MRI of the intracerebral lesions at 0.5 Tesla: comparison of fast spin-echo and conventional spin-echo sequences

The purpose of this study was to identify the angiosome of the medial saphenous artery and vein and to evaluate the use of this cutaneous angiosome as a free skin flap in the dog. In phase 1 of this study, selective angiography of the medial saphenous artery performed in six canine cadavers showed that the skin covering the entire medial femorotibial area, the distal half of the caudal head of the sartorius muscle, and the gracilis muscle were perfused by the medial saphenous artery. In phase 2, a medial saphenous fasciocutaneous island flap was raised and sutured back to the skin edges of the donor wound in three dogs. One hundred percent survival of all of the flaps occurred. In phase 3, a medial saphenous fasciocutaneous microvascular free flap was transferred to a wound that was created over the dorsal metacarpal (n = 3) or metatarsal region (n = 3). The mean length +/- SD of the medial saphenous vascular pedicle was 80 +/- 13 mm (n = 5); the mean diameter +/- SD of the medial saphenous artery was 2.8 +/- 0.2 mm (n = 5) and the mean diameter +/- SD of the medial saphenous vein was 4.2 +/- 0.2 mm (n = 5). One hundred percent of all flaps survived (n = 6). Selective angiography or the distal cranial tibial artery (metatarsal wounds, n = 3) and the median artery (metacarpal wound, n = 3) was performed 3 weeks after surgery. All of the vascular anastomoses were patent and neovascularization of the wound beds was present. This free flap was found to be acceptable for cosmetic reconstruction of wounds located on the distal extremity.     

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE: Reconstruction of soft tissue defects on the lower half of the leg. DESIGN: The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus. MATERIALS AND METHODS: Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years). MEASUREMENTS AND MAIN RESULTS: Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally. CONCLUSIONS: The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.     

The "L" reduction mammoplasty

In the breast reduction technique presented, the nipple and areola are carried on a total breast tissue pedicle elevated from the pectoral fascia. Breast tissues are resected inferior to the areola and from the pectoral aspect of the breast. The residual breast tissues are left in continuity with the nipple. Final repair is done with a medial triangular and a lateral rectangular flap. The resulting scar is "L" shaped without a medial component. The technique is applicable for breast reductions, equalizations, and mastopexies. The operation is safe, leaves satisfactory inconspicuous scars, and carries a very low incidence of complications.     

The double dermal keyhole pattern for breast reduction

A small contribution is made to the dependable keyhole pattern in breast reduction. A double dermal modified keyhole closure is described. It is a simple, versatile, and adaptable method of closure regardless of the pedicle technique used for reduction mammaplasty. A triangular flap (skin and dermis) is incorporated on the medial keyhole flap. A deepithelialized dermal flap is created on the lateral keyhole flap. In the final closure of the wound, the medial triangular flap is sutured over the lateral deepithelialized dermal flap. A double dermal closure at the inverted T region is thereby created. The frequency of occurrence of wound spread and early postoperative wound dehiscence is decreased by this closure, which provides cosmetic improvement and wound support where it is needed the most.     

Posterior interosseous free flap: various types

The posterior interosseous artery is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles. The posterior interosseous artery is anatomically united through two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). In the distal part, the posterior interosseous artery joins the anterior interosseous artery to form the distal anastomosis between them. The posterior interosseous flap can be widely used as a reverse flow island flap because it is perfused by anastomoses between the anterior and the posterior interosseous arteries at the level of the wrist. The flap is not reliable whenever there is injury to the distal forearm or the wrist. To circumvent this limitation and to increase the versatility of this flap, we have refined its use as a direct flow free flap. The three types of free flaps used were (1) fasciocutaneous, (2) fasciocutaneous-fascia, and (3) fascia only. Described are 23 posterior interosseous free flaps: 13 fasciocutaneous flaps, 6 fasciocutaneous-fascial flaps, and 4 fascial flaps. There were 13 sensory flaps using the posterior antebrachial cutaneous nerve. The length and external diameter of the pedicle were measured in 35 cases. The length of the pedicle was on average 3.5 cm (range, 3.0 to 4.0 cm) and the external diameter of the artery averaged 2.2 mm (range, 2.0 to 2.5 mm). The hand was the recipient in 21 patients, and the foot in 2. All 23 flaps covered the defect successfully.     

Clinical analysis of 15 patients with primary malignant melanoma in the genital tract

The penetrating wound of palm with the defect of tissues was usually caused by blunt crushing of gun-shot injury. It was difficult to treat clinically. In order to repair the skin defect of palm and dorsum in one operation, 2 kinds of dumbbell-shaped double-leaf flap were desigened. From February 1993 to March 1996, 5 cases with penetrating wound of palm were treated by this method in which the interosseous posterior artery flap in 4, and the superficial epigastric flap in 1. There were 4 males and 1 female with the ages ranging from 15 to 47 years old. The results were as follows: total survival of the flap in 4 cases and partial necrosis of skin margin of the distal leaf in 1 case. The appearance and function of the flap were satisfactory after a follow-up from 4 months to 3 years. It was concluded that the interosseous posterior artery flap had a long vascular pedicle with its constant anatomical distribution, and the 2nd stage of division of the pedicle of the flap was not necessary. It was a perfect flap in repairing the penetrating wound of the palm with small skin defect. The superficial epigastric flap was cumbersome in appearance and was necessary to divide the pedicle of the flap in 2nd staged operation. It was suitable in repairing the penetrating wound with large skin defect. Regarding the operative technique, a meticulous debridement and the appropriate flap area were required, and the blood vessel of the flap should not be compressed by the surrounding tissues. The advantages of this operation provided a simple method to handle, high rate of survival, and one-staged operation.     

Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap

A distally based medial adipofascial flap, based on the lower perforator originating from the posterior tibial vessels, is described. It has been used successfully to cover tibial bone and/or plate exposure on the lower leg in 5 patients.     

Posterior interosseous reverse forearm flap: experience with 80 consecutive cases

The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Alterations of lymphocyte subsets in patients with recurrent fetal wastage positive for antiphospholipid antibodies treated with Chinese herbal medicine

The delay technique is an established method of enhancing flap survival. This investigation attempts to determine which of two delay techniques results in the best delay effect by measuring their relative abilities to capture adjacent vascular territories in a rat model. A dorsal flap based on the iliac branch of the iliolumbar artery with a captured random zone corresponding to the axial territory of the lateral thoracic artery was used in the evaluation. Sprague-Dawley rats (350-400 g) were randomly assigned into three groups. Group I was the control group. In group II, the circumferential borders of the animal's dorsum were incised without undermining and the dominant pedicle of the lateral thoracic flap was divided. In group III, the medial and lateral borders of the flap were incised and undermined as a bipedicled flap, violating the musculocutaneous perforators. The dominant pedicle of the lateral thoracic artery was also divided. Group III had the greatest survival with only 9% of flap area necrosis compared to 28% and 21% for groups I and II, respectively. These differences were statistically significant. The results suggest that musculocutaneous perforators provide a substantial vascular source to the tissue at risk and should be considered in selecting a delay technique.     

An in vitro comparison of apical microleakage after obturation with JS Quick-Fill or lateral condensation

In order to investigate the blood supply of osteo-periosteal flap of lateral inferior part of tibia, 40 lower limbs of adult cadavers were observed. The result showed that the superior malleolar branch was the biggest branch on the lateral inferior part of tibia and served as the main blood supply to the above area. It originated from the anterior tibial artery, 3.1 +/- 0.8 cm above the intermalleolar line. During its way to the anterior border of the tibia, it gave out the ascending and descending branches. The ascending branch was along the anterior border upward and anastomosed with the musculo-periosteol branch of the anterior tibial artery at the level of 6.3 +/- 1.3 cm above the intermalleolar line. The decending branch was anastomosed with the anterior medial malleolar artery. For the anastomosis between the superior malleolar branch with the peripheral vessels, the osteo-periosteol flap could be designed at the lateral side of the lower part of tibia in size of 8-10 cm x 4-6 cm. This was a new donor area of osteo-periosteol flap for repair of non-union of bone in lower end of tibia or arthrodesis of the ankle joint.     

Galeal pedicle flap of the occipital region for pharynx reconstruction: anatomic and clinical considerations

Surgeons are still searching for the ideal method for pharynx reconstruction after tumor ablation. The objective of this study was to prove the anatomic and clinical viability of an occipital galeal pedicle flap for hypopharynx reconstruction. We studied anatomic details in 50 fresh adult cadavers. The dissections were performed after posterior galea exposure, silicone injection in occipital vessels, and mobilization of the galeal flap with an 8 x 8 cm square of galea. We also used the proposed flap in three clinical cases after laryngopharyngectomy. The surgical technique and its problems are described. Some of the anatomic data obtained are as follows: occipital artery diameter, 2.69 mm (mean); occipital artery length, 134.25 mm; area of occipital vessels network on galea, 148.77 cm2; pedicle length, 116.63 mm; and success in rotation to pharynx region (100 percent). The flap showed good functional and cosmetic results when used in three patients. A partial necrosis occurred in one case. The pedicled galeal occipital flap has favorable anatomic characteristics for use in head and neck reconstruction. Additional studies are necessary to provide more substantial information about its clinical viability.     

The anatomic basis and clinical applications of flaps based on the posterior tibial vessels

The vascular anatomy of the posterior tibial vessels has been studied in 20 legs of 10 cadavers. The number, size and distribution of the direct cutaneous and direct muscle branches of the posterior tibial vessels were recorded. For analysis, the leg was divided into four equal segments, Zone I being the most distal and Zone IV the most proximal. The direct cutaneous branches were found to cluster mainly around Zone II. The direct muscle branches to the soleus and flexor digitorum longus muscles arose chiefly in Zones II and III. Based on this knowledge, we performed fasciocutaneous, island soleus muscle, musculo-fasciocutaneous and flexor digitorum longus muscle flaps based on the posterior tibial vessels in 12 patients. Four were free fasciocutaneous flaps and eight were pedicled flaps. All flaps survived and there were no major complications. Delayed wound healing was encountered in three patients.     

Quantum computers and intractable (NP-complete) computing problems

The lateral arm free flap has proved to be both a versatile and successful method of reconstruction. Since its introduction a decade ago, however, its application in head and neck reconstruction has been fairly limited. Dissection of the flap, based on the posterior radial collateral branch of the profunda brachii artery, is relatively simple and provides a thin, dependable flap that has the potential to be used as a osteocutaneous flap or as a fasciocutaneous flap alone. The flap contains a sensory nerve that is readily anastomosed and donor site morbidity is limited. Although the pedicle is short, several modifications exist that allow its extension. This flap has been used successfully to reconstruct various defects in the head and neck. Pertinent anatomy, indications, and guidelines for clinical application will be discussed.     

Mode of vascularization of control and basic fibroblast growth factor-stimulated prefabricated skin flaps

This study, using 62 rabbits, examines the rate and pattern of vascular outgrowth from a subcutaneously implanted vascular pedicle, how the newly formed vessels connect to preexisting skin vessels, and whether local application of basic fibroblast growth factor can accelerate the angiogenic process. When the femoral artery and vein of rabbits are implanted beneath the skin, angiogenesis from both the pedicle and small blood vessels within the adjacent skin begins within 3 days. Perfusion with India ink reveals connections between the pedicle and dermal vessels as early as 5 days after implantation of the pedicle. Provided the pedicle does not thrombose, skin flaps based on it may survive completely when elevated as early as 2 weeks after implantation. Flap survival depends on the development of a small number of vascular connections between vessels arising from the pedicle and preexisting dermal vessels. If elevation is delayed until 4 weeks after implantation a flap may survive even if its pedicle has thrombosed. Prolonged release of basic fibroblast growth factor adjacent to the pedicle significantly increases the survival of flaps elevated 1 week after implantation but does not alter the survival of flaps elevated at 2 and 4 weeks.     

Comparison of two different delay procedures in a rat skin flap model

The overall objective of this study was to investigate how a strategic delay procedure could generate large flaps survival. On the basis of the vascular anatomy in 10 rats, a long three-territory skin flap spanning the length of the rat dorsum was designed. This flap was distally based on the deep circumflex iliac artery. The adjacent territories consisted of a large perforator of the posterior intercostal artery and the lateral thoracic artery in sequence. Two different vascular delay procedures were used and compared in nine animals. One dorsal midline incision was used to perform the two different delay procedures. The limited delay technique was performed by ligating a large cutaneous perforator of the posterior intercostal artery on one side of the rat. The extensive delay procedure was completed by ligating the cutaneous perforators of the posterior intercostal artery and the lateral thoracic artery on the other side of the rat. After a delay period of 10 days, the paired flaps were elevated, respectively, and sutured back in place. Seven days later, the area of viable skin flap was measured by the paper template technique. The animals were then killed, and the dorsal skin arteriograms were obtained by injecting a lead oxide mixture. Vascular changes of the paired flaps were assessed. In the extensive delay group, 100-percent survival was seen in four animals and distal partial necrosis was observed in five animals. The average survival area in the extensive delay group was 85.5 +/- 14.2 percent (mean +/- SD), whereas the flaps in limited delay group showed 100-percent survival in all animals (p < 0.05). In flaps that survived completely, the choke vessels among three vascular territories anastomosed throughout the flap. In the partially necrotic flaps, some choke and true anastomoses existed between the deep circumflex iliac and the posterior intercostal artery territories and the flap necrosis occurred in the third territory. This study suggests that the limited delay technique (ligation of one artery in the territory adjacent to the base of the flap) was the more effective delay procedure in the rat dorsal skin flap model.     

Total knee arthroplasty covered with pedicle peroneal flap

Three cases of total knee arthroplasty (TKA) covered with pedicle peroneal flaps are reported. One peroneal flap was performed after TKA to correct post-TKA skin necrosis. Two peroneal flaps were performed before TKA to replace previous traumatic scar formed around the knee. All three TKAs were successful after the procedure. The thickness, elasticity, appearance, and durability of the peroneal flaps were more suitable for the skin around the knee than the gastrocnemius muscle flap or the local fasciocutaneous flap. As the peroneal flap was elevated as a pedicle flap, freedom of transfer was good, microanastomosis was not necessary, and no donor sites were needed from the contralateral limb. Scar tissue around the knee can be effectively replaced by the pedicle peroneal flap before TKA.     

The second dorsal metacarpal flap with vascular pedicle composed of the second dorsal metacarpal artery and the dorsal carpal branch of radial artery

A pedicle second dorsal metacarpal flap, comprising the second dorsal metacarpal artery, the partial carpal arterial arch of the dorsal hand, and the dorsal carpal branch of radial artery, was designed. The flap may be rotated through two axes of rotation, one at the entry of carpal branch of radial artery into the first dorsal interosseous muscle and one at the entry of the recurrent cutaneous branch arising from the second dorsal metacarpal artery into the skin. The method introduced can increase as much as possible the length of the vascular pedicle of the second dorsal metacarpal flap. Thus, it can cover a small defect at a more distant area. If the width of this flap is not more than 3 cm, the donor site can be closed directly. The flap had been used in five cases with no necrosis of the flap or complication of the donor site. In further investigation of the postoperative patients, no stiffness and tightness have been observed through a short period of rehabilitation of the hand. The results are satisfactory. The anatomy, the operative technique, and three selective cases are described here.     

Nucleotide sequence of plasmid pAQ1 of marine cyanobacterium Synechococcus sp. PCC7002

A delay in identifying incipient flap failure may inevitably lead to complete pedicle thrombosis and the no-reflow phenomenon. The authors report a clinical case of a lateral arm free flap that suffered complete pedicle thrombosis. They successfully salvaged this flap, a type C fasciocutaneous "flow-through" flap, by manually moving the thrombus from proximal to distal in the main flap artery. This freed the septofasciocutaneous upward-perforating branches, by smoothing and applying firm pressure to the vessel, combined with thrombolytic therapy. Their technique is offered as an alternative procedure for salvaging a failing flow-through flap.     

''Low-risk'' myelodysplastic syndrome is associated with excessive apoptosis and an increased ratio of pro- versus anti-apoptotic bcl-2-related proteins

The aim of this study was to develop a free flap of the male prepuce. First, a dissection feasibility study was performed in eight male cadavers. Dissection proved feasible, and the mean surface area of the prepuce, when folded out, was 46.7 cm2. The mean pedicle length was 15 cm, with a mean diameter of the inferior external pudendal artery at its origin of 1.2 mm and a mean diameter of the inferior external pudendal vein at its origin of 1.9 mm. Next, a viability study was performed by isolating a prepuce free flap during male-to-female sex reassignment procedures. The flap as well as the residual skin of the penis shaft remained well perfused. Thereafter, the new prepuce free flap was successfully applied for the reconstruction of defects of the floor of the mouth, tongue, and oropharynx in two patients. The thinness and pliability of the flap, its large surface area, the long vascular pedicle, and the limited donor-site morbidity are the major advantages of this new flap. The possibility to raise the flap simultaneously with the tumor resection is an additional advantage. The small caliber of the flap artery seems to be the only drawback.     

Cerebral revascularization by omental free flap using contralateral superficial temporal vessels as recipient vessels: case report

BACKGROUND: Although the most common technique of cerebral revascularization is superficial temporal artery to middle cerebral artery bypass, we occasionally encounter a situation in which the ipsilateral superficial temporal artery is not available. Treatment may require several techniques including long vein graft bypass. METHODS: A 54-year-old man experienced transient ischemic attacks, and cerebral angiography revealed occlusion of the right common carotid artery. Cerebral blood flow study revealed reduced perfusion reserve capacity of the right cerebral hemisphere. We applied an omental free flap to the brain surface using the contralateral superficial temporal vessels as recipient vessels. RESULTS: Cerebral blood flow study revealed improvement of perfusion reserve capacity. Cerebral angiography revealed good collateral circulation from the omentum to the brain. The patient has not experienced a transient ischemic attack, following additional ligation of the occipital artery 13 months after the first operation. CONCLUSIONS: Because an omental flap has a long pedicle and its circulation can be monitored easily, this method is safe and as effective as a long bypass graft in a patient such as ours in whom the ipsilateral superficial temporal artery is not available for anastomoses.