Floor plan - 2013 Annual Meeting - American Association for Hand ...

Aesthetic Perforator Free Flap for Soft Tissue Restoration
Institution where the work was prepared: Samsung Medical Center, Seoul, South Korea
Goo-Hyun Mun, MD; Jai-Kyung Pyon; Samsung Medical Center
PURPOSE:
By the increased capability of customized flap tailoring and markedly reduced donor site morbidity with the introduction of perforator
flaps, it is now able to fulfill both functional and aesthetical requirements more so than in the past. As previous approaches with this
concept were mostly limited to the reconstruction of the face or the breast, we are now to introduce authors' cases of elective surgery
for soft tissue restoration in the non-facial region using the concept of aesthetic free flaps.
METHODS:
From March 2006 to May 2007, 10 free flap transfers were performed in 10 patients for aesthetic purposes of the restoration of soft tissue
and/or skin. Reconstruction of the lower extremity was in 6 cases, the upper extremity in 2 cases, the neck and buttock each in 1
case. The patient group was composed of 7 females and 3 males, and age ranged from 14 to 59 years (mean: 31.9 years). After the
utmost important step of recreation of the actual soft tissue defect, precise designing and elevation of the flap was followed by microsurgical
vascular anastomosis and elaborate flap insetting with thickness control.
RESULTS:
Among the 10 cases, the deep inferior epigastric artery perforator (DIEP) free flap was transferred in 6 cases and the thoracodorsal artery
perforator (TDAP) free flap in the 4 cases. Flap sizes ranged from 34 x 20 cm to 18 x 5 cm. All 10 flaps were successfully transferred without
any flap loss. The operative results were able to meet the aesthetic demands of the patients. Further corrections such as debulking
were needed in a patient.
CONCLUSIONS:
With the continuing refinements in perforator flap surgery, microsurgical tissue transfer has become more readily considered armamentarium
in expanded application. Established soft tissue deficit in the non-facial regions developed by the trauma, infection or previous
surgery could be restored to meet the high cosmetic demands of the patients. Aesthetic perforator free flap would be a valuable option
in restoration of soft tissue in various parts of body.
Reconstruction of Segmental Femoral Defects with Living Bone Allografts Combined with
Host-derived Neoangiogenesis: Mechanical, Histologic and Radiographic Analysis
Institution where the work was prepared: Dept. of Orthopedic Surg., Microvasc. Research Lab., Mayo Clinic,
Rochester, MN, USA
Goetz A. Giessler, MD; Patricia F. Friedrich; Allen T. Bishop, MD; Department of Orthopedic Surgery, Mayo Clinic
Living musculoskeletal allografts currently require long-term immunosuppression to maintain viability, impractical due to associated
risks for non-life-critical tissue transplantation. We have previously demonstrated an alternative method using implanted host-derived
vessels to replace the allogeneic nutrient circulation. These vessels maintain measurable blood flow, generate extensive neoangiogeneic
capillaries and form new bone when combined with short-term immunosuppression. In this study, we have used this method to reconstruct
large segmental femoral defects. A segmental femoral defect was created in Dutch-Belted rabbits. Reconstruction was performed
using a free vascularized allogeneic femoral diaphyseal transplant from a New Zealand White rabbit. Rigid fixation allowing
immediate full weight-bearing was performed. In addition to microvascular repair of the nutrient artery circulation, a pedicled inferior
epigastric fascial flap was placed within the medullary canal. Survival time was 16 weeks. Five groups of 10 Dutch-Belted rabbits each
included a pedicled autograft control group, and four allograft groups which varied in fascial flap patency (patent or ligated) and
immunosuppression with 0.08 mg/kg Tacrolimus (+ or -). Healing was quantified by X-ray. Microangiography and Spalteholz bone clearing
allowed quantification of neoangiogenesis. Mechanical properties were evaluated using 4-point bending. Quantitative histomorphometry
assessed bone remodeling. X-ray analysis using a grading schema demonstrated an equivalent healing response when autograft
controls were compared to immunosuppressed allografts with patent fascial flaps. The latter group demonstrated
roentgenograms of faster healing as well as the lowest relative ultimate strength and elastic modulus values of all groups. This is an indication
of biologic activity, including a greater blood supply and a higher rate of bone remodeling than other groups. It correlated with
findings from microangiography (the highest amount of neoangiogenesis among all groups) and histomorphometric analysis of bone
turnover. Not surprisingly, the lowest angiogenesis and bone remodeling values were found in the non-immunosuppressed allograft
femurs with a ligated intramedullary flap. Surgical angiogenesis from host-derived fascial flaps can provide greater blood flow and
improved rates/grading of healing in immunosuppressed allogeneic bone transplants than other groups. Material properties of this
group were also less than the other groups. Thus, while the vascularized tissue allotransplants treated with immunosuppression and fascial
flap implantation maintained flow and viability at levels higher than other groups, we found this to weaken the graft more as well.
As the demonstrated active bone turnover ultimately replaces the graft with host-derived cells, this process in the long-term may result
in a more stable graft with minor rejection.
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