Reconstruction of fingertip defects with digital artery perforator flap.

OBJECTIVE: The aim of this study was to present our findings for the use of the digital artery perforator (DAP) flap in the covering of digital pulp defects. METHODS: The study included 15 patients who underwent reconstruction of the fingertip using a DAP flap between July 2007 and February 2012. The blood supply of the perforator island flap was based on the distal and either radial or ulnar sides of the digit. Donor sites were closed using skin grafting in all cases. Static two-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWM) testing was performed at the final follow-up to determine extension loss and sensorial improvement. RESULTS: Mean follow-up was 22 (range: 7 to 62) months. Flaps size was between 2 x 1 cm and 2.5 x 1.5 cm. Temporary venous congestion was observed in 12 of the 15 patients and was without complication. All patients returned to their normal daily activities and work within an average of 39 (range: 30 to 45) days. Mean two-point discrimination was 5.3 mm and SWM test results were between 3.61 and 4.56 at the final follow-up. CONCLUSION: The DAP flap appears to be a reliable procedure with several advantages as a single-stage operating procedure, easy to harvest, good sensory recovery and preservation of digital arteries.

Metatarsal artery perforator-based propeller flap.

Soft-tissue defects of the distal foot that involve an exposed tendon and bone demonstrate a reconstructive challenge for plastic surgeons. This report investigates the feasibility and reliability of metatarsal artery perforator (MAP)-based propeller flap for reconstruction of the distal foot soft-tissue defects. Between July 2011 and June 2012, six patients underwent distal foot reconstruction with seven MAP-based propeller flaps. Five flaps were based on the third metatarsal artery and two flaps were based on the first metatarsal artery. The flap size ranged from 4 × 2 cm to 8 × 4 cm. All flaps completely survived. Two patients developed transient distal venous congestion, which subsided spontaneously without complications. There were no donor site complications. All patients were ambulating without difficulty within the first month of surgery. MAP-based propeller flaps can be used to repair the distal foot soft-tissue defects, providing sufficient skin territory and excellent esthetic and functional recovery.

Comparing different postconditioning cycles after ischemia reperfusion injury in the rat skin flap.

Ischemic postconditioning is a useful manipulation to reduce the undesirable effects of ischemia-reperfusion (I/R) injury. The beneficial results of this phenomenon against I/R injury have been seen in several flap models. However, there are no published works comparing different postconditioning (post-con) cycles in skin flaps. In this study, we investigated the effectiveness of different post-con cycles in a skin flap model. Epigastric island flap (6 × 3 cm) model which was based on the left superficial epigastric artery and vein was used, and complete 6 hours of ischemia was generated by occlusion of the pedicle. Forty male Wistar rats were allocated into 5 groups (n = 8 in each group). Group 1 (sham group): the elevated skin flap was repositioned without an episode of ischemia. Group 2 (control group): skin flap was elevated and 6 hours of complete ischemia was induced by clamping the pedicle. Group 3 (post-con 1): After ischemia, post-con was performed by 6 cycles of 15 seconds of repeated I/R periods. Group 4 (post-con 2): After ischemia, post-con was performed by 6 cycles of 30 second of repeated I/R periods. Group 5 (post-con 3): After ischemia, post-con was performed by 6 cycles of 60 second of repeated I/R periods. Flap viability was assessed 1 week after the surgical procedure, the necrotic area of the skin flap was measured using image analysis on the computer. The area of flap necrosis was statistically significant between the control and post-con group 4 and group 5, and no statistically significant difference was obtained between the control and post-con group 3. Groups 4 and 5 demonstrated lesser area of flap necrosis than the control group and group 4 was superior to group 5. The results revealed that the post-con applied by means of 6 cycles of 30 seconds yields the best protection against I/R injury in the rat skin flap model.

Comparing various surgical delay methods with ischemic preconditioning in the rat TRAM flap model.

Both surgical delay and ischemic preconditioning (IP) have been shown to be effective in improving the survival of flaps. We used a variety of flap delay methods and IP to increase the surviving area of the transverse rectus abdominis musculocutaneous (TRAM) flap in rats, and the results are compared in between. A 6-× 3-cm-sized TRAM flap in 40 Wistar rats was allocated into five groups. Group 1: TRAM flap was elevated from nondominant pedicle, and the flap was sutured to the original bed. Group 2: Left superior deep epigastric vessels (SDEV) were cut; 1 week later, TRAM flap was elevated. Group 3: Only skin incision was done; 1 week later, TRAM flap was elevated. Group 4: Skin incision was done, and the left SDEV were cut; 1 week later, TRAM flap was elevated. Group 5: TRAM flap was elevated; IP was performed using three cycles of 10 minutes of repeated ischemia/reperfusion (I/R) periods, and the flap was sutured to the original bed. The surviving area of the flap was statistically significant between the control and groups 2, 4, and 5 (p < 0.001), and groups 4 and 2 were superior to group 5. Although preconditioning has been intensively studied for the last two decades and partly provided its beneficial effects in I/R injury, we determined the IP increased the surviving area of the TRAM flap but not effective as much as surgical delay method.

Treatment of a supernumerary large breast with medial pedicle reduction mammaplasty.

UNLABELLED: Accessory breast tissues including nipples, areolas, and glandular tissue may develop on the chest in addition to two normal breasts. An accessory breast with a complete ductal system, areola, and nipple is termed a "supernumerary breast." Supernumerary nipples are fairly common, but complete supernumerary breasts are rare. This report describes an 18-year-old woman who presented with a complete supernumerary breast including a nipple-areola complex located on the upper outer quadrant of her left breast and causing severe breast asymmetry. She was referred to the authors for aesthetic reasons. Unilateral reduction mammaplasty was performed to remove the supernumerary breast and correct the breast asymmetry. The medial pedicle Wise technique was used for en bloc resection of the ectopic breast, including the nipple-areola complex together with the upper outer breast quadrant. The woman's postoperative course was uneventful. At 8 months after surgery, she was very satisfied with the results. Ectopic breast tissue can be treated by a variety of methods such as liposuction or excision. However, breast deformation because of a complete supernumerary breast is very rare, and research on the treatment of such patients is lacking. No reports describing surgical treatment for this condition were identified in the literature. The authors suggest that unilateral breast reduction is the most appropriate treatment, allowing excision of the accessory tissues, with the best possible cosmetic outcome. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of lateral lower lip defects with transverse lip advancement flap.

BACKGROUND: Lower lip defects between one and two thirds of the lower lip are usually reconstructed with neighboring tissues from the upper lip, cheeks, or the mentum or a combination of these tissues. In this article, we offer a simple and effective reconstruction option that can be used for lateral defects between one third and two thirds of lower lip tissue. Utilizing the tremendous flexibility and expandability of the lip tissue, we tried to minimize the incisions and scar, and maximize the sensation and function with transverse advancement flap. PATIENTS AND METHODS: Ten patients with lateral lower lip defects, after tumor ablation, were treated by this technique. After excision of tumor, the existing incision is extended to medial by following the natural labiomental crease. Full-thickness incision is ended at the level of commissure not to disturb the buccal and marginal mandibular branches of the facial nerve. Intraoral incision is made 1 cm above the gingivobuccal sulcus .The mental nerve was dissected and preserved to keep the sensorial innervation of the lower lip. Thus, transverse advancement labial flap that includes the orbicularis oris with intact neurovascular supply is freed to provide the desired advancement. RESULTS: Satisfactory functional, aesthetical, and sensational results were obtained. CONCLUSION: A dynamic reconstruction can be provided with superior results in terms of lip appearance and function with transverse lip advancement flap. In planning a lip reconstruction, we think that transverse lip advancement flap should be considered as a second ladder after primary closure.

Complex partial nasal reconstruction using free prelaminated temporoparietal fascial flap.

The reconstruction of nasal defects together with nasal lining, skeletal support, and skin loss constitutes difficulty to plastic surgeons. We present a single-stage reconstruction of the defect formed on the nasal tip, columella, septum, and upper lip after tumor excision by performing free temporoparietal fascial flap, costal cartilage, and skin graft. In this case, cartilage support was created by the graft taken from costal cartilage, and free temporoparietal fascial flap was wrapped around this cartilage scaffold. Skin graft taken from scalp was placed on the skin surface, and skin graft taken from the thigh was placed on the mucosal surface. Vascular anastomoses were performed on the labial artery and the concomitant vein. In consequence of this operation, a nasal reconstruction with acceptable esthetic and functional results was provided in a complex nasal defect. Internal lining, skin, and cartilage structures were replaced in one single stage and with single flap and graft.

Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction.

Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Coverage of the testicles and constituting a good cosmetic appearance are major expectations from a successful reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own characteristics. In our series, between January 2006 and January 2010, the medial circumflex femoral artery perforator flap was used in 7 male patients for scrotal coverage after Fournier gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; however in one flap 2 perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement. Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an acceptable scrotal contour and cosmesis. No major complication was seen due the perforator flap surgery, in 2 patients wound dehiscence were noted and they healed by secondary intention or by secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site. All these advantages can be accomplished in 1 procedure.

Reconstruction of large palatal defects using the free anterolateral thigh flap.

The ideal reconstructive method for the palatal defect should provide durable, stable coverage, and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Although small and usual palatal defects can be repaired easily using local adjacent tissues, successful closure of large, complex defects is still a challenging problem. Numerous free tissue options have to date been described for large palatal defects. Although the radial forearm flap constitutes a good option for ideal reconstructive goals, the sacrifice of a major artery to the hand and the skin graft to the forearm with its high potential risk of complications are evident problems attendant upon this donor site. Since the first report of the anterolateral thigh flap, this has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Between April 2005 and May 2009, 8 free anterolateral thigh flaps were used to reconstruct defects of the palate. The study involved 6 male and 2 female patients, their ages ranging from 3 to 45. Five patients had palatal defects due to congenital cleft palate deformity, 2 patients had defects due to tumor resection, and the remaining patient had a palatal defect due to a gunshot wound. The size of the flaps ranged from 8 to 14 cm in length and from 4 to 7 cm in width. Facial vessels were used as recipient vascular sources in all patients. Primary thinning of the flap was performed in all cases. Donor sites were closed directly and healed uneventfully in all patients. There were no postoperative complications and all flaps survived totally. No debulking was needed. All patients, and their families in the case of child patients, were satisfied with the results of their surgical treatment. In conclusion, although it has some irregularity in derivation from the main vessels, with its evident structural and cosmetic advantages the anterolateral thigh flap can be considered an excellent and ideal free flap option for most large palatal defects that cannot be closed by regional tissue in selected patients. It can reconstruct defects in single stage with well-vascularized tissue, resulting in minimal donor site morbidity.

Clinical experience with free anterior interosseous flaps.

Despite versatility of the forearm as a flap source, anterior interosseous flaps from the dorsal forearm has not gained popularity among other alternatives. In our clinical experience, we investigated the feasibility of free anterior interosseous flap as a donor site. Between January 2002 and January 2006, 10 free anterior interosseous flaps were used in 10 consecutive cases. Five flaps were used for coverage of the defects of the hand and fingers, whereas another 5 flaps were used for head and neck defects. In all cases, this flap was selected when a thin flap was needed. All flaps survived completely except 1, where partial marginal necrosis was seen, and this necrosis was healed by secondary intention. Only 2 donor sites could be closed directly, and the others were skin grafted. Free anterior interosseous flap is a useful alternative with distinct advantages: it is a thin flap, major extremity arteries are preserved, the vascular pedicle is long enough and caliber is satisfactory for microsurgery, composite flaps with tendon, bone, nerve, and muscle are available, and it has a good texture, especially for hand defects. The 2 major disadvantages are visible donor area scar and technically demanding dissection. In conclusion, free anterior interosseous flaps are a good selection and should be in the armamentarium of a microsurgeon, when a thin flap is needed for hand and head and neck reconstruction.

Midface reconstruction.

In the midface, two polyhedron-shaped maxillary units are separated by the central midportion, which includes the nasal area. The midface includes such facial features as the nose, cheek, and upper lip, and posteriorly it extends to the anterior skull base. In the superoinferior direction, the midface includes the soft and bony tissue from the orbital cavity to the oral cavity. Laterally, the midface extends to the temporal bone. Although most superficial skin defects of the midface can be covered by various standard reconstructive modalities, because of the need to evaluate the nature of the tissues involved and because of structural and also functional considerations, the management of large, full-thickness defects is a challenge for reconstructive surgeons. Advances in microsurgical techniques have permitted reliable wound closure and a substantial decrease in patient morbidity with low complication rates while allowing a variety of reconstructive flap options in a single stage. To create a reconstructive algorithm, several classification systems have been proposed, mostly relating to the extension, location, and tissue involvement of the defect. Defects can be classified as simple soft tissue defects and complex defects. The complex three-dimensional defect is classified under four types: types I to IV. Although maxillary prostheses are nonliving tissues and may cause discomfort for the patient, in special situations they can be reconstructive options requiring special experience. Essentially, the method of reconstruction should be selected on an individual basis, bearing in mind the medical situation; the age and prognosis of the patient; the size, extension, and composition of the defect; and the availability of local or distant tissues.

The old and ill: influence and impact on the reconstructive effort.

Head and neck reconstruction is often mandatory in elderly and ill patients, especially after tumor ablation. Even complex reconstructive procedures can be done in the elderly population after careful evaluation. The morbidity and mortality rates increase with age, thus the risks and benefits of surgical intervention must be weighed precisely. The functional capacities of the vital organs and the limitations should be assessed. The only significant preoperative guide for the risk of the operation is the American Society of Anesthesiologists (ASA) score. According to this scoring system, ASA 3 and 4 patients are more prone to complications. For a successful reconstructive procedure in old and ill patients, detailed preoperative evaluation is mandatory. Based on this evaluation, the type and duration of the surgery can be properly selected, and postoperative monitoring can be handled individually.

Effect of cyclooxygenase-2 on ischemic preconditioning of skin flaps.

Ischemic preconditioning is a useful tool to fight against reperfusion injury. This phenomenon is very complex and the underlying mechanism has various branches. Every study on ischemic preconditioning helps us to better understand this process. We aimed to investigate the effectiveness of cyclooxygenase-2 (COX-2) on ischemic preconditioning of skin flaps in the rat. A 6 x 3 cm-sized left epigastric artery flap was used and the pedicle was isolated to perform the ischemic preconditioning via microvascular clamp application. The preconditioning protocol was 2 cycles of 15 minutes ischemia and 15 minutes reperfusion periods. Sixty female Wistar rats weighing between 210 and 260 g were used for the experiment. Animals were allocated randomly into 6 groups, each group containing 10 animals. Group 1: Only 6 hours of ischemia was done after the flap elevation, neither ischemic preconditioning nor COX-2 inhibitor was used; Group 2: 6 hours of global ischemia was induced just after the ischemic preconditioning; Group 3: In addition to the same procedures in group 2, 2 doses of COX-2 inhibitor were given before and after the final ischemic insult; Group 4: 6 hours of ischemia was applied to the flap 24 hours after its elevation, no preconditioning or any other interventions were done; Group 5: The same ischemic protocol was used after the flap elevation but the 6 hours of ischemia was performed 24 hours after the preconditioning; Group 6: The same procedures of group 5 were done and in addition, 2 doses of COX-2 inhibitor was given, starting 24 hours after the ischemic preconditioning. All flaps were followed for 1 week then necrotic flap portions were measured and represented as a percentage to the whole flap area. Statistical analyses revealed meaningful differences between groups 2 and 3 (P < 0.05), 2 and 1 (P < 0.05), 5 and 6 (P < 0.05), 5 and 4 (P < 0.05). However, there was no statistical difference between groups 3 and 1 (P > 0.05), 6 and 4 (P > 0.05). As a conclusion, ischemic preconditioning has both early and late protective effects on ischemia-reperfusion injury in the skin flap model. By antagonizing COX-2 receptors the beneficial effects of IP were reversed. This result indicated that COX-2 has a specific role in the mechanism of both early and late effects of ischemic preconditioning in skin flaps.

A reverse-flow composite flap in the rat.

Reverse-flow flaps are currently particularly used for the reconstruction of defects of the distal part of the extremities. Despite their common usage there have been many reports of postoperative complications, especially resulting in partial or total flap necrosis. There is insufficient knowledge of flap haemodynamics, physiology and wound healing properties in reverse-flow flaps. Development of the proper experimental models is needed to investigate these issues. The purpose of this study was to describe a new reverse-flow flap model in the rat. A total of 20 adult Wistar rats weighing 200-250 g were used in this experiment. In five rats, the vascular anatomy of the auricle of the rat was determined by anatomic dissection and microangiography. In the experimental group (N=5), 1x1 cm reverse-flow composite flaps were harvested as a semi-island shape, based on the distal course of the medial branch of the anterior auricular artery. In the control group, consisting of five rats, the flap was designed and raised based on the proximal course of the medial auricular artery, again in a semi-island shape. In the remaining five animals, a square-shaped composite tissue of the whole layer of the auricle, 1x1 cm in size, was harvested dividing all the bases circumferentially. The composite tissue was replaced in situ. While the former was considered a conventional antegrade-flow flap subgroup, the latter was designated as a graft subgroup. All flaps were replaced in situ. The survival of the flap was evaluated on postoperative day 7 by direct observation and microangiography. The skin island of all the reverse-flow flaps and conventional antegrade-flow flaps survived completely giving a success rate of 100%, whereas all grafts in the control group underwent complete necrosis. Microangiographic studies revealed the vascularity of the reverse-flow and antegrade-flow flaps, identifying the course of the auricular arteries. In conclusion, with its evident advantages of easy to design and harvesting, reliable survival pattern and consistent vascular structure, our new flap model will provide a means for future studies on flap haemodynamics, physiology in reverse-flow flaps.

Reversed anterior interosseous flap.

Reversed flaps from the forearm have been firmly established for hand coverage. Each has its own advantages and disadvantages. The reversed anterior interosseous flap is one option with special advantages in hand reconstruction. From January 2002 to July 2003 we used this flap in five consecutive male patients aged between 36 and 59. The defects were located on the first web space (2), on the dorsal side of the thumb (1), on the first metacarpal bone (1), and on the volar side of the wrist (1). Flap size was between 6 x 3 cm and 11 x 7 cm. All flaps healed without any problem and no complication was observed during the postoperative period. The major advantage of this flap is the preservation of the main arteries of the upper limb. Other advantages are as follows: good texture and colour for hand reconstruction, satisfactory rotation arc, and availability of composite and fascial flaps. Besides its advantages, the major disadvantages are unsightly donor area scar and the need for meticulous technique. As a conclusion, we found this flap very useful in hand reconstruction for coverage of small and moderate sized soft tissue defects of the hand.

The effect of ischemic preconditioning on secondary ischemia in skin flaps.

Ischemic preconditioning is a useful manipulation to reduce the undesirable effects of ischemia. The beneficial results of this phenomenon against ischemia-reperfusion have been seen in different flap models; however, all these studies have focused on primary ischemia. In this study, we investigated the effects of ischemic preconditioning on secondary ischemia in a skin flap model. We used the 6- x 3-cm-sized epigastric skin flap in 40 Wistar rats. In all animals, primary global ischemia of 2 hours was followed by 4 hours of either arterial or venous secondary ischemia 24 hours after the primary ischemia and ischemic preconditioning (IP) was tested in this protocol. Ischemic preconditioning was performed by 2 cycles of 15 minutes of repeated ischemia/reperfusion periods. The animals were allocated into 4 groups: group 1 (n = 10 animals): primary ischemia (2 hours) + secondary arterial ischemia (4 hours); group 2 (n = 10 animals): IP + primary ischemia (2 hours) + secondary arterial ischemia (4 hours); group 3 (n = 10 animals): primary ischemia (2 hours) + secondary venous ischemia (4 hours); group 4 (n = 10 animals): IP + primary ischemia (2 hours) + secondary venous ischemia (4 hours). Flap viability was assessed 1 week after the surgical procedure, and surviving flap area was recorded as a percentage of the whole flap area. Group 1 was compared with group 2, and group 3 was compared with group 4 to evaluate the effects of ischemic preconditioning against secondary arterial and venous ischemia. t test and Mann-Whitney rank sum tests were used for statistical analysis. There were statistical differences both between groups 1 and 2 and groups 3 and 4. The results revealed that ischemic preconditioning was an effective procedure to reduce the flap necrosis as a cause of secondary ischemia in skin flaps.

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction.

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.

Release and free flap reconstruction for trismus that develops after previous intraoral reconstruction.

BACKGROUND: Oral cancer patients receive wide excision of oral structures and reconstruction of the intraoral defects with skin grafts and/or local, regional, or free flaps. Trismus is a common postoperative sequela, even without postoperative radiotherapy. Trismus decreases patients' quality of life and can have detrimental effects on their oral hygiene and nutritional status. METHODS: Between May of 1999 and June of 2003, 11 patients were operated on for release of trismus and reconstruction after previous intraoral reconstructions. The patients had been reconstructed with skin grafts (n = 4), radial forearm flaps (n = 3), anterolateral thigh flaps (n = 1), artificial dermis (n = 1), radial forearm flaps with skin grafts (n = 1), and pedicled pectoralis major flaps with skin grafts (n = 1). Eight patients had received postoperative radiotherapy. The patients presented with a mean interincisal distance of 3.1 mm (range, 0 to 10 mm). RESULTS: After trismus release, the intraoral soft-tissue defects were reconstructed with one or two free flaps (six anterolateral thigh flaps, nine forearm flaps, and one fibula osteoseptocutaneous flap). Fifteen of the 16 flaps were successful, with one flap failure. Average interincisal distance was 33.4 mm immediately after the release (range, 27 to 35 mm) and 18.9 mm (range, 5 to 30 mm) at a mean follow-up time of 22.7 months (16.1 mm in the radiated group and 26.3 mm in the nonradiated group). The mean amount of improvement was 15.8 mm. CONCLUSION: The use of free flaps to reconstruct the defects created after trismus release in patients with previous intraoral reconstruction is a viable option that yields reasonable, long-lasting improvements in mouth opening, intraoral hygiene, and quality of life.

Guidelines for the optimization of microsurgery in atherosclerotic patients.

We review the pathogenesis of atherosclerosis and the issues that must be taken into consideration when performing microsurgery in atherosclerotic patients. Atherosclerosis is a systemic disease, and may affect the success of microsurgery. Atherosclerotic patients have a tendency toward thrombosis, because the nature of the arteries is changed. Such patients are usually old and have additional medical problems. To increase the success rate of microsurgery in atherosclerotic patients, special precautions should be considered. Patients must be evaluated properly for the suitability of microsurgery. The microsurgical technique requires a meticulous approach, and various technical tricks can be used to avoid thrombosis. Recipient-vessel selection, anastomotic technique, and the use of vein grafts are all important issues. Prophylactic anticoagulation is recommended in severely atherosclerotic patients. Close monitoring of the patient and flap is necessary after the operation, as with routine microvascular free-tissue transfers. We conclude that atherosclerosis is not a contraindication for microsurgery. If the microsurgeon knows how to deal with the difficulties in atherosclerotic patients, microsurgery can be performed safely.