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Background The objective of this study was to examine the effectiveness and safety of lower pole (LP) approach in retroperitoneal laparoscopic radical nephrectomy (LRN). Methods One hundred thirty-two renal cancer patients were scheduled for selective retroperitoneal LRN. The surgery parameters and outcomes were compared. Out of 132 patients, 78 (59.1%) patients underwent LRN via LP approach, while 54 (40.9%) patients underwent LRN via lateroposterior space (LPS) approach. Results Compared to LPS group, the LP group had a higher body mass index (27.0 ± 1.7 kg/m2 vs. 24.5 ± 1.8 kg/m2, P

Soft-tissue defects of the little finger are challenging especially when bone, tendon or vascular pedicle is exposed because of trauma. The hypothenar island flap is easy to harvest and has a good colour and texture match to the little finger pulp. We present nine clinical cases of soft tissue defects of the little finger covered using the reversed hypothenar fasciocutaneous island flap. This article intends to highlight the ease of elevation and good clinical results of the hypothenar flap which is rarely used.

Purpose This report describes the palatal approach to gain access for osteodistraction of the anterior maxilla to improve the vector of force during distraction. Patient and Methods This case report illustrates a novel approach to anterior maxillary osteodistraction. The palatal approach allows the maxillary segment to be moved anteriorly and inferiorly. This is in contrast to the buccal approach, in which the palatal tissue creates a vector of force toward the palate. The vascular pedicle for the transport segment is the labial mucosa and musculature. Results In the present case, the alveolar segment was advanced 3.6 mm anteriorly and 12.2 mm inferiorly as measured by pre- and postoperative computed tomograms. This patient with a large vertical alveolar defect and high smile line had successful restoration with dental implants. The result has been stable for 14 months. Conclusion In this case, the palatal approach to the anterior maxillary osteotomy was shown to be an effective method of reconstructing a large vertical anterior defect.

Background Controversy exists regarding whether or not, or, if so, how quickly free flaps can achieve neovascularization from the surrounding tissue bed and independence from the vascular pedicle. In this paper, we document the survival of free flaps despite early vascular pedicle thrombosis and review the literature regarding the period of time believed to be required for flap autonomy to occur. Design Case series Setting Harbor-UCLA Medical Center Patients We report 3 cases in which pedicle failures occurred within 2 weeks of free flap transfer. The first patient suffered repeated leaks from the vascular anastomosis with hematoma formation occurring on postoperative days 4, 6, and 17, ultimately requiring ligation of the pedicle. The second patient developed a salivary leak and accumulation of saliva around the pedicle, which was found thrombosed on postoperative day 11. The third patient lost Doppler signals from the pedicle on postoperative day 7 and 8, each occasion necessitating a return to the operating room for anastomotic revision. However, on postoperative day 9, the signal was lost yet again and no further revisions were attempted. Results Two of the 3 flaps survived completely and the third was noted to have near complete survival. Conclusion Microvascular free flaps can survive despite complete pedicle failure as early as 10 days after surgery. The mechanism behind this may involve the process of neovascularization. We conclude that early free flap pedicle failure does not necessarily equate to complete flap loss.

O monorquidismo é um quadro raramente descrito em equinos, que não apresenta descrições prévias na literatura nacional. Trata-se de um equino adulto brasileiro, com oito anos de idade, sem raça definida, porém com características de raças de origem nacional. Por abordagem inguinal do lado esquerdo, localizou-se a túnica vaginal intacta, que, aberta, continha a cauda de um epidídimo mal formado, o ducto deferente e um delgado pedículo vascular, mas sem indícios de testículo. Exames histológicos e hormonais confirmaram a ausência de tecido testicular. Conclui-se que os exames histológicos e hormonais são essenciais para o diagnóstico de monorquidismo que, apesar de raro, também pode acometer equinos nacionais

Objectives/Hypothesis Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised. Study Design Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center. Methods Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated. Results Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in

Issues of tissue defects replacement after radical surgery for tumors of the head and neck do not lose their relevance. The article presents the results of plastics and replacement of the perforating combined defects of the floor of the mouth, portion of the upper and lower lips, the angle of the mouth, cheeks, neck lateral parts with simultaneous reduction of the configuration and function of the operated organs. Depending on the depth and nature of the existing tissue defect various methods of plastics were applied using arterialized flaps on the vascular pedicle in a free and non-free version. Satisfactory cosmetic and functional results were achieved in patients allowing to improve life quality and to adapt socially.

The recipient incision adipofascial flap offers a simple approach to address a tight skin closure over a vascular pedicle. This technique is not just fast and easy to perform but also adds little to no morbidity, removing a potential source of flap failure.

Background Microvascular compromise from arterial or venous occlusion is a common cause of free flap failure. The salvage rate following a microvascular compromise is dependent on detecting the problem early and intervening quickly. Methods The ViOptix tissue oximeter measures tissue oxygen saturation using the near-infrared spectroscopy technology. The ViOptix device has an alarm capability to warn of potential compromise to tissue perfusion. The tissue oximetry readings are visible on the bedside monitor and are relayed to a webpage link, which is accessible on a personal computer or mobile device, allowing real-time monitoring. This article presents a case where real-time monitoring allowed almost immediate detection of inadvertent pedicle compromise allowing flap salvage by repositioning without surgical intervention. Results In the case presented, the patient's nurse inadvertently positioned a pillow under the location of the vascular pedicle likely causing microvascular compression. The ViOptix reading dropped and for this reason the nurse contacted the Plastic Surgery team. The drop was confirmed remotely and the flap was urgently evaluated in person. Once the pillow was removed, the ViOptix readings normalized and Doppler signals strengthened in the flap. Discussion While tissue oximetry monitoring does not by itself ensure flap survival, it provides critical information than conventional flap monitoring would allow giving the microsurgeon the opportunity to make a quicker decision. ViOptix tissue oximeters are able to detect vascular compromise even before conventional clinical symptoms are present. Alas in several cases by the time clinical symptoms develop the flap may be beyond salvage.

The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and low morbidity along the flap-donor area. Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle underwent cutaneous coverage surgery with a reverse-flow sural flap with an exteriorized pedicle, without violation of the skin between the base of the flap pedicle to the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. The respective length and width of the flap were a mean average of 7.45 cm × 4.18 cm. All the flaps survived. Partial loss of the flap occurred in 3 patients, ranging from 20% to 30%. The mean average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 (range 4 to 8) cm. Our results showed that the 2-stage reverse sural flap ensures good flap survival and low morbidity.

Of the different etiologies of acute scrotal pain, testicular torsion is the only real emergency. It occurs when the testicle is abnormally mobile and twists on its vascular pedicle potentially resulting in testicular infarction. If testicular torsion is suspected, patients should be examined using color Doppler ultrasound with grayscale imaging, which is highly sensitive and specific. Successful manual detorsion of testicular torsion leads to reperfusion, which is immediately visible with Doppler ultrasound. But in cases of successful manual detorsion, surgical exploration with orchiopexy is still necessary.

PubMedID: 29033290 Purpose: Subchondral perfusion of osteochondral grafts has been shown to be important in preventing long-term cartilage degeneration. In carpal reconstruction, subchondral perfusion from the graft bed is limited. This study's purpose was to compare the histological characteristics of cartilage in osteochondral grafts supported by synovial imbibition alone to cartilage of vascularized osteochondral flaps that have both synovial and vascular pedicle perfusion. Methods: Two adjacent osteochondral segments were harvested on the medial femoral trochlea in domestic 6- to 8-month-old pigs. Each segment measured approximately 12 mm × 15 mm × 17 mm. One segment was maintained on the descending geniculate artery vascular pedicle. The adjacent segment was separated from the pedicle to serve as a nonvascularized graft. A thin layer of methylmethacrylate cement was used to line the harvest site defect to prevent vascular ingrowth to the subsequently replaced specimens. The pigs were maintained on a high-calorie feed and returned to ambulation and full weight-bearing on the surgical legs. The animals were sacrificed after 6 months and the specimens were reharvested, sectioned, and examined. The cartilage was graded by 2 pathologists blinded to the origin of specimens as vascularized flaps or nonvascularized grafts. Results: All specimens were assigned scores utilizing the International Cartilage Repair Society grading system. Scoring for chondrocyte viability, cartilage surface morphology, and cell and matrix appearance was significantly higher in the vascularized osteochondral group than in the graft group. Conclusions: When deprived of subchondral perfusion from underlying bone, osteochondral vascularized flaps in an intrasynovial environment demonstrate superior cartilage quality and survival compared with nonvascularized grafts. Clinical relevance: In locations in which perfusion from surrounding bone may be limited (ie, proximal scaphoid or proximal lunate reconstruction), articular reconstruction using vascularized osteochondral flaps will yield superior cartilage organization and architecture than nonvascularized osteochondral grafts. The clinical and functional relevance of this finding requires further study. © 2018 American Society for Surgery of the Hand

and methods: Twenty rats were used in this study. The 3 3 3c m 2 epigastric skin island flaps were elevated on either side. The animals were randomly assigned to two groups; an arterial occlusion group (n 510) and a venous occlusion group (n 510). The StO2 values of the flaps were observed for over 30 min for the pedicle artery or venous occlusion, followed by an additional 30 min release. Results: The baseline StO2 value was 78.4% 63.2% in the arterial occlusion group, compared to 78.5% 65.8% in the venous occlusion group, with no significant differences (P >0.05). The StO2 values decreased immediately after arterial occlusion, whereas a temporal StO2 increase was initially observed after venous occlusion, followed by a StO2 decrease. The StO2 values decreased 27.3% 67.1% after arterial occlusion and 28.4% 619.1% after venous occlusion at 30 min after pedicle vessel clamping (P >0.05). The StO2 values were 0.4% 65.8% lower than baseline 30 min after arterial release (P >0.05), while 18.9% 611.3% lower than baseline 30 min after venous release (P

Summary Background The posterior interosseous artery (PIA) perforator flap can be used for reconstruction of soft-tissue defects of fingers. Based on the multiple perforators from the posterior interosseous artery, we describe a technique to reconstruct the multi-finger defect in the use of the free multilobed PIA perforator flap. Methods PIA perforators from different areas of the forearm were used to design a free multilobed skin paddle for multi-finger skin defect reconstruction. Each paddle without the deep fascia had separate perforators. To increase the perforator pedicle length, the courses of the PIA perforators were dissected from the superficial layer of the deep fascia to the subcutaneous layer. Results The flap was raised as a unilateral free bilobed PIA perforator flap in 10 cases of two-finger defects, a free trilobed PIA perforator flap in two cases of three-finger defects, and a bilateral free bilobed PIA perforator flap in one case of four-finger defects. The average effective vascular pedicle length and trunk pedicle length were 8.3 and 3.1 cm, respectively, for the bilobed flap, and 6.3 and 4.0 cm, respectively, for the trilobed flap. All flaps survived except one paddle with tip necrosis. At 10.8 months (range, 4–27 months) after surgery, 10 cases showed satisfactory cosmetic appearance, while the fingers were bulky in the remaining three cases. The average score of static two-point discrimination in 10 innervated paddles was 12.9 mm. The remaining 20 paddles recovered only protective sensation. The average total active motion (TAM) of each finger was 164° before surgery and 187° at the latest follow-up. Conclusions Free multilobed PIA perforator flap is a good candidate for reconstruction of multi-finger skin defect. Clinical question/level of evidence: Therapeutic, Ⅳ.

Oncologic resections near the shoulder create challenging reconstructive problems. In addition to severe contour defects and the risk for functional deficits resulting from contractures, there may be exposed bone and peripheral nerves rendering simple skin graft closures suboptimal long term. The lateral arm flap is a versatile septofasciocutaneous flap based on the posterior branch of the radial collateral artery in the lateral intermuscular septum of the upper arm. This paper details our experience with 3 patients who underwent wide local excision or radical resection of soft tissue tumors of the upper arm and closure with pedicled lateral arm fasciocutaneous flaps. Flap size ranged from 6 × 10 cm to 5 × 15 cm. Two flaps were transferred as 180-degree pivotal flaps; 1 flap was transferred as an advancement flap. There were no immediate postoperative complications or long-term functional deficits. The pedicled lateral arm flap is a safe and reliable option for soft tissue coverage of anterolateral shoulder defects. The vascular pedicle lies deep within the mid-upper arm and is rarely at risk during extensive tumor extirpation. The adjacent donor site allows for a single operative field without the need for repositioning and furthermore results in a skin paddle requirement that is one half the width of the original defect.

Introduction: Head and neck oncological resections may result in composite oro-mandibular defects involving the oral mucosa (lining), mandibular bone and the skin (cover). Reconstructive options for such defects have evolved over a period. Free fibula flap reconstruction is currently accepted the world over as the gold standard for oro-mandibular defect reconstruction. Existing literature provides conflicting views about the use of a particular side and orientation of the fibula flap for achieving the optimal outcome. The purpose of this study is to confirm anatomically the effect of bone, soft tissue and vessel orientation on the ease of doing reconstruction. Materials and Methods: This is a cadaveric study. A mandibular model with a defect was used. This was pre plated to maintain continuity. Composite fibula flaps of the same dimension were harvested from both legs of a fresh cadaver. The harvested flaps were used to reconstruct the mandibular defect in different orientations and the best configuration for each reconstructive requirement was assessed. Results: Keeping the peroneal surface for plating, that is, facing outwards, four different configurations of the fibula flap are possible for a given mandibular defect. With a posterior vascular pedicle ipsilateral fibula is suitable for skin cover and contralateral for mucosal lining and the reverse for an anteriorly placed pedicle. Conclusion: The algorithm based selection of appropriate sided fibula flap facilitates complex mandibular reconstruction by placing the right kind of tissue at the right place and helps in reducing the donor site morbidity by allowing the surgeon to harvest only the required amount of skin.

Objective: To expound the clinical effect of a new operation by transplanting double segment triangular fibula flap with vascular pedicle to repair the forefoot with lateral bone defect, and to study how to improve the operation method in the following stage. Methods: The inclusion criteria: More than 2 phalangeal and metatarsal bones defects of the lateral forefoot, widespread skin and soft tissue defects on pelma and dorsal foot, and destruction of the anterior aspect of foot arch, which seriously affects the foot function. There was one case of clinical application in November 2014. The repairing method is as followed: the harvested vascularized free fibula was cut into 2 segments and then they were folded into a right angle. According to selected control points on the residual metatarsals, an optimal stereo triangular net was constructed. Meanwhile, according to flow-through mode, the free anterolateral thigh flap was incorporated to repair the forefoot and foot arch. Results: Postoperative bone flaps all survived. After a 17-month following up, it was found that the grafted fibular healed well, shape of the foot was good, weight-bearing walking was practical, a slight limp and discomfort with plantar pain existed, sensory recovery reached S3 level and functional recovery of weight-bearing walking by forefoot reached W3 level, comprehensive evaluation was good, and there were wear scar and ulcer on the plantar flap during long-time walking for patients, such results were excellent according to foot function scoring criteria. Conclusion: In this operation the grafted fibula was fold into a triangle according to actual need, which though not completely restores the tridimensional structure of the longitudinal, transverse arches of the lateral foot makes weight-bearing walking possible, besides, its appearance and function is satisfactory. Such an operation has overcome the shortage of non-tridimensional structure of the transverse arch etc. in traditional operations and it should be an ideal operation in repairing serious defects on the lateral forefoot through further improvement.

Supplemental Digital Content is available in the text., Background: The metatarsophalangeal joint (MTPJ) of the lessor toe has been used to reconstruct the metacarpophalangeal joint. When an oblique osteotomy of the metatarsal head is performed, the orientation of the vascular pedicle is crucial to preserve the blood supply to the MTPJ. This study was conducted to identify the path of the nutrient artery to the MTPJ. Methods: We reviewed our operative records in consecutive series of 45 patients during toe or joint harvest. Retrograde dissection of the vascular pedicle was performed starting from the distal communicating artery at the first webspace toward the first dorsal metatarsal and first plantar metatarsal arteries. All the vessels related to the MTPJ were explored and ligated if the MTPJ was not included in the flap. Results: The condylar branches to the proximal phalanx and the metaphyseal branches to the second metatarsus were barely identifiable during the dissections. The articular branch running perpendicularly from the plantar artery toward the plantar surface of MTPJ was verified in all cases. The articular branches originated either from the first plantar metatarsal artery (92.1%) or from the tibial plantar digital artery (7.9%). The external diameter of the articular branches was around 0.5–1 mm. When the articular branch was included and preserved, the metatarsal heads oozed immediately after the flap was reperfused. Conclusions: The study demonstrated the constant and sizable articular branch of the MTPJ that originates from the plantar artery system. The consistency of the vascular anatomy enables oblique osteotomies of the metatarsal head to be performed without fear of injury to the pedicle.

This article describes the use of implant-enhanced and total-autologous latissimus dorsi myocutaneous flaps in breast reconstruction. It addresses the indications for use of this reconstruction alternative, which have recently been expanded thanks to the advent of high-volume fat grafting. Given its straightforward dissection, reliable vascular pedicle, variety of approaches, and potential for excellent aesthetic results, use of latissimus dorsi flaps may be considered among first-line options in selected patients.

BACKGROUND It is not always possible to use the anatomically variable free anterolateral thigh (ALT) flap for reconstructive surgery. An anteromedial thigh (AMT) flap serves as a good alternative, and shares the same vascular pedicle as the ALT flap. METHODS Of 698 reconstructions performed in 2006 to 2013 following head and neck tumor ablation surgery, ALT flaps were used in 653 patients. Eighteen free AMT flaps were harvested to replace variant nonviable ALT flaps. RESULTS The lack of a sizable perforator in the ALT flap territory was the main reason for changing the reconstruction plan. Anteromedial thigh flap size ranged from 10 × 4 to 30 × 8 cm. The flap survival rate was 100%. The follow-up period ranged from 3 to 56 months. CONCLUSION During head and neck reconstruction, when no sizable perforator is available during harvest of the ALT flap, successful reconstruction can be achieved using the ipsilateral AMT flap without additional donor-site morbidity.

Summary:. Late arterial thrombosis of a free flap is rare and usually unsalvageable because it is hard to detect. We herein report 2 cases of arterial thrombosis of a free flap after microvascular head and neck reconstruction due to the combined factors of pedicle artery loop and compression by a swollen submandibular gland, the occurrence of thrombosis in both of which was > 72 hours after the operation. In case 1, the arterial thrombosis was undetectable, and it was too late for a successful take-back operation, so the flap was lost. However, we applied the lessons learned from case 1 and were able to detect the late arterial thrombosis of case 2 at an early stage; we subsequently salvaged the flap successfully. During the take-back operation in both cases, it was found that the submandibular gland became swollen and compressed the pedicle artery, which then became occluded due to a steep loop formation. Postoperative swelling of the submandibular gland can sometimes compress the vascular pedicle, and complete occlusion of the pedicle artery may occur when it is looped. Meticulous care concerning the geometry of the vascular pedicle is required to avoid such complications.

Introduction The Expanded Endonasal Approaches (EEAs) have been widely used for various skull base lesions. The reconstruction of the skull base defects is of vital importance to prevent postoperative complications. The vascular pedicled-nasoseptal flap (Hadad-Bassagasteguy flap) is used as a workhorse in reconstruction of majority of the defects. Aim The purpose of this study was: (a) To assess the postoperative MRI appearance of vascularised pedicled nasoseptal flap for its viability; (b) To determine the variations in MRI that may suggest potential flap failure. Materials and methods A prospective study of 13 patients was done, who underwent endoscopic skull base surgery with reconstruction using the Hadad-Bassagasteguy flap. Pre-operative MRI was done to assess the size, extent and location of the lesion and a postoperative MRI was done to evaluate flap configuration, enhancement patterns, location, flap thickness and signal intensity characteristics. Results The postoperative MRI of all patients showed a detectable flap covering over the skull base defects forming an "open cup" appearance. They were uniformly isointense on T1-weighted/ fat suppressed images to the adjacent nasal mucosa and hyperintense on T2-weighted images. On the MRI scans done after four weeks, all 13 of our patients had enhancing flaps. One flap migrated slightly to the left side; however, there was no Cerebrospinal Fluid (CSF) leak. Conclusion Vascular pedicle nasoseptal (Hadad) flaps are being widely used. MRI is a very useful tool in assessing the viability of the flap postoperatively and to evaluate for variations that may suggest potential flap failure.

To improve the current knowledge of rectus abdominis innervation, so as to identify a safe area where the vascular pedicle should be dissected to reduce the risk of nerve damage during deep inferior epigastric perforator (DIEP) flap harvesting. Ten abdominal wall dissections were performed. Perforating arteries were identified and classified into nerve-related perforators and non-nerve-related perforators depending on the presence of nerve branches crossing vessels. The width of rectus abdominis and the distance between perforators and lateral edge of rectus abdominis muscle were measured. In contralateral hemi-abdomen, full-thickness specimens were sampled for microscopical analysis. Nerves enter the rectus sheath piercing the lateral edge (60% of cases) or the posterolateral surface of the sheath (40% of cases). They enter the rectus abdominis muscle at a mean distance of 4.3 cm from the lateral margin of the sheath. Within rectus abdominis, nerves have a mean thickness of 200.3 µm and split into 2–4 sensitive and 2–4 muscular branches. Close relationship between muscular branches and deep inferior epigastric artery perforators were shown. The mean distance between nerve-related perforators and the lateral edge of the rectus abdominis was of 3.26 ± 0.88 cm. The mean distance between non-nerve-related perforators and the lateral edge of the rectus abdominis was of 6.26 ± 0.90 cm. To spare nerves and reduce donor-site complications, a perforator located beyond an imaginary line of 3.26 ± 0.88 cm far from the lateral edge of rectus abdominis muscle should be included in the DIEP flap.

Background The distally based medial hemisoleus (MHS) flap was found useful for repairing soft-tissue defects of the lower third of the leg; however, its reliability is controversial. We used a combination of static and dynamic techniques to investigate the vascular supply of distally based MHS muscle flaps to better establish their use in repair of lower-third leg defects. Methods We performed an anatomic study of 18 cadaver legs. For 6 legs, we performed dynamic angiography, which allowed for obtaining MHS muscle radiographs after pulsed injection of contrast medium in distal pedicles. Results The mean length of MHS muscle was 25.4 cm, the mean width was 6.9 cm, and the mean surface area was 87.5 cm. A mean of 3 distal posterior tibial vascular pedicles was directly connected to this medial subunit. These pedicles were present in all 18 cadaver legs. We observed complete opacification of the 6 MHS muscles through distal pedicles. Radiography revealed opacification of a vascular path from 1 distal pedicle to 1 proximal vascular pedicle of the MHS muscle. The mean level of this main distal pedicle was 14.5 cm to the tip of the medial malleolus. The level was at 38.2%, on average, from the bottom of the entire tibia. Conclusions The distally based MHS muscle flap has constant blood supply, so it could be a useful flap to repair soft-tissue defects of the lower third of the leg. Moreover, knowledge of the average location of the main distal pedicle can help in increasing the use of the distally based MHS flap.

Objective The posterior thigh region has been neglected as a donor site for free perforator flaps, likely due to difficulties in positioning the patient during surgery. This study describes the clinical application of the posterior thigh perforator flap based on the third perforating artery of the profunda femoris artery (PFA). Methods The free posterior thigh perforator flap based on the third perforating artery of the PFA was used for reconstruction of soft tissue defects in nine patients between February 2010 and May 2014. Results Flap sizes ranged from 12 × 7 cm to 20 × 13 cm. The length of the vascular pedicle averaged 10.28 cm, and the mean diameters of the third perforating artery and venae comitantes were 1.68 and 1.14 mm, respectively. All of the perforators originated from the PFA. Of the 9 free flaps used in 9 patients, 7 flaps survived completely. There were no early complications in these flaps. During the follow-up period, no patient experienced cold intolerance, scar contracture, or scar pain. There were no functional impairments at the donor or recipient sites. Conclusions The posterior thigh flap based on the third perforating artery of the PFA is an excellent option for reconstructing soft tissue defects. The anatomical location of the third perforating artery is relatively consistent. The vascular pedicle is relatively longer and has large caliber vessels. The scar at the donor site can be well concealed with low morbidity. The skin color and texture of this flap show satisfactory results.

Non-absorbable Hem-o-Lok clips are commonly used for vascular pedicle control or suture stabilisation during laparoscopic or robotic reconstructive procedures. As they are placed close to suture line and with tension, these clips have a propensity to migrate. We report a case of a 22-year-old man with history of bilateral robotic pyeloplasty presenting with left inferior calyceal stone. He underwent left mini percutaneous nephrolithotomy which revealed an encrusted migrated Hem-o-Lok clip that was used to close the mesenteric window formed during transmesocolic pyeloplasty. Thus, these clips should be used sparingly and only at places where other effective alternatives are unavailable.

The aim of this study is to compare short- and long-term outcomes of totally laparoscopic right colectomy (TLRC) and laparoscopically assisted right colectomy (LARC), using propensity score matching (PSM) analysis. A retrospective analysis of patients who underwent laparoscopic right colectomy between January 2006 and July 2016 was conducted. PSM analysis was performed to overcome patient selection bias between the two surgical techniques. A total of 116 patients were reviewed. After PSM, 54 patients for the TLRC group and 54 patients for the LARC group were compared. TLRC was associated with shorter post-operative hospital stay (6.81 vs. 4.79 days; p

The middle and distal part of the nose has multiple well-defined cosmetic units with a distinct outline, color, consistency, sebaceous content, texture and function. Crossing these units with surgical incisions can lead to a more visible scar. Here we will deal with the case of an 84-year-old patient with basal cell carcinoma of the junction between the dorsum and the alar of the nose and the management of the resulting loss of surgical substance with the Marchac flap. This frontal flap described by Marchac is an axial flap based on a vascular pedicle emerging near the inner palpebral ligament, allowing coverage of the loss of substance while respecting the nasal subunits and less thickness difference is present.

The posterior thigh flap is a workhorse flap for reconstruction in the gluteal region. The main vascular pedicle of the flap is commonly the descending branch of the inferior gluteal artery, although it is at risk for transection during sarcoma resection. We report successful reconstruction of an infragluteal defect resulting from sarcoma resection with a venous-supercharged freestyle posterior thigh flap in the absence of the descending branch of the inferior gluteal artery. A 77-year-old man underwent sarcoma resection in the infragluteal region. The descending branch of the inferior gluteal artery was sacrificed. We found a sizable perforator through the long head of the biceps femoris and harvested a posterior thigh flap on the basis of that perforator with a freestyle approach. The flap gradually developed a congestive appearance after transfer. We therefore anastomosed the vein of the second perforator to an accompanying vein of the sciatic nerve at the recipient site. The complete flap survived, and the postoperative course was uneventful. We believe that combined use of the freestyle approach and the perforator-supercharging technique can enhance the versatility and the safety of pedicled perforator flap transfer.

In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap's region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN.

Objective This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps. Methods Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters. Results The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P

BACKGROUND We conducted an experimental study to investigate if it would be possible to re-elevate a flap at a standard flap site if its vascular pedicle was mutilated previously and there was a preexisting scar formation at the pedicle site. MATERIALS AND METHODS Thirty-five male Sprague-Dawley rats were divided into 3 groups. In the control group (n = 5), animals received a procedure in which unilateral axial pattern abdominal flap was elevated, and then sutured to its original place. The remaining 2 groups underwent 2-stage procedures. In the first stage, scar tissue was created with either a skin incision (group 2, n = 15) or excision (group 3, n = 15) at the prospective pedicle site of the abdominal flap. In the second stage, abdominal flap was raised in 5 rats as a scar-pedicled flap at day 7, day 21, and day 42. Flaps were sutured in their places. Seven days later, flap survival was evaluated. RESULTS Control flaps had complete survival (day 7, 95.5%; day 21, 94.8%; and day 42, 94.5%). Group 2 and group 3 flaps raised on day 7 (group 2, 65.4%; group 3, 63.9%) and on day 21 (group 2, 65.7%; group 3, 66.7%) showed decreased survival compared to control group flaps (P < 0.05). On day 42, group 1 flaps had better survival when compared to group 2 flaps (82.6% vs 70.0%, P < 0.05). Group 1 flaps showed progressive vascular network formation as evidenced by contrast medium first in the proximal two thirds of the flaps on day 7, and later via visualization of the axial pattern vascular tree on day 42. In group 3, approximately half of the flap was filled with barium contrast and no single pedicle was identified on day 42. CONCLUSIONS Preexisting scar tissue and pedicle division in the pedicle site of a standard flap diminished dimensions of surviving flap when compared to control flaps. Incision-scar-pedicled flaps achieved better survival compared to excision-group flaps, particularly in the late postoperative period. The study findings showed that it may be possible to raise a flap from previously mutilated site secondary to scar formation and pedicle injury.

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh. © 2014 Wiley Periodicals, Inc. Microsurgery 35:279–283, 2015.

Reconstruction of the ascending portion of the mandible, including the angle, ramus, and condyle, can be a challenging surgical problem. Many treatment options are available, but no single procedure has been able to restore long-term form and function in every case. Currently, autologous nonvascularized bone grafts are the most common treatment, with the costochondral graft as the historic leader. Nonvascularized grafts can often restore vertical height and normal function but may face the challenge of long-term durability secondary to bone resorption. Emerging techniques in microvascular surgery may offer an alternative approach with the benefits of resistance to resorption and infection by maintaining a viable blood supply to the graft. Vascularized grafts may thus be used to full advantage in cases where prior surgery, scarring, disrupted vasculature, or radiation damage may compromise the long-term surgical success of a nonvascularized graft. This article reviews the literature and summarizes key points regarding nonvascularized and vascularized treatment modalities for reconstruction of the ascending mandible. In addition, we present the use of the femoral medial epicondyle free flap based on the descending genicular vascular pedicle as a novel reconstruction of the ascending portion of the mandible with minimal donor-site morbidity. Knowledge of all available options will aid the surgeon in achieving the optimal reconstruction for their patient and improve long-term outcomes.

The sonographic findings and corresponding pathology reports of 83 premenopausal and 55 postmenopausal women were retrospectively reviewed to evaluate the significance of color Doppler imaging in the evaluation of the endometrium. Premenopausal women had flow noted in the single malignancy case and in 16 of 21 (76%) polyps, with 7 polyps (33%) presenting as a vascular pedicle. In postmenopausal women, flow was seen in 3 of 5 (60%) malignancies and 5 of 9 (56%) polyps, with 2 polyps (22%) presenting as a vascular pedicle. Postmenopausal women with thin endometria had flow in 1 of 2 (50%) polyps, while those with thicker endometria had flow in 4 of 7 (56%) polyps and 3 of 5 (60%) malignancies. The data showed that color Doppler imaging was useful in detecting vascular pedicles in endometrial polyps, but it was not otherwise helpful as an independent predictor of malignancy.

Objectives The use of bowel for vaginal construction is a well-established procedure. In this paper, the lessons learned from 36 vaginoplasties over a 34-year period are discussed. Methods Between 1980 and 2013, 36 patients between 1 and 21 years of age underwent vaginal construction. In 27 of the 36 patients, an inverted V-shaped perineal skin flap was incorporated into the posterior wall of the neovagina, and, when required, a detubularized pouch was used to avoid traction on the vascular pedicle. In nine patients, the sigmoid colon was anastomosed, in a circumferential manner, to the short blind-ending vaginal dimple. Results Two of the nine sigmoid vaginas, where the perineal skin flap was omitted, developed introital stenosis. None of the sigmoid neovaginas that included the perineal flap developed stenosis. One patient with ileal segment vagina, at the onset of puberty, developed introital stenosis after 10 years; this was successfully corrected. Nineteen out of 28 patients available for long-term follow up were sexually active and reported no dyspareunia. Conclusions Detubularization and reconfiguration to form a pouch reduces the traction on the mesentery of the bowel segment, which ensures adequate blood supply to the distal entero-cutaneous junction. The inverted V-shaped perineal skin flap should be incorporated in the anastomosis to avoid circumferential suture line and introital stenosis.

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet.

Background When anterolateral thigh (ALT) perforators are inadequate, exploration of the contralateral thigh or a new flap may be required. If the anteromedial thigh (AMT) perforators were useable in these instances, harvest could proceed from a single donor site. The purposes of this study were to define the AMT perforator anatomy and examine the relationships between the AMT and ALT perforators. Methods A total of 100 consecutive thighs were explored. The ALT and AMT perforator size and number were documented. The relationship between ALT and AMT size and number was examined using Fisher exact test, logistic regression, and linear regression. Results The main blood supply to the AMT flap was the rectus femoris branch (RFB) off the descending branch of the lateral circumflex femoris artery. AMT perforators were only present in 51% of the thighs and most likely a single perforator near the midpoint and 3.2 cm medial to the line connecting the anterior superior iliac spine and the patella (perforator B location). Patients with one or fewer ALT perforators had fourfold increased chance of an AMT perforator. Patients with small or no ALT perforators usually had a large AMT perforator. After assigning numeric values to perforators based on size, lower ALT perforator scores were significantly related to higher AMT scores. Conclusion The RFB is the main vascular pedicle of the AMT flap. There is an inverse relationship between size and number of ALT and AMT perforators: when ALT perforators are inadequate, AMT perforators are typically useable.

Background Vascularized bone grafts of the hand are a promising option for treatment of hand abnormalities. Therefore, the purpose of this study was to analyze the arterial anatomy of the dorsal aspect of the second metacarpal base to further investigate this possible donor site for bone grafts. Methods The authors examined 16 fresh frozen cadaveric hands by using a C-arm cone beam computed tomography scanner and depicted the three-dimensional course of the second dorsal metacarpal artery and measured the diameter, length, and arc of rotation of this nutritive vessel. In addition, the authors dissected six of the hands under a dissecting microscope and, after selective injection of gelatin dye solution, the authors analyzed the vessel entrances into the bones histologically. Results In all examined hands, the second dorsal metacarpal artery was a nutritive vessel to the dorsal base of the second metacarpal. The average diameter was 1.3±0.4 mm and the average length of the vascular pedicle was approximately 3.3±0.3 cm. In 14 of 16 cases, the arc of rotation was sufficient to reach the lunate without difficulty. Histologic analysis showed an intrinsic blood supply in the donor region with a vessel diameter of approximately 58 μm. A clinical case with application in Kienbock disease is presented. Conclusion Pedicled vascularized bone grafts from this area are suitable for clinical application to treat Kienbock disease if standard donor sites are unavailable.

Abdominal desmoid tumors are so called non-metastatic tumors. They occur by proliferation of fibroblasts of muscle, fascia or aponeuroses. After breast reconstruction with a DIEP flap (Deep Inferior epigastric Artery Perforator Flap), a progressive growth of a desmoid tumor was seen around the DIEP-anastomosis. A total excision was not possible without compromising the vascular pedicle. With taking into account a recurrence rate up to 65% another operation is probably necessary. In this case the main vessels of the graft have to be cut out and a necrosis of the flap can or may appear.

Background The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. Methods The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozen cadaveric lower limbs. This was analyzed together with 22 clinical cases. Results Cadaveric dissection showed that there were 1–2 perforators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% musculocutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, the foot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 ± 0.8 mm. Vascular pedicle length ranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 ± 0.3 mm. One flap failure was seen due to arterial thrombosis. The overall flap survival rate was 95%. Conclusions The proximal lateral lower leg flap has the advantages of being thin and pliable, quick to harvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in the majority of cases. © 2014 Wiley Periodicals, Inc. Microsurgery 35:115–122, 2015.

Currently, the choice for recipient vessels in microvascular breast reconstruction is made between axillary and internal mammary regions. The authors report their experience with anastomosis to a new, unconventional, axillary recipient vessel, the serratus anterior muscle vascular pedicle. Among 340 deep inferior epigastric perforator (DIEP) flap breast reconstructions performed between 2004 and 2013, 11 were successfully revascularised to the serratus anterior (SA) pedicle: In three cases, complications led to a salvage procedure, while in eight cases, anastomosis to this recipient site was electively planned. The pedicle was constantly present, with calibre always comparable to that of flap's pedicle. At the mean 24-month follow-up, no recipient site complications were observed. The SA muscle pedicle resulted as a reliable choice in salvage procedures and a suitable option for recipient vessel selection in elective cases.

Summary:. A defect of the central upper lip vermillion generally requires “like for like” reconstruction because this part of the upper lip can attract attention and has a unique structure and color. In this article, we report use of a labial artery-based horizontal long cross-lip flap for central upper lip vermillion reconstruction. In the first stage of surgery, a horizontal long vermillion flap from the lower lip starting at the left commissure with a vascular pedicle containing an inferior labial artery was raised and transposed to the upper vermillion defect. In the second stage, 12 days later, the pedicle was divided to complete the reconstruction. There were no postoperative complications in articulation or eating, and the patient was satisfied with the esthetic outcome. This surgical technique reduces microstomia and inconvenience in eating and speaking compared with a common horizontal cross-lip flap and provides better color- and texture-matched tissue compared to reconstruction using a tongue flap or mucosal flap. The technique is simple, requires a relatively short surgical time, has minimum donor-site morbidity and permits good esthetic and functional reconstruction of the central upper lip vermillion for a relatively small defect.

Ovarian torsion (also termed as adnexal torsion) refers to partial or complete rotation of the ovary and a portion of fallopian tube along its supplying vascular pedicle. It occurs commonly in reproductive age group; more on the right side (60%) and often presents with acute lower abdominal pain lasting for few hours and up to 24 h, accounting for 2.7% of acute gynecological conditions. It is one of the devastating conditions, hampering blood supply of ovary which may lead to total necrosis of ovarian tissue and complications, if not diagnosed and managed in time. Hence, we present a case on a twisted ovarian cyst in postmenopausal woman with unusual symptomatology leading to delayed diagnosis and loss of an ovary.

Objective To propose a distinct anatomical classification for the superior thyroid pole that may serve as a surgical landmark and could help reduce complications in thyroid surgery. Materials and Methods A comprehensive anatomical study based on existing literature and surgical observations. Results The proposed superior pole classification is based on two parameters that closely interact: one is the shape of the superior pole and the other is the structure of the vascular pedicle of the superior pole. We have come up with three distinct types of superior thyroid pole anatomical structure that may be predictive of the risk for both hemorrhage and nerve injury. Conclusions Superior pole classification may serve as a guiding tool during thyroid surgery in order to reduce complications such as bleeding and injury to the external branch of the superior laryngeal nerve. J. Surg. Oncol. 2015 111:15–17. © 2015 Wiley Periodicals, Inc.