动脉端侧吻合在游离组织瓣移植术的应用

目的：探讨动脉端侧吻合在游离组织瓣移植术的应用效果。方法：在46例47个游离组织瓣移植术中，将游离组织瓣动脉蒂断端修剪成90度截面13个，45度斜面26个，鱼口状8个。应用两定点间断、两定点连续和四定点连续缝合法分别吻合28、10和9个动脉吻合口。结果：2例术中发生吻合口脱落微血栓堵塞皮瓣惟一皮支，经逆行推出血栓解除危象。三种端口之间及三种端侧吻合方法之间，栓塞发生率的差异无显著性（P＞0．05）。46个组织瓣成活，1例皮瓣因静脉栓塞部分坏死。结论：应用动脉端侧吻合技术移植组织瓣安全可靠。     

Peripheral arteriovenous anastomosis: an alternative technique in a free flap transfer.

Prevention of thrombosis in the inflow and outflow vessels of a free flap is a problem of current interest. The method of creating a peripheral arteriovenous anastomosis within a free flap was validated in an experimental study and substantiated in a clinical case. No thrombotic complications were observed in 16 transfers of saphenous fasciocutaneous flaps in a dog model, as well as in an elderly patient with free radial forearm flap transfer to an irradiated foot. Scanning electron microscopy of the venous anastomosis proximal to the arteriovenous fistula revealed the difference of pathologic changes as early as 4 hr following surgery. It is the conclusion of the authors, that performing a distal arteriovenous fistula in a free flap, is an effective procedure for prevention of early occlusion in a proximally anastomosed artery and vein.     

Reestablished circulation after free radial forearm flap transfer

New circulation in the free flap reestablished at the recipient site is the key to successful microvascular reconstructive surgery. This study is the first evaluation of long-term circulatory changes in nine free radial forearm flap transfers. Postoperatively, color Doppler studies revealed that the flow volume through the arterial pedicle increased rapidly during the first 3 days, gradually increased until day 14 (exceeding flow volume through the facial artery of the unoperated contralateral side), then decreased slightly until the sixth month. The pulsatility index, representing vascular resistance downstream, decreased successively. Ohm's law explains that this flow increase is caused by reduced vascular resistance downstream, attributed to changes in the vascularity of the transferred flap and in the recipient bed. The authors believe the circulatory changes are determinants of the clinical properties of the flap. This study addresses the importance of clarifying the events that transpire at the macroscopic circulatory level in the transferred free flap.     

Successful retrograde arterial inflow through a muscular branch in a free anterolateral thigh chimeric flap transfer

In this report, we present a case in which a free anterolateral thigh (ALT) flap was transferred for head and neck reconstruction after oropharyngeal cancer ablation, and a retrograde arterial inflow was used to salvage the flap when the main arterial pedicle showed usual repeated spasms. The flap was raised as a chimera flap comprising a fasciocutaneous flap and a vastus lateralis muscle flap. After reperfusion, the pedicle artery exhibited spasms repeatedly and vascular flow was unstable. Therefore, we performed arterial supercharge. In the distal portion of the muscle flap, a small arterial branch was dissected as a reverse-flow arterial pedicle. The recipient artery was also a retrograde limb of the superior thyroid artery. The flap survived; however, postoperative ultrasonographic echo evaluation revealed that the spastic descending branch of the lateral circumflex femoral artery was obstructed and that the reverse-flow muscular perforator alone nourished the whole flap. In free ALT flap transfer, a small perforator level artery was able to nourish a flap, even in a retrograde manner. Moreover, when the vasculature of the free flap is unstable, retrograde arterial supply to a small perforator can be an option to save the flap transfer.     

Coverage of big toe defects after wrap-around flap transfer with a free soleus perforator flap

In thumb reconstruction, a wrap-around flap transfer from the big toe gives excellent results aesthetically and functionally; however, there may be some problems at the donor site, such as delayed wound healing and skin ulceration. In 10 patients, a free soleus perforator flap was used for immediate coverage of defects of the big toe with wrap-around flap procedures. Eight flaps survived completely, and the time required for wound healing was less than 1 month. Two flaps developed partial necrosis and required additional skin grafts. The average follow-up period was 46 months. There were no patients requiring defatting of the flaps. There were no patient complaints, such as postoperative skin erosion or ulceration. All patients were satisfied with the outcome. A free soleus perforator flap is an available method for covering defects of the big toe after wrap-around flap transfer.     

游离膝上外皮瓣移植覆盖(足母)甲皮瓣切除后的创面

目的探讨拇甲皮瓣带足背皮瓣切取后，供区创面应用游离膝上外皮瓣移植覆盖的手术效果。方法2003年4月-20Q5年12月，我院对8例拇指大面积套状撕脱伤的患者，在进行游离拇甲皮瓣带足背皮瓣移植再造拇指的同时，再应用游离膝上外皮瓣移植覆盖足背供区的创面。结果术后再造拇指全部存活，覆盖足部供区的皮瓣全部存活。术后随访时间为6-18个月，再造拇指外形和功能良好，指腹两点分辨觉为6．8mm。供区拇趾保留全部长度，并有跖屈和背伸功能，但皮瓣较臃肿，其中4例行皮瓣修整术。供足及膝部行走、跑步均无疼痛。6例足功能分析显示，动态、静态足底应力分布与对侧十分接近，步态正常。结论利用游离膝上外皮瓣移植覆盖足背供区创面，能够很好地保留供足的功能。该方法尤其适用于拇指皮肤缺损较多，采用蹰甲皮瓣移植再造时需扩大切取足背皮瓣供区创面的患者。     

Poor surgical technique produces more emboli after arterial anastomosis of an island flap

To answer the question "Are more emboli produced after a small artery anastomosis has been performed poorly?", we used the isolated rat cremaster muscle. The number of emboli seen downstream from a small artery anastomosis were counted after using two anastomotic techniques. Direct observations using intravital microscopy of emboli passing through the principal arteriole of the cremaster revealed that surgical technique using a large needle (poor execution) caused a significantly higher number of emboli to be produced at the site of small artery anastomosis than was noted after a fine needle technique.     

Additional venous anastomosis in free profunda artery perforator flap transfer using the posterior accessory saphenous vein

BackgroundThe profunda artery perforator (PAP) flap has recently been widely used for head and neck as well as breast reconstruction. Although this flap has various advantages, its vascular pedicle is relatively smaller and shorter than that of other workhorse flaps such as the anterolateral thigh flap. The posterior accessory saphenous vein (pASV) is a branch of the great saphenous vein, which runs in the posteromedial aspect of the thigh and can be included in the PAP flap. Here, we present the anatomical characteristics of the pASV and feasibility of its use in PAP flap transfers.Patients and methodsAn anatomical study of the pASV was conducted in nine lower extremities of five patients using ultrasonography. Several landmarks such as point A (the point where the pASV crosses the posterior border of the adductor longus muscle), point B (the point where the pASV merges with the great saphenous vein) and the inguinal crease, were marked. Distribution of the pASV was plotted, and several distances were measured. On the basis of the anatomical study, nine free PAP flap transfers were performed.ResultsIn the anatomical study, the mean diameter of the pASV was 3.4 and 4.9 mm at points A and B, respectively. The mean available length of the pASV was 9.4 cm. In clinical cases, all flaps completely survived. No flap-related complication was observed. The pASV was included in the PAP flap in eight cases. The mean length of the harvested pASV was 8.6 cm, and the mean diameter was 3.3 mm. Indocyanine green angiography showed effective drainage using the pASV alone.ConclusionsThe use of the pASV can be an effective option, particularly for head and neck reconstruction, and its application in various types of reconstructive surgery can be widened.     

Neovascularized free cutaneous cartilage flap transfer with microsurgical anastomosis: an experimental model in the rabbit

In preparation for this study in rabbits, preliminary trials were conducted in rats rather than rabbits because they are more economical and are believed to develop neovascularization more rapidly. Using modifications of techniques described by Duarte, the superficial inferior epigastric vessels were planted between the folded leaves of full-thickness grafts of rat ear cartilage. These preparations showed signs of neovascularization and new cartilage formation adjacent to the pedicle when harvested from the groin three weeks later. Encouraged by the success of this preliminary investigation in the rat, we moved on to the rabbit ear model because it provides a larger area of cartilage to work with. The central vessels of the pinna were dissected out and then placed in a subcutaneous (extraperichondrial) pocket of a random-pattern, distally based, full-thickness ear flap. Three weeks later, the flaps, now neovascularized by their neopedicles of implanted central vessels, were harvested and transferred as free chondrocutaneous free flaps to the donor site of the same preparation created on the contralateral pinna. Modifications of these techniques may be useful where chondral or chondrocutaneous flaps are needed, such as for pinna, nasal alar, or nasal septal reconstructions.     

Clinical experiences in free flap transfer.

In this series of 62 free flap transfers, 48 (80%) have been successful. There have been a significant number of vascular complications, 39% of which the majority were arterial thrombosis. Fifty per cent of those which thrombosed were salvaged on exploration and revision of the vessels. The frequency of complications has diminished with experience but they remain significantly high. Free flap surgery demands considerable expertise in both donor site dissection and microvascular technique. Two surgeons with microvascular experience, each with adequate assistance, are preferred and ready availability of operating room is essential. Close postoperative observation and readiness to revise anastomoses are equally important. About 50% of failed free flap sites have been repaired by application of split skin grafts.     

Brachial plexus injury after transfer of free Iatissimus dorsi musculocutaneous flap

Free latissimus dorsi muscle transfer is widely used for functional reconstruction of flexion of elbow and fingers after brachial plexus injury at later stage, as well as for soft tissue coverage because of its large size and long and reliable pedicle with adequate vessel diameter.