Neural correlates of trauma-related single word processing in posttraumatic stress disorder.

Interpersonal violence (IPV) is one of the most frequent causes for the development of posttraumatic stress disorder (PTSD) in women. One key component in PTSD is altered processing of trauma-related cues, leading to emotional symptoms. In the everyday environment, words with trauma-associated semantic content represent typical, albeit abstract, trauma-related stimuli for patients suffering from PTSD. However, the functional neuroanatomy associated with processing single trauma-related words in IPV-PTSD is not understood. The present event-related functional magnetic resonance imaging study investigated the neural basis of trauma-related word processing in women with IPV-PTSD relative to healthy controls (HC) during a non-emotional vigilance task in which the emotional content of the words was task-irrelevant. On the behavioral level, trauma-related relative to neutral word stimuli evoked more unpleasant feelings, higher arousal as well as anxiety in IPV-PTSD patients as compared to HC. Functional imaging data showed hyperactivation to trauma-related versus neutral words in the basolateral amygdala (BLA) and cortical language-processing regions (inferior frontal gyrus, posterior cingulate cortex, angular/supramarginal gyrus) in IPV-PTSD compared to HC. These results propose a role of the BLA in hypervigilant responding to verbal trauma associated cues in IPV-PTSD. Furthermore, the particular involvement of cortical language-processing regions indicates enhanced processing of trauma-related words in brain regions associated with analysis and memory of verbal material. Taken together, our findings suggest that both subcortical and cortical mechanisms contribute to automatic responsivity to verbal trauma cues in PTSD.

Specific amygdala response to masked fearful faces in post-traumatic stress relative to other anxiety disorders.

BACKGROUND: Altered amygdala activation to fear-related stimuli has been proposed to be a potential neural correlate of heightened threat sensitivity in anxiety- and stress-related disorders. However, the role of stimulus awareness and disorder specificity remains widely unclear. Here we investigated amygdala responses to conscious and unconscious fearful faces in patients suffering from panic disorder (PD), generalized anxiety disorder (GAD), or post-traumatic stress disorder (PTSD) and in a large sample of healthy controls (HC). METHODS: During event-related functional magnetic resonance imaging participants (n = 120; 20 PD, 20 GAD, 20 PTSD, 60 HC) were confronted with briefly presented fearful faces, neutral faces, and non-faces in a backward masking paradigm. The design allowed for the analysis of trial-by-trial face detection performance and amygdala responses to fearful v. neutral faces. RESULTS: All participants exhibited increased amygdala activation to fearful v. neutral faces during conscious trials. Specifically during unconscious face processing, the PTSD, compared with all other groups, showed higher right basolateral (BLA) amygdala activity to fearful v. neutral faces. CONCLUSIONS: The present study shows that BLA amygdala hyperactivity during unconscious, but not conscious, processing of fearful faces differentiates PTSD from the investigated disorders. This finding suggests an automatic and specific neural hyper-responsivity to general fear cues in PTSD and supports the idea of categorical differences between PTSD and other anxiety-related disorders.

Transdiagnostic brain responses to disorder-related threat across four psychiatric disorders.

BACKGROUND: There is an ongoing debate whether transdiagnostic neural mechanisms are shared by different anxiety-related disorders or whether different disorders show distinct neural correlates. To investigate this issue, studies controlling for design and stimuli across multiple anxiety-related disorders are needed. METHOD: The present functional magnetic resonance imaging study investigated neural correlates of visual disorder-related threat processing across unmedicated patients suffering from panic disorder (n = 20), social anxiety disorder (n = 20), dental phobia (n = 16) and post-traumatic stress disorder (n = 11) relative to healthy controls (HC; n = 67). Each patient group and the corresponding HC group saw a tailor-made picture set with 50 disorder-related and 50 neutral scenes. RESULTS: Across all patients, increased activation to disorder-related v. neutral scenes was found in subregions of the bilateral amygdala. In addition, activation of the lateral amygdala to disorder-related v. neutral scenes correlated positively with subjective anxiety ratings of scenes across patients. Furthermore, whole-brain analysis revealed increased responses to disorder-related threat across the four disorders in middle, medial and superior frontal regions, (para-)limbic regions, such as the insula and thalamus, as well as in the brainstem and occipital lobe. We found no disorder-specific brain responses. CONCLUSIONS: The results suggest that pathologically heightened lateral amygdala activation is linked to experienced anxiety across anxiety disorders and trauma- and stressor-related disorders. Furthermore, the transdiagnostically shared activation network points to a common neural basis of abnormal responses to disorder-related threat stimuli across the four investigated disorders.

[Tendon transfers for peroneal palsy - functional outcome]. / Motorische Ersatzplastiken zur Therapie der Peroneusparese - funktionelle Ergebnisse.

PURPOSE: Patients with persistent peroneal palsy may require treatment for gait disturbances if conservative treatment is not tolerated. Transfer of the tibialis posterior tendon can restore foot extension and improve the patients gait pattern. PATIENTS AND METHODS: Retrospective analysis (mean follow-up 40.8 months) of 13 patients. (7♀, 6♂; 1998-2005) after tibialis posterior tendon transfer through the interosseous membrane to the tibialis anterior and peroneus longus tendons. Evaluation focussed on hospitalisation periods, perioperative morbidity, functional outcome (range of motion, strength, pain and gait), return to work rate and self assessment with the Funktionsfragebogen Hannover (FFbH). RESULTS: 7 iatrogenic, 5 posttraumatic and 1 congenital peroneal palsy were treated. The patients presented after an average of 8.3 months (hospitalisation 11 days). Perioperative morbidity was 38.4% (15.4% reoperation rate). The mean active range of motion of the ankle was 3°/0°/56° (extension/flexion), the average strength was 3 (MRC) and pain was 4 (visual analogue scale 1-10). 12 patients were evaluated with normal or improved gait pattern without ortheses. The mean FFbH score was 70.9%. CONCLUSION: If conservative treatment for peroneal palsy fails to improve functional outcome tendon transfers such as the tibialis posterior tendon transfer are a considerable treatment option. However, significant morbidity rates have to be anticipated. Consecutive patients should be referred in good time to specialised units.

[Outcome assessment after reconstruction of complex defects of the forearm and hand with osteocutaneous free flaps]. / Rekonstruktion kombinierter Knochen-/Weichteildefekte an Hand und Unterarm durch freie osteokutane Lappenplastiken.

PURPOSE: Complex defects of the forearm and hand often require microvascular reconstruction with composite osteocutaneous free flaps for limb salvage. Here, a postoperative outcome analysis of 15 patients is presented, who were treated by free composite tissue transplantation between 1992 and 2004 in a single institution. PATIENTS AND METHODS: The assessment focused on the range of motion, the pain and grip strength as well as on the patient's individual physical functioning and self perception, measured with the DASH questionnaire. Additionally complications, return to work and the donor site morbidity were documented. RESULTS: Reasons for the combined defects were trauma, infections or malignant tumors. The patients' average age was 38 years. The average osseous defect was 11.7 cm (range, 6 to 21 cm), all patients suffered from additional soft tissue defects. Microvascular osteoseptocutaneous fibula transplantations (n = 8), osteocutaneous scapular or parascapular flaps (n = 6) and osteocutaneous lateral arm flaps were performed for reconstruction. The mean hospitalisation time was 39.3 days (range, 18 - 73 d). All defects could be reconstructed in a one-step reconstructive procedure after sequential debridements or after radical tumour resection. Two patients developed a pseudarthrosis, one had to undergo an ablation procedure due to persistent infection; however, the flap was well perfused. Every patient had a markedly reduced hand function compared with the unaffected extremity, however the functional results were satisfactory with a mean DASH score of 25.3 (range, 0 to 42). This reflects only a moderate disability in activities of daily living. From the patients' point of view the functional results were more than acceptable when the potential alternatives were taken into consideration. This was also reflected by a high individual satisfaction. CONCLUSION: This retrospective analysis demonstrates that limb salvage with osteocutaneous free flaps is an important tool in the armamentarium for the treatment of composite defects in the forearm and hand. Functional results are good and the patient's high individual satisfaction justifies the use of these difficult reconstructive procedures.

[The influence of published studies and position papers on the prescription of peri- and post-menopausal hormone therapy]. / Der Einfluss publizierter Studien und Stellungnahmen auf die Verordnung der peri- und postmenopausalen Hormontherapie.

Until the end of the 1990's it was thought that hormone therapy has a lot of positive health effects and should be prescribed for nearly all women. Recently conducted studies have shown that menopausal hormone therapy has a higher health risk especially for breast cancer and cardiovascular disease. In this study we investigated to what extent hormone therapy changes could be identified during the past years. We therefore analysed data of a German health insurance (Gmünder ErsatzKasse=GEK) from 2001-2005. It was shown, that studies and recommendations, as well as statements of different German institutions, which were published during this period lead to an important decrease in respect of hormone therapy prevalence. It seems that the most important impact of this topic came from the results of the Women's Health Initiative study (WHI) and the followed controversial discussion in Germany. In respect of the individual five years age groups the changes were very different and for the older women especially there were no decreases detectable. It must be expected that frequently the diagnoses of Osteoporosis results in a treatment of hormone therapy over a long period and that the recommendations and statements (as mentioned above) are not implemented sufficiently. Therefore, it is necessary to conduct an evidence based hormone therapy treatment in the practitioners daily work, to keep health risks low. Furthermore, physicians should be more engaged to show their patients alternatives instead of hormone therapy. They should also advise and support their treated patients how to quit hormone therapy.

The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps.

Distally based DMCA flaps are well established in reconstructive hand surgery. They comprise the dorsal flap described by Quaba and the DMCA flaps described by Earley, Milner and others. The most frequent indications for these flaps are soft tissue defects of the dorsum of the proximal phalanx and the total length of the finger. Since its introduction several modifications have been developed to match specific defect requirements; these include: the development of pure fascial DMCA flaps, the use of DMCA flaps in dorsally grafted burned hands and modifications in design to avoid 'tunnelling' and to permit skin-skin defect closure. The purpose of this article is to provide an overview of the evolution and refinements of the DMCA flaps based on the experience of a single centre. The DMCA flaps provide one stage coverage of excellent quality with independent vascularisation and permit primary closure of the recipient site without sacrificing relevant arteries (e.g. proper digital artery). However, the DMCA flaps also possess drawbacks, for example, apart from the fact that this technique is quite demanding, possible hair growth and a visible scar on the exposed dorsal part of the hand present aesthetic problems for some patients. Despite these limitations, DMCA flaps are considered to be extremely useful.

[Body contouring surgery after massive weight loss. Part I: abdomen and extremities]. / Plastisch-chirurgische Korrekturen der Körperform - Rekonstruktion und Asthetik. Teil I: Abdomen und Extremitäten.

Body contouring surgery is traditionally part of plastic surgery training. Reconstructive techniques are needed most in trauma cases, tumor reconstructions, treatment of degenerative diseases and metabolic diseases such as Madelung's deformity, body contouring after massive weight loss, and all aesthetic plastic surgery. With various surgical techniques, liposuction became an important option in the overall treatment plan. Body contouring surgery in the massive weight loss patient is a rapidly expanding field of plastic surgery. Its challenge is the management of excess skin remaining after bariatric surgery. To achieve an aesthetic body contour, patients must accept numerous long scars. They must understand that recurrent laxity and scar migration is not necessarily a failure of the operation but rather an expected outcome. Body contouring surgery is challenging, time-consuming, and not without complications. The patient population has very real aesthetic and appearance concerns that must be addressed in an effective, definite, and safe manner.

[Plastic surgical body form correction. Part II: Face-lift, periorbital surgery, and breast augmentation and reduction]. / Plastisch-chirurgische Korrekturen der Körperform--Rekonstruktion und Asthetik. Teil II: Facelift, periorbitale Chirurgie, Mammaaugmentation und Mammareduktion.

The demand for a younger appearance is increasing as the average age of the population increases. Extensive anatomic studies in recent years have improved for facial and breast reconstruction the understanding of anatomic structures and the basis of the aging process. Numerous new surgical techniques have resulted. This understanding of the anatomy of aging and the diversity of surgical methods have made the attainment of naturally young facial appearance more easily possible, in which repositioning of the tissue plays a more important role than lifting. In the past, plastic surgery of the eyelids aimed primarily at hiding the aging process, not at true anatomic restoration. Modern techniques in this field aim more toward redistribution of fatty tissues and the anatomic restoration of aging structures. In this way long-term results are stabilized and secondary stigmata can be avoided. New concepts have also been established in breast surgery that allow more natural results, particularly in augmentation. Although no single method may be designated as superior, there still exists an optimal technique suited to every patient's anatomy and personal wishes.

[Blast injuries of the hands. Patterns of trauma and plastic surgical treatment]. / Explosionsverletzungen der Hände. Verletzungsmuster und plastisch-chirurgische Therapie.

BACKGROUND: Blast injuries of the hand represent a demanding surgical emergency for the reconstructive hand surgeon. Commercially available fireworks are often regarded as less dangerous compared to combat ammunition, but the following examples demonstrate their real potential for devastating hand injuries. Some of the closed injuries can represent a pitfall for correct assessment of trauma severity. PATIENTS AND METHODS: Fifty patients who were seen after fireworks explosions from December 1995 until April 2005 were analyzed in respect to their patterns of injury and their subsequent surgical treatment. The severity was graded using the Hand Injury Severity Score (HISS). The majority of patients were injured during the New Year's day celebrations and presented with complex blast injuries due to commercially available, CE-certified fireworks. RESULTS: Depending on the size of the explosives comparable patterns of injury were seen. Larger shells led to traumatic subtotal amputations of the exposed fifth finger ray and thenar ray. Complex destructions with multiple fractures and avulsions of the midhand were also present. Smaller explosives caused multiple lacerations in the palm of the hand, subcutaneous flexor tendon ruptures, and closed fingertip fractures. DISCUSSION: Acute neurapraxias and neural compartment syndromes were clinically present. All patients (50) had to be operated primarily, and subsequent operations were necessary in 19 cases (number of operations 1-4, med. 1). In the HISS grading, 18 "minor" (HISS <20), 16 "moderate" (HISS 21-50), 7 "severe" (HISS 51-100), and 9 "major" (HISS >100) explosion injuries were present (range: 2-155, med. 47). CONCLUSION: Blast injuries of the hand need a fast, strategically planned surgical approach. This is also true for presumably harmless, CE-certified fireworks. In a multiple patient scenario, triage based on surgical urgency may be necessary. A detailed clinical examination and surgical exploration is mandatory to avoid possible pitfalls like in closed injuries. Profound skills in reconstructive and microvascular hand surgery are essential to achieve an optimal clinical outcome.

[Improved outcome of nerve injuries in the upper extremity]. / Motorische und sensible Ersatzoperationen an der oberen Extremität.

Nerve injuries in the upper extremity can result in severe disability. In the past three decades, progress in microsurgical techniques and instruments have resulted in improved outcomes for nerve injuries. If the prognosis is reasonably good, nerve repair is usually preferred over tendon or flap transfer procedures. However, lesions of peripheral stem nerves such as high radial nerve palsy may still yield unsatisfactory results, despite technically well-executed nerve repair. Prognosis further depends on the age of the patient; the regenerative process is delayed in older patients. Further criteria for the indication for tendon transfers are the personal and professional profiles of individual patients. Tendon or flap transfers to restore sensation can be performed at any time post trauma when it becomes clear that long-term rehabilitation is required. These procedures abbreviate the interval during which hand function is severely impaired, so that patients have alternatives to persistent nerve palsy with the need of permanent external splints, and long and costly rehabilitation can be shortened. Sophisticated techniques allow minimal donor site morbidity and leave options open in case function of the reconstructed nerve returns. The present article gives an overview of the most common procedures to restore hand function and sensation in the most important digits and provides help for decision making.

[Experiences with the distally based dorsal metacarpal artery (DMCA) flap and its variants in 41 cases]. / Erfahrungen mit der distal gestielten, dorsalen Metakarpalarterien (DMCA)-Lappenplastik und ihren Varianten in 41 Fällen.

Distally based DMCA flaps are an established procedure for soft tissue reconstruction in the hand. Since the introduction of the DMCA flaps, several variants have been developed to match specific defect requirements. The aim of this retrospective study is to give an overview of the experience with the DMCA flaps based on a single center's experience. 41 distally based DMCA flaps have been performed from 2000 to 2004. Twenty-nine times a distally based DMCA flap has been performed, nine times the extended distally based DMCA flap and three times a distally based DMCA fascial flap. In summary, 34 flaps showed no complications, five had a partial necrosis, but were successfully treated with split-thickness skin graft, and two flaps were lost due to infections. The distally based DMCA flaps II to IV have proven to be reliable flaps, but nevertheless require sufficient surgical experience. They are suitable for any kind of defects, including burn reconstruction. Defects of the entire finger can be covered by the various variants of the DMCA flaps.

[Defect coverage of the hand with the free serratus fascial flap]. / Defektdeckung an der Hand mit dem freien Serratus-Faszien-Lappen.

PURPOSE: Coverage of exposed functional structures such as tendons, bones, vessels or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. Free fascial flaps are possible alternatives to cutaneous, fasciocutaneous and muscle flaps. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free serratus fascial flaps in our department. METHOD AND CLINICAL MATERIAL: From 1994 to 2002, ten patients underwent free fascial flap coverage of the hand with eleven serratus fascial flaps. Six patients could be re-examined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was after 34 months. RESULTS: Average active range of motion of the hand, functional improvement and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. CONCLUSION: We recommend the use of free serratus fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps since the functional results are excellent; no additional procedures were necessary and the aesthetical results are appealing.

Coverage of soft-tissue defects of the hand with free fascial flaps.

Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result. The purpose of this retrospective study was to evaluate the functional and aesthetic results after coverage of the hand with free fascial flaps. From 1994-2002, 14 patients underwent free fascial flap coverage of the hand with 4 tempo-parietal fascia flaps and 11 serratus fascia flaps. Eight patients could be reexamined and answered a questionnaire about their satisfaction with the functional and aesthetic results. The mean follow-up was 41.7 months. Average active range of motion of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients. No secondary debulking or other contouring procedures were required. We recommend the use of free fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are excellent, no additional procedures were necessary, and the aesthetic results are appealing.

[Defect coverage and reconstruction of thumb sensibility with the first dorsal metacarpal artery flap]. / Neurokutaner Insellappen nach Foucher. Weichteildeckung und Rekonstruktion der Sensibilität am Daumen.

INTRODUCTION: The "Foucher" flap is a pedicled neurovascular island flap of the first dorsal metacarpal artery. METHODS: From 1992 to 2000, thirty-three neurocutaneous island flaps from the dorsal aspect of the index finger (FDMCA flap) were performed for defect coverage and reconstruction of sensibility in the thumb. RESULTS: Static 2-PD over the flap area averaged 10.8 mm (range 4-15), compared to 8.2 mm (4-15) over the dorsal aspect of the contralateral index finger. Response to the SW monofilaments showed no difference to normal skin or only diminished light touch in 76% (19/25) patients. Seventy-six percent (19/25) were able to return to their previous jobs or resume previous activities. CONCLUSION: Based on negligible donor site morbidity of the flap and the good sensate quality and aesthetic appearance, the Foucher flap has become our first choice in defect coverage and restoration of sensibility of the thumb.

[Free fibula transfer. Analysis of 76 consecutive microsurgical procedures and review of the literature]. / Freier Fibulatransfer. Analyse einer Serie von 76 konsekutiven mikrochirugischen Operationen und Literaturübersicht.

Since its introduction by Taylor in 1975, microvascular free fibula transfer has become the gold standard in osseous reconstructions requiring vascularized bone transfer. Various modifications of the free fibula have been described in the literature. We reviewed a series of 76 free vascularized fibula transfers during a 7-year period. Data was retrospectively analyzed with respect to type of procedure and outcome, general surgical complications, and flap-related (specific) complications. Of all 76 free fibula flaps, 47 cases healed uneventfully (62%). Interestingly, 53% of all extremity reconstruction cases had at least one of the above complications, whereas in maxillofacial cases the complication rate was only 25%. Complete osseous consolidation at the time of evaluation was confirmed in 58 patients (76%). Complete flap failure occurred in four patients (5%). The complication rates reflect the complexity of the procedures and appear strongly related to the underlying disease and predisposing medical risk factors. Time will tell if advances, e.g., in the field of tissue engineering, will eventually replace autologous vascularized bone transfer.

Distraction lengthening of thumb metacarpal.

The purpose of this retrospective study was to evaluate the clinical outcome of distraction lengthening of the thumb metacarpal without bone grafting in seven patients with traumatic thumb loss. The distraction was stopped after 57 (range, 42 to 91) days, giving a median lengthening of 28 (range, 20-36)mm. It took an average of 155 (range, 118-196) days for bony consolidation to occur. The mean pinch power was 72% of that of the uninjured hand. The two-point discrimination on the pulp of the reconstructed thumb was 10 (range, 8-12)mm. There were no major complications.

Late remote ischemic preconditioning in rat muscle and adipocutaneous flap models.

The purpose of this study was to determine whether remote ischemic preconditioning can be induced by a late mechanism. The rat cremaster flap model was used for assessment of ischemia-reperfusion injury. In the control group (N = 9), 2 hours of flap ischemia was induced after preparation of the cremaster muscle. Ten minutes of ischemia of the contralateral hind limb was induced 24 hours before flap ischemia in the late remote ischemic preconditioning group (LRIP) (N = 8). In vivo microscopy was performed after 1 hour of flap reperfusion in each animal. The epigastric adipocutaneous flap model was used for the second part of the experiment. Three hours of flap ischemia was induced in the control group (N = 8). A similar late remote ischemic preconditioning protocol as in the LRIP group was used for the second late remote ischemic preconditioning group (N = 8). A significantly higher muscle red blood cell velocity in the capillaries, first-order arterioles, and venules, and a higher capillary flow as well as a decreased number of "stickers" were observed in the late remote ischemic preconditioning group compared with the first control group (p < 0.05). Average flap necrotic area was not significantly different within the second control group and the second late remote ischemic preconditioning group in the adipocutaneous flaps. These data show that late remote ischemic preconditioning attenuates ischemia-reperfusion injury in muscle flaps, whereas it is ineffective in adipocutaneous flaps.

Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant.

BACKGROUND: There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity that are >6 cm in length, especially those that are associated with soft-tissue defects. The purpose of the present review was to report on our experience with fifteen patients who received an osteoseptocutaneous fibular transplant for reconstruction of a humeral defect. METHODS: The study cohort included eight male patients and seven female patients with an average age of forty-one years. The indications for the procedure included segmental nonunion (nine patients), a gunshot wound (three), a defect at the site of a tumor resection (two), and failure of an allograft-prosthesis reconstruction (one). The fibular graft was fixed by means of intramedullary impaction in eleven patients, was used as an onlay graft in three, and was used as a strut between the intact diaphysis and the humeral head in one. RESULTS: The average length of the segmental humeral defect was 9.3 cm. The average length of the fibular graft was 16.1 cm, and the average length and width of the skin paddle were 8.1 and 4.5 cm. The average duration of follow-up was twenty-four months. Three patients had venous thrombosis and underwent a successful revision of the anastomosis. Four patients had early failure of graft fixation. Three patients had a fracture of the fibular graft within the first year postoperatively. All but one of these latter seven patients were successfully treated with open reduction, internal fixation, and additional bone-grafting. One patient with an infection at the site of a nonunion and signs of graft resorption required a second fibular transplant. CONCLUSIONS: The osteoseptocutaneous fibular transplant is an effective treatment for combined segmental osseous and soft-tissue defects of the arm. However, the application of this technique to the arm is more complex than application to the forearm and is associated with a higher rate of complications.

Perforator flaps--the history of evolution.

This article reviews the recent evolution of perforator flaps. The tie between perforator flaps and skin flaps as well as perforator flaps and musculocutaneous flaps is explained. The paraumbilical perforator flap, the deep inferior epigastric artery flap (DIEP flap), the gluteal artery perforator flap (GAP flap) and various perforator flaps and perforator-based flaps are described in combination with the review of the relevant literature. As a prospect into the future, the technique of "supra-microsurgery" is presented.