Vascularized Pedicled Flap Research Articles

The vascular channel of the axial flap and the host bed at the earliest period after restricted (not free) transposition

In order to investigate the vascular channel change of the flap and vascular bond formation dynamics in the zone of flap-recipient (host) bed after transposition we worked out an experimental model with different variants of vascular pedicle flap preparation (intact pedicle flap, periarterial, perivenous and combined sympathectomy). The vascular channel was investigated with the help of clinical evaluation and investigation of anatomical macro-micro specimen. Clinical-anatomical finding demonstrates abnormal operation of microcirculatory flap channel after all kinds of vascular wall denervation. It was found out that in any variants of flap transposition conduction, the flap lifting and crippling of surrounding tissues causes unavoidable loss of additional (collateral) blood supply sources and disorder of lymph venous outflow. Conduction of pedicle flap sympathectomy in different variants causes additional abnormalities during integration of complicated tissue complex. Preservation of adventitious membrane of arterial vessels creates the most favorable conditions for flap integration and adaptation.

Maxillary sinus osteoplasty with vascularized pedicled bone flap

This article describes the use of a vascularized pedicled bone flap, superiorly based on schneiderian membrane, for osteoplasty of maxillary sinus. A rectangular bony window was created on the anterior maxillary wall and pedicled from its inner surface with the schneiderian membrane attached to it and left intact superiorly. After the sinus pathology was addressed, the pedicled bony window was repositioned and stabilized with sutures. This technique was performed in 9 maxillary sinuses in 9 patients. A nasoantral window was opened in all of the cases. The follow-up ranged between 12 and 38 months. Healing in all patients was uneventful. In 1 case, a temporary hypoesthesia of the infraorbital nerve was recorded. The procedure provides excellent visibility and access in the maxillary sinus, permitting the use of an advancement buccal pedicled flap for closure of an existing oroantral communication.

The remucosalizing alar cartilage flap: a reconstructive option for repairing nasal septal perforations

The objective of this study is to assess the results of repairing septal perforations with a vascularized pedicled alar cartilage island flap. Using the external rhinoplasty approach, a vascularized flap of alar cartilage, harvested as a cephalic trim and pedicled on the ascending columellar branches of the superior labial artery was raised. Bilateral mucoperichondrial septal flaps were elevated and the alar flap was transposed and secured within the defect and bilaterally overlaid with temporalis fascia. Silastic sheets were placed and remained in situ until the grafts were revascularized from the peripheries of the defect as well as centrally from the alar flap. The revascularized temporalis fascia acted as a scaffold for nasal remucosalization. The alar flap also increased the long-term structural robustness of the repair. Between 1999 and 2003, 14 patients with septal perforations ranging from 10 to 31 mm underwent septal reconstruction using this technique. There were nine males and five females. The flap was successfully raised in all cases and long-term closure was maintained in 12 patients (86%). The alar cartilage flap is an effective technique for repairing septal perforations in selected patients. It provides vascularized tissue which nourishes the grafts during remucosalization, and a cartilaginous framework, which affords long-term structural support to the repair. It also obviates the need to transpose nasal mucosa and create a secondary defect. The rhinoplasty approach furthermore permits additional nasal deformities to be corrected at the same time.

Soft tissue reinforcement interposition flaps in hypospadias repair

ABSTRACT Purpose: To discuss the role and mechanism of action of soft tissue reinforcement interposition flaps (strifs) in hypospadias repairs (reinforced hypospadiac urethroplasties). Materials and methods: between 2000-2005, 120 consecutive hypospadiacs (distal 85, mid 20, proximal 15), who underwent primary reinforced urethroplasties employing different types of strifs, were retrospectively analyzed. the strifs were highly vascular soft tissue pedicled flaps (devoid of epithelium) interposed between neo-urethras and the covering skin to reinforce the neo-urethras against fistula formation. the strifs were harvested, without much donor site deformity, from: preputial skin, penile skin and scrotal skin by de-epithelialization. those from buck′s fascia, corpus spongiosum and tunica vaginalis are strifs without epithelium anyway, therefore do not need de-epithelialization. redo urethroplasties and micropenises were not included. seven patients were excluded because they had incomplete follow-up. the remaining 113 (distal 84, mid 17, proximal 12) were followed up for nine to 40 months for number, size, location, spontaneous closure and persistence of urethro-cutaneous fistula (ucf), and other complications with regard to the severity of hypospadias, method of neourethral re-construction, types of strifs employed and skin cover used. a total of 158 strifs and 124 skin covers were used in 113 hypospadiac urethroplasties. Results: the first surgery was curative in 74 (65%) of 113 patients. in the remaining 39 (35%), various complications included 12 urethro-cutaneous fistulas (ucfs), 10 urethral strictures, six cases each of penile torsion and meatal stenosis and five cases each of superficial necrosis and poor cosmesis. of these 39 patients, 25 (64%) recovered with conservative treatment and 14 (36%) required re-operation, i.e. ucfs and strictures in four cases each and penile torsion, meatal stenosis and dog-ears in two cases each. all the 12 ucfs were single, pinpointed and were located at the corona in five and at the shaft in seven. eight (67%) of the 12 ucfs healed spontaneously during the follow-up period of 12 weeks.Conclusions: harvesting strifs is technically easy, however, great care is required in their handling, accurate placement and suturing over and around the re-constructed neo-urethras for their secured reinforcement against fistula formation. use of strifs in hypospadias repairs decreases fistula-associated morbidity but does not absolutely prevent fistula formation. the strifs reduce the size and prevent multiplicity of ucfs and locate the ucfs eccentrically well away from the neo-urethra to facilitate their spontaneous (conservative) as well as subsequent (surgical) closure. the mechanism of action of strifs is multi-factorial, like acting as a mechanical barrier; preventing suture line superimposition; inducing neo-angio-genesis; working as biological drain; providing mechanical support; and, filling the dead spaces.

Spontaneous Large Volume Adipose Tissue Generation from a Vascularized Pedicled Fat Flap Inside a Chamber Space

A novel method of spontaneous generation of new adipose tissue from an existing fat flap is described. A defined volume of fat flap based on the superficial inferior epigastric vascular pedicle in the rat was elevated and inset into a hollow plastic chamber implanted subcutaneously in the groin of the rat. The chamber walls were either perforated or solid and the chambers either contained poly(D,L-lactic-co-glycolic acid) (PLGA) sponge matrix or not. The contents were analyzed after being in situ for 6 weeks. The total volume of the flap tissue in all groups except the control groups, where the flap was not inserted into the chambers, increased significantly, especially in the perforated chambers (0.08 +/- 0.007 mL baseline compared to 1.2 +/- 0.08 mL in the intact ones). Volume analysis of individual component tissues within the flaps revealed that the adipocyte volume increased and was at a maximum in the chambers without PLGA, where it expanded from 0.04 +/- 0.003 mL at insertion to 0.5 +/- 0.08 mL (1250% increase) in the perforated chambers and to 0.16 +/- 0.03 mL (400% increase) in the intact chambers. Addition of PLGA scaffolds resulted in less fat growth. Histomorphometric analysis rather than simple hypertrophy documented an increased number of adipocytes. The new tissue was highly vascularized and no fat necrosis or atypical changes were observed.

Reconstruction of Neck Scar Contractures Using Supraclavicular Flaps: Retrospective Study of 30 Cases

The supraclavicular flap is used to cover chin and neck region defects. Its main vascular supply is the supraclavicular artery, and it can be harvested as either a skin pedicled flap or an island flap (vascular pedicled flap). The island flap has a wide rotation arc, and both the color and texture match are better for reconstructing contour-sensitive areas such as the chin and neck than those of free flaps harvested from distant sites. Between March of 2001 and November of 2004, 32 supraclavicular flaps were used for reconstructions in 30 patients at the authors' hospital. If circumstances demanded it, the authors transferred the flaps through skin tunnels to reduce continuous scar formation between the donor and recipient sites. Twenty-eight of the 32 flaps survived completely, but there were three cases of distal necrosis and one case of 90 percent necrosis. Twenty-nine of the 30 patients were satisfied with both the functional and aesthetic results. The benefits of the supraclavicular island flap are clear: it is thin but reliable, and easy to harvest.

Soft tissue reinforcement interposition flaps in hypospadias repair

Purpose: To discuss the role and mechanism of action of soft tissue reinforcement interposition flaps (STRIFs) in hypospadias repairs (reinforced hypospadiac urethroplasties). Materials and Methods: Between 2000-2005, 120 consecutive hypospadiacs (distal 85, mid 20, proximal 15), who underwent primary reinforced urethroplasties employing different types of STRIFs, were retrospectively analyzed. The STRIFs were highly vascular soft tissue pedicled flaps (devoid of epithelium) interposed between neo-urethras and the covering skin to reinforce the neo-urethras against fistula formation. The STRIFs were harvested, without much donor site deformity, from: preputial skin, penile skin and scrotal skin by de-epithelialization. Those from Buck's fascia, corpus spongiosum and tunica vaginalis are STRIFs without epithelium anyway, therefore do not need de-epithelialization. Redo urethroplasties and micropenises were not included. Seven patients were excluded because they had incomplete follow-up. The remaining 113 (distal 84, mid 17, proximal 12) were followed up for nine to 40 months for number, size, location, spontaneous closure and persistence of urethro-cutaneous fistula (UCF), and other complications with regard to the severity of hypospadias, method of neourethral re-construction, types of STRIFs employed and skin cover used. A total of 158 STRIFs and 124 skin covers were used in 113 hypospadiac urethroplasties. Results: The first surgery was curative in 74 (65%) of 113 patients. In the remaining 39 (35%), various complications included 12 urethro-cutaneous fistulas (UCFs), 10 urethral strictures, six cases each of penile torsion and meatal stenosis and five cases each of superficial necrosis and poor cosmesis. Of these 39 patients, 25 (64%) recovered with conservative treatment and 14 (36%) required re-operation, i.e. UCFs and strictures in four cases each and penile torsion, meatal stenosis and dog-ears in two cases each. All the 12 UCFs were single, pinpointed and were located at the corona in five and at the shaft in seven. Eight (67%) of the 12 UCFs healed spontaneously during the follow-up period of 12 weeks. Conclusions: Harvesting STRIFs is technically easy, however, great care is required in their handling, accurate placement and suturing over and around the re-constructed neo-urethras for their secured reinforcement against fistula formation. Use of STRIFs in hypospadias repairs decreases fistula-associated morbidity but does not absolutely prevent fistula formation. The STRIFs reduce the size and prevent multiplicity of UCFs and locate the UCFs eccentrically well away from the neo-urethra to facilitate their spontaneous (conservative) as well as subsequent (surgical) closure. The mechanism of action of STRIFs is multi-factorial, like acting as a mechanical barrier; preventing suture line superimposition; inducing neo-angio-genesis; working as biological drain; providing mechanical support; and, filling the dead spaces.

Clinical and Anatomical Study of Superficial Cervical Artery Flaps: Retrospective Study of Reconstructions with 41 Flaps and the Feasibility of Harvesting Them as Perforator Flaps

The superficial cervical artery musculocutaneous flap was first reported by Nakajima and Fujino in 1984; the present authors developed it for use as a skin flap in 1990, and in 1993, they succeeded in harvesting it as a free flap. Since 1986, they have harvested 41 superficial cervical artery flaps of various types from 32 patients to reconstruct head and neck scar contractures and intractable ulcers. In a retrospective clinical study, the authors classified these 41 flaps into three types according to their pedicles: musculocutaneous pedicled flaps (n = 5); muscle pedicled flaps (n = 14), and vascular pedicled flaps (n = 22). In an anatomical study, they harvested 10 flaps from five preserved cadavers and took microangiograms of the trapezius muscle and dorsal skin to identify the distribution of the superficial cervical artery. Thirty-six flaps survived completely, and both the aesthetic and functional results were good. Among the other five flaps, partial necrosis was observed in four and complete necrosis was seen in one. Among the 36 surviving flaps, 23 were more than 30 cm long. The authors fully confirmed from their clinical and anatomical studies that the superficial cervical artery flap is useful for reconstruction of the head and neck regions. In each flap, the superficial cervical artery was found to be a "transverse cervical perforator" or "trapezius perforator" and was large enough to be used as a vascular pedicled flap, suggesting that it can be elevated as a "perforator flap."

Temporary Intentional Leg Shortening and Deformation to Facilitate Wound Closure Using the Ilizarov/Taylor Spatial Frame

Infected tibial nonunions with bone loss pose an extremely challenging problem for the orthopaedic surgeon. A comprehensive approach that addresses the infection, bone quality, and overlying soft-tissue integrity must be considered for a successful outcome. Acute shortening with an Ilizarov frame has been shown to be helpful in the treatment of open tibia fractures with simultaneous bone and soft-tissue loss. Cases in which the soft-tissue defect considerably exceeds bone loss may require an Ilizarov frame along with a concomitant soft-tissue procedure; however, there are a number of potential difficulties with vascularized pedicle flaps and free tissue flaps, including anastomotic complications, partial flap necrosis, and flap failure. The technique described in this report involves acute shortening and temporary bony deformation with the Ilizarov apparatus to facilitate wound closure and does not require a concomitant soft-tissue reconstructive procedure. Once the wound is healed, osseous deformity and length are gradually corrected by distraction osteogenesis with the Ilizarov/Taylor Spatial frame.

The Superficial Cervical Artery Flap: Twenty Years' Experience and Development of the Flap

The superficial cervical artery (SCA) is a superficial branch of the transverse cervical artery. The SCA supplies the upper part of the trapezius muscle. Since 1986, we have harvested SCA flaps for the reconstruction of neck scar contractures and intractable ulcers of the parietal region. We developed the SCA flap for use as a skin flap in 1990, and in 1993 we succeeded in harvesting it as a free flap. We first employed the flap with a musculocutaneous pedicle, but later we developed the flap as a muscle pedicled flap and a vascular pedicled flap. Moreover, we have successfully employed the flap as a "Super-thin flap," and as microvascular augmented flaps for harvesting extremely large flaps safely. In the 1980s and early 1990s the concept of "perforator flaps" was unknown, but the SCA is now considered to be a perforator. Thus, we can call the flap the SCA perforator (SCAP) flap. The SCAP flap has a wide rotation arc and low donor-site morbidity, and our clinical studies clearly show that it is useful for reconstruction.

Venous congestive flap salvage with subcutaneous rtPA

Free-flap success has been the rule with technical advancements in microsurgery. Despite improvements, thrombosis and flap loss still occur occasionally. Salvaging a sick flap can be a harrowing experience, even in the most experienced hands. Thrombolysis using intravenous and intra-arterial urokinase, streptokinase, and/or tissue plasminogen activator (rtPA) administered through the flap vascular pedicle has been reported in free-flap salvages. In such situations, success depends on early diagnosis and emergent exploration. Recently, we successfully used rtPA subcutaneously to salvage a venous congested free transverse rectus abdominus myocutaneous (TRAM) flap. Here, we report on that case.

Use of Cortoss for reconstruction of anterior cranial base: a preliminary clinical experience

Management of cerebrospinal fluid (CSF) leak due to a variety of clinical conditions is a challenging problem for the neurosurgeon, and life-threatening complications can arise unless the CSF leak is handled appropriately. Numerous methods have been described and used for prevention of CSF rhinorrhea, including vascularized pedicle flaps, free vascularized flaps, grafts, and alloplastic materials. The primary objective of this study is to evaluate the role of Cortoss, which provides three-dimensional reconstruction with watertight and weight-bearing support in the treatment of anterior cranial base bony defects. Ten consecutive patients with anterior skull base defects including frontal bone, frontal sinus, cribriform plate, orbital roof, ethmoid sinus, planum sphenoidale, sphenoid sinus, secondary to tumor invasion or traumatic injury were included in this study. The surgical technique is simple and effective, and consists of filling the bony defect with Cortoss. Surgical glue was required for dural repair only. Lumbar CSF drainage in the postoperative period was performed in two patients. These patients had fractures in the lateral walls of their sphenoid sinuses, which were managed via intracranial route. At a mean postoperative follow-up time of 8.9 months, none of the patients had developed complications including infections, meningocele, or recurrent CSF fistula. The use of Cortoss in the case of anterior skull base defects seems to be safe, effective, quick, and a feasible method for reconstruction. This technique may eliminate the use of adjunct materials including fat, muscle, fascia, and bone.

The nutrition of active muscle flaps

In the last 25 years, techniques utilising muscle flaps to perform mechanical work have become part of the reconstructive surgeon's repertoire. In this paper, these techniques and the particular physiological challenges faced by active flaps are discussed and a sub-classification of muscle flaps into passive and active is proposed. A series of experiments are described that were designed to compare local pO(2) and gaseous perfusion, at multiple sites in pedicled tibialis anterior muscle flaps and controls, using specially developed dual amperometric microelectrodes, in an in vivo rabbit model. No significant difference in perfusion was found comparing flaps and controls until the flap's vascular pedicles were divided and ligated, and then flap perfusion fell to zero. Flap and control oxygenation varied significantly only during mobilisation and again, after pedicle division and ligation (F[13,55] = 12.3; P < 0.001)]. This absence of functional ischaemia as a consequence of mobilisation in the model used suggests the practice of delaying electrical conditioning of muscle flaps in dynamic cardiomyoplasty and neoanal sphincteroplasty might be unnecessary if these data are reproduced in human latissimus dorsi muscle. The relevance of these findings to free flap oxygen consumption and to the delay phenomenon is discussed.

Vascularized muscle pedicle flap for osteonecrosis of the femoral head.

Osteonecrosis is a devastating, locally progressive degenerative condition that mainly affects young adults. Osteonecrosis of the femoral head requires biological hip reconstruction. This article describes a technique that uses a vascularized muscle pedicle flap as a viable bone graft for treatment of this condition.

GRACILIS MUSCLE SLING FOR SELECT INCONTINENT “BLADDER EXSTROPHY CRIPPLES”

Functional reconstruction of children born with bladder exstrophy results in a successful outcome in the majority. However, failed bladder neck repair, especially after multiple surgical attempts, compromises the quality of the tissues and, thus, limits surgical options. In these cases conventional sphincteroplasty and other continence procedures, such as rectus sheath sling or artificial urinary sphincters, are ill-advised due to ischemia and fibrosis of the bladder neck. We transferred the gracilis muscle as a vascularized pedicle flap around the bladder neck in 5 children born with bladder exstrophy, of whom 3 were "exstrophy cripples" with multiple previous failed attempts at reconstruction, and 2 were older with failed prior attempts at bladder closure. In the latter 2 cases a 1-stage repair was performed, which included bladder augmentation, ureteroneocystotomy, epispadias repair and bladder neck wrap with gracilis muscle. The other 3 children underwent gracilis muscle wrap of the compromised bladder neck. All 5 children were dry between clean intermittent catheterization 2 to 13 years postoperatively. Complications included urinary tract infection in all 5 cases, stomal stenosis in 2, small bowel obstruction in 1 and bladder stones in 2. However, no complication was related to the gracilis muscle transfer. Vascularized gracilis muscle flap can be used to wrap around the compromised bladder neck of incontinent patients born with bladder exstrophy. The muscle appears to provide a leak proof, cough competent sling that increases bladder outlet resistance and, thus, provides dry intervals between catheterization. The long-term results of up to 13 years have been satisfactory.

Gracilis muscle sling for select incontinent "bladder exstrophy cripples".

Functional reconstruction of children born with bladder exstrophy results in a successful outcome in the majority. However, failed bladder neck repair, especially after multiple surgical attempts, compromises the quality of the tissues and, thus, limits surgical options. In these cases conventional sphincteroplasty and other continence procedures, such as rectus sheath sling or artificial urinary sphincters, are ill-advised due to ischemia and fibrosis of the bladder neck. We transferred the gracilis muscle as a vascularized pedicle flap around the bladder neck in 5 children born with bladder exstrophy, of whom 3 were "exstrophy cripples" with multiple previous failed attempts at reconstruction, and 2 were older with failed prior attempts at bladder closure. In the latter 2 cases a 1-stage repair was performed, which included bladder augmentation, ureteroneocystotomy, epispadias repair and bladder neck wrap with gracilis muscle. The other 3 children underwent gracilis muscle wrap of the compromised bladder neck. All 5 children were dry between clean intermittent catheterization 2 to 13 years postoperatively. Complications included urinary tract infection in all 5 cases, stomal stenosis in 2, small bowel obstruction in 1 and bladder stones in 2. However, no complication was related to the gracilis muscle transfer. Vascularized gracilis muscle flap can be used to wrap around the compromised bladder neck of incontinent patients born with bladder exstrophy. The muscle appears to provide a leak proof, cough competent sling that increases bladder outlet resistance and, thus, provides dry intervals between catheterization. The long-term results of up to 13 years have been satisfactory.

Failure of free flap reconstruction and its prevention

In order to determine the causative factor of microvascular free flap failure and discuss its prevention, we rewiewed 126 patients undergone head and neck reconstruction by the flaps including 67 radial forearm flaps, 26 rectus abdominis myocutaneous flaps, 22 free jejunal flaps, and 11 free colon flaps at Oita Medical University. Out of the total number, 13 flaps (10%) developed a vascular complication and total free flap necrosis occurred in 8 flaps (6.3%). The incidence of diabetes mellitus, hypertension, and previous operation of head and neck was high and they were considered to be risk factors of the free flap f alure. The comlication was due to arterial failure in five flaps and venous congestion in 8 flaps. Cause of the arteial obstruction was thought to be arteriosclerosis which is intrinsic factor of artery itself. Reexploration for the rescue of flaps was attempted, but no flap could be salvaged. The trouble on veins was caused by extrinsic factors that included hematoma and the planning of microvascular anastomosis. Abnormality of the flap was found ralatively early and 5 of 8 flaps could be salvaged. In order to prevent the free flap necrosis, therefore, it was conclued as following. (1) Changing over from a free flap to a vascular pedicled flap should be considered when severe arteriosclerosis is observed during the operation. (2) Avoiding compression of the vein by hematoma and abscess et al, and appropriate planning of microvascular anastomosis are important. (3) The reexploration is initiated as soon as posible in venous congestion.

Topographisch-anatomische studie des lateralen oberarmtransplantats

An anatomic and topographic study of the lateral upper arm free flap for the clinical use in reconstruction. Defects of the laryngopharynx and the oral cavity after cancer ablation are increasingly reconstructed by free microvascular anastomosed tissue transfer. Besides the jejunum transplant we use the free radial forearm flap frequently. This flap is suitable for restoring intraoral and pharyngeal integrity. Major disadvantages are the requirement of a skin graft to obtain wound closure and the cosmetic deformity. The lateral upper arm free flap is intended as alternative method for the fasciocutaneus tissue transfer. Based on our dissection of ten cadavers we demonstrate the anatomy of the flap, the harvesting technique, and present data of vascular pedicle length, vessel calibers, and flap size. The vessel calibers of the profound brachial artery (X = 2.5 mm) and its terminal branch, the posterior radial collateral artery (X = 1.8 mm), are comparable to the radial artery. The pedicle length can be extended up to 13 cm by using a lateral approach. The subcutaneous tissue volume was 1.3 cm in average, and compared to the radial flap rather thick. Because of his bulky and strong fascia the lateral arm flap seems to be useful as a fascia-fat flap in facial augmentation or as a fascia flap in soft tissue reconstruction. Disadvantageous are the difficult dissection technique and the loss of sensitivity on the lateral aspect of the forearm. Where a fasciocutaneous flap is indicated, we prefer the radial forearm flap.

SURGICAL REPAIR OF URETHRAL CIRCUMCISION INJURIES

Purpose The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries. Materials and Methods In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue. Results The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively. Conclusions The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.

Anatomic bases of the vascularized hepatic teres ligament flap.

The hepatic ligamentum teres was investigated in 30 adult specimens. The ligament represents a fibrous remnant of the umbilical v. and a small irregular lumen still exists in the ligament in adult life. The ligament is supplied by one set of independent round ligament a. and paraumbilical vv. Since the proximal segment of the ligament is easily mobilised and since the ligamentous a. originates from the right hepatic a. near the hilum, a proximal vascularized pedicle flap of the ligamentum teres has been recommended. Surgical repair of the extrahepatic bile duct using a vascularized pedicle flap of the ligamentum teres has been carried out successfully in 12 patients.