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Purpose: Since hand and facial tissue transplantation are new treatments, risk data must be derived from early reports of the few cases done to date combined with extrapolations from other procedures with similar risks. This manuscript summarizes data from both sources including eight separate studies that measure the real and perceived risks associated with hand and facial tissue transplantation., Methods: Real Risks: Several large clinical studies describing risk data from kidney transplant recipients (10-years experience) and risk data from 49 human hand transplants in 33 recipients (>10 years experience) were reviewed. Perceived Risks: Over 500 subjects with different life experiences (facially disfigured, amputees, laryngectomees, kidney transplant recipients, transplant and reconstructive surgeons, and controls) were surveyed using a standardized and validated risk assessment instrument., Results: Real Risks: Contrary to earlier estimates the risks of acute rejection are higher (80-85%) while the risks of chronic rejection (<5%) and other complications are lower than previously reported. Perceived Risks: Despite different life experiences, those questioned would accept similar amounts of risk to receive different types of transplant procedures (hand, foot, face, larynx, and kidney) but all would accept the most risk for a facial tissue transplant. Kidney transplant recipients, who live with the risks of immunosuppression, would accept the most risk while facially disfigured individuals and reconstructive surgeons, who have real-life experience with facial disfigurement, would accept the least., Conclusions: These studies contribute to the growing body of risk data necessary for moving hand and face transplantation into mainstream medicine.

The human face and facial transplantation have long captured the interest and imagination of scientists, the media and the lay public. The face is central to our identity, and our communication with the outside world. It is this great importance we attach to our face that makes facial disfigurement such a devastating condition. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation or congenital birth defects. Herein we discuss some of the principal psychosocial considerations which have preceded the clinical introduction of facial transplantation, and which continue today after cases have been performed world-wide., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Meeting patients' expectations is essential for successful outcomes in reconstructive surgery. In the case of new procedures like facial transplantation that carry with them many unknowns and real, or potential, risk of toxic side effects this becomes especially important. In this study we assessed patient expectations in facial transplantation by surveying individuals with facial disfigurement (n = 34), reconstructive surgeons (n = 45), and controls from the general population (n = 148). Questions focused on quality of life improvement, esthetic and functional outcomes. Student t test was used to compare means of the 3 study groups. All groups projected low quality of life for nontreated disfigured persons, controls responding the most negatively (M = 1.91), followed by disfigured persons (M = 2.91; t = 2.14, P

Background: Composite tissue allotransplantation of hand, facial and other tissues is now a clinical reality. The terminology, treatment principles, drug combinations, dosage schedules and mechanisms of the immunosuppression medications on which contemporary transplant surgery is based are unfamiliar to plastic surgeons and most healthcare providers outside the field of transplantation medicine. With this in mind, the purpose of this manuscript is to provide plastic surgeons with a comprehensive and understandable review of key immunological principles relevant to composite tissue allotransplantation., Methods: We present an overview of the immunological basis of composite tissue allotransplantation aimed at the plastic surgery readership, based on our own experience plus manuscripts sourced from MEDLINE, EMBASE, text books, ancient manuscripts and illustrations., Results: In this manuscript we provide the reader with a brief history of composite tissue allotransplantation (CTA), a concise description of the immunological terminology, treatment approaches, risks associated with immunosuppressive therapy, risk acceptance, and current research avenues relating to contemporary CTA., Conclusion: Today, as transplant and reconstructive surgeons join forces to move hand and facial tissue allotransplantation into the clinical arena, it is important that plastic surgeons have an understanding of the major immunological principles upon which this new treatment is based.

Background: Human facial tissue allotransplantation is now a clinical reality. Proponents of this new treatment contend that the benefits outweigh the risks, while the critics argue they do not. This debate has been presented in great detail in the bioethics literature but has not been brought to the attention of the plastic surgery community., Methods: The purpose of this paper is to provide a synopsis of the key issues being debated in facial transplantation by presenting to the plastic surgery community a synopsis of an ethical debate published in the 2004 summer issue of the American Journal of Bioethics., Results: Presented is a set of ethical guidelines for facial transplantation in the form of a "target article." Alongside this are written commentaries from 15 experts in related fields, along with responses to these commentaries. Together, this discussion makes up a landmark exercise in open display and public and professional discussion and evaluation and serves as a comprehensive list of the major ethical issues being debated today in the field of facial tissue allotransplantation., Conclusions: Plastic surgeons play a central role in the care of facially disfigured patients and will therefore lead the introduction of facial tissue allotransplantation into the clinical arena. Consequently, it is important that they be aware of, and indeed that they play a key role in forming, the debate surrounding this new treatment. It is with this in mind that we present this synopsis to the plastic surgery readership.

Background: Immunosuppression-related risks are foremost among ethical concerns regarding facial transplantation. However, previous risk estimates are inaccurate and misleading, because they are based on data from studies using different immunosuppression regimens, health status of the transplant recipients, tissue composition, and antigenicity. This review provides a comprehensive risk assessment for facial transplantation based on comparable data of immunosuppression, recipient health status, and composition and antigenicity of the transplanted tissue., Methods: The risk estimates for face transplantation presented here are based on data reported in clinical kidney (10-year experience) and hand transplantation (5-year experience) studies using tacrolimus/mycophenolate mofetil/corticosteroid therapy. Mitigating factors including ease of rejection diagnosis, rejection reversibility, infection prophylaxis, patient selection, and viral serologic status are taken into account., Results: Estimated risks include acute rejection (10 to 70 percent incidence), acute rejection reversibility (approximating 100 percent with corticosteroid therapy alone), chronic rejection (<10 percent over 5 years), cytomegalovirus disease (1 to 15 percent), diabetes (5 to 15 percent), hypertension (5 to 10 percent), and renal failure (<5 percent)., Conclusions: A review of these data indicates that previously reported estimates of immunosuppression-related risks are outdated and therefore should no longer be used. These updated risk estimates should be used by facial transplant teams, institutional review boards, and potential recipients when considering the immunologic risks associated with facial transplantation.

Although the first face transplants have been attempted, the social and psychological debates concerning the ethics and desirability of the procedure continue. Critics contend that these issues have not yet been sufficiently addressed. With this in mind, the present article seeks to elaborate on key psychological and social factors that will be central for addressing the ethical and psychosocial challenges necessary to move face transplantation into mainstream medicine. The goals of this article are to (1) discuss the psychosocial sequelae of facial disfiguration and how face transplantation may relieve those problems, and (2) delineate inclusion and exclusion criteria for the selection of research subjects for face transplantation. The article uses concepts from symbolic interaction theory in sociology to articulate a theoretically coherent scheme for comprehending the psychosocial difficulties of facial disfiguration and the advantages offered by facial transplantation. The authors conclude that the psychosocial implications of disfigurement warrant surgical intervention and that research in the area of face transplantation should continue.

Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.

According to the World Health Organization "Global burden of disease study", future demographics of trauma are expected to show an increase in morbidity and mortality. In the past few decades, the field of trauma surgery has evolved to provide global and comprehensive care of the injured. While the modern day trauma surgeon is well trained to deal with multitrauma patients with injuries involving several systems, the ever-increasing nature and variety of multitrauma has left lacuna in certain areas. One such area is the management of abdominal wall injuries, which has been the domain of both plastic and reconstructive and general surgeons. The trauma surgeon is adept at treating the contents of the abdomen but not always the container. If not managed properly complications associated with abdominal wall injuries can lead to increased morbidity and mortality. In considering reconstruction of the abdominal wall in multitrauma patients proper evaluation, scrupulous planning, appropriate, and meticulous technique improve the chances for success with minimal complications. In the present article, we provide a brief description of the most commonly used procedures, and more importantly we outline the principles and guidelines applied to abdominal wall reconstruction in order to inform the trauma surgeon of different available treatment options. In doing so, we hope that this review will assist trauma surgeons in their overall care of patients that present with abdominal injuries.

Each year an estimated 7-million people in the USA need composite tissue reconstruction because of surgical excision of tumors, accidents and congenital malformations. Limb amputees alone comprise over 1.2 million of these. This figure is more than double the number of solid organs needed for transplantation. Composite tissue allotransplantation in the form of hand and facial tissue transplantation are now a clinical reality. The discovery, in the late 1990s, that the same immunotherapy used routinely in kidney transplantation was also effective in preventing skin rejection made this possible. While these new treatments seem like major advancements most of the surgical, immunological and ethical methods used are not new at all and have been around and routinely used in clinical practice for some time. In this review of composite tissue allotransplantation, we: (i) outline the limitations of conventional reconstructive methods for treating severe facial disfigurement, (ii) review the history of composite tissue allotransplantation, (iii) discuss the chronological scientific advances that have made it possible, (iv) focus on the two unique clinical scenarios of hand and face transplantation, and (v) reflect on the critical issues that must be addressed as we move this new frontier toward becoming a treatment in mainstream medicine.

Background: The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant., Methods: To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures., Results: The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures., Conclusions: This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.

In spite of the extensive experimental work on vascular washout in free flap surgery, an optimal temperature for the washout solution has not been established. This study was designed to determine the effect of the washout solution temperature on the degree to which the microcirculation is cleared of blood. The cremaster muscle flap in the rat was used, in which the microcirculation can be directly viewed and the presence of blood and perfusion parameters within various vessels can be measured during and after washout. Washout was started with a single, high-pressure infusion and continued at 130 mmHg for 15 minutes. The temperature of the washout solution was either 2-3, 20-22, or 35 degrees C. In all three groups, washout cleared the microcirculation almost completely within the first minute. However, we observed that a cold or room temperature washout cleared the microcirculation more completely than a warm washout did. The temperature of the washout solution did not effect post washout capillary perfusion and/or arterial diameters., (Copyright 1999 Wiley-Liss, Inc.)

Reconstruction of long-segment tracheal defects is a problem for the reconstructive surgeon. Difficulties arise with the use of prosthetic materials because of their propensity for infection and extrusion. Autologous tissue is limited by poor structural characteristics and technical complexity. We propose a simple composite bioprosthesis that, through a process of prefabrication and subsequent neovascularization, may provide a functional tracheal analogue superior to existing forms of reconstruction. Ten rats had composite flaps constructed by combining an isolated, perfused, mucosectomized segment with an outer covering of a ring-reinforced woven Dacron vascular graft. This unit remained in the intraabdominal milieu for 20 days and was then inspected for viability, incorporation of jejunum and graft, flexibility, and tolerance to negative pressure. Seven experimental animals survived the initial phase. The jejunal bioprostheses in all cases tolerated negative pressures to -200 mmHg, rotation of 180 degrees, and flexion to 90 degrees without collapse of the graft segments. Vascular casts and standard histologic examination showed neovascularization of the Dacron graft and dense fibrovascular ingrowth into the interstices of the graft. We conclude that prefabrication utilizing autologous and prosthetic components to create a single axial flap for transfer is a feasible solution to long-segment tracheal reconstruction. Neovascularization permeates the full thickness of the prosthetic component and is accompanied by dense fibrous ingrowth during the delay period. This neotracheal analogue also possesses structural characteristics similar to those of the native trachea and a durable submucosal layer that can support ingrowth of epithelium.

In microvascular surgery, procedures may be both technically and physically demanding. Precise movements sustained over long hours in addition to typically compromised surgeon and assistant positioning lead quickly to physical and mental fatigue. Many of the positioning problems encountered are related to the fact that the eyes of the surgeon must be continually fixed to the microscope eyepieces. This study explores a possible solution: a microscope system that eliminates the need to view the operative field through the microscope eyepieces. A Three-dimensional On-screen Microsurgical System (TOMS) was used and contrasted with conventional operative microvascular surgery in the laboratory setting. The surgeon's comfort, his ability to instruct microsurgical technique, pertinent technological performance, and the procedure itself were evaluated using a standardized questionnaire. Based on data collected in this study, we conclude that divorcing the surgeon's eyes from the microscope eyepieces using the TOMS may make prolonged microvascular procedures less physically demanding and may increase the comfort level of both the surgeon and his assistant, although refinements to the technology are required.

In this study, simulated "poor" repairs applied to transverse incisions in the iliac arteries of 40 rats were the basis for comparing the effect of variations in blood flow on thromboembolism. Using vital microscopy and digital image processing, we performed 2 experiments. In the first experiment (n = 20), the reduction of post-repair blood flow by approximately 50% resulted in an 83% reduction in the total number of emboli appearing in the microcirculation of the cremaster muscle distal to the repair. In the second experiment (n = 20), the same reduction in blood flow typically resulted in larger repair-site thrombi which required significantly more time to grow to their maximum size. We conclude that reducing pedicle artery blood flow to approximately half in our rat model during reperfusion can protect the downstream microcirculation from embolic injury without increasing the incidence of thrombotic occlusion.

Purpose: We compared autogenous vein pedal and peroneal bypasses, focusing on extremities that could have a bypass to either artery., Methods: From 1985 to 1993 we performed a total of 175 pedal and 77 peroneal autogenous vein bypasses for rest pain (n = 75, 30%) and tissue loss (n = 177, 70%). One hundred ninety-six (78%) in situ saphenous vein and 56 (22%) reversed or composite vein bypasses were performed. One hundred fifty-two of these 252 bypasses were performed in extremities with both the pedal and peroneal arteries patent by arteriography. The vascular surgeon chose to perform 99 pedal and 53 peroneal vein bypasses in these 152 extremities., Results: The angiogram score of the outflow arteries were similar for pedal and peroneal bypasses with the Society for Vascular Surgery and the International Society for Cardiovascular Surgery and modified scoring systems. At 2 years the primary and secondary patency rates for pedal bypasses (70% and 77%) were not significantly different compared with those for peroneal bypasses (60% and 72%). Limb salvage rates at 2 years were similar for pedal and peroneal bypasses for all patients (74% and 73%), patients with both pedal and peroneal arteries patent (83% and 72%), diabetics (76% and 66%), and patients with tissue necrosis (77% and 71%)., Conclusions: Pedal and peroneal artery bypasses with equivalent angiogram scores have similar long-term graft patency and limb salvage. The choice between pedal or peroneal artery bypass should be based on the quality of vein and the surgeon's preference.

Neovascularization or angiogenesis is an essential yet poorly understood component of the healing process. In wound healing research, there is a lack of models enabling quantitative and continuous measurements of wound neovascularization. The hairless mouse ear wound model permits quantitative measurements of wound epithelialization and neovascularization continuously throughout the healing process. On the ears of male homozygous (hr/hr) hairless mice, standardized circular full thickness dermal wounds are produced; then, using vital microscopy, these two processes are directly viewed and measured at day 0 and every third day thereafter until these are complete. This model system and its application to clinically relevant situations are reviewed.

Although free tissue transfer success has been greatly improved by developments in operating microscopes, microsutures, microinstruments, and technique, free flap and replant failure remain a significant problem under certain adverse circumstances. The nature of these failures is often multifactorial and remains poorly understood. A greater understanding of the processes involved would provide the potential for greater pharmacological control of any adverse conditions prevailing and would thus offer the prospect of more effective adjunctive therapy in the presence of such adverse conditions. Research endeavors in this area have been hindered by the absence of good research models. The isolated rat cremaster muscle model is a recently developed model that simulates the conditions of free tissue transfer. Using this model, both thrombus formation and numerous microcirculatory parameters can be measured. The microcirculatory parameters studied to date include the formation of thromboembolism, capillary perfusion, vessel diameters, red blood cell velocity, leukocyte-endothelium interaction, and microvascular leakage. The isolated rat cremaster muscle model addresses many of the shortcomings of earlier research models and offers the promise of answering at least some of the many unanswered questions relating to free flap and replant failure.

Angiogenesis, the formation of new blood vessels, is essential to a variety of normal and pathologic processes such as wound healing and tumor growth. In microsurgery the development of new vessels between the transferred tissue and the recipient bed is critical to the final outcome of the reconstruction. Several experimental models have been previously developed to study angiogenesis and the effect that new substances have on regulating this process, but they lack the ability to make quantitative measurements. Therefore, we have developed an animal model using the homozygous (hr/hr) hairless mouse ear; by using intravital microscopy and computer-assisted analysis, angiogenesis can be quantitatively measured. Using this model we showed that basic fibroblast growth factor and transforming growth factor beta significantly increased total vessel length by 32% and 63%, respectively, during 20 days following subcutaneous injection. In this paper the importance of angiogenesis research to reconstructive microsurgery is presented and discussed.

Revascularization of distal occlusive disease in the diabetic has been markedly enhanced by microsurgical techniques. Extremely small, heavily calcified vessels are able to be reliably reconstructed using microsurgical techniques and high magnification. Additionally, revascularization followed by microsurgical free tissue transfer has proven to be a valuable alternative to amputation in patients with major soft-tissue loss, or bony or tendon lesions requiring soft-tissue reconstruction. Although metabolic risks are potentially high, we have experienced a very low morbidity and mortality with a thorough medical work-up and follow-through in conjunction with these major procedures. It is our expectation that judicious application of microsurgical techniques in treatment of the ischemic diabetic lower extremity will continue to improve the chances for long-term bipedal ambulation in this patient population.

An expansion prosthesis to stretch commissures and fibrotic muscles is often essential for patients recovering from head and neck trauma or burns. The prosthesis is easily made in one appointment using Triad resin and a 7 mm expansion screw. Depending on the frequency of use, varying degrees of opening of the jaws can be obtained. The prosthesis is inexpensive to make and can easily be modified as needed. It is convenient for use because the patient controls the pressure that is applied by the prosthesis.

The decade of adolescence of microsurgical techniques of head and neck reconstruction has led to a further clarification of the indications and methods for microsurgical reconstruction of head and neck defects. A review of the defects and the variety of flaps available for reconstruction leads to an increased understanding of the advantages and disadvantages of these various methods. When assessing a defect in the head and neck for microsurgical reconstruction, the surgeon should consider the various advantages of the flap to be used and weigh them against the disadvantages. The specialty has long since passed the point when one or two donor flaps could be considered to answer all of the reconstructive questions. We must now thoughtfully consider all the available options before settling on a course of treatment.

Sixty-five patients received 68 inframalleolar arterial grafts for severe rest pain, foot ulceration, or gangrene. Patients were elderly with an average age of 68 years (median 72); most had several operative risk factors. Reversed saphenous vein grafts were used early, but most conduits were in situ vein grafts. The recipient vessel was the dorsalis pedis artery in 39 patients, the posterior tibial in 27, and tarsal branches in two. Preoperative angiography was routinely performed with biplanar and digital arterial techniques, but in nearly a third a suitable bypass vessel was not identified preoperatively. When vessels were identified there was usually only a single patent artery suitable for bypass grafting below the knee. There were five postoperative deaths (7.6%). Eight grafts (11%) required early revision for thrombosis or retained valve, and six were salvaged and remained patent. Poor vein quality appeared responsible for the two early failures. Six late graft occlusions occurred from 4 to 39 months (mean 14 months). Three of these patients had no recurrence of their ulceration, but two required amputation, and one has continued rest pain. One additional amputation was required in a patient with a patent graft. Eleven late deaths (16%) occurred (nine with patent grafts) primarily of cardiac causes.

Six patients had major deficits reconstructed with microsurgical free tissue transfer. In contrast to some opinions that free tissue transfer is a "method of last resort," these patients were selected for microsurgical reconstruction as a method of first choice due to the qualities desired in the reconstruction, the reliability of the technique, and the desire to minimize the functional or aesthetic deficit at the donor site. Microsurgical techniques allowed a reconstruction in these cases that would have been difficult or impossible by conventional techniques, while they markedly improved the quality and reliability of the reconstruction and decreased the donor morbidity. Microsurgical free tissue transfer has been reported to have a success rate of 94% in centers where a significant volume of surgery is done. We believe the continued refinement of microsurgical techniques and their increased application will improve the results of reconstruction in a large category of severe traumatic and cancer defects.

Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. Embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynaud's phenomenon are pointed out.

Mandibular reconstruction with microvascular bone transfer was carried out in 10 patients, including 8 with far advanced intraoral carcinoma and 2 with posttraumatic facial and mandibular defects. Eight patients presented with compromised defects as a result of radiation injury, infection, and scarring. Nine patients experienced primary bony union with complete functional and esthetic reconstruction of the mandible, and two patients eventually received dentures. This technique has resulted in a more effective, more reliable, and earlier reconstruction compared with conventional methods.

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.

Successful reconstruction for excisional defects of the head and neck and esophagus was accomplished in 93 percent of our patients using microvascular free tissue transfer. Complete failure occurred in 7 percent of the patients. Major defects after head and neck cancer surgery constituted the main indication for use of microvascular free tissue transfer for reconstruction. Ninety-four percent of the patients had undergone an extensive excisional procedure. A wide range of cutaneous, myocutaneous, and osteocutaneous free flaps, as well as free bowel autotransfers were used. Complete failure was three times higher in the previously irradiated patients (4 of 41 patients) compared with nonirradiated patients (1 of 34 patients). Morbidity and mortality rates were consistent with expected ranges in patients who were undergoing major head and neck resection. Donor site complications occurred in 23 percent. Thin flaps are favored for reconstruction of anterior defects in the oral cavity, whereas bulkier flaps are more suitable for deeper defects in the oropharynx and hypopharynx. The advantages are both aesthetic and functional. The free jejunal autograft is considered the reconstructive method of choice for defects produced by laryngopharyngoesophagectomy. Highly developed and sophisticated microsurgical skills continue to be the mainstay of success. The implication of free tissue transfer failure, especially for defects of the upper aerodigestive tract, are impressive in terms of morbidity, mortality, and cost. These considerations limit the application of this method of reconstruction to centers that have sophisticated and productive reconstructive surgeons with microsurgical skills.

We describe a reliable experimental method for direct, continuous measurement of the rate of blood flow in an island skin flap, using an electromagnetic flowmeter applied to the artery of the flap. The canine saphenous island flap model, developed as part of this study, is a large (11 x 14 cm) island flap, based solely on the saphenous artery (2 mm in diameter). We describe the anatomy of the flap and the method of raising it. Electromagnetic flowmetry is the only method of blood flow determination that provides immediate, continuous, and quantitative measurement of flow. We describe the principles and pitfalls of the electromagnetic flowmeter and the numerous rules of practice that must be observed to obtain consistent results. A validation study was carried out, in which we simultaneously measured arterial inflow with the flowmeter and venous outflow from the flap using direct collection. This study was based on the assumption that at any point in time the arterial and venous rate of flow were equal. We present the results of the study, which show an extremely close linear relationship between the measured and actual rates of flow. We intend to use this experimental method to study the factors that affect the rate of blood flow in free skin flap transfer.

There is a highly dependable free flap donor site of moderate size on the posterolateral aspect of the distal upper arm. The area is supplied by the posterior radial collateral artery, a direct continuation of the profunda brachii. The flap area is supplied by a direct cutaneous nerve. It can be raised on its own, with underlying tendon, with bone, or with fascia only. This article describes our findings in 32 cadaver dissections and in 23 clinical cases.

Six cases are presented demonstrating uncomplicated primary healing following early microvascular reconstruction for complex electrical and deep thermal injuries. We advocate early preservation of eschar and the prevention of infection with the use of penetrating topical antibacterial agents, removal of the soft-tissue eschar when clinically indicated, and immediate coverage of the undebrided bone through the provision of well-vascularized tissue. Microvascular free tissue transfer should be considered as a primary method of reconstruction for complex electrical or thermal injury whenever clinically feasible. These reconstructive techniques offer an early, reliable means of definitive reconstruction, preserving function, providing uncomplicated healing, and promoting early rehabilitation.

The dorsalis pedis flap provides thin, hairless tissue for a variety of intra oral defects. Due to concerns for the donor site, reconstructive surgeons have largely overlooked this flap, despite its numerous desirable qualities. The paper focuses on the anatomy of the first dorsal metatarsal artery and techniques which insure the preservation of adequate flap vascularity. The prevention of donor site complications centers around meticulous attention to the placement of skin grafts, with a secure tie-over dressing and the use of a posterior splint. Patients are allowed to ambulate in the early postoperative period only when venous compression is provided with an ace bandage. Vigorous attention to detail on reconstructing the foot has minimized donor site complications. The dorsalis pedis flap continues to be an important method of reconstruction in our armamentarium of free tissue donor sites.