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The term propeller flap was introduced for the first time by Hyakusoku to define an island flap, based on a subcutaneous pedicle hub, that was rotated 90 degrees to correct scar contractures due to burns. With the popularization of perforator flaps, the propeller movement was applied for the first time to a skin island vascularized only by an isolated perforator, and the terms propeller and perforator flap were used together. Thereafter, the surgical technique of propeller flaps evolved and new applications developed. With the “Tokyo consensus,” we proposed a definition and a classification schema for propeller flaps. A propeller flap was defined as an “island flap that reaches the recipient site through an axial rotation.” The classification included the SPP (SPP) flap, the perforator pedicled propeller (PPP) flap, and the supercharged PPP (SCP) flap. A recent update added a new category, the axial pedicled propeller (APP) flap. Here we propose our updated and comprehensive classification of propeller flaps, taking into account the previous classification and subsequent publications. Based on their vascular pedicle, we consider the following five types of propellers: (1) SPP flap, 2.PPP flap, its subtype (2a) SCP flap, (3) APP flap, (4) muscle propeller flap, and (5) chimeric propeller flap. The variables that can be taken into account in the classification are as follows: type of nourishing pedicle, degrees of skin island rotation, position of the nourishing pedicle, artery of origin of the pedicle, and flap shape.

Background Microsurgery training is critical to the practice of microvascular procedures in many surgical areas. However, even simple procedures require different levels of complex skills. Therefore, simulation-based surgical training, mainly in the area of vascular anastomosis, is of great importance. In this paper, we present a new microsurgery training model for the development of basic to advanced microsurgical skills. Methods Porcine kidneys were purchased from a legal butchery slaughterhouse. First, kidneys were washed with water to remove blood and clots inside vessels. Then, dissection was performed throughout the vascular pedicle from the renal arteries to the segmentary branches. Finally, the longitudinal sectioning of the kidney parenchyma was performed to expose the vessels necessary for training. Sixty end-to-end anastomoses were performed. Specific instruments and materials were used to perform anastomoses and dissections with magnification by a video system. We evaluated the diameter of vessels, time to perform anastomosis, and patency of anastomosis. Results There was no great anatomical variation among the porcine kidneys. The total length for dissection training was 25.80 ± 7.44 cm using the arterial and venous vessel. The average time to perform arterial anastomoses was 23.79 ± 4.55 minutes. For vessel diameters of ≤ 3, 4 to 6, and 7 to 10 mm, the average procedure times were 27.68 ± 3.39, 22.92 ± 4.12, and 20.77 ± 3.44 minutes, respectively. Regarding venous anastomosis, the average duration of the procedure was 26.17 ± 4.80 minutes, including durations of 31.61 ± 3.86, 25.66 ± 4.19, and 21.24 ± 3.79 minutes for vessel diameters of ≤ 7, 8 to 10, and >10 mm, respectively. Positive patency was achieved in all surgeries. Conclusion The porcine kidney provides an inexpensive and convenient biological model for modeling microanastomosis with high fidelity to vascular structures.

Background The anatomy and physiology of venous drainage in the reversed flow vascular pedicle is controversial and there have been few well-designed, controlled studies to effectively evaluate the physiology. We evaluated the available evidence for venous drainage to synthesize the conclusions of these studies, and to identify areas in need of further research. Methods Electronic databases were searched for articles published from January 1, 1950 to November 1, 2017. A total of 316 citations were screened for inclusion. Fifty articles met inclusion criteria and underwent review, yielding 12 articles for final data analysis. Three principal study types were found: human cadaveric (7), animal (3), human clinical (1), and mixed (1). Results We identified two main theories regarding the mechanism of venous drainage in reverse flow flaps. The “avalvular bypass” theory is based on the findings of intact valves of the venae comitantes, and venous outflow through the crossover pattern of the communicating branches and bypass pattern of the collateral branches. Alternatively, the “valvular incompetence” theory implies that pedicle dissection, proximal ligation, and insetting of the flap cause physiologic changes, such as increased venous pressure, denervation, and simultaneous proximal and distal filling, which together result in valvular insufficiency. Conclusion The mechanism by which retrograde venous outflow occurs in reverse flow flaps remains controversial. Nonetheless, a few well-designed studies have contributed to the understanding of venous anatomy and outflow. Most likely, the true mechanism is based on venous outflow that occurs via the “avalvular bypass” route initially and the “valvular incompetence” route later.

Background Breast reconstruction using deep inferior epigastric artery perforator (DIEP) free flap is widely used because of the advantages of minimizing donor-site morbidity, but it requires technical competency in vascular dissection. This study evaluated the influence of patient factors and vascular status on the time and speed of dissection of the vascular pedicle. Methods DIEP free flap procedures were performed in 49 patients assigned to immediate or delayed reconstruction groups. Factors that significantly influenced the time required and the speed of dissection were evaluated. Results The average total dissection time was 55.9 minutes (34.5 minutes for the intramuscular dissection and 21.4 minutes for the submuscular dissection). The dissection speed for the total vascular pedicle was 2.65 cm/10 minutes (1.71 cm/10 minutes for the intramuscular dissection and 4.30 cm/10 minutes for the submuscular dissection). The presence of a Pfannenstiel scar, length of the vascular pedicle in the intramuscular area, and the number of microclips used significantly correlated with the total dissection time. Conclusion The length of the intramuscular pedicle, number of microclips used, and presence of a Pfannenstiel scar significantly correlated with the total dissection time of the vascular pedicle. An assessment prior to the surgery can reduce the time of operation and make it easier to elevate the flap.

Zusammenfassung Zielsetzung: Durchführung eines sternalen Knochen- und Weichteil-Débridements nach abgelaufener Sternumosteomyelitis mit simultaner Defektdeckung mittels gefäßgestielten Latissimus-dorsi-Lappens. Indikation: Tiefe sternale Wundheilungsstörungen können mittels verschiedener Lappenplastiken gedeckt werden. Der Latissimus-dorsi-Lappen bildet eine schnelle, suffiziente und zuverlässige Deckungsoption für sternale Defekte. Des Weiteren kann bei ausgeprägter Radikalität des Weichteil- und Knochen-Débridements eine einzeitige Deckung erfolgen. Methode: Aufzeigen einzelner OP-Schritte zur Durchführung eines sternalen Débridements mit simultaner Defektdeckung mittels gefäßgestielter Latissimus-dorsi-Lappenplastik. Schlussfolgerung: Die Radikalität des Débridements ist entscheidend für den weiteren Therapieerfolg und erlaubt es, Débridement sowie simultan die lappenplastische Deckung durchzuführen. Das gleichzeitige Arbeiten von 2 Operateuren verkürzt dabei die Operationszeit für den Patienten deutlich.

Soft-tissue defects of the little finger are challenging especially when bone, tendon or vascular pedicle is exposed because of trauma. The hypothenar island flap is easy to harvest and has a good colour and texture match to the little finger pulp. We present nine clinical cases of soft tissue defects of the little finger covered using the reversed hypothenar fasciocutaneous island flap. This article intends to highlight the ease of elevation and good clinical results of the hypothenar flap which is rarely used.

Background Microvascular compromise from arterial or venous occlusion is a common cause of free flap failure. The salvage rate following a microvascular compromise is dependent on detecting the problem early and intervening quickly. Methods The ViOptix tissue oximeter measures tissue oxygen saturation using the near-infrared spectroscopy technology. The ViOptix device has an alarm capability to warn of potential compromise to tissue perfusion. The tissue oximetry readings are visible on the bedside monitor and are relayed to a webpage link, which is accessible on a personal computer or mobile device, allowing real-time monitoring. This article presents a case where real-time monitoring allowed almost immediate detection of inadvertent pedicle compromise allowing flap salvage by repositioning without surgical intervention. Results In the case presented, the patient's nurse inadvertently positioned a pillow under the location of the vascular pedicle likely causing microvascular compression. The ViOptix reading dropped and for this reason the nurse contacted the Plastic Surgery team. The drop was confirmed remotely and the flap was urgently evaluated in person. Once the pillow was removed, the ViOptix readings normalized and Doppler signals strengthened in the flap. Discussion While tissue oximetry monitoring does not by itself ensure flap survival, it provides critical information than conventional flap monitoring would allow giving the microsurgeon the opportunity to make a quicker decision. ViOptix tissue oximeters are able to detect vascular compromise even before conventional clinical symptoms are present. Alas in several cases by the time clinical symptoms develop the flap may be beyond salvage.

Background When anterolateral thigh (ALT) perforators are inadequate, exploration of the contralateral thigh or a new flap may be required. If the anteromedial thigh (AMT) perforators were useable in these instances, harvest could proceed from a single donor site. The purposes of this study were to define the AMT perforator anatomy and examine the relationships between the AMT and ALT perforators. Methods A total of 100 consecutive thighs were explored. The ALT and AMT perforator size and number were documented. The relationship between ALT and AMT size and number was examined using Fisher exact test, logistic regression, and linear regression. Results The main blood supply to the AMT flap was the rectus femoris branch (RFB) off the descending branch of the lateral circumflex femoris artery. AMT perforators were only present in 51% of the thighs and most likely a single perforator near the midpoint and 3.2 cm medial to the line connecting the anterior superior iliac spine and the patella (perforator B location). Patients with one or fewer ALT perforators had fourfold increased chance of an AMT perforator. Patients with small or no ALT perforators usually had a large AMT perforator. After assigning numeric values to perforators based on size, lower ALT perforator scores were significantly related to higher AMT scores. Conclusion The RFB is the main vascular pedicle of the AMT flap. There is an inverse relationship between size and number of ALT and AMT perforators: when ALT perforators are inadequate, AMT perforators are typically useable.

Abdominal desmoid tumors are so called non-metastatic tumors. They occur by proliferation of fibroblasts of muscle, fascia or aponeuroses. After breast reconstruction with a DIEP flap (Deep Inferior epigastric Artery Perforator Flap), a progressive growth of a desmoid tumor was seen around the DIEP-anastomosis. A total excision was not possible without compromising the vascular pedicle. With taking into account a recurrence rate up to 65% another operation is probably necessary. In this case the main vessels of the graft have to be cut out and a necrosis of the flap can or may appear.

The purpose of this study was to overcome the disadvantages associated with the shortness of the vascular pedicle of subscapular system combined flaps when performing the maxillary reconstruction procedure. Combined flaps of the subscapular artery system were used for maxillary reconstruction. A latissimus dorsi myocutaneous flap, a scapular fasciocutaneous flap, and two kinds of scapular bone flaps were elevated as combined flaps. Next, the circumflex scapular artery (CS) and vein were cut off from the combined flaps and anastomosed to the serratus anterior branch, thereby establishing chimeric flaps. Then, maxillary reconstruction was performed using these flaps. We encountered two patients who underwent maxillectomy for maxillary cancer. Satisfactory improvements in facial shape were obtained in both cases. In cases in which combined flaps of the subscapular artery system are used for maxillary reconstruction, the biggest problem is that the vascular pedicle does not reach the recipient vessel in the neck due to the shortness of the CS. Therefore, vein grafts are generally performed to extend the flaps to the maxilla. Our novel procedure has the great advantages of long vascular pedicles and high flexibility in setting the flaps without the use of vein grafts.

OBJETIVO: Através de um modelo experimental, pretendemos criar inferências sobre a viabilidade do enxerto ósseo vascularizado da crista ilíaca em ratos e verificar suas características histológicas. MÉTODO: Foram utilizados 21 ratos, que foram divididos em dois grupos: o primeiro consistindo por animais submetidos à técnica de enxerto ósseo vascularizado e pediculado sobre o ramo ilíaco da artéria iliolombar; o segundo (grupo controle) sofreu o mesmo procedimento do primeiro com a adição da ligadura do pedículo vascular. A viabilidade dos enxertos ósseos foi verificada durante três semanas, através da visualização direta do enxerto, histologia e imunoistoquímica. RESULTADOS: Todos os enxertos vascularizados avaliados na primeira semana apresentaram viabilidade segundo a observação direta, histologia e imunoistoquímica. Entretanto, na segunda e terceira semanas os enxertos mostraram-se inviáveis em 75% dos casos quando submetidos à avaliação segundo a observação direta e em 50% dos casos quando realizada a análise histológica e imunoistoquímica. CONCLUSÃO: Alguns enxertos vascularizados em sua concepção tornaram-se inviáveis e passaram a se comportar como enxertos não vascularizados sob a análise da observação direta e histológica. Apesar da possibilidade de falha, o uso de enxertos ósseos vascularizados deve ser incentivado, pois a histologia descritiva demonstrou maior densidade celular na porção óssea medular, osteócitos com maior funcionalidade na deposição de matriz óssea, com rede vascular intraóssea preservada. OBJECTIVE: Through an experimental model, our aim was to create inferences about the viability of vascularized bone grafts from the iliac crest in rats and investigate their histological features. METHODS: Twenty-one rats were used, divided into two groups: the first consisted of animals that were subjected to the technique of vascularized bone graft pedicled onto the iliac branch of the iliolumbar artery; the second (control group) underwent the same procedure as performed on the first group, with the addition of ligation of the vascular pedicle. The viability of the bone grafts was observed for three weeks, by means of direct observation of the graft, histology and immunohistochemistry. RESULTS: All the vascularized grafts evaluated in the first week showed viability according to direct observation, histology and immunohistochemistry. However, in the second and third weeks, direct observation showed that 75% of the grafts were unviable, while histological analysis and immunohistochemistry showed that 50% were unviable. CONCLUSIONS: Some grafts that are designed to be vascularized became unviable and began to behave like nonvascularized grafts under direct observation and histology. Despite the possibility of failure, use of vascularized bone grafts should be encouraged, because descriptive histology shows greater cell density in the medullary bone portion, and osteocytes that function better regarding deposition of bone matrix, with preservation of the intraosseous vascular network.

Eight dissections in four embalmed cadavers were performed to investigate the possibility of vascularized scapular grafting for osteonecrosis of the humeral head. When the angular branch was used as the nutrient vessel, the mean length of the vascular pedicle was 12.4 cm, which was sufficient for transferring the scapula into the humeral head. Based on the anatomical study, a 27-year-old man with corticosteroid-induced osteonecrosis of the right humeral head was treated by vascularized scapular grafting. The pedicled vascularized scapula was successfully transferred into the humeral head using the angular branch. The patient's right shoulder pain disappeared following surgical recovery. He had no limitations of right shoulder motion 3 years after the surgery. Magnetic resonance imaging at 1 year after the surgery indicated revascularization of the humeral head. The humeral head did not collapse during a 3-year follow-up with radiographic evaluation. This procedure has the potential to be a new joint-preserving procedure for osteonecrosis of the humeral head.

Since the introduction of microsurgery and free flap transfers, the techniques of dissection and harvesting of flaps and their vascular pedicles have continuously advanced. As the vascular pedicles of free and pedicled flaps should be protected during their harvest or dissection, the usual trials to protect pedicle vessels depend ultimately on the surgeon and clinical experience. A new microsurgical instrument, the vessel protector, facilitating protection and holding of the vascular pedicle has been developed. Through experimental and clinical trials, the instrument has been demonstrated to protect the structures inside a distal coiled end while also holding them. This has several advantages over conventional dissection by jeweler's forceps and scissors.

In the quixotic quest for the “ideal” flap, the major attribute of the medial circumflex femoral artery perforator flap is its minimal donor-site deformity even if primary closure is not possible and a skin graft must be used. This source vessel captures the medial groin skin territory, and therefore sometimes has been referred to as the “medial groin” flap. This flap can be moderately large, the donor site easily hidden by clothing, the flap almost always has at least a single relatively large musculocutaneous perforator, and the location of the vascular pedicle has a consistent location already familiar to most microsurgeons. The history and approach specifically in the development of the medial circumflex femoral artery perforator flap is presented here to explain the rationale as to why this donor site deserves consideration in the hierarchy of cutaneous flap selection.

When it is necessary to apply free flaps for foot reconstruction, the choices are limited. Conventionally, split-thickness skin-grafted muscle flaps and fasciocutaneous flaps from the back or thigh have been two major options, but these methods take substantial time to wearing normal shoes. As an alternative, the authors use the deep inferior epigastric perforator (DIEP) flap with an external pedicle. After elevation and thinning of the flap, the vascular pedicle is anastomosed at a site distant from the skin defect of the foot. About 20 days after that, the pedicle is severed, and the skin island is trimmed and sutured. This method provides thin and wide coverage within a limited time, and donor-site morbidity is minimal both functionally and aesthetically.

Guneren, Ethem/0000-0002-5981-7010; Demir, Ahmet/0000-0002-8820-3122 WOS: 000228608300005 PubMed: 15880296 This article describes a pedicle-lengthening procedure (the Y-V-I principle) that reverts a Y-shaped vascular structure into an I-shaped vascular structure, and its application to the latissimus dorsi muscle. If the Y-shaped vascular structure is divided proximal to the branching point and ligated, it becomes a V-shaped vascular structure. To obtain a linear I-shaped vascular structure, the V is opened, and the length of the vascular pedicle will become equal to the combined length of both limbs of the V. This report indicates that the latissimus dorsi flap may be transferred based on the circumflex scapular artery or the serratus branch.

Biliary conduits are constructed in operations for choledochal cysts. A wide variety of options are available for biliary tract reconstruction. We present our experience of treating six children with choledochal cysts by using the appendix as a biliary conduit. After mobilizing the appendix on its vascular pedicle, nonrefluxing, tunneled anastomosis was made with the 2nd part of the duodenum and the appendix. The operative procedure was simple and less time-consuming. Postoperative evaluation was done with the help of HIDA scan and ultrasound examination. Postoperative cholangitis was conspicuously absent in the two years of follow-up. One child has been lost to follow-up. From our preliminary experience, the operation seems simple and satisfying. Though the long-term efficacy still remains to be proven, the appendix should prove durable as a functional conduit.

The principle of prefabricated flaps is based on the transformation of a formerly random-pattern vascularized flap, through implantation of a vascular pedicle, into a newly neovascularized axial flap, which can be transferred after a period of neovascularisation from the prepared donor site to the recipient site by using microvascular techniques. In 30 Chinchilla Bastard rabbits weighing from 3700 to 4200 g, a skeletonized arteriovenous pedicle with distal ligation harvested from the femoral and saphena magna artery and vein was implanted beneath an 8 x 15 cm abdominal skin flap to investigate the neovascularisation process in the flap over the course of time. In order to prevent neovascularisation occurring from the underlying vascular bed into the flap, a silicon sheet measuring 8 x 15 cm x 0.25 mm was placed and fixed on the abdominal wall. Flap vitality and neovascularisation process in prefabricated flaps were evaluated by macroscopic observation, blood analysis, selective microangiography, histology and scintigraphy at the various time intervals of 4, 8, 12, 16 and 20 days. The study results showed that newly formed vessels sprouting from the implanted pedicle were seen four days after pedicle implantation. With the retention time of pedicle in the flaps, they continued to grow, became meander and more dense. Respective connections between newly formed vessels and the originally available vasculature of the abdominal flap were markedly observed in the 12- and 16-day groups. Twenty days after prefabrication, the abdominal flap was completely perfused by the blood flow supplied from the newly implanted arteriovenous pedicle through newly formed vessels arising from the implanted pedicle and their rich vascular communications. The neovascularisation in the prefabricated flap consisted of the implanted pedicle, newly formed vessels, the originally available vasculature and their vascular connections. In comparison to the control group (the quantification was determined of 100 %), the vessel quantity in the prefabricated flap of the 20-day group had increased to 98.7 %. As a pre-clinical test, prefabricated flaps through arteriovenous pedicle implantation with special advantages can be a new useful method in plastic and reconstructive surgery.

Covering of soft tissue injuries on the lower leg is frequently a difficult challenge. In this article the sural artery flap is presented as a valuable therapeutic plastical surgery method for covering of these defects. Within the middle dorsal area of the lower leg, and centered above the sural nerve, an island of skin is cut out and the subcutane vascular pedicle is prepared along the nerve. The won skin flap is rotated into the defect and fixed without tension. The flap pedicle is covered with meshcraft, the wound closing of the donor-site defect is usually done primarily. This article reports on 25 men and 10 women, who were treated between May 1997 and December 2003 using the neuro vascular sural flap. With 30 of the 35 patients the flap healed without functional impairment, only one patient experienced a necrosis leading to the loss of the flap, while in 4 cases a partial loss of the skin island was registered. By means of meshcraft transplantation a complete healing was achieved. The superficial sural artery flap usually results in a reliable and complete healing of soft tissue defects within the area of the lower legs with justifiable operational expenditures also with old and vascular-ill patients.

This report presents our experience with the thoracodorsal artery perforator flap. Its use and pitfalls are critically highlighted, especially the application of this flap as an island flap. Only few publications on this recently described flap are available, possibly because of the high level of skill needed in its preparation. In our hospital, this flap was twice used as an island flap, both of which failed, and ten times as a free flap one of which was a failure. Harvesting of this flap is a delicate procedure involving transmuscular vessel preparation, additionally transposition as an island flap is limited in range. Based on our limited experience, we can recommend use of this flap only in carefully selected cases. This procedure has to be performed by experienced microsurgeons, after training on cadavers, and after preoperative color Doppler imaging for determining the precise location of the main perforators. Only in cases, where a long vascular pedicle for an appropriate free tissue transfer is necessary, and where aesthetic appearance as well as minimizing donor-site morbidity are more important than a potentially higher failure rate, utilizing this perforator flap is justified.

Background Complex defects of the forearm and hand are associated with the loss of important structures. Single-stage reconstruction of these defects requires composite tissue transplantations. The subscapular region offers various components for the coverage of complex defects. The scapular and the parascapular flaps can be used each as cutaneous, fasciocutaneous and osteocutaneous or as a combined flap as well. The purpose of this study was to present our experience with the combined scapular-parascapular free flap for defect coverage of the forearm and hand in 13 patients. Patients and method Evaluation of 12 patients who underwent coverage of forearm and hand defects with the combined scapular-parascapular free flap during a five-year period. Other treatment options are discussed. Results Average age of the patients was 39 years, there were ten male and two female patients. Average follow-up was 20 months. Eleven patients suffered from massive trauma, one patient from severe infection of the forearm and hand. The defect size varied from 12 x 8 cm to 45 x 20 cm. In nine cases, a cutaneous and/or fasciocutaneous scapular-parascapular flap was used, two patients underwent defect coverage with an osteocutaneous scapular-parascapular flap, and in one patient, a "four-flap-mega-flap" was transplanted. One flap developed a partial necrosis. Eight patients developed a good or very good functional outcome with their hand and forearm, two patients have a moderate degree of disability. Two patients can use their hand as a supporting hand. Conclusion This study demonstrates that the combined scapular-parascapular free flap is a reliable treatment choice for early coverage of defects of the forearm and hand. The advantages are the long, large and consistent vascular pedicle, the possibility of combination with other flaps and "custom-tailoring", including whatever component is necessary to close the particular defect.

SummaryThis report documents an anomalous blood supply to an omocervical free skin flap in a dog. Consideration of this anomaly should be taken into account when harvesting this skin flap to prevent inadvertent injury to its blood supply.An omocervical free skin flap, which had an anomalous pathway of its vascular pedicle, was used to cover a full-thickness skin wound on the front limb. This vascular anomaly has not been reported in the dog.

A cutaneo-subcutaneous flap based on the lateral superior genicular artery was anatomically investigated and applied in three clinical cases. Consistent anatomy, a long vascular pedicle, fairly easy dissection, primary donor closure, and minimal donor-site morbidity are the most important advantages when a medium-sized flap is needed. The flap may be used as a thin, delicate, free cutaneous-subcutaneous transfer for reconstruction of skin defects. It may also be applied as an axial flap to cover defects of the popliteal region.

A mature teratoma was identified in a two-month-old girl who was operated for a sacrococcygeal mass. The cystic components of the mass were accidentally opened during surgery, and a solid, rudimentary organ resembling a heart emerged. It had a vascular pedicle and a pulsation like cardiac activity different from the infant's heart rate. The mass was totally excised together with the coccyx, and in histological examinations, it was diagnosed as a mature teratoma and a rudimentary heart. To the best of our knowledge, the case presented in this report is only the second case of a cardiac development in a teratoma in the literature. In the light of data obtained about this case and related literature, we consider that fetus-in-fetu and teratoma may not be irrelevant entities, and that they possibly have the same developmental malformation. We also suggest that such an intermediate case is a combination of fetus-in-fetu and teratoma.

The serous membrane is considered suspect as one of the obstacles responsible for delaying the acceptance of free jejunal grafts. A model was created of subcutaneous transfer of jejunum from which the serous membrane had been experimentally removed and the authors compared acceptance rates for intestine with and without a serous membrane. Results showed acceptance rates of 0 percent, 37.5 percent, 87.5 percent, and 100 percent respectively, for intestine devoid of serous membrane in which the vascular pedicle had been ligated 4, 5, 7 and 14 days after transfer. When these findings were compared with the results of an experiment on intestine with an intact serous membrane, statistically significant differences were detected between the acceptance rates of the groups ligated 5 and 7 days after transfer. The acceptance time required for intestine devoid of serous membrane was shown to be shorter.

The authors describe two successful reconstructions of recurrent pressure sores with free fasciocutaneous flaps. In Case 1, a free lateral thigh flap pedicled on the first and third direct cutaneous branches of the deep femoral vessels was used to cover a large recurrent sacral pressure sore. The vascular pedicle was dissected to the deep femoral trunk proximally and anastomosed to the inferior gluteal vessels. In Case 2, a free medial plantar flap was transferred to a recurrent ischial pressure sore. The vascular pedicle was dissected to the posterior tibial vessels proximally. The long vascular pedicle of the flap was passed through the femoral subcutaneous tunnel, and end-to-side microvascular anastomoses were performed to the superficial femoral trunk without any vein grafts. The authors advocate the use of free tissue transfer for recurrent pressure sore reconstruction.

Previous work has shown that corticocancellous bone chips placed in a titanium chamber with an arteriovenous vascular pedicle will result in a pre-formed vascularized bone graft. The present study was designed to determine whether these grafts can be transferred as an island or free vascularized bone graft, and to examine the material properties of these grafts. Thirty-two male, New Zealand white rabbits were divided into four groups based on the time of sacrifice following the initial chamber implantation. Injected molded cylindrical polyethelyne chambers, measuring 22 mm long and with an 8-mm inner diameter, were used. Corticocancellous bone chips were placed in the chambers and each chamber was implanted in the mid-thigh, with saphenous vessels running through the chamber. The chambers were implanted into the right and left thigh of each animal. To test the hypothesis of the possibility of transferring this graft as an island or free vascularized graft, ligation of the distal vascular pedicle on one side was achieved at re-exploration at 3, 6, 9, and 12 weeks. The contralateral side served as a control in which the vascular pedicle was not ligated. In the controls, bony bridging between the corticocancellous bone chips was observed after 7 weeks. A solid bone graft was present within the chamber by 10 weeks. However, histomorphometric evaluation indicated significant bone resorption. By 13 weeks, resorption progressed to the point where only small islands of bone remained. Ligation of the distal vessels resulted in thrombosis of the vessels within the chamber. Necrosis of newly-formed bone was observed in the area adjacent to the vascular thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Various techniques of harvesting the free Gracilis flap have been described. The authors describe their experience in the use of a 'limited' incision in harvesting this flap, as compared to the long medial incision, for both a segmental as well as total flap harvest. Whole or partial Gracilis harvest could be done using small incisions avoiding long scars using the conventional approach. Twenty-one free Gracilis muscle transfers were performed. In 12, a short proximal curved incision was used to dissect a segment of the muscle with its pedicle and with an added small incision near the knee, the whole muscle could be dissected and delivered. The described technique of tracing the vascular pedicle by retracting both the borders of the adductor longus, was followed. This gave a better and easier access to the whole length of the pedicle, vis-a-vis the classic approach of dissecting the pedicle below the adductor longus, which was performed in nine cases.

The authors have developed a technique for postoperative monitoring of transferred free flaps, making the removal of gauze dressings unnecessary. Their technique involves the transparent, hydrogel wound dressing, Clear Site. A Doppler probe can also be directly applied over this material, to examine the patency of the vascular pedicle. An adhesive border on the sheeted material keeps the flap aseptic, thus providing fewer opportunities for wound infection. A wider use of this transparent dressing technique in free-flap surgery is expected.

Since May 1981, the authors have transferred 14 free peroneal flaps, with no failures. The advantages of this flap are that the subcutaneous fat is thin, branches of the peroneal artery can be easily located, the vascular pedicle is long, and vessel diameter at the junction of the peroneal artery is 1.0 to 1.5 mm. After the branches of the peroneal artery and vein are identified and carefully preserved, they are anastomosed to preselected vessels at the recipient site, using the operating microscope at 10 to 16 X magnification. When two branches of the peroneal artery are used, a larger flap is obtainable, but no sequelae or dysfunction at the donor site have been observed. In the reported series, the anastomoses were all carried out by one surgeon (HN).

We tried to find out the validity of 16 wellknown signs indicating an acute traumatic aortic rupture on plain chest radiographs of 22 patients. Angiographically 11 of all patients had a tear at the aortic isthmus. It turned out that 7 of the 16 signs (widened mediastinum, loss of the aortic knob contour, opacification in the aortopulmonary window, bulging of the vascular pedicle predominantly to the left, left apical cap, depression of the left main stem bronchus and displacement of the right paraspinous interface) are of great diagnostic value.

The use of dual vascularized fibula transfer on a single vascular pedicle for reconstruction of long bone defect is described. This technique involves dividing one length of donor vascularized fibula into two segments, without cutting the vessels. The vessels are then folded, thereby supplying blood circulation to both bones. Since 1985 the authors have treated six cases of bone reconstruction using this method. Two of these six cases are reported, with follow-up periods of over one year.

Current techniques of free muscle transplantation with microvascular anastomosis have the disadvantages of limitation of available donor sites, loss of donor muscle function, and the possibility of donor site defect or deformity. Using modifications of a "secondary tissue flap" created by neovascularization of a given tissue, neovascularized muscle flaps with pedicle vessels were created by wrapping external abdominal oblique muscles around the superficial inferior epigastric blood vessels. Different pedicle types were examined to explore possible differences in neovascularization. In 60 rats, four groups of neovascularized muscle flaps were created and transplanted as free flaps, with a high degree of success. After transplantation, neovascularization of the flaps was evaluated by histology and latex casts of vascular tree of the muscle flaps. Degree of neovascularization differed, depending on the type of vascular pedicle used to create the flap.