0.05, ANOVA), but levels in zone 3 (most ischemic) showed no significant difference.

Moderate ischemia stimulated VEGF protein expression in muscle as well as skin. However, endogenous up-regulation did not reach levels of exogenous VEGF administered in previously reported studies. Therefore, endogenous VEGF is unlikely to achieve optimal production. The results do support utilization of VEGF as an adjunctive microsurgical therapy in the future.

Effect of Amifostine on Pre- and Postoperative Irradiation Damage in Microvascular Anastomoses, Nerve Regeneration, and Wound Healing. Atakan Aydin, Rasym Meral, and Aly Mezdedy. Department of Plastic and Reconstructive Surgery, Istanbul University Medical Faculty, Turkey.

A comparative study was undertaken to evaluate the possible effects of amifostine on irradiation damage in the healing of microvascular anastomoses, nerve regeneration through neurorrhaphy, and flap survival, either with preoperative irradiation+surgery or surgery+postoperative irradiation in New Guinea pigs.

One hundred and twenty adult male New Guinea pigs were divided into 3 main groups (40 animals in each), to study microvascular healing, nerve regeneration, and flap survival. Femoral arteries, ischiatic nerves, and pedicled groin flaps were used in the three groups, respectively. In each group, 4 subgroups were created comprising 10 animals. In subgroups I, II (in subgroup II, a single dose of 40 mg/m² amifostine was administered intraperitoneally a half-hour prior to irradiation), the animals were exposed to radiotherapy with a dose of 20 Gy in a single fraction at a 170,916 cby/min dose rate, at an 80-cm source to a skin distance from 3 to 4 cm in the groin or gluteal fields involving the femoral artery, groin flap, or ischiatic nerve according to the main group, using a Co60 megavoltage radiotherapy machine. The animals were operated on under general anesthesia 2 weeks later. During the operation, femoral microarterial anastomoses, ischiatic nerve neurorrhaphy, and groin flap dissection, including the epigastric vessels, were performed (each in one group), and all operation sites were closed primarily.

In subgroups III, IV, the animals were operated on, and after 2 weeks were irrradiated as in subgroups I, II, but in subgroup IV, a single dose of 40 mg/m² amifostine was administered intraperitoneally a half-hour prior to irradiation. All animals were explored under general anesthesia after 1 month. Patency for vessel anastomoses, flap viability, and percentage trophic changes and muscle weight were evaluated, and histopathologic specimens were taken to evaluate vessel and nerve regeneration (axon-count in nerve, and motor endplate count in muscle) for PCR, DNA, and RNA testing. Some beneficial effects of amifostine on wound healing and nerve regeneration were observed both clinically and microscopically.

Radiotherapy kills cells by chemically altering DNA, either by ionization of DNA or by production of highly reactive, diffusible free radicals generated by ionization of other cellular constituents. Endogenous thiols and their ions react with both free radicals and irradiation-induced DNA radicals, and may increase cell survival, if the interactions occur prior to DNA damage or fixation. Amifostine appears to act with a mechanism similar to that of the endogenous thiols. Therefore, its radioprotective effect is probably mediated in part via enhancement of oxygen removal and induction of hypoxia, effects produced by thiol oxidation reactions. These results may suggest that in both pre- and postoperative radiotherapy, amifostine can protect from radiation side-effects, and can increase therapeutic potentials.

Quantitative Color Monitoring of Flap Congestion in an Experimental Rabbit Ear Flap Model. Daisuke Ishigaki, Hiroyuki Tsuchida, Hideo Kashiwa, Noriaki Kikuchi, and Toshihiko Ogino. Department of Orthopaedic Surgery, Yamagata University School of Medicine, Japan.

Flap congestion is an important complication in microsurgical flap surgery. Clinically, observation of flap color is commonly used in the assessment of flap congestion. However, the evaluation of color is subjective, and does not always adequately identify changes in flap color. Quantitative evaluation of flap color would be desirable in objective assessment. The purpose of this study was to investigate the distinctive color pattern of skin congestion, and to examine the validity of the colorimeter in quantitative flap color monitoring.

A congested flap model was created in 5 rabbit ears. The ears were amputated at the level of 4 cm from the apex, except for the posterior auricular artery. One hour after surgery, a small incision was made in the congested flap to draw blood from the flap. Skin color was measured with a colorimeter in the same region, and and L* a* b* color system was used for color evaluation.

Before surgery, the normal color of the rabbit ear was evaluated as high L* (light color), high a* (bright red), and plus value of b* (yellowish), while the color of the congested flap was evaluated as lower L* (dark color), lower a* (dull red), and minus value of b* (bluish). The colorimeter was able to detect color improvement when blood was drawn.

These results indicated that quantitative color monitoring with the colorimeter is useful for the assessment of flap congestion. Compared with gross color assessment with the human eye, color measurement is reproducible and is subject to examiner bias. The colorimeter is a simple and non-invasive device for clinical application.

Free Vascular Bundle Transfer for Neovascularization of the Tissue: Clinical and Allogeneic Experimental Study. Ritsu Aoki, Hiko Hyakusoku, Takashi Hirai, Koichiro Oki, and Hiroshi Mizuno. Department of Plastic and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan.

Since 1980, these authors have had experience with facial reconstructions, using prefabricated flaps, as follows: 1) forehead reconstruction with a pedicle-pedicle type lateral neck flap (1 case); 2) eyebrow reconstruction with a secondary vascularized retroauricular reverse hair stream flap (2); 3) eyebrow reconstruction with a tandem island hairy flap (2); 4) nose reconstruction with an expanded median forehead flap (3); 5) nose reconstruction with a secondary cartilage graft radial forearm flap (1); 6) male upper lip reconstruction with a secondary bearded flap (2); 7) helical reconstruction with a secondary vascularized flap (4); 8) total ear reconstruction with a secondary cartilage grafted flap (4), radial forearm (2), groin (1), secondary vascularized supraclavicular flap (1); 9) eyelid reconstruction with a secondary skin-grafted temporal fascial flap (1).

Their original technique was a free superficial temporal vascular bundle transfer for making a secondary vascularized flap, which was presented in 1984 and 1987. Recently, they used a deep epigastric artery and vein as a vascular bundle for implantation. In addition, an experimental study of the allogenic vascular bundle implantation for making a secondary vascularized flap has been done, and a preliminary report was presented in 1996.

They are currently investigating the usefulness of the allogeneic vascular bundle as a vascular crane for neovascularization of donor tissue. Its capability of contribution to in vivo tissue engineering was presented, demonstrating successful fistula closure using the free allogeneic bundle in rabbits.

Clinical Monitoring and Free Flap Perfusion Complications. R. Giunta, A Geisweid, E. Biemer, and A.M. Feller. Departments of Plastic Surgery, Rechts der Isar University Hospital, Munich, and Behandlungszentrum, Vogtareuth, Germany.

The aim of the presented study was to present a new clinical classification of disturbances of the circulation in free flaps, and to assess the results of treating the complication at each of the stages described.

Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized according to the time required for recapillarization, the color of the transplant, and the bleeding on puncture.

Complications occurred in 69 cases (36%), including intraoperative revisions during the first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of loss increased in progressive stages to 41%. With venous disturbances, the losses which occurred in stage I and II were predominantly partial. In 164 cases (85%), the flaps remained undamaged. In 15 cases (8%), there was partial loss of the transplant, and in a further 13 cases (7%), complete loss finally had to be accepted.

The results confirmed that the presented clinical classification is indeed a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led to a positive result for the patient in the overwhelming majority of cases.

Functional Long-Term Outcome Following Tissue Transfer in Mutilating Foot Injury. Peter Benner. University Hospital Gasthuisberg, Catholic University of Leuven, Belgium.

The importance of a microvascular soft-tissue envelope for fracture healing in types IIIB and IIIC defects is well-recognized. Although early coverage is advantageous, because of the step-child position of the damaged foot in resuscitation efforts, more than a quarter of all victims with severe foot injury will suffer a useless extremity.

The long-term results of treatment with post-primary free tissue transfer in mutilating complex foot injury are difficult to evaluate. The various pathogenic mechanisms, together with the great variability and lack of validity of the foot scores used, make comparisons among different patient series often invalid. To assess the best reconstructive management, a retrospective study was designed respecting timing, sensory restoration, postoperative complications, dynamic gait analysis, and functional outcome. Twenty-nine consecutive free flaps (12 radial forearm flaps, 9 latissimus dorsi, 1 LD+serratus+rib+scapula, 1 serratus+rib, 2 latissimus upper arm flaps, 2 rectus abdominis flaps, 1 anterolateral thigh flap, 1 anterior plantar medial) were performed in 28 patients with complex foot trauma over a 3-year period. Two-thirds were polytraumatized.

The severity of the mutilating foot injury was graded with 6.4 points (mangled extremity severity score), and identified thrombosis and partial flap necrosis (1), lost skin graft (1), hematoma (2), and an infection rate of 19.7% There was 1 secondary lower-leg amputation, and 2 debulkings of muscle flaps. Follow-up duration was 14 months.

To quantify regained foot function, the three most popular evaluation systems were applied simultaneously: 1) the Maryland foot score; 2) the Merle d'Aubigne score; 3) the foot point scores of pain, gait, stability, support, limp, functional activities (shoes, stairs, terrain), cosmesis, and motion. A supplementary subunit of the AOFAS scale evaluated alignment (total 100 points). The d'Aubigne score is easy to use and includes 18 points. 2PD ranged from 19 to 36 mm. Skin-grafted muscle flaps showed twice the amount of 2PD, compared to healthy surrounding tissue. Still, two latissimus dorsi flaps showed recurrent skin breakdown and ulceration. 15/28 patients had ``good'' or ``excellent'' results, 9/28 were graded as ``satisfactory,'' and the remaining 4 patients had ``unsatisfactory'' foot function. Three of 4 of all Maryland points were achieved, as well as 66.2% of the AOFAS scale, and 13.4/18 d'Aubigne points.

Unfavorable results were due to 1) multilevel fractures with periosteal stripping; 2) devitalization of the tarsal bones; 3) aviator's astragalus; 4) compromises concerning the treatment; 5) delayed soft-tissue coverage; and 6) post-traumatic fibrosis below the flap. Dynamic pedobarography seems senseless unless a plantigrade skeleton is not achieved. Fasciocutaneous flaps are a prime choice for the perimalleolar region, the hindfoot, and the dorsum in moderate-sized defects. Skin-grafted muscle flaps can wrap the entire foot following crush or avulsion injuries, while multiple-layer loss is best substituted by similar compound tissue. (``If it looks like a foot, it will work like a foot,'' Hansen, 2000)

Head and Neck Reconstruction: 13 Years of Microsurgical Experience. O. Papadopoulos and N. Tsakoniatis. Laiko University Hospital and Henri Dunant Hospital, Athens, Greece.

The authors presented their experience over the last 13 years using free and pedicled flaps, in order to compare and codify their optimal use in relation with localization and stage of the disease, age, and general condition of the patient.

Twenty-three patients were treated and 24 free flaps were used. The mean age of the patients was 53 years (range: 25 to 81 years), and the ratio of male to female was 19:4. Histologically, there was a predominance of SCC (13), BCC (3), Merkel carcinoma (2), esophageal carcinoma (2), and maxillary SCC (1). Two cases of calvarial osteomyelitis were treated as well. No traumatic loss of tissue needed to be covered. Localization of cancer in this series was everywhere in the head and neck, except the mandible. The majority of free flaps used were latissimus dorsi, simple MC, or combination with serratus and rib (12 patients), but also antebrachial flaps (8), epiploon (1), TFL (1), and jejunum (2). Three flaps suffered from venous thrombosis and consequent total necrosis, and 1 flap (antebrachial) suffered from venous thrombosis and consequent total necrosis; one flap (antebrachial) suffered necrosis of the cutaneous component. These 4 patients were managed using traditional methods. Mean follow-up time was approximately 5 years, and the survival rate was 90%. The hospital mean stay was 16 days.

More than 10 years of free tissue reconstruction of the whole body has permitted the reevaluation of the importance of traditional methods, and the balance of choices between free and pedicled flaps in relation to disease outcome and survival, operative difficulty, hospital stay, and cost.

Dealing with head and neck reconstruction is an exciting and challenging domain of plastic surgery, and the association of functional and aesthetic results is of paramount importance. Microsurgery has been the key to a more aggressive and meticulous treatment of cancer.

Simultaneous Reconstruction of Complex Defects with Combined Lip-Switch Procedures and Free Flaps. Yung-Kuei Her, Seng-Feng Jeng, Yur-Ren Kuo, and Fu-Chan Wei. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung, Kaosiung Hsien, Taiwan.

Massive facial defects including the oral sphincter, are challenging to reconstructive surgeons. This study presented the authors' approach to simultaneous reconstruction of complex defects with combined lip-switch procedures and free flaps.

From January 1997 to December 2000, 16 patients were studied, following ablative oral cancer surgery. Twelve were cases of buccal cancer, 2 lower-lip cancer, and 2 maxillary cancer. One-third of upper and/or lower lips were excised. A switch flap from the opposite lip was used for reconstruction of the oral commissure. Among them, 8 patients were reconstructed with radial forearm flaps, 6 patients with fibula osteocutaneous flaps, and another 2 patients with anterior lateral thigh myocutaneous flaps.

Free flap survival was 94%. One case failed due to arterial occlusion, which needed another radial forearm flap for reconstruction. All the patients had good-to-excellent oral competence. A majority of 75% of the patients had an adequate oral stoma, and could eat a soft diet. Most of the patients have an acceptable appearance.

Immediate reconstruction of defects using a lip-switch procedure resulted in excellent oral competence. The free flap can be used to reconstruct the soft tissue of the intraoral and external cheek skin. This simple procedure can provide the patient with a useful oral stoma and acceptable cosmesis.

Mandibuar Reconstruction with Microsurgical Fibula Flaps Following Wide Resection for Ameloblastoma. William Lineaweaver, Feng Zhang, and Jeffrey Caplan. Division of Plastic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A.

Ameloblastomas are locally invasive mandibular tumors arising from dental elements or keratocysts. Curettage or enucleation results in 90% recurrence rates, while wide resection with margins of uninvolved bone are curative in 95% of the cases.

Large lesions with mucosal ulceration present complicated reconstructive problems following definitive reconstruction. Three such lesion cases (size ranging from 5 to 9 cm) were treated with microsurgical fibular osteocutaneous flaps. All healed with functional resullts. An orocutaneous fistula developed in one patient after loss of the skin paddle, but this complication healed with local mucosal flap coverage. Complications were otherwise negligible. Follow-up has been simple, with no radiographic or physical recurrences noted with up to 18 months of follow-up.

Fibular osteocutaneous flaps offer an effective reconstruction following wide resection of large ameloblastomas.

Rectus Abdominis Musculocutaneous Flap and Reconstruction Plate for Oromandibular Reconstruction. Kayo Nakamura, Sigehiro Ikemoto, Kouichi Hirotomi, Yuri Kanno, and Jiro Maegawa. Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Japan.

Osteocutaneous free flaps are generally accepted as optimal for oromandibular reconstruction; however, these may be more invasive than the flap and plate methods, considering the prognosis of the patients. One of the biggest complications of the flap plate options is skin perforation. To prevent skin perforation of the plate, the authors apply a rectus abdominis musculocutaneous flap and reconstruction plate for oromandibular reconstruction. This paper presented and discussed the usefulness of the flap as an alternative method.

Between 1993 and 1998, the method was applied in 14 patients. Average follow-up period was about 3 years. The oral soft-tissue defect was repaired first, using a free rectus abdominis musculocutaneous flap, and the plate was then fixed. The plate was wrapped by the rectus muscle and subcutaneous tissue of the flap, to prevent exposure of the plate and to minimize dead space around the plate.

The transferred flap was successful in all the patients. Six patients died of the original disease, and two dropped out of the follow-up. As far as can be observed, there was no plate exposure, no loosening, and no fistula formation. Dislocation of the condyle of the plate was observed in one patient.

The authors believe that this method is reliable and an alternative option for oromandibular reconstruction.

One-Stage Reconstruction of Large, Composite Cheek-Gum Defects with the Extended Rectus Abdominis Flap. Vijay V. Haribhakti, and Samir Kumta.

Advanced stage and recurrent cancers of the cheek that qualify for surgical treatment invariably entail extensive resections of the cheek, mandible, and facial skin, together with significant loss of contiguous tissues like the lips, floor of mouth, maxilla, and oropharyngeal walls. These large and complex defects pose significant challenges for the reconstructive surgeon and lead to permanent crippling of oral function, if not adequately reconstructed. The authors presented their experience with reconstruction of 7 such defects employing the extended rectus abdominis flap based on the deep inferior epigastric artery. All patients but one had recurrent, locally advanced cancers following failed surgery and/or radiotherapy, and were in good general health and free from distant metastases. Six were men and one was a woman, all in their fourth or fifth decades of life. All patients had large, composite, through-and-through cheek defects with loss of half the mandible, and variable portions of the lips and maxilla. In two cases, the mucosal defect extended posteriorly to the oropharyngeal wall.

The flap design in all patients was based on an oblique axis extending from the umbilicus to the ipsilateral scapular angle. It included a medial myocutaneous component, a central de-epithelialized portion, and a further lateral fasciocutaneous component. Depending on the requirements in each case, the medial skin was used for lining or cover, the central portion of the flap buried between the inner and outer components of the defect, and the lateral skin used for the remainder of the defect. No bony reconstruction was performed. It was always possible to close the donor area primarily without using meshes or grafts.

All flaps survived completely, and the only postoperative complications were dehiscence and sepsis, which were anticipated because of the large, necrotic tumors presenting in devitalized fields. One patient required surgical debridement and re-suturing. The average hospitalization was 2 weeks.

Despite lack of bony reconstruction, acceptable contour was achieved in most cases. The color match between the facial and abdominal skin was good. The functional results were variable, and were significantly affected by the extent of loss of mandible, tongue, floor of mouth, and lips

Given the highly challenging defects that were repaired, the guarded long-term prognosis of these patients, and the need for an efficient one-stage approach, the results were gratifying.

Folded Double Paddled Free Flaps for Head and Neck Reconstruction. Nazim Cerke, Atakan Aydin, Murat Topalan, and Metyn Erer. Department of Plastic and Reconstructive Surgery, Istanbul University Medical Faculty, Istanbul, Turkey.

The authors reported their experience with reconstruction of full-thickness defects of the oral cavity and pharyngo-esophageal region after wide surgical cancer ablation using different types of free flaps during the past 10 years.

Twenty-two radial forearm flaps, six latissimus dorsi flaps, and three rectus abdominis flaps were used in a bi-paddled fashion for full-thickness defects of the cheek, floor of the mouth, maxillectomy, and pharyngostoma defects resulting from cancer resection. The flaps provided both intraoral lining and skin cover in all cases.

All the flaps survived. In one latissimus dorsi transfer, a partial skin necrosis occurred in the distal paddle. No major complications were observed. Salivary fistula developed in 6 cases, which healed spontaneously up to 4 weeks postoperatively. The patients started oral feeding around 3 weeks postoperatively.

Double paddled free flap reconstruction of the oral cavity has many advantages. It is a one-stage reconstruction, patient recovery is shorter, and patient quality of life is better.

Facial Reconstruction of Barraquer-Simons Lipodystrophy with Simultaneous Bilateral Free TRAM Flaps. B.C. Coessens, J. Van Geertruyden, and J.V. Berthe. Department of Plastic and Reconstructive Surgery, Free University of Brussels, Belgium.

Barraquer-Simons lipodystrophy is characterized by an atrophy of the subcutaneous fat limited to the upper part of the body, including the face. The use of bilateral free TRAM flaps in two patients was presented for a one-stage reconstruction of facial deformities.

Two women, aged 35 and 38 years of age, presented with the typical appearance of partial lipodystrophy, an extreme bilateral fat atrophy of the face, arms, and trunks. They complained of their peculiar gaunt aspect being responsible for psychological troubles and social exclusion. In both patients, bilateral TRAM flaps were harvested, drawing on the abdomen the pattern of the planned facial reconstruction. It was intended to fill the cheeks with the additional volume created by the rectus muscles; the deepithelialized skin would help create a smoother contour and improve the volume deficit in the malar and mandibular regiions. A skin paddle, 4×7 cm, was left intact for vascular monitoring of the flaps. The face was bilaterally dissected in a subcutaneous plane through a facelift approach extended to the submandibular region to reach the facial vessels on both sides. Monitoring cutaneous paddles were sutured into the submandibular incisions.

In both patients, healing was uneventful. The monitoring skin paddles were removed at 4 months postoperatively. No other revision surgery had to be performed. Surgery lasted less than 5 hr, since no change of position and only one donor site dissection were required. At more than 6 months and 2 years, respectively, the result was stable and symmetric, with a high degree of patient satisfaction.

Two cases of Barraquer-Simons lipodystrophy in which facial contour was restored with the use of simultaneous bilateral deepithelialized TRAM flaps were presented. In both cases, stable facial appearance over time was obtained, along with limited donor-site morbidity.

Reconstruction with Free Flaps after Total Glossectomy. N. Felici, G. Montemari, G. Bellocchi, and B. Pesucci. Department of Plastic and Reconstructive Surgery, Az. Osp. S. Camillo, Forlanna, Rome, Italy.

These authors reported their experience in reconstruction of the tongue after total glossectomy for cancer. Between 1997 and 2000, three total tongue reconstructions were performed with the rectus abdominis muscle free flap. No partial or total flap necroses occurred and, in all cases, good tongue mobility was achieved; all patients can speak and be understood by relatives (one case) and other people in normal conversations (two cases). The experience, even if in a limited series of cases, demonstrated that the rectus abdominis muscle free flap is a safe, suitable, and reliable flap for total tongue reconstruction.

Pre-Expanded Arterialized Venous Free Flaps for Burn Contracture of the Cervicofacial Region. Sang-Hyun Woo and Jung-Hyun Seul. Yeungnam University Hospital, Taegu, Korea.

Despite the fact that arterialized venous flaps provide thin, good quality tissue to defects of the face and neck, their clinical applications have been limited by an unstable postoperative course and necrosis of the flap. The authors tried to resolve these problems by applying tissue expansion techniques to the arterialized venous flap before flap transfer. Three cases of pre-expanded arterialized venous free flaps were used for postburn scar contracture of the cervicofacial region. 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. One could successfully reconstruct the cervicofacial region after excision of postburn contractures with pre-expanded arterialized venous flaps with no marginal necrosis or unstable postoperative course. 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. Pre-expanded arterialized venous flaps are another and novel option for free flap reconstruction of the face and neck.

Role of Coronoidectomy and Temporal Muscle Myotomy in Reconstruction of Fibrosis of the Buccal Mucosa. Morten Kildal, Fu-Chan Wei, Yang-Ming Chang, Wen-Sun Tsang, and Wei-Chao Huang. Department of Plastic Surgery, University Hospital, Uppsala, Sweden; Departments of Plastic and Reconstructive Surgery, and Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.

Severe limitation of mouth opening is debilitating to patients both physically and psychologically, as it seriously affects speech, mastication, and oral hygiene. Surgical release of fibrotic tissue has been the treatment of choice, but normal mouth opening cannot always be achieved by soft-tissue release only. The importance of coronoidectomy and temporal muscle myotomy in such cases of moderate-to-severe trismus was discussed.

From 1997 to 1999, 16 consecutive patients with moderate-to-severe trismus were treated with surgical release and free flap reconstruction. Two patients were excluded from the study, as they developed oral cancer within 3 months after surgery. Thirteen patients had a diagnosis of submucous fibrosis, and one patient developed trismus because of postoperative scarring after previous tumor resection. All patients were males, with a mean age of 39 years (range: 19 to 56 years). The surgical approach included extensive release of fibrotic soft tissue in the affected cheeks, with or without coronoidectomy and temporal muscle myotomy. Preoperative interincisal distance was a mean of 16 mm (range: 5 to 30 mm). Bilateral free radial forearm flaps were used to reconstruct all buccal mucosa defects. Interincisal distances were measured preoperatively and at an average follow-up of 12 months (range: 4 to 30 months).

In three patients (21%) with moderately advanced trismus, defined by a preoperative mouth opening of 20 to 30 mm, simple soft tissue release increased the interincisal distance a mean of 15 mm to 43 mm (range: 40 to 45 mm), which was sufficient for normal mouth opening. In 11 patients (79%), all with a preoperative interincisal distance of less than 18 mm, simple soft tissue release was considered inadequate, as the interincisal distance increased to only 26 mm (range: 20 to 33 mm). Thus, coronoidectomy and temporal muscle myotomy were performed, increasing the interincisal distance to a mean of 39 mm (range: 35 to 45 mm). Interincisal distance at the time of follow-up was a mean of 34 mm (range: 20 to 50 mm). All flaps survived, but one had partial necrosis.

Complete release of trismus because of buccal fibrosis and scarring can be achieved in a majority of patients only with a combination of soft tissue release, coronoidectomy, and temporal muscle myotomy. Soft tissue release and coronoidectomy seemed to contribute equally to the final interincisal distance in this group of patients. In some patients with more moderate trismus, simple soft tissue release can be sufficient. Free flap reconstruction of the resulting defects is a safe and reliable procedure with good long-term results.

Traumatic Brachial Plexus Injuries in Children, Excluding Obstetric Palsy: Outcome of Surgical Treatment by Nerve Grafting and Nerve Transfer. Tarek A. El-Gammal, Amr E. Ali, and Mohammed M. Kotb. Reconstructive Microsurgery Unit, Assiut University Hospitals, Assiut, Egypt.

Traumatic brachial plexus injuries in children, excluding birth palsy, have seldom been reported. In this study, the authors presented 11 cases operated on between 1995 and 1998, and followed-up for at least 2 years. All patients were males, with an average age of 11 years (average: 3 to 16 years). The denervation time averaged 3.8 months (range: 1 to 8 months). Seven patients had two or more root avulsions, and four patients had avulsion of all roots. A total of nine grafting and 27 extraplexal neurotization procedures were used. Donor nerves included the intercostal nerves, phrenic nerves, spinal accessory nerve, and contralateral C7 root. Elbow flexion was restored in all but two cases. Shoulder abduction varied from 30 to 70 degrees, according to the method of reconstruction. The triceps recovered in three cases, and finger and wrist extensors in two cases. Wrist and finger flexion was obtained in two cases. Sensory recovery in the palm reached S2/S2+. Harvesting the phrenic nerve and contralateral C7 root resulted in no residual morbidity. Compared to adults, children have a higher incidence of root avulsions, a similar recovery rate of elbow and shoulder function following plexus reconstruction, but the recovery is more rapid.

Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Transplant Recipients. Tzong-Bor Sun, Peter C. Neligan, Erik Ang, Patrick J. Gullane, and Gerry O'Leary. Wharton Head and Neck Center, and Division of Plastic Surgery, Princess Margaret Hospital, University Health Network, University of Toronto; and Buddhist Tzu-Chi General Hospital, Taiwan.

Significant improvements in transplantation technology and immunology have made organ transplantation a practical solution for many end-stage diseases. The increased risk of malignancy in the immunosuppressed patient is a recognized complication. Reconstructive microsurgeons are called on with increasing frequency to perform free tissue transfer in these transplant recipients. The purpose of this study was to identify the problems of free tissue transfer for head and neck reconstruction in transplant recipients.

Between July 1993 and March 2000, a retrospective study of 529 free tissue transfer operations was undertaken in the Wharton Head and Neck Program, Toronto. There were 9 free flaps performed in 7 patients for reconstruction of post-transplantation head and neck cancer. These included 5 renal transplants, 1 liver transplant, and 1 bone marrow transplant. The histopathology of all these head and neck tumors was squamous cell carcinoma.

There was no perioperative mortality. Flaps used included 1 fibular osseocutaneous flap, 1 scapular fasciocutaneous flap, 1 lateral arm fasciocutaneous flap, and 6 radial forearm cutaneous flaps. Eight of 9 free flaps healed uneventfully.

These authors' experience suggested that performing free tissue transfers for head and neck oncologic reconstruction in transplant recipients is a safe and effective procedure, with acceptable morbidity. The side effects of immunosuppression and further existing medical conditions demand multispecialty perioperative metabolic monitoring and surgical care.

Six Years after Face Replantation. Abraham Thomas. Department of Plastic and Microsurgery, Christian Medical College, Ludhiana, India.

Avulsion of the scalp poses a challenge in replantation; with the addition of the face, although rare, it is difficult to utilize the ordinary hypotheses pertaining to avulsion injuries of the scalp alone. The problem becomes more complex when associated with the loss of portions of the skull or facial musculature, beside the integument itself. In instances of avulsion injuries of an organ, recovery of muscle function, sensory recovery, and hair growth are unpredictable, and any further long-term results would add to knowledge and planning in the future.

The author described the long-term results in a 9-year-old girl, who had avulsion injury of the scalp and face, with subsequent replantation. She is now 6 years post-replantation, and demonstrates good growth of hair, recovery of muscle function, and improved cosmesis.

Technical Refinements of Free Fibula Osteocutaneous Flaps for Head and Neck Reconstruction. Seng-Feng-Jeng, Yuan-Cheng Chiang, and Yi-Tien Liu. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung Hsien, Taiwan.

The aim of this reported study was to propose the authors' technical refinements of fibula osteocutaneous flaps for reconstruction of mandibular defects larger than 8 cm.

Forty-one fibula osteocutaneous flaps were used for composite mandibular reconstructions in 39 patients; 96% were primary reconstructions. The bone gap averaged 10.5 cm (from 8 to 21 cm). Skin flaps were raised between 32×8 cm and 20×7 cm. It was possible to sculpt the entire hemimandible, with the need for fewer osteotomies (from none to two). The bone flap was used to match the defect, and rigid fixation was achieved by using miniplate fixation. The portion of the skin flap required for oral lining was retained, and the remainder carefully deepithelialized or folded. It could be used to provide soft tissue to replace any loss of musculature in the floor of the mouth or cheek and neck contour.

Thirty-nine flaps were successfully transferred (96%). Total reconstructive time averaged 6.75 hr. The osteotomy number from none to two, averaged 0.3. All reconstructive bone healed primarily. Two patients with osteomyelitis required further surgical debridements. Four patients had superficial neck infection; they all healed by secondary suture. Most of the patients were satisfied by both the aesthetic and functional results.

For large bone defects exceeding 8 cm, the authors attempted to limit the number of osteotomies of the fibula to a maximum of two, to decrease the chance of possible bone devascularization and to shorten the operating time significantly. A portion of the skin flap was deepithelialized or folded to provide soft tissue for replacement of cheek contour.

Fate of Combined Usage of Devitalized and Vascularized Bone Grafts. Koichiro Ihara, Mitsunori Shigetomi, Keiichi Muramatsu, Tetsu Tsubone, and Shinya Kawai. Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, Ube, Japan.

There have been several reports about the drawbacks of devitalized bone grafts (DBG) which have have often been used after oncologic resection. These authors have used vascularized bone grafts (VBG), in combination with DBG, to overcome the drawbacks. This reported study was undertaken to evaluate the fate of these graftings.

Since 1992, 7 patients received this type of surgery for reconstruction of oncologic defects. Two patients were excluded from the study because of total necrosis of the flap and insufficient follow-ups. The mean age of the 5 patients was 26 years (range: 5 to 50 years). Involved bones were the tibia in 2, pelvis, forearm, and femur in 1 each. Pathology included chondrosarcoma in 2, osteosarcoma in 1, and other conditions in 2. The mean follow-up period was 20 months.

Devitalized procedures were irradiation in 4 patients and autoclave in 1. Donors of the VBGs included four fibulas and one scapula. There were no microsurgical complications, and bony union was obtained in all patients at a mean time of 5 months after surgery. Resorption of the DBG was not encountered, and union was recognized at the interface between both grafts. Large gaps still remained even after a long period. Collapse of the subchondral area could not be prevented in the case of osteochondral grafting.

The combination of DBG and VBG achieved a useful reconstruction after large oncologic defects. VBG provided favorable circumstances for incorporation of the DBG. However, the effect is limited, and placement of the grafts is critical to maximize the combination effect.

Mobilization of a Congenital Proximal Radioulnar Synostosis Using a Free Vascularized Fascio-Fat Graft. Fuminori Kanaya. Department of Orthopedic Surgery, School of Medicine, University of the Ryukyus, Japan.

Congenital proximal radioulnar synostosis is a rare congenital anomaly characterized by a fixed rotation of the forearm, ranging from neutral rotation to maximum pronation. In a review of reports of mobilization procedures and their outcomes, all but one procedure in 23 forearms failed in reankylosis. The author devised a new mobilization procedure and reported his results.

He performed an index procedure and could follow-up more than 1 year on 21 patients (19 boys and 2 girls, with ages ranging from 5 to 13.5 years, mean: 8.3 years). Five patients had bilateral ankylosis, and the procedure was performed on the dominant side (three on the right and two on the left). Sixteen patients had unilateral ankylosis (left in 11 and right in 5). The forearm was ankylosed between neutral and 90 degrees of pronation in 20 patients. One who received a failed mobilization previously showed ankylosis in 30 degrees of supination. Radius head dislocation was seen in all but 1 patient (posterior dislocation in 14, anterior in 5, and radial in 1).

The operation consisted of 4 procedures. First, separation of the synostosis was performed with a high-speed drill. Second, radius osteotomy was performed to reduce the dislocated radius head and to improve supination in 18 of 21 patients. One of the other 3 patients received a later osteotomy. Third, the biceps tendon that was detached by the separation of the synostosis was re-attached to the dorsal cortex of the radius. Finally, a vascularized fascio-fat graft was harvested from the ilsilateral upper arm and inserted between the separated radius and ulna. An above-elbow plastic splint was applied for 3 weeks. Then, gentle active motion exercises were started. Patients returned to regular sports activity after 3 months. Follow-up ranged from 1 year to 7 years and 9 months.

Neither circulation problems or neurologic complications occurred, except in 1 patient who showed a transient radial nerve palsy. No patient showed recurrence of the ankylosis. The mean range of active forearm rotation of 18 patients receiving osteotomy was 82 degrees (supination 20 degrees and pronation 62 degrees), and that of 3 patients not receiving osteotomy was 43 degrees; all of them showed radius head dislocation. One patient received a later improved forearm rotation from supination of 0 degrees and pronation of 30 degrees before the osteotomy, to supination of 30 degrees and pronation of 45 degrees after that. All patients reported improvements in the ability to perform gymnastics, throw a ball, hold a bowl of soup, and accept objects such as coins.

Use of a vascularized fascio-fat graft prevented re-ankylosis after separation of the synostosis. Radius osteotomy reduced the dislocated radius head and improved supination. This mobilization procedure provided the ability to rotate the forearm and improved the quality of the child's daily activities.

Comparing Sural Neurocutaneous and Free Flaps for Reconstruction of Leg Wounds: Indications and Outcomes. Loren S. Schechter, Mark A. Grevious, David H. Song, Risal Djohan, and Robert F. Lohman. Section of Plastic Surgery, University of Chicago, Chicago, Illinois, U.S.A.

Free flaps are the method of choice for reconstruction of many leg wounds. Neurocutaneous flaps are a relatively recent addition to the armamentarium of techniques for lower extremity reconstruction. The role of sural neurocutaneous flaps for soft tissue reconstruction of the leg, compared to free flaps, has not yet been fully defined. The authors analyzed 47 patients, operated on consecutively between January 1999 and May 2001, who required either sural flaps or free flaps for reconstruction of leg wounds. Patient demographics, indications, complications, and outcome data were presented.

Sural flaps were attempted in 22 patients and successfully completed in 21 (in one patient with collagen-vascular disease, the skin paddle did not appear to be perfused, and the flap was replaced prior to transfer). In 3 patients, the sural nerve was divided distally and the skin paddle was transferred to the proximal third of the leg. Reversed sural flaps were used in the remainder of patients. Free flaps were used for 25 patients (18 rectus abdominis flaps and 7 radial forearm flaps). The two groups of patients were similar with respect to age, sex, American Society of Anesthesiology class, tobacco use, and wound duration. There was a trend (p=0.03) toward greater utilization of radiotherapy among patients with free flaps (20%), compared to patients undergoing sural flaps (0%). The free flaps were larger than the sural flaps: 200 cm² vs. 22 cm², p<0.0001. Patients with free flaps also required more ICU days than did patients with sural flaps: 4 days vs. 0.5 days, p<0.0001. In the free flap group, there were 2 major complications (total flap necrosis) and 7 other complications treated non-operatively, including donor site complications (3), flap congestion treated with leeches (1), partial skin graft loss (2), and minor wound separation (1). In the sural flap group, there were no episodes of total flap necrosis. However, there were 2 major complications, including congestion treated with leeches, leading to partial flap necrosis (1), and inability to transfer the flap (1). There were 5 other complications treated non-operatively, including distal edge necrosis (2), minor wound separation (2), and partial skin graft loss (1). One of the free flap patients with total flap necrosis required a below-knee amputation, and now ambulates with a prosthesis, 3 ambulate with a cane, 2 with walkers, and 19 ambulate without aids. One of the sural flap patients ambulates with a walker, 2 with a cane, and 19 ambulate without aids.

Sural flaps can be useful for treating small wounds of the leg, without resorting to microsurgery or muscle transfers. Free flaps are the method of choice for treating large wounds, but are also associated with a greater need for ICU care. There is minimal risk of total flap necrosis with sural flaps, but minor wound healing problems are common.

Acute Grafting in Traumatic Peripheral Nerve Injuries. William Lineaweaver, Vipul Sud, and James Chang. Division of Plastic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A.

Primary nerve grafting in traumatic injuries is rarely performed because of the uncertainty of the extent of injury, the limited availability of nerve grafts, and the damage to adjacent soft tissue. In this report, the authors presented two cases of acute nerve grafting, following trauma, the first of the common peroneal nerve, and the second of the ulnar nerve above the elbow, with sensory and motor recovery. While compelling general arguments against primary post-traumatic nerve grafting exist, these cases illustrated that in certain favorable and critical situations, acute nerve grafting can be successful.

Partial Toe-to-Hand Transfer for Fingertip Reconstruction in Adults. D. Corcella, P. Pradel, D. Guinard, and F. Moutet. Department of Hand and Reconstructive Surgery, University Hospital, Grenoble, France.

The purpose of this reported study was to investigate the clinical results of partial toe transfers for digital pulp reconstruction in adults. In all cases, the microsurgical procedure was performed in secondary intention, either after contraindication for fingertip replantation or necrosis of the replanted segment.

Fourteen partial toe transfers were performed between December 1997 and September 2000 by one of the authors. The series included 8 pulp transfers and 6 custom-made composite flaps, harvested from the big or second toe. The mean age of the population was 34.6 years. All procedures were performed for reconstruction of traumatic defects of the thumb (9 cases) or long fingers (5 cases) distal to the DIP or IP joints. The delay between trauma and reconstruction was 1.3 months.

In seven cases, the authors used the ``short pedicle technique'' with a dissection limited to the toe and the first web space, while a conventional dissection was carried out for the other cases. This approach was designed to limit the cosmetic sequelae on the dorsal aspect of the donor foot. Shortness of the pedicle led to performing vascular anastomoses at the digital level on small caliber recipient vessels. Nerve sutures were done, as far as possible, at the distal phalanx level on the recipient finger.

Three secondary procedures were required for arterial complications in three patients, leading to one flap necrosis. The static two-point discrimination ranged from 7 to 11 mm, with a mean follow-up of 14.3 months. The functional and cosmetic results were judged to be good by the patients, despite light nail dystrophy for partial composite toe transfers. All the patients but one, with a pulp reconstruction of the thumb, judged the results as very good. No sequelae were noticed in the donor toe, except a moderate claw nail deformity for the partial toe transfer procedures. For all the patients, walking was possible on postoperative day 5, and none of them presented with shoe-fitting problems within 4 weeks postoperatively.

No local or loco-regional flap can fulfill functional criteria for fingertip reconstruction, when the trauma includes nail, bone, and pulp defect. Composite partial toe-to-hand transfers avoid severe claw nail deformity on the recipient finger, and have the best potential for pulp sensory recovery. The ``short pedicle'' approach is a demanding technique, but provides an acceptable donor site morbidity. For the authors, partial toe-to-hand transfers should be added to the armamentarium for fingertip reconstruction, especially with distal finger amputation in young adults.

New Method of Thumb Reconstruction Using Big and Second Toe Elements. Marek Molski. Department of Plastic Surgery, Medical Center for Postgraduate Education, Warsaw, Poland.

The author's modification of thumb reconstruction, using big and second toe elements, was presented. Two separate portions were raised on one common pedicle to form the future thumb. The main element, including bones, tendons, and soft tissue, was taken from the second toe. The flap, comprising nail, nail matrix, and lateral fragment of the second toe pulp, was prepared and left in situ. A similar flap was raised on the hallux. Winding of the hallux flap around the second toe portion allowed for the formation of a nearly normal thumb. The nail and nail matrix were harvested subperiosteally without any bone fragment of the distal phalanges. Harvesting of minimum tissue volumes from the hallux, and covering the wound by a similar flap from the second toe, markedly limited big toe deformation, typical for this type of procedure. The nail of the second toe appeared acceptable on the slightly thinner hallux. Scars were not localized on the weight-bearing surfaces.

Best indications for this procedure include cases in which the thumb is amputated at the proximal phalanx level. Rare anatomic variation of toe vascularity may restrict application of this method. Individual length differences between the hallux and the second toe sometimes make it difficult to place the hallux flap in the proper position on the thumb. A small hallux valgus deformity may appear when the second toe is too short.

Thumb reconstruction was carried out in 5 patients: a 10-year-old girl, a 10-year-old boy, a 34-year-old female, and two males aged 25 and 27 years, with follow-up of from 8 weeks to 12 yeears after amputation (mean: 2 years and 9 months). In all cases, the thumbs were in the dominating right hands. All thumbs were amputated at the proximal phalanx level. Right feet were the donor sites. The transferred parts survived without any complication. The follow-up was 7 months to 6 years and 4 months (mean: 3 years 3 months). The reconstructed thumbs were very close in shape and length to normal. Secondary modeling was carried out twice 2 years after reconstruction. The range of motion in the interphalangeal joints was 20 to 45 degrees, and 2 PD between 3-5 to 6-10 mm.

Anterolateral Thigh Flap Based on Perforators Directly Arising from the Femoral System. Ping-Wen Lai, Nai-Hsiong Kueh, and Seng-Feng Jeng. Trauma and Emergency Department, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Pedicle variations were discussed at length in the anterolateral thigh perforator (ALTP) flap. Most perforators arose from the lateral circumflex femoral vessels (LCFV). Absence of cutaneous perforators from the LCFV was also described. The authors presented their experience in the use of the cutaneous perforators directly arising from the femoral system as the main vascular pedicle for ALTP flaps.

From July 1998 to March 2001, 78 ALTP flaps were used for soft tissue reconstruction. In these flaps, using the cutaneous perforator directly arising from the femoral system for the main pedicle was possible in 9 flaps. In these flaps, the preoperative flap design and preparation were the same as in other flaps. But the cutaneous perforator directly arising from the femoral system was the largest or the single perforator, which was included in the flap base.

In this reported series, the ratio of using the cutaneous perforator arising from the femoral vessels as the vascular pedicle of the ALTP flap is 11.5% (9/78). Seven flaps were successfully transferred. Two flaps were lost due to arterial insufficiency. All the perforators were of the musculocutaneous type. The length of the pedicle could reach 15 cm, and the diameter of the arteries was from 1.0 to 1.5 mm. The size of these flaps did not differ from others. More time was required for flap harvesting due to more intra-muscular dissection.

When absent or small cutaneous perforators from the LCFV were found in ALTP flap harvesting, using the perforator directly arising from the femoral vessels as a pedicle for the ALTP is an alternative method. However, the small pedicle of the flap and the greater technical demand are clinical limitations, and a higher flap failure rate can be expected.

Reverse Anterior Tibial Artery Flap for Reconstruction of Foot Donor Sites Utilizing the Same Vessel System. Dong Jia Sheng, Peng Yeong Pin, Lim Beng Hai, and Robert W.H. Pho. Department of Orthopaedic Surgery, National University of Singapore.

Many osteoplastic techniques have been described for reconstruction of the hand utilizing donor tissue from the foot. Hallux transfer in various forms (trimmed toe, partial toe, and toe pulp transfer) has been shown to give excellent results for thumb reconstruction. One of the major drawbacks is the severity of donor site morbidity in terms of wound healing, gait, and cosmesis.

These authors proposed a new concept of reconstructing the hallux or foot donor site, using a reverse flow anterior tibial artery flap from the same leg. The skin is raised from the distal third of the leg on the anterolateral surface, based on previously undescribed periosteal perforators. The distally based vascular pedicle relies on the anastomosis between the posterior tibial and anterior tibial system around the ankle and in the foot. The authors were able to raise two flaps from the same vessel system in continuity-the distal one with antegrade flow as a free flap, and a proximal flap with reverse flow as a reverse pedicle flap to cover distal wounds. The technique allows for minimization of donor morbidity by limiting the surgery based on the distal anterior tibial vessels in the same limb.

They presented the anatomy of the vascular anastomosis around the ankle, illustrating the relevant vessels to be preserved for raising the reverse anterior tibial flap. They reported a series of 32 cases. In all of them, the donor site was reconstructed with reverse anterior tibial flaps. There were no failures, and the patients obtained satisfactory function and very good cosmesis of the reconstructed foot.

Functional Evaluation of Thumb Reconstruction According to the Level of Amputation. Kwang-Suk Lee, Jong-Woong Park, and Woong-Kyo Chung. Department of Orthopedic Surgery, Seoul, Korea.

In 1980, Morrison and O'Brien reported their experiences with the reconstruction of an amputated thumb, using a wrap-around neurovascular free flap from the big toe, but its indication was limited distal to the metacarpophalangeal joint. These authors investigated the earlier functional results, according to the level of amputation.

They performed 37 wrap-around free flaps from the big toe for the reconstruction of thumbs amputated distal or proximal to the MP joint. The amputation was distal and proximal to the MP joint in 25 and 12 cases, respectively. They concluded that amputation proximal to the MP joint is not an absolute contraindication to a wrap-around free flap procedure for thumb reconstruction. However, for a better functional outcome, they recommended iliac bone block fixation in the position of 30 degrees flexion and 45 degrees internal rotation.

Pinching and grasping power were not significantly different according to the level of amputation, but the results of two-point discrimination were better in cases amputated proximal to the MP joint. The opposition of the reconstructed thumb to the other fingers was completely possible in all cases amputated distal to the MP joint. In the 12 cases amputated proximal to the MP joint of the thumb, opposition was possible in 6 cases in which the iliac bone block was fixated in the position of 30 degrees flexion and 45 degrees internal rotation. However, in the other 6 cases in fixation of 30 degrees flexion and 30 degrees internal rotation, opposition of the reconstructed thumb to the ring and little fingers was not possible in 5 cases, and only to the little finger in 1 case.

Fingertip Reconstruction with an Arterialized Thenar Venous Flap. Sunao Furuta, Masayuki Hayashi, Yoshimasa Ishigaki, and Shigeharu Uchiyama. Plastic Surgery Unit, Suwa Red Cross Hospital, Suwa, Japan.

An arterialized thenar venous flap, previously reported by Iwasawa et al. (1997), was used to repair fingertip defects or deformities in 11 cases. Two flaps were used for coverage of palmar defects, 5 for reconstruction of the fingertip after amputation, and 4 for reconstruction of claw nail deformities. An iliac bone graft was simultaneously harvested in 6 cases to restore length of the distal phalanx. The length and width of the flap ranged from 3.0 to 6.0 cm, and 1.0 to 2.5 cm, respectively. The donor site was closed primarily in all cases. All the flaps survived completely. Protective sensation of the finger pulp was obtained in all cases as well.

An arterialized thenar venous flap is a glabrous skin flap which provides not only a good color and texture match for the fingertip, but also protective sensation over the reconstructed pulp. Moreover, a large flap can be harvested with minimal donor site morbidity. Thus this flap offers an alternative choice for reconstruction of a fingertip defect that is difficult to cover utilizing a local flap.

Arteriovenous Loop as a Preoperative Procedure for the Management of Difficult Defects in the Lower Extremity. Sobhi Hweidi, Gaber Ali, Wail Ayad, and Yehia Zakaria. Department of Plastic Surgery and Microsurgery, Zagazig University, Egypt.

The aim of this study was to demonstrate the value of establishing a preliminary arteriovenous fistula loop before free tissue transfer in the lower limb, when local recipient vessels are not available or are inadequate.

Over a 10-year period (1990-2000), free tissue transfers were used to reconstruct 147 lower extremity defects. In 32 of these cases (22%), an initial arteriovenous loop was necessary to overcome the problem of inadequate recipient vessels. Wound debridement was done in the same procedure. One to 3 days later, free tissue transfer was performed, utilizing both sides of the loop as recipient artery and vein.

The success rate of the procedure was 93.75%. In one patient, early clotting (after 18 hr) led to failure of the loop after two unsuccessful trials at revision. In two patients, anastomotic clotting was discovered after flap transfer. Revision was successful in salvaging one flap; in the other patient, extensive reclotting involving the whole loop, led to flap failure.

The preliminary arteriovenous loop is a useful technique in difficult and complex lower limb defects. It is usually indicated in secondary defects with extensive zones of injury, irradiation, electric burns, and in diabetes and peripheral vascular diseases.

Perforator Based V-Y Flaps in the Lower Limb. N.S. Niranjan. Plastic Surgery, St. Andrew's Center, Broomfield Hospital, Chelmsford, UK.

The lower limb is a frequent site for the occurrence of defects resulting after trauma and after the excision of pre-malignant and malignant skin lesions. The majority of these defects can be effectively reconstructed with split-thickness skin grafting. Since 1981, when Ponten first described the random pattern fasciocutaneous flap in the lower leg, this has become a popular method of local flap reconstruction for lower limb defects not amenable to split-thickness skin grafting. However, this necessitates split-thickness grafting of the donor site of the flap, leaving an unsightly divot and a poor aesthetic result.

The principle of the V-Y advancement flap has been used since its first description by Blasius in 1848 for the reconstruction of small defects. The author described a V-Y advancement flap, the design of which included distinct perforator vessels used to reconstruct defects of up to 10×6 cm in size. These flaps were planned in an oblique manner, and could be up to 12×8 cm in size. An attempt was made, when possible, to include branches of the long saphenous, superficial peroneal, or sural nerves. The defect is closed primarily, giving adequate stable cover, particularly in the pretibial area, without an unsightly divot. This technique has been used successfully to reconstruct defects in the lower limb in a total of 25 patients. Over the years, the author has modified the flap design to suit the orientation of the defect. Modifications and long-term results of the technique were presented.

Reconstruction of Radiation Ulcer in the Lumbosacral Region. Myong Chul Park. Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Suwon, Korea.

At one time, radiation used to be a major therapeutic modality for cervix carcinoma of the uterus. Some patients who received this treatment developed chronic radiation ulcer that could not be treated with a conventional flap method. The author reported 7 cases of radiation ulcers in the lumbosacral region that were treated with free flap coverage and perioperative hyperbaric oxygen therapy.

From October 1998 to April 2000, 7 patients with radiation ulcer in the lumbosacral region were treated. Patient ages ranged from 45 to 74 years (average: 63.3 years). The method included pre- and postoperative hyperbaric oxygen treatment, and a latissimus dorsi myocutaneous free flap transfer. All patients underwent complete recovery.

For the treatment of radiation wounds, the conventional local flap is not adequate for complete healing. Wide and radical debridement is mandated. For a vascularized muscle transfer, careful dissection of the recipient vascular pedicle, which has already been damaged by radiation, is important. The superior gluteal vessels were used for anastomosing the vascular pedicle. Hyperbaric oxygen therapy (HBO), which has been established as a useful tool under other conditions, was successfully applied for these irradiation damages. Perioperative HBO proved to be necessary in providing a better wound environment for complete and early healing. The author reported a combined treatment regimen for radiation ulcer in the lumbosacral area.

Reconstruction in the Sacral Area Using Free Flaps. Tanaka Katsumi, Murakami Ryuichi, and Fujii Tohru. Department of Plastic and Reconstructive Surgery, Nagasaki University School of Medicine, Japan.

In the treatment of large and complex sacral wound defects, it is usual to repair with local or adjacent tissue, such as myocutaneous and perforator flaps. However, it is sometimes difficult to apply these more conventional methods, because of extensive wounds and previous multiple operations. In such cases, these authors select free flaps to obtain reliable closure.

Between January 1992 and December 2000, 9 flaps were utilized in 8 patients for sacral wound defect. There were 9 males and 1 female, between the ages of 25 and 72 years. Three patients were paraplegics with unilateral recurrent ischial ulcers, bilateral in 1 patient, and 4 patients suffered from malignant soft tissue tumor. Four paraplegic patients underwent free medial plantar flaps with a portion of the calcaneous, and 4 patients underwent free latissimus dorsi flaps after tumor resection. The recipient vessels were a branch of the deep femoral vessels in 4 cases, and a branch of the medial circumflex femoral vessels in 1 case. Others underwent anastomoses to the superior and inferior gluteal vessels. All flaps survived completely, and there was no recurrence of pressure ulcers, and little morbidity at the donor site after surgery.

Certainly, a risk of flap necrosis was considered, using free flap transfer to the sacral area. However, free flaps were recommended, if it is difficult to apply more conventional methods.

Radial Forearm Flap in Reconstructive Microsurgery. B.A. Omurzakov, M.A. Mateev, H.S. Bebesov, O.N. Nasyranbekov, and K.K. Ismailahunov. Department of Plastic and Reconstructive Microsurgery, National Hospital of Kyrghyzstan, Bishkek.

The radial forearm flap is widely used in plastic and reconstructive surgery. It has special advantages that differ from other vascular flaps: easy harvesting and a lack of bulk. There is one important demerit-small breadth and a problem in closing the donor area. The aim of this reported study was the development of a new technique of increasing the size of the radial forearm flap based on the septal construction of the blood supply of the flap.

Between 1989 and 1999, these authors have used 103 radial forearm flaps for reconstruction of soft tissue defects. They used their technique for increasing radial forearm flap size in 14 cases. The method includes the following. After raising the flap, they cut the flap longitudinally, without damaging the septal vessels up to the radial vessels. The flap is then extended perpendicular to the cut line, and the remaining defect is covered by a split-thickness skin graft. This technique is a method of increasing the size of the radial forearm flap.

In 14 cases, the technique was used, and all 14 flaps survived. The maximum flap size was 16×27 cm. The size of the flap was increased by 30%, with a mean follow-up of 3 years, with a good cosmetic appearance and functional results. All cases of failure were due to thrombosis of the microanastomosis, conditions at the recipient area, inflammation, and sclerosis of the recipient veins.

Using the described technique of increasing the size of the radial forearm flap was an effective and aesthetic method for reconstruction of soft tissue defects. As a vascular tendon, nerves, and facial tissue graft may be raised with the radial forearm flap, its most expedient use is the reconstruction of composite and extensive defects. One must utilize additional skin grafting for covering the donor area when using a radial forearm flap with a width of more than 6 cm.

Individually Designed Posterior Interosseous Artery Perforator Flaps. R. Giunta, A. Geisweid, B. Lukas, E. Biemer, and A.M. Feller. Departments of Plastic Surgery, Rechts der Isar University Hospital, Munich; and Behandlungszentrum, Vogtareuth, Germany.

Perforator flaps contrast with classical fasciocutaneous and musculocutaneous flaps, supplied by only a single perforating branch. These flaps have been developed from musculocutaneous flaps, with the main aim of reducing donor site morbidity by preserving muscle function. The aim of this paper was to present the technique of individually planned perforator flaps of the posterior interosseous artery, on the basis of simple Doppler sonography.

The reliability of simple Doppler evaluation was examined in a study of 286 preoperatively localized perforating branches used in breast reconstruction. A total of 162 were confirmed in intraoperative dissection; in 37 of these 46 perforator flaps (80%), a preoperatively localized perforating branch could be used for flap perfusion. According to these results, the authors consider the reliability of a simple acoustic Doppler probe to be sufficient to analyze the individual distribution of the perforating branches.

Based on these results, 5 individually designed perforator flaps, supplied by a single perforating branch of the posterior interosseous artery, were planned for coverage of various defects in the upper extremity. In all cases, a flap based on a single perforating branch was possible. In 3 cases, a preoperatively localized vessel was used; in the remaining cases, a preoperatively undetected perforating branch was used. In 4 cases, successful defect coverage was obtained. One case failed due to venous insufficiency.

In the authors' experience, the possibility of planning individually designed flaps is the major advantage for the application of the perforator flap technique. This is especially true in cases in which the harvesting of a fasciocutaneous flap is unreliable or impossible, due to anatomic variations. On the other hand, dissection of the pedicle is technically more difficult, and the individual distribution of the perforating branches requires a high degree of flexibility. However, they do consider this new technique to be a useful extension in the armamentarium of options for soft tissue coverage of the hand.

Free Thenar Flaps in Finger Reconstruction. Jung Wu, Chih-Hung Lin, and Fu-Chan Wei. Division of Trauma and Emergency Surgery, and Department of Plastic and Reconstructive Surgery, Chung Gung Memorial Hospital, Taipei, Taiwan.

Between February 1996 and May 2001, 6 patients with soft tissue defects in the fingers received free thenar flaps. Patients included 5 males and 1 female, aged from 27 to 48 years (average: 34 years). The blood supply of the flap is based on the superficial palmar branch of the radial artery, which can be palpated and confirmed by Doppler flowmetry immediately above the tubercle of the scaphoid bone at the palmar wrist crease.

A curved incision was made over the palmar wrist crease to expose the radial artery. The location of the superficial palmar branch was identified, before the planned flap designed on the thenar prominence was elevated at the subfascial level. The flap ranged from 4.0 to 6.5 cm in length and 1.5 to 2.7 cm in width (average: 5.5×2.1 cm). The arterial anastomosis was done with either the radial or ulnar side digital artery of the fingers. All donor sites were closed directly, and all transfers survived completely without complication. At an average of 19-month follow-up, patients showed thin, durable, and good tissue matching reconstruction with protective sensation. No case required secondary debulking or revision procedure.

The free thenar flap provides good glabrous skin that can be readily harvested from the hand, with little sacrifice at the donor site. The flap provides an excellent alternative in coverage of pulp or even a long, large defect of the finger.

Temporary Ectopic Implantation of Amputed Mid Forearm in the Contralateral Forearm. Wang Jiangning. Dalian, China.

A case was reported in which the author designed a temporary ectopic implantation for mutilated extremity salvage.

The patient was a boy, whose left forearm was severed in machinery. There were devastating segmental injuries, arterial defect, extensive comminuted open fracture, soft tissue defect at the stump, together with the patient's generally poor condition. Primary implantation was impossible. The left hand was implanted in the contralateral forearm. Eighty-one days later, after vein transplantation was used to re-establish the humeral artery defect, plates to fix the fractures, and skin grafting to repair the soft tissue defect, the definitive replantation was performed. At the same time, a cross-forearm flap was designed, which insured that the hand was viable. Twenty-three days after replantation, arteriography validated that the second trial at vascularity was unobstructed. Then, the bridge of the pedicle skin tube was cut, and the radial vessels were re-established. The patient can now flex and extend his left elbow freely. Protective sensibility in the severed hand has been recovered, and he is able to use his left hand for some ordinary work, such as driving.

According to the authors, the technique is indicated in segmental injuries in which the distal portion is relatively undamaged, but the injuries themselves are extensive, ill-defined, badly contaminated, and radical debridement would lead to loss of important structures. These structures may be perfused but, in the case reported, were not healthy enough to be covered with skin. There were also other severe organ and system injuries. Under these conditions, immediate replantation did not seem feasible. The forearm had distinct advantages for temporary ectopic implantation. At the second stage, the cross-forearm flap containing radial vascular vessels could be dissected with the severed hand from the opposite forearm, and tubed. The skin tube was cut when the second attempt at vascularity was sufficiently demonstrated; therefore, the definitive replantation was safer.

Vascularized Periosteal Grafts of the Distal Forearm and Hand. K.N. Malizos, Z.H. Dailiana, and J.R. Urbaniak. Departments of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A., and University of Thessaly, Larissa, Greece.

Recent experimental studies have demonstrated that vascularized periosteal grafts (VPGs) are promising alternatives for the reconstruction of small skeletal defects and defects in poorly vascularized environments, due to their osteogenic properties and their flexibility and adaptability to the recipient sites. The absence of anastomoses and the lack of donor site morbidity are additional advantages of the pedicled VPG. The purpose of this reported study was to identify the donor sites, and to determine the recipient sites, for pedicled VPGs of the distal forearm and hand.

The vascular anatomy and donor sites of VPGs of the hand, wrist, and distal forearm were studied in 10 fresh cadaver upper extremities, injected with latex. The extent of the microcirculation, dimensions, anastomoses between the major nutrient branches of each graft, and the arc of rotation of their pedicle(s) were assessed.

VPGs could be raised from the following sites. Dorsal distal forearm: A) radial: 1,2 intercompartment artery VPG; 2,3 intercompartment artery VPG; 4^th extensor compartment artery VPB. B) ulnar: oblique dorsal ulnar artery VPG. Palmar distal forearm: a) radial: palmar metaphyseal arch VPG; palmar carpal arch VPG. B) ulnar: palmar carpal arch. Dorsal hand: 1^st dorsal metacarpal artery, 2^nd dorsal metacarpal artery. The dimensions of the VPG ranged between 1×2 cm and 3×5 cm, and their arcs of rotation covered dorsally the distal half of the forearm, the wrist and the hand to the interphalangeal (IP) joints, and palmarly the lower third of the forearm and the wrist.

Several pedicled VPGs have been identified in the presented cadaveric study. The grafts can be used (with or without additional bone grafts or substitutes) for the reconstruction of small skeletal defects and for the treatment of necrotic lesions and non-unions located in the region extending from the distal half of the forearm to the IP joints of the hand. The choice of the most suitable of the described VPGs will be based on the anatomic location and the dimensions of the recipient site.