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Donor-site morbidity in four patients after reconstruction with free neurovascular rectus femoris muscle was examined through a series of strength tests in which the leg with rectus femoris muscle harvested was compared with the contralateral leg with an intact rectus femoris muscle. The tests were conducted with three testing devices: (1) the 'Con-Trex Leg-press' in which the force and power of right and left leg extensions at 0.2 and 0.4 m/s in a knee angle from 50 to 90 degrees were tested separately; (2) the isometric power tester, which enabled the unilateral evaluation of the isometric leg extension at three knee angles: 50, 70 and 90 degrees ; and (3) at the 'SP-Force Platforms' in which the patients performed a counter-movement jump where the amplitude of the ground reaction force, the parameters maximum force, and the jump height were calculated in order to compare the right and left leg during a single dynamic movement. Our results showed that the patients (with one exception) demonstrated a balanced relationship between the donor leg and the intact contralateral leg. The patient that primarily demonstrated a large strength deficit was retested 3 months later and showed, after an extensive rehabilitation and training program, an impressive increase in strength. The authors concluded that there is no significant limitation in the strength of the donor leg after removal of the rectus femoris muscle and consequently no significant functional donor-site morbidity. We believe that for the realisation of such results that the intraoperative linking of the vastus lateralis muscle with the vastus medialis muscle, especially in their lower third, and an extensive postoperative rehabilitation and training program are essential.

Background: The gluteal fold represents an important aspect of the gluteal region. Destruction of this anatomic landmark as a consequence of trauma or tissue harvest can result in an aesthetically disturbing disfigurement. A technique for reconstruction of the gluteal fold and preliminary results are presented., Methods: The newly formed gluteal fold is created by fixation of a deepithelialized skin flap to the periosteum of the tuber ischiadicum., Results: The operative procedure is quick and easy to apply. The method is used mainly for patients with a distorted gluteal fold after tissue harvest for breast reconstruction. However, it also can be used after trauma such as that associated with burn injuries. In all patients, reconstruction of the gluteal fold yielded aesthetically pleasing and reliable results with high patient satisfaction., Conclusions: The authors present a simple and effective technique for reconstruction of the gluteal fold by a deepithelialized skin flap. The technique is applicable for patients who have lost their natural gluteal sulcus, with a resultant altered buttock shape, after trauma or other causes.

Microsurgical tissue transfer has constantly improved the therapeutic options for reconstruction in the head and neck region, but the ideal flap has yet to be found. The purpose of this study is to discuss the aesthetic potential of the free gracilis muscle flap in difficult head and neck reconstruction. We report our experience with the free gracilis muscle flap in seven patients who underwent reconstruction in the head and neck region for a variety of indications. In all seven patients, the transplanted muscle flaps healed well, with no flap loss. Postoperative complications consisted of skin-graft loss in one patient requiring a second split-thickness skin graft. Donor-site morbidity was minimal in all patients. For difficult reconstruction in the head and neck region, the free gracilis muscle flap offers a number of advantages, including reliable vascular anatomy, relatively great plasticity, and a concealed donor area. Thus this type of flap offers a valuable option whenever an aesthetically pleasing result is sought., (Copyright (c) 2005 Wiley-Liss, Inc.)

After harvesting of the sural nerve, the patient developed a partial palsy of the common peroneal nerve due to a lesion of the peroneal nerve and a neuroma of the sural nerve stump. Motor function recovered after performing neurolysis of the common peroneal nerve and mobilization of the neuroma. The sural nerve, in this case originating from the common peroneal nerve, was harvested using a nerve stripper and four small skin incisions. Direct lesion by the forced use of the nerve-stripping instrument followed by the formation of a neuroma close to the peroneal nerve are the suspected reasons for motor dysfunction. Although many authors report using a nerve stripper as a safe, less invasive method to gain nerve material for transplantation, we recommend lengthening the skin incision so as to be aware of anatomical variations and to refrain from pulling the nerve distally to avoid the described complications.

Background: It is common for traumatologists to see avulsion injuries with resulting composite skin flaps. Simply reattaching the avulsed flap by suturing it back into its bed may result in ischemic necrosis of the distal portion of the flap., Case Report: The authors present a case in which an extensive avulsion injury of the dorsum of the foot with amputation of the fourth and fifth toe was treated by defatting the avulsed flap and reattachment as a full-thickness graft. Healing was uneventful and no skin necrosis was encountered. At 1-year follow-up there was a stable skin situation at the dorsum of the foot. The patient has no difficulties with wearing shoes. However, there is diminished sensibility., Conclusions: Indications for this type of surgical technique include all types of avulsion or degloving injuries that create composite skin flaps prone to undergo ischemic necrosis if simply reattached. This quick and easy method should be in the armamentarium of each surgeon possibly dealing with this type of injury.

The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients' ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.

Objective: The purpose of this article is to report our preliminary results regarding microsurgical repair of the sural nerve after nerve biopsy, in an attempt to reduce the well-described sensory morbidity and neuroma formation., Methods: Three patients with a suspected diagnosis of peripheral neuropathy underwent sural nerve biopsies to establish definitive diagnoses. A 10-mm segment of the sural nerve was resected with local anesthesia. After harvesting of the specimen, the proximal and distal nerve stumps were carefully mobilized and united with epineural suture techniques, under a surgical microscope. Sensory evaluations (assessing the presence of hypesthesia/dysesthesia or pain) of the lateral aspect of the foot, in regions designated Areas 1, 2, and 3, were performed before and 6 and 12 months after the biopsies. A visual analog scale was used for pain estimation., Results: The biopsy material was sufficient for histopathological examinations in all cases, leading to conclusive diagnoses (vasculitis in two cases and amyloidosis in one case). The early post-biopsy hypesthesia, which was present for 4 to 8 weeks, improved to preoperative levels as early as 6 months after the nerve repair. Sensory evaluations performed at 6- and 12-month follow-up times demonstrated that none of the patients complained of pain at the biopsy site or distally in the area innervated by the sural nerve. Ultrasonography performed at the 12-month follow-up examination revealed normal sural nerve morphological features, with no neuroma formation, comparable to findings for the contralateral site., Conclusion: Microsurgical repair of the sural nerve after biopsy can eliminate or reduce sensory disturbances such as paraesthesia, hypesthesia, and dysesthesia distal to the biopsy site, in the distribution of the sensory innervation of the sural nerve, and can prevent painful neuroma formation. To our knowledge, this article is the first in the literature to report on microsurgical repair of the sural nerve after nerve biopsy. Decreased side effects suggest that this technique can become a standard procedure after sural nerve biopsy, which is commonly required to establish the diagnosis of various diseases, such as peripheral nerve pathological conditions, vasculitis, and amyloidosis. More cases should be analyzed, however, to explore the usefulness of the technique and the reliability of sural nerve biopsy samples in attempts to obtain conclusive diagnoses.

The search for a reliable technique for functional genitourinary tissue replacement remains a challenging task. The most recent advances in cell biology and tissue engineering have utilized various avascular and acellular collagen scaffolds with or without seeded cells. These techniques, however, are frequently complicated by tissue necrosis, contracture and resorption due to limited vascularization. We employed a new three-stage, evolving animal model with stage I optimizing the culture delivery vehicle, stage II employing a seeded vascularized capsule flap, and stage III adding a contractile matrix in the form of pedicled gracilis muscle prelaminated with autologous, in vitro-expanded urothelial cells to reconstruct an entire supratrigonal bladder-wall defect in rats.Specimens stained with hematoxylin and eosin (H&E), alpha(1)-actin staining, and a specific immunohistochemical staining (AE(1)&AE(3)-anticytoceratin monoclonal antibody stain) showed a continuous, multilayered, functioning urothelial lining along the transposed prelaminated gracilis flap in the animals of the final-stage experiment. Successful urinary reconstruction requires a contractile neoreservoir resistant to resorption over time and a stable, protective urothelial lining. We demonstrated that a gracilis muscle flap can be seeded with autologous cultured urothelial cells suspended in fibrin glue. This prelaminated flap can be safely transposed onto its pedicle and become successfully integrated into the remaining bladder wall, demonstrating urothelial lining and the potential to contract. Further studies in larger animals with urodynamic assessment is warranted to determine if this type of bladder-wall replacement technique is suitable for urinary reconstruction in humans.

Tissue expansion is an established method for the correction of scars and tissue defects. During pregnancy the abdominal skin becomes gradually stretched over the growing uterus, providing a "natural" tissue expander. We present a case of a woman with posttraumatic scarring of the lower abdomen and thigh where tissue expansion during pregnancy was successfully used for scar correction.

Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.

In severely injured lower extremities with loss of the anterior compartment, the free functional rectus femoris musculocutaneous flap was used to restore extension of the foot and in soft-tissue reconstruction. From June 2000-July 2002, 3 patients were treated with this technique. Mean follow-up of the 3 patients was 27 months. Electromyography and the Stanmore system (recording pain, need for orthosis, ability to wear normal shoes, activity level, muscle power, active extension of the foot, and foot posture) were used to assess results of functional rectus femoris transfer. One patient had an excellent result, one patient had a good result, and one patient had a poor result, as assessed by the Stanmore system. Free functional rectus femoris transfer can obtain excellent results in treating foot-drop and soft-tissue defects due to lower leg compartment syndrome and loss of all muscles of the anterior compartment. (c), ((c) 2004 Wiley-Liss, Inc.)

The anteromedial thigh (AMT) flap is reviewed in terms of its vascular anatomy and previous clinical reports in the literature. Our own series of 5 patients treated with this flap for defects in the head and neck region and lower extremity is presented. Although several authors controversially discussed vasculature, we constantly found the pedicle as an emerging septocutaneous perforator at a point where the medial border of the rectus femoris muscle is crossed by the sartorius muscle. In all 5 patients, the AMT flap provided stable coverage with no flap loss. Based on our findings, we conclude that the anteromedial thigh flap offers all the advantages of fasciocutaneous flaps. Therefore, we recommend this flap as an alternative for defects requiring coverages of thin to moderate skin thickness. However, it should be remembered that variations in vascular anatomy are possible., (Copyright 2003 Wiley-Liss, Inc.)

Background: Complex and large soft-tissue defects of the dorsum of the hand, which cannot be covered with skin grafts or local flaps have to be reconstructed by means of free tissue transplantation. The purpose of this study was to present our experience with free fasciocutaneous flaps and muscle flaps with split-thickness skin graft for defect coverage of the dorsum of the hand in eight patients., Patients and Method: Evaluation of eight patients who underwent coverage of the dorsum of the hand with free flaps during 1997 to 2001 is presented. Other treatment options are discussed., Results: Average age of the patients was 57 years and average follow-up was 25 months. For defect coverage we used a later alarm flap in four cases, a gracilis muscle flap with split-thickness skin graft in three cases and a latissimus dorsi flap with split-thickness skin graft in one case. In five patients we performed an extensor tendon reconstruction. Three of those cases achieved a good, one a fair and one case had a bad functional result. In one patient we had a partial flap loss. Muscle flaps with skin graft revealed better esthetic results than fasciocutaneous flaps., Conclusion: Microvascular free-tissue transplantation has expanded our options, giving us the opportunity for more refinement in hand reconstruction and improving the standards for a successful outcome.

We report on a 19-year-old male patient with partial destruction of the index metacarpophalangeal joint due to traumatic middle hand amputation. Six months after replantation the metacarpophalangeal joint defect was reconstructed with an osteochondral metatarsal head graft from the second metatarsophalangeal joint. At a follow-up period of four years the patient achieved full metacarpophalangeal extension, with 40 degrees of flexion and grip strength equal to 90 % of the contralateral index finger. Magnetic resonance imaging showed enhancement of contrast medium as a sign for vitality of the transplant.

Free tissue transplantation is nowadays regarded as an established method in reconstructive surgery - even in infants. Adequate diameters of vessels for microsurgical anastomosis have been shown in numerous studies. Especially the latissimus dorsi muscle seems to be ideal as a standard flap in this age group. The main disadvantage of this muscle flap lies in its donor-site morbidity with the risk of scar contracture and limitation of shoulder movement. A possible solution to this problem is the endoscopically-assisted harvest of this muscle. A three-year old boy sustained a subtotal amputation of his right heel with consecutive necrosis of soft-tissue. After debridement, a latissimus dorsi-muscle flap was transplanted to cover the defect. The flap was harvested endoscopically-assisted through a single, 2 cm long incision in the left axilla. Healing of the flap was uneventful. At 30 months follow-up the patient showed stable conditions at the right heel without limitations of movement and a hardly visible scar in the left axilla without any noticable growing impairment. Free microvascular muscle-flaps are the treatment of choice in infants with extensive traumatic defects. With the use of minimally invasive operation techniques it is possible to significantly reduce donor-site morbidity and increase therapeutic success even in the youngest patients.

A case is presented in which the gracilis muscle was transversely split into two free flaps for coverage of two separate defects in a patient with a multi-segment fracture of the metatarsal bones and the ankle joint.

Sagging of the remaining breast behind the inframammary fold after breast reduction or breast augmentation may necessitate revisional surgery. The authors achieved inframammary fold reconstruction by reconstruction of the inframammary crease ligament through a deepithelialized skin flap that is anchored to the periosteum of the fifth or sixth rib. They present their simple and safe technique.

Unilateral blepharochalasis is an extremely rare disorder with an unknown etiology and pathogenesis. The authors present a 22-year old patient in whom a right-sided skin overhang of the upper eyelid caused visual field impairment. The condition was corrected by a standard blepharoplasty. The histological examination suggested a localised anomaly of the lymphatic system and an almost complete absence of elastic fibres as the causative agent.

The effects of a topically applied combination of nonivamide and nicoboxil in improving skin perfusion and preventing distal flap necrosis were tested in a random-pattern dorsal skin flap model. Forty male Wistar rats were randomized into two groups (n = 20), and a standardized dorsal random-pattern skin flap was raised on each rat. Animals in the experimental group were treated with the topically applied drug combination four times per day for 6 days, whereas in the control group only a placebo ointment was applied each time. Skin flap viability was evaluated on day 7, and the extent of skin flap necrosis was compared between the two groups. The topically applied combination of nonivamide and nicoboxil resulted in a statistically significant decrease in skin flap necrosis, compared with the control group (mean percentage of skin flap necrosis in the nonivamide/nicoboxil-treated group, 22.6 +/- 6.0 percent; control group, 36.8 +/- 4.3 percent; p< 0.05). The topical combination of nonivamide and nicoboxil was effective in reducing ischemic necrosis in failing random-pattern skin flaps in this rat model. The results of this study suggest that such a topical drug application might have significant effects in the reduction of ischemic necrosis in the distal parts of skin flaps, and this treatment might also have applications as prophylactic therapy for risky skin flaps.

The free paraumbilical perforator flap that was developed with only the perforator penetrating the rectus abdominis muscle seems nearly ideal from the donor-site perspective, because it reduces morbidity virtually to that of an abdominoplasty. However, it requires "supermicrosurgery" skills for suturing of vessels with diameters of 0.7 mm or less, making the procedure technically demanding and risky. Another significant disadvantage of that technique is that the flap has very short vascular pedicles. To overcome the disadvantages of the free paraumbilical perforator flap, a minor modification in flap harvesting that improves the vessel size and length is described. Results for a total of 15 patients who underwent breast reconstruction with modified free paraumbilical perforator flaps are presented, and the advantages and disadvantages of this flap are discussed.

Neurofibromas are benign tumors arising from neuroectodermal tissues. They may occur as solitary lesions, or multiple, in which case they are referred to as neurofibromatosis, or von Recklinghausen's disease. We report about a 17-year-old patient with neurofibromatous elephantiasis located in the lateral aspect of the left hemithorax. CT showed massive chest wall infiltration and retroperitoneal tumor growth, but no abnormalities of the cranium. Our surgical treatment consisted of a two-stage, palliative tumor debulking and defect coverage with a splitthickness skin graft. The operative and postoperative course was uneventful.

Activator protein 1 (AP-1) is thought to play an important role in the expression of genes expressed in response to ischemia-reperfusion injury. In this report, the activation of AP-1 in rat skeletal muscle during reperfusion after a 4-hour ischemic period was studied. AP-1 activation displayed a biphasic pattern, showing peak activities at 1 hour after perfusion and from 4 hours to 12 hours after perfusion. Inhibition of AP-1 activation was investigated using a potent nuclear factor kappa B inhibitor, proline dithiocarbamate (Pro-DTC). AP-1 binding activity at 1 hour of reperfusion was significantly reduced (29.0 +/- 10.1% SEM; p < 0.05) after intravenous administration of Pro-DTC (n = 7 animals in each group). Further elucidation of the role of AP-1 is warranted in hopes of developing strategies to reduce the deleterious effects of ischemia-reperfusion injury.

Background: Massive weight loss following bariatric surgery frequently results in body contour deformities like ptotic and hypoplastic breasts, redundant abdominal tissue and loose skin especially in the medial thigh area. This redundant tissue can be used for breast augmentation in the case of hypertrophic ptotic breasts., Method: In 3 patients who underwent a vertical banded gastroplasty and consecutively lost more than 60% of their body weight, a breast augmentation with a transverse gracilis myocutaneous free flap was performed., Results: Bilateral myocutaneous gracilis free flap breast augmentation resulted in an esthetic, pleasing result, with additional correction of the redundant skin from the medial thigh region., Conclusion: Autologous breast augmentation with a simultaneous medial thigh lift can be performed safely, after successful weight loss following bariatric surgery.

Major defects of the lower lip have been repaired in many ways. Of these, some employed flaps from the chin, cheek or upper lip. Some of these procedures employed flaps without regard for the facial grooves or landmarks. Some methods required incisions through nerves supplying the orbicularis oris and the flaps used for the lower lip reconstruction. Of the many methods of reconstruction that have been reported, we believe that the Webster technique should be considered as the first choice for lower lip defects larger than 80% of the total. Because this technique interferes minimally with the sensation of the lower lip and a satisfactory cosmetic outcome with a functional lower lip is achieved, the sensation and muscle function of the upper lip are unaffected. In addition to discussing the advantages of the Webster method, in this paper we present a minor modification in the dissection of the orbicularis oris muscle in an attempt to improve the motor innervation and to provide adequate oral competence and labial functioning in expression and speaking. Motor function and innervation of the lips after reconstruction was documented by clinical findings as well as electrophysiological methods.

The authors present an easily designed and accomplished technique of one-stage reduction mammaplasty and nipple-areolar reconstruction for patients with large or medium-size breasts and for patients missing the nipple-areolar complex. The technique has low inherent risks, and the symmetry of the breast is maintained to the maximum. In addition to the cosmetic improvement, using this technique benefits the patient further by avoiding postoperative corrections or adjustments.

Recent advances in cell biology and tissue engineering have used various delivery vehicles for transplanting varying cell cultures with limited success. These techniques are frequently complicated by tissue necrosis, infection, and resorption. The purpose of this study was to investigate whether urothelium cells, tracheal epithelial cells, and preadipocytes cultured in vitro could be successfully transplanted onto a prefabricated capsule surface by using fibrin glue as a delivery vehicle, with the ultimate goal for use in reconstruction. In the first step of the animal study, tissue specimens (bladder urothelium, tracheal epithelial cells, epididymal fat pad) were harvested for in vitro cell culturing, and a silicone block was implanted subcutaneously or within the anterior rectus sheath to induce capsule formation. After 6 to 10 days, when primary cultures were confluent, the animals were re-anesthetized, the newly formed capsule pouches were incised, and the suspensions of cultured urothelia cells (n = 40), tracheal epithelial cells (n = 32), and preadipocytes (n = 40) were implanted onto the capsule surface in two groups, one using standard culture medium as a delivery vehicle and the second using fibrin glue. Histologic sections were taken, and different histomorphologic studies were performed according to tissue type. Consistently in all animals, a highly vascularized capsule was induced by the silicon material. In all animals in which the authors used fibrin glue as a delivery vehicle, they could demonstrate a successful reimplantation of cultured urothelium cells, tracheal epithelial cells, or preadipocytes. Their animal studies showed that capsule induction in combination with fibrin glue as a delivery vehicle is a successful model for transplantation of different in vivo cultured tissue types.

The aim of our study was to evaluate if the amount of resected breast tissue has an influence on breast sensitivity after inferior pedicle mammaplasty. In the prospective study, 15 patients (30 breasts) were divided into two groups: group I (less than 400 g resection) and group II (more than 400 g resection). Preoperatively and six months postoperatively a touch test (Semmes-Weinstein monofilaments) and temperature (warm and cold) tests were performed. The study showed that all patients had increased touch sensitivity six months after inferior pedicle mammaplasty regardless of the amount of resection. In group I an average of 65% and in group II an average of 83% retained sensitivity for temperature postoperatively. These results suggests that this mammaplasty technique preserves intercostal nerves within the inferior pedicle and reliefs chronic nerve traction injury and improves thereby breast sensibility.

Between May 1989 and December 2000 in 24 adult patients with pectus excavatum, a subcutaneous implantation of silicone prostheses was performed. Of the 24 patients, 20 were followed. During follow-up the authors encountered seroma complications in 13 patients and postoperative hematoma in 4 patients. The patients stayed in the hospital 5 days on average, and showed excellent aesthetic results in 80% (N = 16), good results in 10% (N = 2), and fair results in 10% (N = 2). Patient satisfaction was also taken into consideration. A follow-up survey questioned whether patients were satisfied with the cosmetic outcome. On a scale of 1 to 5 points, with 1 point being the highest level of satisfaction, 85% of patients used ratings of 1 and 2 to express satisfaction levels. Silicone implant correction of pectus excavatum in adult patients without any impairment of cardiopulmonary function has value. The major advantages are the minimally invasive operation, the short hospital stay, good aesthetic results, and high patient satisfaction

Different approaches to breast reconstruction have been described and nowadays nearly optimized. One major aim in further developments is to reduce donor site morbidity as low as possible. Theoretically, the lowest donor site morbidity could be achieved by using tissue that would be normally discarded during an operation necessary for a different reason. The authors present a new method of breast reconstruction in a mastectomy patient who needed a reduction mammaplasty on the remaining side in addition to the reconstruction. A single-stage split-breast flap from the reduced contralateral side pedicled on its internal mammary perforators was used, thus lowering donor site morbidity by using otherwise discarded tissue. The technical details, patient selection, advantages, possible pitfalls, management of complications, and the risk factors for contralateral malignancy are discussed.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments.

The unreliability of the distal skin component of the gracilis myocutaneous free flap has been frequently reported. To improve the reliability of the skin we orientated the cutaneous paddle in a transverse direction in the proximal third of the gracilis muscle, as first described by Yousif et al in 1993. Their anatomical studies showed that cutaneous branches of the dominant proximal pedicle have a pronounced tendency to travel in a transverse direction, supplying the skin anteriorly over the adductor longus and sartorius muscles and extending beyond the posterior margin of the gracilis muscle. We adopted this transverse design and transferred myocutaneous gracilis flaps measuring up to 17 x 9 cm. The transverse gracilis myocutaneous flap was dissected in the subfascial plane to include the peri-gracilis fascia, which preserved the fascial vascular network and thus optimised skin-paddle perfusion. Ten transverse gracilis myocutaneous free flaps were performed over 3 years. Skin paddles ranged in size from 10 x 7 cm (70 cm(2)) to 17 x 9 cm (153 cm(2)) with a mean of 113.4 cm(2). Five defects were located in the head and neck region, three in the lower leg, one in the thigh and one in the thorax. Patients were followed for an average of 16.6 months (range: 6--46 months). Minor complications (donor-site wound dehiscence and flap-wound-edge separation) occurred in four patients;however, all 10 flaps survived and healed with complete cutaneous survival., (Copyright 2001 The British Association of Plastic Surgeons.)

Objective: The purpose of this study was to investigate whether in vitro cultured tracheal epithelial cells can be transplanted onto a prefabricated capsule surface in vivo for possible use in tracheal reconstruction., Methods: Tracheal epithelial cells from 12 donor inbred rats were harvested for culture and expansion. In 16 recipient inbred rats, 2 sterile cylinders made of silicone rubber were implanted in each rat bilaterally in the folds of both the left and right anterior rectus sheath by wrapping the sheaths around the cylinders to induce a capsule formation. Ten days later, the cell cultures were divided and suspended in 1 of 2 delivery vehicles (standard culture medium or fibrin glue) and implanted onto the capsule surface. To compare the 2 delivery vehicles, we used fibrin glue on one side and the standard culture medium on the other., Results: After 2 (group 1, n = 8) and 4 (group 2, n = 8) weeks, histologic findings, immunohistochemical staining, and electron microscopy demonstrated the capsule to be covered with a tracheal neoepithelium in group 1 and additional ciliated cells and secretory cells in a confluent layer in group 2 but only on the side with fibrin glue as the delivery vehicle. No viable epithelial cells were identified on the side with the standard culture medium in either group., Conclusion: We conclude that cultured epithelial cells can be successfully transplanted onto a prefabricated capsule surface with fibrin glue, which will differentiate into morphologic, nearly normal epithelium, showing potential for tracheal reconstruction.

The purpose of the study was to transplant autologous cultured urothelial cells onto a muscle via fibrin glue as a delivery vehicle to create a vascularized, living matrix lined with urothelium that could subsequently be used for urinary reconstruction. Bladder tissue specimens from male Wistar rats (n = 32; 350--500 g) were harvested for urothelial tissue culture. After 8--10 days when the primary cultures became confluent, the cultured urothelial cells were injected underneath the rectus sheath onto the rectus muscle. As delivery vehicle we compared standard culture media and fibrin glue. At 1- and 4-week intervals following urothelial cell grafting, sections of the muscle were analyzed for urothelial graft take using Hematoxylin & Eosin and immunohistochemical staining. The histology demonstrated viable, multilayered clusters of urothelium cells on the muscle surface only in the group using the fibrin glue delivery vehicle. We conclude that a muscle can be successfully prelaminated with autologously cultured urothelial cells via fibrin glue and has therefore potential for urinary reconstructions.

Purpose: Recent advances in cell biology and tissue engineering have involved various avascular or acellular scaffolds with or without seeded cells. These techniques are frequently complicated by tissue necrosis, contracture and resorption. We used a vascularized matrix prelaminated with autologous cultured urothelial cells to reconstruct bladder wall defects., Materials and Methods: A silicone block inserted into the right groin of 50 male Wistar rats directly superficial to the inferior epigastric vessels was used to induce capsule pouch formation. Urothelial cells harvested simultaneously and cultured were then suspended in fibrin glue and seeded into the newly formed capsule after removing the silicone block. After 1 week the prelaminated flap was transposed into a surgically created bladder wall defect. Experimental groups included rats with a urothelial cell seeded capsule pouch sacrificed at 1 and 4 weeks, respectively, after bladder reconstruction. In control rats scaffolds were treated only with fibrin glue or saline before transposition., Results: Hematoxylin and eosin and immunohistochemical staining showed a continuous multilayered urothelial lining along the transposed prelaminated capsule flap in the experimental groups with better survival compared to controls treated only with fibrin glue (80% mortality) or saline (100% mortality). The surviving 3 control animals did not have a urothelial lining., Conclusions: Vascularized prefabricated flaps lined with culture derived urothelial cells were successfully used for bladder reconstruction in a rat model. The technique of prefabricating a vascularized scaffold lined with autologous urothelial cells may provide a method for future reconstruction of the genitourinary systems.