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Background: Collecting lymphatics have lymph-drainage function with contraction of smooth muscle cells. Patients with edema have lost this drainage function due to degeneration of smooth muscle cells. Lymphaticovenular (LV) anastomosis salvages smooth muscle cells from reversible degeneration (mild edema), but muscle cells cannot be recovered from irreversible degeneration (severe edema). Therefore, in severe edema, LV anastomoses cannot reestablish the drainage function of the lymphatic system.To overcome this weakness of LV bypass methods for severe edema, new methods were instituted for repair of this missing drainage function using a lymphadiposal flap from the contralateral foot for hemilateral edema, or transfer of lateral thoracic lymph nodes for bilateral edema., Methods: A total of 13 cases were repaired with lymphadiposal flaps and additional LV anastomoses. These cases have frequent phlegmon or cellulitis or resisted to previous LV anastomoses and/or compression therapy. The ages ranged from 15 to 75 years. There were four cases of primary edema and nine cases of secondary edema., Results: Regarding the lymphadiposal flap (n = 8), three cases showed an excellent response (37.5%; no need for compression therapy), four cases had a good response (50%; improvement with compression), one case showed no change (12.5%; no improvement), and there were no cases of deterioration. Regarding the lateral thoracic lymph nodes transfer (n = 5), two cases had a good response (40%), three showed no improvement (60%), and there were no cases of deterioration., Conclusion: It is concluded that lymphadiposal flap or lymph nodes transfer is suitable for severe edema having frequent cellulitis in unilateral or bilateral lower extremities resisting previous LV anastomoses and/or compression therapy., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Reconstruction using flaps with good blood circulation is appropriate for covering an intractable ulcer or a fistula in which tendon or bones are exposed. A non-vascularised perifascial areolar tissue (PAT) graft can also survive in such an area. This study reports the versatile application of a PAT graft for use as a non-vascularised graft material. A total of 32 patients were treated between April 2004 and December 2010 (16 men and 16 women). The donor sites were the inguinal region in 20, the thigh in 11, and the subclavian region in one. There were 13 inlay grafts to the dead space after tumour resection, eight closures for cerebrospinal fluid leakage, seven skin ulcers with exposed bones and tendons, three fistulas, and one vascular leak of the common carotid artery. The total survival rate of the grafts was 91%. The complications associated with this procedure included infection in 9% and seroma in the donor site in 19%. However, all cases improved after conservative treatment. The PAT is a pliable loose areolar tissue with a rich vascular plexus, and the harvesting technique is quite simple and minimally invasive. The PAT graft could therefore represent an alternative for flaps that are used as a free graft material for the reconstruction of such defects as intractable skin ulcers, fistulas or dead spaces that usually require reconstruction with vascularised flaps.

We report the case of a 39-year-old man with a dermatofibrosarcoma protuberans (DFSP) on the right shoulder. A wide surgical excision of the tumour was performed, creating a 12-cm-wide defect. An anterolateral thigh flap created from two semicircular skin paddles was harvested and the two skin paddles were slid towards each other to cover the circular defect. The sliding technique is a useful design that preserves the suprafascial plexus and enables a single perforator to supply two split-skin paddles. Using this design, the donor site can be closed primarily without requiring a skin graft. This technique can be applied to other free flaps to reconstruct wide defects after the resection of cancers., (Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: It is well known that free vascularised nerve grafts have a potential for rapid axonal sprouting. However, they are not very popular as the surgical techniques are complicated. With the recent development of supramicrosurgical techniques and microanatomy of nerve trunks, a new method, 'fascicular turnover method', using vascularised fascicular flap was used for repairing nerve gaps. METHODSAND RESULTS: Arterial embalming method, using rat sciatic nerves, was employed to observe fascicular micro-vascularisation. Rich vascular network systems were observed within and outside the rat island nerve flaps. Four cases with digital and facial nerves gaps were repaired with fascicular turnover flap without a nerve graft. Three patients had digital nerve gaps (10-20mm in length) and one had a 3-cm facial nerve gap. The results of sensory recovery of digital nerve gap were 3.22-3.66 (Semmes-Weinstein values) and 6-12mm (moving two-point discriminations) at 6 and -16 months after surgery, respectively., Conclusion: The advantages of this method are: retention of the normal donor nerve, a shorter operation time and repair of the digital nerve gaps under local anaesthesia. Fascicular flap is a vascularised nerve flap with fast and accurate nerve sprouting in comparison to a non-vascularised graft. Excellent nerve regeneration can be expected even in cases with longer nerve gap and scarred recipient bed. It is a simple and quick surgery compared to free vascularised nerve flaps. In addition, there is no functional loss because of the sacrificed fascicle in the operated area. The only disadvantage is the need to employ superficial palmar branch of radial artery (SPRA)-microsurgical techniques using a 50-micron needle., (Copyright 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Thoracodorsal artery perforator (TAP) flap is not yet popularised because the dominant large muscle perforators are often absent. Even in those cases, small capillary perforators exist around the proximal portion of the lateral border of the latissimus dorsi muscle, and they have a potential of a large skin territory. To overcome the weakness of thoracodorsal artery muscle perforator (TAP-MCp) and septocutaneous perforator (TAP-SCp) flaps, we present a new TAP flap with capillary perforators (TAPcp) flap., Methods and Results: A total of 14 patients with upper-limb defects were repaired with free TAPcp flap. Among them were three combined TAP flaps with vascularised scapula bone flap and eight flow-through flaps. Recipient sites were one axilla, three upper arms, one elbow, two forearms and seven hands. The only postoperative complication was a partial necrosis of the flaps., Conclusion: A new TAP flap with capillary perforators is very useful for the reconstruction of upper limb. The advantage is easier elevation within short time (does not require intramuscular dissection) with long or short vascular pedicle. The flap can be elevated in a supine position, and even lateral descending branch can be a pedicle vessel. The flap can be a flow-through flap and is less invasive, because the remaining muscle can be preserved along with the motor nerve., (Copyright (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Summary Background: Eye socket reconstruction for orbital contracture after removal of retinoblastoma remains challenging, because it is often accompanied by atrophy of facial soft tissue, malar bone and temporal muscle., Case Description: A 45-year-old woman with a contracted eye socket underwent reconstructive surgery with a trilobed thoracodorsal artery perforator (TAP) adiposal flap with skin island. The flap was successfully transferred to expand the eye socket and augument hypoplastic facial tissue. A short pedicle TAP adiposal flap through the mid-axillary line was obtained with the patient in a supine position. The T portion of the lateral intramuscular branch was transected as a pedicle vessel and flow-through vascular anastomosis was carried out., Conclusion: TAP adiposal flap obtained with the patient supine is very useful for reconstruction of the eye socket, eyelid, temporal muscle, and malar tissue. The advantages of the short pedicle TAP flap are that it is minimally invasive, can be transferred with only a lateral muscular branch of the thoracodorsal system, and preserves the main trunk of the thoracodorsal artery and nerve and the branch to the serratus anterior. Flow-through vascular anastomosis is possible and the flap can be harvested without the need for secondary debulking.

A modified technique of interrupted suturing for the posterior wall in end-to-side microvascular anastomosis is presented. It has advantages, especially for the suturing of the pedicle vein and the internal jugular vein in head and neck reconstructions when the pedicle vessel is so short that it cannot be turned over to expose the posterior wall. The pedicle vein is located vertical to the internal jugular vein, and the first stitch begins at the left end of the vessels for a right-handed person. To facilitate the exposure of the left edge of the vessels, the donor vessel is rotated approximately 90 degrees. The advantage of our technique is clear visualization of each suture by rotating the pedicle vessel. Subsequent to the interrupted suturing of the posterior wall, the anterior wall can be sutured by conventional methods. This modified technique is useful for end-to-side microvascular anastomosis, which the microsurgeon may find useful.

Three cases in which island medial plantar artery perforator flaps were successfully transferred for coverage of the plantar defects are described. This perforator flap is different from the medial plantar flap based on the medial plantar artery. The flap has no fascial component and is nourished only with the perforator of the medial plantar vessel. Therefore, transection of the medial plantar artery is usually unnecessary. This flap can cover defects on the forefoot and heel without transaction of the medial plantar system. The advantages of this flap are no need for deep or long dissection for the medial plantar vessel, no exposure of the plantar sensory nerve, a short time for flap elevation, minimal donor-site morbidity, relatively large flap survival, and no damage of both the posterior tibial and medial plantar neurovascular systems.

Wide resection of a malignant tumor in the parotid gland often results in loss of a long segment of facial nerve, as well as a soft-tissue defect. With conventional nerve grafts, functional recovery of the facial nerve is poor in cases with risk factors that might inhibit nerve regeneration, such as a history of irradiation and a recipient bed scarred from previous operations. For such cases, a vascularized nerve graft is reported to be more effective than a nonvascularized nerve graft. This paper describes the first successful use of a free vascularized lateral femoral cutaneous nerve graft combined with an anterolateral thigh flap to repair the facial nerve and a soft-tissue defect. This method is technically simple, has minimal donor-site morbidity, and typically results in successful nerve recovery.