The Vascular Basis of the Pronator Quadratus Muscle Flap and Its Use in Clinical Cases.

Background Pronator quadratus (PQ) is a deeply situated muscle in the forearm which may occasionally be utilized for soft-tissue reconstruction. The purpose of this anatomical and clinical study was to confirm vascular supply of PQ muscle (PQM) in order to optimize its transfer and confirm its utility in clinical situations. Methods In Part A of the anatomical study, fresh human cadavers ( n = 7) were prepared with an intra-arterial injection of lead oxide and gelatin solution, and PQM and neurovascular pedicle were dissected ( n = 14). In the anatomical study Part B, isolated limbs of embalmed human cadavers ( n = 12) were injected with India ink-gelatin mixture and PQ were dissected. Results PQ is a type II muscle flap, with one major pedicle, the anterior interosseous (AI) vessels and two minor pedicles from the radial and ulnar vessels. The mean dimensions of the muscle were 5.5 × 5.0 × 1.0 cm 3 , mean pedicle length was 9.6 cm, and the mean diameter of the artery and the vein was 2.3 mm and 2.8 mm, respectively. The dorsal cutaneous perforating branch (DPB) of the artery supplied the skin over the dorsal forearm and wrist. This branch also anastomosed with the 1, 2 intercompartmental supraretinacular artery (ICSRA). Conclusion This study confirms the potential utility and vascular basis of the PQM flap and its associated cutaneous paddle. In the clinical part, two patients with nonhealing wounds exposing the median nerve and flexor tendons in the distal forearm were treated using the PQM flap with good results.

A surgical review of the priority claims attributed to Abraham Groves (1847-1935).

BACKGROUND: The practice of surgery had changed little over millennia when Abraham Groves and William Osler attended medical school together in Toronto, Ontario. The invention of anesthesia sparked such rapid development that by the time of Groves' and Osler's deaths, surgical practice resembled the current model. Several priority claims have been attributed to Groves' life in surgery, including aseptic surgery (1874), suprapubic lithotomy (1878), appendectomy (1883), surgical gloves (1885) and cancer radiotherapy (1903). These claims arise from an autobiography written by Groves at the age of 87 years in 1934. METHODS: The purpose of this paper is to assess these priority claims from a modern surgical perspective. We did a systematic search of contemporary (1873-1934) and modern journals for articles by or about Groves. We searched relevant archives and museums. We reviewed the 1934 autobiography, notes held by descendants, reminiscences by contemporaries and collateral information. We assessed the information not only for priority but also for the development of organized surgical thought. RESULTS: Groves published frequently throughout his career; thus far we have located 36 papers, almost all of which were published in Canadian journals. He spoke regularly at regional meetings in Ontario. Many medical students apprenticed with him (including his brother, son and grandson), he established a hospital and he founded a school of nursing. His contemporaries published complimentary reminiscences, but no correspondence with his classmate, William Osler, is known. Groves' priority claims for aseptic surgery, suprapubic lithotomy and radiotherapy are supported by contemporary publications. Groves independently developed an organized surgical system that remains valid today. Priority claims for appendectomy and the use of surgical gloves are entirely consistent with that system. CONCLUSION: Although Groves' impact was reduced by his location and the limited circulation of the journals in which he wrote, he demonstrated a systematic understanding of modern surgery well ahead of his contemporaries.

Neurovascular territories of the external and internal oblique muscles.

The purpose of this study was to document the extent of the arteries supplying the external and internal oblique muscles and the connections among the vascular territories. Ten adult human cadavers underwent whole-body arterial perfusion (200 ml/kg) with a mixture of lead oxide, gelatin, and water, through the carotid artery. The external and internal oblique muscles were dissected and subjected to radiography. The vasculature of each muscle was analyzed by using the paper template technique. The areas of the vascular territories of the individual intercostal arteries within the external oblique muscle varied from 9 to 22 percent. The area of the vascular territory of the muscular branch of the deep circumflex iliac artery was 5 to 18 percent. The ascending branch of the deep circumflex iliac artery supplied a mean of 35.7 percent of the vascular territory of the internal oblique muscle. The lower six posterior intercostal arteries supplied a mean of 48.5 percent. The lateral branches of the deep inferior epigastric artery supplied a mean of 15.8 percent. This information provides the basis for the design of external and internal oblique muscle flaps for functional muscle transfer.

Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: anatomical basis and clinical applications.

The cutaneous perforators of the radial artery adjacent to the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve were investigated, and the vascular anatomical features of the reversed forearm island flap supplied by those accompanying perforators were documented. Ten fresh cadavers were systemically injected with lead oxide, gelatin, and water. Twenty forearms were then dissected, and an overall map of the cutaneous vasculature and source vessels was constructed. The accompanying arteries were observed to lie along the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve and to nourish the skin through cutaneous branches. Vascular communication among these cutaneous vessels was evaluated, to determine the cutaneous vascular territory of the radial forearm flap. This anatomical information facilitates flap design in the forearm region. Clinical experience regarding the usefulness of the reversed forearm island flap for hand reconstruction for a series of five patients is presented.

Vascular basis of intrinsic muscle flaps in the hand.

BACKGROUND: Intrinsic hand muscles can occasionally be used as pedicled flaps for wound coverage or functioning transfer in hand trauma. The purpose of this study was to define the vascular supply of the individual intrinsic muscles of the hand for potential use of these muscles as muscle flaps. METHODS: In part A, 10 fresh cadavers were injected using a lead oxide-gelatin injection technique. The intrinsic muscles were meticulously dissected, removed, and radiographed. The number, type, and diameter of the vascular pedicles of each muscle and their distribution within the muscle were analyzed. The area of the vascular territory supplied by each source vessel was calculated. In part B, 10 embalmed cadavers were injected with red latex and a similar dissection protocol was followed. RESULTS: The 18 hand muscles each received an average of 3 +/- 1 vascular pedicles. The average diameter was 0.8 +/- 0.2 mm; the length and width of the area supplied by each pedicle was 2.2 +/- 0.4 cm and 1.0 +/- 0.2 cm, respectively. The vascular territories of the majority of hand muscles were aligned longitudinally along their long axes. Nine intrinsic hand muscles have been identified that can potentially be used as a muscle flap or musculocutaneous or musculo-osseous flap. CONCLUSIONS: The size and course of the vascular pedicles to the hand muscles are variable. This anatomical study provides an improved understanding of the vascular supply of the intrinsic muscles of the hand and provides further information to assist in the design of intrinsic hand muscle transfer.

The posterior thigh perforator flap or profunda femoris artery perforator flap.

BACKGROUND: The thigh donor site has been used extensively for microsurgical tissue transfer; however, the posterior thigh has been neglected as a potential donor site. The perforators of the profunda femoris artery supply large cutaneous territories that could be useful for lower extremity coverage. The purpose of this article is to evaluate the anatomical basis of the posterior thigh perforator flap and to provide anatomical landmarks with which to facilitate flap dissection. METHODS: Six fresh cadavers underwent a whole-body, intraarterial injection of a lead oxide and gelatin preparation. The integument of the posterior thigh was dissected (n = 11), and perforators of the profunda femoris artery were identified. Their type (septocutaneous versus musculocutaneous), course, size, and location were documented by angiography and photography. Surface areas were measured with Scion Image Beta 4.02. Results are reported as mean +/- SD. RESULTS: The average number of profunda femoris cutaneous perforators in the posterior thigh was 5 +/- 2 (65 percent septocutaneous and 35 percent musculocutaneous), the average internal diameter was 0.8 +/- 0.3 mm, and the pedicle length was 29 +/- 14 mm from the deep fascia and 68 +/- 33 mm from the profunda femoris artery. The average profunda femoris cutaneous vascular territory was 229 +/- 72 cm, with a 46 +/- 13-cm perforator zone. Cutaneous perforators can be found on a line extending from the ischium to the lateral femoral condyle. CONCLUSIONS: The profunda femoris provides cutaneous perforators of large caliber supporting a substantial cutaneous territory. This flap will likely be clinically useful in lower extremity reconstruction as a free or pedicled flap.

Application of three-dimensional digitalized reconstruction of an anterolateral thigh flap and an arterial dorsalis pedis flap.

Developments in the field of digitalized technique and three-dimensional (3D) reconstruction methods allowed a precise description of anatomy structures. With the development of Visible Human Project (1989) and Virtual Chinese Human (VCH) techniques, we could get more precise anatomic images. Digitized visible models of these structures can be a useful tool in clinical training. Combining modern radiology and VCH techniques, we designed a method to establish digitized visible models of anterolateral thigh (ALT) flap and arteria dorsalis pedis (ADP) flap from adult fresh cadaver specimens perfused with lead oxide-gelatine mixture and VCH Male III dataset. The 3D reconstructed visible models established from these datasets perfectly displayed the anatomic structures of ALT flap and ADP flap. This is the first report on the ACFL and ADP structures which were reconstructed digitally.

A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: anatomic basis and clinical applications.

The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15-24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.

The vascular basis of the thoracodorsal artery perforator flap.

BACKGROUND: Musculocutaneous perforator flaps, or more simply, perforator flaps, have become increasingly popular in microsurgery because of numerous advantages, including reduced donor-site morbidity. The thoracodorsal artery perforator flap is a cutaneous flap based on cutaneous perforators of the thoracodorsal vessels. The objective of this study was to document the vascular anatomy of this flap in human cadaveric studies. METHODS: The anatomy of the perforators of the thoracodorsal artery was studied using a modified lead oxide-gelatin injection technique in 15 fresh human cadavers. Each fresh cadaver was injected with lead oxide, gelatin, and water, and then cooled to 4 degrees C for 24 hours before dissection. The torso was dissected to identify all cutaneous perforators in the region of the back and flank. RESULTS: The mean area of the primary and secondary zones supplied by the thoracodorsal artery was 255 cm2 and 345 cm2, respectively. The mean length of the major and minor axes was 18 cm and 13 cm, respectively. The maximum dimensions of the skin that could potentially be supplied by the thoracodorsal artery averaged 600 cm2, with a major axis length of 28 cm and a minor axis length of 27 cm. A mean number of 5.5 perforators with a mean diameter of 0.9 mm (range, 0.5 to 1.5 mm) supplied this zone. The ratio of musculocutaneous to septocutaneous perforators from the thoracodorsal artery was 3:2. The length of the thoracodorsal pedicle when harvested along with the perforator was 14.0 cm, with the vessel diameter being 2.8 mm at the origin. The most proximal perforator was seen at the level of the inferior angle of the scapula, 3.0 cm medial to the anterior border of the muscle. The intramuscular course of the perforators averaged 5 cm (range, 3 to 7 cm). Septocutaneous perforators from the thoracodorsal artery supplying the skin in addition to the musculocutaneous perforators were seen in 60 percent of specimens. CONCLUSIONS: The thoracodorsal artery perforator flap is a reliable cutaneous perforator flap that is very useful in a wide variety of clinical applications.

The vascular basis of perforator flaps based on the source arteries of the lateral lumbar region.

BACKGROUND: Perforator flaps based on the integument of the trunk have been well described in the literature; however, the anatomy of many donor sites has yet to be adequately documented. The integument of the lateral lumbar region of the trunk is supplied by a number of source arteries (lower posterior intercostal, lumbar, superior epigastric, deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac, deep circumflex iliac) whose large perforators may be suitable for perforator flap harvest. The purpose of the current study was to describe the vascular anatomy of these perforators in the lateral lumbar region. METHODS: A series of five fresh human cadavers were studied using a lead oxide-gelatin injection technique. The integument of the trunk (10 sides or hemitrunk specimens) was dissected, and the perforating vessels (diameter > or =0.5 mm) were identified, noting vascular origin, diameter, and pedicle length. Radiographs of tissue specimens were digitally analyzed using the software Scion Image for Windows (Scion Corp., Frederick, Md.) to determine vascular territories. RESULTS: The source vessels contributed a summed mean of 33 perforators per hemitrunk, with a mean emerging vessel diameter of 0.7 +/- 0.2 mm and a corresponding mean superficial pedicle length of 31 +/- 24 mm. The total area of skin supplied directly by these 33 perforators was 1200 cm2, equating to a mean area of 37 cm2 per perforator. CONCLUSION: The authors have comprehensively described the anatomy of perforators of the lateral lumbar region of the trunk.

Perforator flaps: evolution, classification, and applications.

In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.