Decreased Donor Site Morbidity Research Articles

Spiral free perforator flaps for completely degloved thumb reconstruction

Objective To determine the effect of resurfacing completely degloved thumbs by free perforator flaps in a spiral fashion. Methods A retrospective case series study was made on 22 patients with completely degloving injury of the thumb treated by different free perforator flaps in a spiral fashion from June 2009 to December 2014, including 19 male and 3 female patients at the age of 18-46 years (mean, 27.8 years). A total of 13 patients were reconstructed using the medial arm perforator flaps ranging in size from 8.0 cm×3.0 cm-14.5 cm×3.5 cm, and 9 patients were reconstructed using the peroneal artery perforator flaps ranging in size from 6.0 cm×3.5 cm-21.0 cm×10.0 cm. Follow-up was made to evaluate the sensation, appearance and function of the thumbs and the recovery of flap donor sites. Results All flaps survived completely, with no occurrence of postoperative vascular crisis and infection. Only one medial arm flap and one soleus perforator flap distal flap showed blood flow disorder in the distal sections and were healed uneventfully after conservative therapy. Function and cosmetic recovery of the reconstructed thumbs were good. Follow-up ranged from 9 to 22 months (mean, 14.5 months). Two-point discrimination test of the flaps was recovered to 6-13 mm. No linear scar contracture was left. Flap donor site wound healed primarily. All patients were satisfied with the overall results. Conclusion The free perforator flap in a spiral fashion can avoid linear scar contracture, maximally decrease donor site morbidity and achieve satisfactory functional recovery and good aesthetic restoration, indicating a good candidate for reconstruction of thumb degloving injury. Key words: Thumb; Finger injuries; Free perforator flap transplantation

Prescription stimulant non-medical use: Literature review

Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe.

Distraction First Metatarsophalangeal Arthrodesis With Tricortical Calcaneus Autograft: Technique Tips.

Level V.

Biomechanical Characterisation of the Human Auricular Cartilages; Implications for Tissue Engineering.

Currently, autologous cartilage provides the gold standard for auricular reconstruction. However, synthetic biomaterials offer a number of advantages for ear reconstruction including decreased donor site morbidity and earlier surgery. Critical to implant success is the material’s mechanical properties as this affects biocompatibility and extrusion. The aim of this study was to determine the biomechanical properties of human auricular cartilage. Auricular cartilage from fifteen cadavers was indented with displacement of 1 mm/s and load of 300 g to obtain a Young’s modulus in compression. Histological analysis of the auricle was conducted according to glycoprotein, collagen, and elastin content. The compression modulus was calculated for each part of the auricle with the tragus at 1.67 ± 0.61 MPa, antitragus 1.79 ± 0.56 MPa, concha 2.08 ± 0.70 MPa, antihelix 1.71 ± 0.63 MPa, and helix 1.41 ± 0.67 MPa. The concha showed to have a significantly greater Young’s Elastic Modulus than the helix in compression (p < 0.05). The histological analysis demonstrated that the auricle has a homogenous structure in terms of chondrocyte morphology, extracellular matrix and elastin content. This study provides new information on the compressive mechanical properties and histological analysis of the human auricular cartilage, allowing surgeons to have a better understanding of suitable replacements. This study has provided a reference, by which cartilage replacements should be developed for auricular reconstruction.Electronic supplementary materialThe online version of this article (doi:10.1007/s10439-016-1688-1) contains supplementary material, which is available to authorized users.

Perforator flaps for reconstruction of lower limb defects

Background: Reconstruction of soft tissue defects in the lower third of the leg remains challenging. Anatomical constraints limit the local options available for complex defects especially lower third of leg. Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. We present our experience with perforator flaps for reconstruction of soft tissue defects in the lower limb . Methods: The study was carried prospectively and 23 patients with lower limb defects treated with various perforator flaps (both elective as well as emergency) were included in the study. A hand-held Ultrasound Doppler was used preoperatively and intraoperatively to detect the perforator vessels . Results: Out of 23 patients, we witnessed partial flap loss in 1 and distal flap necrosis in 3 patients. 4 patients had minor complications which included infection, wound dehiscence and congestion of flap . Conclusions: Perforator flaps may represent a good alternative to the free flaps in the areas were other local reconstructive procedures are not possible. This is a versatile technique and with decreased donor site morbidity limited to a single body area. There is a specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. The main drawback of the perforator flaps however is the higher risk of venous congestion .

Mandibular Tissue Engineering: Past, Present, Future

Almost 2decades ago, the senior author's (M.T.J.) first article was with our mentor, Dr Leonard B.Kaban, a review article titled "Distraction Osteogenesis: Past, Present, Future." In 1998, many thought it would be impossible to have a remotely activated, small, curvilinear distractor that could be placed using endoscopic techniques. Currently, a U.S. patent for a curvilinear automated device and endoscopic techniques for minimally invasive access for jaw reconstruction exist. With minimally invasive access for jaw reconstruction, the burden to decrease donor site morbidity has increased. Distraction osteogenesis (DO) is an invivo form of tissue engineering. The DO technique eliminates a donor site, is less invasive, requires a shorter operative time than usual procedures, and can be used for multiple reconstruction applications. Tissue engineering could further reduce morbidity and cost and increase treatment availability. The purpose of the present report was to review our experience with tissue engineering of bone: the past, present, and our vision for the future. The present report serves as a tribute to our mentor and acknowledges Dr Kaban for his incessant tutelage, guidance, wisdom, and boundless vision.

Modern Perforator Flap Imaging with High-Resolution Blood Pool MR Angiography.

Advances in microsurgical techniques have improved autologous reconstructions by providing new donor site options while decreasing donor site morbidity. Various preoperative imaging modalities have been studied to assess the relevant vascular anatomic structures, with magnetic resonance (MR) angiography traditionally lagging behind computed tomography (CT) with respect to spatial resolution. Blood pool MR angiography with gadofosveset trisodium, a gadolinium-based contrast agent with extended intravascular retention, has allowed longer multiplanar acquisitions with resultant voxel sizes similar to or smaller than those of CT and with improved signal-to-noise ratio and soft-tissue contrast while maintaining the ability to depict flow with time-resolved imaging. The resultant vascular detail enables precise evaluation of the relevant vascular anatomic structures, including the vessel course, size, and branching pattern, as well as the venous arborization pattern. In addition, any architectural distortion, vessel alteration, or injury from prior surgery can be depicted. The reporting radiologist should be aware of pertinent and incidental findings relevant to the planned surgery and the patient's disease so that he or she can assist the microsurgeon in flap design as a member of the multidisciplinary team. Given the lack of ionizing radiation exposure in patients who often have an elevated body mass index, high-spatial-resolution blood pool MR angiography has become the imaging reference standard for the preoperative assessment of perforator flap vascular and soft-tissue morphology in our practice.

Height, Weight, and Age Predict Quadriceps Tendon Length and Thickness in Skeletally Immature Patients

Background: Quadriceps tendon autografts have been used with success in adults and are becoming a popular graft option in pediatric patients because of size, decreased donor site morbidity, ease of harvest, and favorable biomechanical characteristics. However, little is known about the length and thickness of the quadriceps tendon in pediatric patients. Purpose: This study aimed to determine whether quadriceps tendon length and thickness follow a predictable pattern of development based on height, weight, age, and body mass index in skeletally immature patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The height, weight, age, and sex of 151 children between 4 and 16 years old were recorded. Ultrasound measurements of the length and thickness of bilateral quadriceps tendons were performed by a single technician and recorded for statistical analysis. Results: The average quadriceps tendon length and thickness were 6.87 ± 1.49 cm and 0.37 ± 0.12 cm, respectively. Tendon length averaged 3.89 cm at age 4 years and 7.98 cm at 16 years, whereas thickness averaged 0.24 cm at 4 years and 0.40 cm at 16 years of age. There was no significant difference in tendon length or thickness between males and females (P = .97). Tendon length and thickness increased significantly with age, weight, and height (P < .01 for all). Conclusion: The quadriceps tendon is of sufficient length and thickness to be used as an autograft for pediatric patients. The size of the graft is predictable using the age, height, and weight of the patient. Graft length and thickness can be easily confirmed using ultrasound.

Adjuvant neurotrophic factors in peripheral nerve repair with chondroitin sulfate proteoglycan-reduced acellular nerve allografts

BackgroundAcellular nerve allografts are now standard tools in peripheral nerve repair because of decreased donor site morbidity and operative time savings. Preparation of nerve allografts involves several steps of decellularization and modification of extracellular matrix to remove chondroitin sulfate proteoglycans (CSPGs), which have been shown to inhibit neurite outgrowth through a poorly understood mechanism involving RhoA and extracellular matrix-integrin interactions. Chondroitinase ABC (ChABC) is an enzyme that degrades CSPG molecules and has been shown to promote neurite outgrowth after injury of the central and peripheral nervous systems. Variable results after ChABC treatment make it difficult to predict the effects of this drug in human nerve allografts, especially in the presence of native extracellular signaling molecules. Several studies have shown cross-talk between neurotrophic factor and CSPG signaling pathways, but their interaction remains poorly understood. In this study, we examined the adjuvant effects of nerve growth factor (NGF) and glial cell line-derived neurotrophic factor (GDNF) on neurite outgrowth postinjury in CSPG-reduced substrates and acellular nerve allografts. Materials and methodsE12 chicken DRG explants were cultured in medium containing ChABC, ChABC + NGF, ChABC + GDNF, or control media. Explants were imaged at 3 d and neurite outgrowths measured. The rat sciatic nerve injury model involved a 1-cm sciatic nerve gap that was microsurgically repaired with ChABC-pretreated acellular nerve allografts. Before implantation, nerve allografts were incubated in NGF, GDNF, or sterile water. Nerve histology was evaluated at 5 d and 8 wk postinjury. ResultsThe addition of GDNF in vitro produced significant increase in sensory neurite length at 3 d compared with ChABC alone (P < 0.01), whereas NGF was not significantly different from control. In vivo adjuvant NGF produced increases in total myelinated axon count (P < 0.005) and motor axon count (P < 0.01), whereas significantly reducing IB4+ nociceptor axon count (P < 0.01). There were no significant differences produced by in vivo adjuvant GDNF. ConclusionsThis study provides initial evidence that CSPG-reduced nerve grafts may disinhibit the prosurvival effects of NGF in vivo, promoting motor axon outgrowth and reducing regeneration of specific nociceptive neurons. Our results support further investigation of adjuvant NGF therapy in CSPG-reduced acellular nerve grafts.

Lambeaux perforants fins prélevés dans le plan du fascia superficialis : principe et technique opératoire

Perforator flaps have an ever growing place in reconstructive surgery and classical surgical procedures describe sub or supra-fascial plane elevation. In some indications, defatting of perforator flaps may be necessary and different methods have been described, primary or secondary, but may expose to partial loss of the flap or to another operation. Recently, a new method of perforator flap elevation in the plane of the superficial fascia has been described. This method permits to obtain a thin and reliable flap in the same procedure without the need of debulking and while decreasing donor site morbidity. We present the principle and the surgical procedure of this new method. Advantages and drawbacks are discussed with the help of clinical cases.

Immediate nipple reconstruction utilizing the DIEP flap in areola‐sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin-sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46-59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost-effective and feasible technique for recreating a natural-appearing and aesthetic nipple in select patients.

The Art of Block Grafting in the Preparation of Site for an Implant

Currently implants in dentistry have become a successful treatment option for replacement of missing teeth or tooth. However, sufficient width and height of maxillary or mandibular alveolar ridge is a must for implant placement. Deficient ridge may occur due to trauma, other local pathologies or periodontal diseases. Retention and success of implants in insufficient ridge height becomes questionable. A correct diagnosis of the deficient ridge especially in the maxillary posterior region, whether due to pneumatization of the maxillary sinus or due to periodontal disease, needs to be made prior to deciding the treatment protocol. Surgical reconstruction of such alveolar ridge using autologous bone grafts allows implant fixation in an esthetic and functional manner. For repair of most localized alveolar defects, block bone grafts from the symphysis offer advantages over iliac crest grafts, like close proximity of donor and recipient sites, convenient surgical access, decreased donor site morbidity, decreased cost and hidden scar. We hereby present a case of deficient alveolar height in the maxillary posterior region which was reconstructed with intraoral symphysis graft from the mandible before implant placement.

Reconstruções pelveperineais com uso de retalhos cutâneos baseados em vasos perfurantes: experiência clínica com 22 casos

INTRODUÇÃO: As lesões pelveperineais representam grande parcela das interconsultas para o cirurgião plástico em hospitais gerais. O objetivo do presente trabalho é apresentar a experiência obtida no tratamento de pacientes com lesões perineais, sacrais e de quadril com o uso de retalhos com vasos perfurantes. MÉTODO: Foram estudados, retrospectivamente, os pacientes submetidos a avaliação pela equipe da Divisão de Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, nos meses de fevereiro a maio de 2009, que apresentavam feridas em região pelveperineal e no quadril. No total, 22 pacientes foram submetidos a reconstrução com retalhos cutâneos e fasciocutâneos baseados em vasos perfurantes, de acordo com os critérios de inclusão. O período de seguimento médio foi de 6 meses. RESULTADOS: A lesão pelveperineal foi úlcera por pressão em 20 (91%) casos, infecção profunda em 1 (4,5%), e hidradenite perineal em 1 (4,5%). A opção dos retalhos foi previamente estabelecida, dependendo do local da ferida: úlceras sacrais, retalho baseado nas perfurantes da artéria glútea superior em 15 (68,2%) casos; úlceras isquiáticas, retalho baseado nos vasos perfurantes da artéria glútea inferior em 3 (13,6%) casos; e úlceras trocantéricas, retalho tensor da fascia lata perfurante em 2 (9,1%) casos. Retalho fasciocutâneo inervado gluteofemoral foi a opção para a reconstrução pós-síndrome de Fournier em um paciente e após ressecção de hidradenite perineal em outro. Houve necessidade de nova sutura para fechamento primário tardio em deiscência < 10% do perímetro da lesão em 3 (13,6%) casos, durante os primeiros 15 dias de pós-operatório. Não houve casos de necrose > 3% da superfície do retalho. Os resultados foram mantidos no período de seguimento avaliado. CONCLUSÕES: Os resultados obtidos no presente estudo foram satisfatórios e ficou demonstrada a utilidade de retalhos cirúrgicos sem incorporação de músculo para reconstruções pelveperineais. Essa alternativa para tratamento é menos mórbida para as áreas doadoras e preserva o tecido muscular para possível intervenção futura.

Free posterior tibial perforator flap for coverage of donor defect of the big toe after free lateral pulp flap transfer

Objective To explore the application of free posterior fibial artery perforator （PIP） flap for coverage of donor defect of the big toe after free lateral pulp flap transfer and decreasing donor site morbidity. Methods From June 2009 to December 2010, 5 cases of soft tissue defect of the thumb and fingers were treated by free transfer of the lateral pulp flap from the big toe. The resulting defects of the donor big toes were repaired by free PIP flap transplantation. Flap donor sites at the calf were directly closed. Results All flaps survived with desirable appearance and sensation, Mean follow-up time was 7 months. Two-point discrimination in the lateral pulp flaps transferred to the thumb and fingers and in the PIP flaps was 5 mm and 7 mm, respectively. Conduslon PIP flap transfer for coverage of donor big toe defect resulted from flee lateral pulp flap transfer is an ideal surgical procedure. It prevents donor site morbidities such as pain and ulceration. Key words: Surgical flaps; Finger injuries; Soft tissue injuries

Central segment harvest of costal cartilage in rhinoplasty

Our objective was to review our experience with a conservative central boat harvest of costal cartilage in patients undergoing rhinoplasty. It involves taking only the central portion of the rib for reconstruction. When cartilage harvest is performed in the above manner, donor site morbidity is minimized without limiting aesthetic results. The key seems to be preservation of intact costal cartilage on three sides, limiting harvest to the central portion only. This central portion is straight and much less prone to warping than the cartilage toward the periphery. A retrospective review of a single surgeon's experience. All rhinoplasty operations performed by the senior author (Y.D.) from January 2000 to August 2009 that required the harvest of rib cartilage were reviewed. A total of 322 cases were identified in which rib cartilage was harvested via the described technique. In all cases sufficient cartilage volume was obtained for the intended purpose. Average operation time was 10 minutes. No drains were used, and only one patient developed seroma formation. Postoperative pain and scar were minimal. No major complications were noted, and on postoperative analysis there was no evidence of cartilage warping or displacement. When harvesting costal cartilage for rhinoplasty, the above technique allows for sufficient graft tissue while decreasing donor site morbidity and minimizing warping.

Fremdmaterialfreie vordere Kreuzbandplastik mit der Patellasehne in Press-fit-Doppelbündeltechnik

Anterior cruciate ligament (ACL) reconstruction using autologous tendons (BTB patellar tendon, hamstrings, quadriceps tendon) in an implant-free fixation technique is becoming more and more popular due to biological and economical reasons. In 1987 an implant-free press-fit fixation technique of a BTB graft from the medial side of the patellar tendon (via mini-arthrotomy) was introduced and first published during the 4th ESKA Conference 1990 in Stockholm. Special emphasis is given to the anatomical orientation of the BTB graft. During the inside-out femoral press-fit fixation the bone-ligament margin of the graft is placed directly into the femoral insertion line of the natural ACL adapting its double-bundle structure. The graft is fixed by press-fit within the tibial metaphysis and its ligamentous part is secured in the metaphysis by harvested cancellous bone blocks driven into the joint line from the outside. The postoperative regime includes weight-bearing as tolerated and free motion. Out of 159 patients 95 could be seen for follow-up after an average of 10.7 years. The final IKDC knee score revealed 22.1% in group A (very good) and 62.1% in group B (good). The Tegner activity level was 6.8 preinjury and 6.0 postoperatively. The average KT 1,000 side-to-side difference was 1.8 mm. Subjectively no patient complained of instability and 99% of the patients could kneel on hard ground with minimal or no complaints. ACL revision surgery due to graft failure was not necessary in any of the patients. Advantages of the described procedure are a narrow anatomical orientation including the double bundle structure of the ACL, rapid graft incorporation by bone-to-bone healing, lack of bone resorption at the graft-host interface, decreased donor site morbidity, cost-effectiveness and ease of possible revision surgery.

Usefulness of polyetheretherketone (PEEK) cage with plate augmentation for anterior arthrodesis in traumatic cervical spine injury

Background context Even though many clinical reports about cages have been documented in patients with degenerative disorders, reports were scarce for traumatic injury cases, and those cases using metal cages were restricted to only one-level injury. Purpose To evaluate the usefulness of polyetheretherketone (PEEK) cage and plate construction in anterior interbody fusions (AIF) for traumatic cervical spine injuries by analyzing radiographic changes and clinical outcomes. Study design/setting Retrospective study. Patient sample Fifty-eight patients (91 levels) underwent cage and plate construction for treatment of traumatic cervical spine injury. Outcome measures The fusion rate, fusion time, changes of Cobb angle, subsidence rate, and adjacent level changes were assessed as a radiographic outcome. Clinical analysis includes the recovery rate on the American Spinal Injury Association (ASIA) impairment scale and the presence of the complications. Methods We evaluated 58 patients (91 levels) who underwent surgery and had at least 24 months in follow-up study. Radiographic evaluation included the assessment of interbody fusion rate, fusion time, changes of Cobb angle, subsidence rate, and adjacent level changes. Clinical assessment was done by analyzing recovery state of ASIA impairment scale from preoperative period to the last follow-up and by evaluating complications. Results Fifty-four cases showed bony fusion within 3 months after the surgery. The mean Cobb angle between the vertebral bodies was 2.54° before operation, 9.13° after operation, and 8.39° at the latest follow-up. The mean intervertebral disc height was increased by 3.01 mm after the operation, but the mean height was 2.17 mm shorter at the last follow-up than after postoperation. In terms of clinical results, five Grade A cases and one Grade B case as assessed by the ASIA impairment scale were unchanged until the last follow-up. Twenty-three cases of Grade C, 16 cases of Grade D, and 13 cases of Grade E improved to seven cases, 26 cases, and 19 cases, respectively. Three cases went through additional surgery, two posterior fusions for delayed union and posterior instability and one AIF for adjacent level disease. Conclusion The PEEK cage and additional plate fixation is a surgical procedure that decreases donor site morbidity, obtains high fusion rate with rigid fixation, and provides satisfactory clinical outcome for traumatic cervical spine injuries, regardless of the numbers of the involved levels.

Central Quadriceps Tendon for Anterior Cruciate Ligament Reconstruction: Long-term Results (SS-33)

Anterior cruciate ligament reconstruction surgery with the central third quadriceps tendon yields a stable, high functioning knee with little associated morbidity at greater than two years of follow-up. The decreased donor site morbidity and absence of anterior knee pain suggest that the quadriceps free tendon autograft offers a reliable, pain-free, low morbidity autograft alternative in ACL reconstruction. Recent data suggest that this graft may be the least morbid of all currently used ACL autograft reconstruction alternatives. To describe the outcome of anterior cruciate ligament reconstruction (ACLR) using central quadriceps free tendon (CQFT) at a minimum of 2 years post-reconstruction. All patients more than two years from CQFT ACLR were invited to participate. Using the IKDC subjective form and an impartial examiner, range of motion, incisional/anterior knee pain, ligament excursion (KT-1000), and single-leg hop test were performed. The uninvolved knee was examined as a control. 124 patients completed the subjective (80) or both IKDC and objective testing (44). Eleven patients had bilateral reconstructions, four patients were revisions, and one patient had a concomitant meniscal repair. Seventy-one patients (42%) were lost to follow-up. There were five graft failures (4%) and one infection requiring re-operation. The average follow-up was 66 months (median 67, range 24 – 105) and the average IDKC score was 84.7 (89.7, 14.9 – 100). No patient had tenderness to palpation at the graft donor site, anterior knee pain, or extension lag. Knee range of motion was symmetric in all patients. The average difference in KT-1000 was 1.2 mm at twenty pounds (1.0, (-2) – 6) and 1.8 mm at manual maximum (1.2, 0.6 – 7.5). Thirty-eight patients (86%) had <3 mm side-to side difference. The single-leg hop test quotient was 0.96 (0.95, 0.65 – 1.35). CQFT is a reliable, low-morbidity autograft for ACL reconstruction with stable outcomes at an average of 5+ years. Most striking is the absence of extension lag, donor site morbidity and anterior knee pain.

The Superficial Inferior Epigastic Artery (SIEA) flap – different indications for breast reconstruction

Introduction: The lower abdominal skin and fat has become a standard for breast reconstruction because the abdominal tissue can mimic the breast to a high degree. According to the increasing safety and routine of the microsurgical interventions nowadays more attention must be paid to donor site morbidity. The Superficial Inferior Epigastric Artery (SIEA) free flap represents the least invasive microsurgical procedure for breast reconstruction because this operation technique negates the harvest of the rectus muscle and the abdominal fascia. The anatomy, the operative technique and the different indications for the SIEA flaps are demonstrated. Patients: The SIEA flap was used in 11 women for breast reconstruction due to breast cancer. The patients ages ranged from 43 to 60 years (mean 52 years). The patients data were reviewed for the following variables: age, indication, uni- or bipedicle SIEA-flap, complications, follow up in years. Results: The mean follow up was 23 months. We had no total flap loss, but one flap showed distal tip necrosis resulting in loss of less than 10% of the flap. Two patients required revision due to hematoma and seroma. The mean period of hospitalization was 11 days. Contralateral breast reduction was performed in two patients and 3 patients required a flap „thinning“ procedure by open technique as secondary procedure. Conclusion: The SIEA flap is safe in the hands of experienced microsurgeons and should be popularized in our opinion. The postoperative results are equal to breast reconstructions with the DIEP or TRAM flap, but with the major advantage of a decreasing donor site morbidity.

The Perforator Pedicled Propeller (PPP) Flap Method: A Report of Two Cases

Perforator flaps are thin free-tissue transfers consisting of skin and subcutaneous tissue which have the advantage of decreasing donor site morbidity. We have reconstructed postburn scar contractures using "propeller flaps" of the remaining healthy skin around the recipient sites. In this paper, we report on two cases and describe the concept of using "perforator flaps" and "propeller flaps" together as what are called "perforator pedicled propeller (PPP) flaps." Patient 1 was an 18-year-old man with a sacral pressure ulcer. The soft tissue defect was reconstructed with a rotated superior gluteal artery PPP flap. Patient 2 was a 53-year-old woman who presented with an open fracture of the right elbow. The skin defect over the fracture was covered with a rotated deep brachial artery PPP flap raised on the lateral upper arm. The PPP flaps are useful for burn reconstruction and repairing various types of wound. Moreover, microsurgery is unnecessary. The PPP flap may be classified into two types: the central axis type and the acentric axis type. The central axis PPP flap is significant when used as a 90-degree-rotation island flap, and the acentric axis PPP flap is significant when used as a 180-degree-rotation island flap. Both types are easy to harvest and useful for repairing various kinds of wound.