The tailored latissimus dorsi free flap.

A technique is described for dissection of the latissimus dorsi free flap which yields musculocutaneous cover accurately tailored to the primary defect. It involves exposure high into the axilla, early transverse incision of the muscle to enhance visualization of the pedicle, and transection of the muscle close to the point at which the thoracodorsal artery enters. This last step eliminates the bulky portion of the muscle between this point of vascular supply and its insertion.

Preferential use of end-to-side arterial anastomoses in free flap transfers.

In our early clinical experience with free flaps, we used end-to-end arterial anastomoses and in 9 our of 24 we had complete failures--7 of which were due to early arterial thrombosis. Contrarily, in 41 consecutive free flaps with end-to-side anastomoses we have not had a single failure. At the same time that we began using the end-to-side anastomoses, we also began using the latissimus dorsi free flap as our flap of first choice, and we agree that this was probably an additional reason for our improved success rate. The use of end-to-side anastomoses has the following advantages: (1) a high success rate; (2) preservation of all existing vessels in an injured extremity; (3) greater freedom of operative planning; and (4) technical simplicity in terms of access to the vessels. For us, these advantages have made end-to-side anastomosis the technique of choice in the transfer of free flaps.

Early microsurgical reconstruction of complex trauma of the extremities.

Five hundred and thirty-two patients underwent microsurgical reconstruction following trauma to their extremities. They were divided into three groups for the purpose of review. Group 1 underwent free-flap transfer within 72 hours of the injury, group 2 between 72 hours and 3 months of the injury, and group 3 between 3 months and 12.6 years, with a mean of 3.4 years. The results were analyzed with respect to flap failure, infection, bone-healing time, length of hospital stay, and number of operative procedures. The flap failure rate was 0.75 percent in group 1, 12 percent in group 2, and 9.5 percent in group 3 (p less than 0.0005 early versus delayed; p less than 0.0025 early versus late). Postoperative infection occurred in 1.5 percent of group 1, 17.5 percent of group 2, and 6 percent of group 3. Bone-healing time was 6.8 months in group 1, 12.3 months in group 2, and 29 months in group 3. The average length of total hospital stay was 27 days for group 1, 130 days for group 2, and 256 days for group 3. The number of operations averaged 1.3 for group 1, 4.1 for group 2, and 7.8 for group 3.

Arterial autografts in microvascular surgery.

The use of autogenous arterial grafts for long arterial defects in replantation or tissue transfer is recommended. Some grafts are taken from the superficial temporal artery, but the majority are taken from the subscapular arterial tree. The match which can be achieved to vessels in the hand, both proximally and distally, is far superior to that with reversed vein grafts.

Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part.

A method of salvage of mutilated extremities with temporary ectopic implantation of the undamaged distal part is described. We suggest that this method is indicated in devastating segmental injuries of extremities, where the distal part is devascularized and where a necessary radical debridement would include the structures which are indispensable for a good functional result of the replantation but which would possibly survive if treated with an open-wound technique. The method could also be used in cases where an essential length of limb could be preserved by open-wound management with improvement of the functional and aesthetic result of replantation. The method is contraindicated in injuries where perfusion of the distal part is preserved. The lateral upper part of the thorax is suggested as a convenient site, with the thoracodorsal artery and vein as recipient vessels. The timing of replantation of the ectopic implanted part must be carefully planned to avoid complications caused by remaining necrotic tissues or infection. The importance of intensive physiotherapy of the ectopic implanted part is stressed.

Preferential use of the posterior approach to blood vessels of the lower leg in microvascular surgery.

A posterior approach to the vessels of the lower leg, with particular emphasis on the posterior tibial artery, is presented as the method of choice for microvascular free-tissue transfer to the region. This approach offers wide exposure, better definition of the zone of injury, appropriate selection of the recipient vessel and of the site of anastomosis, and enough room for microsurgical work. Exposing the large posterior tibial artery down to the distal third of the lower leg facilitates the use of end-to-side anastomosis and makes the transfer of large muscle flaps to that region more predictable, in part by obviating the need for long vein grafts. This exposure leaves no functional and few aesthetic deficits.

Immediate forearm reconstruction with a functional latissimus dorsi island pedicle myocutaneous flap.

Immediate forearm reconstruction with a functional latissimus dorsi island pedicle myocutaneous flap was performed following a shotgun injury to the left forearm. The procedure provided excellent coverage of the defect and eliminated the need for multiple procedures and the immobilization required for groin or abdominal pedicle flaps. In addition, the latissimus muscle provided active flexion of the wrist and limited finger flexion.

The saphenous neurovascular free flap.

A new neurovascular free-flap donor area on the medial side of the knee is described. The flap is supplied by the saphenous artery, a branch of the descending genicular artery. It is drained both by the long saphenous vein and by the saphenous venae comitantes. Its nerve supply is from the medial femoral cutaneous nerve above the knee and the saphenous nerve below the knee. The flap is thin, has a long vascular pedicle (up to 15 cm) and a dependable nerve supply, and can be made quite large. The principal disadvantage is the donor wound, which requires grafting in most cases. We describe the anatomy of the saphenous flap, the method of raising it, and our early clinical experience with it both as a free flap and as a pedicled flap. Potential uses of the saphenous flap and its broader significance in relation to flaps on the lower extremity are briefly discussed.

Free lateral arm osteocutaneous neurosensory flap for thumb reconstruction.

Three cases are described to illustrate the use of the lateral arm osteocutaneous neurosensory flap in thumb reconstruction. The merits of such a method and its place in the repertoire of techniques for this problem are discussed.

[The surgical treatment of preperitoneal inguinal hernia: a comparison between the methods of Rives and Stoppa]. / Il trattamento chirurgico dell'ernia inguinale pre-peritoneale: confronto tra le metodiche di Rives e di Stoppa.

In groin hernia surgery pre-peritoneal prosthetic repair is a valid alternative to traditional inguinal repair in patients with a large area of transversalis fascia weakness: direct, inguinoscrotal, recurrent, bilateral hernias. Pre-peritoneal prosthetic surgical approach by Rives' technique (little unilateral prosthesis) has been used in 121 cases (24% bilateral and 67% recurrent hernias) and by Stoppa's technique (great bilateral prosthesis) in 95 cases (26% bilateral and 55% recurrent hernias). The results demonstrated 9.9% morbidity and 5.7% recurrences by Rives' technique vs 3.1 morbidity and complete absence of recurrences by Stoppa's technique. These results confirm the validity of large prosthetic pre-peritoneal repair in groin surgery.

Epithelialized microvascular iliac crest flap for reconstruction of subglottic and upper tracheal stenosis: a preliminary report.

A new method for the management of laryngotracheal stenosis using an epithelialized microvascular iliac crest flap is described. This flap offers firm support to the frontal wall, an inner epithelial lining, and is well vascularized. The operation must be carried out in two sessions: skin grafting the flap and transfer with interposition of the flap. In the reconstruction procedure, the otolaryngologist and an experienced microvascular surgeon should cooperate. The method is suitable particularly for solving severe stenosis of the cricoid region and of the upper part of the trachea.