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As microsurgery gains in popularity, surgical training becomes more critical. There have been numerous studies assessing resident involvement in an array of surgical subspecialties; however, there is a dearth of data as it relates to patient outcomes in the field of Reconstructive Microsurgery. A retrospective review was conducted by searching for all free tissue transfer cases from 2011 to 2012 in the NSQIP database. Study groups were divided based on presence of a resident. The flaps were then subdivided into type of free flap. The primary outcome was the development of major complications, defined as return to OR or flap loss. Secondary outcomes were total hospital length of stay, total operative time, and minor complications defined as surgical site infection, wound dehiscence, and bleeding not requiring return to OR or readmission. A total of 462 free tissue transfers were identified, 92 of which were performed without resident participation, and 369 included resident participation. The majority of flaps of cases were done for breast reconstruction. After adjusting for comorbidities, cases in which residents participated had a statistically significant increase in bleeding, SSI, and total operative time. Interestingly, cases involving a PGY-6 and above conferred a protective effect from developing major complications. Resident involvement in Reconstructive Microsurgery cases is safe, with only a slightly higher probability of minor complications. There was no difference in major complications, and in fact, having a chief resident and above participate in the case conferred a protective effect. Attending surgeons can be confident that their patients will be safe, and that involving residents will not negatively affect their outcomes. Level of evidence: Level III, risk/prognostic study.

Introduction: Free tissue transfer has added to the plastic surgeon's armamentarium and has afforded patients more chances towards limb salvage in recent decades following severe trauma. Venous congestion is a common occurrence, can be the result of several reasons and has devastating results in patients' outcomes. Recent studies have highlighted the importance of restrictive fluid administration. We hypothesized that a restrictive fluid administration in the intra – operative period would be associated with a lower incidence of venous congestion in patients undergoing free flap reconstruction of traumatic defects of the extremities. Methods: All patients undergoing a perforator free flap soft tissue reconstruction of traumatic defects of the extremities, from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities and technical aspects of the operation were extracted. The study population was divided in two groups based on the amount of fluids administered (restrictive: < 6 ml/kg/hr; liberal: ≥ 6 ml/kg/hr). Multivariate analyses were performed to identify the impact of fluid strategy on the development of clinically significant venous congestion. Results: A total of 75 patients were identified. Out of these, 24 patients had clinically significant venous congestion. Fluid administration strategy [AOR (95% CI): 1.53 (1.22, 1.92)], use of the superficial venous system [0.03 (0.01, 0.26)], operative time [1.98 (1.97, 1.99)] and age>50 [5.60 (1.10, 28.52)]. A cut – off analysis identified 6 ml/kg/hr as the cut off point for fluid administration. Liberal fluid administration (≥6 ml/kg/hr) was independently associated with a higher incidence of venous congestion and return to the OR for flap debridement, both overall and after exclusion of anastomotic revisions. Conclusions: Venous congestion in free flap reconstruction following traumatic defects of the extremities remains high. Several factors are associated with congestion. Liberal fluid administration ≥6 ml/kg/hr is independently associated with this complications and should be avoided when possible.

Objective: The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure. Materials and Methods: All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0–48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound. Results: A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days. Conclusion: Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

In this special interview series, we profile members of The FEBS Journal editorial board to highlight their research focus, perspectives on the journal and future directions in their field. Nikos Karamanos is Professor of Biochemistry in the Department of Chemistry, University of Patras in Greece. He joined the editorial board of The FEBS Journal in 2020, having previously served on the advisory board for several years.

A novel and innovative forecasting framework is proposed to generate newbuilding ship price predictions for different vessel types and shipping markets, incorporating recent developments in the dynamic field of artificial intelligence and machine learning algorithms. Based on the advantages of the support vector machine framework, an appropriate support vector regression (SVR) model is specified, tested, and validated for ship price forecasts. The SVR predictive performance is subsequently comparatively evaluated against standard time-series forecast models, such as the ARIMA models, based on convenient statistical criteria. The predictive power of the SVR model is found to be superior to that of the ARIMA model, delivering satisfactory, robust, and promising results. This is the first empirical application of an SVR model to ship price forecasts and can contribute valuable feedback to investment, financing, and risk management decisions in the global shipping business.

Carpal tunnel is the most common peripheral compressive neuropathy. Nonoperative management may provide temporary alleviation of symptoms, but in most cases surgical decompression is warranted. There are a multitude of approaches ranging from open release under general anesthesia to wide awake in-office endoscopic carpal tunnel release. The present article describes the technical considerations for the single incision, antegrade approach to endoscopic carpal tunnel release using the SEGWay system and technique.

Background The use of tissue oximetry for monitoring following free tissue transfer has become a common practice across the United States to facilitate early detection of poor flap perfusion in the postoperative setting. There is no consensus on the optimal value, below which there is a higher chance of wound complications in patients undergoing free flap breast reconstruction. Methods Patients undergoing free flap breast reconstruction from 2015 to 2018 were retrospectively reviewed. Patients who returned to the operating room for a revision of the anastomosis were excluded from analysis. Patients were divided in two groups based on the development of late complications. Those were defined as fat necrosis, wound dehiscence, or distal flap ischemia/necrosis that developed after discharge from the hospital. Mean percutaneous oximetry readings of the first 24 hours were recorded and the mean change from the initial reading was calculated. The correlation between tissue oximetry change and development of complications was explored. Results A total of 120 patients were identified. The mean age was 53, while the mean body mass index was 33. A total of 38 patients developed late wound complication. History of smoking, diabetes mellitus, neoadjuvant radiation therapy, and the mean change of the tissue oximetry reading were identified as independent predictors of wound complications. The absolute number of the tissue oximetry reading did not predict late complications. A multivariate analysis revealed that patients who experienced a mean decrease Conclusion In patients undergoing free tissue breast reconstruction, tissue oximetry readings do not predict late wound complications. However, the mean change at 24 hours from the initial reading does. A decrease of

Introduction: As more breast cancer educational resources are transitioned from printed materials to online formats, it is important to identify the patients that are at risk for low health literacy and who still need access to printed materials. The purpose of this study is to evaluate breast cancer patient health literacy and internet access in the South Texas region and to establish how they prefer to learn about their condition and surgical options. Methods: A 15-item questionnaire was given to patients with newly diagnosed breast cancer at the University Texas Health San Antonio Mays Cancer Center including a validated 3-question health question health literacy assessment, defining patients with high (HHL) or low health literacy (LHL). Patients enrolled in the study were 21 years old or older and planning to undergo mastectomy or lumpectomy for ductal carcinoma in situ, stage I, II, III, or prophylaxis (n=112). Patients who had cancers other than breast cancer were not eligible to participate. Questionnaires were included in the analysis if they were greater than 90% completed. Relationships between demographics, and type of media use were assessed. Results: English was the preferred language for 79.5% of the patients followed by Spanish for 17.9%. Seventy nine percent of breast cancer patients had high health literacy while 21% had low healthy literacy. LHL was associated with high school level education (High school: 83%, College: 17%, p=0.001) and patients with LHL were less likely to access the Internet for healthcare information, (LHL: 28%, HHL 69%, p< 0.001). After adjusting for differences: language, education, age, and cancer stage, possession of a smartphone and access to Internet at home was not associated with Internet use for healthcare information. Regardless of level of education, patients preferred receiving information via printed materials (High school: 60.2%, College: 71%, p=0.581). Neither groups preferred using supplemental videos (High school: 79% and College: 89%, p=0.58). There was no correlation between the level of education and the number of resources patients used to gain knowledge about their breast cancer and reconstructive options (Spearman correlation = 0.111). Conclusion: The majority of South Texas breast cancer patients do have access to the internet but still prefer written materials over online resources. This preference was not driven by patients’ language, educational level, or access to the internet or a smartphone. However, patients that had low health literacy were less likely to use the internet for health related information. As more healthcare information is being digitized, access to printed materials and traditional methods of education should still be available to avoid disparities in health education delivery. Further study will be done to determine the reason for preference of written over online educational materials and the utility of implementing interventions such as courses to teach patients about utilization of online resources. Citation Format: Bao-Quynh Julian, Efstathios Karamanos, Kari Eugenia Smith, Maryam Elmi, Amita Rashmikant Shah. The association of health literacy with internet usage for breast cancer patient education [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-06.

Metasurfaces based on quasi-bound states in the continuum (quasi-BICs) constitute an emerging toolkit in nanophotonic sensing as they sustain high quality factor resonances and substantial near-field enhancements. It is demonstrated that silicon metasurfaces composed of crescent shaped meta-atoms provide tailored light-matter interaction controlled by the crescent geometry. Significantly, this metasurface not only exhibits a fundamental quasi-BIC resonance, but also supports a higher-order resonance with tunable electromagnetic field enhancement and advantageous properties for sensing. The higher-order resonance shows twice the sensitivity of the fundamental one for bulk refractive index sensing. It is further demonstrated that both the fundamental and higher-order resonances can be exploited for sensing ultrathin layers of biomolecules in air and buffer solutions. Specifically, when measuring in buffer solution, the figure of merit of the sensor, defined as the change in the spectral position of the resonance normalized to its full width at half maximum, is a factor of 2.5 larger for the higher-order resonance when compared to the fundamental one. Due to its high sensitivity and potential for straightforward microfluidic integration, the silicon crescent metasurface is ideally suited for real-time and in situ biosensing, enabling compact sensing devices for a wide range of diagnostic applications.

The paper presents a combined experimental and numerical investigation of cyclic loading response of an internally pressurized steel piping system. The piping system comprises three elbows and is subjected to quasi-static end-displacement excitation. Global deformation and local strain measurements are obtained, indicating significant strain ratcheting at the critical locations of the elbows. The piping system failed under low-cycle fatigue undergoing through-thickness cracking at the flank of the most strained elbow. Post-fatigue metallographic examination of the elbows indicated that fatigue cracking initiates from the inner surface of the pipe elbow. In all elbows, several micro-cracks develop along the inner surface of elbow flanks, whereas the outer surface remained practically intact before through-thickness cracking. Finite element simulations, with a properly calibrated cyclic-plasticity model calibrated properly in terms of small-scale material tests, provide very good predictions in terms of local strain evolution at critical locations.

Introduction Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. Methods All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. Results A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. Conclusions The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.

Even the best surgical technique can be undone by poor postoperative flap care. Postoperative care includes extremity dressing, extremity positioning in the postoperative period, and aggressive postoperative monitoring.

The scapular and parascapular flaps are cutaneous flaps that have been extensively used in the treatment of soft tissue reconstruction and are a favored flap for the treatment of severe hemifacial microsomia. The scapular and parascapular flaps are based off of branches of the extensive subscapular arterial system. The subscapular artery provides a number of branches, each of which separately can serve as a pedicle for a flap (the latissimus dorsi muscle, the anterior serratus muscle, the tip of the scapula, the lateral edge of the scapula, and the cutaneous portions of the scapular and parascapular flaps). As a result, it is an ideal choice for chimeric flaps. The harvest of the scapular or parascapular flap has minimal donor site morbidity. The dissection of the flap is relatively easy and the anatomy is constant since this is an axial cutaneous flap. The dissection becomes more tedious if a chimeric flap is to be utilized. The skin of the back is usually thin and pliable; however, it can be very thick in obese patients. This is taken into account when choosing a flap for a defect requiring a thin pliable flap. The flap is harvested with the patient in the lateral decubitus position and changes in the patient’s position intraoperatively may be needed. Finally, the scar does tend to widen and may be cosmetically unacceptable for some patients.

The medial sural artery flap was first described by Cavadas in 2001. It is a newer flap that combines the benefits of the anterolateral thigh flap and the radial forearm free flap: It is a thin flap that makes it ideal for more distal soft tissue reconstruction of the extremity, while it has minimal donor site morbidity. It can often be closed primarily, resulting in a cosmetically acceptable scar. The blood supply to the flap runs parallel to the muscle fibers, resulting in muscle preservation during dissection, and it makes it ideal for patient desiring no muscle sacrifice (Fig. 29.1). Its dissection is based on the same principles as the gastrocnemius muscle flap. Its skin territory is the skin overlying the medial gastrocnemius. It needs to be noted that an analogous lateral sural perforator artery flap can be designed based on the lateral sural artery in the same fashion. We usually include the superficial venous system if possible (greater saphenous vein – GSV) for drainage. Although a good flap, it should be noted that the MSAP flap is not as reliable as other more commonly used flaps (e.g., the ALT flap) and has a steep learning curve due to its highly random vascular territory. Sometimes, during dissection, a reliable perforator is not encountered and the MSAP flap cannot be used. The medial sural artery has many muscular branches that need to be identified and ligated, making the dissection tedious and time consuming.

The superficial circumflex iliac artery perforator (SCIP) flap is a relatively new modification of the traditional pedicled groin flap. The groin flap is an axial flap that utilizes the superficial circumflex iliac artery (SCIA) that lies caudal to the inguinal ligament. The SCIP flap utilizes a perforator from the SCIA that branches off the SCIA usually in the midpoint of the inguinal ligament and travels superior to it. It then courses parallel to the inguinal ligament about 2 cm superior to it. As a perforator flap, it does not sacrifice any muscle and the level of dissection is just below the Scarpa’s fascia. The superficial circumflex iliac vein (SCIV) is usually included in the flap to aid with drainage and the superficial inferior epigastric vein (SIEV) may be incorporated as well if its territory is included in the flap design. The SCIP flap is an excellent option in non-obese individuals for reconstructing distal extremity defects since it is a thin flap that avoids the excessive bulk seen with other reconstructive options. The dissection is relatively easy; however, the pedicle can often be short and the diameter of the vessels small, making microsurgical anastomosis more challenging compared to other more traditional flaps and oftentimes require super-microsurgery techniques for a successful result. We prefer to use this flap in patients with normal BMI who do not have diabetes and do not smoke. Due to the small size of vessels, an end-to-end anastomosis with a named vessel is usually difficult. We prefer to perform an end-to-side anastomosis with a named vessel.

The dorsalis pedis (DP) fasciocutaneous flap is an axial pattern flap base on the dorsalis pedis artery. It is a thin flap and can be used as the flap of choice for the reconstruction of the dorsum of the foot as a pedicled flap by rotating it around its axis, or as a free flap for the reconstruction of the hand and other small soft tissue defects. It has a reliable vascular and sensory anatomy and allows for a sensate reconstruction. This is an important factor when used in weight-bearing areas of the body. When the radial forearm flap is not available, the DP flap with its long vascular pedicle and thin fasciocutaneous component provides a good option. Several variants of the DP flap include an osseocutaneous flap using the second metatarsophalangeal joint for hand reconstruction. Also, a composite vascularized flap utilizing the extensor tendons of the toes can be used for complex thumb reconstruction when there is tendon loss.

Historically, limb salvage for severe injuries was amputation. This avoided the complications of sepsis and potentially life-threatening exsanguination. As the science and techniques of medicine have evolved, so has limb reconstruction. These advances have been driven by medical changes in fracture management, management of vascular and nerve injuries, and soft tissue coverage. The increasing complexity of war injuries have served as a driving force for application of new concepts for limb reconstruction utilizing emerging medical techniques. A multidisciplinary approach is now used at advanced trauma centers as well as military centers of excellence. Extremity reconstruction remains a rapidly evolving field and previously established wisdom is constantly challenged. Our textbook is from the viewpoint of trainees and recent graduates. It provides a comprehensive review of different techniques for osseous and soft tissue reconstruction of the extremities.

The reverse flow superficial sural artery flap (RSSA), which was first described by Donski and Fodgestam, and later popularized by Masquelet et al., is a distally based pedicled fasciocutaneous flap. It can be used to cover defects of the distal third of the leg, the ankle, and the foot when free tissue transfer cannot be performed. The RSSA flap derives its blood supply in a reversed fashion via perforating vessels from the peroneal artery to the superficial sural artery. These can be found 5–7 cm proximal to the lateral malleolus. The main advantage of the RSSA is the ease of dissection without sacrificing a major blood supply to the leg. The donor site can be closed primarily or reconstructed with a split thickness skin graft, incurring minimal morbidity to the patient. The main disadvantage of the RSSA is that it is associated with a high incidence of venous congestion. This is mainly due to the fact that the venous outflow relies on the venae comitantes of the superficial sural artery and the lesser saphenous vein. There is minimal contribution from the deep venous system. As it is theorized that the flap design might contribute to venous congestion, the design of the flap and its pedicle has evolved. We have a low threshold for performing a delay procedure for this flap if any signs of venous congestion are evident during dissection or after rotation of the flap.

The sartorius muscle flap is a type IV (segmental blood supply) Mathes–Nahai flap. It is located in the upper thigh and is an excellent option for reconstruction of the groin. It has traditionally been used due its ease of harvesting by non-plastic surgeons (such as vascular surgeons or general surgeons) in order to cover the femoral vessels, following inguinal lymphadenectomy or debridement of an infected bypass graft. Its segmental blood supply allows a wide range of reconstructive options: a simple myoplasty involves placing the muscle under tension and moving part of the fascicles medially, enough to cover the vessels. On the other spectrum, the muscle can be transected, either distally or proximally, and rotated in order to fill the medial space and provide the necessary coverage. When distally based, the sartorius muscle can be rotated to cover small defects of the knee. The donor site morbidity is minimal.

The lateral arm flap is a fasciocutaneous flap that can be used either as a pedicled or a free flap. It is a relatively thin flap, although that might not be the case in obese patients or patients with excess skin of the arms, and is mainly used for hand reconstruction as well as head and neck reconstruction. Its major advantage is that it does not sacrifice a major blood supply to the arm. It can be harvested as a fasciocutaneous, fascia-only or osteocutaneous flap, depending on the reconstructive needs of the patient. The flap dimensions can be up to 6×12 cm and the donor site defect can be closed primarily most of the times. The surgical scar produced is often easily concealed. The flap dissection is easy and the anatomy is reliable and constant. It allows the utilization of two teams, minimizing the operative time. When used as a free tissue transfer, the lateral arm flap derives its blood supply from the posterior radial collateral artery. On the other hand, when used as a reverse flow pedicled flap, it derives its blood supply from the recurrent radial collateral artery. The vascular pedicle has a small diameter (1–3 mm) and requires an experienced microsurgeon. The posterior cutaneous nerve needs to be sacrificed during flap dissection, resulting in paresthesias of the lateral arm and that needs to be discussed with the patient prior to proceeding.

Fingertip amputations are common injuries that can pose a reconstructive challenge to the plastic surgeon. When evaluating a fingertip amputation, one must take into consideration the geometry of the amputation (transverse, volar oblique, or dorsal oblique), the size of the defect, the level of the amputation, the critical structures exposed, and the importance of each digit. Digital functionality varies. For the middle ring and little finger, length preservation is important. Sensation preservation is most important for the index finger and the thumb and the ulnar border of the little finger.

The radial forearm flap (RFF) is one of the first flaps utilized in reconstruction of soft tissue defects. It can be used either as a pedicled flap with the pivot point either distal, at the wrist, or proximal at the antecubital fossa, or as a free flap. It is a workhorse flap for reconstruction of distal extremity defects where a thin and pliable flap is needed. It is also very commonly used for reconstruction of head and neck defects. Its dissection is easy and can provide a very long pedicle (up to 15 cm), which can avoid the use of vein grafts in specific cases. The venous drainage is reliable, and the cephalic vein can easily be incorporated to assist with the outflow. It can also be a sensate flap, if the medial or lateral antebrachial cutaneous nerves are incorporated with the flap design, something very useful when reconstructing heel defects. The RFF can be raised as a chimeric flap, incorporating bone from the distal radius or the palmaris longus tendon. Multiple skin paddles can be designed along the course of the radial artery based on reconstructive needs. Finally, the long and relatively big diameter pedicle makes it an ideal “flow-through” flap because it can be used as a vascular conduit for other flaps to be anastomosed to, in an end-to-side fashion. Of extreme importance, an intact palmar arch and satisfactory blood flow via the radial artery are absolute requirements. Disadvantages include cosmetically unacceptable donor site for patients. It also sacrifices a major blood vessel, which always needs to be discussed with the patient prior to surgery.

The ulnar forearm fasciocutaneous flap is a perforator flap that is anatomically similar to the radial artery forearm flap. A thorough anatomic understanding of the vascular supply of the hand and a good clinical exam are necessary for appropriate flap selection. The ulnar and radial arteries are the two main arteries that provide blood supply to the hand, with the ulnar being the larger of the two. Distally, the two arteries merge to form two palmar arches: one deep and one superficial. When the arches are intact, vascular perfusion can often be maintained with the existence of one artery or the other. The superficial palmar arch is mainly formed by the ulnar arch with the aid of a smaller superficial branch of the radial artery. The superficial palmar branch is incomplete in 1/5 of the patients and supplies typically the little, ring, long finger, and the ulnar aspect of the index finger. The deep palmar arch on the other hand is formed mainly by the radial artery with the aid of the deep palmar branch of the ulnar artery. Contrary to the superficial palmar arch, it is almost always complete and provides blood supply to the thumb and the radial aspect of the index finger. A preoperative Allen’s test can help define radial or ulnar dominance of the hand with regards to the vascular supply, as well as the presence of complete palmar arches. Since the superficial palmar branch is more likely to be incomplete, sacrifice of the radial artery may lead to ischemic changes in the hand more often than sacrifice of the ulnar artery. If that is the case, a radial forearm flap should not be harvested and an ulnar forearm flap should be considered. On the rare occasion where the distal blood supply of the radial and ulnar arteries is completely independent, the use of either the radial or ulnar forearm flap cannot be justified. It needs to be noted that due to a paucity of ulnar cutaneous perforators distally in the forearm, the ulnar forearm flap cannot be designed as distal as the radial forearm flap. Of note, the ulnar pedicle is shorter than the pedicle of the radial forearm flap. However, the skin overlying the ulnar aspect of the forearm is usually thinner and less hair bearing compared to the radial aspect and may result in a more cosmetically acceptable result for some patients. The donor site defect is also more easily concealed. However, the ulnar forearm flap is associated with significant post - operative morbidity, since it is harvested from an area of the forearm that is used to rest the upper extremities during daily activities (for example when using a keyboard or when writing). Finally, similar to the radial forearm flap, the ulnar forearm flap can be raised as chimeric flap with the ulna, and or flexor carpi ulnaris. It can also be used as a flow-through flap if distal revascularization is desired.

The soleus muscle is located in the superficial posterior compartment of the leg deep to the gastrocnemius muscle and serves as the second plantar flexor of the foot. It is considered to be the flap of choice when reconstructing defects of the middle portion of the lower leg. It is a bipenniform muscle with independent neurovascular bundles for the medial and lateral components, allowing for harvest of a hemisoleus, or the entire soleus as needed. The blood supply of the soleus muscle, while constant, requires a very good anatomic knowledge for a successful dissection. In addition, the vascular supply is in close proximity to the tibia, and as a result, fractures to the tibia may result in compromise of the blood supply and failure of the attempted reconstruction. The soleus muscle can be used in conjunction with other local flaps to reconstruct more extensive defects (upper and middle third defects). In addition, it results in minimal donor site morbidity, both cosmetically and functionally and is an ideal pedicled local flap for reconstruction. The donor site can be closed primarily, while a split thickness skin graft can be applied on top of the transferred muscle at the same time to complete the reconstruction.

The RF is a type I Mathes–Nahai muscle flap, with its blood supply derived from the profunda femoris. The rectus femoris is one of the four muscles of the anterior thigh and is a powerful hip flexor and knee extensor, contributing significantly in balanced ambulation. Harvest of the RF can have up to 20% reduction in knee extension strength.

The toe-to-thumb transfer provides the best functional outcome in patients sustaining traumatic amputations of the thumb who desire reconstruction. While it can be used successfully in patients with congenital hypoplastic thumbs, index finger pollicization is often the procedure of choice. Adequate length of the proximal phalanx with preservation of an intact and supple MCP and CMC joint is a prerequisite for a toe-to-thumb transfer. This procedure is technically challenging and should not be attempted by inexperienced surgeons in extremity reconstruction. A successful outcome for this procedure requires detailed knowledge of the structural anatomy. The first webspace needs to be of normal width. Any first webspace contracture needs to be treated well in advance. The first webspace may be addressed with scar excisions, z-plasty, or pedicled flap at least 3 months prior to a toe-to-thumb transfer.

The propeller flap has been recently been defined by the Tokyo consensus in 2011 as: “ an islanded flap that reaches the recipient site through an axial rotation of ≥ 90 degrees.” The propeller flap is similar to the propeller of a boat with two blades moving around a pivot point. The first authors to describe the use of a propeller flap were Hyakusoku et al. in 1991. Hallock et al. in 2006 combined the terms “propeller” and “perforator” flaps to describe a flap of the posteromedial thigh to cover an ischial pressure sore. The flap used a single perforator and was rotated around 180 degrees to cover the defect. Since its conception, propeller flaps have gained popularity and have become a reasonable option for reconstructing limb defects, especially lower third leg defects. Traditionally, due to the paucity of soft tissue in the distal third of the lower leg, the reconstructive options are limited to free tissue transfer or, more recently, to the use of a propeller flap, when free tissue transfer and long operative times are not advised. However, propeller flaps are based on defined angiosomes associated with named fasciocutaneous perforators and can be used to cover defects of the head, torso, or limbs depending on the reconstructive needs of the patient. There are more than 500 perforating vessels in the body, with the upper limb averaging about 48 perforators and 15 vascular territories and the lower limb averaging 93 perforators and 21 territories. There are several advantages when a propeller perforator flap is employed: the main axial vessel that provides arterial blood supply to the limb is preserved, the dissection is faster and less complicated compared to a free flap, and the defect is reconstructing with neighboring soft tissue, aiding in reconstructing “like with like” in terms of skin texture, thickness, pigmentation, and other skin qualities. Because the propeller flap does not have a specific flap design, the rest of this chapter focuses on discussing important principles that will aid in the flap design, perforator selection, flap dissection and inset that may be applied in any perforator propeller flap anywhere around the body.

Originally described in 1956 by Dr. Littler, the Littler flap is a heterodigital flap (from another digit) that can provide coverage for soft tissue defects of the fingers, especially the thumb. The Littler flap is a sensate, vascularized flap that originates from the ulnar volar aspect of the middle finger or the radial aspect of the ring finger. It is an easy to harvest flap and can be performed under local anesthesia in selected patients. Significant donor site morbidity includes painful neuromas, scar contractures, and altered hand anatomy. When a Moberg flap (Chap. 9) or FDMA flap (Chap. 10) is not an option, we use the Littler flap to provide sensate reconstruction of the tip of the thumb. This has the added benefit of thumb length preservation. Healing by secondary intention with dressing changes is not an option when there is exposure of bone and/or tendons.

Local soft tissue rearrangement involves a wide array of local flaps that can be utilized to close soft defects in the extremities. While local random flaps are relatively easy to perform, their utility is limited in traumatic or chronic wounds. The traumatic zone of injury and chronic soft tissue changes limits the effectiveness of small random soft tissue flaps. The random V–Y flap, rhomboid flap, and rotational flaps that are discussed in this chapter are good options for reconstructing small acute iatrogenic wounds. Lengthening of a scar and scar contractures is often addressed by the use of Z-plasties; however, occasionally, an adjacent soft tissue transfer is appropriate.

The tensor fascia lata muscle flap is a Mathes–Nahai type I (one single dominant pedicle). While this muscle flap can be used for a variety of reasons, we choose this flap mainly for three reasons: (a) to reconstruct groin or pelvic defects (including the area of the iliac wing) as a V–Y advancement flap or as a rotational flap, (b) as part of a chimeric free flap when a targeted muscle reinnervation is being performed, and (c) when a knee soft tissue reconstruction with a concurrent patellar tendon reconstruction is needed, as the iliotibial tract can be transformed into a relative strong tendinous structure. While the flap can be harvested as a muscular flap only, we almost always harvest it as a musculocutaneous flap, with the skin overlying the muscle in the lateral aspect of the leg. Two-thirds of the proximal skin from the anterior superior iliac spine (ASIS) to the knee can be safely harvested without concerns; however, an extended skin paddle can also be harvested. If the skin paddle harvest extends distally to the proximal two-thirds, then one needs to understand that the blood supply to the distal aspect is often unreliable. As a result, a delay procedure is recommended in these cases. The skin paddle design can be made in a V or a more circular pattern depending on the reconstructive needs and the shape of the wound that needs to be covered. It needs to be noted that the muscle, even though small, is significantly bulky and that needs to be taken into account when deciding the suitability of the flap for the proposed reconstruction. The vascular pedicle anatomy is consistent with adequate length (6 cm) and good diameter (2 mm), making it an easy target for microvascular anastomosis. The functional donor site defect morbidity is minimal; however, it can leave a significant cosmetic defect, which needs to be discussed, especially with female patients.

Free tissue transfer is a complex surgery that involves multiple steps, all of which are critical for a successful outcome. In the previous chapters, we discussed various concepts of flap design and selection as well as postoperative monitoring (see Chaps. 2 and 3). The dissection of the recipient vessels is an important step to ensure atraumatic vascular inflow and outflow to the flap. Exposure of recipient vessels in the extremity is dependent on safe dissection as injury to these vessels can compromise vascular supply to the distal extremity.

The posterior interosseous artery (PIA) flap was first described in the 1980s by Masquelet and Zancolli and has been used predominantly for the reconstruction of hand defects. It is an axial flap that derives its blood supply from the posterior interosseous artery. It is most commonly used as a reversed flow pedicled flap to reconstruct defects of the dorsal hand. However, it has been used as a direct flow pedicled flap to reconstruct more proximal defects of the arm or the elbow, or even as a free flap when other options are not available. Its main advantage is that it does not require the sacrifice of the two main vessels of the hand, namely, the radial and the ulnar artery. It is a good option when the patient does not have an intact palmar arch or has had previous procedures where the radial artery or ulnar artery has been sacrificed due to the danger of developing hand ischemia postoperatively. Examples would include coronary artery bypass graft harvest, complications from radial artery canalization, or previous use of a radial or ulnar forearm flap. Based on body habitus, the skin of the PIA flap is most often thin and pliable, making secondary debulking procedures less likely. It has a long pedicle and will reach far enough to provide soft tissue coverage to the MCP joints and the first webspace. This flap is used for small defects (

The latissimus dorsi (LD) flap is a Mathes–Nahai type V flap (one major pedicle, multiple minor pedicles) and is the widest muscle in the human body. It is a workhorse flap in the armamentarium of the plastic surgeon. It is commonly used to reconstruct multiple, wide, or long lower extremity defects. Also, the ability to tuck the muscle deep into the wound allows for effective filling of unusual wound dimensions. The muscle serves as an external rotator and adductor of the humerus, and its sacrifice does not result in a significant defect for the patient. In addition, it has a very reliable blood supply, with a pedicle that is long (up to 15 cm) and wide (up to 5 mm if taken at the subscapular), making it an easy microsurgery target. The muscle is also quite thin, making it easy to be draped around difficult surfaces. It can be harvested as an innervated flap based on the thoracodorsal nerve. Finally, it can be harvested as a chimeric flap, with the addition of serratus anterior muscle, fasciocutaneous component (scapular/parascapular), or osseous segments (tip of the scapula or lateral border of the scapula).

The gastrocnemius muscle flap has been a workhorse flap for decades in reconstructing defects of the upper third of the leg. It is a very reliable and easy to perform muscle flap that can reliably cover defects of the upper third up to 15 cm distal to the knee. While both heads of the gastrocnemius muscle can be harvested, we prefer to harvest the medial head whenever possible for two main reasons: (1) the medial head is usually bigger and longer and thus can reconstruct larger defects compared to the lateral head and (2) the lateral head of the gastrocnemius is in close proximity to the common peroneal nerve at the proximal fibula, and as a result, the nerve can be damaged during flap harvesting. We prefer to use this flap when traumatic wounds of the upper third of the leg needs to be reconstructed, or when the knee joint is exposed (e.g., after an infection following a total knee arthroplasty); however, some middle third defects can be reconstructed as well. The flap can be used in combination with other flaps (soleus, propeller flap, etc.) providing a wide range of reconstructive options for the upper and middle lower leg. The gastrocnemius muscle serves to plantar flex the foot, but harvesting one head does not result in a significant donor site morbidity. A hemi-gastrocnemius and a hemi-soleus can be safely harvested at the same time without the patient experiencing a clinically significant defect in plantar flexion of the foot. There is a significant aesthetic donor site defect that can occur, and this should be taken into account when discussing this reconstructive option especially in children and female patients. The donor site can be closed primarily and the muscle can be skin grafted in a single stage procedure.

The first dorsal metacarpal artery (FDMA) flap is a fasciocutaneous flap that is mainly used in the reconstruction of the thumb. However, it can be applied to the reconstruction of the ulnar aspect of the dorsum, the wrist, and for first webspace reconstruction. The flap was originally described by Hilgenfeldt, and subsequently modified by several surgeons. The FDMA is a type of island flap that has an average pedicle length of around 7 cm, making it an ideal flap for reconstruction of the thumb due to its wide arc of rotation. The FDMA flap is based off the first dorsal metacarpal artery, which is a branch of the radial artery, and as such, patients with injury to the radial artery at the anatomic snuffbox are not candidates for this flap. The flap may be a sensate flap if the branch of the superficial branch of the radial nerve (SBRN) is harvested with the flap, something that can increase the functionality of the reconstruction.

The gracilis muscle flap is a long muscle located in the medial thigh with one dominant pedicle and secondary pedicles. It is a Mathes–Nahai class II. It has a very reliable and consistent blood supply. It serves to flex the knee, adduct the thigh, and medially rotate the tibia on the femur. Harvesting the muscle leaves minimal to no donor site morbidity and makes it an excellent option for free tissue transfer. The gracilis muscle is about 25 cm long and, with the addition of the tendinous attachments, it gains an extra 10 cm for a total of 35 cm. It is 5 cm wide and 3 cm thick and is the flap of choice for narrow localized defects of the upper or lower extremity. A functional free gracilis flap has been used to restore upper extremity function. While we prefer to harvest it as a muscle flap, the flap can be harvested as a musculocutaneous flap from the medial thigh, with the skin being supplied by musculocutaneous perforators. We find that the island skin flap is unreliable and we choose to use different flaps when a cutaneous portion is needed. The gracilis muscle is innervated by the obturator nerve and can easily be harvested as a functional muscle flap. Given its tendon’s and anatomy, the gracilis muscle flap is our flap of choice when restoration of finger flexion, finger extension, or elbow flexion is desired. The gracilis muscle flap is an ideal flap for facial reanimation as well, but this is beyond the scope of this book. During flap harvest, proper identification of the gracilis muscle is of paramount importance to avoid dissection of the wrong muscle.

The rectus abdominus muscle is the main flexor of the torso and is located in the anterior abdominal wall. It has a dual blood supply, superior from the superior epigastric artery, which is a continuation of the internal mammary artery and inferior by the deep inferior epigastric artery, which is a branch of the external iliac artery. It is a Mathes–Nahai type III flap (2 major pedicles). The rectus abdominus muscle is a very versatile flap that is used in various reconstructive scenarios. It can be used as a pedicled flap based on either of the two pedicles, or as a free flap. While we prefer to use it in extremity reconstruction as a muscle-only flap, the rectus abdominus has been widely used as a musculocutaneous flap. Based on the pattern of the skin flap, the rectus abdominus musculocutaneous flap can be designed with a vertical skin paddle overlying the ipsilateral muscle (VRAM) or with a transverse skin paddle overlying both recti muscles (TRAM). The rectus abdominus muscle can be used as a pedicled flap based on the inferior epigastric artery to reconstruct perineal defects (VRAM being the flap of choice for perineal defects). When other smaller regional flaps are not adequate for coverage, the rectus abdominus flap is excellent for proximal groin/thigh defects. Pedicled flaps based on the superior epigastric artery are widely used in sternal and breast reconstruction, but these are not covered in this book. When used as a free flap, the pedicle of choice is the deep inferior epigastric artery since it has a longer pedicle and a bigger diameter, making it more suitable for microsurgical anastomosis. The dissection of the flap is straightforward, often allowing a two-team approach. Given the morbidity of postoperative hernias and destabilization of the anterior abdominal wall, we tend to avoid the use of this flap unless other viable options are not available.

The anterolateral thigh (ALT) flap was first described by Sing et al. in 1984 and is a perforator fasciocutaneous flap. In recent decades, it has become the most commonly performed flap for reconstruction of the head and neck, extremity, trunk, and even perineum. Its popularity is mainly due to its long pedicle, versatility in flap design, reliable blood supply, and its relative standardization of operative technique. In our practice, it has become the workhorse flap when a free tissue transfer is needed for reconstruction of defects of the lower third of the leg. Its close proximity to other flaps and its unique vascular anatomy allows it to be harvested with muscle (tensor fascia lata or vastus lateralis) or tendon (iliotibial band). Furthermore, it can be used as a flow-through flap when distal revascularization is needed. Finally, the ALT flap can be used as a neurotized flap and provide sensation in critical areas (such as the heel of the foot) using the lateral femoral cutaneous nerve. The ALT flap can be harvested in a suprafascial or subfascial fashion, depending on the reconstructive needs and the surgeon’s experience. The ALT flap may be small or large, depending on the reconstructive needs. While some flaps may be thick, they can safely be thinned. When this is done, we prefer to thin the flap in situ, with the pedicle dissected but not ligated and under the guidance of real-time fluorescence imaging to assist with safe debridement. The donor site can sometimes be primarily closed; however, often, a split thickness skin graft is needed. The donor site may be cosmetically unacceptable for female patients and some degree of paresthesias in the lateral thigh can be encountered.

The free fibula flap is a workhorse flap for osseous free tissue transfer in extremity reconstruction. It is also the flap of choice for mandibular defects, but this is beyond the scope of this book. The fibula has several advantages that makes it an ideal choice when long bone defects reconstruction via osteogenesis is required: It is a long bone that can provide up to 25–30 cm of length when harvested; it is mainly comprised of cortical bone, making it ideal for rigid fixation; it is a straight bone that is triangular in cross section, providing adequate support after reconstruction; it can be shaped to fit the defect via multiple osteotomies without compromising its blood supply due to its segmental vascularization; once the anatomy is understood, the dissection is relatively fast and easy to perform; there is minimal donor site morbidity and finally the vascular pedicle is long and the diameter of the peroneal artery and veins are large making the anastomosis less challenging. An in-depth understanding of the anatomy of the lower leg, including the contents of all four compartments is of paramount importance to perform a safe dissection. The proximal and distal ends of the fibula need to be left in situ, to avoid destabilization of the leg. This is especially important in children, where destabilization can lead to a valgus deformity of the ankle. During dissection, care needs to be taken to identify the common peroneal nerve as it courses around the neck of the fibula. Inadvertent injury can result in loss of function of the muscles of the anterior compartment of the leg (foot drop) and loss of sensation along the course of the superficial peroneal nerve. The flexor hallucis longus (FHL) muscle is the most vulnerable muscle during dissection, and loss of its function may result from the harvest. Additionally, fibrosis of the tendon can lead to permanent flexion deformity of the great toe.The free fibula flap can be harvested as an osseous or osseoseptocutaneous flap with a skin paddle in the lateral aspect of the flap based off septocutaneous peroneal perforators. While sacrifice of the peroneal vessels usually does not result in distal foot ischemia, a preoperative angiogram may be of value in patients with significant peripheral arterial disease.

The pectoralis major (PM) flap is a Mathes–Nahai type V flap (one major pedicle, multiple minor pedicles). While it is very useful in the reconstruction of the head and neck, as well as sternal reconstruction, these indications are beyond the scope of this book and will not be discussed. When it comes to extremity reconstruction, the uses of the pectoralis major flap are limited, since there are other options in the armamentarium of the plastic surgeon. We prefer to use this flap mainly for pedicled functional muscle transfer to restore the deltoid function whenever other options are not available. The PM flap has also been utilized as a functional muscle flap to restore FDP function following Volkmann’s ischemic contracture of the forearm; however, we feel that an innervated gracilis muscle flap is technically easier and results in a negligible donor deficit, making the gracilis muscle the flap of choice in our practice for FDP function restoration. Anatomically, the pectoralis major muscle can be divided into three anatomically distinct portions: the clavicular portion, the sternal portion, and the costal portion (Fig. 16.1). The PM flap can be harvested as a split muscle flap, thus maintaining some of the function and minimizing the donor deficit, or as a whole muscle, most commonly when used for head and neck reconstruction. We prefer to harvest the clavicular and sternal portion of the flap, leaving the costal portion attached to the humerus to allow adequate functionality. The pectoralis major muscle allows for (1) flexion of the humerus, (2) adduction of the humerus, (3) medial rotation, and (4) stabilization of the humerus. The PM flap is usually based off of the thoracoacromial pedicle and if preservation of functionality is desired, the lateral pectoral nerve is preserved. Main disadvantages of the flap include the short pedicle (only 3 cm) and the aesthetically non-pleasing donor side defect, especially in females.

We breakdown free tissue transfer for extremity reconstruction into five major steps: (1) preoperative planning, (2) flap dissection, (3) microsurgical arterial and venous anastomosis, (4) flap insetting, and (5) postoperative care. Each step independently contributes to a successful outcome. Planning and execution of flap insetting occurring at the end of a long operative day is often under appreciated. In cases where flap insetting is not carefully planned, the results may be suboptimal, even if the flap harvest and microsurgical anastomoses are performed with 100% technical competency. This chapter discusses techniques that have proven useful to us while insetting the flap. The senior surgeon considers this step to be critical to our overall success and is always present during flap closure and insetting.

Primary closure of a wound is the simplest reconstructive option in the soft tissue reconstructive ladder. When used, adequate soft tissue must be available to avoid excessive wound tension. A wound closed under excessive tension will lead to wound dehiscence or an unacceptably wide scar.

The anteromedial thigh (AMT) flap is not our first flap of choice, mainly due to its highly variant vascular anatomy and the less favorable donor site defect compared to the ALT flap. However, it is a good option in the plastic surgeon’s armamentarium when dissecting an ALT flap and no suitable perforators are found during surgical exploration. As a matter of fact, when harvesting an ALT flap, we always perform the anteromedial incision first and we do not proceed with the lateral incision until we have verified that there are adequate perforators that can carry the ALT flap with good inflow and outflow. If no suitable perforators are found, we typically explore the medial thigh in the subfascial plane to assess whether an AMT flap can be harvested. If a good perforator of the innominate (or medial branch/rectus femoris branch) of the descending branch of the lateral femoral circumflex is found, then an AMT is an option. If the decision is made to proceed with harvesting an AMT, then the previously performed medial incision of the ALT serves as the lateral aspect of the AMT. The AMT, similarly to the ALT flap is a Cormack type B flap. As discussed above, the most common blood supply to the flap is the innominate branch which courses posteromedial to the rectus femoris muscle. If that branch is small and not suitable to carry a flap, then the flap can be shifted to a more inferomedial aspect of the thigh. The blood supply to this newly designed flap are the septocutaneous branches surrounding the sartorius muscle arising from the femoral artery and vein.

Background:. Clostridium difficile–associated infections (CDI) have a significant impact on morbidity and mortality of hospitalized medical and surgical patients. There is a paucity of data regarding the incidence, impact, and modifiable risk factors in the plastic surgery population. Methods:. The ACS NSQIP database was retrospectively queried for all cases performed by plastic surgeons during 2016. All plastic surgery cases, combined cases, demographics, and baseline clinical characteristics were extracted from the database. The study population was divided into 2 groups based on the development of CDI. Independent variables for development of CDI were identified. Results:. During the study period, a total of 29,256 patients underwent a procedure by plastic surgery, with the most commonly performed procedures involving the breast (58%) and trunk (14%). Only 44 patients developed post-operative CDI (0.1%). Factors independently associated with development of CDI were wound classification at the end of the surgery, COPD, procedures involving the trunk, and surgery for reconstruction of pressure ulcers. Outpatient surgery was associated with decreased odds of developing CDI [AOR (95% CI):0.2 (0.1, 0.4), adj P < 0.001]. Staying overnight did not increase the odds of developing CDI; however, staying for >1 day in the hospital was associated with an increased risk of CDI development [AOR (95% CI): 1.03 (1.01, 1.13), adj P = 0.001]. Combined cases, ASA, body mass index, diabetes, and active smoking were not associated with CDI. Conclusions:. CDI are rare in the plastic surgery population and are most associated with trunk/decubitus ulcer reconstructions, inpatient hospital stay, and contaminated wounds. The patients that usually fit in these categories have acutely or chronically infected wounds, which are often treated with systemic antibiotics. For patient with decubitus ulcers and other trunk reconstruction, the guidelines for pre and post-operative systemic antibiotic usage is not well defined. For patients who have had trunk reconstruction, development of evidence-based antibiotic stewardship guidelines may help these patients by limiting antibiotic usage and thereby reducing the incidence of CDI.

Interactions of cancer cells with matrix macromolecules of the surrounding tumor stroma are critical to mediate invasion and metastasis. In this study, we reproduced the collagen mechanical barriers in vitro (i.e., basement membrane, lamina propria under basement membrane, and deeper bundled collagen fibers with different array). These were used in 3D cell cultures to define their effects on morphology and behavior of breast cancer cells with different metastatic potential (MCF-7 and MDA-MB-231) using scanning electron microscope (SEM). We demonstrated that breast cancer cells cultured in 2D and 3D cultures on different collagen substrates show different morphologies: i) a globular/spherical shape, ii) a flattened polygonal shape, and iii) elongated/fusiform and spindle-like shapes. The distribution of different cell shapes changed with the distinct collagen fiber/fibril physical array and size. Dense collagen fibers, parallel to the culture plane, do not allow the invasion of MCF-7 and MDA-MB-231 cells, which, however, show increases of microvilli and microvesicles, respectively. These novel data highlight the regulatory role of different fibrillar collagen arrays in modifying breast cancer cell shape, inducing epithelial-to-mesenchymal transition, changing matrix composition and modulating the production of extracellular vesicles. Further investigation utilizing this in vitro model will help to demonstrate the biological roles of matrix macromolecules in cancer cell invasion in vivo.