Search

Background: War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors' purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes., Methods: A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps., Results: Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent versus 26 percent; p = 0.475). However, there was a significantly higher flap failure rate in the muscle compared with the fasciocutaneous group (13 percent versus 6 percent; p = 0.030). Although there were more overall extremity complications in the muscle group (59 percent versus 47 percent; p = 0.030), there were no significant differences in soft-tissue infection, osteomyelitis, or amputation rates., Conclusions: There are many flap options that provide adequate coverage in extremity salvage. Complication rates did not differ significantly between muscle and fasciocutaneous flaps, with one exception--flap failure rates were significantly higher in our muscle-based flap cohort of patients. Nonetheless, each of these flap types has utility in our patients based on individual wounding patterns, flap availability for reconstruction, and rehabilitation goals., Clinical Question/level of Evidence: Therapeutic, III.

Background: Combat-related extremity injuries frequently require vascular repair within the combat theater before undergoing definitive reconstruction. This study examines the outcomes of early vascular repair with secondary soft-tissue extremity reconstruction over the past decade of war trauma., Methods: War-related extremity injuries necessitating a downrange vascular procedure followed by a definitive limb reconstruction were reviewed. Patient demographics, type and location of vascular injuries, vascular intervention, and soft-tissue reconstruction procedures were examined. Outcomes of vascular repair, tissue transfer, and limb salvage were analyzed., Results: From 2003 to 2012, 79 extremities in 78 patients had a vascular injury requiring in-theater intervention followed by 87 staged flap reconstructions performed distal to the vascular repair. Of the 74 arterial injuries requiring intervention, 27 were proximally located, with 73 percent requiring bypass. The early primary patency rate was 66 percent and the early primary-assisted patency rate was 93 percent for proximal artery repair procedures. The flap complication rate was 31 percent. Overall complications were examined by subtype and were not significantly different compared with flaps performed without a proximal vascular injury in the same limb. The flap success rate (93 percent) and the limb salvage rate (81 percent) were similar to the comparison cohort., Conclusions: This represents one of the largest series of traumatic extremity injuries requiring secondary limb reconstruction with tissue transfer following a vascular intervention. The authors identified no significant difference in outcomes related to flap coverage or limb salvage for patients with or without vascular injuries. Reconstructive options in combat extremity trauma are not limited by proximal vascular injury., Clinical Question/level of Evidence: Therapeutic, III.

Purpose: Definitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan., Methods: A clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013., Results: During this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59 days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism., Conclusion: Reconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.

Prognostic test for estimation of viability of cutaneous flap (PTEVCF) was proposed. It was used while the nutrient pedicle amputation conduction, when "italian" plasty was formated. This test is based on determination of intensity of the cutaneous flap hyperemia after ischemia-reperfusion of recipient's tissues conduction with subsequent temporary arrest of the blood flow from the donor's region; also the method of the tissues preparation, using the ischemia-reperfusion procedures for the tissues removed, and for the tissues, constituting complex of the recipient wound--a flap, was applied. PTEVCF and the method of the tissues preparation were successfully applied in 5 patients while formation of the extremities flaps, based on a temporary nutrient pedicle.

We devised a cube advancement flap and reported its usefulness for treating defects of the face. Here we report its use to treat five cases of extensive scarring of the limbs with similar satisfactory results.

Background: Microsurgical perforator flaps are useful in an array of reconstructive scenarios, but their technical complexity, steep learning curves, and prolonged operative times may limit their widespread adoption. Alternatively, the keystone island flap combines perforator-based vascularity with relative simplicity of nonmicrosurgical tissue rearrangement. This article reviews the authors' reconstructive experience using the keystone flap to reconstruct large trunk and extremity defects., Methods: The authors performed a retrospective chart review of patients undergoing keystone flap reconstruction between 2002 and 2008. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications, and follow-up care were evaluated and are presented in this article as an uncontrolled case series., Results: Twenty-eight patients underwent keystone flap reconstruction. The average wound size measured 15.0 ± 11.7 × 13.0 ± 7.9 cm (250.5 ± 379.4 cm2). The average length of stay, including tumor resection, was 6.36 ± 6.68 days. A 35.7 percent overall complication rate was noted; partial and total flap loss was observed in only 7 percent of patients. One patient (3 percent) failed reconstruction and required alternative wound closure., Conclusions: The keystone flap can be applied to large defects of the trunk and extremities, obviating the need for either microsurgical techniques or extensive operative time while achieving primary wound healing. Despite minor complications, the 97 percent reconstructive success rate compares well to published rates of microsurgical tissue transfers but has several advantages: short operative times, high reproducibility, ease of use, and favorable aesthetic outcome. The authors conclude that the keystone flap is a reliable and effective reconstructive surgical technique for reconstruction of soft-tissue defects.

Large bone defects of extremities, especially those associated with soft tissue defects, represent difficult reconstructive problems. Chimeric flap is a suitable option for reconstruction of complex bone and soft-tissue defects. In this report, we present the experience on use of the peroneal artery perforator chimeric flap for the reconstruction of complex bone and soft tissue defects in the extremities in 16 patients. The bone defects were located in the tibia in 8 patients, in both tibia and fibula in 1 patient, in the ulna in 2 patients, in both ulna and radius in 2 patients, and the metatarsal bone in 3 patients. The flap was created with skin paddle and fibula bone segments based on independent perforators. The sizes of flap ranged from 8 x 6 to 20 x 11 cm(2), and the length of fibular grafts ranged from 6 to 22 cm. All flaps survived completely. Bone union was ultimately obtained in all cases at 5 to 11 months, while two cases suffered from stress fractures in 12 month and 18 month after operation, respectively, which eventually healed with external fixation treatment. The follow-up time ranged from 12 to 37 months. The definite bone hypertrophy was observed from X-ray at 18 months after operation. In conclusion, our results show that the peroneal artery perforator chimeric flap is a good option for reconstruction of complex bone and soft-tissue defects of extremities, particularly for those with three-dimensional defects and bone defects exceeding 6 cm in length.

Objectives: To investigate the curative effect of skin flap and allogenic tendon in reconstructing limbs function of complex soft-tissue defect., Methods: From May 2001 to December 2007, 43 cases of complex soft-tissue defect of limbs were repaired by pedicled skin flaps, free skin flaps, cutaneous nerve nutrient vessel skin flaps and arterial island skin flaps for primary stage, then the function of the limbs were reconstructed with allogeneic tendon after 2-3 months of skin flap operation. There were 31 males and 12 females, aged 5-53 years (mean 25 years). Injury was caused by machine in 28 cases, by traffic accident in 14 cases and others in 1 case. There were 27 cases in upper limb, 16 cases in lower limb. Twenty-six cases complicated by bone fracture, dislocation and bone defect, the most of bone defect were cortical bone defect. The sizes of skin and parenchyma defect were 9 cm x 4 cm to 37 cm x 11 cm, the length of tendon defect was 6 to 26 cm. The sizes of skin flaps were 10 cm x 5 cm to 39 cm x 12 cm. Allogeneic tendons were used 2-6 strips (mean 4 strips)., Results: Forty-three cases were followed up for 5-56 months (16 months on average), all flaps survived. The donor area healed by first intention, the incision healed by first intention in second operation, and no tendon rejection occurred. The clinical healing time of fracture was 3-8 months, and the clinical healing time of allograft was 6-8 months. Six cases were given tenolysis for adhesion of tendon after 3-5 months of tendon transplantation. The postoperative flexion of wrist joint was 20-50 degrees, the extension was 20-45 degrees. Articulation metacarpophalangeal and articulation interphalangeal could extend completely. The flexion of articulation metacarpophalangeal of thumb was 20-45 degrees, the flexion of articulation interphalangeal was 30-70 degrees. The flexion of articulation metacarpophalangeal and articulation interphalangeal of the other fingers was 60-90 degrees. The postoperative ankle can extend to neutral position, the neutral position of ankle was 30-50 degrees. The flexion of articulation metatarsophalangeal and articulation interdigital was 20-40 degrees. The extension of articulation metatarsophalangeal was 30-60 degrees., Conclusion: Through designing systematically treatment plan, practicing operation by stages, preventing adhesion of tendon actively and exercising function reasonably, the functions of limbs reconstructed by allogenic tendon and skin flap can leads to satisfactory effect.

We compared the effectiveness of free tissue transfer in repairing high-voltage electrical extremity injuries with conventional multistage procedures. Patients were matched for age, sex, level of injury, voltage, and burn surface area; results were compared using the paired Student T test. Free tissue transfer was performed a mean of 19.1 +/- 10.6 days after the injury occurred, and definitive wound closure and limb salvage were achieved in 87.5% of patients after a mean of 23.0 +/- 9.1 days after the injury. The overall flap survival rate was 80% (13 of 15 flaps). Three flaps failed, two of which were lower-limb flaps at the knee level used for patients with injuries to both upper and lower limbs. Both patients required upper and lower proximal ipsilateral limb amputations. One upper-extremity flap failed after pedicle avulsion 4 days after surgery, but a second free tissue transfer was successful in salvaging this limb 4 days later. The number of surgeries, time required to achieve wound closure, and length of hospitalization were all statistically significantly lower in the free flap group compared with those in the conventional treatment group.

Objective: To summarize the effectiveness of the improved surgical techniques in fasciocutaneous flaps of the limbs., Methods: From February 1999 to December 2005, 58 patients (39 males, 19 females, aged 10-68 years) underwent repairs of the skin defects with improved fasciaocutaneous flaps of the limbs. Twenty-one patients had the skin defects in front of the tibial bone in the middle and lower parts, 12 patients had the skin defects in the heels, 16 patients had the skin defects in the ankles, 3 patients had the skin defects around the knees, 1 patient had a wide sacrococcygeal bedsore, and 5 patients had the skin defects in the wrists and hands. The wounds ranged in size from 5 cm x 3 cm to 18 cm x 12 cm. According to the wound locations, the following flaps were selected: 4 cutaneous antebrachii medialis nerve and basilic vein fasciocutaneous flaps, 1 cutaneous antebrachii lateralis nerve and cephalic vein fasciocutaneous flap, 3 saphenous nerve and great saphenous vein fasciocutaneous flaps, 1 cutaneous nerve of thigh posterior fasciocutaneous flap, 32 reverse sural nerve and saphenous vein fasciocutaneous flaps, and 17 reverse saphenous nerve and great saphenous vein fasciocutaneous flaps. The dissected flaps ranged in size from 6 cm x 4 cm to 18 cm x 13 cm. The donor wounds underwent straight sutures in 39 patients, and the skin-grafting (6 cm x 3 cm to 13 cmX 6 cm) was performed on 19 patients after the donor wounds were closed., Results: The wounds healed by first intention, and the flaps survived completely in 54 patients. The flaps developed partial necrosis in 4 patients. The follow-up for 1-20 months (average, 8 months) revealed that the flaps had a satisfactory appearance with a soft texture and the function was also satisfactory., Conclusion: A fasciocutaneous flap of the limbs is an ideal flap for repairing defects in the skins and soft tissues of the limbs. The survival rate of the flap can be further improved by an improvement of the surgical techniques.

Objective: To analyze the feasibility of reverse island flaps pedicled with cutaneous nerve nutrient vessels in repairing the defect on distal parts of extremities., Methods: Thirty patients with tissue defect in distal extremities, complicated by exposed vessels, nerve, tendons, and/or bones ,were repaired with island flaps pedicled with neurocutaneous nutrient vessel. Among them, five cases were grafted with flaps with external forearm cutaneous nerve vessels, eleven cases were grafted with flap containing sural neural nutrient vessels in its pedicle,and 14 cases with saphenous nerve nutrient vessels in the pedicles., Results: The flaps of 28 cases survived with perfect appearance and function. In one case partial necrosis occurred because of compression on the pedicle, but the patient healed after dressing, and another case with necrosis of the edge of the flap due to infection, but also healed after skin grafting., Conclusion: The reverse island flaps pedicled with cutaneous nerve nutrient vessels which are constant in anatomy, with reliable blood supply, can be recommended because its simple operative technique, non-injurious to main blood vessels and muscles, the repair of distal defects of the extremities.

Objective: To introduce the new progress of perforator flaps as an new reconstruction technique., Methods: The literature both at home and abroad was reviewed, and the research findings of different perforator flaps were summarized., Results: The advantage of perforator flaps versus musculocutaneous flaps was the reduced morbidity of the donor site with preservation of the nerves, muscles and deep fascia. The postoperative complications at donor sites reduced., Conclusion: Perforator flap was the new and reliable technique for reconstruction of tissue defect and may be one of the primary choices in the future.

Objective: To summarize and review the development and experience of anastomosis vascular pedicle free composite tissue flap., Methods: From July 1987 to March 2007, 321 patients with complete records were treated. Fourteen tissue flaps were applied for the repair of trauma or tumor excision defects of the body, and for organ reconstruction., Results: Vascular crisis occurred in 20 patients within 48 hours postoperatively. Necrosis occurred at flap end in 6 patients. The total survival rate was 94.8%. The main experience was: (1) Training to grasp the basic micro-vascular anastomosis technique was very important starting up period for surgeons. The basic technique should be often practiced to ensure the safty of clinical application. (2) Restoring appearance and function were equally important in practice. (3) Utilizing the minimal invasive methods and decreasing the loss of function of donor site were important for improvement of reconstruction quality. The purpose was to achieve functional and esthetic restoration in the condition of lowest donor site scarification., Conclusion: The application of free composite tissue flap is important for the development of plastic surgery. There are extensive applications for free flap, especially for those critical patients. The application of free flap could decrease the mobility rate, shorten the treatment period, ease the pain of patients and improve the reconstruction effect. The experience of donor site selection, the strategy of poor recipient site condition, the advantages and disadvantages of muscle flap, the applications time, infections wound treatment and application, are helpful for the future application.

Objective: To evaluate the clinical use and outcome of a rectus abdominis microvascular free flap for wound closure in dogs., Study Design: Retrospective case series., Animals: Dogs (n=9) with complex extremity or oral wounds., Methods: Medical records (2002-2006) of dogs that had a rectus abdominis free tissue transfer to close an extremity or oral wound were reviewed., Results: Nine dogs were identified: 5 had distal extremity wounds, 3 had oral palatal defects, and 1 had a large hygroma excised. A rectus abdominis free tissue transfer with a caudal epigastric vascular pedicle was successfully used for management of these wounds. No major complications occurred with the donor site and a good cosmetic and functional outcome occurred in all dogs., Conclusion: The rectus abdominis is a versatile muscle that can be used for reconstructing cutaneous and oral defects with repeatable success., Clinical Relevance: Free tissue transfer of the rectus abdominis muscle is a clinically useful technique for closure of a variety of difficult soft tissue wounds.

Tissue expansion in combination with flap transfer has been widely reported as preexpansion of flaps, but only once as expansion of a free flap after transfer. Three free flaps and one pedicled flap were expanded after transfer. Indication, timing of expander implantation and explantation, technical aspects, and complications are reviewed. Indications for expander implantation after flap coverage were adjacent scar contracture, a secondary ulcer, or correction of contour deformity. The expander was placed as early as 4.5 months after free flap transfer. Low grade infection and seroma were complications necessitating early expander removal in two cases. The outcome was satisfactory in all four patients. Tissue expansion after flap transfer has been shown to be a reliable reconstructive option in selected cases. Indications are rare and include hypertrophic scar formation, scar contracture, secondary ulceration, or reconstructive procedures. In early free flap expansion, it is critical to avoid mechanical pressure of the pedicle. In musculocutaneous flaps, this can be accomplished by placing the expander subcutaneously. If more than 6 months have passed since transfer of the flap, the randomized blood supply is sufficient to place the expander anywhere under the flap.

Modern approaches to the treatment of cicatricial deformation of extremity are presented. The results of treatment of 20 patients using the tissue expanding method are adduced. During the expander implantation and dermotension in 20% of patients the complications had occurred. The analysis of the results obtained permits to consider dermotension the method of choice in the treatment of the extremity cicatricial deformation.

Limb reimplantation techniques using composite free-tissue transfer and microsurgical salvage of traumatized extremities have become standard reconstructive methods. Mechanisms for working with free-tissue transfers have advanced, specifically in regard to the use of thin-wire fixators: combining microsurgical techniques and thin-wire fixators helps in salvaging limbs that otherwise might be amputated. Also, combining the Ilizarov method with microsurgical techniques for limb salvage provides a new use for flaps. A further development in the use of flaps is the application of free-tissue transfers to preserve amputation levels in the war-injured. So-called fillet flaps serve as "spare parts" and can be customized for specific recipient sites. The so-called perforator flap makes use of feeder vessels, thus providing cutaneous and other composite flaps without sacrificing major vessels. Finally, the advent of the sural flap has made it possible to avoid microsurgical reconstruction but still provide adequate, well-vascularized cover, particularly in the distal third of the leg.

Reconstruction of extremity war injuries begins with aggressive forward resuscitative care and stabilization of the trauma patient. After serial care in progressively better supported medical environments, definitive management is done at the level V military treatment facility. Aggressive forward care coupled with rapid air transport has enabled increasingly complex care to be administered at the continental United States military facilities; however, it has also made the decision between limb salvage and amputation more challenging. Yet to be determined are (1) the optimal timing of definitive wound closure or coverage in coordination with fracture stabilization and (2) the optimal types of flap for both upper and lower extremity reconstruction. Records of patients with complex lower and upper extremity wounds who were treated at the National Naval Medical Center between September 2004 and June 2006 reveal useful short-term data. Longer-term data, such as fracture union rate, time to ambulation, range of motion and global function of salvaged limbs, patient satisfaction with limb salvage, and average cost, are not yet available.

Objective: To evaluate the clinical effects of fibula flap grafts on the repair of the extremities with traumatic compound tissue defects., Methods: In 12 cases, the fibula flap grafts were employed to restore the extremities with traumatic compound tissue defects. Of the 12 patients, 9 were males, 3 were females; their ages ranged from 12 to 45. There were 2 cases of tibia defect combined with fibula fracture, 2 cases of tibia defect, 2 cases of radius defect, 3 cases of ulna defect, 1 case of calcaneus defect, and 2 cases of first-metatarsus defect. The bone defect length ranged from 4.2 to 10.6 cm, 7.8 cm in average. The skin defect area ranged from 10.0 cm x 4.5 cm to 27.0 cm x 15.0 cm. The free transplantation of fibular flaps were used in 9 cases, the lapse operation were used in 2 cases, retrograde shift were used in 1 case., Results: Post-operational vein crisis and common peroneal nerve traction injury were observed in category mentioned above respectively. All the 12 fibula flaps survived after proper treatments such as removal of great saphenous vein. Follow-ups were done for 6 to 24 months. Both the transferred fibula and the recipient broken end reflected bones were healed. Four patients underwent the second-phase reconstruction operation of tendon moving power. One wrist and 1 ankle underwent arthrodesis in 3 to 6 months. All the effects were satisfactory., Conclusion: The fibula flap grafts provide a relatively better alternative to repair the extremities with long bone compound tissue defects. In addition, the sensory function reconstruction of fibula flaps should be given full attention.

Objective: To investigate the application of free flaps in combined transplantation and its clinical outcome., Methods: From January 1991 to December 2003, 56 cases of combined transplantation involving cutaneous or myocutaneous flaps were performed to repair extremely large soft tissue defects, large-sized skin and segmental bone defects and to simultaneously reconstruct the missing thumb and repair the associated skin defects in the first web space. Of the 56 patients, 37 were males, 19 were females. Their ages ranged from 5 to 41, 27.6 in average. The transplants included latissimus dorsi myocutaneous flap, scapular flap, lateral femoral flap, big toe skin-nail flap, and fibula. To establish blood circulation in the transplants, the common vascular pedicle was anastomosed directly to the vessels in the recipient site in 35 cases but to the selected vessels in the healthy limb in 21 through a cross-bridge procedure. Results With failure in 2 cases of combined transplantation of latissimus dorsi myocutaneous flap and vascularized fibula, all the transplants survived well. In the 32 cases of long bone defects with successful repair, the transplanted fibula united with host bones 14.5 weeks after operation on the average. A mean follow-up of 28 (10-128) months revealed that function in all cases was recovered, while one patient, who underwent a successful combined transplantation of latissimus dorsi myocutaneous flap and vascularized fibula, required amputation of the involved leg 3 years after repair because of the repeated ulcers in the toes., Conclusion: The application of free flaps in combined transplantation can lead to an effective repair of complicated tissue defects of the limb and to a successful reconstruction of the associated missing thumb.

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.

Traumatic limb injuries requiring free tissue transfer for coverage, often lack healthy recipient vessels adjacent to the defect. In these patients, vein grafts are required to bridge the gap of either the artery, vein or both. For the latter situation, a temporary arteriovenous fistula (AVF) can be created and allowed to mature and then divided and used as recipient artery and veins for the free flap. These cases are challenging and several variables including vein graft length, vein graft diameter, and arterial inflow affect the patency of the vessels and the final outcome of the reconstruction. Sixty-five defects were reconstructed with free tissue transfers using vein grafts of significant length (>20 cm for the arterial gap). The ipsilateral or contralateral great saphenous veins were used for vessel lengthening in all cases. Inflow arteries were either major arteries (superficial femoral, popliteal or brachial), or lesser arteries (sural, anterior or posterior tibial, thoracodorsal, or superior gluteal). The patients were divided into those that underwent AVF followed by free tissue transfer in two stages (n = 6), AVF followed by free tissue transfer in one stage (n = 28) and patients that underwent vein grafting for the arterial defect only with (n = 6) or without (n = 25) a simultaneous bypass graft for lower limb revascularization. In the two-stage AVF group, the rate of occlusion of the graft after AVF creation was 50% (3/6); re-exploration rate was 33.3% (2/6); free flap failure rate was 33.3% (2/6); and limb salvage rate was 83.3% (5/6). In the one-stage AVF group: re-exploration rate was 28.6% (8/28); free flap success rate was 89.3% (25/28); and limb salvage rate was 92.9% (26/28). In the long vein graft group for arterial defects only: re-exploration rate was 25.8% (8/31); free flap success rate was 96.8% (30/31); and limb salvage rate was 87.1% (27/31). In patients where the graft was anastomosed to a major artery the re-exploration rate and free flap failure rate were 22.4% (11/49) and 8.2% (4/49). In patients where the graft was anastomosed to a lesser artery, the re-exploration rate and free flap failure rate were 43.4% (7/16) and 12.5% (2/16). The limb salvage rate was comparable in both groups (89.8%, 44/49, versus 87.5%, 14/16). In all groups, patients undergoing re-exploration were noted to have a an arterial gap of 31.78 cm as compared with the patients that did not require re-exploration which had an arterial gap of 26.26 cm. Vein grafting for bridging vascular defects is a safe procedure when proper indications and techniques are followed. Although a longer graft length seemed to be associated with a higher re-exploration rate, there was no statistical significance. One-stage AVFs can be used with good results, however, two-stage AVFs are associated with a high graft occlusion rate, wound failure rate and limb amputation rate. In all cases, a large caliber graft such as the great saphenous vein provided a large (relatively low resistance) conduit for bridging the defect.

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.

Based on the dissection of 20 fresh cadavers, the authors have detailed further the vascular anatomy of the thoracodorsal artery and its cutaneous perforator vessels. The thoracodorsal artery showed a constant bifurcation into a horizontal branch and a lateral branch, located on the deep surface of the latissimus dorsi muscle 4 cm (range, 3-6 cm) distal to the inferior scapular border and 2.5 cm (range, 1-4 cm) medial to the lateral free margin of the muscle. In 20 specimens there was a total of 64 musculocutaneous perforators larger than 0.5 mm. Thirty-six perforators (56%) originated from the lateral branch and 28 perforators (44%) originated from the horizontal branch. All perforators originated within a distance of 8 cm from the neurovascular hilus and ran in proximity with the horizontal or lateral branches. In 11 dissections (55%) there was also a direct cutaneous branch originating from the extramuscular course of the thoracodorsal artery before the neurovascular hilus. This cutaneous branch did not pierce the latissimus muscle but rounded the lateral muscle edge and supplied the overlying subcutaneous tissue and skin. It is hoped that the constant anatomy will encourage surgeons in the future to use the thoracodorsal artery perforator flap more often.

Microvascular transfer of the omentum has several unique advantages for the reconstruction and revascularization of extremity wounds. The omentum provides well-vascularized, malleable tissue for reconstruction of extensive soft-tissue defects and has a long vascular pedicle (35 to 40 cm) with sizable vessels, which reduces some of the potential technical challenges of microsurgery. It can also be used for flow-through revascularization of ischemic distal extremities. The unique properties of the omentum make it an ideal tissue for the reconstruction of difficult extremity defects, allowing simultaneous reconstruction and revascularization. Experience with six free omental tissue transfers for upper-extremity and lower-extremity reconstruction is described. Three of the cases involved distal anastomoses to take advantage of the flow-through characteristics of the flap, providing distal arterial augmentation. All flaps accomplished the reconstructive goals of wound coverage and extremity revascularization. The omentum is a valuable, often overlooked tissue for the treatment of difficult extremity wounds.

The use of top-quality tissue in covering soft-tissue loss, and precocity in reconstructing injuries and restoring function, are major prerequisites for obtaining a good surgical result. Earlier methods of reconstruction, based on a delay, for various periods of time, in reconstruction, have gradually become obsolete. The employment of more aggressive techniques and research supporting the "as-early-as possible" morphological and functional reconstruction path has become the rule in dealing with emergency reconstructive interventions. This path has been opened by data that describe and clarify the reaction of skin, muscles, and osteoarticular vascular anatomy to traumatic injury. This research, combined with the current availability of a great number of both simple and complex free flaps, has spurred the development of the concept of the "emergency free flap." Here, the authors present a new classification of emergency free flaps, based on their experience using these procedures to treat traumatic injury., (Copyright 2003 Wiley-Liss, Inc.)

Objective: To summarize and analyze the main point on the reconstruction of traumatic tissue defects of limbs with vascularized skin and multi-tissue flaps., Methods: Sixty-seven cases of traumatic tissue defects of limbs were reconstructed with 14 kinds of skin or multi-tissue flaps. The operative methods included local transposition, cross-transposition with vessel pedicles and vessel anastomosed free transplantation., Results: Forty cases with vessel anastomosed free transplantation and 26 cases with local or cross-transposition of vessel pedicled flaps were survived. In the followed up cases, 53 cases were satisfied with the outward appearance of the skin flaps. All the cases with bone flap or skin-bone flap resulted in union. And the cases with motor nerve anastomosed myocutaneous flap transplantation had recovered to 2-3 grade muscle contraction ability., Conclusion: It is important that the appropriate flaps and operative methods should be chosen according to the size, location, depth and structure of the tissue defects. To raise the success rate and to gain better operation effect, the correct manipulation in operation and the rational postoperative treatment are necessary.

The serratus anterior muscle has been suggested as a versatile and reliable flap for reconstruction of head and neck and extremity injuries. The adipofascial layer overlying the serratus anterior muscle is the anatomic layer, which is supplied by the same branch of thoracodorsal artery. Even though great progress has occurred in the prevention of postoperative adhesion of extremity injuries, the problem has not been completely solved and is still of special importance in complex injuries. Between March of 1995 and February of 1996, seven patients underwent reconstructive operation as a result of soft-tissue defects of the upper or lower extremities or the scalp. We transferred free adipofascial tissue overlying the serratus anterior muscle in three patients and both serratus anterior muscle and adipofascial tissue in four patients. A free adipofascial flap overlying serratus anterior muscle was transferred when a gliding surface was required, owing to the exposure of tendons and neurovascular structures. The average duration from operation to follow-up examination was 8 months (from 4 to 16 months). The results of the operations were satisfactory in functional and cosmetic aspects. This kind of flap was very effective in reconstruction of soft-tissue defects and gliding surfaces for these reasons: easy dissection, the capability of obtaining a long vascular pedicle, large-sized flap, composite flap including muscle or rib, and the fact that there was no serious functional or cosmetic deficit at the donor site.

A profusion of terms are currently used to describe free flap wound closure. It is important to broadly standardize nomenclature when embarking on a comparison of functional outcomes between institutions. Therefore, a series of 68 "emergency" (within 24 hours) free flaps performed by a single surgeon were reviewed with respect to a total experience of 188 free tissue transfers to formulate a consistent nomenclature applicable to free flap wound closure in general. The nomenclature presented divides free flap closure into three categories: "primary free flap closure" (12 to 24 hours), "delayed primary free flap closure" (2 to 7 days), and "secondary free flap closure" (after 7 days). This system is analogous to the standard terms "primary," "delayed primary," and "secondary wound closure." It is consistent with known biologic and microbiologic principles of wound closure in general and should provide a simple basis for classifying free flap wound closure. Illustrative examples are presented to highlight the classification scheme.

Trauma to the extremities often results in a complex bony and soft-tissue injury requiring free flap reconstruction. Muscles from various body sites have been used in extremity reconstruction since the early 1970s. The gracilis muscle is usually not considered the first choice for free flap reconstruction of these defects. It is usually relegated to small defects or used to reanimate the face. Our purpose is to present our experience with the gracilis muscle as a first-choice flap in reconstruction of traumatic extremity defects. A retrospective review of all gracilis muscle free flap transfers for traumatic extremity wounds between 1988 and 1995 at the Naval Medical Center Portsmouth was performed. Twenty-five patients age 20 to 71 years (mean, 29.7 years) underwent 26 free flaps to the lower leg, ankle, foot, or forearm to cover traumatic wounds. Defects ranged in size from 3 x 3 cm (9 cm2) to 13 x 18 cm (234 cm2), with a mean of 75.5 cm2. There were no flap losses and all wounds healed. Nine patients experienced 11 complications, which consisted of minor wound separation (16%), wound infection (12%), partial or complete loss of split-thickness skin graft (8%), thrombosis of graft with successful revascularization (4%), and nonunion of an underlying fracture (4%). Our overall success rate for gracilis free flap reconstruction of traumatic wounds is 100%. The gracilis free muscle flap has become our first option for tissue coverage in traumatized extremities. It leaves minimal functional defect limited to the side of the primary injury and provides a good cosmetic result. It can cover large defects when the epimysium is cut, and allows an epidural block to be performed for sympathectomy effect and pain control in the affected extremity during the immediate postoperative period.

Soft tissue defects of the extremities are infrequent within the spectrum of general surgery and are predominantly found with perfusion disorders of macro- and microcirculation in the lower extremities. In the upper extremity, they are more frequently seen after i.v. cytostatic drug administration and tumor resections. This article describes the most frequent causes of complex defects of the extremities. Common flaps for the reconstruction of these defects and the pathway to decision making are elucidated.

Although many trauma centers are primarily "adult-oriented," the presentation of unusual life- or limb-threatening wounds in children occasionally have mandated urgent microvascular tissue transfer for salvage. For these rare instances, should a microsurgical team accustomed to dealing with adult trauma patients even attempt to meet such a specialized challenge? A retrospective analysis of all free flaps performed by the author's team in trauma patients from 1984 to 1993, revealed only 10 pediatric patients who had had 11 separate free flaps. Their ultimate success rate was 90.9 percent--statistically the same rate (87.0 percent) as for 93 adult free flaps. The majority of these pediatric flaps were for urgent coverage of the lower extremity and they were all successful, eliminating any need for traditional pedicled flaps during the same time period. Improvement in technical expertise and judgment seemed to be more important factors than actual chronological age in determining free-flap success in general, and in children in particular. Therefore, free flaps in the pediatric population can be appropriately performed in an adult trauma center.

The purpose of this study was twofold: (1) to determine if there is a relationship between a critical quantity of bacteria and infection in complex extremity wounds, and (2) to compare the positive and negative predictive values, sensitivities, and specificities of the following laboratory and clinical tests of potential wound infections: quantitative cultures, swab cultures, mechanism of injury, severity of fracture, and wound position. Fifty patients were evaluated who had 50 free-tissue transfers. Twenty-eight patients had quantitative cultures prior to flap coverage. All 50 patients were evaluated for wound position, presence or absence of a fracture, and mechanism of injury; 16 patients had swab cultures. The best positive predictive value (89 percent) and negative predictive value (95 percent), along with sensitivity (89 percent) and specificity (95 percent), for predicting wound infection were those of quantitative cultures. This demonstrates that in the clinical setting of this study, the test with the highest utility and validity is quantitative cultures.

The clinical application of the musculo-cutaneous flap of musculus tensor fascia lata has been limited because it includes muscle and it is very thick. To correct this disadvantage, the ascending branch of the lateral femoral circumflex artery, which is the supplying artery, is dissected up to its entrance into the tensor muscle of the fascia lata, then the upper, middle and lower branches were identified, and the upper and middle branches are ligated, followed by resection of the muscle, resulting in a fascia lata flap supplied by the lower branch only. The flap contains the lateral femoral cutaneous nerve. It is a good flap to repair a defect of skin and to restore sensory function at the same time. It has been used in 15 cases with good effect.

Use of the adipofascial turn-over flap has been extended to cover such complex wounds of the extremities as defects over exposed joints and fracture sites. Experience with 10 consecutive cases and long-term follow-up confirmed that this flap is easy to plan and quick to raise, with minimum donor site morbidity and high success rate.

Three cases are described in which a second microvascular free flap, transplanted after a delay of several months, was provided perfusion by re-using the recipient vessels of the first flap in end-to-end fashion. In each patient healing of the second flap was uneventful, and both transplants continue to survive. Prior to harvesting the second transplant, a careful intraoperative examination was performed in which the vascularity of the original transplant was assessed. In each case, recipient vessel re-use represented the least risky of several options. The results of the present series suggest that vascularization from the transplant bed or surrounding tissues proceeds despite the fact that, initially, the only source of blood for the free flap flows through a single axial vessel. This single vessel can therefore be divided without loss of the transplant as long as the transplant bed has already provided vascularization to the flap. In our opinion, the timing of the second procedure and the quality of the transplant bed are the key factors in the survival of the transplants.

Thirty-five consecutive patients treated with the radial forearm flap were reviewed. This flap was used in head and neck reconstruction in 25 patients, soft-tissue cover of an extremity in 9 patients, and as a new technique for penile reconstruction in 1 patient. Osteocutaneous flaps were used for mandibular reconstruction in 13 patients. In 6 patients innervated flaps were used to provide sensation on the dorsum of the hand or on the weight-bearing surface of the foot. There was only one total flap failure and no partial failures. Recipient-site complications were few, with prompt healing and very acceptable appearance. Donor-site complications included partial loss of the skin graft with tendon exposure in 10 patients (33 percent), an unsatisfactory appearance in 5 patients (17 percent), and one case of radial fracture (8 percent). On functional testing, there was no significant loss of strength or joint mobility in the donor extremity in 19/20 patients. The authors recommend measures to reduce donor-site morbidity and conclude that, with an acceptable donor site, this flap is valuable in a variety of reconstructive applications.