Search

Indocyanine green (ICG) fluorescence angiography can be used to quickly and accurately localize parathyroid glands during parathyroid and thyroid surgery with minimal risk. Because the technique relies on an intact vascular pedicle, it can also be used to assess parathyroid gland perfusion, which can be used as a surrogate for postoperative parathyroid gland function. Several commercially available near-infrared imaging systems can be used for this technique, and their adoption for a wide array of indications has grown in recent years. ICG fluorescence angiography should be considered as an adjunctive method for parathyroid localization during parathyroid surgery.

The latissimus dorsi flap was first described in 1906 by Tansini; it was then put apart for almost 70 years until it was proposed again from authors as Olivari, Schneider, Muhlbauer, and others. It is a versatile flap due to its remarkable dimensions and easiness of dissection and the length of the vascular pedicle. It is very thin and can be easily adapted to correct any defect. It can be used as a simple muscular flap covered by a skin graft or also as a myocutaneous flap. If the muscle alone is harvested, it can be raised either as a whole unit or only its anterior portion, preserving the nerve and the functionality of the unused muscle portion.

Pedicled and free flaps have become major instruments in the reconstruction of complex body defects. Traditionally used clinical signs such as flap color, capillary refill time, temperature, and Doppler ultrasound assessment of the vascular pedicle remain the gold standard for flap evaluation. Indocyanine green angiography is a safe, quick, and repeatable imaging technique that can be utilized to help decision making in pedicled and free flap surgery. Here we discuss the application of indocyanine green angiography in pre-, intra-, and postoperative settings to identify pedicle location, evaluate tissue perfusion, visualize anastomotic patency, detect arterial insufficiency or venous congestion, help design flaps, and avoid postoperative complications.

Esophageal cancer is associated with high mortality due to early spread. When indicated, an esophagectomy can be performed with reconstruction, most commonly using the stomach, with the right gastropepiploic artery serving as the vascular pedicle. While there are many ways to perform the surgery, the combination of laparoscopy and thoracoscopy (Ivor – Lewis) has gained popularity. The present chapter describes that approach.

Soft tissue free flaps are used for a variety of head and neck reconstructions. The anterolateral thigh (ALT) flap has been a versatile tool in head and neck reconstruction since the mainstream use of microvascular anastomosis for free tissue transfer. The ALT flap has a known history of variable vascular anatomy. Most of this variability lies within perforator anatomy and vascular aberrations distal to the lateral circumflex femoral artery (LCF). Few vascular aberrancies have been described proximal to the LCF. Here we present a case of report of an ALT whose arterial vascular pedicle was a branch directly off the femoral artery. The case highlights an unusual anatomical variant of the ALT flap, and the importance of a thorough and meticulous dissection.

Antegrade flow digital artery flaps enjoy a reputation for versatility and reliability with a robust vascular pedicle and the capability of resurfacing small to moderate sized defects in virtually any part of the hand. More than five decades of experience and evolution of surgical techniques with this class of intrinsic hand flaps makes this an indispensable part of the hand surgeons armamentarium when it comes to soft tissue reconstruction in the hand. Variant techniques and variable resurfacing indications are described for these class of flaps in this article. The main disadvantage or limitation lies in the need to sacrifice a digital artery.

Significant developments have enabled the transformation of phalloplasty to a functional organ. Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle. Increased complications compared with nonphalloplasty cohorts remain one of the biggest challenges, including rates of infection, erosion, mechanical malfunction, and malposition. Nonetheless, the placement of penile prosthesis within a phalloplasty enables trans men to achieve a once near-impossible goal of penetrative sexual intercourse without an external device.

Introduction This study demonstrates the effectiveness of a microvascular clamp to simulate parathyroid adenoma excision with respect to intraoperative parathyroid hormone (ioPTH) changes in vivo. Methods Cases in which microvascular clamps were employed intraoperatively in conjunction with intraoperative parathyroid hormone(ioPTH) assays were reviewed. ioPTH values were recorded throughout these procedures to assess the efficacy and reversibility of tissue ischemia using microvascular clamps. Results Application of a microvascular clamp across the vascular pedicle of a parathyroid adenoma resulted in a significant ioPTH drop in 95% of cases (N = 20). Removal of the clamp resulted in complete or partial rebound of ioPTH in 90% of cases (N = 20). Conclusion The use of a microvascular clamp to temporarily occlude a parathyroid gland’s vascular pedicle is an effective simulation of gland excision with respect to ioPTH changes. Rebound of ioPTH levels after clamp removal demonstrates that this technique is generally reversible. Level of evidence 2b, Retrospective cohort study.

Highlights • Dorsoepigastric flap is a variant of the classic lattisimus dorsi flap that utilizes less muscle tissue. • It is an appropriate reconstructive alternative and has the advantage of functional preservation of the lattisimus dorsi muscle. • It must be considered as part of the repertoire of the reconstructive surgeon when fixing complex defects of the upper limb., Introduction Dorsoepigastric flap (DF), first described by. Haddad and Jimenez, is a variant of the classic lattisimus dorsi musculocutaneous flap that only utilizes a minimum quantity of muscle tissue, through which the vascular pedicle passes by. It has been used primarily as an acceptable alternative in mammary reconstruction when the use of thoraco abdominal muscles is not viable, and offers several advantages such as adequate flap volume with generous cutaneous island dimensions and functional preservation of the latissimus dorsi. Presentation of a case We report the case of a 12 year old male, who suffered a left upper limb injury secondary to high power firearm shot. He presented extensive damage to the skin, soft tissues and bone structures and was treated with primary reconstruction using DF and peroneal grafts. Three years later, a shoulder prosthesis was placed to improve limb function with unobjectionable results. Conclusion DF is a useful resource that has been merely used in the context of complex upper limb reconstruction, and must be considered essential in the repertoire of the reconstructive surgeon when facing traumatic defects of the upper extremity.

Sternoclavicular joint infection is very rare. Osteomyelitis is a known complication of septic sternoclavicular joint. Once this condition is diagnosed, aggressive management including antibiotic and surgical debridement is warranted. Patients are often left with sizeable sternoclavicular defects that may need surgical reconstruction. In this report, we describe the use of a completely detached pectoralis major flap for the reconstruction of a large sternoclavicular defect after resection for osteomyelitis. Briefly, after the debridement of the infected sternoclavicular joint, the pectoralis major was detached from its sternoclavicular attachments and further detached from the humeral attachments rendering it completely detached on a vascular pedicle. The muscle was advanced to cover the defect and secured. Patient recovered well without any surgery related complication. She retained good use of the ipsilateral upper extremity. The pectoralis major can be completely detached to provide ample coverage for sternoclavicular joint reconstruction if needed.

The aim of this study was to evaluate the feasibility of the Versius surgical robotic system for transanal total mesorectal excision (taTME) in a preclinical setting. Dry laboratory and cadaveric sessions were first conducted for three experienced colorectal surgeons in order to gain familiarity with the modular surgical system and the robotic workstation. After introduction, the system was configured to allow for synchronous, totally robotic taTME in a cadaver. Using the modular robotic system, one surgeon performed the abdominal portion of the operation, including colonic mobilization and vascular pedicle ligation while simultaneously a second surgeon performed the transanal portion of the operation to the point of rendezvous at the peritoneal reflection, where the operation was completed cooperatively. The operation was successfully completed in 195 min demonstrating preclinical feasibility of this unique approach with an emerging robotic system. This is the first preclinical assessment of the Versius surgical robotic system for taTME. The ability to work simultaneously carries the theoretical advantage of reducing surgical time and thereby reducing overall operative costs. It may also allow surgeons to maintain focus on critical parts of the operation by halving the fatigue associated with long, complex cases such as taTME.

Background Pedicle ossification is thought to arise from the residual perieosteum left along the pedicle during the fibula free flap (FFF) harvesting. Pedicle ossification in head and neck reconstruction can cause trismus, pain on mastication/turning the neck, or neck swelling. Methods Two patients reported in this article developed severe trismus within 6 months after mandibular reconstruction with FFF. CT scans revealed ossification along the vascular pedicle interfering with mouth opening. Both patients underwent surgical debridement of the heterotopic bone. Results Surgical debridement of the heterotopic bone led to the resolution of trismus in both patients with pedicle ossification. Conclusions Pedicle ossification is a complication of FFF that can be effectively managed by removal of heterotopic bone. However, it is best prevented at the time of initial surgery. In this article, a new modified FFF harvesting technique is introduced to prevent pedicle ossification and reduce the ischemia time.

SUMMARY. Precise perforator mapping of the epifascial and subcutaneous course of the perforator flaps, including the precise detection of the skin point, is mandatory for successful preoperative flap design and planning of supramicrosurgery. We investigated the effectiveness of contrast-enhanced B-flow (BCEUS) imaging for perforator mapping and preoperative perforator flap planning and compared it with B-flow ultrasound, contrast-enhanced ultrasound, and color Doppler ultrasound. Sixteen patients who received an individualized perforator flap reconstruction were included in the study. Preoperative perforator mapping includes the following structures: subfascial course of the pedicle, fascial penetration point, subcutaneous course (epifascial and subcutaneous), and perforator skin point. The precision of the preoperative perforator mapping was analyzed for color Doppler ultrasound, contrast-enhanced ultrasound, B-flow ultrasound, and BCEUS. Each technique was able to precisely display the subfascial course of the vascular pedicle, including the fascial penetration point. However, only BCEUS enabled precise mapping of the epifascial and subcutaneous (suprafascial) course, including the skin point of the perforators with a clear delineation. Precise knowledge of the suprafascial course of the perforators is mandatory for successful supermicrosurgery and perforator flap planning. BCEUS imaging facilitates full perforator mapping, which improves the safety of flap harvesting. However, BCEUS is technically demanding and requires an experienced sonographer.

Introduction: The computed tomographic angiography (CTA) renal donor protocol is an established method of preoperative renal vascular pedicle evaluation in prospective renal donors. However, CTA is associated with significant radiation exposure and intravenous contrast administration. The newer noncontrast-enhanced magnetic resonance angiography (NCE-MRA) techniques, especially arterial spin labeling (ASL) with steady-state free precession (SSFP) hold promise as an effective alternative. We prospectively compared CTA with NCE MRA for accuracy in the evaluation of renal arterial anatomy in prospective renal donors. Methods: A total of 43 subjects underwent CTA followed by NCE MRA in a prospective comparative study. The number of renal arteries and early branching of renal arteries were noted in both kidneys in all subjects. Intermodality agreement was calculated using “K” (Kappa) statistics and 95% confidence interval for both modalities. Results: A total of 63 single, 21 double, and 2 triple arteries were detected in 43 subjects on CTA. CTA showed an early branch in 17 kidneys. NCE MRAshowed 64 single arteries, 20 double arteries, and 2 triple arteries. A total of 14 kidneys showed an early branch. Unweighted Kappa statistic of agreement between CTA and NCE MRA for number of renal arteries and for frequency of early branching was 0.9707 and 0.8822, respectively. Conclusions: The newer NCE MRA techniques such as ASL with SSFP among others are potential alternatives for CTA, in the evaluation of prospective renal donors.

Objective The latissimus dorsi (LD) muscle flap is frequently used for free tissue transfer to reconstruct large defects of the extremities. As a free flap, the LD also can be harvested as a muscle-sparing flap (MS-LD), preserving the innervation and insertion of the remaining muscle. Conventional harvesting of the LD flap, however, results in a long scar on the lateral back. Harvesting using an endoscopic approach minimizes donor site morbidity. We present our modified endoscopic technique with CO2 insufflation and standard endoscopic instruments for harvesting the LD or MS-LD muscle flap. Patients and methods Ten patients (mean age 43 years, range 22–66) underwent endoscopically harvested LD or MS-LD free-flap reconstruction for upper and lower extremity defects. Harvesting required only a short (3–5 cm) incision in the axilla for dissection of the vascular pedicle and the motor nerve, and the remainder of the dissection was performed endoscopically with CO2 insufflation. Dissection was achieved through three of four 5-mm ports and 30° view angle optics. Results Six of the flaps were MS-LD flaps. The largest flap size was 18 × 16 cm. Mean flap harvest time was 164 min (range 105–270 min). One total flap was lost 3 days postoperatively due to anastomotic thrombosis in a trauma patient who was later diagnosed with hypercoagulopathy. No donor site scar or wound complications were observed during the follow-up (20.1 months). Conclusions Endoscopic harvesting of an LD muscle free flap with CO2 insufflation and standard laparoscopic equipment is a feasible option for free-flap reconstruction.

Fetus in fetu is a rare congenital condition where a vertebrate fetus is found within the body of its host twin. It features a monozygotic parasitic twin attached via a vascular anastomosis to its host circulation. This report describes an instance of fetus in fetu with a variant presentation of its vascular pedicle to its host via the inferior epigastric vasculature.

Zusammenfassung Zielsetzung: Durchführung eines sternalen Knochen- und Weichteil-Débridements nach abgelaufener Sternumosteomyelitis mit simultaner Defektdeckung mittels gefäßgestielten Latissimus-dorsi-Lappens. Indikation: Tiefe sternale Wundheilungsstörungen können mittels verschiedener Lappenplastiken gedeckt werden. Der Latissimus-dorsi-Lappen bildet eine schnelle, suffiziente und zuverlässige Deckungsoption für sternale Defekte. Des Weiteren kann bei ausgeprägter Radikalität des Weichteil- und Knochen-Débridements eine einzeitige Deckung erfolgen. Methode: Aufzeigen einzelner OP-Schritte zur Durchführung eines sternalen Débridements mit simultaner Defektdeckung mittels gefäßgestielter Latissimus-dorsi-Lappenplastik. Schlussfolgerung: Die Radikalität des Débridements ist entscheidend für den weiteren Therapieerfolg und erlaubt es, Débridement sowie simultan die lappenplastische Deckung durchzuführen. Das gleichzeitige Arbeiten von 2 Operateuren verkürzt dabei die Operationszeit für den Patienten deutlich.

In reconstructive surgery, there is a clinical need for adequate implants to repair soft tissue defects caused by traumatic injury, tumor resection, or congenital abnormalities. Adipose tissue engineering may provide answers to this increasing demand. This study comprehensively reviews current approaches to adipose tissue engineering, detailing different cell carriers under investigation, with a special focus on the application of adipose-derived stem cells (ASCs). ASCs act as building blocks for new tissue growth and as modulators of the host response. Recent studies have also demonstrated that the implantation of a hollow protected chamber, combined with a vascular pedicle within the fat flaps provides blood supply and enables the growth of large-volume of engineered soft tissue. Conceptually, it would be of value to co-regulate this unique chamber model with adipose-derived stem cells to obtain a greater volume of soft tissue constructs for clinical use. Our review provides a cogent update on these advances and details the generation of possible fat substitutes.

BACKGROUND Vascularized composite allotransplantation represents an important advancement in the field of reconstructive microsurgery and has continued to increase in popularity. The significant clinical morbidity associated with flap failure represents an important barrier to even more widespread use of these techniques. Early identification of vascular compromise has been associated with a higher salvage rate, yet most surgeons rely only on clinical assessment intraoperatively. Spatial frequency domain imaging (SFDI) presents a noncontact, objective measurement of tissue oxygenation over a large field of view. This study aims to evaluate the use of SFDI technology in hemifacial composite flap compromise as could occur during facial transplant. METHODS Six composite hemifacial flaps were created in three 35-kg Yorkshire pigs and continuously imaged using SFDI before, during, and after 15-minute selective vascular pedicle occlusion. Arterial and venous clamping trials were performed for each flap. Changes in oxyhemoglobin concentration, deoxyhemoglobin concentration, and total hemoglobin were quantified over time. RESULTS The SFDI successfully measured changes in oxygenation parameters in all 6 composite tissue flaps. Significant changes in oxyhemoglobin, deoxyhemoglobin, and total hemoglobin were seen relative to controls. Early and distinct patterns of alteration were noted in arterial and in venous compromise relative to one another. CONCLUSIONS The need for noninvasive, reliable assessment of composite tissue graft viability is apparent, given the morbidity associated with flap failure. The results of this study suggest that SFDI technology shows promise in providing intraoperative guidance with regard to pedicle vessel integrity during reconstructive microsurgery.

Background:. Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients. Methods:. Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient’s reconstructive journey. Results:. Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest. Conclusion:. The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

The aim of the work is to establish the possibility of mathematical modeling of the injuries formation in the mobile and fixed spleen under shock impact to the region of the left middle axillary line of the chest. A spleen injury with a pinched and movable vascular pedicle was simulated, for which were created two models in three-dimensional virtual space - the spleen model and the rib-sternum segment model. Differences in the concentration and localization of stresses arising on the spleen were noted in cases of fixed and non-fixed vascular pedicle. It was found that under the same conditions of injury (place of application and direction of the injury, impact force), «critical» stresses that can lead to ruptures occur on the spleen, which has a fixed vascular pedicle.Установление возможности математического моделирования образования повреждений подвижной и фиксированной селезенки при ударном воздействии в область левой средней подмышечной линии груди. Моделировали травмы селезенки с «защемленной» и подвижной сосудистой ножкой, для чего в трехмерном виртуальном пространстве создали две модели — модель селезенки и модель реберно-грудинного сегмента. Отметили различия концентрации и локализации напряжений, возникающих на селезенке в случаях фиксированной и нефиксированной сосудистой ножки. Установили, что при одинаковых условиях травмирования (место приложения и направление травмирующего воздействия, сила удара) «критические» напряжения, способные привести к разрывам, возникают на селезенке, имеющей фиксированную ножку.

Study Objective To determine the feasibility, time taken, completeness of removal of the retained products conception (RPOC) by outpatient hysteroscopy (OH) Design Prospective Study with a follow up of 4 weeks. Setting Private Hospital Based Outpatient Setting. Ethical committee approval was obtained Patients or Participants All women treated by OH for RPOC Type 0,1 & 2, following first trimester abortion/ termination of pregnancy with Tab mifepristone 200 mg - Tab misoprostol 800 ug protocol from March 2017 to January 2020. A total of 44 women were included, and informed written consent was obtained. Interventions OH was performed using a 5 mm continuous flow office hysteroscope (Bettocchi Office Hysteroscope size 5, Karl Storz, Tuttlingen, Germany) with a 2.9 mm rod lens optical system, without the use of premedication or anesthesia before, during or after the procedure. Intrauterine pressure was maintained at 60 mmHg using an electronic pump. RPOC was excised from its base with a 5 Fr semi rigid scissors and removed from the uterine cavity with a semi rigid grasper. A vascular pedicle of Type 2 RPOC was cauterized using a bipolar electrode connected to a electrosurgical unit by a bipolar high frequency cord. Measurements and Main Results The maximal size of RPOC removed was 2.5 cm. Mean size of the RPOC treated was 1.8 cm. Mean time taken for removal of RPOC was 22 minutes. Complete removal of RPOC was achieved in a single setting, and none of these women required a second procedure. Mean VAS(visual analogue score of pain) score was Conclusion Outpatient hysteroscopy with complete removal of retained products is feasible without any form of anesthesia and negligible complications. Preoperative assessment of the size and type of RPOC by a transvaginal doppler ultrasound adds to the success of this technique.

Background During free-tissue transfer for scalp reconstruction, pedicle lengthening may be required when finding a recipient vessel is difficult because of defects from previous surgery. Arteriovenous (AV) bundle interposition grafting is a good option. This study compared 2 sequences of AV bundle interposition grafting when flap pedicle lengthening is needed. Methods Two anastomosis methods were used. In the recipient lengthening type (R type), the flap was harvested and the AV bundle was harvested from a donor vessel for lengthening. In the flap lengthening type (F type), the flap was harvested first. Next, in contrast to that in the R type method, the authors performed anastomosis with a flap pedicle and bundle before the AV bundle was harvested. Results The mean flap pedicle length was 8.75 cm (range, 5-11 cm). The AV bundle had a mean length of 9.25 cm (range, 6-13 cm), meaning that 13 cm of additional pedicle length can be added. The mean length of the extended vascular pedicle was 18 cm (range, 14-23 cm). Conclusion This study compared the results of F type and R type AV bundle interposition grafting. The F type allowed easy monitoring of the anastomosis of the flap pedicle and ensured flap stability by reducing continuous ischemic time. Finally, this study confirmed the efficacy and safety of the AV bundle interposition graft in scalp reconstruction.

Background. Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options.Patients and Methods. This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15).Results. Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case.Discussion. LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.

The colon is the most time-tested and frequently used organ for oesophageal replacement. The advantages of colonic replacement include good blood supply, easy access, and availability of adequate length with a vascular pedicle while leaving enough colon behind for appropriate function. Most surgeons adopt this procedure because of the fast learning curve and ease of performing the procedure, minimal early complications, and good long-term results.

The success of tissue engineering hinges on the rapid and sufficient vascularization of the neotissue. For efficient vascular network formation within three-dimensional (3D) constructs, biomaterial scaffolds that can support survival of endothelial cells as well as formation and maturation of a capillary network in vivo are highly sought after. Here, we outline a method to biofabricate 3D porous collagen scaffolds that can support extrinsic and intrinsic vascularization using two different in vivo animal models—the mouse subcutaneous implant model (extrinsic vascularization, capillary growth within the scaffold originating from host tissues outside the scaffold) and the rat tissue engineering chamber model (intrinsic vascularization, capillary growth within the scaffold derived from a centrally positioned vascular pedicle). These in vivo vascular tissue engineering approaches hold a great promise for the generation of clinically viable vascularized constructs. Moreover, the 3D collagen scaffolds can also be employed for 3D cell culture and for in vivo delivery of growth factors and cells.

Objectives In this study, we presented a novel hybrid perfusion mode in an attempt to provide a new strategy to improve the survival of an extended large flap and discuss its possible mechanisms. Materials and Methods A 14 × 10 cm flap was designed on the rabbit abdomen. Ninety-six rabbits were randomly divided into three groups based on the flap perfusion mode: control group I (CON 1, physiological perfusion mode with bilateral deep inferior epigastric vascular pedicles intact), control group II (CON 2, physiological perfusion mode with single deep inferior epigastric vascular pedicle intact), hybrid nourished group (physiological perfusion as in CON 2 combined with arterialized venous nonphysiological perfusion mode, referred to as a hybrid perfusion mode). Flap survival, status of vascular perfusion, microvasculature, histopathology, expression of CD34, eNOs, VEGF and metabolic status of the flaps by LC-MS were assessed in each group. Results The results of “hybrid nourished” flaps were similar to the traditional flaps in terms of flap survival, level of vascular perfusion and microvasculature except the status of metabolites. Conclusions The feasibility of this novel hybrid perfusion mode will greatly extend the indications of flap transfer and efficiently improve the survival reliability of large flaps. In a sense, this mode will be an ideological emancipation for the field of flap surgery.

Before the 1950s, due to the lack of in-depth studies carried on the cutaneous vasculature, the pedicled random pattern flap was the mainstream in flap surgery; during 1950s–1960s, studies on flap vessels resulted in the advent of muscle flap and axial pattern flap; in 1970s, along with the development of the organ transplants using the microsugical technique, the free flap, musculocutaneous flap and musculoskeletal flap involving with vascular anastomosis were applied in clinical practice; since 1980s, the flourishing and development of microdissection greatly promoted the development of flap surgery, and many achievements were gained in flap surgery, not only in theoretical field, but in the clinical application of relevant technologies. A variety of new types of flaps were developed and employed in surgeries, such as flap with main artery, reverse-flow island flap, fasciocutaneous flap, flap with intermuscular septal vascules, distally pedicled flap, venous flap, subcutaneous vascular plexus flap, veno-neurocutaneous vascular flap and perforator flap. With continuous increase of flap donor sites, the transposition of flap with a vascular pedicle was widely applied in clinical practice.

The circumflex scapular artery perforator flap is an axial flap with the trilateral space perforator of circumflex scapular vessel as its vascular pedicle. This flap was first reported by Gilbert in 1979. Nassife introduced the applied anatomy of combined scapular/parascapular bilobar flap in 1982, which was used to repair huge leg defect by Koshima and Soeda in 1985, and also to repair the high-voltage electric burn of upper limb by Cerkes. Angriginant used expanded scapular flap to repair cervical contracture in 1994.

The nutritious vessel of perforator flap is tinier than that of axial pattern flap, so during the procedure of flap design, dissection, vascular pedicle dissociation and flap transplantation, slight carelessness will result in complications, including major ones and minor ones.

As the color, thickness and texture of skin at the pectoral region are all extremely similar to those of the cephalofacial skin, the pectoralis major myocutaneous flap (by Ariyan 1979) and thoracic triangle skin flap (by Bakamjian 1968) used to repair the cephalofacial soft tissue defects are both based on this region. However, the pectoralis major myocutaneous flap is bulky and impair the function of the donor site, and the thoracic triangle skin flap is inconvenient to use in flap transposition because of position and length of the vascular pedicle. Prof. Yixin Zhang reported the successful application thoracoacromial artery perforator flap (TAAP) in clinic practice. This flap could be used in coverage of soft tissue defects at the cephalofacial area, the shoulder joint and the superior area of the arm.

BACKGROUND Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases. METHODS This study aimed to determine the distance (cm) and surface area (cm2 ) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens. RESULTS The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm2 compared to 85.36 cm2 after division of both the origin and insertion. CONCLUSION Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects.

Background Free intestinal flaps for pharyngolaryngoesophagus reconstruction may require revision operations, including free flap re-inset for functional improvement. This report aimed to present our experience on vascular pedicle division at the secondary procedure of free flap re-inset for functional improvement in pharyngoesophageal reconstruction. Patients and methods Eight male and seven female patients, with a mean age of 52 years old (range: 28-78 years), underwent pharyngoesophageal stricture (n = 7) and hypopharynx carcinoma reconstruction (n = 8) with three free jejunal and 12 free ileocolonic flaps. During revision procedure to shorten the flap for functional improvement, which was performed at 3 months after the initial operation, there were 11 venous and 4 arterial pedicle division cases. The intestinal flap circulation signs, such as presence of normoperistalsis, pink color, moderate secretion, and bleeding at puncture site, were observed for 1 hr. Results No venous pedicle divisions required reanastomosis. However, all arterial pedicle division cases required immediate restoration with a vein graft because of immediate intestinal changes. No postoperative complications were seen, excluding a patient with anterior wall reconstruction who had arterial division and reanastomosis. Patients were followed up for a median duration of 28 months. Conclusion For revision operations involving free intestinal flaps, the arterial pedicle must be protected or repaired if transected, whereas the venous pedicle does not necessitate such a maneuver.

If cross-sectional imaging techniques often disclose the presence of an accessory spleen, they seldom detect a wandering accessory spleen. This latter diagnosis can be challenging but important and derives great benefit from computed tomography with curved multiplanar and three-dimensional reconstructions displaying the long vascular pedicle connecting the small mass to the splenic vessels. We call this anatomical complex the "Jokari sign", in reference to the ball-on-a-string racket game.

While anatomical variations of the subscapular vessels are frequently encountered during axillary dissection, little is found in the literature. The aim of this cadaveric study was to define arterial and venous anatomical variations and frequencies of the subscapular vascular pedicle and its terminal/afferent vessels in women. We performed 80 dissections of the axillary region on forty female formalin-embalmed cadavers. Each anatomical arrangement was photographed and recorded on a scheme before analysis. We propose a new classification of the subscapular pedicle variations. We observed three types of subscapular arterial variation. The type Ia was the most frequent arrangement (71% of our dissections), the type Ib was observed in 11% and the type II in 18% of cases. We observed four types of subscapular venous variation. The type Ia was observed in 63% of cases, the type Ib in 14%, the type II in 14% and the type III in 10% of cases. This knowledge of the anatomical variation arrangement and frequencies of the subscapular vascular pedicle will assist the surgeon when dissecting the axillary region for malignant or reconstructive procedures.

Large and complex bone defects represent challenging clinical scenarios, typically requiring autologous vascularized bone transplants. In order to bypass the numerous associated limitations, here we aimed at ectopically prefabricating a bone graft surrogate with vascular pedicle. A hollow cylinder of devitalized cancellous bone was used to define the space of a large bone substitute. This space was filled with devitalized pellets of engineered hypertrophic cartilage as bone-inducing material, in combination or not with stromal vascular fraction (SVF) of adipose tissue as source of osteoprogenitors and endothelial cells. Vascularization of the space was targeted through axial insertion of an arterio-venous (AV) bundle. Constructs were subcutaneously implanted in nude rats for 12 weeks and analyzed for bone formation and vascularization by histology and microtomography. Retrieved constructs were extensively vascularized in all conditions, with vessels sprouting from the AV bundle and reaching a higher density in the axially central volume. Bone tissue was formed through remodeling of hypertrophic cartilage, and quantitatively correlated with de novo vascularization. Our study demonstrates feasibility to prefabricate large, pedicled bone grafts in predefined shapes. The combination of an AV bundle with engineered hypertrophic cartilage provided a germ for the coupled processes of vascularization and bone formation. The demonstrated osteoinductivity of devitalized hypertrophic cartilage offers the opportunity of implementing the proposed regenerative surgery strategy through off-the-shelf materials.

Background: When performing partial toe-transfer flaps with a short vascular pedicle, as the flap becomes smaller, the likelihood of securing veins in the flap decreases. The purpose of this study was to clarify how frequently the partial toe-transfer flap with a short pedicle (free vascularized half-big toenail flap) contains veins and elucidate how frequently we can secure the veins with an artery via the first web space approach alone, using the Genial Viewer (a near-infrared light transmission imaging device). Methods: We observed the dorsal vein images of the bilateral big toes of 250 volunteers (male, n = 125; female, n = 125) using the device. We counted the total number of dorsal veins in the big toe, the veins that crossed the margin of the region equivalent to the half-big toenail flap, and the veins that branched off from the fibular side of the flap area. An unpaired Student’s t-test was used for the statistical analyses. Results: All of the dorsal big toes contained veins. The mean number of the veins was 2.3 (range, 1–4). Branched-off veins were observed in the area equivalent to the half-big toenail flap in 496 (99.2%) of the big toes, and the mean number of veins was 1.9 (range, 0–4). In four cases, the region contained no veins (unilaterally). Branched-off veins were observed in the first web space in 440 (88.0%) of the big toes, and the mean number of veins was 0.9 (range, 0–2). Conclusions: The present study indicated high consistency of the veins in partial toe-transfer flaps with a short vascular pedicle and the high possibility of harvesting a flap with only exposing the first web space. In addition, in most cases, the flap will include one or, at most, two veins in the first web space.

Background The skin bridge in the perforator-plus flap is considered as an additional source for arterial input and venous drainage apart from the perforator. However, its exact role requires further elucidation. Materials and methods Forty rats that underwent flap elevation with a size of 9 × 3 cm on the dorsum were evenly divided into a perforators-intact group with an intact vascular pedicle, an artery-deficient group with the artery ligated, a vein-deficient group with the vein ligated, and a perforators-deficient group with both vessels ligated. The blood perfusion was measured using a laser Doppler flowmeter. On the seventh day, the necrosis rate of the flaps was calculated and the diameter of vessels in the skin bridge was measured. Results The perfusion pattern was similar between the perforators-intact group and vein-deficient group, as well as between the perforators-deficient group and artery-deficient group. The blood perfusion was much more robust in the perforators-intact and vein-deficient groups. The necrosis rate in the perforators-deficient group (26 ± 1%) was not significantly different from that in the artery-deficient group (29 ± 1%), both of which was significantly larger than that in the perforator-intact (11 ± 3%) and vein-deficient groups (12 ± 4%) ( P ˂ 0.001). The venous network of the skin base in the vein-deficient and perforators-deficient groups dilated dramatically, whereas the arterial network in the artery-deficient and perforators-deficient groups had a very modest expansion. Conclusions The skin base in a perforator-plus flap is much more important as an additional route for vein drainage than for arterial input.

Various flaps are used for skin defects of the dorsal hand and fingers. A sensory flap is not essential, but a thin and good color-matched flap is suitable, and donor site mobility of the flap should be considered. A reverse or free posterior interosseous artery perforator flap is one of the standard flaps. This flap requires no major arterial sacrifice, but direct closure of the donor site is difficult when the width of the flap is >3 cm, and there is also the risk of posterior interosseous nerve injury, especially the motor branch of the extensor carpi ulnaris muscle. The deltoid or acromial branch of the thoracoacromial artery has a large skin perforator, and this perforator is the vascular pedicle of the free thoracoacromial artery perforator flap. This flap is not bulky, is pliable and well color-matched for the dorsal hand, and direct closure of the donor site is easier than the posterior interosseous artery perforator flap. A free thoracoacromial artery perforator flap based on the deltoid or acromial branch is a good option for dorsal hand and finger reconstruction.

Background The oblique branch of the lateral circumflex femoral artery is considered an alternative vascular pedicle of the anterolateral thigh (ALT) flap. However, the oblique branch has several advantages over the descending branch. Methods A total of 61 consecutive ALT free flaps were harvested according to Yu's ABC system. Vascular pedicle dimensions and length, artery course, perforator origins, and flap harvest time with the oblique branch or the descending branch were recorded. We classified the ALT flaps with oblique branches into three types according to the origin of perforator B. Type I flaps were those where perforator B originated from the descending branch. Type II flaps were those without perforator B. Type III flaps were those where perforator B originated from the oblique branch. Results The mean ± standard deviation (SD) diameter of the oblique branch at its origin was 1.68 ± 0.51 mm, with an average ± SD pedicle length of 12.92 ± 3.7 cm, while that of the descending branch was 2.27 ± 0.49 mm and 18.73 ± 5.14 cm, respectively. The percentage of septocutaneous perforators from the oblique branch was 35.59%, while that from the descending branch was 15.38%. The flap harvest time with the oblique branch was 33.73 ± 11.68 minutes, while that of the descending branch was 52.27 ± 7.21 minutes. Based on the origin of perforator B, 7 cases had type I ALT flaps, 4 had type II ALT flaps, and 10 had type III ALT flaps. Various ALT flaps based on the oblique branch were harvested, and good clinical results were achieved. Conclusion The oblique branch is sufficiently large and can be reliably used as the flap pedicle. It may be the preferred vascular pedicle for ALT free flaps.