Muscle Harvest Research Articles

Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

A safe approach to sparing the rectus muscle in abdominal-based microvascular breast reconstruction—TRAM, MS-TRAM, DIEP or SIEA?

There has been an international drive towards the use of abdominal-based perforator (deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA)) flaps for breast reconstruction as they provide the ideal tissue whilst minimizing donor site morbidity, post-operative pain and recovery times. Ultimately, what is desired is a safe and reliable reconstruction. We retrospectively reviewed 245 consecutive abdominal-based free flaps performed by three surgeons at a single institution between January 2002 and March 2008. Primary breast reconstructions were planned as DIEPs, but a safe, flexible approach to flap selection was adopted with the most appropriate flap performed depending on the perforator anatomy at the time of surgery. Chest wall resurfacing procedures for extensive recurrent disease, inflammatory breast carcinoma or following radionecrosis were planned as transverse rectus abdominis myocutaneous (TRAM) flaps. The incidence of flap complications was compared including total and partial flap loss, returns to operating room, seroma, abdominal hernia/bulge, fat necrosis and delayed wound healing. Patient age, body mass index (BMI), smoking status, co-morbidity and pre- and post-operative radiotherapy were recorded. Two hundred patients, mean age 48 years (range, 26–74 years), underwent a total of 245 abdominal-based microvascular breast reconstructions. Twelve salvage TRAM flaps were performed for chest wall resurfacing. Of the remaining 233 flaps, 151 (65%) were immediate and 82 (35%) were delayed reconstructions. Flaps included 171 DIEPs, 38 muscle-sparing (MS)-TRAMs, 2 TRAMs and 22 SIEA flaps. Of the 233 reconstructions, 39 flaps (16.7%) in 31 patients received radiotherapy. Mean follow-up was 2.6 years. There were three (1.3%) complete flap losses and three (1.3%) partial flap losses. Rates of fat necrosis were 3.0% and abdominal hernia/bulge 1.7%. We present an algorithm to aid decision-making in autologous breast reconstruction that reflects our safe flexible approach. We have achieved excellent success rates in autologous breast reconstruction and conclude that in order to minimize complications, a safe flexible approach towards muscle harvest must be maintained in our drive to use perforator flaps.

Robotic Harvest of the Rectus Abdominis Muscle: A Preclinical Investigation and Case Report

In an attempt to decrease donor-site morbidity for rectus abdominis muscle harvest during free tissue transfer, we developed a technique of minimally invasive harvest. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in two cadavers for dissection and harvest of four rectus abdominis muscles. After the cadaver dissections were performed, the technique was used in a 30-year-old woman to harvest the left rectus abdominis muscle for free tissue transfer to a lower extremity defect. Four cadaver dissections for harvest of the rectus abdominis muscle using the da Vinci Surgical System were performed. In the cadavers and actual case, three ports (11 mm, 11 mm, and 15 mm) were used to access the abdominal cavity and perform the dissection. An additional 3 cm incision was used to remove the muscle from the abdominal cavity. The patient has not developed any surgical-site morbidity, including bulge or hernia in the 6 months postprocedure. Minimally invasive harvest of the rectus abdominis muscle is possible with the assistance of the da Vinci Surgical System. Potential benefits may include decreased surgical-site morbidity. Also, this may provide an approach to minimally invasive transperitoneal reconstruction.

Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction

Background Breast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity. Methods The investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy. Results Five patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed. Conclusions For selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.

Myo-mechanical analysis of isolated skeletal muscle.

To assess the in vivo effects of therapeutic interventions for the treatment of muscle disease 1,2,3, quantitative methods are needed that measure force generation and fatigability in treated muscle. We describe a detailed approach to evaluating myo-mechanical properties in freshly explanted hindlimb muscle from the mouse. We describe the atraumatic harvest of mouse extensor digitorum longus muscle, mounting the muscle in a muscle strip myograph (Model 820MS; Danish Myo Technology), and the measurement of maximal twitch and tetanic tension, contraction time, and half-relaxation time, using a square pulse stimulator (Model S48; Grass Technologies). Using these measurements, we demonstrate the calculation of specific twitch and tetanic tension normalized to muscle cross-sectional area, the twitch-to-tetanic tension ratio, the force-frequency relationship curve and the low frequency fatigue curve 4. This analysis provides a method for quantitative comparison between therapeutic interventions in mouse models of muscle disease 1,2,3,5, as well as comparison of the effects of genetic modification on muscle function 6,7,8,9.

Myo-mechanical Analysis of Isolated Skeletal Muscle

To assess the in vivo effects of therapeutic interventions for the treatment of muscle disease 1,2,3, quantitative methods are needed that measure force generation and fatigability in treated muscle. We describe a detailed approach to evaluating myo-mechanical properties in freshly explanted hindlimb muscle from the mouse. We describe the atraumatic harvest of mouse extensor digitorum longus muscle, mounting the muscle in a muscle strip myograph (Model 820MS; Danish Myo Technology), and the measurement of maximal twitch and tetanic tension, contraction time, and half-relaxation time, using a square pulse stimulator (Model S48; Grass Technologies). Using these measurements, we demonstrate the calculation of specific twitch and tetanic tension normalized to muscle cross-sectional area, the twitch-to-tetanic tension ratio, the force-frequency relationship curve and the low frequency fatigue curve 4. This analysis provides a method for quantitative comparison between therapeutic interventions in mouse models of muscle disease 1,2,3,5, as well as comparison of the effects of genetic modification on muscle function 6,7,8,9.

Breast reconstruction using deep inferior epigastric artery perforator flap

Breast reconstruction with autologous tissue has been generally accepted as a reliable procedure, the preferred donor site being lower abdominal tissue. To sacrifice the minimal amount of muscle tissue and to reduce donor site morbidity, the concept of a perforator flap was applied to the fields of breast reconstruction, such as the deep inferior epigastric artery perforator (DIEAp) flap. The DIEAp flap provides essentially the same soft tissue components as the transverse rectus abdominis muscle (TRAM) flap while significantly reducing harvesting of the rectus muscle from the abdominal wall, thereby minimizing donor site morbidity; which includes abdominal weakness, hernia, and postoperative pain, with decreased recovery time. However, there are some concerns about the tedious and risky dissection of intramuscular perforators, and the variable vascularity of the flap supplied by tiny perforators. According to our novel flap harvesting techniques, using bipolar electrocauterization for intramuscular dissection is useful in preventing injury to the tiny perforators. Including some fibers of rectus muscle and soft tissue without full isolation and skeletonization around the pedicles is also useful for prevention of vascular injury and intraoperative vessel spasms. Moreover, the flap must include 2 to 3 reliable perforators, regardless of lateral or medial rows, for prevention of postoperative fat necrosis. The superficial inferior epigastric vein can provide additional venous drainage. These surgical tips can aid in overcoming the pitfalls of the DIEA perforator flap in breast reconstruction. The DIEAp flap is an excellent choice for breast reconstruction. According to our experience, it has been shown to be a safe and reliable method for providing good results and patient satisfaction with minimal donor morbidity in breast reconstruction.

Insulin resistance syndrome blunts the mitochondrial anabolic response following resistance exercise

Metabolic risk factors associated with insulin resistance syndrome may attenuate augmentations in skeletal muscle protein anabolism following contractile activity. The purpose of this study was to investigate whether or not the anabolic response, as defined by an increase in cumulative fractional protein synthesis rates (24-h FSR) following resistance exercise (RE), is blunted in skeletal muscle of a well-established rodent model of insulin resistance syndrome. Four-month-old lean (Fa/?) and obese (fa/fa) Zucker rats engaged in four lower body RE sessions over 8 days, with the last bout occurring 16 h prior to muscle harvest. A priming dose of deuterium oxide ((2)H(2)O) and (2)H(2)O-enriched drinking water were administered 24 h prior to euthanization for assessment of cumulative FSR. Fractional synthesis rates of mixed (-5%), mitochondrial (-1%), and cytosolic (+15%), but not myofibrillar, proteins (-16%, P = 0.012) were normal or elevated in gastrocnemius muscle of unexercised obese rats. No statistical differences were found in the anabolic response of cytosolic and myofibrillar subfractions between phenotypes, but obese rats were not able to augment 24-h FSR of mitochondria to the same extent as lean rats following RE (+14% vs. +28%, respectively). We conclude that the mature obese Zucker rat exhibits a mild, myofibrillar-specific suppression in basal FSR and a blunted mitochondrial response to contractile activity in mixed gastrocnemius muscle. These findings underscore the importance of assessing synthesis rates of specific myocellular subfractions to fully elucidate perturbations in basal protein turnover rates and differential adaptations to exercise stimuli in metabolic disease.

Reply

Sir: Momemi et al. question the value of the gracilis perforator flap. In their opinion, a complex dissection is not justified to save the gracilis muscle, which is functionally not relevant. We would like to answer first their technical comments and second the general need for the gracilis perforator flap. First, Momemi et al. mention concern about muscle viability after harvest of the extended gracilis perforator flap. The gracilis muscle has more than two pedicles: Macchi et al. report two to five pedicles,1 and Cavadas et al. report three to four pedicles.2 Shatari et al. always found some arteries at the origin of the muscle having a mean maximum diameter of 0.34 mm and suggested that they might be able to support the whole gracilis without supply from the main pedicle.3 Our clinical experience confirms more than two pedicles. Theoretically, it might therefore be possible that a nonvascularized muscle is left behind if two pedicles are incorporated. However, we did not encounter this in clinical practice, and most likely other pedicles supply the gracilis muscle. The argument of a functional impairment with the extended gracilis flap caused by an intramuscular dissection and scarring is rather surprising. Even with complete muscle harvest, a functional impairment is not likely; therefore, we do not believe that intramuscular dissection results in impairment. We performed an intraoperative neural stimulation of a proximal aspect of the intact obturator nerve. This resulted in gracilis muscle contraction and does—in our opinion—very well reflect a functional neuromuscular unit that we left behind after harvest of the perforator flap. Obviously, if only the muscle itself is stimulated, this does not show anything about an intact neuromuscular unit. The transverse incision for raising the gracilis muscle flap is definitely a technical improvement.4,5 Regarding a skin island, we have taken the gracilis muscle with a transverse, vertical, or combined skin island. The quality of the scar can vary significantly, and we have seen excellent and unacceptable scars with either skin flap. With a larger transverse flap, the scar commonly descends distally. With a smaller transverse flap, tissue bulk is limited. Schoeller et al.5 had to use bilateral gracilis flaps to reconstruct one breast in 15.3 percent of their reconstructions. Some indications therefore require the longitudinal flap design, which allows for a larger tissue bulk and which still leaves an acceptable scar on the inner thigh. Second, we agree that indications for the gracilis perforator flap are rare, and—according to the literature—harvest of the gracilis muscle does not cause any clinically relevant impairment. Saving the muscle is therefore not our primary indication, but the need for a thin fasciocutaneous flap is. The same applies to the anterolateral thigh flap. Harvesting a muscle cuff of the vastus lateralis has—to our knowledge—not shown any functional impairment. For many indications, perforator flaps have become state of the art, with better aesthetic results, decreased donor-site morbidity, and increased quality of life. Whereas the first perforator flaps—such as the deep inferior epigastric perforator flap—have revolutionized microsurgical reconstruction, more recent achievements such as the thoracodorsal artery perforator flap or superficial gluteal artery perforator flap have had less impact. Still, these flaps have enriched the family of perforator flaps, as does the gracilis perforator flap. Even if indications are rare, the gracilis perforator flap is a useful addition to the techniques available for reconstruction. Steffen P. Baumeister, M.D. Department of Plastic and Reconstructive Surgery Markus Krankenhaus Frankfurt, Germany Alberto Peek, M.D. Clinic of Plastic Surgery Holle & Peek Frankfurt, Germany

PR15 NEW TECHNIQUE IN PERINEAL AND POSTERIOR VAGINAL WALL RECONSTRUCTION: SUPERIOR AND INFERIOR GLUTEAL ARTERY PERFORATOR FLAPS

Purpose: Perineal and posterior vaginal wall reconstruction following abdominoperineal and local cancer resection requires replacement of dead space and restoration of function. Ideal reconstructive options include those which avoid muscle sacrifice, do not interfere with colostomy formation, and avoid the use of irradiated tissue.Methodology: We present our experience with a new technique for perineal and vaginal reconstruction: superior and inferior gluteal artery perforator (SGAP or IGAP) flaps. We describe the operative technique and outcome in 14 consecutive patients. Six cases were performed as primary reconstruction and 8 cases were delayed, with all receiving preoperative radiotherapy.Results: Immediate reconstructions underwent preoperative imaging with ultrasound only, while delayed reconstructions underwent preoperative CTA. Postoperatively, patients were ambulated immediately, with all bed rest and sitting performed on the contralateral buttock or side for 4 weeks. There were no flap failures or partial flap losses, and no postoperative hernias. Four patients developed early minor wound dehiscence that was resutured in three cases. Revisional surgery was performed for reduction of three bulky flaps. All female patients reported resumption of sexual intercourse following this procedure.Conclusion: Gluteal artery perforator flaps are good options for perineal reconstruction, avoiding the donor site morbidity associated with rectus abdominis or gluteus maximus muscle harvest.

The Effects of botulinum toxin A on muscle histology during distraction osteogenesis

Distraction osteogenesis is a highly successful method of bone formation, yet muscle fibrosis and contractures can result in significant morbidity. In the current study, we investigate the efficacy of botulinum toxin A in preventing fibrosis and potentially increasing muscle development in distracted muscles. Fifteen New Zealand White rabbits underwent tibial distraction at 1.5 mm/day until a 20% gain was achieved. Treatment groups were divided by drug (saline or botulinum toxin) and target muscle (gastrocnemius or tibialis anterior). Two additional control animals received no treatment. Bromeodeoxyuridine was delivered continuously throughout the 8-week experiment, and following muscle harvest. Tissues were stained for BrdU, Pax-7, vimentin, and haematoxylin and eosin staining. Mitotic activity increased in all distracted animals; however, in the animals receiving botulinum toxin A injections into the gastrocnemius, the antagonist tibialis anterior suffered up to 9% less fibrosis than distraction alone (p = 0.024). Use of botulinum A toxin did not appear to promote or improve neogenesis of muscle fibers, nor did it decrease fibrosis in the injected muscles. It appears from this study, and a previously published study on the effects of this toxin on muscle function, that botulinum A toxin maybe of some benefit in decreasing morbidity in the antagonist muscle but not the muscle injected with the toxin.

The Semi-Open Approach to the Gracilis Muscle Flap: Aesthetic Refinements in Gracilis Muscle Harvest

The gracilis muscle flap is certainly among the most versatile sources of vascularized tissue available for microsurgical reconstruction. However, the aesthetic appearance of the resultant scar has frequently been a source of dissatisfaction. Various minimal invasive techniques have been proposed, all of which aim to reduce scar formation. Drawbacks of endoscopic techniques, however, include a steep learning curve as well the need for special technical equipment. A semi-open approach without endoscopic assistance is presented, characterized by a short transverse incision in the groin area without a counterincision distally. This technique was performed in six patients (mean age, 48.8 years). Mean incision length was 8.8 cm, and average muscle harvesting time was 49 minutes. We suggest the semi-open approach to the gracilis muscle flap because it does not require special instruments and training and is characterized by easy performance and a short incision in the inconspicuous groin area with resultant better cosmesis.

Angiogenesis induced by autologous whole bone marrow stem cells transplantation.

It has been presumed that unknown cells and growth factors in bone marrow might promote angiogenesis, so angiogenesis effect could be enhanced by autologous whole bone marrow (WBM) stem cell transplantation. We compared capillary ratio induced by autologous WBM and bone marrow-mononuclear cells (BM-MNCs) to evaluate the anigiogenic effect of auotologous WBM. In addition, the combined effect of WBM transplantation and granulocyte colony-stimulating factor (G-CSF) injection was examined in an ischemic canine model. After creating ischemic limb model, autologous WBM and isolated BM-MNCs were transplanted into the ischemic muscle. In other experiments, autologous WBM with recombinant human G-CSF (rhG-CSF) and autologous WBM without rhG-CSF were transplanted into the ischemic muscle. In this study, normal saline was injected into the contralateral sites in each ischemic model as a control group. After 8 weeks of transplantation, angiography and muscle harvest were performed, and then the anigiographic findings and capillary density, as assessed by immunohistochemical staining, were investigated and analyzed. In comparison with the control group, BM-MNCs and WBM transplantation groups showed higher ratios of the capillary density (1.5±0.01 times, p<0.001 and 1.6±0.15 times, p=0.005, respectively). Between the BM-MNCs and WBM transplantation groups, the capillary ratio was 1.2 folds higher in the WBM group than that in the BM-MNCs group, but there was no significantly different (p=0.116). The angiogensis ratios of both the WBM without G-CSF group and the WBM with G-CSF groups were higher (1.6±0.15 times, p=0.004 and 1.8 ±0.01 times, p=0.005, respectively) than that of the control groups. In comparison with the WBM without G-CSF group, the WBM with G-CSF transplantation group revealed a 1.1 folds higher angiogenesis ratio, but there was no statistically significant difference (p=0.095). Autologous WBM transplantation is a simpler method and it is not inferior for inducing therapeutic angiogenesis as compared with isolated BM-MNCs transplantation. In addition to autologous WBM transplantation, intravenous G-CSF injection enhances the angiogenic effect of autologous WBM in an ischemic limb.

Harvest of latissimus dorsi muscle for intrathoracic transposition: is it always necessary to harvest the whole muscle?

We read with interest the paper by Abolhoda et al. about a harvest technique for pedicled transposition of latissimus dorsi muscle, and congratulate the authors [1]. We are used to transpose intrathoracically the whole latissimus dorsi muscle to obliterate an infected apical or mid-thoracic dead space and we use the same technique as described by the authors but we have modified the harvest technique when we use the latissimus dorsi muscle to protect a bronchial stump at risk of bronchial insufficiency. The latissimus dorsi vasculature is such that vascular supply to the muscle is based on the thoracodorsal vessels. Once these vessels enter the muscle they show a constant division into a horizontal branch and a branch that runs about 2.5 cm medial and parallel to the anterior muscle border [2]; thus an ideal condition for the creation of a split muscle flap with a great rotation arc that can be placed into the chest cavity without tension and can be stuck on the bronchial stump atriskofinsufficiency.Thissplit muscleflapisbasedon the lateral branch only of thoracodorsal vessels that can be easily observed and controlled while raising the flap. This harvest technique is very easy and quicker than the harvest technique required for the whole latissimus dorsi, the bulk of the split muscle flap is such that it can be passed through an intercostal space even without rib resection and the flap is very well vascularised. We have since now used this technique in 13 patients with bronchial stump at risk of bronchial insufficiency with good results and without any complication.

Increased Antiangiogenic Protein Expression in the Skeletal Muscle of Diabetic Swine and Patients

Antiangiogenic protein expression is increased in skeletal muscle in the setting of diabetes. In animal studies, diabetes was induced in 8 Yucatan miniswine via single alloxan injection at age 8 months, followed by skeletal muscle harvest 15 weeks later. Eight nondiabetic Yucatan miniswine served as controls. In patient studies, skeletal muscle was harvested from 11 nondiabetic patients and 10 patients with type 2 diabetes mellitus undergoing initial elective coronary artery bypass graft surgery. Skeletal muscle samples were analyzed via Western blotting and zymography for protein expression and enzyme activity. The study was performed in an academic medical center. Skeletal muscle expression of plasminogen, collagen XVIII, angiostatin, endostatin, matrix metalloproteinases 2 and 9, and tissue inhibitor of metalloproteinase 2. Skeletal muscle expression of plasminogen and collagen XVIII (precursors of angiostatin and endostatin, respectively) remained similar between nondiabetic and diabetic swine and patients. Expression of angiostatin and endostatin was increased 1.70-fold and 1.84-fold, respectively, in diabetic swine relative to control swine. Endostatin expression was increased 1.69-fold in diabetic patients relative to nondiabetic patients. Matrix metalloproteinase 2 expression and activity were significantly increased in the skeletal muscle of diabetic swine and patients. Antiangiogenic protein levels are increased in the skeletal muscle in the setting of diabetes. Angiostatin, endostatin, and matrix metalloproteinases may offer novel therapeutic targets to improve collateral formation in patients with diabetes.

Value of latissimus dorsi flap (LDF) in breast conserving surgery (BCS)

This paper describes a method of immediate breast reconstruction following conservative breast surgery. The technique is innovative in that axillary clearance, quadrantectomy and the harvest of the latissimus dorsi muscle are carried out through a small transverse axillary incision with no incision in the breast.

The pectoralis major muscle flap in reconstruction of secondary breast cancer

The use of a new technique for harvesting of the pectoralis major muscle in the reconstruction of locally recurrent breast cancer is presented and illustrated in two cases. This technique provides the versatility of the myocutaneous flap but avoids the significant donor site morbidity and unreliability of the skin paddle.

Partial muscle harvest: Our first 100 cases attempting to preserve form and function at the donor site

The authors report their first 100 partial muscle flaps as a strategy to preserve form and function of the donor site in muscle transplantation. Between 2003 and 2007, 62 partial superior latissimus (PSL) flaps and 38 partial medial rectus (PMR) flaps were transplanted for head and neck, upper and lower extremity, and chest wall reconstruction. All flaps survived. There were hematomas at the donor sites in two PMR cases. Form and function were preserved at the donor site in all cases. The PSL provided comparable muscle volume and pedicle length to the entire rectus abdominis muscle. An additional benefit was its use as a functional muscle. The PMR flap provided comparable muscle volume to the gracilis muscle. An additional benefit was a much longer vascular pedicle. Small to moderate sized flaps can be harvested from the fabric of the latissimus dorsi and rectus abdomenis muscles and be reliably transplanted. When positioned at the superior edge of the latissimus or medial edge of the rectus muscle, adequate blood flow and innervation to the residual muscle result in preservation of form and function at the donor site. The benefits of muscle transplantation can be realized without the associated morbidity of muscle harvest.

Use of Kirschner Wires as Endoscopic Retractors

We read with great interest the article of Dr. da Silva Freitas [1] titled Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases, which presents an up-to-date and useful therapy scheme. Of special interest to us was the use of the endoscopic technique for latissimus dorsi musculocutaneous flap harvest as an option for reconstruction of pectoralis major muscle agenesis in one of their cases. This demonstrates clearly that the number of endoscopic interventions in the repertoire of the plastic surgeon is growing very rapidly. Unfortunately, the steep learning curve and dependence on expensive equipment can be discouraging for the beginner. Innovative alterations of the technique are therefore of the utmost importance because they can cut down on equipment costs and overcome technical obstacles. The technique for endoscopically assisted harvest of latissimus dorsi muscle has been given detailed description in the literature previously by various authors [2,3]. Except for personal preferences and differences of infrastructure, the technique is well settled and reliable. One of the few technical points about which a disagreement still exists concerns the creation and maintenance of the optic cavity. Various techniques have been used besides carbon dioxide insufflation, with varying degrees of success, such as balloon dissection and hydrodissection [4]. Both of these methods have received positive and negative criticism. We present a simple method for assisting flap dissection and increasing exposure in a patient with Poland’s syndrome. A 19-year-old boy presented with a left pectoralis muscle agenesis. An axillary incision and three 5-mm ports were used for flap harvest and inset. Figure 1 shows the use of two Kirschner wires with a diameter of 3 mm to maintain the subcutaneous working space. The first Kirschner wire is placed through the axillary incision parallel to the anterior axillary line. The second wire is placed parallel and posterior to the first one. When both wires are elevated simultaneously, they create a ‘‘tent’’ over the dissected portion of the muscle, which leads to greater exposure of the working space. As the dissection proceeds, the wires can be repositioned for better visualization. The dissection of the most medial portions of the latissimus dorsi muscle where it fuses with the spinal muscles is especially facilitated. The wires can be used for the recipient site in a similar fashion. This innovation enabled us to control a wide field endoscopically with little effort and to reduce the operation time.

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.