A locus for autosomal recessive hypodontia with associated dental anomalies maps to chromosome 16q12.1

Lumbosacral defects on 20 patients were covered with a perforator-based flap. Cutaneous perforators derived from the 9th and 10th intercostal arteries, the 4th lumbar artery, and multiple gluteal perforators that penetrate the gluteus maximus muscle were used as vascular pedicles. Minor complications occurred in five cases. Using this method, minimal morbidity of the donor site is expected because the gluteus maximus need not be sacrificed. Accordingly, perforator-based flaps are especially indicated for ambulatory patients, but for paraplegic patients as well. Even in the event of recurrence, another perforator-based or musculocutaneous flap can be elevated from the ipsilateral side because of the presence of multiple perforators in the lumbosacral and gluteal regions.     

Superior gluteal vessel as recipient for free flap reconstruction of lumbosacral defect

When the lumbosacral soft-tissue defect cannot be closed with a local flap, the option of a free flap should be considered. However, very few cases of free flaps have been reported, the reason being mainly difficulties in finding a suitable recipient vessel. Several vessels, such as inferior gluteal vessel, extension of thoracodorsal vessel with vein graft were reported as recipient vessels, but each one had its own drawbacks. The superior gluteal vessel has been used as a donor vessel in breast reconstruction after mastectomy but is thought to be undesirable as a recipient for microvascular anastomosis, mainly because of technical difficulty. From May of 1993 to March of 1997, five patients (one man and four women) received microvascular transfer of latissimus dorsi myocutaneous flaps using the superior gluteal vessel as a recipient. Their ages ranged from 11 to 64 years (mean 44 years of age). The causes of lumbosacral defects were tumor (1), trauma (1), radiation (2), and pressure sore (1). Before free flap transfer, the patients received an average of 2.8 operations for sacral lesions. Mean follow-up period was 12.4 months (2 to 40 months). A lateral approach was used to the superior gluteal vessel after elevation and retraction of gluteus maximus muscle. A thoracodorsal artery and vein were anastomosed to superior gluteal artery and vein in three cases, whereas in two cases, one artery and two veins could be anastomosed. All the flaps survived with complete recovery from sacral lesions. During the follow-up period, one case of partial skin graft necrosis and one case of a small superficial pressure sore developed, but there was neither dehiscence nor recurrence. The superior gluteal vessel is large in caliber, constant, with numerous branches, lying in proximity to the lesion, and relatively unaffected despite previous radiation. The technical difficulties with the deep location and short pedicle length can be overcome with some modifications in approach to the vascular pedicle. The superior gluteal artery and vein can be used as a recipient for the free tissue transfer when the lumbosacral defects cannot be covered with a conventional method.     

The distally based forearm island flap in hand reconstruction

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.     

Cell cultures and nephrolithiasis

Large bone flaps for free transfer can be successfully and safely harvested based on the deep branch of the superior gluteal artery. The anatomy is consistent, the vessels are large, and the complications of this technique are minimal.     

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.     

Comparative pathogenesis of human WA1 and Babesia microti isolates in a Syrian hamster model

The medial thigh flap is a perforator-based flap nourished with septocutaneous or muscle perforators originating from the femoral vessels. To date, 8 patients have been repaired with this flap and extended or connected flaps including this flap: 4 patients with lower leg defects and 4 patients with intraoral and neck defects. The advantages of this flap are (1) several pedicle perforators exist for this flap, which makes possible duplicated vascular anastomoses to establish reliable circulation of the transferred flap; (2) the flap can be extended or connected to other neighboring flaps in the anterior thigh, so that extensively wide defects can be closed in one stage; (3) the great saphenous vein can be simultaneously used as a vein graft or for venous drainage for the flap; (4) the anterior branch of the femoral nerve can be used for sensory potential; and (5) there is minimum morbidity of the donor defect and a large dominant vessel for the leg can be preserved. The suitable indications for this flap are defects after removal of skin cancer in the foot or lower leg and wide defects after resection of head and neck cancer, which can be reconstructed with the flap connected to neighboring skin flaps. The disadvantages of this flap are that it has a small, short vascular pedicle and the bulkiness of the flap's fatty tissue often requires thinning.     

Remnant-like particle cholesterol levels in patients with dysbetalipoproteinemia or coronary artery disease

Fibula osteocutaneous free tissue transfer to reconstruct the oromandibular complex is a widely recommended technique following oncologic resection. Preoperative determination of adequate perfusion to the donor extremity is necessary to assure lower extremity viability after flap harvest. Vascular variations and/or peripheral arterial occlusive disease (PAOD) may exist whereby sacrifice of peroneal vessels can cause ischemia to the lower leg and foot. Additionally, variability of cutaneous perforators can make the fibula skin paddle viability unpredictable. Color flow Doppler (CFD) is a reliable modality to preoperatively assess the lower extremity in fibula osteocutaneous free tissue transfer patients. Prospective CFD examination of 38 consecutive patients (76 legs) considered for fibula free flap reconstruction was performed. A standard protocol was designed to evaluate the lower extremity vasculature and identify cutaneous perforators with CFD. Findings were studied with respect to flap choice, operative findings, and reconstruction outcomes. Number of cutaneous perforators and their impact on skin paddle design were also recorded. Color flow Doppler's ability to image peroneal vessels as well as determine collateral and distal perfusion were effective. CFD accurately identified bilateral vascular anomalies in one patient (2.6%), and significant arterial disease in three patients (7.9%). Cutaneous perforators were also accurately mapped and confirmed intraoperatively in 31 patients. In several instances, the information provided by the CFD examination altered flap selection, 4/38 patients (10.5%), or skin paddle design, 5/32 patients (15.6%). Color flow Doppler allowed successful fibula transfer in all the free flap candidates with normal exams. It has the advantages of low cost and no morbidity. CFD allows for accurate mapping of fibula cutaneous perforators which facilitates skin paddle design. We recommended the use of preoperative CFD in all patients being considered for fibular free flap surgery.     

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.     

The surgical anatomy of the perforating branches of the basilar artery

The perforating branches of the basilar artery were examined in 14 brain stems injected with india ink or methylmethacrylate. Three groups of the perforators were distinguished: the caudal, the middle, and the rostral. The caudal perforators varied in number from two to five and in diameter from 80 to 600 microns. In addition to their terminal branches, which entered the foramen cecum, the perforators occasionally branched off the pontomedullary artery, the pyramidal vessels, and the hypoglossal branches. The middle perforators arose either separately from the basilar artery or along with the basilar artery collateral branches. They ranged in number from five to nine and in diameter from 210 to 940 microns. The perforators gave rise to the pontomedullary artery (8.3%), the long pontine arteries (25.0%), and the anterolateral vessels (100%). The rostral perforators originated from the terminal part of the basilar artery (91.6%), as well as from the superior cerebellar artery (91.6%) and the posterolateral artery (16.6%). They varied in number from one to five and in diameter from 190 to 800 microns. The anastomoses among various perforating vessels were noted in 41.6 to 66.6% of the cases. The authors discussed the possible clinical significance of the anatomical data observed in this study.     

Treatment of complex postoperative lumbosacral wounds in nonparalyzed patients

Postoperative infections after back operations can produce complex wounds with myonecrosis, deep dead space, and exposed orthopedic hardware, bone, and dura. Three ambulatory patients with complex postoperative back wounds that resulted from infections were treated successfully with antibiotics, debridement, irrigation, and closure of deep dead space with a superior gluteal muscle flap. Several surgical maneuvers can be performed to increase the length of the superior gluteal muscle flap. The inferior portion of the gluteus maximus was left intact to preserve gluteus maximus function. All three patients obtained healed wounds. The exposed A.O. plating system was not removed. There has not been any recurrence of infections. The superior gluteal muscle flap is a reasonable flap to fill deep dead space in the low back and has some advantages over free flaps.     

Anatomical study of the cutaneous perforator arteries and vascularisation of the biceps femoris muscle

We present an anatomical study that describes the distribution of the cutaneous perforators (CP) of both heads of the biceps femoris muscle.

Material and methods

In this study, we dissected 18 legs from nine cadavers. The study was centered on the biceps femoris muscle and musculocutaneous perforator arteries from both muscular heads. Only perforator arteries with comitant vein diameters of over 0.5 mm were selected. The vascular origin and length were also studied. In all cases, measurements were taken from the bicondyle line.

Results

The measurements taken from the muscle bellies of the biceps gave the following results; for the long head 33.91 cm as medium length (SD=2.70) and for the short head 23.85 cm as medium length (SD=2.96).The total number of perforator arteries obtained from the two muscle bellies was 139, with the greatest percentage located in the lower half of the thigh. The majority follow an intramuscular route (80.48%) and less frequently they are septals (19.52%).The lengths of perforator arteries from its origin in the axial vessel of the muscle to the subcutaneous fat were, for the short head 5.01±1.33 (3.0–10.0), whereas the same measurement, in the long head was 4.54±1.36 (2.5–9.0).The principal vascular origin of the perforator arteries was the popliteal artery in both muscle bellies, whilst the second arterial vessel in importance was the first and second profunda perforator artery.

Conclusion

From the results obtained in our work, we can deduce that it is always possible to locate perforator arteries in both muscle bellies; most frequently they have intramuscular distribution and are located in the proximity of the vascular septum. Their most common origins are the popliteal artery and first and second profunda perforator artery. Finally, it is possible to design pedicle and free flaps, with less morbidity and more versatility than musculocutaneous flaps.     

Topographic-anatomic study of tissue transplants of the inguinal region

We performed 25 fresh cadaver dissections to describe the anatomy of the superficial and deep circumflex iliac artery and the superficial inferior epigastric artery to determine how they could least to used as donor vessels for the free transfer of groin flaps and living iliac bone. With injection of ink the capillary region of these vessels was stained in (iliac crest) bone, the internal oblique muscle and skin of the groin and thigh. The superficial and deep circumflex iliac artery were shown to be the main supply vessels of the groin and thigh and could be found in 96%-100% of cases. The venous drainage of this region followed from a superficial system (superficial circumflex iliac veins) and a deep venous system (Vv. comitantes accompanying arterial branches). Both venous systems could always be found. The superficial circumflex iliac artery was shown to only supply the skin and was the main donor vessel to the skin and soft tissue transplants. The deep circumflex iliac artery supplied the pelvic bone, the internal oblique muscle and a small constant area of skin above the iliac crest. Bone, muscle and bone, muscle and skin transplants could be obtained with this donor vessel, with enlargement of the skin area possible by combining two arterial branches combined in one transplant. With an average vessel diameter of 1.5 mm (superficial circumflex iliac artery) and 3 mm (deep circumflex iliac artery) both vessels could be used satisfactorily for microvascular transplantation. Different tissues including muscle, bone and skin could be obtained in adequate amounts to replace composite defects in the upper aerodigestive tract.     

Extra-hippocampal lesions and alteration of didactic knowledge (semantic explicit memory)

The acetabular labrum appears as a bundle of distinctly circular lined up collagenous fibers. It surrounds the limbus tangentially and is separated from the cartilagenous covered facies lunata through a thin gap (fissure) except of a small zone in the craniocaudal part. The labrum is strongly fixed with the transverse acetabular ligament. A vascular anastomotic ring surrounds the capsular attachment. It derives its blood supply especially from the superior gluteal vessels, the obturator artery and one ascending branch of the medial femoral circumflex artery. The innervation of the acetabular labrum is coming from a branch of the nerve to the quadratus femoris muscle and from the obturator nerve. There are all types of mechanoreceptors in the labrum. The acetabular labrum is able to exert a high tensional force on the rim of the acetabulum. This plays a very important role in view of the physiological, load depending incongruity of the articulating parts of the hip-joint.     

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.     

Clinical application of rhombotrapezious island musculocutaneous flap for skull base and/or craniomaxillary operation with malignant tumor

Regional pedicled musculocutaneous flaps are the mainstay of the head and neck reconstruction. They provide a rapid, highly reliable and single-staged technique that is applicable in most cases. The rhombotrapezious island musculocutaneous flap is valuable in the base and craniomaxilloface reconstruction. In this study we updated our experience with the rhombotrapezious island musculocutaneous flap (RTIMF) in 6 cases from 1989 to 1993. Dissections were performed on 9 cadavers, 4 preserved and 5 fresh, yielding 18 pairs or dorsal scapular and transverse cervical artery for evaluation. In the five fresh cadavers, the arteries were selectively cannulated and injected with colored latex. 67% with dorsal scapular and transverse cervical artery commonly arose from the thyro-cervical trunk. 33% with the dorsal scapular artery directly arose from the second part of the subclavian artery. In the period of 1989-1993, 6 rhombotrapezious island musculocutaneous flaps with vascularized pedicle were used for immediate repair in the skull base or craniomaxillary cancer operations. There was no complication of the flaps. Donor site complications were relatively minor. The disturbance in shoulder function was well tolerated. We advocated the incorporation of both the greater and lesser rhomboid muscle to form the compound rhombotrapezious flaps to enhance the vascular supply to the overlying skin. The major advantage of the RTIMF are that it provides a long paddle of thin pliant, hairless skin and muscle that can be rotated as far as the craniomaxilloface and scalp in a single stage. It offers the longest arc of rotation and thus the greatest versatility for the skull base or craniomaxillary reconstruction.     

Relationship between imaging and pathological features and clinical factors in surgical cases of temporal lobe epilepsy]

The advantages of the free TRAM flap over the conventional Tram flap are known. The use of its main pedicle--the deep inferior epigastric system--improves the blood supply, decreasing the risk of skin and fat necrosis. The harvesting of 5-7 cm of muscle, and the preservation of its lateral border decreases the risk of abdominal wall bulge or hernias. Delayed breast reconstructions in patients submitted to radiotherapy were performed by end to side anastomosis between flap vessels and axillary vessels, avoiding the thoracodorsal irradiated vessels, and improving the blood flow. Ten patients were submitted to breast reconstruction by free TRAM flaps. There was one total flap necrosis, and one delayed healing around the periumbilical suture. Neither skin nor fat necrosis were seen. One patient developed an abdominal wall bulge. Two patients presenting tumor metastasis abandoned the plastic surgery outpatient clinic. Two patients refused the nipple-areolar complex (NAC) reconstruction. The outcome of five NAC reconstructions was very good, breasts being symmetrical without an opposite breast operation.     

Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture

Superior gluteal artery injury is a rare but well-known complication of abdominal trauma, usually in association with pelvic fractures. Embolization has become the most effective treatment for pelvic hemorrhage with regard to superior gluteal artery injury, due to difficult surgical access. We report an unusual case of a superior gluteal artery rupture without pelvic fracture. The patient presented with profound hypotension after blunt trauma. Angiography revealed an injured superior gluteal artery, which was successfully embolized.     

Arteriovenous cross-flow flap in rats: a novel skin flap

Angiosomes are blocks of tissues, composed of the integument and underlying deep structures, supplied and drained by a named artery and its accompanying vein. The purpose of the current study is to describe a new principle, which allows extension of the territory of an angiosome into the adjacent angiosome, thus enabling the creation of a large skin flap (arteriovenous cross-flow flap). Epigastric skin flaps, measuring 8 x 8 cm, were raised in 30 Sprague-Dawley male rats. In group A (single-pedicle flap), the flaps were based on the epigastric artery and vein on the ipsilateral side, and the contralateral pedicle was divided. In group B (cross-flow flap), the epigastric vein on the ipsilateral side and the epigastric artery on the contralateral side of the flap were divided. In group C (skin graft), the vascular pedicles were divided bilaterally. A definitive assessment was made on the seventh day. Digital images of the flaps were analyzed using an imaging software and the areas of skin survival and necrosis were determined. Lead oxide microangiogram was performed in another set of flaps both acutely and 1 week after flap elevation. The percent survival flap area in group A was 69.94, in group B was 89.07, and in group C was 13.00. All the groups are statistically different, with a p value < 0.001. The microangiograms showed striking differences in the vascular pattern in the cross-flow and the single-pedicle flaps. It is clearly demonstrated that the arteriovenous cross-flow flaps have increased survival of skin when compared with the conventional axial-pattern flaps.     

Dermal microvasculature and tissue selective thinning techniques (ultrasound and water-jet) of short-time expanded skin in dogs

Certain reconstructive procedures, like auricular reconstructions, require thin and well-vascularized skin. The aims of this study were to analyze if the increased survival of expanded skin flaps was due to morphologic changes of the dermis, if thinning of short-time expanded skin was possible without harm to the microcirculation and if tissue selective cutting methods could be used to resect subcutaneous fat without damaging its vessels. Eighty-two 200-ml expanders were implanted into the trunk regions of 26 beagles and filled immediately with sterile saline. In the first series of experiments, the expansion was terminated after intervals of 0.5-5 weeks and dermal vessels were analyzed morphometrically. In the second series the expanded flaps were raised after 2 weeks and thinned solely surgically or with the additional use of an ultrasonic knife or with cutting by water jet. In contrast to sham flaps, the expanded skin showed only very few areas of necrosis and these were located superficially in most cases. The relative volume of the dermal vessels and their quantity showed a significant increase after the expansion. Additionally, the subcutaneous tissue could be thinned down to 0.4 mm with the water-jet-cutter. Findings demonstrated that the method used could create a well-vascularized skin flap of minimal thickness that could be very helpful for special reconstructive procedures.