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An anatomic study was performed to analyse the proximal perforator vessels of the gracilis musculocutaneous flap. Twenty-three cadaver legs preserved by the method of Thiel were carefully dissected 24h after the proximal vascular pedicle was injected with a red silicone mass. Nine additional cadaver legs were injected with ink, to visualise the skin area supplied by the proximal perforators, respectively, clarified by a modified Spalteholz technique to demonstrate the anatomic course of the perforators. A considerable variation in numbers and localisation of proximal cutaneous perforators was found. One to four perforators were seen within an area of 6 x 6 cm(2) at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter ranged from 0.5 to 1.0 mm. The ink-injections showed an oval shaped angiosome with a mean surface of 88 cm(2) at the level of the proximal gracilis pedicle. We conclude from this anatomic study, that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by experienced hands bearing in mind the unpredictable perforator-anatomy.

We have devised a new approach for transferring the pedicled latissimus dorsi myocutaneous flap to the head and neck region, and have applied it successfully in several patients. Our approach is rapid and increases the arc of rotation in order to cover defects of the lower lateral and posterior aspects of the head and neck. The vascular pedicle is protected between the scapula and the rib cage. We have used this approach in 15 patients over the last 9 years with good results.

This report describes free transfer of transverse colon for reconstruction of the hypopharynx and cervical oesophagus. The transverse colon based on the middle colic vessels was used in three patients following laryngo-pharyngo-oesophagectomy for hypopharyngeal squamous carcinoma. There were no flap failures or intra-abdominal complications. Solid diet was well tolerated. Transverse colon is easy to harvest, has a long vascular pedicle, wide diameter and good ischaemic tolerance. Contrast studies showed it to be a wide bore passive conduit. Compared with currently available options these features may allow better outcome in pharyngo-oesophageal reconstruction and warrant further evaluation.

A detailed anatomical study of the terminal branches of the twelfth thoracic nerve (subcostal nerve) based on observations made during dissections of 23 embalmed cadavers is presented. In all 23 cadavers, the twelfth thoracic nerve had an ascending branch which joined the deep inferior epigastric vascular pedicle about half way between the lower border of the umbilicus and the symphysis pubis. This observation, we believe, explains how it is possible to preserve sensation in the deep inferior epigastric musculocutaneous flap.

We have developed a new model of thin flap prefabrication in the rabbit with an exteriorised vascular pedicle in a skin tube. Study of these prefabricated flaps after transfer demonstrated that distal flap survival improved as the interval between implantation and flap transfer increased. Exteriorising the pedicle minimises both donor deformity and pedicle trauma and allows easier experimental study of the neovascularisation process in flap prefabrication.

The authors report a case of reconstruction of a great toe in a young boy, following amputation proximal to the IP joint and exposure of the MP joint. A local flap was chosen for its lesser morbidity, and plantar skin was selected as optimal coverage for weight-bearing surfaces on the first ray. Very few local flaps fulfill these conditions. The Y-V technique of elongation of a vascular pedicle, first described by Martin in 1991, was used to bring a medial plantar flap to the toe, doubling its normal arc of rotation distally. Technical points are highlighted and outcome is reported at 18 months follow-up.

Since Song first reported the anterolateral thigh flap in 1984, this flap has been applied widely in clinical practice. In 1997, we found that the proximal end of the vascular pedicle of the anterolateral thigh flap showed active bleeding. We therefore believed that this flap could form the reverse-flow flap, which can be used clinically. From 1997 to 2002, two patients who suffered from soft tissue defects in their lower extremities have been repaired successfully with the reversed flow anterolateral thigh island flaps. The reverse-flow anterolateral thigh island flap with reliable blood supply and long vascular pedicle can be designed to repair soft tissue defects around ipsilateral knee joint or contralateral distal rejoins of the leg, especially in the difficulty cases.

Summary Another perforator flap, the gracilis perforator flap, has recently been added to the armamentarium of reconstructive surgeons. A detailed study of the anatomy of this flap was undertaken in this study. Forty-seven dissections were performed in cadavers and clinical cases of gracilis muscle harvesting for various reconstructive reasons. According to our findings, at least one musculocutaneous perforator of large calibre was found in the majority of the dissections performed (87%), emanating from the proximal third of gracilis. All the perforators were located within a radius of 7cm from the point of entrance of the gracilis main vascular pedicle. In their majority, they emanated proximal to that point (83%) from the middle part (anteroposterior axis) of the muscle (62%). The intramuscular course of the perforators was easily followed and few muscular branches were encountered, before they joined the main vascular pedicle. A sensory branch of the anterior obturator nerve, accompanying the perforators, was occasionally found (29%). Finally, a superficial vein, branch of the greater saphenous, was always found within the skin territory of the flap in all dissections performed in cadavers.

The reconstruction of three-dimensional structures is one of the most challenging problems in plastic surgery. While shaped frameworks incorporated within soft tissue envelopes often lose their fine detail, the integration of a blood supply to a stable biomaterial scaffold allows skin graft cover and emphasis of fine detail. The aim of this study was to evaluate whether a porcine derived isocyanate crosslinked collagen tissue matrix (Permacol™) could be vascularised from an isolated vascular pedicle and subsequently sustain an overlying skin graft as a pedicled prefabricated flap. A vascular induction technique was employed using the epigastric pedicles in Sprague-Dawley rats to vascularise 2×2 cm 2 pieces of Permacol™ of standard 0.75 and 1.5 mm thickness Permacol™ and laser treated Permacol™ of 0.4 and 0.75 mm thickness. Flaps were able to support overlying skin grafts as early as 2 weeks following vessel implantation and laser treated Permacol™ had an increased vascularity compared to standard Permacol™ with no evidence of degradation. The study showed that Permacol™ could be a useful matrix for use in tissue engineered flaps.

An anterolateral thigh flap is very useful in head and neck reconstruction because of its long and large-caliber vascular pedicle, large skin territory and elevation simultaneous with tumour resection. However, the number and locations of cutaneous perforators vary individually, and thus, it is not widely used because flap elevation is often complicated and time-consuming owing to unexpected anatomical variations. To overcome this disadvantage, we assessed the number and locations of cutaneous perforators preoperatively by colour Doppler flowmetry. These data were compared with the intraoperative anatomical findings and their reliability evaluated. A total of 48 cutaneous perforators were found by preoperative colour Doppler flowmetry scanning of 17 anterolateral thigh flaps. All the perforators except two were found intraoperatively. Doppler scanning failed to detect four perforators. Colour Doppler flowmetry assessment therefore has a 92% true-positive rate and a 95.8% positive predictive value. All the flaps except one included multiple perforators, and sufficient blood circulation was observed in all cases. No flaps were unexpectedly changed to anteromedial thigh flaps or contralateral anterolateral thigh flaps because of inappropriate cutaneous perforators or the absence of perforators. Though this investigation is relatively time-consuming (30-40 min) and requires skill, it is very useful for preoperative flap planning and increases the reliability and safety of elevating an anterolateral thigh flap.

We report our experience with the thoracodorsal artery perforator flap. Its use and pitfalls are critically highlighted, especially in terms of its application as an island flap. Publications on this recently described flap are scarce, possibly because it is rarely used as a result of the high level of skill needed in its preparation. In our hospital, we have used this flap twice as an island flap, both of which failed, and ten times as a free flap, one of which failed. Transfer as a free flap is a delicate procedure involving transmuscular vessel preparation; transposition as an island flap is limited by range. Based on our limited experience, we recommend this flap only in very selected cases. This procedure has to be performed by experienced microsurgeons, after training on cadavers, and after preoperative colour Doppler imaging to determine the precise location of the main perforators. Use of this perforator flap is indicated in cases where a long vascular pedicle for an appropriate free tissue transfer is necessary, and where aesthetic appearance and minimising donor-site morbidity are more important than a potentially high risk of failure.

Cutaneous vascular anatomy of the flank and the hip was studied in the rat. Investigation was done by anatomical dissection, ink injection to the axial artery and flap harvesting in living rats. Anatomical dissection and India ink injection revealed that the rat's flank and hip skin derives its blood supply from the iliac branch of the iliolumbar artery, which originates from the lateral aspect of the abdominal aorta. The vascular territory of the iliac branch of the iliolumbar artery was defined as follows: the medial border—along the midline of the back from the 12th rib to the proximal part of the tail; the lateral border-anterior axillary line corresponding with the length of the medial border; the cephalic border—a line joining the medial and lateral border at the level of the 12th rib; and the caudal border—the posterior lateral line of the hip. On the basis of the vascular territory demarcated by India ink injection, bilateral vascular pedicle island cutaneous flaps were harvested in living rats. Results showed total survival of all flaps. This flap is easily made, and it could be used as a reliable model for flap research.

The combined use of flaps based on the subscapular vascular system for limb reconstructions has been infrequently reported. Such combinations have mainly been used for mandibular and facial reconstructions. We have used these flaps as free flaps for lower limb reconstructions in 7 patients, in 6 cases after trauma and in one after infection. A latissimus dorsi muscle or musculocutaneous flap and serratus anterior muscle flap were used together in 4 cases, and a latissimus dorsi muscle flap and parascapular flap in 3 cases. All cases healed satisfactorily. The indications for the combined use of these flaps are to resurface two separate defects simultaneously or to resurface very large defects. The anatomy of the subscapular vascular system allows the combined use of two or more flaps. It has the advantage of requiring anastomosis of one vascular pedicle only. Such combined flaps are particularly suitable for resurfacing defects wider than their length, in relation to the long axis of the limb.

The serratus anterior free muscle flap is useful in lower limb reconstruction, as it combines a moderate quantity of muscle with a long vascular pedicle. There are known vascular anatomical variations, for example the blood supply may come from the thoracodorsal pedicle, directly from the subscapular pedicle or from the axillary artery and vein. We present a case with a totally independent arterial supply to the flap from the first intercostal artery, while venous return from the flap went back as usual to the subscapular pedicle.

The scope of the scapular free flap is increased by the development of a further technical variation. The standard scapular flap is lengthened by use of a lateral (axillary) extension, without compromise of shoulder movement. The technique was used in 23 unipedicled and 1 bipedicled free scapular flap transfers in adults and children. An average increase in flap length of 30\% was achieved. Lateral extension of the flap facilitates harvesting of the flap and closure of the donor defect. It is particularly useful in cases where shortage of local tissues in flap recipient areas prevents primary closure over the vascular pedicle.

In cadavers the septocutaneous perforating vessels branching off the distal segment of the peroneal artery were studied. An area of skin approximately 7 × 12 cm above the ankle was noted to be perfused by these and intraoral defects in 8 patients have been repaired using the supramalleolar flap as a variation of the peroneal flap developed by Yoshimura. Owing to its thinness and the long and wide vascular pedicle, the flap is particularly suitable for reconstructing mobile parts of the oral cavity, and in selected cases may be considered as an alternative to a radial flap.

We have refined the Ravitch technique of sternal elevation for surgical correction of funnel chest. Our major modification is introducing a living rib strut for supporting the elevated sternum. The left 5th rib with a vascular pedicle from the internal thoracic artery is turned 180 degrees beneath the sternum. We have used this method in 10 cases. The results have all been satisfactory.

A series of 27 successful Superficial Inferior Epigastric Artery free flaps were analysed for a number of clinical and surgical variables. The anatomy and surgical technique of the flap are detailed and its advantages and disadvantages relative to other free flaps used for soft tissue contour are considered. Analysis of the variety of recipient sites of this flap is presented, as are details of the vascular pedicle and our experience with its constancy. It has been found to be a safe flap in experienced hands, with an aesthetic donor site scar, no functional loss and it lends itself to subsequent recontouring with suction assisted lipectomy or open techniques.

The free scapular flap, supplied by a single circumflex scapular vascular pedicle, can be safely extended beyond the midline of the back. The upper back can be a donor for very large and long flaps, ideal for resurfacing large defects.

In 7 cases involving 8 fingers, amputation of the distal phalanx of the finger with defects of the pulp were covered by island flaps with the digital vessels acting as reverse vascular pedicles. The survival of the island flap was successful in all cases. The vascularisation of the island flap is derived from the digital palmar arch which is the anastomosis between the radial and ulnar sides of the finger. This method uses a single operative field and covers the defect with volar skin having similar qualities. However, due to problems in sensory recovery, we limit the indications for this method to the middle, ring and little fingers of the non-dominant hand.

A technique is described which safely transfers a free flap vascular pedicle beneath a skin bridge to its intended anastomotic site. The method has been used routinely in this unit without complication during the past 5 years.

Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound. The authors' experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version.

The operation of transfer of the extensor digitorum brevis muscle to the face in the treatment of unilateral facial palsy (Thompson and Gustavson, 1976) has been further modified by immediate anastomosis of its vascular pedicle to the superficial temporal vessels. Six of our ten patients showed some new movement but in only three did this approach symmetry with the other side. Long term follow-up showed that improvement can be expected for up to two years after transfer. Our technique is assessed critically and suggestions are made for further improvement.

A proximal hypospadias, despite multiple procedures, may remain uncorrected either totally or because of multiple fistulae. In such circumstances there is often a severe shortage of skin on the ventral surface of the penis and scrotal skin may already have been used. The microvascular transfer of a radial forearm flap may then be used and, because of the thinness of the flap, a tube may be developed from it as well as covering skin. The long vascular pedicle ensures a good vascular input at the recipient site by anastomosis of the radial vessels to the femoral vessels. Two cases are presented which would have proved difficult to reconstruct by any other means.

A purely cutaneous free flap overlying the infraspinous region of the scapula has been used successfully in three cases. It is of intermediate thickness, predominantly hairless and is based on the cutaneous branch of the circumflex scapular artery. Te dissection of the flap is easy, quick and safe, resulting in a minimal pedicle length of 3 cm but this can be lengthened significantly by the inclusion of the more proximal vessels. The vessel diameter and its distribution make revascularization predictable. In this vessels. The vessel diameter and its distribution make revascularization predictable. In this series, the longest flap used was 24 cm and the widest was 12 cm, the width being limited by the ability to achieve primary closure. The only donor site disability is related to a tight linear transverse scar. These is no functional limitation nor distortion of the axillary contours. This contrasts with the thicker and widely used latissimus dorsi free flap. The scapular flap should replace the latissimus dorsi flap where the size of the defect to be covered is within the critical dimensions of this flap. The scapular flap can be combined with the latissimus dorsi flap for larger areas of skin cover, or the two flaps can be separated still based on their common vascular pedicle to cover two areas with diverging axes.

Summary A one-stage method of total reconstruction of the external ear in microtic patients is described. The auricular framework is fashioned from autogenous rib cartilage. Cover is provided by a vascular pedicle of the conchal area and by the aponeurotic layer which protects the posterior surface supplemented by a full-thickness skin graft. The surgical technique is described and the indications for the operation are indicated.

A method for the repair of defects in small blood vessels is described, using an oversized onlay autogenous vein patch tacked to the adventitia. The technique has been evaluated experimentally and it has been shown that vessels repaired with a patch remain patent with normal blood flow. By contrast, vessels repaired by direct suturing have a high incidence of mural thrombus formation and sluggish flow. The clinical usefulness of the method is illustrated by a case report describing the salvage of a free flap with a damaged vascular pedicle.

Microvascular anastomosis can be achieved by eversion of the upstream vessel and over an external cuff and insertion of this into the downstream vessel. This technique, first described in 1900, was initially tested in 13 rat femoral vein anastomoses using small polythene cuffs. Two anastomoses failed and 11 were patent at 7 days. After control studies, in 16 rat epigastric flaps the femoral vein in the vascular pedicle was divided and anastomosed using an external cuff. Thirteen flaps survived. The principles underlying this method appear sound, and form the basis for microvascular anastomotic devices currently being developed.

An extensive area of radionecrosis over the shoulder was treated by wide excision and closed with a pectoralis major myocutaneous flap. To reach the surgical defect the vascular pedicle of the flap had to be rotated 180°. No complications were encountered. This result illustrates another application of the use of this flap. It may be prudent to leave a good deal of muscle around the vascular pedicle in those manoeuvres which require large angles of rotation.

Four cases of successful reconstruction of scalp and skull defects are described. The advantages of the free inferior epigastric flap are that it is large enough to cover massive defects of the head and has an excellent vascular pedicle which allows it to be directly sutured to recipient vessels in the neck without interpositional vein grafts.

The pattern of blood supply to the clavicular and sternocostal portions of the pectoralis major muscle was studied in the cadaver with X-rays of injected specimens. The major blood supply to the sternocostal part was derived from the pectoral branch, although in about 50% of cases the clavicular branch provided minor contributions. This finding supports the clinical experience that it is safe to isolate the full length of the vascular pedicle, deep to the clavicular portion of the muscle, in the preparation of a pectoralis major myocutaneous flap.

The pectoralis major myocutaneous island flap is useful for axillary reconstruction following resection of tumour and skin in the axilla. It is a useful alternative to the latissimus dorsi flap, particularly when the vascular pedicle of the latissimus dorsi muscle is infiltrated by tumour or has been sacrificed by previous surgery.

The anterolateral thigh flap is based on the septocutaneous perforators of the lateral circumflex femoral artery. Little has been written about anomalies of its vascular pedicle. We report two variants of the pedicle vessel in eight patients in whom this flap was used, and absence of the perforators in five other cases in whom it was attempted. The anterolateral thigh flap has the advantages of thin and pliable skin, long and large pedicle, inconspicuous donor scar and the technical possibility of combination with fascia, sensory nerve and iliac bone. If the perforators are absent, a tensor fasciae latae musculocutaneous flap or anteromedial thigh flap is available with only minor changes of the flap outline.

The dorsalis pedis flap has several advantages: the skin is thin and hairless, a long vascular pedicle with relatively large diameter vessels is available, and a cutaneous nerve supply is also available if needed. It may be used as a free flap or as a local pedicle flap; we have combined both methods in 2 patients.

This study was undertaken to evaluate the influence of variations in the vascular pedicle on survival of island flaps. Abdominal island flaps were raised in 128 rats based on the left superficial epigastric vessels. Our results show that stenosis of about one-third of the original external diameter of the artery and vein of the pedicle in our model did not have any significant influence on the survival of the flap and ligation of the femoral artery distal to the branch to the flap did not produce any statistical difference in the viability of the flap.

The serratus anterior muscle and rib composite flap has been well described for oral and mandibular reconstruction. The flap may also be used in combination with the latissimus dorsi flap based on the common thoracodorsal vascular pedicle, a blood supply which has hitherto been proven to be reliable. This case demonstrates a totally independent arterial supply to the serratus anterior and latissimus dorsi muscles.

Six cases of reconstruction using the tensor fasciae latae myocutaneous free flap are described and in three of these a neuro-sensory flap was used. Four cases involved a lower limb reconstruction, one an upper limb reconstruction and one an abdominal wall reconstruction. Reduction of the bulk of the flap by transection of the muscle between the superior and inferior branches of the vascular pedicle was performed in four cases. One case of partial failure occurred in the lower limb group.

A case is presented in which a hole was drilled through the wall of an ossified cavity in the femur to take the pedicle of a myocutaneous free flap to its recipient vessels. This technique provided a successful solution to a difficult clinical problem.

A technique of nerve grafting is described whereby a nerve "graft" is raised, maintaining its blood supply via a vascular pedicle. It is then transposed to reconstruct a defect in an adjacent nerve. Although there is little clinical evidence that this technique results in better nerve regeneration when compared with conventional nerve grafting, the method has advantages which are discussed.

A clinical case is reported in which a fascio-cutaneous forearm pedicled flap was used. The flap was based on the previously described inferior cubital artery. Anatomical studies suggested that this vessel could be the basis for a fascio-cutaneous free flap possessing an exceptionally long vascular pedicle. This flap is described and its implications discussed in relation to the radial forearm (Chinese) flap.

Esser (1918) used a forehead flap with a vascular pedicle passed through a subcutaneous tunnel for a one-starge repair of nasal defects. Lexer (1931) also used the forehead skin based on the temporal vessels of one side. This flap, however, cannot be taken to the lower third of the face. The visor flap is designed to transfer large areas of forehead to the middle and lower thirds of the face but is sometimes not long enough for the lower third. It is considered necessary to delay such flaps before transfer (Schroder, 1972) and a further stage is required to return the skin pedicles. I have been transferring large forehead flaps based on bilateral pedicles of the superficial temporal arteries and veins for one-stage reconstructions of the lips and chin.