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Summary Background Free functional muscle transfers represent the ‘criterion standard' for smile reconstruction in facial paralysis. The gracilis muscle is a common donor muscle; however, no data exist regarding the volume of the muscle tissue that is necessary for symmetric commissure excursion. Methods All patients with facial paralysis receiving a free functional muscle transfer for facial reanimation surgery between January 2009 and November 2015 were retrospectively analysed. Only patients with unilateral facial paralysis and documented weight of the muscle portion were included. The extent of oral commissure amplitude was determined from standardised photographs. Results In total, 42 free functional gracilis transfers were performed during the study period, of which 22 met the inclusion criteria. Eight muscles were innervated by a cross-facial nerve graft (CFNG) and 14 by the masseteric nerve. Segments between 19 and 50 g of weight (mean: CFNG, 33.9 g and masseteric nerve, 31.7 g; p = 0.59) were transferred. Coaptation to the masseteric nerve led to increased commissure excursion compared to coaptation to the CFNG. We observed a significant increase in commissure excursion with increasing muscle weight in the masseteric nerve group. In this group, four patients underwent secondary flap debulking in flaps weighing ≥27 g. In the CFNG group, only one patient, who had an initial flap weight of 50 g, underwent secondary flap reduction. Thinning reduced the oral commissure movement but improved the symmetry of commissure excursion and the aesthetic result. Conclusion The ideal muscle weight depends on the donor nerve and should be smaller for masseteric nerve than for CFNG coaptation in adults.

The incidence of scalp tumors requiring radical excision increases with age. Free flap surgery is the standard reconstructive option for large defects; however, there is an ongoing uncertainty about its safety in the elderly. We conducted a review of data and report on 19 patients aged ≥75 years and 13

Interscapulothoracic amputation (ISTA) encompasses the removal of the upper limb, scapula and clavicle. As the reconstructive and oncologic limb-saving techniques improved, the indications for this formidable procedure decreased. However, it is still the appropriate procedure in cases with extensive oncologic or traumatic involvement of the shoulder girdle. Following ISTA, the surgeon is not only faced with a large defect but also with severe functional and aesthetic impairments. A solution to these problems is the immediate reconstruction with a free composite transfer from the amputated extremity. We successfully treated three oncologic cases and one traumatic case using this technique. The recipient vessels included the subclavian artery and vein in three cases and the internal thoracic vessels in one case. After a mean follow-up time of 4.5 years, two of the three tumour patients were free of recurrent disease. In all cases stable wound closure was achieved. Three out of four patients would opt for surgery again, in spite of the high occurrence of complications. One patient died after a 14-year event-free postoperative course. We conclude that the defect following ISTA can be successfully covered using a free composite tissue transfer of the amputated disease-free elbow and forearm, while simultaneously reconstructing the shoulder silhouette and axilla. This procedure reduces functional and aesthetic impairments and improves the quality of life.

Prior to the advent of a multidisciplinary approach to the treatment of soft-tissue sarcomas, surgical treatment consisted of extremity amputation. Advances in treatment modalities such as radiotherapy allowed more limited resections with similar survival rates. As local control is the primary objective in the management of these neoplasms, distally located tumours pose a particular reconstructive challenge. Limb preservation is now possible due to the availability of microsurgical techniques. A retrospective analysis was conducted assessing the suitability of the free anterolateral thigh (ALT) flap for distal-extremity reconstruction after wide local excision of sarcomas. Nine patients were included in the study with a median follow-up period of 36 months. In all patients, tumours were located at or distal to the elbow and knee, respectively. All flaps survived. In one patient, the ALT donor site was addressed with a split-thickness skin graft after wound dehiscence was observed postoperatively after initial primary closure. The free ALT perforator flap is an ideal flap for the reconstruction of distal-extremity defects after sarcoma resection as it allows coverage of large skin defects with minimal donor-site morbidity. Its thinness addresses the shallow defects typically encountered in the distal extremity and thus avoids the bulkiness encountered after reconstruction with musculocutaneous flaps.

Reconstruction of extensive distal phalangeal defects with exposure of tendon, bone, or joint can be particularly a difficult problem. For assessment of the value of the reverse homodigital island flap patients with distal phalangeal avulsion and crush injuries who were treated from January 2005 to April 2006 were analysed retrospectively. Main outcome measurements included flap survival rate, sensory restoration, occurrence of cold intolerance, length of occupational disability, and joint mobility. Eleven patients were included in the study. Only one patient suffered from venous congestion with partial flap necrosis, requiring debridement with subsequent skin grafting. The minimum follow-up was 6 months. The static 2-point discrimination had a mean value of 9 mm. None of our patients complained of cold intolerance or residual joint contracture. All patients returned to full occupational activity within an average time period of 4.5 weeks. In conclusion, the reverse homodigital island flap is an excellent option for 1-stage reconstruction of distal phalangeal defects.

Multiple cell-cell interactions control bone morphogenesis and vascularization. We have employed a spheroidal coculture system of endothelial cells (EC) and osteoblasts (OB) to study cell contact-dependent gene regulation between these two cell types that may play a role in regulating OB differentiation and EC angiogenic properties. Coculture spheroids differentiate spontaneously to organize into a core of OB and a surface layer of endothelial cells. Individual spheroid culture of EC or OB leads to significant alterations in gene expression compared to standard monolayer culture (upregulation of Tie-2 in EC; upregulation of angiopoietin-2 in osteoblasts). More importantly, spheroidal coculture of endothelial cells and osteoblasts leads to significant changes of gene expression in both cell populations (upregulation of VEGFR-2 in EC; downregulation of VEGF, and upregulation of alkaline phosphatase in osteoblasts). These changes are dependent on cell-cell contact and are not seen in stimulation experiments with conditioned supernatants. Collectively, the data demonstrate complex bi-directional gene regulation mechanisms between EC and OB that are likely to play a critical role during OB differentiation and in controlling the properties of angiogenic EC.