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Extensive posterior chest wall defects, especially those closer to the midline of the trunk, pose surgical challenges in plastic surgery. In these cases, prior to tissue coverage, the status of the pleural cavity and skeletal support need to be addressed to obtain a functional and anatomical reconstruction. We recently operated upon a patient presenting with an aggressive ossifying fibromyxoid tumour located in the lower dorsal paraspinal region on the right side. After ablative surgery and intra-operative radiotherapy, a broad defect in the chest wall of 15 x 10 cm, including the proximal part of five posterior ribs, was presented. It required immediate bony frame reconstruction, which was resolved with a Goretex patch wrapped with a de-epithelised myocutaneous pedicled transverse rectus abdominus myocutaneous (TRAM) flap, transposed through the right hemithorax. The patient was extubated 2 days after surgery and discharged in 10 days. We describe the use of an intra-thoracic TRAM flap to reach the posterior chest wall defects, and we propose its specific indication for reconstruction of extensive posterior chest wall defects when other options are unavailable., (Copyright (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The development of the DIEP flap established an accepted concept of reconstructive surgery, but in patients who demonstrate inadequate in vivo flap perfusion, alternative surgical options to improve vascularisation are limited. We present a 42-year-old patient, with a left mastectomy whose breast was reconstructed with a DIEP flap. After anastomosis to the internal mammary vessels there was insufficient arterial perfusion of the flap. The situation was resolved by using an independent medial perforator artery emerging from the peritoneal layer (epiperitoneal vessels). This new pedicle was anastomosed end-to-end to the distal portion of the inferior epigastric artery. We consider that epiperitoneal vessels can be an emergency pedicle when needed and a possible alternative to the main pedicle of the DIEP flap.

Unlabelled: The benefits of a VEGF-secreting endothelised scaffold on the survival of distal flaps with early pedicle flap division were evaluated in a rabbit model. We bioengineered a scaffold based on a fibrin matrix in which endothelial cells, genetically modified with a VEGF-encoding adenoviral vector were embedded. We distributed subjects in four groups., Control: Eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold. The pedicle was divided after a period of 5 days; and eight rabbits conditioned with endothelial cells embedded in a fibrin scaffold but in this group the pedicle was divided after a period of 2 days., Treatment: Eight rabbits conditioned with VEGF-secreting endothelial cells embedded in a fibrin scaffold; the pedicle was divided after a period of 5 days. And eight rabbits conditioned with VEGF-secreting endothelial cells but the pedicle was divided after a period of 2 days. The percentages of survival were 95.62+/-4.95% for the VEGF-producing scaffold vs. 51.25+/-45.88% for a non-VEGF secreting scaffold when sectioning the pedicle after 5 days. The percentage of survival of flaps in the group grafted with the VEGF-secreting scaffold was 55.62% compared to 2.5% in the group receiving the non-VEGF scaffold when the pedicle was sectioned after 2 days. The CD 31 immunostaining studies showed a dramatic increase in angiogenesis in the flaps conditioned by the VEGF-producing scaffolds. These data revealed that endothelised VEGF-secreting scaffold during flap creation could be a suitable approach in reconstructive surgery.

We have done an experimental study in lambs in which we investigated the influence of flow rate on free microvascular flaps using polytetrafluoroethylene (PTFE) vascular grafts. We set up five surgical groups in which blood flow was progressively increased through the PTFE vascular graft. In group I (venous autograft) we observed just one vascular thrombosis which was located at the site of the anastomosis. In group II (PTFE 3 x 10 mm) all the microvascular flaps became necrosed after the third postoperative day. In group III (PTFE 3 x 10 mm) necrosis also developed in all cases, but the anastomoses remained permeable no longer than eight days. In group IV (3 x 15 mm) the permeability in the microvascular free flaps was about 40% after 21 days, and in group V (3 x 10 mm) it reached 70%. To match graft flow rates with flap survival we did a regression analysis of flow rates for groups II, III, and V and the corresponding survival periods for the flaps. There was a clear and highly significant relationship (r = 0.717, p = 0.0001). In conclusion, it is necessary to maintain blood flow through the prosthesis at a rate higher than the thrombogenic threshold. When the flow rate in the vessels through the PTFE grafts was higher, the viability of the flaps was better. The ideal surgical technique should always be based on an arteriovenous fistula distal to the PTFE vascular graft. It is necessary to maintain blood flow through a prosthesis at a rate higher than the thrombogenic threshold.