Free flap neovascularization: Fact or fiction?

The dependence of free flaps on the original vascular anastomosis was investigated using color duplex . Although functional and morphological changes in flaps have been previously documented, showing the formation of new vessels across the flap inset, this was not observed in this study. Even after 1 year after surgery the free flaps were still dependent on the original anastomoses for their blood supply, with no other significant vessels obvious on duplex to supply the flap. This evidence as well other published reports suggest that at least the lower extremity and the chest wall do not develop collateral circulation to a free tissue transfer. Late postoperative division of the vascular pedicle either in the lower limb or the chest wall should be approached with the knowledge that neovascularization across the flap margins is the exception rather than the rule

Treatment of extensive bone and soft tissue defects of the lower limb by traction and free-flap transfer.

Twenty patients with extensive bone and soft tissue defects and posttraumatic osteomyelitis were treated between 1983 and 1995. In all cases an external fixator was used for bone fixation. Bone defects were managed with the Ilizarov intercalary bone transport. Two types of traction were used: the Ilizarov type and a 'new' Ljubljana type. The results of treatment were compared between the two types of traction. In all cases delayed bony union was observed. Osteomyelitis never reactivated. All patients were satisfied with treatment. They were all independent except for one amputee. The Ljubljana traction method was found to have the following advantages: no discrepancy in leg length, no orthopaedic support was needed, the aesthetic outcome was better, the traction time was reduced and there was less soft tissue damage during bone traction

Arterial T and Y grafts

Presented is the use of an autogenous arterial T graft for the salvage of a thrombosed arterial end-to-side anastomosis. The T-graft concept also offers the possibility of replacing a segment of artery in patients with arterial vessel wall defects, stenosis, obliteration, or disease during free latissimus dorsi or scapular flap transfer. The arterial T graft is harvested from the axilla and consists of segments of the subscapular, circumflex scapular, and thoracodorsal arteries. The large diameter of these vessels offers a good match with the arteries of the lower leg and forearm. The arterial Y graft consists of the same arteries and is used as an interpositional graft to revascularize two distal vessels from one proximal vessel

Sampling of internal mammary chain lymph nodes during breast reconstruction byfree flaps from the abdomen

The role of internal mammary chain lymph node removal in breast cancer is still not clarified. Although it has been proven that elective dissection of the internal mammary chain nodes does not improve survival, their selective treatment based on sentinel lymph node biopsy is under evaluation. There is another possibility to establish the status of internal mammary chain nodes--sampling of the nodes during the preparation of the site for microvascular anastomosis to the internal mammary artery and vein for free flap transfer. From August 2002 to December 2003, 54 free flaps were performed for breast reconstruction. In 11 cases, an internal mammary chain lymph node was harvested. A positive internal mammary chain node was found in only one case. In this case, the treatment policy was changed by adding irradiation to the internal mammary chain. The sampling of internal mammary chain nodes during preparation of the site for microvascular anastomosis to the internal mammary artery and vein should be a part of the reconstructive procedure after total mastectomy for invasive breast cancer because it could change the treatment plan

Free tissue transfer for reconstruction of traumatic limb injuries in children

Free tissue transfer was used for the reconstruction of soft tissue defects in 94 children. Of the 127 procedures performed, the latissimus dorsi, scapular skin, lateral arm skin, rectus abdominis, and gracilis were used with the greatest frequency. The microsurgical success rate was 96\%. Microsurgical failures were repeated, successfully, and in all cases the limbs were salvaged. Other than having to deal with decreased vessel size and avoiding continuous suture lines, there appears to be little difference in technique or outcome of free tissue transfer when compared to adults

The posterior interosseous arterial graft

The posterior interosseous artery is a suitable donor vessel for harvesting autogenous arterial grafts which are often necessary for thumb or finger revascularization or replantation. Grafts 8 to 10 cm long can be taken from the dorsal ulnar aspect of the forearm ranging in caliber from 1 to 1.5 mm. The arterial graft can be harvested together with the lateral branch of the posterior interosseous nerve, offering the possibility of vascularized nerve transfer. Removal of the posterior interosseous artery does not influence peripheral perfusion or leave functional deficits. During dissection, care must be taken not to harm motor branches of the posterior interosseous nerve. We report a patient in whom this technique was used successfully

Measurement of sudomotor fibre regeneration by sympathetic skin response after complete division of peripheral nerves in children

Sympathetic Skin Response (SSR) was measured in 14 paediatric patients (age range 3-15 years, mean 7.2 years) following repair of lacerated upper limb peripheral nerves (median, ulnar or both). All nerves had been completely divided and were repaired by primary epineural repair. Measurements of SSR were made at regular, 1-2 monthly, intervals during nerve regeneration in 6 patients. A further group of 7 patients had single SSR measurements at the end of nerve regeneration (21-63 months). A 4-year-old boy was also followed up from 10 to 21 months following replantation of a proximally amputated right upper limb. The method was first standardised in 16 healthy volunteers (age range 3-17 years, mean 9.4 years). Patients over 6 years of age were also clinically tested for return of sensation. The results show that the objective measurement of sudomotor nerve regeneration in children is possible with this method. They demonstrate its universal acceptance by children as young as 3 years old

Femoral head necrosis treated with vascularized iliac crest graft

We reviewed 24 hips with avascular necrosis of the femoral head in 24 patients treated with vascularized iliac bone grafts 12 years after operation. In 7 patients the necrosis was classified as Ficat Stage II and in 17 patients as Stage III. Eight patients showed poor results. In 6 hips with fair results, moderate progression of the necrosis was noted at 3 to 8 years postoperatively. In 5 hips showing good results, slow progression with incipient signs of arthrosis were noted 8 years after surgery. In the remaining 5 patients with excellent results, no evidence of progression was noted 9 to 14 years postoperatively. The method described is recommended for treatment in the Ficat Stage II and early Stage III, when necrosis does not yet involve the complete femoral head