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The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

After multiple thoracotomies, local muscles are often transected or sacrificed for the treatment of intrathoracic infection. In these conditions, free tissue transfers are described as an alternative. Five anterolateral thigh musculocutaneous free flaps were used for the treatment of complicated large chronic empyema defects and bronchopleural fistulas with a special flap inset and gauze-packing method, the so-called tissue plug technique. All flaps survived completely without complication. There was no sign of recurrent infection, and the bronchopleural fistulas were sealed and the empyema cavities completely obliterated. We concluded that the tissue plug technique is an alternative for the management of difficult empyema cavities and bronchopleural fistulas in selected patients where the soft tissue flap is not enough to fill the complete dead spaces.

Recently several studies have addressed the venous problem and confirmed that venous ischemia is more injurious to tissue viability than arterial ischemia of equivalent duration. There are different methods of managing venous-compromised pedicled flaps. Between June 1996 and November 2003, our center treated two submental, five Becker, nine posterior interosseous, three distally based sural, and three colon pedicled flaps (22 flaps in total), which had venous congestion either at the time of flap elevation or immediately after inset of the flap. These cases of venous congestion were managed with an immediate additional venous anastamosis. After vein anastomosis, venous congestion reduced gradually, then improved, and finally disappeared completely in the postoperative follow-up days with all flaps surviving in their entirety. Reexploration was not required for the microsurgical venous anastomosis. In conclusion, flap necrosis resulting from venous congestion causes prolonged hospitalization, multiple debridements, and additional procedures to cover the exposed structures. Additional vein anastomosis, which is a simple, rapid, and reliable auxiliary procedure, may increase complete flap survival and lead to successful end results, both functional and cosmetic.

Neophalloplasty remains one of the most challenging efforts in plastic and reconstructive surgery. The complex functional and aesthetic requirements are difficult to attain with consistency and safety. The current gold standard technique involves the use of a radial forearm tube-in-tube free flap, which also requires the placement of a stiffening prosthetic device for dual function. We report the safe use of the free fibula osteocutaneous flap to create a functional, cosmetically-acceptable penis utilizing the principles of prefabrication and controlled fistula method in one case of gender dysphoria.

An experimental study was designed to examine whether the blood supply of the muscle would be maintained by a reverse flow from the random pattern skin flap through the musculocutaneous perforators. A flap model containing rat rectus abdominis muscle and randomly based overlying abdominal skin was designed. Sixty rats were divided into four experimental groups as follows. In group I, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, immediately after flap elevation. In group II, scintigraphy and microangiography were performed in 10 and 6 rats, respectively, 2 days after flap elevation. In group III, surviving skin paddle area was evaluated in 16 rats 7 days after flap elevation. After evaluation of surviving skin paddle area, the same animals were used for microangiographic (n=6) and scintigraphic (n=10) studies at the same day. In group IV, histopathologic examination was done in six flap muscles each 2 and 6 weeks after flap elevation (n=12). The mean percentage of surviving skin paddle area was 95.6 +/- 6.5% on postoperative day 7. Microangiography showed progressively developed blood flow from the skin to muscle through the musculocutaneous perforators in groups II and III, respectively. The radioisotope uptake of the operated muscle was 40.9 +/- 12.8% immediately after flap elevation (group I), 58.3 +/- 15.6% on postoperative day 2 (group II), and 70.7 +/- 25.6% on postoperative day 7 (group III). There was a significant difference only between group I and group III ( P<0.05, analysis of variance). Histopathologically prominent atrophy, lipomatoses, and fibroses were revealed at week 6. The poor circulation and viability outcomes of the muscle revealed in the study are because of immediately insufficient blood microcirculation at the distal part of the random pattern skin flap.

In this study, the authors explored the feasibility of transplanting a "pectoral skin flap" as an alternative model for composite skin allotransplantation research. Genetically inbred male Lewis rats (LEW; RT1l) (n = 13), weighing 250 to 300 gr, were used as recipients and Brown Norway rats (BN; RT1n) (n = 8) rats were used as donors. Five Brown Norway rats had bilateral and three had unilateral flap harvest with a total of 13 flap transplantations to Lewis rats. All flaps were transplanted to the groin regions of the recipients and microsurgical anastomoses with 10-0 nylon were performed between the axillary vessels of the flaps and the femoral vessels of the recipient animals. The mean operation time was 55 min, with an ischemia time of 25 min. All transplantations were successful immediately postoperatively. The recipient animals were treated with Cyclosporine A (16 mg/kg/day) from the day of the surgery for 1 week, and then discontinued. One flap developed infection at postoperative day 11 and one flap had partial (50 percent) necrosis. The early signs of rejection started 8 to 9 days after the cessation of the immunosuppressive treatment, and all flaps were acutely and uniformly rejected within 3 to 4 days. The feasibility of harvesting two flaps from one donor animal allowed saving donor animal lives and reducing donor-specific variables.