The lateral arm/proximal forearm flap.

The classic lateral arm flap is constrained by limited skin availability, thick subcutaneous tissue, a short vascular pedicle, and inconsistent sensory innervation. We report modifications of the lateral arm flap which increase its skin availability, provide thin sensate skin, and extend the overall reach of the flap. The vascular anatomy of the lateral arm/proximal forearm flap was studied in 10 fresh anatomic specimens.

Tissue generation with growth factors.

Background: An in vivo experimental model was introduced to determine whether the mitogenic effect of recombinant platelet-derived growth factor (rPDGF) could be used to generate potentially useful tissue.

Methods: In Lewis rats, the extended femoral arteriovenous bundle was placed within silicone chambers containing collagen disks. The disks could deliver their content of rPDGF-BB (125 to 131 micrograms/disk) either as a rapid pulse or as a slow release.

Closure of complex abdominal wall defects with bilateral rectus femoris flaps with fascial extensions.

Large full-thickness abdominal wall defects present a difficult reconstructive problem. Synthetic mesh has significant drawbacks and should be used only as a temporizing measure. Ideally abdominal wall defects should be resurfaced with well-vascularized autologous fascia and skin.

Reconstruction of a near total male urethral defect with a microvascular free flap.

We describe a new technique for reconstruction of a traumatic near total male urethral defect. With this procedure a microvascular free flap transfer of the radial forearm skin is used to create a 23 cm. neourethra extending from the urogenital diaphragm to the glans of the penis.

Prevention of thrombosis by topical application of tissue factor pathway inhibitor in a rabbit model of vascular trauma.

The extrinsic pathway of coagulation is initiated when tissue factor complexes with factor VII. A naturally occurring protein inhibitor of this complex, tissue factor pathway inhibitor (TFPI), has recently been isolated and the cDNA coding for this protein cloned. We used a rabbit ear artery model of crush/avulsion injury and microvascular repair to investigate the efficacy of TFPI as a topically applied antithrombotic agent.

Prefabricated microvascular shoulder free flap for forehead reconstruction.

In a case with a large forehead defect following tight scalp bandaging in childhood, a prefabricated microvascular shoulder free flap was used for reconstruction. A free forearm fascial flap, with the radial artery and the concomitant vein as pedicle, was harvested and inserted under a subcutaneous pocket opened in the left shoulder region which served as the future "prefabricated free flap". In addition, a tissue expander was placed in this pocket to provide the necessary tissue expansion to enable primary donor site closure.

Advances in total phalloplasty and urethroplasty with microvascular free flaps.

This article focuses on the lateral arm free flap as the option that comes closest to meeting the diverse aesthetic and functional goals of phalloplasty. The authors introduce a new technique for incorporating a prefabricated neourethra within the lateral arm to permit the coexistence of an erectile prosthesis alongside a fully vascularized urethra that extends to the distal tip. The unrecognized value of the radial forearm free flap for urethroplasty is also discussed and a case of reconstruction following urethral loss is presented.

Refinements in hand coverage with microvascular free flaps.

The specialized tissue requirements or dorsal and palmar skin are analyzed and options for full-thickness replacement outlined in detail. Thoughtful and accurate preoperative planning is the key to success. Dorsal coverage with a variety of pedicled and free fasciocutaneous flaps are quite satisfactory.

Avoiding free flap failure.

To obtain up-to-date statistics on free flap success rates, a survey of 644 consecutive free flaps performed by nine expert microsurgeons was conducted in 1991. Analysis of the failures shed light on the current problem areas. Because operative experience is the most important factor related to improved success rates, a questionnaire aimed at probing the experts for the lessons learned as their success rates improved was sent to 12 expert microsurgeons.

Free flap surgery. The second decade.

After 2 decades of increasing expertise, microvascular free tissue transfer has gradually evolved from being a procedure of last resort to become a first choice reconstructive procedure. Improved success rates, reduced operative time, and patient morbidity have widened the indications for the procedure. This has profoundly affected our reconstructive principles and, in many instances, reversed some well-established dogmas of wound care, cancer resectability, and salvage of multilated parts.

Principles of flap prefabrication.

Clinical flap prefabrication can be classified according to the basic technique of plastic surgery used for the prefabrication. There are currently three methods: (1) delay or expansion; (2) grafting; and (3) vascular induction by staged transfer. Illustrative cases are given to point out the advantages and indications for each method.

Salvage in a case of ring avulsion injury with an immediate second-toe wrap-around flap.

A nonreplantable complete degloving injury to the small finger of a young woman was treated with the immediate microsurgical transfer of a second-toe wrap-around flap. One year after the operation, the donor foot was free of symptoms, and the reconstructed finger had an excellent cosmetic appearance, a range of motion of 0/90 degrees at both the metacarpophalangeal and the proximal interphalangeal joints, and a two-point discrimination of 6 mm. In selected patients, when the degloved skin envelope cannot be revascularized and when the skeletal and tendinous units are still intact, an immediate second-toe wrap-around flap may be a good alternative to amputation.

Monitoring of free flaps with surface-temperature recordings: is it reliable?

Surface-temperature recording (STR) is one of the oldest and simplest methods of postoperative monitoring of free flaps. Its usefulness, however, remains poorly documented, and its problems, not well understood. To assess its value, we reviewed our series of 600 consecutive free flaps where surface-temperature recording was the main method of monitoring used and a detailed temperature record was kept.

Thigh adductor flap: an experimental model for free flap transfer in the rat.

A new model of rat muscle free flap transfer is presented. The flap is based on a long pedicle originating from the femoral vessels and continuing down to the distal saphenous margin at the ankle. The distal portion of the semitendinosus muscle is harvested along with the saphenous artery and great saphenous vein.

Bilateral lower limb salvage with free flaps in a patient with sickle cell ulcers.

A patient with long-standing bilateral circumferential lower extremity sickle cell ulcerations refractory to conservative management was successfully treated with bilateral free latissimus muscle transfers. This report confirms the value of free tissue transfer in the treatment of these difficult skin ulcerations. Exchange transfusions that brought the SS hemoglobin below 30% were crucial to the prevention of sickling in the microcirculation of the flap during its obligate period of ischemia.