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.

A random-pattern skin-flap model in streptozotocin diabetic rats.

BACKGROUND: Flap operations are frequently performed in diabetic patients. Nevertheless, we could find no experimental study examining diabetes mellitus's effect on the flaps' survival. For this reason, we designed this study as a random-pattern skin-flap model of diabetic rats in 1999. METHODS: We used 72 rats weighing about 200 g each. The animals were divided into 2 groups, 1 experimental (diabetic) and 1 control (nondiabetic). Following their diabetic periods, we elevated the rats' modified McFarlane flaps and measured their viable flap areas. RESULTS: The mean percentage of the flap area surviving was 51.40% in the 2-week experimental group. It was 48.20% in the 4-week experimental group and 36.70% in the 8-week experimental group. The mean percentage of flap area surviving was 65.87% in the united control group (the total of all control groups). The mean surviving skin-flap area in the united control group was significantly higher than in the 4- and 8-week experimental groups. Moreover, the mean surviving flap area in the 8-week experimental group was significantly lower than in the 2-week and 4-week experimental groups. CONCLUSIONS: Our study demonstrated that a 4-week diabetic duration for rats is sufficient to observe diabetes' deleterious effects on the flaps' viability. These effects were significantly established, however, after 8 weeks of diabetes. To obtain definitive results, at least 8 weeks of diabetic duration are preferred for similar studies.

Neuromuscular and neuromusculocutaneous flaps in the rat.

Since the introduction of flaps based on the vascular structures of the cutaneous nerves, these have gained increasing popularity in reconstructive surgery. The purpose of this study is to describe a new concept in which the flap is supplied solely by the intrinsic vasculature of a motor nerve. A total of 94 Wistar rats weighing 200-250 g were used in this experiment, which was divided into three sections. In section I, the neural anatomy of the posterior thigh region was investigated. In section II, the flap study using experimental and control groups, was performed. In the experimental group neuromuscular and neuromusculocutaneous flaps were created. The biceps femoris muscle was harvested based solely on its motor nerve as a neuromuscular flap, and together with its overlying skin it was similarly raised as a neuromusculocutaneous flap. In the control group, conventional muscle and musculocutaneous flaps were harvested based on the caudal femoral-popliteal artery vascular axis, and a graft subgroup was created ligating both the constant vascular structure and the motor nerve. In section III, with the intention of augmenting the survival areas of neuromuscular and neuroumusculocutaneous flaps, a surgical delay procedure was applied. On postoperative day 7, the viability of all flaps was evaluated using direct observation, microangiography, and tetrazolium blue stain techniques. The results of the anatomic studies demonstrated a consistent motor nerve arising from the sciatic nerve to the biceps femoris muscle with evident perineural vasculature. Average muscle viability levels of neuromuscular, neuromusculocutaneous, delayed neuromuscular, delayed neuromusculocutaneous, conventional muscle and musculocutaneous flaps were 20.6 +/-7.58, 22.4 +/- 4.21, 86.4 +/- 6.14, 85 +/- 4.21, 89.6 +/- 4.48, and 88.0 +/- 5.51%, respectively. Survival levels of the skin paddles of the neuromusculocutaneous, delayed neuromusculocutaneous, and conventional musculocutaneous flaps were calculated as 13 +/- 17.51, 67 +/- 30.29, and 97+/-4.21%, respectively. In the graft subgroup the viability of muscle and skin paddle was almost nil. In conclusion, our new flap model in a favored laboratory animal is of benefit to researchers in providing a means for future various types of investigations into this new concept. The technique might be considered in further experimental research studies and appropriate clinical situations.

Unique superiority of microsurgical repair technique with its functional and aesthetic outcomes in ring avulsion injuries.

Although ring avulsion injuries are not common, when they do occur their management is still a challenging problem in reconstructive surgery. In this report, we present our microsurgical experiences with Kay's class III and IV ring avulsion injuries. A total of six patients with ring avulsion injuries were operated on between 2000 and 2004. Three patients were in class III with inadequacy of both arterial and venous circulation, and the remaining three were in class IV. The study consisted of four male and two female patients whose ages ranged from 23 to 43 (mean age 32). Average ischaemic time was 2.2 h (range 1-4 h). The ring finger was involved in all cases and microsurgical repair was performed using axillary block anaesthesia. The bone was detached at the level of the distal interphalangeal joint and soft tissues at the proximal phalanx level with the preserved proximal interphalangeal joint and flexor digitorum superficialis tendon in all cases. Because the zone of injury is more extensive, we debrided the avulsed digital artery over a long distance, and used long interpositional vein grafts radically in all patients. Venous drainage was accomplished by performing at least two vein anastomoses using vein grafts when necessary. Both digital nerves were repaired primarily after debridement. Results indicated that microsurgical repair had a success rate of 100%. The authors conclude that microsurgical reconstruction of ring avulsion injuries with intact proximal interphalangeal joint and flexor digitorum superficialis tendon yields superior results, both functionally and aesthetically, even in complete amputation.

Is it possible to increase the survival of the transverse rectus abdominis musculocutaneous flap following previous abdominoplasty using a delay procedure? An experimental study in the rat.

BACKGROUND: Although, because of the disruption of perforators, abdominoplasty has been suggested as a major contraindication for patients undergoing autologous breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap, many researchers encourage the search for a means of improving the survival of the skin paddle of the flap in patients who have undergone previous abdominoplasty. In this study, the effect of the surgical delay phenomenon on the survival of the TRAM flap following abdominoplasty was investigated. METHODS: Thirty adult Wistar rats were used: the control group (n = 6), the short-term group (n = 12), and the long-term group (n = 12). In the control group, a standard superior pedicled TRAM flap was harvested with no abdominoplasty procedure, and the flap was replaced in situ. In all other animals, an abdominoplasty procedure was performed initially. The short-term and long-term groups were divided into two subgroups: the abdominoplasty plus TRAM-only subgroup (n = 6), and the abdominoplasty plus delay plus TRAM subgroup (n = 6). In the short-term group, the experiment was performed 1 month after abdominoplasty, whereas the same surgical procedures were applied 6 months after abdominoplasty in the long-term group. RESULTS: The short-term abdominoplasty plus TRAM subgroup, the long-term abdominoplasty plus TRAM subgroup, the short-term abdominoplasty plus delay plus TRAM subgroup, the long-term abdominoplasty plus delay plus TRAM subgroup, and the conventional superior pedicled TRAM flap group showed 2.33 +/- 3.01 percent, 13.33 +/- 8.76 percent, 24.17 +/- 13.57 percent, 60 +/- 8.94 percent, and 70.83 +/- 9.70 percent survival rates for the skin paddle, respectively. CONCLUSION: The data demonstrate that surgical delay after long-term abdominoplasty can enhance the survival rate of the skin paddle of the TRAM flap.

Rationale for reconstruction of large scalp defects using the anterolateral thigh flap: structural and aesthetic outcomes.

The advent of free tissue transfer has provided multiple options that allow preservation and maintain both the structural and aesthetic status of the scalp. Since the first report of the anterolateral thigh flap in 1984, it has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Eleven free anterolateral thigh flaps were used to reconstruct soft-tissue defects of different regions of the scalp. Two of these flaps were used for the occipital region, six for temporal regions, two for the frontoparietal midline region, and the remaining flap for a defect of the forehead. The study consisted of 10 males and one female whose ages ranged from 18 to 82 years (mean age: 52.5 years). Six patients had primary or recurrent cancer, four had acute or subacute wounds resulting from trauma or craniotomy, and one had high-tension electrical burn injury. The size of the flaps ranged from 14 to 27 cm in length and from 6 to 18 cm in width. The overall flap success rate was 100%. In two cases, primary thinning of the flap was performed to reconstruct a tissue defect of the temporal region in one patient and a forehead defect in the other. In two patients, the fascial layer of the flap was used as a source for a vascularized fascial flap to cover defects of the dura mater. No secondary corrections, including debulking procedures or scar revision, were necessary. No infections or hematomas were observed. Six cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed directly. No donor-site morbidity was observed. The authors conclude that with its evident structural and cosmetic advantages, the anterolateral thigh flap can be considered an excellent flap option for most scalp defects.

Effect of systemic creatine monohydrate supplementation on denervated muscle during reinnervation: experimental study in the rat.

The purpose of this experimental study was to evaluate possible upgrading effects of systemic creatine monohydrate administration on the reinnervation of denervated muscle. At the same time, the protective effect of the agent on denervated muscle until ultimate reinnervation after nerve repair was quantified. The functional outcome of muscle reinnervation after creatine monohydrate application was compared with a control group. Forty adult Wistar rats weighing 180 to 220 g were used. The right sciatic nerve was dissected, exposed, and cut at the level of the midthigh in all rats. The experimental design consisted of two groups: experimental (animals were fed creatine monohydrate) and control (gavage feeding was provided by saline). Both groups were divided into two subgroups: subgroups A and B for the experimental group, and subgroups C and D for the control group. In subgroups A and C, the nerves were repaired with four 10-0 epineurial stitches. In subgroups B and D, both the proximal and distal ends of the nerves were ligated and no neural anastomosis was performed. In the experimental groups (subgroups A and B), the rats were fed by daily supplementation of oral creatine monohydrate, 300 mg/kg body weight. In the controls (subgroups C and D), oral supplementation was provided by saline. Functional recovery was evaluated using walking track analysis, pinching test, and limb circumference and toe contracture measurements at the end of 6 months, after which the rats were sacrificed and nerve specimens from both ends of the repair sites and the whole gastrocnemius muscle were obtained to document the results of the histomorphometric and histochemical studies, including light microscopic examinations and muscle weight measurements. The mean functional recovery values in subgroups A, B, C, and D were 91 percent, 80 percent, 87 percent, and 59 percent, respectively. Functional recovery improved significantly in the experimental groups (in both the surgically repaired and unrepaired subgroups), compared with the control groups (p<0.05). The pinching test revealed a statistically significant difference in nerve conduction between the experimental and control groups (p<0.05). The limb circumference ratio of the surgically treated side to the untouched side in subgroups A, B, C, and D were noted as 0.95, 0.89, 0.91, and 0.87, respectively, and the difference between the experimental and the control groups was statistically significant (p<0.05). The differences between subgroups A and B, C and D, A and C, and B and D were also significant. The surgically repaired and creatine-supplemented subgroups demonstrated the best results in toe contracture index. The muscle weight measurement results were concordant with the results of the limb circumference ratio. In both surgically repaired subgroups (subgroups A and C), there were qualitatively significant amounts of myelinated fibers in the nerve distal to the anastomotic site; there were no myelinated fibers in the distal stumps of subgroups B and D. Histochemical analyses of the contents of the muscle fiber types also revealed no significant difference. Overall, the results showed the useful effect of oral creatine supplementation on both surgically repaired and unrepaired nerve injuries. The best results were obtained from surgically repaired nerve injuries and also from the systemic creatine-supplemented subgroups. This study confirms that systemic administration of creatine monohydrate has a protective and upgrading effect on the functional properties of denervated muscle, especially in surgically reinnervated subjects.

Open guide suture technique for safe microvascular anastomosis.

Despite the evident advances in microsurgery, anastomosis of small vessels or anastomosis of vessels having size discrepancy, remains one of the most precise and technically demanding issues in replantation surgery and free tissue transfer procedure. The patency of the vascular anastomosis is critical and essential for a successful outcome. In this study, a microvascular anastomosing technique called open guide suture technique is introduced. The technique starts with a conventional whole-layer stitch and continues under the control of a guided suture that is inserted but not completed to a knot 180 degrees distant from the initial suture. Recently, we used this technique in 30 free flap transfers and 4 replantation procedures. A total of 103 anastomoses were performed. Only 1 flap, which had both arterial and venous problems, and 1 finger replantation case that had arterial problems required revision. Both the revised cases were salvaged, giving a revision rate of 2.91% for the total number of anastomoses (3 of 103), and a 100% success rate for final flap and replanted part survival. In conclusion, this technique provides a safe anastomosis performed under completely clear visualization at each step with well-arranged knot intervals.

Simultaneous bilateral microvascular tissue transfer for soft-tissue defects of the lower extremities in pyoderma gangrenosum.

Pyoderma gangrenosum is a necrotizing skin disease of unknown etiology. The lesions are painful and occur mostly on the lower extremities, either single or multiple, but can appear in any region of the body. The authors report a case of pyoderma gangrenosum involving bilateral skin lesions over the anterior surface of the legs in a 13-year-old male patient. The lesions presented with ulcerative colitis, which is one of the most commonly associated diseases of pyoderma gangrenosum. After examination, systemic immunosuppressive treatment was administered and the progression of the disease was controlled. The lesions were treated with the simultaneous application of two free anterolateral thigh fasciocutaneous flaps after radical debridement. The procedure was successfully performed and no recurrence was observed. Although microvascular free tissue transfer cannot be performed in a standard fashion in pyoderma gangrenosum cases because of the risk of pathergy response, it should be considered as a surgical option in selected cases, otherwise difficult to manage, with the simultaneous application of appropriate systemic medical treatment.

Experiences with microsurgical tissue transfers in elderly patients.

The combination of advances in microsurgery and the improvement of anesthetic management with increased understanding of the physiology of preoperative and postoperative care has significantly raised the upper age limit for free-flap transfer in elderly patients. Despite pessimistic opinions regarding elderly patients who have poor recovery potential and decreased physiological reserves, the unique feature of free-tissue transfer is that it allows the transfer of well-vascularized tissue to defects in a single-stage procedure, and leads to improved quality of life. In this report, a retrospective analysis of 55 patients aged 50 and older who underwent microsurgical tissue transfer is presented. Hospital and our own records were used to review various parameters. The preoperative medical status of each patient was assessed using the American Society of Anesthesiologists (ASA) Classification of Physical Status. Each patient's preoperative medical records, age, sex, transferred tissue type, and length of operation were outlined. Postoperative recorded parameters were the fate of flaps and the short-term postoperative outcome, including surgical complications, medical morbidity, and death within 30 days of surgery. Fifty-eight microvascular tissue transfers were performed in 55 consecutive patients. The study comprised 38 male and 17 female patients, with a mean age of 64.8 years. ASA classification status was class 1 for 15 patients, class 2 for 26 patients, and class 3 for 14 patients. Twenty-five flaps were used for lower extremity reconstruction, 32 flaps were used for head and neck reconstruction, and 1 was used for breast reconstruction. The average operative time was 5.7 h, ranging between 2-13 h. There were 14 major medical complications, resulting in an overall medical complication rate of 25%. There were 3 deaths within 30 days postoperatively. Thus, the overall surgical mortality rate was 5.4%. The longer operation times were associated with the development of postoperative total medical and surgical complications (P = 0.008). While the relationship between ASA class and medical complications was significant (P = 0.0007), no significant relation was determined between ASA class and surgical complications (P = 0.66). It was revealed that the greater the age group, the greater the occurrence of postoperative medical complications (P = 0.0001). The relationship between postoperative surgical complications and age groups was not significant (P = 0.07). It was also demonstrated that the advanced age of patients was associated with a higher ASA class (P = 0.0017). Eleven flaps required reoperation for vascular compromise. While 10 of these were salvaged with vascular anastomosis revisions, one flap was lost. Thus the overall flap success rate was 98.3%. In conclusion, if a patient's medical problems do not constitute a handicap, age itself should not be considered a barrier to free-flap transfer. It is important to be familiar with preoperative medical problems and possible postoperative medical complications in order to achieve a successful outcome. Contrary to what is generally suggested, surgical complications do not constitute a special consideration in older patients.

A rare and serious complication of the radial forearm flap donor site: osteomyelitis of the radius.

Although the radial forearm flap has become a workhorse for the reconstructive surgeon, it has some known disadvantages, especially relating to donor area complications. The authors present a serious but rare complication of the radial forearm donor site. Osteomyelitis of the radius at the flap donor site was observed in a 48-year-old man 5 weeks after flap surgery. Although the flap was raised fasciocutaneously without a bony portion, infection of the radius was determined. The infection was successfully treated with surgical debridement and simultaneous administration of a proper antibiotic regimen. One should keep in mind that osteomyelitis of the radius may be encountered as one of the serious donor site complications of the radial forearm flap that may have detrimental effects on hand functions.

The penile flap in the rat: description and autotransplantation.

Considering both its unique structural and functional properties, the reconstruction of the penis is still a challenging problem in reconstructive surgery. Reconstruction may be required in many situations, including traumas, congenital abnormalities, and female-to-male transsexual surgery. Currently, the only natural reconstructive method for the penis is its microvascular reattachment in amputation cases. In all other situations, and in nonreplantable amputations, there is no alternative but to reconstruct the penis using autologous tissues to create the most similar substitute, hoping for a possible allogeneic transplantation in the future. There are many unresolved issues and unanswered questions related to functional recovery after replantation of the penis. In this study, to overcome these drawbacks and to guide and show the feasibility of allogeneic transplantation of the penis in humans in the future, we describe a penile composite tissue flap based on the internal pudendal artery and its autotransplantation in an economical animal species. Fifty adult male Sprague-Dawley rats weighing 400 to 500 g were used. In 20 rats, the vascular anatomy of the male perineal region was determined by anatomic dissections. Based on this anatomic study, the penile composite flap was created based on the internal pudendal vessels. In 10 rats, the penile flap was raised as an island flap based on its vascular pedicle and replaced in situ. In 10 rats, distant flap transfer was accomplished to determine the feasibility of the flap being transferred as a free flap and to demonstrate the viability of the flap components in a heterotopic region. For this purpose, the flap was transferred to the groin region performing anastomoses between internal pudendal vessels and superficial epigastric vessels. In the control group (n=10), while the same surgical procedure was performed, the flap was transferred to the groin region but no anastomosis was performed. The procedure required approximately 3 to 4 hours of operating time in the free flap group. Five of the animals died in the early postoperative days, while all others survived. Direct observation and microangiography were used to assess the viability of the flaps. On the basis of direct observation on the seventh postoperative day, all the pedicled flaps survived completely. In the free-flap group, all but 1 of the vascularized flaps showed complete survival, whereas all the nonvascularized flaps completely necrosed. The authors conclude that the penile flap of the rat offers the following advantages: (1) the composite tissue flap is harvested from a small animal species, (2) the flap is an exact representation of the clinical original penile composition, (3) it can be transferred as a free flap without the need for an isogeneic animal, (4) the vascular pedicle is consistent and allows for microvascular anastomoses. The flap will provide a means for future physiological studies, especially for replantation cases. The feasible autotransplantation of the penile flap with successful results will also guide researchers towards the future allogeneic transfer of the penis in humans.

Flow-through, functioning, free musculocutaneous flap transfer for restoration of a mangled extremity.

Reconstructing a mangled extremity requires careful, complete examination of the functional and structural status of the injured part. Although the vascular status of the injured extremity is a priority, simultaneous reconstruction of skeletal, vascular, and neuromuscular structures should be considered in a combined approach. The purpose of this study was to describe a one-stage reconstruction of both soft-tissue coverage and revascularization for a lower extremity, along with functional restoration of an anterior lower leg. For this purpose, the functioning transfer of a free latissimus dorsi musculocutaneous flap as a flow-through type was performed. The results demonstrate that the technique is extremely useful in limb-salvage procedures from both functional and structural viewpoints.

Reliability of free-flap coverage in diabetic foot ulcers.

As microsurgery advances, microsurgical free-tissue transfers have become the reconstructive method of choice over staged or primary amputation, and enabling independent ambulation in difficult lower-extremity wounds. In this report, we present our experiences with free-tissue transfer for the reconstruction of soft-tissue defects in 13 diabetic foot ulcers. Following radical debridement, soft-tissue reconstruction was achieved in the following ways: anterolateral thigh fasciocutaneous flap in 5 patients, radial forearm fasciocutaneous flap in 3 patients, lateral arm fasciocutaneous flap in 1 patient, gracilis musculocutaneous flap in 1 patient, tensor fascia latae flap in 1 patient, deep inferior epigastric perforator flap in 1 patient, and a parascapular flap in the remaining patient. In 8 cases, diabetic wounds were in the foot, while wounds were at the level of the lower leg in the remaining patients. In all patients, vascular patency was confirmed by the Doppler technique. In suspicious cases, arteriography was then performed. While all flaps survived well in the postoperative period, one patient died from cardiopulmonary problems on postoperative day 16 in an intensive care unit. Amputation was necessary in the early postoperative period because of healing problems. In the remaining 10 cases, all flaps survived intact. In one case, arterial revision was performed successfully. The ultimate limb salvage rate was 83% for the 12 patients. Independent ambulation was achieved in these cases. During the follow-up period of 8 months to 2 years, no ulcer recurrence was noted, and no revascularization or vascular bypass surgery was needed before or after the free-tissue transfers. The authors conclude that free-tissue transfer for diabetic foot ulcers is a reliable procedure, despite pessimistic opinions regarding the flap survival and low limb salvage rates. It should be considered a useful reconstructive option for serious defects in well-selected cases.

The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities.

The goal of soft tissue reconstruction in the lower extremities is to provide a functional and cosmetically acceptable limb. The anterolateral thigh flap has become one of the most popular options for soft tissue defect reconstruction recently because of the large amount of skin available and the reliable and versatile nature of this material. The purpose of this article is to present our experiences with the free anterolateral thigh flap for the reconstruction of soft tissue defects of the lower extremity. From April 2002 to October 2003, 31 consecutive free anterolateral thigh flaps were used. There were 24 male and 7 female patients, and their ages were between 3 and 78 years. The size of the flaps ranged from 11 to 34 cm long and 6 to 16 cm wide. In 9 patients, the flaps were harvested in a flow-through manner to both reconstruct soft tissue defects and protect and maintain the vascular status of the lower extremities. In these patients, the pedicle was interposed between vascular gaps, either present or created, in the extremity. The patency of distal anastomosis with the course of the distal vessel was confirmed by using conventional Doppler flow monitoring in flow-through flaps. In 4 cases, thinning of the flap was performed. In 3 patients, flaps were used in a neurosensorial fashion. Four flaps required reoperation due to vascular compromises. While 3 of these were salvaged, 1 flap was lost due to recipient arterial problems. Sixteen cases underwent split-thickness skin grafting of the donor site. No infection or hematomas were observed. We conclude that the anterolateral thigh flap is an ideal and versatile material, especially for lower extremity reconstructions, with its functional and cosmetic advantages, and it can be considered a suitable alternative to the most commonly used conventional soft tissue flaps.

New experimental flap model in the rat: free flow-through epigastric flap.

This study describes a free flow-through flap model in the rat for use in the evaluation of the physiologic and hemodynamic characteristics of this type of flap in clinical practice. The rat is a preferred animal model because it is inexpensive, readily available, and reliable. There is no free flow-through flap model available for laboratory animals, although this model gained popularity in clinical use recently. Twenty Wistar rats weighing 200-250 g were used in our experiment. In 5 rats, the vascular anatomy of the groin and proximal thigh region was determined by anatomic dissection. The experimental design consisted of two groups. In the experimental group (N = 5), a flow-through epigastric skin flap was harvested based on the femoral artery, preparing both its proximal and distal stumps. The flap was transferred to the contralateral groin, and end-to-end vascular anastomosis was performed between a proximal and distal stump of the femoral arteries of the flap and recipient site. The proximal stump of the femoral vein of the flap was anastomosed to the femoral vein of the recipient site. The control group was divided into two subgroups. In all control group rats (N = 10), the flap was harvested in the same manner, and transferred to the contralateral groin, but standard free-flap procedure with one artery and one vein anastomosis was performed in 5 rats (conventional free-flap subgroup), and anastomosis was not performed between the flap and the recipient site in the remaining 5 rats (graft subgroup). Survival of the flap was evaluated on postoperative day 7 by direct observation, and microangiography was performed to delineate the vascularity of the flow-through flap. The results showed that all flaps survived in the experimental group and the conventional free-flap subgroup of the control group, whereas in the graft subgroup, all flaps underwent total necrosis. The authors conclude that the flow-through epigastric flap for the rat is a simple and reliable model for future physiologic and pharmacologic studies.

Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap.

This article reports the simultaneous reconstruction of maxillary and mandibular defects caused by a close-range gunshot blast to the face with one fibular osteocutaneous flap combined with an anteroateral fasciocutaneous flap. A fibular osteocutaneous flap was used for both mandibular and maxillary defects, using multiple osteotomies and discarding a central bony segment and an oral floor defect. An anterolateral thigh flap was used to cover a three-dimensional defect of both the intraoral mucosal region, as well as external skin and soft tissue defects, including some on the upper and lower lips. The results demonstrated that the method was a good choice in the reconstruction of large composite facial defects, both aesthetically and functionally.

Gluteal perforator flaps for coverage of pressure sores at various locations.

Flap coverage is essential for successful treatment of pressure sores, and musculocutaneous flaps have been preferred universally. Development of perforator flaps supplied by musculocutaneous perforators has allowed reconstructive surgeons to harvest flaps without including muscles. Perforator flaps have enhanced the possibility of donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity is also reduced. Between November of 1998 and June of 2002, the authors used 35 gluteal perforator flaps in 32 consecutive patients for coverage of pressure sores located at sacral (n = 22), ischial (n = 7), and trochanteric (n = 6) regions. The mean age of the patients was 53.1 years (range, 5 to 87 years), and there were 16 male and 16 female patients. All flaps in this series were supplied by musculocutaneous arteries arising from gluteal muscles. Patients were followed up for a mean period of 13.6 months. Wound dehiscence was observed in two patients and treated by secondary closure. Three patients died during the follow-up period. All flaps survived except one that had undergone total necrosis, and only one recurrence was noted during the follow-up period. Gluteal perforator flaps are safe and reliable options for coverage of pressure sores located at different locations. Freedom in flap design and low donor-site morbidity make gluteal perforator flaps an excellent choice for pressure sore coverage.