Springer Japan KK

Susumu Tamai (Editor in Chief)

Masamichi Usui . Takae Yoshizu (Eds.)

Experimental
and Clinical
Reconstructive
Microsurgery
With 850 Figures, Including 79 in Color

i Springer
Susumu Tamai, M.D., Ph.D.
Director
Nara Microsurgery . Hand Surgery Institute, West Nara Central Hospital
5-2-6 Hyakurakuen, Nara 631-0024, Japan
Professor Emeritus
Department of Orthopedic Surgery, Nara Medical University
840 Shijo-cho, Kashihara, Nara 634-8522, Japan

Masamichi Usui, M.D., Ph.D.

President
East Hokkaido Hospital
7-19 Wakatake-cho, Kushiro, Hokkaido 085-0036, Japan

Takae Yoshizu, M.D., Ph.D.

Chairman
Niigata Hand Surgery Foundation
1-18 Shinko-cho, Niigata 950-8556, Japan

ISBN 978-4-431-67998-1 ISBN 978-4-431-67865-6 (eBook)

DOI 10.1007/978-4-431-67865-6
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Foreword

This monumental text is without a doubt the most complete on this subject in the
world today, prepared by an outstanding microsurgical researcher, clinician, and
teacher, who has been active for the past 40 years since the very inception of micro-
surgery. There is certainly no one more qualified to present this material. The detailed
history of microsurgery, with over 240 references, will be an invaluable source for
researchers and clinical students, teachers, technicians, Ph.D.s, and M.D.s, both young
and old.
There are almost 100 chapters in this book: 24 on experimental surgery, 10
on replantation, 32 on techniques of harvesting, 20 on clinical applications, and 6
chapters on pre- and post -operative management.
The section on experimental surgery is particularly timely with the expansion of
microsurgical replantation and transplantation into the field of composite tissue allo-
grafts. The microsurgeon of today must be familiar with these immunological tests
and immunosuppressants, as well as the various animal models for future research.
The section on clinical replantation is particularly thorough, covering replantation
in detail, and techniques for harvesting composite tissues from all areas of the body.
The contributions of Japanese micro surgeons are well represented, and almost every
chapter contains a pearl of some sort. The chapter on lower leg and foot replants,
often thought to produce an inferior result to a prosthesis, describes six patients, ages
16 to 74, all walking and working after replantation. The chapter on ear replants con-
firms that this is one of the most difficult of replants, but worth attempting, even if
no vein is present.
The section on techniques for donor harvesting of several composite tissues is
most informative, covering the well-described areas, as well as a series of new flaps
about the hands and unique applications of venous flaps.
The 20 chapters on clinical applications provide the reader with a view of the
sophistication of microsurgical replantation and transplantation that has occurred in
Japan in the last 40 years. For example, the chapter on double fibular grafts for
femoral reconstruction contains an example of multiple microvascular transplants
performed simultaneously to solve a monumental reconstructive problem.
Dr. Tarnai in his preface states that he hopes that this text will fulfill the needs
of young microsurgical researchers and reconstructive surgeons as a historical
reference and valuable source of specific information in the entire field of recon-
structive microsurgical replantation and transplantation. He has achieved this goal.

Harry 1. Buncke, M.D.

The Buncke Clinic, San Francisco, CA, USA

v
Foreword

I am proud to introduce Dr. Tarnai's remarkable achievement: Experimental and

Clinical Reconstructive Microsurgery. This book contains not only Dr. Tarnai's
fascinating personal experiences but also scientific and experimental publications
on microsurgery and its application to hand surgery and other medical specialties.
The major accomplishments of the leading microsurgeons in Japan are also pre-
sented and, thanks to Dr. Tarnai, are now readily available to the world.
The numerous, comprehensive chapters include experimental material, obstacles
that had to be overcome, microscopes and the development of microsurgical instru-
ments, the world's first successful digit replantation, the history of microsurgery, and
techniques of microsurgery. Clinical applications are described along with the pre-
vention and correction of complications. Preoperative planning, postoperative care,
avoiding complications, and ways of solving complications are covered.
Experimental and Clinical Reconstructive Microsurgery is a monumental publica-
tion, and, to the best of my knowledge, is the first gathering of a nation's experience
in microsurgery over a 40-year period. It serves as a stimulus for all surgeons and
as a "must-obtain" publication for all microsurgeons, whether hand or reconstruc-
tive microsurgeons. My particular hope is that young surgeons, including plastic,
orthopaedic, and even some interested general surgeons, will read this book and
understand that in medicine nothing good is done alone and that teams of surgeons
contribute to what is now truly the international field of hand and microsurgery.

Harold E. Kleinert, M.D.

Kleinert, Kutz and Associates Hand Care Center, PLLC
Louisville, KY, USA

VII
Preface

Almost a century has passed since Alexis Carrel reported the three-stay suture tech-
nique of vascular anastomosis, performed by hand, in the early 1900s, and it has been
more than 40 years since the first description of the microvascular anastomosis con-
ducted under a microscope by Julius Jacobson in 1960. In the early 1960s, I was doing
experimental studies of canine limb replantation in the postgraduate program in the
Department of Orthopedic Surgery, Nara Medical University, under the guidance of
the late Professor Yutaka Onji. Shigeo Komatsu and I were the first in Japan to start
microvascular surgery, in 1964. In July 1965, we succeeded in replanting a completely
amputated thumb, which was the world's first successful digit replantation. There-
after, microvascular surgery rapidly progressed throughout Japan, among hand,
orthopedic, and plastic surgeons. In the first 20 years of the development of micro-
surgery, more than 150 surgeons, from both Japan and overseas, came to our ortho-
pedic laboratory at Nara Medical University to learn microsurgical techniques. In
1972, the International Society of Reconstructive Microsurgery was established. My
colleagues and I organized the first Congress of the Japanese Society of Recon-
structive Microsurgery in 1974 in the city of Kashihara, in Nara Prefecture.
Since celebrating my retirement in April 2000 from Nara Medical University,
where I spent almost 40 years doing research and clinical practice in the field of hand
and microsurgery, I have planned a monograph on microsurgery in English. Over
the past several decades, there have been many monographs on microsurgery pub-
lished in the world, but most of them were primarily for the application of micro-
surgical techniques in clinical reconstructive surgery. I have believed for a long time
that such a monograph should include not only the essential laboratory techniques
or microsurgical methodology for laboratory research but also the fundamental tech-
niques of harvesting several composite tissues and their grafting techniques. Because
microsurgery includes many kinds of clinical disciplines, it is impossible for a single
author to produce a monograph covering all aspects in this field. Therefore, I asked
my colleagues and some invited guests to contribute chapters on specialized fields
for this multi-authored book. It has taken almost 3 years to receive their manuscripts
and to edit them carefully. Drs. Masamichi Usui in Sapporo and Takae Yoshizu in
Niigata were nominated to the Editorial Board to assist me.
I hope this monograph will fulfill the needs of young microsurgical researchers
and reconstructive micro surgeons and that they will find it an essential textbook of
microsurgery, not only in Japan but also throughout Asia, Europe, and the United
States.

Susumu Tamai, M.D., Ph.D.

December 2002

IX
Contents

Foreword by Harry J. Buncke, M.D. .............................. . V

Foreword by Harold E. Kleinert, M.D. ........................... . VII
Preface .................................................... . IX
List of Contributors .......................................... . XVII
Acknowledgements .......................................... . XXIII
Color Plates ................................................ . XXV

A The History of Microsurgery

S. Tarnai ............................................. . 1

B Operating Microscope and

Microsurgical Instruments
S. Tarnai ............................................. . 25

c Experimental Microsurgery .. 33
1 Microvascular Anastomoses in the Rat
A. Fukui ............................................ . 35
2 Micronerve Suture and Graft in the Rat
Y. Yanase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3 Essential Laboratory Techniques .......................... . 53
3.1 Technique of Microangiography
A. Fukui ............................................ . 55
3.2 Technique for Making a Vascular Corrosion Cast
T. Sempuku .......................................... . 57
3.3 Technique for Making a Spalteholz Cleared Specimen
T. Sempuku .......................................... . 59
3.4 Technique of Fluorochrome Labeling
M. Okumura ......................................... . 61
3.5 Technique of Bone Scintigraphy in Vascularized Bone Grafts:
Three-Phase Bone Imaging
A. Minami and K. Itoh ................................. . 65
3.6 Biochemical and Biological Analysis of Bone Viability
H. Ohgushi and M. Akahane ............................. . 70

XI
XII Contents

3.7 Blood Flow Assessment and Direct Observation

of Microcirculation
Y.lnada . . ... . . . ... . . .. . . ... . . . . . . .. . . . .. . . ... . . . . .. . . 75
3.8 Technique for Measuring Choline Acetyltransferase Activity
of the Peripheral Nerve
M. Akahane and H. Yajima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.9 Technique of Cholinesterase Staining of the Peripheral Nerve
F. Kanaya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.10 Tissue Preservation
H. Ono and Y. Nakagawa ................................ 88
3.11 Transplantation Immunology
M. Tarnai and K. Sagawa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4 Limb Replantation in the Rat
A. Minami and N. Iwasaki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
5 Canine Limb Replantation and Replantation Toxemia
M. Usui and S. Ishii ..................................... 104
6 Skin and Muscle Flaps in the Rat
Y. Hirase ............................................. 111
7 Customized Neovascularized Prefabrication in the Rat
Y. Hirase ............................................. 115
8 Vascularized Tibiofibular Graft in the Rat
S. Mizumoto and T. Kohno ............................... 121
9 Vascularized Ulna Graft in the Rat
N. Yamaoka, S. Tarnai, and S. Mizumoto ..................... 129
10 Vascularized Metatarsal Graft in the Rabbit
K. Kawanishi .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
11 Vascularized Tail Bone Graft in the Rat 141
11.1 Cancellous Bone Graft Model
T. Sempuku ........................................... 143
11.2 Intervertebral Disk Graft Model
A. Kugai ............................................. 146
12 Allograft of Composite Tissues: Experimental Model in the Rat
A. Minami and N. Iwasaki. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

D Preoperative and Postoperative Management .. 155

1 Preoperative Planning and Evaluation of the Vascular System in
the Donor and Recipient
S. Toh . . . . ...... . . . . ... . . . . .. . . . . . ..... . . ... . . ... . . . .. 157
2 Postoperative Monitoring and Observation
M. Beppu . . . . . . . ... . . . . ... . . . . ... . . . . ... . . . .. . . ..... . . 162
3 Perioperative and Postoperative Antithrombotic Agents
H.Ono . . . . . . ... . . . . . .. . . . . .. . . . . . .... . . ... . . .... . . ... 166
 Contents XIII

4 Continuous Local Heparinization

y. Inada, A. Fukui, and S. Mizumoto . . . . . . . . . . . . . . . . . . . . . . . . 169
5 Complications and Salvage Procedures
H. Yajima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
6 Postoperative Management and Rehabilitation in
Limb/Digit Replantation
Y. Maki and T. Yoshizu .................................. 179

E Clinical Reconstructive Microsurgery . . . . . . . . .. 183

1 Replantation .......................................... 185
1.1 Arm Replantation
M. Matsuda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
1.2 Forearm Replantation
S. Toh, S. Nishikawa, and S. Inoue 193
1.3 Hand Replantation
H. Nakashima and H. Yonemitu ........................... 197
1.4 Replantation of Multilevel Amputation Through the
Forearm and Hand
M. Shibata ........................ '. . . . . . . . . . . . . . . . . . . . 203
1.5 Digital Replantation
Y. Inada, A. Fukui, and S. Tarnai ........................... 209
1.6 Replantation of the Lower Leg and Foot
M. Usui, I. Muramatsu, and K. Masuda. . . . . . . . . . . . . . . . . . . . . . 219
1.7 Extremity Trauma: Limb Salvage Versus Primary Amputation
Y. Inada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
1.8 Replantation of a Completely Amputated Penis
S. Tarnai .............................................. 231
1.9 Replantation of a Completely Amputated Ear
N. Isogai and H. Kamiishi ................................ 237
1.10 Replantation of a Totally Avulsed Scalp
H. Kamiishi and N. Isogai ................................ 241
2 Harvesting Techniques for Several Composite Tissues .......... 245
2.1 General Concepts of Skin Flaps
Y. Shintomi, Y. Yamamoto, K. Nohira, and H. Furukawa 247
2.1.1 Scapular Flap
K. Fujisawa ........................................... 251
2.1.2 Lateral Arm Flap
H. Nakashima ......................................... 254
2.1.3 Radial Forearm Flap
T. Sakada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
2.1.4 Reverse Posterior Interosseous Flap
A. Fukui ............................................. 262
XIV Contents

2.1.5 Arterialized Island Flap in the Digits and Hands

Y. Inada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
2.1.6 New Flaps in the Hand
S. Omokawa, S. Mizumoto, A. Fukui, and S. Tarnai 275
2.1.7 Groin Flap
H. Ohtsuka ........................................... 281
2.1.8 Peroneal Flap
G. Nishi .............................................. 287
2.1.9 Dorsalis Pedis Flap
F. Us ami and M. Iketani ................................. 292
2.1.10 Medial Plantar Flap
M. Shibata and R. Sakamura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
2.1.11 Hemipulp Flap and First Web Flap
y. Maki and T. Yoshizu .................................. 301
2.1.12 Free Thin Deep Inferior Epigastric Artery Perforator (DIEP) Flap
I. Koshima, K. Inagawa, and T. Moriguchi . . . . . . . . . . . . . . . . . . . . 305
2.1.13 Venous Flap
A. Fukui ............................................. 309
2.2 General Concepts of the Donors for Muscle Transplantation
Y. Akasaka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
2.2.1 Latissimus Dorsi Muscular and Musculocutaneous Flap
H.Ono............................................... 323
2.2.2 Rectus Abdominis Myocutaneous Flap
K. Nohira, Y. Yamamoto, and Y. Shintomi . . . . . . . . . . . . . . . . . . . . 327
2.2.3 Gracilis Musculocutaneous Flap
Y. Akasaka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
2.2.4 Vascularized Tendon Graft
H. Yajima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
2.2.5 Temporoparietal Flap
K. Arashiro, K. Ishida, and H. Ohtsuka . . . . . . . . . . . . . . . . . . . . . . 339

2.3 General Concepts of the Donors of Vascularized Bone Grafts

H. Yajima and S. Tarnai .................................. 342
2.3.1 Fibula
S. Toh, K. Arai, and M. Yasumura 349
2.3.2 Scapula
H. Hirata ............................................. 355
2.3.3 Ilium
A. Fujimaki ........................................... 359
2.3.4 Vascularized Thin Corticoperiosteal Graft from the
Medial Femoral Condyle
M. Beppu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
 Contents XV

2.4 Toe
T. Yoshizu 367
2.5 Toe Joint
T. Yoshizu 373
2.6 Wrap-Around Flap
Y. Maki and T. Yoshizu ................................. . 379
2.7 Vascularized Nail Grafts
1. Koshima and T. Moriguchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
2.8 Prefabricated Flap (Muscle Vascularized Pedicle Flap and Others)
Y. Shintomi, H. Furukawa, K. Nohira, and Y. Yamamoto ....... . 388
2.9 Intestine
Y. Yamamoto, H. Minakawa, T. Sugihara, K. Nohira, and
Y. Shintomi ........................................... . 392
2.10 Omentum
H.Ohtsuka 396
3 Clinical Applications .. :................................. 401
3.1 Primary Reconstruction in the Upper Extremity
Y. Kino, K. Kondoh, and K. Suzuki . . . . . . . . . . . . . . . . . . . . . . . . . 403

3.2 Thumb and Digit Reconstruction

T. Yoshizu ............................................ 410
3.3 Brachial Plexus Injury
Y. Akasaka and T. Hara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
3.4 Congenital Radioulnar Synostosis
F. Kanaya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
3.5 Congenital Pseudarthrosis
S. Toh, K. Tsubo, and S. Narita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
3.6 Traumatic Soft Tissue Defects in the Extremities
M. Shibata ................... ~ . . . . . . . . . . . . . . . . . . . . . . . . 444

3.7 Vascularized Fibular Graft for Traumatic Bony Defect and

Incurable Nonunion
M. Beppu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
3.8 Chronic Osteomyelitis and Infected Nonunion
H. Yajima and S. Tarnai. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
3.9 Double Fibula Grafts for Femoral Reconstruction
Y. Tomita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
3.10 Microsurgical Reconstruction Following Wide Resection of
Malignant and Potentially Malignant Bone and Soft
Tissue Tumors
M. Usui and S. Ishii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
3.11 Avascular Necrosis of the Femoral Head
H. Yajima and K. Kawate ................................ 476
XVI Contents

3.12 Treatment of Avascular Necrosis of the Femoral Head with a

Pedicled Vascularized Iliac Bone Graft
A. Fujimaki ........................................... 481
3.13 Avascular Necrosis of the Femoral Head Treated by Vascularized
Scapular Bone Graft
K. Fujisawa ........................................... 485
3.14 Emergency Free Flap and Spare Surgery
T. Naitoh, M. Usui, S. Ishii, and Y. Tsuchida .................. 490

3.15 Elbow Joint Reconstruction Using Metatarsophalangeal Joint

of the Great Toe
M. Shibata ............................................ 496
3.16 Mandibular Reconstruction
K. Horiuchi and H. Yajima ............................... 502
3.17 Reconstruction of the Oral Cavity and Esophagus
Y. Yamamoto, H. Minakawa, T. Sugihara, K. Nohira, and
Y. Shintomi ........................................... 510
3.18 Breast Reconstruction
K. Nohira, Y. Yamamoto, and Y. Shintomi . . . . . . . . . . . . . . . . . . . . 515
3.19 Soft Tissue Defect Reconstruction Using Omentum or
Fascial Flap
K. Ishida, K. Arashiro, and H. Ohtsuka . . . . . . . . . . . . . . . . . . . . . . 519
3.20 Treatment of Lymphedema: Lymphaticovenous Anastomosis
I. Koshima and T. Moriguchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525

Subject Index ................................................ 529

List of Contributors

AKAHANE, MANABU
Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho,
Kashihara, N ara 634-8522, Japan

AKASAKA, Y OSHIHISA
Senpo Tokyo Takanawa Hospital, 3-10-11 Takanawa, Minato-ku, Tokyo 108-8606,
Japan

ARAI, KOICHI
Department of Orthopaedic Surgery, Daido Central Hospital, 127 Daido, Naha,
Okinawa 902-0066, Japan

ARASHIRO, KEN
Division of Plastic and Reconstructive Surgery, Okinawa Chubu Hospital, 281
Miyazato, Gushikawa, Okinawa 904-2293, Japan

BEPPU, MORoE
Department of Orthopedic Surgery, St. Marianna University School of Medicine,
2-16-1 Sugao, Miyamae-ku, Kawasaki 216-0015, Japan

FUJIMAKI, ARIHISA
Orthopaedic Clinic, Tokyo Hospital of Ishikawajima-Harima Heavy Industries Co.,
Ltd., 2-15-17 Tsukuda, Chuo-ku, Tokyo 104-0051, Japan

FUJISAWA, KOHZO
Suzuka Kaisei General Hospital, 112-1 Koh, Suzuka, Mie 513-0836, Japan

FUKUI, AKIHIRO
Department of Orthopaedics, Nara Prefectural Mimuro Hospital, 1-14-16 Mimuro,
Sango-cho, Ikoma-gun, Nara 636-0802, Japan

FURUKAwA, HIROSHI
Department of Plastic and Reconstructive Surgery, Hokkaido University School of
Medicine, North 14 West 5, Kita-ku, Sapporo 060-8638, Japan

HARA, TETSUYA
Tokyo Metropolitan Rehabilitation Hospital, 2-14-1 Tsutsumidori, Sumida-ku,
Tokyo 131-0034, Japan

HIRASE, YUICHI
Saitama Hand Surgery Institute, Saitama Seikeikai Hospital, 1721 Ishibashi,
Higashi-matsuyama, Saitama 355-0072, Japan

XVII
XVIII List of Contributors

HIRATA, HITOSHI
Department of Orthopaedic Surgery, School of Medicine, Mie University, 2-174
Edobashi, Tsu 514-8507 Japan

HORIUCHI, KATSUHlRO
Nakatani Dental Clinic, 4-11-3 Nohara-nishi, Gojo, Nara 637-0036, Japan

IKETANI, MASAYUKI
Iketani Orthopedic Clinic, 1233-21 Gomigaya, Tsurugashima, Saitama 350-2202,
Japan

INADA, YUH
Department of Emergency and Critical Care Medicine, Department of
Orthopedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara
634-8522, Japan

INAGAWA, KIICHI
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine
and Dentistry, Okayama University, 2-5-1 Shikata, Okayama 700-8558, Japan

INOUE, SADAHIRO
Inoue Orthopaedic Clinic, 37-7 Eto, Ishie, Aomori 038-0003, Japan

ISHIDA, KUNIHIRO
Division of Plastic and Reconstructive Surgery, Okinawa Chubu Hospital, 281
Miyazato, Gushikawa, Okinawa 904-2293, Japan

ISHII, SEIICHI
Department of Orthopedic Surgery, Sapporo Medical University, South 1, West 16,
Chuo-ku, Sapporo 060-8543, Japan

ISOGAI, NORITAKA
Department of Plastic Surgery, Kinki University School of Medicine, 377-2
Onohigashi, Osaka-sayama, Osaka 589-8511, Japan

ITOH, KAZUO
Department of Radiology, JR Sapporo Hospital, North 3, East 1, Chuo-ku,
Sapporo 060-0033, Japan

IWASAKI, NORIMASA
Department of Orthopaedic Surgery, Hokkaido University School of Medicine,
North 15, West 7, Kita-ku, Sapporo 060-8638, Japan

KAMIISHI, HIROSHI
Department of Plastic Surgery, Kinki University School of Medicine, 377-2
Onohigashi, Osaka-sayama, Osaka 589-8511, Japan

KANAYA, FUMINORI
Department of Orthopedic Surgery, School of Medicine, University of the
Ryukyus,207 Uehara, Nishihara, Okinawa 903-0215, Japan

KAWANISHI, KOICHI
Department of Orthopaedic Surgery, Takita Hospital, 2-13 Jhonan-cho,
Yamatokoriyama, Nara 639-1016, Japan
 List of Contributors XIX

KAWATE, KENJI
Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho,
Kashihara, N ara 634-8522, Japan

KINO, Y OSHITAKE
Department of Orthopaedic Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-cho,
Nakagawa-ku, Nagoya 454-0854, Japan

KOHNO, T AKESHI
Kohno Clinic, 1272-6 Kankakuji, Takatori, Takaichi-gun, Nara 635-0154, Japan

KONDOH, KIKUO
Department of Orthopaedic Surgery, Nakatsugawa Municipal General Hospital,
1522-1 Komaba, Nakatsugawa, Gifu 508-8502, Japan

KOSHIMA, ISAo
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine
and Dentistry, Okayama University, 2-5-1 Shikata, Okayama 700-8558, Japan

KUGAI, ATSUO
Department of Orthopaedic Surgery, Osaka-Saiseikai Tondabayashi Hospital,
1-3-36 Koyodai, Tondabayashi, Osaka 584-0082, Japan

MAKI, YUTAKA
Niigata Hand Surgery Foundation, 1-18 Shinko-cho, Niigata 950-8556, Japan

MASUDA, KAZUYUKI
Asahikawa Kosei Hospital, 24-111-3 Ichijo,Asahikawa, Hokkaido 070-0831,
Japan

MATSUDA, MAsAo
Division of Surgery, Chukyo Hospital, 1-1-10 Sanjo, Minami-ku, Nagoya 457-8510,
Japan

MINAKAWA, HIDEHIKO
Department of Plastic and Reconstructive Surgery, Sapporo National General
Hospital, 4-2 Kikusui, Shiroishi-ku, Sapporo 003-0804, Japan

MINAMI, AKIO
Department of Orthopaedic Surgery, Hokkaido University School of Medicine,
North 15, West 7, Kita-ku, Sapporo 060-8638, Japan

MIZUMOTO, SHIGERU
Mizumoto Orthopedic Surgery Clinic, 2-313-1 Gojo, Gojo, Nara 637-0042, Japan

MORIGUCHI, T AKAHIKO
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine
and Dentistry, Okayama University, 2-5-1 Shikata, Okayama 700-8558, Japan
XX List of Contributors

MURAMATSU, IKuo
National Hakodate Hospital, 18-16 Kawaharacho, Hakodate, Hokkaido 041-8512,
Japan

NAITOH, T AKAFUMI
Ohasa Clinic, 2-17 Ohasa-Nakamachi, Ebetsu, Hokkaido 060-0854, Japan

NAKAGAWA, Yon
Division of Orthopaedic Surgery, National Insurance Medical Center of Nara,
404-1 Miyako, Tawaramoto-cho, Shiki-gun, Nara 639-0302, Japan

NAKASHIMA, HIDECHIKA
Orthopaedic Surgery Unit, Kumamoto Kinoh Hospital, 6-8-1 Yamamuro,
Kumamoto 860-8518, Japan

NARITA, SHUNSUKE
Department of Orthopaedic Surgery, Mutsu General Hospital, 1-2-5 Ogawa-cho,
Mutsu, Aomori 035-0071, Japan

NISHI, GENZABURO
Department of Orthopaedic Surgery, Aichi-ken Koseiren Kainan Hospital,
Yatomi-cho, Ama-gun, Aichi 498-8502, Japan

NISHIKAWA, SHINJI
Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562,
Japan

NOHIRA, KUNIHIKO
Soshundo Plastic Surgery, South 1 West 4, Chuo-ku, Sapporo 060-0061, Japan

OHGUSHI, HAJIME
Tissue Engineering Research Center (TERC), National Institute of Advanced
Industrial Science and Technology (AIST), 3-11-46 Nakouji, Amagasaki, Hyogo
661-0974, Japan

OHTSUKA, HrSASHI
Surgical Division (Plastic and Reconstructive Surgery Section), Ehime University
Hospital, Shitsukawa, Shigenobu-cho, Onsen-gun, Ehime 791-0295, Japan

OKUMURA, MOTOAKI
Orthopedic Clinic, Todaiji Seishien, Handicapped Children's Hospital, 406-1
Zoshi-cho, Nara 630-8211, Japan

OMOKAWA, SHOHEI
Department of Orthopedics, Ishinkai-Yao General Hospital, 1-41 Numa, Yao,
Osaka 581-0036, Japan

ONO, HIROSHI
Division of Orthopaedic Surgery, National Insurance Medical Center of Nara,
404-1 Miyako, Tawaramoto-cho, Shiki-gun, Nara 639-0302, Japan
 List of Contributors XXI

SAGAWA, KIMITAKA
Department of Transfusion Medicine, Kurume University School of Medicine,
67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan

SAKADA, T AKENORI
School of Health and Social Services, Saitama Prefectural University, 820 San-
nomiya, Koshigaya, Saitama 343-8540, Japan

SAKAMURA, RITSUO
Department of Functional Neuroscience, Division of Plastic and Reconstructive
Surgery, Niigata University Graduate School of Medical and Dental Sciences,
1-757 Asahimachi-dori, Niigata 951-8520, Japan

SEMPUKU, T AKEO
Department of Orthopaedic Surgery, Saiseikai Chuwa Hospital, 323 Abe, Sakurai,
Nara 633-0054, Japan

SHIBATA, MINORU
Department of Functional Neuroscience, Division of Plastic and Reconstructive
Surgery, Niigata University Graduate School of Medical and Dental Sciences,
1-757 Asahimachi-dori, Niigata 951-8520, Japan

SHINTOMI, Y OSHIHISA
Soshundo Plastic Surgery, South 1 West 4, Chuo-ku, Sapporo 060-0061, Japan

SUGIHARA, TSUNEKI
Department of Plastic and Reconstructive Surgery, Hokkaido University, North
14 West 5, Kita-ku, Sapporo 060-8638, Japan

SUZUKI, KIYOSHI
Kiyoshi Orthopaedic Clinic, 78 Hanadaniban-cho, Toyohashi, Aichi 441-8014, Japan

T AMAI, MAKoTo
Department of Orthopaedic Surgery, Kumamoto Orthopaedic Hospital, 1-15-7
Kuhonji, Kumamoto 862-0976, Japan

TAMAI, SUSUMU
Nara Microsurgery Hand Surgery Institute, West Nara Central Hospital, 5-2-6
Hyakurakuen, Nara 631-0024, Japan

TOH, SATOSHI
Department of Orthopaedic Surgery, Hirosaki University School of Medicine,
5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan

TOMITA, YOSHITSUGU
Department of Orthopaedic Surgery, Ohta General Hospital, 1-50 Nishin-cho,
Kawasaki-ku, Kawasaki 210-0024, Japan

TSUBO, KENJI
Department of Orthopaedic Surgery, Aomori City Hospital, 1-14-20 Katsuta-cho,
Aomori, 030-0821, Japan
XXII List of Contributors

TSUCHIDA, YOSHIHIKO
Department of Orthopedic Surgery, Sapporo Medical University, North 1 West 17,
Chuo-ku, Sapporo 060-8556, Japan

U SAMI, FUMIAKI
Usami Orthopedic Clinic, 3-11-10 Shimohoya, Nishi-Tokyo City, Tokyo 202-0004,
Japan

USUI, MASAMICHI
East Hokkaido Hospital, 7-19 Wakatake-cho, Kushiro, Hokkaido 085-0036, Japan

Y AJIMA, HIROSHI
Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho,
Kashihara, N ara 634-8522, Japan

YAMAMOTO, YUHEI
Department of Plastic and Reconstructive Surgery, Hokkaido University, North 14
West 5, Kita-ku, Sapporo 060-8638, Japan

YAMAOKA, NOBUYUKI
Department of Orthopedic Surgery, Nara Medical University, 840 Shijo-cho,
Kashihara, Nara 634-0813, Japan

Y ANASE, Y OSHIAKI
Orthopedic Surgery, Kitano Hospital, Tazuke Kofukai Medical Research Institute,
2-4-20 Ohgimachi, Kita-ku, Osaka 530-8480, Japan

Y ASUMURA, MASAHIRO
Department of Orthopaedic Surgery, Ajigasawa Central Town Hospital, 110-1
Garno, Maito-machi, Ajigasawa, Nishitsugaru-gun, Aomori 038-2761, Japan

Y ONEMITU, HIROYUKI
Orthopaedic Surgery Unit, Kumamoto Kinoh Hospital, 6-8-1 Yamamuro,
Kumamoto 860-8518, Japan

YOSHIZU, TAKAE
Niigata Hand Surgery Foundation, 1-18 Shinko-cho, Niigata 950-8556, Japan
Acknowledgements

My hearty thanks are expressed to all fellow contributors of this monograph, includ-
ing invited guests, for their great efforts in writing their chapters in English.
I especially thank Drs. Usui and Yoshizu for their efforts in editing more than 90
manuscripts over the past 2 years. Without their hard work, this book would not have
been completed.
I also thank the publisher, Springer-Verlag Tokyo, which kindly accepted my
request to publish a monograph on microsurgery in English. Special thanks go to the
Springer staff, who worked on this book over the past several years.
My thanks also extend to myoid friends of more than 30 years in the field of hand
and microsurgery, Drs. Harry J. Buncke in San Mateo, California, and Harold E.
Kleinert in Louisville, Kentucky, who kindly wrote the Foreword for this monograph.
My sincere gratitude extends to my teacher, the late Professor Emeritus Yutaka
Onji, for his kind guidance and encouragement. I also thank Professor and Chair-
man Yoshinori Takakura, Professor Emeritus Kenji Masuhara, and the alumni of the
Department of Orthopedic Surgery, Nara Medical University, for their great en-
couragement and financial support. Without them, this book would not have been
published.
Finally, I thank my wife Aiko and my family for their overwhelming support and
understanding. I look forward to presenting a copy of this book to my many friends,
both here in Japan and worldwide, who have kindly supported me throughout my
tenure at Nara Medical University over the past 40 years.

Susumu Tarnai, M.D., Ph.D.

December 2002

XXIII
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A. The History of Microsurgery
The History of Microsurgery
SUSUMU TAMAI
Pare (1552) [1] described the first vascular ligature,
and in 1759 Hallowell [2] repaired a wound in the bra-
chial artery by thrusting a pin through the margins of
the wound and tying a thread around it. In 1820, Jones
[3] studied the healing process in vascular injuries
in animals and stressed the importance of neointima,
which had regenerated at the suture site. In 1877, Eck
[4] performed his well-known portacaval shunt opera-
tion for portal hypertension.
The first successful end-to-end anastomosis of the
carotid artery in sheep was reported by J assinowski
in 1889 [5]. He used fine curved needles and fine silk
to make interrupted stitches placed close together. He
avoided penetrating the intima at the anastomoses with
the suture needle. Murphy (1897) [6] first reported
experimental and clinical end-to-end suture by means
of an invagination technique of artery and vein. In 1902,
Alexis Carrel [7] reported vascular end-to-end anasto-
mosis by hand with a three-stay suture technique, which
has been a fundamental technique of vascular sur-
gery up to now. He published his manuscript on his vas-
cular anastomosis technique and its applications to
transplantation of several organs in animals, written in
French, in Lyon Medicale in 1902. Hoephner (1903) [8]
first performed limb replantation at the mid-thigh in
dogs. Goyanes in 1906 [9] and Lexer in 1907 [10] per-
formed autogenous vein grafting. The discovery of an
anticoagulant substance by McLean in 1916 [11] gave
vascular surgeons a method of preventing thrombosis at
the inner surface of the suture site. In 1918, Howell and
Holt [12] named this substance "heparin," and the final
purification of heparin by Charles and Scott in 1933
[13] made it safe to prescribe this substance to clinical
patients. It was one of the revolutions in the develop-
ment of vascular surgery.
In 1912, Charles C. Guthrie [14], in Pittsburgh, pub-
lished a monograph entitled "Blood Vessel Surgery and
its Applications." In this monograph, several pioneering
achievements on the replantation of amputated limbs in
dogs and also transplantation of the canine head to the
neck of another dog are outlined. Carrel and Guthrie
worked together in the laboratory to transplant several
organs, such as the heart, kidney, and ovary. Carrel was
awarded the Nobel Prize in 1912 for the development
of his vascular anastomosis technique. According to the
description of the history of vascular surgery by Lee
et al. (1983) [15], before Carrel and Guthrie's stand-
ardization of vascular surgery, there was considerable
debate over whether the intima of the blood vessels
should be included in vascular repair. Thereafter, the
report of including the intima in suturing made vascu-
lar anastomoses uniformly successful. However, at the
beginning of vascular surgery, the application of vascu-
lar anastomosis was limited to large vessels, because fine
suture materials and delicate instruments for small-
vessel anastomoses had not been developed and throm-
botic problems also had not been solved.
The Dawning Period of Microsurgery
(End of 1950s-1970)
The introduction of the operating microscope led to a
revolution in almost every surgical discipline. Nylen
[16], who was a clinical assistant in otorhinolaryngology
in the Karolinska Medical School, first recognized the
need for magnification in ear surgery, and in 1921 he
used a monocular microscope for a few cases of chronic
otitis and pseudo-fistula formation. Holmgren [17] in
Stockholm reported the first microsurgical fenestration
for otosclerosis using a binocular operating microscope
in 1923. The history of otosclerosis surgery parallels the
history of the operating microscope. Since that time,
several types of ear surgery were technically improved
with the use of this new tool, and in the following two
decades ear surgeons extended the use of the operating
microscope to one-stage fenestration, tympanoplasty,
stapes mobilization, and labyrinth and endolymphatic
operations. Initially problems of inadequate illumina-
tion and inconvenient working distance significantly
delayed the routine use of the operating microscope in
daily practice.
Perritt in 1950 [18] first described the use of a
binocular microscope in ophthalmic surgery. In 1951,
Littmann [19] of the Carl-Zeiss Company manufactured
a prototype of the OpMi-l, a microscope equipped with
coaxial illumination for use as a colposcope or otoscope
3
4 A. The History of Microsurgery
that is still used today. It became commercially available
in 1953 and began to be utilized quite rapidly and with
increasing frequency in the operating room.
In 1953, Harms [20] in Tubingen and Barraquer in
Buenos Aires adapted the microscope to eye surgery,
which was the true beginning of ophthalmic micro-
surgery. Barraquer in 1956 [21] first adapted the slit
lamp to the Zeiss operating microscope and also intro-
duced ceiling suspension for the microscope, making it
more suitable for ophthalmic surgery. He also made
several fine-tipped microsurgical instruments, such
as the well-known Barraquer-type needle holder and
forceps, which are still in use today.
Malis in the mid-1950s [22] first used a microscope to
study and resect adhesions formed by scar tissue on the
cerebral cortex of cats. In 1957 the first application of
microsurgery to human brain surgery was made by
Kurze [23], a neurosurgeon in Los Angeles. He devel-
oped a posterior fossa transmeatal approach to the
internal auditory canal and used this technique for the
total removal of acoustic neurinomas in a 5-year-old
patient, without facial nerve damage.
The use of fine instruments for otology and ophthal-
mology allowed surgeons to begin experimental neu-
rovascular surgery near the end of the 1950s. Jacobson
and Donaghy [24] in Vermont worked together to apply
the operating microscope to intracranial microvascular
surgery. The development of the bipolar coagulator
by Malis in 1956 [25] promoted further development
of microsurgery, because a completely bloodless field,
which needed for accurate microsurgery, could now be
attained.
At the end of the 1950s, Harry 1. Buncke [26] in
San Mateo, California, started his experimental work
on microsurgery after his training in skin flap surgery
under Professor Gibson in Glasgow. Buncke was ini-
tially interested in developing a type of mechanical vas-
cular suturing machine, but failed to do so. Later he
attempted small-vessel anastomosis by hand under a
microscope. Starting with replantation of amputated
rabbit ears, he and his colleagues performed several
microsurgical experiments in which they replanted or
transplanted digits, toes, and free flaps in rats and rhesus
monkeys. In order to perform microsurgical anasto-
moses of small vessels, he consulted the jewelry and
microassembly industry to borrow their micromani-
pulative techniques and instrumentation. The first
suture material was a single strand of cocoon silk that
he obtained from the Japanese Trade Center in San
Francisco and rendered blue with Tintex dye. Buncke
then was able to make small needles by hand-drilling
a 25-micron hole in stainless steel wire 75 microns
in diameter. It was of special interest to Japanese
microsurgeons that Japanese cocoon silk had con-
tributed to the early development of microsurgery at
the end of the 1950s. In order to perform his experi-
ments, Buncke remodeled a garage at his home into a
laboratory. Buncke's wife Constance, a dermatologist,
sometimes assisted him with his experiments in his
home laboratory. Since that time, Buncke, who has been
called "the father of microsurgery," published many
articles on experimental and clinical microsurgery
[27-30], and in the following 20 years, he trained a
number of microsurgeons from all over the world.
In May 1958 in Japan, a historic challenge for replant-
ing or revascularizing an amputated extremity was met
by Onji and Tarnai in the Department of Orthopedic
Surgery, Nara Medical University Hospital, Nara. A 12-
year-old girl was brought into the hospital immediately
after her right thigh had been run over by an electric
train. The mid-thigh was severely crushed and nearly
amputated. The damaged femoral vessels were com-
pletely obstructed with thrombosis. Following extensive
debridement of the wounds, we restored all the tissue as
nearly as possible to its original state, anastomosing the
femoral artery and vein with 7-0 braided silk sutures for
eye surgery. The extremity remained viable for 3 weeks
but became necrotic due to massive infection at the
replanted site, resulting in vascular thrombosis in the
fourth week.
In August 1959, we had another patient, a 47-year-old
woman whose right thigh was almost amputated by an
electric saw. Fortunately, a small amount of tissue in the
anteromedial aspect of the upper thigh, including the
femoral artery and vein, remained intact, somewhat like
a simulated amputation of the limb in an experimental
animal. We repaired all the cut tissue, including the
sciatic nerve, so successfully that the patient could walk
without crutches 2 years later. After 10 years she had
only a small area of hypalgesia remaining on the lateral
aspect of her right leg.
We learned from these two clinical cases that an
amputated leg could be revascularized or replanted
only if we successfully anastomosed the main vessels,
after proper cleansing and debridement of the wounds,
as quickly as possible after the injury. These events
represented the world's first trial of extremity replanta-
tion and revascularization, three to four years before
the arm replantation by Malt in 1962.
Following these clinical experiences, an experimental
project in limb replantation was started in the fall of
1959 by Onji, Murai, and Tarnai. We attempted the
amputation and replantation procedure on the canine
thigh every day, using hand suturing techniques for vas-
cular anastomoses, but we were unable to obtain suc-
cessful results in the first year because of difficulty in the
vascular anastomosis of the femoral vessels, which were
less than 3 mm in diameter. In 1961, after the Inokuchi
blood vessel suturing apparatus was introduced, we
finally achieved the first successful replantation of the

Fig. 1. Dr. Julius H. Jacobson. From [36], with permission
canine thigh [31,32]. Coincidentally, at almost the same
time at the end of the 1950s, experimental research on
the replantation of amputated extremities was also per-
formed by Snyder and Knowles [33] in the United
States and by Lapchinsky [34] in Russia. Both groups
published their works in English in 1960.
In the same year, I found a brief historical article on
microsurgery for anastomoses of I-mm blood vessels
by Jacobson and Suarez in Surgical Forum [35] (Fig. 1).
This article had a great impact on our group in Japan, and
we became aware of the necessity of microsurgery.
According to an article by Comroe in 1977 [37], a
pharmacologist at the University of Vermont had asked
Jacobson, "How can the periarterial nerves on the
carotid artery in a dog be removed?" Jacobson had tried
to cut the carotid artery completely and reanastomose it,
but recognized the difficulty in doing this with his naked
eyes. He tried again and again, experimenting with
binocular loupes or magnifying lenses in the operating
field, but failed to reanastomose the vessel. Finally, he
brought in an operating microscope for otology and
started vascular anastomoses under the microscope.
Thus, Jacobson started microvascular surgery in 1960.
Jacobson used a pair of bulldog clamps with an
adjustable vise and stabilizer of the vascular clamps at
the vascular anastomosis. However, his clamps and
approximator were too large and heavy to be of practi-
cal use for repair of I-mm vessels.
In my case in Japan, I initially crafted a hand-made
double microclip from a pair of Scoville-Lewis clips
used for brain surgery and a 22-gauge hypodermic
The History of Microsurgery 5
needle. Thereafter, I tried to improve it several times,
and finally a medical instrument company in Japan,
the Crown Jun Company, manufactured a very useful
metallic double clip. Later in 1986, another medical
instrument company in Japan, the Kyowa Precision
Instruments Company, modified this to a plastic dispos-
able clip [38], and now three sizes of double microclips
and single clips are commercially available worldwide.
Acland [39] in Glasgow and O'Brien [40] in Melbourne
also developed their own metallic microsurgical clips.
In 1959, Walz [41] reported the first gynecological use
of the operating microscope in fallopian tube surgery.
Troutman in New York in 1960 [42] first installed a
motorized zoom objective lens in his microscope for
ocular surgery. It became popular several years later.
Finally, in 1964 we were able to buy a diploscope from the
Carl-Zeiss Company, the first to be used in Japan. We
then started our training in microvascular anastomoses
using Jacobson's article as our bible of microsurgery.
In 1962, Malt and McKhann [43] in Boston achieved
the world's first arm replantation in a 12-year-old boy
whose arm had been run over by a train, producing a
complete amputation. When I was in the United States
several years ago, I read a newspaper story about this
same patient, now in his mid-twenties, having been
caught by police for stealing something from a store,
using his replanted hand. I reflected that if Professor
Malt had not succeeded in replanting this person's arm,
his life certainly would have been different.
In 1960, Harrold E. Kleinert started a hand and
microsurgery fellowship program at the Department of
Surgery, University of Louisville, Kentucky. In 1962,
Kleinert and Kasdan [44] succeeded in replanting an
incompletely amputated thumb with digital vascular
anastomoses. This was the first report of an incompletely
amputated digit replantation with digital vessel repair
in a clinical case. In the beginning Kleinert had made a
tremendous effort to create microsurgical instruments.
It was a very difficult task, because the instrument com-
panies were not able to understand the requirements of
microsurgery at that time. Chen Zhong Wei and his col-
leagues [45] in Shanghai succeeded in replanting a com-
pletely amputated hand in January 1963 and a severed
index finger in 1965, following our successful thumb
replantation in Japan. In October 1963, Inoue and his
colleagues [46] in Japan succeeded in replanting a com-
pletely amputated hand in a 26-year-old man, the first
such replantation in Japan.
In the field of experimental microsurgery, Lee and
Fisher [47] in Pittsburgh in 1961 published their first
paper on the portacaval shunt in rats using a binocu-
lar loupe. They used 7-0 silk sutures, the smallest avail-
able suture material at that time. They created new
opportunities for microsurgical applications of organ
transplantation in the rat, which was an important
6 A. The History of Microsurgery
experimental animal for the study of transplantation
immunology due to the availability of several inbred
strains.
In the following 10 years, after Lee moved to Scripps
Clinic and Research Foundation in La Jolla, he and his
associates performed transplantations of the heart, lung,
kidney, testicles, liver, pancreas, and stomach [48-54].
Although Lee had not used an operating microscope for
his experimental microsurgery, he was undoubtedly one
of the world's greatest teachers of microsurgery and
trained many micro surgeons in multiple disciplines.
In Australia, Owen started microsurgical research in
1964 by transplanting kidneys in rabbits and mice to
study immunological suppression [55]. Thereafter he
applied his technical skills to neonatal surgery, trau-
matic surgery, urology, and gynecology. He also con-
ducted workshops on microsurgical techniques in
several countries and trained many microsurgeons.
Goldwyn and his associates (1963) [56] tried to trans-
plant large abdominal flaps in dogs, but they failed
because they were not able to use microsurgical instru-
ments and techniques.
The first free skin flap transplant, an abdominal skin
flap based on the superficial epigastric vessels using the
Carrel patch technique in a dog, was achieved by Krizek
and his associates [57]. Their work was published in
Plastic and Reconstructive Surgery in 1965. This contri-
bution was one of the milestones in experimental free
tissue transfers, using an axial pattern flap in the field of
reconstructive. surgery. Among the coauthors with
Krizek, it is worthy of special mention that a Japanese
plastic surgeon, Tasaburo Tani from Okayama, contri-
buted to this historical achievement in the early 1960s.
In the field of peripheral nerve surgery, Ito (1964) [58]
in Japan reported the funicular suture of the peripheral
nerve, based on the intraneural topographic atlas. James
Smith [59] in New York also reported his "skewer
method" for repairing peripheral nerves, as funicular
matching. Thereafter, Bora [60] and Hakstian [61]
respectively contributed to funicular orientation and
repair of the nerves.
On July 27, 1965, Komatsu and I [62] achieved a
microsurgical replantation of a left thumb completely
amputated at the metacarpophalangeal joint level in a
28-year-old male worker. The amputated thumb was
perfused with heparin solution before the operation. We
repaired two volar arteries and two dorsal veins under
a Carl-Zeiss diploscope, and the thumb was revascular-
ized successfully. For the arterial anastomoses we used
8-0 monofilament nylon suture, which was the smallest
suture material available at that time. It happened to be
a sample given by Jacobson to my late boss, Professor
Yutaka Onji, in 1964, when he visited Dr. Jacobson
at Mt. Sinai Hospital in New York. For the venous
anastomoses, we used 7-0 braided silk sutures made
by Ethicon, which was also the smallest size commer-
cially available that year. The thumb was successfully
replanted without any postoperative complications.
John Cobbett [63] in England published a paper on
the fundamentals of microvascular surgical techniques
in Surgical Clinics of North America in 1967, in which
he especially stressed the importance of "eccentric stay
suture at 120 degrees" or "asymmetric biangulation."
Compared with ordinary stay sutures at 180 degrees
apart, the needle never catches the posterior wall when
it is inserted in the anterior wall of the vessel, as the vas-
cular lumen stays open due to the stretching of the stay
sutures. Cobbett was initially interested in the vasaclar
stapler and visited Japan to meet with Drs. Inokuchi in
Kyushu and Nakayama in Tokyo, who were well known
for their own vascular staplers. Cobbett in 1966 dropped
by Nara to see me on his way from Tokyo to Fukuoka
and discussed our case of thumb replantation, the first
in the world.
In 1965, Lougheed [64] performed a thrombectomy
of the internal carotid artery. Pool [65] and Rand and
Jannetta [66] reported the use of microtechniques for
intracranial aneurysm surgery. In 1966, Donaghy and
Yasargil organized the first symposium on microsurgery
at the University of Vermont, and most of the early
workers in this field were present.
At the end of 1966, Ikuta in Hiroshima, Japan, under
Professor Tsuge, also started his microsurgical training
and worked with miniature vessel anastomoses.
Donaghy and Yasargil in 1967 [67] succeeded in a
bypass operation for an embolism of the middle cere-
bral artery by means of a superficial temporal artery to
middle cerebral artery anastomosis (the so-called ST A-
MC anastomosis). Thereafter it was called the extracra-
nial to intracranial bypass (EC-IC bypass) [68].
In 1967, a gynecologist, Swolin [69], performed a
microdissection of the hydrosalpinx, and David,
Brackett, and Garcia [70] studied the effects of micro-
surgical removal of the rabbit uterotubal junction.
Tamai and his associates performed the first experi-
mental transplantation of skeletal muscle in a dog with
microneurovascular anastomoses in 1968 [71]. They
transplanted the rectus femoris muscle to the contra-
lateral thigh and followed it for 1 year. The transplan-
tation was proved successful by electromyography, light
microscopy, and electron microscopy.
In the same year, Yang and his colleagues [72] in
Shanghai performed 2nd toe-to-hand transfers in five
cases; however, in the English medical literature, the
hallux-to-thumb transfer by Cobbett [73] in East
Grinstead, England, performed 2nd in April 1968, was
noted as the first in the world. Actually, 6 months pre-
viously Buncke had attempted a human toe transplant,
 The History of Microsurgery 7

Table 1. Chronology of presidents, chairmen, and congress sites of the International Microsurgical Society (IMS)
No. Year President Chairman Congress site

1970 D.w. VonBekkum D.W. VonBekkum Rijwijik, Holland

2 1972 M.l. Orloff M.l. Orloff and R. Cortesini San Diego, CA, USA
3 1974 G.Mazzoni G. Mazzoni Rome, Italy
4 1976 1. Hashimoto E Chavez-Peon Mexico City, Mexico
5 1978 E. Owen T.S. Lie Bonn, Germany
6 1981 E Chavez-Peon E. Owen Sydney, Australia
7 1982 M.l. Orloff l.M. Dubernard Lyon, France
8 1984 l.M. Dubernard S.Arena Pittsburgh, PA, USA
9 1986 G. Brunelli G. Brunelli Brescia, Italy
10 1989 K. Harii T.S. Chang Shanghai, China (canceled)
11 1992 l. Terzis P. Soucacos Rhodes, Greece
12 1994 S. Tarnai S. Tarnai Nara,Japan
13 1996 H.B. Williams H.B. Williams Montreal, Canada
14 1998 W. Boeckx K.N. Malizos Corfu, Greece
15 2000 Ee. Wei

but after 12 hours of hard work in the operating room The Developing Period of
he had to abandon the operation.
Fujino [74] in Tokyo first achieved the transfer of a
Microsurgery (1971-1980)
mammary gland composite flap in dogs, using an
Inokuchi vascular stapling machine, which resulted in At the beginning of the 1970s, organ transplantation in
successful secretion of milk. rats was performed actively by Lee's group, including
In 1967, when I was staying in the United States, I first the heart, lung, testicle, and stomach.
spoke by telephone with Buncke in San Mateo and told The first International Microvascular Transplantation
him of my first case of thumb replantation. He affirmed Workshop was organized by Van Bekkum and held
that this case was the world's first, and he invited me to in September 1970 in Rijswijik, Netherlands, during
join the world's first Panel on Microsurgery at the the biennial International Congress of the Transplanta-
American Society of Plastic and Reconstructive Sur- tion Society. It was also the first meeting of the
geons in New York in November 1967. The panelists International Microsurgical Society (IMS). Since that
were Buncke, Cobbett, Smith, and myself. It was pro- time, it has continued biennially until 1998 with the
bably the first panel on microsurgery in the field of tremendous efforts of the Honorary President Lee,
reconstructive surgery. Buncke presented his experi- Owen, and other founding members listed in Table 1 ,
mental work on rabbit ear replantaion and on replan- who served as presidents and/or chairmen of the
tation and transplantation of the big toe in the rhesus congress in the past. Prior to the Ninth IMS Congress
monkey. Cobbett reported his first case of hallux-to- in 1986, meetings were principally organized by experi-
thumb transfer. Smith presented his method of skewer- mental micro surgeons, and the majority of the attendees
ing peripheral nerves. My presentation on thumb were colleagues from experimental microsurgery,
replantation created a sensation, as the world's first case neurosurgery, general surgery, pediatric surgery, otorhi-
of a digit replantation. nolaryngology, ophthalmology, urology, gynecology,
This was in contrast to the event in March 1966, when and so on. At the 1986 IMS Congress in Brescia, Italy,
Komatsu presented this same case report at the ninth organized by Giorgio Brunelli, it was noted that the
meeting of the Japanese Society for Surgery of the participants also included reconstructive micro surgeons
Hand in Tokyo. The case was received with incredu- in the fields of hand surgery, orthopedic surgery, and
lity by most of the audience, since at that time few plastic surgery.
could understand the anastomosis of digital vessels less In 1972, O'Brien established a microsurgical teach-
than 1 mm in diameter under an operating microscope. ing laboratory in Melbourne, Australia. He performed
However, this case report was published in Plastic and tremendous work, experimentally and clinically, and
Reconstructive Surgery in 1968 [62], with kind recom- also trained a number of micro surgeons from around
mendation by Buncke. Thereafter, this article has been the world.
recognized by many as the first report of digit replanta- Garcia (1972) [75] first described microsurgical tubal
tion with microvascular anastomoses. anastomosis for reversal of sterilization.
8 A. The History of Microsurgery

Table 2. Chronology of presidents, chairmen, and congress cilis muscle and by Ikuta [81] in 1975 with a pectoralis
sites of the International Society of Reconstructive Micro- major muscle for Volkmann ischemic contracture of the
surgery (ISRM) forearm.
No. Year President Chairman Congress site In the field of peripheral nerve microsurgery, Millesi
1 1972 H. Millesi H. Millesi Vienna, Austria [82], followed by Terzis [83], Williams [84], Samii [85],
2 1973 H. Millesi H. Millesi Vienna, Austria and Brunelli [86], contributed significantly to the
3 1975 1.R. Cobbett 1.R. Cobbett East Grinstead, England development of funicular or fascicular nerve repair and
4 1977 H.I Buncke H.I Buncke San Francisco, USA
5 1979 M. Ferreira M. Ferreira Guaruja, Brazil
grafting experimentally and clinically. According to
6 1981 B.M. O'Brien B.M. O'Brien Melbourne, Australia Millesi [87], interfascicular nerve grafting produced
7 1983 B. Strauch B. Strauch New York, USA recovery of useful function in 80% of his patients.
8 1985 S. Tarnai A. Gilbert Paris, France This equaled the results obtained with primary
9 1988 Z.w. Chen K. Harii Fuji, Japan nerve repair under ideal conditions. Williams and
10 1991 I.G. Taylor E. Biemer Munich, Germany
11 1993 E. Biemer H. Millesi Vienna, Austria
Terzis (1976) [88] initiated intraoperative fascicular
12 1996 1.B. Steichen R. Pho Singapore recordings for the lesion in continuity in peripheral
13 1999 1. Baudet W. Shaw Los Angeles, USA nerve injury. Taylor and his associates (1976) [89]
14 2001 V. Meyer performed vascularized nerve grafts in a clinical case
with satisfactory results.
The Fourth Congress of the IMS was held in Mexico
City in 1976 under the presidency of Isamu Hashimoto
McLean and Buncke (1972) [76] succeeded in trans- from Kyoto and the chairmanship of Chavez-Peon.
planting the omentum to the denuded scalp created by At this time, the name "International Microsurgical
the removal of a squamous cell carcinoma, and placed Society" was approved and the society was officially
a split-thickness skin graft over the omentum. incorporated. The constitution and bylaws were also
At the Tokyo Metropolitan Hospital, under the accepted.
encouragement of the late Ohmori, Sr., Harii and As specialists in orthopedic surgery, we have dreamed
Ohmori, Jr., started microvascular surgery in 1969 and of the vascularized bone graft or living bone graft. It
succeeded in a temporal free flap transfer in September became possible through the experimental work by
1972 [77]. It was the first clinical free skin flap transfer Buncke (1967) [90], Strauch (1971) [91], Tarnai and his
in the world, although the medical literature has cited colleagues (1971) [92], McCullough and Fredrickson
the report of the groin flap transfer by Daniel and (1973) [93], Oestrup and Fredrickson (1973) [94], and
Taylor in 1973 [78] as the first. Doi (1977) [95].
In October 1972, another international microsur- Clinical success in transplantation of a vascularized
gery group, the International Society of Reconstructive fibula graft for congenital pseudarthrosis of the ulna was
Microsurgery (ISRM), was established, and the first achieved by Ueba and Fujikawa [96] in Japan in 1973.
symposium was held in Vienna, organized by Millesi. Taylor and his colleagues [97] performed a vascularized
Ninety-seven papers were presented at the symposium, fibular graft for nonunion of the tibia in 1974, which was
covering the fields of cerebrospinal surgery, otorhino- generally accepted as the world's first clinically success-
laryngology, reconstructive surgery, peripheral nerve ful free vascularized bone graft in the medical literature.
surgery, and vascular surgery. Among the founding Taylor [98] also raised the possibility of the transplan-
members of the ISRM, Acland, and Cobbett from tation of the iliac osteocutaneous flap. Coincidentally,
England, Jacobson and Kleinert from the United States, Tarnai [99] succeeded in transplanting the same flap in
Berger, Meisel, and Millesi from Austria, Brunelli from 1976, unaware of Taylor'S prior achievement. Taylor's
Italy, O'Brien from Australia, Samii from West Germany, tremendous effort in this field has radically changed the
and Tarnai from Japan attended. The second symposium concept of free bone grafting. In the vascularized bone
of this society was again organized by Millesi and held in graft, the bony union occurs like fracture healing, but
Vienna in 1973. Since then, this meeting has been held without the process of "creeping substitution."
every two years, as shown in Table 2. Miller (1975) [100] in Australia reported the first suc-
It was decided that this society would encompass only cessful replantation of an avulsed scalp with microvas-
reconstructive microsurgery in the fields of orthopedics cular anastomoses.
and plastic surgery and that it would have a closed mem- Between 1972 and 2000, Tarnai trained approxima-
bership system, basically differing from the IMS. tely 150 microsurgeons from all over Japan as well as
In 1973, the first case of a pectoralis major muscle other countries at the Orthopedic Department of Nara
transplantation was reported by a Shanghai group [79], Medical University. In conjunction with the increas-
followed by Harii and Ohmori [80] in 1973 with a gra- ing number of microsurgeons, the Japanese Society of

Reconstructive Microsurgery was established in 1974 by
the great efforts of those who included Fujino, Harii,
Ikuta, Ohmori, and Tarnai. The first meeting was held
under the presidency of Tarnai in Nara in 1974, and
thereafter it has been held every year, with approxi-
mately 800 members attending.
It is worthy of special mention in the history of
microsurgery that the axial pattern skin flap transfer
advocated by McGregor and Jackson (1972) [101]
has become a routine procedure in the field of plastic
and reconstructive surgery, with a 90% success rate in
most microsurgery centers [102]. Several new flaps
and new ideas have been reported over the years,
with significant improvements in suture materials and
micro instruments.
Baudet and his group (1976) [103] proposed the term
"musculocutaneous flap" and stressed the usefulness of
the latissimus dorsi musculocutaneous flap based on the
thoracodorsal vessels. Since then, the concept of a mus-
culocutaneous flap has become popular among recon-
structive microsurgeons.
Urologists also have used microsurgery, mainly
for pediatric urology and urinary tract surgery, but
in addition, Silber (1976) [104] was successful in
autotransplantation of the intra abdominal testis to the
scrotum. Silber (1977) [105] reported reversal of male
sterility by vasovasostomy, with a 76% pregnancy
rate. Replantation of an amputated penis and scrotum
was first performed by Tarnai and his colleagues [106]
in June 1976, followed by Cohen and his colleagues
(1976) [107] in Boston. These achievements, performed
by an orthopedic surgeon and a plastic surgeon,
were just the beginning of urological applications of
microsurgery.
James (1976) [108] reported the world first successful
microsurgical replantation of an avulsed large segment
of the upper lip and nose.
Clodius in 1976 [109] reported lymphatic micro-
surgery, and thereafter primary or secondary lym-
phedema in the extremities could be treated with
microsurgicallymphaticovenous shunts.
In the field of plastic and reconstructive surgery, facial
reanimation with nerve and muscle transplantation and
breast reconstruction with musculocutaneous flap trans-
fers became popular from the tremendous efforts of
Smith (1976) [110], Anderl (1973) [111], Harii (1979)
[112], and Robbins (1979) [113].
Replantation surgery was popularized all over the
world by the end of the 1970s. Among the main replan-
tation centers in the world, Chen and his associates
[114] in China, Kleinert and his associates [115,116] in
the United States, O'Brien and his associates [117] in
Australia, and Tarnai and his associates [118] in Japan
reported more than 80% to 90% success rates and
The History of Microsurgery 9
stressed the importance of functional recovery for
the replants. Usui et al. (1978) [119] reported a can-
ine experimental study on replantation toxemia after
replantation of the ischemic limb, and showed the bene-
ficial effect of cooling the limb in ice water for preser-
vation.Gordon and his colleagues (1978) [120] studied
the histological changes in the skeletal muscle after
temporary occlusion of the blood circulation in rats.
According to their results, the period of warm ischemia
of the muscle should be limited to about 1 hour. Biemer
and his associates (1978) [121] in Germany, MacLeod
and his colleagues (1978) [122] in Australia, Tarnai and
his associates (1978) [123] in Japan, and Yoshizu and his
colleagues (1978) [124], also in Japan, reported their
experiences with replantations, with an average success
rate ranging from 74% to 100%. Van Beek and his col-
leagues (1978) [125] reported their well-known "ribbon
sign" at digital replantation, which indicates unsuitabil-
ity of the vessel to be anastomosed in digital replant a-
tions. Stirrat and his colleagues (1978) [126] reported
the importance of temperature monitoring in digital
replantation. Cooney (1978) [127] stressed the impor-
tance of interpositional artery and vein grafts, when
there is significant blood vessel damage, to obtain satis-
factory survival of replants. Ikuta (1978) [128], Meuli
and his colleagues (1978) [129], Urbaniak and his asso-
ciates (1978) [130], and Tupper (1978) [131] reported
management of bone stabilization in replantation
surgery.
Morrison and his colleagues (1978) [132] reported the
neurovascular free flap from the first web space of the
foot and its usefulness in thumb reconstruction.
Goald (1978) [133] reported a follow-up study of
microlumbar discectomy in 147 patients, with a 96%
recovery rate. He emphasized that it is safe, effective,
and economical for the patients. Williams (1978) [134]
also reported micro lumbar discectomy in 530 patients.
The operating time averaged 37 minutes and the hospi-
tal stay 3.1 days. Satisfactory results were obtained in
91 % of his patients.
Gomel (1978) [135] reported microsurgical salpin-
gostomy for hydrosalpinx, with a postoperative patency
rate of 90%. Among the 41 patients followed for more
than 1 year, 29% had one or more intrauterine
pregnancies, and 27% had live births.
In 1978, Lie organized the Fifth Congress of the Inter-
national Microsurgical Society in Bonn, and in 1978,
Ferreira presided over the Fifth Symposium of the
International Society of Reconstructive Microsurgery in
Guaruja, Brazil.
Taylor and his associates (1979) [136] showed the
superiority of the deep circumflex iliac vessels as the
supply for free groin flaps, compared with the superfi-
cial circumflex iliac vessels. The former are larger in
10 A. The History of Microsurgery

diameter and provide more reliable blood flow than the tubal reanastomosis, with pregnancy rates of 60% to
latter. 82%.
Chen and his colleagues (1979) [137] reported
12 cases of congenital pseudarthrosis of the tibia, which
were treated with vascularized fibular grafts and
The Fully Matured Period
obtained satisfactory bony union. of Microsurgery (1981-1997)
It is very important to know whether the anastomosed
blood vessels have achieved patency after vascularized Urbaniak and his colleagues (1981) [148] reported
bone grafting. Bos (1979) [138] showed the reliability microvascular management of ring avulsion injuries.
of bone scintigraphy with 99ffiTc-diphosphonate to assess They succeeded in treating 9 ring fingers among 24
patency of the vascular anastomoses in vascularized acute ring avulsion injuries. They illustrated guidelines
fibular grafting as early as the first postoperative week. for a practical classification of three types with regard
Previously, it was impossible to obtain this information to digital revascularization for this injury: Class I, circu-
for timely reexploration of the anastomoses if the lation adequate; Class II, circulation inadequate; and
circulation had deteriorated postoperatively. Class III, complete degloving or complete amputation.
Hurwitz (1979) [139] reported successful microvascu- Microsurgical revascularization is the treatment of
lar transplantation of a canine metacarpophalangeal choice for Class II injury, but Class III injury at the proxi-
joint. He showed its viability using tetracycline labeling. mal phalanx and complete degloving injury are usually
Biemer (1980) [140] proposed definitions of ter- best managed by surgical amputation of the digit.
minology and classification in replantation surgery. He Tarnai and his colleagues [149] reported 229 digital
referred to minor replantation as "microreplantation" replantations in 157 patients, performed between 1965
and to major replantation as "macroreplantation." and 1979, with a success rate of 89.5%. In most of their
Replantation was also "divided into total replantation patients, sensation recovered to more than protective
and subtotal replantation. The latter was classified into sensation, and approximately 50% of the cases had two-
five types: Type I, bone connection; Type II, extensor point discrimination of less than 15 mm. Restriction of
tendon connection; Type III, flexor tendon connection; range of motion was a problem in the replantation at
Type IV, nerve connection; and Type V, skin or soft tissue "no-man's-land" of digits.
connection. Biemer also classified amputation zones in Tamai was invited as the Founder's Lecturer to the
the hand. 36th Annual Meeting of the American Society for
Kleinert and his associates (1980) [141] reviewed 245 Surgery of the Hand in Las Vegas in 1981, organized by
patients with replantation of 347 extremities. According Buncke, and he presented his experience with limb and
to functional evaluations using assessment criteria that digit replantation.
included two-point discrimination, grip strength, range In 1981, Owen organized the Sixth Congress of the
of motion, cold intolerance, and return to employment, International Microsurgical Society in Sydney, and
success rates averaged 70% between 1970 and 1978. O'Brien held the Sixth Symposium of the International
Hamilton et al. [142] from Melbourne also reported Society of Reconstructive Microsurgery in Melbourne,
160 digital replantations in 120 patients between Australia.
1970 and 1978, with an overall success rate of 74%. The Doi (1982) [150] performed thumb reconstruction in
best results were obtained with replantation of the six patients using wrap-around flap transfer; compared
thumb. with toe-to-hand transfer, their results were superior
Morrison and his associates (1980) [143] described cosmetically and functionally.
a unique procedure for thumb reconstruction, the Nassif from the Baudet group [151] introduced a new
wrap-around flap taken from the big toe. It has become flap, the parascapular flap, which is nourished by a direct
the most popular procedure for thumb reconstruction, cutaneous artery of the circumflex scapular artery. The
replacing transfer of the big toe. advantages of this flap are the uniform presence of
Foucher (1980) [144] reported free partial toe trans- large-diameter vessels with long pedicles, excellent
fer in mutilated hand reconstruction in 12 cases and intradermal network with rich anastomoses, hairless
stressed its usefulness, in that he introduced the twisted skin, a moderate amount of subcutaneous tissue, and the
toe flap from the big toe and the second toe to create a possibility of primary closure of the. donor site.
custom-made new distal part of a digit. O'Brien and his associates [152] reported free muscle
Pennington et al. (1980) [145] reported successful transfers to the limbs in seven patients to provide motor
replantation of a completely avulsed ear using function to severely injured limbs, mainly by applying
microvascular anastomoses. free gracilis microneurovascular flap transfers.
Gomel (1980) [146] and Winston (1980) [147] Chen and Yan (1983) [153] reported the free fibular
published their follow-up results on microsurgical osteocutaneous flap transfer, describing its anatomy and

harvesting technique. In January 1979, they performed
the first fibular osteocutaneous flap transfer successfully.
Using a 20-cm-long fibular segment, with a 20 x 6cm
skin flap, they performed reconstruction of an infected
nonunion of the forearm bones in a 22-year-old woman.
Chow (1983) [154] showed the importance of endo-
thelial integrity for patency of the microvascular
anastomoses with his histopathologic study on 178
microvascular anastomoses of the murine femoral artery.
Lister and his associates [155] analyzed their toe
transfers in 54 patients, with a success rate of 90.7%. In
their cases, reexploration of the vascular anastomoses
was required in 13 patients (34.2 %), but 4 failed
salvaging attempts. Several secondary surgeries were
necessary in 26 patients. The pinch strength between
great toe transfer and second toe transfer to the thumb
was 35.7% and 15.6%, respectively.
Poppen from the Buncke group (1983) [156] evalu-
ated 10 patients with great toe to thumb transfer;
sensory recovery was directly related to the patient's
age, the joint motion of the transferred toe was limited,
and cold intolerance was present in all.
In 1983, Strauch organized the Seventh Symposium
of the International Society of Reconstructive
Microsurgery in New York. At the business meeting,
a new administrative system was instituted, with the
president managing the society and the chairman
organizing the scientific meeting.
The IMS had been organized biennially through 1984
by the leadership of experimental micro surgeons, such as
Lie for the Fifth in Bonn, Owen for the Sixth in Sydney,
Dubernard for the Seventh in Lyon, and Arena for the
Eighth in Pittsburgh. Over the years, the gatherings had
increased in numbers, with participants from several
different surgical disciplines from all over the world.
Manktelow et al. (1984) [157] reported 12 cases of
muscle transplantation to the forearm to reconstruct
digit flexors. Among them, 11 muscles survived and 9 of
them provided a full range of motion, with a maximum
grip strength 50% of normal.
Experimental allotransplantation of vascularized
composite tissues also was brought into a new era with
the development of a new immunosuppressive agent-
cyclosporin A. Schoofs (1984) from the Baudet group
[158] reported microvascular free femur transplantation
in a rat to study the bone physiology in auto- and allo-
transplantation. Siliski et al. (1984) [159] reported
vascularized whole knee joint allografts in rabbits with
immunosuppression by cyclosporin A. They performed
21 vascularized knee joint allotransplantations between
incompatible strains. Some of the animals immunosup-
pressed with cyclosporin A (15 mg/kg/day) survived up
to 100 days without rejection.
In Japan, Yoshimura (1984) [160] first reported
clinical application of a new flap, the venous skin graft.
The History of Microsurgery 11
It became a matter of concern among reconstructive
micro surgeons to explan how this flap could be suc-
cessful. Baek et al. (1985) [160] reported their experi-
mental study on the venous flap and suggested that
capillary diffusion could occur without the continuous
flow of blood through a capillary.
Yoshimura and his colleagues (1984) [162] also
reported the peroneal flap, which is nourished by the
cutaneous perforators from the peroneal vessels. This
flap can be utilized not only as a skin flap but also as an
osteocutaneous fibula graft. They also introduced a
small peroneal flap, the buoy flap, which was attached
to the vascularized fibula for postoperative monitoring
of the blood circulation to the bone.
Yamano (1985) [163] attempted replantation in the
distal phalanx of 87 digits with a 94.3% success rate, and
stressed its efficacy in obtaining satisfactory function
and cosme sis. The distal digit replantation had not been
well accepted by hand surgeons in the United States and
Europe because it is a time-consuming procedure and
because it delays the patient's return to work.
In 1985 the Eighth Symposium of the International
Society of Reconstructive Microsurgery was held in
Paris under the presidency of Tamai and the chairman-
ship of Gilbert.
Free or pedicled composite tissue transfers for the
immediate reconstruction of tissue defects following
tumor resection in the trunk and extremities became
popular. Usui et al. (1986) [164] reported six cases of
microsurgical composite tissue transfers following wide
resection of bone and soft tissue sarcoma in the upper
extremity. They used a vascularized fibula graft in five
cases and muscle transfer in one case. In five successful
cases, there were no local recurrences or distant
metastases.
Gloviczki et al. (1986) [165] reported canine
experiments with lymphaticovenous anastomoses,
demonstrating that the occlusion rate was high. They
concluded that the chances of success were better
with several anastomoses performed in the early stages
of lymphedema, before significant tissue fibrosis
and complete loss of lymphatic valvular function
developed.
Godina (1986) [166] reported microsurgical recon-
struction following extremity trauma in 532 patients.
They were divided into three groups: group 1 underwent
free flap transfer within 72 hours after the injury,
group 2 between 72 hours and 3 months, and group 3
between 3 months and 12.6 years. The flap failure
rate was 0.75% in group 1, 12% in group 2, and 9.5%
in group 3. Postoperative infection occurred in 1.5%
of patients in group 1, 17.5% in group 2, and 6% in
group 3. The average length of hospitalization was 27
days in group 1, 130 days in group 3, and 256 days in
group 3.
12 A. The History of Microsurgery
Oestrup and Berggren (1986) [167] developed a new
instrument for fast and safe mechanical microvascular
anastomosis, named UNILINK. It could be used for
both end-to-end and end-to-side anastomosis of small
arteries and veins and also for other small tubular struc-
tures. The time for anastomosis was within 2 to 3
minutes, and the overall patency rate was 98%.
Brunelli organized the Ninth Congress of the Inter-
national Microsurgical Society in Brescia, Italy, in 1986,
with the attendance of reconstructive microsurgeons
from all over the world. The emphasis had moved from
experimental microsurgery to clinical research on
reconstructive microsurgery in the fields of hand and
orthopedic surgery, plastic and reconstructive surgery,
and so on. The number of participants from the experi-
mental organ transplantation surgery group had
significantly decreased from previous years.
Kawabata and his colleagues (1987) [168] reported
early microsurgical reconstruction of the brachial
plexus in birth palsy. Microsurgical nerve repair was
carried out on the basis of intraoperative diagnosis
approximately 6 months after delivery, and the results
in six infants were encouraging.
Jones and his associates (1987) [169] performed
microsurgical reconstruction of the hand in four
patients with systemic scleroderma presenting with
Raynaud's phenomenon. Two patients experienced
immediate resolution of severe pain and rapid healing
of their digital ulcers.
Koshima and his associates (1988) [170] reported a
free vascularized nail graft and a double onychocuta-
neous flap transfer for nail reconstruction.
Schubert and his colleagues (1988) [171] achieved a
microsurgical replantation of a full-thickness amputa-
tion of the lower lip and chin by a horse bite in a 12-
year-old boy, with anastomoses of the inferior labial
artery and vein.
Valauri from Buncke's group (1988) [172] introduced
prefabricated neovascularized free muscle flaps in rats
to overcome the disadvantages of free muscle trans-
plantation, which included limitation of available donor
sites, loss of donor muscle function, and deformity of the
donor site defect. They created the flap by wrapping the
external abdominal oblique muscle around the superfi-
cial inferior epigastric blood vessels, and then trans-
planted them as free flaps. This work has been continued
by Hirase and his colleagues [173,174], with several
variations of the flap developed in the following years.
Harii (1988) [175] reported technical refinements of
free muscle transfer for reanimation of facial paralysis,
and Manktelow (1988) [176] reported on extremity
reconstructions, advocating the usefulness of gracilis
muscle transfers for the reconstruction of finger flexors
and extensors.
Fig. 2. Executive members at the Ninth Symposium of the
International Society of Reconstructive Microsurgery (ISRM)
in Fuji, Japan, 1988. From left to right: O'Brien McCB, Taylor
GI, Strauch B, Millesi H, Biemer E, Chen ZW, Steichen JB,
Harii K, and Tarnai S
On April 17-22, 1988, Harii organized the Ninth
Symposium of the International Society of
Reconstructive Microsurgery at Mt. Fuji, under the
presidency of Chen (Fig. 2). Owing to the support of
the Japanese Society of Reconstructive Microsurgery,
this symposium was a great succeess.
For replantation surgeons, replantation of the limb
and digits without function has no purpose other than
superficial cosme sis. To obtain satisfactory function of
the replants, several secondary reconstructive surgeries
are very important. Jupiter and his colleagues (1989)
[177] performed flexor tenolysis on 41 replanted digits
at an average of 10 months postoperatively, and the
total active range of motion increased from a mean of
72 degrees to 130 degrees.
Replantation of the fingertip to the distal interpha-
langeal joint has been controversial for many years.
Because of social customs in Japan, it was perceived by
several surgeons to be indicated there if the surgery was
technically possible. Tsai and his colleagues (1989) [178]
and Goldner and his colleagues (1989) [179] reported
replantations at the distal phalangeal amputation of
digits. The survival rate of 26 fingertips among Tsai's
patients was 69%. The cosmetic appearance was excel-
lent, and patient satisfaction was high. The success rate
of 42 complete amputations distal to the distal inter-
phalangeal joint among Goldner's patients was 81 %,
and the average operating time was 4.6 hours. The
patients returned to work after an average of 2.5 months
without any additional surgery. The average total cost of
treatment was $7500, which was higher than that of
conventional procedures.
Fukui et al. (1989) [180] reported continuous local
intraarterial infusion of anticoagulants, such as uroki-

nase, prostaglandin Ej, heparin, and low-molecular-
weight dextran through a Teflon catheter inserted into
the artery, for salvaging problematic digit replantations
with damaged arteries.
Whitney from Buncke's group (1989) [181] per-
formed multiple microvascular transplants (MMTs) in
94 patients with 198 flaps, with an overall success rate
of 95 %. These flaps were divided into two groups: group
I, simultaneous MMTs in 38 patients with 76 flaps; and
group II, sequential MMTs in 56 patients with 122 flaps.
Whitney suggested that simultaneous MMTs were a
reliable and cost-effective method of reconstruction.
Valauri and Buncke (1989) [182] reviewed their series
of 80 great toe transplants to reconstruct the thumb.
They stressed that it is a safe, reliable, and efficient
means of thumb reconstruction that offers significant
advantages over other techniques and few disadvan-
tages. Wei et al. (1989) [183] reviewed 26 combined
second and third toe transfers to reconstruct missing
adjacent fingers, and described the indications, technical
considerations, and donor site complications.
For postmastectomy breast reconstruction, Coleman
and Boswick (1989) [184] reported the usefulness of
the transverse rectus abdominis musculocutaneous
(TRAM) flap on the deep inferior epigastric vessels,
both as a transposition flap and as a free flap transfer.
In 1989, the Tenth Congress of the International
Microsurgical Society was scheduled to take place in
Shanghai under the presidency of Harii and the
chairmanship of Chang, but it was canceled due to the
1989 democracy protests in Tiananmen Square.
Koshima and Soeda (1989) first used a deep epigas-
tric perforator flap (DIEP) using only one single perfo-
rator without rectus abdominis muscle [185].
As the ultraminiature model for practicing microsur-
gical dissection and microvascular anastomoses, Chiu
and his colleagues (1990) [186] advocated rat ear reat-
tachment, and Bao (1990) [187] reported murine big toe
transplantation.
Buck-Gramcko (1990) [188] reported the significant
contribution of microsurgery to the treatment of
congenital malformations of the hand. Microsurgery
enables hand surgeons to operate on the tiny hands of
infants during the first 2 years of life without damaging
anatomical structures, and also allows the use of several
new procedures using microdissection techniques and
microneurovascualr anastomoses.
Khouri and Shaw (1991) [189] reported a rat model
of prefabrication of composite free flaps. The knee joint
was wrapped with the ipsilateral superficial inferior
epigastric fascia, pedicled on the superficial inferior
epigastric vessels, and orthotopic ally transferred 2
weeks later. They applied this technique to a toe joint
transfer to the finger joint. A temporalis fascia flap was
The History of Microsurgery 13
wrapped around the proximal interphalangeal joint of
the second toe and revascularized to the dorsalis pedis
vessels. Six weeks later, the joint wrapped with the
temporalis fascia flap was harvested and transferred to
the hand with vascular anastomoses. This method solved
the difficulty of harvesting an anatomically complex
vascularized toe joint.
Valauri (1991) [190] reviewed the anatomy and
physiology of the medicinal leech, which has been used
for treating venous insufficiency following microsurgi-
cal free flap transfers and replantations. He discussed
the indications, technique of application, and potential
complications of the use of leeches.
Nystrom and his colleagues (1991) [191] investigated
the relationships between traumatic digital amputation,
replantation, and cold intolerance. Cold intolerance is
related to the original injury, not to the reconstructive
surgery, and it is a major reason for disability after
digital amputation.
Daigle and Kleinert (1991) [192] conducted a retro-
spective study of major limb replantation in 15 patients
under 18 years of age. Their overall survival rate was
87%. In 93% of the patients, the replanted limb func-
tioned and looked better than a prosthesis.
Taras and his colleagues (1991) [193] at Duke
University reported 162 replantations in 120 children
under the age of 16 years, with an overall success rate
of 77%. The replanted digits attained 81 % of normal
longitudinal skeletal length at maturity.
Feller, Graf, and Biemer (1991) [194] reported
replantations in 2040 patients from 1975 to 1988. They
emphasized the importance of the liberal use of vein
grafts in avulsion and crush injuries. The best functional
results were achieved in replantation of distal finger
parts.
Gayle et al. from Buncke's group (1991) [195]
reported lower extremity replantation, which has been
controversial. The successfully replanted lower extrem-
ity provided a superior functional and esthetic result for
the patient. They stressed that improved surgical tech-
niques and experience make it an excellent alternative
to prosthetic substitution.
Arnez (1991) [196] from Ljubljana, Yugoslavia,
advocated emergency free tissue transfer in complex
lower extremity injuries on an emergency basis during
the first 24 hours after an accident. He reported that it
provided a better result than delayed primary treatment
in terms of lower free flap failure rate, lower infection
rate, lower number of operations until the final
outcome, shorter time of hospitalization, shorter time
of bone healing and weight-bearing, and lower cost of
treatment.
Buncke and his associates (1991) [197] stressed the
contributions of microvascular surgery to emergency
14 A. The History of Microsurgery

hand surgery in the areas of replantation and free tissue

transplantation. They proposed that the classical
principle of hand surgery, "preserve length and func-
tion," could now be modified to "restore length and
function."
Akasaka and his associates (1991) [198] had used
intercostal nerve crossing to the musculocutaneous
nerve to achieve elbow flexion since 1965. In 1978, they
introduced free muscle transplantation, which was then
replaced with the longstanding paralyzed biceps brachii
muscle, combined with intercostal nerve crossing in
delayed presentations of complete brachial plexus
injury.
Wei and his colleagues (1991) [199] reported a micro-
surgical second toe wrap-around flap technique. This
was used to reconstruct the distal half of the finger with Fig. 3. Past presidents at the Tenth Symposium of the ISRM
in Munich, Germany, 1991. From left to right: Millesi H (first
circumferential loss of skin and nail, associated with an
and second), Ferreira MC (fifth), Taylor GI (tenth), Cobbett
uninjured proximal interphalangeal joint and an intact JR (third), O'Brien McCB (sixth), Biemer E (eleventh),
insertion of the flexor digitorum superficialis tendon. Strauch B (seventh), Chen ZW (ninth), Tarnai S (eighth), and
Thirteen flaps in 10 patients showed adequate func- Buncke HJ(fourth)
tional recovery and excellent esthetic appearance.
Jupiter et al. (1991) [200] advocated limb reconstruc-
tion by free tissue transfer combined with the Ilizarov
method of limb lengthening. He reported that gradual transferred with vascular anastomoses as an autoge-
lengthening does not compromise the blood vessels. nously vascularized allograft. The results showed a
This could be called the dawning of the application of remodeling pattern comparable with that of a con-
tissue engineering to microvascular surgery. ventional vascularized bone autograft, even without
In 1991, Biemer held the Tenth Symposium of the immunosuppressive treatment.
International Society of Reconstructive Microsurgery in The Eleventh Congress of the IMS was organized by
Munich, under the presidency of Taylor (Fig. 3). President Terzis and Chairman Soucacos in Rhodes,
Foucher and Norris (1992) [201] reported distal Greece, in 1992. There had been a 6-year break since the
digital replantation of 98 complete and incomplete Ninth Congress in Italy in 1986. There were 235 atten-
amputations in 95 patients, with a 65.5% success rate. dees from 11 countries, and over 250 papers were
They stressed that distal replantation is a fast and presented. At the business meeting, Tamai was elected
worthwhile procedure providing acceptable sensibility, president and chairman for the next 2 years. Based
no proximal interphalangeal joint limitation, and good on the changes in the membership categories and the
cosmetic appearance. Koshima et al. (1992) [202] also differing interests of experimental micro surgeons in
reported distal phalangeal replantation using arteriove- the IMS, a new society, the International Society for
nous anastomoses to improve the success rate. In 33 Experimental Microsurgery (ISEM), was established in
digits of 23 patients, the survival rate was 91 %, with 1992, and its first congress was held in Rome. Thereafter,
excellent results. congresses were held in Kanazawa, Japan, in 1994,
Camacho and Wood (1992) [203] described a com- Wurzburg, Germany, in 1996, and London, Canada, in
parative study of two fundamentally different tech- 1998. This new society has focused on the link between
niques of multiple digit replantation, a digit-to-digit and current experimental microsurgery and transplantation
a structure-by-structure method, and concluded that the research.
latter method was advantageous in terms of shorter Walton and Brown (1993) [205] reported a com-
operation time and better survival rate. In my experi- posite graft of a biomaterial with an autogenous vascu-
ence at Nara Medical University Hospital, surgeons lar pedicle. The pedicle, sealed with silicone sheeting,
were divided into two teams if enough staff was avail- provided fibrovascular outgrowth completely integrat-
able: one team for macro surgery of bone and tendon ing the biomaterial scaffolds at 6 weeks, which allowed
repair and the other team for microsurgery of nerve and a split-thickness skin graft on it. This composite could
blood vessels. Braun (1992) [204] reported a very inter- be transferred micro surgically as a free graft.
esting experiment in the rat. A bone taken from DA rat Nolan and Bowen (1993) [206] reviewed extremity
was implanted in a muscle of the recipient Lewis rat, transplantation to its current state of development.
and 6 weeks later a bone-muscle composite graft was They described the history of laboratory research on
 The History of Microsurgery 15

extremity transplantation before immunosuppression,

as well as reviewing several current immunosuppressive
agents.
Gu and his associates (1993) [207] reported a large
series of toe transfers to reconstruct thumb and fingers
in 30 cases, performed from 1966 to 1989. The survival
rate was 95.55%. Arakaki and Tsai (1993) [208] ana-
lyzed 122 cases of thumb replantation, with a survival
rate of 71%. Among them, 20 thumbs required
re-exploration for vascular compromise, and 9 were
salvaged with 45% success.
Doi and his colleagues (1993) [209] reported 58 rein-
nervated free muscle transplantations in 46 patients
with brachial plexus injury, limb salvage following
tumor surgery, and so on. In patients with brachial Fig. 4. Executive members attending the twelfth Congress of
plexus injury, the average elbow motion was -25 the International Microsurgical Society (IMS) in Nara, Japan,
degrees of extension and 90 degrees of flexion, with 3 1994. From left to right: Owen E, Tarnai S, Lee S, Terzis JK,
to 4 power on the Highet scale after the reconstruction and Williams HB
of the elbow flexor.
In 1993, Millesi organized the Eleventh Symposium
of the International Society of Reconstructive
Microsurgery in Vienna as an anniversary symposium the proximal site failed and required a secondary
after a 10-year interval from the first and second autogenous bone graft to obtain final union.
symposia held in Vienna in 1972 and 1973. It was In October 1994, Tamai organized the Twelfth
attended by fewer participants, but included many Congress of the International Microsurgical Society in
microsurgical pioneers from all over the world. Nara, with approximately 230 participants from 21
Staley and his colleagues (1994) [210] performed countries (Fig. 4). The IMS had been organized by
experiments on intracorporeal laparoscopic jejunal several experimental microsurgeons from many dif-
harvesting in the pig and dog. They then reported the ferent areas. However, beginning with the Ninth
first case of a patient who underwent a laparoscopic Congress in 1986, the emphasis was placed on the fields
jejunal harvest, intracorporeal small bowel anastomosis, of plastic and reconstructive surgery as well as hand and
and microvascular anastomoses in the neck for recon- orthopedic surgery. Thereafter, the subsequent six meet-
struction of the laryngopharynx. ings were organized by reconstructive microsurgeons.
Elander and his colleagues (1994) [211] reported Tamai had made great efforts to revive and promote
purine metabolism of the micro surgically transferred activity in each specialty from all microsurgical fields,
free muscle in 11 patients. The biopsy specimens were such as experimental, otorhinolaryngology, ophthalmol-
taken during ischemia and after 1 hour of reperfusion. ogy, neurosurgery, gynecology, urology, and so on.
They were analyzed for ATP to uric acid and creatine However, among the 230 participants at the Twelfth
phosphate by high-pressure liquid chromatography. Congress, 200 were hand and orthopedic surgeons and
Their experimental results demonstrated that skeletal plastic surgeons.
muscle could tolerate ischemia for up to 2 hours in a Tissue expander was introduced in the field of
clinical situation without permanent damage to the microsurgery and also marked the beginning of tissue
muscular tissues. engineering. Russell and his colleagues (1995) [213]
Doi and his associates (1994) [212] reviewed the expanded the scapular fasciocutaneous flap for 6 to 12
current concepts of vascularized bone allografts, weeks in 14 patients, and then it was transferred to other
describing the history of laboratory research on vascu- sites. Tissue expansion increases the area of the flap and
larized osteochondral allografts using immunosuppres- decreases its thickness.
sion, as well as their experimental and preliminary Skoulis and his colleagues (1995) [214] performed
clinical experience. On July 7,1988, they performed the rat experiments for nerve expansion prior to end-to-
world's first vascularized fibular allograft to a 2-year-old end repair of the short nerve gap. They reported that
boy who had congenital pseudarthrosis of the right expansion of a normal nerve and/or proximal segment
tibia. The donor fibula was taken from his mother. of a transected nerve was better tolerated than distal
Although they used cyclosporin A and methylpre- segment expansion. This suggested that the presence of
donisolone postoperatively, the grafted bone was an axon may have a beneficial effect in minimizing a
rejected at 2 weeks. Distal bone union was obtained, but deforming mechanical insult.
16 A. The History of Microsurgery
Vilkki in Finland (1995) [215] reported a series of 18
microsurgical toe transfers for congenitally adactylous
hands, with satisfactory functional improvement and
epiphyseal growth of the phalanges of the transferred
toes. Historically microsurgical transfer of the great toe
to the radius in a 33-year-old woman, who had a partial
avulsion of the hand, was reported by Furnas and
Achauer in 1983 [216].
Doi and his colleagues (1995) [217] reported their
challenges to the functional reconstruction of the totally
paralyzed upper extremity with brachial plexus injury, by
means of double free muscle transfers. In the first opera-
tion, a free muscle transfer was performed to restore
finger extension and elbow flexion, whereas in the
second operation, another free muscle transfer was per-
formed to restore finger flexion. The gracilis muscle or
latissimus dorsi muscle was used as the donor muscle. Ten
patients were followed up for at least 1 year. Seven out of
10 patients recovered elbow function and finger motion.
Five patients could use their hands in daily activities.
In conjunction with the development of replantation
of limbs and digits and microvascular free flap transfers,
reperfusion injury or the no reflow phenomenon was
recognized as one of the causes of revascularization
failure. Allen and his colleagues (1995) [218] reviewed
the etiology of this phenomenon, which included
intracellular calcium overload, oxygen-free radical-
mediated damage, and altered arachidonic acid metab-
olism. Agents demonstrated to prevent the no reflow
phenomenon included calcium channel blockers, pro-
staglandin analogs, thromboxane synthesis inhibitors,
vasodilators, and thrombolytics, as well as many antioxi-
dants. Yabe et al. (1996) [219] showed the effectiveness
of oxygenated perfluorochemical perfusion on the
viability of ischemic skeletal muscle in inhibiting the
generation of free radicals and in preventing ischemia-
reperfusion injury. Ablove et al. (1996) [220] showed
that high-energy phosphates and free radical scavengers
such as superoxide dismutase were beneficial in survival
of an ischemic limb replantation model. Ferrari et al.
(1996) [221] also proved the role of allopurinol in pre-
venting free radical injury to the skeletal muscle and
endothelial cells using a model of reperfusion injury in
ischemic rat hind limbs.
Lin and Levin (1996) [222] reported an application of
the balloon-assisted endoscopic tissue expander for
harvesting donor tissue. The advantages of the tech-
nique were that pre expansion of the donor flap could
be used for a large tissue defect reconstruction, a large
optical cavity could be created for endoscopic surgery,
and the donor site could be closed primarily without
skin grafting.
A new entity of skin flap, the thin flap, is a defatted
flap that has become popular in free skin flap transfers,
such as the thin groin flap and the thin rectus abdominis
musculocutaneous flap, which had been reported in
1980 by Thomas [223] Kimura and Satoh (1996) [224]
used an anterolateral thigh flap thinned to 3 to 4mm as
a free thin flap.
In June 1996, the 13th Congress of the IMS, organized
by Bruce Williams, was held in Montreal. At the
Executive Council Meeting, the concept of combining
the two societies, the IMS and the ISRM, was approved.
Originally these two societies had different characteris-
tics, but became similar with time. Membership in the
two societies overlapped in many cases, especially
within the field of reconstructive microsurgery.
Attendance at two separate but similar international
conferences was not only time-consuming for members
but was expensive as well. The establishment of the
International Society of Experimental Microsurgery in
1992 by some members of the IMS was an additional
reason for the merger of the two societies.
Chuang (1997) [225] reported 47 functioning free
muscle transplantations in the upper extremity that
were performed from 1986 to 1994 in Chang Gung
Memorial Hospital in Taipei. None of the cases involved
brachial plexus injury, but they included severe upper
extremity injuries, such as 15 severe Volkmann's
contractures, 21 severe crushing and traction injuries,
and 11 complicated replantation cases. Most patients
achieved significant functional improvement.
The Turning Period from Autogenous
Tissue Transplantation to Allogeneic
Tissue Transplantation (1998-)
Hidalgo and his colleagues (1998) [226] retrospectively
reviewed a large series of 716 consecutive free flap
reconstructions in 698 patients with oncologic surgical
defects at the Memorial Sloan-Kettering Cancer Center
in New York. The recipient sites were the head and neck
(69%), trunk and breast (14%),lower extremity (12%),
and upper extremity (5%). The donor flaps included the
rectus abdominis in 195 cases, fibula in 193, forearm in
133, latissimus dorsi in 69, jejunum in 55, gluteus in 28,
scapula in 26, and 7 others in 17. The overall success rate
was 98%, but 57 flaps (8%) were reexplored and 40
(70% ) were salvaged. Postoperative complications were
seen in 34 % of cases.
Boyer and Mih (1998) [227] stressed the usefulness
of microvascular surgery in the reconstruction of con-
genital hand anomalies. Factors that must be considered
include the patient's age, vessel availability, and lack of
other possible reconstructive options. Vilkki (1998)
[228] reported a unique method of treatment for Bayne

type IV radial club hand using a microvascular second
metatansaphalangeal joint transfer to reconstruct the
absent half of the wrist joint. Pollicization was added
later. Nine of 12 of these procedures had satisfactory
results.
The concept of minimally invasive surgery has
become popularized worldwide. Endoscopic harvesting
of the microsurgical free tissue transfer donors and
robot-assisted surgery have been developed and are
increasingly prevalent in every surgical discipline.
Spiegel and his colleagues (1998) [229] reported six
patients with gracilis muscle endoscopic harvesting and
micro neurovascular transplantation. The scars from the
endoscopic technique were quite small, 5 cm proximally
and 1.5 cm distally. Jain and his colleagues (1998) [230]
reported on the superiority of endoscopic techniques,
which enable both adequate magnification and applica-
tions of microsurgery. Stephenson and his colleagues
(1998) [231] performed robotically assisted microsur-
gery for endoscopic coronary artery bypass grafting in
porcine experiments. Margossian and his colleagues
(1998) [232] reported robotically assisted laparoscopic
tubal anastomosis in a porcine model. Although laparo-
scopic tubal anastomosis had been associated with
surgeon's fatigue as well as neck, shoulder, and back
pain, it could be comfortably performed with robotic
assistance. These authors (1998) [233] also reported
uterine horn anastomosis using the above procedure
with a satisfactory patency rate. They advocated that the
robotic technology has the potential to make laparo-
scopic microsuturing easier.
Doi and his associates (1998) [234] reported canine
experiments with revascularized intercalary bone allo-
grafts from the tibial diaphysis with administration of
cyclosporin A for 3 months. Bony union was achieved
at both ends, and after withdrawal of cyclosporin A, the
bone became nonviable due to rejection but the skele-
tal structure remained intact.
Nakajima and his colleagues (1998) [235] proposed
the concept of the adipofascial pedicled fasciocutaneous
flap using the accompanying arteries of the cutaneous
veins, cutaneous nerves, or both. The accompanying
arteries of the cutaneous veins branched not only to
the vein wall but also to the skin, i.e., venocutaneous
perforators.
In autumn 1998, the news of a human hand allo-
transplantation performed in Lyon, France, appeared in
the mass media throughout the world. On September
23, 1998, a 48-year-old man received a right distal
forearm and hand allograft taken from a brain-dead
donor. Since the replantation of amputated extremities
had became possible, hand allotransplantation by hand
surgeons and microsurgeons was, of course, technically
feasible. However, there has been controversy about the
The History of Microsurgery 17
merits and demerits of such an organ transplantation
for a non-life-threatening condition, with regard to the
side effects of the current immunosuppressive agents.
The following year, Dubernard and his colleagues
(1999) [236] reported the 6-month follow-up results of
the human hand allotransplantation. With the use of
immunosuppressive agents including anti thymocyte
globulins, tacrolimus, mycophenolic acid, and pre-
donisone, mild clinical and histological signs of cuta-
neous rejection were seen at 8 to 9 weeks
postoperatively but disappeared afterward. The
progress of sensory and motor function was satisfactory,
as reported by the attending surgeons.
In November 1998, the American Society for Surgery
of the Hand commented on the newsletter as follows:
"The risk-to-benefit ratio for the transplantation of a
cadaveric hand/forearm has yet to be convincingly
established. Until current immunosuppressive pharma-
cology has vastly improved, hand and forearm trans-
plantation should be considered a high-risk procedure
that is still in a very early experimental phase."
However, on January 25, 1999, another hand allo-
transplantation was performed by Breidenbach and
his colleagues in Louisville, Kentucky, on a 37-year-old
man. The postoperative functional results have been
satisfactory. Thereafter, six cases of hand allotransplan-
tation have been reported worldwide. It appeared that
the era of allotransplantation of composite tissues and
upper extremities had burst into the field of recon-
structive microsurgery.
EI-Barrany, Marei, and Vallee (1999) [237] performed
a quite beneficial anatomical study relating to vascular-
ized nerve grafts. Using 30 cadavers, they mapped the
blood supply of peripheral nerves by injecting red latex
into the arteries. They reported five patterns of blood
supply to the peripheral nerves. According to their
experimental evidence, the most suitable donors for a
vascularized nerve graft were the ulnar nerve and the
saphenous nerve.
Taylor (1999) [238] reported four cases of free vascu-
larized nerve transfer in the upper extremity that were
followed up for 20 years. In these cases, the rate of axon
regeneration across the vascularized nerve bridge and
beyond to the hand was 1.5 mm per day.
Terzis, Vekris, and Soucacos (1999) [239] reported 204
patients with devastating brachial plexus injuries who
underwent several reconstructions: nerve reconstruc-
tions in 577 nerves, microneurolysis in 89, vascularized
nerve grafting in 120, and muscle transfer in 107. Their
results were good to excellent in the range of 15% to
75%, depending on the tissues reconstructed.
In the field of experimental microsurgery, several a
rticles have been published on organ transplantation
in mice and rats.
18 A. The History of Microsurgery
Campisi (1999) [240] reported modern diagnostic
protocols for lymphedema and his experience with
microsurgical lymphatic-venous anastomosis and
lymphatic-venous-Iymphatic plasty. The overall results
were encouraging, when microsurgery was performed
in the earlier stages of the disease. In another report,
Campisi and Boccardo (1999) [241] also advocated
microsurgical management of lymphedema. From 1973
to 1997, 843 patients were treated with derivative
lymphatic-venous or lymphatic-capSUle-venous anasto-
moses and reconstructive vein interpositional grafting
(lymphatic-venous-Iymphatic plasty). The reduction of
edema depended on the stage of the pathology.
In the past several years, there has been considerable
discussion about a merger between two microsurgery
societies, the International Microsurgical Society and
the International Society of Reconstructive Micro-
surgery. Originally these two societies had different
characteristics, but they have become similar with time.
Many members of the two societies overlapped, espe-
cially within the field of reconstructive microsurgery.
Attendance at two separate but similar international
conferences was not only time-consuming for members
but also expensive. The establishment of the Interna-
tional Society of Experimental Microsurgery in 1992 by
some members of the IMS was an additional reason for
the merger of the two societies. At the Fourteenth IMS
meeting on August 28 and 29, 1998, in Corfu, Greece
(President, W. Boeckx), and the Thirteenth ISRM
meeting on June 22-26, 1999, in Los Angeles (President,
J. Baudet; Chairman, W. Shaw), it was agreed to merge
the two societies. At the latter meeting, it was decided
that the name of the new society would be the World
Society for Reconstructive Microsurgery (WSRM). The
first WSRM officers were elected: V Meyer, President;
F.C.Wei, President-Elect, who became the Scientific
Chairman for the Inaugural Meeting of the WSRM,
2001, Taipei; and J. Terzis, Secretary-Treasurer.
The temporoparietal fascia is a very useful vascular-
ized flap for reconstructive surgery or for prefabrication
of flaps. Tellioglu and his associates (2000) [242] inves-
tigated the anatomy and histology of this flap and advo-
cated the term "temporoparietal myofascial flap" based
on the superficial temporal vessels. This mutilayered
flap can be used to reconstruct all defects when fine,
pliable, thin, multilayered flaps are required.
In January 2000, allotransplantation of both hands
from a brain-dead donor was performed in Lyons,
France; in March 2000, another allotransplantation of
both hands was performed in Innsbruck, Austria. In
March 2000, President Cooney of the American Society
for Surgery of the Hand announced, "No further trans-
plants should be performed until doctors from around
the country can examine Scott (the first case in
Louisville) and confirm his progress. The group would
also like to see more animal research." Since the func-
tional recovery of Scott's transplanted hand has been
surprisingly good, several surgeons worldwide appear
to be anxious to attempt the operation. Hand allo-
transplantation was subsequently performed in Italy
in October 2000 and also in Malaysia between twin
babies. However, on October 23, 2000, the first patient
with hand allotransplantation from France underwent
amputation of the transplanted hand due to poor func-
tional recovery and intolerable pain. There have been
several controversial opinions on the merits and demer-
its of such an organ allotransplantation for a non-
life-threatening condition under current immunosup-
pressive treatments. In cases of liver or kidney
transplantation, we can expect the patient to gain
immunological tolerance when the immunosuppressive
therapy is discontinued. According to Breidenbach in
Louisville, the clinical course of his patient, Scott, is
similar to that in kidney transplantation, with almost the
same immunosuppressive treatments. He believes his
patient will be able to gain immunological tolerance in
the near future.
The indication for hand allotransplantation is also
controversial among hand surgeons. A patient under-
going hand amputation under immunosuppressive
therapy, who already has had an organ transplantation,
would be a good candidate for this surgery. A patient
with bilateral hand amputation, either congenital or
traumatic, especially a blind person, may be another
candidate, but unilateral amputation may not be an
absolute indication for this surgery. The death of a
patient from the sideeffects of immunosuppressive
agents following hand allotransplantation would cause
severe criticism of such an organ transplantation for a
non-life-threatening condition. Although hand surgeons
in Japan are very interested in performing a hand allo-
transplantation in the near future, it would be wise to
wait until the final outcome of the patients worldwide
who have already undergone hand allotransplantation
can be confirmed.
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172. Valauri FA, Hirase Y, Buncke HJ (1988) Prefabricated
neovascularized free muscle flaps: pedicle variations.
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173. Hirase Y, Valauri FA, Buncke HJ (1988) Neovascularized
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174. Hirase Y, Valauri FA, Buncke HJ (1988) Neovascularized
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175. Harii K (1988) Refined microneurovascular free muscle
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176. Manktelow RT (1988) Functioning microsurgical muscle
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177. Jupiter JB, Pess GM, Bour CJ (1989) Results of flexor
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178. Tsai TM, McCabe SJ, Maki Y (1989) A technique for
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179. Goldner RD, Stevanovic MV, Nunley JA, Urbaniak JR
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214--220
180. Fukui A, Maeda M, Sempuku T, Tamai S, Mizumoto S,
Inada Y (1989) Continuous local intra-arterial infusion
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damaged arteries. J Reconstr Microsurg 5:127-136
181. Whitney TM, Buncke HJ, Lineaweaver WC, Alpert BS
(1989) Multiple microvascular transplants: a preliminary
report of simultaneous versus sequential reconstruction.
Ann Plast Surg 22:391-404
182. Valauri FA, Buncke HJ (1989) Thumb reconstruction-
great toe transfer. Clin Plast Surg 16:475-489
183. Wei FC, Colony LH, Chen HC, Chuang CC, Noordhoff
MS (1989) Combined second and third toe transfer. Plast
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184. Coleman JJ 3d, Bostwick J (1989) Rectus abdominis
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185. Koshima I, Soeda S (1989) Inferior epigastric skin flaps
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186. Chui DT, Chen L, Chen ZW (1990) Rat ear reattach-
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788
187. Bao JY (1990) Toe replantation in the rat. J Reconstr
Microsurg 6:251-253
The History of Microsurgery 23
188. Buck-Gramcko D (1990) Progress in the treatment of
congenital malformations of the hand. World J Surg 14:
715-724
189. Khouri RK, Upton J, ShawWW (1991) Prefabrication of
composite free flaps through staged microvascular trans-
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190. Valauri FA (1991) The use of medicinal leeches in micro-
surgery. Blood Coagul FibrinoI2:185-187
191. Nystrom A, Backman C, Bertheim U, Karlsson L, Carls-
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intolerance. J Reconstr Micosurg 7:175-178
192. Daigle Jp, Kleinert JM (1991) Major limb replantation in
children. Microsurgery 12:221-231
193. Taras JS, Nunley JA, Urbaniak JR, Goldner RD, Fitch
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194. Feller AM, Graf P, Biemer E (1991) Replantation
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195. Gayle LB, Lineaweaver WC, Buncke GM, Oliva A,
Alpert BS, Billys JB, Buncke HJ (1991) Lower extremity
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196. Arnez ZM (1991) Immediate reconstruction of the lower
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197. Buncke HJ, Buncke GM, Lineaweaver WC, Oliva A,
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World J Surg 15:418-428
198. Akasaka Y, Hara T, Takahashi M (1991) Free muscle
transplantation combined with intercostal nerve crossing
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199. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS
(1991) Second toe wrap-around flap. Plast Reconstr Surg
88:837-843
200. Jupiter JB, Kour AK, Palumbo MD, Yaremchuk MJ
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201. Foucher G, Norris RW (1992) Distal and very distal
digital replantations. Br J Plast Surg 45:199-203
202. Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa S,
Yamasaki M (1992) The use of arteriovenous anastomo-
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Plast Reconstr Surg 89:710--714
203. Camacho FJ, Wood MB (1992) Polydigit replantation.
Hand Clin 8:409-412
204. Braun C (1992) Autogenously vascularised bone allo-
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205. Walton RL, Brown RE (1993) Tissue engineering of bio-
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206. Nolan LM, Bowen V (1993) Extremity transplantation:
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207. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM (1993)
Free toe transfer for thumb and finger reconstruction in
300 cases. Plast Reconstr Surg 91:693-700
24 A. The History of Microsurgery
208. Arakaki A, Tsai TM (1993) Thumb replantation: survival
factors and re-exploration in 122 cases. J Hand Surg 18:
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209. Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y
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210. Staley CA, Miller M, King TJ, Clem M, Ota DM (1994)
Laparoscopic intracorporeal harvest of jejunal tissue for
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211. Elander A, Fogdestam I, Schersten T, Soussi B (1994)
Purine metabolism during microsurgical transfer of
human skeletal muscle. Scand J Plast Reconstr Surg
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212. Doi K, Akino T, Shigetomi M, Muramatsu K, Kawai S
(1994) Vascularized bone allografts: review of current
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213. Russell RC, Khouri RK, Upton J, Jones TR, Bush K,
Lantieri LA (1995) The expanded scapular flap. Plast
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214. Skoulis TG, Lovice D, von Fricken K, Terzis JK (1995)
Nerve expansion. The optimal answer for the short nerve
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215. Vilkki SK (1995) Advances in microsurgical reconstruc-
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216. Furnas DW, Achauer BN (1983) Microsurgical transfer
of the great toe to the radius to provide prehension after
partial avulsion of the hand. J Hand Surg 8A:453-460
217. Doi K, Sasaki K, Kuwata N, Ihara K, Kawai S (1995)
Double free muscle transfer to restore prehension fol-
lowing complete brachial plexus avulsion. J Hand Surg
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218. Allen DM, Chen LE, Seaber AV, Urbaniak JR
(1995) Pathophysiology and related studies of the no
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219. Yabe Y, Ishiguro N, Shimizu T, Kawasaki S, Sasaki Y,
Iwata H (1996) A perfluorochemical prevents ischemia-
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220. Ablove RH, Moy OJ, Peimer CA, Severin CM, Sherwin
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221. Ferrari RP, Battiston B, Brunelli G, Casella A, Caimi L
(1996) The role of alloputinol in preventing oxygen
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cells after ischemia-reperfusion. J Reconstr Microsurg
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222. Lin CH, Levin LS (1996) Free flap expansion using
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223. Thomas CV (1980) Thin flaps. Plast Reconstr Surg 65:
747-752
224. Kimura N, Satoh K (1996) Consideration of a thin flap
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lateral thigh flap. Plast Reconstr Surg 97:985-992
225. Chuang DC (1997) Functioning free-muscle transplanta-
tion for the upper extremity. Hand Clin 13:279-289
226. Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY (1998) A
review of 716 consecutive free flaps for oncologic surgical
defects: refinement in donor-site selection and technique.
Plast Reconstr Surg 102:722-732,733-734 (Discussion)
227. Boyer MI, Mih AD (1998) Microvascular surgery in the
reconstruction of congenital hand anomalies. Hand Clin
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228. Vilkki SK (1998) Distraction and microvascular epiph-
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229. Spiegel JH, Lee C, Trabulsy PP, Coughlin RR (1998)
Endoscopic harvest of the gracilis muscle flap. Ann Plast
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230. Jain AK, Sasaki S, Engels B, Oldenbeuving NB, Poindex-
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231. Stephenson ER Jr, Sankholkar S, Ducko CT, Damiano
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232. Margossian H, Garcia-Ruiz A, Falcone T, Goldberg JM,
Attaran M, Miller JH, Gagner M (1998) Robotically
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8:69-73
233. Margossian H, Garcia-Ruiz A, Falcone T, Goldberg JM,
Attaran M, Gagner M (1998) Robotically assisted
laparoscopic microsurgical uterine horn anastomosis.
Fertil Steril 70:530-534
234. Doi K, Akino T, Shigetomi M, Muramatsu K, Kawai S
(1998) Revascularized intercalary bone allografts with
short-term immunosuppression with cyclosporine in the
canine. Plast Reconstr Surg 101:793-801
235. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S,
Fujono T (1998) Accompanying arteries of the cutaneous
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neuroadipofascial pedicled fasciocutaneous flap. Plast
Reconstr Surg 102:779-791
236. Dubernard JM, Owen E, Herzberg G, Lanzetta M,
Martin X, Kapila H, Dawahra M, Hakim NS (1999)
Human hand allograft: report on first 6 months. Lancet
353:1315-1320
237. El-Barrany WG, Marei AG, Vallee B (1999) Anastomic
basis of vascularized nerve grafts: the blood supply of
peripheral nerves. Surg Radiol Anat 21:95-102
238. Taylor GI (1999) Free vascularized nerve transfer in the
upper extremity. Hand Clin 15:673-695
239. Terzis JK, Vekris MD, Soucacos PN (1999) Outcomes
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devastating paralysis. Plast Reconstr Surg 104:1221-1240
240. Champisi C (1999) Lymphoedema: modern diagnostic
and therapeutic aspects. Int AngiolI8:14-24
241. Champisi C, Boccardo F (1999) Role of microsurgery in
the management of lymphedema. Int Angiol 18:47-51
242. Tellioglu AT, Tekdemir I, Erdemli EA, Tuccar E, Ulusoy
G (2000) Temporoparietal fascia: an anastomic and
histologic reinvestigation with new potential clinical
applications. Plast Reconstr Surg 105:40-45
B. Operating Microscope and
Microsurgical Instruments
Operating Microscope and
Microsurgical Instruments
SUSUMU TAMAI
Microsurgical techniques require the application of
Halsted surgical principles-"gentle handling and
exceedingly accurate approximation of tissues are of
paramount importance"-to the ultrafine structures of
the human body.
Microsurgery is divided into three fundamental tech-
niques: microdissection, microvascular surgery, and
microneuro-surgery. Microdissection is the most basic
technique in handling not only small blood vessels and
nerves but also other fine structures. By the meticulous
combination of these three techniques, microsurgery is
now widely applied in several surgical disciplines.
With the pioneering work of Jacobson and Suarez
in 1960, in addition to the significant development of
the operating microscope, microsurgical instruments,
and fine suture materials, the anastomosis of vessels
less than 1 mm in external diameter and funicular
suture of the peripheral nerves has become possi-
ble by microsurgical hand sutures. During the first
decade, its pioneers investigated microsurgical in-
strumentation, techniques, and related experimental
research.
In the second decade, techniques of microvascular
surgery and microneurosurgery have been nearly stan-
dardized throughout the world.
Operating Microscope
The operating microscope is the essential tool for
performing atraumatic dissections of fine tissue and
repairs of miniature blood vessels and nerves.
In the operating room, microsurgery is generally per-
formed by at least two persons, the operator and the
assistant, who sit opposite each other. For this purpose,
a two-person operating microscope had been efficient.
At Jacobson's request, Littman of Carl-Zeiss designed
and produced the world's first two-person stereoscopic
microscope-the "diploscope" of the early 1960s. Most
of the worldwide well-known pioneers of reconstructive
microsurgery in the 1960s, such as Buncke, Cobbett,
Keinert, Smith, and Tarnai, as well as others, bought this
type of microscope and applied it to their research and
operations. Thereafter, the OPMI 6-D (Fig. 1), used for
brain neurosurgery and otorhinolaryngology, the OPMI
7-D (Fig. 2), and the MD, used for plastic and
reconstructive surgery, were manufactured. The OPMI
6-D was originally designed for one person but
was remodeled for two-person use, equipped with
fiberoptic illumination, an electromotive ceiling mount,
motorized zoom magnification, and focusing control
by pedal. It has been used by reconstructive micro sur-
geons from the mid-1970s up to the present time.
Compared with the OPMI 7-D, this microscope has
several advantages in its movability and handling, since
it can focus without losing sight of the operating
field when the microscope is tilted. The binocular tubes
are capable of a tilting arc of 60, and an X-Y coupling
that allows horizontal movements with the foot control
is also very advantageous. A fiberoptic illuminating
system is able to supply enough brightness to the
operating field to allow microvascular anastomosis of
minute vessels. If a beam splitter is mounted on the
microscope, an observer's ocular tube, a 35-mm camera,
a 16-mm movie camera, or a video camera can be
attached.
The most recent model of the microscope from the
Carl-Zeiss Company is OPMI PRO magis (Fig. 3),
which is available not only for plastic and reconstruc-
tive surgery but also for almost all surgical disciplines.
It provides motorized fine focusing and zoom controls.
Top-Class optics and illumination ensure a brilliant and
high-contrast image with excellent color fidelity and
depth of focus.
Several kinds of standard operating microscope are
commercially available not only from the Carl-Zeiss
Company, but also from Leica Microsystems (Fig. 4),
Nagashima, Olympus Optics, and others. Figure 5
shows a two-person operating microscope, M680 from
Leica Microsystems, which was recently installed in
the operating room of our institute. It has two
independent zooms and two independent internal
focusing systems, which offer ideal conditions for
cooperation between the surgeon and the assistant. It
is also equipped with a video camera for recording
operative procedures.
27
28 B. Operating Microscope and Microsurgical Instruments

........ij
:,"r'''~~,J
.
i.. '.
'f'

,~i~

'.j.,'. .~
la".. ..,~j
I
~~I
l'" .,'
.I: .
~

Fig. 3. Carl-Zeiss Operation Microscope OPMI PRO magis

Fig. 1. Carl-Zeiss Operation Microscope OPMI 6-D

Fig.2. Carl-Zeiss Operation Microscope OPMI 7-D Fig. 4. Leica M680


Microsurgical Instruments
To perform microvascular surgery, and microneuro-
surgery within the restricted operating field under an
operating microscope, microsurgical instruments should
be small and designed for limited movements.
The spring-handled needle holder, scissors, and
jeweler's forceps are the minimum necessary (Fig. 6).
Fig.S. Olympus OME-5013K/5012K
Fig. 6. Microsurgical instruments: scissors, needle holder,
forceps
Operating Microscope and Microsurgical Instruments 29
Needle Holder
The Castroviejo or Barraquet-type needle holder,
approximately 14cm in length without a crutch, should
have fine jaws capable of grasping a 50- to 100-micron
needle and a 10- to 20-micron thread. Straight and
curved jaws are available, depending on the surgeon's
choice. For microsurgery in the superficial layer, a
needle holder with straight jaws may be suitable, but in
the deep layer, one with curved jaws is better. An angu-
lated jeweler's forceps can be substituted for a needle
holder. Koshima uses a finer-pointed needle holder for
his supramicrosurgery, as shown in Fig. 7.
Scissors
Scissors approximately 14cm in length with sharp
blades, both curved and straight, aid in the dissecting
and cutting of the vascular ends or adventitia, but the
curved serrated blade may be suitable for cutting fine
monofilament suture materials without slippage.
Forceps
Straight, nontoothed jeweler's forceps (Nos. 3, 3-C, 4,
and 5) are preferable. The tips should be fine, smooth,
well fitted, and capable of catching 10- to 20-micron
monofilament nylon threads accurately.
Clips or Clamps
Microvascular clips or clamps are available in a variety
of sizes, designs, and clipping powers. Although the
Fig.7. Ultrafine needle holder designed by Prof. Koshima and
manufactured by Medicon Germany
30 B. Operating Microscope and Microsurgical Instruments

choice depends on the surgeon, a micro-double clip is

the most useful instrument for microvascular anasto-
mosis, enabling the surgeon to make suitable approxi-
mation of each cut end of the vessel without tension.
Three kinds of Tarnai metallic micro-double clips from
the Crown Jun Company and also four kinds of dispos-
able plastic double clips from Bear Medic Corporation
in Japan are commercially available (Fig. 8a and b).
They can be applied to blood vessels 0.2 to 3.0mm in
diameter. A single clip is also available for temporary
clipping of the vessel ends. Table 1 shows the standards
of Tarnai micro-double clips. Their clipping power can
be changed to the surgeon's specifications during man-
ufacturing. The S & T Company and the Weck Company a
also manufacture microclips that are available world-
wide. Metallic clips and clamps should be handled care-
fully by the nurses in the operating theater, especially
when they are cleaned of blood or clots.

Other Accessories and Equipment

Surgical spears or small sponges for removing blood at

the suture site.
Heparinized saline or Ringer solution (1000 units per
100ml) in a 2.0-ml syringe with a 30-gauge angulated
blunt needle, to irrigate the inside of the vascular
lumen for washing out blood. b
Rubber or plastic color-contrast background sheet. A
yellow color may be suitable for use with arteries and Fig. 8. a Tarnai metallic microclips (Crown lun). b Tarnai's
dark green for veins and nerves. disposable plastic microclips (Bear Medic Corporation)
Bipolar coagulator.

Table 1. Standards of Tarnai metallic and disposable plastic double clips

Type of clip Weight (g) Clipping power (gf)
Microvascular double clip (metal)-Crown Jun
L 0.407 90 (60-120)
M 0.279 60 (30-90)
S 0.088 43 (20-60)

Microvascular double clip (disposable )-Bear Medic

TKL-2-60 0.42 60
TKL-2-120 0.42 120
TKM-2-30 0.304 30
TKM-2-60 0.304 60
TKS-2-20 0.2 20
TKS-2-40 0.2 40
TKF-2-30 0.06 30
TKF-2-15 0.06 15
 Operating Microscope and Microsurgical Instruments 31

Suture Materials Although several sutures are commercially available

Fine suture materials are essential for successful repair
of minute vessels. Monofilament nylon threads mounted
on minineedles (atraumatic tapered needle) with 3/8
circle curvature are preferred by most microsurgeons.
Several years ago, the absorbable polyglycolic acid
suture became commercially available for microvas-
cular surgery and microneurosurgery, but recently it
has been seldom used in this field. This material tends
to coil during suturing, which makes micro anastomosis
difficult.
internationally from such makers as Crown Jun, Davis
& Geck, Ethicon, Bear Medic Corporation, and S
& T, all manufacturers use the USP (United States
Pharmacopeia) designations for suture diameter. Table
2 shows the sizes and diameters of the needles and
threads manufactured by Crown Jun, Bear Medic
Corporation, Ethicon, and S & T.
Because these suture materials are quite fragile and
easy to cut, mostly at the junction between the needle
and the thread, the scrubbing nurses should be well
trained in handling these materials.

Table 2. Suture materials: sizes and diameters of needles and threads

a.
Manufacturer Needle diameter (J..l) Needle length (mm) Thread (USP)
Crown Jun
50 2.5-3.0 12-0 (8-9 J..l)
70-100 3.0-4.0 11-0 (15-19J..l)
70-150 3.0-5.0 10-0 (25-29 J..l)
100-150 4.0-5.0 9-0 (35-39 J..l)
150-200 4.0-6.0 S-O (45-49 J..l)
Needle: 3/SR taper point Thread: monofilament nylon
Bear Medic
SO 3.0 11-0 (19 J..l)
SO 4.0 11-0 (19 J..l)
100 4.0 11-0 (19 J..l)
100 4.0 10-0 (21 J..l)
100 4.0 9-0 (34 J..l)
150 5.0 S-O (45J..l)
Needle: 3/SR or 1I2R taper point Thread: monofilament nylon

b.
Needle length (mm) Diameter (J..l) Threaq length (mm) Thread diameter (USP)

Ethicon 11-0 10-0 9-0 S-O

BV 75-3 3.S 75 13 0
BV 130-3 3.7 130 13 0 0 o
BV 50-3 4.0 50 13 0
BV 130-4 4.7 130 13 0 0 o
Needle: 3/SR taper point Thread: monofilament nylon (Ethilon)
S&T 11-0 10-0 9-0 S-O
7V13 4.0 70 10 0
7V33 4.0 70 10 0
7V43 5.0 70 10 0
7V43 5.0 70 10 0
10V43 5.0 100 20 0
lOV43 5.0 100 20 0
lOV43 5.0 100 20 0
14V33 4.0 140 20 0
14V33 4.0 140 20 0
14V33 4.0 140 20 o
Needle: 3/SR taper point Thread: monofilament nylon

o means attached thread to each needle.

c. Experimental Microsurgery
1. Microvascular Anastomoses in the Rat
AKIHIRO FUKUI

To acquire skilled microsurgical technique, experi- threaded with two supporting sutures at an angle of 120
mental practice using the rat abdominal vessels, ap- using eccentric stay sutures (asymmetric biangulation),
proximately 1.0mm in size, is necessary. The surgical as proposed by Cobbett [2] (Fig. 7). With the use of this
technique is itemized as follows. procedure, the risk of threading the vascular wall of the
posterior surface will be decreased during suturing of
the anterior surface of the anastomosis site. However, it
End-to-End Anastomosis is not necessary to maintain an angle of 120. Indeed,
we sometimes thread both amputation stumps with
End-to-End Anastomosis of Microvessels two supporting sutures at an angle of 135 (Fig. 8) [3].
Threading the distal region of both amputation stumps
with the Same Outer Diameter
first will facilitate subsequent threading at the proximal
region of the amputation stumps. However, threading
Arterial Anastomosis
the amputation stumps with two supporting sutures is
The field of operation should be established under a the most difficult technique for beginners, because it is
microscope of 6-10 magnification. According to the the hardest part of end-to-end anastomosis. The wall
method proposed by O'Brien [1], a piece of yellow vinyl edge of the lower segment is picked up, and the tip
tape should be placed on the background of the target of the needle is placed in the vessel lumen and then
artery to increase the visibility. Subsequently, the artery penetrates the vascular wall (Fig. 9). The anterior wall
should be exposed by carefully separating the sur- of the opposite vessel is lifted up with the forceps and
rounding tissues under a microscope using two forceps passed through the distal vessel. The suture material is
held in both hands. After sufficient exposure by separa- pulled and then moved back to the same point as pre-
tion, the artery should be double-clipped with a clip viously defined in the other vessel segment and through
applicator, initially at the proximal part and sub- the vessel wall (Fig. 10). A single knot should be made
sequently at the distal part. The interval between the three times. We use the oblique insertion method to
micro-double clips should be approximately 1 cm (Fig. suture the vascular wall. Theoretically, this procedure
1). After the magnification has been increased, the will limit the number of sutures exposed on the vascu-
exposed artery should be cut at the midpoint of the lar lumen, as well as facilitating the achievement of wall-
artery between two clips with the micro scissors at a to-wall coaptation. However, it is technically difficult
right angle. One clean cut should be made (Fig. 2). to stick a needle into the lumen at an ideal angle. The
Usually, the end of the vessel is shortened because of right-angled insertion of a needle naturally increases
spasm (Fig. 3). After the wall has been picked up to the number of sutures exposed on the vascular lumen,
hold the vessel, the lumen of the artery should be ir- as well as increasing the frequency of malcoaptation
rigated with heparinized lactated Ringer's solution or of the vascular wall (Fig. 11). The second-stay suture is
low-molecular-weight dextran solution (1000 U/dl) to placed at the point 120-135 using a suture (Fig. 12).
remove sufficient residual blood and blood clots using After a knot is made, the stay suture is left long
a blunt-tipped 25-gauge needle (Fig. 4). Subsequently, for traction during the operation (Fig. 13). During
the adventitia, which projects from both vessel ends, is microvascular anastomosis, the length of the bite, that
grasped with the forceps at the vessel end and trimmed is, the interval between the amputation stump and
with the scissors circumferentially (Fig. 5). The ampu- the needle insertion site, is also an important issue.
tated stumps should then be brought close together However, the length of the bite varies depending on the
maneuvering a clip with slides on a bar until the dis- size of the vessels, the thickness of the vascular wall, and
tance between them is approximately 5 mm (Fig. 6). the sizes of the needles and sutures. The third tie is made
Both amputated stumps of the artery should be between two-stay sutures using the same technique

35
36 C. Experimental Microsurgery

Fig. 1. The micro-double clips are applied Fig. 4. The lumen is irrigated with heparinized lactated
Ringer's solution or low-molecular-weight dextran (1000 U/dl)
using a blunt-tipped 25-gauge needle

Fig. 2. With the micro scissors, the midpoint of the artery is

cut at a right angle
Fig. 5. The adventitia, which projects from both vessel ends,
is trimmed circumferentially

Fig. 3. The end of the vessel is shortened by spasm

Fig. 6. Both ends of the artery are approximated by maneu-

vering a clip
 1. Microvascular Anastomoses in the Rat 37

=:==~-<~>-====== ==:::==--"(~
a b

Fig. 7. Scheme of stay suture. a Traditional method. Symmet-

rical stay suture at an angle of 180. b Eccentric stay suture.
Asymmetric stay suture at an angle of 120-130
Fig. 10. Insertion of the needle into the opposite lumen

6 .titche.
e 9 .titche. 8 .titch

Fig.8. Position of stay suture and number of knot. Number of

\ ;
knot will depend on the outside diameter of vessel

a b

Fig. 11. Scheme of the needle insertion to the vessel wall.

a Oblique insertion method. b Right-angled insertion method.
Exposure of the sutures on the vascular lumen and mal
coaptation of vascular wall are seen

Fig. 9. Insertion of the needle into the lumen

Fig. 12. The second-stay suture IS placed at the point

120-135 using a suture
38 C. Experimental Microsurgery
Fig. 13. The stay sutures are left long for traction
Fig. 14. The third tie is performed between two stay sutures
Fig. 15. The fourth tie is performed
Fig. 16. Anastomosis of the anterior wall is finished
Fig. 17. After the vessel is turned over, the anterior wall of
the opposite vessel is lifted and the forceps are inserted into
the lumen to prevent damage to the inner wall
(Fig. 14). The fourth tie is made between two-stay
sutures using the same technique (Figs. 15 and 16).
After the anterior surface of the amputation stumps
has been sutured, the double-clipped artery should be
rotated in a 1800 arc to suture the anterior surface sim-
ilarly. The first tie is made at the midportion of the wall.
The forceps is inserted into the lumen gently to prevent
damage to the inner wall, and the vessel is lifted up.
Then, the needle is passed through the vessel wall (Fig.
17). The anterior wall of the opposite vessel is lifted and
passed through the distal vessel; the suture material is
pulled and then moved back to the same point (Fig. 18).
The first tie of the posterior wall is finished (Fig. 19).
Thus an artery 1 mm in outer diameter will be closed
with interrupted sutures made by approximately eight
stitches at intervals of O.4mm. After the entire circum-

Fig. 18. The needle is passed through the distal vessel wall
Fig. 19. The first tie is finished
ference of the artery has been sutured, the clip in the
periphery should be initially removed to confirm the
absence of anastomotic bleeding due to back bleeding.
Subsequently, blood flow should be restored by remov-
ing the clip in the central part (Fig. 20). Blood leaking
out of the anastomotic site can be easily stopped by soft
compression with gauze. However, leakage of blood
from the anastomotic site should be stopped by addi-
tional suture after reclipping the artery, or wrapping
with a piece of fat is required.
Venous Anastomosis
The venous wall is inelastic and thinner than the
arterial wall. Therefore, it is sometimes difficult to see
through the lumen of a thinner vein, resulting in far
more difficult anastomosis. In addition, the adventitia
1. Microvascular Anastomoses in the Rat 39
Fig. 20. After the double clip is released, good pulsation is
seen
Fig. 21. The micro-double clip is applied to the vein
should be preserved as much as possible, minimally so
as not to decrease the elasticity of venous wall. More-
over, the eccentric stay suture is very useful for repair-
ing an amputated vein, because the risk of threading the
venous wall of the reverse side can be reduced by using
interrupted sutures performed by pulling up a support-
ing suture while repeatedly washing and expanding the
venous lumen with a heparinized lactated Ringer's solu-
tion. The length of the bite and the suturing intervals for
venous anastomosis tend to be greater than those for
arterial anastomosis.
First, the loS-mm vein is lifted and the micro-double
clip is applied to the vein. Usually the vein shows dilata-
tion without vascular wall contraction (Fig. 21). The
midpoint of the vein between the two clips is cut at a
right angle with the micro scissors. Because the wall of
the vein is thin and inelastic, the wall shrinks after the
40 C. Experimental Microsurgery

Fig. 22. After the stay suture is finished, the lumen is washed Fig. 23. The vessel is turned over after anastomosis of the
with heparinized lactated Ringer's solution anterior wall has been completed

vein is cut. It is necessary to irrigate the lumen with

heparinized lactated Ringer's solution for ballooning of
the lumen just prior to insertion of the needle (Fig. 22).
After the anastomosis of the anterior wall has been
completed, the vessel is turned over and the lumen is
irrigated. Because the posterior wall is usually adherent
to the anterior wall, a knot of anterior wall can be seen
in the lumen (Fig. 23). When venous anastomosis is com-
pleted, blood flow should be restored by first removing
the clip in the central part of the anastomotic site, fol-
lowed by unclipping in its periphery. Blood leakage is
usually weak because of low venous pressure (Fig. 24).
In addition, the patency test should be performed, as
described in the previous section.
Fig. 24. Good venous flow is seen after the double clip is
End-to-End Anastomosis of Microvessels released
with Different Outer Diameters

Various devices are required during end-to-end anasto-
mosis of vessels with different outer diameters. When
two vessels with a 2: 1 ratio of outer diameters are anas-
tomosed, a pair of thin forceps should be initially
inserted into the thinner vessel to enlarge its lumen by
approximately 50%. The amputation stumps of both
vessels should be threaded with two supporting sutures
at an angle of 180 (Fig. 25). If possible, the central parts
0 with a 2: 1 or greater ratio of outer diameters (Fig. 27).
of the amputation stumps should be sutured by one
stitch using a slightly longer suture while both of the two
supporting sutures are pulled to support the amputation
stumps at three points. Thus, two vessels with a 2: 1 ratio
in outer diameters are easily anastomosed by using
interrupted sutures at small and regular intervals. The
posterior surfaces of the amputation stumps should also
be sutured by the same procedure. Figure 26 shows the
resumption of blood flow in an anastomosed artery.
When two vessels whose ratio of outer diameters is 2: 1
or more are anastomosed, the amputation stump of the
thinner vessel should be cut obliquely to decrease the
difference in outer diameters. Futher luminal enlarge-
ment by insertion of a pair of forceps into the thinner
vessel will facilitate end-to-end anastomosis of vessels
Autogenous Vein Graft
If end-to-end anastomosis of arteries is difficult because
of the presence of vascular defects, autogenous vein
grafting is indicated. In some specific cases, grafting of
a vein to another vein may be required. Briefly, a vein

Fig. 25. End-to-end anastomosis of vessels with different
outer diameters
Fig. 26. After the double clip is released, good flow is seen
Cut obliquely ! :
Fig. 27. Scheme of end-to-end anastomosis with 2: 1 or larger
ratio of outer diameters
1. Microvascular Anastomoses in the Rat 41
whose outer diameter is similar to that of the artery
should be harvested within the same operative field or
from other regions. Then, the excised vein should
be marked in its periphery so as not to mistake the
direction of the valves. After luminal irrigation with a
heparinized lactated Ringer's solution, the excised vein
should be stored in a cold saline solution. The proximal
and distal ends of the recipient artery should be
clamped with single clips. Each lumen is washed with
solution (Fig. 28). Subsequently, both the proximal part
of the recipient artery and the distal of the vein graft
should be clamped with a double clip before suturing
(Fig. 29). Since the wall thickness markedly differs
between the recipient artery and vein graft, it is difficult
to achieve wall-to-wall coaptation. Therefore, it is desir-
able to anastomose both vessels so as to adhere the
amputation stump of the recipient artery closely to the
tunica intima of the vein graft. After anastomosis has
Fig. 28. The grafted vein is placed between arterial defects
Is~p I' - - - - - ---t\'\
Grallednln
rTI L - I_ " - - ,
, -- - - ' - - (
Is,:p I
' - -+-'L--f---' ....- H.'\. i
Single clip
tt
Ooublecllp
Fig. 29. Scheme of vein graft technique to the arterial defects
42 C. Experimental Microsurgery
Fig. 30. After the double clip is released, good blood flow is
seen
Fig. 31. The grafted vein is put beside the recipient artery
been completed, the lumen of the vein graft should be
filled with a heparinized lactated Ringer's solution again
before confirmation and adjustment of the length of the
vein graft. Subsequently, the distal part should be anas-
tomosed after clipping. After the entire circumference
of the artery has been repaired by anastomos is of the
vein graft, the double clip should be initially removed.
If the blood leakage is not occurred at the distal anas-
tomotic site, a single clip previously applied to the prox-
imal part of the anastomotic site is removed. Because of
arterial pressure, the vein graft will be markedly dis-
tended from its original size (Fig. 30).
End-to-Side Anastomosis
End-to-side anastomosis is used to anastomose the
amputation stump of the donor vessel to the lateral
, lB
IT!
I prox.)
J::;;;k=)
lB
~
) II
,~ ,
~
)
Ea*
tt J
Single clip Double clip
Fig. 32. Scheme of end-to-side vein graft to the recipient
artery
Fig. 33. After the double clip is released, good blood flow is
seen
foramen prepared on the side of a recipient vessel. The
recipient vessel should be double clipped, and then it
should be relaxed by slightly decreasing the interval
between the two clips. Subsequently, a lateral foramen
is prepared with an outer diameter similar to that of the
donor vessel. A circular part of the wall of the recipient
vessel, which is picked up with forceps, should be
removed with scissors. Sometimes, the side of the recip-
ient vessel is only excised laterally for end-to-side anas-
tomosis [4]. However, we do not usually select the third
procedure, because there is a risk of anastomotic steno-
sis. Subsequently, the amputation stump of the donor
vessel should be excised obliquely, considering the angle
between the recipient and donor vessels (Fig. 31). If the
outer diameter of the donor vessel is small, inserting
forceps into the vascular lumen should enlarge it. After
luminal irrigation with a heparinized lactated Ringer's
solution, both the upper and lower poles should be

threaded with two stay sutures. That is, the central part
of the anastomotic site should be initially threaded with
one stitch of supporting suture using a procedure similar
to that of end-to-end anastomosis. Furthermore, several
interrupted sutures should be made at appropriate
intervals between the upper and lower poles. After the
anterior surface has been sutured, the double-clipped
anastomotic site should be rotated in a 180 arc to
suture the posterior surface (Fig. 32). After the entire
circumference of the anastomotic site has been closed
by interrupted sutures, blood flow should be restored by
unclipping the recipient vessel (Fig. 33). As a result, the
orifice (lateral foramen) of the preoperatively relaxed
recipient vessel will be extended due to longitudinal
tension by blood flow after the removal of the double
clip. Therefore, anastomotic stenosis rarely occurs in
vessels repaired by end-to-side anastomosis. In addition,
1. Microvascular Anastomoses in the Rat 43
attention should be focused on the angle between the
recipient and donor vessels. Considering the direction
of blood flow, the ideal angle between the two vessels
should not exceed 90.
References
1. O'Brien BM (1977) Microvascular reconstructive surgery.
Churchill Livingstone, New York, pp 50-78
2. Cobbett JR (1967) Small vessel anastomosis. Br J Plast
Surg 20:16-20
3. Tarnai S, Fukui A (1984) Fundamental techniques of
microvascular anastomosis. In: Olszewski WL. CRC hand-
book of microsurgery. Vol II. Raton, Florida, pp 3-23
4. Daniel RK, Terzis JK (1977) Reconstructive microsurgery.
Little, Brown, Boston, pp 61-115
2. Micronerve Suture and Graft in the Rat
Y OSHIAKI Y ANASE
In the last several decades, great advances have been
made in surgery of the peripheral nerves. Anatomical
studies by Ito [1] and Sunderland [2], the concept of
tension-free nerve repair by Millesi [3], intraoperative
stimul~tion or recording of individual funiculi by
HakstIan [4] and Nakatsuchi [5], and other experimen-
tal studies have significantly influenced our knowledge
of nerve injury and repair. The advantages of using an
operating microscope, microinstrumentation, and atrau-
matic suture materials are remarkable. Microsurgery
helps to improve the results of peripheral nerve repair,
because intraneural neurolysis is safer, identification of
intraneural topography is easier, and the nerve suture
technique is much less traumatic.
Anatomy of the Peripheral Nerve
Within a peripheral nerve, the nerve fiber (the axon and
its sheath) is a functional unit. Bundles of these fibers
~onta.ined in a specialized tubular membrane, the per-
Illeunu~, form the smallest surgical unit (a funiculus).
The fUnIcular contents are under axoplasmic pressure
and .are therefore always round in cross-section (Fig. 1).
FUnIcular plexuses result in two significant changes in
the internal structure of the nerve trunk: the number
and size of the funiculi vary (Fig. 2) [1], and the funicu-
lar pattern is altered so rapidly that transverse sections
of the nerve taken more than a few millimeters apart
fail ~o ~resent precisely the same pattern (Fig. 3) [2].
FUnIcuh ~ay pass singly along the nerve or may be
arranged III groups. Surrounding the funiculi and
funicular groups and binding them together is a loose
areolar tissue called the intraneurial epineurium (or
mesoneurium). Surrounding all of these to form the
outer layer of the peripheral nerve is a more or less
tubular membrane, the circumferential epineurium
(Fig. 4).
44
Historical Review of Experimental
Nerve Repair and Nerve Grafting
The first documentation of repair of a severed periph-
eral nerve is attributed to Ferrara in 1608, but no inter-
est .was dir~cted toward nerve repair and techniques
untIl the mld-1800s. Laugier, in 1864, described end-
to-end suture of peripheral nerves. Markoe, in 1885,
reported a technique in which the divided ends of the
nerve were cut tangentially to increase the surface area
for nerve contact. Several other procedures were
described, including side-to-side binding, transfixation
suture, transposition suture, and the suture "a distance"
method (Fig. 5). Unfortunately, in the nineteenth and
early twentieth centuries there were not enough surgi-
cal researchers or instruments for adequate analysis of
nerve degeneration and regeneration. Since World War
I, the surgical technique for nerve repair has varied
according to the surgeon's caprice or his/her serious
research [6].
Among these techniques may be considered the
interrupted epineural suture [7], the intraneural mono-
suture [8], the intrafascicular suture [4,9], the interfasci-
cular suture [10], the sheathing technique, the plasma
~lot technique, the adhesive technique, and the epineur-
lal sleeve technique (Fig. 6).
A historical review of the management of nerve gaps
reveals techniques that were even more creative than
those u~ed to perform end-to-end anastomosis. Gap
closure IS generally accomplished either by producing
an apparent increase in the length of the nerve or by
decreasing the distance the nerve segment has to
traverse.
Increasing the Apparent Length
Nerve stretching
Nerve mobilization
Nerve pedicles
Nerve grafts
Tubulization: rubber tubes, rolled Cargile gauze, fat and
fascial sheaths, hardened and fresh blood vessels,
 2. Micronerve Suture and Graft in the Rat 45

a c

b d

Fig. 1. Cross-sections of funiculi. a The funicular contents are b Stained with toluidine blue (x40); c, d scanning electron
under axoplasmic pressure and are always round in cross- micrograph (c xl00, d x700)
section. b-d A population of well-myelinated fibers is noted.

a b

209 mm proximal to the medial 162 mm proximal to the medial

proximal end of the tibia proximal end of the tibia

Fig. 2. Sections from a specimen of the human sciatic nerve b

illustrating variations in the size and number of the funiculi
along its length. The sections were made 209mm (a) and Fig. 3. Changes in funicular patterns in two cross-sections
162 mm (b) above the medial proximal end of the tibia [1] O.8mm apart (human radial nerve) [2]
46 C. Experimental Microsurgery
Nutrient vessels
Axon (with endoneurium)
Perineurium
Epineurium
Funiculi
Fig. 4. Basic structures of the peripheral nerve
Fig. 5. Suture "a distance" method. In this technique, conti-
nuity is restored leaving a small gap that provide a scaffold-
ing for downgrowth of regenerating axons
metal tube, collagen tube, millipore elastic, poly-
galactin, polyorthester, polyglycolic acid [11], and
expanded polytetrafluoro-ethylene (ePTFE) tube [12]
Decreasing the Distance the Segment has
to Traverse
Joint positioning
Nerve transposition from normal anatomic locations
Shortening of long bones
Release or resection of restraining soft tissues
Nerve Repair
Management of peripheral nerve injuries is a difficult
problem when a critical distance is present between the
nerve ends, whether a tension-free repair is possible, and
whether the internal topography of the peripheral nerve
permits a group fascicular repair. Both clinical and
experimental studies have been used to evaluate the use
of a microscope [3], end-to-end suture versus nerve graft-
ing [3], and epineural suture versus funicular suture [13].
a b
c
-I~ d
Fig.6. Schematic diagrams of several nerve repair techniques.
a Epineural suture, b funicular suture, c combination of per-
ineural and epineural suture, d epiperineural suture
There is little conclusive experimental evidence to
suggest that one technique is better than another. Effec-
tive nerve repair depends on sensory and motor axons
making appropriate connections with their distal end
organs. Recently, several experiments on neurotropism
using silicone chambers showed that regenerating nerve
fibers were selectively attracted to the distal stump (Fig.
7) [14-16]. The results of nerve repair will be influenced
by the extent of the injury, timing of the repair, fascicular
anatomy, reattachment of the injured nerve, surgical
technique, microinstrumentation, and suture materials.
Experimental Study of Micronerve
Suture and Graft in Rat
Preparation
Instruments
We use a pair of jewellers' forceps, a needle holder, and
two or three spring-loaded micro scissors. My preference
in suture material is atraumatic monofilament nylon
suture ranging from 8-0 to 10-0.
 2. Micronerve Suture and Graft in the Rat 47

Mesothelial chamber
Silicone
chamber

Sciatic nerve
a

Regenerating nerve

Fig.8. A piece of light-yellow latex balloon serves as an effec-

tive background
Fig. 7. Schematic diagram of Lundborg study. a After a
segment of the sciatic nerve is resected, the nerve stumps are
introduced into the openings of the mesothelial chamber,
leaving a lO-mm gap. b After 1 month, a thin nerve structure
is regenerated through the chamber to bridge the gap. c, d
Experimental model to demonstrate that the proximal stump
of peripheral nerve will discriminate in the silicone Y tube
between nerve ending and other tissue

8-0 nylon suture a

Operative Field in the Rat

We used Wistar rats. After anesthetizing the rats with
sodium pentobarbital (3-Smg/100g of body weight)
intraperitoneally, we removed the fur from the lateral b
side of the hind leg and disinfected the thigh. The sciatic
nerve was exposed through a longitudinal skin incision
over the lateral thigh. A piece of light-green or yellow
latex balloon served as an effective background (Fig. 8).
It is readily available, cheap, and does not give a bright
reflection.

Epineuria/ Suture Fig. 9. Epineural repair. a, b Corresponding bundles of funi-

The sciatic nerve was transected sharply with microscis-
sors. After a clean section, the two nerve stumps
retracted in accordance with the elasticity of nerve
tissue. Both stumps were reattached by interrupted
8-0 nylon suture through the epineurium (Fig. 9). Note
the trauma caused by the passage of the needle in the
process of suturing the nerve. The operating microscope
enables the surgeon to critically place the sutures in
the epineurium for accurate alignment of the funiculi.
Technically, it is important that nerve ends be trimmed
until pouting funiculi are identified and corresponding
bundles of funiculi are approximated with epineurial
stay sutures. In clinical cases, when dealing with a large
nerve, funicular bundles should be identified proximally
culi are approximated with epineural sutures. c In epineural
repair, undesirable overriding, offset, or buckling of the funi-
culi may occur
and distally and matched with what appear to be corre-
spondiI).g units. However, accurate funicular matching
can be done only in primary repair of sharply ampu-
tated nerves. Despite attempts at accurate alignment in
epineurial repair, undesirable overriding or buckling of
the funiculi may occur, as compared with the results of
epiperineurial (or funicular) suture. The anastomosis
should never be too tight, and the nerve ends should
be lightly drawn together until they are just in contact.
Goto [17] has shown histologically the difficulty of
48 C. Experimental Microsurgery
Fig. 10. Histological comparison between epineural and perineural repair. a Epineural suture showing undesirable matching
of the funiculi. b Funicular suture showing accurate approximation of the funiculi [17]
effecting exact funicular apposition with epineurial
suturing (Fig. 10).
Funicular (Perineural) Repair
Several alternatives to funicular suturing are reported.
In clinical cases, it is difficult to approximate each
funiculus, so I prefer to perform epiperineurial suturing
after identifying several groups of funiculi [18].
In experimental primary repair cases, funicular (or
perineural) repair is technically easier than clinical
repair, because the funicular pattern remains even and
has no gapping. To reconnect the two stumps, no exten-
sion of nerve tissue beyond its original length is neces-
sary. Funicular repair requires the use of an operating
microscope with high magnification and necessitates
accurate placement of the sutures. It is also important
that the suture needle enter through the epineurium to
the perineurium at the peripheral part of the funiculus.
The sciatic nerve is transected sharply with microscis-
sors, and the circumferential epineurium is dissected
from the end of the nerve. Then the funiculi are matched
to one another according to size. Usually in the rat
sciatic nerve, three to five funiculi are seen but not
formed into bundles. The gelatinous intrafunicular con-
tents protruding from the perineural cuff are trimmed,
and two sutures of 10-0 nylon thread are then placed at
1800 from each other. Sutures are made for each funicu-
lus in the same way (Fig. 11).
Nerve Grafting
The problem of bridging gaps in peripheral nerves has
been the subject of considerable experimental investi-
gation. Many methods have been devised for bridging
gaps clinically and experimentally in injured nerves,
such as cable, inlay, interfascicular, vascularized, tubular,
homo-, and hetero-grafts (Fig. 12).
Conventional Nerve Graft
In general, the encouraging results obtained experi-
mentally are in contrast to the frequent and disap-
pointing failures recorded clinically. Experimentally, we
take segments of peroneal and sural nerve 1 cm in
length just distal to the trifurcation of the sciatic nerve
and grafted to the contralateral sciatic nerve. Some
popular developments in nerve grafting have been in
refinements such as Millesi's interfascicular nerve graft.
The disadvantages of autologous nerve grafting include
harvesting the autograft from a second operative site,
consequent loss of end-organ innervation, and shortage
of autogenous nerve graft material for extensive nerve
injuries.
Vascularized Nerve Grafts
Several investigators found that small-diameter nerve
grafts revascularized spontaneously, and that revascu-
lalization using microvascular techniques was not nec-
essary [19]. In contrast, the larger-diameter nerve graft
for a long defect did not revascularize well. Such a nerve
graft would provide a suitable model for investigating
the potential merits of a vascularized nerve graft. A
number of experimental studies established definite
indications for vascularized nerve grafts [20,21].
However, the benefits of this technique remain hypo-
thetical. It is not clear whether axonal regeneration in
vascularized nerve grafts is superior to that in conven-
tional nerve grafts [22].
 2. Micronerve Suture and Graft in the Rat 49

a C

b d

Fig. 11. Funicular repair. a Interfascicular contents protrud- to one another by size, and two sutures are placed at 180 0 from
ing beyond the perineurium. b-d The funiculi from the two each other
paired bundles are arranged facing each other and matched

d
\
Vascular bundle

Fig. 12. Nerve grafting

methods. a Cable graft, b
c
inlay graft, c interfascicular
nerve graft, d vascularized
e nerve graft, e tubulization
nerve graft
50 C. Experimental Microsurgery
D (.) I (u C
Avilene-PGA lube
G1
a
b 1. Ito T (1977) Surgery of the peripheral nerve. Igaku Shoin,
Fig.13. Tubulization nerve repair. a Pham experimental tech
nique with avitene-PGA tube. b Technique of inserting the
nerve into the artificial nerve
Artificial Nerve Graft
The tubulization nerve repair technique has improved
remarkably with the development of bioabsorbable
materials. Tubulization nerve repair has three theoreti-
cal advantages: an inflammatory reaction to the suture
material is absent; fibroblast penetration into the repair
site is prevented; and the conduit may be filled with
growth factors or cells and oriented fibers or left empty
to prefill with body fluids. Tubulization has been tried
with Millipore, collagen membrane, vein, silastic mem-
brane, polyglycolic acid (PGA) tube, and ePTFE tube.
Ph am [11] reported an experimental study using a PGA
tube held in place with avitene (Fig. 13). The PGA tube
provides a barrier at the repair site against the sur-
rounding inflammation of wound healing, and the
avitene applied around the tube and nerves provides an
adhesive bond that holds the ends of the nerve within
the tube instead of suturing. Stanec [12] introduced the
use of ePTFE to manage nerve gaps in clinical cases.
Unfortunately, the inability of this conduit to provide
good results in longer gaps (4.l-6.0cm) negates the
major clinical value of this device. Terris et al. [23] inves-
tigated the potential for enhancing peripheral nerve
regeneration by manipulating the neural microenviron-
ment with laminin-fibronectin solution, dialyzed plasma,
collagen gel (CG), or phosphate buffer solution (PBS)
in a silicone tubulization repair model. They concluded
that these exogenous matrix precursors (CG and PBS)
do not enhance the rate or degree of recovery of periph-
eral nerve function.
Another approach using tubulization was carried out
in neurotropism. Recent work has shown conclusively
that neurotropism does exist and that there is a high
degree of specificity associated with neurotropism. The
proximal stump of a peripheral nerve will discriminate
between a nerve ending and other tissue. Lundborg
et al. [14] emphasized the importance of this phenom-
enon and recommended loose epineural suture (like
"a distance" method) for repair of injured peripheral
nerves.
References
Tokyo, pp 64-80 (in Japanese)
2. Sunderland S (1978) Nerves and nerve injuries. Churchill
Livingstone, London and New York, pp 31-37
3. Millesi H (1973) Microsurgery of peripheral nerve. Hand
5:157-160
4. Hakstian RW (1968) Funicular orientation by direct stim-
ulation. An aid to peripheral nerve repair. J Bone Joint
Surg 59A:1178-1186
5. Nakatsuchi Y, Matsui T, Honda Y (1980) Funicular orien-
tation by electrical stimulation and internal neurolysis in
peripheral nerve suture. Hand 12:65-73
6. Mackinnon SE, Dellon AL (1988) Surgery of the periph-
eral nerve. Thieme Medical Publishers, New York, pp 89-
129
7. Edsage S (1964) Peripheral nerve suture. A technique for
improved intraneural topography. Acta Chir Scand
(Suppl) 331:1-104
8. Snyder CC (1981) Epineurial repair. Orthop Clin North
Am 12:267-276
9. Bora FW (1967) Peripheral nerve repair in cats. The fas-
cicular stitch. J Bone Joint Surg 49A:659--666
10. Kutz JE, Sheealy G, Lubbers I (1981) Interfascicular nerve
repair. Orthop Clin North Am 12:277-286
11. Pham HN, Padilla JA, Nguyen KD, Rosen JM (1991)
Comparison of nerve repair techniques: suture vs avitene-
polyglyconic acid tube. J Reconstr Surg 7:31-36
12. Stanec S, Stanec Z (1998) Reconstruction of upper-
extremity peripheral-nerve injuries with ePTFE conduits.
J Reconstr Surg 14:227-237
13. Yamamoto K (1974) A comparative analysis of the
process of nerve regeneration following funicular and
epineurial suture for peripheral nerve repair. Arch Jpn
Chir 43:276-301
14. Lundborg G, Dahlin L, Danielson N, Hansson HA,
Johannesson A, Longo FM, Valon S (1982) Nerve regen-
eration across an extended gap: a neurobiological view
of nerve repair and the possible involvement of neu-
rotrophic factors. J Hand Surg 7A:580-587
15. Brushart TM, Seiller WA (1987) Selective reinnervation
of distal motor stumps by peripheral motor axons. Exp
NeuroI97:289-300
16. Ochi M (1992) Experimental evidence of selective axonal
regeneration in allogenic and isogenic Y-chamber. Exp
Neuro1115:260-265

17. Goto Y (1967) Experimental study of autologous nerve
graft using funicular suture technique. Arch Jpn Chir 36:
478-484 (in Japanese)
18. Yamamoto K, Yanase Y, Hirotani H (1977) New idea for
peripheral nerve repair. J Jpn Orthop Assoc 51:928-930
19. Best n, Mackinnon SE, Evans PJ, Hunter P, Midha R
(1999) Peripheral nerve revascularization: histomorpho-
metric study of small- and large-caliber grafts. J Reconstr
Microsurg 15:183-190
20. Pho RWH, Lee YS, Rujiwetpongstorn U, Pang M (1985)
Histological studies of vascularized nerve graft and con-
ventional nerve graft. J Hand Surg 10B:45-48
2. Micronerve Suture and Graft in the Rat 51
21. Shibata M, Tsai TM, Firrel J, Breidenbach WC (1988)
Experimental comparison of vascularized and nonvascu-
larized nerve grafting. J Hand Surg 13A:358-365
22. McCulough CJ, Gagey 0, Higginson DW, Sondin BM,
Crow JC, Sebille A (1984) Axon regeneration and vascu-
larization of nerve grafts: an experimental study. J Hand
Surg 9B:323-327
23. Terris DJ, Cheng ET, Utley DS, Tarn DM, Ho PR, Verity
AN (1999) Functional recovery following nerve injury and
repair by silicone tubulization; comparison of laminin-
fibronectin, dialyzed plasma, collagen gel, and phosphate
buffered solution. Aur Nas Laryn 26:117-122
3. Essential Laboratory Techniques
3.1 Technique of Microangiography
AKIHIRO FUKUI
Microangiography is an essential method of evaluating
blood circulation in several tissues. Blood circulation in
the bone or skin is frequently evaluated in the fields of
orthopedic and plastic surgery. The following procedure
of aortography is used to evaluate blood circulation in
animal tissues.
Anesthesia
A rat weighing 150-250 g is anesthetized with pen-
tobarbital sodium intraperitoneally (50mg/kg body
weight). After the rat has been placed in the supine posi-
tion on the dissecting board, the extremities are fixed
with tape. The hair is removed with clippers.
Procedure
A longitudinal skin incision is made from the neck to
the pubis. The sternum bone and peritoneum are cut
with scissors, and the thoracic cavity is opened.
Bleeding from the internal thoracic artery should be
stopped with a hemostat. When the pleura is removed
by scrubbing with a swab, the lungs atrophy, and the
beating heart can be observed directly beneath the
pleura. The connective tissue around the heart should
be carefully separated with a swab. A Teflon tube is
inserted into the aorta until its tip reaches the ascend-
ing aorta by lifting the aorta with a thread passed under-
neath the aortic arch. The Teflon tube is then fixed by
ligating with a thread to prevent the tube from slipping
off the aorta (Fig. 1). Cutting the abdominal vein after
separation of the abdominal aorta and vein results in
exsanguination. A manometer is attached to the instil-
lation tube to prepare the perfusion circuit, and the
perfusate in a bottle should be pressurized to approxi-
mately 120mmHg, a normal blood pressure level in
animals (Fig. 2). Warm heparinized physiological saline
is injected and perfused via the ascending aorta at a
pressure of about 120 mmHg. A micropaque solution
is then perfused after venous blood has been drained
from the abdominal vein. The micropaque solution
should be prepared by mixing water, micropaque, and
gelatin at a ratio of 12: 4 : 1. Heating the mixture to
approximately 80C should dissolve the gelatin. Sub-
sequently, as performed during injection of heparinized
physiological saline, the mixed micropaque solution
should be pressurized and injected via the ascending
aorta after reducing the temperature to approximately
40C. The volume of the injected micropaque solution
varies, depending on the part of the animal body to be
examined. However, 100ml is sufficient for examina-
tion of the entire rat body, and perfusion of blood
vessels in the respective abdominal organs with the
micropaque can be directly observed. The abdominal
vein should be clipped at both the central and the
peripheral regions to prevent further defluxion of the
micropaque when the micropaque has been sufficiently
drained out from the abdominal vein. Subsequently, the
body of the animal should be stored in a freezer for
about 30 minutes until the gelatin is set. When a large
animal is used, the nutrient artery and vein of the
animal tissue to be examined should be clipped to
prevent defluxion of the micropaque before the tissue
is removed from the animal's body. The animal tissue is
then stored in a freezer. Although gelatin becomes inef-
fective when the micropaque solution is stored at room
temperature, excessive micropaque can be stored in a
freezer and reused after it is defrosted and warmed.
Subsequently, radiography of the animal tissue should
be performed with soft x-rays. However, the dose and
time of radiography, vary depending on the thickness
of the animal tissue. The results of micro angiography
on rat dorsal skin and rabbit ears are shown in Figs. 3
and 4.
When micro angiography of the hind limbs is required
in a large animal, the procedure described above can be
performed by inserting a Teflon tube into the abdomi-
nal aorta.
55
56 C. Experimental Microsurgery

Common carotid artery

ICompressor I"---;r- . . . - -<

~---~

Arch of aort.a

Ascending aorta

Fig. 2. The perfusion circuit for irrigating the blood from the
circulatory system and injecting the micropaque solution

Fig.I. A Teflon tube is inserted into the aorta and ligated with
a thread

Fig. 4. Microangiogram of the rabbit ear

Fig. 3. Microangiogram of the murine dorsal skin (arrows)

3.2 Technique for Making a Vascular Corrosion Cast
TAKEO SEMPUKU

Many different methods have been employed in the with casting medium, such as the femoral artery for the
anatomic study of the blood vessels [1], which is indis- lower limbs or the axillary artery for the upper limbs. In
pensable for developing new experimental models and exposing the site, great care should be taken to cut as
new surgical methods in the field of microsurgery. few vessels as possible and to cauterize the cut vessels,
Vascular corrosion casting is one of the most useful because damaged or cut arterial vessels are potential
technical methods of demonstrating circulation [2,3]. efflux pathways for the injected casting medium.
Swammerdam is usually cited as the inventor of the It is important to rinse the circulatory system free of
solidifying injection mass; he injected hot wax into the blood, because blood would act as an obstacle to the
coarser blood vessels in 1672. In 1685, Bidloo injected casting medium. Injection of anticoagulants or their
Rose's metal, a fusible alloy containing bismuth and administration to the rinsing solution maintains blood
mercury, into the lung and boiled the specimen to fluidity and promotes improved injection of prepara-
decompose the tissue surrounding the vessels. In 1704, tions. I usually use heparinized saline (10 units/ml) as
Ruysch injected a colored metal, the composition of the rinsing solution. Heparinized saline may be drip-
which he kept secret, into the coronary vessels and infused until the perfusate is essentially free of blood:
then allowed larvae and maggots to attack and dis- approximately 100ml is needed when injecting into the
integrate the muscle tissue. In 1748, Lieberkiihn used aorta and 20ml into the axillary artery. The optimal per-
Swammerdam's mass, wax mixed with turpentine and fusion pressure in rinsing the vascular system remains
stained with cinnabar, and corroded parenchyma with controversial. So far, it is generally accepted that the
nitric acid. He was said to be the first to use true corro-perfusion pressure should be equal to the mean arterial
sion. Later investigators used various materials, such as pressure at the injection site (physiological pressure).
wax, wax with resin, metals with a low melting point, However, perfusion by gravitation (hydrostatic pres-
shellac, olive oil treated with osmic acid after injection,sure) is sufficient for rinsing, as Lametschwandtner
celloidine, celluloid, nitrocellulose [4], latex emulsion [5],
et al. [7] mentioned.
and mixtures of these and other materials as an injection The Batson No.17 plastic replica and corrosion
mass. Corrosion was carried out with hydrochloric kit (Polysciences, Warrington, PA, USA) contains a
acid, a solution of sodium hypochlorite (Javelle water), monomer base solution, a catalyst, a promoter, and two
potassium hydroxide, pepsin, and other substances. pigments. An amount of 0.5 to 2.5 mg of a pigment is
In 1935, Schummer introduced methyl methacrylate added to 20 ml of base solution, depending on the depth
as the casting medium of choice for the vasculature. of coloration wanted, and is vigorously mixed with a
Batson No.17 anatomical corrosion compound has been spatula. The solution is divided into two equal parts,
commonly used for vascular casting since Batson [6] adding 2.4 to 4 ml of the catalyst to one half and two or
developed the proprietary prepolymerized methacry- three drops of the promoter to the other half. Then the
late preparation in 1955. The materials are partially half of the base solution containing catalyst is mixed
polymerized monomers that are fully polymerized to a with the other half of the base solution containing pro-
stable polymer after injection through the action of the moter, and the combined mixture is stirred for about
catalyst and the promoter. 30 s. Because the working time is generally between 20
and 30 min, injection should be made within this time.
It is desirable that injection pressure be controlled.
Technique of Vascular Corrosion Lametschwandtner et al. [7] said that because of the
Casts in Rats characteristic physico-chemical properties of casting
media, there is a possibility that each medium has a
Immediately after a rat is sacrificed by ether inhalation, central injection pressure much higher than the periph-
a catheter is inserted in the aorta or the main artery eral pressure when injection is made into the larger
close to the specific tissue or organ one intends to fill supplying vessels that are far from the target organ or

57
58 C. Experimental Microsurgery
Fig. 1. Vascular corrosion cast of a human fibula (left, medial
view; right, lateral view). 1: lateral inferior genicular artery, 2:
artery of the neck, 3: anterior tibial artery, 4: peroneal artery,
5: anterior recurrent tibial artery. (See Color Plates)
tissue. Injection pressure is usually controlled at a con-
stant physiological pressure, which is commonly thought
to range from 95 to 120mmHg, by hand, by manometer,
by transducers, or by inspection of the injection site
under the dissecting microscope. It is also reported that
studies done with high injection pressures show good
casting of the entire vascular system without extensive
extravasation. I usually infuse the casting material into
the vessel under 120mmHg. Pressure is monitored using
a manometer, and the injection rate is adjusted contin-
uously to maintain a pressure of 120mmHg. Ten milli-
liters of medium is sufficient to fill the vascular system
of the lower half of a rat. The artery and vein should
be ligated at the end of injection. The plastic usually sets
within 2 to 3 h, but the quality of the cast is greatly
improved by keeping the specimen in water or a refrig-
erator overnight to dissipate the polymerization
exotherm.
After the mass has fully cured, the organ or the tissues
that are intended for maceration must be removed from
the rat and immersed in 11 % sodium dihydrochloride
solution to remove the soft tissue surrounding the cast.
It will take half a day to several days to corrode the
tissue. It is recommended that the specimen be removed
from the maceration solution several times and rinsed
in water. After maceration, the casts are thoroughly
rinsed and then dried (Fig. 1). They may be subsequently
embedded in clear methyl methacrylate resin.
The vascular corrosion casts are usually examined
under a magnifying glass or dissecting microscope.
Recently the technique of scanning electron microscopy
(SEM) of vascular corrosion casts was developed to
examine the microvasculature [? ,8]. For this technique,
some commercially available media are used: Mercox,
methyl methacrylate, modified Batson No.1?, Araldite
CY 223, and Tardoplast. The high viscosity of Batson
mixture mandates modification of this compound for
microcorrosion casting. Batson No.1? medium is usually
diluted with methyl methacrylate monomer before
injection. The viscosity of the casting medium is impor-
tant, especially for the technique using SEM: it should
be as low as possible to obtain a complete filling of the
capillary bed and good endothelial cell replication, but
should be high enough to produce minimal shrinkage of
the medium.
The method of vascular corrosion casting is an essen-
tial technique for investigating the vascular anatomy,
especially as a pilot study demonstrating which blood
vessels should be preserved and elevated for vascular-
ized tissue grafts. If precise knowledge of the vascular
anatomy is required, the technique using SEM of vas-
cular corrosion casts is helpful.
References
1. Whitten MB (1928) A review of the technical methods of
demonstrating the circulation of the heart. A modification
of the celluloid and corrosion technic. Arch Int Med 42:
846-864
2. Narat JK, Loef JA, Narat M (1936) On the preparation
of multicolored corrosion specimens. Anat Rec 64:155-160
3. Sempuku T, Tarnai S, Mizumoto S, Yajima H (1993) Vascu-
larized tail bone grafts in rats. Plast Reconstr Surg 91:
502-510
4. Batson OV (1935) A new material for corrosion prepara-
tions. Science 81:519-520
5. Batson OV (1939) Latex emulsions in human vascular
preparations. Science 90:518-520
6. Batson OV (1955) Corrosion specimens prepared with a
new material. Anat Rec 121:425
7. Lametschwandtner A, Lametschwandtner U, Weiger T
(1990) Scanning electron microscopy of vascular corrosion
casts-technique and applications: update review. Scanning
Microsc 4:889-941
8. Burger PC, Chandler DB, Gordon K (1984) Scanning
electron microscopy of vascular casts. J Elect Microsc Tech
1:341-348
3.3 Technique for Making a Spalteholz
Cleared Specimen
TAKEO SEMPUKU
Many methods and injection materials have been
used to demonstrate the vascular system. The technique
of vascular corrosion casts has been developed as
described in the chapter in this volume on "Technique
for Making a Vascular Corrosion Cast." Spalteholz
[1] described a method of clearing specimens in 1907.
He employed a chrome-yellow gelatin with subsequent
clearing. The injected organs were fixed in a 10%
solution of formaldehyde, dehydrated in alcohol, and
immersed in synthetic oil of wintergreen, which could
penetrate the tissues, giving them a uniform refractive
index similar to the fluid in which it was placed. In
this way, the organ was rendered semitransparent, so
that the injected vessels, which remained opaque,
stood out prominently against the clear parenchyma.
This method has been modified by some investigators
[2,3].
Technique of Making Cleared
Specimens in Rats
Immediately after a rat is sacrificed by ether inhalation,
a midline incision is made to expose the abdominal
viscera from the sternal notch to the symphysis. The tho-
racic cage and/or abdomen are opened, the thoracic
to abdominal aorta is isolated, and an 18-gauge poly-
ethylene cannula is inserted distally. The right atrium
or the renal vein is opened to serve as a drain vent. An
injection of about 5 ml of heparinized saline avoids the
formation of thrombi. The animal is perfused with
approximately 100ml of heparinized or nonheparinized
saline until all of the visceral blood volume can be
flushed out and the returned perfusate becomes clear.
If necessary, selected vascular beds may be perfused
through their accessible artery and drained through a
similar vein.
The silicone rubber injection compound Microfil
(Flow Tech, Carver, MA) is used as the injection mate-
rial in our laboratory [4]. Others [5,6] have injected
the barium sulfate suspension Micropaque (Guerbet
GmbH, Sulzbach, Germany) in gelatin or a combined
solution of India ink (Pelikan carbon black) and 10%
buffered formalin. Microfil injection kits are composed
of compound, diluent, and curing agent. The colors of
the available compounds are white, orange, blue, red,
yellow, and clear. Each compound has a slightly differ-
ent viscosity and specific gravity. The compound should
be blended with an equal quantity (by weight) of the
diluent. Volume mixing requires 5 ml of diluent for
every 4 ml of compound. The mixture of compound
and diluent is catalyzed with 5 % (by weight or volume)
of the curing agent. I prefer to add the curing agent
separately to the compound and to the diluent before
mixing. After catalyzation the mixture will have a vis-
cosity suitable for injection of the microcirculation. The
working time is 20min.
The silicone rubber is infused through the aortic
cannula or the accessible artery. The infusion pressure
will vary with the animal's mean systemic pressure.
For organs from the dog, cat, rat, and human, a pressure
of 150 mmHg for arterial filling has been used, and 25
to 50mmHg for venous fillings. Rubber injection is
continued until the injection mass flows freely from
the atrial or venous vent. The vent and the arterial
cannula are then clamped, and the animal is placed
under refrigeration at 4C overnight to allow
polymerization.
Technique of Alcohol-Methyl
Salicylate Clearing
Specimens are harvested by careful dissection; dehy-
drated in a 70% solution of ethanol for a few days, in
90% ethanol for one day, and in absolute ethanol for
one day; and then immersed in methyl salicylate for 12
to 24h for clearing. Before immersion, depilation should
be performed, and thick organs should be cut into 1-cm
slices. If the tissue has not cleared, return to the 90% or
100% ethanol stage and repeat the final step for clear-
ing. Brain tissues must be allowed 2 days for each step,
with an alcohol solution change every day. The clear
specimens may be preserved in methyl salicylate for
years (Fig. 1).
59
60 C. Experimental Microsurgery
Fig.I. Spalteholz cleared specimen of a murine tail (left, prox-
imal; upper, ventral). The caudal artery runs along the ventral
aspect of the tail bones and branches to supply each tail bone.
The venous system is also shown. (See Color Plates)
Technique of Glycerin Clearing
Specimens are obtained by careful dissection and placed
in a 50% mixture of water and glycerin. At successive
24-h intervals, the glycerin concentration is raised to
75%,85%, and finally pure glycerin. By this procedure,
the tissue is cleared and rendered transparent.
The method of obtaining a Spalteholz cleared speci-
men is a useful and essential technique for the study of
the vascular anatomy of various tissues and organs
[7]. Microscopic examination readily allows three-
dimensional visualization of the vascular system.
References
1. Hirsch C, SpaJteholz W (1907) Coronararterien und
Herzmuskel. Anatomische und experimentelle Unter-
suchungen. Deutsche Med Wchnschr 1:790-795
2. Gross L (1921) The blood supply to the heart in its anatom-
ical and clinical aspects. Paul B Hoeber, New York, pp 1-10
3. Wolfe K (1956) Plastic-embedded hearts-Cleared and
corroded specimens. AMA Arch PathoI61:153-158
4. Sempuku T, Tarnai S, Mizumoto S, Yajima H (1993) Vascu-
larized tail bone grafts in rats. Plast Reconstr Surg 91:502-
510
5. Scapinelli R (1997) Vascular anatomy of the human cru-
ciate ligaments and surrounding structures. Clin Anat 10
:151-162
6. Caffesse RG, Castelli WA, Nasjleti CE (1981) Vascular
response to modified Widman flap surgery in monkeys.
J PeriodontoI52:1-7
7. SpaJteholz W (1924) Die Arterien der Herzwand.
Anatomische Untersuchungen an Menschen- und Tier-
herzen. S Hirzel, Leipzig, pp 13-18
3.4 Technique of Fluorochrome Labeling
MOTOAKI OKUMURA
It was first reported by Milch and his associates in 1957
that animals of several species administered tetracycline
antibiotics showed localization of the antibiotics in
areas of new bone formation [1,2]. The localization of
the antibiotics could be easily detected by fluorescent
microscopy. Ibsen and Urist suggested that the major
mode of skeletal tetracycline binding was its chelating
activity with the calcium, and the antibiotic-calcium
complex could associate with the apatite in newly
formed bone matrix [3]. Since then, a number of
workers have used antibiotics and other compounds as
bone markers in the study of bone formation in humans
as well as in animal models [4-8]. Several markers show
different colors under fluoromicroscopy. The technique
of fluorochrome labeling has been described in many
articles [8-13]. We used this technique to study new
bone formation after the implantation of bone-bonding
biomaterials such as porous hydroxyapatite ceramics
[14-19]. We made a large number of serial undecalcified
sections from each implant and observed them to detect
bone growth accurately [11-13]. This chapter describes
the bone markers used for fluorochrome labeling and
the process of preparation of un decalcified thin sections.
Bone Markers
For humans, only tetracycline antibiotics (tetracycline,
20mg/kg daily for 4 days orally, 1 g/day in the adult)
can be used. For experimental animals, tetracycline,
calcein, and xylenol orange are frequently used. Before
injection of bone markers, the animals must be precon-
ditioned in the experimental environment because
altering the animal's environment, diet, and activity
causes extensive changes in remodeling activity, which
often exceed those produced by the experimental
variable [8].
Tetracycline Antibiotics
Tetracycline hydrochloride (TC) (Acromycin; Wyeth
Lederle Japan). Two hundred fifty milligrams of TC
was dissolved in 25 ml of sterilized distilled water and
injected subcutaneously at a dose of 50mg/kg.
Oxytetracycline hydrochloride (OTC) (Terramycin;
Pfizer Pharmaceuticals). OTC was injected at 15-25 mglkg
intravenously.
Calcein (Nacalai Tesque, Kyoto, Japan)
Five hundred milligrams of sodium bicarbonate was dis-
solved in 25 ml of saline, and 375 mg of calcein was the
slowly added to 25 ml of the 2 % sodium bicarbonate
with stirring. The calcein solution was then filtered
through a Millipore filter (200llm pore diameter) and
injected intravenously at a dose of 15 mg/kg.
Xylenol Orange (Nacalai Tesque,
Kyoto, Japan)
Five hundred milligrams of sodium bicarbonate was dis-
solved in 25 ml of saline, and then 1.5 g of xylenol orange
was slowly added to 25ml of the 2% sodium bicarbon-
ate with stirring. The xylenol orange solution was then
filtered through a Millipore filter (200llm pore diame-
ter) and injected intravenously at a dose of 90mglkg.
Preparation of Undecalcified
Sections
Our routine procedure for preparing undecalcified
thin sections is the following: (1) fixation with 70%
ethyl alcohol; (2) staining with Villanueva bone stain; (3)
dehydration; (4) infiltration; (5) embedding in methyl
methacrylate; and (6) sectioning.
The following solutions are prepared for this process:
(1) 70%,95%, and 100% ethyl alcohol.
(2) Villanueva osteochrome bone stain [12].
(Working solution: 500 to 750mg of the stain powder
(Polyscience, Warrington, Pennsylvania) is dissolved in
100ml of 70% methanol solution.
(3) Acetone (Nacalai Tesque, Kyoto, Japan).
61
62 C. Experimental Microsurgery
(4) Methyl methacrylate monomer (Wako Pure
Chemical Industries, Osaka, Japan).
(5) Prepolymerized embedding medium.
(a) For the initial embedding use: methyl methacry-
late monomer 500ml; polymethyl methacrylate beads
(Wako Pure Chemical Industries,) 200 g; and benzoyl
peroxide (Wako Pure Chemical Industries,) 5 g.
Do not add the methacrylate beads into the monomer
solution at once. Small amounts of the beads should be
repeatedly added to the monomer with stirring until
they are completely melted. The benzoyl peroxide is
then added to the polymethyl methacrylate/methcrylate
monomer solution.
(b) For supplemental use: methyl methacrylate
monomer 500ml; polymethyl methacrylate beads 200g;
benzoyl peroxide 7.5 g.
These embedding media are kept in the refrigerator
at 4C.
Fixation
Bone or implant materials obtained at biopsy, autopsy, or
sacrifice should be immediately put in 70% ethyl alcohol.
Staining
The specimens are stained in the Villanueva bone stain
solution for 72 h.
Dehydration
(1) 70% ethyl alcohol: 60min
(2) 95% ethyl alcohol: 90min
(3) 95% ethyl alcohol: 90min
(4) 100% ethyl alcohol: 90min
(5) Acetone: 90min
Infiltration
(1) 50% acetone and 50% methyl methacrylate
monomer: overnight
(2) Methyl methacrylate monomer: 24h
(3) Prepolymerized embedding medium: 24h in
refrigerator
Embedding
Fill the disposable molds (Peel-A-Way; Polyscience)
with prepolymerized medium, place the specimens on
the bottom of the molds, and keep them in the refrig-
erator for 24 h.
Polymerize in a vacuum oven at 30-35C and 20-30
mmHg negative pressures.
During this polymerization period, careful observa-
tion is needed to detect the complete curing, because
bubble formation in the medium and shrinkage after
curing may occur. If shrinkage of the plastic is observed
during curing, add more embedding medium for sup-
plemental use. Approximately 4 to 5 days of hardening
are required before the sections are cut.
Cutting Process
This chapter describes the process of cutting sections for
fluorochrome analysis. If other staining methods, such
as toluidine blue stain, are used, refer to the procedure
for wet sections [12].
Several sectioning machines are used for cutting
thin sections of bone tissue. In our laboratory, we use
the Jung K microtome (Jung, Germany) or the 2045
Multicut rotary microtome (Leica Instruments, Germany).
Satisfactory sectioning results require technical skill and
experience, a flat and clear surface on the bone speci-
men, a sharp knife at the correct angle, and a slow and
steady sectioning speed.
Procedures for Sectioning
Cutting should be done with moderate humidity and
temperature on the block surface. For this purpose, we
usually breathe on the block surface during the cutting
procedure for 5- to 10-/lm-thick sections. The section-
ing may cause coiling of the specimens, which can be
avoided by spreading the specimens with the tweezers.
If the specimen is very brittle or hard to cut, such as
the hydroxyapatite implant, the surface of the implant
in methyl methacrylate is coated with cyanoacrylate and
then cut.
Trim away excess plastic from each section.
Mount with Eukitt's mounting medium or Canada
balsam.
Thirty to fifty grams of weight is applied on the cover
glass for 24 h to prevent wrinkling of the thin specimens.
If the sections are observed under fluoromicroscopy,
yellow-colored tetracycline, green-colored calcein, and
orange-colored xylenol orange can be clearly observed.
Figures 1 and 2 show our experimental results. Porous
hydroxyapatite ceramics combined with rat marrow
cells were implanted subcutaneously in the back of
syngeneic Fischer rats and harvested 6 weeks after
surgery. The ceramics combined with marrow cells showed
consistent new bone formation in the pore regions. To
observe the de novo bone dynamics in the pore regions,

Fig. 1. Photograph under light microscopy showing an unde-
calcified section of hydroxyapatite ceramic with marrow
cells 6 weeks after implantation. The newly formed bone (B)
is in direct contact with the ceramic in the pore region.
Mineralized bone (B, unstained) and narrow seams of osteoid
(arrows, purplish red) are distinguished in this section. H indi-
cates hydroxyapatite ceramic. (Villanueva bone stain, x300)
(See Color Plates)
Fig. 2. The same section as in Fig. 1 under fiuoromicroscopy.
Yellow tetracycline (T), green calcein (C), and xylenol orange
(X) were administered 3, 4, and 5 weeks after implantation,
respectively. (See Color Plates)
3.4. Technique of Fluorochrome Labeling 63
undecalcified sections of the ceramics were studied by
fluorochrome labeling. Fluorochrome labeling showed
yellow tetracycline (administered 3 weeks after implan-
tation) near the ceramic surface, and green calcein
(administered 4 weeks after implantation) and xylenol
orange (administered 5 weeks after implantation) close
to the center of the pore. These results clearly showed
that bone formation began directly on the surface of the
ceramic and proceeded in a centripetal direction toward
the center of the pore.
Conclusions
We describe our method of obtaining good-quality 7-
/-lm-thick undecalcified sections for fluorochrome label-
ing. Multiple fluorochrome labeling is useful not only
for bone histomorphometry, but also for the identifica-
tion of bone viability and the dynamic aspects of newly
formed bone, which are important in research on bone
tissue transplantation.
References
1. Milch RA, Rall DP, Tobie JE (1957) Bone localization of
the tetracyclines. J Natl Cancer Inst 19:87-93
2. Milch RA, Rall DP, Tobie JE (1958) Fluorescence of tetra-
cycline antibiotics in bone. J Bone Joint Surg 40A:897-91O
3. Ibsen KH, Urist MR (1964) The biochemistry and the
physiology of the tetracyclines: with special reference to
mineralized tissues. Clin Orthop 32:143-169
4. Frost HM, Villanueva AR, Roth H (1960) Tetracycline
staining of newly forming bone and mineralizing cartilage
in vivo. Stain TechnoI35:135-138
5. Frost HM, Villanueva AR, Roth H (1960) Measurement
of bone formation in a 57 year old man by means of tetra-
cyclines. Henry Ford Hosp Med Bull 8:238-254
6. Tapp E (1966) Tetracycline labelling methods of measur-
ing the growth of bones in the rat. J Bone Joint Surg 48B:
517-525
7. Raman A (1969) Appositional growth rate in rat bones
using the tetracycline labelling method. Acta Orthop
Scand 40:193-197
8. Frost HM (1969) Tetracycline-based histological analysis
of bone remodeling. Calc Tiss Res 3:211-237
9. Villanueva AR (1974) A bone stain for osteoid seams in
fresh, unembedded, mineralized bone. Stain Technol 49:
1-8
10. Mathews CHE, Mehr I (1979) Staining and processing
bone specimens for simultaneous tetracycline-osteoid
seam assessment and histomorphometric quantitative
analysis. J Histotechnol 2:23-24
11. Konno T, Takahashi H (1983) Preparation of undecalcified
bone sections. In: Takahashi H (ed) Handbook of bone
morphometry. Nishimura, Niigata, Japan, PIl 28-33
64 C. Experimental Microsurgery
12. Villanueva AR (1983) Preparation and staining of miner-
alized sections of bone. In: Takahashi H (ed) Handbook
of bone morphometry. Nishimura, Niigata, Japan, pp
45-55
13. Jee WSS, Inoue J, Jee KW, Haba T (1983) Histomorpho-
metric assay of the growing long bone. In: Takahashi H
(ed) Handbook of bone morphometry. Nishimura,
Niigata, Japan, pp 101-124
14. Ohgushi H, Okumura M (1990) Osteogenic capacity of
rat and human marrow cells in porous ceramics: experi-
ments in athymic (nude) mice. Acta Orthop Scand
61:431-434
15. Okumura M, Ohgushi H, Tarnai S (1991) Bonding osteo-
genesis in coralline hydroxyapatite combined with bone
marrow cells. Biomaterials 12:411-416
16. Okumura M, Ohgushi H, Tarnai S, Shors EC (1991)
Primary bone formation in porous hydroxyapatite
ceramic: a light and scanning electron microscopic study.
Cells Mater 1:29-34
17. Okumura M, van Blitterswijk CA, Koerten HK, Ohgushi
H, Tarnai S (1990) Experimental study of vascularized
hydroxyapatite implants combined with rat bone marrow
cells: a preliminary report. In: Hulbert JE, Hulbert SF
(eds) Bioceramics. Vol 3. Rose-Hulman Institute of
Technology, Terre Haute, IN, pp 309-317
18. Okumura M, Ohgushi H, Takakura Y, van Blitterswijk
CA, Koerten HK (1992) Analysis of primary bone
formation in porous alumina: a fluorescence and scanning
electron microscopic study of marrow cell induced osteo-
genesis. Biomed Mater Eng 2:191-201
19. Sempuku T, Ohgushi H, Okumura M, Tarnai S (1996)
Osteogenic potential of allogeneic rat marrow cells in
porous hydroxyapatite ceramics: a histological study. J
Orthop Res 14:907-913
3.5 Technique of Bone Scintigraphy in Vascularized
Bone Grafts: Three-Phase Bone Imaging
AKIO MINAMI and KAZUO ITOH
Vascularized bone grafts have been widely used for the
treatment of various problems, and excellent results
have been reported [1-11]. Assessment of the viability
of the grafted bones is clinically important in the man-
agement of postoperative accidents, such as occlusion of
vascular anastomoses.
A septocutaneous skin paddle is useful for monitor-
ing graft circulation [1,5,12]. In most of our recent cases,
we have used a peroneal flap elevated with the fibula,
according to the method of Yoshimura et al. [12] and an
osteocutaneous flap of the ilium [5]. The procedure is
not unduly difficult. The vascular supply to the peroneal
septocutaneous skin flap from the peroneal vessels [12]
and to the groin skin flap from the direct osteocuta-
neous branches of the deep circumflex iliac vessels [5]
was constant, although the diameter of the vascular
pedicles was variable. However, in some cases, such as
spinal application, the use of a skin flap is not practical
because of the depth of the recipient site. In such cases,
we use 99m-technetium (99m-Tc) methylene diphos-
phonate (MDP) bone scans. Because bone imaging
reflects the vascularity and metabolic activity of the
bone, it has been of value in the assessment of the via-
bility of vascularized bone grafts [13-18]. The practical
procedure of bone scintigraphy is introduced, and three-
phase bone imaging for monitoring the viability of vas-
cularized bone grafts is described.
Procedure
Radiopharmaceuticals
The propensity for certain radionuclides to concentrate
in bone was first recognized in the early 1920s, with the
observation of the effects of ingested salts on painters
of luminous watch dials and the subsequent demon-
stration that the uptake was in bone. Skeletal scinti-
graphy offered as much as other nuclear medicine
procedures that had rapidly become routine. Much of
their value lay in the use of 99m-Tc radiopharmaceuti-
cals, reflecting the ideal properties of this radionuclide
for clinical use [19].
Technique of Three-Phase Bone Imaging
After an intravenous bolus injection of 20mCi (750
MBq) of 99m-Tc MDP for adults [scaled down to a
minimum of 5mCi (187.5MBq) for children], a blood
perfusion phase image (PI) of the bone graft site was
taken every 3 to 5 s by a large-field-of-view gamma
camera with a low-energy, all-purpose, parallel-hole
collimator. After a few minutes, a blood pool image
(BPI) of 500 kcounts (kets) to 700kets was taken at the
same position. Three to four hours after the injection,
multiple projection images of the bone phase (bone
images, BI) were obtained, each consisting of 250 to
700 kets, depending upon the graft site and the admin-
istered dose. In order to bring the collimator as near
as possible to the target area, a pinhole collimator was
occasionally used and magnified bone imaging was
acquired. The study described above was carried out
serially at 1 week, 2 weeks, 3-4 weeks, and 6-8 weeks
after surgery.
Scoring of Three-Phase Bone Imaging
To analyze the serial bone imagings semiquantitatively,
the findings for each phase (PI, BPI, and BI) were
graded retrospectively into groups, containing 3 to 5
degrees of uptake. The grading was based on visual
inspection of the imaging appearance at the bone graft
site. If the radioactivity at the site of the bone graft on
PI and BPI appeared to be equal to or less than that
at the surrounding area or the contralateral site, the
finding was graded as 0; a substantial increase was
graded as 2. Grade 1 was intermediate between 0 and
2. On BI, no bone uptake of radiophosphate was graded
as 0, faint uptake was 1, normal uptake (almost the same
as the untreated corresponding bone or the recipient
bone shaft) was 2, increased uptake was 3, and greatly
increased uptake (the same as or higher than the uptake
at the stump of the recipient bone) was 4.
65
66 C. Experimental Microsurgery

Patients
The authors reviewed 16 patients (9 males and 7
females) who have received vascularized bone grafts.
Their ages ranged from 2 to 59 years, with an average
of 29 years. The follow-up period ranged from 24 to 60
months. Eleven fibulae and seven iliac bones were
grafted to 16 recipient sites: 7 tibiae, 3 femurs,3 humeri,
1 ulna, 1 mandible, and 1 lumbar spine. Nine of the 11
fibular bones were grafted without cutaneous flaps. The
two fibular bones were transferred with osteocutaneous
flaps to repair massive skin defects secondary to tumor
resection and trauma. Conversely, all the iliac bones
were transferred with cutaneous flaps.

Results
Fibular Grafts

A successful clinical outcome was achieved in nine vas-

cularized fibular grafts. Two patients suffered stress frac-
ture of the transferred bone. In those two patients,
occlusion of the grafted vascular pedicle at 1 week
postoperatively was confirmed by contrast angiography.
The success rate of the reconstruction was 82% (9/11)
in this series. In grafted bones with successful clinical
outcome, obviously increased activity of PI at the
grafted site, grade 2, was observed, particularly within 1
to 2 weeks of surgery (Figs. 1 and 2). The increased
radioactivity of PI diminished gradually but seemed to
persist for 1 to 2 months after surgery (Fig. 3a). High
activity of BPI at the graft site was also demonstrated,
and it either paralleled or remained more persistent
temporally than that in blood perfusion (Fig. 3b). Bone
uptake of the radiophosphate ranged from grades 1 to
3, with the greatest frequency in grade 2 (Fig. 3c). This
bone uptake of the radiophosphate did not change
significantly over the first 8 weeks. Conversely, in two
cases of occluded vascular anastomoses, no increase
of PI and BPI at the graft site and no bone uptake of
the radiophosphate by the graft bone segment were
observed.
Iliac Bone Grafts
Six out of seven vascularized iliac bone grafts were suc-
cessful. An early complication was encountered in one
patient. Imaging findings of PI and BPI in cases without
early complication were preponderantly grade 2 within
1 to 2 weeks of surgery (Fig. 3a and b). This generally
decreased thereafter, except for two cases of high-grade
Fig. 1. Radiograph of a free vascularized fibula grafted on the
right femur (from Itoh et al. [18], with permission)
PI and BPI that persisted up to 8 weeks postoperatively.
The latter finding was not encountered in free vascu-
larized fibular grafts. The bone uptake of radiophos-
phate in vascularized iliac grafts with successful clinical
outcome was always 3 to 4. This increased bone uptake
persisted without significant change for up to 8 weeks.
Only one patient in this series showed negative findings
of PI, BPI, and bone uptake on day 8 after surgery.
Although the simultaneously transferred skin flaps were
partially alive, some vascular accident to the transferred
bone was strongly suggested from the results of bone
imaging. Hyperbaric therapy was conducted after the
first bone imaging. Subsequent serial bone imagings
showed improvement of image grades of PI, BPI, and
bone uptake in the grafted bone. This may be accounted
for by an improvement in the microvascular circulation
of the grafted ilium and/or by conventional creeping
substitution of a failed microvascular graft, although the
mechanism is not clear. This patient had a successful
clinical outcome at follow-up 12 months after bone
grafting, although partial necrosis of the flap was
present. In the other patient, the transferred bone was
completely absorbed 3 years afterward, although the
three-phase bone imaging performed two weeks after
the operation demonstrated positive findings. Unfortu-
nately, serial bone images of this patient were not
obtained, because no prospective protocol for bone
 3.5. Technique of Bone Scintigraphy in Vascularized Bone Grafts
Fig.2. Serial three-phase bone images in a patient who had a
successful clinical outcome. Upper row: blood perfusion
images. Middle row: blood pool images. Lower row: delayed
bone images. Increased activity of blood perfusion and blood
pool phase images at the grafted site (black arrows) is
observed at 1 week (left column) , 2 weeks (second column),
grafts had been established at that time. The success rate
for reconstruction using a vascularized ilium graft was
86% (6/7).
Discussion
The sensitivity and reliability of bone imaging to assess
the viability of vascularized bone grafts have been dis-
cussed [13-16]. Most of the discussions agree that bone
imaging is a noninvasive, simple, and sensitive tool
to assess the viability of vascularized bone grafts.
However, Breggren et al. [17] have warned of the unre-
liability of bone imaging as a diagnostic tool to assess
the viability of bone grafts when it is performed more
than 1 week postoperatively. They point out that even
if the major portion of the graft is not viable, the bone
imaging can still be positive. This is reported to be due
to the presence of new bone formed on the surface of
a dead bone more than 1 week postoperatively. Nutton
et al. [20] have emphasized that early, dynamic bone
67
and 6 weeks (third column) postoperatively, and is graded as
2. At 8 weeks (right column), no increase (grade 0) in the activ-
ity of blood perfusion and blood pool phase images is demon-
strated. The grafted bone uptake of radiophosphate is
increased (grade 3) and notably unchanged up to 8 weeks
postoperatively (from Itoh et al. [18], with permission)
imaging increases the versatility of the process. Never-
theless, no study has demonstrated the versatility of
serial three-phase bone imaging in the vascularized
fibular and iliac bone grafts for monitoring the early
activity of the grafted bone. On study produced the
same results as the report using a canine model [20]:
increased blood perfusion and blood pooling at the site
of the bone graft persisted 1 to 2 weeks after grafting.
These parameters probably reflect persistent postoper-
atively hyperthermia, congestion, or both around the
site of the bone graft and patency of the vascular pedicle
graft. However, sequential studies can give less infor-
mation on vascular patency of the graft bone 4 weeks
after surgery when blood perfusion returns to normal.
Bone uptake did not change notably within the initial 8
postoperative weeks. These results may imply that vital
information on the grafted bone can be obtained with
the three-phase study delayed bone images only in the
early phase of the grafting [21]. Bone grafts with vascu-
lar complications showed decreased radiophosphate
concentrations in all three phases of imaging.
68 C. Experimental Microsurgery

I!!
0 Conclusions

____~ m_m~
()
(I) +2

____ __ _
c
0
'iii ______
Three-phase imaging was undertaken to monitor the
:J +1
't:
I m:~ viability of vascularized bone grafts after surgery.
Co
"C
0 0 In most of the patients who had a successful clinical
.e
0
iii outcome, the results were positive: blood perfusion and
2 3 4 5 6 7 8 blood pool radioactivity at sites 2 weeks postoperatively
a Aging of grafted bone (weeks)
and became equal to surrounding tissue therafter. The
grafted bone uptake of radiophosphate was constantly
positive in these cases. Conversely, the results were neg-
ative in three cases with postoperative vascular compli-
cations. Serial three-phase bone imaging is a useful tool
to monitor the viability and early complications of vas-
cularized bone grafts after surgery in cases without a
2 3 4 5 6 7 8
cutaneous flap.
b Aging of grafted bone (weeks)

+4

__ ________
I!!
8
(I)
+3
~ :~o

a +2
~

:J --o---------------~

a~ +1
~------ __co~----------___ o
III

2 3 4 5 6 7 8
c Aging of grafted bone (weeks)

Fig. 3. Imaging score of the grafted bone versus aging of

the grafted bone. a Blood perfusion activity, b blood pool
activity, c bone uptake. 0-0, successful vascularized fibular
grafts; e-e, vascularized fibular grafts with stress fracture;
D.-D., successful vascularized iliac grafts; .-., vascularized
iliac grafts with anastomosis failure; ., vascularized iliac grafts
with bone lysis; 8-8, successful vascularized iliac and fibular
grafts (from Hoh et al. [18], with permission)

Fig. 4. Radiograph of vascularized ilium with skin flaps

grafted on the right humerus (from Hoh et al. [18], with
permission)

WEEtc: I wEEK 2 a

Fig. 5. Serial three-phase bone images in a patient who had second column, 2 weeks postoperatively; third column, 4
a successful clinical outcome. Grafted bone uptake of radio- weeks postoperatively; right column, 8 weeks postoperatively
phosphate is graded as 4. Left column, 1 week postoperatively; (from Hoh et al. [18], with permission)
 3.5. Technique of Bone Scintigraphy in Vascularized Bone Grafts
References
1. Minami A, Vsui M, Ogino T, Minami M (1986) Simulta-
neous reconstruction of bone and skin defects by free
fibular graft with a skin flap. Microsurgery 7:38-45
2. Minami A, Ogino T, Sakuma T, Vsui M (1987) Free vas-
cularized fibular grafts in the treatment of congenital
pseudarthrosis of the tibia. Microsurgery 8:111-116
3. Kaneda K, Kurakami C, Minami A (1988) Free vascular-
ized fibular graft in the treatment of kyphosis. Spine
13:1273-1277
4. Minami A, Kaneda K, Itoga H, Vsui M (1989) Free vas-
cularized fibular grafts. J Reconstr Microsurg 5:37-43
5. Minami A, Ogino T, Itoga H (1989) Vascularized iliac
osteocutaneous flap based on the deep circumflex iliac
vessels-Experience of 13 cases. Microsurgery 10:99-102
6. Minami A, Itoga H, Suzuki K (1990) Reverse-flow vascu-
larized fibular graft: A new method. Microsurgery
11:278-281
7. Minami A, Kaneda K, Itoga H (1992) Treatment of
infected segmental defect of long bone with vascularized
bone transfer. J Reconstr Microsurg 8:75-82
8. Minami A, Kimura T, Matsumoto 0, Suzuki K (1993) Frac-
ture through united vascularized bone grafts. J Reconstr
Microsurg 9:227-232
9. Minami A, Kutsumi K, Takeda N, Kaneda K (1995) Vas-
cularized fibular graft for bone reconstruction of the
extremities after tumor resection in limb-saving proce-
dures. Microsurgery 16:56--64
10. Minami A, Kaneda K, Satoh S, Abumi K, Kutsumi K
(1997) Free vascularized fibular strut graft for anterior
spinal fusion. J Bone Joint Surg 79B:43-47
11. Kasashima T, Minami A, Kutsumi K (1998) Late fracture
of vascularized fibular grafts. Microsurgery 18:337-343
69
12. Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Veno T
(1983) Free vascularized fibular transplant. A new method
for monitoring circulation of the grafted fibula. J Bone
Joint Surg 65A:1295-1301
13. Lau RSF, Leung PC (1982) Bone graft viability in vascu-
larized bone graft transfer. Br J Radiol 55:325-329
14. Lisbona R, Rennie WRJ, Daniel RK (1980) Radionuclide
evaluation of free vascularized bone graft viability. Am J
Radiol 134:387-388
15. Frame JW, Edmondson HD, O'Kane MM (1983) A radio-
isotope study of the healing of mandibular bone grafts in
patients. Br J Oral Surg 21:277-289
16. Zimberg EM, Wood MB, Brown ML (1985) Vascularized
bone transfer: Evaluation of viability by postoperative
bone scan. J Reconstr Microsurg 2:13-19
17. Breggren A, Weiland AJ, Ostrup LT (1982) Bone scintig-
raphy in evaluating the viability of composite bone grafts
revascularized by microvascular anastomoses, conven-
tional autogenous bone grafts, and free non-vascularized
periosteal grafts. J Bone Joint Surg 64A:799-809
18. Itoh K, Minami A, Sakuma T, Furudate M (1989) The use
of three-phase bone imaging in vascularized fibular and
iliac bone grafts. Clin Nucl Med 14:494-500
19. Subtanian G, McAfee JG (1971) A new complex for 99m-
Tc for skeletal imaging. Radiology 99:192-196
20. Nutton RW, Fitzgerald RH, Kelly PJ (1985) Early detec-
tion bone-imaging as an indicator of osseous blood flow
and factors affecting the uptake of 99m-Tc hydroxymeth-
ylene diphosphonate in healing bone. J Bone Joint Surg
67A:763-770
21. Lalonde DH, Williams HB, Rosenthall L, Viloria JB.
(1984) Circulation, bone scans, and tetracycline labeling in
microvascular and vascular bundle implanted rib grafts.
Ann Plast Surg 5:366-374
3.6 Biochemical and Biological Analysis of
Bone Viability
HAJIME OHGUSHI and MANABU AKAHANE
Bone tissue consists of cellular and extracellular matrix
components. The main cellular components are bone-
forming osteoblasts and bone-resorbing osteoclasts.
Bone tissue is formed by active osteoblasts, which
fabricate extracellular matrix made of hydroxyapatite
crystal and organic elements. The major part of the
organic elements consists of collagen molecules, and
osteoblasts deposit hydroxyapatite crystals on the col-
lagen molecules. In the process of bone tissue regen-
eration, such as fracture repair, osteoblasts play a
fundamental role in regeneration. In bone grafting
surgery, fresh autogenous bone is superior to allogeneic
or artificial bone graft substitutes, because many
osteoblasts reside in the fresh bone. Compared with
the free autogenous bone graft, the vascularized
bone graft has been available for massive osseous
defects, because the vascularization can nourish
almost the entire graft, resulting in survival of osteo-
blasts in the graft (See the chapters by S. Mizumoto, N.
Yamaoka, and K. Kawanishi, this volume). There-
fore, measuring the activity of osteoblasts in the graft
is essential to assess graft viability, which reflects osteo-
genic capacity.
Alkaline phosphatase (ALP) localizes on the cell
membranes of osteoblasts, and its activity correlates
well with osteoblastic activity [1,2]. Osteocalcin is a non-
collagenous protein that is exclusively synthesized by
osteoblasts [3,4]. These findings indicate the impor-
tant role of these proteins (ALP and osteocalcin) in
bone metabolism. After production of osteocalcin by
osteoblasts, the protein accumulates in the extracellular
matrix of bone tissue. Therefore, the osteocalcin content
is well correlated with the volume of bone tissue, but
not with osteoblastic activity. The general cascade of
protein synthesis in the cell is mRNA synthesis from the
corresponding DNA gene, followed by translational
activity of RNA polymerase on the mRNA strand
matching the protein sequence. Consequently, detection
of osteocalcin mRNA correlates well with the rate of
production of osteocalcin by osteoblasts, indicating that
70
the amount of mRNA correlates with osteoblastic
activity [5].
Here, we report a method of measuring ALP activity
and the amount of osteocalcin mRNA; the former is
based on enzyme assay and the latter utilizes Northern
blot analysis.
Measurement of ALP Activity
Reagents
1. 2-Amino-2-methypropandiol (AMP) Buffer (pH
9.8). Dissolve 2.94g of AMP in 500ml of distilled
water, and adjust the pH to 9.8 by adding concen-
trated acetic acid.
2. Assay Buffer. Dissolve 10mg of MgCh[6H20] and
186mg of p-nitrophenyl phosphate in 50ml of the
AMP buffer. The buffer is prepared just before the
measurement of ALP.
3. O.2N NaOH
All the reagents were purchased from Nakarai Tesque,
Kyoto, Japan.
Protocol of ALP Assay [6,7]
Bone fragments are removed, weighed, and homoge-
nized with a microhomogenizer in ice-cold 0.2%
Nonidet P-40 containing 1mM MgCh, and the
homogenate is centrifuged at 20,000g for 15min at 4C.
Ten microliters of the supernatant is added to 1 ml of
the assay buffer and incubated for 30min at 37C. The
reaction is stopped by adding 2ml of O.2N NaOH, and
OD 410 nm is measured by spectrophotometer. The ALP
activity (}lmol/30min/10}l1 supernatant) is calculated
by the equation (sample OD 4!O - blank OD 41o ) x 2001
5.91. Blank activity (blank OD 41o ) is measured without
adding the supernatant (only assay buffer is incubated
and NaOH is added).
 3.6. Biochemical and Biological Analysis of Bone Viability
Northern Blot Analysis of
Osteocalcin mRNA
Preparation of Total RNA from
Bone Tissue
Bone fragments are pulverized under liquid nitrogen
into a powder. The powder is homogenized with 2ml of
ISOGEN (RNA extraction kit; Nippon Gene, Toyama,
Japan) in a tube, and then OAml of chloroform is added.
After vigorous shaking, the mixture is centrifuged, and
the aqueous phase is transferred to a new tube con-
taining 1 ml of isopropanol. After centrifugation at
12,000g, the RNA can be recovered by precipitation.
The precipitate is gently washed with 1 ml of 75 %
ethanol. Then it is centrifuged again, and the precipitate
is dissolved in DNAase and RNAase free water. The
total RNA solution is transferred to another new tube
containing an equal volume of phenol. After vigorous
vortexing, the mixture is centrifuged. The supernatant is
concentrated by precipitation with ethanol. Quantita-
tion of RNA is performed by spetrophotometoric deter-
mination at 260nm. Preparation of RNA from hard
tissue such as bone is difficult compared with prepara-
tion from other soft tissues. Many of the other com-
mercially available RNA isolation kits do not work well,
and RNA can be best obtained from bone by a tradi-
tional guanidine isothiocyanate/cesium chloride density
gradient method [5]. However, the method needs an
ultracentrifuge, and we therefore recommend the alter-
native simple method described here [8].
Labeling of cDNA
For Northern blot analysis of rat osteoca1cin mRNA,
we found that relatively short strands of sense cDNA
can be used [9]. In this section, we introduce the
Northern blot analysis using short DNA, because the
DNA can be easily obtained from various companies.
Both sense and anti-sense nucleotides corresponding
to the region of Leu [16]-Glu [31] of rat osteoca1cin
are prepared and labeled with 32p ATP using T4 poly-
nucletide kinase (Bethesda Research Laboratories
Life Technologies, Bethesda, MD, USA). Specific
radioactivity of 370MBq/ml is used for the labeling. Six
microliters of 32p ATP, 2111 (10pmol) of DNA, 5111 of
forward reaction buffer, 2111 of T 4 kinase, and 11111
of water are incubated for 30min at 37C and then
for 10min at 68C. The labeled DNA fraction can be
separated by G-50 DNAase free Nick column equili-
brated by TE buffer (10mM TrisCl, 1mM EDTA,
pH 704).
71
RNA Electrophoresis and Northern Blot
Ten micrograms of RNA is fractionated by electro-
phoresis on a 1.2% agarose formaldehyde gel. The frac-
tionated RNA is transferred to a nylon membrane
(Immobilon N, Millipore, Tokyo, Japan). Prehybridiza-
tion and hybridization with the 32P-labeled oligomer of
rat osteoca1cin is performed at 77C in Quickhyb solu-
tion (Strategene, La Jolla, CA, USA) for 25 and 120min,
respectively. Post-hybridization wash in 2 x SSC, 0.1 %
sodium dodecyl sulfate (SDS) at 77C for 15min (twice)
and in 0.1 SSC, 0.1 % SDS at 60C for 30min is per-
formed. The SSC is 0.15M NaCl, 15mM sodium citrate.
The membrane is exposed to Kodak X-Omat film
(Eastman Kodak, New York, NY, USA) at -80 C for D
24h with intensifying screen [5,9]. The visualization and
quantitation of the mRNA band can also be performed
with a BAS 1000 image analyzer (Bioimaging analyzer
GAS 1000 MacBAS, Fuji Photofilm, Tokyo, Japan) [8].
Sometimes the blot analysis showed a high background,
probably due to the nonspecific binding of labeled DNA
to many other RNAs. The temperature of hybridization
is crucial for the Northern analysis using this short-
strand oligo DNA. We therefore recommend that whole
osteoca1cin cDNA be used as a probe that can be
labeled by the random primer method [5,9]. However,
if the protocol described here is strictly followed, oligo
DNA can be used to detect rat osteoca1cin mRNA, and
the DNA can be ordered easily. Details of the method
of RNA electrophoresis and blotting are described
elsewhere [10].
Significance of ALP Activity in the
Vascularized Periosteum
The vascularized bone graft has various advantages
because of its significant osteogenic capacity as com-
pared with that of any of other graft materials, includ-
ing free autogenous bone graft [See the chapters by S.
Mizumoto, N. Yamaoka, and K. Kawanishi, this volume].
However, vascularized bone grafts are also associated
with disadvantages, one of which is that the size and
configuration of the donor bone are strictly limited [See
the chapter by H. Yajima, this volume]. Another disad-
vantage is the morbidity of the donor site, which
sacrifices the normal bone architecture. Because the
tissue surrounding the bone (periosteum) has osteo-
genic properties, the use of a vascularized periosteum
graft may overcome the disadvantages of a vascularized
bone graft, because we can harvest periosteum without
taking bone tissue, so that morbidity is less than with a
bone graft.
72 C. Experimental Microsurgery
ALP activity (/1 moles/30min/implant)
12
lO t
8
6
4
2
o Periosteum
o 2 aSCla
Postimolantation (w\s)
Fig. 1. Alkaline phosphatese (ALP) activity of periosteum-
ceramic composites (perios) and fascia-ceramic composites
(fascia) implantation. ALP activity represents micromoles of
substrates released after 30min of incubation
We have developed a new experimental model of the
vascularized periosteum-hydroxyapatite composite in
rats [11]. Coralline hydroxyapatite ceramics (with pore
diameters measuring 190 to 230 Ilm, Interpore Interna-
tional, Irvine, CA, USA) were used and cut into cubes
weighing 20 mg. An incision was made along the medial
side of the femur and tibia. A medial portion of tibial
periosteum (3 x 15 mm) was elevated on a vascular
pedicle of the saphenous vessels. The periosteum was
wrapped around the ceramic cube and transferred to a
subcutaneous pouch on the medial aspect of the thigh.
For the control, the fascia of the medial aspect of the leg
(3 x 15 mm), nourished by the saphenous vessels, was
elevated on its vascular pedicle. Then it was wrapped
around the ceramic and transferred in the same man-
ner as the above-described vascularized periosteum-
ceramic composites. These implants were harvested 2 to
8 weeks after implantation. The histological findings
showed that none of the vascularized fascia-ceramic
composites showed bone formation; however about
half of the vascularized periosteum-ceramic composites
showed bone formation at 2 weeks, and all of the com-
posites showed bone formation after 4 weeks. These his-
tological findings were well correlated with the findings
of ALP activity of the composites. As shown in Fig. 1,
only traces of ALP activity were detected in the vas-
cularized fascia-ceramic composites, whereas signifi-
cantly high activities were found in the vascularized
periosteum-ceramic composites.
Because bone is a hard tissue, a decalcifying process
is needed to demonstrate an ordinal histology, so that a
long period is needed to obtain the results. In contrast,
Fig. 2. Histology of marrow-ceramic composites (a) and rat
cancellous bone (b). The composite was implanted at a sub-
cutaneous site and harvested 4 weeks postimplantation
as shown in the protocol described in this section, mea-
suring the ALP activity of the implants (bone) is easy
and takes only few hours. This biochemical assay is very
convenient and also can show the quantitative data.
Significance of ALP Activity and
Osteocalcin mRNA in the Osteogenic
Capacity of Marrow Cells
As described, the periosteum graft may have clinical sig-
nificance in bone reconstruction surgery. However, har-
vesting the periosteum is still not an ideal procedure,
because of damage to the tissue surrounding the perio-
steum to be harvested. In consideration of the tissue
morbidity, we have developed another system to
produce osteogenic properties on porous hydroxyap-
atite ceramics with minimal invasion of the host tissue
[8,9,12-19]. The method utilizes ceramics impregnated
with bone marrow cells, and the composite of marrow
and ceramics shows consistent new bone formation
when implanted at subcutaneous sites. Because the
bone marrow cells can be obtained by needle aspiration,
the morbidity is minimum. As shown in Fig. 2, com-
posites of rat marrow cells and ceramics implanted in
rat subcutaneous sites showed new bone formation with
lining of active osteoblasts at about 3 to 4 weeks postim-
plantation. The histological features are almost the same
as those in normal rat cancellous bone. The histology
indicates osteoblastic activity of the marrow-ceramic
composite comparable to that of cancellous bone [17].
To quantify the osteoblastic activity, the ALP activities
of the composites and of cancellous bone were mea-
sured. The ceramics used were the same as those used
for vascularized periosteum-ceramic composites. As
shown in Table 1, the ALP activities of the composites
harvested at 4 to 6 weeks are 80% to 60% of that of
10mg of rat cancellous bone. However, the actual
bone volumes in the composite and the cancellous
 3.6. Biochemical and Biological Analysis of Bone Viability 73

Table 1. Osteogenic index of cancellous bone and marrow-ceramic composite transplantation

Measurement Cancellous bone Marrow-ceramic (4 weeks postimplantation) Marrow-ceramic (6 weeks postimplantation)
ALP activity" 10.19 8.94 6.52
Osteocalcin content b 2.69 1.17 1.77
Osteogenic indexc 3.79 7.64 3.68

ALP, alkaline phosphatase

a Miuomoles of p-nitorophenol released per one marrow-ceramic composite or rat cancellous bone (lOmg) after 30min of incubation at 37C.
b Miuograms of osteocalcin per one marrow-ceramic composite or rat cancellous bone (lOmg) was calculated by radioimmunoassay methods.

C Ratio of ALP activity to osteocalcin content of the marrow-ceramic composite or cancellous bone.

bone could not be determined. In order to measure the

bone volumes, the contents of osteocalcin protein,
which correlate with the bone volume, were measured
in both composites and cancellous bone. The ratios of
ALP activity to osteocalcin content of the composites
and cancellous bone were then measured. The ratio of
cancellous bone was 3.79 and those of the composites
at 4 and 6 weeks postimplantation were 7.64 and 3.68,
respectively. The ratio reflects the specific activity of
the osteoblasts and can be defined as the osteogenic
index [17]. These data indicate that the bone-forming
capability (osteoblastic activity) of the composite is
comparable to that of cancellous bone.
The total RNAs were also extracted from the com-
Fig. 3. Northern blot analysis of mRNA for osteoca1cin.
posite at 4 weeks postimplantation, ceramic without
Marrow-ceramic composites and ceramics alone were
marrow at 4 weeks postimplantation, marrow cells,
implanted at subcutaneous sites and harvested at 4 weeks
and cancellous bone and were utilized for Northern postimplantation. Total RNA was extracted from the marrow-
blot analysis against rat osteocalcin oligomer DNA, as ceramic composite (4+), ceramic without marrow (4-), rat
described in the previous section. As shown in Fig. 3, cancellous bone (CB), and rat marrow (MA). The RNAs were
signals of osteocalcin mRNA were not detected in the denatured, electrophoresed, stained with ethidium bromide
ceramic without marrow and marrow cells; however, the (upper pant affigure: visualized by UV irradiation), and trans-
signals were clearly detected in the composite and can- ferred to a nylon membrane. Ribosomal RNAs of28S and i8S
cellous bone. Importantly, the signal of the composite is are indicated
comparable to that of rat cancellous bone. The intensity
of the composite was about 70% of that of cancellous
bone [9]. Again, this gene expression analysis confirmed
the strong osteogenic (osteoblastic) activity of the
marrow-ceramic composite. Our recent findings also tissues. Another method of identifying osteoblastic
showed osteogenic activity of the human marrow- activity is detecting the mRNA of osteocalcin. The
ceramic composite, especially when we used cultured method is relatively complicated but is very specific and
human marrow cells [18,19]. All of these findings sensitive. These findings indicate that these biochemical
prove the clinical significance of the marrow- and gene expression analyses are very useful tools to
ceramic composite in the fields of orthopedic surgery, develop new therapeutic approaches in reconstructive
cranio-maxillo-facial surgery, plastic surgery, and microsurgery.
neurosurgery.

Acknowledgments. We thank Dr. Y. Dohi, Department

Conclusions
Measuring the alkaline phosphatase actlVlty of the
bone-and bone forming tissue is an easy and reliable
way to determine the osteoblastic activity of these
of Public Health, Nara Medial University, for her
help regarding the biochemical assay for ALP and
Osteo-calcin. We also acknowledge Dr. E. Shors,
Interpore International, for providing the Interpore
ceramics.
74 C. Experimental Microsurgery
References
1. Woldarski KH, Reddi AH (1986) Alkaline phosphatase
as a marker of osteoinductive cells. Calcif Tissue Int 39:
382-385
2. Yoshikawa T, Ohgushi H, Okumura M, Tarnai S, Dohi Y,
Moriyama T (1992) Biochemical and histological se-
quences of membranous ossification in ectopic site. Calcif
Tissue Int 50:184--188
3. Price PA, Parthemore JG, Detos LJ (1980) New bio-
chemical marker for bone metabolism. J Clin Invest 66:
878-883
4. Price PA, Lothringer JW, Baukol SA, Reddi AH (1981)
Developmental appearance of the vitamin K-dependent
protein of bone during decalcification: Analysis of miner-
alizing tissues in human. J BioI Chern 256:3781-3784
5. Ohgushi H, Dohi Y, Tarnai S, Tabata S (1993) Osteogenic
differentiation of marrow stromal stem cells in porous
hydroxyapatite ceramics. J Biomed Mat Res 27:1401-1407
6. Reddi AH, Sullivan NS (1980) Matrix-induced endochon-
dral bone differentiation: Influence of hypophysectomy,
growth hormone, and thyroid-stimulating hormone.Endo-
crinology 107:1291-1299
7. Dohi Y, Ohgushi H, Tabata S, Yoshikawa T, Dohi K,
Moriyama T (1992) Osteogenesis associated with bone
Gla protein gene expression in diffusion chambers by bone
marrow cells with demineralized bone matrix. J Bone
Min Res 7:1173-1180
8. Akahane M, Ohgushi H, Yoshikawa T, Sempuku T, Tarnai
S, Tabata S, Dohi Y (1999) Osteogenic phenotype expres-
sion of allogenic rat marrow cells in porous hydroxyap-
atite ceramics J Bone Min Res 14:561-568
9. Ohgushi H, Okumura M, Yoshikawa T, Tarnai S, Tabata S,
Dohi Y (1992) Regulation of bone development and
the relationship to bioactivity: Osteoblastic phenotype
expression of marrow stromal stem cells on the surface
of bioactive materials. In: Ducheyne P, Kokubo T, Van
Blitterswijk CA (eds) Bone-bonding biomaterials. Reed
Healthcare Communications Publishers, Leiderdorp, The
Netherlands, pp 47-56
10. Watson JD, Gilman M, Witkowski J, Zoller M (1992)
Recombinant DNA. In: Scientific American Books, W.H.
Freeman and Company, New York
11. Ishida H, Tarnai S, Yajima H, Inoue K, Ohgushi H,
Dohi Y (1996) Histologic and biochemical analysis of
osteogenic capacity of vascularized periosteum. Plastic
Reconst Surg 97:512-518
12. Ohgushi H, Goldberg VM, Caplan AI (1989) Heterotopic
osteogenesis in porous ceramics induced by marrow cells.
J Orthop Res 7:568-578
13. Okumura M, Ohgushi H, Tarnai S (1991) Bonding osteo-
genesis in coralline hydroxyapatite combined with bone
marrow cells. Biomaterials 12:411-416
14. Ohgushi H, Okumura M, Tarnai S, Shors EC (1990)
Marrow cell induced osteogenesis in porous hydroxyap-
atite and tricalcium phosphate: A comparative histomor-
phometric study of ectopic bone formation. J Biomed Mat
Res 24:1563-1570
15. Sempuku T, Ohgushi H, Okumura M, Tarnai S (1996)
Osteogenic potential of allogeneic rat marrow cells in
porous hydroxyapatite ceramics: A histological study.
J Orthop Res 14:907-913
16. Inoue K, Ohgushi H, Yoshikawa T, Sempuku T, Tarnai S,
Dohi Y (1997) The effect of aging on bone formation
in porous hydroxyapatite. Biochemical and histological
analysis. J Bone Min Res 12:989-994
17. Inoue K, Ohgushi H, Toshikawa T, Okumura M, Tarnai S,
Dohi Y (1992) Osteogenic activity of marrow/hydroxyap-
atite composite (Quantitative analysis of bone formation).
In: Yamamuro T, Kokubo T, Nakamura T (eds) Bio-
ceramics. Vol. 5. Kobunshi Kankokai, Kyoto, Japan, pp
125-130
18. Ohgushi H, Okumura M (1990) Osteogenic capacity of rat
and human marrow cells in porous ceramics. Experiments
in athymic (nude) mice. Acta Orthop Scand 61:431-
434
19. Yoshikawa T,OhgushiH, UemuraT,NakajimaH,Ichijima
K, Tarnai S, Tateisi T (1998) Human marrow cells-derived
cultured bone in porous ceramics. Biomed Mater Eng 8:
311-320
3.7 Blood Flow Assessment and Direct Observation
of Microcirculation
YUH INADA
The measurement of the regional blood flow in several
tissues such as bone, muscle, tendon, nerve, and skin is
quite important experimentally and clinically in order
to evaluate their viabilities in microsurgical free tissue
transfers. Out of several techniques, it has been gener-
ally accepted that the radioactive microsphere tech-
nique (RAM) has been a "gold standard" method for
the measurement of experimental tissue blood flow
since the report of Rudolph and Heymann [1]. One
of the first studies on blood flow using various sized
nonradioactive glass microspheres was performed by
Prinzmetal and his colleagues (1948) to observe arteri-
ovenous anastomoses in the rabbit visceral organs and
showed encouraging results. In this method, micros-
pheres were collected and counted microscopically.
Thereafter, other investigators have applied nonradio-
active microspheres to measure the cochlear blood
flow [2,3], adrenal gland blood flow [4], and myocardial
blood flow [5,6]. The injected glass microspheres were
counted in thick histological sections. The technique of
serial sectioning and counting micro spheres under a
microscope is much more time consuming than deter-
mining the number of spheres by measurement of their
radioactivity, so most investigators have used radioac-
tive micro spheres.
Radioactive Microsphere Technique
Pang and his colleagues [7] reviewed the theory and
methodology of RAM for the determination of cardiac
output and regional blood flow. According to their
report, there are several criteria established in earlier
studies [8-12] that govern the use of RAM. First,
microspheres are well mixed at the site of injection
(usually left intraventricular injection), rheologically
similar to red blood cells, and are distributed to organs
or tissues in direct proportion to the blood supply.
Second, the microspheres are completely trapped in the
capillary bed in the initial circulation. Third, the extent
of embolization of vascular beds by micro spheres
should not affect the systemic hemodynamics. In addi-
tion, it has been suggested that the reference blood
sample and the tissue or organ under consideration
should contain at least 400 micro spheres to reduce
random error [13].
Theoretical Consideration and
Laboratory Technique
Commercially available microspheres are polystyrene
beads of uniform size with radioactive isotopes sealed
inside. The beads are nonbiodegradable at body tem-
perature. Microspheres used by most researchers are
15 flm in diameter because the bead diameter is the
same as that of red blood cells. Therefore, these micros-
pheres are trapped in the capillary beds, where the
vessels are 4-8 flm in diameter. Beads (usually 2 x 106 to
4 X 106 in number) are injected into the left ventricle
where they are well mixed and expelled with the blood.
However, the diameter of an arteriovenous (AV) anas-
tomosis is larger than 15 flm, and some micro spheres
may escape through AV anastomoses to become
trapped in the capillary beds of the lungs (end organ).
Therefore, micro spheres that are 15 flm in diameter are
used for the measurement of capillary blood flow. For
the measurement of total blood flow, larger micros-
pheres must be used (e.g., 50 flm diameter) because they
will be trapped in the capillaries and the AV anasto-
moses. The AV shunt flow is the difference between total
and capillary blood flows. Microspheres with different
gamma-emitting isotopes can be measured simultane-
ously by a multiple-channel counter. This allows the
measurement of blood flow to the target organ over a
period of time by performing multiple injections of
beads with different isotopes. The detailed mathematics
required to derive the formulas for calculation of
cardiac output and regional-tissue or organ blood flow
has been published and previously will not be intro-
duced here [7,12,14,15].
Pang and his colleagues have performed several
studies [16-20] of reconstructive surgery using RAM,
and stated that an ideal technique for the determination
of blood flow in laboratory animals should have the fol-
lowing characteristics: (1) it should measure separately
75
76 C. Experimental Microsurgery
Microsphere (diameter:15/lm)
l-
Microspheres escape through AVA
(Arterio-venous anastomosis)
Fig. 1. Illustration of microsphere technique. Radioactive
micro spheres (diameter lSI-1m) are injected and mixed in the
left ventricle, and are distributed and trapped in the capillar-
ies (diameter 4-8/lm) of the organ
or simultaneously the quantitative capillary blood flow
to the skin, muscle, and bone; (2) it should provide con-
secutive and highly reproducible determinations of cap-
illary blood flow; (3) it should be inexpensive and easy
to perform; and, (4) it should be noninvasive.
Of several techniques, it has been generally accepted
that RAM is the best method for the measurement of
experimental-tissue blood flow. The disadvantages of
this technique are that it requires special equipment, it
requires disposal of animals after the measurement,
presents a radiation risk, and is expensive.
Nonradioactive Colored-Microsphere
Technique
To avoid the disadvantages of RAM, the nonradioactive
colored-microsphere technique (NRACM) provides an
effective alternative method. This method has already
been evaluated in a comparative experiment on the
measurement of myocardial blood flow, and a good cor-
relation with the results of RAM was demonstrated [6].
Since then, interest has focused on NRACM as a new
method of blood flow measurement. We reported the
laboratory techniques and theoretical explanation for
the measurement of regional blood flow of axial pattern
flaps in rabbit using NRACM [21]. Tsuchida et al. [22]
also reported changes in hemodynamics in rabbit
jejunal flaps due to ischemia, venous congestion, and
reperfusion using this method.
Laboratory Techniques
Nonradioactive colored microspheres, 15 11m in diame-
ter (E-Z Trac, Los Angeles, CA, USA), have five colors
(red, green, orange, black, and blue) instead of contain-
ing different radioactive isotopes.
The rabbit is anesthetized with an intramuscular
injection of ketamine (40mg/kg), acepromazine (0.5
mg/kg) and atropine (0.01 mg/kg). General anesthesia is
maintained by inhalation of oxygen, nitrous oxide, and
halothane (2 %). After performing tracheotomies, a tra-
cheal tube is inserted and the rabbit is mechanically
ventilated with room air. When stabilization of the
general condition is achieved with controlled ventila-
tion, the measurement is started. A polyethylene
catheter (internal diameter O.2mm, external diameter
0.5 mm, Natume, Tokyo, Japan) is filled with heparinized
saline (15 IU/m1) and is inserted into the left ventricle
from the left common carotid artery. Entry of the
catheter into the left ventricle is confirmed by the
change in arterial pressure gradients. Another catheter
is inserted into the right femoral artery to take a refer-
ence blood sample. Then a target tissue (e.g., skin flap,
osseous flap, composite tissue, etc.) is elevated and
sutured back into the same position. Rectal temperature
is controlled at 37C using a thermosensor (Sibaura
Electro, Tokyo, Japan).
A one-shot injection of nonradioactive colored
microspheres (2 x 106 to 4 x 106 in number) into the left
ventricle is possible in each animal. A reference blood
sample is drawn from the right femoral artery at a rate
of 2.5 mllmin for 2 min. Thirty seconds after beginning
blood sampling, a one-shot injection of microspheres is
performed and followed immediately by a one-shot
injection of 2 ml of saline solution into the left ventricle.
During injections, the blood pressure of the left ven-
tricle is monitored. After confirming the stability of
blood pressure in the left ventricle, the other different
coloured microspheres are injected. Following the injec-
tion of microspheres, each rabbit is killed with an intra-
venous overdose injection of pentobarbital sodium and
potassium chloride.
Counting Techniques
After the animal is killed, blood and tissue samples are
collected and weighed immediately. A reference blood
sample and nonradioactive colored microspheres are
extracted from the tissues in accordance with the E-Z
Trac protocol. The tissue sample (1-2 g) is placed in a
50-ml polypropylene centrifuge tube, to which 45 ml
of tissue/blood digest reagent 1 is added. The tube is
placed in a heated water bath (80-90C) for alkaline
 3.7. Blood Flow Assessment and Direct Observation of Microcirculation
hydrolysis. Tissue/blood digest reagent 2 is added to the
sample to bring the total liquid volume to 15 ml and the
tube is centrifuged for 30min. The supernatant is dis-
carded and each sediment is resuspended in lOml of
microsphere-counting reagent and centrifuged for a
further 15 min. After removal of the supernatant,
microsphere counting reagent is added to each sedi-
ment to bring the total solution volume to OAOml.After
vortex mixing, the sample is ready for microsphere
counting.
Immediately after collection of reference blood,
about 5 ml of the blood is mixed with ethylenediamine
tetraacetic acid dis odium salt in a 50-ml centifuge tube.
Blood hemolysis agent is added to each blood sample
to bring the total volume to 50 ml. Microspheres are
then extracted by centrifugation and numbers are deter-
mined by using a hemo-cytometer and microscope.
Blood flow values are calculated from the equation: Qm
= (Cmx Qr)/C where Qm is the regional blood flow per
gram (mllmin/g), Cm is the microsphere count per gram
of tissue, Qr is the withdrawal rate of the reference
blood sample (mllmin), and Cr is the microsphere count
in the reference blood sample.
The main advantages of NRACM are that there is
no need for special equipment or complicated
manipulation of animals and it is a nonradioactive, and
therefore, safe, system. Furthermore, it is less expensive
than RAM (about 20% of the cost of 5lCr RAM), mul-
tiple injections can be carried out in the same animal,
and, unlike the radioactive method, is stable over
extended periods, which enables measurement of flow
values from previously frozen tissues. In addition, the
distribution or pattern of blood flow can be seen by
direct histological observation and can be correlated
with blood flow. The disadvantages of NRACM are that
considerable time is required for the recovery of micros-
pheres and data showed slightly more scatter than
RAM.
Fluorometric Assessment
Sodium fluorescein was used clinically for assessment of
skin blood flow and prediction of skin viability in flap
surgery in 1949 [23]. Thereafter, several clinical reports
were published recommending the use of this dye for
prediction of skin-flap viability using visual assessment
[24-27]. This technique is simple and inexpensive.
Sodium fluorescein (15 mg/kg) is injected intravenously
over about 1 min. The injected dye diffuses across the
capillary wall into extracellular fluid within 10-15min,
but it does not penetrate cells. The skin tissue with good
blood supply is stained by this dye when exposed to
an ultraviolet light source with a wave-length of 360-
77
400 nm. Areas of skin with poor blood supply appear
dark blue under ultraviolet light. Because fluorescein
diffuses into the extracellular fluid, fluorometry detects
the extracellular-fluid concentration of fluorescein.
There are limitations to the visual fluorescein test for
prediction of skin viability in flap surgery. It is prone
to SUbjective error in the interpretation of marginal
fluorescence and it allows only one assessment per day
because the large dose of sodium fluorescein required
for visual assessment stains the skin for 12-18 h. In addi-
tion, observations from animal studies demonstrated
that the visual fluorescein test underestimated skin-flap
viability when the test was performed within 5 h of flap
elevation [28-30]. This was most likely the result of
changes in skin perfusion over time and significant areas
of marginal fluorescence. Silverman and his colleagues
[31] reported that the use of a fiberoptic dermofluo-
rometer for the assessment of skin fluorescence may
improve the accuracy of predictions of skin viability in
rat random-pattern skin flaps. Surface-skin fluorometry
has been compared to laser Doppler velocimetry in the
prediction of skin viability in human myocutaneous
flaps. Kreidstein et al. [32] reported that skin-surface
fluorometry is a noninvasive, inexpensive, and techni-
cally simple method for monitoring skin-flap perfusion.
Furthermore, the surface dye fluorescence index (DFI)
and microsphere radioactivity index (MRI) were highly
correlated, indicating that DFI provided a valid assess-
ment of capillary blood flow in human skin flaps. They
recommended the use of DFI for prediction of skin
viability in skin-flap surgery.
It is important that a low dose of fluorescein be used
so that the background fluorescein concentration in the
extracellular fluid is low after a subsequent washout
period before the next assessment in case of repeated
measurements.
Gas Clearance
Radioactive microspheres provide the most reliable and
quantitative method of blood flow assessment, and
despite the expense, they are frequently used in the
laboratory setting. However, since the micro spheres
embolize in all body tissues and contain radioactive
materials, they cannot be used in humans. The meas-
urement of regional blood flow with an inert gas was
first described by Kety and Schmidt in 1945 [33]. In
1964,Aukland et al. [34] provided the technology for the
continuous measurement of tissue concentrations of
inert gas. Since that time, this method has become
widely accepted for measurement of brain and spinal
cord blood flow based on studies comparing hydrogen
gas (H 2) clearance with the 14C-antipyrine autoradi-
78 C. Experimental Microsurgery
Injection of
microspheres
Blood pressure /
arterial gas analysis
monitoring
- - Hemothermic
blanket control
Fig. 2. Illustration of published reference blood sampling
technique in rabbit for circulation of cardiac output and
regional blood flow. The withdrawal pump is used as a "sur-
rogate" organ
ographic technique [35], and radioactive assessments in
the kidney and myocardium of dogs. Other studies have
demonstrated good correlation between H2 clearance
and direct measurement of blood flow in the kidney and
myocardium of dogs [36].
Hydrogen-clearance methods [37] involves inhalation
of H2 by the animal until the tissue is saturated, and then
H2 is removed from the inspired gases. The theoretical
basis of H2 clearance has been well described elsewhere
[33,34,36,38]. The tissue concentration of the gas over
time is given by the equation
C =Coe- Ft
where C is tissue concentration, Co is tissue con-
centration at time 0, F is blood flow/volume, and t
is time. Recently, the usefulness of the H2 clearance
technique was demonstrated in prediction of viability
of human digital replantation. However, one disad-
vantage of this method is that movement of the sub-
ject disrupts the monitoring electrodes. This means
measurement in conscious animals is impossible. A
second disadvantage is the length of time required for
measurement.
The advantage primary is that blood flow can be
detected in any tissue where a platinum electrode can
be inserted. In addition, multiple flow assessments
can be made over long periods of time, and it is inex-
pensive and noninvasive in comparison to the other
methods [37].
Laser Doppler Flowmetry
Clinically, laser Doppler flowmetry (LDF) is a non-
invasive, repeatable, easy technique that provides
a quantitative measurement of skin blood flow. It
compares favorably with other monitors such as tran-
scutaneous oxygen tension, skin pH, skin tempera-
ture, photoplethysmography, and surface ultrasound
Doppler.
Despite these advantages, however, several re-
searchers have pointed out that the quantitative
determination of skin blood flow by LDF is still sub-
ject to uncertainty. From their experimental comparison
of LDF and RAM for the measurement of blood
flow in pig skin flaps, Rival et al. [39] reported three
important observations as follows: (1) there was a high
correlation in skin blood flow rates measured by RAM
and LDF; (2) skin blood flow rates measured by LDF
were consistently higher than the corresponding rates
measured by RAM; (3) the discrepancies between the
measurement of skin blood flow by LDF and RAM
were quite consistent in normal skin samples (16%) and
skin flaps (22 %) at flow rates higher than 2 ml/min per
100 g, but the discrepancy was considerably higher
(>160%) when the flow rate was below 2mllmin per
100 g as measured by RAM. They speculated that
discrepancy was most likely caused the partial meas-
urement of both nutrient and arteriovenous shunt flows
by LDF because RAM is known to measure only nutri-
ent blood flow. Recently, a laser Doppler perfusion
imager (Lisca, Linkoping, Sweden), which uses LDF
technology to scan 1- to 2-mm2 adjacent areas over an
area of 12 x 12 cm, was developed and provides a repro-
ducible, quantitative comparison of regional distribu-
tion. It records gray-scale or color-coded images of the
microvascular perfusion of the evaluated extremity
before and after reconstructive surgery. Some authors
demonstrated this utility in the follow-up and planning
of plastic and reconstructive surgery or hand surgery
[40-43].
Direct Observation of Microcirculation
Several established models allow clear observation of
the microvasculatures of normal tissue. These include
the hamster cheek pouch [44], the rabbit ear chamber
[45], the cat tenuissimus muscle [46], and the mesentery
[47]. The rat cremaster model [48-50] has also been
widely used in microcirculatory research because of its
transparency and convenience.
Acland et al. [51] reported the first observation of
embolic events in the microcirculation distal to the
site of small blood vessel surgery using a rat cremaster
 3.7. Blood Flow Assessment and Direct Observation of Microcirculation
model. Barker et al. [52] also observed and quantified
changes in capillary perfusion using a rat cremaster
model. Direct in vivo observation of microcirculation
must be included as a valuable method for studies of
micro emboli or angiogenesis.
Summary
The measurement of the regional blood flow in several
tissues is important experimentally and clinically in
order to evaluate tissue viabily in microsurgical free
tissue transfers. Of several techniques, it has been
generally accepted that RAM is a "gold standard"
method for the measurement of experimental-tissue
blood flow. All other methods have been evaluated by
comparison to with RAM. Therefore, we should rightly
understand the theoretical considerations and labora-
tory technique of RAM. In addition, direct in vivo
observation of microcirculation must be included as
a valuable method for studies of micro emboli or
angiogenesis.
References
1. Rudolph AM, Heymann MA (1967) The circulation of the
fetus in utero. Circ Res 21:163-184
2. Axelsson A, Angelborg C, Larsen HC (1983) The micros-
phere surface technique for evaluation of cochlear vessels
and circulation. A preliminary report. Acta Otolaryn-
golica 95:297-305
3. Angelborg C, Slepecky N, Larsen HC, Soderberg L (1987)
Colored micro spheres for blood flow determinations
twice in the same animal. Hear Res 27:265-269
4. Hamaji M, Miyata M, Kawashima Y (1985) A study of
the vascular arrangement in the rat adrenal gland using
nonradioactive micro spheres. Cell Tissue Res 240:277-
280
5. Shell W, Kligerman M, Chang A-L, See H, Meerbaum S,
Corday E (1985) Measurement of myocardial blood flow
with nonradioactive microspheres (abstract). Circulation
72 (Suppl 11, IIIJ):III-191
6. Hale SL, Alker KJ, Kloner AA (1988) Evaluation of
nonradioactive colored microspheres for measurement
of regional myocardial blood flow in dogs. Circulation
78:428-434
7. Pang CY, Neligan P, Nakatsuka T (1984) Assessment of
microsphere technique for measurement of capillary blood
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8. Neutze JM, Wyler F, Rudolph AM (1968) Use of radioac-
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9. Batrum RJ, Berkowitz DM, Hollenberg NK (1974) A
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10. Heyman MA, Payne BD, Hoffman HE, Rudolph AM
(1977) Blood flow measurements with radionuclide-
labeled particles. Prog Caridiovasc Dis 20:55-79
11. Daniel RK, Williams HB (1973) The free transfer of skin
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12. Wagner HN, Rhodes BA, Sasaki Y, Ryan JP (1969) Studies
of the circulation with radioactive micro spheres. Inves
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13. Buckberg GD, Luck JC, Payne DB, Hoffman HE, Archie
Jp, Fixler DE (1971) Some sources of error in measuring
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14. Sasaki Y, Wargner HN (1971) Measurement of the dis-
tribution of cardiac output in unanesthetized rats. J Appl
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15. Archie JP, Fixler DE, Ullyot DJ, Hoffman HE, Utlev JR,
Carlson EL (1973) Measurement of cardiac output with
end organ trapping of radioactive microspheres. J Appl
PhysioI35:148-154
16. Pang CY, Forrest CR, Neligan PC, Lindsay WK (1986)
Augmentation of blood flow in delayed random skin flaps
in the pig: effect of length of delay period and angiogen-
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17. Pang CY, Neligan PC, Forrest CR, Nakatsuka T, Sasaki
GH (1986) Hemodynamics and vascular sensitivity to
circulating norepinephrine in normal skin and delayed
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78:75-84
18. Kreidstein ML, Levine RH, Knowlton RJ, Pang CY (1995)
Serial fluorometric assessments of skin perfusion in
isolated perfused human skin flaps. Br J Plast Surg
48:288-293
19. Rival R, Bance M, Antonyshyn 0, Phillips J, Pang CY
(1995) Comparison of laser flowmeter and radioactive
microspheres in measuring blood flow in pig skin flaps.
Laryngoscope 105:383-386
20. Chiodo AA, Gur E, Pang CY, Neigan PC, Boyd B,
Binhammer PM, Forrest CF (2000) The vascularized pig
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1004-1012
21. Inada Y, Tarnai S, Mizumoto S, Ono H, Kawanishi K, Fukui
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22. Tsuchida Y, Aoki N, Fukuda 0, Nakano M, Igarashi H
(1998) Changes in hemodynamics in jejunal flaps of
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23. Hynes W, McGregor AG (1949) The use of fluorescein in
estimating the blood flow in pedicled skin flaps and tubes.
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80 C. Experimental Microsurgery
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158-162
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26. McCraw JB, Myers B, Shanklin KD (1977) The value of
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27. Slinger R, Lewis CM, Franklin JD, Lynch JB (1978) Fluo-
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Assessment of the fluorescein dye test for prediction of
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Serial fluorometric assessment of skin perfusion in
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3.8 Technique for Measuring Choline
Acetyltransferase Activity of the Peripheral Nerve
MAN ABU AKAHANE and HIROSHI Y AJIMA
Fascicular or funicular nerve repair has been commonly
performed in the field of orthopedic and plastic surgery
in accordance with the recent advances in microsurgical
techniques and instrumentation [1). However, it is diffi-
cult to identify the sensory and motor fascicles or funi-
culi in a mixed nerve. For this reason, it is difficult to
match the proximal and distal ends of the sensory and
motor fascicles or funiculi accurately. The main causes
of failure of reinnervation after nerve suture or nerve
grafting is inappropriate matching of motor and sensory
fascicles. Therefore, in cases of peripheral nerve repair,
precise identification of motor and sensory nerve fasci-
cles is critical to obtain a successful outcome [2].
To identify a motor and a sensory fascicle of a mixed
peripheral nerve, various methods have been applied:
intraneural topography [3,4], intraoperative nerve
stimulation [5], histochemical methods such as carbonic
anhydrase activity and cholinesterase activity [6,7],
and biochemical methods such as the measurement of
choline acetyltransferase (ChAT) activity of motor fas-
cicles [8,9]. The methods used for this purpose were
either inaccurate and time-consuming or unpleasant to
the patients. Recently, however, all the above methods
have been improved and modified by many authors
[10-16].
The enzymatic activity of ChAT has been previously
found to differ between motor and sensory nerve fasci-
cles [10]. In peripheral nerve tissue, ChAT, an enzyme
catalyzing the formation of acetylcholine, is synthesized
in the cell body (Fig. 1) and transported by axoplasmic
flow to the nerve terminals [17,18]. Previous study
reported that ChAT activity in the ventral spinal roots
was higher than that in the dorsal spinal roots in the
peripheral nervous system, and that there was a differ-
ence in ChAT activity between the motor and sensory
fascicles of the human sciatic nerve [19].
The radiochemical method for the determination of
ChAT was first developed by Fonnum [9,20] and modi-
fied by many authors, including Engel [10,11] and
Ohgushi [21]. Engel reported a rapid identification
method for nerve fascicles based on the enzymatic activ-
ity of ChAT. The ChAT activity of motor nerve fascicles
was significantly higher than that of sensory nerve fas-
cicles. Therefore, Engel concluded that it was possible
to match the motor and sensory nerve cut ends accu-
rately based on the difference in ChAT activity.
Our first report on the measurement of ChAT activ-
ity was published in 1983 [21). The conclusion of the
paper was similar to that of previously published reports
by other authors [10,11). However, in our subsequent
work using the rat [22], we indicated that the ChAT
activity level of regenerated nerve was comparable to
that of intact motor nerve and was also significantly
higher than that in the damaged nerve. Therefore, we
concluded that the viability of motor nerve could be
evaluated by measuring ChAT activity. We have applied
ChAT activity measurement for the evaluation of motor
nerve viability in patients with brachial plexus palsy
and also for identification of motor and sensory fasci-
cles of the intercostal nerve, as the donor motor nerve
for transfer to the paralyzed upper extremity. In this
chapter, we focus on the technique of ChAT activity
measurement.
Buffer Preparation
The following buffers were used in ChAT activity
measurement:
Buffer A: 50mM sodium phosphate buffer, pH 7.4;
300mM NaCl; 0.5% Triton X-100; 20mM ethylenedi-
aminetetnaacetic acid (EDTA)
Buffer B: 940 ~l of buffer A, 50 ~l of 5 mM eserine,
1O~1 of l.OM choline chloride, pH 7.4
1- 14 C-Iabeled acetyl-coenzyme A (60mCi/mmol),
sodium tetraphenylboron solution (15 mg/ml in
diisobutyl ketone), and toluene scintillation mixture
(500ml toluene solution with 2g of Omniflour) were
also prepared.
Harvesting of Nerve Segment
Nerve stumps were exposed under an operating micro-
scope, and the nerve segments were harvested from
the proximal nerve stump. In clinical cases, a 1-mm
81

82 C. Experimental Microsurgery
HOCH2CH 2 N+ (CH 3h
CHOLINE
o buffer A
II
CH3C-SCoA
Acetyl-CoA
CoASH
o
II
CH 3C-OCH 2CH 2 N+ (CH 3)3
ACETYLCHOLINE
Fig. 1. Enzymatic activity of choline acetyltransferase
(ChAT). (From [22], with permission)
nerve segment was harvested, and the ChAT activity
was measured according to the following method.
Measurement of ChAT Activity
The harvested nerve slice was placed in a micro tube
containing 400 ~l of buffer A and then homogenized.
After centrifugation (12,000g) for 10min at 4C, the
supernatant was transferred to another microtube and
used as an enzyme solution for the following procedure.
Fifty microliters of 1- 14 C-Iabeled acetyl-coenzyme A
was added to 170 ~l of buffer B for substrate solution.
Ten microliters of this substrate solution was added to
microtubes containing 10 ~l of the enzyme solution. The
enzyme and substrate solutions were mixed in a vortex
mixer and incubated at 37C for 30 min. After the incu-
bation, 50 ~l of sodium tetraphenylboron solution was
added, and the microtubes were centrifuged at 3000 rpm
(2000g) for 3min at 4C. Twenty microliters of super-
natant was transferred to a vial containing 4ml of
toluene scintillation mixture. Finally, the radioactivity
was measured in a liquid scintillation counter (Packard,
Medriden, Connecticut USA), and the result was
expressed as counts per minute (cpm). The radioactiv-
ity reading without the enzyme solution was used as
a background control, which was subtracted from the
radioactivity of each sample (Fig. 2).
The measurement of radioactivity took 1 h to
complete. For clinical application, this technique does
not affect the operation time, because the distal nerve
stumps have to be exposed and prepared for nerve
suture while ChAT activity measurement is performed
on the proximal nerve segment.
iJ
Centrifuge microtube 10.ul of incubation
+ mixture (radiolabelled
10.ul of phosphate
1
Acetyl-CoA in buffer)
..
nerve slice
Incubation for 30
minutes at 37C
fl. _+50 .u of tetraphenylboron
1
~ in diisobutyl ketone
c.P Centrifugation
I
~ (2000 x g, 2 minutes)
~ 20 0' '"pematao'
Counting vial --w- 10 ml of
scintillation cocktail
Fig. 2. Schematic diagram of choline acetyltransferase
(ChAT) activity measurement. (From [22], with permission)
Experimental Data and Discussion
We previously reported two experimental results using
F344 rats [22]. The first set of data showed the differ-
ence in activity between the ventral and posterior roots.
The mean ChAT activities of the ventral roots (motor
nerves) and posterior roots (sensory nerves) were 5461
3176cpm and 132 56cpm, respectively. These data
showed that the activity of motor nerves was signifi-
cantly higher than that of sensory nerves. The second set
of data showed the time course of ChAT activity level
after injury of the motor nerves. As time passed, the
activity in the distal segment of the injured nerve
decreased rapidly within 1 week after the injury. In con-
trast, the activity of the proximal segment was main-
tained for a long time (90 days in the experimental rats)
(Fig. 3).
These results indicate that the motor and sensory fas-
cicles of the peripheral nerves can be identified by the
ChAT technique within 1 week after injury. However,
more than 1 week after injury, it is difficult to identify
the motor and sensory fascicles in the distal segment of
the injured nerves. In contrast, in the presence of high
activity in the proximal segment for a long time after
injury, it is useful to isolate the motor fascicles from the
injured nerve and to evaluate the motor nerve viability
in the proximal segment of the nerves. These results led
us to think that it is possible to repair the nerve injury
 3.8. Measurement of Choline Acetyltransferase Activity
(cpm)
14000
-
12000
.... ~--\
10000
8000 ~ \
6000 \ \..
4000 \ 4:376-380
2000 \ Melamed R, Rimon S (1982) Intraoperative nerve fasci-
L cle identification using choline acetyltransferase. A pre-
o liminary report. Clin Orthop 165:228-232
o 3 5 7 30 90
(day)
Fig. 3. Time course of ChAT activity after nerve injury. The
activity in the distal segment (open circles) of the injured
nerve decreased rapidly after the injury. However, it remained
for a long time in the proximal segment (solid circles)
accurately using our method within 1 week after the
injury. However, after more than 1 week, it is difficult to
repair it accurately, because the activity level of the
distal segment becomes low.
In clinical cases, such as muscle transplantation for
elbow fiexoplasty in brachial plexus palsy, one can iden-
tify the motor branches of the donor nerves, in addition
to evaluating the viability of the motor fascicle. There-
fore, one can transfer donor motor nerves to the recip-
ient motor nerves with minimal loss of motor activity,
resulting in successful recovery of the transplanted
muscle.
References
1. Millesi H, Meissl G, Berger A (1972) The interfascicular
nerve grafting of the median and ulnar nerves. J Bone
Joint Surg (Am) 54:727-750
2. Millesi H (1979) Microsurgery of peripheral nerves. World
J Surg 3:67-79
3. Sunderland S (1945) The intraneural topography of the
radial, median and ulnar nerves. Brain 68:243-299
4. Sunderland S (1953) Funicular suture and funicular exclu-
sion in the repair of severed nerves. B J Surg 40:580-587
5. Hakstian RW (1968) Funicular orientation by direct stim-
ulation. J Bone Joint Surg (Am) 50:1178-1186
6. Karnovsky MJ, Roots L (1964) A "direct-coloring"
thiocholine method for cholinesterases. J Histochem
Cytochem 12:219-221
7. Riley DA, Lang DH (1984) Carbonic anhydrase activity
of human peripheral nerves: possible histochemical aid to
nerve repair. J Hand Surg 9A:112-120
83
8. Gruber H, Freilinger G, Holle J, Mandl H (1976) Identifi-
cation of motor and sensory funiculi in cat nerves and
their selective reunion. Br J Plast Surg 29:70-73
9. Fonnum F (1966) A radiochemical method for the
estimation of choline acetyltransferase. Biochem J 100:
479-484
10. Engel J, Gane! A, Melamed S, Rimon, Farine I (1980)
Choline acetyl transferase for differentiation between
human motor and sensory nerve fibers. Ann Plast Surg
11. Ganel A, Farine I, Aharonson Z, Horoszowski H,
12. Yunshao H, Shizhen Z (1988) Acetylcholinesterase: a his-
tochemical identification of motor and sensory fascicles
in human peripheral nerve and its use during operation.
Plast Reconstr Surg 82:125-130
13. Szabolcs MJ, Gruber H, Schaden GE, Freilinger G,
Deutinger M, Girsch W, Happak W (1991) Selective
fascicular nerve repair: a rapid method for intraoperative
motorsensory differentiation by acetylcholinesterase
histochemistry. Eur J Plast Surg 14:21-25
14. Landi A, Copeland SA, Wynn PCB, Jones SJ (1980) The
role of somatosensory evoked potentials and nerve con-
duction studies in the surgical management of brachial
plexus injuries. J Bone Joint Surg (Br) 62:492-496
15. Van Beek A, Hubble B, Kinkead L, Torro S, Suchy H
(1983) Clinical use of nerve stimulation and recording
techniques. Plast Reconstr Surg 71:225-240
16. Sugioka H, Tsuyama N, Hara T, Nagano A, Tachibana S,
Ochiai N (1982) Investigation of brachial plexus injuries
by intraoperative cortical somatosensory evoked poten-
tials. Arch Orthop Traumat Surg 99:143-151
17. Hebb CO, Waites GMH (1956) Choline acetylase in
antero- and retro-grade degeneration of a cholinergic
nerve. J Physiol 132:667-671
18. Jablecki C, Brimijoin S (1975) Axoplasmic transport of
choline-acetyltransferase activity in mice: effect of age
and neurotomy. J Neurochem 25:583-593
19. White HL, Wu JC (1973) Kinetics of choline acetyltrans-
ferases (EC2.3.1.6) from human and other mammalian
central and peripheral nervous tissues. J Neurochem 20:
297-307
20. Fonnum F (1975) A rapid radiochemical method for the
determination of choline acetyltransferase. J Neurochem
24:407-409
21. Ohgushi H, Tarnai S, Masuda S, Masuhara K (1983)
Choline acetyltransferase activity in the differentiation
between motor and sensory funiculi in peripheral nerve
(in Japanese). Seikeigeka 34:2034-2039
22. Yajima H, Kawanishi K, Ohgushi H, Tarnai S (1995)
Experimental study on choline acetyltransferase activity
measurement for brachial plexus injury. Microsurgery 16:
679-683
3.9 Technique of Cholinesterase Staining of the
Peripheral Nerve
FUMINORI KANAYA
Intraoperative identification of motor and sensory fas-
cicles will help to align motor to motor fascicles and
sensory to sensory fascicles in the repair of peripheral
nerve injuries. Correct alignment of motor and sensory
fascicles will improve functional recovery after periph-
eral nerve repair. There are four different methods
to identify motor and sensory fascicles: anatomical,
electrophysiological, histochemical, and radioisotopic.
Anatomical knowledge is essential to guide the sur-
geon, and nerve topography is fairly constant in distal
median and ulnar nerves [1,2]. However, knowledge of
anatomy and topography is not sufficient to ensure
avoiding fascicular misalignment in a long nerve defect
or in a proximal nerve lesion [3].
Intraoperative nerve stimulation to identify motor
and sensory fascicles has been reported in fresh cases
[4,5]. However, this method is technically demanding,
and mixed fascicles and sensory fascicles cannot be dif-
ferentiated in the proximal stump because both respond
to stimulation.
Identification by measurement of choline acetyl-
transferase activity using radioisotopes may have higher
sensitivity; however, it is more expensive and requires a
scintillation counter (see the chapter by M. Akahane,
this volume). I will present histochemical identification
of motor and sensory fascicles by the acetylthiocholine
method.
Karnovsky and Roots reported a histochemical
method to reveal the localization of cholinesterase
using acetylthiocholine as a substrate [6]. Since motor
fibers show higher cholinesterase activity, Gruber [7]
used this method to differentiate motor and sensory fas-
cicles; however, it required 20 to 24 h to obtain results.
He harvested nerve specimens in the first surgery, and
definitive nerve repair was performed in 2 to 3 days.
Sumita [8] and He [9] modified this method by chang-
ing both the pH and the temperature of Karnovsky's
incubation media to shorten the incubation time to less
than 1 h. Their incubation media were essentially the
same as Karnovsky's. However, Sumita [8] added a
nonspecific cholinesterase inhibitor and He [9] did not.
Sumita's staining is specific, but faint, in motor axons,
and He's staining is darker in sympathetic fibers than in
84
motor axons. We modified Karnovsky's stammg to
obtain specific motor axon staining within 1 h [10] (Figs.
1 and 2). We changed both the pH and the temperature
of the incubation medium and added iso-OMPA (non-
specific cholinesterase inhibitor) (Table 1).
Preparation of the Solution
The advantages of this histochemical staining are that it
is rapid, inexpensive, and easy to use in any hospital
where frozen histologic sectioning is available. The
staining solution should be prepared freshly on every
occasion. All components of the solution, except
acetylthiocholine iodide and tetraisopropyl pyrophos-
phoramide, are stable for at least 3 months before
mixing if they are kept refrigerated.
We made a kit to make preparation of the solution
easy even for those unfamiliar with such procedures [11]
(Table 2). All the chemicals can be purchased from
Sigma (St. Louis, MO, USA). Bottle A and tubes 1, 2,
and 3 can be stored at 4C until needed. Bottle B
(acetylthiocholine iodide) and bottle C (tetraisopropyl
pyrophosphoramide) can be stocked as powders at
-20C for more than 1 year.
Procedure of Staining
1. Orientation of Nerve Stumps
Both the proximal and the distal stumps were exposed
and sectioned back to obtain good fascicular structures.
To maintain the orientation of the specimens, the fol-
lowing procedure was used. Two 9-0 sutures were placed
at the volar aspect and four at the radial aspect. Then
the nerve was cut at the middle between the sutures so
that one volar suture and two radial sutures were left
on the nerve specimen (Fig. 3a). Placing these marking
sutures was essential to prevent loss of the nerve's
orientation, since the nerve stump will rotate easily and
the water-soluble ink used to mark the nerve will spread
easily.
 3.9. Technique of Cholinesterase Staining of the Peripheral Nerve 85

a a

b b

Fig.l. Serial sections of motor fascicles of rabbit sciatic nerve
(a,b x 40). a Stained with our modification, which required
45 min of incubation. b Stained with Gri.iber's modification,
which required 24 h of incubation. (from [10], with permission)
Fig.2. Specimens of human radial nerve stained with our mod-
ification (a,b x 250). a Motor fascicle shows specific motor axon
staining. Myelinated axons not showing specific staining are
sensory axons from the muscle spindles and Golgi apparatus.
(See Color Plates) b Sensory fascicle shows no specific staining

Table 2. Materials and preparation of solution

Table 1. Incubation medium Ingredient Amount
Ingredient Amount (mM)
Bottle A : 0.1 M Sodium phosphate buffer (pH 7.5) 75.0ml
Acetylthiocholine iodide 3.0 Bottle B: Acetylthiocholine iodide 60mg
Sodium phosphate buffer (pH 6.5) 65.0 Bottie C: Tetraisopropyl pyrophosphoramide 20mg
Sodium citrate 5.0 Tube 1: 0.1 M Sodium citrate 5ml
euso. 3.0 Tube 2: 30mM euso. lOml
Potassium ferricyanide 0.5 Tube 3: 5 mM potassium ferricyanide 10ml
Tetraisopropyl pyrophosphoramide 0.6
(iso-OMPA, nonspecific cholinesterase inhibitor) Add bottle A to bottle B, shake well for 1 to 2min.
Add tube 1 to bottie B, mix by inversion for 5 to lOs.
Add tube 2 to bottle B, mix by inversion for 5 to lOs.
Add bottle B to bottle e , shake well for 5 min or until dissolved.
Add tube 3 to bottle e, mix by inversion for lOs.
2. Preparation of Specimens
After the orientation mentioned above, the speci-
Nerve specimens were sent to the pathology depart- mens were embedded in optimal cutting temperature
ment, where the volar suture was replaced with red (OCT) compound without fixation and immediately
paint, and the radial sutures were replaced with green frozen by isopentane cooled by liquid nitrogen. From
paint, because suture materials in a frozen section each specimen, five frozen sections, 20!lm thick, were
deform and crush the specimen during cutting (Fig. 3b). cut with a cryostat.
86 C. Experimental Microsurgery
Distal stump Proximal stump
// ""\
"'" f >r: 1-\ 1-o
i
~ \~ :'
)c
", ;;l
a
b
x:
c but distal stumps cannot be stained after 5 days (Fig. 4).
Fig. 3. Orientation of nerve specimens and repair. a Both the
proximal and the distal stumps are exposed and sectioned
back to obtain good fascicular structure. Two 9-0 sutures are
placed at the volar aspect and four at the radial aspect. Then
the nerve is cut at the middle between the sutures so that one
volar suture and two radial sutures were left on the nerve
specimen. b The volar suture is replaced with red paint and
the radial sutures are replaced with green paint. Then frozen
sections are made from the specimen and stained. A dark-
staining fascicle indicates the motor fascicle. c Correct align-
ment of motor and sensory fascicles is obtained by rotating
distal nerve stump to 90 counterclockwise. Proximal and
distal nerve stumps are connected with a sural nerve graft
3. Staining
One section was stained with hematoxylin-eosin to eval-
uate degeneration of myelin and intraneural fibrosis.
The other four specimens were stained by our solution
preheated to 45C and incubated. The specimens were
rapidly dehydrated and mounted at 45,60, and 90min.
One section was preserved in case a specimen needed
to be replaced. The red and green paints, which indicate
the volar and radial aspect of the nerve stump, were
clearly visible in the specimen. The result was reported
when the differentiation of motor and sensory fascicles
was confirmed. In the fresh case, the entire procedure
Fig. 4. Distal specimen stained 5 days after injury. (x40) This
specimen required 90 min of incubation to differentiate motor
and sensory fascicles. Five small motor fascicles are located at
the top (arrow) and two larger sensory fascicles at the bottom
(arrowheads). Strong nonspecific staining of interfascicular
perineurium was seen because of over incubation. After 5 days
of nerve laceration, motor and sensory fascicles could not be
identified by this method. (See Color Plates)
takes less than 1 h. Proximal stumps are always stained,
4. Nerve Repair
Motor-to-motor and sensory-to-sensory fascicles were
correctly matched by using the pattern of staining. In
longstanding cases or cases with nerve defects, sural
nerve grafting may be required (Fig. 3c).
Discussion
Within 5 days after injury, we can identify motor and
sensory fascicles in both proximal and distal stumps
by histochemical, electrophysiological, or radioisotopic
methods. However, after 5 days we cannot identify
motor and sensory fascicles of the distal nerve stump by
this method because of Wallerian degeneration and loss
of enzyme activity in the distal nerve. Thus, distal motor
fascicles need to be identified by anatomical methods or
surgical dissection for correct alignment of motor and
sensory fascicles.
Although knowledge of anatomy and topography is
essential for surgeons to repair nerves, this knowledge
is not sufficient to ensure avoiding fascicular mis-
alignment in a long nerve defect or in a proximal nerve
lesions. Even in the distal nerve lesion where nerve
topography is fairly constant, nerve stumps may be
rotated after injury.
 3.9. Technique of Cholinesterase Staining of the Peripheral Nerve
We can differentiate motor and sensory fascicles in
less than 1 h by this method. Our method has the fol-
lowing advantages over other: it is inexpensive and easy
to use in any hospital where frozen histologic section
is available; the degree of fibrosis can be evaluated at
the same time; and the intraneural location of motor
and sensory fascicles can be identified in one histologic
section.
References
1. Jabaly ME, Wallance WH, Heckler FR (1980) Internal
topography of major nerves of the forearm and hand:
a current view. J Hand Surg 5:1-18
2. Chow JA, van Beek AL, Meyer DL, Johnson MC (1985)
Surgical significance of the motor fascicular group of the
ulnar nerve in the forearm. J Hand Surg 1OA:867-872
3. Sunderland S (1945) The intraneural topography of the
radial, median, and ulnar nerves. Brain 68:243-299
4. Hakstian RW (1968) Funicular orientation by direct
stimulation. An aid to peripheral nerve repair. J Bone
Joint Surg 50:1178-1186
87
5. Gaul J (1986) Electrical fascicle identification as an
adjunct to nerve repair. Hand Clin 2:709-722
6. Karnovsky MJ, Roots L (1964) A "direct-coloring"
thiocholine method for choline esterase. J Histochem
Cytochem 12:219-221
7. Gruber H (1976) Identification of motor and sensory
funiculi in cut nerves and their selective reunion. Br J Plast
Surg 29:70-73
8. Sumita J, Tajima T (1979)Distribution of motor fiber of
human median nerve by Karnovsky staining. Seikeigeka
30:1427-1429 (in Japanese)
9. He Y, Zhong S (1988) Acetylcholinesterase: a histochem-
ical identification of motor and sensory fascicles in human
peripheral nerve and its use during operation. Plast
Reconstr Surg 82:125-130
10. Kanaya F, Ogden L, Breidenbach WC, Tsai T-M, Schcker
L (1991) Sensory and motor fiber differentiation with
Karnovsky staining. J Hand Surg 16A:851-858
11. Kanaya F, Jevans AW (1992) Rapid histochemical identi-
fication of motor and sensory fascicles: preparation of
solution. Plast Reconstr Surg 90:514-515
3.10 Tissue Preservation
HIROSHI ONO and Yon NAKAGAWA
Both replantation and transplantation surgery require
a period of ischemia during the procedure until revas-
cularization. Skeletal muscle is the most intolerant
of ischemia among all structures in an extremity. As
a result, although the replantation of major limbs or
transferred muscular tissues after prolonged periods
of ischemia can lead to viable replants in many cases,
their functional outcome is often poor due to degen-
eration of the muscle. A myocutaneous flap with
prolonged ischemia can exhibit almost complete mus-
cle necrosis in association with persistent viability of
the overlying skin. Clinically, it is therefore very im-
portant to determine the maximum ischemic time
that ensures not only survival of the tissue but also
reasonable muscular function, and to establish how to
prolong the critical period. For most tissues (skin,
muscle, bone, and nerve) involved in replantation or
reconstruction, 3 h of normothermic ischemia is well
tolerated [1].
It is generally accepted that 90% to 95% of replan-
tations or free tissue transfers should be successful [2].
Harashina reviewed 200 cases of free tissue transfers
and found an overall success rate of 94.8%. This figure
includes reexploration in 12 cases (6%), 5 of which
were salvaged [3]. In a retrospective study, Lidman and
Daniel found that reexploration of anastomoses was
required in 26% of their cases in order to achieve an
overall success rate of 94% [4]. After reexploration,
however, 5 % to 10% of tissues became necrotic because
of ischemia-reperfusion injury or obstruction of anasto-
mosed vessels. Much clinical and research study has
focused on how to improve the overall patient success
rate following ischemia-reperfusion injury from the
90% to 95% range to 100% success. On the other hand,
with the development of transplantation immunobiol-
ogy, we are now able to perform transfers of stored allo-
geneic [5] or xenogeneic donor tissue for reconstructive
procedures. Along with adequate regulation of immune
rejection, it is necessary to effectively preserve and pre-
pare these tissues so that they will tolerate prolonged
periods of warm or cold ischemia. The study of tissue
preservation is therefore essential for progress in recon-
structive surgery.
88
Pathophysiology of
Ischemia-Reperfusion Injury
Ischemia itself is the primary component of ischemia-
reperfusion injury. It is characterized by a lack of
oxygen and a conversion of cellular metabolism to
anaerobic pathways. Adenosine triphosphate (ATP) is
used as a cellular energy source. The more active the
cell metabolism, the faster the expenditure of energy
reserves. Skeletal muscle cannot tolerate longer periods
of ischemia in the limb, because this tissue has a highly
active metabolism. Hypothermia is known to retard cel-
lular metabolism and thus serves to increase tissue tol-
erance to ischemia [6]. An important result of ischemic
injury is a marked increase in intracellular calcium
concentration.
After the reestablishment of blood supply to the
ischemic limb, active oxygen intermediates, specifically
the superoxide anion radical (0 2.), hydrogen peroxide
(H 20 2 ), and the hydroxyl radical (OH.), appear on the
site of the tissue injury. These active oxygen inter-
mediates are produced through two major processes:
the xanthine oxidase system and the NADPH oxidase
system. Fantone et al. have reported that the appear-
ance of neutrophils associated with reperfusion injury
can be almost entirely attributed to the production
and release of the superoxide anion radical derived
from an NADPH oxidase-dependent system [7].
Reactive oxygen intermediates are a factor in endothe-
lial cell swelling, acting to increase capillary permeabil-
ity. In the reperfusion phase, a marked increase in
intracellular calcium ion concentration, along with
direct mechanical effects of oxygen radicals on the
endothelial cells, results in nonspecific protease and
phospholipase activation. These enzymes trigger ele-
ments of proinflammatory mediator synthesis, such as
the platelet-activating factor (PAF) , and a variety of
eicosanoid compounds (prostaglandins). PAF promotes
platelet accumulation and aggregation, the accumula-
tion and activation of leukocytes, increased vascular
permeability, vasoconstriction, and the modulation of
cytokine production. Eicosanoids also exacerbate the
 3.10. Tissue Preservation 89

impairment of capillary flow during reperfusion. These Table 1. Patency rates

reactions eventually lead to cell death. Preservation Group preserved Group preserved
period (h) at -le at 40C
4 10/10 (100%) 10/10 (100%)
Tissue Preservation Methods 8 10/10 (100%) 10110 (100%)
12 10/10 (100%) 10/10 (100%)
24 10/10 (100%) 10/10 (100%)
Ever since Allen first studied the effects of tempera- 48 9/10 (90%) 7/10 (70%)
ture on the tolerance of extremity tissues to ischemia 72 8/10 (80%)* 3/10 (30%)*
[8], hypothermia has been considered beneficial for
maintaining tissue viability. The beneficial effects of * p < 0.05.
The patency rate of the group preserved at -le for 72 h was sig-
hypothermia are thought to be decrease in oxygen- nificantly higher than that of the group preserved at 4e for 72h.
dependent metabolism; decrease in postischemic The patency rates of the group preserved at -le up to 48 h were the
hyperemia, thereby decreasing the early inflammatory same as those of the group preserved at 4e up to 48h.
response; decrease in tissue damage; and increase in
recovery rates to normal levels. Muramatsu et al. stated
that amputated extremities must be preserved in ice
water (OC to 4C) and that blood recirculation should
be initiated within 6 hours of ischemia [9]. Van Alphen
et al. reported that after 5 hours of hypothermic
ischemia at 5C, severe reactive proliferation of fibrob-
lasts between muscle cells is seen with increasing fre-
quency, according to the increase in ischemic time [10].
In clinical studies, Francel et al. reported that locally
applied hypothermia protects the muscle units and
might improve the function of transferred muscle [11].
In recent years, in order to prolong ischemic time in an
amputated limb, several kinds of storage solutions have
been used for tissue preservation (e.g., the Euro-Collins
solution and the University of Wisconsin solution).
Kihara et al. concluded from their experimental study
that skeletal muscle could be preserved for 9 hours
in 4C Euro-Collins solution [12]. Yokoyama et al.
reported that transplantation of rat limbs preserved in
cold Euro-Collins solution to recipient rats that had
Fig. 1. Light micrographs of the anterior tibial muscle in the
been pretreated with coenzyme QlO might allow longer
transplanted limb after 8 h of preservation at -1C. Note the
periods of preservation [13].
slight hyaline degeneration of the muscle fibers and the partial
In the studies mentioned above, basic methods of muscle fiber separation from the endomysium (hematoxylin
storing a severed tissue in moist, cool conditions with and eosin stain, x200)
ice or ice water were used [14]. The recommended tem-
perature for hypothermic storage without freezing the
tissues is approximately 4C. However, no evidence
has been presented to support the selection of this tem- 48, and 72h, the limbs were transplanted to other inbred
perature [15,16]. We therefore investigated the most rats using microsurgical techniques. We evaluated the
effective temperature for hypothermic storage without vascular patency of anastomoses by direct observation
freezing to prolong ischemic tolerance in an amputated and performed histological examinations on the seventh
murine hindlimb model [17]. We first measured the day after replantation. Although the patency rates of
freezing points of the calf muscle and the subcutaneous the group with limbs preserved at -1C for 48h were
tissue of the foot in the amputated limbs. The highest the same as those of the group with limbs preserved at
freezing point was -1.5C, which was recorded in the 4C for 48h, the patency rate of the group with limbs
calf muscle. To prevent freezing in any of the tissues in preserved at -1C for 72 h was significantly higher than
the amputated limbs, the lowest temperature for non- that of the group with limbs preserved at 4C for 72h
freezing preservation was defined as -1C. After the (Table 1). The histology of the skeletal muscles pre-
preservation of amputated limbs at a subzero, non- served at -1C for 8 h (Fig. 1) was closer to normal than
freezing temperature (-1C) and at 4C for 4, 8, 12, 24, the histology of those preserved at 4C for 8h (Fig. 2).
90 C. Experimental Microsurgery
Fig. 2. Light micrographs of the anterior tibial muscle in the
transplanted limb after 8h of preservation at 4C. Note the
proliferation of fibroblasts, separation of muscle fibers, inter-
stitial infiltration, hyaline necrosis, vacuolation, and disap-
pearance of sarcolemnal nuclei (hematoxylin and eosin stain,
x200)
Bone viability with osteoblastic activity was maintained
in the grafted limbs preserved at -1C for 72 h, but the
limbs preserved at 4C for 72 h showed dead bone,
without osteoblastic activity. We concluded from this
study that hypothermic preservation at -1C is more
useful than preservation at 4C. In order to clarify the
reason why preservation at -1 C is more effective, we
also examined the vascular functions of the tissue
preserved at -1C. The vascular compliance and the
contractility of vascular smooth muscle of freshly
amputated hindlimbs and of hindlimbs preserved at
both 4C and at -1C for 12,24,48, and 72 h were eval-
uated using an extracorporeal circulatory system with
fresh blood [18,19]. Vascular compliance was measured
under physiologic circulatory conditions (blood pres-
sure of the amputated limb maintained at 80 to
150 mmHg). Vascular compliance after storage at -1C
for 12h or longer decreased significantly from that of
freshly amputated limbs. Vascular compliance after
storage at 4C for 12h did not differ significantly from
that of freshly amputated limbs. However, after storage
at 4C for 24h or longer, vascular compliance decreased
significantly. To evaluate the contractility of vascular
smooth muscle, the arterial blood pressure in the ampu-
tated limbs was temporarily increased with injections of
norepinephrine. Contractility after storage at -1C for
up to 24h did not differ from that of freshly amputated
limbs. However, this property decreased significantly
after 48 h or longer. We were able to preserve vascular
smooth muscle contractility for at least 12h of storage
at 4C. However, smooth muscle contractility decreased
markedly following storage at 4C for 24h or longer.
These results suggested that storage at -1C was in-
ferior to storage at 4C with respect to vascular compli-
ance, which gives a rough estimate of the cold injury, but
was superior to storage at 4C with regard to smooth
muscle contractility, which gives a rough estimate of the
maintenance of energy sources. In the future, we need
to research methods for minimizing cold injury and
maintaining the energy source at -1C.
Cryopreservation has been used for the storage
of single sperm [20], ovule [21], and bone marrow cells
[22]. In 1992 Hirase reported a step-wise method of
cryopreservation for skin flaps by modification of an
embryonic preservation technique [23]. However,
Bowers reported drastic degenerative changes in skele-
tal muscle cells and capillaries after freezing and thawing
[24]. Kreyberg [25] and Weatherly-White [26] demon-
strated that transplanted tissue is unable to survive due
to microvasculature damage resulting from the freeze-
thaw insult. In situations where there is a large amount of
tissue involved, such as an amputated extremity or a
whole organ, this procedure is difficult to apply.
Another therapeutic approach is to administer phys-
iologic washout solutions. Rosen et al. demonstrated
that perfusion washout using an acellular plasma sub-
stitute improved tissue tolerance to ischemia with an
associated delay in the onset of vascular hypermeabil-
ity [27]. Pulsatile hypothermic perfusion using Univer-
sity of Wisconsin solution was more effective than
topical cooling alone [28,29]. However, a continuous
hypothermic or normothermic perfusion method is not
used at present in clinical replantation or transplanta-
tion because of its complexity and high cost.
Treatment of Ischemia-
Reperfusion Injury
To prevent ischemia-reperfusion lllJury after the
reestablishment of circulation, many pharmacological
approaches have been studied. Antithrombotic agents
such as heparin [30], urokinase, streptokinase [31],
and prostaglandin [32] were proved to be effective
in ischemia-reperfusion injury because of their throm-
bolytic or vasodilatory effects on the vasculature. Active
oxygen intermediates have demonstrated an ability to
produce significant postischemic cellular injury. Weiss
et al. reported that oxygen radical scavengers, such
as superoxide dismutase (SOD), prevented the no
reflow phenomenon and improved bone and muscle cell

survival in an ischemic extremity replant model [16].
Douglas et al. demonstrated the beneficial effects of
ibuprofen on ischemia-reperfusion injury of the
microvascular free flap [33].
During reperfusion after ischemic insult, a marked
increase in intracellular calcium ion concentration
results in cell injury. Many research projects have shown
the effect of calcium channel blockers on peripheral
ischemia in random and in axial pattern flaps. We also
examined the effect of a calcium antagonist (nicardip-
ine hydrochloride, Yamanouchi Pharmaceuticals, Tokyo,
Japan) on vascular resistance in ischemia-reperfusion
injury [34]. Decreases in vascular resistance after the
intra-arterial injection of the calcium antagonist were
significantly larger in the ischemia-reperfusion group
than in the freshly replanted group. These results
suggest that an increase in calcium ion concentration is
one of the causes of ischemia-reperfusion injury, and
that a calcium antagonist should be effective in treating
ischemia-reperfusion injury.
A deeper understanding and more effective treat-
ment of ischemia-reperfusion injury will contribute to
the future goal of reconstructive surgery using trans-
plants of tissues that have been stored for extended
periods of time. Preventing ischemia-reperfusion injury
in microsurgery would certainly make a major contri-
bution to the success of such procedures.
References
1. Hickey MJ, Hurley JV, Angel MF, O'Brien BM (1992) The
response of the rabbit rectus femoris muscle to ischemia
and reperfusion. J Surg Res 53:369-377
2. Fukui A, Tarnai S (1994) Present status of replantation in
Japan. Microsurgery 15:842-847
3. Harashina T (1988) Analysis of 200 free flaps. Br J Plast
Surg 41:33-36
4. Lidman D, Daniel RK (1981) Evaluation of clinical
microvascular anastomoses: reasons for failure. Ann Plast
Surg 6:215-223
5. Dubernard JM, Owen E, Herzberg G, Lanzetta M, Martin
X, Kapila M, Hakim NS (1999) Human hand allograft:
report on first 6 months. Lancet 353:1315-1320
6. Francel TJ, Vander Kolk CA, Yaremchuk MJ (1992)
Locally applied hypothermia and microvascular muscle
flap. Ann Plast Surg 28:246-251
7. Fantone JC, Ward PA (1982) Role of oxygen-derived free
radicals and metabolites in leukocyte-dependent inflam-
matory reactions. Am J PathoI107:397-418
8. Allen PM (1938) Resistance of peripheral tissues to
asphyxia at various temperatures. Surg Gynecol Obstet
67:746-751
9. Muramatsu I, Takahata N, Usui M, Ishii S (1985) Meta-
bolic and histologic changes in the ischemic muscles of
replanted dog legs. Clin Orthop 196:292-299
3.10. Tissue Preservation 91
10. Van Alphen WA, Smith AR, ten Kate FJW (1988)
Maximum hypothermic ischemia in replants containing
muscular tissue. J Hand Surg 13A:427-434
11. Francel TJ, Vander Kolk CA, Yaremchuk MJ (1992)
Locally applied hypothermia and microvascular muscle
flap transfers. Ann Plast Surg 28:246-251
12. Kihara M, Miura T, Ishiguro N (1991) Preservation of
skeletal muscle in tissue transfers using rat hindlimbs.
Plast Reconstr Surg 88:275-284
13. Yokoyama K, Itoman M, Takkagishi K, Yamamoto M
(1992) Protective effects of coenzyme QI0 on ischemia-
induced reperfusion injury in ischemic limb models. Plast
Reconstr Surg 90:890-898
14. Tarnai S (1978) Analysis of 163 replantations in an 11 year
period. Clin Plast Surg 5:195-202
15. Van Giesen PJ, Seaber AV, Urbaniak JR (1983) Storage of
amputated parts prior to replantation-an experimental
study with rabbit ears. J Hand Surg 8:60-65
16. Weiss AC, Carey LA, Randolph MA, Moore JR, Weiland
AJ (1989) Oxygen radical scavengers improve vascular
patency and bone-muscle cell survival in an ischemic
extremity replant model. Plast Reconstr Surg 84:117-
123
17. Nakagawa Y, Ono H, Mizumoto S, Fukui A, Tarnai S
(1998) Subzero nonfreezing preservation in a murine limb
replantation model. J Orthop Sci 3:156-162
18. Ono H, Nakagawa Y, Mizumoto S, Tomita N, Tarnai S
(1995) Evaluation of vascular compliance and vasocon-
strictive reactions in amputated hindlimbs of rats. J
Orthop Res 13:375-381
19. Ono H, Nakagawa Y, Mizumoto S, Tarnai S (1997) Vascu-
lar compliance and vasoconstrictive reactions in rat
hindlimbs: comparison between storage temperatures of
-1C and 4C. J Reconstr Microsurg 13:409-414
20. Zavos PM, Graham EF (1981) Preservation of turkey
spermatozoa by the use of emulsions and supercooling
methods. Cryobiology 18:497-505
21. Ohyama Y, Asahina E (1972) Supercooling injury in the
egg cell of the sea urchin. Cryobiology 9:22-28
22. Kurnick NB, Nokay N, Hampton B (1967) Survival of
frozen stored human and mouse bone marrow cells.
Radiat Res 32:706-722
23. Hirase Y, Kojima T, Uchida M, Takeishi M (1992) Cryop-
reserved allogeneic vessel and nerve grafts: hind-limb
replantation model in the rat. J Reconstr Microsurg 8:
437-443
24. Bowers WD Jr, Hubbard RW, Daum RC, Ashbaugh P,
Nilson E (1973) Ultrastructural studies of muscle cells
and vascular endothelium immediately after freeze-thaw
injury. Cryobiology 10:9-21
25. Kreyberg L (1950) La stase et son role dans Ie develop-
ment de la necrose. Acta Pathol Microbiol Scand Suppl
91:40-50
26. Weatherly-White RCA, Sjostrom B, Paton BC (1964)
Experimental studies in cold injury. II. The pathogenesis
of frostbite. J Surg Res 4:17-22
27. Rosen HM, Slivjak MJ, McBrearty FX (1985) Preischemic
flap washout and its effect on the no reflow phenomenon.
Plast Reconstr Surg 76:737-747
92 C. Experimental Microsurgery
28. Gordon L, Levinsohn DG, Borowsky CD, Manojlovic RD,
Sessler DI, Weiner MW, Baker AJ (1992) Improved
preservation of skeletal muscle in amputated limbs us-
ing pulsatile hypothermic perfusion with University of
Wisconsin solution. J Bone Joint Surg 74A:1358-1366
29. Wang WZ, Anderson G, Firrell JC, Tsai TM (1998)
Ischemic preconditioning versus intermittent reperfusion
to improve blood flow to a vascular isolated skeletal
muscle flap of rats. J Trauma 45:953-959
30. Xiaolu L, Cooley BC, Fowler JD, Gould JS (1995)
Intravascular heparin protects muscle flaps from
ischemiaireperfusion injury. Microsurgery 16:90-93
31. Goldberg JA, Pederson WC, Barwick WJ (1989) Salvage
of free tissue transfers using thrombolytic agents. J
Reconstr Microsurg 5:351-356
32. Feng LT (1988) Vasoactive prostaglandins in the impend-
ing no-reflow state: evidence for a primary disturbance in
microvascular tone. Plast Reconstr Surg 81:755-764
33. Douglas B, Weiberg H (1987) Beneficial effects of ibupro-
fen on experimental microvascular free flaps: pharmaco-
logic alteration of the no-reflow phenomenon. Plast
Reconstr Surg 79:366-371
34. Nakagawa Y, Ono H, Mizumoto S, Fukui A, Tarnai S
(1994) Effect of a calcium antagonist on the vascular re-
sistance of preserved murine hind limbs. Jpn J Reconstr
Microsurg 7:155-162
3.11 Transplantation Immunology
MAKOTO TAMAI and KIMITAKA SAGAWA
On September 23, 1998, the first successful human
allogeneic hand transplantation using immunosuppres-
sive agents was performed in Lyon, France by an inter-
national surgical team [1]. The hand was successfully
transplanted from a 41-year-old brain-dead man to a
48-year-old man with traumatic amputation at the
right forearm. According to the follow-up report, the
transplanted hand was not rejected with some sensory
and motor nerve regeneration at 6 months post-
operatively. However, the hand was subsequently
amputated in London on February 2, 2001 at the
patient's request. Council of the American Society for
Surgery of the Hand stated that chronic rejection
had been taken place on the transplanted hand [2].
The patient seemed to be an irresponsible and psycho-
logically unstable person, who temporarily escaped
from the supervision by the surgical team and de-
faulted the scheduled immunosuppressive therapy and
rehabilitation [1].
The second successful allogeneic hand transplanta-
tion was achieved in Louisville, Kentucky, USA, in
January 1999. The surgeons periodically reported
through the internet on a satisfactory clinical outcome
of the recipient's health and graft survival
(http://www.handtransplant.com). Thereafter, there
have been reported through the mass media more
than 10 cases of allogenic hand transplantation in the
world.
Allogeneic transplantation of solid organs, including
liver, heart, and kidney, has been achieved successfully,
with viability of the transplanted organs, because of the
development of methods for immunosuppression. In
orthopedic or reconstructive surgery, xenogeneic or
allogeneic tissue transplantation has been performed
with various combinations of immunosuppressive treat-
ments, such as cryopreservation, irradiation, and the
use of immunosuppressive agents. Transplantation of
composite tissue such as hand seems to be difficult
compared with single organ transplantation, because
the graft contains several kinds of tissues with different
antigenicity. For example, in allogeneic hand transplan-
tation, the skin is most likely to be rejected [1]. There
is also a risk of inducing a graft-versus-host reaction
(GVHR), because the immunocompetent T cells trans-
planted with bone marrow in the limb can attack the
recipient. The nonspecific immunosuppressive treat-
ments are associated with viral infections, the genera-
tion of neoplasm, and various complications [3,4]. The
long-term viability and the functional recovery of the
transplanted limb and its influence on the recipient are
still unclear.
Because of the increased indications for transplanta-
tion in different surgical disciplines, the development of
effective and specific methods of immunosuppression is
needed.
Bases of Transplantation Immunology
Transplants are classified as auto grafts, isografts, allo-
grafts, or xenografts, according to the genetic homology
between the recipient and the donor [5]. An autograft
is an organ or tissue transplant from one place to
another in an animal. An isograft is a transplant be-
tween two genetically identical amimals, such as mono-
zygotic twins or clones. An allograft is the common
clinical transplant, which is performed between two
animals belonging to the same species but genetically
not identical. A xenograft is a transplant between two
animals that are not of the same species.
Rejection of the transplanted tissue occurs naturally
in allografting or xenografting but in autografting or
isografting under the graft become necrotic. These
phenomena are caused by the immunological reactions
of the recipient against the tissue presenting foreign
antigens.
The proteins that act as foreign antigens are the prod-
ucts of major histocompatibility complex (MHC) genes,
i.e., human leukocyte antigens (HLAs) in human beings.
HLAs are cell-surface glycoproteins that are classified
as class I or class II antigens from the functional point
of view of antigen presentation [6,7]. Class I molecules
present auto antigens, and class II molecules present
foreign antigens [8,9]. Class I MHC refers to the HLA-
A, B, and C regions, whereas class II MHC refers to the
HLA-DP, DQ, and DR regions [10].
93
94 C. Experimental Microsurgery
T cells play important roles in the immunological
rejection of transplanted tissue. T cells recognize the
foreign antigens on antigen-presenting cells (APCs) and
intiate the acute- and chronic-phase reactions through
the activation of effector cells [11]. When the recipient
already has antibodies to the donor tissue, the hyper-
acute reaction progresses.
Although immunological rejection is nonspecifically
suppressed by many kinds of immunosuppressive chem-
ical agents, methods of donor- tissue-specific immuno-
suppression are now being investigated for use in
transplantation to reduce the side effects of these drugs
[3,4]. Tolerance is often induced regardless of the pres-
ence of the antigen [12]. To perform a successful trans-
plantation, it is important to understand the process of
the immune reaction caused by the transplantation and
the mechanisms of immunosuppression.
Recognition of Foreign Antigen
HLA plays an important role in antigen presentation
and also itself acts as the antigen in the host-versus-graft
reaction (HVGR) [5]. HLA is glycoprotein, the product
of multiple closely linked genes on a single chromosome
that are usually inherited as an intact unit [10]. Reac-
tions to HLA are the primary cause of graft rejection.
This histocompatibility complex, or HLA region, also
contains genes of complement and immune responses.
The HLA gene has various polymorphisms and varies
not only among different species but also among the
members of a species. Although the polymorphisms of
the HLA gene play an important role in the mainte-
nance of the strain by varying the sensitivity against
many diseases, the differences in the HLA gene cause
immunological rejection in transplantation.
HLA molecules are involved in antigen presentation
on the cell surface [7,13]. In the normal physiological
situation, the peptides that are derived from normal cel-
lular components by intracellular degradable pathways
are presented on the cell surface associated with self-
HLA molecules [6,14]. HLA molecules are not equally
distributed on all cells of the human body. Class I anti-
gens are expressed on nearly all nucleated human cells.
They are highly expressed on spleen, bone marrow,
liver, and kidney and weakly expressed on muscles. They
are associated with the presentation of auto antigens,
including virus-derived peptides. On the other hand,
expression of class II molecules is restricted to APCs, B
cells, endothelial cells of the vessels, and epithelial cells
of the skin, and are associated with the presentation of
foreign antigens. The expression of HLA molecules on
the cell surface is variable and controlled by cytokines:
interferon-y (IFN-y) and tumor necrosis factor-a (TNF-
a) are powerful inducers of HLA expression on many
types of cells that would otherwise express HLA mole-
cules weakly [15].
It is suggested that the rejection of graft in allogeneic
transplantation begins with the recognition of foreign
antigens on the donor APCs (passenger cells) by T cells
of the recipient [8]. T cells commonly recognize the
foreign antigens that were processed in the self-APC
and presented on its surface with class II HLA mole-
cules by T-cell receptor (TCR) and activated to initial-
ize the immune response [11]. The foreign peptides with
allo-class II molecules on the donor APCs can directly
activate recipient T cells, because the structures of HLA
molecules are different but similar among humans. The
CD3 molecule is necessary for this recognition, and it
constructs a TCR-CD3 complex. Since the class II mol-
ecules have affinity with CD4 molecules on the T cells,
besides the class I with CD8, the foreign pep tides with
class II molecules are recognized by CD4-positive T
cells. Furthermore, many adhesion molecules cooperate
in the conjugation between T cells and APCs.
Although both CD4-positive and CD8-positive T
cells of the recipient are activated by recognition of
class II and class I molecules on the graft, respectively,
the differentiation of CD8-positive cytotoxic T lympho-
cytes (CTLs) is largely dependent on the stimulation
of CD4-positive T cells by allogeneic class II molecules
present on the donor APCs. Alternatively, pre-CTL may
be directly activated by foreign APCs, reSUlting in the
production of cytokines that stimulate autocrine growth
and differentiation into CTLs [16].
The activated CD4-positive helper T cells proliferate
and stimulate the various effector mechanisms for
graft rejection by secreting cytokines (Fig. 1) [17,18].
Macrophages (M<j, natural killer (NK) cells, killer T
cells, and CTLs are activated to attack the grafted tissue
directly, and B cells are also activated to produce anti-
bodies to alloantigens on the graft.
The reaction following the conjugation between TCR
and allo-class II molecules of passenger cells is violent
and is called the alloreaction.
Types of Rejection
If the recipient of the allogeneic transplant has a fully
functional immune system, transplantation almost in-
variably results in some form of rejection. The stage
and the progress. of rejection are commonly estimated
by timely tissue biopsy. Graft rejection is usually classi-
fied into three phases, hyperacute, acute, and chronic,
on the basis of clinical features, post-transplantation
period, and histopathology. It is likely that preven-
tion rather than therapy will be the best treatment for

f f ~
Immunoglobulin
hhhhhh
.------, /'
-=..L-~
Cell-mediated cytotoxicity Cell lysis Inflammation
Fig. 1. Role of effectors in rejection. Recognition of allo-
antigen presented with human leukocyte antigen (HLA) class
II molecule on the surface of allogeneic antigen-presenting
cell (A PC) by T-cell receptor (TCR) of CD4-positive T-helper
cell (Th) is a trigger of various effector mechanisms. Th cells
secrete various cytokines and activate effector cells. B cell (B)
is activated to differentiate and produce immunoglobulins, i.e.,
antibodies. The antigen-antibody complex formation induces
antibody-dependent cell-mediated cytotoxicity (ADCC) co-
operating with killer T cells (K) or complement-derived cell
lysis (classical pathway). Complement can also be activated
rejection, but successful intervention will probably
require a better understanding of its pathogenesis.
Hyperacute Rejection
Hyperacute rejection is characterized by rapid throm-
botic occlusion of the graft vasculature that begins
within minutes after the reperfusion of the graft [5]. This
reaction occurs very rapidly in patients who already
have antibodies against the donor tissue. The anti-allo-
HLA antibodies are induced by prior blood transfusion,
3.11. Transplantation Immunology 95
without the immune complex (alternative pathway).
Macrophages (M<l are powerful inducers of inflammation.
Complement has a role as anaphylatoxin to recruit inflam-
matory cells to the site of inflammation and activate their
effector mechanisms. Cytotoxic T lymphocytes (CTL) can be
activated to differentiate by a signal from Th cells. There may
be a alternative mechanism of CTL activation by direct recog-
nition of the antigen on the surface of the allogeneic APC.
As a result of these cell-mediated and antibody-mediated
immune pathways and nonspecific inflammatory reactions, the
graft is rejected
multiple pregnancies, or prior transplantation. The anti-
bodies bind to the endothelium of the transplanted
organ and activate complements, which results in
endothelial cell injury due to formation of the mem-
brane attack complex, initiates coagulation, and exposes
subendothelial collagen, resulting in platelet adhesion
and aggregation. The histology of a graft rejected hyper-
acutely does not show evidence of inflammatory cell
infiltration. The antibodies against the ABO blood
antigens or the minor histocompatibility antigens also
cause the hyperacute rejection. The current methods of
screening donor/recipient pairs by performing ABO
96 C. Experimental Microsurgery

and crossmatching have almost eliminated this dreadful
event.
Acute Rejection
Acute rejection is characterized by the destruction of
the vascular endothelial cells and the parenchymal cells
of the graft [5]. The histology shows the infiltratio~ of
mononuclear cells, including CTLs, NK cells, and kIller
T cells, into the graft [18]. This reaction takes days or
weeks to become manifest and is due to the primary
activation of T cells and the consequent triggering of
various effector mechanisms. The humoral and cell-
mediated pathways are activated following T-cell acti-
vation by APC. The acute vascular injury is often
mediated by IgG antibodies against the alloantigens on
the endothelial cells of the graft and involves activation
of complements. In addition, T cells contribute to vas-
cular injury by responding to alloantigens presented on
vascular endothelial cells, leading to direct lysis of these
cells, or the production of cytokines that recruit and
activate inflammatory cells, causing endothelial cell
death [15]. Allo-reactive CTL-mediated cytotoxicity is
also important in the acute rejection. The vascular and
parenchymal cells that express allo-class I antigens are
the targets of CTLs. CTLs recognize the target antigen
associated with a cell-surface HLA molecule by cell-to-
cell contact with the adhesion molecules and cause cell
lysis by directly attacking the cell membrane of the
target cell, activating the membrane attack complement
system, or inducing apoptosis on the ~arget cell.
In patients whose T cells have prevIOusly been se~sI
tized to antigens on the graft, the second-set reactIOn
occurs and leads to accelerated cell-mediated rejection,
which violently progress.
Chronic Rejection
Chronic rejection is characterized by fibrosis with loss of
normal organ structures [5]. The pathogenesis of chronic
rejection is less well understood than that of acute rejec-
tion. Depending on the genetic disparity between donor
and recipient, and despite the use of immunosuppressive
agents, graft rejection slowly progresses by humoral
factors. The weak but recurrent reactions cause tissue
damage to the graft in months or years.
Methods of Preventing Rejection
Matching of the recipient and donor is necessary before
performance of the allogeneic tissue transplantation to
eliminate rejection of the graft and the occurrence of
GVHR. A pair that is compatible for a larger number
of HLA antigens is selected, and of course it is neces-
sary that the ABO blood type be matched and the recip-
ient be negative in preformed antibodies against donor
antigens. Any preexisting immunity of the prospective
transplant recipient to the antigens of a selected donor
is qualitatively evaluated by crossmatching. This c.a~ be
tested by incubating donor lymphocytes WIth reCIpIent
serum. Generally, a planned donor-to-recipient trans-
plantation does not proceed when the result of cross-
matching is positive.
The alleles of HLA-A, B in class I and HLA-DQ, DR
in class II antigens are identified by the serological
typing method or molecular analysis [19]. Serological
tissue typing refers to the complement-dependent
cytotoxicity test and is performed to determine the
degree of compatibility, especially in class I antigens.
Viable lymphocytes are incubated with antisera for
certain A-, B-, or C-locus antigens. Positive cell-serum
interactions characterize the HLA antigens of the cells.
Tissue typing by a molecular method for class I alleles
is also performed if appropriate.
Tissue typing for class II antigens is usually per-
formed by molecular analysis. The mixed lymphocyte
reaction (MLR) can also be used to test the respon-
siveness of recipient lymphocytes to antigens expressed
on donor cells. Low recipient antidonor MLR responses
are associated with excellent graft survival. However,
the 4 to 5 days required for the MLR test restrict its use
to transplantation from a living donor. Even in trans-
plantation from a brain-dead donor, sensitive and accu-
.
rate typing has been achieved by using the polymer~se
chain reaction (PCR) to identify HLA genes. The entIre
legion of the genes that encode the polymorphic
residues of class II antigens is amplified by PCR and
directly sequenced [20].
Although the larger numbers of matches in HLA
class I antigens between recipient and donor contribute
to satisfactory graft survival, it is independently
obtained when they share only the same class II anti-
gens, especially HLA-DR.
Methods of Immunosuppression
Rejection can be prevented or treated by immunosup-
pression of the host, minimizing the immunogenicity
of the graft, or inducing immunological tolerance. The
methods for immunosuppression at transplantation are
classified into two categories: the antigen-nonspecific
method, using various immunosuppressive agents, and
the antigen-specific method, which induces immuno-
logical tolerance against the foreign antigen.

For example, in the case of allogeneic hand trans-
plantation in France, combination therapy with
tacrolimus, mycophenoric acid, steroids, anti-thymocyte
globulin, and anti-CD25 monoclonal antibody was
used for induction, and the combination of tacrolimus,
mycophenolic acid, and predonisolone was used for
maintenance therapy [1]. The selection of immunosup-
pressive agents, their doses, and usages varies with their
combinations and is different among the countries or
the institutes in which the transplantation is performed.
Nonspecific Immunosuppression
Nonspecific immunosuppression abolishes the immune
system regardless of the antigen. The immunosuppres-
sive agents include macrolide antibiotics (cyclosporine,
tacrolimus, and sirolimus), antiproliferative drugs (aza-
thioprine, mycophenolic acid, cyclophosphamide, and
methotrexate), adrenocortical steroids (prednisolone),
and T-cell reactive antibodies. These agents are com-
monly used in various combinations because they inter-
fere with different stages of the immune pathway, and
this provides more effective immunosuppression than
the use of each agent separately [21].
Fungal Macrolides
Fungal macrolides contammg cyclosporine
(Cyclosporin A), tacrolimus (FK506), and sirolimus
(Rapamycin) have potent immunosuppressive activities
[22,23]. Cyclosporine and tacrolimus can suppress
cytokine production byT helper cells by interfering with
the activation of cytokine genes and, directly or indi-
rectly, reducing the expression of the receptors for IL-2
on lymphocytes undergoing activation [24]. Sirolimus
interferes with the intercellular signaling pathways of
the IL-2 receptor and thus prevents IL-2-dependent
lymphocyte activation [25]. Since the major complica-
tion of these drugs is kidney damage, their doses should
be controlled by frequently measuring the whole blood
concentrations.
Metabolic Toxins
Azathioprine (Imuran) is an antiproliferative drug that
is an analogue of 6-mercaptopurine [5]. Its incorpora-
tion into the DNA of dividing cells prevents further
proliferation. The drugs in this category were popular
in transplantation until the beginning of the clinical
application of cyclosporine. The major complication of
these drugs is bone marrow suppression. New anti-
proliferative drugs with minimal cytotoxicity, such as
mycophenolic acid (RS61443) and brequinar sodium
(BQR, DUP-785), are still under investigation [26,27].
3.11. Transplantation Immunology 97
Adrenocortical Steroids
Steroids have antiinflammatory properties and suppress
activated macrophages, interfere with APC function,
and reduce the expression of MHC antigens [5]. In
effect, steroids reverse many of the actions of IFN-y on
macrophages and transplanted tissues.
Complications of Immunosuppressive
Agents
The clinical results of transplantation using these agents
are acceptable; however, the long-term use of these
agents is still associated with adverse effects. Many of
these drugs cause various side effects resulting from
their cytotoxicity [3]. Further, the patients often mani-
fest two clinical problems caused by immunosuppres-
sive therapy. First, they are particularly susceptible
to infections, especially by viruses. Infection by
cytomegalovirus is common in patients with immuno-
suppressive treatment and contribute to arteriosclerosis
in chronic rejection. Second, the patients have an
increased proclivity to the development of certain
tumors, including B-celllymphoma, squamous cell car-
cinoma of the skin, and Kaposi's sarcoma [4]. It is pos-
sible to reduce the total doses of immunosuppressive
drugs and minimize the adverse effects by using several
drugs together in various combinations [28]. In addition,
further improvements in immunosuppressive effects
and reduction of side effects may be obtained with the
introduction of new drugs.
T-cell-reactive antibodies
New nonspecific but more selective agents are under
development. Monoclonal antibodies against inter-
leukin-2 (IL-2) or lymphocyte surface molecules, espe-
cially CD3, IL-2 receptor (CD25), and other adhesion
molecules, can be used to eliminate cells or to block
their function. They are important agents for treating
acute rejection. The most widely used antibody is
OKT3, the first anti-CD3 antibody to reduce T-cell
activity [29,30]. Anti-IL-2 or -CD25 antibodies can
prevent T-cell activation by blocking binding of IL-2 to
activated T cells [31-33]. Other antibodies in clinical
trials block T-cell adhesion molecules, such as LFA-1 or
VLA-4, or their ligands, such as ICAM-l and VCAM-l,
respectively [34-36]. These antibodies prevent T cells
from homing into the allograft.
The major limitation on the use of mouse monoclonal
antibodies is that human recipients rapidly develop
anti-mouse immunoglobulin (Ig) antibodies that elimi-
nate the injected mouse Ig. For this reason, attempts are
being made to produce human monoclonal antibodies
98 C. Experimental Microsurgery
or human-mouse chimeric antibodies that may be less
immunogenic.
Specific Immunosuppression
Many foreign antigens can induce tolerance, depending
on their physicochemical form, dose, and route of
administration [5,37]. Exposure of an individual to such
antigens not only fails to induce specific immunity but
also inhibits lymphocyte activation by subsequent
administration of the same antigens. Antigen recogni-
tion by specific T cells in the absence of costimulators
can induce immunologic tolerance. The suppressor T
cells may be also concerned with this phenomenon [38].
For example, specific immunosuppression is clinically
achieved by donor-specific transfusion (DST) [39]. Pre-
vious transfusion of donor blood intravenously into the
recipient can induce tolerance against donor antigens.
On the other hand, DST can also induce sensitization
against donor antigens in some cases [40]. The mecha-
nisms of this form of tolerance are not well understood.
Summary
Clinical transplantation has been performed as treat-
ment of various organ disorders to save the patients'
life. The indications for transplantation have extended
to reconstruction of the extremities, not to save the
patient's life but to improve his quality of life. Consid-
ering the fact that there is a possibility of increased risk
of infection or malignant neoplasms to the recipient due
to nonspecific immunosuppressive treatments, trans-
plantation of the extremities should not be performed
thoughtlessly at the present time. In cases where it is
indicated, doctors should perform transplantation with
consideration of the influence of the transplantation on
the human body, the mechanism of the immune reac-
tion, the effects and the usage of immunosuppressive
agents, and the risk to the patient's life. Development of
specific immunosuppressive methods will increase the
success and safety of transplantation.
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4. Limb Replantation in the Rat
AKIO MINAMI and NORIMASA IWASAKI
Historical Background
Replantation of amputated parts of the body by
microvascular techniques has become a fairly common
clinical procedure. To improve the success rate of this
procedure, a considerable number of basic studies have
been performed using experimental models of various
animals [1-4]. The rat hind limb amputation and replan-
tation model has been especially widely used because
rats are inexpensive and easy to handle, and because the
diameter of their femoral vessels approximates that of
the human finger and of various subcutaneous island
flaps.
In the 1960s, rat models were established by Buncke
et al. [5] and by Harashima and Buncke [6] to investi-
gate some aspects of microvascular replantation. In
these models, the hind limb was amputated through the
midthigh level and reimplanted immediately, reestab-
lishing circulation by microminiature repairs of the
femoral artery and vein. These authors reported success
rates of 33 %-92 %, depending on variables for the
reestablishment of circulation following replantation
which they introduced during the procedures. In 1979,
Shapiro and Cerra [7] presented a more sophisticated
rat model differring from the previous ones in several
ways. The amputation was performed just below the
inguinal ligament, allowing the reimplantation to in-
clude repairs of the sciatic and femoral nerves. Tendon
and ligament repair of the major muscle groups was also
performed. Shapiro and Cerra stated that there was an
immediate success rate of approximately 80% with this
model. In addition, they demonstrated that the histo-
logical findings of each tissue at four months showed
remarkably good tissue, with minimal signs of insult.
Research efforts in the field of replantation and
microsurgery have focused on improving the survival of
the replanted limb by maximizing the success of anas-
tomosis and developing tissue preservation techniques
[8-18]. The model utilizing the rat hind limb can be
easily applied to the studies on these points. For maxi-
mizing the success of anastomosis, a large number of
studies have been performed on the role of perfusion
washout and reperfusion injury [6,19-23]. Particularly,
100
in recent years, there have been many attempts to clarify
the relationship between ischemia-induced reperfusion
injury (i.e., the no-reflow phenomenon) and oxygen-
related free radicals. Various free-radical scavengers
and specific inhibitors of free-radical generation have
been tested for their ability to protect against ischemic
reperfusion injury in the ischemic flap and replantation
rat models [24-31]. Recent studies have clarified the
effects of various preservation solutions [6,32,33]' Thus,
as previously mentioned, the replantation model using
the rat hind limb can be adapted for various studies
in the field of microsurgery. It is also an easy model
for microvascular surgeons to use to improve their
techniques.
Materials and Methods
Animals and Anesthesia
Inbred male Lewis rats weighing approximately
250-300 g are used as the experimental model. Because
of their gentle nature, this strain is widely used for
studies in microsurgery. Pentobarbital sodium (Nembu-
tal) is used for anesthesia via intraperitoneal injection
at 1 mllkg body weight.
Amputation Procedures
The right hindlimb of the anesthetized rat is shaved and
prepared after immobilization of the rat in a supine
position on a operating table (Fig. 1). A circumferential
incision is made at the midthigh level (Fig. 2). The prox-
imal skin flap is raised to the inguinal region, and the
inferior epigastric vessels are divided. Under the guid-
ance of an operating microscope, the femoral sheath is
opened. The femoral artery and vein are the carefully
isolated between the inguinal ligament and the division
into the saphenous and popliteal vessels (Fig. 3). All
arterial and venous branches in this region are electro-
cauterized and divided. The musculature and femur are

Fig. 1. Shaved hindlimb of anesthetized Lewis rat
Fig. 2. Circumferential skin incision at the mid thigh level
divided at midthigh (Fig. 4). Microvascular clamps are
then applied to the artery and the vein, proximally and
distally to the level of amputation. These vessels, as well
as the adjacent femoral nerve, are then sharply divided.
The lumen of each divided vessel is carefully washed
with heparinized saline solution (lOIU/ml).
4. Limb Replantation in the Rat 101
Fig. 3. Exposed femoral artery and vein. The femoral artery
and vein are isolated between the inguinal ligament and the
division into saphenous and popliteal vessels
Fig. 4. Donor's right hind limb with an intramedullary
Kirschner wire to fix the replanted femur
Replantation Procedures
The femur is shortened 5 to 8 mm to reduce the tension
on the vascular anastomosis and fixed with an
intramedullary Kirschner wire (0.045 inch). The muscle
ends are grossly sutured with 4-0 non absorbable suture
material. Using a standard microvascular technique, the
anastomoses of the femoral artery and vein are per-
formed with six to seven interrupted 11-0 nylon sutures.
The artery is usually repaired first to confirm the venous
102 C. Experimental Microsurgery
Fig. 5. Replanted hind limb
return after removing the vascular clamps. If the model
is applied to the functional assessment of the replanted
limb, the sciatic and femoral nerves are repaired with
epineural sutures of 10-0 or 11-0 nylon. After adequate
reperfusion has been confirmed, the skin is closed with
simple 4-0 nylon sutures (Fig. 5). The total operating
time averages 2 to 2.5h.
Postoperative Management
Adequate antibiotics are given on the day of operation
or the first postoperative day. No systemic anticoagula-
tion agent is administered postoperatively. To prevent
autophagia of the replanted limb, a plastic collar is
placed around the rat's neck (Fig. 6). Cast or plaster
immobilization is not applied to the limb, because it
does not allow the rat mobility.
References
1. Buncke HI, Schulz WP (1976) Experimental digital ampu-
tation and reimplantation. Plast Reconstr Surg 36:62
2. Buncke HI, Schulz WP (1966) Total ear reimplantation in
the rabbit utilizing microminiature vascular anastomoses.
Br I Plast Surg 19:15-22
3. Hayhurst IW (1976) Complications of digital implanta-
tion. In: Daniller AI, Strauch B (eds) Symposium in
microvascular surgery. c.v. Mosby, St. Louis
4. Tsai TM (1975) Experimental and clinical application of
microvascular surgery. Ann Surg 181:169-177
Fig. 6. After operation, a plastic collar is placed around the
rat's neck to prevent autophagia of the replanted limb
5. Buncke HI, Daniller AI, Schulz Wp, Chase RA (1967)
The fate of autogenous whole joints transplantated by
microvascular anastomoses. Plast Reconstr Surg 39:333-
341
6. Harashima T, Buncke HI (1975) Study of washout solu-
tions for microvascular replantation and transplantation.
Plast Reconstr Surg 56:542-548
7. Shapiro RI, Cerra FB (1977) A model for reimplantation
and transplantation of a complex organ: The rat hind limb.
I Surg Res 24:501-506
8. Abramson DL, Shaw WW, Kamat BR, Harper A,
Rosenberg CR (1991) Laser-assisted venous anastomosis:
A comparison study. I Reconstr Microsurg 7:199-203
9. Bass LS, Treat MR, Dzakonski C, Trokel SL (1989) Suture-
less microvascular anastomosis using the THC:YAG laser:
A preliminary report. Microsurgery 10:189-193
10. Han SK, Kim SW, Kim WK (1998) Microvascular anasto-
mosis with minimal suture and fibrin glue: Experimental
and clinical study. Microsurgery 18:306-311
11. Hyland WT, Botens SR, Minasi IS (1981) Are-appraisal
and modification of the Lauritzen technique of microvas-
cular anastomoses. Br I Plast Surg 34:451-453
12. Kiyoshige Y, Tsuchida H, Hamasaki M, Takayanagi M,
Watanabe Y (1991) CO 2 laser assisted microvascular
anastomosis: Biochemical studies and clinical applica-
tions. I Reconstr Microsurg 7:225-230
13. Lauritzen C (1978) A new and easier way to anastomose
microvessels. Scand I Plast Reconstr Surg 12:291-294
14. Ruiz-Razura A, Lan M, Cohen BE (1989) The laser
assisted end to side microvascular anastomosis. Plast
Reconstr Surg 83:511-517
15. Ruiz-Razura A, Wiener TC (1991) CO 2 laser assisted
microvascular anastomosis: Biochemical studies and clin-
ical applications. Invited discussion. I Reconstr Microsurg
7:231-264
16. Sully L, Nightingale G, O'Brien BMcC, Hurley IV (1982)
The sleeve technique in microarterial anastomosis. Br I
Plast Surg 34:451-453

17. Swartz WM, Cha CJM, Ambler M, Clowes GHA (1976)
Prolonged ischemia in the replanted rat leg: A biochemi-
cal and morphologic study with microvascular techniques.
Surg Forum 27:565-568
18. Vale BH, Frenkel A, Trenka-Benthin S, Matlaga BF (1986)
Microsurgical anastomosis of rat carotid arteries with the
CO 2 laser. Plast Reconstr Surg 77:759-766
19. Chait LA, May JW, O'Brien BM, Hurley N (1978) The
effects of perfusion of various solutions on the no-reflow
phenomenon in experimental free flaps. Plast Reconstr
Surg 61:421-430
20. Gould IS, Sully L, O'Brien BM, Das SF, Knight KR,
Hurley JV (1985) The effects of combined cooling and
perfusion on experimental free-flap survival in rabbits.
Plast Reconstr Surg 76:104-109
21. Rosen HM, Slivjak MJ, McBrearty FX (1985) Preischemic
flap washout and its effect on the no-reflow phenomenon.
Plast Reconstr Surg 76:737-747
22. Rosen HM, Slivjak MJ, McBrearty FX (1987) Delayed
microcirculatory hyperpermeability following perfusion
washout. Preischemic flap washout. Plast Reconstr Surg
79:102-107
23. Rosen HM, Slivjak MJ, McBrearty FX (1987) The role of
perfusion washout in limb revascularization procedures.
Plast Reconstr Surg 80:595-603
24. 1m MJ, Shen WH, Pak CJ (1984) Effect of allopurinol on
survival of hyperemic island skin flaps. Plast Reconstr
Surg 73:276-278
25. Manson PN, Narayan KK, 1m MJ (1986) Improved sur-
vival in free skin flap transfers in rats. Surgery 99:211-215
4. Limb Replantation in the Rat 103
26. Sagi A, Ferder M, Levens D, Strauch B (1986) Improved
survival of island flaps after prolonged ischemia by per-
fusion with superoxide dismutase. Plast Reconstr Surg
77:639-644
27. Weiss APC, Moore JR, Randolph MA, Weiland AJ (1988)
Preventing oxygen free-radical injury in ischemic revas-
cularized bone grafts. Plast Reconstr Surg 82:486-497
28. Weiss APC, Carey LA, Randolph MA, Moore JR, Weiland
AJ (1989) Oxygen radical scavengers improve vascular
patency and bone-muscle cell survival in an ischemic
extremity replant model. Plast Reconstr Surg 84:117-123
29. Yokoyama K, Homan M, Takagishi K, Sekiguchi M,
Yamamoto M, Nakamura K (1993) The effect of superox-
ide production on the replantation of rat limbs after cold
ischemia. J Reconstr Microsurg 9:61-68
30. Yokoyama K, Homan M, Takagishi K, Sekiguchi M,
Yamamoto M (1992) Protective effects of coenzyme Q10
on ischemia-induced reperfusion injury in ischemic limb
models. Plast Reconstr Surg 90:890-898
31. Whitney TM, Wang KK, Sternbach Y, Chaklis-Haley D
(1997) Reduction of ischemic reperfusion edema with
corticotropin-releasing factor (CRF) in rat hind limb
replantation. Ann Plast Surg 38:416-419
32. Kihira M, Miura T, Ishiguro N (1991) Preservation of
skeletal muscle in tissue transfers using rat hindlimbs.
Plast Reconstr Surg 88:275-284
33. Norden MA, Rao VK, Southard JH (1997) Improved
preservation of rat hindlimbs with the University of
Wisconsin solution and butanedione monoxine. Plast
Reconstr Surg 100:957-965
5. Canine Limb Replantation and
Replantation Toxemia
MASAMICHI U SUI and SEIICHI ISHII
It is generally accepted that Hoephner [1] first success-
fully performed experimental replantation of ampu-
tated limbs in dogs in 1903. Carrel and Guthrie [2] also
attempted experimental replantation of completely
amputated thighs in dogs in 1906. Thereafter interest in
replantation research diminished and was restarted by
Lapchinsky [3], Snyder et al. [4], and Onji et al. [5] in
Japan in the 1960s.
It is well known that a state of shock may develop
after experimental replantation of an amputated limb
that contains voluminous muscle. This phenomenon is
called replantation toxemia [6,7], and it is thought to
arise from edema of the replanted extremity, hyper-
kalemia, metabolic acidosis, and the transfer of toxic
metabolites to the recipient from the replant. Contro-
versy continues as to which of them is most related to
the development of toxemia.
History of Experimental Study
Fukunishi [8] confirmed that the survival rate of
dogs subjected to 3 h of limb ischemia was 85 %, whereas
all animals subjected to 6 h of limb ischemia died of
toxemia. He noted severe metabolic acidosis, hyper-
kalemia, and increase of kinin, which caused hyperper-
me ability of the capillaries and severe edema in the
replanted hind limb of the 6-h ischemia group. Eiken
et al. [9] concluded that edema of the replanted limb
was the main cause of death.
Mehl et al. [6], however, opposed this theory because
they could not find any difference in the degree of
edema between the dogs that died and those that sur-
vived. Kohama [10] also concluded that fluid loss due to
edema of the replanted limb could not be a main factor
in toxemia. Onji et al. [11] and Kohama [10] regarded
hyperpotassemia as the important factor in toxemia.
They observed hyperpotassemia and severe electrocar-
diographic changes indicative of potassium intoxication
in their experimental animals just before death. On the
other hand, Mehl et al. [6] believed that replantation
toxemia was closely related to metabolic acidosis
104
and could be combatted effectively by amine buffer
therapy.
From our experience, we know that cooling of the
amputated limb is effective for prevention of replanta-
tion toxemia. However, the reason that cooling is ef-
fective remains unknown. We have reported the
experimental results that cooling of the canine ampu-
tated limb, with or without perfusion by fluorocarbon,
was effective for prevention of replantation toxemia
[12,13]. In this chapter we will describe the essential
points of our experiments.
Experiment 1: Effect of Hypothermia
on an Amputated Limb
We performed this study to answer the following ques-
tions: Is cooling of amputated limbs really effective
for prevention of replantation toxemia? How long can
ischemia be prolonged if the amputated limb is kept in
hypothermia? Of the three probable causes-limb
edema, potassium leakage, and lactate production from
the replanted limb-which is most closely related to the
development of replantation toxemia?
Materials and Methods
Fifty-five adult mongrel dogs weighing between 10 and
15 kg were used. After sodium pentobarbital anesthesia
(30mg/kg), a hind leg of the dog was amputated com-
pletely at the midthigh and perfused with physiologi-
cal saline solution containing heparin. After that, the
animals were divided into four groups, depending on the
method of preservation of the amputated limbs: limb
preserved in ice water for 6h (6-IW), preserved in ice
water for 12 h (12-IW), maintained at room temperature
of 25-27C for 6 h (6-RT), and maintained at room tem-
perature of 25-27C for 12h (12-RT).
Recirculation was established by anastomosis of
the femoral artery and vein. The artery was sutured with
No. 8-0 or 9-0 monofilament nylon using an operating
microscope. The femoral vein was connected by a sili-
 5. Canine Limb Replantation and Replantation Toxemia 105

cone T-tube. All other tissues were kept unattached
without osteosynthesis or musculocutaneous sutures.
During the experiment, the animal received 500 ml of
hydroxyethyl starch (HES) + 5% glucose (12-h ischemia
group) intravenously. All dogs were intubated and per-
mitted to breathe spontaneously (Fig. 1).
The dogs were observed for 6 h following recir-
culation to determine whether or not they died from
replantation toxemia. At the same time, limb weight was
measured and potassium, pH, and lactate in the arterial
and venous blood were determined. The first blood
samples were taken as controls from the jugular vein
and the carotid artery just before recirculation. After
that, a series of samples was collected at 30- or 60-min
intervals for 6h. The arterial blood was taken from the
carotid artery and the venous blood from the T-tube
connecting vein.
Results
Survival Rate
In the experiment with 6 h of ischemia, all 10 animals
survived in the 6-IW group. On the other hand, replan-
tation toxemia was not prevented completely when the
limbs were maintained at room temperature, because
only 8 of 15 survived. The survival rate was also inves-
tigated in the experiments with 12h of ischemia, and it
was lower than that of the 6-h ischemic group. Two of
10 experimental dogs died of toxemia, even when the
limbs were cooled in ice water (Table 1).
Edema of the Replanted Limb
Limb edema developing following replantation was
recorded by comparing the limb weight at different
times, just after recirculation and 6 h after recirculation.
The increase in limb weight is shown in Table 2. These
results suggest that cooling is effective for prevention of
edema of the amputated limb (Table 2).
Potassium Leakage from Amputated Limb
The potassium level rose markedly immediately after
recirculation and then dropped rather rapidly to normal
within 2 or 3 h. However, there were significant differ-
ences between the 6-IW and 6-RT groups. As shown in
Fig. 2, the rising level returned to normal more quickly
Table 1. Survival rates in experiment 1
6h 12h
Group No. % No. %

Ice water group 10/10 100 8/10 80

Room temperature group 8/15 53 5110 50

Table 2. Limb edema in experiment 1 (g)

Group 6h 12h
Ice water group 68 24 127 9
Room temperature group 88 35 330 40

mEq/L
9
Venous blood

mEq/L
6
Arterial blood
5

4~'
T
c 0 1/2 1 2 3 4 5 6hrs. c 0 1/2 1 2 3 4 5 6hrs.
Fig. 1. Schematic illustration of canine limb replantation. A Hours after recirculation Hours after recirculation
hind leg was amputated at the middle of the thigh, and recir-
culation was established by microsurgical anastomosis of the Fig. 2. Changes in potassium in ice water (open circles) and
femoral artery and connection of the vein by a silicone T-tube room temperature (closed circles) groups (6h of ischemia)
 106 C. Experimental Microsurgery

in the 6-IW group. Cooling in ice water was effective for group. Limb edema in the RT group was twice that in
prevention of potassium leakage from amputated limbs, the IW group. A similar result was observed in the sur-
even if the ischemia time was prolonged to 12h (Fig. 3). viving animals. The degree of edema in the animals that
died was compared with that of surviving ones. Contrary
pH and Lactate to expectation, the edema observed in the animals that
died was less than that in the survivors in both the RT
Various degrees of acidosis were observed in all exper-
and the IW groups.
imental groups after recirculation. In the experiment
As shown in Figs. 3 and 6, there were no significant
with 6h of ischemia, the pH of the effluent blood
differences in the changing curve pattern and in the
dropped remarkably just after recirculation. After that,
degree of increase in potassium between the surviving
the pH rose gradually and reached a value of 7.25 to
animals and those that died. In venous blood of the
7.30 at 30 to 60min after recirculation. Such changing
animals that died, the potassium level rose to 10mEq/1
curve patterns were similar in the 6-IW and 6-RT
immediately after circulation. After that, IW dropped to
groups, but the degree of fall in pH of these two exper-
6mEq/1 within 1 h and remained at that level until the
imental groups was different. The pH of the 6-IW group
animal's death. On the other hand, serum potassium
was 7.070 0.030 at the time just after recirculation, and
this numerical value was slight, as compared with the 6-
RT group (6-RT = 6.977 0.024). Moreover, the pH of
the 6-IW group returned to normal more quickly than
7.5 7.5
that of the 6-RT group. Acidosis developed gradually to Venous blood --1, Arterial blood

~~
such a condition that the pH level was 7.25 to 7.35 at 2 7.4 7.4
to 5 h after recirculation. The pH of the arterial blood
showed a tendency to compensate with passage of time, '0 7.3 7.3
0
but only the 6-IW group reached a normal pH value at 0

~ 7.2 7.2
6h after recirculation (Fig. 4). :E
c
One can also see in Fig. 5 that the changes in pH Ic. 7.1 7.1
are inversely proportional to those in lactate. From
such a relationship between pH and lactate, it might be 7.0 7.0
assumed that the acidosis observed in the experimental
6. 6.9
animals was due to lactate production in the amputated 1
limb as a result of anaerobic metabolism (Fig. 5). c 0 1/2 1 2 3 4 5 6hrs. c 0 1/2 1 2 3 4 5 6hrs.
Hours after recirculation Hours after recirculation
Changes in Edema, Potassium, pH, and Lactate in
Fig. 4. Changes in pH in ice water (open circles) and room
the Animals That Died
temperature (closed circles) groups (6h of ischemia)
The increase in limb weight at the time of death was 105
45 g in the 12-IW group and 228 38 g in the 12-RT

Lactate Lactate
mEq/L (mg/dl) pH (mg/dl)
pH
9 80 80
7.5 Venous blood 7.5 Arterial blood
8 Venous blood
7.4 1, 60
7.4
60

'~---3---t---t"+-+-1
~
40 40
"8o
.1
7
mEq/L 7.3 7.3
:0 t--
6 " 6
7.2
20 20

~: 1il~
7.2
Arterial blood 0 0
5
7.1 7.1

4r~ 7.0 7.0

T T 6.9 6.9
c 01/2 1 2 3 4 5 6hrs. c 0 1/2 1 2 3 4 5 6hrs.
T
Hours after recirculation Hours after recirculation c 01/2 1 2 3 4 5 6hrs. c 01/2 1 2 3 4 5 6hrs.
Hours after recirculation Hours after recirculation
Fig. 3. Changes in potassium in ice water group (6h [open
circles] and 12h [closed circles] of ischemia). From [12], with Fig. 5. Changes in pH (closed circles) and lactate (open
permission circles) in the 12-IW group. From [12], with permission
 5. Canine Limb Replantation and Replantation Toxemia 107

increased progressively in the arterial blood level and
reached to 5.4mEq/1 when measured just before death
(Fig. 6).
There were significant differences in the values of pH
and lactate production between the surviving and the
dead animals. In the latter, the fall of pH became more
prominent in the arterial and the venous blood with the
lapse of time after recirculation. The animals died when
metabolic acidosis developed to produce a pH of 7.05
to 7.15. On the other hand, changing curve patterns of
lactate were inversely proportional to those of pH. As
shown in Fig. 6, lactate increased linearly in accordance
with the fall in the pH value (Fig. 6).
Experiment 2: Effect of Fluorocarbon
Perfusion on the Preservation of
Amputated Limbs and Prevention of
Replantation Toxemia
As long ago as 1966, Clark and Gollan [14] demon-
strated the high solubility of oxygen in fluorocarbon.
Since then, fluorocarbon has been used successfully as
a substitute for the oxygen-carrying function of ery-
throcytes in experimental studies on the preservation of
isolated organs [15,16]. Experiment 2 was undertaken
to assess the effect of fluorocarbon on the preservation
of an amputated limb and prevention of replantation
toxemia.
Materials and Methods
Animals and Operative Techniques
Fifty adult mongrel dogs, weighing 10 to 15 kg, were
used. Anesthesia and operative techniques were as same
as for experiment 1. The dogs were divided into two
groups: in one group the limbs were perfused with
fluorocarbon; in the other group they were either not
perfused at all or were perfused with lactated Ringer's
solution. Each group was further subdivided into two
subgroups, in which the limbs were stored at different
temperatures (Table 3).
Fluosol-43, diluted with lactated Ringer's solution to
lOw/v% concentration, was the particular preparation
of fluorocarbon we used (Table 4). The fluorocarbon
was oxygenated, since the oxygen pressure in fluoro-
carbon has to be maintained at more than 440mmHg.
Perfusion with the oxygenated fluorocarbon was at a
pressure of 50cmHzO and was continuous or intermit-
tent (for 20 min and repeated three or five times). After
6 h of ischemia, the circulation was re-established by the
same method as in experiment 1.
Observations
The dogs' survival rate, edema of the replanted limb,
and changes in potassium, pH, and lactate in the blood
were determined by the same methods as in experiment
1.

Table 3. Experimental groups and numbers of animals in

experiment 2
Group Room temperature Ice water
No perfusion 15 10
mEq/L Intermittent perfusion with FC 9 6
11 K Continuous perfusion with FC 6 5
Continuous perfusion with LR 5
10
,'
," '
7.5 FC, Fluosol-43 diluted with lactated Ringer's solution; LR, lactated
9
! ': 7.4
Ringer's solution alone.
8
: "
mg/dl

: i~i
Lactate

5
HI] :: 7.0
80
50
~1-.t+l:
:
Table 4. Composition of fiuosol-43
Ingredient
FC-43
w/v%
20
4 t' Pluronic F-68 2.56
NaCI 0.60
T 6.9 f,-~_ _~_ 201"
KCI 0.034
c 01/2 1 2 3 4 c 01/2 1 2 3 4 c 01/2 1 2 3 4
CaCb 0.028
Hours after recirculation Hours after recirculation Hours after recirculation
MgCl2 0.020
NaHC0 3 0.210
Fig.6. Changes in potassium, pH, and lactate in arterial (open
Glucose 0.180
circles) and venous (closed circles) blood of animals that died Hydroxyethyl starch 3.0
(12h of ischemia). From [12], with permission
108 C. Experimental Microsurgery

Results Potassium Leakage from Amputated Limbs

Survival Rates
Table 5 shows the survival rates of the dogs 6 h after
replantation. In the group with limbs preserved in ice
water, all the animals survived without developing
replantation toxemia, whether the limbs had been per-
fused with fluorocarbon or not. In those with limbs pre-
served at room temperature, the survival rate was
higher among those whose limbs had been perfused
with fluorocarbon than in the nonperfusion group
(Table 5).
Edema
Edema was recorded by comparing the weights of the
limb at three different times: just after amputation, just
before replantation, and 6 h after circulation was re-
established. Weight changes are shown as percentages
of the original weight (Table 6). In the perfusion group,
limb edema developed significantly more than in the
nonperfusion group, irrespective of the difference in
thermal conditions. When the amputated limb was per-
fused with fluorocarbon, the degree of edema was sig-
nificantly less than when it was perfused with lactated
Ringer's solution alone. In the latter group, considerable
edema had already developed before replantation.
Table 5. Survival rates in experiment 2
Group Room temperature Ice water
No perfusion 8/15 (53%) 10/10 (100%)
Intermittent perfusion with FC 8/9 (89%) 6/6 (100%)
Continuous perfusion with FC 5/6 (83%) 5/5 (100%)
Continuous perfusion with LR 5/5 (100%)
FC, Fluosol-43 diluted with lactated Ringer's solution; LR, lactated
Ringer's solution alone.
In the effluent venous blood, the potassium level rose
markedly immediately after the re-establishment of cir-
culation and returned to a stable value 30min later. In
the groups perfused with fluorocarbon, the potassium
level quickly returned to a stable value, which was sig-
nificantly lower than that in the group with no perfu-
sion. There was no significant difference in potassium
level between those with limbs preserved at room tem-
perature and those with limbs preserved in iced water
(Fig. 7). On the other hand, the potassium level in the
arterial blood remained within normal limits through-
out the 6 h after replantation.
pH and Lactate
In the effluent venous blood, the pH dropped markedly
just after the circulation was re-established. After that,
the pH rose gradually and reached a stable value. Al-
though the changing curve patterns of pH resembled
each other, the fall in pH was less significant in the per-
fusion groups than in the nonperfusion group. When the
amputated limb was perfused with fluorocarbon and
preserved in iced water, the fall in pH was least and the
pH value returned to normal by 30min after replanta-
tion. In none of the other groups, regardless of thermal
conditions, did the pH value of the arterial or venous
blood return to the control value during the 6 h of obser-
vation (Fig. 8). Figure 9 shows the changes in lactate in
the arterial and venous blood. In the effluent venous
blood, the lactate level rose markedly just after replan-
tation in each group. The degree of increase in lactate
Room temperature group Iced water group
Potassium
mEqll mEq/1
8 8

7 7

Table 6. Weight changes of the limb in experiment 2 6 6

(percentage change of original weight) 5 5
After 6h after 4 4
Group perfusion replantation
3 3
Room temperature group
No perfusion 15.6 5.7 2 2
Intermittent perfusion with FC -3.1 1.6 18.2 2.7
Continuous perfusion with FC -4.5 2.3 24.9 3.7
T TL~~~~~~
C 0 1/2 1 2 3 4 5 6hrs c 0 1/2 1 2 3 4 5 6hrs
Ice water group
No perfusion 13.0 3.9
99
ti
H H
,!
QQ No perfusion ( mean SE)
Intermittent perfusion
Continuous perfusion
Intermittent perfusion with FC -4.8 1.2 28.4 3.9
Continuous perfusion with FC -3.4 1.2 26.8 2.7
Fig. 7. Changes in potassium level of venous blood from the
Continuous perfusion with LR 20.6 2.8 51.3 7.9
replanted limb. C, Control level before amputation. In Figs.
FC, Fluosol-43 diluted with lactated Ringer's solution; LR, lactated 7-9, perfusion was with Fluosol-43 diluted with Nartmann's
Ringer's solution alone. solution. From [12], with permission
 5. Canine Limb Replantation and Replantation Toxemia 109

Room temperature group Iced water group Room temperature group Iced water group
pH pH Lactate
7.5 Venous blood 7.5 Venous blood mgldl mg/dl
50 Venous blood 50 Venous blood
7.4 7.4

7.3 7.3
30 30
f/
.~i~jtJt~~I~k+/_fI
1 1"'1 -- 1
7.2 7.2
f
7.1 7.1 10 10

7.0 7.0 c 0 1/2 1 2 3 4 5 6hrs c 0 1/2 1 2 3 4 5 6hrs

6.9 6.9 mg/dl mg/dl
T T 50 Arterial blood 50 Arterial blood
c 01/2 1 2 3 4 5 6hrs c 01/2 1 2 3 4 5 6hrs

30
pH pH
Arterial blood Arterial blood
7.6 7.6

~
7.5 7.5 10

7.4 7.4 r~
\{f.f-lf~W-+L~+ c 0 1/2 1 2 3 4 5 6hrs c 0 1/2 1 2 3 4 5 6hrs

7.3 ffftt{ 7.3 r QQ gg No perfusion (mean SE)

7.2 7.2
T T
c 0 1/2 1 2 3 4 5 6 hrs c 01/2 1 2 3 4 5 6hrs
99 99 No perfusion ( mean SE)
~, ,~ Intermittent perfusion
H H Continuous perfusion
Fig. 8. Changes in pH level. From [13], with permission
was less in the perfusion groups than in the nonperfu-
sion group. At 6 h, however, the lactate value returned
to normal only in the group in which the limbs had been
continuously perfused with fluorocarbon and preserved
in ice water; this same group also showed least change
in the arterial blood (Fig. 9).
Discussion
Kohama [10], studying replantation of limbs after 6 h
of ischemia, stated that the survival rate in the winter
was higher than that in the summer. Mehl et al. [6] also
reported that when the amputated limbs were kept in
hypothermia, dogs could tolerate 13 h of ischemia. In
China, limbs preserved at 4C were clinically replanted
successfully 108 h after amputation [17]. These differ-
ences in the time limit of limb ischemia seem to result
from the different methods of the experiments, but
there is agreement among these reports with regard to
the effect of hypothermia on the amputated limb.
In experiment 1, when the amputated limb was
cooled in ice water, 10 of 10 animals could tolerate 6h
and 8 of 10 survived 12h of limb ischemia. On the other
hand, only 8 of 15 animals survived when their limbs
"i F+ Intermittent perfusion
H H Continuous perfusion
Fig.9. Changes in lactate level. From [13], with permission
were subjected to 6h ischemia at room temperature.
It is reasonable to assume that the time limit of limb
ischemia is between 6 and 12 h if an amputated limb is
stored in ice water.
By cooling the ischemic limb, Paletta et al. [18] and
Eiken et al. [9] confirmed that the degree of limb edema
was decreased markedly. Mehl et al. [6] observed that
systemic acidosis was significantly prevented by cool-
ing. Meer et al. [19] and Kohama [11] reported that
potassium leakage from the ischemic limb was inhibited
when the environmental temperature of the experimen-
tal animals was low. On the basis of our observations,
cooling of the amputated limb certainly is effective for
prevention of limb edema, potassium leakage, and
lactate production from the replanted limb.
When time of ischemia was prolonged from 6 to 12 h,
changes in limb edema, potassium, pH, and lactate were
increased, and the survival rate of the dogs decreased.
From the result, it is logical to believe that limb edema,
hyperpotassemia, and metabolic acidosis have a close
relationship to replantation toxemia. Controversy con-
tinues as to which of them is most related to the devel-
opment of toxemia.
In experiment 1, the marked difference between the
dead and the surviving animals was in pH and lactate in
the blood. In the animals that died, systemic arterial pH
measurement showed a progressive fall accompanied by
an increase in lactate in the venous and arterial blood.
Although hyperpotassemia was observed in the animals
that died the increase in the potassium level was almost
110 C. Experimental Microsurgery
equal to that in the surviving dogs. Therefore, it is diffi-
cult to believe that hyperpotassemia is a main cause of
death. As for the edema of the replanted limb, the limb
weight of the surviving animals was rather greater than
that of those that died.
In experiment 2, perfusion of the amputated limb
with fluorocarbon was significantly effective in the pre-
vention of metabolic acidosis: the fall in pH (Fig. 7) and
the increase in lactate (Fig. 8) in the blood were signifi-
cantly prevented by perfusing the amputated limb with
fluorocarbon, especially in ice water. Conversely, there
was no significant difference in the changes in potassium
level of the arterial blood between the groups perfused
with fluorocarbon and the nonperfusion group. Limb
edema, occurred more among the groups that were per-
fused with fluorocarbon than in the nonperfusion group
(Table 6). The survival rate of the animals was also much
improved by perfusion of the amputated limb with
fluorocarbon. Darby [20], Thrower et al. [21), and
Wildenthal et al. [22] reported that marked decreases
in myocardial contractility and arterial blood pressure
were caused by infusion of lactate into dogs.
It therefore seems that metabolic acidosis due to
accumulation of lactate in the replanted limb plays an
important role in the development of replantation
toxemia. This is because lactate production in the ampu-
tated limb after 12h of ischemia is no longer inhibited,
even by cooling in ice water, and triggers a systemic
metabolic acidosis, which finally leads to replantation
toxemia.
References
1. Hoephner E (1903) Ueber Gefaessnaht, Gefassetrans-
plantationen und Replantation von amputierten Extrem-
itaeten. Arch Klin Chirm 70:417-471
2. Carrel A, Guthrie CC (1906) Complete amputation of the
thigh with replantation. Am J Med Sci 131:297-301
3. Lapchinsky A (1960) Recent result of experimental trans-
plantation of preserved limbs and kidneys and possible
use of this technique in clinical practice. Ann NY Acad
Assoc 64:539-571
4. Snyder CC, Knowles RP, Mayer PW, Hobbs JC (1960)
Extremity replantation. Plast Reconstr Surg 26:251-263
5. Onji Y, Murai Y, Tarnai S, Hashimoto T, Yamaguchi T,
Akiyama H, Tsujimoto A (1963) Experimental surgery on
resuscitation and reunion of amputated or nearly ampu-
tated leg. Plast Reconstr Surg 31:151-165
6. Mehl RL, Paul HA, Shorey W, Schneewind J, Beattie EJ
(1964) Treatment of "toxemia" after extremity replanta-
tion. Arch Surg 89:871-879
7. Tarnai S (1963) The experimental study on reunion
of amputated leg. J Jpn Orthop Assoc 37:375-382 (in
Japanese)
8. Fukunishi H (1968) Studies on cause of shock following
replantation of amputated extremity. J Nara Med Assoc
19:127-138
9. Eiken 0, Nabseth DC, Mayer RF, Deterling RA Jr (1964)
Limb replantation. Arch Surg 88:70-77
10. Kohama A (1969) Changes following recirculation of
ischemic leg. Cent Jpn J Orthop Traumat 12:555-580 (in
Japanese)
11. Onji Y, Kohama A, Tarnai S, Fukunishi H, Komatsu S
(1967) Metabolic alteration following replantation of
amputated extremity. J Jpn Orthop Assoc 41:55-63
12. Usui M, Ishii S, Muramatsu I, Takahata N (1978) An
experimental study on "replantation toxemia": the effect
of hypothermia on an amputated limb. J Hand Surg 3:
589-596
13. Usui M, Sakata H, Ishii S (1985) Effect of fluorocarbon
perfusion upon the preservation of amputated limbs.
J Bone Joint Surg 67B:473-477
14. Clark LC Jr, Gollan F (1966) Survival of mammals breath-
ing organic liquid equilibrated with oxygen at atmospheric
pressure. Science 152:1755-1756
15. Kamada N, CaIne RY, Wight DGD, Lines JG (1980)
Orthotopic rat liver transplantation after long-term
preservation by continuous perfusion with fluorocarbon
emulsion. Transplantation 30:43-48
16. Kowalewski K, Kolodej A (1977) Electrical and mechani-
cal activity of isolated canine stomach perfused with fluo-
rocarbon emulsion. Surg Gynecol Obstet 145:347-352
17. Report of the American Replantation Mission to China
(1975) Replantation Surgery in China. Plast Reconstr
Surg 52:476-489
18. Paletta FX, Wilman V, Ship AG (1975) Prolonged tourni-
quet ischemia of extremities. J Bone Joint Surg 42-A:
945-950
19. Meer CVD, Valkenburg PW, Ariens AT, Benthem RMJV
(1966) Cause of death in tourniquet shock in rats. Am J
Physiol 210:513-525
20. DarbyTD (1961) Effects of2-amino-2-hydroxymethyl-13-
propanediol during shock and catecholamine administra-
tion. Ann NY Acad Sci 92:674-686
21. Thrower WB, Darby TD, Aldinger EE (1961) Acid-base
derangements and myocardial contractility. Arch Surg 82:
76--85
22. Wildenthal K, Mierzwiak DS, Myers RW, Mitchell JH
(1968) Effects of acute lactic acidosis on left ventricular
performance. Am J PhysioI214:1352-1359
6. Skin and Muscle Flaps in the Rat
YUICHI HIRASE
With advances in microsurgical techniques and mate-
rials, it has been possible to investigate free transfer of
living tissue in great detail. Successful transfer has been
demonstrated in animals, especially in rats. Rats are
inexpensive and easy to keep in the laboratory, and their
anatomy and immunogenesis are relatively well under-
stood. Therefore, the rat is the most suitable animal for
experiments on microsurgery in the laboratory. Some
kinds of skin and muscle flaps have been especially
selected for experiments to develop microsurgical tech-
niques and investigate the effect of drugs.
In this report, a few representative flaps are presented
because of their availability for experiments. Some of
them have been developed for the practice of micro-
surgical techniques of free tissue transfer, and others
have been used for other purposes, for example, as a
model of allogeneic tissue transfer or a model of tissue
changes due to vascular disorders. The techniques for
harvesting flaps are described, and their history is
presented.
Materials
Rats weighing between 250 and 400 g are anesthetized
with pentobarbital intraperitoneal injection with an
initial dose of 40mg/kg, followed by 0.2-0.3mllh or as
needed.
Techniques for Harvesting Flaps
Epigastric Flap (Groin Flap)
The rat epigastric flap vascularized by the superficial
epigastric vessels has been the most available model of
a microsurgical flap in small animals. In order to raise
this flap, the vascular anatomy of the lower abdominal
area in the rat should be studied. The femoral vessels
are found beneath the inguinal ligament and divide into
the superficial epigastric vessels, which vascularize the
inferior abdominal wall (Fig. 1). The external diameters
of the femoral artery and vein are 0.9-1.0mm and
1.2-1.4 mm, respectively. The external diameters of epi-
gastric artery and vein are 0.3-O.5mm and 0.6-O.8mm,
respectively [1]. First, the flap, measuring 3 by 5 cm, is
outlined on the inferior abdominal region unilaterally.
The medial border of the flap is cut parallel to the
midline, and the abdominal wall is carefully reflected to
confirm its good vascular supply from the inferior epi-
gastric vessels (Fig. 2). The flap is then elevated by
cutting the other margins of the flap, and the inferior
epigastric and femoral vessels are identified for dissec-
tion. Lidocaine is dropped on these vessels for 10min to
relieve spasm. The distal part of the femoral vessels
dividing into the inferior epigastric vessels is ligated.
Now the flap is elevated completely and prepared for
harvesting for free tissue transfer.
Latissimus Dorsi and Serratus Muscle Flap
The thoracodorsal artery supplies the latissimus dorsi
and serratus anterior muscle in the rat, in the same
anatomical fashion as in the human. In the rat, the
thoracodorsal artery and vein average 0.57 mm and
0.71 mm in external diameter (Figs. 3 and 4) respec-
tively, at their origins and can be used as pedicles aver-
aging 19mm in length to the latissimus dorsi muscle and
27mm to the serratus anterior muscle [2]. Usually the
latissimus dorsi muscle is easier to elevate than the
serratus muscle (Fig. 5).
Hind Limb Replantation
This microsurgical model was initially developed to
study the transplantation of large amounts of tissue,
including bone, joint, muscle, and skin. The groin region
is opened first to identify the femoral artery and vein
(Fig. 6). The epigastric vessels and profunda femoris
vein are ligated to be cut. Microvascular clamps are then
applied to the artery proximal to the origin of the epi-
gastric artery and to the vein proximal to the profunda
vein. The femoral neurovascular bundle is cut. The
111
112 C. Experimental Microsurgery
Fig. 1. a Anatomy of the groin region in rat. b: 1 Epigastric
skin flap, 2 superficial epigastric vessels, 3 femoral vessels
Fig. 2. Good vascularization from bilateral epigastric vessels
in the abdominal wall
a b
Fig. 3. Elevation of latissimus dorsi muscle flap. a Incision. b
Anatomy: 1 latissimus dorsi muscle, 2 thoracodorsal vessels
femur is divided at the midpoint. All muscles are cut at
the mid-femur level. Now the hind limb is completely
amputated for transplantation. At reattachment
surgery, the limb is prepared by shortening the distal
femur by 2-3 mm to reduce the tension on the vascular
Fig.4. Distinct structure of thoracodorsal vessels coming into
the latissimus dorsi muscle
Fig. 5. Elevation of the latissimus dorsi muscle flap
a b
Fig. 6. Limb replantation model. a Amputation of limb. b: 1
Femoral vessels, 2 saphenous branch, 3 amputation line. c
After replantation by microsurgical anastomosis
anastomoses [3]. Bony fixation is achieved with an
intramedullary Kirschner wire, and the muscles are
repaired by suturing. The sciatic nerve is repaired with
epineural sutures of 10-0 nylon. The femoral vein is
anastomosed before the artery in order to minimize
 6. Skin and Muscle Flaps in the Rat 113

blood loss after arterial anastomosis [3]. The femoral

nerve is also sutured. Once adequate perfusion has been
established and the muscle has been sutured, the skin
incisions are closed.

Discussion
The free flap in the rat has great advantages as a model
for microsurgical experiments, because rats are easy
animals to deal with and are relatively inexpensive. The
vascular anatomy of the rat is consistent, and the dia-
meters of the vessels are suitable for practicing the
anastomosis technique. The epigastric skin flap and the
latissimus dorsi muscle flap [2] are especially suitable Fig. 7. Amputation of BN rat posterior limb and cryopre-
models of skin and muscle flaps for simulating clinical served artery and vein from Lewis rat as interposition for
reattachment
free flap procedures. The epigastric flap is usually trans-
ferred by microsurgical anastomosis of the femoral
vessels, because the larger vessels seem to give more
reliable surgical results [4]. However, Ruby et al. [1]
reported that the Acland technique [5,6], with the flap
based on the epigastric vessels, is a reliable model for
free transfer. This flap has been used for many purposes
in experiments, especially to study circulatory disorders
and the viability of skin flaps. Raskin et al. [7] and
Dickson and Sharpe [8] reported the importance of pH
monitoring when using the epigastric skin flap model in
rats. The author [9] also reported pH monitoring using
the epigastric skin flap and the latissimus dorsi muscle
flap in rats. Other papers report the availability of these
flaps in a vascular occlusion model [10-13] and a model
for tolerance of ischemic time [14]. In conclusion, these
findings demonstrate that these skin and muscle flap
models offer microvascular surgeons a simple and reli-
able approach to perfusion assessment of free flaps Fig. 8. A few weeks after replantation, complete survival is
in rats. seen without administration of immunosuppressive agents
De la Pena et al. [2] reported free transfer of the latis-
simus dorsi muscle and serratus muscle. They concluded
that these muscles were technically easier to transfer
and are a useful standard model for pharmacological
and biochemical studies in transplanted muscle. allogeneic joint transfer model [17-21]. The author [22]
Since Shapiro and Cerra [3] described the technique developed a technique for long-term cryopreservation
of rat hind limb reattachment, many microsurgical of vessels and nerves. On the basis of this model, the
reports have been published using this model. Most of availability and reliability of cryopreserved vessels and
them used this replantation model of immunological nerves were proved by their successful interposition in
allogeneic transfer. Doi [15] examined the effects of the reattachment of the. amputated hind limb [Figs. 7
administration of five types of immunosuppressive and 8].
drugs after allogeneic replantation of the hind limb, and In addition to these models, many microsurgical
showed the possibility of finger transplantation in models in the rat have been reported, and some of them
humans in the future. Lipson [16] described the are very useful for the development of surgical tech-
anatomy of the rat hind limb and reported the results niques before clinical trials [23]. These skin and muscle
of syngeneic grafts. flaps will become increasingly available in the future not
On the basis of these findings, some anatomical types only as replantation models but also for monitoring
of vascularized knee joint transfer were reported as an more complicated projects.
114 C. Experimental Microsurgery
References
1. Ruby LK, Greene M, Risitano G, Torrejon R, Belsky MR
(1984) Experience with epigastric free flap transfer in the
rat: Technique and results. Microsurgery 5:102-104
2. De-La-Pena JA, Lineweaver W, Buncke HJ (1988)
Microvascular transfers of latissimus dorsi and serratus
anterior muscles in rats. Microsurgery 9:18-20
3. Shapiro RI, Cerra FB (1978) A model for reimplantation
and transplantation of a complex organ: The rat hind limb.
J Surg Res 24:501-506
4. Strauch B, Murray DE (1967) Transfer of composite grafts
with immediate suture anastomosis of its vascular pedicle
measuring less than 1 mm in external diameter using
microsurgical techniques. J Plast Reconstr Surg 40:
325-329
5. Acland RD (1980) Microsurgical practice manual. c.v.
Mosby, St. Louis
6. Parsa FD, Spira M (1979) Evaluation of anastomotic tech-
niques in the experimental transfer of free skin flaps. Plast
Reconstr Surg 63:696--699
7. Raskin DJ, Erk Y, Spira M, Melissinos EG (1983) Tissue
pH monitoring in microsurgery: A preliminary evaluation
of continuous tissue pH monitoring as an indicator of per-
fusion disturbances in microvascular free flaps. Ann Plast
Surg 11:331-339
8. Dickson MG, Sharpe DT (1985) Continuous subcuta-
neous tissue pH measurement as a monitor of blood flow
in skin flaps: an experimental study Br J Plast Surg 38:
39-42
9. Hirase Y, Cho SH, Park BK, Kojima T (1991) Tissue pH
monitoring in microsurgery: Experimental model of
muscle, cutaneous flap in rats (in Japanese). J Jpn Soc
Microsurg 4:145-150
10. Harashina T, Sawada Y, Watanabe S (1977) The relation-
ship between venous occlusion time in island flaps and flap
survivals. Plast Reconstr Surg 60:92-95
11. Nakajima T (1978) How soon do venous drainage chan-
nels develop at the periphery of a free flap? A study in
rats. Br J Plast Surg 31:300-308
12. McKee NH, Clarke HM, Manktelow RT (1981) Survival
following vascular compromise in an island skin flap. Plast
Reconstr Surg 67:200-204
13. Su C-T, 1m MJ,Hoops JE (1982) Tissue glucose and lactate
following vascular occlusion in island skin flaps. Plast
Reconstr Surg 70:202-205
14. Ballantyne DL, Reid CA, Harper AD, Shaw WW (1980)
The effects of short-term preservation on microvascular
free groin flaps in rats. J Microsurg 2:101-105
15. Doi K (1979) Homotransplantation of limbs in rats. Plast
Reconstr Surg 64:613-621
16. Lipson RA, Kawano H, Halloran PF, McKee NH, Pritzker
KPH, Langer F (1983) Vascularized limb transplantation
in the rat. Transplantation 35:293-299
17. Yamaguchi T, Hamada Y, Akamatsu N, Sato H (1987)
Experimental study concerning allograft of vascularized
composite tissue (second report) (in Japanese). Jpn J
Transpl 22:463-468
18. Yamaguchi Y, Akamatsu N, Hamada Y, Sato H, Toshima
T, Hagino T (1989) Experimental study on vascularized
fresh whole joint allograft transplantation (in Japanese).
J Jpn Orthop Assoc 63:296--307
19. Yamaoka N, Tamai S, Mizumoto S (1997) Experimental
study of vascularized bone grafts in rat : Effect of
mechanical loading on bone dynamics. J Orthop Sci 2:239-
247
20. Black KS, Hewitt CW, Woodard TL, Adrig LM, Litke DK,
Howard EB, Achauner BM, Martin DC, Furnas W (1982)
Efforts to enhance survival of limb allografts by prior
administration of whole blood in rats using a new survival
end-point. J Microsurg 3:162-167
21. Tsucbida Y, Usui M, Naitoh T, Takahashi T, Murakami M,
Ueda T (1997) Limb allografts in rats treated with anti-
ICAM-1 and anti-LFA-1 monoclonal antibodies. J
Reconstr Microsurg 13:107-110
22. Hirase Y, Kojima T, Uchida M (1992) Cryopreserved allo-
geneic vessels and nerve graft : Hind limb replantation
model in the rat. J Reconstr Microsurg 8:437-443
23. Chiu DTW, Chen L, Chen Z-W (1990) Rat ear reattach-
ment as an animal model. Plast Reconstr Surg 85:782-788
7. Customized Neovascularized Prefabrication
in the Rat
YmCHI HIRASE
Neovascularization is an essential process in natural
wound healing, but the precise mechanism of neovas-
cularization is not well understood. On the basis of
this unknown consequence of wound healing, the
vascular implantation technique can be selected to
create customized neovascularized tissue for prefabri-
cation. This concept has been advanced by combination
with microsurgical technique to provide customized
tissue that specifically meets the size, contour, and tissue
type requirements of a given defect.
These types of flaps have been utilized both experi-
mentally and clinically. Neovascularization of a given
tissue was first described by Erol [1], who reported
neovascularization of a skin graft placed over a blood
vessel. After the required length of time had elapsed,
this neovascularized tissue was raised as a pedicled
flap for reconstruction of a burned ear. Shen [2] and
Hyakusoku [3] also reported similar clinical cases in
which a secondary axial pattern cutaneous flap was
created by implantation of a blood vessel under a
special type of skin. Shintomi [4] implanted a small pedi-
cled muscle flap instead of a vessel under the skin. Hori
and Tamai [5] used the vessel implantation technique
clinically for Kienbock's disease, to create neovascular-
ization in the non vascularized lunate. Experimentally,
Erol and Spira [6] and Erk et al. [7] created a musculo-
cutaneous flap by skin graft on the sartorius muscle, and
Erol and Spira [8] reported a technique to create a com-
posite tissue flap secondarily by skin graft over the
omentum. The author [9-15] also reported further
experimental investigations of this technique by creat-
ing many types of composite tissue, and confirmed the
utility of these secondary vascularized flaps for reliable
microsurgical free tissue transfer. On the basis of these
reports, some representative types of neovascularized
prefabricated flaps are described, and their potential in
the field of microsurgery is discussed.
Representative Studies
Neovascularized Muscle Flap
A laterally based external abdominal oblique muscle
flap, 1.5cm in width x 2.5cm in length, was elevated in
the groin region. The inferior epigastric artery and vein
were isolated to be wrapped by the muscle flap (Fig. 1).
Two weeks later, even after the base of the muscle flap
had been out, good bleeding was observed on the
surface of the muscle flap because of neovasculariza-
tion. The muscle flap could be harvested with the neo-
vascularized pedicle and successfully transferred as a
free flap (Fig. 2) [16].
Pedicle Variations
This study [15] was performed to determine whether
the type of implanted vascular pedicle influenced the
amount of neovascularization when the initial muscle
flap was used. The inferior epigastric vessels were
enveloped by the muscle flap, either passing through it
(flow-through) or tied at the distal end of the pedicle
(non-flow-through). In the flow-through type, artery-
only and vein-only pedicle groups were also made. In
each type, the inferior epigastric artery and vein were
isolated with or without perivascular areolar tissue as
subgroups. In addition to these groups, an arterial-
venous fistula was created by anastomosis between the
inferior epigastric artery and vein in an end-to-end
fashion also to be implanted into the muscle flap (Fig.
3). Two weeks later, the base of the muscle flap was
cut, and the neovascularized muscle flap supplied by the
inferior epigastric vessels was harvested, including the
femoral artery and vein, which were anastomosed end-
to-end to the contralateral femoral vessels. Three days
after transfer, the muscle flap was harvested again for
histologic examination and demonstration of the vascu-
lar tree model by latex intravascular injection. The
degree of neovascularization was evaluated on the basis
of these results.
As a result (Table 1), flow-through artery and vein
pedicles appeared to result in the best neovasculariza-
tion, and slightly less neovascularization was observed
in the artery-only and arterial-venous fistula pedicle
groups. A small amount of neovascularization was
evident in non-flow-through artery and vein pedicles
and in artery-only pedicles. No muscle flaps were suffi-
ciently neovascularized for harvesting in the vein-only
pedicle group. The removal of perivascular tissue
115
116 C. Experimental Microsurgery

b
a a
I

,,'/
-
~

""i
::
;;
-::
:? /:
~ ~
I

d
c
3J
~ .,..
~
/ ./
./
/
~/
,
Fig. 1. a Incision. b 1 Oblique abdominal muscle flap, 2 infe-
rior epigastric artery and vein, 3 femoral artery and vein. Fig. 3. Muscle flap preparation. a Flow-through artery and
c Preparation of flap. d Completion of the first stage vein type. b Flow-through artery type. c Non-flow-through
artery and vein type. d Arterial-venous fistula type

Table 1. Muscle flaps with pedicle variations

Flow-through Non-flow-through
Flap type w. w/o. w. w/o.
AN E E E B
A G B P B
V B B
A-V E E

w., With areolar tissue;

w/o., without areolar tissue;
AN, artery and vein;
A, artery only;
V, vein only;
A-V, arterial venous fistula;
E, excellent;
G,good;
Fig. 2. Postoperative condition of microsurgical free transfer P, poor;
B, bad.

resulted in thrombosis in the artery-only, non-flow- bundle is sandwiched between the muscle flap and the
through pedicle group. cutaneous flap (Fig. 4).

Myocutaneous and Osteomyocutaneous
Flaps
Myocutaneous Flap
A laterally based cutaneous flap is elevated in the epi-
gastric region [14]. A laterally based muscle flap from
the external abdominal oblique muscle equal in size to
the cutaneous flap is then elevated. The inferior epigas-
tric artery and vein are then isolated, and the vascular
Osteomyocutaneous Flap
A full-thickness bone fragment is harvested from the
iliac crest [14]. The inferior epigastric vessels are dis-
sected in the groin region. The iliac crest bone frag-
ment is bivalved like a clam, and the inferior epigastric
vascular bundle is sandwiched between the halves of
the bone fragment (clamp flap) [10]. This clam flap
is then sandwiched between the cutaneous flap and
the abdominal muscle flap, as described before (Fig.
5).
 7. Customized Neovascularized Prefabrication in the Rat 117

Fig.4. Myocutaneous flap preparation. a Incision. b 1 Muscle

flap, 2 skin flap, 3 superficial inferior epigastric vessels, 4 Fig. 6. Postoperative condition of microsurgical free transfer
femoral vessels. c Elevation of muscle and skin flap for wrap-
ping. d Completion of myocutaneous flap. e Free transfer in
second stage

Fig. 5. Clam-muscle flap preparation. a The vascular pedicle

is placed between the two halves of the iliac crest bone that
are then approximated loosely. b A muscle flap is elevated.
c The iliac crest bone with the vascular pedicle is wrapped Fig. 7. Myocutaneous flap demonstrates viable muscle and
by the muscle flap. d In the second stage, the vascular pedicle skin. (x62.5) (See Color Plates)
and the muscle flap is cut and transferred to the contralateral
side with vascular anastomosis

Two weeks later for the myocutaneous flap and 3
weeks later for the osteomyocutaneous flap, each flap is
dissected to be harvested with the vascular pedicle of
the femoral artery and vein. Neovascularization is con-
firmed by bleeding from the surface of the muscle flap
even after transection of muscle and cutaneous flaps
from their origin. This neovascularized flap is then free
transferred with end-to-end anastomosis to the con-
tralateral femoral vessels (Fig. 6). This flap is rehar-
vested 3 days after transfer to confirm its survival and
neovascularization by histologic examination (Fig. 7).
Fat Flap
A pedicle flap of abdominal fat is made in the lower
abdominal region. This fat flap is used to wrap the iso-
lated inferior epigastric vascular bundle gently. The
edge of the fat flap is sutured, and the fat flap and vessel
preparation is wrapped with a sheet of Marlex mesh
[12] (Fig. 8).
Two weeks later, the base of the fat flap is cut. Neo-
vascularization is confirmed by observation of bleeding
from the surface of the flap. This neovascularized fat flap
118 C. Experimental Microsurgery
a b
Fig. 8. Fat flap preparation. a The vascular pedicle is wrapped
by the pedicled fat flap. b The entire flap and vessel prepara-
tion is wrapped with a Marlex mesh sheet. c In the second
stage, the flap was harvested and transferred to the contra-
lateral femoral vessels as a free flap
Fig. 9. Postoperative condition of microsurgical free transfer.
(See Color Plates)
is harvested with the femoral vascular bundle and trans-
ferred to the contralateral femoral vessels. One week
later, the transferred flap is harvested again, and the
Marlex mesh sheet is removed (Fig. 9). The viability of
the flap is examined by histologic study (Fig. 10).
Arterial Venous Neovascularization of Flaps
On the basis of the concept of neovascularization, inter-
position of a vein graft between the artery and vein can
be used as the implanted vascular bundle. It is possible
to create neovascularized skin, muscle, and osseous flaps
for free transfer [13]. In this report, the neovascularized
Fig. to. Fat flap demonstrates viable fat. (x62.5)
muscle flap is made by the vein grafted arterial venous
fistula as the representative flap.
Skin Flap
An H -shaped incision is made in the lower abdomen,
and a cephalically based 3 x 1 cm abdominal flap is
raised. The external oblique muscle and the inferior epi-
gastric vessels are identified. The epigastric vein is dis-
sected in the groin region, and a segment 2cm in length
is harvested as a vein graft. The vein graft is anasto-
mosed to the epigastric artery of the right groin and the
epigastric vein of the left groin region. An arterial-
venous fistula with interposition vein graft is thus made.
The wound is closed by the abdominal skin flap over the
arterial-venous fistula (Fig. lIa and b). Two weeks
later, the skin flap is isolated as an island flap with the
arterial-venous fistula as a vascular pedicle (Fig. lIc),
and the epigastric vessels are dissected in both groin
regions. The neovascularized skin flap is harvested by
division of the fistula at the femoral vessel level. The flap
is "switch" transferred by rotating it 180 degrees, and
the arterial-venous fistula is anastomosed end-to-end
to the contralateral epigastric artery and vein. These
anastomoses must be performed to maintain blood flow
through the graft in the same relative direction (Fig.
lId). This means that the original anastomosis of the
right epigastric artery is connected to the left epigastric
artery, and that of the left epigastric vein is connected
to the right epigastric vein (Fig. 12).
 7. Customized Neovascularized Prefabrication in the Rat
a b
1st Stage
c d
2nd Stage
Fig. 11. Vein-grafted skin flap preparation. a Construction of
arterial-venous fistula by vein graft between both sides of epi-
gastric vessels. b complete construction. c skin flap elevation.
d switch transferred
Fig.12. Postoperative condition of microsurgical free transfer
Three days later, the transferred neovascularized flap
is harvested again for histologic examination to confirm
its viability (Fig. 13).
Discussion
Microsurgical tissue transfer is an essential procedure in
reconstructive surgery. However, it has some disadvan-
tages because of the limitation of available donor sites
and loss of donor site function. Therefore, development
of the neovascularized flap technique has tremendous
potential, because it could greatly expand the appli-
cability of microsurgical transfers. The technique of
119
Fig. 13. Vein-grafted skin flap demonstrates viable condition.
(xIS)
creating vascularized composite tissue by implantation
of a vascular bundle into the combined tissue has great
potential, not only in clinical practice but also as an
experimental model to investigate the wound healing
process. If the growth factor for new vascular forma-
tion is elucidated, it may become possible to develop
agents promoting vascularity and anti-growth agents for
tumors. In such studies, the neovascularized flap may be
the ideal experimental model.
In the field of clinical surgery, the concept of the
neovascularized flap often appears complicated. The
concept of the neovascularized flap is understood to
have two meanings. One is the combination of various
kinds of vascularized tissue, and the other is the combi-
nation of non vascularized bone graft or skin graft with
vascularized tissue. The former should be called the
"real neovascularized flap" and the latter the "graft
flap" or "implant flap." In the history of the develop-
ment of flaps in the pursuit of a thinner flap, the graft
flap may have the greater possibility in clinical practice,
because it has a wider range of donor sites, and a very
thin flap can be created by combining multiple types
of tissue in spite of having an axial pattern flap. The
concept of the graft flap has developed recently in the
field of tissue engineering to produce tissue using arti-
ficial agents in the field of vascularization [17,18].
Although it has the disadvantage of requiring surgery
twice, the surgical technique is simple, and the tem-
poroparietal fascia is often used as the vascularized
120 C. Experimental Microsurgery
material in combination. Khouri et al. [19] reported a
case of neovascularized joint transfer from the toe to
the hand by wrapping the joint with temporoparietal
fascia as prefabrication. In order to obtain a thinner skin
flap for prefabrication, some interesting experimental
and clinical studies have been performed using a tissue
expander [20,21].
In the meantime, the microsurgical technique has
been used for the majority of allogeneic tissue transfers
in clinical practice. There are some experimental and
clinical reports of cryopreserved allogeneic tissue trans-
fer. The author has reported the technique of cryop-
reservation [22] for experimental allogeneic transfer.
The successful transfer of long-term cryopreserved
artery and vein in monkeys [23] provides especially
good evidence of the reliability of this technique. In the
transfer of cryopreserved vessels, nerve, and dermis, it
has become clear that the administration of immuno-
suppressive agents is not necessary, even in allogeneic
transfer, because the antigenicity of tissue is reduced by
freezing. On the basis of these data, it became possible
to use cryopreserved allogeneic vessels as a vascular
implant for making a neovascularized flap [24].
The process of neovascularization is not clear, but the
technique of creating a neovascularized prefabricated
flap has great potential experimentally and clinically.
This technique will be important for the advancement
of studies of tissue engineering and allogeneic tissue
transfer.
References
1. Erol 00 (1976) The transplantation of a free skin graft
into a vascularized pedicle flap. Plast Reconstr Surg 58:
470--477
2. Shen TY (1981) Vascular implantation into skin flap:
Experimental study and clinical application. A prelimi-
nary report. Plast Reconstr Surg 68:404--409
3. Hyakusoku H, Okubo M, Umeda T, Fumiiri M (1987) A
prefabricated hair-bearing island flap for lip reconstruc-
tion. Br J Plast Surg 40:37-39
4. Shintomi Y, Ohura T (1982) The use of muscle vascular-
ized pedicle flaps. Plast Reconstr Surg 70:725-734
5. Hori Y, Tarnai S, Okuda H, Sakamoto H, Takita T,
Masuhara K (1979) Blood vessel transplantation to bone.
J Hand Surg 4:23-33
6. Erol 00, Spira M (1980) Secondary musculocutaneous
flap: An experimental study. Plast Reconstr Surg 65:
277-282
7. Erk Y, Rose FA, Spira M (1983) Vascular augmentation
of skin and musculocutaneous flap. Ann Plast Surg 10:
341-334
8. Erol 00, Spira M (1980) Development and utilization of
a composite island flap employing omentum: Experimen-
tal investigation. Plast Reconstr Surg 65:405--418
9. Hirase Y, Valauri FA, Buncke HJ, Newlin LY (1987)
Customized prefabricated neovascularized free flaps.
Microsurgery 8:218-224
10. Hirase Y, Valauri FA, Buncke HJ (1988) Neovascularized
bone, muscle, and myo-osseous free flaps: An experimen-
tal model. J Reconstr Microsurg 4:209-215
11. Hirase Y, Valauri FA, Buncke HJ (1988) Neovascularized
free cutaneous cartilage flap transfer with microsurgical
anastomosis: An experimental model in the rabbit. Ann
Plast Surg 21:342-347
12. Hirase Y, Valauri FA, Buncke HJ (1988) Neovascularized
free fat flaps: An experimental model. J Reconstr Micro-
surg 4:197-201
13. Hirase Y, Valauri FA, Buncke HJ (1989) Creation of
neovascularized free flaps using vein grafts as pedicles: A
preliminary report on experimental models. Br J Plast
Surg 42:216-222
14. Hirase Y, Valauri FA, Buncke HJ (1988) Prefabricated
sensate myocutaneous and osteomyocutaneous free
flaps: An experimental model. Preliminary report. Plast
Reconstr Surg 82:440--443
15. Valauri FA, Hirase Y, Buncke HJ (1988) Prefabricated
neovascularized free muscle flaps: Pedicle variations. J
Reconstr Microsurg 4:203-207
16. Duarte A, Valauri FA, Buncke HJ (1987) Creating a free
muscle flap by neovascularization: An experimental inves-
tigation. J Reconstr Microsurg 4:15-18
17. Hirase Y, Valauri FA, Buncke HJ (1989) An experimental
model for ear reconstruction with moulded perichondrial
flaps. Br J Plast Surg 42:223-227
18. Isogai N, Landis W, Kim TH, Gerstenfeld LC, Upton J,
Vacanti JP (1999) Formation of phalanges and small
joints by tissue-engineering. J Bone Joint Surg (Am) 81:
306-316
19. Khouri RK, Upton J, Shaw WW (1991) Prefabrication of
composite free flaps through staged microvascular trans-
fer: An experimental and clinical study. Plast Reconstr
Surg 87:108-115
20. Homma K, Sugihara H, Ohura T (1995) Fascia-
vascularized vs. muscle-vascularized prefabricated flaps
using tissue expanders: An experimental study in a rat
model. J Reconstr Microsurg 11:221-229
21. Khouri RK, Ozbek MR, Hruza GJ, Young VL (1995)
Facial reconstruction with prefabricated induced ex-
panded (PIE) supraclavicular skin flaps. Plast Reconstr
Surg 95:1007-1017
22. Hirase Y, Kojima T, Takeishi M, Kwang KH, Tanaka M
(1993) Transplantation of long-term cryopreserved allo-
cutaneous tissue by skin graft or microsurgical anasto-
mosis. Plast Reconstr Surg 91:492-501
23. Hirase Y, Kojima T, Takeishi M, Matsui M, Terao Y (1996)
Long-term cryopreserved allogeneic nervous and vascular
tissue transfer in monkeys. J Microsurg 17:301-305
24. Hirai T, Manders EK, Hughes K, Oki K, Hyakusoku H
(1996) Experimental study of allogeneically vascularized
prefabricated flaps. Ann Plast Surg 37:394-399
8 Vascularized Tibiofibular Graft in the Rat
SHIGERU MIZUMOTO and T AKESHI KOHNO
Recent advances in microvascular surgery have made
it possible to reconstruct large skeletal defects with
autogenous bone grafts on a vascular pedicle. In 1975,
Taylor et al. [1] published the first clinical cases of vas-
cularized fibular grafts for reconstruction of lower limbs
damaged by trauma. Other clinical reports followed,
and the use of vascularized fibular grafts became a well-
established method for solving difficult reconstructive
problems involving the extremities [2,3]. The iliac crest
[4], rib [5], and scapula [6] became alternative sources
of vascularized bone grafts. However, the vascularized
fibula is most widely used in cases in which there are
large skeletal defects of the extremities, because of its
available length, straight shape, and strong cortical
structure [7,8].
Vascularized bone grafts show more rapid union,
incorporation, and hypertrophy than conventional bone
grafts, as described in many clinical reports [2,3,7,8].
Postoperative hypertrophy of the grafts [9-12] is of
particular interest to us. The younger the patient, the
more prominent and rapid the hypertrophy of the graft.
Hypertrophy was more prominent in grafts to the
lower extremities than in grafts to the upper extremi-
ties. However, few reports of its etiology have been
described in experimental studies. In order to clarify the
etiology of postoperative graft hypertrophy, we per-
formed the following experiments using vascularized
tibiofibula grafts in rats.
Anatomical Study of the
Murine Tibiofibula
To investigate the vascular anatomy in the bones of the
murine lower limbs, micro angiography was performed
through the abdominal aorta, using a 25 % Micropaque
solution. Microangiograms showed that the principal
nutrient artery come from the posterior tibial artery
and entered into the medullary canal at the midshaft
of the tibia posteriorly. It then supplied several ascend-
ing branches and a few descending branches in the
intramedullary canal of the tibia. The periosteal blood
supply to the lateral and posterior cortex of the tibia
came mainly from the posterior tibial artery, and perio-
steal branches to the medial cortex came from the
great saphenous arteries (Fig. 1a). Additionally, an arte-
rial corrosion cast of the murine tibiofibula was made
with Batson's No. 17 Anatomical corrosion compound.
The arterial corrosion cast revealed the intramedullary
arterial system in detail (Fig. 1b).
These anatomical studies support the feasibility of
transferring the tibiofibula with microvascular an-
astomoses on the femoral vascular bundle, preserv-
ing the nutrient system through the periosteal and
intramedullary blood supply.
Experiment I. An Isologous
Tibiofibular Graft with or without
Revascularization [12,13]
In order to understand the bone kinetics involved after
vascularized transfer, a series of animal experiments
was carried out using a vascularized or nonvascularized
tibiofibula model in inbred rats.
Seventy-four 7-week-old Fischer strain F 344 rats,
weighing an average of 160 g, were used. Fifty rats were
used for isologous vascularized grafts (group 1), and 24
rats were used as two control subgroups (groups 2A
and 2B). Group 2A underwent a procedure designed to
simulate a conventional bone graft, in which the
tibiofibula from the donor was denuded subperiosteally
and grafted to the recipient's leg. The treatment of group
2B was designed to simulate a case of failed revascular-
ization in the vascularized transfer. The tibiofibula with
surrounding soft tissue and vessels was grafted to the
recipient without microvascular anastomoses.
Methods
Under general anesthesia with pentobarbital sodium
intraperitoneally, the right tibiofibula was isolated on
the femoral vascular bundle from a donor rat. The
121
 122 C. Experimental Microsurgery

Fig. 1. a Microangiogram of a
cross section at the proximal
one-third of the murine leg
showing the periosteal blood
supply from the dominant arter-
Gr.n ies. b Photograph showing a
TIbia corrosion cast of the
intramedullary arteries of the
tibia. (From [13], with permis-
AnI. tibial a. sion)
Post. IIblll I .

Fibula

Sural .

In recipient rats, the right tibia shaft, approximately

Popliteal a & v
Saphenous a & v
Fig. 2. Schematic diagram showing the experimental proce-
dure of the vascularized tibiofibular graft to the bone defect
in the recipient tibia (group 1). (From [13], with permission)
femoral artery and vein were dissected freely, keeping
the musculature just around the tibiofibula intact.
The knee joint was disarticulated and the proximal epi-
physis was completely removed, whereas the distal dia-
physis was transected just distal to the tibiofibular
synostosis.
25 mm in length, was removed to make a recipient bed.
The completely isolated donor tibiofibula with its vas-
cular bundle was transferred orthotopically. The bone
was fixed to the recipient bone by O.6-mm Kirschner
wires or miniscrews with additional wiring. In the
experimental animals in group 1, microvascular anasto-
moses were performed under a microscope at the
mid thigh (Fig. 2). No cast immobilization was applied
postoperatively.
In group 2A, the donor tibiofibula was isolated as
a conventional bone graft and transplanted to a bony
defect in the recipient tibia. In group 2B, the graft was
prepared as in group 1 and was transplanted to the
recipient tibia without microvasular anastomoses.
To evaluate the bony union, roentgenography
was done once a week postoperatively. Fluorochrome
bone markers were administered to examine new bone
formation. All donor animals were given calceine (15
mg/kg i.m.) 5 days preoperatively, and xylenolorange
(90mg/kg i.v), tetracycline (50mg/kg i.m), and calceine
(15mg/kg i.m.) were administered to recipients in
accordance with the protocol shown in Table 1. Five
days after the final administration, the animals were
sacrificed and micro angiography was performed to
determine the patency of the anastomoses.
Specimens were taken from the midshaft of the
grafted bone and immediately fixed with ethyl alcohol.
The specimens were bisected transversely with a
micro bone saw. The proximal half was prepared for a
fluorochrome labeling study, stained with Villanueva
 8. Vascularized Tibiofibular Graft in the Rat 123

osteochrome bone stain, and embedded in methyl were significantly higher in group 1 and than in group
methacrylate. These sectioned undecalcified specimens 2A in the second week (p < 0.05), in group 1 than in
were observed under a fluoromicroscope. The distal group 2B in the second and third weeks (p < 0.01), and
half was decalcified with EDTA (ethylenediaminete- in group 2A and than in group 2B in the third week
traacetic acid), embedded in paraffin, and stained with (p < 0.01). However, at the site of distal osteosynthesis,
hematoxylin and eosin for light microscopy. there were no significant differences among the three
groups. The delay in bony union at the distal osteosyn-
thesis may be due to methodological differences in the
Results osteosynthesis between proximal and distal sites.
Bony Union
To assess the bony union on roentgenograms after
transplantation, 13 rats in group 1,12 rats in group 2A,
and 12 rats in group 2B were followed up (Fig. 3). The
expected bony union rates in each group were calcu-
lated by the life table method (Fig. 4). The expected
bony union rates at the site of proximal osteosynthesis

Table 1. Experimental protocol for fluorochrome bone

labeling (experiment I)
Week
Subgroup -1 1 3 5 7
A Ca Xo Tc
B Ca Xo Tc Ca lw 3w 5w
C Ca Xo Tc Ca Tc
Fig. 3. Roentgenograms of the graft in group 1 (vascularized
Ca, Calcein (15mg/kg Lm.); Xo, xylenol orange (90mg/kg Lv.); Tc,
tetracycline (50mglkg Lm.).
graft). 1w 1 week after transfer; 3w 3 weeks after transfer,
Animals were sacrificed 5 days after the last labeling. bony union was observed at the proximal and distal sites of
osteosynthesies; Sw 5 weeks after transfer

100% 100%

C'
o
::J
CD
................A
c:
::J
o /S.
::J

~
CD

p./(~-----------o
#/:.. /tf.'
..
:...
/ ,

2 3 4 5 7ws 2 3 4 5 7ws
proximal side distal side

Fig. 4. The expected bone union rate was calculated by the from the data. (e) Group 1, (.6) group 2A, (0) group 2B.
life-table method. Rats with unsatisfactory bone union and "* P < 0.01, @ p < 0.05
with questionable union on the roentgenograms were omitted
 124 C. Experimental Microsurgery

Ant

Post
a b

Fig. 5. a Fluoromicrograph and schematic diagram of an
un decalcified cross section of a graft in group 1 after 3 weeks
showing significant new bone formation on the anteromedial
convex of the tibia (x20). The diagram shows the fluo-
rochrome stains. Xo, Xylenol orange; Ca, calceine; Tc, tetra-
cyeline. b Photomicrograph of a graft in group 1 3 weeks after
the operation, showing marked proliferation of osteoblasts
and newly formed osteoid tissue under the periosteum (xlOO).
P, Periosteum; C, cortex; M, bone marrow. (See Color Plates)

Histological Changes
In group 1 (vascularized group) 3 weeks after trans-
plantation, marked new bone formation with prolifer-
ating osteoblasts was observed, with no evidence of
degenerative changes or necrosis of the cortex or
marrow tissue. Fluorochrome bone studies showed
that a large amount of woven bone was located at the
periosteal side of the anteromedial cortex and at the
endosteal side of the posterolateral cortex of the tibia,
with diffuse and wide staining of the fluorochrome (Fig.
5a). Light microscopy showed wide osteoid tissues and
numerous pumped osteoblasts under the periosteum at
the side of new bone formation (Fig. 5b).
After 5 weeks, the previously formed callus became
a dense cortex, and the amount of newly formed bone
decreased. Fluorochrome labeling showed consistent
lamellar bone formation with a continuous line from the
last fluorochrome, and a little bone resorption with dis-
ruption of the preceding fluorochrome in some portions.
After 7 weeks, the findings were similar to those after Fig. 6. Fluoromicrograph of undecalcified cross section of a
5 weeks. Fluorochrome stains showed continuous lamel- graft in group 1 after 7 weeks, showing less newly formed bone
lar bone formation with parallel fluorochrome lines and than after 3 weeks. Black arrows indicate new bone formation,
a little bone resorption (Fig. 6). These findings indicated and white arrows indicate the resorption surface. (See Color
that the remodeling had taken place 3 weeks after Plates)
transplantation.
In control group 2A after 3 weeks, most of the grafted After 5 weeks, each graft showed a considerable
bone appeared dead. On the periosteal surface, bone amount of new bone formation and proliferation of
resorption with invading granulomatous tissue was osteoblasts. However, most grafted bone appeared
observed. The marrow cavity was replaced with fibrous dead. After 7 weeks, the majority of lacunae were occu-
tissue. A small amount of new bone formation was seen pied with osteocytes. Necrotic bone was enveloped by
on the periosteal surface. lammelar bone, as determined by the linear uptake of

fluorochrome. The marrow cavity was replaced with
adipose tissue.
In control group 2B more than 3 weeks after the oper-
ation, the cortical structure of the grafted bone had
not undergone any regenerative changes. Osteocytes
were pyknoted or disappeared from the lacunae, and
the bone marrow was resorbed following transplanta-
tion. The aseptic inflammatory process of the surround-
ing muscle evolved from the recipient site. Scant
fluorochrome uptake was observed.
After 5 weeks, there was very little evidence of
osteoblast proliferation or appositional bone formation.
Most grafted bone appeared dead. After 7 weeks, bone
resorption and appositional bone formation progressed,
but the fluoromicrograph showed a low amount of
uptake.
In comparison with the two control groups, histolog-
ical study showed a significant delay in tissue degener-
ation and vascular incorporation in group 2B, simulating
failed revascularization. These results indicated that
when the vascular anastomoses fail in the vascularized
bone graft, the necrotized soft tissue may act as a barrier
to new vascular infiltration.
Discussion
Microvascular transfer of murine tibiofibula is a good
experimental model for the study of autogenous or allo-
geneic bone transfer using a microvascular technique.
Since the life cycle of the rat is significantly shorter than
that of other experimental animals, such as dogs or rab-
bits, the course of bone degeneration in the graft can
be observed with a relatively short follow-up period
after surgery. This model is good for studying auto-
transplantation or allotransplantation of bone between
animals of different strains or the same strain, since the
histocompatibility among the rat strains has been well
established. In addition, the rat is easier to handle for
surgery and feeding than other animals, such as rabbits
or dogs.
The results of roentgenographic assessment of bony
union indicated that the vascularized bone graft was
superior to the conventional bone graft in bony union.
However, if the revascularization of the graft failed
because of thrombosis, the bony union was delayed due
to the barrier effect of the necrotic muscular sleeve
around the grafted bone, as seen in group 2B. The supe-
riority of a vascularized, living bone graft is evident not
only in bony union, but also in rapid new bone forma-
tion that was confirmed experimentally.
Two different stages of hypertrophy emerged through
histological studies of the vascularized groups. The vas-
cularized bone grafts showed significant new bone for-
8. Vascularized Tibiofibular Graft in the Rat 125
Fig. 7. Fluoromicrograph and schematic diagram of an unde-
calcified cross section of a normally growing tibia labeled
every 3 weeks (x20). Fluorochrome bone labeling indicates
new bone formation (black arrows) and resorption (white
arrows). Large arrow shows the direction of "drift." (See Color
Plates)
mation in the early stage (1 to 3 weeks postoperatively).
The newly formed bone consisted of woven bone with
markedly proliferating os teo blasts beneath the perios-
teum and the endosteum. In the late stage (more than
5 weeks after surgery), fluorochrome labeling showed
that consistent lammelar bone formation and some
resorption had taken place in different portions of each
specimen. The characteristic findings of lamellar bone
formation and bone resorption indicated that remodel-
ing restarted 3 weeks after transplantation in alterna-
tive ways in each vascularized tibia graft to adapt to the
new dynamic environment.
We found a tendency toward cross-sectional bone
growth in vascularized grafts. In each vascularized tibia
specimen in the early stage, new periosteal bone for-
mation was always found at the anteromedial aspect of
the tibia but was rarely seen on other periosteal sur-
faces. The new endosteal bone formation was always
observed at the posterolateral aspect of the tibia. Figure
7 shows a cross section of normally growing tibia. Con-
sistent new bone formation can be seen anteromedially,
and endosteal new bone formation can be seen pos-
terolaterally. Multiple fluorochrome labeling demon-
strated that normal bone growth had a tendency to shift
from a posterolateral to an anteroromedial direction.
The shape of bone was maintained by new bone for-
mation and associated bone resorption. This phenome-
non was called the "drift phenomenon" by Frost [14].
In the vascularized group, marked and rapid new
bone formation, which was observed in the early stage
after transplantation, had a tendency to "drift" to the
ante rome dial direction in the same manner as that ob-
served in the normal tibia. The amount of newly formed
bone and the number of proliferated osteoblasts in the
126 C. Experimental Microsurgery

vascularized tibia were a few times greater than that in Results

normally growing tibia. These histological and morpho-
logical findings indicated that some stimulation had Group 1 (Weight-Bearing)
taken place to the bone-forming surface of the graft
Multiple fluorochrome labeling studies demonstrated
through transplantation with microsurgical revascular-
that the vascularized tibia showed marked periosteal
ization. The stimulation was maintained for 2 or 3 weeks
new bone formation at the anteromedial aspect of the
after surgery. Thereafter, biomechanical factors may
tibia and endosteal new bone formation at the postero-
have influenced the remodeling process of the vascu-
lateral aspect after 3 weeks, as seen in experiment I.
larized bone grafts.
After 5 weeks, additional new bone formation at the
ante rome dial aspect of the tibial cortex was not seen, and
thereafter the site of new bone formation changed to the
Experiment II. Tibiofibular Grafts with other part of the cortex, as described in experiment I.
or without Mechanical Loading After 10 weeks (Fig. 8a) and 15 weeks (Fig. 8b), the
direction of cross-sectional bone growth changed to the
alternative direction, and transformation of the trian-
Experiment II was designed to study the influence
gular shape of the original tibia was seen in accordance
of mechanical loading on vascularized bone grafts
with slow and consistent lamellar bone formation and
using syngeneic tibiofibular grafts in rats. The rats were
associated bone resorption.
divided into two groups. Group 1 (60 rats, weight-
bearing group) had an isologous tibiofibular graft to the Group 2 (Non-Weight-Bearing)
leg, and group 2 (60 rats, non-weight-bearing group) had
a vascularized graft to the abdominal subcutaneous In group 2, with vascularized grafts to the abdominal
space. subcutaneous space, the initial hypertrophy at the
anteromedial aspect of the cortex was similar to that of
group 1 in the early stage (Fig. 9). No clear difference
Methods in the shape or amount of newly formed bone was
observed in group 1.
The tibiofibular graft was prepared from the donor rat After 5 weeks, significant bone resorption resulted in
in the same manner as in experiment I. In group 1, the a disappearance of the preexisting cortical area in some
graft was transferred to a 25-mm bony defect in the parts, identified by fringing of the fluorochrome admin-
recipient tibia orthotopically, with microvascular anas-
tomoses. The bone was fixed to the recipient tibia by
Kirschner wire or miniscrews with additional wiring. In
group 2, the vascularized tibiofibula was transferred
to the abdominal subcutaneous space to investigate the
fate of the graft under non-weight-bearing conditions.
No cast immobilization was applied postoperatively.
The rats were given fluorochrome as shown in Table
2 and followed for a maximum of 15 weeks. Specimens
were prepared for hematoxylin and eosin staining and
undeca1cified Villanueva osteochrome staining.

Table 2. Experimental protocol for fluorochrome bone

labeling (experiment II) H,b
Week
Subgroup -1 1 3 5 7 10 15
Fig. 8. a Fluoromicrograph of undecalcified cross section in a
graft in group 1 after 10 weeks, showing continuous new bone
A Ca Xo Tc formation located medially and laterally in the endosteal side,
B Ca XO Tc Ca and located posteriorly in the periosteal side. The direction of
C Ca XO Tc Ca Tc "drift" has changed to the posterolateral. b Fluoromicrograph
D Ca XO Tc Ca Tc Ca
Ca XO Tc Ca Tc of an undecalcified cross section of a graft in group 1 after 15
E Ca Tc
weeks, showing continuous new bone formation and resorp-
Abbreviations as in Table 1. tion resulting in transformation from the original triangular
Animals were sacrificed 5 days after the last labeling. shape. (See Color Plates)

ant.
Tc
Xo
Ca
Tc
XO
Ca
a
Fig.10. Fluoromicrograph of an undecalcified cross section of
a graft in group 2 after 5 weeks. Arrows indicate significant
bony resorption in the periosteum. In the opposite endosteum,
rapid new bone formation compensates for the loss of bone.
(See Color Plates)
istered previously (Fig. 10). After 7 weeks (Fig. 11a),
marked bone resorption was observed in most sites of
the periosteum, with a small amount of new lamellar
bone formation at the endosteum site. The graft became
round in shape and smaller in size. After 15 weeks (Fig.
11 b), the triangular shape of the tibia changed to an oval
or flat shape as time progressed. Resorption of the pre-
existing cortical area was observed in most periosteal
sites; this was indicated by the disappearance of fluo-
rochrome stains, which was done in the early postoper-
8. Vascularized Tibiofibular Graft in the Rat 127
Fig.9a,b. Fluoromicrograph and schematic diagram of an
undecalcified cross section of a graft in group 2 after 3
weeks, showing significant new bone formation on the
anteromedial cortex of the tibia (x20). The diagram shows
the fluorochrome stains. Xo , Xylenol orange; Ca, calceine;
Tc, tetracycline. (See Color Plates)
b
a,b
Fig. 11. Fluoromicrograph of un decalcified cross section of a
graft in group 2 after 7 weeks (a) and 15 weeks (b), showing
continuous bony resorption in the cortex. (See Color Plates)
ative period. Scant new bone formation was observed in
some sites of the endosteum. The cortical area became
thinner, and the medullar cavity was enlarged.
Discussion
A model was designed that closely resembled the usual
clinical situation, i.e., a large segmental defect in a
weight-bearing bone was bridged by a vascularized
fibular graft with periosteal and medullary blood sup-
plies intact. Instead of an external fixator, bone synthe-
sis with a screw and wire was used, which was less rigid
and allowed the grafts to be stressed. Group 1 was a
model of vascularized bone grafting with mechanical
loading. The animals began to use the operated limbs
around the second or third postoperative week.
128 C. Experimental Microsurgery
The vascularized bone grafts to the tibia defects
demonstrated that cross-sectional bone growth was
maintained with some acceleration of new bone forma-
tion, and that an alternation of the growth direction
occurred 3 weeks after surgery. In the vascularized bone
graft to the abdominal wall, where there was no
mechanical stress to the graft, more bone resorption
than bone formation was seen. These findings suggested
that mechanical stress affects the hypertrophy of the
grafted bone significantly [15,16].
Significant new bone formation in the early stage
was observed in both vascularized tibia groups, with or
without mechanical stress. No difference was seen in
the shape or volume of newly formed bone in the early
stage in both groups. The early active new bone forma-
tion was always located in the anteromedial aspects of
the tibia, where "formation drift" [14] took place in the
normally growing tibia. In this stage, bone formation
was not seen in the opposite aspect of the graft, where
"resorption drift" took place in the intact tibia.
These findings indicated that some stimulation, be-
sides mechanical stress, had taken place on the bone-
forming surface of the grafted tibia in the early stage.
The stimulation worked on the activation and prolifer-
ation of the preexisting osteoblasts, which produced
"formation drift" before transplantation. The mecha-
nisms of such stimulation have not been clarified in
these experiments. We assume that operative inter-
vention may play an important role in producing the
stimulation. This early new bone formation is called
"reactive hypertrophy."
Thereafter, steady new bone formation was observed
in the vascularized bone grafts to the tibia defects, and
bone resorption was seen in the grafts to the abdominal
wall. These findings appear to be a "remodeling" to adapt
to the new dynamic environment after transplantation.
Hypertrophy under mechanical stress is called "adaptive
hypertrophy," as described by Goodship et al. [17].
Conclusion
We can conclude from these experimental studies
that the blood supply to the grafted bone seems to be
essential for bone hypertrophy and early bony union, as
suggested by the results from the groups receiving non-
vascularized bone grafts. Early weight-bearing may
cause faster hypertrophy of the grafted bone.
References
1. Taylor GI, Miller GDH, Ham FJ (1975) The free vascu-
larized bone grafts. Plast Reconstr Surg 55:533-544
2. Moor JR, Weiland AJ, Daniel RK (1984) Use of free vas-
cularized bone grafts in the treatment of bone tumors.
Clin Orthop 175:37-44
3. Yajima H, Tarnai S, Mizumoto S, Inada Y (1993) Vascu-
larized fibular grafts in the treatment of osteomyelitis and
infected nonunion. Clin Orthop 293:256-264
4. Taylor GI, Townsend P, Carletts R (1979) Superiority of
the deep circumflex iliac vessels as the supply for free
groin flaps. Plast Reconstr Surg 64:745-759
5. Buncke HJ, Furnas DW, Gordon L, Achauer BM (1977)
Free osteocutaneous flap from a rib to the tibia. Plast
Reconstr Surg 59:799-804
6. Teot L, Bosse Jp, Monefarrage R, Papillon J, Beauregard
G (1981) The scapula crest pedicled bone graft. Int J
Microsurg 3:257-262
7. Malizos KN, Nunley JA, Goldner RD, Urbaniak JR,
Harrelson JM (1993) Free vascularized fibula in traumatic
long bone defects and in limb salvage following tumor
resection: comparative study. Microsurgery 14:368-374
8. Chew WYC, Low CK, Tan SK (1995) Long term results of
free vascularized fibular graft. Clin Orthop 311:258-261
9. Saffer JW, Field GA, Goldberg VM, Davy DT (1985) Fate
of vascularized and nonvascularized autografts. Clin
Orthop 197:32-43
10. De Boer HH, Wood MB (1986) Bone changes in the vas-
cularized bone graft. J Bone Joint Surg B(71):374-378
11. Brown KLB (1991) Limb reconstruction with vascular-
ized fibular grafts after bone tumor resection. Clin Orthop
262:64-73
12. Mizumoto S, Tarnai S, Yajima H, Yoshii T (1987) Vascu-
larized fibula graft (in Japanese). In: Tarnai S (ed) Micro-
surgery in orthopedics. Seikeigeka Mook 48. Kanehara,
Tokyo, pp 210-226
13. Mizumoto S, Tarnai S, Goshima J, Yajima H, Yoshi T,
Fukui A, Masuhara K (1986) Experimental study of vas-
cularized tibiofibula graft in inbred rats: a preliminary
report. J Reconstr Microsurg 3:1-9
14. Frost HM (1985) The pathomechanics of osteoporosis.
Clin Orthop 200:198-225
15. Chamay A, Tschanz P (1972) Mechanical influences in
bone remodeling. Experimental research on Wolff's law. J
Biomech 5:173-180
16. Uhthoff HK, Jaworski ZFG (1984) Bone loss in response
to long-term immobilization. J Bone Joint Surg B(60):
420-429
17. Goodship AE, Lanyon LE, McFie H (1979) Functional
adaptation of bone to increase stress. J Bone Joint Surg
A(61):539-546
9. Vascularized Ulna Graft in the Rat
NOBUYUKI YAMAOKA, SUSUMU TAMAI, and SHIGERU MIZUMOTO
When a vascularized fibula graft was performed for a
bone defect in the extremity long bones, significant
hypertrophy was observed when the graft was trans-
ferred to a mechanically loaded lower extremity, but less
hypertrophy was observed when it was transfered to the
upper extremities. This phenomenon of hypertrophy is
related to the imposed mechanical stress load [1-3]. We
designed a murine experiment to clarify the etiology of
postoperative hypertrophy of vascularized bone grafts.
We performed syngeneic vascularized ulna transfer to
a segmental bone defect in the rat, with or without
mechanical loading. The bone dynamics of the grafts
were examined by fluorochrome bone labeling and his-
tomorphological measurement.
Materials and Methods
A total of 140 male Fischer strain rats aged 7 weeks
(F344/DuCrj) and weighing 128 to 189g (average,
153 g) were used. The rat ulna was used in this study to
simulate vascularized fibular transfer in clinical cases,
because its straight and slender shape is similar to that
of the human fibula. The rats were divided into three
groups: vascularized ulnar grafting to the tibia with
mechanical loading (group 1), vascularized ulnar graft-
ing without mechanical loading (group 2), and segmen-
tal excision of the radius (group 3). The animals of each
group were divided into four subgroups (7 rats in each)
based on the time of sacrifice. Another 56 rats were pre-
pared as donors for harvesting vascularized ulna grafts.
Operative Procedure
In group 1,28 rats were used as donors and another 28
rats were prepared as recipients. In the donor rat, the
brachial artery and its venae comitantes were dissected
freely. The wrist was dislocated, and then the inter-
osseous membrane was carefully resected to excise
the entire length of the radius. The elbow joint was dis-
articulated by osteotomy of the olecranon. In the recip-
ient rat, the femoral artery and vein were dissected
freely at the mid-thigh. A 2-cm defect of the tibial dia-
physis was made as a recipient bed. The completely iso-
lated ulna with its vascular pedicle was then transferred
orthotopically. Osteosynthesis of the proximal side of
the graft was performed by intramedullary pinning with
an injection needle, and the distal side was synthesized
with stainless-steel wire. Arterial and venous anasto-
moses were carried out with 10-0 nylon suture under an
operating microscope.
In group 2, 28 rats were used as donors and 28 as
recipients. Vascularized ulnar grafting to a bone defect in
the right tibia was performed in the same manner as
in group 1. After that, the ipsilateral femur was severed
in its mid-portion with a microbone saw, and the proxi-
mal and distal ends were reversed. Then the foot was
cut off at the mid-metatarsal level. Finally, the operated
leg was transferred to a subcutaneous pocket in the
abdomen.
In group 3, which included 31 rats, the diaphysis of
the right radius was exposed and a l-cm-Iong segment
of the midshaft was resected with a microbone saw,
taking care not to injure the soft tissues and periosteum
around the ulna. In this fashion, a one-bone forearm was
prepared (Fig. la--c).
The total ischemic period was limited to 90min from
the time of procurement of the graft until the comple-
tion of revascularization [4]. None of the groups under-
went external fixation after surgery, and all animals
were allowed to move freely in their cages.
Fluorochrome Bone Labeling
Fluorochrome bone markers were administered for
examination of new bone formation. Each of the groups
was divided into four subgroups. The rats were admin-
istered xylenol orange 1 week preoperatively, and cal-
ceine and tetracycline were administered in accordance
with the protocol as shown (Table 1). Five days after
the final labeling, the animals were sacrificed by ether
inhalation.
129
130 C. Experimental Microsurgery

Femoral artery and vein

Ulna ---+----r./
Brachial artery Ulna
and vein
Vascular
anastomoses

Femoral artery
and vein
b c

Fig. 1. Schematic diagrams showing the experimental proce- performed, and then the hind limb was transferred to a sub-
dure in each group. a Vascularized ulna graft to a bone defect cutaneous pocket in the abdomen (group 2). c Partial resec-
in the tibia (group 1). b Vascularized ulna graft to the tibia was tion of the radius (group 3)

Histology
Table 1. Experimental protocol of fluorochrome bone
After sacrifice of the animals, vascular patency was labeling
checked by direct inspection of the anastomosed artery Week
and vein under an operating microscope. A transverse Subgroup -1 Operation 1 3 5 7
section 5mm in length was harvested from the midpor- A Xo Ca Td
tion of the graft in groups 1 and 2. A 5-mm-Iong section B Xo Ca Td
was taken at the midshaft of the ulna in the operated C Xo Ca Td
forelimb of the rats in group 3. Simultaneously, a 5-mm- D Xo Ca Tc Tc .j,
long segment of intact ulna was taken from the con- Xo, Xylenol orange (90mg/kg i.v.); Ca, calcein (15mg/kg i.m.); Tc,
tralateral forelimb as a normal control in each rat. These tetracycline (50mg/kg i.m.). Rats were sacrificed 5 days after the last
specimens were fixed in 70% ethanol, stained with labeling (down arrow).

Villanueva osteochrome bone stain, dehydrated in an
alcohol series, and embedded in methyl methacrylate
[5]. These specimens were then cut into 10-micron
sections with a microtome and observed under a
fluoromicroscope.
Histomorphological Measurements
Undecalcified specimens were photographed under the
fluoromicroscope at 40 magnifications. Cross-sectional
bone area was measured on the photograph by using a
microcomputer and drawing tablet. For evaluation of
cross-sectional bone growth and new bone formation,
the following histomorphometric measurements were
performed.
The total cross-sectional bone areas in each section
were measured. In order to standardize the measure-
ments, the cross-sectional bone area was divided by that
of the intact ulna in each animal, and the result was
defined as the "hypertrophy rate." For evaluation of new
bone formation, the area of bone existing between the
line stained with the final fluorochrome and the line
from the preceding label administration was measured.
The bone mass in this area was regarded as having
been formed during the period between the two fluo-
rochrome labelings. The ratio of the bone area obtained
to the total cross-sectional bone area was defined as the
"bone formation rate."
Statistical Analysis
The data. were analyzed statistically using two-way
analysis of variance (ANOVA) and Scheffe's multiple
comparison tests. The findings were considered statisti-
cally significant when p was less than 0.05.
Results
Hypertrophy Rate
In group 1, the hypertrophy rate was 1.93 0.21 (mean
SD) at 1 week and plateaued afterwards, indicating
that the cross-sectional bone growth in group 1 was
nearly twice that in normal controls. In group 2, the rate
was not significantly different from that in group 1 at 1
week. However, at 3, 5, and 7 weeks, the hypertrophy
rate was significantly lower than that in group 1. In
group 3, on the other hand, the rate was significantly
lower at 1 week than in both groups 1 and 2. At the
other time points in group 3, the rate was significantly
9. Vascularized Ulna Graft in the Rat 131
lower than in group 1, but there was no significant
difference in rates between groups 2 and 3.
Bone Formation Rate
The bone formation rate tended to decrease with time
in the normal ulna. In group 1, these values were sig-
nificantly higher than that of normal controls at each
time point. In group 2, the rate was 47.3 5.5 during the
first postoperative week and did not differ from that in
group 1. The rate decreased markedly from 1 to 3 weeks
and from 3 to 5 weeks. From the first week, the bone
formation rate was significantly lower in group 2 than
in group 1, and no differences were noted in this rate
between group 2 and the control group. In group 3, the
rate was significantly higher than in the normal ulna but
significantly lower than in groups 1 and 2. Thereafter, no
differences were noted between groups 3 and 2 or the
control group, but the rate was significantly lower in
group 3 than in group 1 (Fig. 2a,b).
Discussion
Hypertrophy of vascularized bone grafts has been
reported in several clinical studies [6-9]. De Boer and
Wood [3] found hypertrophy in 20% of upper extrem-
ity grafts and 43% of grafts in mechanically loaded
lower extremities, and suggested that hypertrophy was
related to the imposed stress load. Malizos et al. [2]
reported that hypertrophy of vascularized fibula grafts
appeared to be more prominent when an external
fixator was used and partial weight-bearing was allowed
than when an internal fixator had been used and pro-
hibited weight-bearing, and suggested that mechanical
loading was in part responsible for graft hypertrophy.
Mechanical stress loading on bone is known to be a
major factor affecting remodeling of the bone with new
bone formation and resorption. Wolff [10] has demon-
strated that when stress is applied, trabeculae within
the bone develop and align themselves to adopt the
most appropriate shape with a minimum expenditure of
material. An increase in mechanical load on long bones
can produce an adaptive response in which bone for-
mation outpaces resorption [11,12]. Conversely, lack of
mechanical loading may result in loss of bone mass or
bone atrophy [13].
Group 1 was a model of vascularized bone grafting
with mechanical loading. Osteosynthesis was accom-
plished with intramedullary fixation and wiring of the
graft. Group 2 was a model of vascularized bone graft-
ing without mechanical loading. Various procedures
have been reported for reduction of mechanical loading
132 C. Experimental Microsurgery

a b
Hypertrophy rate Bone formation rate
60
2.6

50
2.21 0.21
2.2 1.93 0.21 2.12 0.44
40

1.8 30

20
1.4
10

0
1W 3W 5W 7W -1W Ope. 1W 3W 5W 7W

Statistical analysis of hypertrophy rate Statistical analysis of bone formation rate

1W 3W 5W 7W -1 w-op. op.-1 w 1-3W 3-5w 5-7w

Group 1 vs group 2 n.s. p < 0.01 P < 0.01 P < 0.01 Group 1 vs group 2 n.s. n.s. p < 0.01 P < 0.01 P < 0.01
Group 1 vs group 3 p < 0.01 P < 0.Q1 P < 0.Q1 P < 0.01 Group 1 vs group 3 n.s. p < 0.Q1 P < 0.01 P < 0.01 P < 0.01
Group 2 vs group 3 p < 0.Q1 n.s. n.s. n.s. Group 1 vs control n.s. p < 0.Q1 P < 0.01 P < 0.Q1 P < 0.Q1
Group 2 vs group 3 n.s. p < 0.Q1 n.s. n.s. n.s.
Group 2 vs control n.s. p < 0.01 n.S. n.s. n.S.
Group 3 vs control n.s. p < 0.Q1 n.s. n.s. n.s.

Fig. 2. Rates of bone hypertrophy and bone formation in
experimental groups. Each value represents the mean stan-
dard deviation. Squares group 1; circles, group 2; triangles,
group 3; diamonds, control group. n.s., Not significant. a Quan-
titative analysis of hypertrophy rate for each group. Significant
differences between group 1 and group 2 were observed from
the third week after surgery. b Quantitative analysis of bone
formation rate for each group. Significant differences between
group 1 and the other groups were noted from the third week
after surgery

in previous experiments, including casting, de nervation,
grafting into an abdominal subcutaneous pouch, and
others. Casting is hard to use in small animals such as
rats. Denervation is one of the procedures used to
examine the effect of reduced mechanical stress on
bone. However, it has other problems, as described by
Aro et al. [14]. Accordingly, grafting into a subcutaneous
abdominal pocket was used in the present experiment.
Mizumoto [15] grafted vascularized bone into a sub-
cutaneous abdominal pocket without bony synthesis;
however, the effect of bony contact from the recipient
bed in bone grafting is not negligible. Enneking and
Mindell [16] described the osteoconductive effects of
the recipient bone in their study of kinetics of bone
grafts. Therefore, in the present study, the graft was
transplanted to the tibia, and then the leg was placed in
a subcutaneous pocket in the abdominal wall, keeping
vessels, nerves, and other soft tissue intact by means of
simple osteotomy of the femur in group 2. In this group,
mechanical loading on the graft was minimized. Group
3 was designed to study the effect of simple increase in
mechanical loading on intact bone, using the functional
adaptation model described by Goodship et al. [12].
In groups 1 and 2, the rates of hypertrophy and bone
formation were remarkably high 1 week after surgery.
Extensive bone formation was not seen in group 3. The
significant hypertrophy observed in the early postoper-
ative period in groups 1 and 2 might have been a reac-
tive change due to surgical intervention or ischemia
during surgery, but it was most likely an inflammatory
reaction due to surgical manipUlation of the bone. It did
not correspond to mechanical loading. Following the
initial dynamic growth phase, bone growth continued
and extensive remodeling was observed in group 1. A
high rate of hypertrophy was maintained in group 1
during the entire experimental period, whereas remark-
able declines in the rates of hypertrophy and bone for-
mation were noted in group 2. Alternative remodeling
was demonstrated by activated bone resorption, which
was histologically observed, and decrease in new bone
formation in group 2. Charney and Tschantz [11]
demonstrated that mechanical loading of a long bone

induced hypertrophy of the bone, and Urthoff and
Jaworski [13] showed that reduced mechanical load
resulted decreased bone mass. We observed that
animals began to use the operated limb around the
second to third week after surgery in group 1. Mechan-
ical stress may be the primary factor inducing remo-
deling in vascularized bone graft to adapt to a new
environment.
References
1. DeBoer HH, Wood MB (1989) Bone changes in the vas-
cularized fibular graft. J Bone Joint Surg Br 71B:374-378
2. Malizos KN, Nunley JA, Goldner RD, et al. (1993) Free
vascularized fibula in traumatic long bone defects and in
limb salvaging following tumor resection: comparative
study. Microsurgery 14:368-374
3. Yajima H, Tarnai S (1994) Twin-barreled vascularized
fibular grafting to the pelvis and lower extremity. Clin
Orthop 303:178-184
4. Goshima J (1986) The effect of ischemia on bone
tissue: bone histomorphometrical analysis. J Nara Med
Assoc(Nara Igakukaisi) 37:325-357 (in Japanese)
5. Inoue J, Takahashi H (1983) Processing of undeca1cified
bone specimens and histomorphometric analysis of bone.
Orthop Surg Traumatol(Seikeisaigaigeka) 26:1251-1260
(in Japanese)
6. Takahashi M, Yabe Y, Yoshizawa E, Suzuki T (1979)
Congenital pseudoarthrosis of the tibia treated by
the vascularized free fibula graft. Orthop Surg
Traumatol(Seikeisaigaigeka) 22:1405-1411 (in Japanese)
9. Vascularized Ulna Graft in the Rat 133
7. Tarnai S, Sakamoto H, Fukui A, et al. (1983) Vascularized
fibula graft for the treatment of congenital pseudarthrosis
of long bone. Orthop Surg Traumatol(Seikeisaigaigeka)
26:601-612 (in Japanese)
8. Taylor GI, Buncke HJ, Watson N, et al. (1979) Vascular-
ized osseous transplantation for reconstruction of the
tibia. In: Serrafin D, Buncke HJ, eds. Microsurgical com-
posite tissue transplantation. Mosby, St. Louis, pp 713-742
9. Weiland AJ, Phillips TW, Randolph MA (1984) Bone
grafts: a radiologic, histologic, and biomechanical model
comparing autografts, allografts, and free vascularized
bone grafts. Plast Reconstr Surg 74:368-379
10. Wolff J (1892) Das Gesets der Transformation der
Knochen. Verlag von August Hirschward, Berlin
11. Charney A, Tschants P (1972) Mechanical influences in
bone remodeling. Experimental research on Wolffs law.
J Biomech 5:173-180
12. Goodship AE, Lanyon LE, McFie H (1979) Functional
adaptation of bone to increased stress. J Bone Joint Surg
Am 61A:539-546
13. Urthoff HK, Jaiworski ZFG (1978) Bone loss in response
to long-term immobilization. J Bone Joint Surg Br
60B:420-429
14. Aro H, Eerola E, Aho A (1985) Development of
non unions in the rat fibula after removal of periosteal
neural mechanoreceptors. Clin Orthop 199:292-299
15. Mizumoto S (1987) Experimental study on vascularized
bone graft in rats: with special emphasis on the hypertro-
phy of grafted bone. J Nara Med Assoc(Nara Igakukaisi)
38:667-706 (in Japanese)
16. Enneking WF, Mindell ER (1991) Observations on
massive retrieved human allografts. J Bone Joint Surg Am
73A:1123-1142
10. Vascularized Metatarsal Graft in the Rabbit
KOICHI KAWANISHI
Since the first report by Taylor et al. in 1975 [1] on
vascularized fibula grafts, this technique has achieved
widespread clinical application in conditions such as
congenital or acquired pseudoarthrosis, traumatic bone
defects, and reconstruction after tumor resection. From
October 1976 to May 1992, we treated 117 cases with
vascularized fibula grafts, and satisfactory results were
obtained [2].
In experimental studies on vascularized bone grafts,
Berggren et al. [3] found no difference in bone union
between a model in which a dog rib was implanted
into the mandible and was nourished only by the
periosteal blood flow and a model having an additional
blood supply from the bone marrow blood flow. Shaffer
et al. [4] performed orthotopic ulnar implantation
in dogs, and they found no differences in bone union
or histological results between the vascularized and
nonvascularized bone grafts after 6 months. Goldberg
et al. [5] isolated the ulna with a vascular pedicle and
performed orthotopic implantation. They measured
bone blood flow with the hydrogen washout technique
and found that the difference in bone blood flow
volume between vascularized and free bone grafts
disappeared by 6 weeks after implantation. However,
the mechanical and biological environment of these
experimental models differs from that of clinical cases
in which a vascularized fibula is implanted into a
bony defect in the lower extremity. Weiland et al. [6]
established a model in which a dog rib was implanted
into the femur, and they reported that the vascularized
grafts showed superior early bone union, hypertrophy
in transverse diameter, and strength. Moore et al.
[7] implanted canine vascularized ribs into the ulna,
and they demonstrated superior mechanical strength
3 months after implantation as compared with free
bone grafts. Since 1984, we have focused our attention
on hypertrophy of the vascularized bone graft. Using
rat models of vascularized fibular, ulnar, and coccygeal
vertebral implantation, we could observe early bone
union and hypertrophy. Furthermore, we elucidated
by a fluorochrome-labeling study that mechanical stress
and young donor age accelerated the hypertrophy
[8-14]. However, little information is available on the
134
changes in blood flow associated with hypertrophy.
In the present study, to clarify the relation between
blood flow in the grafted bone and bone dynamics, we
created an experimental model of vascularized bone
grafting using the Japanese white rabbit metatarsal
bone, and we measured the changes in bone blood
flow using the radioactively labeled microsphere
method.
Anatomy
Young rabbits, each weighing about 2kg, were killed
with an overdose of Nembutal administered via the
auricular vein. Immediately the right inguinal region
was incised, the external iliac artery and vein were
exposed, and heparinized physiological saline was
infused through a cannula inserted into the distal end
of the artery. Next, the external iliac vein was cut to
confirm adequate perfusion of the lower extremity.
Batoson's anatomical corrosion compound was infused
through the cannula inserted in the external iliac
artery, and the lower extremity was amputated at the
hip joint and refrigerated. After confirmation that the
resin had hardened satisfactorily, the soft tissue was
removed with sodium hydrochloride solution. In this
way, the relation between the skeleton and the blood
vessels of the lower extremity was investigated. The
saphenous artery and vein originating from the femoral
artery and vein, respectively, at the level of the distal
one third of the femur descended beneath the skin
along the posterior surface of the medial aspect of
the knee. Immediately below the knee joint, they
gave cutaneous branches to the distal end of the
diaphysis of the fibula and the area surrounding the
calcaneus, supplying the plantar region and extend-
ing nutrient vessels to the second metatarsal bone.
From these findings, we understood that it would be
possible to obtain the second metatarsal bone with the
saphenous artery and vein as a vascular pedicle and
implant it in a bone defect prepared in the femur
(Fig. 1).

Fig.I. The saphenous artery extends nutrient branches (*) to
the 2nd metatarsal bone. We understood that it would be pos-
sible to obtain the 2nd metatarsal bone with the saphenous
artery and vein as a vascular pedicle
Materials and Methods
Our experimental protocol was approved by the Insti-
tutional Animal Care and Use Committee of Nara
Medical University. One hundred and twenty young
rabbits, each weighing about 2kg, were used. They were
divided into three groups: a vascularized group (n = 40),
a non-weight-bearing group (n = 40), and a conventional
group (n = 40).
In the vascularized group (Fig. 2), under halothane
anesthesia, the rabbit was immobilized in the supine
position on the operating table, and an incision was
made from the medial side of the ankle joint to the
medial plantar region. The right saphenous artery and
vein were confirmed and detached in a distal direction
up to the level of the second metatarsocuneiform joint.
Next, the digital artery and vein were ligated at the
level of the metatarsophalangeal joint, and the second
metatarsal bone was cut at a site 2 cm distal to the
second metatarsocuneiform joint. The saphenous vein
was then detached proximally, and the short branches
to the posterior surface of the femur just beneath the
knee joint were ligated. The skin incision used for dis-
10. Vascularized Metatarsal Graft in the Rabbit 135
Femur
Vascularized
metatarsal bone graft ----.'-'r-'<-'~>Si'
Saphenous art.
Fig.2. Vascularized group. The right 2nd metatarsal bone was
elevated with the saphenous vessels as a vascularized bone
graft. The graft was transplanted into a 1.5-cm defect prepared
in the femoral diaphysis and fixed with an external fixator
secting the saphenous artery and vein was extended
proximally to the recipient site, and the femur was
exposed between the vastus medialis and rectus femoris
muscles. In the distal and proximal portions of the
femoral diaphysis, 1.6-mm drill holes were made in the
medial and lateral sides of the femur (two holes in each
side), and 1.6-mm stainless steel wires (Z-Wire, Zimmer,
USA) were inserted in these holes. Then, a Styrofoam
board was attached to the femur with the lateral ends
of the 4 wires, and which the femur is fixed by coating
the wires with dental resin (Tray Resin, Shofu, Japan).
With an electric saw, a 1.5-cm segmental bone defect
was created in the diaphysis, and the surrounding
periosteum was completely removed. The joint cartilage
of the proximal end of the vascularized metatarsal bone
was removed, and both ends of the grafted bone were
inserted into the femoral bone marrow. Then, the medial
ends of the steel wires were coated with resin, thus com-
pleting the external fixation. After suturing the skin, the
pulsation of the saphenous artery passing beneath the
skin on the medial side of the thigh was confirmed by
Doppler flowmetry.
In the non-weight-bearing group (Fig. 3), the vascu-
larized metatarsal bone was implanted into the femoral
subcutaneous tissue.
In the conventional group (Fig. 4), the non-
vascularized metatarsal bone graft, in which the soft
tissues were stripped away, was transplanted into the
femoral diaphysis.
136 C. Experimental Microsurgery
Fig. 3. Non-weight-bearing group. The vascularized
metatarsal bone graft was transplanted into the femoral sub-
cutaneous tissue
Femur
Non-vascularized
metatarsal bone graft ----I~-..~
Fig. 4. Conventional group. The nonvascularized metatarsal
bone graft, in which the soft tissues were stripped away, was
transplanted into the femoral diaphysis
Measurement of Bone Blood Flow
The bone blood flow was measured by the radioactive
microsphere method. Under halothane anesthesia, the
respiration was controlled (single ventilation volume:
30ml/cycle, ventilation frequency: 30 cycle/min), and
the temperature was adjusted to 38C. About 2 million
microspheres 15jlm in diameter (NEN 32A, 0.9%
saline, 0.05% Tween 80, 1 MBq/4ml, NEM) labeled with
51Cr were rapidly infused via a catheter (SP25, outer
diameter 0.8mm, inner diameter O.4mm, Natsume,
Japan), inserted via the left carotid artery into the left
ventricle. Starting 30 s before the infusion, blood was
obtained for 2min at a speed of 2.5ml/min from a
catheter inserted into the left brachial artery. The
animals were Killed immediately with an intravenous
overdose of pentobarbital sodium. Then, the grafted
bone and femur were removed, the surrounding tissue
and bone marrow were discarded, their radioactivities
and wet weights were measured, and the blood flow in
each bone was calculated according to the reference
sampling method. Because the microspheres in one
pass through the systemic circulation were trapped by
the capillaries in proportion to the rate of blood flow in
each tissue, if the pump used for blood sampling was
considered as a tissue possessing a constant rate of
blood flow, the absolute blood flow value of a given
tissue can be calculated from the ratio between the
radioactivity in the blood sample and the target tissue
radioactivity by the following equation:
Bone blood flow =
Radioactivity in bone x 2.5 x 100
radioactivity in reference blood x bone weight
The rate of blood flow in the kidneys was measured in
the same way, and the appropriate mixing and dispersal
of the microspheres were confirmed.
Radiographic Evaluations
After the animals were Killed, the bone union between
the implanted bone and the femur, which is the matrix,
was evaluated radiographically using Softex CSM-21.
In addition, the transverse diameters of the implanted
bone and the metatarsal bone on the contralateral
side were measured, and the ratio of the two values was
calculated.
Results
Bone Union
Radiographic examination demonstrated no bone
union 2 weeks after operation in the vascularized group,
whereas at 3 weeks bone union at the proximal junction
was found in 4 of the 8 animals. At 6 weeks, all animals
 10. Vascularized Metatarsal Graft in the Rabbit 137

Bone blood flow Bone blood flow

(mllmin/100g) (mllmin/100g)

20
10 r 17.510.'
20

10

f3.61.7
3.92.2 _ _ _!,6.54.0
3.40.4 ~f3.53.3 13.33.0
~--------------------------------
o 1 3 6 9 12
Postooerative oeriod (week) o 1 3 6 9 12
Postoperative period (week)
Fig.5. Vascularized group: rates of blood flow in grafted bone
Fig. 6. Non-weight-bearing group: rates of blood flow in
grafted bone

Bone blood flow

showed union of the proximal junction, and in 4 of the (mllmin/100g)
8 animals there was union at the distal junction as well.
At 9 weeks, 6 of the 8 animals showed bone union at the
distal junction. At 12 weeks, all animals showed bone
20
union at the distal junction. In the conventional group,
only 1 animal showed bone union at the proximal bone

junction at 6 weeks. At 9 weeks, bone union was found
in 5 of the 8 animals at the proximal junction and in 4
animals at the distal bone junction. At 12 weeks, only
one distal junction still showed nonunion.
Bone Blood Flow
At the time of measurement of blood flow, the systolic
blood pressure was 88-112mmHg (mean, 96mmHg),
with no change in blood pressure. The renal blood flow,
an index of appropriate mixing and distribution of the
microspheres, was 266.8 29.9ml/min/l00g, indicating
that the distribution was uniform. The blood flow in the
left femoral diaphyseal cortex was 2.1 0.7mllminl
100 g. The rates of blood flow in the grafted bone in the
vascularized group at 1 and 3 weeks after operation
were 11.8 5.8 and 17.5 10.2mllmin/l00g, respec-
tively. However, at 9 and 12 weeks, the rates decreased
to 3.9 2.2 and 3.6 1.7 mi/min/100 g, respectively (Fig.
5). The rates of blood flow in the grafted bone in the
non-weight-bearing group were 10.4 7.0 and 7.0 4.9
mi/min/100 g at 1 and 3 weeks after operation, respec-
tively, and then gradually decreased to 3.5 3.3
ml/min/l00 g at 9 weeks and 3.3 3.0 at 12 weeks (Fig.
6). In the conventional group, the rates of blood flow
4 weeks after operation was 3.1 0.6mllmin/l00g,
and it increased to 6.4 2.7ml/min/l00g at 12 weeks
(Fig. 7).
t------- f t
10
6.82.1 6.42.7
3.10.6
o 1 3 6 9 12
Postoperative period (week)
Fig. 7. Conventional group: rates of blood flow in grafted
bone
Bone Hypertrophy
In the vascularized group, a gradual increase in the
diameter of the grafted bone, indicating hypertrophy,
was noted after surgery. At 6 weeks after operation, the
diameter was up to 1.6-fold that of the left second
metatarsal bone in the controls (Fig. 8), although
subsequently no tendency toward hypertrophy was
observed. In the non-weight-bearing group, no hyper-
trophy was detected. In the conventional group, hyper-
trophy was not observed, even after 9 weeks.
Discussion
The hydrogen washout technique and the radioactive
microspheres (MS) method have been used for meas-
urement of bone blood flow. The radioactive MS
 138 C. Experimental Microsurgery
Hypertrophy
ratio
2
I
I
1.58O.16
/f~OO.2~r52O."
I
/"I1.38o.14
1.21O.15
o 3 6 9 12
a Postoperative period (week)
b tory reaction 10 days postoperatively in the rabbit
Fig. 8. a In the vascularized bone graft group, transverse
diameter hypertrophy showed a gradual increase after
surgery, and at 6 weeks after operation it showed up to 1.6-
fold hypertrophy as compared with the left second metatarsal
bone of the control, although subsequently no tendency to
hypertrophy was observed. b The vascularized metatarsal
bone grafts 1 week and 6 weeks after surgery
method is superior to other methods for measurement
of blood flow in deep organs such as the bones. Kane
[15] was first measured canine bone blood flow using
this method in 1969.
Branemark [16] reported that the diameter of the
Haversian canals in the rabbit tibia was approximately
15 11m, and Lunde [17] recognized that MS were
entrapped in the Haversian canals of the femur. These
reports showed that we can apply the radioactive MS
method for measurement of bone blood flow in the
rabbit. Furthermore, some reports indicated that the
one-time MS dosage was 0.3 x 106 to 157 X 106. Never-
theless, the overdosage of MS affected the hemody-
namics. Li [IS] reported that if the sample included
150-250 MS, there would be no problem in measuring
bone blood flow by this method. We performed our
measurement according to his results.
We measured the blood flow of the vascularized bone
grafts using different MS dosages from 0.5 x 106 to 5 X
106 We found that 350-150 MS were taken in the grafted
bone following a dosage of approximately 2 x 106 MS,
and there were no changes in blood pressure. Therefore,
we considered the adequate dosage to be 2 x 106 MS.
Davis et al. [19] reported that there were no changes in
the hemodynamics and action when 1-2 x 106 MS were
injected into the rabbit, and that bone blood flow in the
cortex was hardly influenced by anesthesia.
We showed that bone blood flow increased up to
6 weeks in accordance with hypertrophy of bone in
the vascularized grafts. The vascularized bone graft
increased in diameter to 1.6 times that of the original
bone at 6 weeks. Subsequently, the hypertrophy stopped
(Fig. Sa). The bone blood flow in the graft closely resem-
bled that in the femur after 9 weeks. The bone blood
flow in the graft that was transferred to a subcutaneous
pocket at 1 week increased up to approximately 3 times
the blood flow in the normal metatarsus, but thereafter,
the blood flow decreased. Our senior co-worker, Mizu-
moto, reported rapid hypertrophy of the vascularized
bone graft in the early postoperative stage using the rat
experimental model. He demonstrated that hypertro-
phy induced by mechanical loading occurred after 3
postoperative weeks. Teissier et al. [20] reported that
bone blood flow rapidly increased with the inflamma-
fibular graft model (Fig. 9a).
In our vascularized group and our non-weight-
bearing group, bone blood flow increased rapidly at 1
week. Thereafter, in the vascularized group, bone blood
flow gradually increased, while in the non-weight-
bearing group, blood flow decreased. We think that the
mechanical load accelerated the hypertrophy of bone in
the vascularized graft and that the increased blood flow
supported this phenomenon.
Goldberg et al. [5] isolated a vascularized canine tibia
graft and reimplanted it to the original site. They meas-
ured the blood flow of the grafted bone with the hydro-
gen-washout technique (Fig. 9b). They reported that the
blood flow of the grafted bone increased to the maximal
level at 3 weeks, and subsequently there were no dif-
ference between the grafted bone and the convention-
ally grafted bone at 6 weeks.
This experimental model demonstrated that regard-
less of the absence of hypertrophy of the graft, the
changes in bone blood flow resembled those in the
mechanical loading group in our experiments. We
 10. Vascularized Metatarsal Graft in the Rabbit 139

Teissier's model (rabbit) References

-~
30

/'-
Bone blood flow
(mllmin/100g) 20
1. Taylor GI, Miller GD, Ham FJ (1975) The free vascular-
10 ized bone graft. Plast Reconstr Surg 55:533-544
2. Yajima H, Tarnai S, Mizumoto S (1992) Vascularized
a 0 3 6 9 fibula graft for reconstruction after resection of aggres-
sive benign and malignant bone tumors. Microsurgery
13:227-233
3. Berggren A, Weiland AJ, Dorfman H (1982) Free vascu-
Goldberg's model (dog) larized bone grafts: factors affecting their survival and
30
ability to heal to recipient bone defects. Plast Reconstr
Bone blood flow
(ml/min/100g) 20 Surg 69:19-29
4. Shaffer JW, Field GA, Goldberg VM (1984) A vascular-
10 ized fibula model to study vascularized canine bone grafts.
Microsurgery 5:185-190

I f
b o 3 6
20 Our model (rabbit)
Bone blood flow
(ml/min/100g) 10 L.._ _ _ _ _ _ _ _ _ _ __
o 3 6 9
c Postoperative period (week)
Fig. 9. a Teissier used white New Zealand rabbits weighing
between 3 and 4.5 kg. He transplanted the vascularized fibula
graft to the original site. b Goldberg's model used dogs. He
transplanted the vascularized tibia grafts to the original site.
c Our model
suppose that bone blood flow increased to accelerate
bone union in this model.
Teissier [20] harvested a rabbit vascularized fibula,
returned it to the original site, and measured the bone
blood flow of the graft (Fig. 9a). In this model, the blood
flow increased at 10 days, but thereafter it decreased.
These changes resembled the changes in bone blood
flow in our non-mechanical-loading group (Fig. 7).
We suggest that these changes occurred because the
mechanical loading did not affect the graft in the tibio-
fibular synostosis. Consequently, the blood flow in the
recipient bed and the difference in diameter between
the graft and the recipient bed did not affect the bone
blood flow in the graft, which was, on the contrary,
affected by the mechanical loading.
In conclusion, the vascularized bone graft is superior
in that transfer of the living bone cells and vessels can
react to mechanical loading. This paper is quoted from
"Further Reading [21]".
5. Goldberg VM, Shaffer JW, Stevenson S (1991) Bone
and cartilage allografts. In: Friedlaender GE, Goldberg
VM (eds) Biology and clinical applications. American
Academy of Orthopedic Surgeons, pp 13-26
6. Weiland AJ, Philips TW, Randolph MA (1984) Bone
grafts: a radiologic, histologic and biomechanical model
comparing auto grafts, allografts, and free vascularized
bone grafts. Plast Reconstr Surg 74:368-379
7. Moore JB, Mazur JM, Zehr D (1984) Biomechanical com-
parison of vascularized and conventional autogenous
bone grafts. Plast Reconstr Surg 73:382-386
8. Mizumoto S, Tarnai S, Goshima J (1986) Experimental
study of vascularized tibiofibula graft in inbred rats. J
Reconstr Microsurg 3:1-9
9. Mizumoto S (1987) Experimental study on vascularized
bone graft in rats with special emphasis on the hypertro-
phy of grafted bone. J Nara Med Assoc 38:667-706
10. Mizumoto S, Tarnai S, Yajima H (1988) Vascularized ulnar
graft in inbred rats. J Jpn Soc Reconstr Microsurg 1:6-
15
11. Huang we (1988) How does the age factor influence the
hypertrophy of vascularized bone grafts?-an experimen-
tal study. J Nara Med Assoc 39:756-772
12. Sempuku T, Tarnai S, Mizumoto S (1990) Experimental
study on vascularized tail bone graft in rats. J Jpn Soc
Reconstr Microsurg 3:211-227
13. Sempuku T, Tarnai S, Mizumoto S (1991) Experimental
study on vascularized tail bone graft in rats (The 2nd
report: a long term follow-up study). J Jpn Soc Reconstr
Microsurg 4:164-173
14. Yamaoka N, Tarnai S, Mizumoto S (1997) Experimental
study of vascularized bone grafts in rat: effect of
mechanical loading on bone dynamics. J Orthop Sci
2:239-247
15. Kane WJ, Grin E (1969) Blood flow to canine hind limb-
bone, muscle and skin. A quantitative method and its val-
idation. J Bone Joint Surg 51:309
16. Branemark PI (1961) Experimental investigation of
microcirculation in bone marrow. Angiology 12:230-
239
17. Lunde PKM, Michelsen K (1970) Determination of corti-
cal blood flow in rabbit femur by radioactive micros-
pheres. Acta Physiol Scand 80:39-44
140 C. Experimental Microsurgery
18. Li G, Bronk JT, Kelly PJ (1989) Canine bone blood flow
estimated with micro spheres. J Orthop Res 7:61--Q7
19. Davis TRC, Holloway I, Pooley J (1990) The effect of
anesthesia on the bone blood flow of the rabbit. J Orthop
Res 8:479-484
20. Teissier J, Bonnel F, Allieu Y (1985) Vascularization,
cellular behavior, and union of vascularized bone grafts:
experimental study in the rabbit. Ann Plast Surg
14:494-504
21. Kawanishi K, Tarnai S, Mizumoto S, Yazima H (1992)
Experimental study of vascularized bone grafts in rabbit.
J Jpn Soc Reconstr Microsurg 5:117-125
11. Vascularized Tail Bone
Graft in the Rat
11.1 Cancellous Bone Graft Model
T AKEO SEMPUKU

Vascularized bone grafts are currently used extensively. and lower disks while keeping the caudal artery and
The clinically available donor bones, such as the fibula, veins intact. The vascular bundle is elevated proximally
ilium, rib, scapula, and metatarsus are divided into to the pelvis as a pedicle. The tail bone can be trans-
two groups: long bones consisting mainly of cortical ferred as a pedicle graft to various sites. The endplates
bone and corticocancellous bone containing significant are removed, if necessary.
amounts of cancellous bone. With most previous exper-
imental models, donor tissues were non cancellous long
bones, and consequently, the morphologic dynamics of Vascularized Tail Bone Grafts to
cancellous bone grafts have not been studied. the Femur
Mizumoto et al. performed vascularized tibiofibula
grafts and vascularized ulna grafts in rats [1,2]. The With this model, the dynamics of both the cortical and
experimental models did not permit the examination of the cancellous bone in a graft transferred to a long bone
cancellous bone, because they are long-bone grafts. . were analyzed.
However, they have advantages, because rats can be
treated easily and the rapid turnover of rat bones short-
ens the duration of the experiments. An experimental Materials and Methods
study of a vascularized cortico cancellous bone graft
would provide new insight into the dynamics of bone Seven-week-old male Fischer 344 rats were used. For
grafts. For these purposes, a new experimental model of the vascularized graft group, the fifth or sixth tail bone
vascularized tail bone grafts was developed in rats [3]. was raised on the pedicle of the caudal artery and veins.
The upper and lower endplates were removed with a
micro bone saw. The left femur was exposed, and a 7-
Vascular Anatomy of the Tail in Rats mm-Iong segment of the mid shaft of the femur was
resected. The vascularized tail bone was transferred to
The main nutrient artery of the tail bones is the caudal the gap in the femur and fixed intramedullarily with a
artery, which arises from the end of the abdominal pin 0.5 or 0.7mm in diameter (Fig. 2).
aorta, runs down along the ventral aspect of the tail For the non vascularized graft group, the fifth or sixth
bones, and is surrounded by fascia on the other three tail bone, without vasculature, was transferred to the left
sides. The right and left branches of the artery enter the femur.
marrow cavity at the midpart of each tail bone (Fig. 1) For the control group, the fifth and sixth tail bones
and branch out proximally and distally. The main were harvested from rats that had not received surgical
venous system consists of the venae comitantes and the treatment.
bilateral dorsal subcutaneous veins.
Results
Elevation of the Vascularized In the vascularized graft group, all rats showed bone
Tail Bone union by 6 weeks postoperatively at the distal sites and
by 16 weeks at the proximal sites. Bone union occurred
Sodium pentobarbital anesthesia is usually given much sooner for the vascularized graft group than for
intraperitoneally after light ether inhalation. The the non vascularized graft group.
ventral aspect of the tail is incised longitudinally, and a In the control group, multiple fluorochrome labelings
tail bone is exposed and isolated by dissecting the upper indicated slow concentric periosteal bone formation

143
144 C. Experimental Microsurgery

3 Dorsal Dorsal
Ventral

~~~~~~~~~
Proximal
~__-,--__5~ ~ '---____---'0 Do'"
4 Dorsal
1. Caudal artery
2. Comitant vein
3. Arterial branch into the bone
4. Arterial branch around the bone
5. Tail bone
6. Disc
a Ventral b Ventral

Fig. 1. Schematic drawing of the vascular anatomy of the Dorsal Dorsal

murine tail. The caudal artery runs down along the ventral
aspect of the tail, and the two branches enter each tail bone
at its midpart. Other branches are distributed around the tail
bones (from [3], with permission)

5th tail bone

c Ventral d Ventral

Fig. 3. Schematic drawings of un decalcified cross sections of

Fixation with a wire a, c the control tail bones, and b, d the vascularized grafts to

~
the femur. The shaded areas indicate periosteal bone forma-
tion a, b about 5 weeks after transfer, and c, d from 5 to 16
weeks postoperatively. The vascularized graft shows more
periosteal bone formation than the control tail bone. The
cortex of the vascularized graft is wide and relatively round
(from [3], with permission)

periosteal area. At 3 weeks postoperatively, the newly

Caudal artery
and vein
Fig. 2. Schematic drawing demonstrating the surgical proce-
dure for grafting the vascularized tail bone to the femur (from
[3], with permission)
with maintenance of sharp processes (Fig. 3) and slow
growth in the cancellous trabeculae.
In the vascularized graft group, the extensive distri-
bution of the fluorochrome marker given 1 week after
transfer indicates rapid concentric periosteal bone for-
mation, and many activated osteoblasts were seen in the
formed bone of the cortex became compact, and the
spinous and transverse processes became blunt. From 5
to 16 weeks postoperatively, periosteal bone formation
was more apparent in the vascularized graft group than
in the control group. Activated osteoblasts were still
present in the periosteal area. Cortical width increased,
although endosteal resorption occurred in the cortex
and enlarged the marrow cavity. The bony processes
flattened and became very blunt, and the grafts were
more rounded on transverse section (Fig. 3). In the can-
cellous bone, both bone resorption and bone formation
were markedly activated at 1 to 2 weeks postopera-
tively. At 3 weeks postoperatively, many osteoclasts
and activated osteoblasts were still found. At 5 weeks
postoperatively, the trabecular surface was covered with
lining cells, but some resorption lacunae with osteoclasts
were seen. At 16 weeks postoperatively, in contrast to
the abundant longitudinal cancellous trabeculae in the
control tail bone, the cancellous bone in the vascular-
ized graft was significantly diminished (Fig. 4).

Fig. 4. Photomicrographs of the vertical sections of a the
control tail bone, and b the vascularized graft to the femur
(H&E stain, x50). In contrast to the abundant longitudinal
cancellous trabeculae in the control tail bone, the vascularized
graft contained shorter trabeculae and smaller amounts of
cancellous bone
In the nonvascularized graft group, the bone became
completely necrotic 1 week after transfer and was grad-
ually resorbed from its superficies. At 5 weeks postop-
eratively, the cancellous trabeculae were also resorbed,
and diffuse marrow fibrosis was seen. New living bone
surrounded the dead bone, suggesting revascularization
and bone formation by "creeping substitution."
Discussion
Early bone alterations may be reactive changes to the
surgical procedure, such as the inflammatory reaction.
Following the initial dynamic phase, the vascularized
11.1. Cancellous Bone Graft Model 145
grafts continued to show more periosteal bone forma-
tion, leading to cortical hypertrophy and widening.
These morphologic changes occurred as the bone
adapted to its new situation, that is, weight-bearing. The
spinous and transverse processes became less severe in
the absence of normal mechanical stresses exerted by
tendons surrounding the tail bone, and the periosteal
surface lost its concavity to become more convex. The
cancellous bone of the vascularized graft was gradually
resorbed after 3 weeks, and the trabeculae took on an
architecture characteristic of the femur. Mechanical
stresses may be the principal stimulus for this dynamic
rearrangement.
Conclusions
The murine tail vertebral bone is ideal for studying
vascularized corticocancellous bone grafts, because it
has sufficient amounts of cancellous bone. Furthermore,
the caudal artery supplies both the medullary and
the periosteal vascular systems. The tail bone can be
transferred to various sites if an appropriate length
of vascular pedicle is taken; the surgical technique is
simple, because vascular anastomoses are not necessary.
References
1. Mizumoto S, Tarnai S, Goshima J, Yajima H, Yoshii T, Fukui
A, Masuhara K (1986) Experimental study of vascularized
tibiofibula graft in inbred rats: A preliminary report. J
Reconstr Microsurg 3:1-9
2. Yamaoka N, Tarnai S, Mizumoto S (1997) Experimental
study of vascularized bone grafts in rat: Effect of
mechanical loading on bone dynamics. J Orthop Sci 2:
239-247
3. Sempuku T, Tarnai S, Mizumoto S, Yajima H (1993) Vascu-
larized tail bone grafts in rats. Plast Reconstr Surg 91:
502-510
11.2 Intervertebral Disk Graft Model
ATSUO KUGAI
For the treatment of instability of the intervertebral disk
due to discopathy or destructive spine disease, interver-
tebral fusion is currently performed. However, some
harmful effects have been reported in association with
sacrificing spinal mobility [1,2]. In recent years, artificial
disks [3] or free disk grafts [4,5] have been attempted
with the aim of ideal reconstruction, but these have not
come into wide use yet. Thus, to investigate the potent-
ial clinical application of vascularized intervertebral
disk grafting, a new experimental model was designed,
using a vertebral body-disk unit of the tail in rats.
Dissection of Blood Vessels in the
Tail Vertebrae and Preparation of
the Donor
The major nutrient artery of the rat coccyx is the caudal
artery, which bifurcates from the abdominal aorta, and
the coccygeal vertebral body is fed by bifurcation from
this [6]. Detailed observation of the vascular corrosion
cast reveals multiple vascular plexuses bifurcating from
the caudal artery around the disk, whereas no vascular
systems are observed within the disk or in the human
disk (Fig. 1). Therefore, we considered it might be
appropriate to make a graft model of the vertebral
body-disk unit having the caudal artery and its veins as
vascular pedicles, in order to graft the disk while main-
taining its viability.
Determination of the Viability of the
Vascularized Intervertebral Disk
Materials and Methods
To determine whether the vascularized intervertebral
disk can be grafted as a living disk, vascularized verte-
bral body-disk units of 40 7-week-old male Fischer 344
rats were grafted into the pockets on the abdominal wall
(Fig. 2). Ten rats were killed at 2,4,8, and 12 weeks after
surgery and observed histologically and biochemically.
146
Furthermore, for comparison, the same number of free
transferred body-disk units served as nonvascularized
controls, and the same week-old disks with no operation
served as normal controls. Half of the body-disk units
extirpated each week were made into decalcified speci-
mens with sagittal sections and were observed after
staining with hematoxylin and eosin, Toluidine Blue,
and Safranin-o. For the remaining half, only the disk
portions were taken out, penetrated with 35S-sulfate at
low temperature, and cultured for 24h. Acid-insoluble
fractions of the disks taken out were extracted, and
35S-sulfate uptake was measured as the indicator of the
metabolic activity of disk cartilage.
Results
Histological Findings
In the vascularized disk group, the lamellar structure of
the annulus fibrosus and notochord-like cells of the
nucleus pulposus remained well until 12 weeks after
surgery. In the free-graft group, most cells of the nucleus
pulposus were necrotic 2 weeks after surgery, and the
normal disk structure almost disappeared 12 weeks
after surgery (Figs. 3 and 4).
Biochemical Findings
In the vascularized disk graft group, the mean 35S-sulfate
uptake was equivalent to that in the normal disk group
until 2 weeks after grafting and remained at 60% of the
normal activity from 4 to 12 weeks after grafting. In the
free-graft group, the mean 35S-sulfate uptake was already
reduced to 11 % of that in the normal disk 2 weeks after
grafting and thereafter remained reduced (Fig. 5).
Discussion
Retention of water by the matrix generated from car-
tilage cells plays a significant role in the viscoelasticity
of the disk [7]. However, there is little vascular dis-
Fig. 1. Vascular corrosion cast of a rat coccyx, made by infus-
ing corrosion compound through the abdominal aorta. The
detail revealed multiple vascular plexuses bifurcated from the
caudal artery around the intervertebral disk or body, whereas
no vascular systems were observed within the disk or in the
human disk. (See Color Plates)
Fig. 3. Sagittal section of the vascularized disk 12 weeks after
transplantation. The lamellar structure of the annulus fibrosus
and the nest of nucleus cells are well preserved (Toluidine
Blue stain, x50)

1
Vertebral
body-disk unit

Caudal artery
and veins

Fig. 4. Sagittal section of the free grafted disk 12 weeks after

transplantation. The lamellar structure is almost destroyed
and, the nuclei have completely disappeared (Toluidine Blue
stain, x50)

o 4

Fig. 2. Operative method for the vascularized vertebral disk

graft into the abdominal subcutaneous space. The 10th disk of
the coccyx was dissected and elevated to the central side with
adjacent bodies having the caudal artery and comit veins as
pedicles

1
Weeks

Fig. 5. The columns show the mean values of 35S-sulfate in-

corporation of each group. White columns, normal controls;
hatched columns, vascularized groups; black columns, free
graft groups
148 C. Experimental Microsurgery
tribution within the disk, and the cartilage cells of the
disk are fed by diffusion from neighboring vessels [8].
This study demonstrated that the disk can be grafted
while its biological activity is maintained, that is, as a
living disk, if at is grafted as a vascularized body-disk
unit with continuous blood flow. If such a graft of
composite tissue becomes available in the future, it
may be useful in reconstruction of spinal disorders in
humans.
References
1. Gruss P, Tannenbaum H (1983) Stress exertion on adjacent
segments after ventral cervical fusion. Arch Orthop Trauma
Surg 101:283-286
2. Lee CK (1988) Accelerated degeneration of the segment
adjacent to a lumbar fusion. Spine 13:375-377
3. Hedman TP, Kostuik JP, Fernie GR, Hellier WG (1991)
Design of an intervertebral disc prosthesis. Spine 16:s256-
260
4. Ishihara K, Matsuzaki H, Wakabayashi K (1996) Cryopre-
served intervertebral disc allografts in dogs. J Orthop Sci
1:259-267
5. Katsuura A, Hukuda S (1994) Experimental study of inter-
vertebral disc allograft in the dog. Spine 19:2426-2432
6. Sempuku T, Tamai S, Mizumoto S, Yajima H (1993) Vascu-
larized tail bone grafts in rats. Plast Reconstr Surg 91:502-
510
7. Urban JPG, Holm S, Maroudas A, Nachemson A (1997)
Nutrition of the intervertebral disk. Clin Orthop 129:101-
114
8. Whalen JL, Parke WW, Maur JM, Stauffer ES (1985) The
intrinsic vasculature of developing vertebral end plates and
nutritive significance to the intervertebral discs. J Pediatr
Orthop 5:403-410
12. Allograft of Composite Tissues: Experimental
Model in the Rat
AKIO MINAMI and NORIMASA IWASAKI

Historical Review rejection of rat limb transplants across an extremely

strong MHC barrier and to compare their efficacy with
Early experimental studies of vascularized joint and that of other immunosuppressive agents [17-21].
whole-limb allografts were performed using large As has been noted, during the past three decades,
animal models [1-6]. However, in some studies, a lack research in allogeneic limb transplantation using the rat
of defined major histocompatibility complex (MHC) model has made great progress with the technical
barriers in these animals yielded variable allograft improvement of microsurgery and the development of
rejection and did not permit syngeneic controls. On the immunosuppressive agents.
other hand, the rat is most suitable for studies of organ
allogeneic transplantation, because a variety of inbred
strains are available. In addition, with the development Surgical Procedure
of microsurgical technique, the size of this animal is
sufficient to permit a vascular anastomosis to be Animals and Anesthesia
performed.
In 1962, Schwind [7] reported rat limb allografts Two strains of inbred rats, in which the major histo-
surviving after parabiosis of the immature donor and compatibility antigens have been identified, are used as
recipient. To our knowledge, this is the first report of donor and recipient. All of the rats are adult males
successful allogeneic limb transplantation using a rat weighing 2S0-300g. The donor and recipient are anes-
model. After this successful report, however, larger thetized with pentobarbital sodium (Nembutal) via
animal models, rather than the rat model, were applied intraperitoneal injection at 1 mllkg body weight. The
to experimental studies in this field. In the late 1970s, hind limb of the anesthetized rat is shaved and prepared
with the improvement of microsurgical anastomosis after immobilization in a supine position.
technique and suture materials, the limb transplantation
model using rats had been technically established by
some investigators [8-10]. Following this technical Donor Preparation
establishment, rats have been mainly used for the exper-
imental model of limb allograft. The donor is prepared first. The skin incision is made
The other factor advancing research in this field is the over the anterior aspect of the lower leg, starting 1 cm
development of the new strong immunosuppressants. In proximal to the ankle joint. The incision is extended
the early 1980s, Press et al. [11] and Hewitt et al. [12,13] proximally over the anteromedial thigh to the inguinal
reported prolonged survival of limb allografts in rats region. At 1 cm proximal to the ankle joint, the incision
using a new immunosuppressive agent, Cyclosporine is made circumferentially to attach the donor's skin in
(CyA), which has been shown to be very effective in the foot (Fig. 1). The skin from the ankle joint distally
human solid organ transplantations. Furthermore, in is preserved to monitor circulation and graft rejection.
1987, Goto et al. [14] described a potent new immuno- The skin flap is raised from the limb to level of the
suppressive agent, FK-S06. This new agent has been inguinal ligament. The sciatic nerve is transected at the
reported to be about 10 to 100 times more potent than inferior aspect of the thigh. The femoral vessels and
CyA but has a lower incidence of side effects. In 1989, femoral nerve are dissected microscopically from the
Kuroki et al. [15] and Arai et al. [16] first demonstrated level of the inguinal ligament to just proximal to the
the efficacy of FK-506 against graft rejection in rat limb juncture with the popliteal vessels. All branches, includ-
transplantations. Since these reports, a large number of ing the superficial inferior epigastric vessels, are ligated
experimental studies have been performed to clarify the with an electric bipolar coagulator. After dissection of
effectiveness of CyA and FK-S06 in preventing the the femoral vessels and nerve, the muscles and femur

149
150 C. Experimental Microsurgery

Fig.I. Donor skin incision. The skin incision is made over the Fig. 2. The muscles and the femur are cut transversly at the
anterior aspect of the lower leg. The incision is then extended distal one-third of the thigh. The blood supply of the donor's
proximally over the anteromedial thigh. At 1 cm proximal to limb is maintained by the femoral vessels
the ankle joint, the incision is made circumferentially

are cut transversely at the distal one-third of the femur.

To prevent coagulation in the donor's limb, heparinized
saline solution is given intravenously via the penile
vein (3-4 IU per animal). At this stage, to minimize the
ischemic time, the blood supply of the donor's limb is
maintained by the femoral vessels (Fig. 2).

Recipient Preparation

To prevent self-mutilation, the skin incision is made

over the posterior aspect of the hind limb, starting 1 cm
proximal to the ankle joint. The circumferential incision
is then made lcm proximal to the ankle joint (Fig. 3).
Under the guidance of a microscope, the femoral artery
and vein are carefully dissected between the inguinal
ligament and just proximal to the juncture with the
popliteal vessels. The muscles and femur are then
divided transversely at the proximal one-third of the
thigh. The femoral artery is the clamped and sharply
divided just proximal to the juncture with the popliteal Fig. 3. Recipient skin incision. The skin incision is made over
artery. The femoral vein and nerve are also divided at the posterior aspect of the hindlimb. The circumferential inci-
the same level. sion is then made 1 cm proximal to the ankle joint

Fig. 4. Microscopic anastomoses of the femoral artery and
vein are performed with six to seven interrupted 11-0 nylon
sutures
Orthotopic Limb Transplantation
The donor's femoral vessels and nerve are sharply
divided at the level of the inguinal ligament. The lumen
of each divided vessel of the amputated limb is then man-
ually perfused with heparinized saline solution (10
IV/ml). Bony fixation between the donor and the recipi-
ent is first achieved with an intramedullary 0.045-inch
Kirschner wire. The muscles are approximated with 4-0
nylon sutures. By using standard microsurgical tech-
nique, the anastomoses of the femoral artery and vein are
performed with six to seven interrupted 11-0 nylon
sutures (Fig. 4). A few drops of lidocaine (4%) are
applied on the anastomoses. To minimize the ischemic
time and confirm the venous return, the artery is repaired
first. Once the blood flow has been reestablished, the
femoral nerve is repaired with three to four interrupted
10-0 nylon epineural sutures. Finally, the wound is closed
with simple 4-0 nylon suture. In this model, the donor
skin is attached only in the foot, and the skin coverage
proximal to the ankle joint consists of the recipient's skin
(Fig. 5). Although lactated Ringer's solution (10ml/kg) is
given intravenously to compensate for blood loss, neither
systemic anticoagulation nor antibiotics are used. The
mean ischemic time for the donor limb is 60min, with a
mean operating time of 2.5 h. Postoperatively, a plastic
neck collar is applied for 1 to 2 weeks to prevent self-
mutilation of the grafted limb.
12. Allograft of Composite Tissues 151
Fig. 5. Transplanted limb. The donor skin is attached only in
the foot, and the skin coverage proximal to the ankle joint
consists of the recipient's skin
Rejection of the Grafted Limb
In the absence of immunosuppression, the onset of graft
rejection in rats across a strong histocompatibility mis-
match occurs 3 to 4 days after operation. The visible
signs of the onset are acute erythema and edema in the
donor's foot skin. These changes are rapidly followed by
eschar formation, total necrosis, and mummification
within 2 weeks after grafting.
Application of Immunosuppressive
Agents to Allogeneic Limb
Transplantation
In the absence of immunosuppression, transplanted
organs invariably undergo progressive immune-
mediated injury. Over the past 40 years, various
immunosuppressive agent regimens have been devel-
oped and have transformed transplantation of solid
organs (kidney, heart, lung, liver, and pancreas) into an
established clinical procedure. Although a number of
experimental studies using various immunosuppressant
regimens have demonstrated the success of limb al-
logeneic transplantation, considerable problems must
be solved for the clinical application of the regimens
[11-13,15-21 ].
152 C. Experimental Microsurgery

Table 1. Previous reports on effects of cyclosporine (eyA) treatment on limb allograft survival
Authors Regimen Mean survival time (days)
Black et al. [13] Smglkg/day x 20 days SC then Smg/kg/day SC twice weekly 152
Smg/kglday x 20 days SC then Smglkg/day orally every day 174
Kuroki et al. [15] 15mg/kg/day x 14 days 1M 31
Hotokebuchi et al. [IS] 25 mg/kg/day x 16 days SC 44
25mg/kg/day x 16 days then 25mglkg/day 56
Twice a week for the next 14 weeks SC
Min et al. [19] 25mg/kglday x 14 days SC 30
Biittemeyer et al. [17] 25mglkg/day x 14 days SC 30

1M, Intramuscular injection; SC, subcutaneous injection.

Table 2. Previous reports on effects of FK 506 treatment on
limb allograft survival
Mean survival
Authors Regimens time (days)
Arai et al. [16] 2mg/kg/day single dose 1M
10mg/kg/day single dose 1M
50mg/kglday single dose 1M
Kuroki et al. [15] 0.32mg/kg/day x 14 days 1M
0.64mg/kg/day x 14 days 1M
Fealy et al. [21] 6.0mg/kg/day x 14 days PO
6.0mglkg/day x 90 days PO
Min et al. [19] 1.0mg/kg/day x 14 days 1M
2.0mg/kglday x 14 days 1M
20.0mglkg/day single dose PO
1M, Intramuscular injection; PO, oral administration.
Following the first successful experimental limb allo-
graft immunosuppressed with parabiosis [7], numerous
similar studies have been performed using different
animal models and a variety of immunosuppressant reg-
imens. In the 1970s and the 1980s, experimental studies
were attempted using blood transfusion [22,23], anti-
lymphocyte serum [24], 6-mercaptopurine [8,25], aza-
thioprine [23,25], steroids [8,11,23], and CyA [11-13].
Among these immunosuppressants, CyA has the most
powerful immunosuppressive action and has greatly
improved the survival of clinical organ transplants. CyA
is a calcineurin inhibitor that binds to cytoplasmic
receptors of the T cell. The calcineurin inhibition pre-
vents interleukin-2 (IL-2) gene transcription, thereby
inhibiting T-cell IL-2 production. The first successful rat
limb transplants utilizing CyA were done by Press et al.
[11] and Hewitt et al. [12,13]. Since these successful
studies, it has been shown to prolong the survival of
rat limb grafts, depending on the dosage regimen and
the histocompatibility of the donor and recipient rats
(Table 1). However, administration of CyA does not
completely suppress acute rejection and is associated
with well-recognized side effects, such as hepatotoxicity
and nephrotoxicity.
On the other hand, to conquer the limitations of these
immunosuppressants, several new agents, including
FK506, RS-61443, Rapamysin, and 15-deoxysupergualin
(DSG), as well as combination immunosuppressive
therapy, are currently undergoing experimental and
clinical evaluation. FK506 has been developed as an
16.4 alternative agent to CyA. In comparison with CyA, it is
51.3 about 10-100 times more potent and has a lower inci-
104.4
33.4
dence of side effects. Consequently, FK506 has had an
49.S enormous impact on human vital organ transplantation.
2S.0 In experimental limb transplantation, since the first
>90 report by Arai et al. [16], many studies using the rat
40.0 model have shown that the administration of FK506 sig-
122.0
64.0
nificantly prolongs graft survival (Table 2). However,
the skin component in limb allografts is highly antigenic,
necessitating an immunosuppressant dose of FK506
as much as two to three times higher than that for
other solid organ allografts in the rat. Therefore, even
if FK506 can prolong the graft survival of the limb, the
toxicity of this immunosuppressant must be considered.
At the moment, it is obvious that FK506 and CyA are
the most effective immunosuppressants to prevent
acute rejection of the transplanted limb. However, as
has been pointed out, these immunosuppressive agents
are associated with serious side effects and cannot
control the delayed onset of slow acute or chronic rejec-
tion. These limitations of FK506 and CyA for limb
transplantation are the major reasons why allogeneic
limb transplantations have not been performed clini-
cally. To overcome these limitations, the combination
of low-dose FK506 or CyA and other immunosuppres-
sants, which have different immunossuppressive actions
from that of FK506 and CyA, has been recently applied
to experimental allogeneic limb transplantation.
RS-61443 is the morpholineoethyl ester prodrug of
mycophenolic acid (MPA) and is designed to increase
MPA bioavailability [26]. The mechanism of action is
the depletion of guanosine nucleotides by its active
MPA, resulting in relatively specific inhibition of T-cell
and B-cell proliferation [27,28]. Benhaim et al. [29], in
1996, demonstrated that combined therapy with low-
dose RS-61443 and CyA was efficacious in preventing
the rejection of grafted limbs in the rat while minimiz-
ing drug-induced toxicity. Leflunomide (LEF), an isox-

azole derivative, is a novel immune modulatory agent
[30]. This immunosuppressive agent inhibits the consti-
tutive proliferation of T- and B-celliines, the prolifera-
tion of T cells to mitogenic cytokines, and the response
of B cells to mitogenic stimuli [31]. In 1997, Yeh et al.
[31] showed that the combination of LEF and eyA pre-
vented rejection of rat limb allografts. DSG acts by spe-
cific clonal deletion of activated lymphocytes at the site
of the rejection reaction [32,33]. Muramatsu et al. [34],
in 1997, reported that combination therapy with FK506
and DSG prolonged the survival of limb allografts in
rat. The results of these studies suggested a positive
synergistic immunosuppressive effect with combination
therapy in limb allogeneic transplantation.
The important points to emphasize are that the limb
transplant is a nonvital organ graft and a composite
tissue graft, including the skin. Therefore, we have to
prevent the fatal side effects induced by immunosup-
pressive agents and control the high antigenicity
[35-37]. Previous experimental studies have demon-
strated that various immunosuppressive agent regimens
prevent acute rejection of the grafted limb. However,
drug-induced toxicity and the delayed onset of slow
acute and chronic rejection are still considerable prob-
lems. Before limb allografts can be applied clinically,
future experimental study will have to focus on these
issues. We must develop safe and effective immuno-
suppressant regimens.
References
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tion of the canine knee joint on vascular pedicles 20. Paskert Jp, Yaremchuk MJ, Randolph MA, Weiland AJ
(AAOS proceedings) (Abstract). J Bone Joint Surg 55A:
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2. Goldberg VM, Porter BB, Lance EM (1980) Transplanta-
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3. Reeves B (1968) Studies of vascularized homotransplants
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6. Yaremchuk MJ, Sedacca T, Schiller AL, May JW (1983)
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7. Schwind JV (1962) Homotransplantation of extremities of
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12. Allograft of Composite Tissues 153
10. Shapiro RI, Cerra FB (1978) A model for reimplantation
and transplantation of a complex organ: The rat hind limb.
J Surg Res 24:501-506
11. Press BHJ, Sibley RK, Shons AR (1983) Modification of
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and prednisone: A preliminary report. Transplant Proc 15:
3057-3062
12. Hewitt CW, Black KS, Fraser LA, Howard EB, Martin
DC, Achauer BM, Furnas DW (1985) Composite tissue
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364
13. Black KS, Hewitt CW, Fraser LA, Howard EB, Martin DC,
Achauer BM, Furnas DW (1985) Composite tissue (limb)
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cyclosporine. Transplantation 39:365-368
14. Goto T, Kino T, Hatanaka H (1987) Discovery of FK-506,
a novel immunosuppressant isolated from Streptomyces
tsukubaensis. Transplant Proc 19:4-8
15. Kuroki H, Ikuta Y, Akitama M (1989) Experimental
studies of vascularized allogeneic limb transplantation in
the rat using a new immunosuppressive agent, FK-506:
Morphological and immunological analysis. Transplant
Proc 21:3187-3190
16. Arai K, Hotokebuchi T, Miyahara H, Arita C, Mohtai M,
Sugioka Y, Kaibara N (1989) Limb allografts in rats im-
munosuppressed with FK506. Transplantation 48:782-786
17. Btittemeyer R, Jones NF, Min Z, Rao U (1996) Rejection
of the component tissues of limb allografts in rats
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18. Hotokebuchi T, Arai K, Takagishi K, Arita C, Sugioka Y,
Kaibara N (1989) Limb allografts in rats immunosup-
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19. Min Z, Jones NF (1995) Limb transplantation in rats:
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(1987) The role of cyclosporine in prolonging survival
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Press BHJ (1994) Efficacy of Rapamycin and FK 506 in
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24. Poole M, Bowen JE, Batchelor JR (1976) Prolonged sur-
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(1990) Bioavailability improvement of mycophenolic acid
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27. Allison AC,Almquist SJ, Muller CD, Eugui EM (1991) In
vitro immunosuppressive effects of mycophenolic acid
and an ester prodrug. Transplant Proc 23 (suppI2):10
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Subramanian R, Sollinger HW (1992) The influence of
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(1995) Leflunomide (HWA 486) and its analog suppress
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ongoing rejection, and antidonor antibody synthesis in
mouse, rat and cynomolgus monkey transplant recipients
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catheter injury. Transplant Proc 27:445-447
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Morris RE (1997) Combination leflunomide and
cyclosporine prevents rejection of functional whole limb
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32. Umezawa H, Moriguchi M, Takeuchi T (1985) Suppres-
sion of tissue graft rejection by spergualin. J Antibiot 38:
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33. Walter P, Dickenite G, Feifel G, Thies J (1987) Deoxysper-
gualin induces tolerance in allogeneic kidney transplanta-
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34. Muramatsu K, Doi K, Akino T, Shigetomi M, Kawai S
(1997) Longer survival of rat limb allograft. Combined
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35. Daar AS, Fuggle SV, Fabre JW, Ting A, Morris PJ
(1984) The detailed distribution of HLA-A, B, C
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The detailed distribution of MHC class II antigens in
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401-411
 D. Preoperative and
Postoperative Management
1. Preoperative Planning and Evaluation of the
Vascular System in the Donor and Recipient
SATOSHIToH
In microvascular free tissue transfers, preventing post-
operative vascular complications such as thrombosis
and venous congestion is the first priority to achieve a
successful result. Next, the goal of each tissue transfer
must be fulfilled, and finally the functional and cosmetic
loss in the donor site should also be minimized.
Even in the hands of experts, the majority of throm-
boses are probably due to identifiable technical factors,
such as tight closure and twists or kinks of the pedicle [1].
A better understanding of the causes of free tissue trans-
fer failure and the ways to avoid them is necessary for
these reconstruction procedures to gain wider accept-
ance. One of the main causes of free tissue transfer
failure is inadequate planning and preparation, and
therefore preoperative simulation is very important for
successful outcome. It is important not only to foresee
the complications but also to plan countermeasures. In
this chapter, preoperative planning and evaluation of the
vascular system in the donor and recipient are discussed.
Preoperative Planning
Patient's Health Status
Systemic problems, such as diabetes and cardiovascular,
renal, and pulmonary disease, do not constitute an
absolute contraindication to vascularized free tissue
transfers. However, these conditions should be well
controlled before reconstructive surgery, and the anes-
thesiologist should be consulted about the risk of
anesthetic complications.
The patient's age, sex, and body weight are important
factors. Especially in women, tissue should not be taken
from areas that would normally be exposed to view.
Chronological age per se is not a factor associated
with free tissue transfer failure [2]. However, in elderly
patients, complications at the anastomosis site are
frequent, so vessels with larger diameters should be
selected whenever possible. In very obese patients, a
single tissue transfer is preferred, because it is some-
times difficult to harvest combined tissues such as an
osteoseptocutaneous flap.
Timing
Some controversy exists as to the timing of free tissue
transfer, particularly in posttraumatic limb reconstruc-
tion. Some authors recommend primary free tissue trans-
fer [3,4]. However, many do not believe that there is a
critical time following trauma during which free tissue
transfer should be done. What is much more important
than the timing per se is the expertise with which the
debridement of all devitalized tissue is performed, and
the care given to the exposed delicate structures in the
interim between debridement and flap coverage [1]. In
the case of infections, such as osteomyelitis or infected
nonunion, it is necessary to take some time to control the
infection before reconstructive surgery, such as free
vascularized bone transfer [5].
In the case of toe-to-finger transfer, if the skin defect
of the recipient hand is large or skin reconstruction of
the base of the transferred toe is necessary, skin cover-
age such as a distant pedicle skin graft or rotational skin
graft is recommended prior to toe-to-finger transfer.
Otherwise, the skin defect of the donor site will enlarge,
reSUlting in another donor site problem.
Preoperative Angiography
In the case of injury to major arteries, preoperative
angiography is necessary; otherwise, examination by
Doppler flowmeter and palpation of the artery may be
adequate [6]. On the angiogram, not only the flow of the
artery, but also narrowing and irregularity of the intimal
lining of the vessel, should be checked preoperatively
(Figs. 1 and 2).
Preoperative Simulation
Preoperative simulation is very important for a suc-
cessful outcome. Two operating teams are required to
shorten the operative time, and it is best to schedule
these surgeries at the beginning of the work week,
because revisional surgery is sometimes necessary.
157
158 D. Preoperative and Postoperative Management
Fig.I. This 53-year-old woman had a large posttraumatic skin
defect of the distal part of the lower leg. Angiogram revealed
that the posterior tibial artery remained intact. In such cases,
only the posterior tibial artery is available as the recipient
artery, and side-to-end anastomosis is the only choice
Adequate access to each proposed surgical field
based on the recipient vessels and the donor site should
be considered when positioning the patient on the oper-
ating table. In particular, the position of the operator at
the microvascular anastomosis must be prearranged so
that he or she will be comfortable during the most del-
icate part of the operation.
Skin coverage after the operation should also be care-
fully considered. Healthy skin should be used to cover
the anastomosis site to prevent postoperative vascular
complications.
Evaluation of Vascular System in the
Donor and Recipient
Important Factors to be Considered in
the Donor Site
The characteristics of each donor tissue planned for
use should be considered, such as the size that can be
harvested, the length and diameter of the vascular
stock, the possibility of harvesting as a composite tissue,
and the functional and cosmetic loss in the donor
site.
Fig. 2. This 78-year-old woman had an infected bone defect
of the proximal tibia, and only the peroneal artery remained.
Therefore, ipsilateral pedicle vascularized fibula graft was not
indicated
The most experienced surgeon in the team will be the
best able to select the appropriate tissues. A wide range
of options should be considered, and flexibility of donor
selection is very important.
Free Flap
To prevent donor site morbidity, there should be no
loss of function at the donor site after harvesting of
free tissues. In particular, the forearm flaps, the first
web flap, and the dorsalis pedis flap should be the last
options, because they often result in scar contracture
at the donor site. Because an unsightly scar usually
results from the peroneal or the forearm flaps, such as
the radial forearm or the posterior interosseus flaps,
these should be avoided in patients who are con-
cerned about cosmetic appearance. A groin flap is a very
appropriate free flap, because the donor site is usually
not visible. However, the diameters of the nutrient
vessels in this flap are very small, and there is anatom-
ical variation of the pedicle. Therefore, if this flap is
selected, the recipient vessels must be carefully chosen
to match the diameters of the donor vessels as much as
possible. On the other hand, the diameters of the nutri-
ent vessels of the sub- or parascapular flap and latis-
simus dorsi flap are relatively large and anatomical
 1. Preoperative Planning and Evaluation of the Vascular System in the Donor and Recipient 159

Fig.3. This angiogram of a 69-year-old woman revealed occlusion of the popliteal artery,
and vascularity was maintained by collateral vascular channels. In such cases, the prox-
imal part of the occluded popliteal artery should be selected as the recipient artery.
These cases, however, have a high risk of disruption of vascular supply in the distal part
of the lower leg due to the surgical intervention itself

variation is rare, and therefore these flaps are easy to
use.
When an appropriate recipient vessel does not exist
close to the recipient site, a flap with a long vas-
cular pedicle (10-15cm) should be selected, such as
the peroneal flap or the radial forearm flap. Even
in the sub- or parascapular flap or the latissimus
dorsi flap, if the pedicle is dissected as far as the sub-
scapular artery, a long pedicle of about 10 cm can be
obtained.
Free Vascularized Bone Graft
When a vascularized fibula graft is indicated, it is
very important to notice that the diameters of the
concomitant veins of the peroneal artery are usually
large. The recipient vein should have a diameter as
large as possible. In lower leg reconstruction using the
ipsilateral fibula graft, it is very important to estimate
the vascularity of the distal part of the lower leg
preoperatively. In some cases, the sacrifice of the pero-
neal artery results in vascular insufficiency and even
amputation (Fig. 3). Although the posterior tibial
artery is generally the predominant artery, in some
cases the peroneal artery is larger, and the vascu-
larized fibula cannot be used as an ipsilateral pedicled
transfer.
Free Toe or Toe Joint Transfer
Generally, if the proper digital artery can be used for
the recipient artery, a short pedicle, such as the first
dorsal or the plantar metatarsal artery, is preferable
for the donor artery, because the procedure is simple
and the cosmetic aspect is better in the new recon-
structed digit. However, if there is no recipient vessel
close to the recipient area, the dorsalis pedis and the
great saphenous vein must be harvested with the trans-
ferred toe.
Important Factors to Be Considered in the
Recipient Site
Recipient factors influencing the choice of appropriate
donor tissue are the size of the recipient site, the distance
between the recipient site and the vessels used
for anastomosis, the diameter of the recipient vessels, and
the combination of tissue to be included in the donor.
Care must also be taken to prevent disturbance of the
vascular supply in the area distal to the recipient site. In
160 D. Preoperative and Postoperative Management
some cases, only one major artery remains and bears
responsibility for the vascular supply of the distal part.
To select the appropriate vessels for anastomosis, one
of the most important points is that the diameter of the
vessels should be as close to each other as possible. The
length of the vascular pedicle is determined by the type
of flap, and the anastomosis site in the recipient vessel
must be carefully chosen to give adequate length. There
should be no tension or slackness. The vessels selected
should be away from the sites of previous trauma or
severe radiation. After trauma, widespread changes
occur in the walls and perivascular tissues of the major
vascular bundles. These changes have been called post-
traumatic vessel disease (PTVD) [7]. Vessels affected by
PTVD are more difficult to dissect and are easily
damaged during the dissection. It is said that these
vessels seem to lack the thromboresistant properties of
the healthy vessels after anastomosis [1]. Whenever pos-
sible, the selection of recipient vessels affected by
PTVD should be avoided.
The scar tissue is more extensive when there is in-
fection, and in such cases it may be necessary to con-
sider a vein graft. Preoperative selection of the artery
is generally possible by means of angiography. How-
ever, this is not the case with veins. Generally it is
safer to use the concomitant vein rather than the cuta-
neous vein. Particularly in traumatic cases, even when
an unexpected obstruction is noticed in the cutane-
ous vein, the concomitant vein is generally safe if the
integrity of the artery accompanying it is confirmed by
angiography.
Usually end-to-end anastomosis is the preferred
technique; however, depending on the case, end-to-side
anastomosis may be more appropriate, particularly
when the main artery has to be used as a recipient artery
or when the diameters of the vessels to be anastomosed
are different.
The candidates for the recipient vessels, depending on
the reconstructive region, are as follows:
Supraclavicular region: transverse cervical artery, ex-
ternal jugular vein
Infraclavicular region: thoracoacromial artery,
cephalic vein
Upper arm
Medial approach: ulnar collateral artery and
vem
Lateral approach: radial collateral artery and vein
Distal part of the upper arm: radial recurrent artery
and its venae comitantes
In cases in which the above arteries are not suitable,
the base of each branch of the brachial artery is prefer-
able in end-to-side fashion.
Elbow region: radial recurrent artery and its venae
comitantes
Forearm: radial or ulnar artery, its venae comitantes,
cutaneous vein. If the radial or the ulnar artery is
injured, the proximal part of the injured artery is
used for the recipient artery.
Wrist and hand region
If a long pedicle of the donor tissue is used, the radial
artery is preferable. If a short pedicle is used in a donor
site, the proper digital artery and cutaneous vein are
selected. If end-to-end anastomosis is performed, it is
necessary to evaluate the vascularity of the distal part
of the hand by using the Allen test preoperatively or by
temporary clamping intraoperatively.
Thigh region
Proximal thigh region: lateral circumflex femoral
artery and vein
Midthigh region: muscular branch of the deep
femoral artery and its venae comitantes
Distal thigh region: medial descending genicular
artery
In cases in which the above arteries are not suitable,
the base of each branch of the femoral artery is prefer-
able in end-to-side fashion. A great saphenous vein is
always considered to be a good candidate for the recip-
ient vein in the thigh region.
Knee region
Anterior side: medial descending genicular artery,
great saphenous vein
Popliteal region: muscular branch of the popliteal
artery, its venae comitantes, small saphenous vein
Lower leg
Anterolateral region: anterior tibial artery and
vein, great saphenous vein
Posteromedial region: posterior tibial artery and
vein, small saphenous vein
The pathway of the vascular pedicle should not run
over the bone because of compression by the bony edge.
If the recipient artery cannot be used to provide obverse
flow, the artery at the distal part of the lower leg may
be selected as reverse flow.
Foot region
Dorsal region: anterior tibial artery, dorsalis pedis
artery, great saphenous vein
Plantar region: posterior tibial artery, great saphe-
nous vem.
 1. Preoperative Planning and Evaluation of the Vascular System in the Donor and Recipient 161

References 5. Toh S, Harata S, Ueyama K, Nakamura R, Nishikawa S,

Inoue S (1990) Treatment of infected bone and joint disease
using vascularized tissue transfer. J Jpn Soc Bone Jt Infec
1. Khouri RK (1992) Avoiding free flap failure. Clin Plast
(in Japanese) 4:121-123
Surg 19:773-781
6. Lutz BS, Wei FC, Machens HG, Rhode U, Berger A (2000)
2. Serletti JM, Higgins JP, Moran S, Orlando GS (2000)
Indications and limitations of angiography before free-flap
Factors affecting outcome in free-tissue transfer in the
transplantation to the distal lower leg after trauma:
elderly. Plast Reconstr Surg 106:66-70
prospective study in 36 patients. J Reconstr Microsurg 16:
3. Godina M (1986) Early microsurgical reconstruction of
187-191
complex trauma of the extremities. Plast Reconstr Surg
7. Acland RD (1990) Refinements in lower extremity free
78:285-292
flap surgery. Clin Plast Surg 17:733-744
4. Lister G, Scheker L (1988) Emergency free flaps to the
upper extremity. J Hand Surg 13A:22-28
2. Postoperative Monitoring and Observation
MOROE BEPPU
The most critical complication of replantation and free
tissue transfer is postoperative failure of blood cir-
culation. The failure rate of tissue transfer is generally
about 5%-10%, even when advanced microsurgical
techniques or strict surgical indications are applied.
These microsurgical procedures can only be successful
when the blood circulation of the graft has been main-
tained properly. Therefore, monitoring of blood circula-
tion and postoperative management are significant.
Postoperative Monitoring
Postoperative circulatory disturbance after free tissue
transfer requires rapid and effective treatment. The
diagnosis of circulatory disturbance relies first on sim-
ple clinical examination of the transferred tissue.
Indicators of flap condition, such as color, temperature,
capillary refill, and bleeding on puncture of the flap, all
need to be examined. It is not easy to detect circulatory
disturbance in the early stages, and it is possible to lose
the timing for reoperation. Giunta [1] reported a clini-
cal classification of circulatory disturbance. The com-
parative capillary refill time is impaired (stage 1). With
increasing disturbance of the blood supply or drainage,
a livid discoloration or paleness of the flap appears
(stage 2). If these criteria can no longer be reliably
assessed, the most accurate procedure is to test the cir-
culation by puncturing the flap. If no bleeding occurs,
this generally indicates a severe disturbance of perfu-
sion, with ischemia of the graft (stage 3). Unremitting
ischemia leads eventually to the development of dry
necrosis (stage 4), signifying irreversible loss of the
flap.
In the past few years, many new automatic devices
for monitoring the circulation have been suggested,
which are claimed to be more sensitive than simple
clinical observation. For example, puis oximetry [2], laser
Doppler flowmetry [3], measurement of p02 and pC0 2
[4], temperature control [5], and other methods have
been used. However, there has been no convincing
evidence that any of these methods can detect circula-
tory disturbances earlier than clinical observation.
162
Microsurgeons have to be familiar with a simple clinical
examination of the transferred flap and make a clinical
diagnosis with the assistance of other devices offered
for monitoring circulation. The temperature of the
flap is usually evaluated every 2h postoperatively. The
minimum acceptable temperature is 30e. Any tem-
perature above 30C is usually satisfactory, but with
temperatures under 30C, care must be taken over the
condition of the flap, such as color, temperature, capil-
lary refill, and bleeding on puncture of the flap.
Process of Postoperative Failure of
Blood Circulation
From a clinical point of view, there are three types of
circulatory disturbance: arterial thrombosis, venous
thrombosis, and arteriovenous thrombosis. Arterial
thrombosis causes the grafted tissue to become pale,
cold, and decreased in tension, and more skin folds
occur. There is no capillary refill when the free flap is
compressed by the fingertip or by forceps. The skin
temperature decreases rapidly, and finally venous
thrombosis occurs.
Venous thrombosis causes the grafted skin flap to
become purple-red in color; sometimes blister formation
occurs and the edges of the flap become cyanotic. The
capillary refill is rather rapid in the early stages and grad-
ually slows down in the later stages. About 6-8 h postop-
eratively, the grafted skin flap becomes totally cyanotic.
In our clinical cases, venous problems occur more often
than arterial. In free tissue transfer, a subcutaneous
hematoma compresses the artery and vein and also
extends the vascular pedicle of the transferred tissue.
Complications usually occur within 72h. Postoperative
monitoring has to be done for at least 3 days.
Causes of Circulatory Disorder
The most important cause of circulatory failure is a
thrombosis at the anastomosis site. There are several
causes of thrombosis, including technical failure of the

anastomosis, the condition of the recipient artery and
vein, discrepancy of the diameters of the recipient and
donor artery and vein, inadequate tension of the vessel
and kinking or twisting of the vessel, and inadequately
performed vein graft.
Technical Failure of the Anastomosis
Surgeons have to maintain their microsurgical tech-
nique to prevent endothelial injury during anastomosis.
Both the healthy proximal and distal ends of the vessel
have to be sutured under the microscope. If the vessels
are traumatized, thrombosis can easily result.
Condition of the Recipient Vessels
If the recipient artery and vein are in the scar tissue,
gentle vessel dissection of the recipient site is very
important to prevent mechanical distortion, vasospasm,
and hematoma at the suture site. In particular, chronic
osteomyelitis of the lower extremity results in thick scar
tissue surrounding neurovascular bundles because of
frequent operations.
Discrepancy in Diameter Between the
Recipient and Donor Vessels, Especially
the Veins
Especially in the vascularized fibular graft, venous dis-
crepancy usually occurrs between the concomitant veins
of the anterior tibial artery (recipient) and the peroneal
artery (donor). Clinically, the lower extremity has more
risk of thrombosis than the head and neck and the
upper extremity, because it has more arteriosclerosis
and venous pressure problems than the upper extrem-
ity. The number of recipient arteries and veins in the
lower extremity is much less than that in the head and
neck.
Inadequate Tension of the Anastomosed
Vessel and Kinking or Twisting of
the Vessel
Optimal tension without kinking or twisting of the
vessels is very important for the anastomosis. Too much
tension causes narrowing of the vessel lumen and cir-
culatory disturbances. Especially if an interpositional
vein graft is needed, less tension suture causes kinking
or twisting of the grafted vein, and finally thrombosis
occurs.
2. Postoperative Monitoring and Observation 163
Risk Factors for Postoperative Failure
Smokers, the obese, patients with arteriosclerosis, and
the elderly are at high risk for postoperative failure.
There are also several risk factors for postoperative
failure of blood circulation. The high-risk recipient sites
are the lower extremity, as mentioned previously, and
also the infectious or the irradiated region. The groin
flap has more chance of failure than any other flap
because of its shorter pedicle and small artery diame-
ter, as compared with the size of the flap. The vascular-
ized fibular graft also has more risk factors than any
other tissue because of venous diameter discrepancies
between the donor and recipient site. In contrast, the
latissimus dorsi musculocutaneous flap and the radial
forearm flap have a longer pedicle and a larger diame-
ter of vessels.
Postoperative Care for the Prevention
of Circulatory Disorders
In the case of replantations, the injured hand is gener-
ally kept elevated above the level of the heart. In arte-
rial circulatory disturbance, the hand should be kept in
a lower position or at the level of the heart. In venous
circulatory disturbance, the injured hand has to be
raised up. At every recipient site, regardless of where
the flap was transferred from, the site should be lowered
in cases of arterial circulatory disturbance and elevated
in cases of venous disturbance. Postoperative viability
check of the flap is necessary every hour on the first day,
every 3 h from the second day, and gradually at more
than 3 h up to 2 weeks.
If any problems arise at the transferred flap site, the
dressing should be removed and the suture stitches
removed if necessary to avoid local compression to the
anastomosis site. Pain control is very important for
postoperative blood circulation to prevent vasospasms.
A painkiller or peripheral nerve block is advised to
prevent local pain.
Anticoagulant Therapy
Anticoagulant therapy includes inhibition of coagula-
tive activity (heparin or similar), suppression of
hemagglutination (low-molecular-weight dextran, etc.),
activation of fibrinolysis (fibrinogen or similar), and
inhibition of platelet adherence and agglutination
(aspirin, prostaglandin E), etc.). Previously, we applied
this therapy in all replantation cases, but we have expe-
rienced several complications. When healthy vessels
164 D. Preoperative and Postoperative Management
are ideally anastomosed, anticoagulant therapy is not
always done. Replantations distal to the palm have to
be treated by anticoagulant therapy, because of the
small diameter of the vessels in the digits. Replantations
proximal to the palm need to be treated by anticoagu-
lant therapy only when endothelial injury to the blood
vessels is present, such as in severe crushing or avulsion.
Our Preferred Treatment for
Postoperative Failure of
Blood Circulation
Sterilized Leeches for Congestive Failure
Leeches are used for venous congestion after replan-
tation. One leech can absorb 5 ml of blood in about
20-30min and discharges hirudin, which works as an
antithrombin agent and causes about 50ml of bleeding
per 24 h. This method is useful for venous circulatory
disturbances in replantations, toe-to-hand transfers, and
relatively small free flap transfers.
Continuous Local Heparinization
Mizumoto developed this unique method, which pre-
vents postoperative bleeding by systemic hepariniza-
tion. There are two methods of continuous local
heparinization. One is used for arterial thrombosis: a
catheter is inserted into the artery from the proximal
part of the anastomosis site. The other is used for venous
thrombosis: the catheter is inserted from the distal part
of the anastomosis of the vein. It continues for about
one week and gradually the total dose is decreased.
Postoperative Anticoagulant Therapy for
Tissue Transfer
In the first 3 days postoperatively, low-molecular-weight
dextran, 500 ml per day, is given intravenously. However,
preoperative examination of renal function is very
important to avoid acute renal failure. Prostaglandin
EJ at a dose of 80-120 !!g/day is given intravenously.
Aspirin, one 40-mg tablet 2 to 3 times a day, and
diazepam, 2mg 3 times a day, continue to be generally
prescribed for a period of 2 weeks. Depending on the
circulatory disturbance, 3000 to 5000 units of heparin
are given in one shot intravenously. Furthermore, sys-
temic administration of 5000 to 15,000 units of heparin
per day can be added continuously. However, in cases
with severe damage, particular care must be taken
when giving heparin not to cause excessive bleeding.
Although control of blood circulation is quite impor-
tant, at the same time we need to be aware of the
increased swelling of the flap from internal hemorrhage
that could occur.
In our clinical cases, among 150 cases of vascularized
tissue transfer, failure of blood circulation occurred in
19 cases (12.7%), most of which occurred in recon-
struction of the lower extremity. A salvage operation
was performed in 14 of 19 cases. Nine cases were sal-
vaged and 3 failed, resulting in a final failure rate of
5.3%. The most frequent cause of failure was venous
thrombosis. Early reexploration and thrombectomy is
the most important procedure.
Case Presentation
A 29-year-old man sustained an open fracture of the
left tibia in a traffic accident. Osteomyelitis set in after
surgery at another hospital. After he was transferred to
our hospital, a vascularized fibular graft was performed
for a 7-cm bone defect 5 months after injury (Fig. 1).
Although the preoperative angiogram did not show any
abnormalities in the anterior and posterior tibial arter-
ies, sufficient proximal flow of the anterior tibial artery
was not obtained during surgery. As a result, the per-
oneal artery of the graft was sutured to the distal end
of the anterior tibial artery.
Nineteen hours after the vascularized fibular graft
was performed, the monitoring flap became pale and
the skin temperature decreased (Fig. 2). An arterial
thrombectomy was performed as salvage surgery 5 h
after the problem occurred. Poor blood circulation
occurred again 13 h after the salvage operation. Finally,
because there was no blood circulation, the recipient
artery and veins and muscle sleeve were stripped from
the grafted fibula and a pedicled muscular flap was used
to cover the grafted fibula. Below-knee amputation had
to be performed 2 years and 10 months after surgery,
and the patient is now walking with prosthesis.
Summary
The most critical complication of replantation and free
tissue transfer is postoperative failure of blood circula-
tion. The most important cause of failure is thrombosis
at the anastomosis site. There are several contributing
factors, such as technical failure of the anastomosis; the
condition of the recipient artery and vein; discrepancy
in diameter between the recipient and donor vessels;
inadequate tension, and kinking or twisting of the vessel;
and inadequate vein graft. Therefore, circulatory moni-
toring and postoperative management are important.

Pre-op.
Fig. 1. Plain radiograph at injury and immediately postoperatively
Fig.2. The monitoring flap became pale and skin temperature
decreased 19h after anastomosis of the artery and vein
2. Postoperative Monitoring and Observation 165
Post-op.
References
1. Giunta R, Geisweid A, Feller A-M (2001) Clinical classifi-
cation of free-flap perfusion complications. J Reconstr
Microsurg 17:341-345
2. Strauss JM, Neukam FW, Krohn S, Schmelzeisen R, Bor-
chard F (1994) Postoperative Uberwachung mikrovasku-
larer Lappenplastiken mit der Pulsoxymetrie-Erste
Erfahrungen. Handchir Mikrochir Plast Chir 26:80-83
3. Svenson H, Holmberg J, Sveedman P (1993) Interpreting
laser Doppler recordings from free flaps. Scand J Plast
Reconstr Hand Surg 27:81-87
4. Hiroigoyen MB, Blackwell KE, Zhang, WX, Silver L, Wein-
berg H, Urken ML (1997) Continuous tissue oxygen
tension measurement as a monitor of free-flap viability
Plast Recorstr Surg 99:763-773
5. Khouri RK, Shaw WW (1992) Monitoring of free flaps with
surface recordings: is it reliable? Plast Reconstr Surg
89:459-502
3. Perioperative and Postoperative
Antithrombotic Agents
HIROSHI ONO
Thirty-five years have passed since Komatsu and Tarnai
performed a replantation of a completely severed left
thumb in July 1965 [1], and 25 years or more have
passed since the first clinically successful free tissue
transfer by microsurgery was reported by McLean et al.
in 1972 [2]. Since these procedures were introduced,
operating microscopes and microinstrumentation have
become sophisticated, and the survival rate has accord-
ingly steadily increased. In microsurgical operations, we
pay close attention to the following procedures in order
to improve the survival rate: sufficient debridement is
necessary; end-to-end anastomosis of normal vessels is
recommended as far as possible, and in arterial anasto-
mosis, the site of anastomosis is chosen based on the
intensity of blood flow from the proximal artery; a vein
graft should be applied without hesitation if a defect
remains in the vessels to be anastomosed; and as many
vessel anastomoses as possible should be undertaken.
Despite all precautions, a 10% complication rate in free
tissue transfer and replantation is not uncommon [3].
Some complications may result from thrombotic occlu-
sion at the anastomoses of both arteries and veins,
whereas others may result from alterations of the micro-
circulation, such as reperfusion injury, despite patent
anastomosis. Several local and systemic therapeutic
agents have been used to prevent thrombotic occlusion
during and after microsurgery.
Procedures During Vessel
Anastomosis
Heparin is a standard agent used in topical irrigat-
ing solutions for microvascular anastomosis. Several
studies have presented evidence that patency rates
are improved when heparin is applied topically during
microvascular anastomosis [4,5). Topical heparin signifi-
cantly reduces the incidence of stasis-induced throm-
bosis in venous anastomosis. The binding of heparin to
the vascular intima prevents platelet deposition on the
intimal surface and maintains its anticoagulant effects.
A concentration of 20 units(U)/ml of heparin has been
166
shown to minimize venous thrombotic occlusion [6]. On
the other hand, Cooley et al. have investigated the use
of topically applied urokinase for its capacity of binding
to the arterial sub endothelium and for its ability to
prevent subsequent thrombosis [7]. Urokinase has a
high capacity for binding to the subendothelium, and
surface-bound urokinase shows proteolytic activity
similar to that of urokinase in solution. Experimental
results indicate that urokinase may be a more beneficial
irrigating agent than heparin for the repair of trauma-
tized vessels.
Just after anastomosis, we routinely sprinkle 2%
lidocaine (Xylocaine) on the anastomotic site in order
to reduce the vasospastic reaction in the anastomosed
vessels. Warm saline at 37C is also sprinkled on this site
to keep the vessels warm in order to relieve vasospasm.
Our experimental studies have shown that hypothermia
in the replanted parts increases vascular resistance,
which is attributable to increased blood viscosity as well
as worse vascular compliance, resulting in a low-flow
state [8-10). It is very important to warm an anastomotic
site after microvascular anastomosis.
Acland has mentioned that the period of highest risk
for the formation of thrombosis at the site of vessel
injury may be limited to the first 20 min of flow [11]. We
therefore wait for 30 to 60min after vascular anasto-
mosis to confirm the patency and smooth flow at the
anastomosis site before finishing the operation.
Postoperative Systemic
Antithrombotic Therapy
As preventive and therapeutic measures against throm-
bus formation at the site of microvascular anastomosis,
the intravenous administration of anticoagulants, fibri-
nolytic agents, and vasodilators has been previously
reported [12,13]. The attributes of an ideal antithrom-
botic agent include ease of administration, long dura-
tion of action, a high specificity for thrombus-prone
sites, a high level of efficacy, and absence of systemic
side effects. However, such pharmacological approaches
 3. Perioperative and Postoperative Antithrombotic Agents
place the patient at risk for hemorrhagic complications
and require careful and frequent monitoring of the state
of coagulation.
Our replantation or free-tissue transplantation
patients have been treated routinely with urokinase,
prostaglandin Eh and heparin [14]. The daily doses for
adults are 180,000 international units (IU) of urokinase,
l20llg of prostaglandin Eh and 10,000 units (U) of
heparin. These agents are used either singly or in com-
bination, depending on the condition of the anastomotic
vessels. Urokinase is an effective plasminogen activator,
which has been demonstrated to efficaciously lyse clots
in vivo. It has been used systemically after microvascu-
lar anastomosis to prevent thrombus formation. The
systemic half-life of urokinase is thought to be
approximately 14min. In our clinic, therefore, continu-
ous infusion of lactated Ringer's solution containing
antithrombotic agents is routinely prescribed around
the clock daily for 7 days. Having the effects of both
antiplatelet aggregation and vasodilation, prostaglandin
EJ increases cyclic AMP in platelets and then inhibits
their aggregation. Once prostaglandin EJ relaxes the
vascular smooth muscle, it also has a vasodilatory effect.
Many experimental and clinical reports of replantation
and free tissue transfer have shown that prostaglandin
EJ improves vascular patency in microvascular anasto-
moses [15]. Nevertheless, prostaglandin E J has some
side effects, such as decrease in arterial blood pressure,
bleeding, and hematoma formation. Yamamoto
et al. reported a clinical study in which 120llg of
prostaglandin E J per day was needed to increase the
blood flow in a transferred flap [15]. They demonstrated
that this dose of prostaglandin EJ both lowered arterial
blood pressure and elongated activated partial throm-
boplastin time (APTT), but did not induce bleeding or
hematoma after surgery. Recently, lipo-prostaglandin EJ
has also been used. It has the same effect on patency
after microsurgery as prostaglandin EJ and induces less
pain [16]. The standard dose of lipo-prostaglandin EJ is
lOllg daily. Heparin is an anticoagulant that prevents
the thrombotic occlusion of microvascular anastomoses
by enhancing the activity of plasma antithrombin III to
neutralize activated clotting factors XII, XI, X, IX, II,
and kallikrein. Heparin has been found to be beneficial
in preventing the thrombotic occlusion of microvascu-
lar arterial anastomoses when administered continu-
ously to maintain APTT at two times control values
[17]. Heparin also has a protective effect on micro-
venous anastomoses and microvascular repairs of
damaged arteries. The use of low doses of heparin
(intraoperative bolus of 2000 to 3000 units and post-
operative infusion at a rate of 100 to 400 units per
hour) does not significantly increase the risk of
hematoma formation or of intraoperative bleeding [18],
167
and even 10,000 units of heparin per day causes no
bleeding tendencies or hematoma formation.
The infusion of anti thrombotic agents is started
during operation a few minutes before the anastomosis
is performed. A small dose of heparin administered
before the activation of the coagulation system pro-
duces a useful effect. Thrombi containing urokinase dis-
solve more readily than those without urokinase. These
results suggest that infusion therapy would have a
more pronounced effect if started prior to vascular
anastomosis.
Continuous infusion with 1500ml per day of lactated
Ringer's solution containing anti thrombotic agents
is performed through the central venous system in
order to prevent venous inflammation, which is often
observed when prostaglandin E J is injected intra-
venously. The circulatory condition of transferred vas-
cularized free tissue or replanted digits is monitored
by direct observation of skin color, skin temperature,
skin tension, and capillary filling time. A surface arterial
Doppler signal within the flap is checked for 5 days to
monitor arterial patency. However, we have no direct
means of monitoring venous flow. The diagnosis of
venous thrombosis, based only on significant morpho-
logic changes throughout the flap, is a clear indication
that efforts to prevent it have failed. Among more than
600 free tissue transfers by Serletti et al. in 1998, venous
thrombosis was clinically diagnosed at a mean of 3.6
days postoperatively, with a range of 1 to 6 days [19].
Therefore, the administration of antithrombotic agents
should be performed for 7 to 10 consecutive days after
surgery.
References
1. Komatsu S, Tarnai S (1968) Successful replantation of
a completely cut-off thumb. Plast Reconstr Surg 42:374-
377
2. McLean DH, Buncke HJ Jr (1972) Autotransplant of
omentum to a large scalp defect with microsurgical revas-
cularization. Plast Reconstr Surg 49:268-274
3. Fukui A, Maeda M, Sempuke T, Tarnai S, Mizumoto S,
Inada Y (1989) Continuous local intra-arterial infusion
of anticoagulants for digit replantation and treatment of
damaged arteries. J Reconstr Microsurg 5:127-136
4. Singlair S (1980) The importance of topical heparin in
microvascular anastomoses: a study in the rat. Br J Plast
Surg 33:422-426
5. Ritter EF, Cronan JC, Rudner AM, Serafin D, Klitzman B
(1998) Improved microsurgical anastomotic patency with
low molecular weight heparin. J Reconstr Microsurg 14:
331-336
6. Zinberg EM, Choo DI, Zotter LA (1989) The effect
of heparinized irrigating solution on patency of experi-
168 D. Preoperative and Postoperative Management
mental microvascular anastomosis. Microsurgery 10:103-
107
7. Cooley BC, Hanel DP, Gould JS, Li X, Smith JW (1992)
Antithrombotic benefit of subendothelium-bound
urokinase: an experimental study. J Hand Surg
17A:235-244
8. Ono H, Nakagawa Y, Mizumoto S, Tarnai S (1996)
Changes of blood viscosity by its temperature. J Jpn Soc
Surg Hand 13:610-613
9. Nakagawa Y, Ono H, Fukui A, Mizumoto S, Tarnai S
(1996) The effects of hypothermic stress on blood viscos-
ity and hemodynamic functions in amputated murine
hindlimb. J Jpn Soc Surg Hand 13:592-595
10. Nakagawa Y, Ono H, Fukui A, Mizumoto S, Tarnai S
(1997) The effects of hypothermia on oxygen consump-
tion in amputated murine hindlimb. J Jpn Soc Surg Hand
14:559-562
11. Acland R (1972) Prevention of thrombosis in microvas-
cular surgery by the use of magnesium sulphate. Br J Plast
Surg 25:292-299
12. Schlenker JD, Kleinert HE, Tsai TM (1980) Methods
and results of replantation following traumtic amputa-
tion of the thumb in sixty-four patients. J Hand Surg 5:63-
70
13. Davies DM (1982) A world survey of anticoagulation
practice in clinical microvascular surgery. Br J Plast Surg
35:96-99
14. Fukui A, Tarnai S (1994) Present status of replantation in
Japan. Microsurgery 15:842-847
15. Yamamoto Y, Ohura T, Kuwabara H, Takeno K (1995)
Doses of prostaglandin E1 after transplantation of vascu-
larized free tissue. Gendai-iryo 27:2603-2609 (in Japanese)
16. Tokeshi M, Kanaya F, Futenma C, Ibaraki K (1997) Com-
parative study of Lipo PGE1 and PGE1-CD on patency
after microvascular anastomosis. Seikeigeka-saigaigeka
6:325-327 (in Japanese)
17. Greenberg BM, Masem M, May JW (1988) Therapeutic
value of intravenous heparin in microvascular surgery: an
experimental vascular thrombosis study. Plast Reconstr
Surg 82:463-472
18. Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL,
Bengtson BP, Phillips MD, Kim D, Shusterman MA (1995)
Anticoagulants and hematomas in free flap surgery. Plast
Reconstr Surg 96:643-647
19. Serletti JM, Moran SL, Orlando GS, O'Connor T, Herrera
HR (1998) Urokinase protocol for free-flap salvage
following prolonged venous thrombosis. Plast Reconstr
Surg 102:1947-1953
4. Continuous Local Heparinization
YUH INADA, AKIHIRO FUKUI, and SHIGERU MIZUMOTO
After Komatsu and Tamai first performed the success-
ful replantation of an amputated thumb in 1965 [1],78
medical institutions in Japan reported 3126 cases of digit
replantation up to July 1981 [2]. Thus, replantation
had become an established surgical technique in Japan
within little more than a decade after the world's first
digit replantation.
In our department, 705 (92%) of 770 amputated
extremities were successfully replanted in 491 patients
between 1965 and December 1999. In addition, 244
(94.2 %) of 259 free tissues were also successfully trans-
planted in 255 patients by microsurgery up to Decem-
ber 1989. Although these data suggest the maturity
of microsurgical techniques, failure of replantation or
transplantation due to unsuccessful revascularization is
still possible. The success of digit replantation is greatly
influenced by the appropriate estimation of surgical
indication. However, it is still inevitable that a few
percent of amputated extremities will fail, even when
the surgical indication was correct. Thrombosis in the
anastomosed arteries or veins is the main cause of
failure.
This chapter describes the method of continuous local
intraarterial or intravenous infusion of anticoagulants,
mainly heparin, performed in our department to pre-
vent or treat thrombosis [3]. Because the conditions are
different for digit replantation as emergency surgery
and free composite tissue transplantation as a scheduled
operation, the methods of continuous local intraarterial
or intravenous infusion of anticoagulants are described
separately for these two conditions.
Anticoagulant Therapy in
Replantation Surgery
In limb and digit replantation, anticoagulants are
generally administered intravenously to prevent post-
operative thrombosis for at least 1 week, because most
circulatory disorders take place within 1 week postop-
eratively. Since the beginning of replantation surgery,
we have performed anticoagulant therapy, mainly using
heparin (5000-20,000 units/day). However, heparin
has had to be replaced with urokinase (UK, 240,000
units/day) in some cases because of its side effect of
massive postoperative bleeding. In addition, 60-
120llg/day of prostaglandin El (PGE 1) or lipo-PGE 1 is
concomitantly administered intravenously.
Between May 1965 and May 1987, 331 (86.2%) of
384 amputated extremities were successfully replanted
in our department with the use of this anticoagulant
therapy. However, a low dose of these anticoagulants
was not sufficiently efficacious, whereas higher doses
caused systemic hyperfibrinolysis and adverse hemor-
rhagic reactions. In the 1970s, percutaneous translumi-
nal coronary recanalization (PTCR), in which the
obstructed coronary artery is recanalized by direct
injection of streptokinase (SK) or UK, was reported as
a treatment for intracoronary thrombosis occurring
during the early phase of myocardial infarction [4,5]. In
January 1988, we introduced the continuous intraarter-
ial infusion of anticoagulants for digit replantation to
increase the rate of successful replantation based on
the theory of PTCR. When 68 amputated digits were
replanted using this anticoagulant therapy, a 94% rate
of successful replantation was achieved. Since then,
many amputated extremities, severely crushed or stored
in a state of warm ischemia for a long time, for which
replantation was not indicated previously, have been
successfully replanted [6,7].
Procedure for Continuous Local
Intraarterial Infusion of Anticoagulants
for Digit Replantation
The procedure is indicated for the following cases:
severely crushed or avulsed amputations accompanied
by endothelial impairment or degeneration of blood
vessels to be anastomosed, elderly patients, amputated
digits with warm ischemia for a long period, and cases
with repeated intraoperative thrombosis.
Continuous local intraarterial infusion of anticoagu-
lants (Fig. 1) should be performed soon after the reper-
169
170 D. Preoperative and Postoperative Management
Replanted digits
Fig. 1. Digit replantation (index, middle, ring finger). After
microscopical exposure of the radial artery at the wrist level,
the arterial catheter (28G) is inserted to the site proximal to
the anastomosis
fusion, for the following reasons: it has been reported
that thrombi involved UK are easily dissolved at lower
doses than the usual therapeutic doses [8]; it can be
expected to the irrigation effect for most of thrombi in
the crushed proximal stumps of amputated limbs and
digits, it can be expected to the effective concentration
of anticoagulants before reperfusion.
However, this anticoagulant therapy has sometimes
been indicated for patients with repeated failure of
intraoperative revascularization, even when replanta-
tion of amputated limbs or digits was thought to be easy
preoperatively. After microscopic excoriation of the
main shaft of the major artery or its branch in the prox-
imal part of the amputated stump, anticoagulants were
administered using an indwelling arterial catheter of a
28G teflon tube (L-Cath; Luther Medical Products,
Uhta, USA) through a puncturing needle percuta-
neously inserted into the target artery. It should be con-
firmed directly under a microscope that the indwelling
arterial catheter has been left in the targeted arterial
lumen. Although it was confirmed whether catheter-
ization impaired the targeted artery itself in some
patients on postoperative digital subtraction angiogra-
phy (DSA) [9], no patient showed apparent stenosis of
the targeted artery. The location of the catheter tip is
very important; the arterial catheter should be inserted
slightly before the target position to prevent misinser-
tion into other arterial branches. After insertion, the
catheter should be fixed to the skin by a silk thread
before extubation of the guidewire. Subsequently, the
peripheral end of a high-pressure tube cleanly con-
nected to the syringe of a continuous-infusion pump
should be introduced to the field of operation. After
the exposed artery has been sutured, the presence or
absence of arterial blood reflux can be easily evaluated
by fixing the region between the exposed and connected
sites of the artery with a transparent elastic sheet.
As described above, 40ml of low-molecular-weight
dextran solution containing 120,000 units of UK and
5000-10,000units of heparin was administered twice a
day (total daily dose, 80ml/day) at a rate of 3.3ml/h for
10 days. At the beginning of the continuous local
heparinization (CLH), a low dose of prostaglandin El
was administered, but is not administered at present
because the patients sometimes had redness, swelling,
and pain along the catheter-inserted artery. If it was nec-
essary to administer 60-120/lg/day of prostaglandin E 1,
10/lg/day of lipo-prostaglandin EJ, a vasodilator, was
concomitantly administered intravenously.
Continuous Local Heparinization for
Free Composite Tissue Transfer
In 1991, Mizumoto et al. [10] performed CLH in 14
patients undergoing vascularized free composite tissue
transplantation, in whom salvage surgery was thought to
be unavoidable because of intraoperative thrombosis at
the anastomosis. They reported that complete survival
was achieved in 12 patients, partial necrosis occured in
1 patient, and complete necrosis occured in 1 patient.
Several previous studies suggested the usefulness of
CLH, because the salvage operation in free tissue trans-
fer by means of reexploration and thrombectomy with
or without vein grafting was sometimes difficult [11-13].
CLH is not indicated for all patients undergoing free
tissue transfer, but it is used prophylactically in patients
with repeated intraoperative vasospasm or thrombosis
or with vascular disorders after the second surgery. CLH
is classified into intraarterial (Fig. 2) CLH and intra-
venous (Fig. 3) CLH. Intraarterial CLH is indicated
for patients with repeated intraoperative vasospasm or
thrombosis in the anastomosed blood vessels or after
a second surgery due to arterial thrombosis, whereas
intravenous CLH is mainly indicated for patients with
postoperative venous thrombi. The anticoagulants and
devices used are similar to those used for continuous
local intraarterial infusion for digit replantation. How-
ever, a slightly lower dose of heparin (2400-7200units/
day) is administered using 24-28G teflon tubes accord-
ing to the size of blood vessels used for CLH, because
the extent of the wound for tissue transplantation is

Skin flap
Arterial thrombi
Infusion pump
Fig. 2. Arterial thrombi following free tissue transfer. After
microscopical exposure of the anastomosed artery, removal of
arterial thrombi and reanastomosis are completed, and its
small branch must be identified for the target artery; antico-
agulants are administered using an arterial catheter inserted
into the target artery. The catheter tip should be placed prox-
imate to the bifurcation from the main artery so as not to
injure the reanastomosed main artery
wider than that of digit replantation, and some patients
undergoing vascularized tissue transfer have more
severe underlying diseases. In addition, the above dose
of heparin is prophylactically administered for 3 to 7
days postoperatively or after a second surgery, although
there is no definite index for the duration of CLH. In
cases of salvage of large free tissue transfer, we used
heparin alone and never used UK, because heparin has
some advantages over UK in that it has antagonist and
a short half-life in case of large operative wounds. At
the beginning of the CLH, a low dose of prostaglandin
El was administered; however, it is not administered at
present because the patients sometimes had redness,
swelling, and pain along the inserted artery. If it was
necessary to administer 60-120llg/day of prostaglandin
Eb 10 Ilg/day of lipo-prostaglandin Eb a vasodilator, was
concomitantly administered intravenously.
Discussion
To secure the patency of microsurgically anastomosed
blood vessels, systemic administration of anticoagulants
was initiated in the first case of successful thumb replan-
4. Continuous Local Heparinization 171
Skin nap
o
Infusion pump
Fig. 3. Venous thrombi following free tissue transfer. After
microscopical exposure of the anastomosed vein, removal of
venous thrombi and reanastomosis of the vein are performed,
and its small subcutaneous branch must be identified. The
catheter tip is placed at the subcutaneous vein, and anticoag-
ulants are administered
tation in 1965. Heparin was frequently used in the clin-
ical setting because it was experimentally demonstrated
that heparin significantly increases the patency of
anastomosed microvessels [14,15]. Heparin enhances
the effects of antithrombin by inhibiting the activity of
thrombin [16]; decreases the activity of platelet aggluti-
nation [16], and inhibits the conversion of fibrinogen to
fibrin [17].
Using in vivo microscopy, Barker et al. [18] reported
that peripheral blood flow did not increase in rats with
experimentally induced micro embolisms in the cremas-
ter muscle, although the number of micro thrombi was
significantly decreased after heparin administration.
This finding suggested that prevention of thrombosis
by heparin does not directly contribute to the improve-
ment of peripheral blood flow. Although heparin is
useful for preventing white thrombus formation, it is not
markedly useful for preventing congestive red throm-
bus formation. Moreover, heparin itself does not have a
thrombolytic action, although it is useful for preventing
thrombosis. Therefore, UK has concomitantly been used
in our department because it has a thrombolytic action.
However, it has been reported that UK induces severe
systemic hyperfibrinolysis, even at a dose lower than
that exhibiting a sufficient thrombolytic action. There-
172 D. Preoperative and Postoperative Management

fore, it should always be noted that these anticoagulants Summary

induce a systemic bleeding tendency, even though they
are useful for preventing thrombosis or producing Although microsurgical technique has been established
thrombolytic activity. The disadvantages of these anti- worldwide in the last century, some failures of replan-
coagulants, such as heparin and UK, may be compen- tations and composite tissue transfers are still unavoid-
sated by the following two approaches. able because of vascular thrombosis at the anastomoses.
First, adverse reactions may be limited to the minimal This chapter introduces a method of continuous local
level by increasing the effective blood concentrations intraarterial or intravenous infusion of anticoagulants
of anticoagulants in the target organs, as well as by such as heparin. The location of the catheter tip is very
decreasing the dose of anticoagulants after selective important, depending on the location of the problem.
catheterization into the major nutrient arteries of the With application of continuous local heparinization, a
target organs, as observed in PTCR for coronary artery higher rate of success in replantations and free tissue
thrombosis or clinical cases of microsurgery reported by transfers was achieved as compared with that with
Cange et al. [19]. Although time loss due to selective ordinary systemic infusion of anticoagulants.
venous catheterization and slightly complicated surgical
techniques may be disadvantageous to this procedure,
they are not problematic for experienced surgeons, References
because they are easier than PTCR.
Second, the development of agents that specifically 1. Komatsu S, Tarnai S (1964) Successful replantation of a
act on thrombi without inducing systemic hyperfibri- cut-off thumb. Plast Reconstr Surg 42:374-377
nolysis may greatly contribute to successful replantation 2. Tarnai S (1994) Current status of orthopaedic micro-
or tissue transplantation. It has been reported that surgery in Japan. Clin Orthop 184:24-33
tissue plasminogen activator (t-PA) is useful for treat- 3. Fukui A, Senpuku T, Maeda M, Tarnai S, Mizumoto S
ing various experimentally induced thromboses in the (1988) Analysis of circulatory insufficiency after digit
fields of cardiovascular medicine and neurosurgery. replantation and the effects of intra-arterial anticoagulant
drugs for digit replantation (in Japanese). J Jpn Soc Surg
Recently, it has also been reported that heparin en-
Hand 5:668-667
hances t-PA release, although heparin itself does not 4. Rentrop KP, Blanke H, Karsch KR, Wiegand V, Kostering
have a thrombolytic activity [20]. To our knowledge, no H, Oster H, Leitz K (1979) Acute myocardial infarction;
previous studies have reported the usefulness of t-PA in intracoronary application of nitroglycerin and streptoki-
the field of microsurgery. Therefore, further evaluations nase in combination with transluminal recanalization. Clin
are needed in the future. Cardiol 2:354-363
The two approaches described above may be useful 5. Ganz W, Buchbinder N, Marcus H, Mondkar A, Maddahi
for preventing acute arterial thrombosis. However, J, Charuzi Y, O'Connor L, Shell W, Fishbein MC, Kass
venous thrombosis is a more problematic issue. Since R, Miyamoto A, Swan HJC (1981) Intracoronary throm-
no monitoring system that accurately reflects the state bosis in evolving myocardial infarction. Am Heart J 101:
of venostasis has yet been established, it is quite diffi- 4-13
6. Fukui A, Maeda M, Sempuku T, Tarnai S, Mizumoto S,
cult to salvage venous thrombosis by appropriate timely
Inada Y (1989) Continuous local intraarterial infusion
re-exploration. As shown in the second case, prophy- of anticoagulants for digit replantation and treatment of
lactic intravenous CLH in the skin flap may prevent damaged arteries. J Reconstr Microsurg 5:127-136
venostasis in patients undergoing vascularized tissue 7. Fukui A, Maeda M, Mine T, Inada Y, Mizumoto S, Tarnai
transfer. However, once venous thrombosis develops, S (1992) Continuous local intraarterial infusion after pro-
there is no effective method of salvage. Hjortdal et longed arterial stasis in the fingers and toes. Microsurgery
al. [21] experimentally demonstrated that venostasis 13:62-66
damaged tissues in the skin flap more severely than 8. Ban I (1979) Urokinase and anticoagulant therapy (in
arterial obstruction did. Therefore, further development Japanese). Med Postgrad 17:382-393
of a reliable venostasis-monitoring system is expected 9. Maeda M, Fukui A, Inada Y, Tarnai S, Mizumoto S,
as soon as possible. Senpuku T (1990) Continuous intra-arterial infusion of
urokinase, prostaglandin Eb and heparin for digit replan-
As described previously, the rate of success in digit
tation and treatment of damaged arteries (in Japanese).
replantations and vascularized tissue transfers has
Jpn J Plast Reconstr Surg 33:49-57
increased with the development of microsurgery. How- 10. Mizumoto S, Tarnai S, Yajima H, Huang WC, Fukui A,
ever, failures of digit replantation or tissue transfer still Maeda M (1991) Continuous local heparinization (in
account for less than 10% of the cases, although the Japanese). Seikeigeka 42:19-27
procedures of anticoagulant therapy described in this 11. Harashina T (1988) Analysis of 200 free flaps. Br J Plast
chapter may definitely improve the success rates. Surg 41:33-36

12. Mizumoto S, Tamai S, Yajima H, Huang WC, Yoshii T
(1988) Reoperation of a free tissue transfer (in Japanese).
Jpn J Reconstr Plast Surg 31:883-891
13. Tsai TM, Bennett DL, Pederson WC, Matiko J (1988)
Complications and vascular salvage of free-tissue trans-
fers to the extremities. Plast Reconstr Surg 82:1022-1026
14. Greenberg BM, Masem M, May JW (1988) Therapeutic
value of intravenous heparin in microvascular surgery:an
experimental vascular thrombosis study. Plast Reconstr
Surg 82:463-470
15. Khouri RK, Cooley BC, Kenna DM, Edstrom LE (1990)
Thrombosis of microvascular anastomoses in traumatized
vessels; fibrin versus platelets. Plast Reconstr Surg 86:
110-117
16. Danese CA, Haimov M (1971) Inhibition of experimental
arterial thrombosis in dogs with platelet deaggregating
agents. Surgery 70:927-934
4. Continuous Local Heparinization 173
17. Rosenberg RD (1975) Actions and interactions of
antithrombin and heparin. N Engl J Med 292:146-151
18. Barker JH, Gu JM, Anderson GL, O'Shaughnessy M,
Pierangeli S, Johnson P, Gelletti G, Acland RD (1993) The
effects of heparin and dietary fish oil on embolic events
and the microcirculation downstream from a small artery
repair. Plast Reconstr Surg 91:335-343
19. Change S, Laberg LC, Rivard GE, Garel L (1987) Strep-
tokinase in management of limb arterial thrombosis
following free-flap surgery. Plast Reconstr Surg 79:974-
976
20. Marckwardt F, Klocking HP (1977) Heparin-induced
release of plasminogen activator. Haemostasis 6:370-374
21. Hjortdal VE, Hauge E, Hansen ES (1992) Differential
effects of venous stasis and arterial insufficiency on tissue
oxygenation in myocutaneous island flaps; an experimen-
tal study in pigs. Plast Reconstr Surg 89:521-529
5. Complications and Salvage Procedures
HIROSHI Y AJIMA
Recent advances in microsurgical techniques have
made it possible to transfer various kinds of autogenous
composite tissues. As a result, preservation of extremi-
ties is now possible in cases of severely mutilated limbs
when amputation used to be necessary, and restora-
tion of function is also possible when previously it was
impossible. However, because these grafts are nour-
ished by delicate small vessels, an entire flap can become
necrotic if the circulation of these vessels is disturbed.
For this reason, the success of microsurgery remains
unpredictable. A variety of techniques have been devel-
oped to improve the outcome of microsurgical proce-
dures. One is the development of new flaps with a
large-caliber vascular pedicle. Another is the improve-
ment of suture materials, methods, and instruments. In
addition, new procedures of postoperative monitoring
and salvage techniques have been developed [1]. In this
chapter, the postoperative monitoring of vascularized
composite tissue transfers, the vascular complications,
and their salvage techniques are described.
Postoperative Monitoring
Careful postoperative monitoring is particularly impor-
tant to increase the success rate of tissue transfers.
Postoperative monitoring includes both the surgeon's
subjective observation and the objective data. Objective
methods (e.g., laser Doppler technique) provide sur-
geons with sequential measurement of blood flow but
require special equipment. I have used the hydrogen
clearance technique with UH meter (Unique Medical)
[2]. With this technique, the electrode is inserted into
the flap, muscle, or muscle sleeve around the fibula and
is fixed there. Subsequently, the patient inhales hydro-
gen, and blood flow is calculated based on hydrogen
washout. With this procedure, it is easy to check venous
congestion of the flap. However, surgeons have to
perform the procedure.
Subjective monitoring methods at present are rather
general. Generally, monitoring is done by Doppler
stethoscope and flap skin color. When arterial occlusion
occurs, the color of the flap becomes whitish and the
174
skin temperature decreases. Actually touching the flap
is recommended, because arterial thrombosis can be
missed when judged from flap skin color. If the tem-
perature of the flap decreases, arterial thrombosis is sus-
pected. Because the Doppler stethoscope is a reliable
method for monitoring, postoperative monitoring can
be entrusted to the nurse using it. The Doppler stetho-
scope cannot currently be substituted as a monitoring
procedure for arterial flow. However, arterial auricular
sound can sometimes be heard at the early stage of
thrombogenesis, because the thrombi are still soft.
Later, the auricular sound decreases to low and
becomes distant. Therefore, changes in auricular sound
must be carefully observed. On the other hand, flap
color change is the most common and reliable sign for
the monitoring of venous disorders. A certain amount
of experience is required for accurate judgment of the
venous return by flap color tone. Early venous problems
can be detected by examinination of the margin of
the flap, because the congestion begins there. I have
had little success in salvaging the flap once its center
becomes purple or the arterial auricular sound can no
longer be heard. In addition, flap temperature and cap-
illary refill should be examined. Because the majority of
complications occur within 3 days postoperatively, fre-
quent postoperative monitoring (every 2 to 3h) should
be performed 3 to 4 days postoperatively. Thereafter,
monitoring 2 to 4 times per day may be sufficient [3].
The anastomosis should be reexplored immediately
whenever any circulatory disturbance is suspected.
Contrivance of the Monitoring Method
Monitoring with a Doppler stethoscope and by flap skin
color is performed on skin flaps or musculocutaneous
flaps (Fig. 1). On the other composite tissue transfers,
direct measurement of blood flow in the transplanted
tissues should be performed. Objective methods are
particularly useful when a skin island cannot be used for
monitoring (e.g., in vascularized bone grafts or in free
jejunal grafts). I have also used some other techniques
in lieu of skin islands, such as an interpositional anasto-
 5. Complications and Salvage Procedures 175

Fig. 1. Postoperative monitoring using a Doppler stethoscope Fig. 3. Use of a peroneus brevis muscle flap to monitor the
for a vascularized fibula graft with a monitoring flap circulation of a fibular graft. The tip of the monitoring muscle
is placed in the skin suture line

neously (Fig. 3). In free jejunal grafting, part of the

mesentery is placed subcutaneously for postoperative
monitoring. I believe postoperative monitoring should
Anterior be sufficiently flexible and creative [3].
tibial
artery
Grafted
fibula
I
Causes of Failure in Microsurgery
Peroneal , I

artery - -+-+--41 - I

Arterial The most common cause of flap failure is thrombosis of

II anastomo is
Anterior
tibial
artery
Dorsalis
pedis
artery
Fig. 2. Interpositional arterial anastomosis. When the fibula
is grafted to the leg, the peroneal artery is anastomosed con-
necting, both of its ends to the anterior tibial artery. This allows
monitoring of the grafted fibula by the pulsation of the dor-
salis pedis artery
mosis during fibular transfer to the leg or the forearm
[4] (Fig. 2). This method allows the graft to be monitored
by observing peripheral arterial pulsation. When the
fibula is transferred to an inaccessible location (e.g.,
the pelvis or femur), the length of the subcutaneous
perforator is limited, and an ordinary buoy flap cannot
be used for monitoring [5]. In such cases, the peroneal
muscle is taken with the fibula and placed subcuta-
the vascular pedicle. The risk factors include technical
errors in vascular anastomosis; vascular tension at the
anastomosis site; scars, inflammation, or arterial sclero-
sis at the recipient site; kinking of the vascular pedicle;
and hematoma. There is no way to improve microsurgi-
cal techniques except daily practice by the surgeon.
A suitable vascular tension is necessary at the anasto-
mosed vessels. The impaired condition of the recipient
vessels is the most frequent problem. For example,
thrombosis of the artery sometimes occurs in patients
with osteomyelitis [6] but rarely occurs in patients with
reconstruction after tumor resection [7]. Venous throm-
bosis sometimes occurs when the vein of the flap is anas-
tomosed to the concomitant vein of the anterior tibial
artery, because its caliber is small. The success rate of
free tissue transfers differs according to the location of
the flap reconstruction site. In the lower extremities, the
failure rate is high. In the head, neck, and upper extrem-
ities, on the contrary, the failure rate is low, because arte-
rial sclerotic changes are severe in the aged, and venous
pressure is high in the lower extremities [8]. However,
there are adequate veins in the hand, forearm, and neck.
During surgery, kinking of the vascular pedicle should
be avoided. Especial care must be taken when an island
flap transfer is performed with its vascular pedicle pass-
ing through the subcutaneous tunnel.
176 D. Preoperative and Postoperative Management
Location and Timing of Vascular
Complications
Vascular complications occur most frequently at the
anastomosis site. Venous congestion is more common
than arterial occlusion. In addition, arteriovenous
collapse secondary to a hematoma and postoperative
swelling sometimes occurs. A hematoma sometimes
presses the vascular pedicle.
Vascular complications occur within 72h postopera-
tively in most patients. In my previous report, a vascu-
lar problem developed immediately after surgery in 6
procedures, within 12 hours after surgery in 7, within 24
hours in 11, within 72 hours in 12, and at an unknown
time in 3 [3]. On the basis of these results, frequent mon-
itoring is required within 3 days postoperatively.
Risk Factors for Vascular Problems
The risk factors for failure of a clinical microvascular
anastomosis include advanced age, vascular diseases
(e.g., diabetes mellitus and arterial sclerosis), smoking,
and obesity. The rate of failure is different for different
diseases and recipient sites. Vascular problems occur
frequently in patients receiving radiation or with infec-
tion [9]. Harashina [8] reported higher success rates in
the head and neck (95.1 %) and upper extremity (100%)
than in other regions. In my series, the percentage of
patients who required reexploration following vascu-
larized flap transfer to the head and neck was 8%, which
was lower than for other regions [3]. The results of tissue
transfer to the lower extremities remain unsatisfactory,
with as many as 20% of all cases requiring reexploration
[3]. In addition, the success rate differs for different
donor tissues. In tissues with a vascular pedicle of small
diameter (e.g., groin flap), arterial thrombosis occurs
easily. On the other hand, in tissues with a long and
large-diameter vascular pedicle (e.g., latissimus dorsi
musculocutaneous flap), there is a much lower incidence
of failure. In general, the complication rate is higher in
patients with vein grafts than in those without vein
grafts [9].
Treatment of Vascular Occlusions
The cause of thrombogenesis should be identified
before evacuation of the thrombus at the anastomosed
site. When a thrombus extends over a long segment, it
is suctioned by a polyurethane venular catheter. Irriga-
tion of the thrombus should not be performed before
suction. In cases with flow-through-type tissue transfers
(e.g., peroneal flap, vascularized fibula graft), suction of
the thrombus is performed first, and the remaining clot
is irrigated from the distal stump of the vessels after
removal of the ligated suture at the peripheral vascular
pedicle. Then, isotonic sodium chloride solution with
heparin added (1OU/cc) is used as a perfusate. When
reexploration is performed quickly, reanastomosis is
performed after suction of the thrombus, owing to the
slight damage of the endothelium. However, when reex-
ploration is delayed, vein grafting should be performed
after resection of the damaged area. In cases with
venous occlusion, another draining vein should be
selected. After reperfusion of the flap, anti thrombotic
therapy should be administered. A variety of systemic
agents have been used. Among them, heparin is the
most commonly used (500-1000U/h). A complication
of heparin is postoperative bleeding and hematoma.
Because the vascular pedicle is sometimes stretched
and compressed by hematoma, careful postoperative
monitoring is essential. In addition in all cases, I
have used prostaglandin E] (3-5Ilg/h) and urokinase
(5000-10,000U/h) systemically. Recently continuous
local heparinization has also been used [3,10].
Continuous Local Heparinization
Systemic heparinization is used in most cases after
thrombectomy, but anticoagulation increases the risk
of postoperative bleeding. Recently I have used "con-
tinuous local heparinization," developed by Mizumoto
et al. [10], with excellent results. Heparin is administered
via either of two routes. Arterial heparinization involves
the insertion of a catheter into an arterial branch prox-
imal to the anastomosis (Fig. 4a). This route is preferred
when arterial thrombi have developed. The venous
route involves catheterization to the vein of the graft
(Fig. 4b). In fibular grafting or peroneal flap transfer,
for example, a catheter is inserted via the periphery of
the concomitant vein of the peroneal artery, followed by
heparin infusion in order to prevent thrombosis at
the venous anastomosis. I have used a 24 or 28 gauge
H
Fig. 4. Continuous local heparinization. a Transarterial infu-
sion method. b Transvenous infusion method
 5. Complications and Salvage Procedures 177

ab c

Fig.5. Continuous local heparinization for prevention of arte- formed. Vein grafting was carried out after thrombectomy,
rial thrombosis after peroneal osteocutaneous flap transfer to followed by continuous local heparinization. b Half of the flap
the infected nonunion of the leg. a Arterial insufficiency was developed superficial necrosis. c One year after surgery
recognized 2 days postoperatively, and reexploration was per-

polyurethane catheter (Luther Medical) for continuous

local heparinization (Fig. 5a-c). These catheters have a
guidewire, which facilitates manipulation of the catheter
during insertion. Heparin (100-300U/h) and urokinase
(300-1000U/h) are infused with systemic prostaglandin
El administration. Local heparinization is performed
for 5 to 7 days after operation. The catheter is removed
7 to 10 days after the operation; there is no problem
during this removal. This method is initiated at the time
of reexploration, or during the initial procedure when
vascular constriction occurs, or the risk of postoperative
thrombosis is suspected. In my series, the salvage rate
of reexploration was over 80%, so I was very satisfied with
this procedure. The systemic effect of heparin is minimal
with this method. However, local hemorrhage at the re-
Fig. 6. Coating of the muscle sleeve of the fibula with fibrin
cipient site is sometimes problematic, especially arterial
glue to reduce bleeding. (See Color Plates)
heparinization. To solve this problem, I recently applied
fibrin glue to coat the reverse side of the grafted flap to
reduce bleeding during local heparinization (Fig. 6).
of digital replantation when no venous outflow routes
were available or venous thrombi had developed post-
operatively [11]. In addition, this procedure has been
Treatment of Venous Congestion in applied for salvage of flaps with compromised outflow
Free Flaps Using Medical Leeches [12]. There is no debate that reexploration of the anas-
tomosis is the treatment of choice for venous drainage
The first clinical use of medical leeches was reported problems in free tissue transfers. However, it sometimes
approximately 2500 years ago. Recent reports indicate takes a long time to prepare for exploration because of
the successful application of leeches for the treatment the lack of availability of operating room or staff. It is
 178 D. Preoperative and Postoperative Management
a,b
Fig. 7. a Application of a medical leech for the treatment of
venous congestion after second toe transfer to the little finger.
b Bleeding continues from the bite wound for approximately
24h. (See Color Plates)
easy to use medical leeches if they are always bred in
the hospital. They feed infrequently and can survive up
to 200 days without feeding. Therefore, I recommend
that all microsurgical and hand centers always keep
medical leeches.
Leeches are approximately 12cm long. The body at
rest can contract to about one-third its usual length. The
amount of blood that the leech itself sucks is only about
5 cc. The hirudin injected as the leech bites perfuses
through a wide area and produces a local state of anti-
coagulation that lasts for several hours, and the total
amount of bleeding is about 50 cc. Therefore, when four
leeches are used for the congested flap, 400cc of blood-
letting can be achieved. Leeches should be used until
neovascularization occurs around the flap. Generally
this is 3 to 5 days postoperatively. The use of leeches
is well indicated for small tissue transfer, such as toe
transfer and small free flaps (Fig. 7a and b). In cases with
musculocutaneous flap transfer, such as latissimus dorsi
and rectus abdominis musculocutaneous flaps, the use
of leeches is not practical because too many leeches
would be required.
References
1. Stepnick DW, Hayden RE (1994) Postoperative monitor-
ing and salvage of microvascular free flaps. Otolaryngol
Clin North Am 27:1201-1217
2. Yoshii T, Tarnai S, Mizumoto S, Fujita T, Yamamoto S
(1986) The blood-flow monitoring following microvascu-
lar reconstructive surgery using the hydrogen washout
technique (in Japanese). J Jpn Soc Surg Hand 3:328-333
3. Yajima H, Tarnai S, Mizumoto S, Ono H, Fukui A (1993)
Vascular complications of vascularized composite tissue
transfer: outcome and salvage techniques. Microsurgery
14:473-478
4. Yajima H (1990) Vascularized fibula graft for the treat-
ment of nonunion of the leg. MB Orthop 30:559-566
5. Yajima H, Tarnai S, Mizumoto S, Ono H (1993) Vascular-
ized fibular grafts for reconstruction of the femur. J Bone
Joint Surg 75B:123-128
6. Yajima H, Tarnai S, Mizumoto S, Inada Y (1993) Vascu-
larized fibular grafts in the treatment of osteomyelitis and
infected nonunion. Clin Orthop 293:256-264
7. Yajima H, Tarnai S, Mizumoto S, Sugimura M, Horiuchi K
(1992) Vascularized fibula graft for reconstruction after
resection of aggressive benign and malignant bone
tumors. Microsurgery 13:227-233
8. Harashina T (1988) Analysis of 200 free flaps. Br J Plast
Surg 41:33-36
9. Khouri RK, Cooley BC, Kunselman AR, Landiss JR,
Yeramian P, Ingram D, Natarajan N, Benes CO, Wallemark
C (1998) A prospective study of microvascular free-flap
surgery and outcome. Plast Reconstr Surg 102:711-721
10. Mizumoto S, Tarnai S, Yajima H, Kou B, Fukui A, Maeda
M (1991) Continuous local heparinization for salvaging
vascularized free tissue transfers. Seikeigeka 42:19-27
11. Callegari PR, Moore JH, Degnan GG (1992) The leech
amphitheater for digital replantation. Plast Reconstr Surg
90:511-513
12. Soucacos PN, Beris AE, Malizos KN, Xenakis TA,
Georgoulis A (1994) Successful treatment of venous con-
gestion in free skin flaps using medical leeches. Micro-
surgery 15:496-501
6. Postoperative Management and Rehabilitation in
Limb/Digit Replantation
YUTAKA MAKI and TAKAE YOSHIZU

Postoperative Management Monitoring of the Replant

Dressing and Position of the Replant The replanted digits or hand should be observed every
1 or 2 h for 3 days and every 3 h for another 4 days by
Postoperative management starts in the operating the doctor and nurse. In the uncomplicated condition
room after the replantation surgery has been com- of the digital pulp of replanted digits or hand, the
pleted. Dressing of the hand and arm is important to color is pink, which is more reddish than normal; the
keep the functional position of the replanted digits and volume, in other words, the tension of the digital pulp,
hand and to keep the wound clean by letting the gauze is normal; and the capillary refill is fast. Pale color, cold,
soak up the discharge from the wound. The intrinsic plus volume loss, and slow or no capillary refill show the dis-
position of the fingers, palmar abduction of the thumb, turbance of arterial flow, which indicates spasms, com-
and neutral position of the wrist are the basic functional pression, or thrombosis of the sutured artery. Dark red
positions of the hand, even though both flexor and or violet color with full volume, fast capillary refill, and
extensor tendons are repaired. The first interdigital color improvement after squeezing show venous con-
space should be kept open by packing enough gauze to gestion, which indicates compression or thrombosis of
prevent adduction contracture of the thumb. Thin gauze the sutured vein. Sometimes an increase in interpha-
is sandwiched between the fingers without compressing langeal joint flexion may stretch the anastomosed dorsal
the replanted fingers. Thick gauze is then applied to the vein. In those conditions, changing of the wet and tight
dorsal and palmar aspects of the hand and forearm. A dressing, removal of the tight skin stiches, and realign-
bandage is bound around the gauze dressing from the ment of the finger position should be done at first. If
distal to the proximal direction with mild compression. these conditions are not improved soon, reoperation
After this the position of the hand should be kept al- should be performed as soon as possible. Skin temper-
most in the intrinsic plus position (Fig. 1). In the care of ature monitoring by thermometer is generally used as a
amputation at the proximal metacarpal level, the first quantitative measure. The temperature probes are set
interdigital space and digital MP joints should be tem- on a nonreplanted and a replanted digit, and the tem-
porarily fixed by Kirschner wires in the functional posi- peratures are compared. The continuous low tempera-
tion. A plaster cast or plastic splint is the applied at the ture and sudden temperature drop of the replant may
dorsum of the hand and forearm. When splinting of the indicate circulatory disturbance. However, direct ob-
elbow joint is added, the position of the elbow should servation of the replant by the medical stuff is most
be set around 60. More than 90 of elbow flexion may reliable.
disturb the venous drainage. The digital tips should
be kept open after dressing to check the circulatory
condition.
After the patient is transferred to the recovery room,
Salvage
he or she is laid on the bed for a week with the hand
and forearm elevated on the soft triangular pillow If the anastomosed site of the artery or vein or both
is occluded by thrombosis, after resection of the
except for times of meals and hygiene. The replanted
anastomosis, interposition of a vein graft between the
hand is covered by a cotton pad and towel to keep the
hand warm except for observation times (Fig. 2). The good proximal and distal stumps is the best measure.
If the replanted amputated digital tip is congested
room is also kept warm.
and venous reconstruction is impossible, a small inci-
sion on the digital tip or removal of the nail plate is

179
 180 D. Preoperative and Postoperative Management
added to promote venous drainage. Scratching or
squeezing of the pulp is the done every 30min or
1 h, and a small, wet, heparinized gauze pad is laid
on the bleeding site for 1 week. Sometimes these
procedures can save the replanted digital tip with
congestion.
b after surgery following the schedule of extensor tendon
a surgery, the aim of which is to minimize the extension
c d
Fig.1. Dressing of the replant. a The wound is covered by tulle
gauze. b Gauze packing. c, d A bandage is applied
a-c
Anticoagulants and Antibiotics
We use urokinase 240,000 units per day for 4 to 5 days
and prostaglandin E) 60 units per day for 7 days, added
to the intravenous drip infusion of 2000 ml per day,
including 500ml of low-molecular-weight dextran. If the
crushing of the replanted digits or limb is severe, 10,000
to 20,000 units of heparin per day is continuously added
for 1 week. Antibiotics are administered routinely for 1
week.
Rehabilitation
Mild active-motion exercises of the nonaffected joint,
such as the elbow or shoulder joint in the case of digit
replantation, as well as walking to the rest room, are
generally permitted 1 week after surgery. Exercise of
the replanted finger, wrist, or arm starts 3 or 4 weeks
loss of the proximal interphalangeal (PIP) joint by
attenuation of the sutured extensor tendon. At this
point, bone healing and tendon healing have moder-
ately progressed, and the vascular suture site is almost
covered with regenerating intima. Passive stretching
of the repaired flexor and extensor tendons should
be started 6 weeks after surgery at the earliest. Early
motion exercise of the replanted digit, which has
already been introduced, is mild passive flexion and
extension of the interphalangeal (IP) and metacar-
pophalangeal (MP) joints by the dynamic tenodesis
effect of accompanied wrist motion [1]. This method
starts 1 week after surgery and may prevent contracture
of the digital joints, but it may still be insufficient to
prevent tendon adhesion. To start very early active-
motion exercise of the replant to prevent tendon adhe-
Fig. 2. Position of the replant
on the bed. a Elevation on the
pillow and coverage by towel.
b Coverage by cotton pad.
c Observation of digital tips
 6. Postoperative Management and Rehabilitation in LimblDigit Replantation
a * rubber band
* Tenolysis is planned after 4 to 6 months of rehabilita-
* cated. The result of extensor tenolysis at the finger
b to the metacarpal level, if the forearm muscles have
c When the patient has some sensation in the pulp, a
Fig.3. Splinting for the replant. a Cock-up splint with flexion
assist of metacarpophalangeal (MP) joints, extension assist of
proximal interphalangeal (PIP) joints, and palmar abduction
assist of thumb for replant at forearm or wrist level. b Knuckle
bender with extension assist of distal interphalangeal (DIP)
joints and palmar abduction assist of thumb for replant at
metacarpal level. c Static splint with functional position of the
hand, which is mainly used at night
sion, we need rigid bony fixation, a rigid flexor and ex-
tensor tendon suture technique, and a safe technique of
reconstruction of the artery and vein to resist bending
and traction forces in the swelling of the surrounding
tissue. So far we have not established these techniques.
However, early passive motion exercise of the digits in
the case of upper arm replantation is permissible to
prevent digital joint contracture. Because the recovery
of directly damaged or denervated intrinsic muscle
of the hand is poor, dynamic splinting in the daytime
and static night splinting should be applied for several
181
months to prevent adduction contracture of the thumb
and intrinsic minus contracture of the fingers (Fig. 3).
Maintenance of the intrinsic plus position may increase
the intrinsic plus contracture of the fingers by con-
tracture of interosseous the muscles, which disturb
flexion of the PIP and distal interphalangeal (DIP)
joints. Careful observation should be made to detect this
condition, and intrinsic release operation is indicated if
it occurrs. Because delayed union of the bony fixation
site disturbs the smooth rehabilitation process, early
bone grafting is indicated if it is suspected.
Tenolysis
tion. In cases of digital replantation, if the extensor
mechanism is acting functionally with full passive
flexion of the finger joints, only flexor tenolysis is indi-
proper level is poor. In cases of replantation proximal
functional activity, both extensor and flexor tenolysis is
indicated with a 3-month interval.
Others
sensory reeducation program should be started [2,3]. If
he or she has paresthesia in the pulp, desensitization
exercise should be started, which includes rubbing a
coarse towel over the pulp or grasping and manipulat-
ing soybeans. For good functional sensory recovery,
functional movement of the digits is indispensable.
Release of intrinsic muscle contracture, opponens
plasty, and tendon transfer are planned case by case,
depending upon the circumstances.
References
1. Buncke HJ, Jackson RL, Buncke GM, Chan SW (1995) The
surgical and rehabilitative aspects of replantation and
revascularization of the hand. In: Hunter JM, Mackin EJ,
Callahan AD (eds) Rehabilitation of the hand: surgery
and therapy. CV Mosby, St Louis, Chapter 62, pp 1075-
1100
2. Dellon AL (1981) Evaluation of sensibility and re-
education of sensation in the hand. Williams & Wilkins
3. Parry CBW, Balter M (1976) Sensory re-education after
median nerve lesions. Hand 8:250-257
E. Clinical Reconstructive Microsurgery
1. Replantation
1.1 Arm Replantation
MASAO MATSUDA
Hapfner (1903) is generally credited with the first suc-
cessful experimental limb replantation, which was per-
formed in dogs, with survival from 1 to 9 days [1]. Carrel
and Guthrie (1906) also achieved experimental replan-
tations of completely amputated thighs in dogs, with
temporary success [2). Their idea of replanting an ampu-
tated limb was suggested by the results of transplanta-
tion and replantation of the kidney and thyroid gland.
In 1944, Hall presented a tentative plan for a whole-limb
transplant in human beings by referring to many reports
[3). By this time, surgeons' attitudes and skills were
presumed to be adequate. In 1960, Lapchinsky [4] and
Snyder and associates [5] published their results of
small-vessel anastomosis and the replantation of limbs
in dogs, and reported on a long-term follow-up of a dog
with a functional replanted hind limb. Jacobson and
Suarez first reported the techniques of vascular anasto-
mosis under a dissecting microscope in 1960 [6].
From this base in clinical and laboratory studies,
Kleinert and Kasdan demonstrated the value of vascu-
lar surgery in vascularizing the arm following severe
injury [7). The first successful replantation of a com-
pletely severed arm was done in May 1962 by Malt and
McKhann in Boston [8]. The right arm of a 12-year-old
boy amputated below the shoulder in a train accident
was replaced successfully, and the patient regained
some useful function of the upper extremity. Since then,
within a short period, several cases of successful replan-
tation of limbs were reported [9-11).
Review of the Literature
At present, hand and digit replantation has become
common. By contrast, replantation of the arm is still
rare [12]. The literature suggests that the greater proxi-
mal the amputation, the greater the incidence of com-
plications and the worse the functional results. Of the
36 patients with documented transhumeral replanta-
tion, 4 died of replantation toxemia during hospitaliza-
tion [13). In replantation of the arm, a long time is
required for nerve regeneration, and functional recov-
ery tends to be poor due to joint stiffness, muscular
degeneration, and poor nerve regeneration, especially
in a severely crushed arm or in an elderly patient. There-
fore, the decision for replantation should be made more
cautiously than in distal amputations. The requirements
for the selection of a patient for replantation of the arm
are follows: a healthy person under 60 years of age, no
other serious or life-threatening injury, good condition
of the amputated limb (limited avulsion, single-level
amputation, etc.), and a person who is able to endure a
long period of physical therapy and multiple recon-
structive procedures [14).
With modern microsurgical techniques, the survival
rate of a replanted limb has been increased. Our recent
review of the literature since 1981 has yielded 50 cases
of arm replantation and revascularization [13-19]. In
this group, 40 replanted arms survived, for an overall
survival rate of 80%.
Certainly the success of replantation must be based
not on the immediate viability of the part, but on the
long-term use of the patient's replanted limb. However,
it is difficult to discern the value of limb reattachment
above the elbow in the literature. Most series involved
mixed cases of amputation at various levels and ap-
praised the functional recovery using various criteria.
Several authors established their own criteria
[10,15-18). In our review of the literature, excellent or
good recovery of function after arm replantation ranged
from 10% to 50% [13,16-19]. In our opinion, the proper
criteria for successful replantation of the arm are as
follows: powerful and effective motion of the elbow
joint, possibility of pinching and grasping, sufficient
sensory recovery to the fingertips, and absence of pain
and ischemic symptoms in the replanted part.
Our Series
Patients
Seven patients with amputations of the arm underwent
replantation procedures at Chukyo Hospital in Nagoya
from 1978 to 1991. Three patients had complete ampu-
187
188 E. Clinical Reconstructive Microsurgery

Table 1. Functional results of five patients with arm replantation

Range of motion (all directions) Grade Total
(% of normal) Power (%) of score Final
Case Age
No. (yr) Sex Preserved tissue Shoulder Elbow Wrist Thumb Fingers Pinch Grasp Sensation (Ipsen) evaluation
1 2 F Dorsal skin 21 20 24 0 0 0 0 S3 39 Poor
(4cm)
2 50 M None 70 34 0 0 0 0 0 S3 51 Fair
3 42 M Dorsal skin, 100 81 51 58 42 11 3 S3 89 Good
radial nerve
4 38 F None 71 24 16 0 0 0 0 S3 50 Fair
5 30 M None 100 86 17 21 42 28 9 S3 81 Good

tations, and four had incomplete nonviable amputa-
tions. Five patients were male and two were female.
Their ages ranged from 2 to 52 years, with an average
of 37 years. The total ischemic time ranged from 7.5 to
14 h before revascularization, and the operation time
ranged from 6 to 13 hours. The level of injury involved
the scapula in one patient, the mid-arm in three, and the
distal third of the arm in three. The mechanism of injury
in six patients was avulsion, whereas in one patient it
was crushing by an electric saw.
Results
All of the replanted arms survived. One patient suffered
from severe causalgic pain in the area of the median
nerve after the operation. Neurolysis of the median
nerve was performed, but the neuralgia became worse.
The arm was reamputated 1 year and 3 months after
replantation [14]. One other patient who had postoper-
ative depression leaped to his death 7 days after the
operation. This incident suggests that there is an impor-
tant need for further interest in psychological care after
replantation surgery [20].
The follow-up periods of the remaining five patients
ranged from 6 to 25 years, averaging 14 years. These
patients required multiple secondary reconstructive
procedures for the nerve, tendon, skin, and bone. The
functional results were evaluated by Ipsen criteria, a
modified version of the Tamai classification [18].
According to these criteria, the results were good in two
patients, fair in two, and poor in 1 (Table 1).
Case Reports
Case 1
A 2-year, 10-month-old girl was admitted to our hospi-
talon February 1, 1974, approximately 1 h after ampu-
tation of her left arm through the scapula due to an
automobile accident. Her physical status was stable. Her
left arm was completely severed except for a 4-cm-wide
segment of skin on the posterior side of the shoulder.
The left scapula and humerus were fractured, and the
acromioclavicular joint was completely dislocated (Fig.
1a). All vessels and nerves were transected.
Lavage and debridement of the soft tissue and bone
were carefully carried out. After immobilization of the
scapula, stabilization of the humerus and approximation
of the muscles were achieved. The axillary artery was
anastomosed with 10-0 nylon sutures under the micro-
scope. Then the cephalic vein was anastomosed with 9-
o nylon sutures, and the axillary vein was repaired by
interposition of a 7-cm-Iong saphenous vein graft. The
median, radial, ulnar, and musculocutaneous nerves
were identified and sutured with epineural repairs.
Decompression incisions were made in the arm,
forearm, and hand. The muscle groups and skin were
also approximated. The operation time was 12h, and the
total ischemic time was approximately 5 h. Although the
systemic circulation was unstable throughout the oper-
ation, the patient tolerated it.
The immediate postoperative course was complicated
first by bleeding from the wounds, which required 2600
ml of transfused blood during the first 2 days, and then
by laryngeal edema, which required a tracheostomy.
One week after the operation, the wounds became
infected with enterococci and pseudomonas bacilli (Fig.
1b). The infection was eliminated with antibiotic
therapy during the next 2 weeks. On the 22nd postop-
erative day, the left axillary artery developed thrombo-
sis, which was treated by immediate thrombectomy;
however, parts of the left middle, ring, and small fingers
developed necrosis. Thereafter, the clinical course was
uneventful, and the patient was discharged after 3
months of hospitalization.
Following discharge, a physical therapy and rehabili-
tation program continued on an outpatient basis. The
patient's physical and mental growth were normal, and
she began attending public school. She used the

a b
c,d
Fig. 1. Case 1. a The left arm was completely severed, except
for a 4-cm-wide segment of skin. The left scapula and humerus
were fractured, and the acromioclavicular joint was com-
pletely severed. All vessels and nerves were transected.
replanted arm actively in activities of daily living, such
as feeding, dressing herself, and riding a bicycle.
Up to the present, the patient has been followed for
25 years since the operation. Neurological examination
shows useful pain and touch perception in the hand.
Two-point discrimination is reduced at 2 cm on the
palmar surface. Although somatic motor function
testing shows an absence of finger movement, powerful
movement of the elbow joint ranges from 73 to 130
(Fig. lc and d). The longitudinal growth of the replanted
arm is 83% of the normal one (Fig. Ie ). The active joint
motions of the replanted extremity are shown in Table
1. The functional recovery of this patient is evaluated as
poor by Ipsen criteria.
1.1. Arm Replantation 189
c
b Replanted arm 2 weeks after operation. c, d Twenty-five
years after operation. Powerful flexion is possible. e Longitu-
dinal growth of the replanted arm is 83 % of that on the
normal side
Case 3
A 42-year-old man suffered incomplete amputation of
his left arm by a milling machine on July 16, 1983. The
level of amputation was approximately 8cm proximal to
the elbow joint. All of the tissue except for a 4-cm-wide
skin flap and the radial nerve were crushed and severed.
The physical condition of the patient was good, and
replantation surgery was performed immediately.
Under general anesthesia, lavage and debridement of
the wound were accomplished. The humerus was stabi-
lized by a plate after shortening by 5 cm. One subcuta-
neous vein, the brachial artery, and the brachial vein
were anastomosed in the order named. The median and
 190 E. Clinical Reconstructive Microsurgery
a,b
d,e
Fig. 2. Case 3. a The left arm was completely severed except
for 4-cm wide skin flap and the radial nerve. Two veins, the
brachial artery, the median and ulnar nerves, and the biceps
and triceps muscles were repaired. Decompression fasciotomy
was performed on the forearm. b, c The range of powerful
ulnar nerves were then repaired with 7-0 nylon
epineural sutures. Approximation of the biceps and
triceps muscles and fascia was done with 3-0 nylon
sutures. Decompression fasciotomy was performed on
the forearm, and the wound was closed primarily (Fig.
2a). The overall ischemic time was 7h, and the opera-
tion time was 6.5 h.
Although the postoperative course was uneventful,
the dorsal segment of the skin developed necrosis,
which was successfully treated by skin graft 30 days
postoperatively. Eight months after injury, reconstruc-
tive surgery of a tendon transfer for improving thumb
opposition was performed.
c
r
flexion of the left elbow is sufficient, and the range of
motion is 141. d Movement of the shoulder joint is
normal.e, f The range of motion of the thumb and fingers is
approximately 50% of normal. Pinching and grasping are
possible
At present, 16 years after the operation, the patient
has resumed his original work, and his replanted arm
has been very useful. The power of flexion in his left
elbow is sufficient, and the range of motion is 104.
Pinching and grasping with the left hand are also pos-
sible (Fig. 2b-f). Neurological examination shows useful
pain and touch perception in the fingertips with mild
paresthesia. The patient is highly satisfied with the func-
tional results of his replanted arm. The functional
recovery is evaluated as good by Ipsen criteria.
 1.1. Arm Replantation 191

Cephiillh:
uefn

Radl.1
nl,ue .:11 tilt:
Ie In
G!'kfHH-H-+ arae h. II I
ueln

Fig. 3. Case 5. a Schematic figure. The right arm was com-
pletely severed through the distal third of the humerus. The
humerus was fixed with a plate. The brachial artery, three
veins, and the median and radial nerves were repaired. b, c
Flexion of the right elbow joint is powerful, with a range of
141. Movement of the shoulder joint is normal. d, e Pinching
power (side pinch) between the right thumb and index finger
is approximately 30% and grasping power is 10% that of the
normal side. Range of motion of the thumb and fingers is 31 %
on average
192 E. Clinical Reconstructive Microsurgery
Case 5
A 30-year-old right-handed machinist sustained a com-
plete amputation of the right arm through the distal
third of the humerus from a conveyer-belt accident on
January 22,1991. No further injuries were noted, and an
attempt at limb replantation with a warm ischemic time
of approximately 3 h was made. After lavage and
debridement of the stump of the amputated extremity,
the humerus was shortened 4cm and fixed with a plate.
One of the subcutaneous veins was first anastomosed
with 7-0 suture under the microscope, and the brachial
artery was then repaired in the same way. Additional
anastomoses of the subcutaneous vein and the brachial
vein were performed. The ulnar nerve was extracted dis-
tally, but it could not be repaired because of the absence
of the proximal end. The median and radial nerves were
repaired with epineural sutures. Repair of the biceps
and triceps muscles and fascia was done with 3-0 nylon
sutures. Although the skin edges were approximated as
closely as possible, a skin defect remained on the lateral
aspect of the arm. Three silicone sheet drains were
placed in the subcutaneous space, and decompression
fasciotomy was not performed (Fig. 3a). The operation
time was 6h and 30min, and the total ischemic time was
approximately 7h. No blood transfusion was required.
During the postoperative course, no systemic prob-
lems were encountered, and the circulatory status of the
replanted arm was good. The lateral area of the skin
developed necrosis, which was successfully treated by
skin graft 37 days postoperatively. Eight months after
the injury, ulnar nerve repair using a nerve graft and
bone grafting for bony union were performed. A total
of seven reconstructive surgeries were performed after
replantation, including three operations for tendon
grafting.
Up to the present, the patient has been followed for
8 years. He was able to resume his original work. Pow-
erful flexion of his right elbow joint is possible with a
range of 141. The pinching power (side pinch) between
his right thumb and index finger is approximately 30%
of that on the normal side, and the grasping power is
10% of that on the normal side (Fig. 3b-e). Neurologi-
cal examination shows useful pain and touch perception
in the fingers, with mild cold intolerance. The patient is
very satisfied with the functional results of his replanted
arm. The functional recovery is evaluated as good by
Ipsen criteria.
References
1. Hofner E (1903) Ueber Gefiissnaht, Gefiisstransplanta-
tionen und Replantation von amputierten ExtremiHiten.
Arch Klin Chir 70:417-471
2. Carrel A, Guthrie CC (1906) Complete amputation of the
thigh with replantation. Am J Med Sci 131:297-301
3. Hall RH (1944) Whole upper extremity transplant for
human being: general plans of procedure and operative
technique. Ann Surg 120:12-23
4. Lapchinsky AG (1960) Recent results of experimental
transplantation of preserved limbs and kidneys and
possible use of this technique in clinical practice. Ann NY
Acad Sci 87:539-571
5. Snyder CC, Knowles RP, Mayer PW, Hobbs JC
(1960) Extremity replantation. Plast Reconstr Surg 26:
251-263
6. Jacobson JH, Saurez EL (1960) Microsurgery in anasto-
mosis of small vessels. Surg Forum 11:243-245
7. Kleinert HE, Kasdan ML (1963) Salvage of devascular-
ized upper extremities including studies on small vessel
anastomosis. Clin Orthop 29:29-38
8. Malt RA, McKhann CF (1964) Replantation of severed
arms. JAMA 189:716-722
9. Williams GR, Carter DR, Frank GR, Price WE (1966)
Replantation of amputated extremities. Ann Surg 163:
788-794
10. Chen CW, Qian YQ, Yu ZJ (1978) Extremity replantation.
World J Surg 2:513-524
11. Horn JS (1964) Successful reattachment of a complete
severed forearm; a commentary. Lancet 1:1152-1154
12. Fukui A, Tarnai S (1994) Present status of replantation in
Japan. Microsurgery 15:842-847
13. Wood MB, Cooney WP (1986) Above elbow limb replan-
tation; functional results. J Hand Surg 11 A: 682-687
14. Matsuda M, Kato N, Hosoi M (1981) The problems in
replantation through the upper arm region. J Trauma 21:
403-406
15. Wang SH, Young KF, Wei IN (1981) Replantation of
severed limbs-clinical analysis of 91 cases. J Hand Surg
6:311-318
16. Tarnai S (1982) Twenty years' experience of limb replan-
tation-review of 293 upper extremity replants. J Hand
Surg 7:549-556
17. Russell RC, O'Brien BM, Morrison WA, Pamamull G,
MacLeod A (1984) The late functional results of upper
limb revascularization and replantation. J Hand Surg
(Am) 9:623-633
18. Ipsen T, Lundkvist L, Barfred T, Pless J (1990) Principles
of evaluation and results in microsurgical treatment of
major limb amputations. A follow-up study of 26 consec-
utive cases 1978-1987. Scand J Plast Reconstr Hand Surg
24:75-80
19. Patradul A, Ngarmukos C, Parkpian V (1995) Major limb
replantation: a Thai experience. Ann Acad Med Singapore
24:82-88
20. Schweitzer I, Rosenbaum MB, Sharzer LA, Strauch B
(1985) Psychological reactions and processes following re-
plantation surgery: a study of 50 patients. Plast Reconstr
Surg 76:97-103
1.2 Forearm Replantation
SATOSHI TOH, SHINJI NISHIKAWA, and SADAHIRO INOUE
Amputation of the upper extremity proximally to the
level of the metacarpophalangeal joint is considered a
major limb amputation. Replantation of the upper
extremity was first performed by Malt and McKhann at
the Massachusetts General Hospital in 1962 [1].
However, the first microsurgical replantation of the
forearm was carried out by Chen in China in 1964 [2].
Presently improvements in microsurgical technique and
equipment have led to routine replantation of ampu-
tated parts at microsurgery centers around the world.
Replantation of the forearm has been performed with
a success rate of almost 100% [3,4]. The more proximal
the amputation level, the larger the diameter of the
vessels, so it is easier to repair them. However, the
muscle volume is also greater, and therefore the risk of
irreversible ischemic changes becomes greater. Conse-
quently, it is desirable to replant as quickly as possible
after the injury. As for functional outcome, a clear-cut
amputation in the distal forearm can generally achieve
good results. On the other hand, replantation of a
crushed amputation or replantation in the proximal
forearm seldom has good results.
Chen et al. emphasized that "survival without restora-
tion of function is not a success" [2]. However, replanted
hand is better than an artificial hand, because even
today the motor and especially the sensory ability of
prostheses are not sufficiently developed. Recently
three cases of allotransplantation of the hand have
drawn much attention [5,6]. Although these cases have
not had sufficiently long follow-up periods to allow any
conclusions to be drawn, the possibility exists that this
will become a common procedure if the problems of
immunosupressive medication and the ethical aspects
can be solved [7-10].
In this chapter, we describe the indications for
replantation surgery, standard procedure, and case
presentation.
Indications
Any kind of forearm amputation is a candidate for
replantation, but some patients, such as those with
diabetes or peripheral vascular. disease, should be
excluded. If a smoker is unlikely to be able to quit, that
patient should also be excluded. The general condition
of the patient, such as shock after trauma or major
organ damage, is also considered is deciding whether
the patient should be excluded.
Operative Procedures
General anesthesia is used. A two-team approach for
the complete amputation is preferable, in which one
team explores the recipient proximal stump and the
other team commences exploration and debridement of
the amputated stump. Exploration of the amputated
stump should be carried out in the operating room as
soon as possible after the patient's arrival, because no
general anesthesia is necessary for this procedure. In an
incomplete amputation where there is only a bridge of
some tissues, we usually perform surgery with one team.
However, if it is necessary to reduce the ischemic time
and shorten the operation time, dividing the remaining
tissues to facilitate the two-team approach of dissection
is recommended. A tourniquet is used during the course
of the dissection in the proximal stump, which is per-
formed under 2.5 magnification with a binocular loupe.
After the routine procedure of brushing and washing
with copious amounts of physiological saline solution
containing antibiotics, radical debridement should be
performed with knife and scissors to remove all con-
taminated and crushed tissues. The ulnar and radial
arteries, two to three veins, and the ulnar, median and
radial nerves are identified. If necessary, an additional
skin incision is made to obtain a wider operative field.
Once these nerves and vessels have been located, stay
and marking sutures are applied. After isolation and
debridement of the ends of all tendons and muscles a
4-0 nylon loop needle designed by Tsuge is used for
each tendon to prepare for repair and handling of the
tendons during the operation. This is very useful to
shorten the operation time.
Bony Fixation
After debridement and shortening of both the ulna and
the radius, bony fixation is performed following a final
assessment of the soft-tissue reconstruction to deter-
193
194 E. Clinical Reconstructive Microsurgery
mine whether further shortening of the bone, vein graft-
ing for artery, or nerve grafting is indicated. The length
of bone shortening should be considered depending on
the possible length of soft-tissue repairs. Stable fixation
of the bone is necessary, but the method must be rapid.
For periosteal and intramedullary circulation of the
bone, Kirschner-wire fixation will provide adequate sta-
bility, particularly at the wrist level. In addition, if it is
reinforced with longitudinal wire compression, it will
provide stable compressive fixation and control rota-
tion. This procedure involves minimal stripping of the
surrounding soft tissues. For more proximal level
replantation, plate and screw fixation is preferable,
but too much stripping of muscle may cause muscle
ischemia. To reduce the operating time, a unilateral
external fixator, such as the Orthofix apparatus, is
another useful option.
Repair of Muscles, Tendons, and Nerves
Ideally all muscles, tendons, and nerves should be
sutured prior to the vessel anastomoses, because a
bloodless field makes the operative time shorter.
However, this will depend on the ischemic time, as men-
tioned later. Nerve suture is performed with epineural
sutures using 9-0 nylon combined with fibrin glue.
Generally, recovery of the intrinsic muscles, particu-
larly the thenar muscle, requires a long period, so some
authors recommend primary opponoplasty using one of
the FDS tendons with a free tendon graft.
Vascular Anastomoses
In most cases, nerve repair and vein anastomoses should
be carried out prior to performing arterial anastomoses
in order to avoid excessive blood loss. However, when
the ischemic time of the amputated part exceeds 6 h, the
artery should be anastomosed first. In proximal forearm
amputation in which the amputated part includes
much muscle tissue, arterial repair should be performed
before venous repair, because a rapid return of the
blood with toxic substances, including lactic and pyruvic
acid, can be detrimental to the patient. In such a situa-
tion, the returning blood from the replant bleeds freely
for a while, until the color of the blood becomes pink,
and it is beneficial to give intravenous sodium bicar-
bonate to the patient before venous anastomosis.
Before anastomosis of the vessels, intravenous perfu-
sion with urokinase, heparin, and prostaglandin El is
useful to prevent thrombosis.
Since muscle ischemia leads to increased permeabil-
ity and compartmental swelling will occur following
revascularization, extensive fasciotomies are always
indicated in major limb replantation.
Before the wound is closed, drainage is used to
prevent hematoma, which will compress the sutured
vessels. The drainage tube or sheet should be placed far
away from the site of vessel anastomoses to ensure that
there is no mechanical interference at the anastomoses
site.
Skin Closure
Finally the skin is closed, with or without skin grafting.
In particular, any exposed vessels or nerves should be
covered by local skin plasty as much as possible and
additional split-thickness skin graft as needed.
Postoperative Management
The bulky dressing and bandage must be applied care-
fully so as not to compress the vessels, and the limb is
immobilized in a plaster splint. Postoperatively the limb
is elevated continuously and the fingertips are inspected
at regular intervals. Vital signs and skin temperature
of the digits are monitored. To prevent vascular
thrombosis, intravenous perfusion of urokinase and
prostaglandin E) is routinely used for 1 week after the
operation.
Case Presentation
Case 1: A 21-year-old man sustained amputation of
the right hand at the wrist level when a rope that was
wrapped around his wrist was caught and pulled by
machinery. The patient arrived at our hospital 3 h after
the initial injury. The extensor pollicis longus tendon
was avulsed from the proximal forearm, and the
remainder of the structures were severed at the wrist
level. The roentgenograms revealed that the amputation
level was at the radiocarpal joint. After cleansing and
debridement, proximal carpectomy was performed to
achieve shortening. Radiocarpal temporary arthrodesis
was performed by Kirschner wires. Before the vessels
were anastomosed, all other structures were sutured.
The median nerve and ulnar nerve, the radial and ulnar
artery, and four dorsal cutaneous veins were sutured
end-to-end. The warm ischemic time was 9 hand 45 min.
The postoperative course was uneventful, but 2 months
later the patient went to an air-conditioned movie
theater where he suffered arterial spasm and the tips of

all the fingers in the replanted hand became pale. For-
tunately, intravenous anticoagulant therapy was effec-
tive. As a secondary reconstructive operation, oppo-
noplasty using the flexor digitorum sublimis tendon of
the ring finger was performed 11 months after the re-
plantation. Thirteen years after the initial operation,
he uses his replanted hand in a normal fashion and
is satisfied with it. The grip power is 24 % of that on
the healthy opposite side, and he has 67% of the
total range of motion of the digits and 50% range of
motion of the wrist (flexion 15 and extension 40). Pro-
tective sensation of the digits was achieved. Func-
tional evaluation by Chen's criteria showed excellent
results (Fig. 1).
Case 2: A 49-year-old male butcher sustained incom-
plete amputation of the left non dominant forearm at
the distal one-third by an electric ham-cutter. Only the
volar skin had continuity. The patient arrived at our
hospital 2h after the injury. The left forearm was cut
sharply. The roentgenograms revealed that the amputa-
a
b e
Fig. 1. a Complete amputation at the left wrist in a 21-year-
old man. b Roentgenograms of the amputated hand and the
proximal stump. c After proximal row carpectomy, the radio-
carpal joint was temporarily fixed with Kirschner wires.
1.2. Forearm Replantation 195
tion level was at the distal one-third of the forearm.
After debridement of the wound, the radius was fixed
with Kirschner wires and the ulna with screws. Before
the vessels were anastomosed, all other structures were
sutured except for the FDS tendons. The median nerve
and ulnar nerve, the radial and ulnar artery, and three
dorsal cutaneous veins were sutured in end-to-end
fashion. The warm ischemic time was 6 h. The postoper-
ative course was uneventful. For the secondary recon-
structive operation, resuturing of the EDC tendons was
performed 2 months postoperatively. Ten years after
the initial operation, he can use his replanted hand
in his daily living without any problems. Grip power
is 47% of that on the healthy opposite side, and he has
90% of the total range of motion of the digits and
79% range of motion of the wrist compared with
the normal control (flexion 60 and extension 50).
Protective sensation of the digits was achieved. Func-
tional evaluation by Chen's criteria showed excellent
results (Fig. 2).
c,d
d Roentgenograms 6 years after replantation showing restora-
tion of joint space without any osteoarthritic changes. e After
opponoplasty, the hand became quite useful in activities of
daily living
196 E. Clinical Reconstructive Microsurgery

ab c

de

Fig. 2. a Incomplete amputation of the left forearm at the Kirschner wires in the radius and screws in the ulna. d Ten
distal one-third in a 49-year-old butcher. b Roentgenogram years after the replantation, the patient uses his replanted
after injury. c The hand immediately after replantation and its hand while working as a butcher and is satisfied with it. e
roentgenogram. Skeletal fixations were achieved with Roentgenograms 10 years after replantation

References 5. Dubernard JM, Owen E, Herzberg G, Lanzetta M, Martin

X, Kapila H, Dawahra M, Hakim NS (1999) Human
hand allograft: report on first 6 months. Lancet
1. Malt RA, McKhann CF (1964) Replantation of severed
353:1315-1320
arms. JAMA 189:716-722
6. Jones JW, Gruber SA, Barker JH, Breidenbach WC (2000)
2. Zhong-Wei C, Meyer VE, Kleinert HE, Beasley RW
Successful hand transplantation: one-year follow-up. N
(1981) Present indications and contraindications for
Engl J Med 343:468-473
replantation as reflected by long-term functional results.
7. Lee WP, Mathes DW (1999) Hand transplantation:
Orthop Clin North Am 12:849-870
pertinent data and future outlook. J Hand Surg 24A:
3. Daoutis NK, Gerostathopoulos N, Efstathopoulos D,
906-913
Misitzis D, Bouchlis G, Anagnostou S (1995) Major
8. Foucher G (1999) Prospects for hand transplantation.
amputation of the upper extremity. Functional results
Lancet 353:1286-1287
after replantation/revascularization in 47 cases. Acta
9. Tarnai S (1999) Reflections on human hand allografts.
Orthop Scand Suppl 264:7-8
J Orthop Sci 4:325-327
4. Waikakul S, Vanadurongwan V, Unnanuntana A (1998)
10. Herndon JH (2000) Composite-tissue transplantation-a
Prognostic factors for major limb re-implantation at both
new frontier. N Engl J Med 343:503-505
immediate and long-term follow-up. J Bone Joint Surg
80B:1024-1030
1.3 Hand Replantation
HIDECHIKA NAKASHIMA and HIROYUKI YONEMITU
According to Tamai's [1] definitions of the zones of the
hand and digits, the hand is the zone from the distal
palmar crease to the wrist joint. Thus, the amputation of
this portion is an injury between the metacarpal and
carpal bones. According to the classification of Honda
et al. [2], there were 4 cases of Type A, 5 of Type B, 6 of
Type C, 12 of Type D, and 4 of Type E among 31 cases
(Fig. 1). Twenty-six were complete amputations and 5
were incomplete amputations. The treatments of the
amputated hands of each type are discussed in this
chapter.
Replantation Technique
The amputated hand is lavaged under axillary block
anesthesia with an air tourniquet on the arm in the
emergency room and debrided in the operating room.
Under an operating microscope, the blood vessels and
nerves are marked by colored threads. Then, the flexor
digitorum profundus and the flexor pollicis longus
tendons are also marked. In case of an amputation with
prolonged ischemia, physiological saline containing
heparin (1000 LV.) is injected from the ulnar or radial
artery, so as to wash out the toxic metabolites from the
amputated hand.
To obtain good function at the amputation level, we
try to repair the intrinsic muscle and ulnar nerve motor
branch.
Type A: Amputation at the Carpal Level
An accessory incision is made on the amputation stump
to identify the blood vessels and nerves for their anas-
tomoses, and they are marked by colored threads. The
carpal bones are fused with Kirschner wires after a
minimal shortening. Then, the sutures of the flexor pol-
licis longus, the flexor digitorum profundus of the index
to the little fingers, the extensor pollicis longus and
brevis, the abductor pollicis longus, the extensor digito-
rum communis, and the extensor carpi radialis longus
and brevis are performed one by one.
The next step is to anastomose the ulnar artery, which
is anatomically easy to find. The ulnar nerve is then
sutured. The deep branch of the radial artery, extending
dorsally, is easily visible for anastomosis because of its
size. The palmar superficial branch of the radial artery
is anastomosed if it is big enough. Three or four dorsal
cutaneous veins are routinely anastomosed depending
on the balance of blood circulation. The median nerve
and the superficial branch of the dorsal radial nerve are
sutured. Drains are placed in several sites, and the skin
is roughly sutured (Fig. 2).
Case 1
A 57-year-old man [amputated his left hand] almost
completely at the carpal level. Five years after replan-
tation, the digits are severely stiff due to adhesions of
the flexor and extensor tendons. The hand seems to have
reflex sympathetic dystrophy (RSD) (Fig. 2).
Type B: Amputation at the Level of the
Superficial Palmar Arterial Arch
(Midmetacarpal amputation of four fingers
and metacarpal amputation of the thumb)
The metacarpal bones of the index to the little fingers
and the thumb are fixed with bone plate or Kirschner
wires after minimal shortening. Suturing of the flexor
pollicis profundus, the flexor digitorum profundus
tendons of the index to the little fingers, the extensor
pollicis longus and brevis, the extensor digitorum com-
munis of the index to the little fingers, and the extensor
carpi radialis longus and brevis is carried out. The ulnar
part of the palmar arterial arch, the common digital
artery or proper palmar digital artery of the thumb are
anastomosed, and at least three to four dorsal cutaneous
veins are repaired. The ulnar nerve, the median nerve,
the common digital nerve, and the proper palmar digital
nerve of the little finger are sutured.
The recurrent nerve and the deep branch of the ulnar
nerve are sutured, if possible. In some cases, it is diffi-
cult to find them, depending on the condition of the
wound (Fig. 3).
197
 198 E. Clinical Reconstructive Microsurgery

Type of
amputated hand Type A Type B Type C Type D Type E

Amputation level

2-5 metacarpus
Amputation level
Carpus 1-5 metacarpus thumb proximal 2-5 metacarpus 1-4 metacarpus
Bone
phalanx

2-5
common digital
Radial artery artery Common digital Common digital
Artery Palmar arch thumb: F
and ulnar artery artery artery
proper palmar
digital artery

2-5
Ulnar nerve, median common digital
Nerve nerve Common digital nerve thumb or Common digital Common digital
Superficial radial proper palmar nerve nerve
nerve digital nerve

Fig. 1. Types of hand amputations

ab c

Fig. 2. Case 1: a 57-year-old man with left hand amputation at the carpal level (Type A), with only a small part of the ulnar
skin remaining. a,b Preoperative views. c 5 years after replantation

Fig.3. Case 2: a 50-year-old man amputated his left mid-palm (Type B). a Preoperative view. b,c 6 months after replantation
Case 2
A 50-year-old man had his left hand completely at
the mid-palm amputated by the electric power saw. Six
months after replantation, the hand shows moderate
tendon adhesions, but he can perform a side pinch
between the thumb and the index finger (Fig. 3).
Type C: Amputation at the Level of the
Common Digital Artery of the Index to the
Little Fingers Through the Proximal Phalanx
of the Thumb
The metacarpal bones of the index to the little fingers
and the proximal phalanx of the thumb are fixed
with bone plates or Kirschner wires. In some cases,
the metacarpophalangeal joint is partially involved, but
efforts should be made to preserve the joint itself with
minimum bone shortening. Suturing of the flexor digi-
torum profundus of the index to the little fingers, the
flexor pollicis longus of the thumb, and the extensor
tendons is carried out. Three common digital arteries
of the index to the little fingers are anastomosed.
The radial proper digital artery of the index finger and
1.3. Hand Replantation 199
the ulnar proper digital artery of the little finger are
anastomosed, if possible. The proper digital arteries of
both sides of the thumb are also anastomosed. Three
common digital nerves of the index to the little fingers,
the radial proper digital nerve of the index finger, and
the ulnar proper digital nerve of the little finger are
repaired (Fig. 4, case 3).
Case 3
A 53-year-old woman amputated part of her left hand
obliquely through the thumb to the metacarpopha-
langeal joint of the little finger with an electric power
saw. All metacarpophalangeal joints except for
that of the little finger retained intact. According
to roentgenograms 8 months after replantation, bone
union was completed, although there remained some
angulation deformity of the second metacarpal. Flexion
and extension of the thumb and all fingers except for
the metacarpophalangeal joint of the little finger were
acceptable. Two years after replantation, the Semmes-
Weinstein test result for the thumb was blue, that for
three fingers was purple, and that for the little finger was
red. Two-point discrimination of the thumb was 9mm,
but that of all fingers was within 15 mm (Fig. 4).
 200 E. Clinical Reconstructive Microsurgery

a,b c

d,e r.g

Fig. 4. a e : a 5 -ycar- Id woman amputated her left palm obliqucl with a n

electric power aw (Type ). B.b Pr operative vic\ . (cc olor Plate)
c Roentgenogram 2 month after replan tation. d-g 2 year aftcr rcplantation.
h b Roentgenogram 2 yea after replantation

a,b
c,d
Fig. 5. Case 4: a 45-year-old man amputated his left distal
palm around the MP joint level with an electric power saw
(Type D). a,b Preoperative views. c,d 1 year after replantation
a.b
c,r
Fig. 6. Case 5: a 56-year-old man amputated his left distal
palm from the thumb to the ring finger (Type E). a,b
Preoperative views. (See Color Plates) c,d Preoperative
1.3. Hand Replantation 201
Type D: Amputation at the Level of the
Common Digital Artery of the Index to the
Little Fingers
When the amputation involves the metacarpopha-
langeal joint to the midpart of the metacarpus of the
index to the little fingers, certain preservative measures
are taken for bone fixation and arthroplasty. Anasto-
moses are carried out for the three common digital
arteries of the index to the little fingers. Suturing of the
three common digital nerves of the index to the little
fingers, the radial proper digital nerve of the index, and
the ulnar proper digital nerve of the little finger is
carried out (Fig. 5).
Case 4
A 45-year-old man amputated four fingers of his left
hand around the metacarpophalangeal joint level with
an electric power saw. One year after replantation,
flexion of the proximal and distal intaphalangeal joints
of all fingers is satisfactory but extension is slightly
impaired. The patient can grasp a cup (Fig. 5).
Cod
g,h
roentgenograms. c-g 1 year after replantation. h
Roentgenogram 1 month after replantation
202 E. Clinical Reconstructive Microsurgery
Type E: Amputation at the Metacarpal Level
Through the Thumb to the Ring Finger
Certain preservative measures are taken in amputations
at the metacarpophalangeal joint level. Anastomosis of
the common digital artery from the deep branch of the
radial artery or the proper palmar digital artery in case
of distal metacarpal amputation is carried out. Anasto-
mosis of the common digital artery of the index to the
ring fingers and the proper digital artery is carried out
(Fig. 6).
Case 5
A 56-year-old man amputated the distal part of his left
hand through the thumb to the ring finger amputated
by an electric saw. The thumb was amputated at the
metacarpophalangeal joint level. The index and middle
fingers were amputated at the distal metacarpus, and the
ring finger was amputated at the base of the proximal
phalanx. The metacarpophalangeal joints of all fingers
were fortunately restored, but the metacarpophalangeal
joint of the thumb was fixed inevitably. On X-ray 1 year
after replantation, the metacarpophalangeal joints of all
fingers are intact. Strong tip pinch between the thumb
and the fingers is possible. Two-point discrimination in
each digit is about 10mm. The result of the Semmes-
Weinstein test is purple, which means S3 (Fig. 6).
Discussion
The replantation of cleanly amputated hands is techni-
cally possible. However, the recovery of function may
vary, depending on the condition of the wound, the level
of amputation, and the technical skills of the surgeon in
charge. In our series, the group with Type A amputation
had the worst results. We do not know the reason for
this. Two cases resulted in reflex sympathetic dystrophy.
The groups with Type C and D amputations showed a
good recovery of sensation and acceptable range of
motion of the joints. Most of our patients returned to
work and had useful function of their hands in activities
of daily living. In patients with Type Band E amputa-
tions, the degree of functional recovery of the thumb
significantly affected the final result in the replanted
hand. However, the lateral pinch between the thumb
and the index finger became possible. They used
their hands in activities of daily living. According to the
scoring evaluation of function after hand and digit
replantation by Tarnai, our 26 replanted hands showed
excellent results in 2 (7.7%), good results in 12 (46.1 %),
fair results in 8 (30.8%), and poor results in 4 (15.4%).
In all cases, the patient's satisfaction was greater than
the surgeon's expectations.
References
1. Tarnai S (1982) Twenty years' experience of limb replanta-
tion-review of 293 upper extremity replants. J Hand Surg
7:549-556
2. Honda T, Nomura S, Yamanouchi S, Simamura K, Ugazi Y,
Hashimoto H, Yoshimura M (1983) Clinical survey of
the replanted hands at the level of palm. Orthop Surg 34:
1758-1760
1.4 Replantation of Multilevel Amputation Through the
Forearm and Hand
MINORU SHIBATA
Multilevel amputation is a relatively rare injury. It has
been considered a contraindication for replantation,
because it is difficult to regain useful function. Good
results with major limb replantation are difficult to
attain, and serious complications, such as replantation
toxemia, are always of concern, as well as reperfusion
injury and acute respiratory distress syndrome. Multi-
level amputation often involves major injury, requiring
strategies to perform time-saving, efficient surgery to
avoid serious complications.
Successful replantation of a double-level amputation
through the palm and forearm was first performed at
Niigata University Hospital by the senior colleagues of
the present author in 1974 [1]. Reasonably useful func-
tion was attained in this case, and in several recent
reports, useful function has been regained after multi-
level replantation in the upper limb.
Indications
The basic goal for replantation of multilevel amputation
injury is to attain reasonably useful function and accept-
able appearance of the replanted limb, equivalent to
those for single-level replantation. The following factors
should be considered in deciding whether to perform
replantation.
Ability of the Patient to Tolerate
Replantation Surgery
Replantation of the multiple-level amputation requires
long, tedious surgery, and life-threatening complica-
tions, such as replantation toxemia or acute respiratory
distress which may occur after reperfusion of the major
limb. Total evaluation of the amputation injury and
associated injuries, such as brain injury, must be care-
fully performed, including consideration of preexisting
general health problems, such as heart disease or dia-
betes mellitus.
Level of Injury
The level of the injury may be the most important factor
influencing the final results. The results of replantation
proximal to the elbow joint are often unsatisfactory,
even in cases of single-level injury. Among multilevel
amputation injuries, double-level amputation distal to
the elbow joint may be a good candidate for replanta-
tion. The combination of amputation in the forearm and
the hand may be considered a candidate for replanta-
tion surgery.
Type of Injury
Details of the mechanism of the injury have to be eval-
uated by obtaining an accurate history to classify the
type of injury.
Sharp-cut or guillotine amputation. This type requires
minimal debridement, and the most favorable results
can be expected.
Crush and contusion injury. An irregular wound
caused by blunt trauma may be associated with more
extensive injury than indicated by the external appear-
ance. Adequate debridement is required, but the dis-
tinction between vital and nonvital tissue is often
difficult to make. If debridement at the amputation site
results in significant shortening of the injured upper
limb, replantation may not be indicated.
Avulsion amputation. Damage may be the most
extensive, because of tearing injury, and if the important
component muscles with the neurovascular the tree are
avulsed, considerable limb shortening, such as segmen-
tal resection, is required.
Ischemia Time
The ischemia time should be shortened as much as pos-
sible to retain good muscle function, since muscle is the
tissue most vulnerable to anoxia. The warm ischemia
time should be less than 8h, and 6h would be prefer-
able, although the time limit varies with conditions, such
203
204 E. Clinical Reconstructive Microsurgery
Fig. 1. Double amputation at forearm
as whether the amputated part is cooled during trans-
portation of the patient.
Operative Technique with a
Representative Case
A 24-year-old farmer sustained a relatively clear double
amputation after being caught in a rice-harvesting
machine (Fig. 1). The patient arrived about 3h after the
injury with the amputated forearm and hand in cool
conditions the warm ischemia time was estimated as
1.5 h during transportation. The proximal amputation
level was just distal to the elbow joint, and the distal
amputation level was at the middle of the forearm.
The surgical team was divided into two: one for replan-
tation of the distal amputated part and the other for
replantation of the proximal part.
Preparation of the Amputated Parts
One team started debridement and bone fixation of the
distal amputated part before general anesthesia was
induced in the patient. The radius was fixed using plate
and screws first, and the ulna was prepared for later
fixation through the proximal amputation site using an
intramedullary rod. Debridement of the wounds was
followed by dissection of the neurovascular bundles
and muscles at the amputated sites. Fasciotomy of the
forearm muscles was the performed.
Replantation Procedure
Anesthesia was then induced, and the second team
started debridement and preparation of tissue for
Fig. 2. Preparation at distal replantation and immediately
after finishing all replantation procedures
replantation at the proximal amputation site. The pre-
pared amputated distal parts were reattached to the
elbow by inserting an intramedullary rod from the
olecranon through the proximal to the distal amputated
segments. The brachial artery was repaired at the prox-
imal site, and the radial and ulnar arteries as well as two
cutaneous veins were repaired at the distal site.
At that point, the pneumatic tourniquet was released
and bleeding was allowed for few minutes, and then two
veins were repaired at the proximal replantation site.
The total ischemic time was 9 h, and the operation time
was 9 h. The nerves were repaired and sufficient release
of the flexor compartments was confirmed, and a split-
thickness skin graft was placed on the swollen muscles
in the relaxing skin incision on the volar side of the
forearm (Fig. 2).
Postoperative Care and Rehabilitation
The patient received postoperative anticoagulant
therapy (urokinase 24,000 units, 500ml of low-
molecular-weight dextran solution per day) for 7 days
after the operation. The hand was kept in a functional
position with bulky dressing for 2 weeks, and then a
brace with a outrigger was applied to the thumb and
fingers to assistion extension. The metacarpophalangeal
(MP) joints were mainly kept at 30 of flexion, and the
interphalangeal (IP) joints at 20 of flexion.
Three additional operations for tenolysis and nerve
grafting were performal after the initial surgery. Finally,
the thumb and long finger could perform pinch pre-
hension (Figs. 3,4), and diminished protective sensation
in the palm was regained. The results were rated as
 1.4. Replantation of Multilevel Amputation Through the Forearm and Hand 205

Table 1. Chen's criteria for the evaluation of function after

extremity replantation
Grade Function
Ability to resume original work with a critical
contribution from the reattached parts; range of motion
(ROM) exceeds 60% of normal, including the joint
immediately proximal to the reattached part; recovery of
sensibility to a high grade without excessive intolerance of
cold; muscular power of 4 to 5 on a scale of 1 to 5; muscle
power of grade 3 to 5
II Ability to resume some gainful work but not original
employment; ROM exceeds 40% of normal; recovery of
near-normal sensibility in the median and ulnar
distribution without severe intolerance of cold; muscle
power of grade 3 to 4
III Independence in activities of daily living; ROM of joints
Fig. 3. Hand 5 years 6 months after replantation exceeds 30% of normal; poor but useful recovery of
sensibility (for example, only median or ulnar recovery is
good or quality is only protective in both median and
ulnar areas); muscle power of grade 3
IV Tissue survival with no recovery of useful function

Fig. 4. Hand 5 years 6 months after replantation

grade III (fair) according to the Chen evaluation crite- Fig.S. Before replantation
ria [2] (Table 1).

Other Representative Cases

Case 1

A 54-year-old woman sustained a double amputation of

the left hand by a press machine. The injury was a com-
plete amputation just proximal to the wrist and a incom-
plete amputation at the MP joint level (Figs. 5,6). The
distal part of the finger was connected to the hand by
part of the flexor tendon, but there were no vascular
connections. Replantation surgery was started 2h after
the injury and took lOh 25 min to finish. The wrist joint
was preserved, and the four amputated fingers were Fig. 6. Immediately after replantation
206 E. Clinical Reconstructive Microsurgery

Fig. 7. Powerful finger flexion was attained Fig. 8. The hand is useful in daily living

replanted, except for the index finger, which was com-

bined with another incomplete amputation at the distal
part. The destroyed MP joints of the three fingers were
fused primarily. All flexors and extensors were repaired
except for the flexor digitorum superficialis (FDS)
tendons. The radial and ulnar arteries as well as two
cutaneous veins were connected, and the median the
ulnar nerves were then repaired at the proximal ampu-
tation level. Four arteries, three veins, and all six digital
nerves were primarily repaired, as well as the flexor dig-
itorum profundus (FDPs) and extensors at the distal
replantation site.
At 2 years 6 months postoperatively, the wrist joint
had regained active range of motion of 60 extension
and 42 flexion. Between 70 and range of motion 95
at the IP joints and 7kg key pinch and 19k9 (with Fig. 9. Before operation. The proximal portion was punched
[lAMER] dynomometer) grasping power were ob- out and not available for replantation
tained (Figs. 7, 8). The static two-point discrimination of
the fingers was between 10 and 15mm, and protective
sensation was rated as diminished by the Semmes-Wein-
stein test (purple). The patient is using the replanted
hand usefully in her daily life. This result was assessed
as grade II (good) according to the Chen evaluation
criteria [2].

Case 2

A 30-year old man sustained a double-level amputation

with a press machine. The proximal amputation was
located at the midcarpal level, and the distal amputa-
tion was at the MP joint level (Fig. 9). The metacarpal
portion and thumb were severely crushed, and there
was no indication for replantation. Reconstruction of
the pincer and chuck pinch functions was attempted,
and the index, long, and ring fingers were replanted on Fig. 10. Immediately after replantation
 1.4. Replantation of Multilevel Amputation Through the Forearm and Hand
Fig. 11. Two years 7 months after replantation. The recon-
structed hand is useful in daily living
the proximal carpal bones (Fig. 10). The FDPs and
extensors of the replanted fingers were repaired, as well
as all digital nerves. The postoperative range of motion
in the wrist joint was rated at 30 dorsiflexion and 30
palmar-flexion. The range of motion in the proximal
interphalangeal (PIP) plus the distal interphalangeal
(DIP) joint of the fingers was rated at 135-110.
Sensory recovery in the replanted fingers was evaluated
between diminished light touch and diminished protec-
tive sensation by the Semmes-Weinstein test 2 years 7
months after replantation. The patient can wind a towel
using both hands and uses the replanted hand well in
his active daily living (Fig. 11). This case was rated as
grade II (good) according to the Chen evaluation
system [2] .
Discussion
Replantation of the multilevel amputation is associated
with extremely difficult problems, as can be imagined
from those of a single forearm-level replantation. It
has been questioned whether replantation of a multi-
level amputation should be performed, because of the
limited results. Only a few studies [1,3,4] have been pub-
lished on multilevel replantation; however, all of them
concluded that double amputation is not a contraindi-
cation in all cases.
The indication for replantation of a multilevel ampu-
tation should be based on the type of injury. Basically,
only a double-level amputation can be a candidate for
replantation among multilevel amputations. However,
the decision to replant should be made on a case-by-
case basis. Yousif et al. [5] reported a 25 year-old case
who sustained three level clean cut amputation distal to
207
metacarpal base with reasonably good functional and
esthetic results. The results are strongly affected by
factors associated with amputation levels, conditions
of each amputation site, and additional injury to the
amputated segments. Reasonably good results can
be expected if the levels of amputation are the distal
forearm and finger, with sharp cuts. If the middle ampu-
tated segment is severely crushed or its length is too
short, the distal part may be placed on the proximal
stump in male patients to retain practical functions,
although the appearance of the hand is cosmetically not
ideal, as was shown in Case 2.
Double amputation at two levels in the forearm
involves more serious problems than the combination
of distal forearm and hand levels. However, reasonably
good or acceptable results can still be attained, as was
shown in the first representative case.
Patients with multilevel amputations often are sent
from distant places, and the ischemic time is longer than
for single-level amputations. In the double-level ampu-
tation cases shown here, at least the proximal amputation
site located in the major amputation level and the ampu-
tated segment contained muscles that are vulnerable to
ischemic conditions. Specific considerations for facilita-
tion of efficient surgical procedures have to be made to
attain better results in replantation of double amputa-
tions involving the proximal forearm. If the ischemic
time is prolonged, a fatal reperfusion syndrome can
result. This condition has to be carefully 'avoided by
measurement of systemic serum potassium levels [6].
The proximal amputated part requires reperfusion
within the golden time to regain good function. The
following strategy has to be followed to accomplish effi-
cient surgery, since double-level replantation requires
numerous reconstructive procedures.
To avoid warm ischemic time, the amputated parts
should be transferred to the hospital in a cool condition
as quickly as possible. Immediately after arrival at the
hospital, the amputated parts should be irrigated with
cooled (4C) Celsior solution [7-9] at a pressure of
100cm gravity to wash out stagnant blood. Celsior is a
new extracellular-type ionic solution containing red-
uced glutathione to inactivate oxygen free radicals,
mannitol and lactobionate to prevent tissue edema, and
histidine to buffer intracellular acidosis. This solution
has been developed to act as a storage medium and also
as a perfusion fluid for post-storage graft reimplantation
and early reperfusion in heart transplantation.
Debridement and tagging of the stumps of the
muscles, nerves, and tendons are performed, and the
amputated parts are preserved in a cool condition (4C)
until the patient has been anesthetized and prepared
to undergo replantation. If the induction of anesthesia
or preparation of the proximal stump takes time, the
208 E. Clinical Reconstructive Microsurgery
replantation procedure at the distal amputation site can
be started with bone fixation and soft-tissue repair to
save operative time.
Simple procedures using intramedullary pinning or
plating on the periosteum and fixation using mono cor-
tical screws may be adopted for bone fixation. Before
vascular anastomosis, the tissue is irrigated with a fresh
plasma solution to wash out preservation solution at a
pressure of lOOcm gravity. The artery is repaired first,
and blood is flushed before venous anastomosis to
minimize replantation toxemia and acute respiratory
distress syndrome. Fasciotomy should be performed
on the major amputation parts to avoid compartment
syndrome.
Primary nerve repair, including nerve grafting, is nec-
essary to attain good motor and sensory recovery. Ten-
orrhaphy using multistrand loop sutures as core fixation
and running sutures as peripheral fixation is an efficient
procedure and provides good tensile strength. These
procedures are accomplished with or without pneu-
matic tourniquet control.
Additional surgery, such as tenolysis or tendon trans-
fer, should be considered at least 3 months after replan-
tation to obtain useful hand function.
Postoperative care is one of the most important
factors affecting the final results. Elevation of the
injured upper limb and controlled passive motion exer-
cise of the joints to avoid edema and fibrosis should be
performed immediately after surgery. The joints, espe-
cially the finger joints, should be kept in the functional
position by outrigger splinting. Galvanic stimulation of
the paralyzed muscles may facilitate recovery of motor
function.
A combination of good motivation of the patient
and well-organized postoperative physical therapy is
extremely important to attain reasonably good func-
tional results.
References
1. Yoshizu T, Katsumi M, Tajima T (1978) Replantation of
untidily amputated finger, hand and arm: experience of 99
replantations in 66 cases. J Trauma 18:194-200
2. Chen Z-W, Meyer VE, Kleinert HE, Beasely RW (1981)
Present indication and contraindication for replantation as
reflected by long-term functional results. Orthop Clin
North Am 12:849-870
3. Pho RWH, Satkunananthan K (1982) Problems of a double
level amputation-a case report. Ann Acad Med
(Singapore) 11:273-277
4. Belsky MR, Ruby LK (1986) Double level amputation:
should it be replanted. J Reconstr Microsurg 12:159-162
5. Yousif NJ, Muoneke V, Sanger JR, Matloub HS (1992)
Hand replantation following three-level amputation: a case
report. J Hand Surg 17 A:220-225
6. Waikakul S, Vanadurongwan, Unnanuntana A (1998)
Prognostic factors for major limb re-implantation at
both immediate and long-term follow-up. J Bone Joint Surg
80B:1024-1030
7. Carrier M, Trudel S, Pelletier LC (1999) Effect of Celsior
and University of Wisconsin solution on myocardial metab-
olism and function after warm ischemia. J Cardiovasc Surg
40:8116-816
8. Mohara J, Takahashi T, Oshima K, Aiba M, Yamagishi T,
Matsumoto K, Morishita Y (2001) The effect of Celsior
solution on 12-hour cardiac preservation in comparison
with blood and crystalloid solutions in heart transplanta-
tion. J Cardiovasc Surg 42:187-192
9. Perrault LP, Nickner C, Desjardins N, Dumont E, Thai P,
Carrier M (2001) Improved preservation of coronary
endothelial function with Celsior compared with blood and
crystalloid solution in heart transplantation. J Heart Lung
TranspI20:549-558
1.5 Digital Replantation
YUH INADA, AKIHIRO FUKUI, and SUSUMU TAM AI
Since the pioneering work in microvascular surgery by
Jacobson and Suarez in 1960, numerous experiments
utilizing microsurgical techniques in the anastomoses
of miniature vessels have been performed all over the
world [1]. Thc clinical applications include replantation
of amputated extremities and transplantation of com-
posite tissues, such as digits, toes, skin flaps, bones,
muscles, and so on. Kleinert and Kasdan achieved the
first successful anastomosis of a digital artery in an
incompletely amputated thumb attached by two dorsal
veins and threads of subcutaneous tissue on November
12,1962 [2]. They joined the arterial ends without mag-
nification, using 7-0 silk with continuous over-and-over
sutures. In the field of experimental surgery, Buncke and
Schulz reported their meticulous work on the replanta-
tion of digits in rhesus monkeys and demonstrated the
technical possibility of replanting an amputated digit in
humans [3]. The first successful microsurgical replanta-
tion of a thumb, which was completely amputated at
the metacarpophalangeal joint level, was achieved by
Komatsu and Tamai on July 27, 1965. They repaired two
arteries and two veins using 8-0 monofilament nylon
and 7-0 braided silk sutures, respectively, under a
Zeiss diploscope [4]. On January 8, 1966, surgeons in
Shanghai Sixth People's Hospital succeeded in replant-
ing a completely severed index finger without the aid of
an operating microscope [5]. Since then, many reports
on the replantation of amputated digits have appeared
in the literature [6-18]. Fukui and Tamai [19] surveyed
the present status of replantation in 1994 in Japan,
obtained from 94 members of the Japanese Society of
Reconstructive Microsurgery. The results indicated that
9664 extremities were replanted (157 upper arms, 415
forearms,471 hands, 8320 digits, 33 thighs, 103 legs, 37
feet, and 128 toes); 8227 replants survived, for an overall
success rate of 85%. The survival rate was over 90% in
23 hospitals, and 7 of these hospitals replanted more
than 100 limbs and digits.
In recent years, centralization of service in replanta-
tion surgery has progressed in many countries, espe-
cially in China, Australia, the United States, and Japan.
A replantation center must have the following require-
ments: more than two experienced micro surgeons who
are also trained hand surgeons, trained assistants,
trained nurses, microsurgical facilities, a 24-hour-
available operating room, and a patient ward for hospi-
talization. Research laboratories are also necessary for
the fundamental study of microsurgery and for the
training of young surgeons. A rehabilitation center
attached to the hospital should be available for post-
operative physiotherapy.
Indications for Replantation
The first step for the treatment of upper-extremity
injury is assessment of the patient's condition. A well-
trained trauma team and trauma room are needed
to access mUltiply injured patients according to the
Advanced Trauma Life Support (ATLS) protocol.
All digits amputated at any level should be consid-
ered as candidates for replantation. The local condition
of the wounds, the patient's general condition, and the
patient's age, sex, occupation, and economic status are
evaluated. The patient's wishes for replantation are
also considered. A clean-cut guillotine amputation is the
best for replantation. A moderate crush amputation
may survive with extensive debridement and shorten-
ing. Incomplete amputations with distal ischemia are
also amenable to revascularization. The remaining
bridges of skin and subcutaneous tissue should be kept
intact, because they may provide satisfactory venous
return, and survival can be consistently achieved. Severe
crush or avulsion injuries can be replanted occasionally,
but replantation may be time consuming and the results
may not always be satisfactory.
Many replantation surgeons used to claim that single
amputated digits should not be replanted, except for
the thumb and the border digits. However, with further
advancement of replantation technique and improve-
ment of suture materials in recent years, any digit or any
level of amputation should be considered candidates for
replantation, especially in young women and children,
and digits used for special occupational needs.
If a digit was amputated at the distal interphalangeal
joint, and the patient's condition appears suitable,
209
210 E. Clinical Reconstructive Microsurgery

o
replantation should proceed. It can be achieved easily
with minimal tissue repair and with a short operating
time of approximately one and a half hours. The speed
0
of nerve regeneration is rapid, and satisfactory function
can be gained even though the distal interphalangeal
joint has been fused. Multiple amputations are an
absolute indication for replantation. We generally
attempt to replant the amputated digits if they were
cut proximally to the distal interphalangeal joint. If an
important digit, such as the thumb, has been severely
crushed, the digital transfer of a less important ampu-
tated part may be indicated to reconstruct the more
important one.
Immediately after the accident, the amputated part
should be wrapped in a polyethylene bag, cooled with
ice, and transported to the hospital with the patient
as soon as possible, while the proximal stump is tem-
porarily covered with a bulky dressing for hemostasis.
The duration of ischemia in the amputated digit is
the most important factor in replantation. The maximal
permissible time for replantation of a totally ischemic
digit without cooling in moderate temperatures should
Fig. 1. Tarnai's zones of amputation of digits and hand
not exceed 6 h. VanderWilde et al. [20] reported the
successful replantation of a hand after 54 h of cold
ischemia. Arakaki and Tsai [15] found that survival was
proportional to ischemia time, warm or cold. Leung [21] ing Verdan's method [23]. In multiple digit amputations
reported the successful transplantation of a toe after in the palm, microclips or 9-0 stitches are placed on the
36 h of cold ischemia. Warm ischemia time is more vessel ends for easier reidentification.
critical than cold ischemia time. Milking of the severed part should then be performed
for the purpose of removing microthrombi or emboli
plugging the vessel ends, especially in crush amputa-
Operative Procedure tions. Irrigation of the amputated part using heparin in
low-molecular-weight dextran solutions (1000 units/dl)
Following the preoperative evaluation, the patient is is not routinely performed except for severely crushed
transferred to the operating room. The amputated part amputations or double-level injuries in which the
should be cleaned and debrided first and kept in a patency of the vascular channels in the amputated
refrigerator at 0_4C. General anesthesia is chosen for part must be ensured prior to performing vascular
patients with mutiple digital amputations and for chil- anastomoses.
dren. Continuous cervical epidural anesthesia or axil- Following 5- to 10-mm shortening of bone, depending
lary block anesthesia using xylocaine is routinely used on the soft-tissue injuries, including arterial damage,
in the majority of our cases. bone fixation is carried out with cross-pinnings, an
The operative procedures for hand and digit replan- intramedullary screw [7], a pinning with interosseous
tation are principally the same [22], but there are some wiring [24-26], or a titanium plating system [27-29].
differences in detail, depending on the Tarnai zone of Pinning with interosseous wiring or a titanium screw
amputation level (Fig. 1). If enough micro surgeons are and plating system is recommended for rigid fixation.
available, a two-team approach is used. One team cleans Adjacent joint mobility must not be impaired when
and debrides the severed part while the other team cross-pinning is used. When the amputation is through
thoroughly debrides the amputation stump. The neuro- the joint level, primary arthrodesis is sometimes
vascular bundles on the volar aspect of the digit are inevitable. An intramedullary bone peg graft may be
identified, and after proximal arterial flow has been helpful to achieve early union. When a digit is com-
confirmed, a tourniquet is inflated on the upper arm. pletely amputated at the midshaft of the middle or prox-
To make flexor tendon repair easier, the proximally imal phalanges, the Tarnai method of intramedullary
retracted flexor tendon should be pulled distally and fixation using an ordinary screw is a useful procedure
fixed with a hypodermic needle percutaneously, apply- [7]. This is of course not applied in an incomplete

amputation. The periosteum and surrounding soft
tissues are sutured to prepare a smooth gliding bed for
the repaired tendons. This procedure is very important
to obtain good function of the digit. Next, the extensor
mechanism is repaired with 4-0 braided synthetic
threads, and then the flexor tendon is repaired prima-
rily if possible, even though it was cut at any level. For
flexor tendon repair, we have used the Kirchmayer-
Tarnai modified suture technique. Key sutures using
4-0 to 5-0 prolene or nylon thread are performed intra-
tendinously, followed by circumferential continuous
suturing with 7-0 monofilament nylon. However, in
recent years several multistrand suture techniques have
been advocated [30-33). These methods have better
functional results than the Kirchmayer-Tarnai modified
suture technique. The flexor tendon sheath is also
repaired whenever possible.
The operating microscope is always used when per-
forming vascular anastomoses. The microscope should
be wrapped with a sterilized drape. The arterial anasto-
mosis is performed first. Both arterial ends are identi-
fied lateral to the volar digital nerves, and a Tarnai
double micro clip is applied. The double clip with a
single vise is very useful because it is small, light (0.6 g),
and easy to handle under a microscope. Under high
magnification, the damaged vascular walls are trimmed
with microscissors until the normal intima appears.
End-to-end anastomosis is carried out using 10-0
monofilament nylon sutures. As soon as the anastomo-
sis has been completed, an adult is given 5000 units of
heparin intravenously, followed by deflation of the
tourniquet. If the arterial repair has been successfully
performed, the digit is well revascularized. The col-
lapsed dorsal veins became dilated with the returning
blood. If they do not, reanastomosis should be tried
or another volar artery repaired. The dorsal vein ana-
stomoses are then performed with the tourniquet
reinflated. Usually one artery and two veins are
anastomosed to secure a balanced circulation of the
digit. The more vessels repaired, the better the result.
If the vessels cannot be united because of a defect, an
autogenous vein graft from the forearm or dorsum of
the hand is used. A cross anastomosis of digital arteries
is sometimes useful in avulsion or crush amputations.
In addition, ipsilateral arterial transplantation from the
adjacent fingers is performed for revascularization of
severe crush amputations or degloving injuries. If there
are no suitable veins subcutaneously or in the dorsum
of the digit, the volar veins can be anastomosed.
For zone I cases [11-13], the replantation techniques
are somewhat different from those for other zones.
First, the artery to be anastomosed is located more cen-
trally in the finger pulp. Second, fine microsurgical tech-
nique with 11-0 or 12-0 monofilament nylon sutures,
1.5. Digital Replantation 211
applying a total of four or five stitches, is required. Third,
anastomosis of the veins may be impossible because of
their small size. Therefore, a fish-mouth incision, inter-
mittent needle punctures every 4 h in the first 3 or 4 days
after replantation, removal of the nail [34), or applica-
tion of medical leeches is chosen for venous drainage
instead of venous anastomosis. Fourth, a single lon-
gitudinal pinning from the distal fingertip may be
enough for bony fixation without need for nerve repair.
Spontaneous recovery of the nerve along with the
repaired artery has been reported in zone I replanta-
tion. There is no need for tendon repair. Fingertip
replantation requires super- or ultramicrosurgical tech-
niques, but if the replanted part survives, the cosmetic
and functional results may be excellent, with satisfaction
of the patient.
If possible, primary digital nerve repair is performed.
Repairing both volar nerves is recommended, but single
nerve repair on the important side may yield a satis-
factory result. In avulsion or crush injuries, if direct
nerve repair cannot be achieved primarily, primary or
secondary nerve grafting is advisable. Artificial nerve
grafting may become possible in the near future with
the development of tissue engineering. Microsurgical
epineurial repair may be sufficient for a pure sensory
nerve, but superior results can be expected with a
funicular nerve suture technique.
The skin is closed loosely, and care is taken not to
damage the anastomosed dorsal veins. If the develop-
ment of a critical constriction band at the skin suture
line is suspected, Z-plasties on the skin to be sutured
should be added in the mid-lateral aspects of the digit.
If a skin defect remains, a free split-thickness skin graft
or a distant or free emergency flap transfer should be
performed. A venous flap can also be applied to recon-
struct both venous drainage and a dorsal skin defect.
For a volar skin defect, a free perforator flap, such as
the medial plantar perforator [35,36] or the dorsal ulnar
perforator flap [37], may be chosen for reconstruction.
Finally, bulky dressings are applied and the extremity
is supported with a plaster cast from the upper arm to
the fingertip so that the nails are exposed for postoper-
ative observation.
In the replantation of multiple digits in the palm,
when each digit is connected by a skin bridge, an ice bag
is used on the hand table to cool the digits and reduce
the warm ischemia time during operation. The bones
and tendons of all digits are repaired first by the macro-
surgery team. Then the vascular and nerve anastomoses
are carried out by the microsurgery team. If the digits
are separated, they are replanted individually while the
others are kept in a refrigerator. Two to three teams
participate, changing for every digit, to minimize the
surgeons' fatigue during a prolonged operation.
212 E. Clinical Reconstructive Microsurgery
Postoperative Management
Excessive bleeding during the operation must be
managed with blood transfusion. Normal blood levels
and normal blood pressures should be maintained
during the critical early postoperative period. Acute
hypotension induces thrombosis at the vascular anasto-
moses of the digit. The hand is kept at the level of the
patient's heart or slighty higher. Skin color, tempera-
ture, and tension of the finger pulp must be checked
every 60 min in the first 3 to 4 days and every 2 h in the
following 6 to 7 days. Loss of tension in the finger pulp
is an important signal of arterial insufficiency, whereas
an increase in tension with dark-blue or dark-red
skin indicates venous congestion. Monitoring by ple-
thysmography or thermography may be useful for eval-
uating the circulation of the digit objectively, but a
portable ultrasound stethoscope is more convenient to
use in the patient's room.
Prophylactic use of wide-spectrum antibiotics is con-
tinued for approximately 7 days. The first dressing
changes should be performed on the first postoperative
day because of the risk of constriction by gauze hard-
ened with coagulated blood around the wound,
although some believe that the dressing should be
changed 2 or 3 days postoperatively.
Intravenous administration of heparin at approxi-
mately 2000 units/day in an adult should be started
immediately after the operation and continued for 5-10
days, with daily control of whole-blood clotting time at
about 20min. According to the circulatory conditions
in the digit, increased doses of heparin, additional infu-
sions of urokinase, and low-molecular-weight dextran
solutions are prescribed. If a critical circulatory block is
suspected, especially in the artery, timely reexploration
and thrombectomy should be performed to improve the
circulation. If a thrombus is not found at the arterial
anastomosis, gentle perfusion with heparin in a low-
molecular-weight dextran solution (1000 units/day) at
the proximal and the distal ends of the artery may be
valuable. For venous disorders with congestion in the
replant, continuous squeezing of the replanted part by
hand, while the involved hand is elevated above the
patient's heart, is a reasonable maneuver. In January
1988, we introduced the continuous intraarterial infu-
sion of anticoagulants for digit replantation to increase
the salvage rate from vascular disorders [38,39]. When
68 amputated digits were replanted using this anticoag-
ulation therapy, a significantly higher rate of successful
replantation was achieved (94%) compared with that
by an ordinary intravenous infusion of anticoagulants
(87%). This procedure is indicated for patients with
severely crushed amputated digits accompanying
intimal impairment or degeneration of the blood vessels
to be anastomosed, elderly patients, those with ampu-
tated digits stored in a state of warm ischemia for a
long period, and those with repeated intraoperative
thrombosis.
Rehabilitation should be commenced as soon as
possible after operation, depending upon the level of
replantation, beginning with mild passive and assisted
active exercise of the digit and continuing with active
exercise in a warm bath after the removal of the sutures
at 10 days. From the fourth week more active exercise
using a dynamic splint can be permitted. No cigarette
smoking is permitted throughout.
For zones III and IV digits amputated at the pro-
ximal interphalangeal joint, we recently applied the
dynamic extra-fixator (Compass PIP joint hinge de-
veloped by Hothchikiss-CPJH) 2-3 weeks following
replantation [40,41]. The best indication for use of the
CPJH is zone IV replantation, especially at the level
of the proximal phalanx, and zone III replantation with
severe soft-tissue damage. The CPJH can be applied
easily, even for amputation of four digits from the index
to the little finger. The authors reported that the CPJH
not only improved the functional outcome of replanted
digits in Tamai zone IV, but also reduced the total
number of secondary reconstructive surgeries, such as
tenolysis. This result showed that the CPJH could
reduce the total cost of replantation surgery [42,43].
However, careful insertion of a K-wire should be
performed, taking care not to injure the repaired
neurovascular bundle, when CPJH is applied following
replantation.
Most of our patients leave the hospital at approxi-
mately 3 weeks and are examined once a month at the
outpatient clinic for further evaluation of their func-
tional recovery. Any secondary reconstructive surgeries
on the replanted digit should be performed after more
than 3-4 months, if necessary, when soft-tissue contrac-
ture has subsided. Exceptionally, soft-tissue coverage is
performed as soon as possible after replantation, using
a pedicled flap or a free flap from the adjacent digits,
hand,orfoot.
Representative Case Presentations
Case 1
A 37-year-old man sustained a complete amputation of
his right thumb at the metacarpal level by an aluminum
press. It was ideal for replantation because it was a
typical guillotine amputation (Fig. 2a). Three and a half
hours after the injury, surgery commenced. The bone
was fixed with an intramedullary screw, followed by
repair of the extensor and flexor pollicis longus tendons.
 1.5. Digital Replantation 213

c d

e r

Fig. 2. a Preoperative photograph of the amputated right
thumb under cleansing and debridement. b Angiogram of the
replanted thumb at 1 month reveals patent princeps pollicis
artery and well-fixed metacarpal bone with an intramedullary
screw. c The replanted right thumb at 1 year shows satisfac-
tory function. d The left thumb was amputated just proximal
to the interphalangeal joint. e The replanted left thumb 6
months postoperatively. f Both thumbs at the present time
(right, 4 years 5 months; left, 1 year 6 months)
 214 E. Clinical Reconstructive Microsurgery
Under an operating microscope, one artery, two dorsal
veins, and one nerve were anastomosed microsurgically.
Immediately after revascularization, the thumb turned
pinkish. The skin was closed very loosely with inter-
rupted sutures. Two weeks after the removal of sutures,
physiotherapy was begun in a warm bath. An angiogram
at 1 month revealed a patent repaired artery of the
thumb and a metacarpal bone well immobilized with an
intramedullary screw (Fig. 2b). At 1 year, sensory recov-
ery was confirmed with a two-point discrimination of
10mm. Because of adhesions of the repaired flexor
tendon at the replantation site, the interphalangeal joint
motion was only 100, and the metacarpophalangeal joint
had a flexion contracture at 30 0 The thumb function,
however, was satisfactory for the activities of daily living
(Fig. 2c). Three years later, the patient amputated his left
thumb at the proximal phalanx with the same machine
and came to our hospital again (Fig. 2d). The bone was
immobilized with two Kirschner wires, and the flexor
and extensor tendons were repaired. Then, one artery,
two veins, and one nerve were anastomosed. The post-
operative course was uneventful, and rehabilitation
commenced the day after the operation. Figure 2e
shows the thumb 6 months postoperatively. The final
result at 1.6 years was excellent, with 30 0 of flexion at
the interphalangeal joint and a normal range at the
a b
c finger extcn i n. c Palmar iew with finger Ocxion
metacarpophalangeal joint. The sensory recovery was
also in the normal range, with a two-point discrimina-
tion of 5 mm. Figure 2f shows the right thumb at 4 years
5 months and the left thumb at 1 year 6 months.
Case 2
A 27-year-old man sustained a complete amputation of
his left palm with a press machine, involving the index
to the little fingers at the base of the proximal pha-
langes, including the skin webs (Fig. 3a). Although there
was moderate crushing of the wounds, all digits were
successfully replanted with repair of three arteries, six
veins, and all flexor and extensor tendons, except for
the nerves. Postoperatively the hand developed typical
intrinsic minus deformities of all fingers. Six months
after the replantation, free nerve grafting using the left
lateral femoral cutaneous nerve was performed to
reconstruct the volar digital nerves of all digits. One
year after replantation, a four-tailed tendon graft was
carried out to improve the intrinsic minus deformities
of the fingers (Fig. 3b). At 2 years after replantation,
protective sensation was recovered satisfactorily, with
two-point discrimination of 10-15 mm. Although loss
of extension of all digits at the proximal interphalangeal
_g.3. a Preoperati e photograph of the amputated left di tal
palm. b Rcplantcd four fingers at I year. Palmar vie\ with

Jomts remained, sufficient flexion was obtained, as
shown in Fig. 3c.
Case 3
A 19-year-old man sustained three finger amputations
at Tarnai zone IV by a motorbike chain. The index and
middle fingers were completely amputated at the level
of the distal third of the proximal phalanx, and the ring
finger was incompletely amputated at the proximal
interphalangeal joint (Fig. 4a). The bone was fixed with
Kirschner wires and interosseous wirings for the index
and middle fingers, and with osseous wiring for the ring
finger. Two arteries and four veins were anastomosed
for each digit, and the bilateral common digital nerves
were repaired for the middle and ring fingers, but direct
nerve repair could not be performed at the ulnar side
of the index finger. All three digits survived completely.
a c
b d
Fig. 4. a Preoperative photograph of the completely ampu-
tated right index and middle fingers and incompletely ampu-
tated ring finger. b Lateral roentgenogram shows two
1.5. Digital Replantation 215
Two weeks after the replantation, two CPJHs were
applied to the index and middle fingers (Fig. 4b). Finally,
the total active motion (TAM) of index, middle, and ring
fingers were 215,210, and 210, respectively, at 1 year
of follow-up. No tenolysis was needed for the repaired
tendons. The patient took a new job as an electronic
technologist without any limitations to daily living (Fig.
4c,d)
Case 4
A 40-year-old man suffered complete amputation of his
left ring finger by a press machine (Fig. Sa). The ampu-
tation level was at the proximal one third of the distal
phalanx of the ring finger (Tarnai zone I). Fortunately,
the nail matrix remained at the proximal stump of
the finger. After bony fixation with a Kirschner-wire
through the distal phalanx, one artery, two veins, and one
Compass PIP joint hinges applied for this patient postopera-
tively. The replantated three fingers at one year with finger
extension (c) and finger flexion (d)
 216 E. Clinical Reconstructive Microsurgery

Fig. 5. a Preoperative photograph of the ring finger. b,c Roentgenograms of the distal phalanx 6 months postoperatively. The
replantated ring finger at 1 year, with finger extension (d) and finger flexion (e)

nerve were repaired with 11-0 nylon thread. The digit
survived, but nonunion of the distal phalanx remained 1
month after the replantation. Bone grafting was per-
formed from the distal radius to the bony gap of the
distal phalanx, and a low-profile titanium screw was
inserted under image control (Fig. 5b,c). One year post-
operatively, there were no cosmetic or functional prob-
lems in the ring finger. Satisfactory sensation was noted,
with two-point discrimination of 6-8 mm (Fig. 5d,e).
Summary
Since the first successful replantation of a completely
amputated thumb with microvascular anastomoses
by Komatsu and Tarnai in 1965, digit replantation
has become popular for the treatment of amputation
injuries all over the world, and success rates have been
80%-90% in most replantation centers or units. To
improve the survival rates of replantations, it is
important not only to select the operative indication but
also to apply skilful replantation techniques and ade-
quate postoperative management. However, the major
emphasis has now shifted to the functional recovery
of the replanted digit rather than survival rates. To
improve the functional recovery of the digit at Tarnai
zone IV, the so-called no man's land, which has the
poorest outcome, we introduced the dynamic extrafixa-
tor (the Compass PIP joint hinge) and achieved excel-
lent results, with high patient satisfaction. Early motion
exercise with multistrand tendon suture even in such
replanted digits may improve the range of motion of the
replants.
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25A:415-428
18. Waikakul S, Sakkarnkosol S, Vanadurongwan V,
Unnanuntana A (2000) Results of 1018 digital replan-
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Japan. Microsurgery 15:842-847
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21. Leung PC (1981) Prolonged refrigeration in toe-to-hand
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Joint Surg 42A:647-657
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ton. J Hand Surg 3:427-435
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66:383-394
27. Yamaoka N, Inada Y, Omokawa S, Fukui A, Tarnai S
(1993) Leibinger plate fixation for the treatment of
pseudoarthrosis and malunion following digit replanta-
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extremity. J Hand Surg 23A:308-311
218 E. Clinical Reconstructive Microsurgery
29. Buchler U, Fischer T (1987) Use of a minicondylar plate
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32. Winters SC, Gelberman RH, Woo SL-Y, Chan SS, Grewal
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(in press) Free dorsal ulnar perforator flap for resurfacing
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Inada Y (1989) Continuous local intraarterial infusion of
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S (1992) Continuous local intraarterial infusion after pro-
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(1998) Is the Compass PIP joint hinge effective for the
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1.6 Replantation of the Lower Leg and Foot
MASAMICHI USUI, IKuo MURAMATsu, and KAZUYUKI MASUDA
Successful replantation of a human limb became a
reality in 1962, when Malt and McKahnn replanted a 12-
year-old boy's arm that had been torn off in a streetcar
accident [1]. Since then there have been many reports
of successful replantations of upper extremities, and
some successful lower extremity replantations [2,3]. In
1972 Magee and Parker [4] reported a replantation of a
completely amputated foot. However, there is still rela-
tively little information available about lower extremity
replantation.
We have experienced several cases of replantation of
the lower leg and foot and have reported some suc-
cessful cases [5-7]. In this article, we present two typical
successful cases, one of lower leg and one of foot replan-
tation, and discuss indications for replantation of the
lower leg and foot.
Case Reports
Case 1
A 4-year-old boy sustained a sharp, complete amputa-
tion of the distal one-third of his left leg by a mowing
machine on June 12, 1974. He was transported to our
clinic and arrived about 5 h after the injury. We found
his general condition to be good, and the amputated
part had been preserved in ice water (Fig. 1).
Operation
After the leg had been thoroughly cleaned and
debrided, a chilled solution of low-molecular-weight
dextran containing heparin (lOOOU/100ml) was irri-
gated into the cut ends of the posterior and anterior
tibial arteries until the effluent from the cut veins
became almost clear. Then the tibia and fibula were
shortened a total of 3.5 cm, in the distal and proximal
stumps. After we approximated the replant, internal
fixation was achieved by applying an Eggers plate with
screws only on the tibia. Next, the great and small
saphenous veins were anastomosed with interrupted
8-0 monofilament nylon sutures under an operating
microscope. The posterior and anterior tibial arteries
were sutured, and thus the blood circulation was re-
established. Immediately after revascularization, the leg
became pink and warm. The total ischemic time was
8 h. After this, the tibial, deep peroneal, and sural nerves
were approximated by the epineural suture method,
using an operating microscope. Then the flexor and
extensor tendons of the ankle and toes were sutured
with 3-0 silk, using Kirchmayr's method. The skin was
closed by using a Z-plasty, to provide decompression of
the muscle compartments and to prevent late constric-
tion of a circular scar (Fig. 2).
Postoperative Course and Management
Low-molecular-weight dextran solution (500ml/day)
was given for 10 days after the surgery. Heparin was
not used. The postoperative course was uneventful. The
wound healed primarily. Physical therapy, with active
and passive motion of the joints, was started during the
third week. By the 8th week, bony union was solid and
weight-bearing was permitted. Ten weeks after the acci-
dent, the patient could walk without any support. He
was discharged at the 14th week, wearing a 3-cm lift on
his left heel to compensate for the 3.5-cm inequality in
leg length.
FollOW-Up Data
Seventeen years after the surgery, the patient can walk
and run faster than the average person. He ran 800m in
2 min, 7 s. He has no problems in daily activities. There
is no cyanosis or cold intolerance in his replanted foot.
He has hyperesthesia in the dorsal foot, but normal
sweating was observed in this area. He has full range of
motion in the ankle. The lengths of the tibia, femur, and
metatarsus on both sides were measured by one of us
(M.D.) from X-ray films taken just after replantation
and 4, 11, and 17 years after replantation, as far as they
were available. The discrepancy in leg length has been
gradually overcome by overgrowth. Currently, the tibia
of the affected side is 2cm shorter than that of the con-
tralateral side. On the other hand, the femur of the
affected side is 8 mm longer than that of the normal side,
219
220 E. Clinical Reconstructive Microsurgery

Fig. 3. Photographs 18 years after operation, showing differ-

ent foot sizes. From [7], with permission

so that the final shortening of the replanted limb is

Fig.l. Clean-cut amputation of the left lower leg. From [5],
with permission
1.2cm. The length of the foot is 24.0cm on the affected
side and 25.5 cm on the contralateral side, and the first
metatarsal bone of the replanted side is 2mm shorter
than that of the normal side. The difference in the size
of the feet has increased slightly over the years, as
shown in Fig. 3 and Table 1.
The strength of the invertors, evertors, plantar-flexors,
and dorsiflexors is almost normal on manual muscle
testing. When these parameters were investigated with
the Cybex 11 (Lumex, New York, USA), the absolute
torque (ft-Ib), relative peak torque (torque per unit
weight, %BW), and ratio of the involved side torque to
the uninvolved side (lIU%) were normal except for the
torque of the evertors at 30 deg/s and the plantar-flexors
at 30 and 120deg/s.

Case 2

On July 31, 1981, the left foot of a 54-year-old male

farmer was amputated by a mowing machine. He had
no other life-threatening injuries and no vascular or
chronic disease. The amputation of the Chop art joint-
navicular and cuboid bone of the left foot was complete.
The wound was clean and impairment of the vascular
bed was limited. The ischemic time was 5h (Fig. 4).
Fig. 2. Photograph showing condition immediately afte
surgery
Operation
Table 1. Changes in discrepancies in lengths of legs and feet
in case 1 (cm) The affected limb was washed and cleaned with 0.1 %
Measurement Replantation 4yr llyr 17yr
WN chlorhexizin Maskin (Maruishi Pharmaceutical,
Osaka, Japan). Then, under an operating microscope,
Legs 3.5 1.9 1.5 1.2
the vessels and nerves were isolated and dissected, and
Feet 1.0 1.5
all the damaged tissue was completely resected. The

Fig.4. Amputation through the Chop art joint of the left foot.
(See Color Plates)
bones and joints were minimally trimmed and solidly
fixed by crossing 2.0-mm Kirschner wires on the correct
plantar alignment, and the capsule and ligaments were
tightly sutured. The dorsalis pedis artery and two deep
concomitant veins were anastomosed. Immediately
after the reestablishment of circulation, the rejoined
foot became pink and warm. The total ischemic time
was 7 h. The five superficial saphenous veins were also
anastomosed. The superficial and deep peroneal nerves
and the medial and lateral plantar nerves of the sole
were all repaired. The tendons of the foot were repaired
using the double Tsuge method and running suture
with 7-0 monofilament nylon. The anterior and poste-
rior tibial tendons, the peroneus longus, and the exten-
sor and flexor hallucis longus tendons were repaired.
The skin was sutured loosely to avoid tension on the
skin and pressure on the anastomosed vessels.
Postoperative Course and Management
The affected limb was kept elevated to support venous
return and to avoid constriction and pressure from the
dressing. Low-molecular-weight dextran (10 mg/kg)
was administered to improve blood flow and heparin
(100 U/kg in 24 h) for 7 days. Five hundred milliliters
of saline solution containing 240,000IU of urokinase
(Green Cross, Osaka, Japan) was injected twice a day for
seven days. Five hundred milliliters of saline solution
containing lOng/kg lipo alprostadil (Prostandin; Ono
Chemical Industry, Osaka, Japan) was administered for
2 h twice a day for 7 days, and 5 to l5Ilg/kg/min of diltia-
zem hydrochloride (Herbesser; Tanabe Pharmaceutical,
Osaka, Japan) was also administered for vasospasm.
Range-of-motion exercise imaging walking was initi-
ated in the 2nd week without weight-bearing. In the 4th
1.6. Replantation of the Lower Leg and Foot 221
Fig.5. Photographs 18 years after operation, showing that the
patient can walk on the plantigrade with normal gait
week, walking exercise bearing half the weight with
the plantar arch support was initiated. In the 8th week,
walking exercise bearing the full weight was allowed.
Follow-Up Data
Eighteen years after the operation, the patient still
works as a farmer and can walk on the plantigrade with
a normal gait of over 4km in an hour (Fig. 5). The
rejoined foot is 2 cm smaller, but the same size shoe is
worn on both feet. The circulation in the foot is normal,
and there is no trophic ulcer or callosity. The dorsal
surface of the foot has diminished light touch sensation,
with sensibility levels of 6 and 7 on the Semmes
Weinstein monofilament test. The sole has diminished
protective sensation, with sensibility levels of 7 and 8.
Paresthesia and cold intolerance are minimal (Fig. 6) . .
The radiograph shows solid fusion and no evidence
of avascular necrosis on the rejoined foot, but light
changes of osteoarthritis on the calcaneo-cuboid joint
(Fig. 7).
Discussion
There have been very few reports of successful replan-
tations of completely amputated lower extremities, and
there is still controversy whether an amputated lower
limb should be replanted or not. Some surgeons [8-10]
have said that a lower limb prosthesis is superior to a
222 E. Clinical Reconstructive Microsurgery
Fig. 6. Photographs 18 years after operation, showing no
trophic ulcer or callus. The dorsal and the plantar sensibilities
are 6 and 7 and 7 to 8 by the Semmes-Weinstein test,
respectively
replanted limb. On the other hand, several cases of suc-
cessful replantation of severed lower limbs have been
reported from China [2,3,12,13]. Magee and Parker [4]
and Morrison et al. [12] have reported successful lower
limb replantations. All three cases had a satisfactory
functional recovery. Morrison et al. [12] stated that
limbs undergoing guillotine amputation should usually
be replanted, especially in children.
The function in our two cases has recovered to almost
normal. We consider these successful results to be due
to the excellent recovery of sensory and motor nerve
function, and to the natural compensatory growth that
equalized the discrepancy in leg length in case 1. For
such successful nerve recovery, correct nerve repair by
microsurgical technique seems to be necessary. Also,
Thomason and Matzke [14] stated that there was a clear
Fig. 7. Roentgenogram 18 years after surgery, showing solid
fusion and no evidence of avascular necrosis on the replanted
foot
relationship between the ischemic time and the amount
of nerve recovery.
With respect to epiphyseal growth in a replanted
extremity in a child, Furnas [15] stressed several factors
that influenced growth retardation in experimentally
replanted puppy limbs. He emphasized that minimal
ischemic time, ideal conditions for nerve repair, and
constant weight-bearing were important for the preser-
vation of epiphyseal growth. Since the ischemic time
in our child case was 8 h and no growth retardation
occurred, apparently the epiphyseal growth plate can
tolerate at least 8 h of ischemia.
One of us (M.D.) successfully replanted five ampu-
tated legs in five patients, including case 1 [6]. Although
some patients found it impossible to squat and to run
because of joint contracture of the foot, all of them
could perform other activities without difficulty.
In many cases, the lower extremities of middle-
aged or older people have vascular system impairments
[15,17]. These obstacles were overcome, and six feet
amputated by trauma were replanted successfully by
one of us (I.M.). All six patients were men between the
ages of 16 and 74 years, with an average age of 49.6.
There were two cases of complete, clean-cut amputa-
tions caused by mowing machines. The other four cases
were of partial amputations with no circulation in the
distal parts, avulsed injuries, and severe crushing caused
by high-impact trauma (caused by a caterpillar, a con-
veyor, a tractor, and a traffic accident). All of the feet of
the patients survived. All of the patients can walk with
no pain and with normal sensation and show normal
gaits. All of them returned to their original occupations,
and they are greatly satisfied with the results of the
procedures.

We believe that at least a sharply amputated lower
leg or foot should be replanted if revascularization is
possible within 7 or 8 h and the conditions for nerve
repair are ideal. It is our opinion that a replanted limb
with some degree of useful function is far better than
the best artificial limb.
References
1. Malt RA, McKahnn CF (1964) Replantation of severed
arms. JAMA 189:716-722
2. American Replantation Mission to China (1973) Replan-
tation surgery in China. Plast Reconstr Surg 52:476-489
3. McDowell F (1973) Get in there and replant! (Editorial).
Plast Reconstr Surg 52:562-567
4. Magee HR, Parker WR (1972) Replantation of the foot:
results after two years. Med J Aust 1:751-755
5. Usui M, Minami M, Ishii S (1979) Successful replantation
of an amputated leg in a child. Plast Reconstr Surg 63:
613-617
6. Usui M, Kimura T, Yamazaki J (1990) Replantation of the
distal part of the leg. J Bone Joint Surg 72A:1370-1373
7. Masuda K, Usui M, Ishii S (1995) A 17-year follow-up of
replantation of a completely amputated leg in a child: case
report. J Reconstr Microsurg 11:89-92
1.6. Replantation of the Lower Leg and Foot 223
8. Balas P, Giannikas AC, Harto-Garofalides G, Plessas S
(1970) The present status of replantation of amputated
extremities. Vasc Surg 4:190-209
9. Editorial (1970) Replantation of the foot. BMJ 3:551-552
10. Engber WD, Hardin CA (1971) Replantation of extremi-
ties. Surg Gynecol Obstet 132:901-916
11. Sixth People's Hospital, Shanghai (1967) Reattachment
of traumatic amputations: a summing up of experiences.
China Med 5:392-402
12. Shanghai Sixth People's Hospital (1978) Extremity
replantation. Chinese Med J 4:5-10
13. Morrison WA, O'Brien BMW, MacLeod AM (1977)
Major limb replantation. Orthop Clin North Am 8:343-
348
14. Thomason PR, Matzke HER (1974) Effects of ischemia
on the hind limb of the rat. Am J Phys Med 54:113-131
15. Furnas DWG (1970) Growth and development in
replanted forelimbs. Plast Reconstr Surg 46:445-453
16. Hen Z-W, Zen B-F (1983) Replantation of the lower
extremity. Clin Plast Surg 10:103-113
17. Lesavoy MA (1979) Successful replantation of the lower
leg and foot with good sensibility and function. Plast
Reconstr Surg 64:760-765
1.7 Extremity Trauma: Limb Salvage Versus
Primary Amputation
YUH INADA
Deciding between limb salvage and primary amputation
is a permanent problem for micro surgeons, in particu-
lar when the patient has multiple trauma. Lange [1] said
in 1989 that massive extremity injuries, in particular
open tibial fractures with vascular injuries, present an
immediate and complex decision-making challenge
between an attempt at limb salvage and primary ampu-
tation. However, little is known of the outcomes of
severe limb injury. Nottingham [2] reported a meta-
analysis of the results of treatment of closed tibial frac-
tures and reached the conclusion that the published
clinical and outcome data were insufficient to derive any
therapeutic recommendations.
As sophisticated microsurgical reconstructive
techniques progressed since the 1960s decade, disagree-
ment occurred. Hansen [3], in analyzing his vast per-
sonal experience with managing open fractures, noted
that protracted attempts at limb salvage may destroy a
person physically, psychologically, socially, and finan-
cially, with adverse consequences for the entire family
as well. In spite of the best attempts, the functional
results are often worse than those of amputation.
Unfortunately, the majority of microsurgeons lose their
enthusiasm to reconstruct massive extremity trauma
because of disappointing functional results, in particu-
larly in cases of upper and lower extremity trauma with
neurovascular injuries.
In this chapter, I describe the decision-making chal-
lenge of severe extremity trauma and review previous
work.
Upper Extremity
Among the severe injuries to the upper extremity,
scapulothoracic dissociation [SD] [4-8] and complete
amputation above the elbow joint in adults [10-19]
have become the subjects of discussion because of
severe initial systemic conditions and poor neurologic
recovery.
SD is a rare entity that consists of disruption of the
scapulothoracic articulation. The mechanism of injury is
probably traction caused by blunt force to the shoulder
224
girdle. This lesion is characterized by massive soft-tissue
swelling of the shoulder, lateral displacement of the
scapula as measured radiographically, injury to bone
(acromicoclavicular separation, displaced fracture of
the clavicle, or sternoclavicular disruption), severe
neurovascular injury, and a variety of upper and lower
extremity fractures.
Damschen et al. [6] recently classified SD into three
groups too rational clinical decision making. Patients
presenting with violent lateral distraction and rotational
displacement of the shoulder, causing demonstrable
muscloskeletal injury alone (Type I), require a complete
physical examination, including specific neurologic and
vascular components and a chest radiograph. These
patients can be treated by with orthopedic stabilization
and physical rehabilitation. Type IIA injuries involve
musculoskeletal and vascular trauma, but no neurologic
disruption. The patient has a chance for full recovery
but requires orthopedic stabilization and prompt vas-
cular repair within 4 to 6h. Type IIB injuries include a
subset of patients with neurologic impairment and no
vascular injury. Management depends upon the degree
of neurologic impairment. However, consideration of an
above-elbow amputation and prosthesis fitting may be
most appropriate in complete brachial plexus injuries
with a flail extremity. Type III injuries include a subset
of patients with both neurologic and vascular injuries.
These patients require complete evaluation to select
the management pathway. Arteriography is used to
determine vascular reconstruction options, and an
electromyogram may help predict the functional result.
Vascular control must be obtained, and the brachial
plexus may be evaluated intraoperatively. Complete
disruption may indicate the level of amputation, but
revasularization within 4 to 6h should be performed
if the degree of neurologic impairment is incomplete
or unclear. However, Sampson et al. [7] recommend
arterial ligation only in the patient who is actively
bleeding, and primary amputation in the rare patient
who has limb-threatening ischemia and SD in Type III
injuries. These patients always have multiple injuries,
and the few benefits of revascularizing a flail extremity
need to be carefully weighed against the disadvan-
 1.7. Extremity Trauma: Limb Salvage Versus Primary Amputation 225

tages. The prognosis for functional recovery of the limb bone. Type I1IC fractures have associated arterial injury
in SD is poor because of the severity of the neurologic requiring repair. If there are combined injuries and/or
injury. infrapopliteal vascular injury, the risk of amputation is
Recently, Doi et al. [9] reported the significance high. Caudle and Stern [21] reviewed 62 Gustilo
of elbow extension in reconstruction of prehension Type III fractures. Type IlIA had the lowest rate of
with reinnervated free-muscle transfer following com- complications (27% nonunion, with no deep infection
plete brachial plexus avulsion. They evaluated 24 of 31 on secondary amputation). Type IIIB had a higher
patients and reported that 14 patients were able to complication rate (43% non-union, 29% deep infec-
obtain useful functional recovery of the triceps muscle, tions, and 17% secondary amputations). Type IIIC had
enabling it to stabilize the elbow joint against the trans-
disastrous rates, with 100% of patients having major
fered muscle, which acted as simultaneous elbow flexor complications (78% delayed amputation).
and wrist or finger extensor. Francel et al. [22] demonstrated that only 28%
secured long-term employment and no patient returned
Clinical decision making for patients with Type III SD
injuries may change, depending on the development of to work after 2 years of unemployment following
microsurgical technique and critical care medicine in microvascular soft-tissue reconstruction of a Gustilo
the near future. At present, aggressive primary nerve Type IIIB tibial fracture. In contrast, 68% returned to
reconstruction should be considered for children, even work within 2 years after below-knee amputation with
those with Type III injury. Gustilo Type I1IB and C fractures, and pointed out that
There are no reports of excellent recovery after one of the keys to successful limb salvage in Gustilo
replantation of the completely amputated arm above Type IIIB tibial fractures is soft-tissue reconstruction.
the elbow joint in adults [12,19]' Functional recovery ofHowever, Francel et al. stated that "massive lower
the replanted upper extremity has been reported only extremity trauma victims may have a greater than
in children [13,14]. Recently, Graham and his colleagues 90% limb salvage by early soft-tissue reconstruction,
although functional failures are commonly seen."
[19], using the Carroll test, reviewed the functional out-
comes of 22 amputated arms that were either replanted Similarly, Godina [23] demonstrated the importance
or were replaced by a prosthesis. They reported excel- of early soft-tissue reconstruction for the treatment of
lent or good recovery in 8 replanted limbs (36%), a severe open fractures, but the results can be disap-
significantly higher proportion than in the prosthetic pointing. Failed trials at limb salvage are associated with
group. When the groups were more closely matched increased patient mortality and hospital costs. Moniz
(adults with below-elbow injuries), 6 (50%) in the and his colleagues [24] reviewed the amputation rates
replantation group had good or excellent outcomes, and of patients with skeletal injury with various vascular
the prosthetic group had none. The authors concluded injuries in the lower extremities. Based on their report,
that replantation produces superior functional results the amputation rates were 26% for femoral artery
compared with amputation and a prosthesis. In fact, damage, 54 % for popliteal artery damage, and 38 % for
many micro surgeons have emphasized that patients arterial damage below the knee (20% for one-vessel
with replanted completely amputated arms are highly injury, 33% for two-vessel injury, and 100% for three-
vessel injury). However, the decision between salvage
satisfied, even if the functional results are Chen's grade
III or IV. In this area, there has been no development and amputation is not decided simply by the presence
since the 1970s and 1980s. Further investigation to accel-
of blood-vessel damage.
erate the recovery of the nervous system is expected. Indexes to quantify the severity of trauma to help
Along with efforts to replant the amputated upper decide whether to amputate or to salvage the limb have
extremity, allografting of the hand has attracted world- been proposed by several authors. Published lower-
wide attention. However, no one knows the late func- extremity injury severity scoring systems include the
Mangled Extremity Severity Score (MESS) (Table 1)
tional result of hand allografting at present. In addition,
all hand allografts have been transplanted at the level [25]; the Predictive Salvage Index (PSI) (Table 2) [26];
of the distal forearm, not the arm. the Limb Salvage Index (LSI) (Table 3) [27]; the Nerve
injury, Ischemia, Soft-tissue injury, Skeletal injury,
Shock, and Age of patient (NISSSA) Score (Table 4)
Lower Extremity [28]; the Mangled Extremity Syndrome (MES) (Table
5) [29]; and the Hannover Fracture Scale-97 (HFS-97)
The most problematic injuries are open tibial fractures. (Table 6) [30].
in particular Gustilo type IIIB and C tibial fractures The PSI was introduced by Howe and his colleagues
[20]. Type IIIB fractures are accompanied by extensive [26] in 1987 to assess patients who had combined ortho-
soft-tissue loss with periosteal stripping and exposed pedic and vascular injuries. The PSI was used to help
226 E. Clinical Reconstructive Microsurgery

Table 1. Mangled Extremity Severity Score (MESS) Table 2. Point system for Predictive Salvage Index (PSI)
Variables Points Variable Points
------------------------------------------
Skeletal/soft -tissue injury Level of arterial injury
Low energy (stab; simple fracture; civilian GSW) 1 Suprapopliteal
Medium energy (open or multiple fracture, dislocation) 2 Popliteal 2
High energy (close-range shotgun or military GSW, 3 Infrapopliteal 3
crush injury) Degree of bone injury
Very high energy (above + gross contamination, soft- 4 Mild 1
tissue avulsion) Moderate 2
Limb ischemia Severe 3
Pulse reduced or absent but perfusion normal l' Degree of muscle injury
Pulseless; parasthesias; diminished capillary refill 2' Mild
Cool, paralyzed, insensate, numb 3' Moderate 2
Shock Severe 3
Systolic blood pressure always >90mmHg o Interval from injury until arrival in the operating room (h)
Hypotensive transiently 1 ~ 0
Persistent hypotension 2 6-12 2
Age (yr) >12 4
<30 o A + B + C + D = Predictive Salvage Index
30-S0
>SO 2

aScore doubled for ischemia >6h.

GSW, gun shot wound

Table 3. Limb Salvage Index Scoring System

Location Points Extent of injury
Artery o Contusion, intimal tear, partial laceration or avulsion (pseUdo-aneurysm) with no distal thrombosis and palpable
pedal pulses; complete occlusion of one of three shank vessels or profunda
Occlusion of two or more shank vessels; complete laceration, avulsion, or thrombosis of femoral or popliteal vessel
without palpable pedal pulses
2 Complete occlusion of femoral, popliteal, or three of three shank vessels with no distal runoff available
Nerve o Contusion or stretch injury; minimal clean laceration of femoral, peroneal, or tibial nerve
1 Partial transection or avulsion of sciatic nerve; complete or partial transection of femoral, peroneal, or tibial nerve
2 Complete transection or avulusion of sciatic nerve; complete transection or avulsion or sciatic nerve; complete
transection or avulsion of both peroneal and tibial nerve
Bone o Closed fracture in one or two sites; open fracture without comminution or with minimal displacement; closed
dislocation without fracture; open joint without foreign body; fibula fracture
1 Closed fracture at three or more sites on same extremity; open fracture with comminution or moderate to large
displacement; segmental fracture; fracture dislocation; open joint with foreign body; bone <3cm
2 Bone loss >3 cm; Type lIIB or lIIC fracture (open fracture with periosteal stripping, gross contamination, extensive
soft-tissue injury or loss)
Skin o Clean laceration, single or multiple, or small avulsion injuries, all with primary repair; first degree burn
1 Delayed closure due to contamination; large avulsion requiring STSG or flap closure; second and third degree burns
Muscle o Laceration or avulsion involsion involving a single compartment or single tendon
Laceration or avulsion involving two or more compartments; complete laceration or avulsion of two or more
tendons
2 Crush injury
Deep vein 0 Contusion, partial laceration, or avulsion; complete laceration or avulsion if alternate route of venous return is
intact; superficial vein injury
1 Complete laceration, avulsion, or thrombosis with no alternate route of venous return
Warm 0 <6h
ischemia 6-9h
time 2 9-12h
3 12-1Sh
4 >lSh

STSG, Split -thickness skin graft.

 1.7. Extremity Trauma: Limb Salvage Versus Primary Amputation 227

Table 4. Nerve injury, Ischemia, Soft-tissue Injury, Skeletal injury, Shock, and Age of patient (NISSSA) rating criteria
Type of injury Degree of injury Points Description

Nerve injury (N)' Sensate 0 No major nerve injury

Dorsal Deep or superficial peroneal nerve, femoral nerve injury
Plantar partial 2 Tibial nerve injury
Plantar complete 3 Sciatic nerve injury
Ischemia (I)b None 0 Good to fair pulses, no ischemia
Mild I Reduced pulses, perfusion normal
Moderate 2 No pulse(s), prolonged capillary refill, Doppler pulses present
Severe 3 Pulseless, cool, ischemic, no Doppler pulses
Soft-tissue/contamination (S) Low 0 Minimal to no ST contusion, no contamination (Gustilo type I)
Medium I Moderate ST injury, low-velocity GSW, moderate contamination,
minimal crush (Gustilo type II)
High 2 Moderate crush, deglove, high-velocity GSW, moderate ST injury
may require soft-tissue flap, considerable contamination
(Gustilo type IlIA)
Severe 3 Massive crush, farm injury, severe deglove, severe contamination,
requires soft-tissue flap (Gustilo type IIIB)
Skeletal (S) Low energy 0 Spiral fracture, oblique fracture, no or minimal displacement
(Winquist and Hansen type I, lohner and Wruhs AI, A2)
Medium energy I Transverse fracture, minimal comminution, small-caliber GSW
(Winquist and Hansen type II, lohner and Wruhs A3, Bl)
High energy 2 Moderate displacement, moderate comminution, high-velocity
GSW, butterfly fragment(s) (Winquist and Hansen type III-IV,
lohner and Wruhs BI, B2, B3)
Severe energy 3 Segmental, severe comminution, bony loss (Winquist arid Hansen
type IV, lohner and Wruhs CI, C2, C3)
Shock (S) Normotensive 0 Blood pressure normal, always >90mmHg systolic
Transient hypotension I Transient hypotension in field or emergency center
Persistent hypotension 2 Persistent hypotension despite fluids
Age (A) Young 0 <30yr
Middle I 30-S0yr
Old 2 >SOyr
Total score (N + I + S + S + S + A)

GSW, Gunshot wound; ST, soft tissue.

a Nerve injury assessed primarily in emergency room.
b Score doubles for ischemia >6h.

prevent the trauma surgeon from attempting to salvage
a doomed or useless lower extremity and to permit early
prosthetic rehabilitation to follow definitive primary
amputation. Twenty-one combined lower-extremity
orthopedic and vascular injuries were retrospectively
studied to determine which variables influenced limb
salvage or amputation. The PSI was developed in con-
junction with the interval from injury to revasculariza-
tion, the level of the arterial injury, and the associated
skeletal and neuromuscular injuries. Howe and his col-
leagues reported a sensitivity of 78% and a specificity
of 100%.
The MESS was reported by Johansen and his
colleagues in 1990 [25] to assess patients who had
combined orthopedic and vascular injuries, as was the
PSI. Severely damaged lower extremities in 25 trauma
victims were prospectively analyzed to determine
salvage or amputation. The MESS was developed to
help select trauma victims whose irretrievably injured
lower extremItIes warrant primary amputation. The
MESS was developed on the basis of skeletal/soft-tissue
damage, limb ischemia, shock, and age. Johansen and his
colleagues concluded that a MESS score of 7 or more
was 100% predictive of amputation.
The NISSSA was introduced by McNamara and his
colleagues in 1994 [28] to address perceived weaknesses
of the MESS. Twenty-four patients with Gustilo Type
IIIB and IIIC open fractures of the tibia were retro-
spectively analyzed to further evaluate the value of
the MESS in predicting amputation. They modified the
MESS with a score called NISSSA, applied it to the
MESS and the NISSSA to be highly accurate (p < 0.005)
in predicting amputation, and concluded that the
NISSSA was more sensitive (81.8% vs 63.6%) and more
specific (92.3% vs 69.2%).
The LSI was derived by Russel and his colleagues in
1991 [27] based on the analysis of 70 lower-extremity
injuries involving multiple systems. They concluded that
228 E. Clinical Reconstructive Microsurgery

Table 5. Mangled Extremity Syndrome Grading System Table 6. Hannover fracture scale (HFs)a
Injury Severity Score (ISS) Fracture type
0--25 1 A 1
25-50 2 B 2
>50 3 C 4
Integument Bone loss
Guillotine 1 <2cm 1
Crush/bum 2 >2cm 2
Avulsion/degloving 3 Soft tissues
Nerve Skin (wound, contusion)
Contusion No o
Transection 2 <1/4 circumference 1
Avulsion 3 114-112 2
Vascular 112-3/4 3
Artery >3/4 4
Transected Skin defect
Thrombosed 2 No o
Avulsed 3 <114 circumference 1
Vein 1 114-112 2
Bone 112-3/4 3
Simple fracture 1 >3/4 4
Segmental fracture 2 Deep soft tissues (muscle, tendon, ligaments, joint capsule)
Segmental-comminuted fracture 3 No o
Segmental-comminuted fracture with bone loss <6cm 4 <114 circumference 1
Segmental fracture intra- or extraarticular 5 114-112 2
Segmental fracture intra- or extraarticular with bone loss 6 112-3/4 3
>6cm >3/4 6
Lag time (1 point for every hour >6) Amputation
Age (yr) No o
40--50 Subtotal guillotine 20
50--60 2 Subtotal crush 30
60--70 3 Ischemia/compartment
Preexisting disease 1 No o
Shock 2 Incomplete 10
Total score (MESI) Complete
<4h 15
4-8h 20
>8h 25
absolute indications for amputation from his study Nerves
include a patient with a limb salvage index of 6 or Palmer-plantar sensations
greater, and a patient with Gustilio Type IIIC fracture Yes o
No 8
with associated nerve injury. Seventy limbs in 67
Finger-toe motion
patients were evaluated retrospectively. The LSI Yes o
included seven components related to injury: arterial, No 8
nerve, bone, skin, muscle, vein, and length of warm Contamination
ischemia. A 100% correlation between limb outcome Foreign bodies
and the threshold score was reported. None o
Single 1
The HFS was introduced in 1993 [30] for quantitative Multiple 2
evaluation of open fractures. Originally, the HFS was Massive 10
used to investigate the primary factors responsible for Bacteriologic smear
posttraumatic osteitis, not to decide whether to ampu- Aerobe, 1 germ 2
Aerobe, >1 germ 3
tate or salvage. Sedkamp and his colleagues reported
Anaerobe 2
that a high prognostic index for bone infection was Aerobe-anaerobe 4
found for the amount of bone loss, the fracture type, the Onset of treatment (Only if soft tissue score >2)
type of bacteriologic contamination, deep soft-tissue 6--12h 1
defects, compartment syndromes, vascular injuries, and >12h 3
soft-tissue infections. The HFS included 13 initial char- a Fr.O 1,2-3 points; Fr.O III, 20--69 points; Fr.O IV, >70 points.
acteristics related to injury to the limb, and the recom-
mended amputation thresholds have been refined by a
continued reassessment strategy with use of multiple
 1.7. Extremity Trauma: Limb Salvage Versus Primary Amputation
regression and receiver operator characteristic curves.
The HFS-97 had a sensitivity of 37% (10% for Type lIIB
fractures and 67% for Type mc fractures).
Many authors have disputed the utility of the lower-
extremity injury severity scoring system, while several
indexes were developed.
Bonanni and his colleagues [31] retrospectively
scored 58 lower-extremity salvage attempts over a 10-
year period by using the Mangled Extremity Syndrome
Index (MESI), the MESS, the PSI, and the LSI. Sensi-
tivity, specificity, and Younden's J were calculated for
each index, and the association between observed and
predicted outcomes was tested by chi-square analysis.
Limb salvage failure was defined at four levels: level 1,
secondary amputation (before discharge); level 2, terti-
ary amputation (after discharge); level 3, insensate limb
salvage; and level 4, functional failure. Unsatisfactory
functional outcome was determined by the inability to
perform minimal requirements to walk at least 150 feet
(46m), climb 12 steps, transfer from a bed or tub, move
into a sitting position from a standing position, or move
into a standing position from a sitting position. They
reported that the sensitivity and specificity, respectively,
were 6% and 90% for the MESI, 22% and 53% for the
MESS, 33% and 70% for the PSI, and 61 % and 43% for
the LSI; they concluded that the indices had no predic-
tive utility.
Similarly, Durham and his colleagues [32] reviewed
the MESS, LSI, and PSI for 51 lower-extremity injuries
retrospectively and reported that the sensitivity and
specificity were 79% and 83% for the MESS, 83% and
83% for the LSI, and 96% and 50% for the PSI. They
found no correlation between the long-term functional
and the severity scoring systems, and the concluded that
all of the scoring systems were able to identify the
majority of patients who required amputation; however,
none of these systems were able to predict functional
outcome.
Lin and his colleagues [33], who used sophisticated
microsurgical techniques, retrospectively analyzed the
MESS and the functional outcome 2 years after injury
for 36 lower-extremity revascularizations of Gustilo
Type lIIC, and reported the MESS was able to predict
the secondary amputation rate and the functional result.
They mentioned that the salvaged limbs with MESS ~
9 exhibited a significant difference in achieving ade-
quate function compared with limbs with MESS> 9, and
that the threshold for immediate amputation could be
raised from MESS = 7 to MESS = 9.
Bosse and his colleagues [34] in 2001 conducted a
large, independent, prospective evaluation of the lower-
extremity injury severity scoring systems, including the
MESS, LSI, PSI, NISSSA, and HFS-97, for the treat-
ment of 556 high-energy lower-extremity injuries. They
229
concluded that the analysis did not validate the clinical
utility of any of the lower-extremity injury-severity
scoring systems, and they warned that these scores at or
above the amputation threshold should be cautiously
used by a surgeon who must decide the fate of a lower
extremity with a high-energy injury.
Based on the futility of predicting scoring systems,
Bonanni [31] emphasized that guidelines are needed to
prevent the morbidity of tertiary amputation, insensate
limb salvage, and functional failures. He said that
"the goal of therapy in all patents with mangled lower-
extremities is the restoration of near-normal function
with minimal morbidity in a reasonable time interval.
"The decision whether to amputate or salvage has sig-
nificant repercussions medically, economically, socially,
and medico legally. Even at the present time, there are
no guidelines about decision-making protocol to ampu-
tate or not to amputate. However, many authors agree
that complete loss of the sciatic or posterior tibial nerve
is an absolute indication for amputation [1,20,21,25,
26,35-37].
References
1. Lange RH (1989) Limb reconstruction versus amputation
decision making in massive lower extremity trauma. Clin
Orthop 243:92-99
2. Nottingham (1998) Severe limb injuries. Acta Orthop
Scand 69:47-53
3. Hansen ST (1987) The type-IIIC tibial fracture (editorial).
J Bone Joint Surg 69A:799-800
4. Oreck SL, Burgess A, Levine AM (1984) Traumatic lateral
displacement of the scapula: a radiographic sign of neu-
rovascular disruption. J Bone Joint Surg 66A:758-763
5. Ebraheim NA, An HS, Jackson WT, Pearlstein SR,
Burgess A, Tscherne H, Hass N, Kellam J, Wipperman
BUJ (1988) Scapulothoracic dissociation. J Bone Joint
Surg 70A:428--432
6. Damschen DD, Cogbill TH, Siegel MJ (1997) Scapu-
lothoracic dissociation caused by blunt trauma. J Trauma
42:537-540
7. Sampson LN, Britton JC, Jorgernsen JE, Clark DE,
Rosenberg JM, Bredenberg CE (1993) The neurovascular
outcome of scapulothoracic dissociation. J Vasc Surg 17:
1083-1089.
8. Goldstein LJ, Watson JM (2000) Traumatic scapulotho-
racic dissociation: case report and literature review. J
Trauma 48:533-535
9. Doi K, Shigetomi M, Kaneko K, Heong TS, Hiura Y,
Hattori Y, Kawakami F (1997) Significance of elbow
extension in reconstruction of prehension with reinner-
vated free-muscle transfer following complete brachial
plexus avulsion. Plast Reconstr Surg 100:364-372
10. Ipsen T, Lundkvist T, Barfred T, Pless J (1990) Principles
of evaluation and results in microsurgical treatment of
230 E. Clinical Reconstructive Microsurgery
major limb amputations. Scand J Plast Reconstr Hand
Surg 24:75-80
11. Malt RA, McKhann CF (1964) Replantation of severed
arms. JAMA 189:716--722
12. Wood MB, Cooney WP (1986) Above elbow limb replan-
tation: functional results. J Hand Surg 11A:682-687
13. Beris AE, Soucacos PN, Malizos KN, Mitsionis GJ,
Soucacos PK (1994) Major limb replantation in children.
Microsurgery 15:474-478
14. Daigle JP, Kleinert JM (1991) Major limb replantation in
children. Microsurgery 12:221-231
15. Tamai S (1982) Twenty years experience of limb replan-
tation-review of 293 upper extremity replants. J Hand
Surg 7A:549-556
16. Chen CW, Qian YQ, Yu ZJ (1978) Extremity replantation.
World J Surg 2:513-521
17. Russel RC, O'Brien BM, Morrison WA, Paramull G,
MacLeod A (1984) The late functional results of upper
limb revascularization and replantation. J Hand Surg 9:
623-633
18. Axelrod TS, Buchler U (1991) Severe complex injuries to
the upper extremity: revascularization and replantation. J
Hand Surg 16A:574-584
19. Graham B, Adkins P, Tsai TM, Breidenbach WC (1998)
Major replantation versus revision amputation and pros-
thetic fitting in the upper extremity: a late functional out-
comes study. J Hand Surg 23A:783-791
20. Gustilo RB, Mendoza RM, Williams DN (1984) Problems
in the management of type III (severe) open fractures: a
new classification of type III open fractures. J Trauma 24:
742-746
21. Caudle RJ, Stern PJ (1987) Severe open fractures of the
tibia. J Bone Joint Surg 69A:801
22. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN,
Yaremchuck MJ (1992) Microvascular soft-tissue trans-
plantation for reconstruction of acute open tibial frac-
tures: timing of coverage and long-term functional results.
Plast Reconstr Surg 89:478--487
23. Godina M (1986) Early microsurgical reconstruction of
complex trauma of the extremities. Plast Reconstr Surg
78:285-292
24. Miniz MP, Ombrellaro MP, Stevens SL, Freeman MB,
Diamond DL, Goldman MH (1997) Concomitant ortho-
pedic and vascular injuries as predictors for limb loss in
blunt lower extremity trauma. Am Surg 63:24-28
25. Johansen K, Daines M, Howey T, Helfet D, Hansen
ST (1990) Objective criteria accurately predict amputa-
tion following lower extremity trauma. J Trauma 30:568-
573
26. Howe RH, Poole GV, Hansen KJ, Clark T, Plonk GW,
Koman A, Pennell TC (1987) Salvage of lower extremities
following combined orthopedic and vascular trauma. Am
Surg 53:205-208
27. Russel WL, Sailors DM, Whittle TB, Fisher DF, Burns RP
(1991) Limb salvage versus traumatic amputation. Ann
Surg 213:473--481
28. McNamara MG, Heckman JD, Corley FG (1994) Severe
open fractures of the lower extremity: a retrospective
evaluation of the mangled extremity severity score
(MESS). J Orthop Trauma 8:81-87
29. Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA,
Wheeler JR, Snyder SO, Gayle RG, Schwab CW (1985)
Mangled extremity syndrome (MES): a severity grading
system for multisystem injury of the extremity. J Trauma
25:1147-1150
30. Suedkamp NP, Barbey N, Veuskens A, Tempka A, Haas
NP, Hoffmann R, Tscherne H (1993) The incidence of
osteitis in open fractures: an analysis of 948 open fractures
(a review of Hannover Experience). J Orthop Trauma 7:
473--482
31. Bonanni F, Rhodes M, Lucke JF (1993) The futility of
predictive scoring of mangled lower extremities. J Trauma
34:99-104
32. Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs
D (1996) Outcome and utility of scoring systems in the
management of the mangled extremity. Am J Surg 172:
569-574
33. Lin CH, Wei FC, Levin LS, Su 11, Yeh WL (1997) The func-
tional outcome of lower-extremity fractures with vascular
injury. J Trauma 43:480--485
34. Bosse MJ, Mackenzie EJ, Kellam JF, Burgess AR, Webb
LX, Swiontkowski MF, Sanders RW, Jones AL,
McAndrew MP, Patterson BM, McCarthy ML, Cyril J
(2001) A prospective evaluation of the clinical utility of
the lower extremity injury-severity scores. J Bone Joint
Surg 83A:3-14
35. Lange RH, Bach AW, Hansen ST (1985) Open tibial frac-
tures with associated vascular injuries: prognosis for limb
salvage. J Trauma 25:203-208
36. Rosseler MS, Wisner DH, Holcroft JW (1991) The
mangled extremity. Arch Surg 126:1243-1249
37. Seiler JG, Richardson JD (1986) Amputation after
extremity injury. Am J Surg 152:260-264
1.8 Replantation of a Completely Amputated Penis
SUSUMU TAMAI
Amputation injury of the penis is a relatively rare
condition, which is caused by self-emasculation or
self-amputation in the psychotic individual, by trauma
related to masturbation, by accidental trauma, under
the influence of drugs or alcohol, or by assault by a
jealous spouse or a homosexual lover.
Thirteen primary replantations of a completely or
partially amputated penis had been reported by the end
of 1975 [1-11]. These replantations, however, were
performed as composite grafts without neurovascular
anastomoses. Only after microsurgical replantation of
amputated limbs and digits became possible with the
successful restoration of anatomical structures and with
successful functional outcomes during the 1960s, could
the technique be applied to the replantation of the penis.
The first successful microsurgical replantation of an am-
putated penis was achieved by Tarnai and his associates
in 1976 [12], followed by Cohen and his colleagues [13]
in the same year. Thereafter, there have been a number
of cases reported around the world [14-40]. The surgi-
cal techniques introduced in this chapter are based on
my experience with the world's first penile replantation.
Case Report
A 24-year-old schizophrenic man inflicted multiple
wounds on his abdominal wall, as well as a complete
amputation of the penis and scrotum with a kitchen
knife. When he was transferred to our hospital 11/ Z hours
later, a mass of small intestine was exposed through the
irregular lacerations of his abdominal wall. His penis
and scrotum had been cut off in one piece at their base,
as shown in Fig. 1.
The urologist who first saw this patient consulted us
about the possibility of microsurgical replantation of
the penis. The wounds appeared favorable for replanta-
tion, and his family was very anxious for us to make
every effort to salvage the amputated part.
With the patient under general anesthesia, the
abdominal wounds were examined first, while the
amputated penis and scrotum were refrigerated at 4C.
The general surgeons resected and reanastomosed the
damaged small intestine. The liver wounds and a
stomach perforation were also repaired.
Five hours after the injury, replantation of the penis
and scrotum began. The proximal stump and the ampu-
tated segment were debrided and carefully examined.
The testicles were not found in the scrotum and were
apparently lost at the time of injury. The lacerated
funiculus spermaticus was pulled back into the proximal
wound.
The first step of replantation required passing a ure-
thral balloon catheter through the distal segment and
then through the proximal stump into the bladder. This
provided good alignment and support of the penis and
the proximal stump. Because no bandage or tourniquet
could be applied on the short proximal stump, hemo-
stasis was accomplished with microvascular clips on the
vessels to be anastomosed.
Figure 2 shows a drawing of the cross-sectional
anatomy of the amputated penis. The urologist first
repaired the urethra with interrupted sutures of fine
catgut, while the urethral catheter was positioned in
the bladder. The corpus spongiosum was then sutured
with 5-0 Prolene thread. After the septum pectiniform
had been repaired, the right profunda penis artery,
which was located in the right corpus cavernosum, was
exposed. Using 16x magnification under an operating
microscope, we anastomosed the artery 0.5 mm in exter-
nal diameter with 10-0 monofilament nylon thread. The
tunica albuginea was then repaired to coapt both ends
of the corpus cavernosum. The left profunda artery
was too small for us to anastomose. Immediately after
release of the clip on the sutured right profunda artery,
blood was noted oozing from the cut end of the left
corpus cavern os urn of the penis. As a result, we only
repaired the corpus cavernosum on the left side without
repairing the profunda penis artery.
We then found a dorsal vein approximately 3.0mm in
diameter and anastomosed it with 9-0 monofilament
nylon thread. Two dorsal nerves and two dorsal arteries
measuring 0.8mm in diameter were also repaired under
magnification, as shown in Fig. 3.
Following completion of the neurovascular anasto-
moses and the reestablishment of circulation, the distal
231
232 E. Clinical Reconstructive Microsurgery
Fig.I. The proximal amputation stump, with urethral catheter
inserted (left), and the completely detached penis and scrotum
(right). From [12], with permission. (See Color Plates)
V. dorsalis superficialis
N. dorsalis penis V. dorsalis penis
skin -----,~
penis
~~thfJ----5;:"l'lltum penis
Urethra
Fig. 2. Drawing of the cross-sectional anatomy of the ampu-
tated penis. From [12], with permission
penile segment enlarged and gained color. The Buck
fascia was sutured loosely with 5-0 Prolene thread. The
lacerated ducti deferentes and their comitant vessels
were ligated separately with silk, because both testicles
had been lost at the time of injury. Finally the skin was
closed after inserton of 3.0-mm Penrose drains sub-
cutaneously (Fig. 4).
Bulky dressings were applied around the penis, and
the urethral catheter was fixed on the upper thigh to
maintain the penis in the upright position. The total
operating time for the penile replantation was approx-
imately 4 hours.
The postoperative course was uneventful. The color,
texture, and skin temperature of the replanted penis
remained within normal ranges. Only slight edema of
..
.
..' .(
'-
~.. . ,."'~
".
'
~.t&:;. "
' <I)..
. C\.
.;J.;
'.,;,
Fig.3. The dorsal penile artery is being anastomosed with the
use of a Tarnai micro-double clip. From [12], with permission.
(See Color Plates)
Fig. 4. The penis immediately after replantation. From [12],
with permission. (See Color Plates)
the penile shaft developed subcutaneously, but urinary
drainage was efficient through the urethral catheter.
Systemic heparinization was not used because of the
risk of massive bleeding into the peritoneal cavity from
the repaired abdominal wounds and the risk of forma-
tion of hematomas in the penile shaft. Urokinase 24,000
units daily was given intravenously for 1 week. An
oral sedative was prescribed by a psychiatrist, and the
patient remained quiet and cooperative throughout the
postoperative course. In spite of the uneventful healing
of the penile wounds, one abdominal wound became
infected and was drained. The patient was obliged to
stay in bed for 3 weeks. On removal of the urethral
catheter at that time, a strong urinary stream was
noted.

Fig.5. A urethrogram, performed in the fourth week, demon-
strates a very slight constriction of the urethra at the site of
anastomosis. From [12], with permission
In the fourth week after replantation, urethrography
was performed in an ante grade fashion . On the ure-
throgram, a very slight constriction was demonstrated
at the urethral anastomosis, as shown in Fig. 5.
To confirm the circulation of the penis, pelvic angiog-
raphy and cavernosography were performed in the fifth
week. On the arteriogram, a dorsalis penis artery and a
profunda penis artery were clearly patent, but one
anastomosed dorsalis penis artery appeared to be
obstructed, as shown in Fig. 6. The cavernosograms per-
formed by the technique of Ney et al. [41] demonstrated
a clear septum at the anastomosed site of each corpus
cavernosum (Fig. 7A) . There was a delay in the contrast
medium drainoff, with some medium remaining in the
distal portion 30 minutes after direct injection into the
corpus cavernosum (Fig. 7B).
Five months after replantation, sensation to pinprick
had returned surprisingly well to the glans penis,
although the foreskin was still slightly edematous at the
1.8. Replantation of a Completely Amputated Penis 233
Fig. 6. An arteriogram, performed in the fifth week, clearly
demonstrates two patent arteries supplying the penis. From
[12], with permission
Fig.7. Cavernosograms, performed in the fifth week, demon-
strate a clear septum at the anastomosis site of each corpus
cavernosum immediately after injection of contrast media
(left); 30 minutes after injection of media, some still remains
in the corpora, demonstrating a delay of drainage (right).
From [12], with permission
sulcus coronarius. To lessen the distal edema, multiple
Z-plasties of the skin were carried out on the circum-
ferential scar at the replantation site. Postoperatively
the edema significantly decreased, and at 1 year the
appearance of the replanted penis was normal (Fig. 8).
The patient had regained the capacity for penile erec-
tion, but his sexual capacity was difficult to evaluate
because of the associated schizophrenia. It is inevitable
that the patient will suffer some hormonal effects of the
traumatic castration.
234 E. Clinical Reconstructive Microsurgery
Fig. 8. The replanted penis at 1 year. (See Color Plates)
Discussion
Penile amputation mJury is not common in most
countries. An exception is Thailand, where there were
approximately 100 penile amputations between 1973
and 1980 in Bangkok [16]. Most of these injuries were
caused in violent attacks by wives against philandering
husbands.
Reattachment or replantation of an amputated penis
by the composite graft technique [1-11] has resulted in
several complications. These include sloughing off of
tissue, especially if the volume of the amputated part
is too large to revascularize with time. However, with
application of modern microsurgical techniques of neu-
rovascular anastomoses for replantation, the results
have been much more satisfactory with fewer compli-
cations, as seen in reports from the past quarter-century
[12-40].
The anatomy of the penis and the history of micro-
surgical replantation of the amputated penis have been
well described by Jordan and Gilbert [21] and Zenn et
al. [40]. As shown in Fig. 2, the cross-sectional anatomy
of the penis is simpler than that of a digit, which hand
microsurgeons routinely replant with microneurovascu-
lar anastomoses. The arterial system of the penis derives
from the internal pudendal arteries, which provide the
main blood supply to the penis. At the base of the penile
shaft, after branching to the perineum and corpus spon-
giosum, the artery on each side divides into the dorsal
b
Fig. 9. a Schematic drawings of the arterial system of the
penis. A , Dorsal penile artery; B, deep penile artery; C, inter-
nal pudendal artery. b Schematic drawing of the venous
system of the penis. A , Superficial dorsal vein; B, deep dorsal
vein; C, Corpus cavernosum; D, circumflex veins. From [40],
with permission
penile artery and the deep penile artery. According to
Zenn et al. [40], the arterial and venous system of the
penis is clearly demonstrated. The venous drainage is a
three-level system: the subtunical venular plexus of the
cavernosum, the deep dorsal and circumflex veins, and
the superficial dorsal vein (Fig. 9).
In replanting the amputated penis, the operation
should be carried out in the following order:
1. Insertion of an urethral catheter as a stent, and repair
of the urethra and the corpus spongiosum with an
absorbable thread.
2. Anastomoses of the deep penile artery (0.5 mm) on
both sides, if its microvascular repair is possible.
The tunica albuginea on the corpus cavernosum is
repaired with interrupted sutures.
3. Repair of the dorsal arteries (0.8-1.0mm) and nerves
(O.5-0.7mm) and the deep dorsal vein (3.0mm).
4. Repair of the Buck fascia with interrupted sutures
using an absorbable thread.

5. Repair of the superficial dorsal vein (3.0-4.0mm).
6. Skin suturing.
If the dorsal penile arteries are large enough for
microvascular anastomosis, repair of the deep penile
arteries is not always necessary. Repair of the dorsal
penile arteries, vein, and nerves is essential for the sur-
vival and sensory reinnervation of the penis. According
to the literature, anastomosis of only one artery seems
to be sufficient for erectile function, but anastomoses of
both arteries may provide better arterial supply.
The urethral catheter should be maintained for 2 to
3 weeks postoperatively to prevent scar constriction at
the urethral anastomosis. The replanted penis should be
maintained in the upright position with bulky dressings
or a sponge cage to prevent circulatory disturbance
from kinking or bending of the penile shaft. The ure-
thral catheter can act as a support or stent to keep the
penis in an upright position.
When postoperative medications are presented for
circulatory disorders, heparin should not be used contin-
uously because of the risk of subcutaneous hematomas.
However, urokinase, prostaglandin Ell or both, at the
same doses as those given in digit replantations, may be
used for approximately 1 week. Dextran and aspirin are
frequently used in the United States and Europe. For
venous congestion in the early postoperative days, the
use of medical leeches is advisable. If circumferential
scar contractures develop at the replanted site of the
penile shaft, multiple Z-plasties will be necessary.
References
1. Ehrich WS (1929) Two unusual penile injuries. J Uro121:
239-241
2. Dodson AI (1944) Urological surgery. CV Mosby, St.
Louis, 612-613
3. Price KA (1952) Accidental transection of all corpora of
the penis: repair with good results. J Urol 68:620-623
4. Galleher EP Jr, Kiser WS (1961) Injuries of the corpus
cavernosum. J Urol 85:949-952
5. Best JW,Angelo JJ, Milligan B (1962) Complete traumatic
amputation of the penis. J UroI87:134-138
6. McRoberts JW, Chapman WH, Ansel JS (1968) Primary
anastomosis of the traumatically amputated glans penis:
case report and summary of literature. J UroI100:751-754
7. Tuerk M, Weir WH Jr (1971) Successful replantation of a
traumatically amputated glans penis. Plast Reconstr Surg
48:499-500
8. Mendez R, Kiely WF, Morrow JW (1972) Self-
emasculation. J UroI107:981-985
9. Schulman ML (1973) Reanastomosis of the amputated
penis. J UroI109:432-433
10. Farah R, Cerny JC (1973) Penis tourniquet syndrome and
penile amputation. Urology 2:310-311
1.8. Replantation of a Completely Amputated Penis 235
11. Engelman ER, Polito G, Perley J, Bruffy J, Martin DC
(1974) Traumatic amputation of the penis. J Urol 112:
774-778
12. Tarnai S, Nakamura Y, Motomiya Y (1977) Microsurgical
replantation of a completely amputated penis and scrotum.
Plast Reconstr Surg 60:287-291
13. Cohen BE, May JW Jr, Daly JS, Young HH (1977)
Successful clinical replantation of an amputated penis
by micro neurovascular repair. Case report. Plast Reconstr
Surg 59:276-280
14. Heymann AD, Bell-Thompson J, Rathod DM, Heller LE
(1977) Successful reimplantation of the penis using micro-
vascular techniques. J Urol118:879-880
15. Henriksson TG, Hahne B, Hakelius L, Lantto S, Norlen BJ
(1980) Microsurgical replantation of an amputated penis.
Scand J Urol NephroI14:111-114
16. Frey M (1980) Successful replantation of a completely
amputated penis. Int J Microsurg 2:173-176
17. Bhanganada K, Chayavatana T, Pongnumkul C,
Tonmukayakul A, Sakolsatayadorn P, Komaratat K,
Wilde H (1983) Surgical management of an epidemic
of penile amputations in Siam. Am J Surg 146:376-
382
18. Einarsson G, Goldstein M, Laungani G (1983) Penile
replantation. Urology 22:404-405
19. Yamano Y, Tanaka H (1984) Replantation of a completely
amputated penis by the microsurgical technique: a case
report. Microsurgery 5:40-43
20. Carroll PR, Lue TF, Schmidt RA, Trengrove-Johes G,
McAninch JW (1985) Penile replantation: current con-
cepts. J Urol133:281-285
21. Jordan GH, Gilbert DA (1989) Management of amputa-
tion injuries of the male genitalia. Urol Clin North Am
16:359-367
22. Szasz G, McLoughlin MG, Warren RJ (1990) Return of
sexual functioning following penile replant surgery. Arch
Sex Behav 19:343-348
23. Wandschneider G, Hellbom B, Pummer K, Primus G
(1990) Successful replantation of a totally amputated
penis by using microvascular techniques. Urol Int 45:
177-180
24. Borenstein A, Yaffe B, Seidman DS, Kaplan HY, Tsur H
(1991) Successful microvascular replantation of an ampu-
tated penis. Isr J Med Sci 27:395-398
25. Wells MD, Boyd JB, Bulbul MA (1991) Penile replanta-
tion. Ann Plast Surg 26:577-581
26. Sanger JR, Matloub HS, Yousif NJ, Begun FP (1992)
Penile replantation after self-inflicted amputation. Ann
Plast Surg 29:579-584
27. Aboseif S, Gomez R, McAninch JW (1993) Genital self-
mutilation. J UroI150:1143-1146
28. Altarac S (1993) A case of testicle replantation. J Urol
150:1507-1508
29. Matloub HS, Yousif NJ, Sanger JR (1994) Temporary
ectopic implantation of an amputated penis. Plast
Reconstr Surg 93:408-412
30. Jimenez-Cruz JF, Garcia-Reboil L, Alonso M, Mroseta E,
Sanz S (1995) Microsurgical penis replantation after self-
mutilation. Eur Urol 27:246-248
236 E. Clinical Reconstructive Microsurgery
31. Darewicz J, Gatek L, Malczyk E, Davewicz B, Rogowski
K, Kudelski J (1996) Microsurgical replantation of the
amputated penis and scrotum in a 29-year- old man. Urol
Int 57:197-198
32. Fan J, Eriksson M, Rosenlund AF, Nordstrom RE (1996)
An unusually avulsed penis successfully replanted by
using microsurgical technique. Plast Reconstr Surg 98:
571-573
33. Ishida 0, Ikuta Y, Shirane T, Nakahara M (1996) Penile
replantation after self-inflicted complete amputation: case
report. J Reconstr Microsurg 12:23-26
34. Rantuck AJ, Lobis MR, Ciocca R, Weiss RE (1996) Penile
replantation using the leech Hirudo medicinalis. Urology
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35. Becker M, Hofner K, Lassner F, Pallua N, Berger A (1997)
Replantation of the complete external genitals. Plast
Reconstr Surg 99:1165-1168
36. Kayikcioglu A, Ozcan G (1998) Partial necrosis of an am-
putated penis following replantation in a heavy smoker: a
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37. Nejedly A, Tvrdek M, Bodianova K, Urban M (1998)
Penile replantation-a case report. Acta Chir Plast 40:
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38. Hashem FK,Ahmed S, al-Malaq AA,AbuDaia JM (1999)
Successful replantation of penile amputation (post-
circumcision) complicated by prolonged ischaemia. Br J
Plast Surg 52:308-310
39. Lidman D, Danielsson P, Abdiu A, Fiahraeus B (1999) The
functional result two years after a microsurgical penile
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40. Zenn MR, Carson CC 3rd, Patel MP (2000) Replantation
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41. Ney C, Miller HL, Friedenberg RM (1976) Various
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119: 69-73
1.9 Replantation of a Completely Amputated Ear
NORITAKA ISOGAI and HIROSHI KAMIISHI
Traumatic ear amputation is a rare injury that presents
significant cosmetic impairment, often with psychologi-
cal impact. Prior to the development of replantation
procedures, efforts at reconstruction using various flaps
often resulted in very poor outcomes. The introduction
of microsurgical techniques has led to the achievement
of very favorable aesthetic results. However, damage to
the small vessels from the initial trauma often necessi-
tates deep resection to find adequate vessels and the
subsequent application of interpositional vein grafts.
Furthermore, identification and differentiation of the
small vessels, especially veins, are difficult and can make
the replantation prone to venous congestion. In this
chapter, we present our experience with the anatomy,
surgical approach, postoperative management, and final
outcome of ear replantation.
Anatomy
The superficial temporal vessel and posterior auricular
vessels are two important systems that provide over-
lapping vascular territories to the ear. The blood supply
to the upper portion of the ear arises from the superfi-
cial temporal artery [1], whereas the middle and lower
portions and most of the posterior surface are nourished
by the posterior auricular artery [2]. The dominant
blood supply to the ear comes from the posterior auric-
ular artery, and therefore this vessel is most often used
for the microarterial anastomosis. This artery has a pre-
dictable course along the posterior surface of the ear,
and the branching pattern over the ear is consistent. The
posterior auricular artery gives off three principal
branches: the upper, middle, and lower. These branches
run straight in a cephalic direction above the perichon-
drium. Their occurrence, as determined by cadaveric
studies, is 59% (upper), 100% (middle), and 93%
(lower) (Fig. 1). The branches are sizable, and the mean
external diameters are 0.7mm (upper), 0.6-0.7mm
(middle), and 0.8mm (lower) at the tributary point;
however, these vessels narrow or disappear abruptly in
their courses [3].
Surgical Procedure
There are three main phases of the microsurgical
replantation procedure for the amputated ear: initial
thorough debridement of skin and cartilage, microvas-
cular reconstruction of the posterior auricular artery
and vein, and postoperative management. The avulsion
injury to the ear often generates intimal tears of the
associated vessels [4]. This can make it very difficult
to find healthy vessels of appropriate sizes for the
microvascular repairs. To proceed to revascularization
of the amputated part, one of three techniques has to
be chosen: primary vascular repair, vein grafting, or use
of pedicled vascular axis (superficial temporal or poste-
rior auricular vessels) [5]. Direct anastomosis to the
superficial temporal vessels or posterior auricular
vessels, when they are undamaged, reduces the
incidence of postoperative vascular occlusion. The
venous channels will become visible only after arterial
flow has been restored [6], and thus the arterial side
should be repaired first. The postoperative course is
occasionally complicated by venous thrombosis; this
requires the use of medicinal leeches, mechanical
drainage where leeches are unavailable or cannot be
made to attach, or administration of anticoagulation
for salvage [7-9]. A review of the literature reveals
a high incidence of venous congestion, necessitating
the application of external decompression therapy,
together with early and aggressive treatment with
leech therapy [8], with a resultant high salvage rate.
Because the elastic cartilage framework with no
internally circulating blood constitutes the majority
of the ear mass, the metabolic demand of the ear is
relatively small. Even a single artery repair with
no venous anastomosis can be used successfully,
presumably because of the low oxygen consumption
237
238 E. Clinical Reconstructive Microsurgery
of this tissue [10]. Surgeons attempting ear replanta-
tion should therefore be aware of the high rate of ear
survival in the case of no apparent venous outflow.
Case 1 (Total Ear Replantation)
A 20-year-old woman suffered amputation of her right
ear in a train accident. The lower lateral two-thirds of the
ear was completely amputated (Fig. 2A and B). The
Fig. 1. Arterial distribution of the posterior auricular artery.
Arrow shows the line of the posterior auricular sulcus (modi-
fied from [3], with permission)
Fig. 2. Case 1. A 20-year-old woman involved in a train accident. A Residual ear before replantation. B The amputated ear C
Arrow shows the site of microvascular anastomoses. D Right ear immediately following replantation. (See Color Plates)
patient was transferred to our hospital for evaluation and
possible replantation. Under general anesthesia, the
auricular cartilage was trimmed and sutured in its posi-
tion. The lower branch of the posterior auricular artery
(0.3 mm in outer diameter [11]) was then exposed on the
posterior surface of the ear. The proximal ends of the
posterior auricular artery and vein were isolated and
transposed anteriorly. Arterial end-to-end anastomosis
was performed with 11-0 nylon suture under the
operating microscope. Prior to clamp release, fibrin glue
(Bolheal, Chemo-Sero-Therapeutic Research Institute,
Kumamoto,Japan) was topically applied to seal the gaps
between sutures [12,13]. After removal of the microvas-
cular clamps, there was immediate rapid perfusion of the
replanted segment, which allowed identification of a
small vein. A venous end-to-end anastomosis measuring
0.3 mm in diameter was performed with 11-0 nylon
suture (Fig. 2C and D). The total ischemic time was 8hr.
There were no signs of arterial or venous insufficiency
postoperatively. The replanted ear healed completely,
with 100% survival, resulting in an essentially normal-
appearing external ear (Fig. 3A and B). In addition, the
ear regained normal touch and two-point sensibility,
despite no direct effort at nerve repair. Postoperative
circulation measured by laser Doppler flow meter
(ALF21N,Advance Co., Tokyo, Japan) 6 months after the
surgery demonstrated excellent perfusion and viability
(Fig.3C).
Case 2 (Partial Ear Replantation)
A 29-year-old man sustained complete amputation of
the upper part of the left ear from a machine injury.
Exploration of the amputated part revealed a single
 1.9. Replantation of a Completely Amputated Ear 239

Fig. 3. Case 1. A The normal left ear. B Six months following

right ear replantation. C Laser fiowmetry at 6 months follow-
ing replantation

C
Blood Flow
ml/min/1 009r
20

10

o
Control ear Replanted ear

Fig. 4. a e 2. A 29-yearold man who u taincd a machine

injury. A Re idual ear before replantation . B The amputated
ear. Two month foil wing replantation 0 The n rmal
right ar. Thermograph of th replanted part how d el -
vated kin temp rature ( 6. 0 el iu ) 2 month after
replantali n. FTherm graph of the normal right car h \II
a temperature f 34.00 el iu (ee I r Plate)
240 E. Clinical Reconstructive Microsurgery
identifiable artery measuring O.2mm in diameter on the
posterior aspect of the ear. This artery was anastomosed
end-to-end to a branch of the posterior auricular artery
with 11-0 nylon suture and fibrin glue. There was no
suitable vein for anastomosis (Fig. 4A and B). In the
recovery room, the ear appeared slightly congested and
the congestion continued. We started the patient on
our standard microvascular pharmacologic regimen
(80 ~g/day of prostaglandin E1 and 24,000 units/day of
urokinase intravenously) for 7 days. On the seventh
postoperative day, the appearance of the ear improved.
The replanted ear healed completely, with no significant
residual deformity (Fig. 4C and D). Postoperative ther-
mography (Thermotracer 6T67, Nippon Electric, Tokyo
Japan) demonstrated elevated skin temperature in the
replanted portion (Fig. 4E and F).
Summary
Since the first report of successful microsurgical ear
replantation in 1980 [14], at least 20 cases have been
reported in the English literature. These cases have
involved a variety of different mechanisms of injury
and methods of treatment. In the management of a
traumatically severed ear, microvascular replantation
should be considered as the intervention of first choice.
When the procedure is successful, the cosmetic results
are excellent.
References
1. Park C, Lineaweaver WC, Rumly TO, Buncke HJ (1992)
Arterial supply of the anterior ear. Plast Reconstr Surg
90:38-44
2. Imanishi N, Nakajima H, Aiso S (1997) Arterial anatomy
of the ear. Okajimas Folia Anat Jpn 73:313-323
3. Park C, Shin KS, Kang HS, Lee YH, Lew JD (1988) A new
arterial flap from the postauricular surface: its anatomic
basis and clinical application. Plast Reconstr Surg 82:
498-504
4. Otto A, Schoeller T, Wechselberger G, Ohler K (1999)
Successful ear replantation without venous anastomosis
by using leeches. Handchir Mikrochir Plast Chir 31 :98-101
5. Kind GM, Buncke GM, Placik OJ, Jansen DA, D'Amore
T, Buncke HJ Jr (1997) Total ear replantation. Plast
Reconstr Surg 99:1858-1867
6. Finical SJ, Keller KM, Lovett JE (1998) Postoperative
ramification of total ear replantation. Ann Plast Surg
41:667-670
7. Cho BH, Ahn HB (1999) Microsurgical replantation of a
partial ear with leech therapy. Ann Plast Surg 43:427-429
8. Concannon MJ, Puckett CL (1998) Microsurgical replan-
tation of an ear in a child without venous repair. Plast
Reconstr Surg 102:2088-2093
9. Nath RK, Kraemer BA,Azizzadeh A (1998) Complete ear
replantation without venous anastomosis. Microsurgery
18:282-285
10. Safak T, Ozcan G, Kecik A, Gursu G (1993) Microvascu-
lar ear replantation with no vein anastomosis. Plast
Reconstr Surg 92:945-948
11. Isogai N, Kamiishi H (1989) Usefulness of the silicone
microsurgical background. Plast Reconstr Surg 84:366-
367
12. Isogai N, Fukunishi K, Kamiishi H (1992) Use of fibrin
glue to minimize bleeding of microvascular repairs in
hypertensive rats. Microsurgery 13:321-324
13. Isogai N, Cooley BC, Kamiishi H (1996) Clinical outcome
of digital replantation using the fibrin glue-assisted
microvascular anastomosis technique. J Hand Surg 21B:
573-575
14. Pennington DG, Lei MF, Pelly AD (1980) Successful
replantation of a completely avulsed ear by microvascu-
lar anastomosis. Plast Reconstr Surg 65:820--823
1.10 Replantation of a Totally Avulsed Scalp
HIROSHI KAMIISHI and NORITAKA ISOGAI
Total scalp avulsion is a rare injury that can be success-
fully treated by replantation of the entire isolated scalp
using microvascular anastomosis. The first successful
replantation of a totally avulsed scalp was reported by
Miller et al. in 1976 [1]. Since then, many similar cases
have been reported, in which microvascular reconstruc-
tion played a critical role [2-7]. A clear appreciation of
the underlying anatomy of the scalp and extensive expe-
rience in microvascular anastomosis are required to
achieve a successful outcome following this devastating
injury.
Anatomy of the Scalp
The scalp is composed of five layers in the order indi-
cated by the acronym SCALP (Fig. 1): skin (S), sub-
Cutaneous tissue (C), musculo-Aponeurotic (A), Loose
subaponeurotic layer (L), and underlying Periosteum
(P) [8]. The skin is very thick, with many hair follicles
and associated sebaceous and sweat glands. The subcu-
taneous tissue is a fibro-fatty layer consisting of a dense
connective tissue that is bound by fibrous bundles to
both the overlying skin and the underlying musculo-
aponeurotic layer. The blood vessels and nerves are con-
tained in this subcutaneous layer, and profuse bleeding
occurs when this layer is incised. The musculo-
aponeurotic layer, also called the galea aponeurotica, is
a dense fibrous sheet that connects anteriorly to the
frontalis muscle, posteriorly to the occipital muscle, and
laterally to the temporal fascia.
The subaponeurotic layer is a loose connective tissue
between the musculo-aponeurotic layer and the under-
lying layer of the cranial periosteum. This layer consists
of loose areolar tissue that permits shearing movement
of the scalp over the cranium. The tissue separation
associated with scalp avulsion injuries occurs at this
level. The tendinous connections of the musculo-
aponeurotic layer with adjacent muscles (insertions of
the frontalis and occipitalis muscles and the temporal
fascia) are the most common marginal boundaries of
scalp avulsions.
The pericranium (periosteum) is the deepest layer
of the scalp, overlying the cranium. This layer is firmly
adhered to the cranium, particularly at the suture lines,
and thus is not included in the avulsed portion.
The blood supply of the scalp consists of numerous
anastomoses in a rich network crossing the midline. The
main blood supply originates from the external carotid
arteries and drains via the external jugular veins. The
supratrochlear artery of the frontal area, the superficial
temporal artery in the temporal region, and the poste-
rior auricular artery and occipital artery of the posterior
neck are the main feeding arteries. The venous drainage
of the scalp consists of the concomitant veins, the
perforating veins in the parietal region, and the veins
flowing to the cavernous sinus in the frontal-ethmoidal
region. The superficial temporal artery and vein are
most frequently used to revascularize the avulsed
scalp.
The innervation of the scalp is harder to distinguish
than the vasculature. Sensory afferents to the scalp arise
from the supratrochlear and supraorbital nerves in the
frontal region, the auriculotemporal nerve in the tem-
poral region, the great auricular nerve in the posterior
auricular area, and the greater occipital nerve in the
posterior neck. The motor innervation of the scalp mus-
culature originates in the temporal branch to the frontal
muscles and the posterior auricular branch to the occip-
ital muscles.
Clinical Manifestation
A total scalp avulsion was seen in a female patient
whose long hair was caught in a machine. The area of
torn scalp extended from the galea aponeurotica to
include the frontal muscle, the occipital muscle, and the
temporal fascia. Because of the intimate connection of
the galea aponeurotica to these structures, the margins
of the torn scalp ran around toward the mastoid process
from the supraorbital ridge to the occipital nuchal line.
The eyebrows and upper eyelids were involved in the
line of laceration in the front (Fig. 2). The facial appear-
ance of the patient at the emergency department was
241
242 E. Clinical Reconstructive Microsurgery
Sub-<:utaneous tissue
Musculo-aponeurotlc
Loose subaponeurotic
II I
SCALP
Fig. 1. Layers of the scalp
pale and anemic, consistent with massive blood loss that
often accompanies these injuries. Hypovolemic shock
should be considered as a first priority in the initial
treatment at the emergency department. A thorough
evaluation for potential head and spinal trauma should
also be made.
Treatment of Scalp Avulsion
The avulsed scalp is carefully examined prior to the
microvascular anastomosis. The hair should be cut short
with shaving of a limited area to facilitate skin closure
upon completion of the microvascular anastomoses.
When damaged or necrotic tissue is apparent, debride-
ment should be kept to a minimum. Both surfaces of the
scalp are gently irrigated with a copious amount of
saline solution. The scalp is kept moist and cool accord-
ing to standard sterile technique.
Replantation of Avulsed Scalp
After the establishment of endotracheally admini-
stered general anesthesia, the traumatized recipient
bed is carefully examined. When hemostasis has been
achieved, the transected end of the pulsating superficial
temporal artery is usually readily identified in the
preauricular region. The scalp is replaced anatomically
and sutured loosely. The preauricular area is a privi-
leged site for the microvascular anastomosis. The initial
anastomosis should be undertaken on the superficial
temporal artery (Fig. 3). This allows establishment of
early recirculation to the scalp and also makes it possi-
ble to find outflowing veins that can be used for the
venous anastomosis. After the arterial anastomosis has
been completed and blood flow has been admitted,
major points of venous bleeding from the avulsed scalp
are clamped and prepared for anastomosis. These are
connected to the closest available veins of the recipient
Fig.2. A 22-year-old woman. Preoperative view of patient fol-
lowing total scalp avulsion. The area of tearing extends from
the galea aponeurotica to the frontal muscle, temporal fascia,
and occipital muscle. The eyebrows and upper eyelids are
involved in front
bed. Vein grafting is frequently necessary and makes it
possible to achieve tension-free anastomoses at both
the arterial and venous levels, a key factor in obtaining
a successful result.
After one pair of vessels has been connected, addi-
tional anastomoses should be considered at the tempo-
ral vessels, occipital vessels, and supraorbital vessels
across the midline. In the case of Fig. 3, the left superfi-
cial temporal artery (STA) and vein was anastomosed
first, and then the blackflow into the right supraorbital
vein was identified and anastomosis with interpositional
vein graft (harvested from the dorsal pedis) was accom-
plished. N ahai and colleagues advocate the repair of at
least two arteries and three veins [3]. We prefer to have
more venous repairs than arterial repairs to provide
good venous drainage that leads to less bleeding from
the replanted scalp. After completion of the microvas-
cular anastomoses, microneurorrhaphy of both the
supraorbital and facial nerves should be considered as
additional procedures.
Postoperative Management
Postoperative care for the replanted scalp is similar to
that for other procedures involving microvascular anas-
tomoses (e.g., free flap transfer) until the patient has
attained both local and general stability for the injuries
(Fig. 4). Various methods have been utilized for the
evaluation of postoperative changes of circulation. We
prefer to use medical thermography as a noninvasive
measure of the circulatory status of the replant (Fig. 5).
 1.10. Replantation of a Totally Avulsed Scalp 243

Fig. 3. Appearance of the patient 1 month postoperatively. replanted scalp within a couple of months postoperatively, and
The function of the levator and orbicularis oculi muscles the dermal sensation of the scalp was recovered with the
appeared to have returned. Regrowth of scalp hair was noted. exception of slight hyposensitivity to temperature in the latest
Sensory recovery was noted along the suture line of the result

Fig.5. Thermography of the revascularized scalp 5 days post-

Fig. 4. Appearance at 18 months, with normal hair growth operatively. Circulation across the midline has been estab-
lished in the replanted scalp. (See Color Plates)
244 E. Clinical Reconstructive Microsurgery
Positioning of the head is particularly important in
the early postoperative period. To protect the occipital
region from pressure necrosis, the patient is kept in
the Fowler position with a bulky dressing. A halo frame
in the occipital region is also useful to permit the patient
to maintain a supine position postoperatively.
References
1. Miller GDG, Anstee EJ, Shell JA (1976) Successful replan-
tation of an avulsed scalp by microvascular anastomoses.
Plast Reconstr Surg 58:133-136
2. Alpert BS, Buncke HJ, Mathes SJ (1982) Surgical treatment
of the totally avulsed scalp. Clin Plast Surg 9:145-159
3. Nahai F, Hester TR, Julkiewicz MJ (1985) Microsurgical
replantation of the scalp. Trauma 25:897-902
4. Chater NL, Buncke H, Brownstein M (1978) Revascular-
ization of the scalp by microsurgical techniques after com-
plete avulsion. Neurosurgery 2:269-272
5. McCann J, O'Donoghue J, Kaf-AI Ghazal S, Johnston S,
Khan K (1994) Microvascular replantation of a completely
avulsed scalp. Microsurgery 15:639-642
6. Chen I-C, Wan H-L (1996) Microsurgical replantation of
avulsed scalps. Reconstr Microsurg 12:105-112
7. Cheng K, Zhou S, Jiang K, Wang S, Deng J, Huang W, Chang
T (1996) Microsurgical replantation of the avulsed scalp:
report of 20 cases. Plast Reconstr Surg 97:1099-1106
8. Pansky B (1971) Review of Gross Anatomy, 2nd edn.
Macmillan, New York, pp 14-17
2. Harvesting Techniques for
Several Composite Tissues
2.1 General Concepts of Skin Flaps
YOSHIHISA SHINTOMI, YUHEI YAMAMOTO, KUNIHIKO NOHIRA,
This chapter gives the current concept of skin flaps,
with regard to their blood supply pattern and method
of transfer.
History
Initially, extensive clinical experience with various kinds
of skin flaps showed that skin flaps with length/breadth
ratios less than 1: 2 could survive. This flap survival
concept improved the reliability of skin flap surgery,
although the disadvantages of limited flap length and
rotation arc remained. To solve these problems, an alter-
native skin flap containing an axial arteriovenous system
within it was developed. This type of skin flap had a
greater flap length and rotation arc. In 1973, McGregor
and Morgan classified skin flaps into two categories
according to their vascular anatomy: axial and random
pattern flaps [1]. Classically, an axial pattern flap is
defined as a flap that has an anatomically recognized
arteriovenous system running along its long axis, and a
random pattern flap as a flap that lacks any significant
bias in its vascular pattern. However, many plastic sur-
geons have noticed some predominating axial plexuses
in the skin and underlying fascia based on their clini-
cal experience of random pattern flaps. Cormack and
Lamberty suggested the concept of a flap with an alter-
native vascular pattern that is dependent for its survival
on the fascial network of vessels aligned parallel to the
long axis of the flap: an axial fasciocutaneous flap [2]. At
present, the angiosome concept, which has been devel-
oped by Taylor and colleagues since 1987, supports the
existence of such vascular axiality in the skin and under-
lying tissues along the cutaneous and motor nerves [3-5].
Komatsu and Tamai reported the successful replanta-
tion of a completely severed thumb using the microvas-
cular surgical technique in 1968 [6]. This report became
a trigger to the development of a new concept of micro-
surgical free flap transfer, in which an axial pattern flap
would survive in any area to which it was transferred
if the vascular pedicle was successfully anastomosed to
the adjacent recipient vessels. Five years later, on the
basis of several basic and clinical studies, a successful
and HIROSHI FURUKAWA
transfer of a free flap was first reported [7]. In the 1970s,
the groin flap and the deltopectoral flap were frequently
used as free flaps; however their vascular pedicles were
too small, and they had a wide range of anatomic vari-
ations and survival areas. Such technical difficulties in
microsurgical transfer of these flaps had limited their
clinical applications. Accordingly, many microvascular
surgeons waited for the development of an alternative
type of flap containing a large vascular pedicle with a
constant anatomy, which would be ideal for free flap
transfer. This hope was fulfilled by the introduction of
the myocutaneous flap concept in the late 1970s [8]. The
myocutaneous flap has a large vascular pedicle with a
constant anatomy, so that it can be transferred as a
free flap without difficulty. Since then, the myocutaneous
free flap has been developed for widespread clinical
applications in various fields of reconstructive micro-
surgery. Recently, with the development of micro-
surgical techniques and equipment, some microvascular
surgeons have tried to develop an alternative type of
free flap supplied by a small perforator. This perforator
free flap has the advantages of providing a thinner skin
flap and causing less damage to the donor site, but
has not yet been generally accepted for reconstructive
microsurgery. It is important to select the best flap for
each defect with consideration of the anatomic source,
volume, vascular pedicle size, donor morbidity, and reli-
ability of the flap (Fig. 1). We microvascular surgeons
have to contribute to the development of both recon-
structive microsurgery and macroscopic reconstruction.
Classification
We summarize the current concepts of skin flaps accord-
ing to their vascularity and method of transfer (Fig. 2).
Axial Flap
An axial flap includes an anatomically recognized artery
and its accompanying vein along the long axis of the
flap. The end of the single vascular pedicle is identified
247
248 E. Clinical Reconstructive Microsurgery

even at the distal margin of the flap. This category
contains the radial forearm flap, lateral arm flap, dor-
salis pedis flap, and medial plantar flap (Fig. 3).
Axial Plexus Flap
An axial plexus flap includes either a main trunk or
a branch of an anatomically recognized artery and its
Bone o :Microvascular anastomosis
Fat
Skin
accompanying vein in the proximal region of the
flap. The distal region of the flap is nourished by the
fascial vascular plexus, which has an axiality aligned
parallel to the long axis of the flap. This category con-
tains the deltopectoral flap, scapular flap, and groin flap
(Fig. 4).
The venoadipofascial (VAF) and neuroadipofascial
(NAF) flaps may be placed in this category [9]. These
flaps are supplied mainly by the accompanying small
arteries of a cutaneous vein andlor nerve. The long axis
of the flap is designed along the cutaneous vein andlor
nerve, such as the external jugular vein, cephalic vein,
brachial cutaneous nerve, great saphenous vein, lesser
saphenous vein, femoral cutaneous nerve, sural nerve
(Fig. 5).

spin thickness Random Flap

skin

A random flap is supplied through a randomly oriented

Short & small sized pedicle
Skillful & risky
Less morbidity
Fig. 1. Anatomical principles of free tissue transfer
vascular network. Survival of the flap is limited by its
length-to-breadth proportions (Fig. 6). This category
contains the so-called local flaps, such as the rotation
flap, transposition flap, and advance-ment flap (Fig. 7),
as well as subcutaneous pedicled flaps, such as the
V-Y advancement flap and trans-position flap (Fig. 8),
according to their methods of transfer.

Fig. 2. Current concept of skin flaps with their

blood supply pattern. VAF, venoadipofascial;
NAF, neuroadipofascial
 2.1. General Concepts of Skin Flaps 249

Fig. 3. Schematic drawing of vascularity of an axial flap. Fig. 4. Schematic drawing of vascularity of an axial plexus
Midline indicates an anatomically recognized artery flap. Dark lines indicate a main trunk or branch of an anatom-
ically recognized artery and axial fascial plexus

Fig. 5. Schematic drawing of vascularity of a VAF/NAF flap. Fig. 6. Schematic drawing of vascularity of a random
Midline indicates a cutaneous vein and/or nerve flap

The perforator flap can be placed both in this cate- or osteomuscular region. The flap designed in the areas
gory and in the category of axial plexus flaps [10]. A of the forearm, abdomen, buttock, thigh, and lower
perforator flap is supplied by the perforating vessels leg is clinically developed. The territory of the flap is
from the intramuscular, septocutaneous, intertendinous, dependent on the vascular network pattern connected
250 E. Clinical Reconstructive Microsurgery

r ~

Rotation
0
IL ~

Transpoaltlon
S
~ ~

Advancement
r
Fig. 7. Schematic drawing of method of transfer of a random
flap, so-called local flap: rotation flap, transposition flap, and
advancement flap

Fig. 9. Schematic drawing of vascularity of a perforator flap.

Dark point indicates a perforating vessel

VYadvancem nt
Transposition
Fig.8. Schematic drawing of method of transfer of a random
flap, so-called subcutaneous pedicled flap: V-Y advancement
flap and transposition flap
with the perforating vessels. If the long axis of the flap
is designed along the axial fascial plexus, the flap
belongs to the category of axial plexus flaps. However,
if there is not an appropriate axial plexus connected
with the perforating vessels, the flap belongs to the cat-
egory of random flaps, and it could be called a "vascu-
larly augmented random flap " (Fig. 9).
References
10. Koshima I, Inagawa K, Okumoto K, Moriguchi T (1998)
1. McGregor lA, Morgan G (1973) Axial and random
pattern flaps. Br J Plast Surg 26:202-213
2. Cormack GC, Lamberty GH (1986) The arterial anatomy
of skin flaps. Churchill Livingstone, Edinburgh London
Melbourne and New York, pp 440-441
3. Taylor GI, Palmer JH (1987) The vascular territories
(angiosomes) of the body: Experimental study and clini-
cal applications. Br J Plast Surg 40:113-141
4. Taylor GI, Caddy CM, Watterson PA, Crock JG (1990)
The venous territories (venosomes) of the human body:
Experimental study and clinical implications. Plast Re-
constr Surg 86:185-213
5. Taylor GI, Gianoutsos MP, Morris SF (1994) The neu-
rovascular territories of the skin and muscles: Anatomic
study and clinical implications. Plast Reconstr Surg 94:
1-36
6. Komatsu S, Tarnai S (1968) Successful replantation of a
completely cut-off thumb. Plast Reconstr Surg 42:374-377
7. Taylor GI, Daniel RK (1973) The free flap: Composite
tissue transfer by vascular anastomosis. Aust NZ J Surg
43:1-3
8. McCraw JB, Dibbell DG, Carraway JH (1977) Clinical
definition of independent myocutaneous vascular territo-
ries. Plast Reconstr Surg 60:341-352
9. Nakajima H , Imanishi N, Fukuzumi S, Minabe T, Aiso S,
Fujino T (1998) Accompanying arteries of the cutaneous
veins and cutaneous nerves in the extremities: Anato-
mical study and a concept of the venoadipofascial and/or
neuroadipofascial pedicled fasciocutaneous flap. Plast
Reconstr Surg 102:779-791
Perforator flaps: Recent advancement of microvas-
cular surgery and establishment of a new flap concept.
(Sentsushihiben-Bishokekkangeka no shinpo to aratana
hiben gainen no kakuritu). J Jpn PRS (Nikkeikaishi) 18:
1-8
2.1.1 Scapular Flap
KOHZO FUJISAWA
The scapular flap was originally designed by Dos Santos
based on a cadaveric study of the subscapular branch of
the axillary vessels in 1980 [1] and was first clinically
transplanted by Gilbert in 1982 [2]. Later, Urbaniak [3]
and Sekiguchi [4] reported the usefulness of the flap
in the reconstruction of large soft-tissue defects. The
scapular flap is supplied by the circumflex scapular
vessels, which are the first branches of the subscapular
vessels. The circumflex scapular artery is consistently
large and constant in position. The flap is relatively thin,
with much less subcutaneous fat than the groin flap, and
is hairless, which makes the flap suitable for head and
neck reconstruction.
A very large flap is available. Usually as much as
30cm x 10cm can be taken, and the donor defect can be
closed by direct approximation. The circumflex scapular
vessels give off osseous branches running along the
lateral border of the scapula, which makes it possible to
raise a relatively straight vascularized bone flap as large
as 12 x 2 x 1.S cm, with a triangular cross section inde-
pendent of the skin paddle. The osteocutaneous scapu-
lar flap is mostly used in facial reconstruction, especially
in mandibular and maxillary reconstruction by plastic
surgeons. The author [S] and Sekikguchi [4] have
expanded the application of the osseous flap to ortho-
pedic conditions, such as aseptic femoral head necrosis
and congenital pseudarthrosis of the tibia. The second
branch of the subscapular vessel is the thoracodorsalis
vessel, which descends along the anterior border of the
latissimus dorsi muscle and supplies the whole muscle.
Thus, one can raise a complex composite flap composed
of a scapular cutaneous flap, a scapular osseous flap, and
a latissimus dorsi myo- or myocutaneous flap based on
subscapular vessels that can cover a huge area with a
complex configuration.
Donor Harvesting Technique
Vascular Anatomy (Fig. 1)
The subscapular artery gives off two arteries, the cir-
cumflex scapular artery (CSA) and the thoracodorsal
artery (TDA). The CSA turns posteriorly and travels
through the triangular space, a space bounded superi-
orly by the long head of the triceps muscle, laterally by
the teres major and latissimus dorsi muscle, and medi-
ally by the teres minor muscle. It gives off branches to
the teres muscles and the infraspinatus muscle, and
osseous branches to the lateral border of the scapula,
and then rises to the surface of the back. The artery
descends along the lateral border of the scapula before
dividing into the two cutaneous branches, the transverse
branch and the descending branch, about 2cm below
the triangular space. Based on the territories of the two
large terminal branches, Gilbert designed two types of
scapular cutaneous flaps, the classic transverse flap and
the parascapular flap [2]. The vascular pedicle of the
flaps is 4 to 8 cm in length with a calibre of 1.8 to
2.S mm; however, if the subscapular artery is included,
they can be raised on longer pedicles of 7 to 11 cm with
an external diameter of 3 to Smm. Although the cir-
cumflex scapular artery is accompanied by two large,
thin-walled veins, the subscapular artery often has only
one concomitant vein, especially at its base.
Design of the Flap (Fig. 2)
The scapula is outlined with a skin marker. The trian-
gular space can be palpated lateral to the scapula, and
with this as a guide, the circumflex scapular artery has
to be located with a Doppler probe at the point where
the artery rises to the surface of the back. The point
is 2cm above the posterior axillary fold according to
Urbaniak [3]. In the case of transverse flap, using a
horizontal line from the point across the vertebral spine
and with this line as the axis, the flap is designed supe-
riorly and inferiorly to it. In the case of the parascapu-
lar flap, a line from the same point to the scapular
inferior angle, which corresponds to the course of the
descending branch, is used, and a flap is designed on
both sides of it.
251
252 E. Clinical Reconstructive Microsurgery

B,b

Fig. 1. Schematic drawing of the circumflex scapular artery.},

Axillary artery; 2, subscapular artery; 3, Ascending branch of
circumflex scapular artery; 4, Circumflex scapular artery; 5,
Transverse cutaneous branch of circumflex scapular artery; 6,
Descending branch of circumflex scapular artery

,'...---- .......... "....- ...... \

"
" ... \ \ ........ ~ ............ "- ... ',
. . --1-:----........ :..... . . . . . . -"'--',
_',
""
,
""
','
..............'
....... , \
,/~~///~ , Ii c,d

,
I Fig. 3. a A 46-year-old woman with an extensive ulcer in the
I
I
lower anterior aspect of the right leg. b The ulcer, including
,
I
I
the unstable scar, was excised. A parascapular flap, 27 em x
,,
I
I2cm, was harvested. c The resultant skin defect was covered
,, , with the flap. The subscapularis vessels were anastomosed to
, ,
'-' the peroneal vessels. d Appearance of the leg 2 years post-
operatively. The patient does not have any difficulties in activi-
ties of daily living, such as sitting and walking

especially when the flap is raised as an osteocutaneous

Fig. 2. Design of the scapular and parascapular flaps. A, flap. Once the CSA has been identified by palpation, the
Scapular flap. Draw a horizontal line from the triangular
shoulder joint is abducted to widen the triangular space,
space. The flap extends to either side of the line. B, Paras-
which makes it easier to identify the osseous branches.
capular flap. Draw a line from the triangular space to the lower
angle of the scapula. The flap extends to either side of the line The dissection is continued along the vascular pedicle.
To include the subscapularis vessels, other branches,
including the thoracodorsalis vessels and muscle
Harvesting the Flap branches to the teres muscles, are ligated and cut, taking
meticulous care not to damage the vascular pedicle. For
The incision is first made at the upper border of the flap, donor site closure, the skin edges are approximated
the flap is elevated at a plane just above the deep fascia, directly with the arm in the adducted position. How-
and the CSA is identifed in the triangular space. Some ever, if the defect exceeds 10cm in width, a skin graft is
authors recommend starting the skin incision medially; needed. The shoulder joint has to be immobilized in
however, we have found our approach to be much safer, adduction for a couple of weeks postoperatively.

References
1. Dos Santos LF (1983) The vascular anatomy and dissection
of the free scapular flap. Plast Reconstr Surg 73:599-603
2. Gilbert A, Teot L (1982) The free scapular flap. Plast
Reconstr Surg 69:601-604
3. Urbaniak JR, Koman LA, Goldner RD, Armstrong NB,
Numlay JA (1982) The vascularized cutaneous scapular
flap. Plast Reconstr Surg 69:772-778
2.1.1. Scapular Flap 253
4. Sekiguchi J, Kobayashi S, Ohmori K (1993) Use of the
osteocutaneous free scapular flap on the lower extremities.
Plast Reconstr Surg 91:103-112
5. Fujisawa K, Kato K, Sekiguchi S, Hineno R, Hirata H
(1992) The vascularized scapular osteocutaneous flap for
long bone reconstruction. (in Japanese) Cent Japan J
Orthop Surg Traumatol 35:673-674
6. Hamilton SGL, Morrison WA (1982) The free scapular flap.
Br J Plast Surg 35:2-7
2.1.2 Lateral Arm Flap
HIDECHIKA NAKASHIMA
Song and his colleagues first reported the lateral arm
flap in 1982 [1]. The lateral arm flap was further studied
with cadavers and clinical materials, and was reported
in detail by Katsaros in 1984 [2]. The use of this flap has
been gradually increasing in Japan. This flap can be used
as a sensory flap, and was also used as an osteocuta-
neous flap by Katsaros [3].
Anatomy
The profunda radial artery pierces the lateral intramus-
cular septum between the deltoid insertion and the
triceps brachii, and then bifurcates into the anterior
radial collateral artery (ARCA) and the posterior radial
collateral artery (PRCA). The ARCA passes medially
with the radial nerve. The PRCA runs distally between
the attachment of the lateral head of the triceps and the
brachialis muscles. The nutrient artery of the lateral arm
flap is the PRCA (Fig. 1). In my study of 10 cadavers, all
10 lateral arm flaps received the PRCA and the poste-
rior cutaneous nerve of the arm (PCNA). The PCNA
accompanying the PRCA was seen in 5 of 10 flaps
(Fig. 2).
Harvesting Technique
The PRCA can be observed at about 10cm proximal
to the lateral epicondyle of the humerus. The flap is
designed between 2 and 3 cm proximal to the lateral
epicondyle and the distal end of the deltoid muscle,
and its center line passes between them (Fig. 3).
The incision starts from the anterior margin of the
designed flap and dissects under the lateral head of the
triceps brachii muscle. After penetrating the inter-
muscular septum and branching off, the PRCA can be
observed at about lOcm proximal to the lateral epi-
254
condyle of the humerus. Before confirming the PRCA,
which penetrates the intermuscular septum, one should
confirm the radial nerve running between the brachialis
muscle and brachioradialis muscle. Then the flap is
elevated posteriorly, including the fascia of the triceps
brachii muscle. This flap is innervated by the posterior
cutaneous nerve of the arm (PCNA) and the posterior
cutaneous nerve of the forearm (PCNF). In 5 of 10
cadavers, the PCNA was observed to accompany the
PRCA.
Case Report
A 57-year-old woman had an avulsion injury of the
middle and ring fingers on the palmar aspect of her
left hand. Her middle and ring fingers were amputated
at the middle phalanx, associated with a skin defect at
their palmar aspect (Fig. 4). A 5 x 12cm lateral arm flap
transfer was performed. The PRCA and its comitant
vein were anastomosed to the metacarpal artery and the
comitant vein end-to-end. The flap was successfully
transferred to the left hand. Defatting of the flap was
performed 4 months postoperatively, and the patient
regained a useful hand function.
Discussion
We studied the neurovascular anatomy of the lateral
arm flap using 10 cadavers and 5 clinical cases. We could
find the PRCA, which is the nutrient artery of this flap,
in all of the cadavers and in 5 clinical cases. However,
the PCNA innervated the flap in 50% of the cadavers.
The lateral arm flap has several advantages, such as the
consistent presence of the nutrient artery and vein, easy
elevation of the flap, and its relative thinness. This flap
can be also used as a sensory flap.
 2.1.2. Lateral Arm Flap 255

Fig. 1. utrient ve el of the lateral

arm flap

Anterior radial
collateral artery

Posterior cutaneous
nerve of forearm

Profunda brachii artery

Radial collateral artery

Posterior cutaneous
nerve of arm

Flap

RN

-----b
(4 cases) (2 cases) (2 cases)

PCNF
I CIElI Posterior radial collateral artery (PRCA)
Comitant vein (CV)
c::::=l Posterior cutaneous nerve of forearm
(PCNF)
c::::=l Posterior cutaneous nerve of arm
(PCNA)
c::::=l Radial nerve (RN)
PRCA (1 case) PRCA (1 case)

Fig. 2. Nutrient vessels and nerves of the lateral arm flap in 10 cadavers

A line between the deltoid muscle

and the lateral epicondyle of the humerus

Deltoid Insertion of deltoid Flap Lateral epicondyle Fig. 3. Design of the lateral arm flap. From [2], with
muscle muscle of humerus permission
 256 E. Clinical Reconstructive Microsurgery

a be

d e,f

Fig.4. A 57-year-old woman with an avulsion injury of the left arm (PCNF) and posterior cutaneous nerve of the forearm
middle and ring fingers, associated with a palmer skin defect. (PCNF). f Harvested flap. g 3 weeks after operation. h 4
a Preoperative view. b Design of the flap. c Courses of nerves months after operation. (a-f See Color Plates)
and vessels to he flap. d,e Posterior cutaneous nerve of the

References
1. Song R (1982) The one-stage reconstruction. The upper
arm flap. Clin Plast Surg 9:27-39
2. Katsaros J, Schusterman M, Beppu M, Bamis C, Acland RD
(1984) The lateral upper arm flap: anatomy and clinical
applications. Ann Plast Surg 12:489-500
3. Katsaros J, Tan U (1991) The use of the lateral arm flap in
upper limb surgery. J Hand Surg 16A:598-604
4. Nakashima H, Hirano T, Yamamoto Y, Shimamura Y,
Yonemitsu H (1993) Experience with lateral upper arm
flaps. Orthop Traumatol (Jpn) 42:1228-1230
2.1.3 Radial Forearm Flap
TAKENORISAKADA
The radial forearm flap is prepared from the antero-
radial aspect of the forearm, which is nourished by the
radial artery and two concomitant veins, and by the
brachial cutaneous vein. This flap is also called a radial
"Chinese" forearm flap [1,2], retrograde radial forearm
flap [3], or distally based radial forearm flap [4]. Histori-
cally, however, the flap has also been called a forearm
flap [1,5], forearm island flap [6], reversed forearm flap
[7], including a posterior interosseous arterial flap and
ulnar arterial reverse forearm flap. The radial forearm
flap was first described by Yang Guo Fan, Chen Bao
Qui, and Gao Yu Zi, of the Shenyang Military Hospital,
in 1978 [1]. Muhlbauer visited the People's Republic
of China on a lecture tour in 1980, and Dr. Song, the
medical director of plastic and reconstructive surgery at
the Ba-Da-Chu near Peking, showed his small delega-
tion a number of free radial forearm flaps for recon-
struction of postburn faciocervical contracture [1,5].
They introduced these flaps to European plastic sur-
geons, and the radial forearm flap was then utilized for
reconstruction of the oral cavity, pharynx, and cranio-
cervical cancer, for plastic surgery of the external nose,
and for reconstruction of the amputated penis, making
the most of the characteristics of the flaps, its long vas-
cular pedicle and thinness [1,5,8]. Initially, this free flap
was used to reconstruct contralateral hand injuries, but
it was shown subsequently that the same flap could be
pedicled distally on the radial artery, and such a pedi-
cled flap began to be used as an island flap to cover skin
defects of the ipsilateral hand. In 1981, Stock reported
two cases of hand reconstruction utilizing the reverse
radial forearm flap [9]. Since then, the flap has been
used as a retrograde forearm flap for reconstruction of
defects of nerves, tendons, and bones and for crushing
injuries with large skin defects, and has also been widely
applied to hand surgery [9,10]. Biemer in 1983 extended
the method of thumb reconstruction by developing an
osteocutaneous flap with an incorporated radial bone
segment [9]. A sensory flap including the lateral ante-
brachial cutaneous nerve was subsequently developed.
In 1983, Ried reported the radial forearm flap contain-
ing the palmaris longus tendon and part of the tendi-
nous portion of the brachioradialis muscle [2]. These
vascularized tendon grafts were used for reconstruction
of the extensor tendons of the hand. The radial forearm
flap has the disadvantage of leaving an ugly scar at the
donor site on the forearm. Consequently, the fascial flap,
which does not require skin grafting to the donor site
after flap raising, was developed and used for recon-
struction of the gliding floor of tendons [3]. In 1994,
Sanger reported muscle grafting using a musculocuta-
neous compound flap from the brachioradialis muscle
vascularized by the radial recurrent artery and the per-
forating artery directly bifurcated from the radial artery
[11]. Recently, for minimal sacrifice of the main brachial
vessels, the distally based radial fascio-subcutaneous
flap, which preserves the radial artery and is nourished
by branches from a radial artery at the wrist joint, has
been developed [4]. The radial forearm flap is thin and
flexible and has a long vascular pedicle, and a large
reversed radial forearm flap can easily be raised with-
out requiring microsurgical manipulations. Compound
grafting is also possible with this flap, and it is useful for
reconstruction of crushing injuries of the hand, includ-
ing defects of nerves, bones, and tendons. This article
focuses on reconstruction of the hand using the radial
forearm flap; relevant anatomical and basic matter and
surgical methods are also discussed.
Anatomy and Basic Research
The radial artery and the ulnar artery branch from the
brachial artery at the level 1-2cm distal to the elbow
joint. The radial artery passes through the space
between the inferior margin of the brachioradialis (BR)
muscle and the flexor carpi radialis (FCR) muscle in the
forearm, then extends the superficial palmar branch at
the wrist joint level to form the superficial palmar arch.
The radial artery after branching runs beneath the
tendons of the abductor pollicis longus and extensor
pollicis brevis, reaches the anatomical snuff box, then
passes through the first digital space and connects with
the ulnar artery, forming the deep palmar arch. The
radial artery has a diameter of 2-3 mm at its brachial
portion and has two large comitant veins with a diame-
257
258 E. Clinical Reconstructive Microsurgery

ter of 3-4 mm. The anterior aspect of the forearm has line passing the ulnar margin of the BR muscle at the
many rami from the radial artery, which have been cubital fossa and the radial styloid process, and is
reported to be O.6mm in mean diameter [12]. Fifty covered with the BR muscle in the proximal forearm
percent of the rami from the radial artery branch portion. On this line, we raise the flap within a range of
between the BR and the FCR, and about 19% of them two-thirds distal to the length of the forearm. Although
branch between the BR and the pronator teres [12]. The the maximum size of a free flap was reported to be
palmaris longus is supported by two vascular systems: 10cm in width and 20cm in length, a flap of 10 x 12cm
the muscle belly is nourished by the ulnar artery, and can be collected, even in the case of a reverse flap [14].
the portion more distal than the musculotendinous This size is still large enough for reconstruction of a
junction is nourished by branches from the radial artery. thumb or the dorsal surface of the hand, and its vascu-
The BR is nourished by the radial recurrent artery, the lar pedicle is also long enough. To allow easy reversal of
radial artery, and the profunda brachii artery [12]. In the vascular pedicle when the flap is rotated, the pivot
cutaneotendinous flaps, the palmaris longus tendon can point should be placed 2-3 cm proximal to the wrist joint
be divided into two, and a total of four tendons can be (Fig. I-a). When the vascular pedicle is strongly strained,
grafted, including the FCR and BR tendons [13]. The this pivot point should be moved distally. Although some
circulation in the anterior aspect of the periosteum on consider that a flap of the same size as a skin defect is
the radius bone is nourished by the anterior interosseus large enough owing to the thinness and flexibility of
artery for its medial side and by the radial artery for its the flap, it is safer to plan the flap slightly larger than the
lateral side [12]. Thus, when grafting is performed using defect to be grafted. By using a pneumo-tourniquet, the
an osteocutaneous flap including a segment of the
radius bone, the graft containing the anterolateral
periosteum of the radius should be used.
Venous drainage in reverse radial forearm flaps has
also been investigated extensively. The reverse radial
forearm flap contains three venous systems, the venae
comitantes, the communicating veins between the venae
comitantes, and the vasa vasorum [14,15]. As the pos-
sible mechanisms by which retrograde flows occur
through these venous systems, the presence of a collat-
eral pathway bypassing venous valves, valve incompe-
tence due to venous overswelling, and the absence of
valves in small veins have been suggested [14,15]. In
1997, however, Nakajima demonstrated in his detailed
anatomical and perfusion studies that the three venous
systems listed above did have valves and there was no
retrograde collateral pathway bypassing venous valves.
He consequently suggested that the retrograde venous
flow was due to valve incompetence, and that veins with
a relatively weak valve resistance against the reverse
flow pressure functioned as drainage pathways [15].

Technique of Raising the Flap

This technique involves conducting a preoperative
Allen radial compression test and confirming that the
blood flow of the hand is well maintained by the ulnar
and interosseous arteries, even when the radial artery
is ligated. We usually do not perform preoperative
angiography. Fig. 1. a Elevated radial forearm flap. Design of radial
For reconstruction of the hand, we design preopera- forearm flap based on radial artery and venae comitantes.
tively a reverse arterial flap, taking the radial artery as Asterisk, Brachioradialis muscle (BR); star, flexor carpi radi-
the axis and the palmar side of the wrist joint as the pivot alis (FCR); P pivot point. b Intraoperative photograph of
point in the forearm. The radial artery is located on the radial forearm flap and skin graft on the donor site
 2.1.3. Radial Forearm Flap 259

flap is then raised. We secure the radial artery and two

comitant veins as a vascular bundle at the wrist joint, and
this bundle is raised in the proximal direction. The flap
is incised from its lateral and medial side to reach the
fascia of the BR and flexor carpi ulnaris (FCU) muscle,
and these fasciae are incised. We suture the fascia to the
skin, temporarily to prevent its separation from subcu-
taneous tissues, raising it to the subfascial level. In the
space between the BR and the FCR, the branches of the
radial artery are observed to perforate the fascia and to
nourish the flap and the radial periosteum. If necessary,
we can raise a flap as the composite graft, including the
palmaris longus (PL) tendon and a part of the radius.
The anterobrachiallateral cutaneous nerve is present on
the radial side of the vascular bundle. In the case of a
nonsensory flap, this nerve should not be sacrificed.
However, this nerve is often cut off because of the risk
of damaging the fascia. Even if the nerve is cut off, com-
plaints of sensory disorder are rare. After the comple-
tion of flap raising and prior to cutting of the radial
artery and vein on their proximal sides, the radial artery
and vein are clipped and blood flow in the flap is con-
firmed. After confirming that there is sufficient blood
flow in the flap, the radial artery and vein can be ligated.
In hand reconstruction, the flap is passed through the
subcutaneous tunnel of the wrist joint. Although the flap
can be rotated up to about 1800 , twisting and straining
of the vascular pedicle should be avoided as much as
possible. When the skin defect at the donor site is as
small as about 6cm, primary suture should be per-
formed, and when it is larger than 6cm, split-thickness
skin grafting is done (Fig.1-b). The occurrence of a post-
operative subcutaneous hematoma can be prevented by
inserting more than two drains. Although mild conges-
tion and swelling may be observed in the flap, little
partial necrosis is usually noted.

Advantages and Disadvantages

When a radial forearm flap is used as a sensory flap,

the recovery of perception is relatively poor, and a
two-point discrimination test shows 20mm or more. Fig. 2. a Injury of the right hand. b X-ray 12 months after
Although use of this flap can be considered when toe operation. The bone was fixed into the stump of the first
transfer or a wraparound flap is rejected by the patient metacarpal bone. c 12 months postoperative photograph of
for thumb reconstruction, it is not practical to expect the one stage reconstructed thumb and functional motion. The
recovery of perception at the finger pulp, and it has little lateral brachial cutaneous nerve was connected to the digital
merit as a sensory flap (Fig. 2). Thus, the neurovascular nerve. Two-point discrimination test showed 20mm
island flap from the ring finger is used additionally for
thumb reconstruction. Reported complications of this
flap include an ugly scar, adhesion of flexor tendons at
the donor site, anterobrachial hypesthesia, and reflex
sympathetic dystrophy (RSD) after nerve injury (Fig.
3). In particular, the ugly scar at the donor site is a cos-
260 E. Clinical Reconstructive Microsurgery

Fig.3. Donor defect grafted after transposition of the flap. 16

months postoperative photograph showing pigmentation,
scar, and adhesion of flexor tendons

metic problem, and hence this flap has no indication in

young women. If this flap must be used, only the sub-
cutaneous fascial flap should be grafted in such patients.
Although the radial artery is sacrificed in this flap, the
fingers show good results in the cold tolerance test and
have no particular problem under cold conditions. The
advantages and characteristics of the radial forearm flap
may be summarized as follows:
The flap can be prepared easily without causing any
anatomical modification, and can be achieved by a
single short surgical operation.
The flap has a long vascular pedicle, is thin and flexible,
and does not require postoperative defatting.
A large flap can be collected.
The flap has a relatively low risk, although the ugly scar
at the donor site remains a problem.
The flap allows preparation of compound flaps such
as neurosensory, osteocutaneous, tendocutaneous,
and musculocutaneous flaps.
The flap can be used as a fascial flap alone, and the
gliding floor of tendons can be reconstructed easily.
Because of these advantages and characteristics, the
radial forearm flap is indicated for hand reconstruction,
such as skin defects at the dorsal and palmar wrist joint,
release of adduction contracture of the thumb, and pre-
vention of tendon adhesion (Figs. 2 and 4). The flap
is particularly useful for reconstruction of soft tissue
defect accompanying tendon injuries of the hand in
emergency trauma cases.
Fig. 4. a Adducted contracture of the right thumb. b Appear-
ance 12 months after operation. The radial forearm flap inset
and healed
References
1. Muhlbauer W, Herndl E, Stock W (1982) The forearm
flap. Discussion by Ruyan Song. Plast Reconstr Surg
70:343-344
2. Reid CD, Moss LH (1983) One-stage flap repair with
vascularised tendon graft in a dorsal hand injury using
the "Chinese" forearm flap. Br J Plast Surg 36:473-479
3. Brawn R, Rechnic M, Neill-Cage DJ, School RT (1995)
The retrograde radial facial forearm flap: Surgical ration-
ale, technique, and clinical application. J Hand Surg 20A:
915-922
4. Weinzweig N, Chen L, Chen ZW (1994) The distally based
radial forearm fasciosubcutaneous flap with preservation
of the radial artery: Anatomic and clinical approach. Plast
Reconstr Surg 94:675-684
5. Muhlbauer W, Herndl E, Stock W (1982) The forearm flap.
Plast Reconstr Surg 70:336-342
6. Foucher G, Genechten V, Merle M, Michon J (1984) Single
stage thumb reconstruction by a composite forearm island
flap. J Hand Surg 9B:245-248

7. Mahoney J, Naiberg J (1987) Toe transfer to the vessels of
the reversed forearm flap. J Hand Surg 12A:62-65
8. Chang TS, Hwang WY (1984) Forearm flap in one-stage
reconstruction of the penis. Plast Reconstr Surg 74:251-
258
9. Biemer E, Stock W (1983) Total thumb reconstruction: A
one stage reconstruction using an os teo cutaneous forearm
flap. Br J Plast Surg 36:52-55
10. Soutar DS, Tanner NSB (1984) The radial forearm flap in
the management of soft tissue injuries of the hand. Br J
Plast Surg 37:18-26
11. Sanger JR, Ye Z, Yousif NJ, Matloub HS (1994) The
brachioradialis forearm flap: Anatomy and clinical
application. Plast Reconstr Surg 94:667-674
2.1.3. Radial Forearm Flap 261
12. Inoue Y, Taylor I (1996) The angiosomes of the forearm:
Anatomic and clinical implications. Plast Reconstr Surg
98:195-210
13. Yajima H, Tarnai S, Inada Y (1996) Reverse flow radial
forearm cutaneotendinous flap for soft tissue and tendon
defect in the hand. J Jpn Soc Surg Hand 13:623-626
14. Torii S, Namiki Y, Mori R (1987) Reverse-flow island flap:
Clinical report and venous dranage. Plast Reconstr Surg
79:600-609
15. Nakajima H, Imanishi N, Fujino T (1997) Venous drainage
of the radial forearm and anterior tibial reverse flow flaps:
Anatomical and radiographic perfusion studies. Br J Plast
Surg 50:389-401
2.1.4 Reverse Posterior Interosseous Flap
AKIHIRO FUKUI
Treatment of a skin defect of the hand is difficult
when the blood circulation is poor in the recipient
bed (for example, in the bones and tendons) and the
skin defect is extensive. Pedicle and rotation flaps were
generally used in the past. Recently, however, free flap
transplantation has become more popular with the
development of microsurgery. However, in this case,
attention should be paid to prevent thrombus formation
at the vascular anastomosed site. To solve this problem,
Zancolli et al. [1,2], Penteado et al. [3], and Cost et al.
[4] reported transfer of a posterior interosseous island
flap to a skin defect of the hand. This method has been
widely used.
Harvesting Technique
Branches of the posterior interosseous artery penetrat-
ing to the skin are detected with a Doppler ultrasound
flow meter on the line between the humeral lateral
epicondyle and the ulnar styloid process. Arterial pulsa-
tion can normally be heard in two or three places. A
skin design is made, and preferably also including a
subcutaneous vein as the draining vein to prevent flap
necrosis.
The skin is incised from the edge of the ulna. The
fascia of the extensor carpi ulnaris is incised and sutured
so as not to be detached from the skin. When the fascia
of the extensor carpi ulnaris is separated from the
muscle, the penetrating branches can be found through
the fascia of the extensor carpi ulnaris. The necessary
amount of skin is incised on the radial side (Fig. 1). As
is done in the fascia of the extensor carpi ulnaris, the
fascia of the extensor digiti minimi is incised and
sutured to prevent detachment from the skin. The
branches perforating the skin through the fascia of the
extensor digiti minimi on the radial side are found. The
cutaneous branches of the posterior interosseous artery
are dissected anteriorly and posteriorly, and then the
posterior interosseous artery is exposed. These proce-
dures enable us to remove the flap, including each fascia
of the extensor carpi ulnaris and of the extensor digiti
minimi (Fig. 2).
262
The posterior interosseous arteries and veins
originate in the common interosseous arteries and
veins, penetrate the interosseous membrane, and
bifurcate to the dorsal side of the forearm. The poste-
rior interosseous arteries and veins should be ligated at
this point and the flap reversed toward the distal area.
When the subcutaneous veins are not used for
drainage, the posterior interosseous veins should be
separated up to the more proximal site, so that a vein
about 1.5 cm long can be attached to the flap. This vein
will serve as a draining vein.
It is sometimes difficult to recognize the posterior
interosseous arteries and veins running at the distal site
under the fascia of the extensor carpi ulnaris. When the
flap is reversed, these vessels should not be compressed
between the extensor retinaculum and the skin.
Case Reports
Case 1
The right wrist of a 47-year-old man was caught in a
presser and crushed. Wounds 3 x 7 cm and 2 cm in length
were observed on the radial side of the metacarbopha-
langeal (MP) joint of the thumb, the hypothenar muscle,
and the dorsal surface of the wrist, respectively. The
stumps of the damaged interosseous muscle and the
radial artery were observed on the radial side of the MP
joint of the thumb, and the damaged hypothenar muscle
was exposed. The patient could not move the affected
fingers spontaneously. The thumb and index finger
were pale in color. The whole hand was dark violet in
color as a result of crushing (Fig. 3). Roentgenography
revealed fractures of the proximal phalanx of the index
and the metacarpal bone of the middle finger, and dis-
location of the carpometacarpal (CM) joints of all five
fingers and of the intercarpal bone. After the fracture
and dislocation of the bones had been repaired, the
tourniquet was loosened. The thumb and index finger
did not turn pink. No bleeding from the pulp of the
finger was observed on needle puncture. A zigzag skin
incision from the MP joint of the thumb to the wrist
 2.1.4. Reverse Posterior Interosseous Flap 263

Extensor carpi ulnaris

U: Ulna Extensor digiti minimi
R: Radius Posterior interosseous A & V
Interosseous membrane

Fig. 1. Schema of cross section of the flap

Fig.3. Crush wound with open fracture and dislocation of the

bone accompanying arterial thrombosis

E.t.nsor carp ulna"

Faseia ot E. C. U.

Fig.2. Schema of elevation of the flap. E. C. U, Extensor carpi-

ulnaris; E.D.M., extensor digiti minimi

joint revealed that a thrombus had formed in the ulnar

artery at the proximal of the wrist joint. The thrombus
was resected, and end-to-end anastomosis was per-
formed (Fig. 4). As a result, the index, middle, ring, and
little fingers regained a good color. The thumb, however,
did not recover its normal color. The common digital
arteries from the superficial palmar arch to the thumb
and the index finger were cut when the digital zone from
the superficial palmar arch toward the thumb was care-
fully observed. After a vein graft about 2 cm long taken
from the forearm was transplanted, the thumb regained
a healthy color. Artificial skin was put on the skin defect
on the palm and the dorsal surface of the hand.
However, necrosis occurred on the dorsal surface, and
the extensor tendon was exposed. After digital subtrac-
thrombus - end-t ....nd anastomosis
tlYombus - v.~ n aralt
Fig. 4. Schema of treatment for arterial thrombosis
tion angiography had been performed, we decided to
transfer the reverse posterior interosseous flap with the
posterior interosseous artery, which was shown clearly
by digital subtraction angiography. The flap, 4 x lOcm in
size, was transferred to cover the portion on the dorsal
surface of the hand where the tendon was exposed.
Split-thickness skin grafts were performed for other
264 E. Clinical Reconstructive Microsurgery
Fig. 5. The reverse flap was elevated
Fig. 6. The flap and grafted skin survived completely
portions (Fig. 5). The flap did not swell, and the trans-
ferred skin survived after the operation. The patient has
not been able to grasp objects firmly, but he can play
golf and is satisfied with the result (Fig. 6).
Case 2
A 68-year-old man had all fingers of one hand ampu-
tated completely by an electric saw (Fig. 7). According
to Tarnai's categories, the amputation of the thumb was
in zone III, and that of the other fingers was in zone IV.
Because the thumb was severely crushed, the ampu-
tated index finger was transplanted to the thumb, and
the middle finger and the ring finger were replanted in
their original positions. The little finger was not replanted
because it was not transported to our hospital. The re-
planted digits survived without problems (Fig. 8). After
the metacarpal bone of the index finger was resected, a
Fig. 7. All fingers were amputated completely
Fig. 8. After replantation, contraction of the first web
occurred
reverse posterior interosseous flap about 3 x 7 cm in size
was transferred (Fig. 9). We tried to attach the posterior
interosseous vein to the flap as a draining vein. The
posterior interosseous vein was separated as close as
possible to the most proximal site. As a result, a vein
1.5 cm long could be attached to the flap. The flap was
reversed, and the posterior interosseous vein and the
vein on the dorsal side of the hand were anastomosed.
Then the flap was sutured to the first web space where
the adductor muscle was separated. The primary skin
suturing was performed at the donor site. The flap
survived without postoperative problems (Fig. 10).
Discussion
In the past, pedicle and rotation flaps were generally
used to reconstruct defective hand skin accompany-
ing exposure of the tendons and bones. With the

Fig. 9. The reverse flap was transferred to first web
Fig. 10. The flap survived completely without problems
development of microsurgery, however, free flap
transplantation came to be widely performed. This
method, however, created an inevitable problem in that
a thrombus is formed following vascular anastomosis. To
avoid this condition, several methods of reverse flap
transplantation have been developed, so that vascular
anastomoses are seldom required. Typical examples
include a reverse radial forearm flap and reverse
posterior interosseous flap in the upper extremity.
A few papers have described the reverse posterior
interosseous flaps that were first reported by Zancolli
and Angrigiani [1] and Penteado et al. [3]. This flap can
be used as an osteocutaneous flap for reconstruction of
the thumb [4] and as a neurofasciocutaneous flap [5-7].
When a flap as much as 4cm in width is taken, primary
suturing is generally possible at the donor site. A larger
flap can be removed if skin grafting is to be performed
at the donor site. The reverse posterior interosseous flap
2.1.4. Reverse Posterior Interosseous Flap 265
is the one that has the posterior interosseous artery and
veins as stems and does not damage the main artery to
the hand. This flap does not, therefore, cause a failure of
blood circulation to the hand.
There are some problems in harvesting this flap.
Buchler and Frey [6] reported that the posterior
interosseous nerve crossed the posterior interosseous
artery in 3 of 36 cases. In two of these three cases, the
flap was transferred after division of the nerve and
sutured again. Buchler also reported that 7 of 34 flaps
became partially necrotic due to venous congestion.
Penteado et al. [3] reported absence of the anasto-
mosis at the distal forearm between the posterior and
anterior interosseous artery in 1 of 82 cases.
A posterior interosseous vein of sufficient length
can be attached to the flap by separating it up to the
proximal zone. It can be anastomosed with the vein in
the dorsal side the hand.
In some reports, the medial forearm subcutaneous
nerve included in the flap was sutured with the nerve in
the recipient bed. It can be assumed, however, that
application of a flap including the nerve might have as
poor a prognosis as application of the reverse forearm
flap.
The advantages of the reverse posterior interosseous
flap over the reverse radial forearm flap are as follows:
the reverse posterior interosseous flap causes no dam-
age to the essential arteries to the hand; postoperative
sensory abnormalities do not occur as a result of loss of
the flap; and primary suturing is possible when a small
flap is required (a larger flap can be removed if skin
grafting is to be performed at the donor site).
References
1. Zancolli EA, Angrigiani C (1986) Colgajo dorsal de
antebrazo (en "isla" con pediculo de vasos interoseos
posteriores). Rev Asoc Arg Ortop TraumatoI51:161-168
2. Zancolli EA, Angrigiani C (1988) Posterior interosseous
island forearm flap. J Hand Surg 13B:130-135
3. Penteado CV, Masquelet AC, Chevrel JP (1986) The
anatomic basis of the fasciocutaneous flap of the posterior
interosseous artery. Surg Radiol Anat 8:209-215
4. Costa H, Soutar DS (1988) The distally based island
posterior interosseous flap. Br J Plast Surg 41:221-227
5. Costa H, Smith R, McGrouther DA (1988) Thumb
reconstruction by the posterior interosseous osteocuta-
neous flap. Br J Plast Surg 41:228-233
6. Buchler U, Frey HP (1991) Retrograde posterior
interosseous flap. J Hand Surg 16A:283-292
7. Dadalt LG, Ulson HJR, Penteado CV (1994) Absence
of the anastomosis between the anterior and posterior
interosseous arteries in a posterior interosseous flap: a case
report. J Hand Surg 19A:22-25
2.1.5 Arterialized Island Flap in the Digits and Hands
YUH INADA
Although there are many reconstructive methods for
covering skin defects in the digits and hands, repair of
moderate or major soft-tissue defects still is controver-
sial. Of the various reconstructive methods, this chapter
describes surgical donor harvesting techniques of arte-
rialized island flaps in the digits and hands as follows:
1) Arterialized island flap nourished by the proper
digital artery
- Digital artery island flap, proximally based and reverse
digital artery island flap
- Dorsal middle phalangeal flap
- Reverse digital flag flap
2) Arterialized island flap nourished by the dorsal
arterial network with preservation of the proper digital
artery
- Proximal phalangeal island flap (proximally based and
reverse)
3) Arterialized island flap nourished by dorsal
metacarpal arteries
- Metacarpal artery island flap (proximally based and
reverse)
Digital Artery Island Flap
The digital artery island flap is nourished by the digital
artery with the surrounding areolar tissue, leaving the
proper digital nerve of the donor digit intact. The prox-
imally based digital artery island flap was first reported
by Rose [1] in 1983. Recent vascular research the digital
artery showed a constant vascular network between the
ulnar and radial digital arteries, even at the level of
the distal interphalangeal (DIP) joint [2,3]. In addition,
it is well known that the digital neurovascular bundle
includes a venous network within the surrounding
areolar tissue [4-6].
The distally based digital artery island was first
described by Weeks and Wray [7] in 1973. Kojima et al.
[8] reported a reverse digital artery island flap (RDAIF)
with a long vascular pedicle for the treatment of finger-
tip defects or pulp defects in the finger. Although the
proximally based digital artery island flap had a stable
266
flap take, as described by Rose, 13.3%-30% of the
RDAIF in previous series [9-11] showed venous insuf-
ficiency as a serious complication. However, some
authors found no complications with the RDAIF [8, 12,
13]. To improve venous insufficiency and unstable flap
take, we described the reverse digital flag flap (RDFF)
technique [10]. This type of flap contains a skin pedicle
approximately 2-4mm wide distally to improve venous
insufficiency. Nakayama and Soeda [14] in 1986
reported the importance of a small skin pedicle for
venous drainage in the arterial flap in rat experiments.
According to their results and our clinical results, a
trivial chain of skin within the pedicle of the reverse
digital flag flap appears to provide venous drainage.
Donor Harvesting Technique for the
Proximally Based Digital Artery
Island Flap (Fig. 1) [1]
The proximally based digital artery island flap is
designed to cover the lateral aspect of the donor digit.
The digital artery, mapped with a Doppler flowmeter, is
used as the central axis of the diamond-shaped island.
The exact location of the flap design on the donor digit
is determined by the desired length of the pedicle. First,
a zigzag incision is made over the digital palm. Under
microscopic dissection, the digital artery and its sur-
rounding areolar tissue are carefully dissected from the
proper digital nerve, leaving its areolar tissue for the
small venules to drain the flap. The flap is very carefully
raised from the underlying epitenon of the extensor
mechanism. It is not possible to preserve the small
branches of the proper digital nerve to both the dorsal
and the volar aspects of the digit. The proper digital
nerve is left in continuity. The distal end of the artery
and its areolar tissue are ligated entirely at the tip of the
flap. The flap is nourished only by the digital artery and
its areolar tissue, leaving the proper digital nerve of the
donor digit intact. After a subcutaneous tunnel is devel-
oped between the donor and recipient sites, the flap is
passed through the subcutaneous tunnel. The donor site
 2.1.5. Arterialized Island Flap in the Digits and Hands 267

Proper palmar digital nerve

Fig. 1. Schema shows the proximally based digital artery island flap

b c

Fig. 2. a A 41-year-old woman with a traumatic defect of the
distal phalanx of the right thumb. Two dorsal middle pha-
langeal flaps from the middle and ring fingers were raised and
transferred to the thumb defect with bilateral nerve sutures
between the proper digital nerves in the thumb and both
dorsal branches in the flaps. b Immediately after the opera-
tion. A full-thickness skin graft was performed for the donor
digits. c The flap showed temporary venous insufficiency for a
few days but survived. Static and moving two-point discrimi-
nation was 9mm and 8mm, respectively, at 6 months postop-
eratively. Slight scarring was noted at the donor sites
268 E. Clinical Reconstructive Microsurgery
Flap design
Fig.3. Schemata indicating the procedure of raising the reverse digital artery island flap. *1 Superficial sensory branch of radial
nerve. *2 Dorsal branch of proper digital nerve
is covered with a full-thickness skin graft harvested
from the medial inframalleolar aspect of the foot. Fol-
lowing the release of the air tourniquet, the circulation
of the flap should be confirmed, and it is loosely sutured
with interrupted 4-0 nylon threads (Fig. 2).
Donor Harvesting Technique for the
Reverse Digital Artery Island Flap
(Fig. 3) [8-13,15,16]
The reverse digital artery island flap is designed to cover
the dorsolateral aspect of the involved proximal
phalanx according to the size and shape of the pulp
defect on the same digit. The exact placement of the flap
design on the donor digit is determined by the desired
length of the pedicle. When the innervated flap is ele-
vated for the reconstruction of the pulp defect, a skin
incision between the corresponding metacarpal bones is
carried out at the proximal margin of the flap, and the
superficial sensory branch of the radial nerve is identi-
fied. The branch is dissected proximally, leaving a 1.0- to
1.5-cm nerve tail attached to the flap. First, a zigzag inci-
sion is made over the digital palm. Under microscopic
dissection, the digital artery and its areolar tissue are
carefully dissected from the proper digital nerve,
leaving its areolar tissue including small venules to drain
the flap. The flap is very carefully raised from the under-
lying epitenon of the extensor mechanism. The branch
of the proper digital nerve to the dorsum is also divided
about 1.0cm proximal to the flap margin and is included
in the flap in case of bilateral nerve reconstruction for
major pulp defect. The proper digital nerve is left in con-
tinuity. The proximal end of the artery and its areolar
tissue are ligated at the level of the proximal margin of
the flap. If possible, the surgeon should confirm finger
and flap circulation following release of the air tourni-
quet. The flap is nourished by the digital artery and its
areolar tissue alone, leaving the proper digital nerve of
the donor digit intact. Through a zigzag incision over the
lateral or volar aspect of the involved digit, the vascu-
lar pedicle is dissected to the level of the flap that can
easily be transferred to the pulp defect. The digital
artery is separated from the proper digital nerve to
about 5 mm proximal to the distal interphalangeal joint,
taking care not to injure the middle transverse digital
palmar arch. A tension-free epineural suture with 10-0
nylon thread is performed between the two sensory
nerves attached to the flap and both cut ends of the
digital nerves of the recipient wound. The donor site is
covered with a full-thickness skin graft. Following the
release of the air tourniquet, flap circulation should be
confirmed, and the flap is loosely closed with interruped
4-0 nylon sutures (Fig. 4).
Donor Harvesting Technique for the
Reverse Digital Flag Flap (Fig. 5) [10]
To solve the problems of venous insufficiency and unsta-
ble flap take, we developed the reverse digital flag flap
(RDFF) technique. This flap contains a skin pedicle only
2 to 4mm wide distally, as mentioned previously. The
donor harvesting technique for the flap is similar to that
for the reverse digital artery island flap. The RDFF is
designed like the flag-shaped skin island over the
dorsolateral aspect of the involved proximal phalanx
according to the size and shape of the pulp defect on
the same digit. When the innervated flap is elevated, the
procedure is the same as that for the reverse digital
 2.1.5. Arterialized Island Flap in the Digits and Hands 269

a-c

Fig. 4. a A 16-year-old boy with a complete fingertip ampu- using a zigzag incision, leaving the proper digital nerve intact.
tation (Tarnai zone I) of the right middle finger. A 12 x 15 mm c The flap survived completely without venous insufficiency.
reverse digital artery island flap was designed to cover the Static and moving two-point discrimination was 7mm and 8
palmar aspect of the proximal phalanx. b The flap was raised mm, respectively, without nerve sutures

Fig. 5. a,b Schemata showing the procedure of raising the

reverse digital flag flap. The reverse digital flag flap (RDFF)
contains only about 2 to 4 mm of skin pedicle distally. c The
c raised flap at operation
270 E. Clinical Reconstructive Microsurgery

a b

c d

Fig. 6. a A 35-year-old man with complete amputations of his
left middle and ring fingers, at the level of Tarnai zone 1 by an
electric saw. b A 3 x 5 cm reverse digital flag flap was elevated
with two branches of the digital nerve from the radial aspect
of his middle finger, and nerve sutures were performed for
each digit ipsilaterally. c The amputation stumps of both digits
were covered simultaneously with a large reverse digital flag
flap. d The flap showed complete survival, and was divided
into each digit 1 month after surgery. Slight nail deformity
was noted at 1 year follow-up. A large scar of the donor
site covered with full-thickness skin graft (FfSG) is a
disadvantage

artery island flap. We demonstrated stable flap take

compared with the survival rate of the reverse digital
artery island flap (Fig. 6).

Proximal Phalangeal Island Flap with

Preservation of the Digital Artery
(Fig. 7)
..... Area of coverage
*

The reverse digital artery island flap is used for recon-

struction of major fingertip defects. The main disadvan-
tage of this flap is that it requires sacrifice of a common
digital artery of the donor. To solve this problem, some
recent studies have reported the use of small flaps based
on the dorsal vascular network over the digit and hand.
Oberlin et al. [17] in 1988 and Bertelli and Pagliei [18]
in 1994 anatomically described the dorsal vascular Fig. 7. Design of the proximally based proximal phalangeal
network between the dorsal branches from the proper island flap. *1 Proximal artery. *2 Extensor tendon arcade
digital artery, and showed that a short pedicled island (ETA). *3 Distal artery. *4 Proper digital artery

flap could be elevated and survive completely. Bertelli
and Pagliei named the dorsal arterial network around
the interphalangeal joint the extensor tendon arcade,
and reported clinical applications of the proximally
based and reverse-flow proximal phalangeal island flaps
in 5 cases. Based on these studies and our anatomical
study, we reported the use of a long-pedicled digital
adipo-fascio-cutaneous island flap with preservation of
the digital artery to cover the skin defect of the finger
[19]. This flap was nourished by the vascular network
between the extensor tendon arcade and dorsal
branches stemming from the proper digital artery.
Seventeen flaps were performed in 13 patients for skin
defects exposing deep structures of the finger, such as
tendons, bones, and joints. The sizes of the island flaps
ranged from 1.5 x 2cm to 3 x 4cm. Flap survival was
excellent in 16 of 17 flaps. The largest extended flap, 3 x
4cm, showed venous insufficiency. It was successfully
treated by application of medical leeches for 2 days
postoperatively. All flaps survived, and no patient com-
plained of cold intolerance. In addition, postoperative
thermography showed no impairment of digital blood
supply, except for one digit in one patient who had reflex
sympathetic dystrophy of the hand preoperatively.
This flap not only preserves the proper digital artery,
but also may be useful to prevent cold intolerance as a
serious complication of the conventional reverse digital
artery island flap.
Donor Harvesting Technique for the
Reverse-Flow Proximal Phalangeal
Island Flap (Fig. 8) [17-19]
The reverse flap is designed to cover the lateral aspect
of the base of the proximal phalanx. The palmar border
2.1.5. Arterialized Island Flap in the Digits and Hands 271
Fig. 8. Schemata
showing the procedure
of raising the reverse
proximal phalangeal
island flap. *1 Proximal
artery. *2 Extensor
tendon arcade (ETA).
*3 Distal artery. *4
Proper digital artery
of the flap is incised taking care not to injure the proper
digital artery and nerve and not to serve the dorsal
branches at the level of distal proximal interphalangeal
joint. Next, the dorsal border of the flap is dissected,
taking care not to injure the subcutaneous tissue, from
5 mm dorsal and anterior to the extensor tendon border.
Sometimes the extensor tendon arcade cannot be seen
within the pedicle under tourniquet control. The flap is
raised with fascia and areolar tissue included. Indica-
tions for this flap are lateral defect of the fingertip and
dorsal and palmar defects over the proximal and middle
phalanges (Fig. 9).
Metacarpal Flap (Fig. 10)
In 650 dissections reported by Coleman and Anson [20]
in 1961, the first dorsal metacarpal artery was found in
83.0% of 100 specimens. The second, third, and fourth
dorsal metacarpal arteries pass in the corresponding
interosseous spaces on the dorsal surfaces of the respec-
tive interosseous muscles. In Coleman's studies, the
dorsal metacarpal artery was found in the second inter-
space in 98.7% of cases and in the third interspace in
92% of cases. However, the fourth metacarpal artery
was absent in 17.3 % of 75 specimens. In Adachi's study
[21], the fourth metacarpal artery was absent in 30% of
50 cases. Use of the dorsal metacarpal arterial network
of the hand to provide flaps started with Oberlin [17],
Kuhn [22], and Holevich [23]. Foucher [24] described
the composite Kite flap, a sensitive cutaneous island flap
based on the 1st dorsal interosseous artery and veins,
transferred to the skin defect of the thumb. Earley
[25,26] detailed the arterial supply of the first and
second web spaces, and its surgical applications. When
webspace vascular networks between the palmar and
dorsal arterial and venous networks were described, a
272 E. Clinical Reconstructive Microsurgery

a b

Fig. 9. a A 42-year-old man with a traumatic fingertip defect leaving the proper digital artery and nerve intact. b Postoper-
at the level of Tarnai zone II of the left index finger. A 3 x ative view at 1 year
4cm reverse proximal phalangeal island flap was raised,

Fig. 10. Schemata showing the metacarpal flaps.

The area distal to an arc indicates the area that
can be covered by this flap. *1 First metacarpal
artery. *2 Second metacarpal artery. *3 Third
1S1 dorsa.1metacarpal artery metacarpal artery. *4 Fourth metacarpal artery
island flap 10 the thumb

_~-- P ivol point

Area of coverage

reverse metacarpal flap become possible with a distal
vascular pedicle. Quaba [27] and Maruyama [28]
reported that the reverse dorsal metacarpal flaps
could survive based on these vascular networks in the
webspace. Dautel and Merle [29] described three vas-
cular network types between the palmar and dorsal
arterial systems: direct anastomosis, deep anastomotic
network adjacent to the bone, and superficial anasto-
motic networks. They reported that then frequen-
cies were 13.3%, 56.6%, and 66.6%, respectively, and
that deep and superficial anatomical systems may
coexist.
 2.1.5. Arterialized Island Flap in the Digits and Hands
Fig.n. a A 66-year-old man with a traumatic skin defect over
the fifth proximal phalanx at the dorsal site of replantation of
the left little finger. b The reverse metacarpal flap on the
Donor Harvesting Technique for the
First Metacarpal Flap To The Thumb
Foucher and Braun [24] described the donor harvesting
technique of the first metacarpal flap to the thumb. The
flap is designed to cover the dorsum of the proximal
phalanx of the index finger. The first dorsal metacarpal
artery is dissected up to the proximal end from the
dorsal carpal arch, going through a dorsal S-shaped
incision over the first interweb space. Two veins and
their areolar tissue around the first metacarpal artery
are included in the pedicle. The sensory branch of the
radial nerve into the flap is also included in the island
flap. The radial aspect of the flap is elevated first, taking
care not to injure the first metacarpal artery. Then the
skin island flap is carefully raised circumferentially
from the paratenon of the extensor apparatus and trans-
ferred to the skin defect of the thumb through the skin
tunnel.
Donor Harvesting Technique for the
Reverse Metacarpal Flap [25-30]
The reverse metacarpal flap is dissected under air
tourniquet control, but the upper extremity is not exsan-
guinated too much, so that the pedicle is clearly visible.
A Doppler flowmeter may be useful to confirm the exis-
273
fourth metacarpal vessels was transferred to the defect. c The
flap survived completely and the donor site could be closed
tence of the dorsal metacarpal arteries. The flap design
is determined by the configuration of the extensor
system. The flap is designed to cover the inter-
metacarpal space, and its proximal limit cannot be
extended beyond the point of divergence of the exten-
sor tendons. The incision is started parallel to the long
axis and carried down through the subcutaneous tissue
and the fascia over the dorsal interosseous muscles. The
dorsal metacarpal vessels can be identified under the
fascia and should be included in the flap. When the flap
is elevated over the second intermetacaral space, the
extensor system crosses obliquely over the vessels and
should be retracted proximally and radially. In the other
space, the extensor tendons also overlap the vessels
proximally, and they should be retracted to include the
vessels within the flap. The vessels are divided proxi-
mally and ligated. Flaps are elevated within the vessels
up to the web space, care being taken not to damage the
vascular network between the palmar and dorsal arte-
rial systems. The flap is transferred to the defect, and the
donor site can be closed primarily when the flap size is
less than 2cm in width (Fig. 11).
References
1. Rose EH (1983) Local arterialized island flap coverage of
difficult hand defects preserving donor digit sensibility.
Plast Reconstr Surg 72:848-857
274 E. Clinical Reconstructive Microsurgery
2. Gilbert A, Brunelli G (1991) Homodigital island advance-
ment flap. Finger tip and nailbed injuries. Churchill
Livingstone, pp 65-73
3. Strauch B, de Morura W (1990) Arterial system of the
fingers. J Hand Surg 15A:148-154
4. Eaton RG (1968) The digital neurovascular bundle. Clin
Orthop 61:176-185
5. Bucher U, Frey HP (1988) The dorsal middle phalangeal
finger flap. Handchir Mikrochir Plast Chir 20:147-153
6. Hirase Y, Kojima T, Matumura S (1992) A versatile one-
stage neurovascular flap for fingertip reconstruction: the
dorsal middle phalangeal flap. Plast Reconstr Surg 90:
1009-1015
7. Weeks PM, Wray RC (1978) Management of acute hand
injuries, 2nd edn. Mosby, St. Louis, pp 183-186
8. Kojima T, Hayashi Y, Sakurai N, Kata N, Tsutsida Y (1986)
Eleven cases of vascular pedicle island flap coverage for
difficult skin defects on the hand. J Jpn Soc Surg Hand 3:
350-354
9. Inada Y, Tarnai S, Fukui A, Yajima H, Tabuse H, Miyamoto
S, Inada M (1995) Clinical results in using versatile digital
artery flaps: efficacy of a reverse digital flag flap. Jpn J
Plast Reconstr Surg 38:941-949
10. Lai CS, Lin SD, Chou CK, Tsai CW (1992) A versatile
method for reconstruction of finger defects: reverse digital
artery flap. Br J Plast Surg 45:443-453
11. Kinoshita Y, Kojima T, Hirase Y, Matumua S, Hayashi H
(1993) Experiences in treating postoperative complica-
tions of vascular pedicle digital island flaps. Jpn J Plast
Reconstr Surg 36:161-168
12. Kojima T, Tsuchida Y, Hirase Y, Endo T (1990) Reverse
digital island flap. Br J Plast Surg 43:290-295
13. Sapp JW, Allen RJ, Dupin C (1993) A reversed digital
artery island flap for the treatment of fingertip injuries. J
Hand Surg 18A:528-534
14. Nakayama Y, Soeda S (1986) The unconventional vascu-
lar island flaps-experimental investigation. Jpn J Plast
Reconstr Surg 29:573-580
15. Lai CS, Lin SD, Chou CK, Tsai CW (1993) Innervated
reverse digital artery flap through bilateral neurorrhaphy
for pulp defects. Br J Plast Surg 46:483-488
16. Han SK, Lee BII, Kim WK (1998) The reverse digital
artery island flap: clinical experience in 120 fingers. Plast
Reconstr Surg 101:1006-1011
17. Oberlin C, Sarcy JJ, Alnot JY (1988) Apport arteriel
cutane de la main application a la realisation des lam-
beaux en llot. Ann Chir Main 7:122-125
18. Bertelli JA, Pagliei A (1994) Direct and reversed flow
proximal phalangeal island flap. J Hand Surg 19A:671-
680
19. Inada Y, Fukui A, Murata K, Omokawa S (1999) The
reverse homo digital adipo-fascial island flap with
preservation of the digital artery and nerve. J Jpn Plast
Reconstr Surg 19:489-494
20. Coleman SS, Anson BJ (1961) Arterial patterns in the
hand based upon a study of 650 specimens. Surg Gynecol
Obst 113:409-424
21. Adachi B (1928) Das Arteriensystem der Japaner. Band
1. Maruzen, Kyoto
22. Kuhn H (1961) Reconstruction du pouce par "lambeau de
Hilgenfeldt." Ann Chir Plast 6:259-268
23. Holevich J (1963) A new method of restoring sensibility
to the thumb. J Bone Joint Surg 45B:496-502
24. Foucher G, Braun JB (1979) A new island flap transfer
from the dorsum of the ledex to the thumb. Plast
Reconstr Surg 63:344-349
25. Earley MJ (1989) The second dorsal metacarpal artery
neurovascular island flap. J Hand Surg 14B:434-440
26. Earley MJ, Milner RH (1987) Dorsal metacarpal flaps. Br
J Plast Surg 40:333-341
27. Quaba AA, Davison PM (1990) The distally-based dorsal
hand flap. Br J Plast Surg 43:28-39
28. Maruyama Y (1990) The reverse dorsal metacarpal flap.
Br J Plast Surg 43:24-27
29. Dautel G, Merle M (1991) Dorsal metacarpal reverse
flaps. J Hand Surg 16B:400-405
30. Sawaizumi M, Maruyama Y, Yoshitake M (1995) The
clinical use of dorsal metacarpal flaps for the repair of
skin defects of the hand. Jpn J Plast Reconstr Surg 38:
911-919
2.1.6 New Flaps in the Hand
SHOHEI OMOKAWA, SHIGERU MIZUMOTO, AKIHIRO FUKUI,
The restoration of sensation of the finger is essential
for hand function, and recent research work in vascular
anatomy allowed new flaps in the hand to be developed
[1-10]. Palmar skin defects of the fingers have been
repaired using various local or island flaps in the hand
[11-18]. These flaps are not available to restore large
palmar defects of the fingers, and free flaps from the feet
and toes have been used to provide satisfactory cover-
age of these large defects [19-25]. However, difficulty
with donor site healing on the foot after the transfer
is a common problem. The palmar aspect of the hand
seems to have a high potential for sensory reconstruc-
tion of the fingers [26] and may provide a large and
well-vascularized coverage of the skin and soft tissue
defects. Although split- or full-thickness skin grafts
and two-staged pedicle grafts from the palm have
been widely used for palmar skin defects or tip injuries
of the fingers [27-29], there is a lack of information
regarding vascular and neural anatomy of the palm in
terms of a vascularized flap from this area. There
are several clinical reports in the recent literature
describing potential benefits of vascularized flaps from
the palm for finger reconstruction [30-39]. The follow-
ing sections present the anatomical background and
surgical technique of new flaps from the thenar and
hypothenar area of the hand. Since 1992, the authors
have experienced 32 cases of these vascularized flaps to
treat palmar skin and soft tissue defects of the fingers
with satisfactory results.
Radial Thenar Flap
Anatomical Background (Fig. 1)
Cutaneous vascularity of the thenar eminence is sup-
plied by blood vessels perforating the underlying thenar
muscles or fascia. The anatomical vascular basis of the
radial thenar flap is fasciocutaneous perforators arising
from the superficial palmar branch of the radial artery.
Dye-injection studies of cadaver arms reveal that the
superficial palmar branch supplies the radial aspect of
and SUSUMU TAMAI
the thenar eminence. The skin territory of this branch
averaged 5.1 cm x 3.4cm (length by width), which is
located over the proximal parts of the abductor pollicis
brevis and opponens pollicis muscles. The superficial
palmar branch connects with the other artery in the
palm in 63 % of the hand specimens. This vascular con-
nection enables reverse flow island flap transfer from
the thenar area for thumb reconstruction. The innerva-
tion of the radial aspect of the thenar eminence is chiefly
provided by the palmar branch of the superficial radial
nerve, and occasionally by the lateral antebrachial cuta-
neous nerve.
Harvesting Technique (Figs. 2 and 3)
The superficial palmar branch of the radial artery is
identified by palpation over the tubercle of the
scaphoid. This branch can be traced on the thenar
eminence by using a Doppler flowmeter. The flap
is designed with the traced artery lying in its center.
The dorsal margin of the flap design extends on the ex-
tensor pollicis brevis tendon to include the dorsal
metacarpal veins and palmar branch of the superficial
radial nerve. The skin incision is initiated along the
radio dorsal margin of the first metacarpus and the
radius. The palmar branch of the superficial radial nerve
is identified at the styloid process of the radius and then
carefully dissected and included in the flap. The flap
dissection is continued in a subfascial plane toward the
scaphoid. The arterial nutrient branch to the thenar
muscle is identified and ligated close to the insertion of
the muscle. The flap is safely elevated when soft tissue
attachment between the flap and the superficial palmar
branch is maintained by including the palmar aponeu-
rosis and subdermal fat tissue around the tuberosity of
the scaphoid in the flap. Dissection of the radial artery
toward the elbow is continued until the desired length
of vascular pedicle is obtained. Proximal dissection
of the nerve is also possible by interneural dissection.
Reverse flap is possible in the case where arterial con-
nection between the superficial palmar branch of the
radial artery and other arteries in the palm is assured
275
 Fig. 1. The superficial palmar branch (SPB) runs beneath the Fig. 2. Diagram of radial thenar flap design. RA, Radial
thenar fascia, giving off perforating branches (arrowhead) to artery; SRN, superficial radial nerve
the thenar fasciocutaneous area. The branch in this hand con-
nects with the superficial palmer arch (asterisk). (See Color
Plates)

a,b cd

e,f

Fig. 4. Vascular and neural anatomy of the fasciocutaneous
area of the hypothenar eminence, demonstrated on a cadaver
left hand. The photograph was taken from the dorsum of the
hand. An incision was made on the ulnar/dorsal aspect of the
hand and the dorsal skin was turned over to the palmar side,
maintaining the hypothenar fascia and fasciocutaneous perfo-
rators in the flap. The proximal part of the hand is on the right
of the illustration. The distal half of the ulnar aspect is sup-
plied by multiple fasciocutaneous perforation arteries (aster-
isks with closed centers) from the ulnar palmar digital artery
(UPDA) of the little finger. The proximal half of the ulnar
aspect is supplied by arteries (asterisk with open center)
emerging from the hypothenar muscles (HM). Sensory inner-
vation of the area is chiefly provided by the dorsal branch of
the ulnar nerve (DBUN). UDN, Ulnar digital nerve of the
little finger; D, dorsal; P, palmar. (See Color Plates)
by preoperative Doppler examination. A reverse flap of
approximately 3 x 2 cm is elevated from the proximal
aspect of the thenar eminence. After the superficial
palmar branch has been dissected retrogradely to a
distal point of rotation, the flap is transferred to cover
the defect of the thumb.
Ulnar Hypothenar Flap
Anatomical Background (Figs. 4 and 5)
The skin over the hypothenar eminence is nourished
by musculocutaneous or fasciocutaneous perforators
through the hypothenar muscles or fascia. The hy-
Fig.3. a Palmar skin and soft tissue defect of right index finger
b A 2 x 4.5 cm free radial thenar flap was designed. The area
marked by oblique lines was anesthetized by injection of 1%
lidocaine around the superficial radial nerve. c A fasciocuta-
neous flap pedicled by the radial artery and concomitant vein
and the superficial radial nerve branches. d Immediately post-
2.1.6. New Flap in the Hand 277
-
Fig. 5. Diagram of reverse ulnar hypothenar flap design.
UPDA, Ulnar palmar digital artery; SPA, Superficial pal-
maratch; DUN, dorsal branch of the ulnar nerve
pothenar eminence is divided into three territories
according to the type of nutrient artery supplying each
territory. Among these territories, the distal half of the
ulnar aspect of the hypothenar eminence (about 3 x
2cm, length by width), located over the abductor and
flexor digiti minimi muscles, has a constant vascular and
neural participation and is a feasible donor site for vas-
cularized flap surgery. The ulnar hypothenar flap is har-
vested from this area and based on fasciocutaneous
perforators from the ulnar palmar digital artery of the
little finger and the dorsal or palmar cutaneous branch
of the ulnar nerve.
Harvesting Technique (Fig. 6)
A fasciocutaneous flap is designed at the ulnar aspect
of the hypothenar eminence, which is located over the
distal half of the abductor digiti minimi muscle. The flap
is based on the ulnar palmar digital artery of the little
operative hand view. The donor site was temporarily covered
by artificial skin to reduce the possibility of congestion of the
flap. Delayed primary closure was carried out 2 weeks after
the surgery. e-g One-year postoperative views. There is no
finger stiffness, and the acquired sensibility in the flap area was
6mm of moving two-point discrimination
278 E. Clinical Reconstructive Microsurgery
a,b
Fig. 6. a,b Cursh injuries of the 3rd to 5th finger. Degloved
skin and soft tissue were necrotized in the little finger. c A 2
X 4cm reverse-flow ulnar hypothenar flap was transferred to
cover the defect. The flap was innervated by a small branch
finger, and in the case of pulp reconstruction, the flap is
innervated by the dorsal branch of the ulnar nerve or
branches of the ulnar palmar digital nerve of the little
finger. The flap is dissected in the subfascial plane from
the dorsal side of the hand, and multiple perforating
branches passing transversely from the ulnar palmar
digital artery are identified and included in the flap.
'''___ __ _____ c
from the dorsal branch of the ulnar nerve and the ulnar
palmar digital nerve of the little finger. The longitudinal
donor-site scar was resolved by multiple skin Z-plasties. d,e
Hand appearance 20 months postoperatively
It is important to keep the connection between the
flap and the ulnar palmar digital artery of the little
finger by including multiple perforating arteries and
small veins with fascial tissue over the hypothenar
muscle in order to decrease postoperative congestion of
the flap. After ligation of the ulnar palmar digital artery
and concomitant veins at the proximal side, followed by

retrograde dissection of them to a distal point of rotation,
the flap is transferred to cover the defects of the little
finger. The donor site can be primarily closed with or
without simultaneous mUltiple Z-plasties. After a bulky
dressing has been applied to the wound for 7 days, mobi-
lization of the little finger is permitted to obtain the full
range of motion at the metacarpophalangeal and inter-
phalangeal joints.
References
1. Bayon P, Pho RW (1988) Anatomical basis of dorsal
forearm flap. Based on posterior interosseous vessels. J
Hand Surg 13B:435-439
2. Strauch B, de Moura WJ (1990) Arterial system of the
fingers. J Hand Surg 15A:148-154
3. Dautel G, Merle M (1991) Dorsal metacarpal reverse flaps.
Anatomical basis and clinical application. J Hand Surg
16B:400-405
4. Bertelli JA, Khoury Z (1992) Neurocutaneous island flaps
in the hand: anatomical basis and preliminary results. Br
J Plast Surg 45:586-590
5. Endo T, Kojima T, Hirase Y (1992) Vascular anatomy of
the finger dorsum and a new idea for coverage of the
finger pulp defect that restores sensation. J Hand Surg
17A:927-932
6. Bertelli JA, Pagliei A (1994) A direct and reversed
flow proximal phalangeal island flap. J Hand Surg 19A:
671-680
7. Sherif MM (1994) First dorsal metacarpal artery flap in
hand reconstruction. I. Anatomical study. J Hand Surg
19A:26-31
8. Omokawa S, Ryu J, Tang JB, Han JS (1996) Anatomical
basis for a fasciocutaneous flap from the hypothenar emi-
nence of the hand. Br J Plast Surg 49:559-563
9. Omokawa S, Ryu J, Tang JB, Han J (1997) Vascular and
neural anatomy of the thenar area of the hand: its surgi-
cal applications. Plast Reconstr Surg 99:116-121
10. Karacalar A, Ozcan M (1998) U-I flap. Plast Reconstr
Surg 102:741-747
11. Krag C, Rasmussen B (1975) The neurovascular island
flap for defective sensibility of the thumb. J Bone Joint
Surg 57B:495-499
12. Foucher G, Braun JB (1979) A new island flap trans-
fer from the dorsum of the index to the thumb. Plast
Reconstr Surg 72:344-349
13. Venkataswami R, Subramanian N (1980) Oblique
triangular flap: a new method of repair for oblique
amputations of the fingertip and thumb. Plast Reconstr
Surg 66:296-300
14. Cohen BE, Cronin ED (1983) An innervated cross-finger
flap for fingertip reconstruction. Plast Reconstr Surg 72:
688-697
15. Dellon AL (1983) The proximal inset thenar flap for
fingertip reconstruction. Plast Reconstr Surg 72:698-
704
2.1.6. New Flap in the Hand 279
16. Hirase Y, Kojima T, Matsuura S (1992) A versatile one-
stage neurovascular flap for fingertip reconstruction: the
dorsal middle phalangeal finger flap. Plast Reconstr Surg
90:1009-1015
17. Karacalar A, Ozcan M (1994) Free arterialized venous
flap for the reconstruction of defects of the hand: new
modifications. J Reconstr Microsurg 10:243-248
18. Germann G, Hornung R, Raff T (1995) Two new ap-
plications for the first dorsal metacarpal artery pedicle
in the treatment of severe hand injuries. J Hand Surg
20B:525-528
19. May JW Jr, Chait LA, Cohen BE, O'Brien BM (1977)
Free neurovascular flap from the first web of the foot in
hand reconstruction. J Hand Surg 2:387-393
20. Morrison AW, O'Brien MB, Macheord MA (1980) Thumb
reconstruction with a free neurovascular wrap around flap
from the big toe. J Hand Surg 5A:575-583
21. Tsai TM, Aziz W (1991) Toe-to-thumb transfer: a new
technique. Plast Reconstr Surg 88:149-153
22. Lee WPA, May JW Jr (1992) Neurosensory free flaps to
the hand. Hand Clinic 8:465-477
23. Osaka S, Hoshi M, Sano S, Nozaki M, Yamamoto M
(1996) Description of new composite tissue transfer for
salvage of a complex hand defect. Clin Orthop 328:
91-93
24. Ninkovic M, Wechselberger G, Schwabegger A, Anderl H
(1996) The instep free flap to resurface palmar defects of
the hand. Plast Reconstr Surg 9:1489-1493
25. Foucher G, Chabaud M (1998) The bipolar lengthening
technique: a modified partial toe transfer for thumb recon-
struction. Plast Reconstr Surg 102:1981-1987
26. Gellis M, Pool R (1977) Two-point discrimination distance
in the normal hand and forearm. Plast Reconstr Surg 59:
57-63
27. Patton HS (1969) Split skin graft from hypothenar
area for fingertip avulsions. Plast Reconstr Surg 43:426-
429
28. Mack GR, Neviaser RJ, Wilson IN (1981) Free palmar
skin grafts for resurfacing digital defects. J Hand Surg 6A:
565-567
29. Shenck PR, Cheema TA (1984) Hypothenar skin grafts for
fingertip reconstruction. J Hand Surg 9:750-753
30. Chase RA, Hentz VR, Apfelberg D (1980) A dynamic
myocutaneous flap for hand reconstruction. J Hand Surg
5:594-599
31. Kojima T, Imai T, Endo T (1988) A study on cutaneous
vascularity of the hypothenar region and clinical applica-
tion as the hypothenar island flap. J Jpn Soc Surg Hand
5:645-649
32. Zancolli EA (1990) Olgajo cutaneo en isla del hueco de
la palma. Prensa Media Argentina 77:14-20
33. Rohrich RJ, Ehrlichman RJ, May JM Jr (1991) Sensate
palm of the hand free flap for forearm length preservation
in nonreplantable forearm amputation: long-term follow-
up. Ann Plast Surg 26:469-473
34. Gu YD, Zhang LY, Zhang GM (1992) Hypothenar flap.
Chinese J Hand Surg 8:865-868
35. Vasconez LO, Velasquez CA, RumleyT (1992) Correction
of a first web space contracture with an arterialzed palmar
280 E. Clinical Reconstructive Microsurgery
Iiap. In: Gilbert A (ed) Pedicle flaps of the upper limb.
Martin Dunitz, London, pp 135-138
36. Veda K, Inoue T (1994) The new palmaris brevis muscu-
locutaneous flap. Ann Plast Surg 32:529-534
37. Moiemen MS, Elliot D (1994) A modification of the
Zancolli reverse digital artery flap. J Hand Surg 19B:
142-146
38. Omokawa S, Mizumoto S, Iwai M, Tarnai S, Fukui A (1996)
Innervated radial thenar flap for sensory reconstruction of
fingers. J Hand Surg 21A:373-380
39. Iwasawa M, Ohtsuka Y, Kushima H, Kiyono M (1997)
Arterialized venous flaps from the thenar and hypothenar
regions for repairing finger pulp tissue losses. Plast
Reconstr Surg 99:1965-1970
2.1.7 Groin Flap
HISASHI OHTSUKA
The groin flap is one of the earliest axial pattern or free
flaps. In 1972, McGregor and Jackson [1] described the
vascular basis of the groin flap and introduced the
concept of axial blood supply. Daniel and Taylor [2]
reported the first microvascular transfer of the groin
flap in 1973. Harii and Ohmori's group [3-5] analyzed
the vascular patterns of supply to the groin from 87 flap
dissections in 1975, followed by Taylor and Daniel's 100
cadaver dissections [6].
The groin flap is rather difficult to dissect, because
it has pedicle vessels of small diameter, short length,
and variable anatomy and course, although there is little
functional loss at the donor site from the use of the flap,
and the donor scars are concealable [5,7].
Anatomy
There are two main arterial systems involved in the vas-
cular supply of the groin: the superficial circumflex iliac
artery (SCIA) and the superficial epigastric artery
(SEA). The SEA and SCIA may arise separately from
the femoral artery about 1 and 2 cm below the inguinal
ligament [5], or the SCIA sometimes arises from the
deep femoral artery. Several studies have established
four common variations in the arterial anatomy of this
region [4-7]: (1) both arteries arising from a common
trunk, (2) separate origins with SCIA and SEA of
similar size, (3) separate origins with the dominant
SCIA, and (4) separate origins with the dominant SEA
(Fig. 1). It is more reliable and safer to transfer a groin
flap in the case of the common trunk or the dominant
SCIA. The external diameter of the SCIA or SEA
ranges from 0.5 to 1.5 mm and that of the common trunk
from 1.0 to 2.0mm.
The SCIA runs towards the anterior superior iliac
spine, and the SEA runs upwards through the lower
abdomen. The SCIA usually divides into a superficial
and a deep branch at the medial border of the sartorius
muscle [5,7]. The superficial branch runs very close to
the sartorius fascia.
Most of the nutrient veins terminate at the saphenous
bulb. The superficial circumflex iliac vein (SCIV) almost
always drains into the saphenous bulb, either separately
or with the superficial epigastric vein (SEV) [7]. The
deep accompanying veins (venae comitantes) of the
SCIA and SEA at the femoral triangle drain into
the femoral vein by passing either anterior or posterior
to the femoral artery [7]. The external diameter of the
SCIV and the SEV ranges from 1.5 to 3.0mm.
Harvesting Technique
The SCIA, SEA, SCIV, SEV, femoral artery and vein,
inguinal ligament, anterior superior iliac spine, and so
forth are indicated by several marking pens before
surgery. The flap is designed as a spindle-shaped form,
a parallelogram, or a shape that coincides with the
recipient site (Figs. 2a and 3a). About two-thirds of
the flap lies above the line drawn between the anterior
superior iliac spine and the femoral artery 2 cm below
the inguinal ligament, and one-third lies below this line
[7].
Folded sheets are placed under the ipsilateral
buttock. An incision is made over the course of the
saphenous vein. Dissection of the great saphenous vein
towards the fossa ovalis exposes the SCIV and the
SEV.
The upper boundary of the flap is then incised,
and the skin and subcutaneous tissue are elevated off
the aponeurosis of the external oblique muscle [7]. The
size and course of the SEA and the SEV may be
evaluated during this maneuver. The lateral and
inferior portion of the skin incision is then made (Fig.
3b). The lateral aspect of the flap can be safely elevated
off the deep fascia until the lateral border of the sarto-
rius muscle is reached. The sartorius fascia is elevated
with the flap so as to protect the superficial branch of
the SCIA. The lateral femoral cutaneous nerve may
require division or may remain intact (Fig. 4). Repair of
this nerve is recommended if separation is unavoidable.
The SCIA, SEA, SCIV, and SEV are recognized on
the undersurface of the flap at the femoral triangle.
Each vascular pedicle should be dissected to its
origin from the femoral artery or vein, or from the
281
282 E. Clinical Reconstructive Microsurgery
Fig. 1. Arterial variations in the groin (representative pat-
terns). a The superficial circumflex iliac artery (SeIA) and the
superficial epigastric artery (SEA) arise from a common
saphenous bulb to provide maximal length (Figs. 2b, 3c,
3d, and 4b).
It is better to mark the vascular pedicles with a stitch
or vascular clamp before separation of the flap, because
the vessels will often retract into the subcutaneous fat
and become difficult to find again [7] (Fig. 2c).
Donor site defects can usually be closed with little
undermining (Fig. 2d). A closed suction drain should be
routinely used for 5 to 7 days (Fig. 5). Hypesthesia of
the anterior thigh may occur if the lateral femoral cuta-
neous nerve is injured or separated. Occasionally, a lym-
phocele will develop at the donor site as a result of
injury to the femoral lymphatics during the course of
dissection [7].
The size of a groin flap is usually 6 x 8 to 12 x 25 em,
but it can be as large as 20 x 35 em [7]. The groin
trunk. b Separate origins with SeIA and SEA of similar size.
c Separate origins with the dominant SeIA. d Separate origins
with the dominant SEA
flap has been used for soft tissue coverage for the upper
and lower extremity and for the head and neck area,
including the oral cavity [3,5,7,9-11]. It also has been
used for augmentation of progressive hemifacial
atrophy [12].
Case 1
A 22-year-old woman, who was involved in a love tri-
angle, attempted suicide with gasoline, resulting in a
severe burn scar contracture of the neck (Fig. 6a). The
neck contracture was released by partial excision of
scar tissue (Fig. 6b). The left facial artery and vein were
exposed as the recipient vessels. A 12 x 22 cm groin flap
was raised with a pedicle of the SEA, SCIA, and SCIV

Fig. 2. Elevation of the groin flap in a 22-year-old woman. a
Donor site design, showing the superficial circumflex iliac
artery (SCIA), superficial circumflex iliac vein (SCIV), super-
ficial epigastric artery (SEA), superficial epigastric vein
(SEV), inguinal ligament, and anterior superior iliac supine (X
mark). b The raised groin flap, showing the isolated SEA,
(Fig. 6c). The seIA and the SCIV were anastomosed to
the recipient artery and vein. The flap completely sur-
vived, with no recurrence of contracture, although small
Z-plasties were added 3 months later (Fig. 6d).
Case 2
A 22-year-old man had progressive hemifacial atrophy
on the left cheek to the upper lip (Fig. 7a). Through a
preauricular to submandibular incision, a cheek flap was
raised to make a subcutaneous pocket, and the facial
artery, the facial vein, and its branch were exposed to
serve as recipient vessels. A 10 x 18cm groin flap was
2.1.7. Groin Flap 283
SCIA, and SCIV (arrowheads) from the upper to the lower
direction. c The separated groin flap, showing the vascular
pedicles with microclamps (arrowheads). d Donor site scar 1
year postoperatively (from Shioya and Ohtsuka [8], with
permission)
raised with a pedicle of the common trunk of the SeIA
and the SEA, the SCIV, and the deep accompanying
vein of the SeIA. The groin flap was deepithelialized by
using a dermatome (Fig. 7b) and transferred into the
cheek subcutaneous pocket and revascularized with
anastomoses between facial vessels and the donor
vessels; facial artery to the common trunk of the SeIA
and the SEA, facial vein to the SeIV, and a branch of
the facial vein to the deep accompanying vein (Fig. 7c).
The results were satisfactory, although three consecu-
tive defatting operations were added: 9 months postop-
eratively by the submandibular approach, at 1 year and
1 month by the preauricular approach, and at 3 years
and 3 months by the left nasolabial approach (Fig. 7d).
Fig. 3. Elevation of the groin flap in a 22-year-old man. a lar pedicles. d Close-up view of the vascular pedicles, showing
Donor site design. b Almost completion of elevation of the the common trunk of the SCIA and the SEA, the deep accom-
groin flap. c Dissected groin flap, showing the isolated vascu- panying vein, and SCIV from the upper to the lower direction

Fig.4. Elevation of the groin flap in a 41-year-old male. a The the SEA and the SCIA on the upper, and SEV and the SCIV
groin flap was elevated with the intact lateral femoral cuta- on the lower
neous nerve. b Close-up view of the vascular pedicle, showing

284
 2.1.7. Groin Flap 285

Fig. 5. Donor site closure with a suction drain

Fig. 6. Case 1: A 22-year-old woman with burn scar contrac- groin flap. d One year after a free groin flap transfer (from
ture of the neck. a Severe burn scar of the neck. b Partial scar Shioya and Ohtsuka [8], with permission)
excision and exposure of the recipient vessels. c The separated
286 E. Clinical Reconstructive Microsurgery

Fig. 7. Case 2: A 22-year-old man with left

progressive hemifacial atrophy. a Preoperative
findings. b Deepithelializing groin flap with a
dermatome. c Completion of vascular anasto-
moses (arrowheads) and insertion of the flap.
d Six years after the first operation

References 8. Shioya N, Ohtsuka H (1986) Principles of plastic and

reconstructive surgery. Igaku-Shoin, Tokyo, p 61
9. O'Brien BM, MacLeod AM, Hayhurst JW, Morrison WA
1. McGregor lA, Jackson IT (1972) The groin flap. Br J Plast
(1973) Successful transfer of a large island flap from the
Surg 25:3-16
groin to the foot by microvascular anastomoses. Plast
2. Daniel RK, Taylor GI (1973) Distant transfer of an island
Reconstr Surg 52:271-278
flap by microvascular anastomoses: A clinical technique.
10. Ohtsuka H, Kamiishi H, Saito H, Ito M, Shioya N (1976)
Plast Reconstr Surg 52:111-117
Successful free flap transfers with diseased recipient
3. Harii K, Ohmori K, Torii S, Murakami F Kasai Y
vessels. Br J Plast Surg 29:5-7
Sekiguchi J, Ohmori S (1975) Free groin flaps: Br J Plas~
11. Murakami R, Tanaka K, Kobayashi K, Fujii T, Sakito T,
Surg 28:225-237
Furukawa M, Kobayashi T, Shigeno K (1998) Free groin
4. Ohmori K, Harii K (1975) Free groin flaps: Their vascular
flap for reconstruction of the tongue and oral floor. J
basis. Br J Plast Surg 28:238-246
Reconstr Microsurg 14:49-55
5. Harii K (1983) Groin flap. In: Microvascular tissue trans-
12. Shintomi Y, Ohura T, Honda K, lida K (1981) The recon-
fer, fundamental techniques and clinical applications.
struction of progressive facial hemiatrophy by free vascu-
Igaku-Shoin, Tokyo, pp 48-57
larized dermis-fat flaps. Br J Plast Surg 34:398-409
6. Taylor GI, Daniel RK (1975) The anatomy of several free
flap donor sites. Plast Reconstr Surg 56:243-253
7. Hidalgo DA, Shaw WW (1987) Free groin flaps. In: Shaw
WW, Hidalgo DA (eds) Microsurgery in trauma. Futura
Publishing Company, New York, pp 303-311
2.1.8 Peroneal Flap
GENZABURO NISHI
Free vascularized fibular grafts were clinically applied
by Taylor et al. [1] in 1975 and are now widely and
successfully used for the treatment of extensive bone
defects created by trauma or resection of bone tumors,
as well as for repair of congenital or posttraumatic
pseudarthrosis. However, the inability to simultaneously
cover skin defects and the lack of any means of fre-
quently monitoring the patency of the anastomosed
vessels have been the greatest drawbacks of this
method.
In 1980, Chen et al. [2] simultaneously reconstructed
bone and skin defects by attaching a musculocutaneous
flap to a free vascularized fibular graft in a patient
with defects of the radius and cutaneous scarring of the
forearm as a result of trauma. In 1983, Yoshimura et al.
[3] and Okubo et al. [4] reported on the use of a fibular
graft and skin flap without muscle, after discovering the
existence of a perforating branch of the peroneal artery
that passed through the intermuscular septum between
the peroneus longus and soleus muscles to supply the
skin. Yoshimura et al. referred to this as a "monitoring
buoy flap" and used cadaver specimens to study the
location of the cutaneous branches, their origins, and the
skin territory nourished by these vessels. Yoshimura
et al. [5-7] used these vessels clinically to raise either
island flaps or free flaps and referred to them all as
peroneal flaps.
Anatomy
The peroneal artery, the main feeding vessel of a
peroneal flap, arises from the posterior tibial artery ap-
proximately 6-7 cm below the head of the fibula and
descends along the back of the fibula. As it descends, the
peroneal artery gives off one to three nutrient branches
to the fibula and an average of four or five cutaneous
branches. These cutaneous branches can be broadly
classified into the musculocutaneous type, which pene-
trate the flexor hallucis longus, peroneus longus, or
soleus muscles before reaching the skin, and the septo-
cutaneous type, which pass between the flexor hallucis
longus and peroneus brevis or between the peroneus
longus and soleus (i.e., through the posterior crural
septum) to supply the skin.
Musculocutaneous branches that run within the
soleus are abundant in the upper one-third of the leg,
whereas septocutaneous branches that pass through the
posterior crural septum tend to be more common in the
middle and lower thirds of the leg [8].
Preoperative Tests
The anterior and posterior tibial arteries are sometimes
absent and are compensated for by the peroneal artery.
Their presence therefore needs to be confirmed by
angiography of the donor limb. An alternative method
is to check whether good pulses are palpable for the
anterior and posterior tibial arteries on the dorsum of
the foot and behind the medial malleolus, respectively.
When harvesting a peroneal island flap, particularly
a reverse peroneal island flap, it is advisable to use
angiography to confirm the position of the most proxi-
mal cutaneous branch arising from the peroneal artery,
and the positions of communicating branches between
the peroneal artery and the anterior and posterior tibial
arteries, although this procedure will not identify all of
the cutaneous or communicating branches.
Cutaneous branches arising from the peroneal artery
in the middle to lower thirds of the leg can be identified
by scanning with a Doppler flowmeter along the line
that joins the posterior borders of the head of the
fibula and the lateral malleolus. The points at which
the Doppler unit detects maximum flow correspond to
the sites at which the cutaneous branches penetrate the
fascia. The sound volume of the Doppler unit and the
vessel diameter are correlated, so the points at which
the sound is loudest are marked on the skin. If the sound
is not clearly audible, the vessel may be too small to be
used. This information provides the basis for designing
the size and shape of the flap. A flap 22-25 cm long and
10-14cm wide can be raised over the posterior border
of the fibula.
287
288 E. Clinical Reconstructive Microsurgery
Harvesting Technique
Since the peroneal vessels are located behind the fibula,
the procedure is easier to perform if the patient is
placed in the lateral or prone position, rather than the
supine position. The lateral or prone position is strongly
advisable for those inexperienced in performing this
procedure. When surgery is carried out with the patient
supine, the hip on the donor side is flexed and internally
rotated with the knee flexed at 90 degrees. The peroneal
vessels are freed more easily if a pillow is placed under-
neath the knee and ankle with the leg horizontal to the
bed, so that the leg muscles are gently supported from
below (Fig. 1).
A pneumatic tourniquet is applied. A bloodless field
is attained by wrapping an Esmarch rubber bandage
around the lower limb from the foot to the thigh. The
bandage is not applied too tightly, thereby ensuring that
a little blood remains in the vessels to facilitate identi-
fication of the cutaneous branches. As an alternative
method, the pressure of the pneumatic tourniquet can
be increased after the lower limb has been raised for
several minutes to drain the blood. A pressure of 300 to
350mmHg is used. An outline of the flap, which encom-
passes the cutaneous branches confirmed by Doppler
flowmetry, is then marked on the skin.
The cutaneous branches in the midportion and the
distal one-third of the leg are used for the flap, because
cutaneous branches in the proximal one-third of the leg
sometimes arise from the posterior tibial, anterior tibial,
or popliteal arteries rather than from the peroneal
artery. The midportion and the distal one-third of the
leg contain more septocutaneous branches than muscu-
locutaneous branches.
Fig. 1. The peroneal artery is dissected more easily if a pillow
is placed underneath the knee and ankle with the leg hori-
zontal to the bed
The incision can be started at either the anterior [9]
or the posterior [10] margin of the flap (Fig. 2). When
starting at the anterior margin, care should be taken to
avoid damaging the superficial peroneal nerve, which
emerges directly below the deep fascia at the anterior
border of the peroneus longus muscle. An incision is
made in the deep fascia over the peroneus longus, and
the deep fascia is dissected posteriorly. The skin and
fascia are sutured together temporarily to prevent their
separation. The cutaneous branches arising from the
peroneal artery and penetrating the fascia at the poste-
rior border of the peroneus longus and soleus muscles
can be seen when the fascia and skin are retracted pos-
teriorly (Fig. 3). If the cutaneous branch is too small
or no branch can be identified, the incision is extended
proximally or distally to find a larger branch. If the
cutaneous branch is not located in the middle of the flap,
the design must be modified so that the flap is centered
over the branch. When there are multiple cutaneous
branches in the flap, as many as possible should be
included. Once it has been confirmed that the flap con-
tains a cutaneous branch of sufficient diameter, the pos-
terior margin of the flap is incised along the marked line,
3
Fig. 2. Cross-sectional view of dissection. a, Tibia; b, fibula;
MI, peroneus longus; M2, peroneus brevis; M3, flexor hallucis
longus; M4, soleus; M5, gastrocnemius; M6, tibialis posterior;
M7, flexor digitorum longus; MS, tibialis anterior; M9,
extensor hallucis longus; MIO, extensor digitorum longus; N,
superficial peroneal nerve; 1, peroneal vessels; 2, posterior
tibial vessels and nerve; 3, anterior tibial vessels and nerve' A
anterior approach; B, posterior approach ' ,

a a
Fig. 3. a A cutaneous branch of the peroneal artery can be
seen penetrating the fascia between the peroneus longus and
soleus muscles. b Diagram: MI, peroneus longus; M4, soleus;
F, fascia; C, cutaneous branch of peroneal artery and vein
and an incision is made in the deep fascia above the
soleus muscle, as was done for the anterior portion of
the flap. The fascia is dissected anteriorly and then
retracted in an anterior direction together with the skin.
The muscular branches to the peroneus longus and
soleus muscles are ligated and cut (Fig. 4). It is safer to
include the deep fascia if the flap is large, but small flaps
are less bulky if the fascia is excluded. Next, the skin
and fascia are retracted posteriorly again, the cutaneous
branch is traced to the posterior border of the fibula,
and the intermuscular septum attached to the fibula is
cut (Fig. 5). The cutaneous branch is followed further
toward the back of the fibula, and any branches to the
muscles and fibula are coagulated and cut. If the cuta-
neous branch runs within the soleus muscle, the vessel
is dissected free from the muscle tissue, and the muscu-
lar branches are ligated and cut during this process. The
main trunk of the peroneal artery is reached by cutting
2.1.8. Peroneal Flaps 289
b
Fig. 4. a The fascia is dissected and retracted anteriorly, after
which the muscular branches to the peroneal and soleus
muscles are ligated and cut. b Diagram: MI, peroneus longus;
M3, flexor hallucis longus; M4, soleus; F, fascia; FI, flap; M,
muscular branches; C, cutaneous branches of the peroneal
artery and vein
the flexor hallucis longus muscle at its origin from the
fibula (Fig. 6). Once this has been done, a decision is
made whether to include only the cutaneous branch in
the flap, or whether the main trunk should also be
included, based on the diameter and length of the vessel
to be used for anastomosis at the graft site and the diam-
eter of the cutaneous branch arising from the peroneal
artery. If the peroneal artery is also required, it is dis-
sected centrally and the branches to the flexor hallucis
longus and tibialis posterior muscles are coagulated and
cut as they are encountered until a vascular pedicle of
the required length is freed (Fig. 7). When anastomosis
to a major vessel is necessary at the graft site, the per-
oneal artery is anastomosed as an interpositional graft
to prevent disturbance of the peripheral circulation.
 290 E. Clinical Reconstructive Microsurgery
a a
N M
b b
Fig. 5. a The cutaneous branch is followed to the posterior
border of the fibula, and the intermuscular septum attached
to the fibula is cut. b Diagram: Ml, peroneus longus; M3, flexor
hallucis longus; F, fascia; Fi, fibula; N, nutrient artery of the
fibula; M, muscular branch; C, cutaneous branches of peroneal
artery and vein
In this case, the peroneal artery is dissected distally
from the origin of the cutaneous branch to obtain the
required vessel length. Once a vascular pedicle of the
required length has been dissected, a clamp is applied
to the peroneal artery below the origin of the most
distal cutaneous branch, and the pneumatic tourniquet
is deflated. Circulation in the foot and flap is checked,
and the peroneal artery is ligated and cut distally. The
flap is then freed completely by ligating and cutting the
proximal portion of the peroneal artery (Fig. 8).
References
1. Taylor GI, Miller GDH, Ham FJ (1975) The free vascu-
larized bone graft. Plast Reconstr Surg 55:533-544
Fig. 6. a The main trunk of the peroneal artery is reached by
cutting the origin of the flexor hallucis longus from the fibula.
b Diagram: Ml, peroneus longus; M3, flexor hallucis longus;
M4, soleus; F, fascia; Fi, fibula; Fl, flap; C, cutaneous branches
of peroneal artery; 1, peroneal artery and vein
2. Chen ZW, Bao YS (1980) Microsurgery in China. Clin
Plast Surg 7:437-474
3. Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Veno T
(1983) Free vascularized fibular transplant: A new method
for monitoring circulation of the grafted fibula. J Bone
Joint Surg 65-A:1295-1301
4. Okubo K, Murota K, Tomita Y, Hirane T, Nakura N,
Takahashi F, Kato S (1983) Free vascularized fibular graft
associated with flap. Orthop Traumat Surg 26:577-585
5. Yoshimura M, Imura S, Shimamura K, Yamauchi S,
Nomura S (1984) Peroneal flap for reconstruction in the
extremity: Preliminary report. Plast Reconstr Surg 74:402-
409
6. Yoshimura M, Shimada T, Imura S, Shimamura K,
Yamauchi S (1985) Peroneal island flap for skin defects in
the lower extremity. J Bone Joint Surg 67-A:935-941

a
Fig. 7. a A clamp is applied to the peroneal artery distal to
the point where the most peripheral cutaneous branch arises,
and the tourniquet is removed. (See Color Plates) b Diagram:
Ml, peroneus longus; M3, flexor hallucis longus; M4, soleus;
M6, tibialis posterior; F, flap; Fi, fibula; F1, flap; C, cutaneous
branches of peroneal artery; 1, peroneal artery and vein
7. Yoshimura M, Shimada T, Matsuda M, Hosokawa M,
Imura S (1989) Double peroneal free flap for multiple skin
defects of the hand. Br J Plast Surg 42:715-718
8. Yoshimura M, Shimada T, Hosokawa M (1990) The
vasculature of peroneal tissue transfer. Plast Reconstr
Surg 85:917-921
2.1.8. Peroneal Flaps 291
a
b
Fig. 8. a Circulation in the foot and flap is checked, and the
peroneal vessels are ligated and cut at the same point. b The
free peroneal flap
9. Masquelet AC, Gilbert A (1995) An atlas of flaps in limb
reconstruction. Martin Dunitz, London, pp 167-168
10. Strauch B, Yu HL, Chen ZW, Liebling R (1993) Atlas
of microvascular surgery, anatomy, and operative ap-
proaches. Thieme Medical, New York, pp 228-232
2.1.9 Dorsalis Pedis Flap
FUMIAKI U SAMI and MASAYUKI IKETANI
In 1973, O'Brien and Shanmugan were the first to
mention the possibilities of utilizing the dorsalis pedis
flap as an island flap based on the dorsalis pedis artery
and two or more accompanying venae comitantes [1].
In 1975, McCraw and Furlow reported their cases of
dorsalis pedis flap transplantation based on the vascu-
lar pedicle [2]. These authors precisely described their
anatomical findings on the dorsalis pedis artery and how
to elevate the skin flaps in detail. Because of the length
of the vascular pedicle, the range of the skin graft was
limited to the foot and the ankle, and they treated 11
clinical cases. Their first surgery was performed in 1971
(Fig. 1). Subsequent reports were published on the free
transfer of the dorsalis pedis flap based on microvascu-
lar anastomosis, but it is still unknown who performed
the first successful operation [3-5]. Robinson [6] stated
that it was performed some time in 1975.
Compared with other types of skin flaps, the dorsalis
pedis flap has little subcutaneous fat and a larger vas-
cular diameter, which makes it easier to anastomose.
In addition, if the skin flap includes the superficial
peroneal nerve, it can be utilized as a sensory skin flap.
This skin flap has advantages for grafting to correct a
skin defect in the hand, with the expectation of satis-
factory sensation on the grafted skin flap.
Preoperative Assessment
If the dorsalis pedis artery cannot be palpated before
surgery, it is necessary to confirm its course with a
Doppler flowmeter. Anatomical variation of the dorsalis
pedis artery has been observed in 3 to 5% of cases, and
in such cases the dorsalis pedis flap operation should be
avoided.
Anatomy of the Flap
The blood flow in the proximal part of the dorsalis pedis
flap is supplied by the dorsalis pedis artery or by the
immediate branches from the first dorsal metatarsal
artery. In the center of the skin flap, all the vessels travel
292
much deeper than the extensor tendon group. There-
fore, most of the perforating vessels of the dorsalis pedis
artery or the first dorsal metatarsal artery are severed
at the time of elevation of the flap.
In the distal portion of the flap, if the first dorsal
metatarsal artery is not traveling through the superficial
layer of the first dorsal interosseous muscle, its branches
to the skin flap may be severed at the time of elevation.
Accordingly, in the distal part of the skin flap, the blood
flow may be supplied by communication with the sub-
dermal plexus.
Harvesting Technique
The skin flap should be designed symmetrically to
cover the whole area of the dorsum of the foot, with the
dorsalis pedis artery as an axis, including the long
saphenous vein from the extensor retinaculum pro-
ximally to the first web distally (Fig. 2).
With an air tourniquet placed on the proximal thigh,
an incision is made on the designed skin flap. First, in a
medial skin incision, the deep fascia is incised medially
to the extensor hallucis longus tendon. Proximally the
dissection is performed in contact with the periosteum
of the cuneiform bone; the dorsalis pedis artery, the
deep peroneal nerve, and the venae comitantes appear
above the deep layer of the fascia. Upon confirma-
tion of the neurovascular bundle, they can be dissected
proximally to provide the vascular pedicle by releasing
the retinaculum of the ankle. On the medial side of the
vascular bundle at the site of the cuneiform bone, the
flap with thick subcutaneous tissue is detached laterally
to make contact with the periosteum of the cuneiform
bone (Fig. 3). At this time, the extensor hallucis brevis
tendon is cut and reflected to provide a better visual
range, since the neurovascular bundle travels below the
extensor hallucis brevis tendon. If the dorsalis pedis
artery is traced distally, it can be seen to travel between
the heads of the first dorsal interosseous muscle toward
the sole as a perforating branch, disappearing tran-
siently and appearing again as the first dorsal metatarsal
artery.
 2.1.9. Dorsalis Pedis Flap 293

Fig.1. A vascular pedicle flap was used to repair the easily ulcerated heel scar tissue in a 23-year-old man. We used this method
in 1982. a Easily ulcerated heel scar tissue. b Vascular pedicle flap. c Postoperative vascular pedicle flap and split-thickness skin
graft on donor site. d Six weeks after the operation

Fig. 3. The neurovascular bundle can be dissected proximally

Fig. 2. Maximum size design of the free dorsalis pedis flap. a
Dorsalis pedis artery. b Superficial peroneal nerve. c Long
saphenous vein. d Short saphenous vein
to provide the vascular pedicle by releasing the retinaculum
of the ankle. On the medial side of the vascular bundle at
the cuneiform bone, the flap with thick subcutaneous tissue is
detached laterally to contact the periosteum of the cuneiform
bone. (See Color Plates)
294 E. Clinical Reconstructive Microsurgery

Next, the dissection is performed from the distal to

the proximal direction. By severing and ligating the first
dorsal metatarsal artery at the distal end of the flap, the
dissection is continued proximally. If the first dorsal
metatarsal artery is present within the interosseous
muscle, the flap should be raised to include this muscle,
without injuring the artery. Then, the dissection in
the proximal direction is continued in order to reach the
point where the dorsalis pedis artery bifurcates into the
first dorsal metatarsal artery and a perforating branch.
At this time, the artery traveling from the proximal
end of the cuneiform bone to the distal end of the flap
is visualized. Thereafter, the perforating branch of the
dorsalis pedis artery to the sole is ligated and severed.
The dissection is continued laterally from the second Fig. 4. By severing and ligating the first dorsal metatarsal
metatarsal bone to the lateral side of the foot. It is artery at the end of the flap, the dissection is performed in the
important to retain the paratenon of the extensor proximal direction. The perforating branch of the dorsalis
tendons (Fig. 4). pedis artery to the sole is ligated and severed. The dissection
When the neurovascular skin flap is taken, the super- is continued laterally from the second metatarsal bone to the
ficial peroneal nerve should be included in the flap. If lateral side of the foot. (See Color Plates)
the nerve is not included in the flap, the nerve in the
lateral half of the foot can be retained. In this manner,
the dorsalis pedis flap can be harvested together with
the dorsalis pedis artery, the concomitant vein, and the
superficial peroneal nerve, along with the long saphe-
nous vein (Fig. 5).

Osteocutaneous Flap
If the second metatarsal bone is included in the flap, it
can be utilized as an osteocutaneous flap [6]. The perios-
teum of the second metatarsal bone is mainly nourished
by the blood flow from the first dorsal interosseous
muscle, which receives the branches of the dorsalis
pedis artery or of the arcuate artery. The os teo cutaneous
flap, including the vascularized metatarsal bone with a
maximal length of 7 cm, can be harvested when the Fig. 5. The dorsalis pedis flap can be harvested together with
second metatarsal bone with the periosteum and the the dorsalis pedis artery, the concomitant vein, and the super-
first dorsal interosseous muscle are obtained without ficial peroneal nerve, along with the long saphenous vein
damaging the vessels. The site of the metatarsal bone to
be severed is 1 cm distal to the tarsometatarsal joint of
the second toe, and it is disarticulated distally at the
metatarsophalangeal joint. If the bone is severed in such the blood flow through the para tenon, and it is essential
a manner, both the proximal and the distal transverse to obtain the flap without damaging the paratenon of
arches of the foot can be kept. the extensor tendons.

Tendomusculocutaneous Flap Osteotendocutaneous Flap

If the dorsalis pedis flap is obtained together with the If the flap is harvested with the inclusion of the ex-
extensor hallucis brevis muscle tendon and the extensor tensor tendons and the second metatarsal bone, it is
digitorum communis tendon, it can be utilized as the also possible to reconstruct the skin, tendon, and bone
tendocutaneous flap [7-9]. The tendon is nourished by defects simultaneously by one operation [10].

Fig. 6. Dorsalis pedis donor site 3 weeks after the operation
Skin Defect Closure after
Flap Harvesting
One method is to perform split-thickness skin grafting
on the defect immediately following harvesting of the
flap, and another is to cover the skin defect with an
artificial skin until favorable granulation tissue appears,
followed by split-thickness skin grafting. We place the
extensor hallucis brevis muscle belly on the exposed
cuneiform bone and then perform a split-thickness skin
graft on it. The skin grafting can be done after transfer-
ring the extensor hallucis brevis muscle or the first
dorsal interosseous muscle, in case the para tenon of the
extensor hallucis longus tendon has been removed acci-
dentally during flap harvesting (Fig. 6).
2.1.9. Dorsalis Pedis Flap 295
References
1. O'Brien BM, Shanmugan N (1973) Experimental transfer
of composite free flaps with microvascular anastomoses.
Aust NZ J Surg 43:285-288
2. McCraw JB, Furlow LT (1975) The dorsalis pedis ar-
terialized flap: a clinical study. Plast Reconstr Surg 55:
177-185
3. Daniel RK, Terzis J, Midgley RD (1976) Restoration
of sensation of an anesthetic hand by a free neuro-
vascular flap from the foot. Plast Reconstr Surg 57:
275-280
4. Robinson DW (1976) Microsurgical transfer of the dor-
salis pedis neurovascular island flap. Br J Plast Surg
29:209-213
5. Ohmori K, Harii K (1976) Free dorsalis pedis sensory flap
to the hand, with microneurovascular anastomosis. Plast
Reconstr Surg 58:546-554
6. Robinson DW (1979) Dorsalis pedis flap. In: Serafin D,
Buncke H Jr (eds) Microsurgical composite tissue trans-
plantation. Mosby, St. Louis, pp 257-284
7. Taylor GI, Townsend P (1979) Composite free flap tendon
transfer: an anatomical study and a clinical technique. Br
J Plast Surg 32:170-183
8. Tarnai S, Fukui A, Shimizu T, Yamaguchi T (1983) Thumb
reconstruction with an iliac bone graft and a dorsalis pedis
flap transplant including the extensor digitorum brevis
muscle for restoring opposition: A case report, Micro-
surgery 4:81-86
9. Ohkubo K, Murota K, Tomita Y, Moriyama M, Takahashi
F, Murai T (1984) Free dorsalis pedis flap with toe exten-
sor tendon-vascularized tendon graft. Seikei Saigai Geka
27:983-990 (in Japanese)
10. Tsuji K (1983) A case report of free dorsalis pedis flap
with long toe extensor tendon for finger extension.
Seikeigeka 34:1783-1785 (in Japanese)
2.1.10 Medial Plantar Flap
MINORU SHIBATA and RITSUO SAKAMURA
For the past quarter-century, many kinds of flaps have
been utilized to resurface the weight-bearing surface of
the foot. It has been concluded that the medial plantar
flap is one of the most suitable flaps for this purpose.
The flap is elevated on the medial plantar neurovascu-
lar system from the instep of the foot, which is a rela-
tively non-weight-bearing area, and translocated to the
heel defect. This is occasionally elevated as a reversed
pedicled flap to cover the distal metatarsal head area of
the foot. The medial plantar flap is also used as a free
flap for coverage of the weight-bearing surface of the
contralateral foot.
Mir y Mir first reported the cross-foot method using
medial plantar skin for coverage of the heel of the con-
tralateral foot in 1954 [1]. This distant flap provided the
most durable skin to the weight-bearing area; however,
it was a nonsensate flap and ulceration occasionally
occurred. The medial plantar flap was reported as a
sensate local delayed flap by Shanaham and Gingrass in
1979 [2]. Reiffel and McCarthy described the medial
plantar artery-based sensate flap from the sole area in
1980 [3]. The flap was an elevated supra- or subfascial
flap. Harrison and Morgan reported a sensate instep
island neurovascular flap based on the medial plantar
artery transposed into a calcaneal defect in 1981 [4].
Morrison et al. reported a sensate instep flap as a pedi-
cled fasciocutaneous island flap based on either the
medial or lateral plantar vessel, or both, and as a free
flap in 1983 [5]. Hidalgo and Shaw published an anatom-
ical study of the plantar flap with its clinical applications
[6,7]. They reported that elevation of the local subcuta-
neous sensory plantar flap could be better than the use
of myocutaneous or subcutaneous flaps, which may sac-
rifice important plantar sensation in the treatment of
the plantar defect.
296
Indications
Plantar skin has a unique stable compartmented
padding. Chronic ulcer formation in the heel or
metatarsal head area occasionally is encountered after
burn injury or inadequate resurfacing after trauma.
Resurfacing using translocation of the sensate mid-sole
plantar skin between the heel and metatarsal head pro-
vides the best coverage of the weight-bearing area. For
reconstruction of the defect in the heel after wide resec-
tion of malignant tumors, such as malignant melanoma,
translocation of the mid-sole plantar skin as a pedicled
or a free subfascial flap should be performed. The
reversed medial plantar vessel flap can be translocated
to the defect around the metatarsal head region.
Advantages
The mid-sole skin and its subcutaneous tissue have
a unique mechanical property resistant to the shear-
ing force. Hand skin and subcutaneous tissue have the
same mechanical property, however, this property is
lacking in other distant flaps, such as the groin, dorsal
foot and latissimus dorsi. This anatomical property is
as i:Uportant as sensation in the prevention of ulcer
formation.
Disadvantages
Grafting of skin to the donor site may cause marginal
hyperkeratosis; however, morbidity in the donor site is
minimal. Full-thickness skin grafting is preferable to
obtain stability as well as pain and other discriminating
sensations.

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2 - --+lhl4.!t1
3 -~HH-.itlffi.\ 11.\~--\--'H1--- 8
11-l-IlH-- 6 arches.
4 ~~~~~ ~!~~Hr- 7
9 again, dividing deep to the quadratus plantae and
5 oblique head of the adductor hallucis muscle to form
Fig. 1. Arterial anatomy of the plantar aspect of the foot (1,
superficial branch of medial plantar artery; 2, tibial plantar
superficial artery; 3, common digital plantar superficial artery;
4, superficial plantar digital arteries joining corresponding
plantar metatarsal arteries (5); 6, superficial plantar digital
artery to fourth web space joining plantar metatarsal artery to
same place (7); 8, fibular plantar superficial artery; 9, superfi-
cial plantar arcade formed when 3 and 6 are anastomosed
superficial to flexor digitorum brevis (11); 10, abductor
hallucis muscle) Adapted from Aschner B (1905) Zur
Anatomie der Arterien der Fusshole. Anat Hefte Beit Ref
Anat Entwicklungs 27:345
Anatomical Considerations
Artery
The posterior tibial artery bifurcates into the medial
and lateral plantar arteries after delivering the calcaneal
branch underneath the flexor retinaculum (Fig. 1). The
medial plantar artery divides into superficial and deep
branches under the abductor hallucis muscle. The super-
ficial branch of the medial plantar artery goes into the
medial plantar cleft between the abductor hallucis and
the flexor digitorum brevis muscles, and bifurcates into
the superficial tibial plantar artery and the common
plantar digital artery after delivering a few cutaneous
branches.
The superficial tibial plantar artery penetrates the
abductor hallucis and runs medial to the flexor digito-
rum longus and on the fascia of the flexor hallucis brevis
toward the first metatarsal head, delivering cutaneous
2.1.10. Medial Plantar Flap 297
branches. The superficial tibial plantar artery can be the
artery of the axis of the mid-sole flap.
The common plantar digital artery runs anterolater-
ally between the plantar fascia and the flexor digitorum
brevis muscle to the sole, delivering cutaneous branches
penetrating the plantar fascia at midplantar, and finally
divides into the three common plantar digital arteries.
There may be anatomical variations in the medial
plantar artery, such as the presence of a common artery
without bifurcation to the tibial plantar artery and
common plantar digital artery or division into three
branches of the deep, medial, and medial superficial
The lateral plantar artery crosses the foot between
the flexor digitorum brevis and quadratus plantae
muscle and emerges just beneath the plantar fascia
laterally. After proceeding distally, it courses medially
the plantar arch.
Vein
Cutaneous veins, such as branches of the great saphe-
nous vein, can be included in the vascular pedicle.
However, the medial or lateral plantar artery accompa-
nies good-sized venae comitantes, which are sufficient
to drain the flap and become the venae comitantes of
the posterior tibial artery.
Nerves
The innervation of the medial two thirds of the mid-sole
is derived from the common digital nerves of the medial
plantar nerve. The cutaneous nerves from the lateral
plantar nerve supply the sensation of the lateral one
third of the sole. These sensory branches are derived
from the common digital branches of the plantar nerve
and pierce the plantar fascia. The medial and lateral
plantar nerves run along the clefts between the abduc-
tor hallucis and flexor digitorum brevis and between the
flexor digitorum brevis and abductor digiti minimi,
respectively. The cutaneous branches from the lateral
plantar nerve supply the lateral one third of the flap.
Dissection
As the vascular pedicle, the medial plantar vessel
network is designed in the center of the flap.
298 E. Clinical Reconstructive Microsurgery

Medial Plantar Island Flap Case Presentations

The fasciocutaneous flap is designed in the mid-sole A 66-year-old woman sustained a deep burn injury to
from the region just proximal to the area of the weight- the right heel when she was 5 years old. The wound was
bearing metatarsal heads to just distal to the distal covered with a skin graft, but hyperkeratosis developed,
weight-bearing border of the heel, preserving the lateral and relapsing ulcer formation was noted for more than
border of the sole, which is an important weight-bearing 30 years. A preoperative biopsy revealed squamous-
portion. The medial plantar vessel system usually sur- cell carcinoma around the ulcer region (Fig. 2). Wide
vives in this entire flap. resection of the tumor with a 2-cm safe margin was per-
Dissection is begun from the distal border by placing formed. Calcaneal bone was partly removed because
a transverse incision through the skin and plantar fascia. there was an adhesion with the tumor. A free medial
The superficial tibial plantar artery is identified in the
cleft between the abductor hallucis and flexor digitorum
brevis and cut with its accompanying vein. The flap is
elevated from distal to proximal beneath the plantar
aponeurosis attaching vessels, which serve as the guide
to the plane of dissection. The sensory nerve branches
from the first digital nerve are attached to the flap, and
these branches are microsurgically dissected off the
digital nerve using magnification proximally up to the
pivot point. However, digital nerves may have to be
sacrificed occasionally because of the difficulty of the
dissection. Fascial connections to the cleft between
the abductor hallucis and flexor digitorum brevis are cut.
To obtain more secure blood circulation, the common
plantar digital artery can be elevated with the flap.
The medial plantar vessels and sensory branches of
the medial plantar nerves are traced up to the ankle, ab
dividing the abductor muscle if necessary.
When the flap is elevated on the lateral plantar artery, Fig. 2. a Preoperative condition. Hyperkeratosis with ulcer is
the neurovascular bundle is defined and divided at the noted in the heel. Preoperative biopsy revealed squamous cell
distal border of the flap in the cleft between the flexor carcinoma. b Design for wide resection of the tumor. Incision
digitorum brevis medially and the abductor digiti line was made 2cm outside of the tumor
minimi laterally. The sensory branch is included with the
flap and dissected off the lateral plantar nerve. If the flap
is used as a free flap, the medial or lateral plantar artery
is divided just distal to their bifurcation from the pos-
terior tibial artery. If a longer vascular pedicle is needed,
the posterior tibial artery can be divided.

Rotation Flap

Hidalgo and Shaw [6,7] studied the nervous and vascu-

lar supply of the plantar surface of the foot and found
that the blood supply to the mid-sole is not exclusively
from the medial plantar artery. This is a watershed area,
with important contributions from the lateral plantar
and dorsalis pedis arteries as well. A large, sensate, _ _ ab
medially based rotation flap can be raised in a plane
superficial to the plantar fascia. However, the freedom Fig. 3. a Flap design as the free medial plantar flap on the
of translocation of this rotation flap may be limited to opposite foot. b After elevation of the flap. Excellent circula-
cover the posterior heel. tion was demonstrated after tourniquet release
 2.1.10. Medial Plantar Flap 299

Fig. 4. Inside the elevated flap. The superficial tibial plantar Fig. 5. The elevated and detached free medial plantar flap.
artery and the common plantar digital arteries were elevated Clips were applied to the posterior tibial artery and its two
with the flap as well as the sensory branch of the medial venae comitantes
plantar nerve

Fig. 6. After coverage of the defect with the free medial Fig. 7. Reconstructed heel and donor condition 3 months
plantar flap, excellent perfusion to the flap was noted. Addi- after surgery
tional full-thickness skin grafts were placed at non-weight-
bearing areas to avoid strong tension on the flap
300 E. Clinical Reconstructive Microsurgery
plantar flap 77 x 115 mm in size was elevated from the
opposite foot (Fig. 3). The flap was raised with the
planar aponeurosis, and the muscles were kept intact
(Figs. 4, 5). The posterior tibial artery and two venae
comitantes were anastomosed, and no nerve was
repaired. The flap was successfully transferred (Figs. 6,
7). The donor site was covered with a full-thickness skin
graft. Additional full-thickness skin grafts were placed
on non-weight-bearing parts to avoid tension on the
transferred flap (Fig. 7).
References
1. Mir y Mir L (1954) Functional graft of the heel. Plast
Reconstr Surg 14:444-450
2. Shanaham RE, Gingrass RP (1979) Medial plantar sensory
flap for coverage of heel defects. Plast Reconstr Surg 64:
295-298
3. Reiffel RS, McCarthy JG (1980) Coverage of heel and sole
defects; a new subfascia arterialized flap. Plast Reconstr
Surg 66:250-260
4. Harrison DH, Morgan B (1981) The instep island flap to
resurface plantar defects. Br J Plast Reconstr Surg 34:
315-318
5. Morrison WA, Grabb DM, 0' Brien BM, Jenkins A (1983)
The instep of the foot as a fasciocutaneous island flap and
as a free flap for heel defects. Plast Reconstr Surg 72:56-63
6. Hidalgo DA, Shaw WW (1986) Anatomic basis of plantar
flap design. Plast Reconstr Surg 78:627-636
7. Shaw WW, Hidalgo DA (1986) Anatomic basis of plantar
flap design: clinical applications. Plast Reconstr Surg 78:
637-649
2.1.11 Hemipulp Flap and First Web Flap
YUTAKA MAKI and TAKAE YOSHIZU

The hemipulp flap was reported by Morrison in 1978 [1], flap has recovered. Bleeding points of the flap and vas-
and the first web flap was reported by May in 1977 [2] cular pedicle should be coagulated meticulously. Then
and Strauch in 1978 [3]. These flaps are used as sensory the vascular pedicle is severed and the flap is transferred
flaps for reconstruction of pulp defect of the thumb or to the recipient site. At that time the stumps of the arte-
for reconstruction of sensory loss of the first inter- rial and venous pedicles are picked up with mosquito
digital web space of a mitten hand covered by abdo- forceps on the same direction, and a dotted line is made
minal or groin flap. with a marker (we use Pyoktanin) on the same plane
surface along the vascular pedicle to prevent twisting
of the vascular pedicle during the grafting procedure
(Fig. 7).
Harvesting Technique The skin defect of the donor great toe is covered with
a full-thickness skin graft primarily. If the condition of
Hemipulp Flap the base of the skin defect is poor, the skin graft should
be done secondarily after the formation of granulation
The flap is designed as shown in Fig. 1. To include the tissue.
cutaneous vein in the flap, the proximal pole of the flap
is advanced dorsally. The size of the flap is designed
slightly larger than that of the skin defect of the re-
cipient site.
Dissection starts on the dorsum of the foot to elevate
the cutaneous vein under the pneumatic tourniquet.
Then the first interdigital web space is dissected to
judge the pattern of the main feeding artery of the flap
(first dorsal or plantar metatarsal artery) [4] (Fig. 2).
If this pattern is Gilbert type I or II, the dissection
proceeds dorsally from the distal to the proximal direc-
tion to elevate the first dorsal metatarsal artery and dor-
salis pedis artery. The extent of the dissection is decided
according to the length of the pedicle (Figs. 3 and 4).
If the pattern is Gilbert type III, a plantar incision is
added, and if a long arterial pedicle is needed, the trans-
verse metatarsal ligament and adductor muscle of the
great toe should be severed to split the first inter-
metatarsal space for elevation of the first plantar
metatarsal artery and the dorsalis pedis artery. At the
same time, dissection of the digital nerve should be per-
formed. If a long nerve pedicle is needed, the common
digital nerve is split proximally and cut (Figs. 5 and 6) .
When dissection of the artery, vein, and nerve is com-
pleted, the flap is elevated from the great toe.
When the above procedure is finished, the pneumatic
tourniquet is released, and the flap in the donor site is Fig. 1. Skin incision for harvesting of hemipuip flap. a First
covered with warm wet gauze until the circulation of interdigitai space. b Dorsum of forefoot

301
302 E. Clinical Reconstructive Microsurgery

Cutaneous vein
Hemipulp flap
Type I

Plantar digital artery

to great toe

Type I!
1st plantar metatarsal artery
(small or none)

Fig. 3. Dissection of first interdigital space of Gilbert type I

and II

Lateral plantar digital artery of great toe

Type III

Fig. 2. Anatomy of first dorsal or plantar metatarsal artery

(according to Gilbert). 1 Dorsalis pedis artery, 2 first dorsal
metatarsal artery, 3 plantar digital artery to great toe (large), Lateral proper digital nerve
4 dorsal digital artery to great toe (small), 5 descending of great toe
branch, 6 first dorsal interosseous muscle, 7 metatarsal liga-
ment, 8 first plantar metatarsal artery

Hemipulp flap
Fig. 5. Dissection of first plantar metatarsal artery in Gilbert
type III
Plantar digital artery to great toe

Hemipulp flap

\
Fig. 4. Dissection of first dorsal metatarsal artery

Fig. 6. Split of first intermetatarsal space

 2.1.11. Hemipulp Flap and First Web Flap 303

Cutaneous vein

Cutaneous vein
Digital nerve 1st plantar metatarsal artery
(small or none)

Fig.9. Dissection of first interdigital web space of Gilbert type

I and II

Mosquito forceps

Fig. 7. Elevation of hemipulp flap

1st dorsal metatarsal artery

)
Cutaneous vein

a
\
Fig. 10. Dissection of first dorsal metatarsal artery

Fig. 8. Skin incision for harvesting of first web flap. a First Common digital nerve
interdigital space. b Dorsum of forefoot
Fig. 11. Elevation of first web flap
304 E. Clinical Reconstructive Microsurgery
First Web Flap
The flap is designed as shown in Fig. 8. This flap includes
the lateral proper digital nerve and artery (plantar) of
the great toe and the medial proper digital nerve and
artery (plantar) of the second toe.
Elevation of the dorsal cutaneous vein is done first.
Dissection of the first interdigital web space is done
carefully by the dorsal and plantar approach to deter-
mine the pattern of the feeding artery (Fig. 9).
The Gilbert type I or II pattern requires a dorsal
approach for elevation of the first dorsal metatarsal
artery (Figs. 10 and 11), and the type III pattern requires
a plantar approach for elevation of the first plantar
metatarsal artery. The digital nerve of the flap is dis-
sected plantarly and cut.
The rest of the procedure is the same as that for the
hemipulp flap.
References
1. Morrison WA, O'Brien BM, MacLeod AM, Gilbert A
(1978) Neurovascular free flaps from the foot for innerva-
tion of the hand. J Hand Surg 3:235-242
2. May JW Jr, Chait LA, Cohen BE, O'Brien BBC (1977)
Free neurovascular flap from the first web of the foot in
hand reconstruction. J Hand Surg 2:387-393
3. Strauch B, Tsur H (1978) Restoration of sensation to the
hand by a free neurovascular flap from the first web space
of the foot. Plast Reconstr Surg 62:361-367
4. Gilbert A (1976) Composite tissue transfers from the foot:
anatomic basis and surgical technique. In: Daniller AI,
Strauch B (eds) Symposium on microsurgery. CV Mosby,
St Louis, pp 230-242
2.1.12 Free Thin Deep Inferior Epigastric Artery
Perforator (DIEP) Flap
ISAO KOSHIMA, KIICHI INAGAWA, and TAKAHIKO
The rectus abdominis musculocutaneous flap, first
described by Mathes and Bostwick [1], was developed
for use as an island flap or free flap in the reconstruc-
tion of the breast and the head and neck regions, which
require thick subcutaneous tissues. This musculocuta-
neous flap is versatile but bulky because of the amount
of muscle and thick fatty tissue involved. Therefore, this
flap is too large for the resurfacing of relatively thin
defects. Postoperative abdominal herniation may also
occur after the removal of the rectus abdominis muscle.
To overcome these problems, we previously used infe-
rior epigastric skin flaps without rectus abdominis
muscles [2]. Thereafter, it was found that thin deep infe-
rior epigastric perforator flaps (DIEP flaps), fed by a
muscle perforator from the deep inferior epigastric
vessel, with no muscle component and with removal of
a considerable amount of fatty tissue, could be used
as a further application of this DIEP flap. Here, we
describe two representative patients in whom this new
type of flap was successfully implanted.
Harvesting Technique
The inferior deep epigastric vessels run up the paraum-
bilical region of the abdominal wall longitudinally and
are located below the rectus abdominis muscle. Several
large muscle perforators, which originate from the deep
inferior epigastric artery and penetrate the rectus abdo-
minis muscle, and then feed into the skin, are generally
located within lOcm around the umbilicus. Therefore,
we first outline a skin flap including the perforator trans-
versely or obliquely on one side of the abdominal wall.
The first incision is made through the lateral region
of the flap outline and then is extended to the fascia
of the oblique muscle posteriorly, reaching above the
fascia of the rectus abdominis muscle. Dissection is con-
tinued carefully until the main perforator, penetrating
the overlying fascia of the muscle, can be seen. After
inclusion of only the small fascia around the perforator
and separation of the muscle fibers with a pair of retrac-
tors, both the perforator and the deep inferior epigas-
tric vessels are dissected deeply through the muscle.
MORIGUCHI
Thereafter, the small muscle branches derived from
both the perforator and the deep inferior epigastric
vessels are transected, and the superior end of the deep
inferior epigastric vessels is transected. The flap can
then be raised as an island flap. Bleeding from the
subdermal and subcutaneous layer of the island flap is
noted, so the flap is made thinner be excising the sub-
cutaneous fatty tissue with scissors. Because the sub-
dermal plexus of the capillary vessels is preserved, the
peripheral region of the flap can be as thin as possible,
and only a thin layer of fat (approximately 5mm thick)
is retained to protect the subdermal plexus. However,
resection of the fatty tissue within 3 cm around the
perforator is impossible because of damage to the
pedicle vessels. A purple-pink hue is observed when the
removal of fatty tissue is complete. This is more pro-
nounced in larger thin flaps. Finally, by transecting the
inferior site of the deep inferior epigastric vessels, a free
thin DIEP flap is obtained.
When the donor site is closed, because sufficient
volume of the rectus abdominis muscle and of the ante-
rior sheath is preserved, a split defect of the muscle
can first be closed tightly, and the fascial defect on the
muscle can also be repaired without silicone mesh. The
skin defect is closed with or without a split-thickness
skin graft.
Case Reports
Case 1
A 41-year-old man sustained an accidental avulsion of
his left foot, and a skin defect of both the dorsal and
the plantar foot was covered with a split-thickness
skin graft. After this primary surgery, he complained of
hindrance to walking because of an ulcer and severe
pain on the plantar aspect of the foot. A year and a half
after the primary surgery, a secondary operation was
performed with a free skin flap. After resection of all of
the grafted skin from the foot, a free DIEP flap, meas-
uring 20 x 21 cm and pedicled with a single main per-
forator, was obtained from the upper portion of his left
305
306 E. Clinical Reconstructive Microsurgery
Fig. 1. a Case 1. An avulsion injury of the left foot was
repaired with a split-thickness skin graft, but the patient com-
plained of severe pain on the plantar side in walking. b Outline
of the paraumbilical perforator-based flap. x indicates a dom-
inant perforator. c A partially thinned paraumbilical perfora-
abdominal wall. To reduce the bulkiness of the dorsal
foot undergoing reconstruction, a lipectomy was per-
formed on the medial one-half of the flap, leaving a thin
layer of fat to protect the subdermal vessels. Thus, part
of the flap was a thin DIEP flap. The recipient artery,
the tibialis anterior artery, was anastomosed to the deep
inferior epigastric artery of the flap. The transferred
short saphenous vein and a concomitant vein of the tib-
ialis anterior artery were joined to the double con-
comitant veins of the deep inferior epigastric artery. The
donor defect in the abdominal wall was covered with a
mesh skin graft.
The postoperative course was uneventful, and the
man was allowed to walk 2 months after surgery. Now,
10 years after the secondary surgery, there has been no
recurrence of the plantar ulcer or pain in walking. No
abdominal herniation or remarkable weakness of the
rectus abdominis muscle have been seen at the donor
site. Thinning of the flap was not required because the
repaired foot could be fitted into a regular shoe (Fig. 1).
Case 2
A 50-year-old woman had a squamous-cell carcinoma on
the right temporoparietal region of her scalp. After both
radiotherapy and chemotherapy, a wide area of the scalp
involving the cancer and the periosteum was resected.
tor-based flap was elevated from the superior portion of the
abdominal wall. (See Color Plates) d One year after surgery.
Dorsal view shows little bulkiness of the flap. e One year after
surgery. Plantar view shows no recurrence of the ulcer
An island DIEP flap, measuring 20 x 15 cm and pedicled
with three perforators, was then obtained from the right
abdominal wall. After removal of the fatty tissue of the
flap, with the exception of that around the perforators,
the subdermal plexus of the capillaries was left. Thus, the
flap was made as a free thin flap and was transferred to
repair the prepared recipient defect. The superficial tem-
poral artery was anastomosed to the inferior deep epi-
gastric artery of the flap, and venous anastomoses were
established between the double branches of the superfi-
cial temporal vein and the concomitant veins of the infe-
rior deep epigastric artery. The donor defect was finally
covered with a split-thickness skin graft.
The postoperative course was essentially smooth. At
present, 8 years after surgery, there has been no local or
metastatic recurrence of the tumor, and there have been
no complications at the donor site, such as intestinal
herniation. Because of the thinness of the flap, the
patient has had to wear an artificial hairpiece to conceal
baldness (Fig. 2).
Discussion
Recently, in studies of the vascular supply of musculo-
cutaneous flaps, the muscle perforators for the nutrition
of these flaps have been focused upon. It has been
 2.1.12. Free Thin Deep Inferior Epigastric Artery Perforator (DIEP) Flap 307

b c

Fig. 2. a Case 2. Squamous cell carcinoma of the scalp. b An extremely thin paraumbilical perforator-based
flap pedicled with a few perforators was raised. c Five years after surgery. No recurrence of tumor. (See Color
Plates)

observed that the greater reliability of these flaps is due
to the superior blood supply from muscle perforators
and not to any special qualities of the muscle itself [3].
Regarding the vascular anatomy of the rectus abdo-
minis musculocutaneous flap, it has been reported that
several muscle-perforating arteries originating from the
deep epigastric artery are located around the umbilicus
and at the superior one-third of the lower abdominal
wall [4,5]. A single perforator then gives off a few
ascending branches in the fatty layer and connects to
the subdermal plexus, which is a collection of nutrient
capillaries of the skin [5]. Therefore, by preserving only
one perforator from the deep epigastric vessels, a DIEP
flap without muscle can be made. We previously showed
that the skin territory of this flap pedicled with a single
perforator was almost the same as that of the rectus
abdominis musculocutaneous flap [2].
It is generally accepted that a skin flap is usually
dependent on the subdermal circulation and that, in an
axial pattern flap, this vascularity is reinforced to some
extent by larger vessels along the base of the flap.
Thomas indicated that if the subdermal plexus is
undamaged, the flap should have an adequate blood
supply, and proved this concept to be true in six patients
by using radically thinned pedicled abdominal or groin
flaps [6]. Therefore, by preserving only a small amount
of fatty tissue involving a few ascending branches
derived from the perforator and subdermal plexus of
the vessels of the flap, the DIEP flap can be made much
thinner by removal of a large amount of fatty tissue.
However, it is not certain at this stage whether the other
muscle perforator flap can be made thinner.
Regarding the territory and design of the thin flap, the
pedicle perforators of this thin flap are located around
the umbilicus. This means that during the outlining of
the flap, the proximal center of the flap should be placed
somewhere near the umbilicus. As in the case of the
rectus abdominis musculocutaneous flap, the longitudi-
nal axis of a small flap can be placed in any direction on
the abdominal wall. In a larger flap, the superolateral
308 E. Clinical Reconstructive Microsurgery
longitudinal axis may be most reasonable and safe.
Based on our patients, for whom a thin flap measuring
20 x 15 cm was used with small marginal necrosis, we
assume that this may be the maximum territory of the
thin flap.
Regarding the application of and indications for use
of the thin flap, the advantages of this flap are that the
vascular pedicle, the deep inferior epigastric vessel, is
long and large, and the donor scar can be in an unex-
posed area. There is little possibility of postoperative
abdominal herniation or functional limitation due to the
muscle removal [7]. Its greatest advantage is that thin
flaps can be obtained by removing fatty tissue, making
it especially useful for obese patients. This flap may also
be used for skin cover of the face and neck, for hand
and finger reconstruction, and for resurfacing of neck
contracture. This flap can be used as a perforator flap
with perforator anastomosis, without the deep inferior
epigastric vessel [8].
However, there may be variation in the localization
of the perforator and some technical difficulties in dis-
secting the perforator within the muscle, and there are
also some limitations for use with regard to the vascu-
lar territory of this flap.
References
1. Mathes SJ, Bostwick J (1977) A rectus abdominis myocu-
taneous flap to reconstruct abdominal wall defects. Brit J
Plast Surg 30:282-283
2. Koshima I, Soeda S (1989) Inferior epigastric skin flaps
without rectus abdominis muscle. Br J Plast Surg 42:645-
648
3. Kroll SK, Rosenfield LR (1988) Perforator-based flaps for
low posterior midline defects. Plast Reconstr Surg 81:561-
566
4. Onishi K, Maruyama Y (1986) Cutaneous and fascial vas-
culature around the rectus abdominis muscle: anatomic
basis of abdominal fasciocutaneous flaps. J Reconstr
Microsurg 2:247-253
5. Taylor GI, Corlett RJ, Boyd JB (1980) The versatile deep
inferior epigastric (inferior rectus abdominis) flap. Br J
Plast Surg 37:330-350
6. Thomas CV (1980) Thin flaps. Plast Reconstr Surg 65:
747-752
7. Duchateau J, Dec1ety A, Lejour M (1988) Innervation of
the rectus abdominis muscle: implications for rectus flaps.
Plast Reconstr Surg 82:223-227
8. Koshima I, Inagawa K, Urushibara K, Moriguchi T (1998)
Paraumbilical perforator flap without deep inferior epigas-
tric vessels. Plast Reconstr Surg 102:1052-1057
2.1.13 Venous Flap
AKIHIRO FUKUI
Skin defects are generally repaired with skin grafts
when the recipient condition is satisfactory. When the
condition is not suitable for skin grafting, a distant pedi-
cled flap or local pedicle flap, on microsurgical free flap
transfer, have been used. In the 1980s, the venous flap
was the focus of increasing attention for skin defects of
the fingers and hand, and was gradually extended to
other parts of the extremities. The concept of the venous
flap has been reported experimentally [1-25] and clini-
cally [26-48] by many authors. We report survival of a
pedicled venous flap using the rat model, as well as sur-
vival of venovenous, arteriovenous, arterialized, and
delayed arteriovenous flow-through venous flaps using
the rabbit ear model. For this study, we classified the
venous flap into five types and utilized these flaps
clinically.
Classification of Venous Flaps
The five types of venous flap are the pedicled, ve-
novenous flow-through, arteriovenous flow-through,
arterialized flow-through, and delayed arteriovenous
flow-through venous flaps.
Pedicled Venous Flap
The pedicled venous flap is created by preserving only
the draining vein, and it can be transferred to the neigh-
boring skin defect area.
Case 1
A 42-year-old woman suffered amputation of her right
little finger, which was replanted. The dorsal skin of the
proximal interphalangeal joint, 5 x 5 mm in size, became
necrotic, resulting in exposure of the dorsal aspect of
the proximal phalanx joint. A pedicled venous flap was
raised from the midportion of the ring finger and was
transferred to the skin defect. A split-thickness skin
graft was used to cover the donor site. The flap was gen-
erally bluish-white in color immediately postoperatively
and turned dark-red within 2 to 3 days. Some blisters
gradually formed, but finally the flap survived despite
superficial necrosis (Fig. 1).
Case 2
The left ring finger of a 53-year-old man was injured by
a reaping hook. A skin defect with laceration of the
lateral band on the dorsoulnar side of his little finger
was noted. After the lateral band had been sutured, a
pedicled venous flap from the adjacent skin defect was
transferred. A split-thickness skin graft was used to
cover the donor site and the associated wound on the
ring finger. The flap survived successfully. The healing
process of this flap was almost the same as that of case
1 (Fig. 2).
Venovenous Flow-Through
Venous Flap
This flap can be easily taken from the volar aspect of
the forearm as a free flap, preserving the flow-through
vein passing through the flap, and it is transferred to the
skin defect with anastomosis of the vein with the re-
cipient veins.
Case 3
A 63-year-old man caught his left long finger in a
machine. A skin defect remained on the dorsolateral
area of the proximal phalanx. A flap 10 x 20mm, with
the flow-through cutaneous vein, was harvested from
the volar aspect of the forearm. The flow-through veins
were anastomosed with the digital dorsal cutaneous
vein proximally and distally. The flap was pale immedi-
ately after the operation but became dark-red about
3 days after the operation. A blister then gradually
formed, but finally the flap survived despite superficial
necrosis (Fig. 3).
309
 310 E. Clinical Reconstructive Microsurgery

a c
----------~------~------~

b d

Fig. 1. a Schema of pedicled venous flap transfer. b Dorsal skin of the proximal interphalangeal joint became necrotic. c The
pedicled venous flap was transferred. d The flap survived completely

a
c

b d

Fig. 2. a Schema of sliding pedicled venous flap transfer (preserving draining vein). b A skin defect remained on the dorsal
aspect of the little finger. c The sliding venous flap taken from the adjacent area was transferred. d The flap survived completely
 2.1.13. Venous Flap 311

o
o -

a d

b e

Fig. 3. a Schema of flow-through venous flap transfer (anas-

tomosed proximally and distally). b A skin defect remained
on the dorsal aspect of the middle finger. c The flow-through
venous flap was elevated. d The flow-through venous flap was
c
transferred. e The flap survived completely

Case 4 We created a sliding venous flap at the adjacent part of

A 52-year-old man injured his left little finger with an
electric saw. The patient sustained a 25 x 15 mm skin
defect on the dorsoulnar aspect of his left little finger.
the skin defect, preserving the digital veins proximally
and distally, and it was slid to the defect. The color of
the venous flap remained normal just after the opera-
tion. Superficial necrosis healed within 2 weeks after the
operation (Fig. 4).
 312 E. Clinical Reconstructive Microsurgery

a c

b d

Fig. 4. a Schema of sliding flow-through venous flap transfer. b A skin defect remained on the lateral aspect of the little finger.
c The sliding venous flap was transferred. d The flap survived completely

Arteriovenous Flow-Through
Venous Flap
A flow-through venous flap is harvested and transferred
to a skin defect, anastomosing the proximal vein of the
flap to the recipient artery and the distal end of the vein
to a recipient vein as a draining vein.
Case 5
A 36-year-old man had his left index and middle fingers
caught by a machine. The index finger seemed to be
replant able, but the middle finger sustained a severe
crush amputation at the level of the middle phalanx.
To cover the stump of the middle finger, a 40 x 30mm
venous flap with a flow-through vein taken from the
forearm was transplanted, with the distal end of
the donor vein anastomosed to the digital artery and the
two proximal ends of the donor vein anastomosed to the
digital dorsal veins for drainage. The color of the venous
flap was good just after the operation, and it survived
without problems, although arteriovenous shunting was
observed in the finger (Fig. 5).
Arterialized Flow-Through
Venous Flap
A flow-through venous flap is harvested in the ordinary
fashion; its proximal vein is anastomosed with the
recipient artery, and its distal vein with the recipient
artery.
Case 6
A 55-year-old man injured the volar aspect of his right
little finger with a machine. To cover the skin defect, a
15 x 10mm segment of a venous flap with a flow-
through vein was taken from the forearm, turned proxi-
 2.1.13. Venous Flap 313

0
-
-
I V A

b d

Fig. 5. a Schema of arterialized venous flap transfer (distal: artery-vein anastomosis; proximal: vein-vein anastomosis). b The
ring and little fingers were amputated. c The little finger was replanted, and the ring finger was covered with an arterialized
venous flap. d The flap survived completely

mally to distally, and transplanted. Both the proximal radial artery at the recipient site, and the proximal end
and distal ends of the donor vein were anastomosed to of the vein is anastomosed with the recipient vein for
the radial-side digital artery, creating an interpositional drainage.
graft. The color of the flap became pink, and it survived
without complications (Fig. 6).
Case 7

A 38-year-old man suffered burns covering 60% of his

Delayed Arteriovenous Flow-Through
Venous Flap
In the first stage, an arteriovenous shunt is created
between the dorsalis pedis artery and the greater
saphenous vein on the dorsal side of the foot. Two
weeks later, a flap is designed over the area where
arterial blood flow through the shunt and surrounding
subcutaneous veins is confirmed. The flap containing the
greater saphenous vein as the flow-through vein is
elevated. The distal end of the greater saphenous vein
in the venous flap is anastomosed with the branch of the
body, mainly on the upper half of the trunk and the
dorsum of the left hand. The dorsal aspects of the index
to the little fingers and of the metacarpal region were
involved with exposure of bones, and the extensor
tendons distal to the metacarpophalangeal joint were
destroyed. At the initial stage of creating the venous flap
on the donor foot, the greater saphenous vein on the
dorsum of the foot was exposed and anastomosed end-
to-end with the dorsalis pedis artery. Two weeks later, a
flap13 x 7 cm in size was designed over the area where
arterial blood flow through the shunt and surrounding
subcutaneous veins was confirmed. The flap containing
314 E. Clinical Reconstructive Microsurgery

-
I
a c

b d

Fig.6. a Schema of arterialized venous flap transfer (proximal: artery-vein anastomosis; distal: vein-artery anastomosis). b The
little finger was cut incompletely. c The arterialized venous flap was transferred. d The flap survived completely

the greater saphenous vein as the flow-through pedicle
and a few draining branches of the greater saphenous
vein was elevated. The distal end of the greater saphe-
nous vein in the flap was anastomosed with the dorsal
branch of the radial artery at the recipient site, and the
proximal ends of the veins, including the greater saphe-
nous vein, were anastomosed with the recipient veins
as the draining veins. The flap survived with super-
ficial necrosis of a small marginal area around the flap
(Fig. 7).
Discussion
Ji et al. [2] and Amarante et al. [8] reported that survival
of the pedicled venous flap was experimentally prob-
lematic. On the other hand, Thatte and Thatte [5] and
we [6] reported this flap to be taken well. We [6]
reported that the survival of this flap depends on the
quality of blood circulation in the recipient bed. Thatte
and Thatte [27], Chavoin et al. [28] , and Amarante et al.
[8] reported successful transfer of the flap to the recipi-
ent bed with sufficient blood circulation. Chavoin et al.
[28] and Foucher and Norris [31] reported that such
flaps could be taken even at the site where bone was
exposed.
Baek et al. [4], Thatte and Thatte [5] , Amarante et al.
[8], and we [6] reported experiments showing that flow-
through venous flaps were successful when blood circu-
lation in the recipient bed was favorable. On the other
hand, Sasa et al. [9] reported that the survival rate of
this flap was poor. Honda et al. [26], Tsai et al. [29],
Amarante et al. [8], Tang et al. [30], and we [6] reported
the successful transfer of flaps to the recipient bed, with
and without good blood circulation.
Nakayama et al. [1] demonstrated experimentally
that an arterialized venous flap can survive. Yoshimura
et al. [37], Inoue et al. [38,40], and Nishi et al. [39] have
used similar flaps clinically. Survival of large flaps is not
always satisfactory because of venous congestion in

Fig. 7. a A man suffered burns on the dorsum of the left hand. b Design of flap on the calf. c Schema of delayed arterialized
venous flap transfer. d The delayed arterialized venous flap was transferred, and other areas were covered with a skin graft. e
The flap and skin graft survived completely
the flap. Koshima et al. [41] reported successful trans-
plantation of arterialized venous flaps using the long
saphenous vein clinically. Inada et al. [40] recom-
mended anastomos is of as many draining veins as pos-
sible experimentally to solve flap congestion. Veda
et al. [47] reported that delaying performance of the
venous flap relieved flap congestion in both experi-
mental and clinical studies.
The following conditions are regarded as essential
in successful venous flap procedures: harvest a pedicled
venous flap where the veins have a high venous pres-
sure; harvest a flap with a rich venous network; and
anastomose with many veins to prevent venous
congestion.
2.1.13. Venous Flap 315
References
1. Nakayama Y, Soeda S, Kasai Y (1981) Flaps nourished by
arterial inflow through the venous system: an experimen-
tal investigation. Plast Reconstr Surg 67:328-334
2. Ji SY, Chia SL, Cheng HH (1984) Free transplantation of
venous network pattern skin flaps: an experimental study
in rabbits. Microsurgery 5:151-159
3. Nichter LS, Haines PC (1985) Arterialized venous perfu-
sion of composite tissue. Am J Surg 150:191-196
4. Baek SM, Weinberg H, Song Y, Park CG, Biller HF (1985)
Experimental studies in the survival of venous island flaps
without arterial inflow. Plast Reconstr Surg 75:88-95
5. Thatte RL, Thatte MR (1987) A study of the saphenous
venous island flap in the dog without arterial inflow using
316 E. Clinical Reconstructive Microsurgery
a non-biological conduit across a part of the length of the
vein. Br J Plast Surg 40:11-15
6. Fukui A, Inada Y, Tarnai S, Mizumoto S, Yajima H,
Sempuku T (1988) Skin graft including subcutaneous vein:
experimental study and clinical applications. J Reconstr
Microsurg 4:223-231
7. Fukui A, Tarnai S (1988) Musculocutaneous grafts with
draining vein: an experimental study. J Reconstr Surg 2:
113-122
8. Amarante J, Costa H, Reis J, Soares R (1988) Venous skin
flaps: an experimental study and report of two clinical dis-
tal island flaps. Br J Plast Surg 41:132-137
9. Sasa M, xian W, Breidenbach W, Tsai TM, Sibata M, Firrell
J (1988) Survival and blood flow evaluation of canine
venous flaps. Plast Reconstr Surg 82:319-327
10. Fukui A, Tarnai S, Williams HB (1989) The importance of
venous drainage in rat flaps: an experimental study. J
Reconstr Microsurg 5:19-30
11. Inada Y, Fukui A, Tarnai S, Masuhara K (1989) Experi-
mental studies of skin flaps with subcutaneous veins.
J Reconstr Microsurg 5:249-261
12. Thatte MR, Kamdar NB, Khakkar DV, Varade MA, Thatte
RL (1989) Static and dynamic computerised radioactive
tracer studies, vital dye staining and theoretical mathe-
matical calculations to ascertain the mode of survival of
single cephalad channel venous island flaps. Br J Plast
Surg 42:405-413
13. Inada Y, Fukui A, Tarnai S, Maeda M, Mizumoto S (1990)
An experimental study of the venous flap: investigation of
the recipient vein. J Reconstr Microsurg 6:123-128
14. Yuen OM, Leung PC (1991) Some factors affecting the
survival of venous flaps: an experimental study. Micro-
surgery 12:60-64
15. Noreldin AA, Fukuta K, Jackson T (1992) Role of perive-
nous areolar tissue in the viability of venous flaps: an
experimental study on the inferior epigastric venous flap
of the rat. Br J Plast Surg 45:18-22
16. Fukui A, Maeda M, Tarnai S, Inada Y (1993) "Plasmatic
imbibition" in the rat musculocutaneous pedicled venous
flap: enzymatic proof using horseradish peroxidase. Micro-
surgery 14:114-119
17. Fukui A, Tarnai S, Maeda M, Mii Y, Mine T (1993) The
pedicled venous flap. An experimental study. Br J Plast
Surg 46:116-121
18. Lenoble E, Foucher G, Voisin MC, Maurael A, Goutallier
D (1993) Observation on experimental flow-through ven-
ous flaps. Br J Plast Surg 46:378-383
19. Chow SP, Chen DZ, Gu YD (1993) The significance of
venous drainage in free flap transfer. Plast Reconstr Surg
91:713-715
20. Ueda K, Harada T, Nagasaka S, Inoue T, Harashina T
(1993) An experimental study of delay of flow-through
venous flaps. Br J Plast Surg 46:56-60
21. Smith RJ, Fukuta K, Wheatley M, Jackson IT (1994) Role
of perivenous areolar tissue and recipient bed in the
viability of venous flaps in the rabbit ear model. Br J Plast
Surg 47:10-14
22. Fukui A, Inada Y, Murata K, Tarnai S (1995) "Plasmatic
imbibition" in the rabbit flow-through venous flap, using
horseradish peroxidase and fluorescein. J Reconstr Micro-
surg 11:255-264
23. Fukui A, Inada Y, Murata K, Ueda Y, Tarnai S (1998) A
method for prevention of arterialized venous flap necro-
sis. J Reconstr Microsurg 14:67-74
24. Yuan R, Shan Y, Zhu S (1998) Circulating mechanism of
the "pure" venous flap: direct observation of microcircu-
lation. J Reconstr Microsurg 14:147-152
25. Murata K, Inada Y, Fukui A, Tarnai S (1999) Transfer of
pedicled venous flap containing perivenous areolar tissue
and nerve: an experimental study. Br J Plast Surg 52:
223-229
26. Honda T, Nomura S, Yamauchi S, Shimamura K,
Yoshimura M (1984) The possible applications of a
composite skin and subcutaneous vein graft in the
replantation of amputated digits. Br J Plast Surg 37:
607-612
27. Thatte RE, Thatte RM (1987) Cephalic venous flap. Br J
Plast Surg 40:16-19
28. Chavoin JP, Rouge D, Vachaud M, Boccalon H,
Costagliola M (1987) Island flaps with an exclusively
venous pedicle. A report of eleven cases and a pre-
liminary haemodynamic study. Br J Plast Surg 40:149-154
29. Tsai TM, Matiko JD, Breidenbach W, Kutz JE (1987)
Venous flaps in digital revisualization and replantation.
J Reconstr Microsurg 3:113-119
30. Tang Y, Chen H, Simchon S, Jan K, Chien S (1988) The
relationship between blood flow and survival of venous
flaps. Transaction of 9th Symposium of the International
Society of Reconstructive Microsurgery, Lake Kawaguchi,
Yamanashi, Japan, p 120
31. Foucher G, Norris RW (1988) The venous dorsal digital
island flap or the "neutral" flap. Br J Plast Surg 41:337-
343
32. Fukui A, Inada Y, Maeda M, Tarnai S, Mizumoto S, Yajima
H, Sempuku T (1989) Pedicled and "flow-through" venous
flaps: clinical applications. J Reconstr Microsurg 5:235-
243
33. Thatte RM, Kumta SM, Purohit SK, Deshpande SN,
Thatte RL (1989) Cephalic venous flap: a series of 8 cases
and a preliminary report on the use of 99mTc-Iabeled RBCs
to study the saphenous venous flap in dogs. Br J Plast Surg
42:193-198
34. Thatte RL, Thatte MR (1989) The saphenous venous flap.
Br J Plast Surg 42:399-404
35. Inada Y, Fukui A, Tarnai S, Kakihana T, Maeda M (1991)
The sliding venous flap for covering skin defects with poor
blood supply on the lateral aspects of fingers. Br J Plast
Surg 44:368-371
36. Fukui A, Maeda M, Tarnai S, Inada Y (1993) The pedicled
venous flap. Clinical applications. Br J Plast Surg 46:68-
71
37. Yoshimura M, Shimada T, Imamura S, Shimamura K,
Yamauchi S (1987) The venous skin graft method for
repairing skin defects of the fingers. Plast Reconstr Surg
79:243-248
38. Inoue G, Maeda N (1988) Arterialized venous flap cover-
age for skin defects of the hand or foot. J Reconstr Micro-
surg 4:259-264

39. Nishi G, Shibata Y, Kumabe Y, Hattori S, Okuda T (1989)
Arterialized venous skin flaps for the injured finger. J
Reconstr Microsurg 5:357-365
40. Inoue G, Naeda N, Suzuki K (1990) Resurfacing of skin
defects of the hand using the arterialised venous flap. Br
J Plast Surg 43:135-139
41. Koshima I, Soeda S, Nakayama Y, Fukuda H, Tanaka J
(1991) An arterialized venous flap using the long saphe-
nous vein. Br J Plast Surg 44:23-26
42. Inada Y, Fukui A, Tarnai S, Mizumoto S (1993) The arte-
rialised venous flap: experimental studies and a clinical
case. Br J Plast Surg 46:61-67
43. Kamei K, Ide Y (1993) The pedicled arterialized venous
flap. J Reconstr Microsurg 9:287-291
44. Nishi G (1994) Venous flaps for covering skin defect of the
hand. J Reconstr Microsurg 10:313-319
2.1.13. Venous Flap 317
45. Karacalar A, Ozcan M (1994) Free arterialized venous
flap for the reconstruction of defects of the hand: new
modifications. J Reconstr Microsurg 10:243-248
46. Inoue G, Tamura Y, Suzuki K (1996) One-stage repair of
skin and tendon digital defects using the arterialized
venous flap with palmaris longus tendon: an additional
four cases. J Reconstr Microsurg 12:93-97
47. Ueda Y, Mizumoto S, Hirai T, Doi Y, Fukui A, Tarnai S
(1997) Two-stage arterialized flow-through venous flap
transfer for third degree burn defects on the dorsum of
the hand. J Reconstr Microsurg 13:489-496
48. Fukui A, Inada Y, Maeda M, Mizumoto S, Yajima H, Tarnai
S (1994) Venous flap-its classification and clinical appli-
cations. Microsurgery 15:571-578
2.2 General Concepts of the Donors for
Muscle Transplantation
Y OSHIHISA AKASAKA
Free muscle transplantation was first performed in
1874 by Zielonko, who transplanted muscle of the frog's
thigh into the lymph sac. This experiment and other
similar attempts were unsuccessful, because an ade-
quate blood supply could not be obtained without vas-
cular anastomoses and the muscle tissue showed poor
tolerance to ischemia.
Thompson in 1971 confirmed that a muscle whose
motor nerve had been cut off 2 to 3 weeks previously
could be transplanted successfully on the healthy
muscle belly. However, for such a muscle graft to be
successful, it is necessary for blood flow to occur
and for the muscle graft to be neurotized or reinner-
vated by motor nerve branches. Thompson's technique
is thought to have a low success rate for these reasons
[1,2].
In 1960, the technique of microvascular anastomosis
was established by Jacobson and Suarez. In 1965, Tamai
et al. succeeded in reattaching an amputated thumb.
Then microsurgery gained wide recognition.
Subsequently, technical improvements and advances
in understanding of the microanatomy of skin and
muscles have made the transplantation of various
tissues possible. Free tissue transplantation has come to
be applied for reconstruction of defects or restoration
of functional loss due to trauma and extended tumor
resection. Thus, new developments have been explored
for the use of microsurgery.
In 1970, Tamai et al. first performed free muscle
transplantation using a microsurgical technique and
obtained a 70% success rate [3]. In 1975, Kubo reported
the recovery of muscular function [4]. Harii in 1976
reported a patient with facial nerve palsy treated by
transplantation of the gracilis muscle [5], and Ikuta in
1976 reported two cases of Volkmann's contracture
treated by free muscle transplantation [6]. Shanghai
Sixth People's Hospital in 1976 [7], Schenck in 1977 [8],
and Manktelow in 1978 [9] also reported clinical cases
of muscle transplantation.
318
Indications for Free Muscle
Transplantation
Reconstruction using a free muscle graft with a neu-
rovascular pedicle aims at filling and covering tissue
defects, achieving a good blood supply, and restoration
of function. Since the initial two objectives are also
achieved by a free skin flap transplantation, we will dis-
cuss functional free muscle transplantation in this article.
Functional free muscle transplantation is used for
restoration of motor function in patients with muscle
injury due to Volkmann's contracture or trauma, motor
disturbance following extended muscle resection for
tumor removal, or old nerve paralysis with no possibil-
ity of spontaneous recovery.
In this technique, a donor muscle is harvested with
feeding vessels and motor nerves and is transferred to
the site of the recipient bed, where nerve and vascular
anastomosis is performed under an operating micro-
scope. This procedure is intended to preserve the blood
flow in the grafted muscle and to eventually achieve re-
innervation of the graft. From 3 to 4 months post-
operatively, muscular contraction can be seen when
reinnervation has been achieved and movement
becomes possible.
However, because this technique is complex and a
long time is required until effective muscle contraction
is obtained, a simpler technique, such as tendon trans-
fer, should be chosen if it can be applied. It is also im-
portant to select the appropriate patient, taking into
account the patient's age, accompanying injury,
patience, and motivation [10].
Selection of the Muscle for Grafting
Anatomical and functional factors should be considered
when choosing a muscle graft. Anatomical aspects
include size of the muscle (length and volume), shape
 2.2. General Concepts of the Donors for Muscle Transplantation
of the origin and insertion, and neurovascular anatomy
(position, size, and configuration). Functional aspects
include muscle power and excursion.
Therefore, a donor muscle should satisfy the follow-
ing conditions: The donor muscle should have a shape,
volume, and length corresponding to the recipient site
and the required power. The feeding vessels and motor
nerves of the muscle should be anatomically simple and
should have a large enough diameter for anastomosis.
Removal of the muscle should cause no functional dis-
turbance at the donor site. In consideration of these
factors, the gracilis [10], latissimus dorsi, pectoralis
major, and rectus femoris muscles are commonly chosen
for grafting.
Surgical Procedure
Preoperative Planning
The functional deficit and the vascular and nerve
injuries at the injured site should be assessed precisely,
based on the records of previous operations, findings
on the preoperative examination, electromyography
(EMG), and arteriography. A precise plan for the oper-
ation should be devised, including which of the lost
functions are most valuable to restore, what structures
at the recipient site should be selected as the origin and
insertion of the muscle graft, which vessels and nerves
should be used for anastomosis, which muscle should be
chosen as a graft, the posture of the patient, and the skin
incision.
The vascular system may not be intact at the site of
injury, and vascular abnormality, rupture, and degener-
ation may be present. A preoperative arteriogram is
therefore essential.
Preparation of the Recipient Area
Skin Incision
The skin incision should be designed to achieve good
exposure of the vessels, nerves, origin, and insertion at
the recipient site. After grafting, it is necessary to cover
the lower half of the grafted muscle using skin from the
recipient site without tension.
Dissection of Arteries, Veins, and Nerves
The nerves and vessels are divided in the recipient
area. It is difficult to dissect the vessels and nerves at
a damaged site. Dissection should be commenced at a
scar-free proximal site, and undamaged tissues should
319
be prepared for vascular and nerve anastomosis. The
undamaged motor nerves should be carefully selected,
based on the patient's history, the physical examination,
and the previous operations. Then the usable motor
nerves should be dissected and prepared for anastomo-
sis. Sometimes motor nerves are transferred from
another place, such as intercostal nerves or spinal acces-
sory nerves.
Preparation of the Origin and Insertion of
the Grafted Muscle
The coracoid process, clavicle, or humeral lateral or
medial epicondyle is chosen as the origin of the
grafted muscle, and various tendons are used for the
insertion.
Harvest of the Donor Muscle
The rectus femoris or gracilis muscle is often used in
consideration of the anatomical features of the neu-
rovascular system and the operative procedures. Since
the wound cannot be closed primarily at the recipient
site after grafting because of tissue defects, scarring,
and disuse atrophy, it is usually necessary to harvest the
grafted muscle together with its overlying skin (as a
musculocutaneous flap with a neurovascular pedicle).
During harvesting of the musculocutaneous flap, the
overlying skin can easily become separated from the
muscle, and the perforating arteries supplying the skin
may be damaged. It is therefore recommended to fix
the skin and muscle together at several sites during
dissection.
With muscle transplantation, the tonus of the graft
is important for restoration of function. Marking
sutures are made on the muscle at 5-cm intervals
while the muscle is stretched maximally to provide an
index of muscular tonus. The details of handling the
muscles mentioned above are discussed in another
chapter.
Preparation of the recipient bed and harvest of the
donor muscle can be performed simultaneously by two
teams in order to shorten the operating time, provided
that the scheduled procedures are definitive and are not
likely to be changed during operation.
Muscle Transplantation
Fixation of the Muscle to the Graft Bed
The relationship of the grafted muscle to its bed is
checked, and it is confirmed that the graft is compatible
with the planned origin and insertion, as well as the neu-
320 E. Clinical Reconstructive Microsurgery
rovascular anastomotic sites. When the sites of vascular
and nerve anastomosis have been determined, the
muscle origin is fixed with sutures and the muscle is
provisionally fixed at several sites in order to prevent
movement of the muscle during microsurgical anasto-
mosis. (Manktelow used provisional fixation at the
origin, with both the origin and insertion being sutured
after neurovascular anastomosis.)
Neurovascular Anastomosis
Neurovascular anastomosis is performed under an
operating microscope. In general, one artery and two
veins are anastomosed, and the sequence of anastomo-
sis is first artery, then veins, and finally nerves. The nerve
suture is carried out with precise apposition, without
tension, and without the use of a nerve graft. The nerve
suture should be as close to the grafted muscle as pos-
Fig.1. A 21-year-old man (T.T.) suffered total paralysis of the
left upper limb. He had surgery at another hospital, where
intercostal nerve transfer and trapezius transfer were per-
formed. However, neither of these procedures was effective,
and he was referred to us 6 years after the original injury, in
sible. Finally, hemostasis of the graft bed and the blood
flow and hemostasis of the grafted muscle and skin flap
should be checked again.
Suturing of the Muscle Insertion
The tension of the grafted muscle has a significant influ-
ence on the functional results. Manktelow stretched the
grafted muscle maximally and sutured while extending
it to the maximum amount required for functional re-
construction. Since we are still performing these proce-
dures on a trial basis, we anastomose the grafted muscle
in its physiological length, while the joint is in the
neutral position or slight tension is placed on the muscle
during anastomosis. When anastomosis of the vessels,
nerves, origin, and insertion is complete, the wound is
closed, utilizing the skin flap overlying the transplanted
muscle.
1979. We carried out free muscle transplantation using the 5th
and 6th intercostal nerves to supply the transplant. The figures
show the patient 46 months postoperatively. The movement of
the elbow joint was from 20 0 to 800 and muscle strength was
M3 by manual muscle testing
 2.2. General Concepts of the Donors for Muscle Transplantation
Fig. 2. A 19-year-old man (Y.M.) suffered complete paralysis
due to whole-root avulsion. He was referred to us 2 weeks
later. When the brachial plexus was exposed 1 month after the
accident, it was found that C5 and C6 were avulsed and C7
and C8 were vacant sheaths. Three months after the accident,
Postoperative Management
The arm is placed in a position that avoids tension at
the origin and insertion of the grafted muscle and is
immobilized for 5 weeks by a plaster slab. Swelling
should be controlled to avoid compression, so that good
peripheral blood flow 'is secured.
We have not used any anticoagulants, including
heparin, postoperatively. However, it is recommended
to use low-molecular-weight dextran, urokinase, or
alprosladil albadex for prophylaxis, and the aim should
be to maintain good blood flow in the grafted muscle by
adjusting intravenous fluids when necessary and by per-
forming blood transfusion.
The skin flap should be carefully monitored post-
operatively on the basis of its color and temperature,
although these signs may not always provide a reliable
321
we performed free muscle transplantation for reconstruction
of the wrist extensor, plus reconstruction of the elbow flexor
by intercostal nerve crossing. The figures show the patient 3
years after surgery. (See Color Plates)
indication of the hemodynamics of the grafted muscle.
Because it is difficult to detect postoperative thrombo-
sis early, the vascular anastomosis should be technically
perfect.
From 3 weeks postoperatively, assisted exercises are
commenced to prevent digital contracture and to mobi-
lize the tendon at the recipient site. After 5 weeks, exer-
cises are performed to release joint contracture at the
shoulder, elbow, and wrist. If contraction of the grafted
muscle is shown by electromyography at 4 to 6 months
postoperatively, audiovisual biofeedback exercises are
performed to increase the muscle power. Since a muscle
strength of M3 or greater can be achieved after about 1
year, and it is also possible to increase muscle power
further for up to 2 to 3 years postoperatively, the patient
should be encouraged to continue exercising (Figs. 1
and 2).
322 E. Clinical Reconstructive Microsurgery

References 6. Ikuta Y, Kubo T, Tsuge K (1976) Free muscle transplanta-

tion by microsurgical technique to treat severe Volkmann's
contracture. Plast Reconstr Surg 58:407-411
1. Ikuta Y (1977) Microsurgery. Nankodo, Tokyo, pp 213-232
7. Shanghai Sixth People's Hospital, Shanghai (1976) Free
2. Zhong-Wei C, Dong-Yue Y, Di-Sheng C (1982) In: Zhong-
muscle transplantation by microsurgical neurovascular
wei C, Dong-yue Y, Di-sheng C (eds) Microsurgery.
anastomoses. Report of a case. Chinese Med J 2:47-50
Springer, Berlin, pp 232-260 .
8. Schenck RR (1977) Free muscle and composite skin trans-
3. Tarnai S, Komatsu S, Sakamoto H, Sano S, Sasauchl N,
plantation by microneurovascular anastomosis. Orthop
Hori Y, Tatsumi Y, Okada H (1970) Free muscle trans-
Clin North Am 8:367-375
plants in dogs, with microsurgical neurovascular anasto-
9. Manktelow RT, McKee NH (1978) Free muscle trans-
moses. Plast Reconstr Surg 46:219-225
plantation to provide active finger flexion. J Hand Surg 3:
4. Kubo T, Ikuta Y, Tsuge K (1976) Free muscle transplanta-
416-426
tion in dogs by microneurovascular anastomoses. Plast
10. Manktelow RT, Zuker RM, McKee NH (1984) Function-
Reconstr Surg 57:495-501
ing free muscle transplantation. J Hand Surg 9A:32-39
5. Harii K, Ohmori K, Torii S (1976) Free gracilis muscle
11. Harii K, Ohmori K, Sekiguchi J (1976) The free musculo-
transplantation, with microneurovascular anastomoses
cutaneous flap. Plast Reconstr Surg 57:294-303
for the treatment of facial paralysis. Plast Reconstr Surg
57:133-143
2.2.1 Latissimus Dorsi Muscular and
Musculocutaneous Flap
HIROSHI ONO
The pedicled latissimus dorsi muscular and musculocu-
taneous flap transfers are useful in the reconstruction of
the breast [1], head and neck [2], chest wall [3], upper
extremity [4], and abdominal wall [3], as well as free flap
transfer [5] .Although this flap has come to be extensively
used in reconstructive surgery during the past two
decades, its use is not new. The first person to use the latis-
simus dorsi musculocutaneous flap was Professor Iginio
Tansini of Pavia, Italy [6], who used the flap for wound
closure after radical mastectomy in 1906. The Tansini
method became extremely popular throughout Europe
between 1910 and 1920. In 1912 D'Este used a proximally
based latissimus dorsi musculocutaneous flap to cover a
chest wall defect resulting from mastectomy. In 1939,
Hutchins used a similar flap to prevent postmastectomy
lymphedema. However, the use of skin grafts became the
accepted procedure for wound closure after radical mas-
tectomy, and the widespread acceptance of skin grafts
put the latissimus dorsi musculocutaneous flap to rest.
On the other hand, Schottstaedt et al., in orthopedic
surgery, reviewed functional muscle transposition and
described the transfer of the latissimus dorsi for flexion
and extension of the elbow [7]. Zancolli in 1973 reported
excellent results in eight patients following latissimus
dorsi transfers for elbow flexion [8].
The latissimus dorsi flap became popular again after
a description of its use by Olivari in 1976 [9]. The appli-
cations of this flap were elegantly elaborated upon by
Muhlbauer and Olbrisch in 1977 in their demonstration
of the use of the flap for breast reconstruction [10].
Mendelson and Masson, also in 1977, proved the use-
fulness of this flap in covering radiation ulcers of the
shoulder [4]. Recently, the latissimus dorsi muscular and
musculocutaneous flap has become a significant tool in
the armamentarium of reconstructive surgeons.
Anatomical Characteristics of the
Latissimus Dorsi Muscle
The latissimus dorsi is one of the largest flat, triangular
muscles in the body. Its tendinous origins are in the
spinous processes of the lower six to seven thoracic ver-
tebrae, the lumbar vertebrae, the superior sacral verte-
brae, iliac crest, the external surface of the three to four
most inferior ribs, and frequently in the inferior angle
of the scapula. The muscle fibers run proximally, anteri-
orly, and laterally toward the axilla, pass in front of the
teres major, and then form insertions on the crest, lesser
tubercle, and floor of the intertubercular groove of the
humerus. The latissimus dorsi muscle acts to move the
arm medially and posteriorly, and also rolls the arm
inward in an adducted position. The muscle also acts to
move the scapula in the medial and downward direc-
tions. The absence of this muscle is not noticed in these
daily activities, because of the numerous substitute
muscles, such as the teres major, pectoralis major, and
subscapularis, that can perform its actions.
The primary vascular supply to the latissimus dorsi
muscle is the thoracodorsal artery and vein. These
vessels are branches of the subscapular artery and vein
that originate from the axillary artery and vein, respec-
tively. After originating from the lateral third of the axil-
lary vessels, the subscapular artery and vein bifurcate
into some circumflex scapular vessels and the thora-
codorsal vessels [11]. After giving rise to the circumflex
scapular vessels, the blood supply to the latissimus dorsi
continues as the thoracodorsal artery and vein. In its
course, the artery may give rise to a few branches in the
serratus anterior muscle area before entering the latis-
simus dorsi muscle. The thoracodorsal vessels enter the
deep surface of the latissimus dorsi muscle, high in the
axilla, at a mean distance of 2.1 cm medial to the lateral
muscular border. The thoracodorsal artery is 1.5 to
4.0 mm in external diameter at its origin and 0.5 to
3.5 mm at the neurovascular hilus of the muscle. The
mean length of the thoracodorsal vessels is 9.3 cm. In the
latissimus dorsi muscle, the thoracodorsal vessels bifur-
cate into the upper branch and the lateral vessels [12].
The anterolateral two-thirds (12cm) of the muscle is
supplied by the thoracodorsal artery and vein [13]. The
latissimus dorsi muscle has a strictly segmental blood
supply only in its most posteromedial aspect (6cm).
Paraspinous vessels perforating into the latissimus dorsi
come from the dorsal branches of the posterior inter-
costal arteries of the lowest seven intercostal spaces and
323
324 E. Clinical Reconstructive Microsurgery
Fig. 1. Positioning of the patient. Straight lines show both
anterior (black arrows) and posterior (white arrows) margins
of the latissimus dorsi muscle. Oval line (black stars) shows an
island skin flap on the latissimus dorsi muscle
the dorsal branches of the four lumbar arteries. These
perforators vary from 1 to 3 mm in external diameter
and are located approximately 4cm laterally from the
midline [1]. The collaterals between the thoracodorsal
vessels and the posterior perforators are well developed
in the latissimus dorsi muscle.
The skin overlying the latissimus dorsi muscle is sup-
plied by muscular perforators from the latissimus dorsi
muscle via the thoracodorsal artery. The larger muscu-
locutaneous perforators pierce the proximal part of the
muscle, with smaller perforators distally.
The innervation of the latissimus dorsi muscle occurs
through the thoracodorsal nerve (C6, 7, and 8), which is
derived from the posterior cord of the brachial plexus.
The nerve is observed at a mean distance of 3.1 cm prox-
imal to the subscapular artery and vein, joining them
within 3 to 4 cm and paralleling the vasculature to the
neurovascular hilus of the latissimus dorsi muscle. The
mean length of the thoracodorsal nerve is 12.3 cm,
ranging from 8.5 to 19.0cm.
Harvesting Technique
The latissimus dorsi island muscular or musculocuta-
neous flap is first prepared for removal from the
patient's back as follows. The patient is placed in a
harvesting-side-up, lateral position with the ipsilateral
arm in 90 degrees of flexion at the shoulder and the
elbow in 90 degrees of flexion without any upper limb
fixation (Fig. 1).
The anterolateral skin incision is placed 3 cm in front
of the antero-Iateral margin of the latissimus dorsi
muscle from the axilla to the iliac crest at a necessary
Fig. 2. Anatomy of the thoracodorsal neurovascular bundle.
The thoracodorsal neurovascular bundle (large black arrow)
is between the margin of the serratus anterior muscle and the
latissimus dorsi muscle (black stars). The thoracodorsal artery
gives rise to a few branches to the serratus anterior muscle
(large white arrow) before entering the latissimus dorsi. Small
black arrows show the subscapular artery and vein
length. Exploration through this incision, which reaches
down to a plane deep in the layer of the dorsal fascia of
the latissimus dorsi muscle, shows the anterolateral
margin of this muscle. The operative preparation of the
thoracodorsal neurovascular bundle is relatively simple,
because it is easily identifiable in the areolar space
approximately 10 cm below the apex of the axilla, which
is between the posterior margin of the serratus anterior
muscle and the anterolateral margin of the latissimus
dorsi muscle (Fig. 2). The neurovascular bundle enters
the proximal aspect of the latissimus dorsi muscle on
its deep (anterior) surface, approximately 8 to 12cm
(mean, Wcm) distal to the muscle's tendinous insertion
into the humerus, and approximately 2cm medial to the
lateral margin of the muscle. After identification of the
thoracodorsal neurovascular bundle at the entrance
into the latissimus dorsi, the neurovascular bundle is
divided proximally. The thoracodorsal artery gives rise
to a few branches to the serratus anterior muscle before
entering the latissimus dorsi. Dividing the circumflex
scapular artery and the branches to the serratus ante-
rior to make a single dominant long vascular pedicle
yields a 10- to 12-cm vascular pedicle that is based on
the subscapular artery.
After identification of the thoracodorsal neurovascu-
lar bundle, the overlying skin on the latissimus dorsi
muscle is designed as an island skin flap backwards from
the anterolateral skin incision. The skin island is usually
 2.2.1. Latissimus Dorsi Muscular and Musculocutaneous Flap
Fig. 3. Latissimus dorsi muscle. The latissimus dorsi is a flat,
triangular muscle in the back of the body. The muscle fibers
run toward the axilla. Black arrows show the anterior margin
of the latissimus dorsi muscle. White arrows show the poste-
rior margin of the latissimus dorsi muscle
Fig. 4. Insertion of the inferior angle of the scapula. At the
deep surface of the latissimus dorsi muscle, the insertion of the
inferior ribs and inferior angle of the scapula (black arrow) is
divided with a ligature of perforators coming from the dorsal
branches of the posterior intercostal arteries and the dorsal
branches of the lumbar arteries. Black stars show the poste-
rior margin of the latissimus dorsimuscle
centered over the latissimus dorsi muscle belly, although
the skin island can be oriented transversely across the
upper border of the muscle (Fig. 1). Because the larger
musculocutaneous perforators pierce the upper part of
the latissimus dorsi muscle, it is safer to make a skin
island on the upper part of the muscle than on the lower
325
Fig. 5. Island latissimus dorsi muscular flap. The latissimus
dorsi muscular flap is elevated. Black arrow shows the thora-
codorsal neurovascular bundle. (See Color Plates)
part. The skin defect resulting from harvesting a skin
island up to IOcm by 30cm is usually closed directly, but
a larger defect may require a split-thickness skin graft
in the adult.
The anterolateral border of the latissimus dorsi
muscle can be sharply dissected. Distally, we divide the
latissimus dorsi muscle from its insertion or carry the
incision through the latissimus dorsi muscle if we need
a small muscle (Fig. 3). At the deep (anterior) surface
of the latissimus dorsi muscle, the insertion of the
inferior ribs and inferior angle of the scapula is divided
with a ligature of perforators coming from the dorsal
branches of the posterior intercostal arteries and the
dorsal branches of the lumbar arteries (Fig. 4). Finally,
superior (proximal) muscle division is performed prox-
imally to the entrance of the thoracodorsal neurovas-
cular pedicle into the muscle. The latissimus dorsi
muscle passes in front of the teres major and forms an
insertion with the teres major into the intertubercular
sulcus of the humerus. Therefore, in order to harvest
from the insertion of the latissimus dorsi into the
humerus, a part of the tendinous insertion of the teres
major is also cut. The axillary neurovascular bundle
passes in front of the tendinous insertion of the latis-
simus dorsi to the humerus. The axillary neurovascular
bundle has to be retracted anteriorly when the latis-
simus dorsi insertion is detached from the humeral
periosteum (Fig. 5). Finally, the thoracodorsal neu-
rovascular bundle is cut, leaving a necessary length from
its entrance into the muscle, when the latissimus dorsi
has been designed as a free flap.
326 E. Clinical Reconstructive Microsurgery
References
1. Bostwick J III, Vasconez LO, Jurkiewicz MJ (1978) Breast
reconstruction after a radical mastectomy. Plast Reconstr
Surg 61:682-693
2. Quillen CG (1979) Latissimus dorsi myocutaneous flaps
on head and neck reconstruction. Plast Reconstr Surg 63:
664-667
3. Bostwick J III, Nahai F, Wallance JG, Vasconez LO (1979)
Sixty latissimus dorsi flaps. Plast Reconstr Surg 63:31-41
4. Mendelson BC, Masson JK (1977) Treatment of chronic
radiation injury over the shoulder with a latissimus dorsi
myocutaneous flap. Plast Reconstr Surg 60:681-691
5. Watson JS, Craig RDP, Orton CI (1979) The free latis-
simus dorsi myocutaneous flap. Plast Reconstr Surg 64:
299-305
6. Maxwell GP (1979) Iginio Tansini and the origin of the
latissimus dorsi musculocutaneous flap. Plast Reconstr
Surg 66:686-692
7. Schottstaedt ER, Larsen LJ, Bost FC (1955) Complete
muscle transposition. J Bone Joint Surg 37A:897-918
8. Zancolli E, Mitye R (1973) Latissimus dorsi transfer to
restore elbow flexion. J Bone Joint Surg 55A:1265-1275
9. Olivari N (1976) The latissimus flap. Br J Plast Surg 29:
126-128
10. Muhlbauer W, Olbrish R (1977) The latissimus dorsi
myocutaneous flap for breast reconstruction. Chir Plast
4:27-34
11. Bartlett Sp, May JW Jr, Yaremchuk ML (1981) The latis-
simus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 67:631-636
12. Tobin GR, Schusterman M, Peterson GR, Nichols
G, Bland LI (1981) The intramuscular neurovascular
anatomy of the latissimus dorsi muscle: the basis for split-
ting the flap. Plast Reconstr Surg 67: 637-641
13. McCraw JB, Penix JO, Baker JW (1978) Repair of major
defects of the chest wall and spine with the latissimus dorsi
myocutaneous flap. Plast Reconstr Surg 62:197-206
2.2.2 Rectus Abdominis Myocutaneous Flap
KUNIHIKO NOHIRA, YUHEI YAMAMOTO, and YOSHIHISA SHINTOMI
Since the first clinical case reports of the rectus abdo-
minis myocutaneous flap in the late 1970s, the flap has
become a widely accepted technique for head and neck,
trunk, and extremity reconstruction. The rectus abdo-
minis myocutaneous flap has been used as a superiorly
pedicled, inferiorly pedicled, microvascularly aug-
mented, or free flap, according to the location and size
of the defect. This wide capacity of the transfer fashion
of the flap has led to its common use in the various fields
of reconstructive surgery.
Superiorly Pedicled Rectus Abdominis
Myocutaneous Flap Free Rectus Abdominis
Myocutaneous Flap
In the late 1970s, the superiorly pedicled rectus abdo-
minis myocutaneous flap was introduced for chest wall,
breast, and abdominal wall reconstruction [1-3]. The
flap is nourished by the superior epigastric vascular
system. The superiorly pedicled rectus abdominis
myocutaneous flap, with a skin island consisting of a
transverse ellipse from the lower abdomen, is called the
transverse rectus abdominis myocutaneous (TRAM)
flap, and it has been one of the most popular methods
for breast reconstruction [4].
Inferiorly Pedicled Rectus Abdominis
Myocutaneous Flap
In 1983, Taylor and colleagues presented the inferiorly
pedicled rectus abdominis myocutaneous flap for recon-
struction of the groin, thigh, and perineal regions [5].
The flap is nourished by the deep inferior epigastric vas-
cular system.
Microvascularly Augmented Rectus
Abdominis Myocutaneous Flap
In 1987, Harashina and colleagues demonstrated the
TRAM flap with augmented blood supply through the
inferior epigastric vascular system using microvascular
surgery for breast reconstruction [6]. The microvascu-
larly augmented rectus abdominis myocutaneous flap is
the superiorly pedicled rectus abdominis myocutaneous
flap with microvascular anastomosis between either the
contralateral or the ipsilateral deep inferior or superfi-
cial epigastric vascular system and available vessels
close to the defect. The flap is nourished by both
superior and inferior epigastric vascular systems. The
technique provides more reliable viability of the flap
compared with other styles of the rectus abdominis
myocutaneous flap [7].
In 1979, Holmstrom reported one successful case of
breast reconstruction with the free abdomininoplasty
flap [8]. The following year, Pennington and Pelly
described the use of the free rectus abdominis myocu-
taneous flap to cover the defect in the infracla-
vicular region [9]. Usually, the flap is isolated on the
deep inferior epigastric vascular system, and micro-
vascular anastomosis is carried out between it and
available vessels close to the reconstructed site. The
free rectus abdominis myocutaneous flap, providing a
large volume of soft tissue, a variety of flap designs,
constant vascular anatomy, and harvest on the supine
position, is particularly versatile for immediate head
and neck reconstruction following cancer resection [10].
Harvesting Technique
The procedure for harvesting a free rectus abdominis
myocutaneous flap is as follows. The skin paddle of the
rectus abdominis myocutaneous flap is designed as a
"boomerang" shape based on the vascular territory of
the deep inferior epigastric vascular system [11] (Fig.
1a). Following a skin incision along the design of the
skin paddle, the surrounding region and the superior
and inferior limb of the flap are dissected from just
above the external oblique and anterior rectus sheath.
327
 328 E. Clinical Reconstructive Microsurgery
ab
e,f
Fig. 1. a Design of the free rectus abdominis myocutaneous
flap. b Dissection of the surrounding region of the flap. c
Raising the superior and inferior limb of the flap from just
above the external oblique and anterior rectus sheath except
for the angle of the flap. d Following division of the anterior
rectus sheath and rectus muscle, the deep inferior epigastric
The angle of the flap, in which some perforators are
included in the flap, is left to be attached with the rectus
sheath (Fig.lb and c). The anterior rectus sheath is then
incised 2 to 4cm medially to the lateral border.
The exposed rectus abdominis muscle is divided and
elevated medially by retractors, and the deep inferior
epigastric vascular system is identified at the posterior
surface of the muscle (Fig. Id). The muscular portion
to be harvested is cut cranially and medially, and the
flap is turned downward (Fig. Ie and f). Finally, the
caudal insertion of the muscle is separated so as not to
injure the vascular pedicle, and it is dissected completely
and divided just distal to the external iliac vessels
to obtain the long vascular pedicle (Fig. Ig). The free
rectus abdominis myocutaneous flap based on the
cd
g,h
vascular system is identified. e Cranial and medial dissection
of the flap. f The flap is turned downward. g The caudal
insertion of the muscle is separated, and the vascular pedicle
is dissected to the origin. h The free rectus abdominis
myocutaneous flap is isolated. (See Color Plates)
deep inferior epigastric vascular system is prepared
for transfer to the defect (Fig. Ih). The muscle harvest
is not excessive, and the donor site is directly closed
in a single curved line. There is little postoperative
incompetence of the abdominal wall in the patient's
daily life.
Recently, the free rectus abdominis myocutaneous
flap, combined with the vascularized eighth and ninth
costal cartilages, which are supplied by the perichon-
drial vascular network through the anterior intercostal
vessels connecting with the deep epigastric vascular
system, has been effectively used for restoration of the
craniofacial contour in reconstructive head and neck
surgery [12] (Fig. 2). In addition, several modifications,
such as sparing the anterior rectus sheath or not con-

Fig. 2. The free rectus abdominis myocutaneous flap com-
bined with the vascularized eighth and ninth costal cartilages.
(See Color Plates)
taining the muscular portion technique, have been tried
to reduce abdominal weakness after the rectus abdo-
minis myocutaneous flap has been harvested [13] (Fig.
3a and b).
References
1. Drever JM (1977) The epigastric island flap. Plast
Reconstr Surg 59:343-346
2. Mathes SJ, Bostwick J III (1977) A rectus abdominis
myocutaneous flap to reconstruct abdominal wall defects.
Br J Plast Surg 30:282-283
3. Robbins TH (1979) Rectus abdominis myocutaneous flap
for breast reconstruction. Aust NZ J Surg 49:527-531
4. Hartrampf CR, Scheflan M, Black PW (1982) Breast
reconstruction with a transverse abdominal island flap.
Plast Reconstr Surg 69:21~224
5. Taylor GI, Corlett R, Boyd JB (1983) The extended
deep inferior epigastric flap: A clinical technique. Plast
Reconstr Surg 72:751-764
6. Harashina T, Sone K, Inoue T, Fukuzumi S, Enomoto K
(1987) Augmentation of circulation of pedicled transverse
rectus abdominis musculocutaneous flaps by micro-
vascular surgery. Br J Plast Surg 40:367-370
7. Yamamoto Y, Nohira K, Sugihara T, Shintomi Y, Ohura T
(1996) Superiority of the microvascularly augmented flap:
Analysis of 50 transverse rectus abdominis myocutaneous
flaps for breast reconstruction. Plast Reconstr Surg 97:
79-83
2.2.2. Rectus Abdominis Myocutaneous Flap 329
b
Fig. 3. a The free rectus abdominis myocutaneous flap with
the fascia-sparing technique. b The free deep inferior epigas-
tric perforator (DIEP) flap. (See Color Plates)
8. Holmstrom H (1979) The free abdominoplasty flap and its
use in breast reconstruction. Scand J Plast Reconstr Surg
13:423-427
9. Pennington DG, Lai MF, Pelly AD (1980) The rectus
abdominis myocutaneous free flap. Br J Plast Surg 33:
277-282
10. Nakatsuka T, Harii K, Asato H, Ebihara S (1994) Versa-
tility of a free inferior rectus abdominis flap for head and
neck reconstruction: Analysis of 200 cases. Plast Reconstr
Surg 93:762-769
11. Yamamoto Y, Nohira K, Minakawa H, Sasaki S, Yoshida
T, Sugihara T, Shintomi Y, Yamashita T, Hosokawa M,
Ohura T (1995) "Boomerang" rectus abdominis musculo-
cutaneous free flap in head and neck reconstruction. Ann
Plast Surg 34:48-55
12. Yamamoto Y, Minakawa H, Kokubu I, Kawashima K,
Sugihara T, Satoh N, Fukuda S (1997) The rectus abdo-
minis myocutaneous flap combined with vascularized
costal cartilages in reconstructive craniofacial surgery.
Plast Reconstr Surg 100:439-444
13. Koshima I, Soeda S (1989) Inferior epigastric artery skin
flap without rectus abdominis muscle. Br J Plast Surg 42:
645-648
2.2.3 Gracilis Musculocutaneous Flap
Y OSHIHISA AKASAKA
The gracilis muscle is employed as a free muscle or mus-
culocutaneous flap for filling and covering a soft tissue
defect, although it is narrow in width relative to its
length, so there are some limitations on its use for cov-
erage. The gracilis muscle is also used together with the
motor nerve for transplantation aimed at functional
reconstruction [1,2].
An advantage of the gracilis muscle for functional
muscle transplantation is its tendinous origin as well as
its long tendinous insertion, so that it is of suitable
shape, length, and volume for reconstruction of upper
limb function. It is also a strong muscle with a wide
range of movement and is easy to remove as a muscu-
locutaneous flap, since the neurovascular bundle has a
simple anatomy and lies superficially. Furthermore, the
gracilis can be harvested with the patient in the supine
position, the scar at the donor site is not prominent, and
there is little or no functional disturbance in the leg after
removal of the muscle.
Anatomy of the Gracilis Muscle
The gracilis muscle is one of the adductor muscles of the
hip joint, located in the medial aspect of the thigh. Orig-
inating from the lateral rim of the pubic symphysis, the
gracilis muscle runs downward behind the adductor
longus and sartorius muscles at the medial border of the
thigh and becomes a long tendon for its distal one-third.
The gracilis tendon becomes the pes anserinus together
with the sartorius and semitendinosus muscle tendons,
inserting into the medial aspect of the proximal tibia. It
is a long, ribbon-shaped muscle, 35-50cm long, 3-5cm
wide, and 1-3cm thick (Fig. 1) [3].
In general, the major vessels supplying the gracilis
branch off from the medial femoral circumflex artery or
arise directly from the profunda femoris artery. This
vessel runs between the adductor longus and adductor
brevis muscles to enter the gracilis at a site in the prox-
imal one-third of the muscle (about 10cm distal to the
pubic symphysis). A vascular pedicle can be obtained 4
to 6 cm long with a vessel diameter of 1 to 2 mm. This
artery can supply the entire gracilis muscle adequately,
330
and these vessels are suitable for anastomoses [4]. In
addition to these major vessels, several small vessels
branch off from the femoral artery and vein to enter the
gracilis muscle.
The dominant nerve of the gracilis muscle is the ante-
rior ramus of the obturator nerve, which descends
between the adductor longus and the adductor brevis
and enters the gracilis at a site close to that of the major
feeding vessel. This nerve is formed of two or three fas-
cicles (Fig. 2).
Harvesting Technique
For harvest of the muscle graft, the patient is placed in
the supine position. The lower limb is disinfected from
the pubic tubercle and the iliac crest to the foot, and
then the patient is draped. The hip joint is abducted and
externally rotated, and the knee is flexed to obtain an
adequate operating field on the medial aspect of the
thigh from the groin to the knee. The gracilis muscle lies
beneath a line connecting the origin of the adductor
longus and the tibial tuberosity.
Two cordlike tendons can be palpated posterior to the
medial aspect of the knee joint. A longitudinal incision
of about 5 cm is made along the tendon to expose the
tendinous part of the gracilis. (The sartorius, gracilis,
semimembranosus, and semitendinosus muscles are
found in this order from anterior to posterior, and the
tendinous bands are formed by the gracilis and semi-
tendinosus, with the anterior one being the gracilis
tendon.) After traction is placed on the tendon, the gra-
cilis muscle is identified and its outline is drawn on the
skin with a marking pen. If a musculocutaneous graft is
needed, a skin flap of the correct size should be designed
to lie over the muscle. The center of the skin flap should
be set over the upper one-third of the muscle, and the
length of the flap should be limited to within two-thirds
of the length of the muscle (Fig. 3).
The skin incision should start from close to the middle
of the anterior border of the gracilis and should be
advanced along the outline of the skin flap. The incision
should reach the fascia, and the edge of the gracilis
 2.2.3. Gracilis Musculocutaneous Flap 331

should be identified. During dissection of the muscle, it
is recommended to suture the skin at the margins to the
underlying muscle at several sites in order to prevent
separation of the skin flap from the muscle and conse-
quent damage to the nutrient vessels [5]. The neurovas-
cular pedicle can be seen entering the deep surface of
the gracilis muscle, so dissection should be done with
care at this site.
After the whole circumference of the skin flap is
incised, the muscle is bluntly dissected from the sur-
rounding tissues, except at the entrance site of the neu-
rovascular pedicle.
The major artery, together with two accompanying
veins, can be traced proximally and medially on the
deep surface of the adductor longus muscle. The vascu-
lar side branches should be ligated or cauterized to
allow the development of a long pedicle.
Sartorius Rectus lemoris
VasluS medialis
The obturator nerve, the motor nerve of the gracilis
muscle, runs in a proximal direction between the adduc-
tor longus and the adductor brevis, and this nerve is also
dissected in the proximal direction (Fig. 4).
If the muscle is to be transferred as a functioning
muscle unit, the tension of the grafted muscle has a sig-
nificant influence on the result. After dissection of the
neurovascular pedicle is completed, the hip joint is
placed in the abducted and externally rotated position,
and the knee joint is extended so that the gracilis muscle
reaches its maximal extension. The muscle is marked
with a suture at 5-cm intervals to determine its physio-
logic length [6] .
The nerves and the distal insertion of the muscle
are then cut. To avoid displacement of the muscle, it is
sutured loosely in situ, leaving it attached to the remain-
ing pedicle and origin until the recipient site has been
prepared. When preparation of the recipient site has
been completed, the vascular pedicle is ligated, and the

Obturalor nerve

Gracilis Adductor magnus

Adductor longus Semitendinosus

Fig. 1. Muscles of the medial thigh Fig. 3. Dissection of the gracilis muscle

Inguinal ligament
Femoral ar1ery Profunda femoris artery

Rectus femoris

Vaslus medialis
veln
Sar10rius
Pectineus --~$.e~~~~~
Adduclor longus

Gracilis

Addluctc:>r brevis
Fig. 2. Dissection of the adductor region of the hip
332 E. Clinical Reconstructive Microsurgery
Fig. 4. Gracilis muscle neurovascular pedicle: the major vas-
cular pedicle to the gracilis muscle and the anterior branch of
the obturator nerve. (See Color Plates)
origin of the muscle is cut to allow transfer to the graft
bed (Fig. 5).
After removal of the free muscle/musculocutaneous
graft, a drain is inserted into the wound and closure is
done in layers. The wound can usually be closed by
primary suture.
References
1. Jobe MT (1998) Muscle and musculocutaneous free flaps.
In: Canale ST (ed) Campbell's operative orthopaedics.
Mosby, St. Louis, pp 3219-3221
Fig. 5. Gracilis muscle flap: feeding artery, a motor nerve of
the gracilis muscle, and its long tendious insertion. (See Color
Plates)
2. Wood MB (1990) Atlas of reconstructive microsurgery.
Aspen, Rockville, (Maryland), pp 55-58
3. Zhong-Wei C, Dong-Yue Y, Di-Sheng C (1982) Micro-
surgery. Springer, Berlin, pp 232-260
4. Harii K, Ohmori K, Torii S (1976) Free gracilis muscle
transplantation, with microneurovascular anastomoses
for the treatment of facial paralysis. Plast Reconstr Surg
57:133-143
5. Harii K, Ohmori K, Sekiguchi J (1976) The free musculo-
cutaneous flap. Plast Reconstr Surg 57:294-303
6. Manktelow RT, Zuker RM, McKee NH (1984) Function-
ing free muscle transplantation. J Hand Surg 9A:32-39
2.2.4 Vascularized Tendon Graft
HIROSHI YAJIMA
Tendon grafting is one of the most popular procedures
in the field of hand surgery. The results of tendon graft-
ing have been satisfactory in many cases. However, in
some cases with combined loss of skin and tendons of
the hand, the operative outcome has been very poor.
Such cases have been treated traditionally with staged
procedures, such as free tendon grafting following a skin
cover with a pedicled skin flap transfer. In 1979, Taylor
and Townsend [1] described a one-stage procedure with
a dorsalis pedis cutaneotendinous flap. They used a
dorsalis pedis flap, including the extensor hallucis brevis
tendon and the second extensor digitorum longus
tendon, in a patient who had sustained a degloving
injury to the dorsum of the hand. This was the first
report of the vascularized tendon graft. Vascularized
tendon grafts exhibit several advantages, including
fewer adhesions at the recipient site. This is because
they retain their vascularity after transfer and are trans-
ferred with the surrounding tissues containing the
paratenon. In my experience, tenolysis was required in
only two of seven patients with vascularized tendon
grafts in the hand [2]. There were a few adhesions
between the grafted vascularized tendons and the recip-
ient beds, but they were noticed only at the suture sites.
There have been no clinical reports comparing vascu-
larized tendon grafts with traditional procedures. I have
treated three patients with skin and tendon defects
in the hand by flap transfer and free tendon grafts. In
all three patients, tendon adhesions were recognized
between the grafted tendons and gliding floors. How-
ever, adhesions between the tendons and the flaps were
very slight. These clinical facts suggested that in such
cases, vascularized tendon grafts are superior to nonva-
scularized tendon grafts. In addition, rehabilitation can
be initiated earlier in the postoperative period, because
union of the tendon junction is achieved sooner than
with conventional tendon grafts [3]. These advantages
have been demonstrated experimentally by Singer et al.
[4] and Moriyama [5].
The best indication for the vascularized tendon graft
is in a patient with combined loss of the skin and
tendons of the hand; therefore cutaneotendinous flaps
have been used for most such cases. Morrison [6]
reported vascularized tendon grafts without skin flaps.
They were applied to patients with flexor tendon
injuries instead of a two-stage tendon reconstruction
procedure using an artificial tendon graft. The above
applications are all for the hand. Another application of
the vascularized tendon graft is the reconstruction of
an Achilles' tendon with skin defects. There have been
some reports of this procedure, but they are rather rare.
Donor Tendons for Vascularized
Tendon Grafts
For patients with tendon loss in the hand, a dorsalis
pedis cutaneotendinous flap has generally been used. It
was first reported by Taylor and Townsend [1] in 1979.
Subsequently, other donors for vascularized tendon
grafts have been reported. Reid and Moss [7] described
the radial forearm cutaneotendinous flap in 1983, and
Glasson and Lovie [8] reported the ulnar island cuta-
neotendinous flap in 1988. Other donors for a vascular-
ized tendon graft include the lateral arm flap [9] and the
venous flap [10]. In 1987 Morrison [6] reported the
vascularized extensor digitorum longus tendons and
extensor haullcis brevis tendon without the dorsalis
pedis flap. These tendons are nourished by the vascular
mesentery to the dorsalis pedis arterial system. Morri-
son [6] also reported the new donor for tendon grafting,
which was the sublimis tendon attached via its mesen-
tery to the ulnar artery and venae comitantes.
For reconstruction of the Achilles' tendon, the fol-
lowing have been reported: groin flap with a sheet of the
external oblique aponeurosis [11], vascularized fascia
lata with free lateral thigh flap [12], and radial forearm
cutaneotendinous flap, including the brachioradials, pal-
maris longus, and/or flexor carpi radialis tendons [13,14].
Dorsalis Pedis Cutaneotendinous Flap
This flap is well indicated in patients with a combined
loss of skin and tendons on the dorsum of the hand
[15,16]. The quality of the dorsal skin of the foot is
333
 334 E. Clinical Reconstructive Microsurgery
similar to that of the dorsum of the hand, because they
both have a fine, thin texture. In addition, the flap
provides four vascularized tendons (extensor digitorum
longus tendons) of adequate length. Extensor hallucis
longus and brevis tendons also can be harvested.
However, this procedure is associated with morbidity
at the donor site, including delayed wound healing and
destruction of the arch of the foot due to scar formation
on the dorsum of the foot. For these reasons, some sur-
geons advocate the use of a free skin flap for donor-site
coverage. Otherwise, two-stage coverage should be per-
formed. After the dorsalis pedis cutaneotendinous flap
has been harvested, the recipient site is covered with an
artificial dermis until granulation occurrs, followed by a
full-thickness skin graft.
Radial Forearm Cutaneotendinous
Flap
The radial forearm flap was first described in 1978 at the
Ba-Ba Chung Hospital in the People's Republic of
China [17]. It was initially used mainly as a free flap for
oral reconstruction. After the description of a distally
based pedicled radial forearm flap transfer by Biemer
and Stock [18], it has been used widely for several types
of hand reconstruction. In 1983, Reid and Moss [7] first
reported the radial forearm cut an eo tendinous flap. Sub-
sequently, there have been several reports of the use-
fulness of the radial forearm cutaneotendinous flap. In
the hand, the radial forearm flap has predominantly
been used as a distally based island flap. In distally based
Table 1. Comparison of radial forearm flap and dorsalis pedis flapa
Radial forearm flap
Artery Radial artery
Flap size (max) 20 x 12cm
Tendon Palmaris longusb
Flexor carpi radialis
Brachioradialis
Nerve for VNGc for sensory flap Superficial radial nerve
Lateral antebrachial cutaneous nerve
Bone Radius
Difficulty (operative) Easy
Type of transfer Pedicle graft (reverse)
Donor morbidity
Functional Little
Cosmetic Significant
a From [26].
b Palmaris longus can be divided in the center.
C Vascularized nerve graft.
island flap transfers, there is a possibility of venous con-
gestion in the flap [19,20]. Retrograde flow in the venae
comitantes has been the subject of further study and dis-
cussion. However, no exact theory has been clearly pro-
posed. The problem of venous drainage occurred in only
a few radial forearm flaps. In my clinical experience with
35 cases of distally based radial forearm flaps, no flap
required an additional antegrade venous anastomosis to
the recipient site after surgery [3,19,21].
This flap is also well indicated for patients with com-
bined loss of skin and tendons on the dorsum of the
hand. This technique has some advantages compared
with the dorsalis pedis cutaneotendinous flap (Table 1)
[3]. The radial forearm cutaneotendinous flap is easy to
elevate and does not require microsurgical technique
when it is transferred to the hand as an island flap. This
flap can include three vascularized tendons: the flexor
carpi radialis tendon, brachioradialis tendon, and pal-
maris longus tendon. In addition, the palmaris longus
tendon can be divided into two segments, retaining
blood supply to the tendon [3]. This procedure is similar
to the vascularized sural nerve graft, which is folded
over a number of times [22]. I utilized the preceding
technique for the vascularized tendon graft. In this way,
four tendons can be reconstructed. On the other hand,
this flap has some complications. In the same manner
as a dorsalis pedis flap, delayed wound healing at the
donor site of the radial forearm flap is common.
However, the skin grafts take well at the donor site
of the cutaneotendinous flap, because there are no
exposed tendons, such as the flexor carpi radialis, pal-
maris longus, or brachioradialis tendons, which are the
primary cause of skin graft failure [23]. One of the main
Dorsalis pedis flap
Dorsalis pedis artery
10 x lOcm
Extension hallucis longus
Extension hallucis brevis
Extension digitorum communis
Deep peroneal nerve
Superficial peroneal nerve
Metatarsal bone
Difficult
Free graft
Significant
Easy to hide

disadvantages of this flap is that one of the large vessels
supplying the forearm and hand must be sacrificed.
Therefore, a preoperative Allen test or angiography is
essential. Another disadvantage is that the defect at
the donor site results in a contour deformity that may
be cosmetically unacceptable. Therefore, perhaps for
young people, especially young women, the dorsalis
pedis cutaneotendinous flap is recommended because
the donor site can be hidden under clothing. From the
standpoint of preservation of function at the donor site,
however, the radial forearm cutaneotendinous flap is
superior to the dorsalis pedis cutaneotendinous flap [3].
Harvesting Technique
The flap is designed at the center of the forearm on the
volar side. When the brachioradialis tendon is contained
in the flap, it is designed on the radiovolar aspect. Flap
harvesting is performed under tourniquet control. Dis-
section of the flap starts from the ulnar side. The skin
flap is raised with the deep fascia. The palmaris longus
tendon and/or flexor carpi radialis tendon is mobilized
to preserve an investing sleeve of areolar tissue vascu-
larized from the deep fascia. The radial vascular bundle
is identified after dissection of the flexor carpi radialis
tendon. The flap is elevated carefully, maintaining the
fascial mesentery between the vessels and deep fascia.
Next the flap is elevated from the radial side. When the
brachioradialis tendon is required, it is split in half lon-
gitudinally and included in the flap [7]. Care should be
taken with regard to the superficial branch of the radial
nerve, which should be identified and preserved. Finally,
the vascular bundle is traced distally to the anatomical
snuffbox. The proximal radial artery is then temporar-
ily clamped and the tourniquet is released in order to
examine the blood supply to the hand. The flap is trans-
ferred to the donor site on the vascular pedicle.
The palmaris longus tendon can be used for recon-
struction of the two defective tendons. After elevation
of the flap, the palmaris longus tendon is folded in the
midpoint. A small incision is made in the fascia, and the
tendon is cut [3]. This procedure is similar to the vascu-
larized sural nerve graft, which is folded retaining
vascularization [22]. The donor site is covered by a full-
thickness skin graft from the inguinal region. Tie-over
fixation is made, and a cast is applied.
Case Report
A 35-year-old man sustained a severe injury to the
dorsum of his left hand in a traffic accident (Fig.1a). He
was treated at an emergency hospital with debridement
2.2.4. Vascularized Tendon Graft 335
and artificial skin grafting, and then referred to us. When
the artificial skin was removed, extensor tendon defects
were noted at the index, long, and ring fingers (Fig. 1b).
After debridement, a 10 x 6-cm radial forearm flap with
a 9-cm segment of palmaris longus tendon and a 5-cm
segment of flexor carpi radialis tendon was harvested
from the forearm on its vascular pedicle (Fig.1c). Upon
release of the tourniquet, bleeding from the tendon
stump was noted. The palmaris longus tendon was grafted
to the extensor tendon defects of the middle finger. The
flexor carpi radialis tendon was grafted to the extensor
tendon defects of the index finger. A 2-cm segment of
palmaris longus tendon (nonvascularized) was grafted to
the extensor tendon defect on the ring finger. The flap
was well vascularized, and rehabilitation began with a
dynamic splint 3 weeks after the operation. Follow-up at
19 months revealed a good functional result, and the
patient returned to his original job (Fig.1d and e).
Reconstruction of Achilles' Tendon
and Skin Defects by the Peroneal
Cutaneotendinous Flap
Combined loss of the skin and Achilles' tendon is
a serious therapeutic challenge. It has been treated
traditionally with staged procedures. Achilles' tendon
defects are typically reconstructed with fascia lata
or artificial fabric grafts, or by reflection of a fas-
cioaponeurotic flap from the gastrocnemius muscle.
However, it takes a long time for both tendon and soft
tissue to heal when traditional staged procedures are
used. Moreover, these procedures are less successful in
the presence of infection. A vascularized tendon graft is
indicated in patients with infection. In 1988, Wei et al.
[11] reported reconstruction of the Achilles' tendon
by attachment of a segment of the abdominal external
oblique muscle fascia to a groin flap, rolling up the
fascial strip. This was similar to the technique reported
by Taylor and Townsend [1] in 1979. Lidman et al. and
Inoue et al. [12] described the use of vascularized fascia
lata. In 1991, Cavanagh et al. [14] reported a composite
radial forearm flap, including brachioradialis and flexor
carpi radialis tendons. Recently I have developed a new
procedure for the reconstruction of Achilles' tendon
defects with skin loss using a peroneal cutaneotendi-
no us flap containing the peroneus longus tendon. I have
used this procedure in one patient, and a satisfactory
result was obtained. The peroneal flap was first reported
by Yosimura et al. [24] in 1984. This flap is based on cuta-
neous branches from the peroneal artery that also
supply the septum and fascia. The peroneus longus
tendon can be harvested with an investing sleeve of
336 E. Clinical Reconstructive Microsurgery
c e
areolar tissue vascularized from the deep fascia.
Approximately 15 to 20cm of tendon can be harvested.
However, the vascularity of the distal portion of the
tendon is poor. The peroneus longus tendon is folded
and cut at the midpoint, preserving the blood supply
from the investing sleeve of areolar tissue. Two vascu-
larized tendon grafts are thus created. This procedure is
similar to the folding of the palmaris longus tendon for
hand reconstruction. The peroneal cutaneotendinous
flap can be transferred on the perforating vessels. If the
flap does not reach the recipient site, the peroneal vas-
cular bundle is ligated proximal to the ramification of
the cutaneous branch, and the flap is transferred on the
peroneal vessels as a distally based flap.
Case Report
A 57-year-old man suffered a laceration of the left
Achilles' tendon in a sporting accident. The Achilles'
tendon was repaired at a nearby hospital. About 2
Fig. 1. A 35-year-old man with skin and extensor
tendon defects on the dorsum of the left hand. a Pre-
operative finding. b Diagram showing defects of the
extensor tendons. C A radial forearm flap with a
9-cm section of palmaris longus tendon and a 5-cm
section of flexor carpi radialis tendon was harvested.
(See Color Plates) d Postoperative photograph show-
ing good finger flexion. e Postoperative photograph
showing good finger extension. (From [25], with
permission)
weeks later, pus began to drain from the surgical wound.
Incision and drainage were performed, and cultures
revealed Enterobacter cloacae. Since the infection did
not easily subside, radical debridement was performed.
This resulted in resolution of the infection. However,
it also resulted in a 4 x 2-cm skin defect and a 4-cm
Achilles' tendon defect. The patient was referred to our
clinic 44 days after the injury. Reconstruction was per-
formed 22 days later. Before surgery, the cutaneous per-
forator of the peroneal artery was identified using a
Doppler flowmeter. A flap was designed on the lateral
leg to include this perforator (Fig. 2a). After debride-
ment, there was a 7 x 3-cm skin defect and a 5-cm
Achilles' tendon defect. An incision was made on the
lateral side of the leg along the peroneus longus tendon,
along the posterior border of the flap. The fascia of the
soleus muscle was incised and dissected anteriorly.
Then, the cutaneous perforator of the peroneal artery
was identified and isolated, preserving the branches to
the interseptal fascia (Fig. 2b). A 6-cm vascular pedicle
was created, and a 14-cm segment of the peroneus

a be
Fig. 2. A 57-year-old man with skin and Achilles' tendon
defects. a An 8 x 4-cm peroneal flap including the cutaneous
branch of the peroneal vessels was designed on the lateral leg.
b The peroneal flap was raised on the cutaneous branch of the
longus tendon was harvested with the attached fascia. A
teardrop-shaped skin flap (8 x 4cm) was then elevated
on the cutaneous branch of the peroneal vessels. The
peroneus longus tendon was folded and cut at the mid-
point so as not to disturb the blood supply from the
investing sleeve of areolar tissue. The cutaneotendinous
flap was passed through a subcutaneous tunnel and
turned 180. The 5-cm defect in the Achilles' tendon
was reconstructed with the split peroneus longus
tendon.
The distal stump of the peroneus longus tendon was
sutured to the peroneus brevis tendon side-to-side at the
donor site. The donor site of the flap was covered with a
full-thickness skin graft. The flap survived completely
and healed well. Rehabilitation was started after 5 weeks
of immobilization. Full weight-bearing was allowed at 2
months. At the 9-month follow-up, the functional result
was satisfactory, with ankle motion of 45 in flexion and
20 in extension (Fig. 2c). The muscle power of plantar
flexion of the amble was the same as that of the opposite
side. The patient was able to walk on tiptoes.
References
1. Taylor GI, Townsend P (1979) Composite free flap and
tendon transfer. An anatomical study and clinical tech-
nique. Br J Plast Surg 32:170-183
2.2.4. Vascularized Tendon Graft 337
peroneal vessels with a 14-cm segment of the peroneus longus
tendon. c Photograph showing completely healed wound 9
months postoperatively
2. Yajima H, Tarnai S (1988) Reverse flow radial forearm
flap with vascularized tendons for hand reconstruction.
7th Congress International Federation Society of the
Surgery of the Hand, Monduzzi Editore, Bologna, pp
797-801
3. Yajima H, Inada Y, Shono M, Tarnai S (1996) Radial
forearm flap with vascularized tendons for hand recon-
struction. Plast Reconstr Surg 98:328-333
4. Singer DI, Morrison WA, Gumley GJ, O'Brien BM,
Mitchell GM, Barton RM, Frykman GK (1989) Compar-
ative study of vascularized and nonvascularized tendon
grafts for reconstruction of flexor tendons in zone 2: an
experimental study in primates. J Hand Surg 14A:55-63
5. Moriyama M (1992) Vascularized tendon grafting in the
rabbit. J Reconstr Microsurg 8:83-91
6. Morrison WA (1987) Reconstructive microsurgery.
Churchill Livingstone, Edinburgh, pp 340-346
7. Reid CD, Moss ALH (1983) One-stage flap repair with
vascularized tendon grafts in a dorsal hand injury using
the "Chinese" forearm flap. Br J Plast Surg 36:473-479
8. Glasson DW, Lovie MJ (1988) The ulnar island flap in hand
and forearm reconstruction. Br J Plast Surg 41:349-353
9. Hou SM, Liu TK (1993) Vascularized tendon graft using
lateral arm flap. Acta Orthop Scand 64:373-376
10. Inoue G, Tamura Y (1991) One-stage repair of both skin
and tendon digital defects using the arterialized venous flap
with palmaris longus tendon. J Reconstr Microsurg 7:339-
343
11. Wei FC, Chen HC, Chuang CC, Noordhoff MS (1988)
Reconstruction of Achilles tendon and calcaneus defects
338 E. Clinical Reconstructive Microsurgery
with skin-aponeurosis bone composite free tissue from the
groin region. Plast Reconstr Surg 81:579-587
12. Inoue T, Tanaka I, Imai K, Hatoko M (1990) Reconstruc-
tion of Achilles tendon using vascularized fascia lata with
free lateral thigh flap. Br J Plast Surg 43:728-731
13. Waris TH, Kaarela 01, Raatikainen TK, Teerikangas HE,
Heikkinen ES (1991) Microvascular flaps from the lateral
arm and radial forearm for the repair of defects of the
Achilles tendon region. Scand J Plast Reconstr Surg 25:
87-89
14. Cavanagh S, Pho RWH, Kour AK (1991) A composite
neuro-teno-cutaneous forearm flap in the one-stage
reconstruction of a large defect of the soft tissue around
the ankle. J Reconstr Microsurg 7:323-329
15. Vila-Rovira R, Ferreira BJ, Guinot A (1985) Transfer of
vascularized extensor tendons from the foot to the hand
with a dorsalis pedis flap. Plast Reconstr Surg 76:421-425
16. Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina
PB (1993) Dorsalis pedis flap with vascularized extensor
tendons for dorsal hand reconstruction. Plast Reconstr
Surg 92:1326-1330
17. Song R, Gao Y, Yu Y, Song Y (1982) The forearm flap. Clin
Plast Surg 9:21-26
18. Biemer E, Stock W (1983) Total thumb reconstruction: a
one-stage reconstruction using an osteocutaneous fore-
arm flap. Br J Plast Surg 36:52-55
19. Yajima H, Tarnai S, Mizumoto S, Fukui A, Inada Y (1989)
Reverse flow radial forearm flap transfer in hand
surgery (in Japanese). J Jpn Soc Surg Hand 6:853-
856
20. Yajima H (1996) Clinical findings in the use of reverse-
flow island flaps: The importance of venous drainage (in
Japanese). Jpn J Plast Reconstr Surg 39:1023-1031
21. Yajima H, Tarnai S, Yamauchi T, Mizumoto S (1999)
Osteocutaneous radial forearm flap for hand reconstruc-
tion. J Hand Surg 24A:594-603
22. Breidenbach WC, Terzis JK (1986) The blood supply of
vascularized nerve grafts. J Reconstr Microsurg 3:43-
58
23. Bardsley AF, Soutar DS, Elliot D, Bachelor AG (1990)
Reducing morbidity in the radial forearm flap donor site.
Plast Reconstr Surg 86:287-292
24. Yoshimura M, Imura S, Shimamura K, Yamauchi S,
Nomura S (1984) Peroneal flap transfer for reconstruction
in the extremity: preliminary report. Plast Reconstr Surg
74:402-409
25. Tarnai S, Yajima H, Inada Y (1999) Secondary recon-
struction of the extensor tendons and overlying soft tissue
deficiency. Hand Clin 15:455-466
26. Yajima H, Tarnai S, Fukui A, Ono H, Inada Y (1996) Free
and island flap transfer for soft tissue defects in the hand
and forearm. Microsurg 17:150-154
2.2.5 Temporoparietal Flap
KEN ARASHIRO, KUNIHIRO ISHIDA, and HISASHI OHTSUKA

The temporoparietal fascia is a thin, pliable, well-
vascularized sheet of tissue available in sizes up to 12 x
14 cm [1]. This flap can be applied for the coverage of a
wound that exposes important structures such as nerve,
tendon, or bone. The most consistent and predictable
use as a free tissue transfer has been in the dorsum of
the hand and foot to provide coverage with an overly-
ing skin graft [1-4].
The advantages of this flap are as follows [5,6]:
The donor vessels have an external diameter of 1.8 to
2.7mm in an artery and 2.1 to 3.3mm in a vein in
adults, large enough for their anastomoses, and the
pedicle length is 4 to 5 cm, sufficient to facilitate
transplantation.
Since the flap is thin and pliable, it can provide cover-
by the most superficial layer, the hair-bearing skin.
Directly below the galea aponeurotica is a loose areolar
tissue layer, and next is the deep temporal fascia or
periosteum (Fig. 1). The temporoparietal fascia is con-
tinuous with the superficial musculoaponeurotic system
(SMAS) inferiorly, the galea aponeurotica superiorly,
the frontalis muscle anteriorly, and the occipitalis
muscle posteriorly. The temporoparietal fascia is 2 to
3 mm thick over the parietal area.
Temporal bone
Deep temporal fascia (Periosteum)
Loose areolar layer
Temporoparietal fascia
/ / subculaneous (allayer

I/
age without bulk, especially in the hand and distal
lower extremity. / s~n
It can provide a gliding surface for exposed tendons.
The rich vascularity of the flap can provide enough
blood to a recipient site.
The donor site scar is inconspicuous and is well con-
cealed by temporal hair.
A two-team approach can be applied for the donor and
the recipient site dissection, resulting in shortening of
the operating time.
The disadvantages are as follows:
The amount of donor tissue is limited. However, it can
be solved by a simultaneous use of bilateral flaps like
Superficial temporal
a bucket handle. artery and vein
Alopecia may result if the dissection is too close to the
hair follicles.
The frontal branch of the facial nerve is vulnerable
during dissection.
"IIIIHHg.,~~ Temporalis muscle

Anatomy
The temporoparietal scalp has a five-layered structure.
The galea aponeurotica, which makes up the tem-
poroparietal fascia in its lateral aspect, is the third layer.
Superficial to it is a subdermal fibrofatty layer, followed
Fig.1. Coronal section of the temporal region shows the rela-
tionship of the temporoparietal fascia to the overlying scalp
and the underlying deep temporal fascia and temporalis
muscle. A loose areolar layer is beneath the temporoparietal
fascia

339
340 E. Clinical Reconstructive Microsurgery

The nutrient vessels to the temporoparietal fascia are
the superficial temporal artery (STA) and vein (STV).
The STA is one of two terminal branches of the exter-
nal carotid artery. It takes origin superiorly to the
posterior belly of the digastric muscle and enters the
parotid gland, where it passes between the superficial
and deep lobes. It courses superiorly on the fascial
surface but deep to the superficial temporal vein. In
front of the ear, the artery is about 2mm in diameter
and is slightly smaller than the vein. Five centimeters
superiorly, there is a branch to the frontal area. An
occipital branch originates more distally. A branch of
the STA, the middle temporal artery, which is a feeding
vessel to the temporalis muscle fascia (i.e., the deep
temporal fascia), penetrates it just above the zygomatic
arch.
The normal STY generally runs posterior to the
artery, but in one third of the patients it lies anterior to
the artery. It usually lies within O.8cm of the artery,
although it can be as far as 3 cm from the artery. Just
above the zygomatic arch, it has an external diameter of
2 to 3 mm. During dissection and flap elevation, it can
easily be injured because of its superficial location.
The auriculotemporal nerve, a sensory branch of the
trigeminal nerve, accompanies the superficial temporal
vessels and is located posterior to them. The nerve
passes superiorly to perforate the fascia and supply the
overlying scalp.

Fig. 2. a Preauricular incision with zigzag extension within the hair-bearing scalp. b The flap has been incised and elevated.
c The harvested fascial flap. (b,c See Color Plates)

Fig. 3. a Immediate postoperative view. b Six months postoperative finding. Acceptable donor site scar

Harvesting Technique
With the patient in the supine position, the course of the
superficial temporal artery and any frontal or occipital
extensions should be ascertained with palpation and
Doppler probe. After a vertical preauricular incision has
been outlined with a zigzag cephalad extension (Fig. 2a),
1:200,000 epinephrine solution is infiltrated in the area
of dissection.
Under magnification with binocular loupes, the
superficial temporal vessels in the pre tragal area are
identified first before proceeding superiorly. The vein
has a very thin wall and lies superficial to the artery
in the subcutaneous fat. The dissection next extends
cephalad in the subcutaneous plane, just below the hair
follicles. Dissection in this unnatural plane must be done
carefully so as not to injure the hair follicles. All bleed-
ing points should be meticulously electrocoagulated
with bipolar cautery. The more cephalad hair-bearing
scalp is held tightly to the temporoparietal fascia by
dense connective-tissue bands that pass through a
thicker subcutaneous fat layer. These layers are sepa-
rated by transecting the septa using skin-hook traction
on the scalp and countertraction on the fascia.
The recipient defect is marked on the fascia, and the
periphery is incised. The flap is then elevated off the
underlying deep temporal fascia in a cephalad to caudal
direction. A loose areolar space facilitates dissection
(Fig. 2b and c).
The frontal branch of the facial nerve must be pre-
served during the pedicle dissection. It lies along a line
determined by a point 0.5 cm below the tragus to a point
1.5 cm above the lateral brow.
2.2.5. Temporoparietal Flap 341
After the pedicle has been divided for transfer to
the recipient site, the donor site can be closed with
absorbable sutures in one layer over a drain.
A zigzag incision within the hair-bearing scalp mini-
mizes the donor scar exposure(Fig. 3a and b) [7].
References
1. Upton J, Rogers C, Durham-Smith G, Swartz WM (1986)
Clinical applications of free temporoparietal flaps in hand
reconstruction. J Hand Surg llA:475--483
2. Hirase Y, Kojima T, Bang HH (1991) Double-layered free
temporal fascia flap as a two-layered tendon-gliding
surface. Plast Reconstr Surg 88:707-712
3. Hing DN, Buncke HJ, Alpert BS (1988) Use of the tem-
poroparietal free fascial flap in the upper extremity. Plast
Reconstr Surg 81:534-544
4. Woods JM IV, Shack RB, Hagen KF (1995) Free tem-
poroparietal fascia flap in reconstruction of the lower
extremity. Ann Plast Surg 34:501-506
5. Serafin D, Upton J (1996) The temporal fascia flap. In:
Serafin D (ed) Atlas of microsurgical composite tissue
transplantation. WB Saunders, Philadelphia, pp 323-338
6. Strauch B, Yu HL (1993) Temporoparietal fascia. In:
Strauch B, Yu HL (eds) Atlas of microvascular surgery:
anatomy and operative approaches. Thieme Medical Pub-
lishers, New York, pp 526-533
7. Munro IR, Fearon JA (1994) The coronal incision revisited.
Plast Reconstr Surg 93:185-187
2.3 General Concepts of the Donors of Vascularized
Bone Grafts
HIROSHI Y AJIMA AND SUSUMU TAMAI
Bone grafting is one of the most popular procedures in
the field of orthopedic surgery. The history of bone
grafting is very old. The first documented case of bone
grafting was recorded in the Anecdotal Case History
of Church Literature in 1682. It was reported that
Meekren first performed a bone graft taken from a
canine skull on a patient with a skull defect as a
xenograft [1]. Thereafter, autografting and allografting
have been generally performed. In free bone grafting,
most osteocytes and osteoblasts once died, and the graft
acted as a framework for osteoblastic creeping substi-
tution. Therefore, it takes a long time to obtain bony
union when the recipient site has a large bone defect or
suffers from infection, irradiation, or excessive scarring.
On the other hand, osteocytes and osteoblasts can
survive in the vascularized bone graft, the so-called
living bone graft. Healing between the graft and the
recipient bone is facilitated without the usual replace-
ment of the graft by creeping substitution [2]. This
procedure enables the surgeon to achieve sound bony
union irrespective of the length of the bony defect and
of conditions in the recipient beds.
The vascularized bone graft was first described by
Huntington [3] in 1905. He used the fibula with its own
nutrient blood supply intact for reconstruction of a large
tibial defect. Since then, there have been many reports
of pedicle bone grafts [4]. As a clinical extension of the
vascularized bone graft, the muscle pedicle bone graft
for the treatment of femoral head necrosis was the most
popular [5]. These pedicle vascularized bone grafts have
some disadvantages. It is doubtful whether the blood
circulation to the bone is maintained in these proce-
dures. The other is the limitation of the range of graft
transfer because of the length of the vascular pedicle. In
1971, experimental study of the island vascularized bone
graft with the main nutrient vessels was started by
Strauch and his colleagues [6]. The transfer of free vas-
cularized bone graft was first reported by bstrup and
Fredrickson in experimental work in 1974 [7]. They per-
formed free vascularized rib transfer to the mandibule
using microsurgical anastomosis in canine experiments.
In the English literature, the first clinical application of
free vascularized bone transfer was reported by Taylor
342
et al. in 1975 [8], in which a fibular segment was trans-
ferred from the contralateral leg to reconstruct a large
tibial defect. Thereafter, many reports of free vascular-
ized bone grafting with satisfactory results have been
published.
Advantages of Vascularized
Bone Graft
Vascularized bone grafting has many advantages. First,
this procedure enables the surgeon to achieve sound
bony union irrespective of the length of the bony defect
and of conditions in the recipient beds. For patients with
small bony defects, there is not much difference in bony
union between vascularized and non vascularized bone
grafts. On the other hand, when nonvascularized auto-
genous bone is grafted to a defect more than 7 cm long,
the time required for bone union is significantly longer.
According to Enneking et al. [9], the incidence of
nonunion was 32% after the grafting of a nonvascular-
ized bone 7.5 to 25 cm in length. In my previous report
of a vascularized fibula graft for reconstruction after
resection of bone tumor, the mean time until comple-
tion of bone union was as short as 4.1 months, even
though the bone defects were as large as 12cm, ranging
from 6 to 20 cm [10]. Figure 1 shows a radiograph of the
pelvis of a 21-year-old man in whom a twin-barrelled
vascularized fibula and nonvascularized fibula were
grafted for the reconstruction of a pelvic defect after
resection of a chondrosarcoma. At 5 months, complete
bone unions and hypertrophy are visible at the vas-
cularized fibula grafts, whereas bone union is not
completed at the non vascularized fibula graft. These re-
sults clearly demonstrate the superiority of vascularized
bone grafting from the viewpoint of bone union. In
addition, there have been many reports that demon-
strate the usefulness of the vascularized bone graft
experimentally and clinically.
The second advantage of the vascularized bone
graft is that it is highly resistant to infection because
it is richly vascularized. Therefore, vascularized bone
 2.3. General Concepts of the Donors of Vascularized Bone Grafts
Fig. 1. A 21-year-old man with chondrosarcoma of the left
ilium. a A 20-cm vascularized fibular graft and a 5-cm nonva-
scularized fibular graft were taken from the left leg. The 20-
cm fibula was divided into two segments. b Anteroposterior
grafts have been indicated mainly for patients with
osteomyelitis and infected nonunion [11-14]. In my
experience, there is a remarkable reduction in the fre-
quency of inflammatory exacerbation with vascularized
bone grafting. In my series, local recurrence, including
postoperative fistula formation, was seen in 8 of 57
patients (14%). Fujimaki et al. [13] reported exacerba-
tion of osteomyelitis in 4 of 15 patients (27%), and
Weiland et al. [11] described postoperative fistula for-
mation in 3 of 11 patients (27%). Doi et al. [14] reported
no recurrence of infection in 26 patients who received
vascularized osteocutaneous grafts.
The third advantage of vascularized bone grafting is
the feasibility of one-stage reconstruction with various
tissues in addition to bone. For example, the use of the
peroneal artery as a vascular pedicle makes it possible
to obtain a skin flap, nerves, and muscles, together with
the fibula. In vascularized scapula grafting, the scapular
or parascapular flap and the latissimus dorsi muscle can
be harvested together with the scapula [15]. These tech-
niques are particularly superior to the conventional
343
radiograph 5 months after operation showing hypertrophy of
the grafted fibula (upper two struts). c Nineteen months post-
operatively, there was solid union and no tumor recurrence.
(From [16], with permission)
techniques in cases of malignant bone tumor, where a
wide soft-tissue defect is created by tumor resection,
and in cases of severe open fracture.
The fourth advantage is hypertrophy of the bone
after grafting. This phenomenon is more conspicuous
in vascularized fibular grafting, which is a very interest-
ing feature of this surgery. When a twin-barrelled fibula
[16] was grafted to the segmental defect of the femur
(one strut was fixed within the marrow and the other
was screwed to the side of the femur), significant
hypertrophy was recognized at the inlay grafted fibula
(Fig. 2). On the other hand, little hypertrophy was rec-
ognized at the fibula that was grafted to patients with
upper arm reconstruction [15,17]. Therefore, hyper-
trophy of the grafted bone is thought to be caused
by a longitudinal load. Some experimental studies
have demonstrated the mechanism of hypertrophy after
grafting [18]. The younger the patient, the more rapid
and the prominent is the hypertrophy of the grafted
bone. This phenomenon is accelerated by a stress frac-
ture of the graft.
344 E. Clinical Reconstructive Microsurgery

a b

Fig. 2. An 18-year-old man with infected nonunion of the left of the inlay grafted fibula. b Computed tomography at 18
femur. a Lateral radiograph 18 months after a twin-barrelled months postoperatively
vascularized fibula grafting, showing significant hypertrophy

Table 1. Vascularized bone graft

Characteristics Fibula Scapula Ilium
Length (max) 22-26cm 10-12cm 8-lOcm
Shape Straight Straight Slight curve
Structure Cortical Corticocancellous Corticocancellous
Artery Peroneal Subscapular Deep circumflex iliac
Diameter 2.0-3.0mm 2.0-3.5mm l.5-2.5mm
Vascular stalk 3-lOcm 6-lOcm 5-6cm
Flap (width) 24 x 12cm 25 x 15cm 30 x 15cm
Flap (thickness) Thin Medium Thick
Options Muscle, nerve Latissimus dorsi None
Complications Hammer toe Shoulder dysfunction Abdominal wall hernia,
sensory disorder

From [12], with permission.

Donor Bones 25 x 15cm) or the parascapular flap can be harvested

The most common donor sites for vascularized bone
grafting are the fibula, iliac crest, and lateral border of
the scapula (Table 1). These three bones are generally
used for patients with large defects of the long bones of
the extremities. Among them, only the fibula can be
used for longer defects (over 10 cm) with a linear con-
figuration. The iliac bone and the scapula are selected
for patients with bone defects less than 10cm in length
accompanied by large skin defects. The groin flap
(maximum size, 30 x 15cm) can be harvested together
with the iliac bone. The scapular flap (maximum size,
together with the lateral scapula. However, the cuta-
neous circulation in the groin osteocutaneous flap based
on the deep circumflex iliac vessels is tenuous. Minami
et al. [19] reported a vascularized iliac osteocutaneous
flap based on the deep circumflex iliac vessels, and com-
plete skin flap survival was obtained in only 5 of 11
patients. Doi et al. [14] reported that 3 of 9 patients
required a secondary split-thickness skin graft due to
partial necrosis of the skin flaps. In terms of the bone
volume that can be harvested, the iliac bone is the best
of the three donor bones. The vascularized scapula graft
has been widely used in plastic surgery [20]. The crest
 2.3. General Concepts of the Donors of Vascularized Bone Grafts
of the scapula consists of corticocancellous bone. Its vas-
cular pedicle is long enough (8 to 10cm), and the sub-
scapular artery is a large vessel, measuring 2.5 to 3.5 mm
in external diameter. In addition, in cases with proximal
upper arm lesions (humeral head necrosis), vascularized
scapula graft can be transferred without microvascular
anastomosis. One disadvantage of this procedure is the
need for the patient to change position during surgery.
However, this flap is recommended for young people,
especially young women, because the donor site can be
hidden by clothing.
In addition to the three bones mentioned above, the
rib, radius, ulna, humerus, metatarsus, metacarpus, and
femur have been utilized as donors for vascularized
Fig. 3. Radial forearm osteocutaneous flap. After release of
the tourniquet, bleeding from the radius segment is confirmed
a b
Fig.4. Vascularized bone graft pedicled on the 1-2 intercom-
partmental supraretinacular vessels. a Operative procedure.
[SA, 1-2 intercompartmental supraretinacular artery; RA,
345
bone grafts. The rib can be used for reconstruction of
bones of the extremities, but few surgeons use it now
because of its structural problems (thin and curved).
Part of the radius on ulna has sometimes been used for
patients with bone and soft-tissue defects of the hand or
traumatic loss of the thumb [21]. In general, part of the
radius is harvested, together with a radial forearm flap
based on the radial artery (Fig. 3). This procedure does
not require microvascular anastomoses, and the surgical
technique is easy. Recent advances in the anatomical
study of the vascular network of the hand and the wrist
area have made it possible to transfer various kinds of
pedicled vascularized bone grafts. These procedures
are indicated in patients with KienbOck disease and
scaphoid necrosis [22,23]. Donor bones for vascularized
bone grafts can be harvested from the radius, ulna, and
metacarpal bone. In 1995, Sheetz et al. [23] reported the
extra- and interosseous blood supply of the distal radius
and ulna systematically. They recommended the graft
based on the 1-2 intercompartmental supraretinacular
artery and its branch to the second extensor compart-
ment (a modification of Zeidemberg's technique) and
the graft based on the fourth extensor compartment
artery with retrograde flow through the fifth extensor
compartment artery from the dorsal intercarpal arch.
Some vascularized bone grafts can be taken from the
palmar radius. However, Sheetz et al. [23] reported that
palmar bone grafts have limited usage, in part because
their harvesting and placement require significant dis-
section of important radiocarpal ligaments. Among
them, the vascularized bone graft based on the 1-2
intercompartmental supraretinacular artery is recom-
mended because of its technical ease (Fig. 4).
radial artery; SP, styloid process; OL, osteotomy line. b A
pedicled vascularized bone graft was elevated. VP, Vascular
pedicle; BF, bone flap; DS, donor site
346 E. Clinical Reconstructive Microsurgery
Articular branch of the
descending genicular vessels
Popliteal vessels
Superomedial
genicular
vessels
Fig. 5. Vascularized thin corticoperiosteal graft from the
supracondylar region of the femur. a Diagram showing the
elevation of the corticoperiosteal graft, which is nourished by
In 1991, Sakai et al. [24] reported a free vascularized
thin corticoperiosteal graft from the supracondylar
region of the femur (Fig. 5). This graft is nourished from
the articular branch of the descending genicular artery
and vein. The graft is elastic and readily conforms to the
recipient bed configuration. This method has the best
indication in nonunion without significant bony defects,
where vascularized bone grafts are difficult to apply due
to either their large size or their straight configuration.
Indications for Vascularized
Bone Graft
The most popular indication for a vascularized bone
graft is a traumatic large bony defect. Many orthopedic
surgeons recommend long bone defects of at least 7 cm
as candidates for vascularized bone grafting. In cases
with severe open fracture, both bone and soft tissue
should be reconstructed. In such cases, one-stage recon-
struction can be performed using an osteocutaneous
flap. Therefore, I also recommend the aggressive use of
vascularized bone grafts for patients who have bone
defects associated with extensive soft-tissue defects.
Donor bones to be used for such cases include the
the articular branch of the descending genicular artery. b
Photograph showing the elevation of the corticoperiosteal
graft
fibula, ilium, and scapula. Among them, the fibula has
been most commonly used.
Whenever the conventional bone graft has been
applied, chronic osteomyelitis and infected nonunion
have resulted in several surgical difficulties. Application
of the vascularized bone graft to patients with infected
nonunion brings remarkable improvement in the ther-
apeutic outcome. Although the vascularized bone graft
is highly resistant to infection, it performs better
secondarily after successful subsidence of the inflam-
mation. For not only infected nonunion but also failed
conventional bone grafts, vascularized bone grafting is
indicated. Donor bones should be selected according to
the length of the defect, the type of lesion, and the age
and sex of the patient. For patients with small bone
defects, a free vascularized thin corticoperiosteal graft
from the supracondylar region of the femur is occa-
sionally indicated.
Several procedures have been applied to patients
with congenital pseudoarthrosis, but there have been no
procedures with satisfactory outcome except for a living
bone graft. In terms of bone union, the vascularized
fibula graft is the procedure of choice, and recently the
final bone union rate has been 100%. However, the
vascularized fibula graft cannot solve all problems of
congenital pseudoarthrosis, because the etiology of this
 2.3. General Concepts of the Donors of Vascularized Bone Grafts
ab
.-
i:
Fig. 6. A 68-year-old man with right tibial adamantinoma. a
Preoperative radiograph (lateral view). b A 24-cm vascular-
ized fibula with peroneal flap was transferred for the recon-
struction of the bone and soft-tissue defect. c Anteroposterior
disease has not yet been clarified. Recent application of
bone transport using the Ilizarov apparatus is another
reliable option for this condition.
Recent advances in chemotherapy have made it pos-
sible to perform limb salvage operations in malignant
bone and soft-tissue tumors. Segmental bony defects
after resection of bone tumors have been reconstructed
using autogenous bone grafting, prosthetic replace-
ments, and allografts. Of these, prosthetic replacement
with or without autoclaved autogenous bone grafting
has been most commonly used, although numerous
associated problems have been encountered, such as
durability of the prosthesis and postoperative infection.
Vascularized bone grafting can solve these problems,
except for joint reconstruction. Figure 6 is an example
of this technique that was indicated for a long-bone
defect in the tibia. In addition, this technique is partic-
ularly superior to the conventional techniques in cases
of malignant bone tumors, where a wide soft-tissue
defect is created by tumor resection. The resultant soft-
tissue defect can be covered with a skin flap associated
with the donor bone. In cases where the tumor is located
in the vicinity of the knee joint, arthrodesis using a vas-
cularized bone graft or prosthetic replacement should
347
c
radiograph at 8 years, 11 months postoperatively showing
marked hypertrophy of the grafted fibula. (From [10], with
permission)
be selected according to the patients's age, sex, occupa-
tion, and other factors.
Vascularized bone grafting has recently used for
patients with osteonecrosis. For patients with osteo-
necrosis of the femoral head, the fibula and iliac bone
have been used. For patients with talus necrosis, the
metatarsal bone and thin corticoperiosteal graft from
the femur have been used. Several pedicled bone grafts
from the metacarpal or the radius have been used for
Kienbock disease and scaphoid necrosis.
In the future, the indications for vascularized bone
grafts will become wider, and such grafts will become
more popular.
References
1. DeBoer HH (1988) The history of bone grafts. Clin
Orthop 226:292-298
2. Weiland AJ (1981) Vascularized free bone transplants.
J Bone Joint Surg 63A:166-169
3. Huntington TW (1905) Case of bone transference. Use
of a segment of fibula to supply a defect in the tibia. Ann
Surg 41:249-251
348 E. Clinical Reconstructive Microsurgery
4. Hellstadius A (1942) On the ability of bone tissue to
survive in pedicle bone graft. Acta Chir Scand 86:85-109
5. Meyer MH (1985) Osteonecrosis of the femoral head
treated with the muscle pedicle graft. Orthop Clin North
Am 16:741-745
6. Strauch B, Bloomberg AE, Lewin ML (1971) An ex-
perimental approach to mandibular replacement: island
vascular composite rib grafts. Br J Plast Surg 24:334-341
7. Ostrup LT, Fredrickson JM (1974) Distant transfer of a
free living bone graft by microvascular anastomoses; an
experimental study. Plast Reconstr Surg 54:274-285
8. Taylor GI, Miller GDH, Ham FJ (1975) The free vascu-
larized bone graft: a clinical extension of microvascular
techniques. Plast Reconstr Surg 55:533-544
9. Enneking WF, Eady JL, Burchardt H (1980) Autogenous
cortical bone grafts in the reconstruction of segmental
deficits. J Bone Joint Surg 62A:1039-1057
10. Yajima H, Tarnai S, Mizumoto S, Sugimura M, Horiuchi K
(1992) Vascularized fibula graft for reconstruction after re-
section of aggressive benign and malignant bone tumors.
Microsurgery 13:227-233
11. Weiland AJ, Moore JR, Daniel RK (1984) The efficacy of
free tissue transfer in the treatment of osteomyelitis.
J Bone Joint Surg 66A:181-193
12. Yajima H, Tarnai S, Mizumoto S, Inada Y (1993) Vascu-
larized fibular grafts in the treatment of osteomyelitis and
infected nonunion. Clin Orthop 293:256--264
13. Fujimaki A, Suzuki K (1988) Vascularized bone grafts in
the treatment of osteomyelitis (in Japanese). Shujutu 42:
283-288
14. Doi K (1995) One-stage treatment of infected bone
defects of the tibia with skin loss by free vascularized
osteocutaneous grafts. Microsurgery 16:704-712
15. Yajima H, Tarnai S, Ono H, Kizaki K (1997) Vascularized
bone grafts to the upper extremities. Plast Reconstr Surg
101:727-735
16. Yajima H, Tarnai S (1994) Twin-barrelled vascularized
fibular grafting to the pelvis and lower extremity. Clin
Orthop 303:178-184
17. Yajima H, Tarnai S, Ono H, Kizaki K, Yamauchi T (1999)
Free vascularized fibula grafts in surgery of the upper
limb. J Reconstr Microsurg 15:515-521
18. Mizumoto S, Tarnai S, Goshima J, Yajima H, Fukui A,
Masuhar K (1986) Experimental study of vascularized
tibiofibula graft in inbred rats. A preliminary report.
J Reconstr Microsurg 3:1-9
19. Minami A (1989) Vascularized iliac osteocutaneous flap
based on the deep circumflex iliac vessels: experience in
13 cases. Microsurgery 10:99-102
20. Teot L, Bosse JP, Moufarrege R, Papillon J, Beauregard G
(1981) The scapula crest pedicled bone graft. Int J Micro-
surg 3:257-262
21. Yajima H, Tarnai S, Yamauchi T, Mizumoto S (1999)
Osteocutaneous radial forearm flap for hand reconstruc-
tion. J Hand Surg 24A:594-603
22. Zaidemberg C, Siebert JW, Angrigiani C (1991) A new
vascularized bone graft for scaphoid nonunion. J Hand
Surg 16A:474--478
23. Sheetz KK, Bishop A, Berger RA (1995) The arterial
blood supply of the distal radius and ulna and its poten-
tial use in vascularized pedicled bone grafts. J Hand Surg
20A:902-914
24. Sakai K, Doi K, Kawai S (1991) Free vascularized thin
corticoperiosteal graft. Plast Reconstr Surg 87:290-298
2.3.1 Fibula
SATOSHI TOH, KOICHI ARAI, and MASAHIRO YASUMURA
The first report of a free vascularized fibula graft was
by Taylor et al. in 1975 [1]. Taylor clinically applied it
to a patient with an extensive bony defect due to an
injury to a lower extremity in April 1974. However, the
first free vascularized fibular grafting was actually per-
formed in a patient with pseudoarthrosis of the ulna
by Ueba et al. in December 1973 (see chapter D.3.5) [2].
Thereafter, the procedure was applied to traumatic
bony defects of the femur and humerus and recon-
struction following excision of a malignant tumor, and
its efficacy began to be recognized [3,4]. As the clinical
results attested to the superior osteosynthetic capacity
of the procedure, its application was extended to a wide
range of conditions, such as traumatic pseudoarthrosis,
which is considered to be highly refractory to various
therapeutic procedures, congenital pseudoarthrosis,
infectious pseudoarthrosis, and other conditions that
are associated with poor conditions of the recipient
floor in which conventional free bone grafting did not
hold much promise, such as femoral head necrosis and
reconstruction of the spinal column [5-9]. In each appli-
cation, satisfactory results were reported.
The superficial skin can be incorporated as an
osteocutaneous flap together with underlying fascia
or muscle to provide soft tissue padding, skin cover,
and monitoring flap [10,11].
The fibula is a strong cortical bone and is available
as a straight bone about 25 em in length, which is ideal
for long bone reconstruction. However, one of the main
problems with this procedure is frequent postoperative
fractures of the grafted fibula. In cases with fractures,
the healing time is over 3 months longer than in cases
without fractures [12]. Therefore, efforts to achieve
satisfactory bony reconstruction mechanically in the
primary operation should be made in order to prevent
fracture of the grafted fibula. To prevent fracture, we
recommend the use of an external fixator and a dual
bone graft, such as a folded vascularized fibula graft
(VFG) or combined auto and allo free bone grafts
[13-15]. Depending on the condition of the recipient
site, ipsilateral pedicled VFG is a useful method for
reconstruction of long bone defects in the lower leg [16].
However, when the condition of the tissue surrounding
the vascular pedicle and fibula is not good, and in con-
genital cases, a free VFG is preferable. The proximal
part of the fibula with its fibrocartilage head can be
used for the reconstruction of the distal end of the
radius or humeral head for preserving the joint function
[17]. This procedure can also include the epiphyseal
plate in children and can be applied in patients who
need reconstruction of the epiphysis to preserve
epiphyseal growth [18].
In this chapter, we will describe the harvesting tech-
niques of VFG.
Preoperative Management of the
Donor Site
The nutrient artery of the fibula is the peroneal artery,
which gives off not only some nutrient arteries but also
several periosteal branches. The peroneal artery runs
distally along the medial and posterior aspect of the
fibular diaphysis (Fig. 1).
A Doppler flowmeter is used for preoperative detec-
tion of the perforating point where the cutaneous
branches from the peroneal artery are attached to the
graft. These points are usually located in the middle
third of the outer side of the leg along a line about 1 cm
posterior to the fibula. If skin or soft-tissue coverage
combined with bone grafting is necessary, two or three
cutaneous branches should be included in the flap.
This flap can be used for postoperative monitoring of
the vascularity of the grafted bone.
Harvesting Procedure
The operation is performed under general anesthesia
with the patient in the supine position and with a small
pillow under the buttocks to lift the donor leg slightly.
The donor leg is flexed approximately 50 degrees at the
knee and 60 degrees at the hip with internal rotation as
much as possible, and the foot is laid down on the side
table attached to the operating table (Fig. 2). A tourni-
349
350 E. Clinical Reconstructive Microsurgery
Fig. 1. Cross section of the leg illustrating the plane of dis-
section for harvesting a fibula graft with flap. TA, Tibialis ante-
rior; EDL, extensor digitorum longus; EHL, extensor hallucis
longus; PL, peroneus longus; PB, peroneus brevis; TP, tibialis
posterior; FHL, flexor hallucis longus; FDL, flexor digitorum
longus
quet is used during the course of dissection, which is
performed under 2.5 magnification with a binocular
loupe.
Using a skin marker, a design is made of the extent
of the elliptical skin flap to be incised, including the two
or three cutaneous perforators from the peroneal artery
that are to be raised. The posterior skin incision of the
flap, including the superficial fascia overlying the soleus
muscle, is made and extended along the lateral aspect
of the fibula shaft to the neck proximally and as far dis-
tally as needed, taking care not to injure the sural nerve
and small saphenous vein. The skin is anchored to the
fasciocutaneous layer to prevent tearing and displace-
ment of the vessel. At this point, some branches from
the peroneal vessels can be seen lying just posterior
to the fascia overlying the soleus muscle and the inter-
muscular septum (Fig. 3a,b). Depending on the position
of these branches, the design of the flap and the levels
of cutting the fibula to be harvested are decided. Next,
the anterior margin of the flap to be harvested is incised
and sutured to the fasciocutaneous layer. Using a blunt
elevator or scissors, the interval between the peroneus
longus and soleus muscles is identified and the deep
fascia is incised over the entire length of this fascial
plane.
The peroneus longus and soleus muscles are then
reflected from the fibular diaphysis anteriorly and pos-
teriorly, respectively, using an extraperiosteal technique.
The peroneus longus and brevis muscles attached to the
Fig.2. Position of the patient, skin incision, skin flap, and loca-
tion of the bone graft drawn on the skin. Note that two or
three cutaneous branches should be included in the flap
fibula are sliced with a knife, and hemostasis of bleed-
ing from the small branch is performed meticulously
with a bipolar coagulator (Fig. 3c). Proximally, the
soleus muscle is detached from the fibula and retracted
posteriorly to expose the peroneal artery and its con-
comitant veins. A vessel loop is placed around these
vessels to carefully preserve them. At this point, the per-
oneal vessels entering the proximal border of the flexor
hallucis longus muscle can be seen posteriorly to the
fibula at a point about one-third from the proximal end
(Fig.4a).
The anterior tibial vessels and deep peroneal nerve
are carefully preserved proximally as they are retracted
anteriorly. The proximal and distal ends of the fibula
are dissected subperiosteally and osteotomized with an
oscillating saw, while carefully protecting the vessels
that lie posterior and anterior to the retractor (Fig. 4b).
The periosteum of both ends of the fibula should be
taken as long as possible to be overlapped at the junc-
tion between the recipient bone and grafted fibula.
A bone hook is then inserted into both ends of the
osteotomized fibula, and the graft is carefully retracted
anteriorly and posteriorly to perform the following
procedure.
The anterior crural septum is divided along the length
of the graft, and the extensor digitorum longus, per-
oneus tertius, and extensor hallucis longus are dissected
off the interosseous membrane. The interosseous
membrane is then resected along the entire length of
the graft, using blunt retractors to prevent injury of the
anterior tibial vessels and the deep peroneal nerve
(Fig. 4c). After this resection, the tibialis posterior
muscle can be seen.

b
Fig. 3. a,b The posterior skin incision of the flap and the posterolateral skin incision. c Dissection of the lateral side of the
fibula
b
a
Fig. 4. a The peroneal artery and concomitant veins are pre-
served by a vessel loop. These vessels entering the proximal
border of the flexor hallucis muscle can be seen. b Osteotomy
The graft is then carefully retracted anteriorly, and
detachment of the flexor hallucis longus is carried out
to expose the peroneal vascular pedicle consisting of
the peroneal artery and its two venae comitantes. The
branches from the peroneal artery to the fibula pass
through the flexor hallucis longus muscle. From proxi-
mal to distal, the lateral side of the flexor hallucis longus
muscle, then the peroneal vascular pedicle is dissected
for the length of the graft required, taking care to pre-
2.3.1. Fibula 351
c
c
of the proximal and distal fibula. c Dissection of the anterior
side of the fibula
serve the nerve to the flexor hallucis muscle (Fig. 5a).
The branches arising from the peroneal artery to the
soleus muscle must be coagulated.
The tibialis posterior muscle is dissected along the
length of the graft, because the vascular pedicle must be
left attached to the posterior surface of the inter-
muscular septum to prevent separation from the graft
(Fig. 5b). The posterior surface of the graft contains
the muscular and periosteal vessels. At the level of the
352 E. Clinical Reconstructive Microsurgery
b
Fig. S. a Dissection of the flexor hallucis longus muscle.
b Dissection of the tibialis posterior muscle
distal end of the graft, the peroneal artery and its venae
comitantes are ligated and divided. The fibula is then
freed from all surrounding tissues except for the proxi-
mal vascular pedicle. The vessels are then traced pro-
ximally to their bifurcation from the posterior tibial
vessels. Then the tourniquet is released, and hemostasis
of bleeding from the graft is performed meticulously.
Local irrigation with 10% xylocaine is used to release
spasm of the exposed vascular pedicle induced by the
procedure. This procedure should take about 11/2h to
Fig. 6. a,b Dissection of the folded vascularized fibula graft
complete. After the fibula division, if necessary, a split-
thickness skin graft, which is harvested from the
inguinal region, should be performed for the donor site.
Dissection of the Folded Vascularized
Fibula Graft
This technique involves dividing a donor vascularized
fibula into two segments, without cutting the vessels,
thereby supplying blood circulation to both bones.
Appropriate indications for twin-barrel fibula graft, in
other words, two-folded fibula graft, are cases in which
the discrepancy of diameters between the donor and
recipient bones is marked, the bones to be recon-
structed are in two directions, or simultaneous recon-
struction of the fibula and tibia is needed.
Before division of the fibula, the peroneal vessels are
separated from the periosteum at the point of incision
and for approximately 1 or 2cm on either side, depend-
ing on the exposed length of the reconstructed recipi-

C)
a n b c
Fig. 7. a Distal tibiofibular metaphyseal synostosis of the donor site (Langenskiold-modified by Tarnai). b Two-year, 5-month-
old girl, anteroposterior radiograph after the operation. c Two years after the operation
ent tibia and fibula (Fig. 6a). Then the periosteum in this
area is incised and peeled back. Next, the fibula is cut
and the vessels are folded so that there are two parallel
vascularized fibula segments (Fig. 6b). The peroneal
vessels between the two sections of the fibula are com-
pletely separated from the periosteum, and the perios-
teum that is separated from the vascular pedicle is cut
to lie over the recipient bone. It is most important when
using this method that the periosteum flap attached to
the proximal and distal donor bone adequately covers
the recipient bone. The standard procedures are fol-
lowed for monitoring blood circulation of an attached
skin flap.
Distal Tibiofibular Metaphyseal
Synostosis of the Donor Site after
Harvesting the Fibula
In adult cases, we encourage the patient to move the
toe and ankle postoperatively, as soon as possible after
wound pain decreases. In children, however, to prevent
the development of valgus ankle deformity in the donor
leg, distal tibiofibular metaphyseal synostosis should be
performed primarily [19]. We prefer to use the manner
described by Langenski6ld [20] or the Langenski6ld-
Tarnai modified procedure [19]. First, the cortical bone
flap is cut along three sides and lifted up proximally.
The residual tip of the fibula is folded and inserted to
2.3.1. Fibula 353
the bone flap and the slot under the flap at the distal
metaphysis of the tibia. From the lateral malleolus, one
Kirschner wire is inserted for internal fixation (Fig. 7).
For immobilization, a short leg cast is necessary until
bony fusion is achieved. Care should be taken to prevent
flexion contracture of the big toe when the lower leg
cast is fitted.
References
1. Taylor GI, Miller GD, Ham FJ (1975) The free vascular-
ized bone graft. A clinical extension of microvascular tech-
niques. Plast Reconstr Surg 55:533-544
2. Ueba Y, Fujikawa S (1983) Nine years follow-up of a vas-
cularized fibular graft in neurofibromatosis. A case report
and literature review. Orthop Surg Traumatol (Jpn)
26:595-600
3. Fujimaki A (1977) Free vascularized bone graft to fill up
bone defect. Traumatology (Jpn) 20:537-542
4. Murase M, Adachi N, Ikuta Y, Watari S, Watari S, Kubo T
(1977) Clinical application of the free vascularized bone
graft following tumor resection. Clin Orthop Surg (Jpn)
12:540-547
5. Tarnai S, Sakamoto H, Hori Y, Tatsumi Y, Nakamura Y,
Shimizu T, Fukui A (1980) Vascularized fibula transplan-
tation: a report of 8 cases in the treatment of traumatic
bony defect or pseudarthrosis of long bones. Int J Micro-
surg 2:205-212
6. Weiland AJ (1981) Current Concepts Review. Vascular-
ized free bone transplants. J Bone Joint Surg 63A:166-169
354 E. Clinical Reconstructive Microsurgery
7. Fujimaki A, Yamauchi Y (1983) Vascularized fibular
grafting for treatment of aseptic necrosis of the femoral
head-preliminary results in four cases. Microsurgery
4:17-22
8. Toh S, Tohno S, Harata S, Ohmi Y, Ohtake S, Nakano S,
Ueyama K, Moriyama A, Hayashi A (1985) The vascular-
ized fibula graft for severe kyphosis of spondylitis tuber-
culosa. Clin Orthop Surg (Jpn) 20:1431-1435
9. Doi K, Kawai S, Sumiura S, Sakai K (1988) Anterior cer-
vical fusion using the free vascularized fibular graft. Spine
13:1239-1244
10. Chen ZW, Yan W (1983) The study and clinical application
of the osteocutaneous flap of fibula. Microsurgery 4:11-
16
11. Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Ueno T
(1983) Free vascularized fibular transplant. A new method
for monitoring circulation of the grafted fibula. J Bone
Joint Surg 65A:1295-1301
12. Ihara K, Doi K, Sakai K, Kuwano N, Kawai S (1992)
Fracture of free vascularized fibular grafts. J Jpn Soc
Reconstr Microsurg (Jpn) 5:86-95
l3. Toh S, Harata S, Ohmi Y, Nakahara K, Satoh F, Tsubo K,
Nakamura R, Nishikawa S (1988) Dual vascularized
fibula transfer on a single vascular pedicle: A useful tech-
nique in long bone reconstruction. J Reconstr Microsurg
4:217-221
14. O'Brien BM, Gumley GJ, Dooley BJ, Pribaz JJ (1988)
Folded free vascularized fibula transfer. Plast Reconstr
Surg 81:311-318
15. Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman
A (1988) The "double barrel" free vascularized fibular
bone graft. Plast Reconstr Surg 81:378-385
16. Chacha PB, Ahmed M, Daruwalla JS (1981) Vascular
pedicle graft of the ipsilateral fibula for non-union of
the tibia with a large defect. An experimental and clinical
study. J Bone Joint Surg 63B:244-253
17. Ono H, Yajima H, Mizumoto S, Miyauchi Y, Mii Y, Tarnai
S (1997) Vascularized fibular graft for reconstruction of
the wrist after excision of giant cell tumor. Plast Reconstr
Surg 99:1086-1093
18. Tsai TM, Ludwig L, Tonkin M (1986) Vascularized fibular
epiphyseal transfer. A clinical study. Clin Orthop 210:
228-234
19. Tarnai S, Sakamoto H, Fukui A, Shimizu T, Kamikubo T,
Masuhara K, Tatsumi Y (1983) Vascularized fibula graft
for the treatment of congenital pseudarthrosis of long
bone. Orthop Surg Traumatol (Jpn) 26:601-612
20. Langenskiold A (1967) Pseudarthrosis of the fibula and
progressive valgus deformity of the ankle in children:
Treatment by fusion of the distal tibial and fibular meta-
physes. Review of three cases. J Bone Joint Surg
49A:463-470
2.3.2 Scapula
HIrOSHI HIRATA

The scapula is one of the most frequently used donor the lateral crest of the scapula and compared them
sites for a vascularized bone graft. In 1981, Teot [1] with those of the iliac crest. He found that the scapula
carried out an anatomical study to demonstrate the had an average width of 9.7 2.3mm and an average
potential use of the lateral scapular crest as a free vas- cortical thickness of 2.33 1.6 mm, whereas the iliac
cularized bone graft on a branch of the circumflex crest had an average width of 14.6 3.6mm and an
scapular artery and reported the first clinical application average cortical thickness of 2.55 1.1 mm. Although
of the flap in three patients. There was some controversy the two bones had similar average bone densities, the
over the mode of vascular supply of the scapular bone. value in the iliac crest diminished in specimens from
Swartz [2] extensively studied the vascular anatomy of elderly people, whereas that of the scapula increased
the scapula and reported that the osseous branches with age.
give off only periosteal vessels. In contrast, Sekiguchi The nourishing vessels, the scapular circumflex artery
[3] demonstrated that the branches give off a major and the angular branch with their concomitant veins,
medullary artery, which supplied the entire lateral run constant courses with few variations. The subscapu-
border of the scapula in nearly 90% of his patients. lar artery gives off two branches, the circumflex scapu-
Deraemaecker [4] reported the additional vascular lar artery and the thoracodorsalis artery. The former
supply to the scapula, i.e., the angular branch, which artery turns posteriorly and travels through the trian-
supplies not only the lateral crest but also the distal tip gular space, which is bounded superiorly by the long
and the medial edge of the scapula. Coleman [5] gave a head of the triceps muscle, laterally by the conjoint
detailed description of the angular branch based on an tendon of the teres major and latissimus dorsi, and
extensive anatomical study and reported a bipedicled medially by the teres minor muscle. As the artery
scapular bone flap based on the subscapular artery. He crosses the triangular space, it gives off an osseous
raised the two scapular bone flaps, preserving both the branch approximately 4 cm distal to the lower rim of the
circumflex scapular artery and the angular branch dis- glenoid fossa, which gives off a main medullary artery
secting up to the subscapular artery, which provides a and numerous small periosteal branches along the
significant degree of independence for the two osseous lateral border of the scapula, as Sekiguchi suggested [3].
components as well as a longer pedicle. Once the circumflex scapular artery rises to the surface
of the back, the artery descends about 2 cm along the
lateral border of the scapula and then divides into two
Technical Considerations (Fig. 1) cutaneous branches, the transverse branch and the
descending branch, which supply the overlying skin.
Theoretically, the whole lateral border of the scapula, Thus, two large skin paddles, which are independent of
ranging from just distal to the glenoid proximally down bone flap and constrained only by their vascular leash,
to the inferior pole, as well as the medial edge of the can be raised with the circumflex scapular artery-based
scapula, can be included in the vascularized scapular bone flap. The vascular pedicle of the flap is between 40
bone flap, if both the circumflex artery and the angular and 80 mm in length, and their calibre is 1.8 to 2.5 mm
branch are included in the vascular pedicle. Winging of at the base. Based on anatomical study, Coleman [5] and
the scapula due to harvesting of the bone can be pre- Allen [7] found that the angular branch is a consistent
vented by suturing the serratus anterior muscle back to artery arising 50% from the thoracodorsalis artery and
the remaining scapula bone. The bone obtained from 50% from the crossing branch of the thoracodorsalis
the lateral crest of the scapula is relatively straight, with artery to the serratus anterior muscle. The artery and its
a triangular cross section, and is up to 14 cm in length, concomitant veins course within the alveolar tissue
thinning from superior to inferior. Becker [6] measured overlying the serratus anterior muscle and approximate
the width, cortical bone thickness, and bone density of the scapular tip 2 to 3 cm cephalad to the inferior angle.

355
356 E. Clinical Reconstructive Microsurgery

Fig. 1. Schematic diagram to show subscapularis artery

system. AB, Angular branch; CS, circumflex scapular artery;
LD, latissimus dorsi; GB, osseous branches; SuA, subscapular
artery; SA, serratus anterior; TA, thoracodorsalis artery

The vessels send a number of small branches through

the serratus anterior and subscapularis muscles to the
underlying scapular bone. The distance between the
point of bone penetration of the angular branch and
that of the circumflex scapular artery is 6 to 9 cm, and
there appears to be an adequate collateral flow between
c
the two arterial systems [3]. Therefore, one can raise a
long straight bone flap of up to 8cm supplied solely by
the angular branch from the lateral scapular crest. Fig.2. a Angular branch-based scapular bony flap along with
Hirachi [8] reported that the flap has a long vascular a scapular cutaneous flap and a serratus anterior muscle flap
pedicle of 101 16mm on the average, and the average is transferred to reconstruct a complex bone and soft tissue
arterial calibre is 1.6mm at its base. Or, one can tailor defect in the thenar region. b The necrotic and infected
two distinct vascularized scapular bone segments, one metacarpal segment was removed and reconstructed with a
supplied by the circumflex scapular artery and the other short scapular bony flap. X-ray shows solid healing and
by the angular branch, to make a subscapular artery- remodeling of the osteosynthesis site. c The restored hand has
based bipedicled flap, as described by Coleman [5]. In good function. SA, Serratus anterior; SB, scapular bone flap;
SF, scapular flap
that case, the two distinct vascularized segments can be
separated by approximately 15 cm.
A number of tissues, including the latissimus dorsi scar is a concern with this procedure, it causes little func-
muscle, serratus anterior muscle, ribs, and skin, are nour- tional disability of the shoulder joint.
ished by the branches of the subscapular artery. A
variety of composite flaps can be tailored on a single
vascular pedicle, which makes the subscapular vascular Harvesting Technique
system-based flaps most suitable for the reconstruction
of complex tissue defects in the hand and the face, The patient is placed in the lateral position with the
due to trauma or oncologic resection (Figs. 2 and 3). donor side up. The preparation should include the entire
Although the risk of producing an unsightly donor site upper extremity. A Doppler probe is applied to identi-
 2.3.2. Scapula 357

II c

b d

Fig. 3. a The patient had a recurrent malignant tumor in the myocutaneous flap, and an angular branch-based scapular
neck and osteomyelitis of the clavicle. b,c Large excisional bone flap. X-ray shows solid healing and remodeling of the
defects were reconstructed with a subscapular artery-based osteosynthesis site. SB, Scapular bone flap; SF, scapular flap;
composite flap consisting of a scapular flap, a latissimus dorsi LD, latissimus dorsi myocutaneous flap

fiy the circumflex scapular artery at the point where the

artery comes out of the triangular space. A 12- to 1S-cm
oblique incision is made along the lateral border of the
scapula from the triangular space. To identify the trian-
gular space safely, one should find the interval between
the teres minor and teres major first and then follow it
superiorly into the triangular space. The fascia of the
teres minor is thick and white, whereas that of the teres
major is thin and red, which may be a useful clue to
identify the interval. Once the circumflex scapular
vessels have been identified in the triangular space, the
vessels are dissected up to the subscapular vessel origin,
taking care not to damage the branches. One can iden-
tify the osseous branches approximately 4 cm distal to Fig. 4. The main osseous vessels (large arrows) branching out
the lower rim of the glenoid fossa. The osseous branches from the circumflex scapular vessels (small arrow) within the
usually give off several branches to the distal and lateral triangular space
surfaces of the scapula (Fig. 4). To identify the angular
branch, the plane between the teres major and the latis-
simus dorsi muscles is opened. With both the angular designed according to the reconstructive needs. Using
branch and the circumflex scapular artery protected, electrosurgical dissection, the infraspinatus and sub-
the teres major muscle is detached at its origin and scapularis muscles are incised along the borders of the
retracted laterally. The angular branch is followed dis- proposed bony flap. The bone is then transected with an
tally to the point where it enters the soft tissue. Follow- oscillating saw. Bone supplied by both the circumflex
ing confirmation of the points where the two vascular scapular artery and the angular branch can be harvested
systems approximate the scapula, a bone flap is in continuity or separately. A small amount of bone wax
358 E. Clinical Reconstructive Microsurgery
is used to stop oozing from the cut edge of the bone.
The teres minor muscle is sutured to the subscapularis
muscle, and then the teres major is sutured to the angle
of the scapula. The shoulder should be immobilized in
an adducted position for the first week, and then gentle
motion exercise is encouraged.
References
1. Teot L, Bosse JP, Moufarrege R, Papillon J, Beauregard G
(1981) The scapular crest pedicle grafts. Int J Microsurg
3:257-262
2. Swartz WM, Banis JC, Newton ED, et al. (1986) The osteo-
cutaneous scapular flap for mandibular reconstruction.
Plast Reconstr Surg 77:530-545
3. Sekiguchi J, Kobayashi S, Ohmori K (1993) Use of the
osteo-cutaneous free scapular flap on the lower extremities.
Plast Reconstr Surg 91:103-112
4. Deraemaecker R, van Thienen C, Lejour M, Dor P. (1988)
The serratus anterior scapular free flap: a new osteomus-
cular unit for reconstruction after radical head and neck
surgery (Abstract). In: Proceedings of the Second Interna-
tional Conference on Head and Neck Cancer
5. Coleman n, Sultan MR (1991) The bipedicled osteocuta-
neous scapula flap: a new subscapular system free flap. Plast
Reconstr Surg 87:682-692
6. Becker A, Schenk C, Klesper B, Koebke 1. (1998) Com-
parative densitometric study of iliac crest and scapula
bone in relation to osseous integrated dental implants
in microvascular mandibular reconstruction. J Cranio-
Mandibular Surg 26:75-83
7. Allen RJ, Dupin CL, Dreschnack PA (1994) The latissimus
dorsi/scapular bone flap (the latissimus dorsi bone flap).
Plast Reconstr Surg 94:988-996
8. Hirachi K, Minami A, Kato H, et al. (1998) Anatomical
study on vascularized scapular bone flap. J Jpn Soc Recon-
str Microsurg 11:19-20
2.3.3 Ilium
ARIHISA FUJIMAKI
Both the cancellous and the cortical bone of the ilium
have been commonly used as donor sites for bone grafts.
With the introduction of microsurgery, the use of a
living bone graft has become possible, making the iliac
bone more valuable as the donor site. A vascularized
iliac bone graft was initially applied as an osteocuta-
neous flap, utilizing the superficial circumflex iliac artery
(SCIA) [1-3]. However, Taylor found that the deep
circumflex iliac artery (DCIA) was superior in terms of
blood flow to the iliac bone and suggested using this
system [4,5]. Generally, the anterior to middle portion
of the ilium is taken using the DCIA system, but if the
posterior to central portion is preferred, the superior
gluteal vessels should be utilized [6]. The iliac bone can
be used either as a free vascularized graft or a pedicled
graft, and also a vascularized periosteal graft [7,8].
Vascular Anatomy
The iliac bone is flat, with a rich blood flow. The feeding
blood vessels produce an open meshwork of fine vessels
and have a major communication with the periosteal
arteries [9].
The DCIA originates from the anterolateral side of
the external iliac artery 1-2cm above the inguinalliga-
ment and ascends between the transverse fascia and the
extraperitoneal fat along the inguinal ligament towards
the anterior iliac spine. The initial branch is an ascend-
ing branch near the anterior iliac spine, running into the
abdominal muscle.
Next is a descending branch entering the iliacus
muscle. The DCIA proceeds towards the posterior iliac
spine 2-3 cm below the iliac crest between the iliacus
muscle and the fascia; many branches enter the trans-
versus abdominis and the internal and external oblique
muscles before supplying the skin. Some of these cuta-
neous branches run along the iliac crest. In the deep
area, branches supply the illiacus muscle, and some
anastomose with the periosteal arteries. The DCIA is
1.5-2.5 mm in external diameter, and the pedicle length
from the external iliac artery to the anterior iliac spine
is approximately 6cm. The venae comitantes run almost
parallel with the DCIA and are 2.5-3.0mm in external
diameter at the external iliac vein. The configuration
of the DCIA has few anomalies (Fig. 1). The SCIA
branches approximately 1 cm below the inguinal liga-
ment from the lateral side of the femoral artery, running
to the anterior iliac spine.
Where the sartorius muscle originates from the
anterior iliac spine, it provides branches to the skin and
iliac bone. The SCIA is of small diameter and has many
branches before anastomosing with the superficial epi-
gastric artery. It is not suitable for a vascularized bone
graft.
Clinical Application
A vascularized bone graft (VBG) is generally indicated
for bone defects more than 6 cm in length. The fibula is
mainly used for the long bones of the extremities, and
the iliac bone is used for reconstruction of the mandible
because of its shape. Presently, it is commonly used to
reconstruct bone defects after trauma or resection of
tumor, and also for traumatic, congenital and infectious
pseudoarthrosis, and hip arthrodesis. It is also indicated
for the treatment of aseptic necrosis of the femoral
head. The length of iliac bone used ranges from 4 to
16cm. The greater lengths are cut segmentally at several
sites, maintaining the continuity of the periosteum
and muscle. It can be used in full-thickness or in half-
thickness segments. A vascularized periosteal graft is
useful in the treatment of pseudoarthrosis.
Harvesting Technique
With the patient supine, the public bone, anteror iliac
spine, iliac crest, femoral artery, and inguinal ligament
are marked.
Free Vascularized Bone Graft
The skin incision is slightly curved, starting from the
posterosuperior area of the iliac bone, descending along
359
360 E. Clinical Reconstructive Microsurgery
the iliac crest and medially along the inguinal ligament
to reach the external iliac artery (Fig. 2). The whole
inguinal ligament is exposed, and the abdominal fat pad
is divided to confirm the DCIA and the external iliac
artery. At the base of the DCIA, the inferior epigastric
artery arises from the external iliac and can be used as
a guide. These vessels are followed to the anterior iliac
spine superiorly and on the iliacus muscle along the
inguinal ligament, taking care not to damage or expose
the vessels. Near the anterior superior iliac spine, the
ascending branch running in the abdominal muscle is
confirmed and preserved. The DCIA extends into the
pelvis.
Iliac
crest
Tensor
fasciae
lalae
Lateral
cutaneous -'T+-.d+--Ir:-..:--
nerve
Fig. 1. Vascular anatomy of deep circumflex iliac artery
(DCJA) and vein (DCJV)
(\
Fig. 2. Skin incisions for free vascularized bone graft on the
right and osteocutaneous flap on the left
At the midportion of the iliac crest, an incision is
made along the bony curve. At the lateral side, the
gluteal muscle is seen just below the iliac crest, 0.5 cm
of subcutaneous fat is left over the iliac crest, and the
outer wall of the iliac bone is exposed. At the medial
side are the three layers of abdominal muscle lined by
the transverse fascia. The perforating branches to the
muscle and skin are ligated. At the inner wall of the iliac
bone, the DCIA runs transversely towards the posterior
iliac spine 2-3 cm inferior to the iliac crest and can be
seen under the fascia of the iliacus muscle. Before the
bone is exposed, the lateral cutaneous nerve of the thigh
running between the tensor fasciae latae and the sarto-
rius muscles is preserved. After the DCIA is traced, the
fascia is transected. The iliacus muscle below it is cut
with scissors, leaving about 0.5 cm in thickness on the
inner wall. The distal end of the DCIA is ligated where
the bone is divided. The periosteum is resected accord-
ing to the size of bone required. A sharp osteotome or
oscillating saw is used. The DCIA and deep circumflex
iliac vein (DCIV) are ligated proximally, and the graft
is isolated. There should be good bleeding from the cut
end of the iliac bone (Fig. 3).
Osteocutaneous Flap
With the patient supine, a pad is inserted under the hip
of the donor side to elevate the body, and key markings
are made. The site of the perforating artery is localized
by using a Doppler ultrasound stethoscope, and an
island skin incision is designed centered on the artery.
On the lateral side, the external wall of the iliac bone
is exposed by resecting the gluteus medius muscle,
preserving the periosteum. Superiorly, the abdominal
muscles are separated 3-4cm above the iliac crest.
Fig. 3. Vascularized iliac bone with DeIA system

Traction on the extraperitoneal fat exposes the trans-
verse fascia and the iliacus fascia, and the DCIA is seen
2-3 cm below the iliac crest. Once the DCIA has been
located, the iliacus muscle and fascia are transected,
exposing the inner wall of the iliac bone. The DCIA is
exposed back to its origin, and care is taken to preserve
it. The ascending branch and the muscular branches at
the iliac crest, and also the lateral femoral cutaneous
nerve, are confirmed and preserved.
The origins of the sartorius and iliacus muscles are
divided. At the iliac crest, the required length is marked,
and the periosteum is cut medially and laterally and the
bone is divided, preserving the skin flap attachment. The
distal end of the DCIA is ligated and the osteocuta-
neous flap is separated. Both the bone and the skin
should bleed before the deep circumflex iliac vessels are
divided (Fig. 4a and b).
Vascularized Periosteal Graft
A skin incision is placed at the middle of the iliac crest,
and the internal oblique abdominal muscle is retracted
Fig. 4. Harvested osteocutaneous flap (8) and DCJA system
(b)
2.3.3. Ilium 361
laterally and the transverse fascia transected. In the
pelvis, under the abdominal fat pad, the DCIA runs
transversely 3-4 cm below the crest. The fascia and
muscle are severed by scissors 1-2 cm below these
vessels, displaying the inner wall of the iliac bone. The
required length is determined, and the periosteum is
resected with a sharp knife.
After the distal ends of the DCIA and DCIV have
been ligated, the periosteum is separated carefully from
below upwards to the iliac crest. Once the iliac crest has
been reached, separation of the periosteum from the
central portion, which has been resected previously,
prevents it from being injured on the edge of the crest.
Once the periosteum has been raised and the DCIA and
DCIV have been stretched, a fine network of arteries
can be seen penetrating the iliac bone. Finally, the
DCIA and DCIV are ligated separately at their origins
(Fig. 5).
Management of the Donor Site
after Harvesting
When needed, cancellous bone can be collected from
the bone donor site by using a curette. Since both the
inner and the outer cortex of the iliac bone are thin, care
should be taken to avoid fracture. Bone wax is applied
to the cut bone for hemostasis, and the bleeding muscle
is diathermed. The divided abdominal and gluteal
muscles are sutured, along with the transversalis and
iliacus muscle fascia. If hemostasis is complete, there is
no need for drainage. At the inguinal ligament, the
Fig. 5. Elevated vascularized periosteum with DCJA system
362 E. Clinical Reconstructive Microsurgery
muscle and ligament are sutured firmly to prevent
postoperative herniation. It is not necessary to use a
hydroxyapatite spacer for the bone defect. After the
subcutaneous tissue has been sutured, the skin is closed.
Postoperatively the hip joint is kept slightly flexed to
avoid tension to the sutured areas.
Conclusion
If care is taken with detail, a vascularized bone or
periosteal graft utilizing the DeJA system can be safely
performed and has many applications.
References
1. O'Brien B MC (1977) Microvascular reconstructive
surgery. Churchill Livingstone, Edinburgh, pp 283-284
2. Taylor G, Watson N (1978) One-stage repair of compound
leg defects with revascularized flap of groin skin and iliac
bone. Plast Reconstr Surg 61:494-506
3. Tarnai S (1979) Iliac osteocutaneous neurosensory flap. In:
Serafin D, Buncke H (eds) Microsurgical composite tissue
transplantation. Mosby, St. Louis, pp 391-397
4. Taylor G, Townsent P, Corlett R (1979) Superiority of the
deep circumflex iliac vessel as the supply for free groin flap:
clinical work. Reconstr Surg 64:754-759
5. Sanders R, Mayoui B (1979) New vascularized bone graft
transferred by microvascular anastomosis as a free flap. Br
J Surg 66:787-788
6. Huang G, Hu R, Miao H, Yin Z, Lan T, Pan G (1985)
Microvascular free transfer of iliac bone based on the deep
superior branches of the superior gluteal vessels. Plast
Reconstr Surg 75:68-74
7. Satoh T, Tuchiya M, Harii K (1983) A vascularized iliac
musculoperiosteal free flap transfer: a case report. Br J
Plast Surg 36:109-112
8. Masquelet A, Romana C, Regazzoni P (1989) Vascularized
periosteal graft. In: Aebi M, Regazzoni P (eds) Transplan-
tation. Springer, Berlin, pp 259-262
9. Crock H (1996) An atlas of vascular anatomy of the skele-
ton and spinal cord. Martin Dunitz, London, pp 193-195
2.3.4 Vascularized Thin Corticoperiosteal Graft from
the Medial Femoral Condyle
MORaE BEPPU
The periosteum has the ability to create new bone.
However, a nonvascularized free periosteal graft can
also cause new bone formation but does not offer con-
sistency or the necessary volume. Therefore, this
conventional method is not useful in clinical situations.
However, the vascularized periosteal graft has some
disadvantages in clinical situations. The fact that the
osteogenic property has not been constant or satisfac-
tory may be due to injury of the cambium layer during
separation of the periosteum from the bone. In 1988
Sakai et al. [1] reported a new donor site of the vascu-
larized thin corticoperiosteal graft from the medial
femoral condyle.
Indication
The vascularized periosteal graft is one of the modified
vascularized bone graft techniques. Usually it is used
for the reconstruction of pseudoarthrosis with small
bony defects and unusual shapes, especially in the upper
extremities. Because the upper extremities usually have
nonunions without significant bony defects and have
less surrounding soft tissue, a vascularized iliac crest or
fibular graft is difficult to apply as a vascularized bone
graft, owing either to its large size or to its straight con-
figuration. The pseudoarthrosis of the forearm and the
bony defect of the mandible are good indications for
this procedure.
Vascular Anatomy
The blood supply of the periosteum of the medial
femoral condyle and the supracondylar area of the
femur is derived from the articular branch of the
descending genicular vessels and the superomedial
genicular vessels. The periosteal flap can be established
either on the descending genicular vessels, emerging
from the medial area of the femoral vessels just proxi-
mal to the hiatus in the adductor magnus muscle, or on
the superomedial genicular vessels, emerging from the
medial area of the popliteal vessels. It is important to
note that the descending genicular vessels are longer
and larger than the superomedial genicular vessels
and, therefore, are generally easier to dissect as donor
arteries and vein. Furthermore, the descending genicu-
lar vessels also have a saphenous branch that runs to the
skin, making it possible to provide a skin-flap transfer
at the same time.
Operative Technique
A longitudinal skin incision is made on the medial
aspect of the distal thigh with the patient, whose knee
and hip are flexed and externally rotated, in a supine
position. The fascia is incised, and the vastus medialis
is exposed along with the skin incision. This muscle
is retracted anteriorly and the sartorius muscle is
retracted posteriorly, so that the descending genicular
vessels and superomedial genicular vessels can be iden-
tified. The descending genicular vessels are dissected
from the adductor magnus to their terminal branches
over the periosteum of the medial and supracondylar
areas of the femur. The superomedial genicular vessels
should be tied off before they reach the periosteum.
The graft design is made on the periosteum and the
periphery is cut with an electric cautery. Then, using a
sharp chisel, the outer cortex is raised, taking care not
to separate the periosteum from the bone. Careful dis-
section of the periosteum with the cambium layer is
very important. Thinning the cortical bone attached to
the periosteum makes shaping it as the recipient bone
simpler.
Bleeding from the edge of the periosteum with the
attached thinner bone is evidence of the vascularity of
the donor tissue. If we harvest the vascularized perios-
teum with the monitoring flap, testing the capillary refill
and the temperature of the monitoring flap are standard
methods to assure good blood flow. The pedicle of
the graft should be divided just prior to its transfer, and
then the donor site can be closed. At the same time, the
recipient site is prepared. There are two methods of
harvesting the graft: a vascularized thin corticoperios-
teal graft and a cancello-corticoperiosteal graft.
363
364 E. Clinical Reconstructive Microsurgery

In the case of pseudoarthrosis, the nonunion site is
refreshed and fixed internally or externally, and the
recipient vessels are prepared. The corticoperiosteal
graft is then transferred to the recipient site, and the
pseudoarthrosis site is wrapped around with the graft.
The periphery of the graft is fixed to the recipient bone
with nonabsorbable sutures.
In the case of avascular necrosis of the talus, a bony
hole is made at the neck of the talus. A vascularized
cancello-corticoperiosteal graft is then harvested. When
there is a small bone defect at the recipient site, some
conventional bone chips can be placed between the
bone ends, and then the corticoperiosteal graft can be
wrapped around the defect. The graft is revascularized
by anastomosis of one artery and one vein. The skin
wound is closed after assuring good perfusion of the
graft and the capillary refill, and the temperature of the
monitoring flap. Plaster cast immobilization is applied
until bony union is obtained.
were performed (Fig. 1). Plain radiographs, magnetic
resonance imaging (MRI), and bone scintigram showed
avascular necrosis of the talus 3 months after the injury
(Fig. 2). A vascularized corticoperiosteal graft from the
medial femoral condyle was performed. A vascularized
bone graft 3 x 1.5 x 1.5 cm in length was harvested from
the right medial femoral condyle. The graft was intro-
duced into a recipient site in a bony hole at the neck of
the talus. The branch of the descending genicular artery
was anastomosed to the dorsalis pedis artery and also
to one concomitant vein end-to-end (Fig. 3). Partial
weight-bearing was permitted 1 year after surgery
when the grafted bone was nearly united with the sur-
rounding bone and the bone sclerotic change had also
improved. A plain radiograph, 1 year and 4 months
after surgery (Fig. 4), showed slight arthritic change.

Case Presentation
Treatment of avascular necrosis of the talus following
trauma used to be non-weight-bearing for a long period
of time, and finally arthrodesis of the talocrural joint
was required. We performed a vascularized thin corti-
coperiosteal graft from the medial femoral condyle for
the treatment of avascular necrosis of the talus in four
cases with success.

Case 1 Fig. 2. Tomogram and MRI (T2)

A 17-year-old boy sustained a subtalar dislocation in a

traffic accident. Open reduction and internal fixation

Fig. 3. Elevated vascularized medial femoral condyle bone

Fig. 1. Plain radiograph at injury and immediately postoper- graft and bony hole. a Monitoring flap, b bone, c vascularized
atively. Arrows show dislocated tarsal bones pedicle. (See Color Plates)
 2.3.4. Vascularized Thin Corticoperiosteal Graft from the Medial Femoral Condyle
Fig. 4. Plain radiograph 1 year 4 months postoperatively
Fig.6. Plain radiograph at initial visit. Arrows show avascular
necrosis of the talus
However, the Gd-enhanced MRI showed a similar
intramedullary blood flow compared with the con-
tralateral side. Clinically, the range of motion in the
ankle was preserved, and no pain occurred during
walking. There was no limitation of the activities of daily
living (ADL).
Case 2
A 1S-year-old boy fell from the fourth story of an apart-
ment house, sustaining a fracture of the talus body and
medial malleolus. Open reduction and internal fixation
were performed at another hospital (Fig. 5). Three
months after the injury, avascular necrosis of the talus
was diagnosed and treated by non-weight-bearing using
a patellar tendon bearing (PTB) brace. Six months later
365
Fig. 5. Plain radiograph at injury and immediately
postoperatively
Fig. 7. Plain radiograph 1 year 2 months postoperatively
he was transferred to our hospital for further treatment.
At the initial visit, the plain radiograph showed bone
sclerotic change of the talus body and slight collapse of
both the talus body and the medial malleolus (Fig. 6).
The MRI showed an avascular area at the anteromedial
part of the talus, as seen in Case 1. A vascularized thin
corticope rio steal graft was performed. We harvested a
vascularized bone graft 3.2 x 1.2 x 1.2cm and followed
the same procedures as with Case 1. The difference was
that two veins were connected during this procedure
rather than one. Because a plain radiograph 1 year and
2 months after surgery showed slight cystic and sclerotic
changes, partial-weight-bearing was permitted (Fig. 7).
The Gd-enhanced MRI showed similar intramedullary
blood flow at the anteromedial part of the talus com-
pared to the contralateral side (Fig. 8). The patient had
no pain during walking.
366 E. Clinical Reconstructive Microsurgery
Fig. 8. Gd-enhanced MRI 1 year 2 months postoperatively
Discussion
Pedicle vascularized metatarsal bone grafts [2], vascu-
larized iliac crest grafts [3], and vascularized fibular
grafts [4] have been reported for reconstruction of
avascular necrosis and prevention of the collapse of the
talus.
Doi et al. [5,6] developed a vascularized thin corti-
cope rio steal graft from the medial condyle femur, which
is vascularized from the descending genicular artery.
They reported good clinical results from 5 cases using
this procedure for avascular necrosis of the talus fol-
lowing trauma. This method has several merits: the
medial femoral condyle has a rather thin cortex with a
gentle curved shape; there is no muscle attachment; and
it is technically easy to harvest both the cortex and can-
cellous bone with the periosteum. It is also possible to
harvest skin as a monitoring flap on the saphenous
branch of the descending genicular artery.
Summary
We reported the technique of harvesting a vascularized
thin corticoperiosteal graft from the medial femoral
condyle and discussed its indication. This procedure is
indicated for the reconstruction of pseudoarthrosis of
small bony defects and unusual shapes, especially in the
upper extremities.
References
1. Sakai K, Doi K, Tamaru K, Yamamoto M, Kawai S
(1988) Free vascularized bone and periosteal graft for
pseudoarthrosis in the upper limb. J Jpn Soc Surg Hand
5:698-704
2. Kiyoshige K, Watanabe Y (1993) Vascularized metatarsal
bone graft for the treatment of avascular necrosis of the
talus. J Jpn Soc Surg Foot 14:283-284
3. Sadahiro T, 19awa K, Kawachi T, Fujita S, Okada M, Hoshi-
jima K, Hirosue Y, Okutani Y, Nonami S, Nishiyama T,
Noguchi M, Yamamato H (1986) Vascularized bone graft
on avascular necrosis following traumatic fracture. Cent
Jpn J Orthop Traumat 29:680--683
4. Inoue S, Harada S, Toh S, Nakahara K, Nakamura R (1991)
Vascularized fibula graft for the treatment of posttraumatic
avascular necrosis of the talus. J Jpn S R M 4:85-86
5. Muramatsu K, Doi K, Ihara K, Hiura Y, Kawai S (1990)
Vascularized cancelo-corticoperiosteal graft from the
medial condyle of the femur applied to treatment of avas-
cular necrosis of the talus. Cent Jpn J Orthop Traumat
33:2276-2278
6. Sakai K, Doi K, Kawai S (1993) Free vascularized thin
corticoperiosteal graft. Plast Reconstr Surg 87:290-298
2.4 Toe
T AKAE Y OSHIZU
Second toe transfer, first performed by means of a pedi-
cled tissue transfer by Nicoladoni in 1898, has become
the basis of the evolution of the free toe-to-hand micro-
surgical transfer [1]. In 1966, Buncke performed big
toe-to-thumb transfer in a monkey using microsurgery
[2]. It had been thought that Cobbett was the pioneer
who performed big toe-to-thumb transfer in human beings
[3]. However, according to a 1973 article "Replantation
Surgery in China" by the American Replantation
Mission to China [4,5], the second toe-to-thumb trans-
fer performed by Yao in Shanghai in 1965 was the first
clinical case in the world. Tamai succeeded in the first
big toe-to-thumb transfer in a 45-year-old woman in
Japan in June 1973 [5]. Ohmori reported the second
toe transfer to index finger in a 14-year-old boy in
December 1974 [6]. Tsai suggested the possibility of
combined second and third toe transfer in 1973 [7,8],
whereas O'Brien actually performed this procedure in
1975 in a patient with amputation of four fingers [9].
Vascular Anatomy
Vein
The common dorsal digital vein lies on the dorsal
surface of the metatarsal bone. It communicates with
the dorsal venous arch and the great saphenous vein
proximally.
Artery
After giving off the medial and lateral tarsal arteries at
the dorsal aspect of the foot, the dorsalis pedis artery
divides into three branches at the level of the second
metatarsus: the arcuate artery, the perforating artery
running toward the sole, and the first dorsal metatarsal
artery. At the plantar aspect, the perforating artery com-
municates with the plantar arch, which gives off the first
plantar metatarsal artery. Gilbert classified the anatom-
ical variations of the first dorsal metatarsal artery into
three types [10].
In type I (66%), the dorsal metatarsal artery lies either
superficial to the first interosseous muscle (Ia) or in the
muscle proper (Ib). In this type, the plantar metatarsal
artery springs from the plantar arch. In type II (22 %), the
first dorsal metatarsal artery lies deep on the plantar
aspect of the first interosseous muscle either giving off a
superficial branch at the dorsal aspect (IIa) or as a single
artery without giving off superficial branches (lIb). In
this type, the first plantar metatarsal artery usually
branches from the first dorsal metatarsal artery.
In type III (less than 10%), the first dorsal metatarsal
artery lies superficially or in the first interosseous
muscle. This type of artery is too slender to anastomose.
In type I and type II, the first dorsal metatarsal artery
communicates with the first plantar metatarsal artery
through the perforating artery at the first web space. In
type III, the first plantar metatarsal artery becomes the
main artery. The first dorsal or plantar metatarsal artery
divides into the lateral digital plantar artery of the big
toe and the medial digital plantar artery of the second
toe. When the third toe transfer is to be done, the second
metatarsal artery with a small diameter has to be used
as a donor artery (Fig. 1).
The first dorsal or plantar metatarsal artery is also
utilized for the combined second and third toe transfer.
Because the plantar digital artery of the second toe that
branches from the first plantar metatarsal artery com-
municates with the lateral plantar digital artery of the
same toe through the transverse arteries, the medial
plantar digital artery of the third toe can receive the
reverse blood flow from the lateral plantar digital artery
of the second toe through the second plantar metatarsal
artery (Fig. 2).
Harvesting Technique
Single Toe Transfer
Dissection of soft tissues at any part of the metatarsal
bone is similar, so dissection mainly for the disarticula-
tion of the metatarsophalangeal joint (MTP) is
described here. Checking the presence of the donor
367
368 E. Clinical Reconstructive Microsurgery
1st plantar metatarsal a.
2nd plantar metatarsal a.
Fig. 1. Vascular supply to the second toe and the third toe. The first dorsal or plantar metatarsal artery is suitable as the donor
artery. The second plantar metatarsal artery with a small diameter is used for third toe transfer
artery is important prior to operation. In our experi-
ence, use of the Doppler flow meter is sufficient for this
purpose [8]. Preoperative angiography is not necessary,
because either the dorsal or the plantar metatarsal
artery to be used for a donor artery is present, without
exception.
A triangular skin incision based at the MTP joint
level and continuing to the lazy S incision proximally
is made. First, the dorsal vein is exposed at the level of
the common dorsal digital vein, or up to the level of the
great saphenous vein if necessary (Fig. 3). The dorsal
arch is excised. The medial side of the triangular flap at
the first web space is separated first. Care is taken not
to overexpose the underlying tendon, especially when
a long exten~or tendon is to be utilized. The terminal
branches of the peroneal nerve or other superficial
nerves are not necessarily preserved. Dissection of the
veins is followed by that of the arteries.
In either case, taking a short graft at the metatarsal
level, or taking a long graft using the dorsalis pedis
artery, the perforating artery that is the confluence of
the first dorsal and first plantar metatarsal artery at the
first web space is first exposed, and then the donor
artery that can be used is selected. This procedure can
1st dorsal metatarsal a.
~~.~t. ~
.. .. .,.~
?
1st plantar metatarsal a.
reduce the length of the operation. When exposure of
the arterial system is difficult, it is wiser to dissect the
neurovascular bundle of the big toe or second toe first.
The dissection of the donor artery should be continued
more proximally to obtain an adequate length [11].
When the plantar metatarsal artery is to be used, the
triangular skin incision should be made at the plantar
region. Since the dissection of the metatarsal artery in
the first interdigital space is done by opening between
the first and second toes, the point of arterial division
may be injured by excessive traction. Thus, it is better
for the proper digital artery of the big toe to be ligated
beforehand for easier dissection (Fig. 4).
The dissection of the Gilbert type II dorsal metatarsal
artery is difficult because of the presence of multiple
plantar branches. The artery may need to be dissected
after the excision of the deep transverse metatarsallig-
ament. In these cases, the short graft with an additional
vein graft, if needed, may be preferred. If the plantar
metatarsal artery is to be used, the short graft is pre-
ferred as well, and the vein graft is done in the same
way, if necessary. The bilateral digital nerves and the
long extensor and flexor tendons are severed at an
appropriate length, and the MTP joint is then freed, still

1st dorsal metatarsal a.
, st plantar metatarsal a.
Fig. 2. Dissection of the arterial system for successful com-
bined second and third toe transfer. The first dorsal or plantar
metatarsal artery is utilized as the donor artery. The third toe
is supplied by reverse blood flow through the second plantar
metatarsal artery, which communicates with the lateral plantar
digital artery of the second toe
maintained on its vascular pedicle. The tourniquet is
finally released to assure that the toe is adequately per-
fused (Fig. 5).
Combined Second and Third Toe Transfer
The skin incision and the vascular dissections in the
combined toe transfer are very similar to those in the
single toe transfer (Fig. 6). However, in the case of com-
bined toe transfer, the second plantar metatarsal artery
and the lateral digital arteries of the third toe must be
ligated and divided at the proximal and distal sites
of the plantar digital arterial branching, respectively
(Figs. 7 and 8). Primary wound closure after resection
of the joints can be done by trimming the exposed
metatarsal bones.
Pitfalls
The dissection of the Gilbert type II first dorsal
metatarsal artery is very difficult, because the artery lies
deep at the level of the metatarsal neck. Moreover, in
2.4. Toe 369
a
b
Fig. 3. Skin incision and dissection of vein. a Triangular skin
incisions are made on both the dorsal and plantar aspects, con-
tinuing to the curved or lazy S incision. b The dorsal veins are
dissected proximally to obtain a vessel of sufficient length
some cases, this artery may have short connections with
the medial plantar artery or the plantar digital artery.
Therefore, care must be taken not to injure the vessels,
as described before.
During arterial dissection in the first web, excessive
opening of the first digital space may cause arterial
injury. For this reason, it is better to ligate and divide
the plantar proper digital artery of the big toe
beforehand.
Because there is no skin on both sides of the MTP
joint, adequate skin of the recipient finger should be
preserved. Skin grafting should be done if a skin defi-
ciency remains.
The patient should be well informed that the main
objective of this operation is functional reconstruction,
and that it is difficult to achieve a mobile and cosmeti-
cally satisfactory toe transfer.
 370 E. Clinical Reconstructive Microsurgery

Ext. digitorum longus

1st plantar metatarsal a. FIx. digitorum longus

a b c

Fig. 4. Dissection of artery. a The plantar digital artery of the big toe is divided beforehand to avoid arterial injury due to
stretching of the big toe or second toe. b The donor artery is first selected at the first interdigital space to reduce the operat-
ing time. c The first dorsal metatarsal artery is selected as the donor artery, and the digital nerves, long extensor tendons, and
long flexor tendons are severed at an appropriate length

Ex. digitorum longus

Fl. digitorum longus

Common dorsal digital v.

Plantar digital n.

a 1st dorsal metatarsal a.

Fig. 5. Dissection of the second toe. a All

tissues are freed except for a vascular
pedicle, and circulation in finally checked.
b b Dissection of the second toe with good
circulation. (See Color Plates)
 2.4. Toe 371

2nd plantar melalarsal

Fig. 7. Dissection of the plantar aspect. Once the first dorsal

metatarsal artery has been selected as the donor artery, the
a second plantar metatarsal artery and the lateral digital arter-
ies of the third toe must be ligated and divided

Ext digitorum longus

b
Fix. digilorum longus
1sl dorsal metat.arsal a. a
Fig. 6. Dissection of the .dorsal aspect for combined
second and third toe transfer. a Skin incision. b After dissec-
tion of the dorsal veins, the digital artery to the big toe is
severed beforehand according to the dissection for single toe
transfer

Indications for Toe Transfer

Single Toe Transfer
In consideration of the length and resultant functions of
the second toe, single toe transfer is indicated in the fol-
lowing conditions:
Thumb amputation with poor functions of the other
remaining digits;
Thumb amputation distal to the metacarpophalangeal
joint with complete loss of thumb function;
Finger amputation distal to the proximal interpha-
langeal joint;
Amputation of all fingers other than the little finger
distal to the proximal phalanges;
Amputation of all fingers at the metacarpal level
b
Fig. 8. Combined second and third toe. a Diagram of dis-
section. b Isolated combined second and third toe. (See Color
Plates)
Combined Second and Third Toe Transfer
Combined toe transfer is indicated for amputation of
multiple digits other than the thumb proximal to the
proximal phalangeal base [12]. Although pulp-to-pulp
pinch and hook grips are possible with a single toe
transfer, the more stable chuck pinch (tripod pinch) and
372 E. Clinical Reconstructive Microsurgery
hook grip can be achieved by combined toe transfer [7].
With the addition of two mobile digits, the patient can
grasp heavy objects because of better lateral stability.
References
1. Nicoladoni C (1900) Daumenplastik und organischer
Ersatz der Fingerspitze (Anticheiroplastik und Daktylo-
plastik). Langenbecks Arch Chir 61:606
2. Buncke HJ, Buncke CM, Schultz WP (1966) Immediate
Nicoladoni procedure in the rhesus monkey, or hallux-to-
hand transplantation, utilizing microminiature vascular
anastomoses. Br J Plast Surg 19:332-337
3. Cobbett JR (1969) Free digital transfer-report of a case
of transfer of a great toe to replace amputated thumb. J
Bone Joint Surg B51:677-679
4. Replantation surgery in China. Report of the American
Replantation Mission to China (1973). Plast Reconstr Surg
52:476-489
5. Tarnai S, Hori Y, Tatsumi Y, Okuda M (1977) Hallux-
to-thumb transfer with microsurgical tehnique: a case
report in a 45-year-old woman. J Hand Surg 2:152-155
6. Ohmori K, Harii K (1975) Transplantation of a toe to an
amputated finger. Hand 7:134-138
7. Tsai TM, Jupiter JB, Wolff TW, Atasoy E (1981) Recon-
struction of severe transmetacarpal mutilating hand
injuries by combined second and third toe transfer. J
Hand Surg 6:319-328
8. Lister GD, Kalisman M, Tsai TM (1983) Reconstruction
of the hand with free microneurovascular toe-to-hand
transfer: experience with 54 toe transfers. Plast Reconstr
Surg 71:372-384
9. O'Brien BM, Brenner MD, MacLeod AM (1978) Simul-
taneous double toe transfer for severely disabled hands.
Hand 10:232-240
10. GilbertA (1976) Composite tissue transfers from the foot:
anatomic basis and surgical technique. In: Daniller AI,
Strauch B (eds) Symposium on microsurgery. Mosby, St.
Louis, pp 231-242
11. Wang W (1983) Keys to successful second toe-to-hand
transfer: a review of 30 cases. J Hand Surg 8:902-906
12. Yoshizu T (1996) Reconstruction for severely damaged
hand by double toe transfer (in Japanese). Plast Reconstr
Surg (Advance Series 19):234-252
2.5 Toe Joint
TAKAE YOSHIZU

Since the beginning of the twentieth century, numerous MTP joint capsule and the subchondral bone by giving
experimental and clinical reports on homogenous as small twigs. The cutaneous veins function for drainage.
well as autogenous joint transfer without vascular anas- For these reasons, the metatarsal bone should be ampu-
tomosis have been published [1-5]. However, most joint tated proximal to the transverse arch and the proximal
transfers had poor results, with joint destruction, except phalanx proximal to the transverse artery for MTP joint
for nonvascularized autogenous grafts in children [3,6]. transfer [14,18] (Fig. 1).
Slome in 1966 showed the validity of autogenous joint
transfer performed as a control in an immunosuppre-
sive experiment on vascular pedicle homogenous graft-
ing in dogs [7]. On the other hand, after performing PIP Joint
metatarsophalangeal (MTP) joint transfer in animals,
Daniel (1971) [8], O'Brien (1977) [9], Watanabe and
The dorsal and plantar metatarsal arteries change into
Yoshizu (1978, 1980) [10,11], and Hurwitz (1979) [12]
the dorsal and plantar digital arteries after communi-
suggested the possibility of autogenous small joints
cating with each other by perforating arteries in the
transfers in clinical cases. Clinically, Buncke (1967)
region slightly distal to the deep transverse metatarsal
replaced the destroyed metacarpophalangeal (MP)
ligament. The dorsal and plantar digital arteries, which
joint of the long finger with the uninjured MP joint of
run on both sides of the toe proper, communicate with
the traumatized index finger on its vascular pedicle, with
each other by transverse arteries at both the proximal
good results [13]. Free vascularized transfer of the pro-
phalangeal neck and the middle portion of the middle
ximal interphalangeal (PIP) joint of the toe was first
phalanx. Many small twigs arise from these transverse
performed clinically by Foucher's group in 1976 [14,15].
arteries and nourish the joint capsule and the subcarti-
Later, this same operation was performed by Tsai in
laginous bones of the PIP joint. The dorsal cutaneous
December 1978 [16], by O'Brien in June 1979 [17], and
veins are used for drainage. For vascularized PIP joint
by us in September 1979 [11,18,19]. On the other hand,
transfer, the bone should be amputated at a level pro-
MTP joint transfer to the MP joint was first performed
ximal and distal to the transverse artery, that is, at the
by the author in May 1977 [18], and later O'Brien and
region of the proximal one-third level of the proximal
Tsai presented case reports of free MTP joint transfer
phalanx, and the cervical region of the middle phalanx
in February 1978 and July 1978, respectively.
[10,18] (Fig. 2).

Vascular Anatomy
MTP Joint
The anatomy of the metatarsal artery has already been
mentioned in chapter D.2.4 on toe transfer. The dorsal
metatarsal arteries that run bilaterally parallel to the
metatarsal bone join at the metatarsal neck region with
a dorsal and a plantar transverse artery like a dog col-
lar. The perforating artery from the plantar metatarsal
artery communicates with the transverse arch at the
plantar region. The transverse arch also nourishes the
Harvesting Technique
The vascular pedicle for joint transfer should not be
too long. Moreover, preoperative angiography of the
metatarsal artery is unnecessary, because either the
dorsal or the plantar branch of the metatarsal artery
always exists. The use of a Doppler flowmeter is suf-
ficient to confirm the existence and location of the
artery. Knowing the availability of a sufficient length
of the vascular pedicle is important for planning the
operation.

373
374 E. Clinical Reconstructive Microsurgery

1st plantar metatarsal a. 1st dorsal metatarsal a.

1st dorsal metatarsal a.

I
""

Transverse arch

Fig. 1. Diagram of vascular supply to metatarsophalangeal osteotomized proximal to the transverse artery of the proxi-
(MTP) joint. The first dorsal or plantar metatarsal artery is mal phalanx and proximal to the transverse arch at the neck
selected as a donor artery. The MTP joint should be of the metatarsal bone

1st plantar metatarsal a. 1st dorsal metatarsal a.

1st dorsal metatarsal a.

~ .- ~
TransverseL-a)
. ~iE~~~'F!::::~2\nd plantar metatarsal a.

Transverse arch

Fig. 2. Diagram of vascular supply to proximal interpha- amputated distally at the distal part of the middle phalanx or
langeal (PIP) joint. The first dorsal or plantar metatarsal at the distal interphalangeal joint and proximally at the middle
artery is sutable as the donor artery. The PIP joint should be or a more proximal site of the proximal phalanx

Cutaneous vein
Cutaneous vein
I
Fig.3. Skin incision and dissection of cutaneous vein for MTP
joint transfer. Skin island over the MTP joint. When a larger
skin flap is necessary, a dorsalis pedis flap can be combined
with the MTP joint transfer
Fig. 4. Dissection of first dorsal metatarsal artery and deep
transverse metatarsal ligament. If the first dorsal metatarsal
artery is selected as the donor artery, the digital artery to the
big toe and the plantar metatarsal artery should be ligated.
The deep transverse metatarsal ligament must be cut to widen
the first interdigital space and make the following dissection
easier
MTP Joint
A skin island over the MTP joint is preserved by making
a lazy S incision proximally and a longitudinal incision
extending distally up to the PIP joint. First, a single cuta-
neous vein is dissected proximally. The great saphenous
vein is used only if necessary (Fig. 3). During dissection,
the dominant artery in the first web is confirmed first,
and then the digital artery to the big toe is ligated. The
deep transverse metatarsal ligament is cut to widen the
first interdigital space. The proximal region is cautiously
dissected so as not to detach the first metatarsal artery
from the second MTP joint. The interosseous muscle
attached to the second metatarsus is carefully detached
from the bone (Fig. 4). Next, dissection of the distal
2.5. Toe Joint 375
p,oiUtTIaJ pnalanx
a
Fig. 5. Dissection of MTP joint. a The lateral-side plantar
digital artery and nerve must be kept attached to the toe
proper. After amputation of the middle or distal region of the
proximal phalanx, the proximal side must be cautiously dis-
sected so as not to detach the first dorsal metatarsal artery
from the second MTP joint. b Isolated MTP joint
portion of the MTP joint is carried out by keeping the
neurovascular bundle attached to the proximal phalanx.
At this point, the accompanying digital nerve can be
transected at the MTP joint level. The fibular-side
plantar digital nerve and artery are kept attached to the
toe proper, because the vascular supply of the second
toe is preserved by preserving the second metatarsal
artery and the proper digital artery. The vascular bundle
around the MTP joint lies deep, and the dissection
through the dorsal aspect of the MTP joint level is not
easy. At the dorsal approach, the following dissection
will be easier if the flexor tendon can be retracted to the
plantar side by transecting the extensor tendon and
the proximal phalanx, after the neurovascular bundle at
the proximal segment has been confirmed. The deep
transverse metatarsal ligament of the second interdigi-
tal web space is cut for the dissection of the proximal
side (Fig. 5). When a larger skin flap is necessary, a dor-
salis pedis flap can be combined with the MTP joint
transfer.
376 E. Clinical Reconstructive Microsurgery
a
Fig. 6. Skin incision and dissection of cutaneous vein for the
PIP joint transfer. a A small skin island about 1 cm wide just
over the PIP joint. b Cutaneous vein is dissected distally to the
DIP joint level and proximally to obtain a vessel of sufficient
length
PIP Joint
A small skin island about 1 cm wide over the dorsal
aspect of the PIP joint is preserved as a visible monitor
of circulation, and also as a supple skin over the dorsal
aspect of the joint (Fig. 6). A dorsal longitudinal incision
is made, extending distally from the skin island flap up
to the distal interphalangeal (DIP) joint. Proximally, an
oblique incision is made from the central or slightly
medial portion of the flap to the MTP joint level of the
first web space. From this point, the longitudinal incision
extending to the carpometatarsal (eM) joint is made
parallel to the metatarsal bone. Plantarly, a slightly
curved skin incision is made so as to preserve the
bulging portion of the big toe at the MTP joint. When
the skin flap is dissected proximally, a single vein at the
middle portion of the metatarsus is preserved for anas-
tomosis. In the first web space, the artery is traced proxi-
mally for a distance of about 5 cm, which is long enough
for anastomosis with the common volar digital artery
(Fig. 7).
We suggest transecting the proper digital artery of the
big toe beforehand to avoid the injury that may occur
151 dorsal me1atarsal .
a
Ext. dlgltorvm br8111S
Ext. dlgltorvm lOngus
I
(
b
Fig.7. Dissection of artery. a The plantar digital artery of the
big toe is divided beforehand to avoid arterial injury due to
stretching of the big toe or second toe. b The lateral-side neu-
rovascular bundle is preserved in the intact second toe. The
medial-side neurovascular bundle is cut at the same level of
the osteotomized middle phalanx
during widening of the first web space, which has to be
done to isolate the metatarsal artery. The medial-side
proper digital neurovascular bundle and the soft tissue
around it are preserved for the joint transfer. Because
the proper digital artery is vulnerable to injury during
isolation of the digital nerve, separation of the nerve
from the neurovascular bundle is abandoned, and the
amputation is done at the region of bifurcation of the
proper digital artery proximally and at the DIP joint dis-
tally. The neurovascular bundle of the opposite side is
preserved in the intact second toe. After dissection at
the plantar aspect, amputation either at the level of the
middle phalangeal neck or at the DIP joint, in case the
middle phalanx is too short, is done. The flexor tendon
sheath is longitudinally incised by retracting the pre-
served toe to the plantar side, and the long flexor tendon
is preserved. Because the insertion of the short flexor
tendon functions as the gliding surface, and its resection
may jeopardize the blood flow to the PIP joint, the short

Termlnallendon
FIx. digitorum JongUS
a is indicated only for congenital hypoplastic thumb, in
b disadvantages of this procedure are increasing of joint
Fig.8. Dissection of PIP joint. a The long flexor tendon is pre-
served and the short flexor tendon is transected at the proxi-
mal region of the short vinculum. The proximal phalanx is
amputated at the proximal side and the extensor tendon at the
appropriate levels. b Excised PIP joint
flexor tendon is transected at the proximal region of the
short vinculum. Finally, the graft is excised by amputat-
ing the proximal phalanx and the long extensor tendon
at the appropriate levels [18,19] (Fig. 8).
Pitfalls
One should be careful not to separate the tendon from
the dorsal skin island, which may damage the subcuta-
neous veins.
Indications
Toe joint transfer is indicated in traumatic injuries of
the CM and MP joints of the thumb, as well as the PIP
and MP joints of the fingers. In congenital anomalies,
this procedure is indicated in Blauth type III thumb
hypoplasia and congenital synostosis of the PIP joint.
However, it is noticeable that in congenital anomalies,
the pathology may not be confined to the joint only.
2.5. Toe Joint 377
Therefore it is important to grasp the findings of an
entire digit [14,18,19].
Selection of the Joint Transfer
Toe PIP joint transfer can be performed for recon-
struction of any joints. However, the indications for
MTP joint transfer are limited, because of significant
defect formation in the donor site. MTP joint transfer
which thenar muscle reconstruction is necessary for cos-
metic purposes [14,15].
Advantages and Disadvantages
Autogenous joint transfer functions as a semipermanent
joint with stable and painless motion and can provide
nearly normal growth potential in children [14,20-22].
No Charcot joint-like degeneration has been found in
our series, with follow-up of as much as 20 years. The
extension lag and formation of a large defect in the
donor site after harvesting the MTP joint as the donor.
References
1. Lexer PR (1925) Joint transplantations and arthroplasty.
Surg Gynecol Obst 40:782-809
2. Herndon CH, Chase SW (1952) Experimental studies in
the transplantation of whole joints. J Bone Joint Surg 34A:
564-578
3. Graham WG (1954) Transplantation of joints to replace
diseased or damaged articulations in the hand. Am J Surg
88:136-141
4. Entin MA, Alger JR, Baird RM (1962) Experimental and
clinical transplantation of autogenous whole joints. J Bone
Joint Surg 44A:1518-1536
5. Kettelkamp DB (1972) Experimental autologous joint
transfer. Clin Orthop 87:138-145
6. Goldberg NH, Watson HK (1982) Composite toe (phalanx
and epiphysis) transfers in the reconstruction of the apha-
langic hand. J Hand Surg 7:454-459
7. Slome D, Reeves B (1966) Experimental homotransplan-
tation of the knee joint. Lancet 2:205
8. Daniel G, Entin MA, Kahr DS (1971) Autogenous trans-
plantation in the dog of a metacarpophalangeal joint with
preserved neurovascular bundle. Can J Surg 14:253-259
9. O'Brien BM (1977) Microvascular free small joint trans-
fer. In: O'Brien BM (ed) Microvascular reconstructive
surgery. Churchill Livingstone, New York, pp 284-289
10. Watanabe M, Katsumi M, Yoshizu T, Tajima T (1978)
Experimental study of autogenous toe-joint transplanta-
tion. Anatomical study of vascular pattern of toe-joints as
378 E. Clinical Reconstructive Microsurgery
a base of vascularized autogenous joint transplantation
(in Japanese). Orthop Surg (Seikeigeka) 29:1317-1320
11. Watanabe M, Katsumi M, Yoshizu T, Tajima T (1980)
Experimental study and clinical application of free toe-
joint transplantation with vascular pedicle (in Japanese).
Orthop Surg (Seikeigeka) 31:1411-1416
12. Hurwitz PJ (1979) Experimental transplantation of small
joints by microvascular anastomoses. Plast Reconstr Surg
66:221-231
13. Buncke HJ, Daniller AI, Schultz WP, Chase RA (1967) The
fate of autogenous whole joints transplanted by microvas-
cular anastomoses. Plast Reconstr Surg 39:333-341
14. Foucher G, Sammut D, Citron N (1990) Free vascularized
toe-joint transfer in hand reconstruction: a series of 25
patients. J Reconstr Microsurg 6:201-207
15. Foucher G, Lenoble E, Smith D (1994) Free and island
vascularized joint transfer for proximal interphalangeal
reconstruction: a series of 27 cases. J Hand Surg 19A:
8-16
16. Tsai TM, Jupiter JB, Kutz JE, Kleinert HE (1982) Vascu-
larized autogenous whole joint transfer in the hand. A
clinical study. J Hand Surg 7:335-342
17. O'Brien BM, Gould JS, Morrison WA, Russel RC,
MacLeod AM, Pribaz JJ (1982) Free vascularized small
joint transfer to the hand. J Hand Surg 9A:634-641
18. Yoshizu T, Watanabe M, Tajima T (1985) Experimental
study and clinical application of free toe joint transplan-
tation with vascular anastomosis. In: Tubiana R (ed) The
hand. Saunders, Philadelphia, Vol 2, pp 685-697
19. Yoshizu T (1993) Free vascularized whole toe joint
transfer to the hand (in Japanese). J Joint Surg 12:63-
75
20. Seki T, Tajima T, Kijima H, Yoshizu T, Watanabe M (1987)
Long term follow-up of the free vascularized whole toe
joint with growing epiphysis transfered to the hand (in
Japanese). J Jpn Soc Surg Hand 4:300-304
21. Singer DI, O'Brien BM, McLeod AM, Morrison WA,
Angel MF (1988) Long-term follow-up of free vascular-
ized joint transfers to the hand in children. J Hand Surg
13A:776-783
22. Tomita Y, Tsai TM, Steryers C, Ogden L, Jupiter JB, Kutz
JE (1986) The role of the epiphyseal and metaphyseal
circulations on longitudinal growth in the dog: an experi-
mental study. J Hand Surg 11A:375-382
2.6 Wrap-Around Flap
YUTAKA MAKI and TAKAE YOSHIZU

The wrap-around flap (WAF) was first reported by the long pedicle of the first plantar metatarsal artery
Morrison in 1980 [1]. In Japan Doi introduced the same (Fig. 3). The proper digital nerve of the great toe is
technique in 1981 [2]. In their techniques, the flap, thinner than that of the thumb. If the long nerve pedicle
including the nail matrix and bed, was removed subpe- of the flap is needed, the common digital nerve is split
riosteally from the distal phalanx of the great toe. The proximally and cut. We use only one lateral digital nerve
transferred flap wrapped around the grafted iliac bone for WAF, which is enough for sensory recovery of the
was unstable for the thumb-index pinch, the incidence flap [5].
of nail deformity was increased, and the grafted iliac When dissection of the artery, vein, and nerve is com-
bone under the flap gradually atrophied. To overcome plete, the plantar aspect of the flap is elevated from the
these disadvantages, the flap is harvested with the part great toe (Fig. 4). The 10- to lS-mm-Iong distal phalanx
of the distal phalanx connected with the nail bed, and is cut by an oscillating saw. To prevent damage to the
this vascularized distal phalanx is fixed with the grafted nail matrix, the direction of the oscillating saw should
iliac bone [3,4]. be changed along the dorsal curve of the distal phalanx,
and the tip of the saw should be stopped under the
periosteum of the dorsal cortex. Additional dorsal
Harvesting Technique bending force fractures the dorsal cortex of the distal
phalanx before the tip of the oscillating saw cuts
The flap should be designed within the toe proper, which through the nail matrix. The dorsal skin of the flap is
reduces the deficit of the donor foot. If the skin defect of elevated with a venous pedicle, and the dorsal perios-
the injured thumb is too wide to cover by WAF within the teum of the distal phalanx is cut with scissors (Fig. 5).
toe proper, additional skin coverage by groin pedicle flap When the above procedure is completed, the pneu-
should be done before WAF transfer. The flap is designed matic tourniquet is released, and the flap in the donor
as shown in Fig. 1. The size of the medial based triangu- site is covered with warm wet gauze until the cir-
lar flap remaining on the donor great toe depends on the culation of flap has recovered. Bleeding points of the flap
circumference of the thumb to be reconstructed. The and vascular pedicle should be coagulated meticulously.
width of this flap should be at least 1 cm on the tip of the At that time, the stumps of the arterial and venous pedi-
donor great toe, and enough soft tissue should be left on des are picked up with mosquito forceps on the same
this flap to maintain the circulation. The smaller circum- direction, and a dotted line is made with a marker (we use
ference of the WAF compared with the thumb is com- Pyoktanin) on the same plane surface along the vascular
pensated for by the small triangular flap elevated from pedicle. This marking prevents twisting of the vascular
the recipient stump to insert the radial suture site of pedicle, which lies in the subcutaneous tunnel of the
WAF (see Fig.lb of Chapter D.3.2). recipient site. Then the vascular pedicle is severed and
Dissection starts on the dorsum of the foot to elevate the flap is moved to the recipient site (Fig. 6).
the cutaneous vein under pneumatic tourniquet. The stump of the distal phalanx of the donor great
After that, the first interdigital web space is dissected toe is covered by a medial base triangular flap. The tip
to determine the pattern of the main feeding artery of of this flap should be sutured with no tension so as not
the WAF. to disturb the circulation. Originally the skin and soft
If this pattern is Gilbert type I or II (see Fig. 2 of tissue defect of the donor great toe is covered primarily
Chapter D.2.1.11), the dissection proceeds dorsally from by a cross-toe flap from the second toe and a full-
the distal to the proximal direction (Fig. 2). thickness skin graft (Fig. 7). However, we recommend
If the pattern is Gilbert type III, a plantar incision covering the donor defect with ointment to accelerate
is added, and the transverse metatarsal ligament and granulation tissue formation and secondary full-
adductor muscle of the great toe are severed to elevate thickness skin grafting.

379
 Medialy based
triangular flap

a b c
Fig. 1. Skin incision. a Dorsal skin incision. b Plantar skin incision. Dotted line indicates the advance incision for dissection of
the first plantar metatarsal artery. (Gilbert type III, see Chapter D.2.1.11, Fig. 3.) c Incision of great toe. 1 Top view,2 lateral
view, 3 dorsal view

Cutaneous vein

Cutaneous vein

I
1st dorsal metatarsal artery

Ligated descending branch

1st plantar metatarsal artery Lateral proper digital nerve
(small or none) of great toe

a b

Fig. 2. Dissection of Gilbert type I and II. a Dissection of first interdigital web space. b Dissection of dorsal aspect

Ligated medial plantar digital artery

of 2nd toe

Lateral plantar digital artery

of great toe

a b
 2.6. Wrap-Around Flap 381

Distal phalanx of great toe

Fig. 4. Elevation of plantar aspect of the flap

Triangular flap

Protected lateral digital ---:;;::::~:JIi,tJ

artery and nerve

Sheath of FHL
tendon

Distal phalanx

c
a

'ill ..
x
b d

Fig. 5. Osteotomy of distal phalanx. a Change of direction of phalanx before the tip of oscillating saw cuts through the nail
the oscillating saw along the curve of dorsal cortex of distal matrix. d Elevation of the dorsal aspect of the flap with cutting
phalanx. b Straight cut injures the lateral nail matrix. c Addi- of dorsal periosteum of the distal phalanx by scissors
tional bending force fractures the dorsal cortex of the distal
 Fig. 6. Separated flap and pedicles N, Digital nerve; A, first
dorsal metatarsal artery; V, cutaneous vein; D, Pyoktanin dot

Triangular lIap Cross-loe flap Full-thickness skin graft

a b c
Fig. 7. Closure of the donor site skin. a Triangular flap covers the stump of the distal phalanx with no tension. b Volar skin
defect is covered by cross-toe flap from the second toe. c Dorsal skin defect is covered by full-thickness skin graft

Fig.8. Reduction of the size of the wrap-around flap for recon-

Digital artery struction of a finger. a Reduction of distal phalanx and fatty
tissue. b Resection of medial marginal nail bed and matrix. c
a b c In some cases, resection of the medial paronychium is added

If WAF is used to reconstruct the finger, the volumes
of the soft tissue and distal phalanx and the size of the
nail must be reduced. Defatting of the flap and shaving
of the distal phalanx are done meticulously, and the
medial margin of the nail matrix and bed is resected. In
some cases, the medial paronychium is resected (Fig. 8).
The flap does not have to be reduced to the same
volume as the finger. The slightly larger flap gradually
atrophies and is almost the same size as the other fingers
a few years later [6]. Foucher presented the twisted-toe
flaps technique, which may be a alternative way to
reconstruct distal finger loss [7].
References
1. Morrison WA, O'Brien BM, MacLeod AM (1980) Thumb
reconstruction with a free neurovascular wrap around flap
from the big toe. J Hand Surg 5:575-583
2.6. Wrap-Around Flap 383
2. Doi K, Hattori S, Kwai S, et al. (1981) Thumb reconstruc-
tion with a wrap-around flap from the great toe and iliac
bone graft (in Japanese). Orthop Surg 32:1635-1638
3. Katsumi M, Watanabe M, Kameda I, et al. (1983) Investi-
gation of reconstruction of the thumb by using wrap around
flap method (in Japanese). Orthop Surg 34:1471-
1474
4. Ohkubo K, Murota K, Tomita Y, et al. (1983) Experience
of wrap around flap: 1st report (in Japanese). Orthop Surg
34:1475-1477
5. Yoshizu T (1991) Sensory reconstruction in peripheral
nerve injury of the upper limb (in Japanese). J Jpn Soc Surg
Hand 7:889-892
6. Yoshizu T, Katsumi M, Watanabe M, et al. (1987) Finger
reconstruction with a modified wrap around flap from
the big toe (in Japanese). J Jpn Soc Surg Hand 4:284-
288
7. Foucher G, Merle M, Maneaud M, et al. (1980) Microsur-
gical free partial toe transfer in hand reconstruction: a
report of 12 cases. J Plast Reconstr Surg 65:616-626
2.7 Vascularized Nail Grafts
ISAO KOSHIMA and TAKAHIKO MORIGUCHI
The first thumb reconstruction, in which a second toe
was transferred to the thumb with attachment of the
hand to the foot for several weeks, was introduced by
Nicoladoni in 1897 [1]. Since then, the development of
microvascular surgery has made it possible to transfer
toes for the repair of finger losses [2,3], and functional
and cosmetic refinements of the toes have been devel-
oped by many physicians for partial or total finger losses
[4-7].
Recently, cosmetic reconstruction of only the finger-
nail has been undertaken. To reconstruct these small
components of the finger, partial or total toe trans-
fers composed of an osteoonychocutaneous flap from
the big toe, the distal phalanx of the second toe, or a
vascularized nail graft from the big or second toe have
been used [8-16]. In this paper, we describe the indica-
tions and flap harvesting technique for vascularized
nail grafts, including osteoonychocutaneous flap, and
trimmed great and second toe tip, second toe distal
phalanx.
Harvesting Technique
Vascularized nail grafts transferred from the big toe
consist of vascularized whole nail graft, an onychocuta-
neous flap that includes the nail and a skin flap from the
toe tip, and a thin osteoonychocutaneous flap. The graft
from the second toe consists of the trimmed toe tip,
including the nail, and the distal phalanx of the second
toe. Harvesting techniques for these vascularized nail
grafts are described in the following case reports.
Case Reports
Case 1: Thin Onychocutaneous Flap from
the Big Toe
A 10-year-old girl experienced a nail deficit owing to
fingertip necrosis of the left index finger with a gumma.
384
Seven years after the injury, reconstruction was
planned. After resection of the scarred nail bed and
the periosteum, recipient bilateral digital arteries and
nerves were exposed with bilateral midlateral small-
length incisions on the lateral aspects of the finger.
Recipient cutaneous veins were exposed with a small
incision on the concealed second web space, and a
subcutaneous tunnel was created between the fingertip
and the web defects for passage of a drainage vein.
A free vascularized nail graft (thin onychocuta-
neous flap), measuring 9 x 8mm and involving the ger-
minal and sterile nail matrix, was outlined on the lateral
side of the right great toe. After a narrow skin incision
had been made around the flap without damaging the
distal portion of the dorsal cutaneous vein, a short
length of the lateral proper digital artery and nerve was
dissected as the pedicle artery and sensory nerve. A long
length (Scm) of the dorsal cutaneous vein of the great
toe was also sharply dissected with a knife to the level
of the distal venule near the nail matrix. The proximal
level of this vein should include several cutaneous
branches so that it will not be necessary to rely on a
single venous anastomosis. In order to create a thin
fingertip, this dissection should not include a dorsal
skin flap.
A vascularized nail and nail bed complex was ele-
vated, including the subungual periosteum, the lateral
nail groove, and a small width of the proximal skin flap
over the nail matrix and the distal toetip skin flap.
Subcutaneous fatty tissue of the skin flap was resected
primarily to obtain a thin onychocutaneous flap. This
flap was elevated beneath the periosteum of the distal
phalanx without damaging the germinal and sterile
nail bed. Sometimes this flap includes the superficial
portion of the distal phalangeal bone, and the nail
bed is attached with the use of an air striker to obtain
postoperative firm attachment of the nail and
bone.
The graft was then transferred to the prepared
defect. The proper digital artery and nerve of the toe
were anastomosed to the radial digital artery and the
nerve at the middle phalanx of the finger. Through the
subcutaneous tunnel on the radial midlateral aspect

a,b
Fig. 1. a Case 1. A lO-year-old girl sustained ishemic necrosis of the index fingertip with a
gumma and experienced nail loss and atrophy of the tip. b An onychocutaneous flap was
obtained from the contralateral big toe. (See Color Plates) c One year after surgery
of the finger, the dorsal cutaneous veins of the graft
were led proximally to anastomose with those of the
proximal phalanx of the finger. The small defects of
the finger and donor great toe were covered with a
split-thickness skin graft from the medial plantar
region of the right foot. The postoperative course was
smooth, and no additional surgery has been required
(Fig. 1).
Case 2: Thin Osteoonychocutaneous Flap
from the Great Toe
A 43-year-old woman sustained loss of the distal half
of the distal phalanx of the right thumb following
an accidental injury. Two years after the injury, a free
thin osteoonychocutaneous flap measuring 20 x 40mm
was obtained from the right great toe. This flap, in
which half of the distal phalanx was included and a
considerable amount of the pulpal fatty tissue was
removed, was transferred to the thumb deficit. After
the bone of the flap had been fixed, the dorsalis pedis
artery and the long saphenous vein of the flap were
anastomosed to the radial artery and the cutaneous vein
at the snuffbox of the right hand. The plantar nerve of
the flap was sutured to the ulnar digital nerve at the
proximal phalanx of the thumb. The defect of the big
toe was resurfaced with a cross-toe flap from the second
toe.
The postoperative course was uneventful, and the fix-
ation of the bone was removed 2 months after surgery.
Six months after surgery, the moving two-point dis-
crimination value at the reconstructed fingertip was
2.7. Vascularized Nail Grafts 385
c
8 mm, and that of the Semmes-Weinstein test was 3.22
(Fig. 2).
Case 3: Trimmed Second Toetip for Repair
of Claw Nail Deformities
A 19-year-old woman experienced a claw nail deformity
after accidental amputation of the right little finger-
tip. Sixteen years after the injury, the deformity was
repaired with a trimmed second toetip transfer. After a
U -shaped incision of the affected fingertip had been
made, the distal bone tip and the radial digital artery
and nerve were exposed in the middle phalanx. The
recipient veins were exposed through a small incision
on the fourth web space.
A trimmed second toe tip, including the distal part of
the nail and nail bed, without nail matrix, and the distal
phalangeal bone tip was elevated with a short vascular
pedicle. The flap, pedicled with the plantar digital artery
and nerve, and the dorsal cutaneous vein were trans-
ferred to the fingertip defect, and the bones were con-
nected with cross-fixation using stainless steel wires. The
dorsal vein of the toe was led through a subcutaneous
tunnel on the radial aspect of the finger and anasto-
mosed to the dorsal cutaneous vein in the fourth web
space. The plantar artery and nerve of the toe were
joined to the radial digital artery and nerve in the
middle phalanx of the finger.
The postoperative course was without problems. The
fixation of the transferred distal phalangeal bone was
removed 2 months after surgery, and nail growth was
 386 E. Clinical Reconstructive Microsurgery

c,d
~,~

Fig.2. a Case 2. A 43-year-old woman sustained a crush amputation at work and lost the distal phalanx of the thumb. b A thin
osteoonychocutaneous flap was obtained from the ipsilateral big toe. c Half a year after surgery. Dorsal view. d Palmar view

a,b c,d
Fig. 3. a Case 3. A 19-year-old woman had a claw nail deformity of the little finger caused by accidental amputation of the
fingertip. b A trimmed second toetip, which consisted of the distal phalanx, the sterile matrix, and trimmed skin of the toe tip,
was obtained. c Completion of flap transfer. d Three years after surgery

smooth. The regrown nail of the finger has attached
itself firmly to the transferred matrix (Fig. 3).
References
1. Nicoladoni C (1897) Daumenplastik. Wiener Klinische
Wochenschrift 10:663
2. Buncke HJ Jr, Schulz WP (1965) Experimental digital
amputation and reimplantation. Plast Reconstr Surg 36:
62-70
3. Cobbett JR (1969) Free digital transfer. J Bone Joint Surg
51:677-679
4. O'Brien BM, MacLeod AM, Sykes PJ, Donahoe S (1975)
Hallux-to-hand transfer. Hand 7:128-133
5. Foucher G, Merle M, Maneaud M, Michon J (1980) Micro-
surgical free compound toe transfer in hand reconstruc-
tion: a report of 12 cases. Plast Reconstr Surg 65:616-626
6. Morrison WA, O'Brien BM, MacLeod AM (1980) Thumb
reconstruction with a free neurovascular wrap-around
flap from the big toe. J Hand Surg 5:575-583
7. Doi K, Hattori S, Kawai S (1981) Thumb reconstruction
with a wrap-around flap from the great toe and iliac bone
graft. Jpn J Orthoped Surg 32:1635-1638
8. Koshima I, Soeda S, Takase T, Yamasaki M (1988) Free
vascularized nail grafts. J Hand Surg 13A:29-32

9. Koshima I, Ohno A, Yamasaki M (1989) Free vascularized
osteo-onychocutaneous flap for reconstruction of the
distal phalanx of the fingers. J Reconstr Microsurg 5:337-
342
10. Nakayama Y, lino T, Uchida A, Kiyosawa T, Soeda S
(1990) Vascularized free nail grafts nourished by arterial
inflow from the venous system. Plast Reconstr Surg 85:
239-245
11. Shibata M, Seki T, Yoshizu T, Saito H, Tajima T (1991)
Microsurgical toenail transfer to the hand. Plast Reconstr
Surg 88:102-109
12. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS
(1991) Second toe wrap-around flap. Plast Reconstr Surg
88:837-842
2.7. Vascularized Nail Grafts 387
13. Foucher G, Braun FM, Smith DJ (1991) Custom-made
free vascularized compound toe transfer for traumatic
dorsal loss of the thumb. Plast Reconstr Surg 87:310-
314
14. Koshima I, Moriguchi T, Soeda S, Ishii M, Murashita T
(1992) Free thin osteo-onychocutaneous flaps from the big
toe for reconstruction of the distal phalanx of the fingers.
Br J Plast Surg 45:1-5
15. Foucher G, Sammut D (1992) Aesthetic improvement of
the nail by the "illusion" technique in partial toe transfer
for thumb reconstruction. Ann Plast Surg 28:195-199
16. Koshima I, Moriguchi T, Soeda S (1991) One-stage
reconstruction for amputated thumbs with melanoma.
J Reconstr Microsurg 7:113-117
2.8 Prefabricated Flap (Muscle Vascularized Pedicle
Flap and Others)
YOSHIHISA SHINTOMI, HIROSHI FURUKAWA, KUNIHIKO NOHIRA,
The introduction of free tissue transfer and refine-
ments of microvascular techniques have made it possi-
ble to expeditiously reconstruct difficult defects.
However, one of the problems in reconstructive micro-
surgery is a limitation of flap donor sites. Available flap
donor sites are often limited by local vascular anatomy.
Creation of previously nonexisting flaps and composite
tissues that are ideal for reconstruction is a challenging
problem for plastic and reconstructive surgeons.
This chapter presents the history of the secondary
vascularized flap, and especially a unique donor har-
vesting technique allowing the custom design of free
flaps that fit the tissue requirements of specific defects.
The muscle vascularized pedicle (MVP) flap, which is
categorized as a secondary vascularized flap, is devel-
oped by implanting a vascular bundle surrounded by a
small cuff of muscle into a selected donor site [1]. With
extension of the concept of the MVP flap, any tissue,
such as bone, tendon, and nerve, can be revascularized
and used as a source for free tissue transfer [2,3].
History of the Secondary
Vascularized Flap
The history of the secondary vascularized flap origi-
nated with experimental studies in dogs by Diller et al.
in 1966 and Washio in 1971 [4-6]. They validated the
possibility of creating a transplantable composite tissue
unit by anchoring mesentric vessels to abdominal skin
and subcutaneous tissue, but they were unable to eluci-
date its clinical applicability. Orticochea in 1971 was the
first author to describe a clinical application of second-
ary vascularization in the transfer of the superficial
temporal vessels into the retroauricular conchal skin [7].
After a staging period, the conchal skin was raised suc-
cessfully as a composite flap perfused by the superficial
temporal vessels and transferred as a pedicled tempo-
rofrontal flap for nasal reconstruction. Erol and Spira in
1980 reported a secondary created musculocutaneous
flap by skin graft on the sartorius muscle [8]. Yao in 1981
converted random-pattern skin flaps to axial-pattern
388
and YUHEI YAMAMOTO
flaps by implanting an axial vessel pedicle into a random
skin tube flap in several patients [9]. Hirase and his
group from Buncke group reported several experiments
on prefabricated neovascularized flaps [10]. On the
basis of the clinical need to combine the advantages of
the musculocutaneous flap and the earlier secondary
vascularized flap, in 1982 we introduced a new tech-
nique using a vascular bundle and a small amount of
muscle to create a prefabricated flap, the MVP: flap [1].
Although the volume of the muscle cuff does not exceed
the size of the little finger, it is strongly and directly nur-
tured by the vascular bundle. Our angiographic studies
have shown excellent vascularization of the flap. The use
of a musculovascular pedicle as a carrier for the pre-
fabrication of tissue composites provides more satisfac-
tory functional and cosmetic results.
Harvesting Techniques
Conventional MVP Flap
Any muscle vascular pedicle can be used. Especially
desirable muscles are those which have large and long
vascular pedicles providing easy microvascular anasto-
mosis in free tissue transfer, such as the latissimus dorsi
and serratus anterior muscle with the thoracodorsal
vessels and the rectus abdominis muscle with the
inferior epigastric vessels.
When thin flaps are needed for construction of the
head or neck or the upper or lower extremities, a free
skin flap can be provided that has a thickness of 1 cm or
less. A donor site can be chosen that provides skin of
good color, texture, and volume for facial reconstruction
[11]. The lateral thorax, medial arm, and anterior chest
are typically good donor sites for facial reconstruction.
They are successfully revascularized by implantation of
a small cuff of the latissimus dorsi or serratus anterior
muscle with the thoracodorsal pedicle.
Figure 1 illustrates the harvesting technique of the
conventional MVP flap. The procedure includes three
stages. In the first stage, a pattern of the required flap is
 2.8. Prefabricated Flap (Muscle Vascularized Pedicle Flap and Others) 389

Muscle
vascularized
pedicle (MVP)
a c

Fig. 1. H arve ting technique of the c nventional mu cle a-

cularized pedicle (MVP) flap. a The nap i undermined to the
appropriate thickne including the ubdermal pie u and the
elected va cular bundle urrounded by a mall cuff of mu cle.

:::~.--...-.---~
i di ected and implanted into the undersurface of the flap. b
The va cular bundle, urrounded by a mall cuff of mu cle, i
implanted into the undersurface of the flap. cTwo week later,
a urgical delay procedure i performed by circumferen tiall
MVP flap
inci ing the kin flap on it border. From I to 3 week later,the
b rev a eularized ti ue can be harve ted

designed on the selected donor site. The flap is under-

mined to the appropriate thickness, including the
subdermal plexus, and the selected vascular bundle,
surrounded by a small cuff of muscle, is dissected and
implanted into the undersurface of the flap. The cuff of
muscle needed to revascularize the custom tissue needs
to be approximately 10% to 20% of the size of the flap.
A thin silicone sheet is occasionally placed under the
implanted vascular pedicle to avoid neovascularization
from the bed (Fig. 1a). nssue expander
Two weeks later, a surgical delay procedure is per-
formed by circumferentially incising the skin flap on its Fig. 2. Harvesting technique of expanded MVP flap. An
borders (Fig. 1b). Between 1 and 3 weeks later, in the appropriately sized expander is placed under the muscle cuff.
third stage, the revascularized tissue can be transferred The pre transfer expansion of the MVP flap increases flap vas-
as a conventional free flap to the recipient site (Fig. lc). cularity and allows the possibility of safely including a large
random portion of the cutaneous area

Expanded MVP Flap

Recently, clinical applications of the expanded flap
based on secondary vascularization have been reported
[12-14]. Instead of several surgical delays, the tissue
expansion technique is advocated as a method of
augmentation of the blood supply by its delay effect
[15-17]. We also developed a modification of the MVP
technique using a tissue expander called the expanded
MVP flap. The pretransfer expansion of the MVP flap
increases flap vascularity and allows a large random
portion of the cutaneous area to be safely included.
A small amount of muscle with its vascular pedicle is
dissected and fixed to the subcutaneous layer. At that
 390 E. Clinical Reconstructive Microsurgery
time, an appropriately sized expander is placed under
the muscle cuff (Fig. 2). The expanded MVP flap
requires no surgical delay procedures and provides a
larger survival area of the flap.
MVP Bone Flap
The MVP bone flap technique facilitates an ideal
anatomic correlation between the bone and its long vas-
cular pedicle in the newly built reconstruction. A donor
site can be chosen that provides bone of specific contour
a b,c
d
Fig. 3. Harvesting technique of MVP bone flap. a At first, a
rectus abdominis muscle or myocutaneous flap based on the
inferior epigastric artery and vein is raised. b The iliac crest is
dissected, and the medial surface of the iliac bone is shaved.
The muscle portion of the flap is fixed to the iliac bone with
a wire or anchoring system. c More than 4 weeks after the first
surgery, a surgical delay procedure to the iliac bone is
in maxillary or mandibular reconstruction and has little
morbidity. The iliac bone is typically a good donor site
for maxillary or mandibular reconstruction [2,3].
Figure 2 illustrates the technique of harvesting an
MVP iliac bone flap. At first, a rectus abdominis muscle
or myocutaneous flap based on the inferior epigastric
artery and vein is raised (Fig. 3a). The iliac crest is
dissected, and the medial surface of the iliac bone is
shaved. The surface of the donor bone that is attached to
the selected vascular bundle and a small cuff of muscle is
rasped to the cancellous bone layer to provide rapid and
e
performed. The lateral surface of the ilium is exposed, and the
iliac bone recieves either a vertical or a horizontal osteotomy
at the distal portion where the rectus abdominis muscle is
attached to it. d The MVP bone is elevated about 2 weeks after
the delay, and good bleeding is noticed from the incised
margin of the MVP bone. e The MVP bone flap is harvested
and transferred as a free flap. (See Color Plates)
 2.8. Prefabricated Flap (Muscle Vascularized Pedicle Flap and Others)
reliable revascularization from the implanted pedicle
(Fig. 3b). The muscle portion of the flap is fixed to the iliac
bone with a wire or anchoring system.
More than 4 weeks after the first surgery, a surgical
delay procedure to the iliac bone is performed. The
lateral surface of the ilium is exposed, and the iliac bone
recieves either a vertical or a horizontal osteotomy at
the distal portion where the rectus abdominis muscle is
attached to it. The MVP bone is elevated about 2 weeks
after the delay, and good bleeding is noticed from the
incised margin of the MVP bone (Fig. 3c-e).
References
1. Shintomi Y, Ohura T (1982) The use of muscle vascular-
ized pedicle flaps. Plast Reconstr Surg 70:725-735
2. Shintomi Y, Nohira K, Yamamoto Y, Minakawa H, Ohura
T (1995) MVP (muscle vascularized pedicle) flap and
bone. Panel Discussion, Yokohama: IPRAS
3. 19awa HH, Minakawa M, Sugihara T (1998) Functional
alveolar ridge reconstruction with prefabricated iliac crest
free flap and osseointegrated implants after hemimaxil-
lectomy. Plast Reconstr Surg 102:2420-2424
4. Abbase EA, Shenaq SM, Spira M, EI-Falaky MH (1995)
Prefabricated flaps: Experimental and clinical review.
Plast Reconstr Surg 96:1218-1225
5. Diller JG, Hartwell SW, Anderson R (1966) The mesen-
teric vascular pedicle: Review of its clinical uses and
report of experiments in dogs. Cleve Clin Q 33:163
6. Washio H (1971) An intestinal conduit for free transplan-
tation of other tissues. Plast Reconstr Surg 48:48-51
7. Orticochea MA (1971) New method for total reconstruc-
tion of the nose: The ears as donor areas. Br J Plast Surg
24:225-231
391
8. Erol 00, Spira M (1980) Secondary musculoctuaneous
flap: An experimental study. Plast Reconstr Surg 65:
277-282
9. Yao ST (1981) Vascular implantation into skin flap:
Experimental study and clinical application: A prelimi-
nary report. Plast Reconst Surg 68:404--409
10. Hirase Y, Varauri FA, Buncke HJ, Newlin LY (1987) Cus-
tomized prefabricated neovascularized free flaps. Micro-
surg 8: 218-224
11. Yamamoto Y, Minakawa H, Sugihara T, Shintomi Y,
Nohira K, Yoshida T, 19awa H, Ohura T (1994) Facial
reconstruction with free-tissue transfer. Plast Reconstr
Surg 94:483--489
12. Khuori RK, Ozbek MR, Hruza GJ, Young VL (1995)
Facial reconstruction with prefabricated induced ex-
panded (PIE) supraclavicular skin flaps. Plast Reconstr
Surg 95:1007-1017
13. 19awa HH, Minakawa M, Sugihara T, Homma K (1995)
Cheek reconstruction with an expanded prefabricated
musculocutaneous free flap: case report. Br J Plast Surg
48:569-571
14. Furukawa H, Yamamoto Y, Kimura C, 19awa HH,
Sugihara T (1998) Clinical application of expanded free
flap based on primary or secondary vascularization. Plast
Reconstr Surg 102:1535-1536
15. Ryan TG (1983) Discussion: Increased survival and
vascularity of random-pattern skin flaps elevated in
controlled, expanded skin. Plast Reconstr Surg 72:686-
687
16. Wickman M, Herden P, Jurell G (1991) Circulatory and
metabolic changes in expanded pig skin flaps. Plast
Reconstr Surg 88:650-656
17. Homma K, Ohura T, Sugihara T, Yosida T, Hasegawa T
(1993) Prefabricated flaps using tissue expanders:
An experimental study in rats. Plast Reconstr Surg
91:1098
2.9 Intestine
YUHEI YAMAMOTO, HIDEHIKO MINAKAWA, TSUNEKI SUGIHARA, KUNIHIKO NOHIRA,
Y OSHIHISA SHINTOMI
Transplantation of the intestine is one of the most
satisfactory and straightforward methods of recon-
structing the digestive tract. Many attempts to restore
alimentary continuity from the pharynx to the upper
abdomen have been reported. Historically, the intro-
duction of microvascular surgery is a revolution in the
field of digestive surgery. The microvascular anasto-
motic technique perments revascularization of the auto-
graft of the jejunum (free jejunal transfer) and the oral
end of the gastrointestinal pedicles (microvascularly
augmented [MVA] gastrointestinal pedicles). The
advent of microvascular surgery has played a significant
role in the development of more reliable and less com-
plicated methods of reconstructing the digestive tract.
Harvesting Technique
Free Jejunal Transfer
The history of free jejunal transfer originated with
experimental studies in dogs to develop the technique
of revascularization of the jejunal graft by Seidenberg
and colleagues in 1959 [1]. Two years later, Roberts and
Douglass reported two successful clinical cases of
cervical esophageal replacement by a revascularized
free jejunal autograft [2]. However, in the next two
decades, free jejunal transfer was not fully accepted for
esophageal reconstruction due to the high failure rate.
Based on the development of microvascular surgical
technique and instruments, as well as the accumulation
of basic and clinical studies on the free tissue autograft,
free jejunal transfer has become the most popular and
reliable method for reconstruction of the pharynx and
cervical esophagus at present [3-12].
The procedure for harvesting a jejunal segment is as
follows. Through a mid-upper-abdominal incision, the
ligament of Treitz is identified and a search for a
suitable segment is started. Generally, a segment of
the jejunum nourished by the second or third jejunal
vascular system in the area 45 to 55 cm distal to the
ligament of Treitz is selected. Demonstration of good
feeding mesenteric vascular arcades by transillumina-
392
and
tion is very helpful for selection of the segment (Fig.la).
After the proximal end has been marked with a suture,
the segment is isolated on the pedicle by division of the
mesenterium in a V shape. Finally, the jejunal segment
is harvested with the microclips on the vascular pedicle
(Fig. 1b), and jejunal continuity is reestablished. Usually,
the length of the jejunal segment is matched with the
defect of the digestive tract. However, when the mesen-
teric flap is supposed to be used as a means of obliter-
ating dead space around the wound, as a cover for
the major vessels, as a vascularized bolstering for the
enteral anastomoses, or as a vascularized bed for skin
grafting in case the cervical flaps are deficient (Fig. lc),
a segment more than 30cm long should be harvested
[13].
Microvascularly Augmented Gastrointestinal
Pedicles
More than one decade before the technique of free
jejunal grafting was developed, one successful clinical
case of use of the gastrointestinal pedicle with vascular
augmentation was reported by Longmire in 1947 [14].
The first description of this method was replacement of
the thoracic esophagus by an advanced jejunal loop,
with vascular anastomosis of the jejunal vessels to the
internal thoracic vessels. Nine years later, Androsov
demonstrated a series of 11 cases of esophageal recon-
struction using the jejunal pedicle with arterial vascular
anastomosis alone [15]. In 1962, Nakayama and col-
leagues described in Japanese methods of reconstruct-
ing the thoracic esophagus with MVA gastric, jejunal,
and colonic pedicles with the application of a vascular
anastomosing apparatus developed in their laboratory
[16]. However, in the next three decades, reports of
MVA gastrointestinal pedicles were rare, because these
methods had limited indications for esophageal recon-
struction, in which the conventional gastrointestinal
pedicles showed insufficient blood circulation intraop-
eratively. After the late 1980s, with the advent of
microvascular surgical technique, clinical reports of
esophageal replacement with various kinds of MVA

a C
b me enteric nap. (ec 01 r Plate)
gastrointestinal pedicles have increased [17-22]. These
reports support the view that microvascular augmenta-
tion is an effective way to improve the success rate of
digestive reconstructive surgery.
The purpose of the MVA gastrointestinal pedicle is
to augment blood circulation at the distal end of the
pedicle to prevent serious complications caused by
pedicle ischemia. In the MVA gastric pedicle, the gastric
pedicle, based on the right gastric and right gastroepi-
ploic vessels, is dissected while the left gastroepiploic,
short gastric, or splenic vessels are being prepared as
anastomosing vessels (Fig. 2a). In the MVA elongated
gastric pedicle, the gastric pedicle, based on the right
gastric and right gastroepiploic vessels, is dissected
while the left gastric vessels are being prepared as anas-
tomosing vessels. The gastric pedicle is elongated by an
upward extension of the lesser curvature portion con-
nected with the left gastric vessels, following a parallel
incision to the lesser curvature on the pedicle (Fig. 2b).
In the MVA jejunal pedicle, the jejunal pedicle, with
preparation of the second jejunal vessels as anastomos-
ing vessels, is dissected, dividing the third jejunal and
several arcade vessels to ease extension of the pedicle
(Fig. 2c). In the MVA colonic pedicle, there are two
2.9. Intestine 393
Fi 1. ree jejunaltran fer. a The me enteric a cular arcade
w re d mon trated by tran illumination. b The jejunal
egment ~ a i olated. c The me enteric nap \ a effecti ely
u ed r r ecuring the cervical w undo Arrow indi ate the
methods, depending on whether the right-side or left-
side colon is used. To use the right-side colon, the
colonic pedicle, based on the middle colic vessels, is dis-
sected while the ileocolic vessels are being prepared as
anastomosing vessels (Fig. 2d). To use the left-side
colon, the colonic pedicle, based on the left colic vessels,
is dissected while the middle colic vessels are being
prepared as anastomosing vessels (Fig. 2e).
Finally, there is a controversy whether arterial,
venous, or both anastomoses should be performed
in MVA gastrointestinal pedicles. As early as 1965,
Matsumoto described an experimental study in dogs to
investigate the hemodynamics and the oxygen tension
in the MVA gastric pedicle [23]. In his summary, the
highest change in oxygen tension occurred when both
arterial and venous anastomoses were performed, fol-
lowed by the case in which arterial anastomosis alone
was performed. The case in which venous anastomosis
alone was performed showed only a slightly higher
change than the case with no vascular anastomosis.
Although the need to augment arterial or venous flow
depends on each circulatory condition, we believe that
both arterial and venous anastomoses would be an ideal
addition to MVA gastrointestinal pedicles.
394 E. Clinical Reconstructive Microsurgery
- Left gastroepiploic/short
gastric/splenic vessels
to be anastomosed
- Right gastric/gastroepiploic
vessels
a b
Ileocolic vessels -
to be anastomosed
Middle colic vessels-
d e
Fig. 2. Microvascularly augmented (MVA) gastrointestinal
pedicles. a The MVA gastric pedicle, with either left gas-
troepiploic, short gastric, or splenic vessels as anastomosing
vessels. b The MVA elongated gastric pedicle, with the left
gastric vessels as anastomosing vessels. c The MVA jejunal
References
1. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML (1959)
Immediate reconstruction of the cervical esophagus by
a revascularized isolated jejunal segment. Ann Surg 149:
162-171
2. Roberts RE, Douglass FM (1961) Replacement of the
cervical esophagus and hypopharynx by a revascularized
free jejunal autograft. N Engl J Med 264:342-344
3. McKee DM, Peters CR (1978) Reconstruction of the
hypopharynx and cervical esophagus with microvascular
jejunal transplant. Clin Plast Surg 5:305-312
4. Hester TR, McConnel FS, Nahai F, Jurkiewicz MJ,
Brown RG (1980) Reconstruction of cervical esophagus,
hypopharynx and oral cavity using free jejunal transfer.
Am J Surg 140:487-491
5. Meyers WC, Seigler HF, Hanks JB, Thompson WM,
Postlethwait R, Jones RS, Akwari OK, Cole TB (1980)
Postoperative function of "free" jejunal transplants for
replacement of the cervical esophagus. Ann Surg 192:439-
450
- Left gastric vessels
to be anastomosed
Second jejunal vessels-
to be anastomosed
Right gastric!
gastroepiploic vessels c
Middle colic vessels-
to be anastomosed
Left colic vessels -
pedicle, with the second jejunal vessels as anastomosing
vessels. d The MVA right-side colonic pedicle, with the ileo-
colic vessels as anastomosing vessels. e The MVA left-side
colonic pedicle, with the middle colic vessels as anastomosing
vessels
6. Reuther JF, Steinau H, Wagner R (1984) Reconstruction
of large defects in the oropharynx with a revascularized
intestinal graft: An experimental and clinical report. Plast
Reconstr Surg 73:345-356
7. Jurkiewicz MJ (1984) Reconstructive surgery of the cer-
vical esophagus. J Thorac Cardiovasc Surg 88:893-897
8. Nozaki M, Huang TI, Hayashi M, Endo M, Hirayama T
(1985) Reconstruction of the pharyngoesophagus follow-
ing pharyngoesophagectomy and irradiation therapy.
Plast Reconstr Surg 76:386-392
9. Gluckman JL, McDonough JJ, McCafferty GJ, Black RJ,
Coman WB, Cooney TC, Bird RJ, Robinson DW (1985)
Complications associated with free jejunal graft recon-
struction of the pharyngoesophagus-A multiinstitutional
experience with 52 cases. Head Neck Surg 7:200-205
10. Coleman JJ III, Searles JM Jr, Hester TR, Nahai F,
Zubowicz V, McConnel MS, Jurkiewicz MJ (1987) Ten
years experience with the free jejunal autograft. Am J
Surg 154:394-398
11. Schusterman MA, Shestak K, deVries EJ, Swartz W, Jones
N, Johnson J, Myers E, Reilly J Jr (1990) Reconstruction

of the cervical esophagus: Free jejunal transfer versus
gastric pull-up. Plast Reconstr Surg 85:16-21
12. Theile DR, Robinson DW, Theile DE, Coman WB (1995)
Free jejunal interposition reconstruction after pharyngo-
laryngectomy: 201 consecutive cases. Head Neck 17:83-
88
13. Yamamoto Y, Nohira K, Shintomi Y, Yoshida T, Minakawa
H, Okushiba S, Fukuda S, Inuyama Y, Hosokawa M (1995)
Mesenteric flap in free jejunal transfers: a versatile
technique for head and neck reconstruction. Head Neck
17:213-218
14. Longmire WP Jr (1947) A modification of the Roux
technique for antethoracic esophageal reconstruction:
Anastomosis of the mesenteric and internal mammary
blood vessels. Surgery 22:94-100
15. Androsov PI (1956) Blood supply of mobilized intestine
used for an artificial esophagus. Arch Surg 73:917-926
16. Nakayama K, Yamamoto K, Yazawa T, Makino H, Tamiya
T, Akimoto S, Izumi T, Hashizume S, Odaka M (1962)
Operative procedure using the Nakayama's microvascu-
lar anastomosing apparatus in esophageal surgery
(Shokudo Geka Shujutu ni okeru Nakayamashiki saisho
kekkan fungoki no shujutu jutushiki). Surgical Therapy
(Geka Chiryo) 7:250-257
17. O'Rourke IC, Threlfall GN (1986) Colonic interposition
for oesophageal reconstruction with special reference to
microvascular reinforcement of graft circulation. Aust NZ
J Surg 56:767-771
2.9. Intestine 395
18. Hirabayashi S, Miyata M, Shouzi M, Shibusawa H (1993)
Reconstruction of the thoracic esophagus, with extended
jejunum used as a substitute, with the aid of microvascu-
lar anastomosis. Surgery 113:515-519
19. Matsubara T, Ueda M, Nakajima T, Kamata S, Kawabata
K (1995) Elongated stomach roll with vascular micro-
anastomosis for reconstruction of the esophagus after
pharyngolaryngoesophagectomy. J Am Col Surg 180:
613-615
20. Fujita H, Yam ana H, Sueyoshi S, Shima I, Fujii T, Shirouzu
K, Inoue Y, Kiyokawa K, Tanabe HY, Tai Y, Inutsuka H
(1997) Impact on outcome of additional microvascular
anastomosis-Supercharge-on colon interposition for
esophageal replacement: Comparative and multivariate
analysis. World J Surg 21:998-1003
21. Nagawa H, Seto Y, Nakatsuka T, Kaizaki S, Muto T (1997)
Microvascular anastomosis for additional blood flow in
reconstruction after intrathoracic esophageal carcinoma
surgery. Am J Surg 173:131-133
22. Urayama H, Ohtake H, Ohmura K, Watanabe Y (1997)
Pharyngoesophageal reconstruction with the use of
vascular anastomoses: Operative modifications and
long-term prognosis. J Thorac Cardiovasc Surg 113:
975-981
23. Matsumoto T (1965) Studies on esophageal reconstruc-
tion by means of the pedunculated gastric tube with
additional micro-vascular anastomoses. Arch Jpn Chir
34:1118-1136
2.10 Omentum
HISASHI OHTSUKA
The omentum has been used as a pedicle flap in various
situations, such as covering of chest to axilla defects,
covering of esophageal anastomoses, protecting the
carotid vessels, treating bronchial fistula, treating sternal
osteomyelitis, and treating lymphedema of the upper or
lower extremity. The omentum has also been used as a
free flap since 1972 in various situations, such as treating
difficult and large defects on the scalp and other regions,
correcting progressive hemifacial atrophy, treating
chronic osteomyelitis of the long bones, and revascular-
izing an ischemic lower extremity [1-4]. However, the
indications for pedicle or free omental transfers have
been markedly reduced with the development of pedicle
or free cutaneous or musculocutaneous flaps.
The omental flap has several advantages (see the
chapter by K. Ishida et aI., soft tissue reconstruction
using omental or fascial flap) and can be adapted to
various difficult conditions. The need for laparotomy is
the greatest disadvantage, because of the small risk of
intestinal obstruction throughout the patient's lifetime.
Anatomy
There are some variations in the arterial supply to the
omentum from the gastroepiploic vessels. The right,
middle, and left omental arteries usually run along the
vertical axis of the omentum. Five types of arterial supply
have been described [5]. In type I (accounting for about
80%), the middle omental artery bifurcates in the lower
third ofthe omentum. In type II (about 10%), the middle
omental artery bifurcates or trifurcates in the middle of
the omentum. In type III (about 3% to 6%), bifurcation
or trifurcation occurs close to the gastroepiploic vessels.
In type IV (about 1 % ), there is no middle omental artery.
In type V (quite rare), the left omental artery originates
from the splenic artery. The venous drainage corre-
sponds to the arterial supply. There does not seem to be
any valve in these venous systems.
The amount of the omentum varies depending on age,
sex, and nutritional condition (Fig. 1). The amount and
thickness or bulkiness of the omentum may be estimated
roughly by the body build, i.e., the amount of sub cut a-
396
neous fatty tissue, although there is no precise method to
assess the quality of the omentum preoperatively.
Previous minor abdominal surgery is not a con-
traindication for harvesting the omentum. However,
other donor sites should be considered if there has been
a previous inflammatory process, particularly in the
upper abdomen [5].
The transferred omentum maintains its volume and
nature under normal circumstances [6].
Harvesting Technique
An upper midline abdominal mCISIOn is used. The
omentum is first severed from several splenic attach-
ments. Detachment of the omentum from the transverse
colon can be done by exposing the avascular plane
between these two structures [5]. Sharp dissection of
this plane is performed, although small vessels that
traverse this plane are ligated and separated. The middle
colic vessels should remain intact during dissection.
Separation of the omentum from the greater curvature
of the stomach is performed by clamping and meticu-
lously ligating numerous branches between these struc-
tures [5]. Usually, the left gastroepiploic vessels are
ligated, separated, and marked by stitches (for the
second anastomoses, if necessary), before complete
detachment of the omentum.
An omental flap isolated on the right gastroepiploic
vessels has a large pedicle with an external diameter
averaging 2 to 3mm in adults (Figs. 1b and 1c). The
omentum may be lengthened depending on the figure
of the recipient site. It may also be preserved tem-
porarily during the operation by keeping it cool indi-
rectly on ice (Fig. 2).
Case 1
A 45-year-old woman developed an unstable radiation
ulcer on her head at the age of 27 years. Early in January
1977, a squamous cell carcinoma was detected in part
of the ulcer margin, and the ulcer was treated widely by
 2.10. Omentum 397

Fig. 1. Omentum volumes in patients of different ages. a 4-year-old boy. b 12-year-old girl. c 17-year-old girl.
d 45-year-old woman. e 52-year-old man. f 72-year-old man

Fig. 2. Harvesting of the omentum in a 55-year-old man. a Isolation of the omentum. (See Color Plates)
b Close-up view of the vascular pedicles. c Intraoperative preservation by indirect cooling

cryosurgery with liquid nitrogen, followed by intramus-
cular injections of bleomycin. After the skin carcinoma
had been treated, the patient was referred to us (Fig.
3a). The postcryosurgical ulcer with osteomyelitis of the
skull was thoroughly debrided, and the newly exposed
area was temporarily skin grafted. One month after this
operation, a free omental flap was transplanted by anas-
tomosing the right gastroepiploic vessels to the left
superficial temporal vessels (Fig. 3b).
The free omental flap was covered by a split-skin
graft. The postoperative course was uneventful in
spite of marked sclerotic changes, which were re-
cognized histopathologically in the superficial tem-
poral artery, and insulin therapy for diabetes mellitus.
Good pulsation of the transferred gastroepiploic
artery was palpable even 7 years and 7 months after
the operation. There was no sign of omental resorption
(Fig.3c).
398 E. Clinical Reconstructive Microsurgery

Fig. 3. 45-year-old woman. a Preoperative findings. b Completion of vascular anastomoses. c 7 years and 7
months after the operation

Fig. 4. 12-year-old girl with right progressive hemifacial atrophy. a Preoperative findings. b Completion of
vascular anastomoses. c 5 years after omental transfer

Case 2 seem to change during the first 2 years, but it increased

A 12-year-old girl had progressive hemifacial atrophy
on the right cheek to the upper lip (Fig. 4a). Through a
preauricular to submandibular incision, a cheek flap was
raised to make a subcutaneous pocket, and the facial
artery and vein were exposed as the recipient vessels.
The omental flap was transferred into the cheek subcu-
taneous pocket and revascularized with anastomoses
between the facial vessels and the donor vessels (Fig.
4b). The volume of the transferred omentum did not
a little with a 1S-kg weight gain of the patient during the
subsequent 2 years, resulting in moderate drooping of
the cheek (Fig. 4c).
References
1. McLean D, Buncke HJ (1972) Autotransplant of omentum
to a large scalp defect, with microsurgical revascularization.
Plast Reconstr Surg 49:268-274

2. Harii K (1978) Clinical application of free omental flap
transfer. Clin Plast Surg 5:273-281
3. Ohtsuka H, Kamiishi H, Shioya N (1976) Successful free
flap transfers in two diabetics. Plast Reconstr Surg 61:
715-718
4. Ohtsuka H, Torikai K, Ito M (1980) Free omental transfers
to the lower limbs. Ann Plast Surg 4:70-78
2.10. Omentum 399
5. Hidalgo DA (1987) Omentum free flaps. In: Shaw WW,
Hidalgo DA (eds) Microsurgery in trauma. Futura
Publishing, New York, pp 383-388
6. Ohtsuka H, Shioya N (1985)The fate of free omental
transfers. Br J Plast Surg 38:478-482
3. Clinical Applications
3.1 Primary Reconstruction in the Upper Extremity
YOSHITAKE KINO, KIKUO KONDOH, and KIYOSHI SUZUKI
The term primary reconstruction was first introduced
in 1960 by McCormack, who thoroughly analyzed and
diagnosed press injuries and crush wounds at primary
repair and performed primary reconstruction appropri-
ate for the injuries in the era before microsurgery. He
applied the term "primary reconstruction" to the recon-
structive procedure that improves functional acquisition
at primary repair.
In severe tissue injury of the hand, complications of
the injuries or defects of the compound tissue without
vascularity tend to develop. The introduction of micro-
surgical technique enables us to replant a completely
amputated limb or digit. Furthermore, primary micro-
surgical reconstruction has been performed to cover a
traumatic defect by grafting a composite tissue or uti-
lizing the discarded tissues, resulting in useful structural
reconstruction. We present our cases of primary micro-
surgical reconstructions.
Indication
Primary microsurgical reconstruction is a reconstruc-
tive procedure that is performed on fresh trauma during
primary repair, since secondary reconstruction of fresh
trauma may cause functional loss. In fact, not all of the
patients who visit our institute have fresh injuries. Some
patients visit us 2 to 3 weeks after injury. When patients
are sent to an emergency hospital with ischemic crushed
skin, only revascularization is performed at the initial
examination. Later it is possible to perform free flap
transfer as delayed primary reconstruction after the
extent of necrosis of the crushed skin has been
determined.
The conditions of primary microsurgical reconstruc-
tion, including delayed primary microsurgical recon-
struction, are as follows: Functional acquisition obtained
from primary reconstruction may be better than that
obtained from treatment with secondary reconstruction
alone. The primary reconstruction should be performed
according to the scheme that allows maximal functional
acquisition, including secondary reconstruction and
postoperative management. Therefore, there must be
a hand surgeon with sufficient knowledge concerning
indications and procedures, in addition to facilities.
In primary reconstruction with microsurgery intro-
duced, the following advantages and disadvantages
should be considered. The advantages are as follows:
Microvascular anastomosis allows peripheral revascu-
larization. It enables the damaged tissue and defective
tissue to be replaced with normal well-vascularized
composite tissue, which is useful for the prevention of
scar formation or infection. Primary reconstruction is
expected, which enables the treatment time for com-
pound tissue injuries to be shortened. It can cope with
high-energy injuries or joint destruction, which have
been difficult to reconstruct by conventional means.
Finally, in some cases, reconstruction using discarded
tissues is available.
The following are the disadvantages: A wound scar
remains in the normal donor site where tissues to be
transferred are harvested. Advanced technique and
experience are needed. The surgery takes a long time to
perform. Hematoma and edema are apt to occur due to
the postoperative anticoagulant therapy. One hundred
percent survival cannot be expected. Therefore, in
determining the indication, we examined the medical
and social necessity for the patient. The items to be
examined are as follows: Which advantages should
be thought important in application of microsurgical
reconstruction? Of course, the importance of the
function of the hand to be reconstructed should be
much higher than the disorder of the donor. What meas-
ures should be taken to reduce the damage to the
donor?
Practical Aspects
There is no definite formula for primary reconstruction
with microsurgery. For an emergency outpatient, we
examine the injured hand with reference to radiographs
and plan several reconstructive modes to restore the
function of the hand.
403
404 E. Clinical Reconstructive Microsurgery
Taking into account the patient's wishes, the number
of support staff, the availability of the operating room,
and whether the proposed surgery is suitable, and after
observing the injured hand closely, we make a final deci-
sion. The first thing to consider is the possibility that all
of the crushed fingers can be reconstructed to useful
fingers. In that case, the repair of the damaged tissue
needs replenishment from normal tissue. When recon-
struction of all of the fingers is impossible, the next thing
to consider is whether or not it is possible to reconstruct
one or two useful fingers by collecting usable parts or
tissues from three or four damaged fingers, which will
be discarded. For an injury to a single finger, such as the
thumb, it is necessary to replant.
In performing primary microsurgical reconstruction,
we do not aim at merely repairing the injured tissue and
healing the wound. We select primary reconstruction
procedures that reduce the occurrence of contracture as
much as possible, even if the technique is complicated
or the surgery takes a long time. It is also important to
perform primary and secondary reconstruction of the
pinch and grip of the hand according to the scheme
since the primary repair.
Classification
We classify primary microsurgical reconstruction pro-
cedures into three groups, as shown in Table 1 [1]:
utilization of discarded tissue, utilization of normal
tissue, and replantation of amputated fingers. We omit
replantation of single digits, because it is described by
other authors.
Table 1. Classification of primary microsurgical reconstruction
Primary microsurgical reconstruction by utilization of discarded
tissue (utilization of discarded tissue generated among multiple
injured fingers)
Skin flap
Bone/joint
Skin flap with tendon or bone
Nervelblood vessel
Primary microsurgical reconstruction by utilization of normal tissue
Single finger injury
Reconstruction of the thumb
Reconstruction of the finger
Multiple finger injuries
Reconstruction of the crushed fingers
Degloving injury
Tendon injury
End-to-end replantation of amputated finger (Description of the
single amputated finger is omitted because it is described in details
by other authors)
Utilization of Discarded Tissue
When it is impossible to replant one or more multiply
amputated digits or severely damaged, devascularized
digits, their tissues can be used to reconstruct the
remaining digits. There is no risk of injury to the donors,
which may occur in free tissue transfers. The skin of the
finger to be discarded should be harvested along with
the nerve, which is rarely obtained from other donor
sites. For the reconstruction of the remaining fingers,
any tissue, including the bone, joint, nerve, and skin, can
be used. There are two methods of utilization of the
tissue: transfer of the tissue with blood vessels or with a
neurovascular pedicle, or transfer of the tissue as a free
flap with suturing of the blood vessels of the donor to
the recipient. The first is the method of choice.
Case 1
The right hand of a 35-year-old man was caught in the
gears of a machine and was crushed and amputated. The
carpus was defective and its peripheral part was con-
taminated with oil. At first glance, it seemed impossible
to replant any of the fingers. However, further observa-
tion showed that the shapes of the thumb and little
finger remained. Radiograms showed that the bony
structures of three digits were preserved up to the MP
joint. Because the skin around the palm was crushed
and defective, a pedicled abdominal flap transfer was
performed secondarily. The thumb was osteosynthe-
sized to the radius, and the little finger was osteosyn-
thesized to the ulna. Revascularization was performed
with a vein graft to the artery and vein. Tenorrhaphy and
nerve repair were performed to restore the pinch func-
tion of the hand. The Sauve-Kapandji method was
secondarily performed for the rotational disorder of the
forearm, which allowed pronation and supination. This
is a typical case [2] of primary microsurgical recon-
struction of the pinch of the hand using discarded ampu-
tated tissues. After amputatation of his left thumb 8
years ago and his middle finger 4 years ago, the patient
has been very happy with the satisfactory reconstruc-
tion of his the right hand (Fig. 1).
Utilization of Normal Tissue
In a crush wound produced by a press machine, com-
pound tissues, such as bone, joint, nerve, tendon, and
vessels, suffer blunt, severe trauma or compound tissue
defects. In such injuries, normal tissue should be trans-
ferred to the crushed and defective part of the tissue
after primary revascularization. Scar formation may
occur, resulting in a stiff hand. Once the stiff hand devel-

Fig. 1. A 35-year-old man. The right hand joint was crushed
and amputated. a, b At the initial examination, shapes of the
thumb and little finger narrowly remained. c Amputation
stump: the carpus and skin were defective. d The thumb was
replanted to the radius and the little finger to the ulna. e
Pronation and supination of the forearm were improved by
the Sauve-Kapandji procedure. f Left hand: The thumb was
amputated 8 years before, and the middle finger was ampu-
tated 4 years before right hand's injury. g, h Pinch mobility of
the right hand was obtained. i Useful mobility of both hands
was obtained
ops, improvement in hand function is hardly expected,
even if secondary transfer of normal tissue is per-
formed. The principles of primary microsurgical recon-
struction are (1) primary revascularization; (2) excision
of the crushed tissue and diagnosis of the defective
tissue; (3) primary or delayed primary reconstruction of
the injured bone, nerve, tendon, and skin, according to
the tissue damage; and (4) covering of the deep repaired
tissues with the use of small, medium, or large vascu-
3.1. Primary Reconstruction in the Upper Extremity 405
Fig. 2. A 36-year-old man with incomplete amputation of
the left ring finger. a At the initial examination, rupture of the
flexor tendon, artery, and nerve was observed. b Radiograph
revealed fissure fracture of the proximal phalanx. c The ulnar
artery was anastomosed end-to-end, the venous flap was anas-
tomosed to the radial artery, and the skin crush was covered.
The flexor tendon and nerve were sutured end-to-end. d, e
Flexion and extension of the left index finger 3 months after
surgery are shown
larized free flaps. These procedures allow supple and
useful reconstruction of the hand.
Small, medium, and large free flaps that are fre-
quently used in primary microsurgical reconstruction
are described below.
Case 2
A 36-year-old man ruptured the flexor tendon, artery,
and nerve of the left ring finger, with a fissure fracture
of the proximal phalanx. The left ring finger had poor
blood circulation because of the crushing injury by a
machine. The flexor tendon, artery, and nerve were rup-
tured, and the skin was crushed. The ulnar digital artery
was anastomosed end-to-end, and the peripheral blood
circulation was reconstructed. A venous flap of the
arteries venous type was grafted to the radial digital
artery and the sutured flexor tendon. Although we
recommended tenolysis of the flexor tendon 3 months
after surgery, the patient refused it because of its incon-
venience (Fig. 2).
Case 3
The 1st, 2nd, and 3rd metacarpal bases of 22-year-old
man were punched out by a press machine. It was
impossible to reconstruct the thumb because the bone,
nerve, blood vessels, and tendon were lost from the
first carpometacarpal joint to the mid proximal phalanx.
406 E. Clinical Reconstructive Microsurgery
Fig. 3. A 22-year-old man whose left thumb was amputated
by a press. a, b At the initial examination, the bone, nerve,
blood vessel, and tendon of the left thumb were lost. c, d
Pollicization of the left index finger. The skin defect site was
covered with a vascularized free scapular flap 22 x 7 cm. e, f
Flexion and extension of the thumb 1 month after surgery
Nerves and bones were harvested from the amputated
thumb. Nerves were grafted to the radial digital nerve
defect of the index finger. The nerves in the ulnar side
of the index finger were normal. Pollicization of the
index finger was performed by bone grafting from the
thumb to the bone defect of the second metacarpal
base. The skin defect was primarily covered with a
scapular flap 22 x 7 cm in size. The bones harvested from
the thumb were grafted to the metacarpal bone defect
of the middle finger. Ruptures of the extensor carpi
radialis longus and brevis tendon were sutured prima-
rily. The pinch and grip between the new thumb and the
other digits were reconstructed by such primary micro-
surgical reconstructive procedures (Fig. 3).
Case 4
A 52-year-old man sustained an open fracture of the left
radius and ulna. Rupture of the radial and ulnar arter-
ies was noted, with a skin defect in the forearm. Most
of the flexor tendons were ruptured. After osteosynthe-
sis, revascularization was performed with a vein graft to
the ulnar artery. The pulled-out flexor pollicis longus
tendon and flexor digitorum profundus tendon of the
ring finger were reconstructed primarily by transferring
the flexor digitorum superficialis tendon. Two weeks after
the injury, after thorough debridement of the necrotized
skin in the forearm, a vascularized parascapular flap 27
x IDcm in size was transferred with anastomosis of the
donor artery to the ruptured radial artery. Although
rehabilitation commenced at 4 months, the transferred
tendon developed adhesion. Thus, tenolysis of the flexor
tendon improved flexion and extension of the fingers. In
severe compound tissue injuries, tenolysis is essential.
Tenolysis should not be performed until the joint stiff-
ness of the tendon becomes supple, muscle strength is
restored by sufficient rehabilitation, and a plateau is
observed at which TAM (total active motion) is not ex-
pected to be further improved by rehabilitation (Fig. 4).
The free composite flaps with primary microsurgical
reconstruction are the neurocutaneous flap for sensory
reconstruction, the tendocutaneous flap for extensor
tendon reconstruction, the osteocutaneous flap for
bone/joint defect, and the wrap-around flap for thumb
reconstruction.
Case 5
A 19-year-old man had skin defects on the dorsum of
the left hand and on the index, middle, ring, and little
fingers as a resent of an automobile accident. Extensor
tendon defects were seen at 3,4, 5, and 6 of the Verdan
zone. The extensor digitorum communis was scraped off
from the hand joint up to the proximal interphalangeal
joint, and the skin was scraped off up to the distal inter-
phalangeal joint. The patient visited our institute 2 days
after the injury. A tendocutaneous flap to transferred
from the dorsum of the foot was grafted [4,5], and the
extensor tendon was reconstructed up to the central
band. Three months later, tenolysis of the tendon was
performed only at the tendon suture site. Although
extension and flexion of the fingers are incomplete, the
fingers are supple enough to function (Fig. 5).
Case 6
A I9-year-old man sustained an open wound of the
right little finger with a defect of the central band and

Fig. 4. A 52-year-old man was caught in a rotating machine
and sustained open fracture of the left radius and ulna, rupture
of the radial and ulnar arteries, rupture of the flexor tendon,
and extensive skin defects. a-c At the initial examination. d
After osteosynthesis, revascularization was performed by vein
graft of 7 cm to the ulnar artery. Flexor tendon transfer (FDS 3
~ FPL, FDP4 ~ FDP 3 end suture). e, f 27 x IOcm vascular-
ized free parascapular flap was anastomosed to the radial
artery. g, h Three months after injury and before tenolysis of
the tendon. i, j Two months after tenolysis of the tendon.
Flexion and extension of the finger were improved
3.1. Primary Reconstruction in the Upper Extremity 407
Fig.5. A I9-year-old man with extensor tendon defect of 3, 4,
5, 6 of Verdan zone and skin defect in the left index, middle,
ring, and little fingers. a At the initial examination 2 days after
injury. b On the initial examination day, a flap with tendon,
vascularized pedicle, and free dorsal tendon from the dorsum
of the left foot was grafted. c, d Flexion and extension of the
fingers 4 months after injury. (Tenolysis of the extensor tendon
was performed 3 months after injury)
the overlying skin. The dorsum of the proximal inter-
phalangeal joint of the finger was scraped away to the
bone, the central band had a defecte 3 cm long, and the
skin defect was 4 x 2.5 cm in size. Primary reconstruc-
tion was performed by using a venous flap including the
palmaris longus tendon. Postoperative extension and
flexion of the little finger were almost in the normal
range (Fig. 6).
Case 7
A 23-year-old man sustained a crush injury when his
left elbow was caught in a belt conveyer, resulting in a
defect of the left elbow joint, skin, and triceps muscle.
The dorsal aspect of the left elbow joint was con-
taminated with oil. The wound was washed thoroughly
and debrided, and the skin defect was covered with arti-
ficial skin. Ten days after the injury, bone cement was
inserted into the defect of the elbow joint to be fixed
as a spacer. The triceps muscle was reconstructed with
the latissimus dorsi musculocutaneous flap, and the
wound was closed. Six months later, the wound was
healed without infection. The metatarsophalangeal
joint of the big toe was transferred to the left elbow
joint. Two years after surgery, flexion of the elbow joint
was 116 degrees and extension was -42 degrees,
indicating excellent results. There were no radiological
findings of arthropathy in the reconstructed elbow
joint (Fig. 7).
408 E. Clinical Reconstructive Microsurgery

Fig.6. A 19-year-old man with defect of the central band and

skin of the right little finger. a, b At the initial examination. c,
d Primary microsurgical reconstruction was performed using
venous flap with palmaris longus. e, f Flexion and extension of
the little finger 4 months after injury

Replantation of the Amputated Digit

Ordinary replantation of the amputated digit is

described in detail by other authors and is therefore
omitted here. We describe schematic, two-stage recon-
structive procedures for severe compound tissue
injuries (incomplete amputation).
Case 8
A 49-year-old man sustained incomplete amputation
of the right thumb, middle finger, and ring finger and
complete amputation of the right index finger from an
electrically powered saw. The incompletely amputated
digits were replanted. Even if neurorrhaphy was per-
formed microscopically, postoperative restoration of the
sensory disorder was expected to be poor, because all
the nerves after branching failed to be sutured. First, the
distal phalanx of the thumb was replanted by artery
anastomosis. Second, an island flap with normal sensa-
tion was transferred from the index finger base to the
thumb to restore the sensation of the thumb. Pinch of
the thumb with sensation was reconstructed satisfacto-
rily by this two-stage procedure (Fig. 8).
Fig. 7. A 23-year-old man was caught in a belt conveyer. a, b
At the time of injury: defects of the left elbow joint, skin, and
triceps muscle. c, d Bone cement was molded into the shape
of the elbow joint and inserted into the defective site of the
elbow joint as spacer. The triceps muscle and the skin were
reconstructed with a latissimus dorsi musculocutaneous flap
with pedicle. e Metatarsophalangeal joint of the first toe of
the foot was grafted after 6 months. f-i Flexion and extension
of the left elbow joint 2 months after surgery, with
radiographs. (a,c See Color Plates)
Conclusions
We have described our concept of primary microsurgi-
cal reconstruction and introduced some of our repre-
sentative cases. In primary microsurgical reconstruction,
after preservation of the digit by revascularization, func-
tional reconstruction should be performed. The more

Fig. 8. A 49-year-old man with incomplete amputation of
the right thumb, middle finger, and ring finger and complete
amputation of the right index finger by an electrically powered
saw. a At the time of injury: postoperative sensory disorder in
the right thumb was expected, even if neurorrhaphy was per-
formed. b Second, a island neurovascular flap from the index
finger was transferred to the thumb, and reconstruction of the
sensation of the thumb was planned. c, d Pinch of the thumb
with sensation was restored by primary and secondary sensory
reconstruction
severe the crush, the more the microsurgical technique
will be needed. Furthermore, a graft of normal tissue to
the tissue defect will be required. Such a graft can be
delayed until after primary treatment if vascularization
is maintained to the periphery. Godina [6] found that
the free flap performed within 72 h had the best results.
3.1. Primary Reconstruction in the Upper Extremity 409
We have also reported the outcomes of our cases, in
which surgery performed within 2 weeks after the injury
prevented infection and scar formation and recon-
structed useful hands.
References
1. Kino Y, Nakamura R, Inoue G (1987) Primary microsurgi-
cal reconstruction of the severely mutilated hand. Orthop
Surg Mook No 48:91-108
2. Kondou K, Kino Y, Hattori Y, Suzuki K, Koide T (1994)
Reconstruction of compound tissue injury in the upper
limb using microsurgery. J Jpn Soc Surg Hand 11:733-
735
3. Yoshimura M (1984) A venous skin graft in the treatment
of injured fingers. Jpn Plast Surg 27:474--478
4. Oukubo K, Murota K, Tomita Y, Moriyama M, Takahashi
F, Murai T (1984) Free dorsalis pedis flap with to extensor
tendon- Vascularized tendon graft-. Orthop Surg Trauma-
tol 27:983-990
5. Suzuki K, Kino Y, Hattori Y, Kondou K (1994) Recon-
struction of extensor and overlying skin in dorsal hand
and finger injuries using free flap containing tendons. Jpn
Microsurg 7:46-53
6. Godina M (1986) Early microsurgical reconstruction of
complex trauma of the extremities. Plast Reconstr Surg
78:285-292
3.2 Thumb and Digit Reconstruction
T AKAE Y OSHIZU
Thumb reconstruction by toe transfer was first per-
formed by Yao in 1965 using the second toe. Cobbett
reported it in 1969 by transferring the great toe. Tamai
succeeded in the first big toe-to-thumb transfer in Japan
in 1975. On the other hand, thumb reconstruction with
a wrap-around flap (WAF) from the big toe was
reported by Morrison in 1980 and by Doi in 1981. The
author devised the conventional WAF procedure by
including the distal phalangeal tip in the flap in 1982.
Morrison introduced the identical procedure at a
lecture given in Japan in 1984. Steichen reported that
he had always used this new procedure since 1980 [1].
In 1985, Doi reported a thumb reconstruction using
WAF with a thin sliver of the dorsal cortical bone of the
distal phalanx to preserve the length of the big toe and
prevent deformity of the nail [2] (see the chapter by
y. Maki in this volume).
Indication
Thumb reconstruction using toe transfer has several
advantages compared with conventional methods: cos-
metic appearance, normal number of digits, and better
sensation. However, toe transfer should be indicated
for functional needs and for growing children. On the
other hand, WAF transfer is indicated especially for an
adult with cosmetic as well as functional needs [1,3]' At
present, the latter is preferred, if the carpometacarpal
(CM) joint is functionally normal. Toe transfer with
epiphysis is often indicated in children with congenital
amputation of the digits for esthetic and functional
improvement [4-8].
Operative Technique
Reconstruction of the thumb amputated distally to
the metacarpophalangeal (MP) joint is described here
(Fig. 1a).
410
Wrap-Around Flap
Management of the Skin of the Recipient Thumb
A normal thumb looks thick proximally. To gain a cos-
metically normal appearance of the thumb, the suture
site should be prevented from a dermatogenous con-
striction followed by a simple circumferential suture.
For this purpose, a radially based triangular flap should
be made at the radial side of the thumb stump (Fig. 1b).
To anastomose a radial artery and a cutaneous vein at
the snuffbox, the subcutaneous tunnel that the donor
artery and vein should be passed through must be made
just over the first ray.
Bone Graft
Since the interphalangeal (IP) joint is difficult to
reconstruct, the monocortical iliac bone graft should
be about 1 cm shorter than the contralateral thumb to
make the thumb-opposed fingers-pinch easy. Further-
more, the bone graft should be thick, because the
grafted bone generally undergoes resorption and
atrophy over time (Fig. 1c).
Flap Transfer
The WAF, including one-half to two-thirds of the distal
phalanx, is taken from the ipsilateral big toe (see the
chapter by Y. Maki in this volume).
Management of the Skin, Nerves, and Vessels
The vascular pedicle is passed through the subcuta-
neous tunnel to be anastomosed at the snuffbox. The
width of the nail plate is generally managed during
transfer by trimming the nail bed and nail matrix.
However, the authors now prefer doing this procedure
secondarily only at the patient's wish, because we found
that the nail plate gets about 1 to 2mm smaller postop-
eratively, probably due to the poor vascularity of the
nail matrix. Next, the triangular skin flap made at the
stump is placed at the radial side of the flap. A single
volar ulnar digital nerve is sutured. In our experience,
sensibility of the whole pulp can be recovered by neur-
orrhaphy of this single nerve [9]. Finally, the artery and
vein are anastomosed at the snuffbox.
 3.2. Thumb and Digit Reconstruction 411

a d

Fig. 1. a A IS-year-old girl 12 years after amputation through
the proximal phalangeal base of the left thumb with abdomi-
nal flap coverage. b Reconstruction by iliac bone grafting,
wrap-around flap (WAF) with the distal half of the terminal
phalanx, and triangular flap made at the thumb stump.
c Macroscopic appearance of the thumb with bone resorption
3 years after reconstruction. d Postoperative condition of the
big toe. Coverage with full-thickness skin graft on the granu-
lation tissue 2 weeks after the first operation
 412 E. Clinical Reconstructive Microsurgery
a b
c ncou I . c ppearance and function 3 yea po toperati el
Management of the Donor Site
Formerly, we used the cross-toe flap technique recom-
mended by Morrison, using the second toe to cover the
denuded area on the big toe. However, primary healing
of the full-thickness skin grafts to the plantar sides of
both the big toe and the second toe was insufficient, con-
trary to our expectation. At present, we prefer to use
the full-thickness skin grafts to both the dorsal and
plantar denuded areas of the big toe that are covered
with satisfactory granulation tissue 2 to 3 weeks after
flap harvesting (Fig. ld).
Second Toe Transfer (Fig. 2)
Management of the Thumb
The triangular flap is made with the same purpose as
that of the WAF transfer. Volarly, bilateral proper digital
nerves and the flexor pollicis longus tendon are
exposed. The dorsal approach resembles that in the
WAF transfer. However, in this procedure, the skin inci-
sion needs to be extended to expose the stump of the
extensor pollicis longus tendon.
ig. 2. a 31-yearold man u tained a degl ving injury f
the ~ hole right hand with an amputation of the thumb
through the pro imal phalangeal ba e I ear previou Iy. Hi
hand wa already covered with a groin flap after removal of
the econd ray. b Thumb wa recon tructed b contralat ral
econd to tran f r. and the third ra wa eparatcd imulta-
Transfer
After bone fixation, the flexor and extensor tendons
are repaired. The flexor digitorum brevis tendon is
transected at the region of the chiasma. A midlateral
incision is made at the radial side of the second toe to
have the long and wide triangular flap of the thumb
inserted in this incised portion. This will prevent the
thumb from narrowing due to constriction of the suture
site.
Management of the Nerves and Vessels
The bilateral proper digital nerves are sutured and the
vessels are anastomosed at the snuffbox.
Reconstruction of the Thumb Amputation Proximal to
the MP Joint
When the toe graft needs to include a large amount
of foot skin, primary closure of the donor site will be
difficult. In such a case, the bone graft covered by a
pedicled groin flap (osteoplastic thumb reconstruction)

a b
c good function 4 month after the ccond toe tran fer
should be done prior to the transfer, and the WAF trans-
fer should be done later at the time of the pedicle
severance. It is same in the second toe transfer.
However, in the toe transfer, primary reconstruction
may be indicated, if extensive skin is taken from the
dorsal and plantar aspect of the second metatarsal
region and primary closure of the plantar side may be
possible (Figs. 3 and 4).
3.2. Thumb and Digit Reconstruction 413
Fig. 3. a 39- car-old man sustained amputation of all digit
of both hand from a burn. 'l1le right thumb was amputated
through the middle of the metacarpal. the inde through the
metacarpophalangeal (MP) join!. and the other three digit
through the middle of their re pecti e pro imal phalange
The function f the Ii t carpometacarpal (eM) joint and the
other MP j int were \ ell pre erved. b e contralateral
econd toe di articulated at the metatarsophalangeal (MTP)
joint. with a large area of dor al kin. \ a tran ferred to the
fir t ray. and the fie or and e ten or tendon \ ere repaired 2
month after removal of the econd ra . c Roentgenogram and
Pitfalls and Complications
Care is taken not to injure the nail matrix during
osteotomy of the distal phalanx at the dissection of a
WAF. Since the grafted bone is apt to be resorbed
during the course of time, a comparatively thick bone
graft should be taken. The proximal suture site should
be prevented from scar constriction to gain a cosmeti-
414 E. Clinical Reconstructive Microsurgery
II
Fig. 4. a A 48-year-old woman sustained amputation of
the right thumb through the proximal third level of the
metacarpal with a well-preserved CM joint. b Three days later,
the contralateral second toe, including the MTP joint, with a
large skin flap attached was transferred to the first ray. The
cally normal thumb. For this purpose, the skin should be
closed using a triangular or zigzag skin flap.
Finger Reconstruction
Finger reconstruction using toe transfer is common,
although the contralateral finger transfer has also been
reported [10].
Second or Third Toe Transfer
Second or third toe transfer should be carried out
taking into consideration the functions and appear-
ance of the whole hand, e.g., the presence or absence
flexor and extensor tendons were repaired at the same time.
Denuded areas in the grafted toe and the dorsum of the foot
were covered with full-thickness skin graft. c Macroscopic
appearance and function after 2 years and 6 months
of the remammg digits or the level of amputation
[11-17].
Indication
In a single finger amputation distal to the proximal
intaphalangeal (PIP) joint, second or third toe transfer
is indicated.
In multiple finger amputation distal to the midportion
of the proximal phalanx, double second toe transfer or
single toe transfer is indicated [11,12].
In amputation of the whole finger at the level of the
proximal phalangeal base or metacarpal, a combined
second and third toe transfer using unilateral foot
or double toe transfer using bilateral toes is preferred
to a single toe transfer for better power and hook
gnp.

If all digits are lost, a thumb and an opposed finger
should be reconstructed by a double or triple toe trans-
fer. The WAF transfer may be used for reconstruction
of the thumb.
Operative Technique
Single Toe Transfer
Operative Procedure in Case with Functional PIP Joint
(Fig. 5). A triangular skin flap is made as in thumb
reconstruction. Since arteries of larger caliber are better
for anastomosis, the contralateral second toe is used for
transfer in an index reconstruction, whereas the ipsilat-
eral second toe is used for the little finger. Either of
them can be used for the long or ring finger. Subcuta-
neous tunnels are made in the palmar and dorsal aspects
of the hand for arterial and venous anastomoses, respec-
tively. The functions of the transferred joint are not so
important. Therefore the joint is stabilized by tenodesis
just after bone fixation. The vascular pedicle is pulled
out proximally through the subcutaneous tunnels, and
the anastomoses of vessels are carried out after sutur-
ing of the bilateral nerves and closure of the triangular
flap.
Toe Transfer to an Amputated Digit Proximal to the PIP
Joint (Fig. 6). Tenorrhaphy is performed because joint
functions are needed in this type of amputation. The
extensor tendons should be sutured tightly to minimize
the flexion deformity.
Combined Second and Third Toe Transfer (Fig. 7)
Management of the Recipient Site. A longitudinal inci-
sion is made at the dorsal aspect of the hand. However,
a zigzag incision should be made with consideration of
creases at the palmar aspect. For an adduction contrac-
ture of the thumb, or a significant loss of the index
finger, the second metacarpal should be amputated at
its base so as to broaden the first interdigital space. The
second and third toes are transferred to the third and
fourth rays or the fourth and fifth rays. During bone fix-
ation, the transferred toe should be slightly rotated
towards the thumb, because the toe is too short for the
chuck pinch. Flexor tenorrhaphy is performed after the
extensor tendons have been sutured tightly. The bilat-
eral nerves are sutured, and finally the arterial and
venous anastomoses are done. Free skin grafting is used
for skin loss at the MP joint level.
Foot Reconstruction. The metacarpal head is trimmed
down to be covered with the soft tissue and skin
graft. Because the deep transverse metatarsal ligament
is intact, the foot arch will be preserved and there
3.2. Thumb and Digit Reconstruction 415
will be no problems in activities of daily living (ADL)
(Fig.7c).
Reductionplasty of the Pulp
The pulp size of the new thumb after WAF or toe trans-
fer will usually be large. Defatting and trimming of the
pulp are done by making a hockey-stick incision at the
nonworking surface of the pulp. However, this proce-
dure has the disadvantage that reduction is often insuf-
ficient, and resection of the unilateral digital nerve may
be necessary for this purpose, if toe transfer including
both digital nerves was performed for finger recon-
struction. For this reason, we think that resection of the
central portion of the pulp reported by Wei is safe and
better [18] (Fig. 8).
Pitfalls and Complications
Preoperatively, the patient should be informed that
the shape of the toe to be transferred will not be always
as good as that of a normal finger in appearance, and
the range of motion, especially toe extension, may be
insufficient. Although a little functional disturbance in
ADL occurs after the combined second and third toe
transfer, we prefer the double toe transfer procedure.
In the latter, the operative technique will be easier if
the proper digital arteries to the big toe are anasto-
mosed with each other, and a single metatarsal artery
is anastomosed with a recipient artery. The metatar-
sophalangeal (MTP) joint may be included in the toe
transfer when a long toe is needed. However, the author
avoids performing this procedure, because a large
volume of skin must be obtained from the dorsum of
the foot, as in the dorsalis pedis flap, and also the foot
arch will be lost. When a longer toe transfer is neces-
sary, the bone graft covered by the pedicle or free
skin flap is done first, and the toe transfer is performed
at the second stage. No skin loss at the dorsum of the
foot and fewer complications may occur with this
method. Furthermore, the toe should be fixed in a
slightly rotated position for a better thumb-opposed
finger pinch.
Use of Wrap-Around Flap
Toe transfer to the little finger is cosmetically better
than that to other fingers, because the toenail and the
toe as a whole are relatively small. However, compared
with the WAF method, loss of the toe in toe transfer is
another big disadvantage. In 1980, Foucher reported the
twisted toe transfer [19]. However, this method also has
the disadvantages of loss of the second toe and difficulty
 416 E. Clinical Reconstructive Microsurgery

a b

c d

Fig. 5. a A 22-year-old man sustained amputation of the left
little finger through the middle phalanx, laceration of both
flexor tendons at zone II of the index finger, and destruction
of the proximal interphalangeal (PIP) joint of the ring finger
by a power saw. b Both flexor tendons were repaired 4 days
later, and toe joint transfer to the PIP joint of the ring finger
was performed 2 months later. c The ipsilateral second toe was
transferred to the little finger and the distal interphalangeal
(DIP) joint was stabilized by tenodesis using the flexor digi-
torum longus 6 months after toe joint transfer. d Final func-
tion of the left hand 3 years postoperatively
a b

Fig. 6. a 29- car-old man u tained amputation of multiple

fingers of the right hand by a chain a\ 5 month pre iou I .
The inde and long finger \ ere amputated through the pr -
imal phalange. the ring finger through the middle pha-
langeal ba e. and the lillie finger through the di tal phalan .
b The second toe from each foot \ ere tran ferred to the third
and fourth ray and triangular flap were placed to pre ent
circumferential con Iriction. Tenol si for both flexor tendon
\ a performed 4 month later. C Functional rec ery f the
c ri ht hand I year and 9 m nth p toperativel

b
c

Fig.7. a A 45-year-old man sustained amputation of the right and the third ray was simultaneously removed. c Appearance
hand through the metacarpal level with removal of the second and function of the right hand 8 years and 5 months after
ray. b The combined second and third toes from the con- reconstruction
tralateral foot were transferred to the fourth and fifth rays,
 418 E. Clinical Reconstructive Microsurgery
a b
Fig. 8. Reduction plasty of the pUlp. a Preoperative and operative findings. b Appearance of the left ring and little fingers 3
months after operation
in twisting the skin flap of the second toe to 180. Our
procedure is similar to the WAF transfer and has the
advantage of producing a cosmetically good finger
without loss of the toe [20]. However, the operative indi-
cation is limited only to finger amputation at the middle
phalangeal level.
Foot Dissection (Fig. 9)
In finger reconstruction, unlike thumb reconstruction,
the contralateral big toe is used for transfer. Dissection
is similar to the WAF transfer. Trimming of the skin flap
must be carried out while checking the circulation
before the vascular pedicle is severed. The nail plate of
the reconstructed thumb will become 1 mm shorter than
the trimmed nail size immediately after WAF transfer
at long follow-up. For this reason, we suggest that the
nail complex to be transferred, consisting of nail bed,
nail matrix, hyponychium, and paronychium, should be
1 to 2mm larger than the healthy fingernail. The distal
phalangeal bone to be included in the vascular pedicle
should be trimmed off to the size of the nail. Trimming
of the bone should be done at the side where no neuro-
vascular bundle exists (Fig. 10). Defatting of the toe
pulp is done, and the skin flap is trimmed off to make
the reconstructed finger slightly larger than the healthy
finger. Finally, after confirmation of the good vascular-
ity of the pedicle, the vessels are severed (see the
chapter by Y. Maki in this volume).
Hand Dissection
Hand dissection in WAF transfer is identical to that in
toe transfer.
Reconstruction
The monocortical iliac bone graft is harvested to
augment the stump of the middle phalanx to the normal
length. Dissection of the vessels is similar to that in toe
transfer.
Pitfalls and Complications
The size of the reconstructed finger should be slightly
larger than normal to prevent circulatory disturbance
due to edema and progressive shortening of the nail
size. To ensure a cosmetically good finger, the parony-
chium should be left intact by severing only the nail bed
and the nail matrix. However, the vascularity of the
paronychium may be insufficient. For this reason, a larger
width of paronychium should be preserved in the graft,
and care should be taken not to suture tightly if this pro-
cedure is used.
Special Reconstructive Method
Finger-to-Finger Transfer
Edgerton (1976) performed cross-hand finger transfer
without using microvascular surgery in a case of bilat-
eral constriction band syndrome [21). The postoperative
result was good, with achievement of functional hands
bilaterally. We performed paralyzed left ring finger
transfer using microvascular surgery to the right index
finger amputated at the level of the midproximal
phalanx on 18 June 1975 (Fig. 11). The patient was a 31-

,
~
-----'
," , ... ---- .. ,
, ,
year-old male factory worker whose left upper extre-
mity had been functionally useless since 3 years of age,
when he suffered an idiopathic left hemiplegia. His
right long finger was severely crushed simultaneously.
Morrison performed right normal index finger transfer
to the left hand with all fingers amputated of a 27-
year-old-patient in December 1976 and reported four
cases of finger transfer later [10].
Indication and Advantages
Finger reconstruction with a normal finger has a great
advantage. However, the author thinks that if toe trans-
fer is possible, normal finger transfer, as done by Morri-
3.2. Thumb and Digit Reconstruction 419
Fig. 9. Diagram of dissection of big toe
for successful reconstruction of digit
son, should be abandoned. Finger transfer should be done
only if a functional hand can be achieved by transfer of
an unimportant finger, such as in functionally impaired
bilateral hands due to trauma or congenital anomaly.
Dissection of the Recipient Site
The flexor and extensor tendons of the index finger are
dissected first. The first dorsal and volar interosseous
muscles are transected at the MP joint level. The deep
transverse metacarpal ligament is resected, leaving a
larger portion of it intact at the medial side. The neu-
rovascular bundle is dissected up to the level of the
superficial arch. Two veins are preserved at the MP joint
 420 E. Clinical Reconstructive Microsurgery
Fig. 10. a A 36-year-old woman sustained amputation of the
right index and long fingers just distal to the PIP joint. The
ring finger had already been amputated 6 years previously. b
The index finger was first reconstructed by iliac bone graft and
WAF with partial excision of the nail bed and matrix, includ-
ing paronychium using the contralateral big toe. c One month
level. Finally, the finger is amputated at the level of the
mid-metacarpal shaft.
Dissection of the Donor Site
In our case, we used the contralateral ring finger
for transfer. V flaps with their apices extending to the
later, the long finger was reconstructed by using the ipsilateral
big toe with partial excision of only the nail bed and matrix,
resulting in preservation of the paronychium. d Appearance
2 years after reconstruction. The long finger with preserved
paronychium has a normal appearance
level of the distal palmar crease are made at the volar
and dorsal aspects. The flexor and extensor tendons
are transected at optimum levels, while the second
volar and fourth dorsal interossei are transected at the
myotendinous junctions. The radial deep transverse
metacarpal ligament with a portion attached to the
fourth metacarpal is resected. The artery, vein, and nerve
are transected at the level of the metacarpal base.

a ' - - _--I
c function f the right hand 2 yea and 6 monlh after Iran fer
Reattachment
After fixation of the metacarpal, the ulnar deep
metacarpal ligament is sutured. The wing tendons are
sutured to their respective interossei. After tenorrhaphy
of the flexor and extensor tendons, the common digital
arteries and cutaneous veins are anastomosed and the
common digital nerves are sutured.
Functional Reconstruction with
Joint Transfer
The dissection of the donor site has been mentioned in
the chapter on toe joint transfer (D.2.5). The operative
technique for the PIP joint transfer is mainly described
here [7).
Exposure of the Finger PIP Joint
A longitudinal skin incision is made at the dorsal aspect
of the finger, extending from the midportion of the
middle phalanx to the midportion of the proximal
phalanx. The lateral band, which is necessary for func-
3.2. Thumb and Digit Reconstruction 421
i .11. a 31-year-old man with left hemiplegia of unkno n
etiolog from the age of three ears u tained a pre s injury
10 the right index and long finger b mger-to-finger tran fer
u ing the left completel u ele ring finger. c ppearance and
tioning of the distal interphalangeal (DIP) joint, should
be preserved, unless it is scarred. A portion of the exten-
sor tendon lying over the PIP joint is resected. The level
of transection is at the central slip, a little proximal to
the osteotomy level, proximally, and at the triangular
ligament distally. The length of the finger PIP joint to be
resected should be 2 to 3 mm greater than that of the
toe PIP joint to be transferred. The volar plate and the
scarred tissue should be resected. A longitudinal inci-
sion of about 2 em is made over the dorsal aspect of
the MP joint to expose the subcutaneous vein. Through
this incision the subcutaneous tunnel to the PIP joint is
made by undermining the dorsal skin. A longitudinal
or zigzag incision is made over the volar aspect of the
MP joint to expose the common volar digital artery. The
subcutaneous tunnel is made as in the dorsal aspect.
Exposure of MP and Thumb
Carpometacarpal (CM) Joint
The common extensor tendon is exposed and the
scarred tissue around the MP joint is resected. Volarly,
the flexor tendon is partially exposed to resect the volar
 422 E. Clinical Reconstructive Microsurgery
b
Fig. 12. a A 30-year-old man sustained destruction of the PIP
joint and fracture of the distal phalanx of the right long finger
by a power saw. b The PIP joint of the ipsilateral second toe
with the extensor tendon was transferred 1 year and 6 months
after injury. The PIP joint was temporarily fixed with a
plate of the MP joint. The soft tissue around the eM
joint is resected as well.
Transfer
Transfer to the Finger PIP Joint (Fig. 12)
After fixation of the distal portion of the joint, the pro-
ximal portion is internally fixed. The artery and vein are
passed proximally through the tunnel. The extensor
tendon is sutured tightly with the PIP joint in full ex-
tension. After extensor tenorrhaphy, the PIP joint is
temporarily fixed with a Kirschner wire to maintain the
finger in a fully extended position. If the lateral band is
intact, it should be sutured to the extensor tendon. When
there is a deficit of the lateral band, the terminal tendons
are sutured to each other at the level of the middle
c
Kirschner wire to maintain the finger in a fully extended posi-
tion. c Flexor tenolysis was carried out 10 months later, and a
good range of motion (75 in the PIP joint and 60 in the DIP
joint) without destructive change in the grafted joint was
obtained 6 months after tenolysis
phalanx with the purpose of extending the DIP joint via
the lateral band around the transferred joint. The skin
island of the joint transfer should be sutured without
tension by adding a transverse skin incision on the reci-
pient site if necessary. If there is a skin defect, the full-
thickness skin graft is indicated. Finally, the artery and
vein are anastomosed. The joint defect in the toe is filled
with either the removed proximal phalanx or the iliac
bone graft. The donor site is closed primarily.
Transfer to the Finger MP Joint
The toe PIP joint to be transferred is too small com-
pared to the recipient MP joint. Since extensor tendon
reconstruction is to be done, the site of osteosynthesis
should be aligned better at the dorsal cortex. However,
this procedure may result in scar formation in the volar

II
Fig.13. a An 8-year-old boy with bilateral hypoplastic thumbs
(Blauth type III). Widening of the first interdigital space using
a dorsal sliding flap, centralization of the first CM joint by
Buck-Gramcko's method, and adductor plasty and oppono-
plasty were performed to reconstruct both thumbs over 5
cortical stepping. The dorsal island skin flap may need
to be resected, because it may sink at closure.
Transfer to the Thumb CM Joint (Fig. 13)
PIP joint transfer is the first choice. This procedure is
mainly indicated for congenital anomalies such as
Blauth type III thumb hypoplasia [7,8]. The trans-
ferred joint in the snuffbox is temporarily fixed in
a position of opposition with 120 rotation, as in
Buck-Gramcko's procedure [22]. It is not always neces-
sary to perform tendon transfer for motor reconstruc-
tion simultaneously.
MTP Joint Transfer to the Thumb CM Joint (Fig. 14)
Because of the presence of thenar muscle deficiency
in thumb hypoplasia, reconstruction of the thenar emi-
nence should be performed to achieve a cosmetically
good thumb in that case. For this purpose, second MTP
joint transfer with a large dorsal skin flap may be done.
However, this procedure should not be the first choice,
3.2. Thumb and Digit Reconstruction 423
years, but good stability of the right thumb could not be
obtained. b The second toe PIP joint was transferred to the
right CM joint. c Good function and stability of the right
thumb were obtained 6% years later. The joint space and epi-
physeal plate were well preserved
because it will produce a large skin defect at the donor
foot and necessitates coverage with the free skin flap
and the osseous fusion of the second toe with the third
one.
Pitfalls and Complications
Toe joint transfer results in inadequate joint extension.
To gain adequate extension, it has been proposed that
the strength of the flexor tendons should be weakened
by transferring the toe PIP joint, 2 to 3 mm shorter than
the resected finger joint, and that the volar plate of the
finger PIP joint should be excised to protect the joint
from flexion contracture due to scarring. We also
suggest that the extensor tendon should be sutured
tightly with the PIP joint in full extension, and that the
PIP joint should be temporarily fixed with a Kirschner-
wire to maintain the finger in a fully extended position.
Finally, great care should be taken during bone fixation
not to cause a crossing phenomenon at finger flexion.
424 E. Clinical Reconstructive Microsurgery
II
Fig. 14. a A 16-year-old girl with right hypoplastic thumb
(Blauth type III). b The absent CM joint was reconstructed
with the MP joint of the contralateral second toe and the
hypoplastic thenar eminence with the attached dorsal skin
flap. Abductor plasty by advancement of the long abductor
pollicis tendon and adductor plasty by transfer of the proper
References
1. Steichen JB (1987) Thumb reconstruction by great toe
microvascular wrap around flap. In: Urbaniak JR (ed)
Microsurgery for major limb reconstruction. Mosby, St.
Louis, pp 86-111
2. Doi K, Kuwata N, Kawai S (1985) Reconstruction of the
thumb with a free wrap-around flap from the big toe and
an iliac-bone graft. J Bone Joint Surg 67 A:439-445
3. Yoshizu T, Seki T, Makino M, Nakaya A, Sakya I, Maki Y,
Kanaya H, Yamamoto Y, Tajima T (1984) Comparison of
toe to thumb transfer with wrap around flap with distal
terminal phalanx attached in reconstruction of the thumb
(in Japanese). J Jpn Soc Surg Hand (Nitte Kaishi)
1:701-704
4. O'Brien BM, Black MJM, Morrison WA, MacLeod AM
(1978) Microvascular great toe transfer for congenital
absence of the thumb. Hand 10:113-124
extensor of the index finger were performed simultaneously.
One year later, opponoplasty with the superficial flexor of the
ring finger and fusion of both IP and MP joints were added. c
Fourteen years and 5 months postoperatively, good opposition
and powerful pinch of the thumb were restored. Joint space
was preserved without osteoarthritic changes
5. Smith RJ, Lipke RW (1979) Treatment of congenital defor-
mities of the hand and forearm. N Engl J Med 300:344-349
6. Gilbert A (1982) Toe transfers for congenital hand defects.
J Hand Surg 7:118-124
7. Yoshizu T, Watanabe M, Tajima T (1985) Experimental
study and clinical application of free toe joint transplan-
tation with vascular anastomosis. In: Tubiana R (ed) The
hand. Saunders, Philadelphia, vol 2, pp 685-697
8. Shibata M (2000) Metatarsophalangeal joint transfer for
type III-B hypoplastic thumb. In: Gupta A, Kay SPJ,
Soheker LR (eds) The growing hand. Mosby, London, pp
183-188
9. Yoshizu T (1991) Sensory reconstruction in peripheral
nerve injury of the upper limb (in Japanese). J Jpn Soc
Surg Hand (Niite Kaishi) 7:889-892
10. Morrison WA, O'Brien BM, MacLeod AM (1984) Ring
finger transfer in reconstruction of transmetacarpal
amputations. J Hand Surg 9A:4-11

11. Ohtsuka H, Torigai K, Shioya N (1977) Two toe to finger
transplants in one hand. Plast Reconstr Surg 60:561-565
12. Rose E, Buncke HJ (1980) Simultaneous transfer of the
right and left second toes for reconstruction of amputated
index and middle fingers in the same hand-case report.
J Hand Surg 5:590-593
13. Gordon L, Leitner DW, Buncke HJ, Alpert BS (1985)
Hand reconstruction for multiple amputations by double
microsurgical toe transplantation. J Hand Surg 1OA:218-225
14. Tsai TM, Jupiter JB, Wolff TW, Atasoy E (1981) Recon-
struction of severe transmetacarpal mutilating hand in-
juries by combined second and third toe transfer. J Hand
Surg 6:319-328
15. Wei FC, Chen HC, Chuang CC, Noordhoff MS (1986)
Reconstruction of a hand amputated at the metacar-
pophalangeal level, by means of combined second and
third toes from each foot: a case report. J Hand Surg llA:
340-344
16. Holle J, Freilinger G, Mandl H, Frey M (1982) Grip re-
construction by double toe transplantation in cases of a
3.2. Thumb and Digit Reconstruction 425
fingerless hand and a handless arm. Plast Reconstr Surg
69:962-968
17. Lichtman D, Ahbel D, Marphy R, Buncke HJ (1982)
Microvascular double toe transfer for opposable digits-
case report and rationale for treatment. J Hand Surg 7:
279-283
18. Wei FC, Yim KK (1995) Pulp plasty after toe-to-hand
transplantation. Plast Reconstr Surg 96:661-666
19. Foucher G, Merle M, Maneaud M, Michon J (1980)
Microsurgical free partial toe transfer in hand recon-
struction: a report of 12 cases. Plast Reconstr Surg 65:616-
626
20. Yoshizu T, Katsumi M, Watanabe M, Takano T, Narisawa
H (1987) Finger reconstruction with a modified wrap-
around flap from the big toe (in Japanese). J Jpn Soc Surg
Hand (Nitte Kaishi) 4:284-288
21. Edgerton MT (1976) The cross-hand finger transfer. Plast
Reconstr Surg 57:281-293
22. Buck-Gramcko D (1971) Pollicization of the index finger.
J Bone Joint Surg 53A:1605-1617
3.3 Brachial Plexus Injury
Y OSHIHISA AKASAKA and TETSUYA HARA
Traumatic brachial plexus injury is often caused by
traffic accidents and is particularly often seen in young
motorcyclists. Severe paralysis is common, and the
prognosis is poor in such cases. In fact, it is not rare for
function to be completely lost in one arm, so that a
young person is suddenly handicapped and deprived of
a promising future.
In the treatment of patients with complete paralysis
due to brachial plexus injury, there have been a number
of difficulties, including control of the elbow and shoul-
der joint, reconstruction of the forearm and finger func-
tions, and sensory restoration. Whole roots avulsion
injury is a particularly serious problem, because hardly
any nerves or muscles are usable for reconstructive
surgery, and therefore there has been no method of
functional reconstruction for this injury.
Intercostal Nerve Crossing
A revolution occurred in the treatment of whole roots
avulsion injury in 1963 when Seddon performed an
intercostal nerve crossing for the restoration of elbow
flexion. Seddon transferred the intercostal nerve to the
musculocutaneous nerve via autogenous nerve grafts,
but his procedure was not very successful. In 1965,
Tsuyama dissected an intercostal nerve and sutured it
directly to the musculocutaneous nerve without using a
nerve graft, and he was successful in restoring elbow
flexion with this procedure. Good results could be
obtained with Tsuyama's procedure, because nerve
suture was only performed at one site near the muscle,
so that the distance for the regenerating axon to grow
was short (Fig. 1).
With this procedure, elbow flexion was achieved by
about 80% of patients under the age of 40 who were
treated within 6 months of injury; the percentage
decreased to about 30% when treatment was per-
formed 6 months or more after injury, and to about 20%
when treatment was performed 9 months or more after
injury [1].
Based on our experience and the reports of other
investigators, nerve repair or transfer may be successful
426
if it is carried out within 6 months of injury, but the
results are not promising if surgery is performed after 9
months or more.
Restoration of Elbow Flexion by Free
Muscle Transplantation
Advances in microsurgery have made the transplanta-
tion of various tissues possible. Since 1978, we have
attempted the reconstruction of elbow flexion in delayed
cases of complete brachial plexus injury by transplanta-
tion of free muscle grafts with a neurovascular pedicle
plus intercostal nerve crossing [2] (Fig. 2).
Indication for Free Muscle Transplantation to
Restore Elbow Flexion
Free muscle transplantation to restore elbow flexion is
indicated in patients with complete paralysis who were
injured more than 9 months previously or who did not
respond to nerve grafting or intercostal nerve crossing
[3], and patients with marked fibrous degeneration of
the biceps due to combined injuries such as vascular
injury and humeral fracture.
It is preferable for patients to be under 40 years old,
with no contracture of the elbow joint and no serious
sequelae related to head trauma or spinal cord injury,
and to be motivated to undertake the therapy, includ-
ing postoperative rehabilitation.
Operative Procedure
The operative procedure (Table 1) may be summarized
in five steps: (1) preparation of the recipient area in the
upper arm, (2) mobilization of the intercostal nerve, (3)
harvest of the transplant muscle, (4) muscle transfer and
neurovascular anastomosis, and (5) wound closure.
In order to shorten the operating time, two surgical
teams may perform steps 2 and 3 simultaneously. It is
advisable to perform preoperative arteriography III
order to identify arteries suitable for anastomosis.
 3.3. Brachial Plexus Injury 427

Biceps muscle _ f-tffllllll

Fig. 1. Plan of the method of restoration of elbow flexion by

intercostal nerve crossing Fig. 2. Plan of the method of restoration of elbow flexion by
the combination of free muscle transplantation and intercostal
nerve crossing

Table 1. Operative procedure of elbow flexor reconstruction

1. Preparation of the recipient area
A. Origin of transplant muscle: coracoid process
Insertion of transplant muscle: tendo m. bicipitis
B. Artery: A. circumflexa humeri anterior (A. profunda brachii)
C. Vein: V. cephalica
Vv. brachiales
2. Mobilization of motor nerve
4th and 5th intercostal nerves
3. Removal of transplant muscle
M. rectus femoris (neurovascularized musculocutaneous flap)
4. Free muscle transplantation
A. Fixation of the muscular origin
B. Revascularization
C. Reinnervation
D. Tendon adjustment (tendon fixation)
5. Wound closure Fig. 3. The fourth and fifth intercostal nerves are mobilized
by meticulous dissection as long as possible; at that time, the
ribs are cut temporarily. (See Color Plates)
Preparation of the Recipient Area
The skin is incised along a line joining the coracoid
process to the biceps insertion in the upper arm. Both Mobilization of the Intercostal Nerves
the coracoid process and the biceps tendon insertion are It is essential to provide an intact motor nerve supply
prepared for reception of the transfer muscle. for the transplanted muscle. Since all nerves to the arm
The pectoralis major is cut at the border of the are paralyzed, they cannot be used as motor nerves for
humerus for wide exposure of the axillary and brachial the transplanted muscle. Therefore, two intercostal
arteries and veins. The anterior circumflex humeral nerves are chosen as the motor supply. The fourth and
artery, the profunda brachii artery, or the thoracodorsal fifth intercostal nerves are mobilized atraumatically
artery is prepared as the feeding artery for the grafted and left as long as possible (Fig. 3). The nerves are then
muscle. Venous drainage is effected via the cephalic vein turned over through the axilla into the medial side of
or the venae comitantes of the brachial artery. the upper arm.
428 E. Clinical Reconstructive Microsurgery
Fig. 4. After the origin of the transplanted muscle has been
attached, neurovascular anastomosis is carried out under the
surgical microscope. (See Color Plates)
Harvest of the Transplant Muscle
We favor the rectus femoris for grafting because of its
size, its shape, its muscle power, and the anatomical
aspects of its neurovascular pedicle. The muscle is
removed together with the overlying skin flap and
neurovascular pedicle.
Muscle Transplantation
First, the origin of the transplanted muscle is attached to
the coracoid process and the muscle is loosely sutured in
place in order to provide stability during the neurovas-
cular anastomosis. Then, neurovascular anastomosis
is carried out under the surgical microscope, beginning
with the artery and following with the vein. Technically
perfect anastomoses are vitally important (Fig. 4).
The nerve repair is one of the most decisive aspects
of the procedure in determining muscle function. Two
intercostal nerves are sutured directly to the motor
nerve of the transplanted muscle with precise apposi-
tion, without tension, and without the use of a nerve
graft. The nerve repair should be performed as close as
possible to the neuromuscular junction.
Finally, the distal portion of the transplanted muscle
is sutured to the biceps tendon. At this time, the muscle
should be attached with normal resting tension and with
the elbow in 80 degrees of flexion [4].
Wound Closure
The chest and thigh wounds may be closed by direct
suture. The arm wound is closed by utilizing the skin
flap overlying the transplanted muscle. A drain may be
helpful to minimize the risk of compromise of the muscle
and its neurovascular anastomoses by hematoma.
After surgery, the arm is immobilized in a splint with the
shoulder in slight abduction and the elbow at a right
angle.
Postoperative Management
In the postoperative period, the arm is immobilized for
about 5 weeks, followed by restricted elbow extension
with a sling for an additional 3 weeks. At 8 weeks after
the operation, elbow extension by gravity and passive
exercise are performed in order to prevent flexion
contracture.
Approximately 6 months after the operation, one
may observe contractions of the transplanted muscle
in synchrony with the respiratory rhythm. At this
time muscle, contraction may be strengthened by the
performance of elbow flexion during deep inspiration.
When muscle contraction approaches a strength of
M3, elbow flexion and muscle-strengthening exercise
are encouraged. This eventually results in dissocia-
tion of muscle activity from the respiratory rhythm
and maintains contraction during the expiratory
phase.
Reconstruction of a Wrist Extensor
We have conventionally performed reconstruction by
intercostal nerve crossing for the elbow flexor and
arthrodesis of the shoulder and wrist joint in all cases of
complete palsy due to avulsion injury of the brachial
plexus. Following such a procedure, the patient could
suspend objects from the forearm and hold them under
the arm. But until now we have not had any method of
restoring wrist and finger function in these injuries,
because no suitable muscle is available for tendon
transfer and the motor point of the forearm muscles
is located distally.
After the feasibility of functional reconstruction
using free muscle transplantation had been confirmed,
reconstruction of a wrist extensor by this technique
using the fifth and sixth intercostal nerves, in addition
to the reconstruction of an elbow flexor using third and
fourth intercostal nerve crossing, was performed. We
choose the wrist extensor as the first step toward func-
tional restoration below the elbow joints according to
Zancolli [5] in the functional restoration of paralytic
hands due to cervical injury.
Operative Procedure
The operative procedure used (Fig. 5) is very similar to
that for the elbow but utilizes the gracilis muscle with
an overlying skin flap. The incision should be planned
carefully to permit good exposure of vascular structures
and the sites of origin and insertion of the muscle
(Table 2).

Fig.5. Plan of the method of restoration of wrist extension by
the combination of free muscle transplantation and intercostal
nerve crossing in addition to the reinnervation of the elbow
flexor by intercostal nerve crossing
Preparation of the Recipient Area in the Upper Arm
and Forearm
The incision should be planned carefully to allow good
exposure of the vascular structures and the site of origin
and insertion of the muscle. Flap cover must include the
distal portion of the muscle and tendon to ensure good
gliding.
Two incisions are required. The first is made on the
medial aspect of the upper arm in order to expose the
musculocutaneous nerve and to draw out the intercostal
nerve through the axilla. The second incision extends
from the lateral aspect of the upper arm across the
lateral epicondyle as far as the wrist joint. The radial
artery, the cephalic vein, and the venae comitantes of
the radial artery are prepared as the recipient vessels.
For the motor nerve supply, four intercostal nerves-the
third to the sixth-are mobilized. These four intercostal
nerves are divided into two groups: one is for the mus-
3.3. Brachial Plexus Injury 429
Table 2. Wrist extensor reconstruction by free muscle
transplantation
Transplant muscle: M. gracilis
Artery: A. radialis
Vein: V. cephalica antebrachii
V v. radiales
Motor nerve: 5th and 6th intercostal nerves (3rd and 4th intercostal
nerves-Musculocutaneous nerve)
Origin of muscle: shaft of humerus
Insertion of muscle: extensor carpi radialis birevis
culocutaneous nerve, and the other is for the new wrist
extensor.
Muscle Transfer and Neurovascular Anastomoses
The origin of the transplanted muscle is attached to the
shaft of the humerus in order to ensure end-to-end
anastomosis of the gracilis motor nerve with the inter-
costal nerves. Its insertion is sutured to the extensor
carpi radialis brevis tendon. Neurovascular anasto-
mosis is performed under a surgical microscope. Nerve
suture is carried out between the musculocutaneous
nerve and the third and fourth intercostal nerves, and
between the motor nerve of the transplanted muscle
and the fifth and sixth intercostal nerves. Free nerve
grafts are not used, only direct epineural sutures. In
relation to the tension in the transplanted muscle, the
anastomosis is performed with the elbow at 50 degrees
of flexion and the wrist in 70 degrees of dorsiflexion
(Fig. 6).
Postoperative management follows the course de-
scribed for the elbow procedure.
Results and Problems with
our Procedure
Since 1978, we have performed restoration of elbow
flexion by free muscle transplantation. This technique
has achieved elbow flexion of at least 90 degrees with
muscle power of M4 or more in 60% of treated patients.
The patients with a successful outcome can suspend a
weight of 2 to 4kg from the forearm (Fig. 7).
With forearm reconstruction, muscle power of M3
could be achieved in approximately 60% of the treated
patients at around 1.5 years postoperatively, but they
remained weak and it was difficult to restore the pinch-
ing and grasping function through dynamic tenodesis
(Fig. 8). Possible reasons for this are that the trans-
planted muscle originally acted across two joints and
thus showed a low efficiency; elbow control could not
be achieved; the intercostal nerve contained insufficient
430 E. Clinical Reconstructive Microsurgery

Fig.6. Free muscle transplantation for the restoration of wrist ensure end-to-end anastomosis of the motor nerve of the gra-
extension. Four intercostal nerves are prepared for the motor cilis with the intercostal nerves without the use of a free nerve
nerve of the elbow flexor and wrist extensor. The gracilis graft. Neurovascular anastomosis is carried out under the sur-
muscle is attached to the shaft of the humerus in order to gical microscope. (See Color Plates)

Fig. 7. A 23-year-old man suffered a fracture of the left humerus, complete paralysis of the
left arm, and rupture of the subclavian artery of the left side. Ten months after the accident,
he was referred to us, and we performed free muscle transplantation. The photographs show
the patient 26 months postoperatively. The range of motion of the elbow joint was 25-135
degrees, and he was able to suspend a weight of 4 kg from his forearm

Fig. 8. A 21-year-old man suffered complete brachial plexus
injury of the left arm. He was referred to us 3 months later, at
which time there was no sign of recovery from C5 to Th1. The
brachial plexus was exposed 5 months after the accident, and
it was found that levels C5 to C8 were avulsed. Six months
motor nerve fibers because the distal portions of these
nerves were employed; or the distal portion of the
grafted muscle underwent adhesion. In recent years,
reconstruction using the accessory nerve [6] or the con-
tralateral C7 root has been studied intensively for
the treatment of brachial palsy. Therefore, it may be
necessary to develop a more effective reconstruction
technique, including combined use of such nerves.
References
1. Nagano A, Tsuyama N, Ochiai N, Hara T (1989) Direct
nerve crossing with the intercostal nerve to treat avulsion
injuries of the brachial plexus. J Hand Surg 14A:980-985
3.3. Brachial Plexus Injury 431
after the accident, we performed reconstruction of the wrist
extensor by free muscle transplantation, plus reconstruction
of the elbow flexor by intercostal nerve crossing. Function 3
years after the surgery is shown. With the attachment of an
opponens splint, he can pick up a 2- to 3-cm block
2. Akasaka Y, Hara T, Takahashi M (1990) Restoration of
elbow flexion and wrist extension in brachial plexus paral-
yses by means of free muscle transplantation innervated by
intercostal nerve. Ann Hand Surg 9:341-350
3. O'Brien BM (1977) Microvascular reconstructive surgery.
Churchill Livingstone, London, pp 290-305
4. Manktelow RT (1979) Muscle transplantation. In: Serafin
D, Buncke HJ (eds) Microsurgical composite tissue trans-
plantation. Mosby, St. Louis, pp 369-390
5. Zancolli EA (1979) Structural and dynamic bases of hand
surgery, second ed. IB. Lippincott Company, Philadelphia
& Toronto, pp 229-262
6. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S (1995) Double
free-muscle transplantation to restore prehension follow-
ing complete brachial plexus avulsion. J Hand Surg 20A:
408-414
3.4 Congenital Radioulnar Synostosis
FUMINORI KANAYA
Congenital proximal radioulnar synostosis is charac-
terized by a fixed forearm rotation from neutral to
maximum pronation. It can be extremely disabling,
especially when it occurs bilaterally or fixed at more
than 60 0 pronation. Patients with severe deformity have
trouble getting a cup to the mouth, using utensils, or
accepting objects in an open palm [1]. We devised a
new mobilization procedure for congenital proximal
radioulnar synostosis [2] and present our results.
Early reports of the operative treatment of con-
genital radioulnar synostosis described restoration of
motion by resection of the synostosis and interposition
of fat, aponeurosis, synthetic materials [3], or muscle
flaps [4]. We found only 23 mobilizations in the English
medical literature [5-9]. Miura et al. [8] operated on
eight hands in seven patients. They placed the anconeus
between the separated radius and ulna. Dal Monte et al.
[9] released the synostosis in 12 patients by removing
the part of the radius that was proximal to the synosto-
sis and, in some patients, by using aponeurotic or muscle
flaps to obtain and preserve forearm rotation. They
reported recurrence of a synostotic bridge in every
patient. Sachar et al. [7] reviewed the literature and sub-
sequently did not recommend the mobilization proce-
dure in any circumstances. The only patient who had a
successful result (reported by Dawson [5] in 1912) was
a 33-year-old woman who gained a 60 0 arc of motion
after five operations.
Operative Technique
The operation consists of four procedures: separation of
the synostosis, radius osteotomy, soft-tissue reconstruc-
tion, and a vascularized fascio-fat graft (Fig. 1).
Separation of the Synostosis
A computed tomogram (CT) before surgery helps to
determine the direction of separation (Fig. 2) [1OJ.
Separation of the synostosis was done through both
anterior and posterior approaches. The posterior
approach from the lateral epicondyle to the posterior
crest of the ulna was done first. The anconeus was
432
reflected proximally to expose the posterior aspect of
the synostosis (Fig. 3). The interosseous recurrent
vessels were a good landmark to identify the distal
border of the synostosis. Synchondrosis between the
radius head and ulna was seen in all patients.
Separation of the synchondrosis and synostosis was
accomplished with a steel burr on a high-speed drill. In
addition, the drill was used to shave the radius and ulna
1 cm distal to the synostosis, which usually interfered
with forearm rotation. The biceps tendon, primarily
attached to the volar aspect of the synostosis, was
inevitably detached during separation of the synostosis.
A 2-0 silk suture was placed to the biceps tendon, which
was pulled dorsally and dissected from the surrounding
tissue (Fig. 4).
After separation of the synostosis and synchondrosis,
the radius head was inspected. The annular ligament
could not be identified in the patients with severe dis-
location of the radius head. The anteriorly dislocated
radius head was relatively flat, whereas, the posteriorly
dislocated radius head, which was conical, was trimmed
flat in the sagittal plane and semicircularly in the hori-
zontal plane with a knife and a steel burr (a normal
radius head is concave in the sagittal plane and circular
in the horizontal plane). Exposure of the epiphyseal
nucleus was carefully avoided. The joint capsule and
annular ligament, if any, were preserved as much as pos-
sible and were dissected from the radius head.
Attention was then turned to the anterior exposure.
A hockey-stick incision whose transverse limb was
along the cubital crease and that extended distally
approximately 5 cm in length was designed. The biceps
and brachialis tendons, the brachial, radial, and radial
recurrent vessels, and the median and radial nerves
were identified. Soft-tissue dissection of the anterior
aspect of the synostosis improved forearm rotation.
After separation was completed, more than 100 of 0
forearm rotation was achieved.
Radius Osteotomy
The radius is longer than the ulna in all patients with
the synostosis [11]. A shortening osteotomy of the radius

a b
Fig. 1. Schematic drawings showing the operative procedure.
(From [2], with permission) a The synostosis and synchondro-
sis are resected (dotted line), and a trapezoid bone is removed
to reduce the dislocated radius head. b The radius head is
reduced and the distal fragment is supinated. The radius is
fixed with a four-hole titanium plate. c A vascularized fascio-
is usually necessary to avoid dislocation of the radius
head. The amount of bone resection was determined
preoperatively from the discrepancy of the radius length
and ulna length compared with that of the contralateral
forearm. A flexion osteotomy was added when the
radius head was dislocated posteriorly, and an extension
osteotomy was added when the radius head was dis-
located anteriorly. When the radius was fixed, the distal
radius was supinated to make the center of rotation to
the neutral rotation. However, the desired rotation was
not always achieved because of tightness of the soft
tissue.
The osteotomized radius was fixed with a four-hole
titanium plate.
Soft-Tissue Reconstruction
The anconeus muscle was pulled anteriorly and sutured
to the brachialis tendon to fill the proximal space
created by separation of the synostosis. The detached
biceps tendon was pulled dorsally and sutured to the
dorsal cortex of the radius with a 3-0 nonabsorbable
suture to strengthen the supination force of the biceps.
The dissected capsule around the radius head and
annular ligament, if any, was carefully reefed.
Vascularized Fascio-Fat Graft
A vascularized fascio-fat graft with a small skin flap for
monitoring was harvested from the ipsilateral upper
arm. The surgical procedure was identical to that for
3.4. Congenital Radioulnar Synostosis 433
c
fat graft is inserted in a volar to dorsal direction between the
separated radius and ulna. The small skin flap to monitor via-
bility of the flap is positioned dorsally. The profunda humeri
(donor) vessels are anastomosed to the radial recurrent
(recipient) vessels
harvesting a lateral upper arm flap, with the profunda
humeri vessels serving as the donor vessels. The fascio-
fat graft was 1 cm longer and wider than the space
created by separation of the synostosis. The graft was
placed in the space between the separated radius
and ulna in a volar to dorsal direction. The profunda
humeri vessels (donor vessels) were anastomosed
with the recurrent radial vessels (recipient vessels).
The monitoring skin flap was sutured to the dorsal
skin.
Postoperative Management
An above-the-elbow plastic cast was applied, with the
elbow in 90 of flexion and the forearm in neutral rota-
tion. After 3 weeks, the cast was removed and active-
motion exercises (playing with toys, swimming, and
throwing a ball) were encouraged. After 3 months, we
encouraged patients to participate freely in sports
activities.
Case Presentation
An 8-year, 2-month-old boy had a congenital radioul-
nar synostosis in the left forearm, which was ankylosed
in neutral rotation. He complained of difficulty in
performing gymnastics. The roentgenogram and CT
revealed complete proximal radioulnar synostosis (Figs.
5 and 6). He underwent this procedure. Since the radius
head tended to dislocate posteriorly and laterally after
434 E. Clinical Reconstructive Microsurgery

Fig. 3. Exposure of synostosis through posterior approach in

an 8-year, 2-month-old boy. The forearm is seen from behind
with elbow flexion at 90. Top is distal and bottom is proximal.
The anconeus is reflected proximally to expose the synostosis
(arrowheads). The arrow indicates the radial head

Fig. 2. A series of computerized tomograms (CT) taken at

a lO-mm interval and its three-dimensional reconstruction.
This patient shows posterior dislocation of the radius head
and pronation ankylosis at 80. The direction of separation
(arrows) changes by almost 80 from the proximal and distal
borders of the synostosis

separation, a 3-mm shortening osteotomy with some

flexion and varus was performed.
Two years and 7 months after surgery, there was no
recurrence of the synostosis (Fig. 7), he had 40 of
supination and 60 of pronation, and his performance in
gymnastics was improved.

Results
We performed this procedure On 18 patients (16
boys and 2 girls). Neither circulation problems nor
neurological complications have occurred, except for
transient radial nerve palsy in one patient. All patients
reported improvement in the ability to perform gym-
nastics, throw a ball, hold a bowl of soup, and accept
Fig. 4. Completion of separation of the synostosis. The
forearm is seen from behind. Separation of the synostosis is
completed. The interval between the radius and the ulna is
widened with a disk spreader. The biceps tendon (arrow),
which was attached to the anterior aspect of the synostosis, is
retracted dorsally by pulling a 2-0 silk suture

a,b
Fig. 5. Preoperative roentgenogram. a Anteroposterior
roentgenogram showing proximal radioulnar synostosis. b The
radius head is not dislocated in the lateral roentgenogram
ab
Fig. 6. Preoperative CT and three-dimensional reconstruc-
tion. a CT shows the complete radioulnar synostosis. b Three-
dimensional reconstruction reveals the synostosis without
dislocation of the radius head.
objects such as coins. No patients had recurrence of the
ankylosis. The average range of motion of five patients
followed up for more than 3 years was 83; the average
supination was 26 (range, 10 to 45); and the average
pronation was 56 (range, 30 to 80).
Conclusion
A rotation osteotomy to achieve a neutral or slightly
pronated position is currently the treatment of choice
for the patient whose forearm is fixed with more than
3.4. Congenital Radioulnar Synostosis 435
a,b
Fig. 7. Roentgenograms taken 2 years and 7 months postop-
eratively. a Anteroposterior roentgenogram showing mainte-
nance of the separation between the radius and the ulna. The
translucent area between the radius and ulna indicates pres-
ence of the transplanted fat. b Lateral roentgenogram showing
union of osteotomy site. No dislocation of the radius head is
seen
60 pronation [12]. Mobilization of a proximal radio-
ulnar synostosis is still a challenge for orthopedic sur-
geons. However, successful mobilization in children will
improve their activity more than rotational osteotomy.
Providing the ability to rotate the forearm will improve
a child's activities of daily living and will add more
choice in future endeavors.
References
1. Cleary JE, Orner GE (1985) Congenital proximal radio-
ulnar synostosis. J Bone Joint Surg 67 A:539-545
2. Kanaya F, Ibaraki K (1998) Mobilization of a congenital
proximal radioulnar synostosis with use of a free vascu-
larized fascio-fat graft. J Bone Joint Surg 80A:1186-
1192
3. Ogisyo N, Tajima T, Saito H, Yoshizu T, Shibata M (1991)
Surgical treatments for radio-ulnar synostosis. J Jpn
Orthop Surg 65:S554
4. Yabe Y (1971) A new operation for the congenital radio-
ulnar synostosis (in Japanese). Seikeigeka (Orthop Surg)
22:900-903
5. Dawson HGW (1912) A congenital deformity of the
forearm and its operative treatment. Br Med J 2:833-
835
6. Hansen OH,Andersen ON (1970) Congenital radio-ulnar
synostosis. Acta Orthop Scand 41:225-230
7. Sachar K, Akelman E, Ehrlich MG (1983) Radioulnar
synostosis. Hand Surg 8A:829-838
8. Miura T, Nakamura M, Suzuki M, Kanie J (1984)
Congenital radio-ulnar synostosis. J Bone Joint Surg
9B:153-155
436 E. Clinical Reconstructive Microsurgery
9. Dal Monte AD, Andrisano A, Mignani G, Bungaro P
(1987) A critical review of the surgical treatment of
congenital proximal radio-ulnar synostosis. Ital J Orthop
Traumatol13:181-186
10. Kanaya F (1997) Mobilization of congenital proximal
radio-ulnar synostosis. Techn Hand Upper Extremity Surg
1(3):183-188
11. Tachdjian MO (1990) Pediatric orthopaedics. 2nd edn,
WB Saunders, Philadelphia, pp 180-184
12. Simmons BP, Southmayd WW, Riseborough EJ (1983)
Congenital radioulnar synostosis. J Hand Surg 8:829-
838
3.5 Congenital Pseudarthrosis
SATOSHI TOH, KENJI TSUBO, and SHUNSUKE NARITA
Congenital pseudarthrosis is a rare condition and
remains one of the most difficult conditions to treat in
pediatric orthopedic surgery. Especially, pseudarthrosis
of the forearm is extremely rare compared to that of the
tibia. About 60 patients in the English literature [1] and
4 in the Japanese literature have been reported [2-4].
On the other hand, there are many reports about the
treatment of the congenital pseudarthrosis of the tibia.
For these conditions, numerous surgical techniques
have been attempted with varying degrees of suc-
cess, including bone grafting, fixation and combination
with electrical stimulation. For most established pseu-
darthrosis, initial treatment should be intramedullary
rod ding and bone grafting in North America. As the
primary treatment for pseudarthrosis in both the tibia
and forearm, vascularized fibula graft has achieved a
union rate of almost 100% [1,5]. Various problems are
associated with this method, however, including the long
period of treatment needed until gait is possible without
a brace in the tibia and the hand can be used without a
brace in the forearm; there are also associated compli-
cations such as refracture of the reconstructed bone, leg
length discrepancy, and valgus ankle deformity in the
cases with tibia pseudarthrosis. In this chapter, we will
introduce operative procedures using the vascularized
fibula graft for pseudarthrosis of both the tibia and the
forearm.
Congenital Pseudarthrosis of
the Tibia
Treatment using free vascularized fibular grafting
(FVFG) for congenital pseudarthrosis of the tibia was
first reported by Chen et al. from China in 1979 [6]. In
the Japanese literature, Takahashi et al. first described a
case treated by FVFG from the ipsilateral leg in 1979
[7]. Since then, many papers about treatment using
FVFG have been published. Vascularized bone grafting
facilitates good bony fusion, but refracture of the graft
occurs in many cases [8-10].
We have used FVFG as the first treatment option for
this condition for the past 15 years. Based on our expe-
rience, we feel that FVFG is a reliable procedure to
achieve tibial bony union. Gilbert and Brockman [5]
stated that vascularized fibular transplantation was the
safest technique to treat congenital pseudarthrosis of
the tibia. However, in our series, some cases were com-
plicated by severe valgus ankle deformities and/or
fractures of the graft, making secondary procedures or
long-term immobilization necessary.
Over the course of our experience with these cases,
we have made gradual improvements in this technique.
One of the most important improvements was to try to
reconstruct not only the recipient tibia but also the ipsi-
lateral fibula simultaneously using a divided vascu-
larized fibula (Fig. 1). Another was to use an Ilizarov
external fixator for immobilization, permitting the
patient to walk as soon as possible. The patient treated
by this method, combining a two-folded FVFG to
reconstruct the recipient tibia and ipsilateral fibula and
immobilized in an Ilizarov external fixator, had the best
clinical course of our series.
Indications and Timing of Surgery
In patients with pseudarthrosis, surgery should be per-
formed as soon as possible to prevent leg length dis-
crepancy. However, in patients with anterior bowing
without nonunion (so-called high-risk tibia), surgery
may be delayed, depending on the progression of
leg length discrepancy and curvature of the anterior
bowing. If there is no fracture, a non-weight-bearing
brace should not be used, because it may cause bone
atrophy.
Preoperative Management
Angiography of both lower legs, or at least the recipi-
ent site, is necessary to select the recipient artery and
the mode of vessel anastomosis, whether side-to-end
or end-to-end, and to determine whether a vein graft
will be necessary. In our series, all recipient arteries were
anterior tibial arteries and were sutured end-to-end.
437
 438 E. Clinical Reconstructive Microsurgery
B,b
Fig. I.a,b Reconstruction of the recipient tibia and fibula
simultaneously using a divided vascularized fibula in a 5-year,
3-month-old girl. a Preoperative radiograph. b Radiograph
made 4 years after the operation demonstrating good recon-
struction of both tibia and fibula
The most important and difficult point to decide is the
length of the pathological pseudarthrosis site resection.
Based on the X-ray findings, the pathological pseu-
darthrosis site should be resected as much as possible,
including the thickened sclerotic cortical bone, nar-
rowed intramedurally canal, and surrounding soft tissue
with periosteum. The residual recipient tibia should be
retained at least 2 to 3 cm distally so that both ends of
the grafted bone can be inserted into the intramedul-
lary canal of the recipient tibia in inlay fashion.
However, because the pseudarthrosis site usually exists
at the distal one-third of the tibia, sometimes the resid-
ual distal part of the recipient tibia is not long enough.
Therefore, in cases of established nonunion, the length
of distal tibia that can be resected at the recipient site
may be limited by necessity.
A Doppler flowmeter is used preoperatively to deter-
mine the point at which the peroneal artery gives off its
cutaneous branches, and the monitoring flap with this
perforator can be used as the monitor of graft circula-
tion postoperatively.
The method of choice for immobilization after graft-
ing is the Ilizarov external fixator, which should be con-
structed preoperatively and checked by X-ray after it
has been sterilized for surgery (Fig. 4b).
Operative Procedure
The operating room staff needs to understand that two
surgical teams will be working simultaneously, and that
surgery will last 6 to 9 h and require fitting of an Ilizarov
external fixator. The operation is performed under
general anesthesia with the patient in the supine posi-
tion, with a small pillow under the buttocks to lift the
donor extremity slightly. A tourniquet is used during the
course of the dissection, which is performed under 2.5
magnification with a binocular loupe.
Following the standard procedure for isolating a
vascularized fibula graft on the peroneal vessels, the
fibula is divided into two segments without cutting the
vessels (see chapter D.2.3.1). To prevent the develop-
ment of valgus ankle deformity in the donor leg, distal
tibiofibular metaphyseal synostosis should be
performed primarily (see chapter D.2.3.1). For immobi-
lization, a short leg cast is necessary until bony fusion is
achieved.
Dissection of the Recipient Lower Leg
A longitudinal, curved skin incision is made in the
anterolateral aspect of the lower leg between the tibialis
anterior and the extensor digitorum longus muscle,
extending proximally and distally depending on the
expected length of fibula to be harvested (Fig. 2a). The
incision is carried through the skin and subcutaneous
tissue to the fascia overlying the interval between the
tibialis anterior and the extensor digitorum longus
muscle. Then the interval is identified and, using careful
dissection technique, the anterior tibial muscle is sepa-
rated from the extensor hallucis longus to expose the
anterior tibial artery, its concomitant veins, and the
deep peroneal nerve (Fig. 2b). Because the diameters
of the venae comitantes of the anterior tibial artery
are usually smaller than those of the venae comitantes
of the peroneal artery of the donor bone, we prefer
to use the great saphenous vein as one of the two
recipient veins. The great saphenous vein is exposed
beneath the subcutaneous tissue along the medial side
of the lower leg (Fig. 2c). These vessels are separated
from the surrounding tissue and protected by vascular
tape.
The tibia is exposed subperiosteally by an incision
along the midline of its medial surface. At the site of
pseudarthrosis, the tibia is resected with the periosteum
for the length that was decided according to X-ray find-
ings preoperatively (Fig. 3a). By using the reamer and
surgical airtome, a slot defect is created in the medul-
lary cavity at both ends of the recipient tibia to fit the
diameter of the grafted fibula, which is inserted into the
recipient tibia as an inlay graft. The depth of the slot
must be at least 2 to 3 cm, enough to fix the graft using
Kirschner wires. After the fibula has been dissected and
before the vascular pedicle is cut, the fibula that will be
transferred is measured. A silicone block is then made
a

Fig. 2. Schematic drawings showing the operative procedure. a Longitudinal, curved skin incision. b Exposure of the anterior
tibial artery, its concomitant veins, and the deep peroneal nerve. c The great saphenous vein is exposed

Silicone
block

Fig. 3. Schematic drawings showing the operative procedure. recipient tibia and microvascular anastomosis. d Skeletal
a Resection of the pseudarthrosis site. b Creating a slot defect fixation of the recipient fibula and fitting the Ilizarov external
and using a silicone block as a trial. c Skeletal fixation of the fixator
440 E. Clinical Reconstructive Microsurgery
in the same size and is used as a trial to obtain a proper
fit in this procedure (Fig. 3b). This trial is very impor-
tant to prevent a prolonged ischemic time of the grafted
bone after harvesting. If the slot of the tibia is made to
match the ends of the grafted fibula after harvesting
from the donor lower leg, the ischemic time of the graft
will be too long. At this point in the procedure, the posi-
tion for suturing the vessels and the length of the vas-
cular pedicles of both the graft and the recipient sides
are decided. The vascular pedicle of the grafted fibula
should be placed on the anterior side of the lower leg
when the fibula is grafted to the recipient tibia, and this
should be considered when deciding the length of the
vascular pedicle and position of the anastomosis site.
After this, the tourniquet is released and meticulous
hemostasis is performed.
An inlay graft of the divided proximal fibula to the
recipient tibia is performed. At this time, it is very
important to correct the alignment of the lower leg so
that it is the same as that of the opposite healthy leg.
Usually the patient's ankle on the healthy side has a
slightly varus position in infants, and there is a tendency
for the recipient ankle to develop valgus ankle after this
operation. We therefore fix the graft to the tibia so
that the ankle is in the varus position. To encourage
osteosynthesis between the graft and recipient tibia, 1.5-
mm Kirschner wires are used. The periosteum flap
attached to the proximal and distal donor bone should
adequately cover the recipient tibia (Fig. 3c).
Once the graft is in place, the operating microscope
is positioned, and end-to-end vascular anastomoses
are performed, using the anterior tibial artery, one of
its venae comitantes, and the great saphenous vein as
recipient vessels. Because the anastomosis site should
be as superficial as possible rather than deep, the length
of the recipient and donor vascular pedicles should be
carefully considered (Fig. 3c).
Next, the divided distal fibula is passed through the
deep layer of the tibialis anterior muscle, extensor hal-
lucis longus muscle, and extensor digitorum longus
muscle to the site of pseudarthrosis of the fibula.
The graft is fixed with an intramedullary Kirschner wire
extending from the lateral malleolus into the proximal
fibula. To improve stabilization, including that of the
ankle joint, we apply an Ilizarov external fixator to the
tibia and calcaneus using 1.5 Kirschner wires (Fig. 3d).
The external fixator is necessary to prevent injury to the
vascular pedicle and to maintain the proper alignment
of the lower leg. Pins should not be inserted into the
grafted thin fibula, the site of anastomosis of the vessels,
or the part passing through the main artery and nerve.
However, insertion of pins into the recipient tibia in
which both intramedullary ends contain grafted fibula
will not cause any problems.
Postoperative Care and Monitoring
Anticoagulant such as urokinase (60,000 units per day)
is administered intravenously for 1 week. Heparin is not
used. A minimum of 1 or 2 weeks of bed rest and
elevation of the affected limb is necessary. The flap
attached to the grafted fibula should be frequently mon-
itored for changes in color, temperature, and Doppler
sounds to assess vascularity and circulation.
When bony union is seen on X-ray, usually about 2
months postoperatively, the patient is permitted to walk
with an Ilizarov external fixator. The external fixator is
replaced by the short leg brace when the diameter of
the grafted fibula matches that of the recipient tibia and
good incorporation of the graft is seen. The brace is
removed about 6 months later if the course is unevent-
ful. Until bone maturity is achieved, the patient should
be followed twice a year with X-ray and clinical ex-
amination of not only the affected lower extremity but
also the donor leg (Fig. 4).
Congenital Pseudoarthrosis of
the Forearm
Treatment of this condition by FVFG was first reported
by Tamai et al. in 1980 [3]; however, the first actual
FVFG was performed by Ueba et al. in December 1973
[2] (Fig. 5). Since then, 20 FVFGs have been reported
in the English literature [1] and 4 in the Japanese liter-
ature [2-4]. According to these reports, FVFG has
achieved the best union rate among the reported pro-
cedures [1]. The problems encountered include delayed
union and secondary fracture, as with FVFG for the
tibia. To prevent this, the periosteum of the grafted
fibula should sufficiently overlap both the distal and the
proximal junctions between the grafted bone and the
recipient bone. Careful excision of the abnormal tissue,
while preserving the distal epiphysis, and stable fixation
of the grafted bone are recommended for good results.
Indications and Timing of Surgery
As with pseudarthrosis of the tibia, the procedure should
be performed as early as possible to prevent progres-
sive deformities of the forearm, such as dislocation of
the radial head and osteoarthritic changes of the elbow
or wrist joint.
Operative Procedure
Except for the use of an ordinary hand operating
table, the position of the patient, anesthesia, and dis-

ab
e,f
Fig. 4. Sequence of treatment and follow-up in a 2-year, 5-
month-old girl at the time of the operation. a Preoperative
anteroposterior radiograph. b Preoperative lateral radiograph
putting together the Ilizarov external fixator. c Anteroposte-
rior radiograph after the operation. d Clinical view of the
patient with Ilizarov external fixator 2 months after the opera-
tion. e Anteroposterior radiograph made 2 months after
the operation, demonstrating hypertrophy of the graft. f, g
3.5. Congenital Pseudarthrosis 441
c,d
g,h
Anteroposterior and lateral radiographs made 4 months after
the operation, demonstrating good reconstruction of both
tibia and fibula. h, i Anteroposterior and lateral radiographs
made 6 years after the operation, demonstrating good recon-
struction of the tibia. The junction between the graft and the
distal part of the recipient fibula was fibrous-union, but valgus
ankle deformity did not worsen postoperatively. j, k Clinical
result 6 years after the operation
442 E. Clinical Reconstructive Microsurgery
b
c screw fixation is also available to use for osteosynthesis.
Fig. S. The first case in the world of free vascularized fibular
grafting for congenital pseudarthrosis of the forearm (Cour-
tesy Dr. Yasuo Ueba). a Radiograph after initial right ulna
fracture in 10-year-old boy. b Radiograph prior to vascular-
ized fibula transfer. The patient had three operations within
22 months after the initial fracture, including osteosynthesis
by Kirschner wire, bone grafting with screw, and bone graft-
ing with plate and screw fixation, but all failed. c Postopera-
tive angiogram
section of the graft are the same as for pseudarthrosis
of the tibia.
Depending on the site of pseudarthrosis, the nutrient
vessels to be used are different. In cases of reconstruc-
tion of the radius, the radial artery and cephalic vein are
usually used for anastomosis to the peroneal artery and
vein of the grafted fibula. On the other hand, in cases
with ulna reconstruction, the ulnar artery and basilar
vein are used for the recipient vessels.
In cases with pseudarthrosis of the radius, an antero-
lateral incision is performed to expose the radial artery,
the cephalic vein, and the radial pseudarthrosis. At the
------------------ --------_.-'" ~
----------------<~:~!~
a
Cephalic vein
Radial artery Peroneal artery b
Fig. 6. Schematic drawings of operative procedure for recon-
struction of the radius. a Skin incision. b The periosteum flap
attached to the proximal and distal donor bone adequately
covers the recipient radius
site of pseudoarthrosis, the radius is resected with the
periosteum to preserve the distal radial epiphysis as
much as possible. The surrounding abnormal soft tissue
is also resected. The residual bone defect of the radius
is replaced by a vascularized fibular graft. The graft is
fixed to the radius with an intramedullary K-wire and
supplemented with another K-wire to cross between the
grafted fibula and the recipient radius. Small plate and
It is most important when using this method to be
sure that the periosteum flap attached to the proximal
and distal donor bone adequately covers the recipient
radius. End-to-end anastomosis is performed between
the peroneal artery and the radial artery and between
the peroneal vein and the cephalic vein (Fig. 6). The
standard procedures are followed for monitoring blood
circulation for an attached skin flap.
Postoperative Care
A long arm cast with a window for monitoring the flap
is applied until the solid union is seen on radiographs.
The K-wire is removed 2 to 3 months postoperatively
after early union between the grafted bone and recipi-
ent bone has been achieved. After removal of the K-
wire, further immobilization by a long arm cast or brace
is necessary to achieve solid union.
References
1. Witoonchart K, Uerpairojkit C, Leechavengvongs S,
Thuvasethakul P (1999) Congenital pseudarthrosis of the

forearm treated by free vascularized fibular graft: a report
of three cases and a review of the literature. J Hand Surg
24A:I045-1055
2. Ueba Y, Fujikawa S (1983) Nine years follow-up of a vas-
cularized fibular graft in neurofibromatosis-a case report
and literature review. Orthop Surg Traumatol (Jpn)
26:595-600
3. Tarnai S, Sakamoto H, Fukui A, Shimizu T, Kamikubo T,
Masuhara K, Tatsumi Y (1983) Vascularized fibula graft
for the treatment of congenital pseudarthrosis of long
bone. Orthop Surg Traumatol (Jpn) 26:601-612
4. Ikeda K, Yamauchi S, Shimamura K, Yonezawa K,
Miyazaki S, Nomura S (1988) Two cases of congenital
pseudarthrosis. Orthop Surg (Jpn) 39:33-44
5. Gilbert A, Brockman R (1995) Congenital pseudarthrosis
of the tibia: long-term follow-up of 29 cases treated by
microvascular bone transfer. Clin Orthop 314:37-44
6. Chen CW, Yu ZJ, Wang Y (1979) A new method of treat-
ment of congenital tibial pseudarthrosis using free vascu-
larised fibular graft: a preliminary report. Ann Acad Med
Singapore 8:465-473
3.5. Congenital Pseudarthrosis 443
7. Takahashi M, Yabe Y, Yoshizawa H, Suzuki T (1979) Con-
genital pseudarthrosis of the tibia treated by the vascu-
larized free fibula graft. Orthop Surg Traumatol (Jpn)
22:1405-1411
8. Weiland AJ, Daniel RK (1980) Congenital pseudarthro-
sis of the tibia: treatment with vascularized autogenous
fibular grafts. A preliminary report. Johns Hopkins Med J
147:89-95
9. Kanaya F, Tsai TM, Harkess J (1996) Vascularized bone
grafts for congenital pseudarthrosis of the tibia. Micro-
surgery 17:459-469
10. Minami A, Ogino T, Sakuma T, Usui M (1987) Free
vascularized fibular grafts in the treatment of congenital
pseudarthrosis of the tibia. Microsurgery 8:111-116
11. Tarnai S, Sakamoto H, Hori Y, Tatsumi Y, Nakamura Y,
Shimizu T, Fukui A (1980) Vascularized fibula transplan-
tation: a report of 8 cases in the treatment of traumatic
bony defect or pseudarthrosis of long bones. Int J Micro-
surg 2:205-212
3.6 Traumatic Soft Tissue Defects in the Extremities
MINORD SHIBATA
The free flap technique allows adequate debridement of
contaminated devitalized tissue and coverage of vital
important structures using a sufficiently large soft tissue
with adequate circulation. Wound closure using free
flap has changed the treatment of complex extremity
injuries that were difficult to treat by other means and
often became infected. Previously, such injuries re-
quired prolonged dressing times and ended in crippling
of the patient.
Other associated factors such as timing of the wound
coverage or reconstruction of the injured tissue need
to be carefully considered to attain functional and
improved esthetic results in the treatment of complex
open injuries of extremities.
Timing of Wound Closure
Early wound closure and rapid mobilization of the
joints may produce less pronounced scarring, allow
shorter hospitalization, and give a better range of
motion than the delayed procedures.
However, various factors should be evaluated before
making the decision for the wound closure to avoid
infection after wound closure [1,2]. Breidenbach [1]
stated that the following factors should be carefully
evaluated: debridement, exposure of vital structures,
bacterial load, type of fracture, and anatomical location.
The extent of debridement required and the subse-
quent exposure of vital structures needs to be deter-
mined. If the surgeon believes that debridement is
adequate and all devitalized tissues are radically
removed, an emergency free flap could be indicated.
If the surgeon questions the viability of the remain-
ing tissue in the wound, serial debridement may be
indicated. However, coverage of the complex wound
with exposed vital structures such as nerve, tendon,joint
surfaces, or bone denuded of periosteum needs to be
performed early to prevent drying and preserve their
function. Early coverage within 72 h of injury can
preserve the viability of these structures.
All open wounds are contaminated and the level of
bacteria may be the most significant factor concerning
444
the likelihood of infection. Bacteria load evaluated by
quantitative culture may be the most reliable indicator
for infection [1,3,4]. Quantitative cultures take 24 to
48 h to give results. Quantitative bacteria culture should
be performed as routine examination in all cases with
contaminated wounds [1]. If the surgeon thinks that
debridement was adequate and vital structures are
exposed, emergency free flap may be used for immedi-
ate wound coverage. If a bacteria load of more than
10,000 organisms per gram of tissue is obtained later,
the surgeon should consider performing redebridement
under the flap and keeping one side of the wound open.
Fracture type correlates well with infection as was
shown by Gustilo and Andeon [5]. Open fracture with
severe soft tissue damage needs to be treated ade-
quately to avoid infection.
Although there is no clear evidence, many surgeons
believe that there is a higher incidence of infection of
injuries in lower extremities than in upper extremities
with similar injuries. Thus, more considerations may
need to be made to avoid infection in lower extremities.
When open fracture is involved, external bone fixa-
tion is recommended and immediate or early wound
closure may be followed by bone grafting. However, if
the surgeon believes debridement is adequate and the
quantitative culture is returned showing less than 10,000
organisms per gram of tissue, rigid bone fixation using
an internal fixation device, such as a plate and screws,
may be indicated. When a count of more than 10,000
organisms is obtained, debridement should be repeated
and the wound should be kept open.
As aforementioned, the timing of the closure of the
compound wound with significant soft tissue defect
should be performed as early as possible to attain high
flap success rate, low infection rate and satisfactory ulti-
mate function. If adequate debridement is attained,
including thorough excision of the devitalized tissue,
rigid bone fixation, revascularization, primary repair of
injured tissue, and soft tissue closure using emergency
free flap within 24 h of injury may be indicated as a
one-stage treatment of the severe compound injury.
Good results may also be expected if the early primary
coverage occurs within 72h of injury. Compared with

immediate or early treatment, delayed closure of the
contaminated wound in the upper limb may signifi-
cantly compromise hand function.
Early Wound Closure and Flap
Success Rate
Flap success rate has been a factor of concern in emer-
gency free flap surgery; however, excellent success rates
have been reported by several groups [1,4,6-8]. Early
vascular reconstruction or free flap application in lower
extremity injuries is now considered safer than com-
parable procedures conducted later in the partially
healed tissue.
Early Wound Closure and Infection
Bone Fixation and Infection
The use of nonvital artificial materials for bone fixa-
tion in contaminated wounds has been discussed from
the viewpoint of infection in the past. Recent clinical
reports have showed that early wound closure with rigid
bone fixation using an internal fixation device for open
tibial fracture is quite safe if attended with adequate
debridement of the devitalized tissue [1-4,6,9-11]. Early
soft tissue closure along with bone fixation using an
external bone fixator has also been reported as a safe
alternative procedure.
Primary Reconstruction and Soft
Tissue Coverage
It has become a well-accepted concept that the primary
repair and reconstruction of the injured tissues pro-
vide better results than delayed secondary procedures.
Improved functional and esthetic results have been
recently reported by several authors [1-4,9] using early
reconstruction. These results were shown to be clearly
associated with less postoperative infection and better
wound healing by an adequate blood supply. However,
if the primary reconstruction of the injured tissue is
achieved, these vital tissues need to be covered with
the use of free flap. The use of free vascularized compo-
site flap including bone, tendon, nerve, and vessel may
accomplish simultaneous primary reconstruction and
soft tissue coverage with vascularized skin. Sequential
connection of free flaps using flow through flap may
attain a similar outcome.
3.6. Traumatic Soft Tissue Defects in the Extremities 445
Late Primary or Secondary Wound Closure
It is obvious that distinctly different results are obtained
by the different management of severe injuries such
as extensive open tibial fracture. Most surgeons may
believe that severely contaminated wounds should be
left open when a severe fracture such as Gustilo type
III has occurred. If the surgeon believes that immediate
closure should be avoided, the wound may be kept
open after debridement. Early closure should then be
considered with evaluation of local and systemic factors
because it covers the difficult contaminated wound most
successfully and has a low infection rate.
However, if early reconstruction is not possible or the
patient has been referred from another hospital for late
reconstruction and closure, the timing of wound closure
should be selected after evaluating the condition of the
wound.
Indication for Free Flap Coverage
Reconstruction using free flap is indicated to compound
injuries with wide soft tissue defects which are unable
to be covered with local flaps to protect exposed im-
portant vital structures such as tendon, nerve, joint,
or bone denuded of periosteum. Complex tibia frac-
ture involving extensive bone and soft tissue devas-
cularization, such as Gustillo type III-B or III-C, is a
typical candidate for reconstruction using the free flap
technique.
Flap Selection
Upper Extremity Coverage
For the coverage of relatively small defects, reverse
pedicled flaps can be used. Flaps for upper extremities
should be matched to the recipient skin and the type of
sensory reconstruction required.
Reverse Pedicled Flap
1. Radial forearm flap
Advantages: elevation from the ipsilateral arm,
thin or wide sensate skin, good color matching.
Disadvantages: donor site esthetic morbidity if
skin graft is required, radial artery sacrifice.
2. Posterior interosseous artery flap [12]
Advantages: elevation from the ipsilateral arm,
thin and possibly sensate skin, no major artery
sacrifice, good color matching to dorsal hand.
446 E. Clinical Reconstructive Microsurgery
Disadvantages: occasionally unstable vascular
anatomy, donor site esthetic morbidity if skin graft is
required, occasional flap venous congestion.
3. Combined lateral arm and posterior interosseous
artery flap [13]
Advantages: elevation from the ipsilateral arm,
wide and relatively thin skin, possibly sensate skin.
Disadvantages: donor site esthetic morbidity,
requires anastomosis of posterior radial collateral
artery.
Free Flap
1. Lateral arm flap [14]
Advantages: elevation from ipsilateral arm, stable
vascular anatomy, relatively thin skin at distal
portion, no major vessel sacrifice.
Disadvantages: donor site esthetic morbidity if
skin graft is required, anesthesia on the proximal
lateral forearm.
2. Medial arm flap [15]
Advantages: elevation from the ipsilateral arm,
good matching with hand and forearm, inconspicu-
ous donor-site scar, no major vessel sacrifice.
Disadvantages: relatively unstable vascular ana-
tomy, limited flap size if skin graft is not used.
3. Groin flap
Advantages: inconspicuous donor scar, wide skin,
no functional deficit.
Disadvantages: small and short vascular pedicle,
relatively thick for hand proper.
4. Latissimus dorsi flap
Advantages: stable vascular anatomy, long vascu-
lar pedicle with large diameter, wide flap, can be used
as musculocutaneous or muscle flap with skin graft
attached.
Disadvantages: bulky for hand proper, latissimus
dorsi muscle function deficit.
5. First interdigital space flap
Advantages: good matching with palm skin,
sensate flap.
Disadvantages: limited size, donor site morbidity.
6. Dorsalis pedis flap
Advantages: good matching with dorsal hand skin,
can carry vascularized tendons, sensate flap.
Disadvantages: donor site morbidity.
For Lower Extremity Coverage
Reverse Pedicled Flap
1. Sural nerve neurosensory flap [16]
Advantages: relatively easy dissection, no major
vessel sacrifice.
Disadvantages: sensory loss in sural nerve inner-
vated area, donor site esthetic morbidity if skin graft
is used, limited flap size.
Free Flap
1. Groin flap
Advantages: inconspicuous donor scar, wide skin,
donor site esthetic morbidity.
Disadvantages: small and short vascular pedicle.
2. Latissimus dorsi flap
Advantages: stable vascular anatomy, long vascu-
lar pedicle with large diameter, wide flap, can be used
as musculocutaneous or muscle flap with skin graft
attached.
Disadvantages: latissimus dorsi muscle function
deficit.
3. Anterolateral thigh flap [17]
Advantages: wide flap, no major vessel sacrifice.
Disadvantages: relatively variable vascular ana-
tomy, donor site esthetic morbidity if skin graft is
required.
Representative Cases
Case 1. Emergency Free Flap
A 57-year-old man sustained a press machine injury to
his right hand (Fig. 1). All fingers except for the little
finger were not replant able because of severe crushing.
The little finger remained connected to the hand by the
flexor tendon and showed de vascularizing injury at the
both PIP and DIP joint levels. Debridement was fol-
lowed by replantation and revascularization of the little
finger (Fig. 2). There was a soft tissue defect on the
dorsal hand that connected to the amputated finger
stumps. A medial upper arm flap, 5 x 13 cm in size, was
designed on the medial aspect of the arm. The superior
ulnar collateral artery was identified and the flap was
elevated on this artery (Fig. 3). The flap was transferred
to the defect on the dorsal hand and digital stumps, cre-
ating an artificial syndactyly (Fig. 4). The superior ulnar
collateral artery was connected to the common digital
artery in the second interdigital space. Two cutaneous
veins were repaired and attained excellent perfusion to
the flap. However, the tip of the little finger showed
necrosis and was amputated 7 days after the initial
surgery. The stump was immediately covered with a part
of the previously transferred medial arm flap. The flap
survived completely and the artificial syndactyly was
separated 3 months after initial surgery and the
maximum length of the amputated fingers was pre-
served. Matching of the flap skin texture with that of the
 3.6. Traumatic Soft Tissue Defects in the Extremities 447

Fig. 1. Press machine injury. Fingers were unsalvageable Fig. 2. After replantation and revascularization of the little
except for the little finger finger. This is a moderate-sized soft tissue defect

Fig. 3. A medial arm flap (5 x 13 cm) was elevated. The donor Fig. 4. After wound coverage using free medial arm flap
site was closed primarily

Fig. 5. Tho years and 7 months

after surgery. Matching of the
flap and hand is excellent and
maximal finger length was
obtained
448 E. Clinical Reconstructive Microsurgery

Fig. 6. Condition of open comminuted fracture around knee
just before reconstruction
hand proved excellent and the patient is using the
reconstructed hand with minimal disability (Fig. 5).
Fig. 7. The ipsilateral fibula bone was elevated on peroneal
vessels and turned up to bridge the knee joint. Free iliac bone
grafting was combined. (See Color Plates)

Case 2. Delayed Secondary Reconstruction

Using Chain-Linked Combined Flap

A 47-year-old male factory worker sustained open com-

minuted fracture around his right knee on March 2,
1991. The patient was in a state of shock on admission
to the hospital emergency room and a 1400-ml blood
transfusion was applied immediately. Exploration
revealed open comminuted fracture of the knee involv-
ing femoral condyle, tibia, and patella, and laceration
of quadriceps and biceps femoris muscles as well as
rupture of medial and lateral cruciate ligaments. The
wound was severely contaminated with iron powder Fig.8. A latissimus dorsi musculocutaneous flap was elevated
and thorough debridement was performed, including and used to replace the necrotic soft tissue. The thoracodor-
removal of free fragments from the femoral condyle and sal artery and vein were connected to the distal end of the
bilateral meniscus. Bone fixation was attained using an peroneal vessels of the turned up fibula
external fixator 2 weeks after debridement. Skin graft-
ing was applied to the anterior knee 2 weeks after the
second operation. The patient was referred to our the transferred latissimus dorsi muscle. The Postopera-
hospital 8 weeks after injury with necrotic skin around tive course was uneventful and the wound was success-
the anterior knee (Fig. 6). A preoperative angiogram fully covered without infection. Knee arthrodesis was
confirmed that the popliteal artery was intact and there attained 6 months after surgery without creating leg-
was no sign of deep infection around the knee. An length discrepancy and the patient is able to walk
operation for delayed secondary reconstruction was without a stick (Fig. 9).
performed on May 29, 1991. Knee arthrodesis was
performed after debridement of the necrotic skin on the
knee using ipsilateral fibula (22cm in length) elevated Case 3. Delayed Primary Reconstruction
as a vascularized pedicled flap combined with free iliac
bone grafting (Fig. 7). Coverage of the open wound was A 70-year-old man with relapsing pemphigus vUlgaris
performed using 6 x 12-cm free latissimus dorsi muscu- for the past several years was involved in a traffic acci-
locutaneous flap transfer (Fig. 8). The distal ends of the dent and sustained a scraping injury on the dorsum of
peroneal vessels were used as the recipient vessels for his right hand (Fig. 10). The dorsal skin of the hand and
 3.6. Traumatic Soft Tissue Defects in the Extremities 449

fingers was defective with their extensors at the level

between hand proper and middle finger segment. The
patient was initially treated at an emergency hospital
and was referred to us 2 weeks after injury. A reverse
pedicled radial forearm flap (25 x 10cm) was elevated
and the skin defect of the hand and fingers, excluding
the little finger, was covered to create an artificial syn-
dactyly (Figs. 10,11). The flap completely survived and
the syndactyly of the fingers was separated 3 weeks after
injury. Tendon grafting to fingers was performed 8
months after initial surgery using the left extensor dig-
itorum longus (25 cm in length) (Fig. 12). Stable skin
coverage with adequate and reasonable motion of the
fingers was obtained at 1 year and 4 months after initial
surgery (Figs. 12,13).
Fig. 9. Solid fusion of the knee joint was attained and stable
ambulatory ability was regained

Fig. 10. Preoperative condition

(left). Dorsal skin and extensors
are lost. A radial forearm flap
(25 x lOcm) was elevated
(center) as a reverse pedicled
flap and covered the soft tissue
defect (right). (See Color
Plates)

Fig. 11. Fingers, except for the little finger,

were covered together with the flap creating
syndactyly
450 E. Clinical Reconstructive Microsurgery
Fig. 12. Fingers were separated and extensor was grafted in
the subcutaneous fatty tissue avoiding adhesion
References
1. Breidenbach WC (1989) Emergency free tissue transfer
for reconstruction of acute upper extremity wounds. Clin
Plast Surg 16:505-514
2. McCabe SJ, Breidenbach WC (1999) The role of emer-
gency free flaps for hand trauma. Hand Clin 15:275-288
3. Merritt K (1988) Factors increasing the risk of infection in
patient with open fractures. J Trauma 28:823-827
4. Chen SHT, Wei F-C, Chen H-C, Chuang C-C, Noodhoff
MS (1992) Emergency free-flap transfer for reconstruc-
tion of acute complex extremity wounds. Plast Reconstr
Surg 89:882-888
5. Gustilo RB, Andeon JT (1976) Prevention of infection in
the treatment of 1025 open fractures of long bones. J Bone
Joint Surg Am 58:453-458
6. Godina M (1986) Early microsurgical reconstruction of
complex trauma of the extremities. Plast Reconsr Surg 78:
285-292
7. Ninkovic MM, Hussl H, Heel L, Ander! H (1995)
Zeitpunkt der Versorgung schwerer Verletzungen der
oberen Etremitat durch freie Lappen. Handchir Microchi
Plast Chi 27:297-306
8. Ninkovic MM, Schwam berger AH, Wechelberger G,
Anderl H (1997) Reconstruction of large palmar defects
of the hand using free flaps. J Hand Surg 22B:623-630
9. Byrd HS, Spicer TE, Cinerney G (1985) Management of
open tibial fractures. Plast Reconstr Surg 76:719-728
Fig. 13. The wound was successfully closed and reasonable
function was regained
10. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR,
Poka A, Weiland AJ (1987) Acute and definitive manage-
ment of traumatic osteocutaneous defects of the lower
extremity. Plast Reconstr Surg 80:1-12
11. France! TJ, Vandel Kolk CA, Hoopes JE, Manson PN,
Yaremchuk JY (1992) Microvascular soft-tissue trans-
plantation for reconstruction of acute open tibial frac-
tures: timing of coverage and long-term functional results.
Plast Reconstr Surg 89:478-487
12. Shibata M, Iwabuchi Y, Kubota S, Matsuzaki H (1997)
Comparison of free and reversed pedicled posterior
interosseous cutaneous flaps. Plast Reconstr Surg 99:
791-802
13. Shibata M, Hatano Y, Iwabuchi Y, Matsuzaki H (1995)
Combined dorsal forearm and lateral arm flap. Plast
Reconstr Surg 96:1423-1429
14. Katsaros J, Tan E, Zoltie N (1991) The use of the lateral
arm flap in upper limb surgery. J Hand Surg 16A:598-604
15. Kaplan EN, Pearl RM (1980) An arterial medial arm
flap-vascular anatomy and clinical applications. Ann
Plast Surg 4:205-215
16. Masque!et AC, Romana MC, Wolf G (1992) Skin island
flaps supplied by the vascular axis of the sensitive super-
ficial nerves: anatomic study and clinical experience in the
leg. Plast Reconstr Surg 89:1115-1121
17. Koshima I, Fukuda H, Utsunomiya R, Soeda S (1989) The
anterolateral thigh flap. Variations in vascular pedicle. Br
J Plast Reconstr Surg 42:260-262
3.7 Vascularized Fibular Graft for Traumatic Bony
Defect and Incurable Nonunion
MOROE BEPPU
Treatment of large bony defects of the extremities is one
of the most difficult problems in the orthopedic field.
However, with recent developments in microsurgery,
vascularized bone grafts have made it possible to recon-
struct previously incurable large bone defects, and the
clinical results are improving. Conventional bone grafts
undergo creeping substitution, and both absorption and
replacement of bone occur because of avascularity. In
contrast, the living bone graft can maintain the original
bone strength, achieve early bone union, and prevent
infection because it has good vascularity. As a result, it
has become possible to reconstruct functions even in
patients in whom conventional surgical methods are
ineffective. We have performed vascularized fibular
grafting in cases of large bone defects, which were more
frequent in the lower extremities than in the upper
extremities. We describe our methods here.
Indications
Large bone defects resulting from trauma, curettage of
osteomyelitis, on resection of bone tumors are good
indications for a vascularized fibular graft. Bone defects
greater than 6cm are an indication for a vascularized
fibular graft. Bone transport is an alternative method;
however, we usually choose vascularized fibular grafts
in cases of chronic osteomyelitis, in which the defect is
large and not enough bone stock for bone transport
exists, and in which extensive defects in the bone and
skin take place as a result of necrotizing tissue and
sequestrum.
Donor Site
The donor sites of vascularized bone grafts include the
fibula, iliac crest, scapula, and rib. The fibula and iliac
crest are preferable as donor sites in the orthopedic
field, in which the long bone is a common recipient site.
In the case of a bone defect more than 10cm long, step
osteotomy of the curved portion of the iliac crest is
required for correction of the curved cortico cancello us
bone. In this case, harvesting a long bone graft from the
iliac crest is limited.
Therefore, the indication for the iliac crest is a 6- to
8-cm defect in a long bone. The fibula is a straight,
strong, long, tubular cortical bone, which is useful for
a bone defect of more than 8 cm. Since harvesting a
monitoring flap of the fibula became possible, we have
usually used the vascularized fibular graft as a common
donor site for a large defect in a long bone, regardless
of the length of the bone defect.
Anatomy
The vascular pedicle consists of the peroneal artery
(1.5-2.5mm in diameter) and its two venae comitantes
(2-3mm in diameter), and may be from 1 to 5cm in
length. The main nutrient artery of the fibula is the
peroneal artery, which supplies the proximal osseous
segment at the middle of the fibula and also the seg-
mental vessel to the periosteum.
According to our study [1], skin branches from the
proximal third of the peroneal artery always travel an
intramuscular course. Skin branches from the distal two
thirds of the peroneal artery are usually affixed to the
posterior crural septum. The peroneal artery has three
to seven branches (average, 4.7); each branch con-
tributes to the fibular periosteal blood supply. The most
reliable cutaneous vessels are found in the lower two
thirds of the leg, run posterior to the fibula in the
posterior crural septum, and are always associated with
muscular side branches. A large island of skin supplied
by branches of the peroneal artery can be harvested as
the peroneal flap.
Preoperative Planning for Recipient
Site and Donor Site
The most important factor in conducting this operation
is to prepare the recipient site as well as possible for
the bone graft. Therefore, in many cases this operation
451
452 E. Clinical Reconstructive Microsurgery
is conducted in two stages as primary and secondary
operations. Especially in cases where an infection is
present, the infectious focus should be thoroughly curet-
ted to control infection before the vascularized bone
graft is performed in the secondary operation. In
addition, the pseudoarthrosis site should be resected
extensively to remove fistulas, sequestrum, and necrotic
tissues in the surrounding area as much as possible. If
extensive curettage and soft-tissue reconstruction are
important to reduce the inflammation, the transfer of
vascularized tissue, such as a latissimus dorsi musculo-
cutaneous flap, needs to be done during the primary
operation. If an infection is present, the secondary oper-
ation should not be performed before local inflamma-
tion has been controlled. If no inflammation, such as a
bone tumor, is evident during the primary operation,
the vascularized bone graft should be performed at the
same time.
Angiography of Recipient and
Donor Site
It is very important to determine whether an anomaly
or traumatic injury of the vessel exists in the recipient
site by angiography. Of course, angiography must also
be done in the donor site. If the recipient artery and vein
pass through the scar tissue, it is quite difficult to dissect
these vessels, and vasospasms may occur even though
the angiograph shows normal anatomy.
Doppler Examination for Monitoring
the Flap
To confirm the status of the monitoring flap, preopera-
tive auscultation using Doppler blood flow is the best
method, because angiography is ineffective in detecting
the monitoring flap before surgery. According to our
study, skin marking needs to be done to assure the most
reliable cutaneous vessels of the monitoring flap at the
lower two thirds of the leg. The peroneal vessels run
posterior to the fibula in the posterior crural septum and
are always associated with muscular side branches.
During surgery, it is very important to make small arter-
ies and veins easily detectable before making an inci-
sion in the skin. This is done by creating congestion in
the lower leg by reducing pressure in the air tourniquet
and avoiding the use of an Esmarch bandage. The skin
incision should be started from the anterior side of the
small skin flap with the skin reflected in the posterior
direction. With this procedure, small blood vessels that
enter the skin flap are not overlooked.
Operative Technique
The precise method of harvesting the fibula is described
in another chapter. Here I explain how to set and fix the
fibula for the recipient side, especially for the lower
extremity (femur and tibia).
A single fibula is usually inserted intramedullarly and
is fixed at the proximal and distal sites with two screws
each. The method of double fibular grafts and twin-
barrel grafts is useful for the proximal part of the femur
and tibia, because their diameters are larger than in any
other area. Since the possible length of a fibular graft is
about 20cm, the indication of a twin-barrel fibular graft
is up to 10 cm in length. In femur reconstruction, one of
the fibular grafts is inserted into the intramedullary
canal of the femur, and the other is used an onlay graft
at the medial side of the femur because of better hyper-
trophy. Both grafts should be fixed at the proximal and
distal sites with two screws each. These screws should
be transfixed through the two fibular grafts and the
femur.
When the bone defect is long and complete and the
fibular graft is not properly aligned, the grafted bone
frequently fractures and bone union is delayed. When
the bone defect is short and complete and the alignment
is improper, stress fracture of the grafted bone easily
occurs, but bone union is good and hypertrophy occurs
quickly. Therefore, there is no problem with stress frac-
ture of the short bone defect. However, in the case of a
long and complete bone defect, alignment of the grafted
bone and recipient site is critical to prevent stress
fractures.
Tibial Reconstruction
It is rather difficult to decide how to reconstruct bone
and vessels in traumatized legs. The following methods
can be considered (Fig. 1).
Anterograde bone reconstruction and normograde
anastomosis of the anterior tibial artery. Because the
anastomosis site is deeper at the proximal part of the
tibia, the anastomosis needs to be done more superfi-
cially at the middle part of the tibia.
Anterograde bone reconstruction and interpositional
anastomosis of the anterior tibial artery. When the ante-
rior tibial artery cannot be sacrificed, the anastomosis is
performed by flow-through type reconstruction.
Reversed bone reconstruction and retrograde anasto-
mosis of the anterior tibial artery. The anterior tibial
artery is not available for normograde anastomosis.
The distal part of the anterior tibial artery is used for
retrograde anastomosis. One of the concomitant veins
is anastomosed to the great saphenous vein.
 3.7. Vascularized Fibular Graft for Traumatic Bony Defect and Incurable Nonunion
Fig. 1. a Anterograde bone reconstruction and normograde
anastomosis of the anterior tibial artery. b Anterograde bone
reconstruction and interpositional anastomosis of the anterior
tibial artery. c Reversed bone reconstruction and retrograde
Reversed bone reconstruction and orthodromic anas-
tomosis of the anterior tibial artery. In the case of a bone
defect of the distal part of the tibia, the fibular graft is
fixed antidromic ally. This method allows technical ease
in vascular anastomosis. The reversed dorsalis pedis
artery is anastomosed to the peroneal artery of the
grafted fibula. One of the concomitant veins is anasto-
mosed to the great saphenous vein.
Anterograde bone reconstruction and normograde
anastomosis of the posterior tibial artery. The posterior
tibial artery is not included in the anterior compartment
but in the posterior compartment. The posterior tibial
artery is less traumatized and larger in diameter than
the anterior tibial artery. Not only the artery but also
the vein can be anastomosed from the medial side of
the leg.
Femur Reconstruction
The recipient artery for a twin-barrel fibular graft is a
descending artery of the lateral femoral circumflex
artery. In the case of a double fibular graft, a part of the
thoracodorsal artery with bifurcation is harvested from
the axillary area. The reversed Y arterial graft is very
convenient for reconstruction of the double fibular
graft.
453
anastomosis of the anterior tibial artery. d Reversed bone
reconstruction and normograde anastomosis of the anterior
tibial artery. e Anterograde bone reconstruction and normo-
grade anastomosis of the posterior tibial artery
The recipient veins for reconstruction of the femur
are the great saphenous vein and a branch of the
descending vein of the lateral femoral circumflex vein
[2]. The anastomosis site is very deep inside the muscles,
and monitoring flaps are not useful to verify the circu-
lation because of the squeezing of the cutaneous vessel
of the flap by the hematoma.
Case 1
A 52-year-old woman was injured in a traffic accident
resulting in a fracture of the right humerus. Open reduc-
tion and internal fixation were performed. Subsequently
pseudoarthrosis occurred after 3 operations with a con-
ventional iliac bone graft at another hospital over a 4-
year period (Fig. 2). The patient was then transferred to
our department. Following wide bone resection, a 13.5-
cm fibular graft was performed for an 8-cm bone defect
(Fig. 3). The deep brachial artery was used as the reci-
pient artery. The bone was fixed internally with screws
and also an external fixator. Bone union was obtained
7 months postoperatively. Five years and 4 months post-
operatively good bone remodeling of the grafted fibula
has occurred. There is less hypertrophy of the grafted
fibula compared to the lower extremities because the
upper extremities are basically non-weight bearing.
454 E. Clinical Reconstructive Microsurgery
Case 2
A 27-year-old man was injured in a motorcycle accident,
resulting in an open fracture of the right tibia. Open
reduction and internal fixation were performed at
At initial visit
Fig. 2. Case 1: 52-year-old woman
Immediate post-op
Fig. 3. Case 1: 52-year-old woman
another hospital, but subsequently osteomyelitis oc-
curred. After irrigation and debridement had been per-
formed several times, he was transferred to our hospital.
A 6-cm bone defect was found, and a 14-cm single vas-
cularized fibular graft was performed 11 months after
the initial injury. The external fixator was removed 5
months postoperatively, and weight bearing was
permitted with a patellar tendon bearing (PTB) brace.
Bone union occurred 9 months postoperatively, and
thereafter good hypertrophy of the grafted bone
occurred (Fig. 4). At 2 year and 9 months postopera-
tively, although there is slight limitation of the dorsi-
flexion of the ankle joint, normal range of motion of the
knee joint and good bone remodeling of the grafted
fibula have been obtained without any discrepancy in
leg length (Fig. 5).
Discussion
Our results [3] showed that the mean percent hyper-
trophy of vascularized fibular grafts for bone defects
less than lOcm in length was 57% 41.6%, and the
mean percent hypertrophy of vascularized fibular grafts
for bone defects more than 10cm in length was 20.9%
11.9%. The mean percent hypertrophy of vascularized
fibular grafts for large bone defects of more than 10cm
is statistically significantly lower than that for small
bone defects. We reported that the medullary cavity of
post-op 5yrs. 1 mo
 3.7. Vascularized Fibular Graft for Traumatic Bony Defect and Incurable Nonunion 455

Fig. 4. Case 2: 27-year-old

man

At initial visit After VFG Post-op 6 mos. Post-op 1 yr.

Post-op 2 yrs. Post-op 2 yrs. 9mos.

Fig. 5. Case 2: 27-year-old man
456 E. Clinical Reconstructive Microsurgery
the grafted fibula was narrower in the ante rial posterial
(AP) view than the lateral view, because the cortex was
hypertrophied [3]. These results agree with the report
that the direction of the hypertrophy may be controlled
by some factors originating from the recipient and
donor sites [4]. Furthermore, hypertrophy occurred in
neutral alignment more frequently. In malalignment,
hypertrophy was accelerated on the concave side, which
is the stress-loaded side.
The disadvantage of the vascularized fibular graft for
large tibial bone defects is that the grafted fibula cannot
be hypertrophied the same as the tibia. Therefore, it is
thought that the grafted fibula is biomechanically weak
and its protection is necessary for a long time. The
percent hypertrophy of grafted bone was measured
radiographically by the method of De Boer and Wood
[5]. However, this method is two-dimensional. The
cortical bone hypertrophied in both the outer and the
medullary directions, and the medullary cavity was
narrower from the AP view. The measurement of
percent hypertrophy is not accurate enough to evalu-
ate the hypertrophy of the grafted fibula. Therefore,
we developed a method to measure cortical bone vol-
ume by computerized tomography (CT) scanning [6,7].
Summary
This reconstruction is a very useful treatment for
pseudoarthrosis or defects of the long bones. How-
ever, to obtain better results, this reconstruction
should be performed within a reasonably short period
of time after injury to minimize contracture of joints
in poor functional position due to long treatment
periods.
References
1. Beppu M, Hanel D, Johnston GHF, Carmo JM, Tsai T
(1992) The osteocutaneous fibula flap: an anatomic study. J
Reconstr Microsurg 8:215-223
2. Tomita Y,Murota K, Takahashi F,Moriyama M (1994) Post-
operative results of vascularized double fibula grafts for
femoral pseudoarthrosis with large bony defect. Micro-
surgery 15:316-321
3. Matsushita K, Beppu M, Sasa M, Shimizu H, Kihara H,
Kimura H, Yamaguchi S, Aoki H (1996) Clinical results of
vascularized bone graft for large bone defect-focusing on
transverse hypertrophy of grafted bone. In: Reconstruc-
tive microsurgery-current trends. I S R M, Singapore,
pp 125-126
4. Yamaoka N, Tarnai S, Mizumoto S (1997) Experimental
study of vascularized bone grafts in rats: effect of mechan-
icalloading on bone dynamics. J Orthop Sci 2:239-247
5. De Boer H, Wood M (1989) Bone changes in the vascular-
ized fibular graft. J Bone Joint Surg 71(B): 374-378
6. Hata M, Nango A, Niki H, Hayafune Y, Kato A (1997)
Volume of tarsal bones in congenital clubfoot. J Orthop Sci
2:3-9
7. Izumiyama K, Beppu M, Matsushita K, Shimizu H, Kihara
H, Sasa M, Aoki H, Ohashi K (2000) Bone volume of the
fibula cortex after a vascularized graft. J Jpn S R M
13:33-36
3.8 Chronic Osteomyelitis and Infected Nonunion
HIROSHI YAJIMA AND SUSUMU TAMAI
Before the discovery of antibiotics, osteomyelitis was an
intractable disease associated with a mortality rate as
high as 20% to 30%. In 1929, penicillin was discovered,
and it has been clinically used for almost all patients
with infection, including osteomyelitis. Further devel-
opment of antibiotics has led to a dramatic reduction in
the number of patients with to sepsis and limb amputa-
tion. However, chronic osteomyelitis still remains an
intractable disease. One reason its treatment is difficult
is that alterations in bacterial flora and the appearance
of resistant bacteria have led to a large increase in
patients with chronic inflammation. The appearance and
spread of methicillin-resistant Staphylococcus aureus
(MRSA) has made it especially difficult to control the
infection. Only a few antibiotics are active against
MRSA, and some patients cannot take these antibiotics
owing to drug allergy. For such cases, the only procedure
leading to cure is radical debridement. Chronic pyo-
genic osteomyelitis, which has been operated on several
times in the past but not healed yet, and traumatic
osteomyelitis following an open fracture or iatrogenic
osteomyelitis following an operation. Some cases
require radical debridement to control infection, and it
is then difficult to attain bone union even after control
of the infection. Bone grafting has been used to treat
osteomyelitis or infected non unions, although bone
union is not always achieved and infection recurs in
some patients.
Recent advances in microsurgical techniques have
made it possible to transfer various kinds of autogenous
composite tissues and to apply vascularized bone grafts
for the infected nonunion with remarkable improve-
ment in therapeutic outcome [1-4]. Vascularized bone
grafting has many advantages. This procedure enables
the surgeon to achieve sound bony union irrespective of
the length of the bony defect, which in turn allows the
surgeon to perform extensive debridement of nonunion
and osteomyelitic regions. In other words, vascularized
bone grafts have made it possible to perform radical
debridement of infected regions, so that the therapeu-
tic outcome of intractable osteomyelitis has notably
improved [4]. In many cases, environmental scar tissues
make it difficult to control inflammation. For such cases,
both debridement of diseased bone and ablation of
the soft tissues are required. As for the vascularized
bone graft, simultaneous reconstruction of bone and
soft tissue is possible by vascularized bone grafting with
an attached cutaneous flap. Moreover, the transfer of
tissues with their intrinsic vascular supply confers
greater resistance to infection and a remarkable reduc-
tion in the frequency of inflammatory exacerbation. It
is needless to say that this procedure enhances antibi-
otic delivery in the region of infection and bone defect.
Donor Bones for Vascularized
Bone Graft
Donor bones to be used for vascularized bone grafts
include the fibula, ilium, and scapula [4,5]. The fibula
has generally been used for patients with a bone loss of
up to 10cm. The iliac bone has been selected for those
with a bone loss of less than 10cm accompanied by a
large skin defect [6], and the scapula for those with
mainly skin deficiencies and minor bone defects [7].
According to the medical literature, the fibula is inferior
to the ilium in a few respects, namely, the size of the skin
flap available and the cosmetic problem at the donor
site. In most patients with an infected nonunion, a per-
oneal flap is large enough. For female patients, the
donor site scars cannot be hidden under a skirt. On the
other hand, the donor site can be hidden under cloth-
ing after harvesting of the iliac osteocutaneous flap and
scapular osteocutaneous flap [6,7]. The other problem
with the fibula is the volume of the graft bone. Among
these three donors, the iliac bone is the largest that can
be harvested if the defect is less than 10cm in length.
On the other hand, the fibula can be folded into two
struts preserving the vascular supply; this is called twin-
barrelled vascularized fibula grafting [8]. This technique
is becoming very popular, and most donor bones are
taken from the fibula, except in patients with calcaneal
osteomyelitis.
457
458 E. Clinical Reconstructive Microsurgery

a,b c

Fig.I. A 43-year-old woman with chronic osteomyelitis of the leg. a Preoperative photograph of the
right leg showing original unhealthy skin. b Radical debridement of the infected bone, including the
circumferential unhealthy soft tissue. (See Color Plates) c Completed fibular osteocutaneous flap
grafting

Indication Surgical Procedure

In the 1980s, vascularized bone transfer was an approach
for the management of osteomyelitis. Recently, many
surgeons have tended to perform vascularized bone
grafts secondarily after successful subsidence of the
inflammation. The latter approach is better than the
former approach (vascularized fibula grafting is per-
formed immediately or soon after the radical debride-
ment), in view of the success rate. Minami et al. [9] also
recommended that vascularized bone transfer should be
postponed until sepsis becomes inactive. However, in
cases with skin defects after debridement of diseased
tissues, a one-stage procedure is recommended (Fig.
la-c). Doi et al. [10] advocated one-stage treatment
of infected bone defects of the tibia with skin loss by
free vascularized osteocutaneous grafts. They reported
that the use of a one-stage vascularized osteocutaneous
graft was effective, because extensive debridement can
remove all devitalized and infected tissue and can
increase vascularity in the region of the infection and
osseous defect to enhance antibiotic delivery.
Because the fibula is the most popular donor bone, as
mentioned above, a full account of vascularized fibula
grafting in the treatment of infected nonunion is given.
The surgical procedure is divided into two steps, radical
debridement of the infected nonunion and reconstruc-
tion with a vascularized fibular graft. These two proce-
dures are concurrently performed on patients with
successful control of infection. In patients with an active
infection, the vascularized bone graft should be post-
poned until successful control of the infection after
radical debridement. Many surgeons have advocated
that traditional bone grafting should be performed more
than 3 months after subsidence of the inflammation. On
the other hand, vascularized bone grafting can be per-
formed soon after subsidence of the inflammation. In
patients with large soft-tissue defects (such as Gustillo
type III-c fracture), a vascularized fibula graft with a flap
is transferred soon after debridement, even if inflamma-
tion has not been controlled yet, because soft-tissue cov-
ering can control infection effectively in such cases.

(,ug/ml)
1000
100
10
1 2 3 5 7 10 14 17 21 24 28 31 (day)
Fig. 2. Release rate (Rate of release) of several antibiotics
from bone cement beads. The release of antibiotics by diffu-
sion from the beads was investigated by elution in a phosphate
buffer at pH 7.4. GM, Gentamicin; KM, kanamycin; TC, tetra-
cycline; TIPC, ticarcillin; DKB, dibekacin; CTM, cebotiam;
CFS, cefusulodin
Radical Debridement of
Infected Focus
The extent of bony debridement is initially determined
according to preoperative roentgenograms and/or MRI.
However, it is finally determined at the time of surgery.
Curettage is performed until the normal bone appears.
Not only the infected and devitalized bone, but also
the circumferential scar tissues, including the infected
granulation tissues, should be resected. This is the key
to the successful treatment of osteomyelitis. Extensive
debridement of the lesion can be permitted, because use
of a vascularized bone graft achieves bone union irre-
spective of the length of the bone defect. This approach
differs markedly from conventional bone grafting. For
patients in an active phase of inflammation with heavy
discharge, lesional debridement is followed by closed
irrigation with antibiotic solution [11]. For patients
with mild discharge, antibiotic-formulated bone cement
beads, which contain antibiotics with activity against the
organisms, are implanted to eradicate any remaining
pathogenic organisms [12]. Because bone cement is
hydrophobic, injectable aqueous antibiotics should not
be used; rather, powdered antibiotics should be mixed
with bone cement. The results of my dissolution tests
from the bone cement indicate the superiority of
aminoglycoside homologues, such as gentamicin and
dideoxykanamycin B (Fig. 2) [13]. For patients with
MRS A infection, vancomycin is recommended. For
patients with a rebellious infection, such as an MRS A
infection, filling with antibiotic-formulated bone cement
3.8. Chronic Osteomyelitis and Infected Nonunion 459
that is solidified in a shape conforming to the bone
defect has been performed after closed irrigation to
maximize control of the infection (Fig. 3a and b) [4].
Antibiotic-formulated bone cement is usually left for a
few weeks, depending on the progress of healing in indi-
vidual patients. As soon as the inflammatory symptoms
subside and blood examination results are normal, vas-
cularized fibula grafting is performed (Fig. 3c).
Preoperative arteriography of the recipient side
should be performed, because the recipient vessels are
usually diseased due to chronic infection. However, in
patients with palpable dorsalis pedis and posterior tibial
arteries on the foot, preoperative arteriography is not
necessary in principle.
Vascularized Fibular Graft
In patients with tibial lesions, the donor fibula is usually
obtained from the contralateral leg, and occasionally
from the ipsilateral leg. The latter procedure is indicated
for patients with island flap transfer. When the fibula is
obtained from the ipsilateral leg, vascular release is very
difficult due to the perivascular scars. The reconstructed
leg may be weak because one leg bone is reconstructed.
Therefore, a free vascularized fibula graft from the
contralateral leg is recommended for patients with seg-
mental bone defect in the tibia. In patients with femoral
lesions, it is suggested that the donor fibula be obtained
from the ipsilateral leg. For patients with segmental
bone defects in the femur, a twin-barrelled fibula graft
is required, because a single fibula graft would be easily
broken [14,lS]. As much as 26cm of the fibula can be
taken, and it can be divided into two struts by
osteotomizing at its mid-shaft, preserving the vascular
supply of both struts (Fig. 4a and b) [3]. There are two
methods of fibular grafting: inlay and onlay grafts. If it
can be done, the former procedure is recommended.
When the inlay grafting method is performed, the junc-
tions should be covered with the fibular periosteum.
Fixation of the graft to the recipient bone is usually per-
formed by using screws, and care should be taken not
to disturb the blood supply to the graft. An external
skeletal fixation device is applied to secure the immo-
bilization (Fig. Sa) [14].
The preparation of vessels at the recipient site is per-
formed by using a binocular loupe with 2 to 3 magnifi-
cation. Vascular anastomoses are performed under an
operating microscope. In most cases, exploration of
vessels is difficult because they are buried in scar tissues
or closely adherent to the encircling tissues. In such
cases, the vessels to be anastomosed should be sought
in the anatomically normal site first, and hence, some
cases will require vein grafts [4]. Vascular anastomoses
 460 E. Clinical Reconstructive Microsurgery

a,b c

Fig. 3. A 18-year-old man with posttraumatic infected nonunion of the left tibia. a The defect
was filled with antibiotic-formulated bone cement solidified in a shape conforming to the defect
region after radical debridement. b After the inflammatory symptoms subsided, the antibiotic-
formulated bone cement was removed. (See Color Plates) c Vascularized fibula grafting was
performed in place of antibiotic-formulated bone cement. (From [4], with permission)

of vessels at the normal site, even if they require addi-

tional vein grafts, produce fewer postoperative com-
plications than anastomoses of vessels within scars.
I believe that this maneuver is critical to increase the
success rate of free composite transplantations.

ab
Fig. 4. Twin-barrelled vascularized fibula graft. a The fibula is
divided into two struts by osteotomizing at its midpoint, pre-
serving the vascular supply of both struts. b The twin-barrelled
fibula is grafted to the femoral defect. The flap is used for mon-
itoring purposes only
Postoperative Care
and Complications
Careful postoperative monitoring is particularly impor-
tant in raising the success rate of vascularized fibula
grafts. Several monitoring methods have been reported.
Generally, monitoring is performed by Doppler stetho-
scope and observation of the skin color of the monitor-
ing flap [16]. The anastomosis should be reexplored
as soon as any circulatory disturbances are suspected.
In our series with infected nonunion of the lower legs,
postoperative thrombosis at the vascular anastomoses
or circulatory disturbances in the flap necessitated re-
exploration in 10 out of 57 patients (18%). Because all
complications occurred within 3 days postoperatively,

ab
Fig. 5. A 20-year-old man with posttraumatic infected
nonunion of the right femur. a The right femur with infected
nonunion fixed in an external fixator. b Twin-barrelled vascu-
larized fibular grafting performed for the reconstruction of the
a,b
Fig.6. A 21-year-old woman with chronic osteomyelitis of the
right tibia (failure of vascularized fibula graft). In this patient,
the vascularized fibula graft failed due to thrombosis at the
vascular anastomoses, and soleus muscle flap transposition
was performed after removal of the fibular muscle sleeves. a
Bone union of both sides was achieved 6 months postopera-
3.8. Chronic Osteomyelitis and Infected Nonunion 461
cd
femoral defect. c Anteroposterior radiograph 34 months after
operation showing significant hypertrophy of the grafted
fibula. d Lateral radiograph 34 months after operation. (From
[8], with permission)
c
tively. b Fracture (arrow) of the grafted fibula occurred after
weight-bearing, and the fracture did not unite even after 5
months under conservative treatment. c Five months after the
fracture, the grafted fibula was totally removed and an iliac
bone graft was performed. Bone union was then achieved 4
months postoperatively
462 E. Clinical Reconstructive Microsurgery
frequent postoperative monitoring (every 2 to 3h)
should be performed 3 to 4 days postoperatively.
Thereafter, checking 2 to 4 times per day may be
enough.
The reexploration rate of infected nonunions was
higher than that of other conditions. Finally, in eight
patients, fibular grafts were successfully salvaged by
thrombectomy or vein grafting, but the grafts could not
be salvaged in the remaining two patients in our series
(Fig. 6a-c). Local recurrence, including postoperative
fistula formation, was encountered in 8 out of 57
patients (14%), including one with a failed graft. In six
patients, subsidence of the inflammation was achieved
only by lesional debridement. Fujimaki et al. [17]
reported exacerbation of osteomyelitis in 4 of 15
patients (27%), and Weiland et al. [3] described post-
operative fistula formation in 3 of 11 patients (27%).
Minami et al. [9] reported that recurrence of infec-
tion following union occurred in 1 of 14 patients (7%).
Most of the results were satisfactory compared with the
results of traditional approaches. However, the out-
comes of failed cases were bad. Low et al. [18] advo-
cated that infected nonviable grafts should be removed
completely.
References
1. Taylor GI, Miller GDH, Ham FJ (1975) The free vascu-
larized bone graft: a clinical extension of microvascular
techniques. Plast Reconstr Surg 55:533-544
2. Tarnai S, Sakamoto H, Hori Y, Tatsumi Y, Nakamura Y,
Shimizu T, Fukui A (1980) Vascularized fibula transplan-
tation: a report of 8 cases in the treatment of traumatic
bony defect or pseudoarthrosis of long bones. Int J Micro-
surg 2:205-212
3. Weiland AJ, Moore JR, Daniel RK (1984) The efficacy
of free tissue transfer in the treatment of osteomyelitis.
J Bone Joint Surg 66A:181-193
4. Yajima H, Tarnai S, Mizumoto S, Inada Y (1993) Vascu-
larized fibular grafts in the treatment of osteomyelitis and
infected nonunion. Clin Orthop 293:256-264
5. Yajima H, Tarnai S, Mizumoto S, Sugimura M, Horiuchi
K (1992) Vascularized fibula graft for reconstruction
after resection of aggressive benign and malignant bone
tumors. Microsurgery 13:227-233
6. Taylor GI, Townsend P, Corlett R (1979) Superiority of the
deep circumflex iliac vessels as the supply for free groin
flaps: clinical work. Plast Reconstr Surg 64:745-759
7. Teot L, Bosse JP, Moufarrege R, Papillon J, Beauregard G
(1981) The scapula crest pedicled bone graft. Int J Micro-
surg 3:257-262
8. Yajima H, Tarnai S (1994) Twin-barrelled vascularized
fibular grafting to the pelvis and lower extremity. Clin
Orthop 303:178-184
9. Minami A, Kaneda K, Itoga H (1992) Treatment of
infected segmental defect of long bone with vascularized
bone transfer. J Reconstr Microsurg 8:75-82
10. Doi K, Kawakami F, Hiura Y, Oda T, Sakai K, Kawai S
(1995) One-stage treatment of infected bone defects of
the tibia with skin loss by free vascularized osteocuta-
neous grafts. Microsurgery 16:704-712
11. Compere EL (1962) Treatment of osteomyelitis and
infected wounds by clos- ed irrigation with a detergent
antibiotic solution. Acta Orthop Scand 32:324-333
12. Vecsei V, Barquet A (1981) Treatment of chronic
osteomyelitis by necrectomy and gentamicin-PMMA
beads. Clin Orthop 159:201-207
13. Yajima H, Tarnai S, Yamaguchi T (1988) Muscle flap trans-
fer in the treatment of chronic osteomyelitis (in Japanese).
Seikeigeka 39:1597-1604
14. Jupiter JB, Bour CJ, May JW Jr (1987) The reconstruction
of defects in the femoral shaft with vascularized transfers
of fibular bone. J Bone Joint Surg 69A:365-374
15. Yajima H, Tarnai S, Mizumoto S, Ono H (1993) Vascular-
ized fibular grafts for reconstruction of the femur. J Bone
Joint Surg 75B:123-128
16. Yajima H, Tarnai S, Mizumoto S, Ono H, Fukui A (1993)
Vascular complications of vascularized composite tissue
transfer: outcome and salvage techniques. Microsurgery
14:473-478
17. Fujimaki A, Suzuki K (1988) Vascularized bone grafts in
the treatment of osteomyelitis (in Japanese). Shujutu 42:
283-288
18. Low CK, Pho RWH, Kour AK, Satku K (1996) Infection
of vascularized fibular grafts. Clin Orthop 323:163-172
3.9 Double Fibula Grafts for Femoral Reconstruction
Y OSHITSUGU TOMITA
In recent years, the vascularized fibula graft has been
routinely harvested with a skin flap to serve as a
so-called osteocutaneous flap. This form of treatment
is now widely applied in cases involving extensive
bone and skin defects resulting from traumatic bone
defects, debridement of the infected focus following
osteomyelitis, or excision of bone tumors.
Since 1981 we have successfuly achieved transfers
of double vascularized fibula grafts in 14 patients with
pseudoarthrosis or large bone defect of the femur. This
technique consists of bilaterally harvesting vascularized
fibula grafts and transferring them to the femoral bone
defect, one as an intramedullary graft and the other as
an onlay graft.
Surgical Technique
First Operation
The procedure has two stages, involving a preliminary
and a secondary operation in most cases.
Briefly, if infection is present, the focus is thoroughly
curetted and then a suitable interval is allowed for
the focus to subside prior to the secondary operation.
The pseudoarthrotic region of the femur is extensively
resected, removing as much fistula, sequestrum, and sur-
rounding necrotized tissue as possible. Even if the bone
defect reaches 20 cm or more as a result of the removal
of the pseudoarthrotic region, vascularized bone grafts
provide for suitable reconstruction. Thorough curettage
and resection of the focus of infection and necrotized
tissue are essential.
A marked discrepancy in leg length can occur after
the preliminary operation and is actually seen in many
cases. To avoid or minimize this, it is necessary to
employ wire traction to maintain the proper length as
much as possible in the interval between the prelimi-
nary and secondary operations. In the preliminary
operation, therefore, the scarred soft tissue should be
removed sufficiently to permit the shortened leg to be
extended as much as possible. If the bone defect is
infected, the symptoms of local inflammation must be
allowed to subside before the secondary operation is
carried out.
Second Operation
The procedure for the secondary operation involves the
harvesting of bilateral fibula grafts. To carry out the pro-
cedure, two microsurgery teams are required, with each
team working with one vascularized fibula.
Because it is necessary to harvest the vascularized
fibula grafts together with a small monitoring flap so
that their postoperative viability can be checked, the
skin incision must be designed to include a small flap.
Since the procedure for harvesting a vascularized
fibula graft with flap is well known [1,2] and is discussed
elsewhere in this publication, its description is omitted
here. When the two vascularized fibula grafts have been
harvested, the operation on the femoral site is begun.
Operation on the Femur
When the bilateral fibula grafts have been harvested,
the patient is placed in a supine position, and a long,
S-shaped incision is made in the ventral aspect of the
thigh, beginning at a point 2 to 3 cm distal to the femoral
artery in the groin and extending to the lower end of
the thigh. Because focal curettage has been completed
in the preliminary operation, the pseudoarthrotic region
is exposed to confirm the absence of infection. Next, the
leg length discrepancy is corrected by traction, and the
vascularized fibula grafts are transplanted.
First, one fibula graft is inserted into the intra-
medullary cavity of the femur, while the other fibula
graft is positioned on the lateral aspect of the
femur (Fig. 1), after which the two grafts and the femur
are fixed together by driving two or three screws each
at the proximal and distal ends (Fig. 2). The use of plates
such as those used for fixing fractures is not recom-
mended in this operation because of the possibility of
injuring the blood vessels of the vascularized fibula
grafts.
463
 464 E. Clinical Reconstructive Microsurgery

Fig. 2. Two vascularized fibular grafts (left) and the femur

(right) are fixed together with two screws at the proximal and
distal ends. Plate fixation should not be used

Distal end 01 Ihe lemur

b

Fi . 1. One fibular graft i in erted into the intramedullary

canal of the fe mur, and the other fibula i Iran ferred a an
onla graft. a Photograph; b chemalic dra' ing
Laleral --t--->,..-----;~
Femoral artery
lemoral
circumflex iIr'lr - - t - Prolunda lemoris
artery artery

.Aou UiJ- -r--- Perforating artery

Anastomoses of Blood Vessels

The recipient arteries and veins are selected at the

medial aspect of the thigh in most cases. Since the bifur-
cation of the femoral profunda artery yields excellent
grafts, the medial aspect of the thigh is exposed, and the
femoral profunda artery is cut at the point where it
bifurcates into the muscle (Fig. 3). The femoral medial
muscles are elevated, and the femoral profunda artery
with two branches is led under those muscles toward
the fibula grafts (Fig. 4). This method provides for end- Fig. 3. The branches of the arteria profunda femoris are used
to-end anastomosis of the fibula grafts without vein as the recipient arteries for two fibular grafts

Arterial flow
b b
Fig. 4. Two recipient arteries are led to the grafted fibulas
under the medial muscles of the thigh. Adequate proximal
flow was noted before anastomosis. a Photograph, b Schematic
drawing
grafts (Fig. 5). The veins can also be anastomosed end-
to-end.
The success of this operation depends on satisfactory
blood flow in the artery. It should be kept in mind that
any attempt to anastomose small muscular branches of
a small artery will have no chance of success.
Indications
The indications for this operation should be determined
very carefully, because it involves such extensive
invasion that failure of the procedure would leave the
patient with no alternative but amputation at the thigh.
Thus, this operation is contraindicated for patients over
60 years of age and for patients with systemic conditions
such as diabetes mellitus, cardiac disease, or severe
3.9. Double Fibula Grafts for Femoral Reconstruction 465
Fig.5. The recipient arteries were anastomosed directly to the
donor arteries of the grafted fibulae without vein grafting. a
Photograph; b Schematic drawing
hepatitis. With these qualifications, this surgical tech-
nique is considered an effective treatment of pseu-
doarthrosis of the femur with a large bone defect.
Postoperative Management
The timing with which weight-bearing is permitted must
be carefully determined by observing the progress in
the patient's condition. This is necessitated by the fact
that refracture of the femur at the points of screw fixa-
tion may result in those cases where weight-bearing is
started too early. Rehabilitation should therefore be
conducted with great care. Weight-bearing on crutches
and with the aid of an ischial weight-bearing orthosis
can normally be allowed about 8 weeks after the
operation. On the average, patients can walk with full
466 E. Clinical Reconstructive Microsurgery

II b a b

Fig.6. a 21-year-old-man, immediately after surgery. b 8 years Fig.7. a 30-year-old-man, immediately after surgery. b 9 years
after surgery. Rigid bone union has been obtained after surgery. Transverse hypertrophy of the vascularized
fibular grafts can be seen in the intramedullary graft more
than the onlay graft

weight-bearing and without the aid of a brace or

crutches 1 year and 1 month after the operation.

Representative Cases
All of the patients in our series had received early treat-
ment of their bone fracture at other hospitals. They had
undergone an average of four operations (range, two to
nine) before undergoing our operation. The average
interval between the initial treatment and our operation
was 3 years and 6 months (range, 4 months to 7 years).
The time to bone union ranged from 3 to 10 months
(average, 5 months).
It has been reported that the transverse diameter
of vascularized fibula grafts increases after trans-
plantation, usually about 1 year after the surgery,
when weight-bearing is started [3]. In our study, the
transverse diameter of the vascularized fibula grafts
tended to increase after the fibula grafts had fractured
(Fig. 6). II b
Hypertrophy of the vascularized fibula grafts after
the operation was observed to a greater or lesser Fig.8. a 18-year-old-man, immediately after surgery. b 3 years
degree, with the intramedullary graft exhibiting this after surgery. Transverse hypertrophy of the intramedullary
feature more markedly than the onlay graft (Figs. 7 and grafted fibula is noted
8). The postoperative brace-wearing period is about 1
year. All of the patients could stand on the affected leg
when bone union was completed with hypertrophy.
 3.9. Double Fibula Grafts for Femoral Reconstruction 467

References grafts for femoral pseudoarthrosis with large bony defect.

Microsurgery 15:316-321
3. Malizos KN, Nunley JA, Goldner RD, Urbaniak JR,
1. Taylor GI, Miller GDH, Ham FJ (1975) The free vas-
Harrelson JM (1993) Free vascularized fibula in traumatic
cularized bone graft. A clinical extension of microvascular
long bone defects and in limb salvaging following tumor
technique. Plast Reconstr Surg 55:533-544
resection: comparative study. Microsurgery 14:368-374
2. Tomita Y, Murota K, Takahashi F, Moriyama M, Beppu M
(1994) Postoperative results of vascularized double fibula
3.10 Microsurgical Reconstruction Following Wide
Resection of Malignant and Potentially Malignant
Bone and Soft Tissue Tumors
MASAMICHI U SUI and SEIICHI ISHII
Limb-sparing surgery for malignant tumors in the
extremities has been widely attempted [1,2]. In some
cases, however, radical oncological surgery is incom-
patible with the preservation of limb function. To
resolve this problem, the authors have attempted to re-
construct the tissue loss caused by radical oncological
surgery, using microsurgical tissue transplantation [3-5].
In this paper we will present the surgical procedures and
the outcome of the reconstructed cases.
Types of Reconstructive Procedures
Vascularized Fibular Graft
Bone defect caused by resection of primary bone tumor
or secondary involved bony lesion can be reconstructed
by free vascularized fibular graft (FVFG), free vascu-
larized fibular head graft (FVFHG), and/or pedicled
vascularized fibular graft (PVFG).
Free Vascularized Fibular Graft
A 53-year-old housewife had angiosarcoma of the
radius (Fig. lA). The patient was referred to our
hospital because the pathologic diagnosis of the tumor
was malignant hemangioendothelioma. Wide resection
of the tumor, including a 12-cm length of the radius and
the surrounding muscles [promotor teres (PT), flexor
pollicis longus (FPL), abductor pollicis longus (APL) ,
extensor capri radialis brevis (ECRB)], was performed.
For reconstruction, a free vascularized fibula graft and
tendon transfer were performed (Fig. lB). The bra-
chioradialis and palm oris longus (PL) were transferred
to FPL and extensor pollicis longus (EPL) for flexion
and extension of the thumb, respectively. Figure 1C and
D shows almost normal function of the hand 10 years
and 11 months after surgery. With this type of re-
construction, in which the proximal and distal joints
are preserved, excellent functional results can be
expected.
Figure 2A and B shows osteosarcoma of the distal
tibia involving the adjacent distal physis. In this case, the
468
bone defect after tumor resection was reconstructed by
FVFG. The ankle joint was fused in the functional posi-
tion. The grafted fibula became hypertrophic, and the
patient can walk without any support (Fig. 2C and D).
Figure 3A is a preoperative radiogram showing chon-
drosarcoma of the right acetabulum extending very
close to the sacroiliac joint and the symphysis. The
tumor was resected through the sacroiliac joint, the
symphysis, and the intertrochanteric region. The hip
joint was not opened. Then the pelvic ring and the hip
joint were reconstructed by three pieces of vascularized
fibular graft and the ISOLA system (Fig. 3B). The
grafted fibula became hypertrophic, and the patient
can walk without any support.
Reconstruction of the lumbosacral junction by
FVFG was attempted. Figure 4A and B shows chor-
doma of the sacrum. After tumor resection, reconstruc-
tion of the lumbosacral junction was attempted with two
pieces of FVFG and nonvascularized fibular grafts and
Harrington rods (Fig. 4C). This type of reconstruction
has many problems, which will be discussed later.
Free Vascularized Fibular Head Graft
By grafting a fibula, including the head, some motion in
the wrist or shoulder joint can be preserved. A 14-year-
old girl suffered from osteosarcoma of the left proximal
humerus (Fig. SA). After preoperative chemotherapy,
the tumor was resected, including the glenoid and the
deltoid muscle. The proximal part of the humerus was
reconstructed by FVFHG. The head of the fibula was
suspended from the remaining part of the scapula (sling
procedure) (Fig. SB), and pedicled latissimus dorsi
muscle transfer was also performed to reconstruct the
deltoid muscle. A photograph taken 49 months after
the operation shows the appearance and function of
the reconstructed shoulder (Fig. SC and D).
Pedicled Vascularized Fibular Graft
Instead of FVFG, the ipsilateral fibula can be trans-
ferred with its vascular pedicle for knee joint fusion.
Figure 6A is a preoperative radiogram showing
osteosarcoma of the proximal tibia. After wide resec-
 3.10. Bone and Soft Tissue Tumors 469

c a-d
Fig.2. Hypertrophy of the grafted fibula. a Preoperative radi-
ograph showing osteosarcoma of the distal tibia. b Magnetic
resonance image showing tumor extension near distal physis.
C Reconstruction by free vascularized fibular graft. Arrow
d
shows fatigue fracture of the grafted fibula. d Six years after
surgery, hypertrophy of the grafted fibula can be seen
Fig. 1. Reconstruction by free vascularized fibular graft
(FVFG). a Preoperative radiograph showing angiosarcoma of
the radius. b Postoperative radiograph showing reconstruction
by FVFG. c,d Almost normal function of the hand can be seen
10 years and 11 months after surgery

a b

Fig. 4. Reconstruction of the lumbosacral junction by FVFG.

a Preoperative radiograph showing chordoma of the sacrum.
b Magnetic resonance image showing extensive tumor. C Post-
operative radiograph showing reconstruction of the lum-
bosacral junction by FVFG and sacral bars and Harrington
b
rods following resection of the sacrum

Fig. 3. Reconstruction of the pelvic ring by triple FVFG.

a Preoperative radiograph showing chondrosarcoma of right
acetabulum. b Postoperative radiograph showing reconstruc-
tion of the pelvic ring by three pieces of vascularized fibular
graft and ISOLA system. Grafted fibula shows significant
hypertrophy
470 E. Clinical Reconstructive Microsurgery
a b
c d
Fig.5. Sling procedure by FVFHG. a Preoperative radiograph
showing osteosarcoma of the proximal humerus. b Postopera-
tive radiograph showing sling procedure. c, d Appearance
and function of the reconstructed shoulder 49 months after
operation.
tion of the tumor, knee fusion by a modified Enneking's
method [6] was performed. In this case, a half slice
of the distal femur was turned down, and PVFG was
performed in combination with bank bone grafting
(Fig. 6B and C).
Skin Flap
Skin and/or soft tissue defect following resection of soft
tissue tumor or biopsy tract can be successfully covered
by a free or pedicled skin flap. The free or pedicled
latissimus dorsi flap is a very useful flap. Figure 7 shows
reconstruction of a soft tissue defect on the chest by a
pedicled latissimus dorsi flap. This patient had a recur-
rent malignant fibrous histiocytoma on her left chest.
Figure 7A is a computerized tomographic scan of the
thorax showing recurrent tumor involving the sternum.
After tumor resection, the thorax was reconstructed
with Marlex mesh and the soft tissue defect was covered
by a pedicled latissimus dorsi flap (Fig. 7B and C).
Figure 7D shows the reconstructed thorax 12 months
after surgery.
c
a
Fig. 6. Reconstruction by podicled vascularized fibular graft
(PVFG). a Preoperative radiograph showing osteosarcoma
of the proximal tibia. b Schematic drawing of modified
Enneking's method. c Postoperative radiograph showing knee
fusion by modified Enneking's method
Filleted Flap
In case of amputation for tumors of the extremities,
we can harvest a filleted flap from the amputated part of
the same extremity for reconstruction of the tissue defect
caused by tumor resection. Figure 8A is a computerized
tomographic scan of lymph node metastasis of malignant
melanoma of the soft part of the thigh into the pelvis.
Figure 8B is an illustration of the anterior aspect of the
patient, showing lymph node metastasis and the line of
hindquarter amputation. Figure 8C is an illustration of
the posterior aspect of the patient, showing the wound
scar from the previous surgery. In this case, we had to
perform hemipelvectomy to remove the tumors, and the
line of skin incision is shown. Wound closure seemed
impossible without some kind of skin flap. We used the
filleted flap from the amputated leg (calf), and wound
coverage was successfully performed (Fig.8D and E).
Free Muscle Graft
Sometimes we have to resect all flexor or extensor
muscles in the extremities to resect the tumor radically.
For reconstruction of such a muscle defect, we can use
a free or pedicled muscle graft. Figure 9 shows a 7-year-
old girl with angiosarcoma of her right forearm, which
was rich in vascularity (Fig. 9A and B). After radiation
therapy and chemotherapy, wide resection of tumor,
including the proximal part of the radius and flexor
muscles, was performed. Five years and 2 months after
the initial surgery, a free gracilis muscle graft was
attempted for reconstruction of finger flexion (Fig. 9C

c d
Table 1. Details of 74 grafts
FVFG (free vascularized fibular graft) 36
FVFHG (free vascularized fibular head graft) 14
PVFG (pedided vascularized fibular graft)
Pedicled latissimus dorsi flap
Free muscle graft
Other pedicled flap
Free latissimus dorsi flap
Free filleted flap
and D). Figure 9E and F shows the functional results
11 years after free muscle grafting.
Timing of Reconstruction
Microsurgical tissue transfer can be performed simulta-
neously with tumor resection (primary reconstruction)
or after some delay (secondary reconstruction). In pri-
mary reconstruction the surgery is much easier, because
vessels and nerves can be identified much more easily
than in secondary reconstruction. On the other hand,
patients undergoing primary reconstruction usually require
postoperative chemotherapy, which may have some
adverse effects on tissue healing after reconstruction.
We compared the outcome of 13 cases of primary and
9 cases of secondary reconstruction. The results show
that the adverse effects of chemotherapy, for example,
those on bone union, can be overcome by paying metic-
ulous attention to osteosynthesis. Although individual-
ized treatment is important in applying microsurgical
3.10. Bone and Soft Tissue Tumors 471
Fig. 7. Reconstruction by pedi-
cled latissimus dorsi flap. a Com-
puterized tomographic scan of
thorax showing recurrent malig-
nant fibrous histiocytoma of
left chest. b Reconstruction of
thorax with Marlex mesh. c
Reconstruction of thorax by
pedicled latissimus dorsi flap. d
The reconstructed thorax 12
months after surgery
reconstruction to salvage limbs, primary reconstruction
can be successfully performed when there is a wide sur-
gical margin during tumor resection [7].
8
8
3 Location of Tumors and Methods
3
of Reconstruction
From November 1983 to September 1998, we per-
formed 74 microsurgical reconstructions following
tumor resection on 68 patients with malignant or
aggressive bone and soft tissue tumors (Table 1).
Thirty-five patients were male and 33 were female.
The average age of the patients was 33.3 years (range,
9 to 82 years). Sixty cases were primary malignant
tumors, 3 were metastatic bone tumors, and 5 were
aggressive tumors. Fifty-four cases were bone tumors
and 14 were soft tissue tumors. The histological diag-
nosis was as follows: 31 osteosarcoma, 11 malignant
fibrous histiocytoma, 6 chondrosarcoma, 5 angiosarcoma,
3 giant cell tumor of bone, 3 metastatic bone tumor, 2
chordoma, 2 Ewing's sarcoma, 1 desmoid, 1 dermatofi-
brosarcoma protuberans, 1 malignant melanoma, 1
fibrosarcoma, and 1 diagnosis undetermined (Table 2).
Outcome of the Reconstructed Cases
The following items were investigated: graft survival,
prognosis (primary malignant tumor only), functional
evaluation (tumors of extremity only), and complica-
 472 E . Clinical Reconstructive Microsurgery

Fig. 8. Stump coverage by fillet

graft taken from the same leg.

- - A I'
a Lymph node metastasis of
malignant melanoma of soft part
(arrows). b Anterior aspect of the

o <:1
patient. Arrow shows lymph

I.''b
node metastasis and arrowheads
show line of hindquarter ampu-
tation. c Posterior aspect of the
I patient. Arrow shows wound scar
from the previous surgery and
a arrowheads show line of
hindquarter amputation. d,e
Anterior and posterior aspects of
wound coverage by filleted skin
graft

b c

d e

Table 2. Histological diagnosis (n = 68) tions. Functional status was evaluated by the system of
Osteosarcoma 31
Enneking et al. [8]. The average follow-up periods after
Malignant fibrous histiocytoma 11 tumor resection and after reconstruction were 59.8 and
Chondrosarcoma 6 52.2 months, respectively.
Angiosarcoma 5
Giant cell tumor of bone 3
Metastatic bone tumor 3 Survival of Graft
Chordoma 2
Ewing's sarcoma 2
Desmoid Two grafts (free latissimus dorsi flap and free muscle
Dermatofibrosarcoma protuberans graft) failed to survive. In three cases of FVFG, the
Malignant melanoma 1 patients died of tumor or other causes before evalua-
Fibrosarcoma
tion. Eventually 69 grafts survived, and the ultimate sur-
Diagnosis undetermined
vival rate was 94.5%. Based on the results presented

a graft. e,f Functional results 11
-. ~~
1
c
~ ..... ""-
.. ' - #
here and those of many other reports, the survival rate
of the graft in tumor reconstruction is high.
Prognosis of Disease
Among 60 patients with primary malignant tumors,
one was lost to follow-up. The prognoses of the remain-
ing 59 cases were as follows: 39 continuously disease
free (CDF) (66.1 %),6 no evidence of disease (NED)
(10.2%),2 alive with disease (AWD) (3.4%),10 dead of
disease (DOD) (16.9%), and 2 dead of other causes
(DOC) (3.3%) (Table 3). Microsurgical reconstruction
had no unfavorable influence on the prognosis of the
disease.
Reconstruction of Extremities
The functional scores of FVFG for reconstruction of the
extremities were between 67% and 97%. If the adjacent
joints were preserved, the score was more than 90%
(Fig. 1).
A disadvantage of the vascularized fibular graft is
that this procedure is not effective for reconstruction
of the joint itself, especially in the lower extremity.
Arthrodesis is necessary after resection of the tumor
around the knee joint. However, the functional results
of knee fusion in this series averaged 80% and did
not show deterioration over time (Fig. 5). Arthrodesis
of the knee using a vascularized fibular graft remains an
option for patients who require a painless and stable
limb [9,10].
3.10. Bone and Soft TIssue Tumors 473
Fig. 9. Reconstruction by free
muscle graft. a Angiosarcoma of
right forearm. b Angiogram
showing vascular tumor. c,d
Reconstruction of finger flexor
e muscles by free gracilis muscle
years after free muscle graft
Table 3. Prognosis of the disease (60 primary malignant
tumors)
Prognosis No. of cases %
Continuously disease free (CDF) 39 65
No evidence of disease (NED) 6 10
Aive with disease (AWD) 2 3.3
Dead of disease (DOD) 10 16.7
Dead of other causes (DOC) 2 3.3
Lost to follow-up 1 1.7
On the other hand, in the shoulder and wrist joint,
we have been able to preserve some motion by using
a fibular head graft (Fig. 6). The mean functional score
in wrist or shoulder joint preservation by fibular head
graft was around 80%. The sling procedure reported
here is a simple method, and the graft functions as a
strut for elbow motion. No rigid external fixation after
reconstruction is necessary, and the patient can move
the hand on the affected side to the mouth within 2 to
3 months after reconstruction. This is especially con-
venient for the care of patients who suffer nausea and
vomiting due to postoperative chemotherapy [11,12].
The problem with this procedure is collapse of the
fibular head, which occurred in 40% of cases. Preven-
tion of head collapse by selection of the donor vessels
or additional vessel anastomosis seems necessary, as
in wrist reconstruction by vascularized fibular head
graft [13].
Significant hypertrophy of the graft occurred in the
lower extremity (Fig. 2), and little hypertrophy occurred
in the upper extremity, as recognized in reconstruc-
474 E. Clinical Reconstructive Microsurgery
tion of traumatic cases. Functional free muscle grafting
can result in a contraction power of manual muscle testing
(MMT) 4 if this procedure is performed under ideal con-
ditions (Fig. 9). The results with the pedicled latissimus
dorsi flap were especially stable and satisfactory.
Reconstruction of Pelvis and Hip
FVFG is a useful method for reconstruction of the
pelvic ring, as Yajima and Tamai reported [14]. Although
pelvic ring reconstruction by FVFG was possible in all
patients with low-grade malignant tumors, one patient
with in our series osteosarcoma died of local and distant
recurrence of tumor. The function of the reconstructed
hip and pelvis is usually poor because of wide resection
of the muscles and the nerve around the hip joint.
However, arthrodesis of the hip joint by two or three
pieces of the vascularized fibula resulted in a painless
and stable joint (Fig. 3) [15]. For successful reconstruc-
tion, prevention of hematoma and infection is very
important in this particular region.
Reconstruction of Trunk
A skin flap or musculocutaneous flap was very useful
for wound coverage of the trunk. Reconstruction of the
thoracic cage in combination with Marlex mesh was a
very valuable technique (Fig. 7). Stump coverage in
hindquarter amputation with a filleted flap was also
useful (Fig. 8). The function of the reconstructed trunk
was satisfactory.
The local pedicled flap has been considered con-
traindicated for treatment of malignant tumors, because
this procedure may disseminate tumor cells into the
donor site. However, in our series, there was no tumor
dissemination in any patient who underwent recon-
struction by a pedicled cutaneous or musculocutaneous
flap. If we pay attention to the prevention of tumor dis-
semination by changing surgical instruments and
surgeon's gloves and gown, we can safely perform a
pedicled cutaneous or musculocutaneous flap, even in
cases of malignant tumor.
Reconstruction of Sacrum
The prognosis of sacral tumors is poor. All four of
our patient died of the disease. The prognosis in this
region was poor because it was difficult to achieve
good local control of tumor and to achieve bone union
by FVFG. The patients could move in a wheelchair
but could not walk (Fig. 4). Reconstruction of the
sacrum was too difficult for good results to be achieved,
Table 4. Complications (n = 27)
Nonunion 7
Collapse of fibular head 7
Fracture of the grafted fibula 6
Acute infection 3
Local recurrence 3
Late infection 1
and some changes in strategy for local tumor control
seem to be necessary. Reconstruction should be
attempted only when good local tumor control can
be anticipated.
Reconstruction in Metastatic Bone Tumor
The use of FVFG in cases of metastatic bone tumor is
controversial. We have performed this procedure in
patients with tumors that had a good prognosis, such as
thyroid carcinoma, renal cell carcinoma, or heman-
giopericytoma. Although all patients eventually died,
they survived more than 1 year after the surgery and
maintained good quality of life. We can maintain good
quality of life in selected patients with metastatic bone
tumors by FVFG.
Complications
Distant metastases occurred in 17.6% of patients. In
addition to distant metastases, complications occurred
in 27 patients: 7 had nonunion, 7 collapse of the fibular
head, 6 fracture of the grafted fibula, 3 acute infection,
3 local recurrence of tumor, and 1 late infection (Table
4). Among 7 cases of nonunion, union was achieved 6 in
cases by additional bone grafting, but one case still has
nonunion. Among 6 cases of fatigue fracture of the
grafted fibula, only 1 needed surgery, and the others
were successfully treated conservatively. In the case
of late infection in which the vascularized fibular graft
was used for knee arthrodesis in combination with
allografting, amputation was necessary.
In conclusion, microsurgical reconstruction following
resection of malignant bone and soft tissue tumors is a
safe and useful procedure, except for reconstruction of
the sacrum or a part of the pelvis.
References
1. Eilber FR, Eckard J, Morton DL (1984) Advances in the
treatment of sarcoma of the extremity: current status of
limb salvage. Cancer 54:2695-2701

2. Rosen G, Murphy ML, Huvos ACJ, Gutierrez M,
Marcov RC (1976) Chemotherapy, en bloc resection
and prosthetic bone replacement in the treatment of
osteogenic sarcoma. Cancer 37:1-11
3. Usui M,Ishii S,YamamuraM,MinamiA,SakumaT (1985)
Microsurgical reconstructive surgery following wide
resection of bone and soft tissue sarcoma in the ex-
tremities. J Reconstr Microsurg 2:77-84
4. Usui M, Ishii S, Matsuyama T, Asano S, Yamawaki S, Isu
K, Minami A (1989) Microsurgical reconstruction fol-
lowing wide resection of bone and soft tissue sarcomas
in the extremities. In: Yamamuro T (ed) New develop-
ments for limb salvage in musculoskeletal tumors. Kyocera
Orthopaedic Symposium. Springer, Tokyo, pp 661-666
5. Usui M, Ishii S, Naito T, Wada T, Yamawaki S, Isu K (1996)
Limb-saving surgery in osteosarcoma by vascularized
fibular graft. J Orthop Sci 1:4-10
6. Enneking WF, Shirley PD (1977) Resection-arthrodesis
for malignant and potentially malignant lesions about the
knee using an intramedullary rod and local bone grafts.
J Bone Joint Surg 59B: 223-236
7. Usui M, Ishii S, Naito T, Yamashita M, Yamamura M
(1993) Microsurgical reconstruction in limb-salvage pro-
cedures: comparison between primary and secondary
reconstruction. J Reconstr Microsurg 9:91-101
8. Enneking WF, Dunham W, Gebhardt MC, Malawar M,
Pritchard DJ (1993) A system for functional evaluation
of reconstructive procedures after surgical treatment of
3.10. Bone and Soft Tissue Tumors 475
tumors of the musculoskeletal system. Clin Orthop 286:
241-246
9. Usui M, Ishii S, Naito T, Wada T, Nagoya A, Takahashi T,
Tsuchida Y (1996) Arthrodesis of knee joint by vascular-
ized fibular graft. Microsurgery 17:2-8
10. Wada T, Usui M, Isu S, Yamawaki S, Ishii S (1999)
Reconstruction and limb salvage after resection for
malignant bone tumour of the proximal humerus. J Bone
Joint Surg 81B: 808-813
11. Usui M, Naito T, Yamawaki S, Ishii S (1995) Free vascu-
larized fibular graft for treatment of malignant tumor
of proximal humerus. In: Vastamaki M, Jarovaara P (eds)
Surgery of the shoulder. Elsevier, Amsterdam, pp 471-
474
12. Wada T, Usui M, Nagoya S, Isu K, Yamawaki S, Ishii S
(2000) Resection arthrodesis of the knee with vascular-
ized fibular graft. J Bone Joint Surg 82B:489-493
13. Usui M, Murakami T, Naito T, Wada T, Takahashi T, Ishii
S (1996) Some problems in wrist reconstruction after
tumor resection with vascularized fibular-head graft. J
Reconstr Microsurg 12:81-88
14. Yajima H, Tarnai S (1994) Twin-barreled vascularized
fibular grafting to the pelvis and lower extremities. Clin
Orthop 303:178-184
15. Nagoya S, Usui M, Wada T, Yamashita T, Ishii S (2000)
Reconstruction and limb salvage using a free vascularized
fibular graft for peri acetabular malignant bone tumors.
J Bone Joint Surg 82B:1121-1124
3.11 Avascular Necrosis of the Femoral Head
HIROSHI YAJIMA and KENJI KAWATE
Aseptic osteonecrosis of the femoral head in the adult
is a particularly challenging disorder confronting ort-
hopedic surgeons. There are a number of treatments.
Total hip replacement is the most reliable procedure
and is most popularly indicated. However, it has some
problems, especially the limited durability of the pros-
thesis. Therefore this procedure is not favorably in-
dicated for young patients. The disease is most prevalent
in the third, fourth, and fifth decades of life, with men
being affected four times more often than women.
Various procedures for salvaging the femoral head
affected by osteonecrosis have been attempted for
nonelderly patients. Intertrochanteric osteotomy, trans-
trochanteric rotational osteotomy, and vascularized
bone grafting are the most reliable. The transtro-
chanteric rotational osteotomy reported by Sugioka
et al. [1] has been the most popular in Japan. One
disadvantage of this procedure is that it is not indicated
for patients with broad types of necrosis, such as type
III, according to the classification of the Japanese
Ministry of Health and Welfare (JMHW) (Investigation
Committee for Avascular Necrosis of the Femoral
Head) [2]. On the other hand, vascularized bone graft-
ing can be indicated for these patients. In the 1970s,
muscle pedicle bone grafting was performed as a trial
procedure. Thereafter, vascularized fibula and iliac
bone grafts became popular. The vascularized iliac
bone graft does not require microsurgical technique,
but it is difficult to insert in the highest weight-bearing
area of the femoral head, because it is inserted from
the anterior neck and tends to insert posteriorly [3].
On the other hand, the fibula can be transferred to
this area, because it is inserted from the lateral fem-
oral cortex of the subtrochanteric area. In addition,
the fibula is stronger than the ilium from the point
of their anatomical structure and biomechanical aspect
[4]. This article describes the usefulness, indications,
operative procedures, and clinical results of the vascu-
larized fibula graft for osteonecrosis of the femoral
head.
476
Usefulness of Vascularized
Fibula Graft
The biggest advantage of the vascularized bone graft
is the revascularization of the femoral head with
osteonecrosis. This effect is similar to that of other
revascularization procedures, such as vascular bundle
implantation [5]. The vascularized fibula graft has not
only a biological effect, but also a biomechanical effect,
the prevention of collapse of the femoral head by the
grafted bone. Among donor bones to be used for vas-
cularized bone grafts, the fibula is the strongest because
of its anatomical structure and has the least donor site
morbidity [4,5].
Indications
Several factors should be considered when vascularized
fibula grafting is indicated for patients with femoral
head necrosis. The criteria include the age of the patient,
stage and type of involvement of the femoral head,
functional demands of the individual, and cause of the
disease [6]. We think that the first two parameters are
critical. In general, most surgeons choose an implant
arthroplasty for patients over 50 to 55 years of age.
Therefore, the vascularized fibula graft is indicated for
patients under 55 years of age. Generally speaking, vas-
cularized fibula transfer is indicated for this disease
before marked collapse of the head or secondary artic-
ular degenerative changes occur. It is generally indi-
cated for patients with stage I or II of type Ic, type II,
or type IIIb according to the JMHW classification
(Table 1) [2]. In almost all reports, the results of vascu-
larized fibula grafting for the femoral head in the early
stage (pre collapse stage) were satisfactory [7-10]. For a
patient at stage III, in whom collapse occurs within
5 mm, the vascularized fibula graft can be indicated if
the patient is young. If the necrosis is secondary to a col-
lagen vascular disease, pedicled vascularized bone graft-
ing is recommended because of the high failure rate of
vascular anastomosis.
 3.11. Avascular Necrosis of the Femoral Head 477

Table 1. Classification of osteonecrosis of the femoral head

by the Japanese Ministry of Health and Welfare (investigation
committee for avascular necrosis of the femoral head)
Stages of avascular necrosis of the femoral head
Stage I: preradiological stage
Stage II: early stage (collapse < 2mm)
Stage III: advanced stage (collapse of the femoral head)
Stage IV: late stage (osteoarthritic change)
Types of avascular necrosis of the femoral head
Type I shows a demarcation line in the femoral head, divided into
three types
I-A: necrotic lesions less than 113 of the weight-bearing
surface
I-B: necrotic lesions more than 113 but less than 2/3 of the
weight-bearing surface
I-C: necrotic lesions more than 2/3 of the weight-bearing
surface
Type II shows no demarcaton line, but flattening of the weight-
bearing surface
Fig. 1. Harvesting of the vascularized fibula graft with a mon-
Type III has cystic lesions itoring flap
III-A: cystic lesion is located on non-weight-bearing surface
III-B: cystic lesion is located on weight-bearing surface

Operative Technique
Generally, the anterolateral approach has been used for
vascularized fibular grafting to the femoral head [6-10].
However, we prefer two skin incisions, one for fibular
grafting and the other for vascular anastomosis. Before
the operation, the cutaneous perforators from the per-
oneal vessels should be confirmed by using a Doppler
ultrasound stethoscope. Usually they exist in the distal
third of the leg. If the monitoring flap is harvested from
the distal leg, the flap cannot reach to the surface of the
thigh because of its short vascular pedicle. Therefore
the flap should be harvested up to at least 15 cm from
the tip of the lateral malleolus. However, monitoring
flaps could not always be obtained in 10 of 39 cases in
our series, owing to anatomical problems associated Fig. 2. Diagram showing insertion of the vascularized fibula
with them. graft
The operation is started with the patient in the lateral
position. A sterile tourniquet is placed on the thigh, and
the ipsilateral fibula, which is 15 cm in length, is har- centimeters of tendon. The rectus femoris muscle is then
vested. The method of fibular harvesting is mentioned retracted distally. The lateral femoral circumflex artery
in another chapter (E.3.8) of this volume. It is better for and the concomitant veins are then identified. We
the fibula to be harvested as distally as possible, because usually use the transverse or descending branch of the
a long vascular pedicle can be obtained. In addition, the lateral femoral circumflex vessels for anastomosis.
monitoring flap can be attached at the adequate posi- A lateral approach is used in the subtrochanteric area
tion (Fig. 1). After a fibular segment has been harvested, of the thigh to expose the proximal aspect of the femur.
the patient is changed to the supine position. A slightly After the tensor fasciae latae has been split, the vastus
curved (medial convex) 10-cm skin incision is made at lateralis is reflected from the vastus ridge. Under fluo-
the anterior aspect of the inguinal area. After retraction roscopic control, a guide pin that is used as a compres-
of the sartorius muscle, the attachment of the rectus sion hip screw is inserted into the necrotic lesion of
femoris muscle is detached from the ilium, leaving a few the femoral head. Because collapse has occurred at an
478 E. Clinical Reconstructive Microsurgery
d e
anterolateral area of the femoral head in most patients,
the tip of the fibula should reach to this area. Therefore,
a guide pin is inserted from the slight posterior sub-
trochanteric region to the anterolateral area of the
femoral head at an angle of 145 to 150, and its posi-
tion should be confirmed with roentgenograms (Fig. 2).
A cylindrical hole is made by the reamer of the com-
pression hip screw surrounding and passing over the
guide pin. The hole is enlarged (maximum, 19mm) with
another reamer used for total hip replacement. The
reamer is advanced to just below the subchondral bone
but should not penetrate the articular cartilage. In some
cases, the 19-mm-diameter hole is enlarged by a high-
ig. 3. A 29- ear- Id man \ ilh
leroid-indu edleonecr i f Ihe
left fem ral head ( lage II. I pe 1- ).
11 Prcopcrali c radiograph hm ing
no collap e of Ihe femoral head. b
nleropo lerior radiograph al 42
monlh po loperalivel howing 'olid
bone union al Ihe di lal end of Ihe
grafted fibula and new b ne formalion
al il pro imal end. c -rog-Ieg p ilion
radi graph al 42 m nih p I pera-
Ii el . d Preoperali e magrelic re 0-
nance image (MR I) h wing \ ide
o leonecro i e MR I al 42 monlh
p loperali el howing re a cular-
i7alion uTrounding Ihe grafted fibu la
speed drill when the grafted fibula is too thick. As
much as possible of the reaming necrotized bone in the
femoral head is removed by the use of a high-speed drill
and osteotrites. The cancellous bone chips harvested
from the ilium or the greater trochanteric region are
packed into the area where the necrotized bone was
previously curretted. Before insertion into the core, the
end of the fibular graft is shaved as round as possible by
using a high-speed burr. The graft is then positioned
beneath the subchondral bone and stabilized to the
proximal part of the femur with a titanium screw. In
cases with some collapse of the head, the fibular graft
is hit with a hammer to lift up the collapsed lesion.

ab
Fig.4. A 34-year-old man with steroid-induced osteonecrosis
of the left femoral head. a Preoperative radiograph showing
collapse of the femoral head (stage III, type I-C). b Antero-
posterior radiograph at 1 month postoperatively. c Antero-
The peroneal vascular bundle is introduced anteriorly
through the vastus intermedius muscle. Vascular anas-
tomoses are performed by using another skin incision,
which was made previously in order to identify the
lateral femoral circumflex artery and the concomitant
veins. Vascular anastomoses are performed with 8-0
nylon sutures under an operating microscope. Bleeding
from the edge of the monitoring flap and intramedullary
cavity at the base of the graft confirms the graft's vas-
cularity. The monitoring flap is usually placed along the
lateral thigh incision, and then both wounds are closed.
Our technique differs in two points from the tech-
nique described by Urbaniak [6]. One is the site of the
vascular anastomoses, and the other is the insertion
angle of the fibular graft. Urbaniak [6] performed vas-
cular anastomosis at the lateral aspect of the proximal
femur near the grafted fibula, using the ascending
branches of the lateral femoral circumflex artery. We
performed vascular anastomoses at the anterior aspect
of the proximal femur with the transverse or descend-
ing branch of the lateral femoral circumflex vessels.
Here there are some adequate vessels with diameters
large enough to allow them to be anastomosed. In our
technique, however, a long vascular pedicle (approxi-
mately 7 cm) is required. Therefore, we harvest the
fibula segment as distally as possible. Then, the moni-
toring flap can be harvested in a good location. Urba-
niak et al. [6,7] have not performed postoperative
monitoring using a flap. In our series, circulatory distur-
bances in the flap necessitated reexploration in 4 of 29
3.11. Avascular Necrosis of the Femoral Head 479
c
posterior radiograph at 40 months postoperatively showing
progression of the collapse. Treatment of this case failed, and
total hip arthroplasty was required 42 months after fibular
grafting
patients (14%). In 3 patients, fibular grafts were suc-
cessfully salvaged by thrombectomy, but in the remain-
ing patient the grafts could not be salvaged. This patient
was obliged to receive a total hip replacement later
because the femoral head had collapsed. I recommend
that the monitoring flap be attached in as many cases as
possible in order to improve the operative results. Urba-
niak et al. [7] inserted the fibula into the center of the
necrotic head. According to their report, it was inserted
at an angle of 130 to 135. We also used to insert the
fibula at an angle of 130 to 135. However, collapse
occurred in some patients. Therefore, we have changed
our insertion angle to 145 to 150. In other words, the
tip of the fibula should reach the anterolateral area of
the femoral head, which is the area of the greatest
weight-bearing.
Postoperative Care (Figs. 3 and 4)
Postoperative monitoring is performed by using a mon-
itoring skin flap. In 70% of our patients, it was possible
to harvest a monitoring flap. In other patients without a
skin flap, postoperative monitoring could not be per-
formed. Urbaniak et al. [6,7] performed a digital sub-
traction angiogram on the fifth postoperative day. We
think it is unnecessary to perform an angiography for
postoperative monitoring. If it shows vascular trouble
on the fifth day, reexploration cannot rescue the grafted
fibula, and therefore reexploration should be performed
480 E. Clinical Reconstructive Microsurgery
as soon as possible after vascular trouble occurs. In our
series, the monitoring flap could be obtained in 29 of 39
cases, and it showed color changes after operation,
necessitating reexploration in 4 of 29 patients (14 % ). In
3 patients, fibular grafts were successfully salvaged by
thrombectomy, but the grafts could not be salvaged in
the remaining one. We believe that postoperative mon-
itoring is of utmost important in to attain an improved
outcome.
A short leg cast is applied to the donor leg for 2
weeks. After removal of the cast, the patient begins
touch-down weight-bearing. When bone union at the
distal end of the fibula in the femoral head is confirmed,
generally at 4 to 6 months postoperatively, partial
weight-bearing is allowed. During the next month,
the amount of weight-bearing is gradually increased to
50%. Unassisted full weight-bearing is allowed at 9 to
12 months postoperatively.
References
1. Sugioka Y, Hotokebuchi T, Tsutsui H (1992) Trans-
trochanteric anterior rotational osteotomy for idiopathic
and steroid-induced necrosis of the femoral head. Indica-
tions and long-term results. Clin Orthop 277:111-120
2. Ono K (1987) Diagnostic criteria, staging system, and
roentgenographic classification of avascular necrosis of
the femoral head (steroid induced, alcohol associated, or
idiopathic nature) (in Japanese). In: Ono K (ed) Annual
report of Japanese investigation committee for intractable
diseases, avascular necrosis of the femoral head, under the
auspices of Ministry of Health and Welfare, p 331
3. Leung PC (1987) Use of vascularized pedicle iliac crest
graft in treatment of ischemic necrosis of femoral head.
In: Urbaniak JR (ed) Microsurgery for major limb recon-
struction. CV Mosby, St. Louis, pp 200--204
4. Yajima H, Tarnai S, Mizumoto S, Inada Y (1983) Vascu-
larized fibular grafts in the treatment of osteomyelitis and
infected nonunion. Clin Orthop 293:256-264
5. Tarnai S, Hori Y, Fujiwara H (1987) Treatment of avascu-
lar necrosis of lunate and other bones by vascular bundle
transplantation. In: Urbaniak JR (ed) Microsurgery for
major limb reconstruction. CV Mosby, St. Louis, pp 209-
219
6. Urbaniak JR (1987) Aseptic necrosis of the femoral head
treated by vascularized fibular graft. In: Urbaniak JR (ed)
Microsurgery for major limb reconstruction. CV Mosby,
St. Louis, pp 178-184
7. Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA
(1995) Treatment of osteonecrosis of the femoral head
with free vascularized fibular grafting. J Bone Joint Surg
77A:681-694
8. Brunelli G, Brunelli G (1991) Free microvascular fibular
transfer for idiopathic femoral head necrosis: long-term
follow-up. J Reconstr Microsurg 7:285-295
9. Yoo MC, Chung DW, Hahn CS (1991) Free vascularized
fibular grafting for the treatment of osteonecrosis of the
femoral head. Clin Orthop 277:128-138
10. Sotereanos DG, Plakseychuk AY, Rubash HE (1997) Free
vascularized fibula grafting for the treatment of osteo-
necrosis of the femoral head. Clin Orthop 344:243-256
3.12 Treatment of Avascular Necrosis of the
Femoral Head with a Pedicled Vascularized
Iliac Bone Graft
ARIHISA FUJIMAKI

In the treatment of aseptic necrosis of the femoral
head (ANFH), a variety of surgical operations have been
employed. Not surprisingly, free bone grafts produced
poor results in this avascular environment [1,2]. More
favorable results were obtained with the use of vascular-
ized pedicled bone grafts [3]. In addition, a vascular bundle
was implanted to vitalize the necrotic area [4]. Subse-
quently, with the introduction of microsurgical tech-
niques, the transplantation of a free vascularized fibula
graft as a living bone graft has become possible [5,6].
Alternatively, transplantation of a pedicled iliac bone
graft without vascular anastomoses can produce favor-
able results [7]. This latter technique is popular because
there is less risk of thrombosis, without vascular anasto-
moses. The iliac bone has an abundant blood supply, and
the procedure is confined to one operating field.
Surgical Technique
imaging (MRI), the necrotic lesion in the femoral
head is curetted, although this can be difficult due to
osteosclerotic change. It is not necessary to incise the
femoral head (Fig. 2a and b). The vascular pedicle is dis-
sected towards the external iliac vessels, and the lateral
cutaneous nerve of the thigh is retracted laterally. The
ascending branch of the DCIA is ligated. At the inner
wall of the pelvis, the fascia and muscle of the iliacus
are transected 1-2cm below the vascular pedicle to the
periosteum, where many perforating vessels are seen.
The measured bone block is resected posterior to the
anterior iliac spine, after the periosteum has been
incised to prevent detachment. Because there is no
stress on the bone graft, it is not necessary to take the
full width of bone, 1.5 cm from the medial cortex being
sufficient.
About 2.5 to 3.5 cm of the depth of bone is needed to
include the DCIA. The iliac bone graft should be about
4 x 3 x 1.5 cm in size. The additional cancellous bone is

The operation is performed with the patient supine

with a pad inserted under the hip of the affected side
to elevate the pelvis slightly. A skin incision is made
obliquely down the iliac crest along the inguinal liga-
ment, curving laterally at the femoral artery to cross the
femoral neck and greater trochanter in an "S" shape.
Care should be taken because skin necrosis develops if
the curve is too acute (Fig. 1). The iliac bone is exposed
from the center of the crest and the tensor fasciae and
gluteus medius muscle are turned laterally. Medially, the
external iliac artery is exposed just above the inguinal
ligament, and the route of the deep circumflex iliac
artery and vein (DCIA and DCIV) is confirmed, but not
dissected. The hip joint is exposed by dividing the iliacus
muscle and retracting the sartorius and the rectus
femoris muscles. An H -shaped incision is made in the
anterior surface of the joint capsule to expose the
femoral head, which is inspected, and dislocation of the
hip joint is unnecessary.
A slot for the bone graft 2 cm wide and 3 cm long is
prepared on the anterior femoral neck from the sub-
capital to the intertrochanteric region. With the aid of
the preoperative radiograms and magnetic resonance Fig. 1. Skin incision

481
 482 E. Clinical Reconstructive Microsurgery
a circumflex iliac artery (DeIA system)
b bearing for 3 to 4 months. The patency of the vascular
Fig. 2a,b. Groove for the iliac bone graft at the anterior
subcapital to the neck of the femur
harvested with a curette. The vascular pedicle of the
harvested ilium is 6 to 7 cm in length, which is usually
sufficient to reach the anterior neck of the femur;
however, the measurement should be checked, and it is
essential that there is bleeding from the cut surface of
the bone (Fig. 3).
The pedicle is released completely, while taking care
to avoid torsion and tension. Covering the iliac bone
with a vinyl sheet facilitates transfer under the inguinal
ligament. The curetted femoral head is filled with the
Fig.3. Isolated vascularized iliac crest with the pedicled deep
cancellous bone, and the iliac bone is inserted in place
with the vascular bundle anterior.
The bone graft should be impacted without any addi-
tional fixation. The joint capsule is sutured, leaving
space for the vascular pedicle. The hip joint should
be maintained in a flexed position postoperatively to
prevent tension on the pedicle. (Fig. 4a and b).
Postoperative Management
Bone wax aids hemostasis, and the iliacus muscle is
repaired. The inguinal ligament is also repaired to
prevent herniation. After the subcutaneous suture, the
skin is closed with careful hemostasis. The hip and knee
joints are immobilized in a slightly flexed position for
2 week, and ambulation with crutches avoids weight-
pedicle can be assessed by angiography 3 weeks after
surgery.
Figure 5a and b shows a representative case of avascu-
lar necrosis of the left femoral head in a 43-year-old man,
treated with iliac bone graft on a vascular pedicle. The
MRI before and after surgery is shown in Fig. 6a and b.
Discussion
We have described our experience with a vascular pedi-
cled iliac bone graft for treatment of avascular necrosis
of the femoral head. In 1983 we selected the fibula,
anticipating additional support by the cortical bone.
As to outcome, no pain was reported, and 50% of the
 Fig. 4a,b. The iliac bone with vascular pedicle was placed into
the prepared groove in the anterior femoral neck

Fig. 5 Clinical case: a 43-year-old

man with avascular necrosis of the
femoral head. a Preoperative radi-
ogram. b Postoperative radiogram
a b
at 1 year 2 months
 484 E. Clinical Reconstructive Microsurgery
a graft utilizing the deep circumflex iliac vessels is tech-
b 3. Palazzi C, Xicoy J (1975) The pediculate bone graft as
Fig. 6. a Preoperative MRI. b Postoperative MRI at 1 year
patients had an excellent result, but the rest required
femoral head replacement with an endoprosthesis.
When a free vascularized bone graft is transplanted,
some of the blood vessels around the hip joint must be
sacrificed as recipient vessels and the anastomosis is
critical for the graft survival.
On the other hand, the operation using an attached
pedicled graft is relatively simple. Because only a part
of the iliac bone is used, there is less morbidity. More-
over, the blood flow around the femoral head is not
disturbed. Because dislocation of the hip joint is not
required with this technique, the joint capsule can be
conserved. Recently it has been reported that the vas-
cularized pedicled bone graft is effective for the early
stage of avascular necrosis of the femoral head to
prevent collapse and that in young patients the use of
endoprosthesis can be delayed, because revasculariza-
tion can occur after many months [8].
It was also reported that the prognosis may be
improved if the bone graft is transplanted to support the
lateral aspect of the femoral head because necrosis here
has a poor outcome. We believe this is a good idea [9].
Viability of the bone graft has generally been assessed
by using postoperative scintigraphy or angiography. We
now prefer MRI, which permits examination of changes
in the bone marrow in the femoral head and viability of
the bone graft [10].
The operation can be performed in advanced cases,
but the results are poor, and it is recommended only for
early stages without collapse of the head [11].
Conclusions
The implantation of a vascularized pedicled iliac bone
nically simple and safe. The results are better with less
morbidity in the early stages of avascular necrosis of the
femoral head.
References
1. Phemister D (1947) Treatment of the necrotic head of the
femur in the adult. J Bone Joint Surg 31A:55-66
2. Bonfiglio M, Bardenstein M (1968) Treatment by bone
grafting of aseptic necrosis of the femoral head and
nonunion of the femoral neck (Phemister technique). J
Bone Joint Surg 40A:1329-1346
treatment for aseptic necrosis of the femoral head. Arch
Orthop Unfallchir 83:115-122
4. Hori Y (1980) Revitalisierung des osteonecrotischen
Hiiftkophes durch Gefiissbundel Transplantation.
Orthopaede 9:255-259
5. Judet H, Gilbert A, Judet J (1981) Vascular microsurgery
in orthopaedics. Int Orthop 5:61-67
6. Fujimaki A, Yamauchi Y (1983) Vascularized fibular graft-
ing for treatment of aseptic necrosis of the femoral head-
preliminary results in four cases. Microsurgery 4:17-22
7. Solonen K, Rindell K, Paavilainen T (1990) Vascularized
pedicled bone graft into the femoral head-treatment of
aseptic necrosis of the femoral head. Arch Orthop Surg
109:160-163
8. Salacz T, Manninger J, Szita J, Hankiss J (1993) Aseptic
femoral head necrosis and thrapeutic possibilities by
using a bone graft with a vascular pedicle. Magy Tramatol
Kezseb Plasztikai Seb 36:129-139
9. Ishizaka M, Sofue M, Domae Y, Takahashi H (1997)
Vascularized iliac bone graft for avscular necrosis of
the femoral head. Clin Orthop 337:140-148
10. Wassenaar R, Verburg H, Taconis W, Eijken J (1996) Avas-
cular osteonecrosis of the femoral head treated with a
vascularised iliac bone graft: preliminary results and
follow-up with radiography and MR imaging. Radio-
graphics 16:585-594
11. Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K,
Iwasada S (1997) Vascularized pedicle bone-grafting for
non traumatic avascular necrosis of the femoral head. A 5
to 11 years follow-up. Arch Orthop Trauma Surg 116:251-258
3.13 Avascular Necrosis of the Femoral Head Treated
by Vascularized Scapular Bone Graft
KOHZO FUJISAWA
The goal of surgical treatment for aseptic necrosis of the
femoral head should be to restore the anatomical struc-
ture of the hip joint and its normal function. A number
of surgical treatments have been proposed to prevent
the progression of the disease and stimulate vascular
proliferation and bone regeneration, but none have
been highly successful. Theoretically, vascularized bone
grafting is an ideal method because it can both provide
mechanical support to prevent collapse of the necro-
tized area and introduce rich vascularity deep into the
necrotized bone. With this in mind, we prefer to use a
vascularized scapular bone graft for this condition.
Indications
The stage of involvement of the diseased femoral head
is the most important parameter in patient selection for
this procedure. We use two classification systems; one is
described by Marcus [1] and the other by Ficat and
Arlet [2]. In our experience, the procedure cannot yield
good results when indicated for patients with advanced
conditions, i.e., with apparent collapse of the femoral
head, and should be attempted for aseptic necrosis of
the femoral head in stage I or II (some stage III cases
may also be good candidates) by the former system, or
in stages I, IIA, or lIB by the latter. Although chrono-
logical age does not preclude the microsurgical proce-
dure, the procedure is contraindicated for patients with
collagen vascular diseases or severe diabetes mellitus.
Advantages
Vascularized scapular bone graft has the following
features and advantages:
The nourishing vessels, the scapular circumflex artery
and vein, run a constant course with fewest variations,
and their calibre is 1.8 to 2.5 mm at their bases.
The bone graft has a long vascular pedicle of 40 to
80mm, but it can be elongated up to 70 to 110mm by
including the subscapular artery, which has a diame-
ter of 3 to 5 mm at the origin.
Since the supplying vessels run along the lateral border
of the scapula and give off a main medullary branch, the
graft bone can be raised as a monocortical bone with
three cancellous surfaces, which enhances vascular and
bone ingrowth into the surrounding necrotic tissue [3].
Although the risk of producing an unsightly donor site
scar is a concern with this procedure, it causes little
functional disability of the shoulder, even when a skin
flap is raised on the same pedicle.
Preoperative Planning
Radiograms and preoperative angiograms of both the
donor and the recipient sites are indispensable. They are
quite helpful to determine the selection of arteries to be
dissected and levels to be harvested. The surgeon should
perform thorough evaluations of hip and shoulder func-
tion preoperatively. CT and MRI are the most useful
diagnostic modalities to determine the extent of necro-
sis and collapse of the femoral head, and osteoarthritic
changes of the hip joint. To evaluate bone marrow blood
perfusion in the femoral head, some researchers recom-
mend the use of osteophlebography [4]. However,
osteophlebography is an invasive test, and its resolution
and reliability are not high. It is generally considered
that MRI can depict an avascular area with high sensi-
tivity and specificity; however, as we reported previ-
ously, conventional enhanced MRI sometimes depicts
increased intensity in the bone marrow without blood
perfusion, due to the leakage of gadolinium dietylene
triamine pent acetic acid (Gd-DTPA) from capillaries
surrounding the avascular tissue [5]. Therefore, we
recommend the use of dynamic MRI instead. It is
useful not only in the preoperative evaluation but also
in demonstrating vascular ingrowth from the vascular-
ized bone graft into the surrounding tissue.
Operative Technique
A two-team approach is used, with one team to prepare
the hip joint and the other to harvest the scapular bone
graft with its vascular pedicle.
485
486 E. Clinical Reconstructive Microsurgery

Fig. 1. Schematic diagram to show the vascular-pedicled

scapular bone flap
Fig. 3. Angiography of the external iliac/femoral artery
system. } Femoral artery, 2 femoral lateral circumflex artery

Fig.2. Angiography of the subscapularis artery system.} Sub-

scapular artery, 2 circumflex scapular artery, 3 bone branches
of the subscapular artery, 4 thoracodorsalis artery

The joint capsule of the hip joint is exposed through

an anterior iliofemoral incision. The insertion of the
rectus femoris muscle is detached and reflected distally
to expose the lateral femoral circumflex artery and b
veins, and usually the transverse branches are isolated
to serve as the recipient vessels, which have diameters Fig. 4. Bilateral aseptic necrosis of the femoral head. a Plain
of 1.8 to 2.0 mm. The joint capsule of the hip joint is then X-ray. b CT scan
 3.13. Avascular Necrosis of the Femoral Head Treated by Vascularized Scapular Bone Graft
J
a
Fig.5. a A 50 x 13 x 13 cm trough extending from the femoral
neck to the femoral head is created. As much necrotic bone
within the femoral head as possible is removed through the
bone trough by using a high-speed drill until bleeding from
the cancellous bone is seen. b The cancellous bone chips from
the iliac crest are placed at the bottom of the cavity. The har-
vested scapular bone (45 x 12 x 12 cm) is plugged into the
incised in a T-shaped fashion. A trough of 50 x 13 x
13 mm is made from the equator area of the femoral
head down to the middle part of the femoral neck ante-
riorly, through which the necrotized bone and the sur-
rounding eburnated bone are thoroughly removed with
a high-speed drill until a well vascularized cancellous
bone is exposed. Care has to be taken not to penetrate
the articular cartilage.
At the donor site, a 12- to IS-cm oblique incision is
made along the lateral border of the scapula from the
triangular space, which is the point where the long head
of the triceps passes deep to the teres major and latis-
487
femoral head to support the subchondral bone. The fibrin glue
is used to stimulate vascular ingrowth from the vascularized
bone into the cancellous bone chips. The transverse branch of
the lateral femoral circumflex artery and its accompanying
veins 1 are anastomosed with the circumflex scapular artery
and veins 2. (See Color Plates)
simus dorsi muscles. A Doppler probe can be used to
localize the point of the cutaneous perforators. After the
circumflex scapular artery has been identified in the tri-
angular space, the vessels are dissected up to the origin
of the subscapular artery. One can identify the main
periosteal vessels approximately 4cm distal to the lower
rim of the glenoid fossa. The main periosteal vessels
usually give off several branches to the distal and lateral
surfaces of the scapula. Therefore, care must be taken
not to damage the vessels, especially when the graft is
used as a mono cortical graft by the removal of anterior
and posterior cortical bones. In general, the bone graft
 Fig. 6. Eight years after surgery. Although the hip joints show
mild limitation of motion, it is painless. The patient could
return to his original job and enjoy jazz dancing

120

100

.-.0
f Il
I:
B
I:

'i 60

b
Q
(1)
40

~+-------~------.-------~----~
o 100 200

Time (sec.)

Dynamic MR study at seven months

c

Fig. 7. MR images taken 7 months after surgery. a Conven- femoral head [region of interest (ROn 2]. This is in good
tional non enhanced MR image; b conventional enhanced MR contrast to the left unoperated side (ROI 4), which shows
image; c ROIs for dynamic MR study. The dynamic study negligible blood perfusion. Squares, ROI 1; diamonds, ROJ 2;
clearly shows significant blood perfusion in the operated right circles, ROJ 3; triangles, ROI 4
 3.13. Avascular Necrosis of the Femoral Head Treated by Vascularized Scapular Bone Graft
is tailored to be a little smaller than the trough made in
the femoral head and neck so that it can be accommo-
dated and can work as a strut. As I mentioned before,
the bone graft has a vascular pedicle of 40mm with an
external diameter of 1.8 to 2.5 mm. Then, cancellous
bone chips are harvested from the iliac bone through
another small incision made over the iliac crest and
packed into the cavity in the femoral head through the
trough. The scapular bone graft is hammered into the
trough, with the vascular pedicle being anterior. During
the placement of the graft, care must be taken not to
damage the vascular pedicle. The operating microscope
is then moved into the operative field, and transverse
branches of the lateral femoral circumflex artery and
its two accompanying veins are anastomosed to the
circumflex scapular vessels. Before the joint capsule
is closed, fibrin glue is injected into the graft bed to
stimulate bone and vascular ingrowth from the graft
into the surrounding tissue.
Postoperative Management
Basically, anticoagulant therapy is not used postopera-
tively. The hip joint is immobilized at 30 degrees of
flexion, 15 degrees of abduction using skin traction for
489
3 to 4 weeks. The patient is allowed to walk using
crutches without weight-bearing for 20 weeks, and then
with progressive weight-bearing for the following 8
weeks. To monitor the revascularization from the vas-
cularized bone graft in the femoral head, we carry out
dynamic MRI every 3 months postoperatively.
References
1. Marcus ND (1973) The silent hip in idiopathic aseptic
necrosis. J Bone Joint Surg 55A:1351-1366
2. Ficat RP, Arlet J (1980) Necrosis of the femoral head.
In: Ficat P, Arlet J, Hungerford DS (eds) Ischemia and
necroses of bone. Williams and Wilkins, Baltimore, pp 53-
74
3. Sekiguchi J, Kobayashi S, Hokubo E, Nomura T, Katoh F,
Shiba N (1992) Free vascularized scapular bone grafting.
Orthopaed Surg 35:1223-1229 (in Japanese)
4. Funayama K, Akiyama F (1982) Early diagnosis of the
avascular necrosis of the femoral head by intraosseus phle-
bography. Seikeigeka Mook 24:144-154
5. Fujisawa K, Hirata H, Inada H, Morita A, Takeda K,
Hibasami H (1995) Value of dynamic MR scan in predict-
ing vascular ingrowth from vascularized scapular trans-
plant used for treatment of avascular femoral head
necrosis. Microsurgery 16:673-678
3.14 Emergency Free Flap and Spare Surgery
TAKAFUMI NAITOH, MASAMICHI USUI, SEIICHI ISHII,
In 1965, Komatsu and Tarnai succeeded in the re-
plantation of a completely amputated thumb [1]. Since
then, this kind of microsurgical operation has become
essential in the field of reconstructive surgery. This
technique has been applied to develop a variety of free
flaps, and this development has helped to evolve the
technique of grafting an emergency free flap (EFF).
The EFF has permitted us to do both primary repair
and reconstruction of traumatic soft-tissue defects. As a
result, the EFF has changed the conventional concept
of emergency medicine, especially for reconstruction of
tissue defects.
Definition of EFF
Lister et al. defined the EFF as a free flap to be applied
within 24h after injury or immediately after the first
debridement [2,3]. Godina defined the early free flap as
a free flap to be implanted within 72 h after injury and
initial debridement, in conditions in which free flap
transfer would be unlikely to cause either flap necrosis
or infection [4]. In this chapter, free flap tranfer
performed within 72 h after injury is defined as EFF.
Indications for EFF and
Preoperative Evaluation
Indications
Out of the cases with traumatic soft tissue defects, those
who satisfy the conditions below are considered to be
the indications of EFF.
An open wound with the vital tissue (nerve, tendon,
bone, and joint) exposed, but uncoverable with a free
skin graft or regional pedicle flap.
An open wound with necrotic tissue considered likely
to worsen unless covered with another tissue in which
blood circulation is good.
An open wound such as Gustillo type III -B or C,
according to a classification of open fractures for
490
and YOSHIHIKO TSUCHIDA
which a free flap is indicated cosmetically and/or
functionally [5].
An open wound accompanied by a loss of composite
tissue (partial loss of tendon, nerve, bone, and/or
blood vessel).
An open wound in an amputated limb where replanta-
tion is not indicated.
Preoperative Evaluation
Even the open wounds that satisfy the aforementioned
indications require proper evaluation of the function of
injured limbs and the patient's general condition. EFF
should not be applied to any of the following patients:
Patients with cerebral and/or cardiovascular injury.
Aged patients or patients with complications such as
hepatic insufficiency, tendency to hemorrhage, dia-
betes mellitus, and anemia.
A crush injury or an open wound with necrosis at the
edge of the wound that involves evaluation difficulties.
Patients for whom an EFF application is considered
inferior to a prosthesis in terms of the functions
expected.
Advantages and Disadvantages
of EFF
Advantages
Tissue management may be easier by EFF than by a
standby operation.
The free flap transfer may decrease the rate of infection
caused by insufficient blood circulation.
Total operation time may be decreased to a minimum.
Rehabilitation may start early after surgery.
Total hospital time will be reduced and medical costs
may be reduced.

Disadvantages
If an infection takes place, it will result in a surgical scar
in the portion where the flap was harvested.
If an error is made in determining the functional goal
of the operation, it may lead to a useless limb.
Long operation time.
In some cases, the necessity to EFF and/or flap selection
has to be judged from the patient's condition during
the operation. Unless the patient and his or her family
have given satisfactory informed consent concerning
what kind of operation is acceptable, there may be
postoperative problems.
This operation obviously cannot be performed without
a micros urge on who is able to perform an EFF.
Complications such as thrombus formation and flap
necrosis may occur.
Flap Selection
The use of flaps from the chest wall should be avoided
in patients with respiratory problems, because it would
preclude lung expansion and might lead to complica-
tions. If it is necessary to keep the patient in bed for a
long period, harvesting the flap from the patient's back
should be avoided from the nursing point of view. For a
woman, a groin flap would be more desirable than a flap
from the upper arm, forearm, or lower leg.
In cases with small bone defects, a conventional iliac
bone graft should be performed. If the defect is large,
however, a vascularized bone graft should be per-
formed, and in such an implantation a groin flap with
vascularized iliac bone, a peroneal flap with vascular-
ized fibula, or a scapular flap with the scapula is suitable.
A radial forearm flap with the radius and a dorsalis
pedis flap with the metacarpal bone also are applicable.
To prepare a flap with the nerve or with the tendon,
it is recommended to use a dorsalis pedis or a radial
forearm flap. For a volar skin defect of the finger, a
variety of sensory flaps from the foot are adaptable. For
a small defect in the hand, a venous flap or a lateral arm
flap may also be implanted.
In the case of a severe amputation injury that cannot
be replanted, spare surgery may be indicated by
covering the defect with the filet flap taken from the
amputated limb.
3.14. Emergency Free Flap and Spare Surgery 491
Operative Procedure
Preoperative Preparation
In the preoperative stage, angiography should be per-
formed to make certain of the locations of the arteries
at both the recipient and the donor sites. If angiography
is impossible, a Doppler flowmeter should be used. The
operative posture of the patient should be determined,
with consideration of the location of the flap elevation.
It is desirable to allow both open wound treatment and
flap harvesting to be done in an identical posture.
Treatment of Recipient Site
Patients treated within 6-Sh after injury are eligible
for an EFF. Under general anesthesia, the patient is
scrubbed and debrided thoroughly. Washing is per-
formed using a large amount (10-301) of physiological
saline. The EFF can be applied after making certain that
the wound has been fully debrided. If the wound is
insufficiently debrided, wet dressing should be applied
while leaving the wound unchanged from the open con-
dition. Within 72h, the wound should be debrided again
and the EFF should be applied. If there is concern about
an infection during the second debridement, wet dress-
ing should be continued. After waiting for the granula-
tion tissue to increase, the wound should be covered
with a free skin graft or free flap.
Representative Cases
Case 1. A 55- Year-Old Woman with a Skin
Defect on the Dorsal Side of the Left
Middle Finger
The patient had an open wound on the dorsal side of
the proximal interphalangeal (PIP) joint in the middle
finger, accompanied by a partial defect of the extensor
tendon. The PIP joint could not be extended. On the day
of injury, the wound was washed and debrided. A 3 x 2
cm venous flap with the palmaris longus tendon was
taken from the same side of the forearm (Fig. 1). After
the palmaris longus tendon had been grafted at the
extensor tendon defect, two veins in the flap were anas-
tomosed to the veins on the dorsal side of the finger on
a flow-through basis. The flap survived without conges-
tion, and the patient was able to extend the PIP joint
following rehabilitation (Fig. 2).
 492 E. Clinical Reconstructive Microsurgery
a-c
Fig.1. a Preoperative condition of the right middle finger. The
extensor tendon was ruptured. b After debridement. The prox-
imal phalanx was exposed. c Venous flap with the palmaris
longus tendon was designed in the distal forearm
Case 2. A 19- Year-Old Man with a Skin
Defect on the Dorsal Side of the Left Hand
The patient was injured when his left hand was caught
in a noodle-making machine. Multiple fractures of
both the metacarpal and the proximal phalanx were
observed (Fig. 3a,b). The first and fifth fingers had been
incompletely amputated, and a wide open wound was
B,b
Fig. 2. a Harvested venous flap with the palmaris longus
tendon. b One month after surgery, the flap was well adapted
and finger extension was possible
Fig. 3. a Skin defect was
observed on the dorsal side
of the left hand and exten-
sor tendons were exposed.
b Multiple fractures of the
fingers were observed. c
One and a half years after
surgery, the groin flap was
well adapted
observed on the dorsal side of the hand, with the exten-
sor tendons exposed. Before the wound was closed,
the fractures were treated by K-wires, and the first and
fifth fingers were replanted with a vein graft. For the
skin defects of the hand, a 9 x 4.5 cm free groin flap was
transferred. The flap survived, but the fifth finger fell
into necrosis. Although the range of motion of his
fingers was limited, it did not turn out to be an impedi-
ment in his daily life (Fig. 3c).

ab
Case 3. A 50-Year-Old Man with a Soft-
Tissue Defect and an Open Fracture of the
Right Radius (Gustillo type /IIC)
The patient was injured when his right arm was pulled
into a working machine. An open wound was found on
the right forearm, accompanied by a laceration of the
radial artery and fracture of the radius (Fig. 4a,b). After
washing and debridement, the radius fracture was
treated by plate fixation. To cover the open wound, a 15
x 5 cm square of anterolateral flap from the right thigh
was harvested. The nutritional artery in the flap was
interpositioned and implanted at the defect of the radial
artery (Fig. 4c). The flap survived without complications.
A light degree of contracture remained in the fingers,
but this did not turn out to be an impediment in his daily
life (Fig.4d).
Case 4. A 52- Year-Old Man with Right
Forearm Amputation
The patient arrived at our clinic 1 h after the distal one
third of his left forearm had been amputated when he
caught his hand and wrist in a machine. The amputated
left hand was severely damaged. The muscles in the
forearm were severely avulsed, and there were wide
skin defects from the middle of the upper arm to the
distal forearm. Fortunately, the function of the elbow
joint was well preserved. Amputation of both the radius
and the ulna was performed 7 cm distal from the elbow
joint, but there was a large soft-tissue defect in the ante-
rior portion of the elbow joint (Fig. 5). We harvested a
3.14. Emergency Free Flap and Spare Surgery 493
Fig. 4. a Preoperati e
appearance. The kin defect
~ a ob erved n the radial
ide f the r rearm . b X-ra
ph to raph h wing the
radiu fracture. c nterolat-
eral thigh nap \ a har-
ve ted. The artery wa
taken in aT hape. d nc
year after urgery, the flap
\ a well adapted
c,d
a-c
Fig.5. a, b Preoperative condition of the amputated hand. The
muscles in the forearm were avulsed from the radius and the
ulna. The radial and ulnar arteries and the median and ulnar
nerves were also avulsed. c Residual condition of the left
upper extremity. A massive skin defect was observed in the
anterior aspect of the distal upper arm on the distal forearm
20 x 8 cm free latissimus dorsi musculocutaneous flap
(LD m-c flap) from the right side. The thoracodorsal
artery and vein of the flap were anastomosed to the
radial artery and subcutaneous vein of the forearm,
respectively. The residual skin defects on the upper arm
were covered with a meshed split-thickness skin graft.
The flap took well without problems (Fig. 6a). At
5 months after the injury, defatting of the flap with
skin plasty was performed. By 9 months after the
injury, 20-85 elbow motion was possible and the
stump appeared suitable for the fitting of the prosthesis
(Figs. 6b, 7).
 494 E. Clinical Reconstructive Microsurgery
a b
Fig. 6. a Postoperative photograph showing the free LD m-c
flap at the end of the stump and the anterior side of the elbow
joint. b Nine months after surgery, the condition of the stump
was good. Defatting with skin plasty was performed 5 months
after surgery
a b X-ray finding at the bone union. c Appearance in the third
b and debridement, external fixation was performed in
Fig. 7. Range of motion of the left elbow while the patient is
wearing the prosthesis. a Extension. b Flexion of elbow joint
Fig. 8. a Preoperative condition. External fixation was per-
formed in another hospital. A wide skin defect was observed
on the front of the lower leg and on the fibular side. b X-ray
image on admission. c After debridement and internal fixa-
tion. A massive skin and muscle defect was observed on the
anterior side of left lower leg
Fig. 9. a The LD m-c flap was designed on the same side.
month after operation
Case 5. A 30-Year-Old Man with an
Open Fracture of the Lower Left Leg
(Gustillo type IIIB)
The patient sustained an open fracture of the left tibia
and fibula, accompanied by a massive soft-tissue defect
on the left lower leg, in a traffic accident. After washing
another hospital. The patient was transferred to our hos-
pital, 12h after the injury. Seventy-two hours after the
injury, the left lower leg was washed and debrided under

general anesthesia. A group of the extensor muscles was
seriously damaged and were surgically removed. The
tibialis anterior artery was found to be intact, and the
tibialis posterior and peroneal arteries were occluded
(Fig. 8). The tibia fracture was fixed with screws. On the
same side, an LD m-c flap and a serratus anterior muscle
flap were harvested. The size of the former flap was 25
x 5 cm. The thoracodorsal and circumflex scapular arter-
ies were harvested together with the flap and were inter-
positioned and implanted in the tibialis anterior artery.
Both of these flaps were transplanted on the fracture
site, and a mesh skin graft onto the muscle was per-
formed. The flap survived without problems, although
the fracture had delayed union. Because the fracture
site was well covered with these flaps, additional bone
grafting was easily performed (Fig. 9).
Summary
Development of the emergency free flap (EFF) has
helped us make progress with techniques to treat trau-
matic soft-tissue defects. To popularize the EFF in the
3.14. Emergency Free Flap and Spare Surgery 495
future, it is important for those orthopedic or plastic
surgeons who have learned microsurgery to take part in
emergency surgery for traumatic cases. The EFF will
substantially improve the methods of treatment in the
emergency medical field.
References
1. Komatsu S, Tarnai S (1968) Successful replantation of a
completely cut-off thumb. Plast Reconst Surg 42:374
2. Lister G, Schecker L (1988) Emergency free flap to the
upper extremity. J Hand Surg 13A:22-28
3. Lister G (1988) Emergency free flaps. In: Green DP (ed)
Operative hand surgery. Churchill Livingstone, New York,
pp 1127-1150
4. Godina M (1986) Early microsurgical reconstruction of
complex trauma of the extremities. Plast Reconstr Surg
78:285-292
5. Gustillo RB, Anderson JT (1976) Prevention of infection
in the treatment of one thousand and twenty-five open
fractures of long bones. J Bone Joint Surg 58A:453-458
3.15 Elbow Joint Reconstruction Using
Metatarsophalangeal Joint of the Great Toe
MINORD SHIBATA
The elbow is a non-weight-bearing joint and functions
whenever the hand is used. From the viewpoint of the
total upper-limb function, it is extremely important to
reconstruct a mobile, painless elbow joint. Elbow pros-
theses are mainly selected for the replacement of the
traumatically destroyed, flail, or ankylosed stiff elbow
joint. Despite the development of the various types
of elbow prostheses using new materials and based on
different concepts, several serious complications have
been recognized and most of them still remain unavoid-
able. If elbow arthroplasty is indicated in children,
growth of the reconstructed tissue is always of concern
and reconstruction using autogenous tissue transfer
is the present solution for this problem. The author
believes that in many cases, elbow arthroplasty using the
metatarsophalangeal (MTP) joint of the great toe is the
procedure of choice to obtain a mobile, painless, and
durable elbow joint.
History of Joint Transfer
The importance of the revascularization of the trans-
ferred joint or joint components has been repeatedly
confirmed by several experimental studies and clinical
applications early in the twentieth century [1,5]. Experi-
ments using dogs [6-8] and monkeys [9-11] during the
1950s to the 1980s were sometimes followed with clini-
cal cases. These studies included mobilization of the
ankylosed stiff elbow using the nonvascularized toe
MTP joint.
Vascularized toe joint transfer was studied using
monkeys in the Orthopaedic Department of Niigata
University and was reported by Watanabe et al. in 1978
[9]. This study was followed by reports that included
both experimental and clinical cases in 1980 [10] and
1985 [11]. The importance of the vascular reconstruction
of the transferred joint was clearly demonstrated. The
first free vascularized toe MTP joint was transferred to
the finger MP joint in 1977 in Niigata.
Based on these experimental and clinical experiences
including cases with long-term follow-up of more than
10 years, we reconstructed a severe shotgun injury to the
496
elbow with considerable bone defects by transferring
vascularized MTP joint of the great toe on January 27,
1988. This was the first case of reconstruction of a trau-
matically destroyed elbow joint using vascularized MTP
joint transfer. We applied this procedure to two more
adult cases with traumatically destroyed elbow joints,
and, most recently, to a child with a congenitally stiff
elbow associated with Crouzon's disease, on August 12,
1998.
Anatomical Considerations
Elbow Joint
The elbow is a hinge joint and allows flexion and exten-
sion. The proximal radioulnar joint permits rotation by
trochoid articulation. Both are synovial joints and com-
municate with each other. The capsule of the elbow joint
consists of a thin membrane anteriorly and posteriorly,
and it is thickened at the radial and ulnar collateral
ligaments.
Elbow Extensors
The prime extensor muscle of the elbow is the triceps
which is weakly assisted by the anconeus. The triceps
tendon inserts into the posterior aspect of the upper
surface of the olecranon. The anconeus has a tendinous
origin from the lateral epicondyle and a more extensive
insertion into the lateral border of the olecranon. The
superficial forearm extensor muscles originate from the
distal end of the humerus. The brachioradialis has strong
flexor action on the elbow at zero forearm rotation. The
extensor carpi radialis brevis, digitorum communis,
digiti minimi, and carpi ulnaris share a common tendon
of origin that is attached to the front of the lateral epi-
condyle. The extensor carpi ulnaris also arises from the
lateral ligament of the elbow. There is a common surface
aponeurosis that blends with the triceps fascia and deep
fascia of the arm.
 3.15. Elbow Joint Reconstruction Using Metatarsophalangeal Joint of the Great Toe
Elbow Flexors
The Prime flexor muscles of the elbow are the biceps
brachii and the brachialis. The biceps is a supinator
of the forearm and inserts into the posterior aspect of
the radial tuberosity with a short, stout tendon. The
brachial is locates to anterior of anterior capusull and
inserts into the front of the coronoid process with a
short, strong tendon. The five superficial flexor muscles
of the forearm arise from a common origin from the
front of the medial epicondyle. The flexor digitorum
sublimis has a humero-ulnar head, arising from the
upper half of the medial border of the coronoid process
and a further origin from the medial supracondylar
ridge. The flexor carpi radialis, a weak pronator, and the
palmaris longus share a common epicondylar origin.
Stability of the Elbow Joint
There is usually a valgus angle at the elbow that is deter-
mined by the articulation of the ulna and radius with
the humerus.
Stability of the elbow joint is provided by the ulno-
humeral joint, bone contact in the radiohumeral joint,
and the bilateral collateral ligament and joint capsule
that are reinforced by muscle insertion and origin. In
reconstruction of the elbow joint, these components
have to be in balance to attain reasonable stability and
flexion-extension mobility.
The First Metatarsophalangeal Joint
The MTP joint is a condylar joint and allows some ulnar
and radial deviation as well as good flexion and ex-
tension. The stability of the MTP joint alone is not
sufficient to provide the firmness required by the
functioning elbow. The final stability of the recon-
structed elbow joint mostly depends on the preservation
of the original bony structure such as the radio humeral
joint, and, on the medial and lateral collateral ligaments
that are toughened by inserting or originating muscles.
The range of motion of extension is much larger than
that of flexion and this anatomical feature has to be
considered when insetting the donor joint in the
elbow.
Indications
Based on the results of the long-term follow-up of more
than 13 years, the author believes that elbow arthro-
plasty using MTP joint transfer provides a durable,
497
useful outcome. However, surgical procedures are com-
plicated and donor morbidity needs to be carefully con-
sidered. Appropriate indication is in traumatic cases of
young individuals with acute severe injury or unsatis-
factorily treated irreducible joint fracture. The author
believes that mobilization of the congenitally stiff elbow
is highly beneficial because this procedure can endow
independent, active daily life to the patient; however,
this type of reconstruction requires a long follow-up to
ensure a favorable outcome.
Operative Procedures with an
Illustrative Case
On August 12, 1988, a 40-year-old man accidentally sus-
tained a shot-gun wound to his right elbow. The patient
was admitted to an affiliated hospital of Niigata Uni-
versity in a state of shock and was rapidly resusci-
tated. Exploration revealed complete laceration of the
brachial artery and median nerve, and partial laceration
of the radial and ulnar nerves. There was a 10-cm-Iong
defect in the elbow involving the entire elbow joint and
the distal portion of the humerus (Fig. 1). In the initial
surgery, the lacerated brachial artery and nerves were
repaired and most of the free fragments were removed
to avoid infection.
The patient was referred to Niigata University
Hospital and elbow reconstruction was performed 12
days after injury. It was planned to reconstruct the
elbow joint using the MTP joint of the contralateral
great toe. Figure 2 shows the condition of the elbow on
admission.
Fig. 1. X-ray film taken before debridement. The elbow joint
is completely destroyed, including the distal humerus shaft
498 E. Clinical Reconstructive Microsurgery
Fig. 2. X-ray film before elbow reconstruction. Olecranon
fracture was reduced and fixed at initial surgery. Humeral
component of the elbow is lost with distal humeral shaft
Surgical Teams
The surgical team was divided into two; one for the
preparation of the recipient site and the other for the
dissection of the donor MTP joint.
Preparation of Recipient Site
In the recipient site, careful dissection was carried out
and space to receive the MTP joint flap was created by
removing scarred tissue in the bone defect. The humerus
and ulna were prepared for later bone fixation and the
brachial artery and a cubital cutaneous vein were dis-
sected out and prepared for vascular anastomoses.
Preparation of Donor Site
In the donor site, the MTP joint was elevated on the first
dorsal metatarsal arterial system along with the dorsalis
pedis artery and a pair of venae comitantes (Fig. 3). A
7-cm-Iong MTP joint flap with almost the entire proxi-
mal phalanx was elevated (Fig. 4). An iliac bone block
was grafted in the defect of the MTP joint and fixed by
inserting Kirschner wires in crisscross fashion.
Insetting and Bone Fixation of the
Metatarsophalangeal Joint Flap
The MTP joint was set in the defect with its plantar
aspect on the anterior side of the elbow. Bone fixation
at the proximal site was obtained by end-to-end appro-
Fig. 3. A small monitoring buoy flap was elevated with the
metatarsophalangeal (MTP) joint (right) but the flap was
ablated later
Fig. 4. Elevated MTP joint flap. (See Color Plates)
ximation of the humerus and the first metatarsal in an
anteriorly bending position of about 30 to convert
the plantar flexion angle into elbow flexion. This was
achieved using Kirschner wires in crisscross fashion
combined with the tension band wiring method. At the
distal site, the proximal toe phalanx was inserted into
a hole that had been created in the articular surface of
the olecranon, also, in an anteriorly bending position
of about 30, to convert the original plantar flexion
into elbow flexion. Immobilization using crisscross
Kirschner wire fixation was used to fix the proximal
phalanx to the olecranon (Fig. 5). The passive range of
elbow motion was 0-120 and there was moderate
instability in medial and lateral directions caused by the
complete loss of the stabilizing action of the medial and
lateral collateral ligaments and the radio-humeral joint.
 3.15. Elbow Joint Reconstruction Using Metatarsophalangeal Joint of the Great Toe
Dorsal aspect
of MTP joint
b Fig.6. Postoperative angiogram demonstrating patent end-to-
Fig. 5. Schematic drawings of the insetting of the flap and
bone fixation. a Medial orientation. b Anterior orientation
Vascular Anastomosis
The dorsalis pedis artery was connected to the brachial
artery in end-to-side fashion under microscope. Two
venae comitantes were anastomosed to the cutaneous
veins in an end-to-end manner. No monitoring buoy flap
was used.
Postoperative Course
A long arm cast was applied postoperatively. However,
3 weeks later, displacement of the proximal bone fixa-
tion site was noted and refixation of the bone was
performed with combined iliac bone grafting. A
499
side anastomosis (arrow) of the artery
Hoffman-type external fixator was applied to ensure
immobilization of the bone fixation site.
Ten weeks after joint transfer, the external fixator
was removed and the elbow joint was allowed active
flexion-extension exercise under the restraint of a brace
with a hinging joint. Bone union was attained 3 months
postoperatively and the elbow hinge brace was used
until 6 months after joint transfer.
Early and Long-Term Results
An angiogram at 3 months postoperatively demon-
strated patent artery at the end-to-side anastomosis site
(Fig. 6). One year postoperatively, the active range of
500 E. Clinical Reconstructive Microsurgery

lib

Fig. 7. One year 4 months after joint transfer. The joint con-
gruity is good c,d

Fig. 8. X-ray films show the reconstructed elbow joint is well

preserved and functional 13 years 6 months after surgery.
motion of the reconstructed elbow joint was 25-110 a A-P view. b Oblique view. c Lateral elbow-extention view. d
(Fig. 7). It was noted that there was moderate lateral Lateral elbow-flexor view
instability in the resting position, but no pain was
associated with active or passive motion of the elbow
joint.
Thirteen years 6 months postoperatively, there was
0-120 active range of motion and no pain on motion
or at rest was apparent (Figs. 8, 9). X-ray film confirmed
well-maintained joint congruity. The patient occasion-
ally feels some lateral instability with the unilateral use
of the injured upper extremity. The patient can lift a 3-
kg sand bag with his right hand without difficulty. The
patient experienced no difficulty in lifting heavy objects
using both hands.

Discussion
Semiconstrained elbow joint replacement may be
selected for severe acute traumatic cases as well as
for traumatic arthrosis with considerable bone defect. Fig. 9. The reconstructed elbow joint is mobile and painless
However, although this type of prosthesis is generally 13 years 6 months postoperatively
 3.15. Elbow Joint Reconstruction Using Metatarsophalangeal Joint of the Great Toe
very reliable in a specific group of elderly people, it is
not an alternative procedure to osteosynthesis in young
patients. This point was stressed by Schneeberger and
Morrey [12] from the results of their own studies in
which patients underwent elbow arthroplasty using
semiconstrained prostheses. Other types of elbow pros-
theses are suitable for rheumatoid patients and trau-
matic cases in the elderly but not for young working
patients.
In regard to congenital problems, children with stiff
or extensive flail problems can be treated by recon-
struction using autogenous tissue parts. Reconstruction
using allograft has not been indicated for patients with
congenital elbow problems. However, reconstructive
procedures using tissue engineering may be indicated
for this difficult problem in the near future despite the
need for such patients to learn how to use elbow flexors
and extensors after surgery. The problem of congenitally
stiff elbow is distinct from those of rheumatoid or trau-
matic cases and may limit the maximal range of motion
of the reconstructed elbow joint.
At the present time, the author recommends elbow
reconstruction using autogenous toe joint transfer for
the active, young patient. Mobile, painless, and growing
joints can be reconstructed by autogenous tissue trans-
fer to give useful hand function, as was attained in our
cases.
References
1. Judet H (1908) Essai sur la greffe es tissues articulaires.
Comp Rend Acad D Sciences 146:193-196
2. Judet H (1908) Essai sur la greffe es tissues articulaires.
Comp Rend Acad D Sciences 146:600--603
501
3. Axhausen G (1912) Uever den histologischen Vorgang bei
der Transplantation von Gelenkenden, insbesoundere
tiber die Transplantationsfahikeit von Gelenllnorpel und
Epiphysenkorpel. Ach F Klin Chir 99:1-50
4. Lexer E (1908) Substitution of whole or half joint from
freshly amputated extremity by free plastic operation.
Surg Gynecol Obestet 6:601-607
5. Lexer E (1925) Joint transplantation and arthroplasty.
Surg Gynecol Obstet 40:782-809
6. Herndon CH, Chase SW (1952) Experimental studies in
the transplantation of whole joints. J Bone Joint Surg Am
34:564-578
7. Entin MA, Alger JR, Baird TK (1962) Experimental and
clinical transplantation of autogenous whole joints. J Bone
Joint Surg Am 44:1518-1536
8. Hurwitz PJ (1979) Experimental transplantation of small
joints by microvascular anastomoses. Plast Reconstr Surg
64:221-231
9. Watanabe M, Katsumi M, Yoshizu T, Tajima T (1978)
Experimental study of autogenous toe-joint transplanta-
tion-anatomical study of the vascularized pattern of toe
joints as a base of vascularized autogenous joint trans-
plantation (in Japanese). Seikeigeka 29:1317-1320
10. Watanabe M, Katsumi M, Yoshizu T, Tajima T (1980)
Experimental study and clinical application of free toe-
joint transplantation with vascular pedicle (in Japanese).
Seikeigeka 31:1411-1416
11. Yoshizu T, Watanabe M, Tajima T (1985) Experimental
study and clinical application of free toe joint transplan-
tation with vascular anastomosis. In: Tubiana R (ed) The
hand, vol 2. Saunders, Philadelphia, pp 685-697
12. Schneeberger AG, Morrey BF (1985) Semiconstrained
elbow replacement: results in traumatic condtions. In:
Morrey BF (ed) The elbow and its disorders, 3rd edn.
Saunders, Philadelphia, pp 646-654
3.16 Mandibular Reconstruction
KATSUHIRO HORIUCHI and HIROSHI YAJIMA

A successful mandibular reconstruction must not only Donor Selection (Table 1)

restore the continuity of the missing bone segment but
also provide soft tissues for external coverage and Rib
intraoral lining. It also improves the functions of phona-
tion and deglutition as well as mastication, including The overlying soft tissue territory of the vascularized rib
dental restoration. Although autogenous nonvasculari- graft is bulky and frequently unreliable. The morbidity
zed bone grafts and alloplastic implants, either alone or associated with the dissection and the limited width of
in conjunction with pedicled soft tissue flaps, had been the bone have made the rib graft obsolete for clinical
traditionally employed, these procedures gave rise to practice.
complications, such as resorption of the grafted bone,
extrusion of the implant, and infection.
Since 1970, various attempts have been made to Second Metatarsal Bone
provide a periosteal blood supply to bone based on
pedicled osteomyocutaneous flaps [1]. However, these The second metatarsal bone with the dorsalis pedis flap
pedicled flaps have not come into wide use because of is considered for short segmental defects of the anter-
the poor vascularization of the bone and limited bone ior or lateral mandible associated with soft tissue re-
requirements. quirements. Ting et al. [11] reported that the second
Since McCullough and Fredrickson [2] first reported metatarsophalangeal joint and metatarsal bone are
microsurgical reconstruction of the mandible using ideal substitutes for the ascending ramus and temporo-
composite neovascularized rib grafts in 1970, various mandibular joint.
free vascularized bone or composite grafts have been
developed. These include the iliac crest [3], second Iliac Crest
metatarsal bone [4], radius [5], scapula [6], and fibula
[7-10]. For composite tissue requirements, which may
It has been generally accepted that the vascularized iliac
include oral lining and external skin, these tissues can
bone graft based on the deep circumflex iliac vessels is
be provided in a single stage. These free tissue transfers
a preferred choice. However, the ilium has a predeter-
are considerably more resistant to infection. Therefore,
mined shape that hampers accurate contouring in some
microvascular mandibular reconstruction should be con-
patients, and donor-site morbidity has been described,
sidered the procedure of choice for bone replacement
including pain and inability to ambulate early, with pos-
in irradiated tissue beds and for immediate composite
sible late abdominal hernia. Moreover, significant limi-
tissue reconstruction.
tations of this flap include its bulk and the difficulties of
The choice of flap is based on several factors: the size
three-dimensional positioning of the bone and separat-
and contour of the bone defect, the associated intraoral
ing skin paddles for simultaneous external and intra-
lining and/or external soft tissue coverage requirements,
oral coverage [6]. In an attempt to overcome these
the availability and orientation of the recipient vessels,
problems, the internal oblique-iliac crest osteomyocuta-
and the experience of the surgeon.
neous flap [12] or the combined sensate radial forearm
and iliac crest free flaps [13] have been used.

Scapula

The vascularized scapular graft is also said to be useful

for mandibular reconstruction because of its greater

502
 3.16. Mandibular Reconstruction 503

Table 1. Comparision of vascularized bone grafts for mandibular reconstruction

Variable Fibula Ilium Scapula Radius Second Metatarsal Rib

Bone
Length (cm) 22-26 10-14 10-14 10-15 5---{) 20-30
Thickness x width (cm) 1.5 x 1.5 2.0 x 5.0 1.5 x 3.0 1.5 x 0.7 1.0 x 1.0 0.7 x 1.5
Bone quality Good Moderate Moderate Fair Good Poor
Skin flap
Maximum size (cm) 12 x 24 15 x 25 15 x 25 10 x 20 10 x 10 10 x 15
Thickness Moderate Bulky Bulky Thin Thin Bulky
Blood supply
Bone Good Good Good Good Good Fair
Skin flap Good Fair Good Good Good Fair
Dissection of flap Fairly easy Fairly easy Fairly easy Easy Easy Difficult
Shaping of bone Difficult Easy Fairly easy Fairly easy Difficult Easy
Wearing of denture Possible, but Possible Possible, but Impossible Impossible Impossible
difficult difficult
Osseointegrated implant Possible Possible Possible, but Impossible Possible, but Impossible
difficult difficult
Donor morbidity Minimal Abdominal Minimal Radius Delayed healing Thoracotomy
hernia fracture

versatility [6]. However, its major disadvantage is a
longer operative time than that for any other flap,
because the flap dissection must be performed in the
lateral position. Moreover, in the scapular osteocuta-
neous flap, the skin paddle may be too bulky for inta-
oral soft tissue reconstruction.
Radius
The thinness and pliability of the radial forearm flap are
generally considered ideal for intraoral lining. Although
there have been several reports on full-thickness re-
construction of the mandible using the vascularized
hemiradius with the radial forearm flap [5], it is impos-
sible to achieve oral rehabilitation with a conventional
denture or osseointegrated implants because of its
limited bone width. Therefore, we [8] recommend the
radial forearm flap with hemiradius as the first choice
for intraoral lining reconstruction, including partial-
thickness reconstruction of the mandible after marginal
mandibulectomy in order to maintain tongue mobility
and oral function (Fig. 1).
Fibula
The vascularized fibular graft has been used less often
than the vascularized iliac bone or scapular grafts
for mandibular reconstruction. However, we [7-10]
have employed it for mandibular reconstruction since
1987 because of its length (up to 24cm), its flexibility
in shaping the bone using multiple osteotomies, the
minimal donor-site morbidity, and the possibility of
three-dimensional positioning of separate skin islands
in relation to the bone (Fig. 2). In addition, the bicorti-
cal structure of the fibular graft is ideal for inserting
osseointegrated implants, which show good primary
stabilization. None of the other vascularized bone
grafts except the metatarsal bone provide this kind of
structure. Immediate implantation may be unsafe for
the vascularization of the grafted bone, although some
investigators [14] recommend it. Therefore, we [15]
employed secondary implantation, which has the advan-
tage of taking into account prosthodontic requirements
such as implant direction and location.
Since Hidalgo [7] recommended the use of the fibula
free flap for mandibular reconstruction in 1989, it has
become a popular donor-site choice. However, Hidalgo
did not recommend that the fibula be used with a skin
island for reconstructing mandibular defects combined
with large intraoral soft tissue loss owing to the unreli-
ability of a septocutaneous blood supply. Thereafter,
however, a skin island with the fibular graft was used in
at least 91 % of patients [16]. In our 16 cases, the skin
islands survived completely, even in two separate flaps.
If mandibular reconstruction requires a short segment
of the fibula that does not include the vessels to the skin,
a vascular pedicle containing the cutaneous branches
may be harvested beyond the extent of the bone
required [17].
504 E. Clinical Reconstructive Microsurgery
Fig. 1. Vascularized hemiradius graft with radial forearm flap
for partial-thickness defect of the mandible. a A 9-cm hemi-
radius graft with radial forearm flap. b A nonvascularized iliac
bone was placed between the hemiradius and the remaining
Technical Points in the Application of
the Fibular Graft
There are two other problems in mandibular recon-
struction using the vascularized fibular graft. First, in
the average Japanese person, the fibula is approximately
1.5 cm thick, and the single-strut fibular graft results
in difficulty in wearing dentures or osseointegrated
implants [9]. The double-barrel fibula has often been
used to the lower extremity and pelvis because of
improved mechanical stability [18,19]. Using this tech-
nique, we [17] first reported mandibular reconstruction
using the double-barrel fibular graft in 1995 to resolve
the limited bone width, and the graft provided more
than 4cm of alveolar height without damaging bone
viability (Fig. 3).
mandible after osteotomizing to fit the defect. c Postopera-
tive intraoral view. d Postoperative radiograph. (a-c See Color
Plates)
The harvested fibula is shaped with several
osteotomies to fit the mandibular defect without dam-
aging the vascular bundle, using the prefabricated tem-
plates. The osteotomized bones are folded into two
parallel lengths. At the folding point, a 1-cm portion of
the fibula is discarded to prevent stretching or com-
pressing of the vascular bundle. At the curving point, the
fibula is contoured by wedge osteotomies. The
osteotomized bones are fixed along the inferior border
of the mandible and alveolar ridge with Kirschner wires
or titanium miniplates. The double-barrel fibula can be
applied even for reconstruction of the hemimandible,
up to approximately 14cm in length (Fig. 4).
Osseointegrated implants may improve masticatory
function even in patients treated with the single fibular
graft. However, the low vertical height of the recon-
structed bone results in problems with the crown/fixture

Fig.2. Single-strut fibular graft for angle-to-angle reconstruc-
tion. a Preoperative facial view in a patient who underwent
mandibular reconstruction using an alumina ceramic alloplast
for ameloblastoma. It was exposed externally in the mental
region. b Preoperative radiograph. c A 20-cm fibular graft with
two skin paddles. d Bone shaping with two osteotomies. e
3.16. Mandibular Reconstruction 505
Postoperative radiograph after the fibular graft. f Postopera-
tive facial view after genioplasty. g Postoperative radiograph
after genioplasty (from [9], with permission). h Implant-sup-
ported overdenture. i Bar attachment with magnets. j Radi-
ograph after implant therapy. Crown/fixture ratio is greater
than 1: 1. (c,d See Color Plates)
506 E. Clinical Reconstructive Microsurgery
Fig. 3. Double-barrel fibular graft. a Preoperative radiograph
in a patient with mandibular osteoradionecrosis. b A 14-cm
fibula was osteotomized at the midportion without damaging
the vascular bundle. c The two struts were folded into paral-
lei lengths. d Postoperative radiograph revealed that not only
the inferior border of the mandible but also the alveolar ridge
were reconstructed (from [9], with permission). e Postopera-
tive facial view. f Postoperative intraoral view. g Postoperative
intraoral view with patient wearing a conventional denture. h
Postoperative intraoral view after implant therapy. i Occlusal
view of the mandibular arch after implant therapy. j Postop-
erative radiograph after implant therapy. (b,c See Color
Plates)

Fig. 4. Hemimandibular reconstruction using the double-
barrel fibular graft. a Preoperative radiograph in a patient with
ameloblastoma. b The double-barrel fibular graft resembles
the hemimandible after shaping with multiple osteotomies.
ratio and oral hygiene. If the crown/fixture ratio is
greater than 1: 1, the longevity of the prosthesis will be
endangered. In contrast, in patients with the double-
barrel fibular graft, osseointegrated implants only
into the upper portion of the graft can improve the
crown/fixture ratio and oral hygiene and bring them
close to their predisease state [15].
The second problem is how to simulate the mandi-
bular defect with the osteotomized fibula. In order to
3.16. Mandibular Reconstruction 507
c Sural nerve graft for reconstruction of the inferior alveolar
nerve. d Postoperative radiograph. e Postoperative frontal
view. f Postoperative lateral view. (b,c See Color Plates)
perform mandibulectomy and osteotomies of the fibula
accurately and quickly, replicas of the mandible and
fibula (acrylic plastic) are made preoperatively from
three-dimensional CT scans [17] (Fig. 5). Guide tem-
plates are then prefabricated from the reconstructed
model. Extraperiosteal miniplate osteosynthesis of the
osteotomized bone segments is used without elevating
the periosteum, so as not to damage the periosteal blood
supply.
508 E. Clinical Reconstructive Microsurgery
Fig. 5. Simulation surgery using a life-size model. a Replicas
(life-size models) of the mandible and fibula were made pre-
operatively from three-dimensional CT scanning. b,c Tem-
plates prefabricated from simulation surgery resembled the
mandibular defect precisely (from [9], with permission). d A
24-cm fibula with two skin paddles. e Five fragments of the
fibula were fixed with titanium miniplates extraperiosteally
References
1. Snyder CC, Bateman JM, Davis CW (1970) Mandibulo-
facial reconstruction with live osteocutaneous flaps. Plast
Reconstr Surg 45:14-19
2. McCullough DW, Fredrickson JM (1972) Composite
neovascularized rib grafts for mandibular reconstruction.
Surg Forum 23:492-494
3. Talor GI, Townsend P, Corlett R (1979) Superiority of
the deep circumflex iliac vessels for free groin flaps: Clin-
ical work. Plast Reconstr Surg 65:745-759
4. Bell MSG, Barron DT (1980) A new method of oral recon-
struction using a free composite foot flap. Ann Plast Surg
5:281-287
along the inferior border of the mandible and alveolar ridge.
f Postoperative frontal view. g,h Radiographs revealed a
precise reconstruction simulating the mandibular defect (from
[9], with permission). i Postoperative intraoral view after
implant therapy. j Occlusal view of the mandibular arch after
implant therapy. k Postoperative radiograph after implant
therapy
5. Soutar DS, Widdowson WP (1986) Immediate reconstruc-
tion of the mandible using a vascularized segment of
radius. Head Neck Surg 8:232-246
6. Swartz WM, Banis JC, Newton ED, Ramasastry SS,
Jones NF, Acland R (1986) The osteo-cutaneous scapular
flap for mandibular and maxillary reconstruction. Plast
Reconstr Surg 77:530-545
7. Hidalgo DA (1989) Fibula free flap: A new method of
mandibular reconstruction. Plast Reconstr Surg 84:71-79
8. Horiuchi K, Kamibayashi T, Hattori A, Fujimoto M, Inada
I, Nakahashi K, Yoshida S, Ohtsuki H, Sugimura M (1992)
Clinico-statistical study on reconstruction of composite
mandibular defect. Jpn J Oral Maxillofac Surg 38:763-
774

9. Horiuchi K, Hattori A, Yoshioka M, Kamibayashi T,
Sugimura M, Yajama H, Tarnai S (1995) Oromandibular
reconstructions using the fibular osteocutaneous flap. Jpn
J Plast Reconstr Surg 38:603-613
10. Yajima H, Tarnai S, Mizumoto S, Sugimura M, Horiuchi K
(1992) Vascularized fibula graft for reconstruction after
resection of aggressive benign and malignant bone
tumors. Microsurgery 13:227-233
11. Ting Z, Chang T, Wang T, Wang W, Feng SZ (1988)
Vascularized metatarsophalangeal to ankylosed temporo-
mandibular joint replacement. Ann Plast Surg 15:497-500
12. Urken ML, Vickery C, Weinberg H, Buchbinder D,
Lawson W, Biller HF (1989) The internal oblique-iliac
crest osseomyocutaneous free flap in oromandibular
reconstruction. Otolaryngol Head Neck Surg 115:339-
349
13. Urken ML, Weinberg H, Vickery C, Aviv JE, Buchbinder
D, Lawson W, Biller HF (1992) The combined sensate
radial forearm and iliac crest free flaps for reconstruc-
tion of significant glossectomy-mandibulectomy defects.
Laryngoscope 102:543-558
3.16. Mandibular Reconstruction 509
14. Sclaroff A, Haughey B, Gay WD, Panieool R (1994)
Immediate mandibular reconstruction and placement of
dental implant. Oral Surg 78:711-717
15. Yamamoto K, Horiuchi K, Fujimoto M, Sugimura M
(1999) Mandibular reconstruction using fibular graft.
In: Varma AK (ed) Oral oncology. Macmillan India, New
Delhi, pp 311-314
16. Hidalgo DA (1991) Aesthetic improvements in free-flap
mandible reconstruction. Plast Reconstr Surg 88:574-588
17. Horiuchi K, Hattori A, Inada I, Kamibayashi T, Sugimura
M, Yajama H, Tarnai S (1995) Mandibular reconstruction
using the double barrel fibular graft. Microsurgery 16:
450-454
18. Jones NF, Swartz WN, Mears DC, Jupiter JB, Grossman A
(1988) The "double barrel" free vascularized fibular bone
graft. Plast Reconstr Surg 81:378-385
19. Yajima H, Tarnai S (1994) Twin-barreled vascularized
fibular grafting to the pelvis and lower extremity. Clin
Orthop 303:178-184
3.17 Reconstruction of the Oral Cavity
and Esophagus
YUHEI YAMAMOTO, HIDEHIKO MINAKAWA, TSUNEKI SUGIHARA, KUNIHIKO NOHIRA,
and Y OSHIHISA SHINTOMI
Reconstruction of the Tongue and
Oral Floor
Case 1
A 72-year-old man presented with TINIMO squamous
cell carcinoma of the right lateral tongue. He was
treated with radiation therapy (40Gy) preoperatively
and underwent a right hemiglossectomy, including
partial resection of the oral floor, as well as right
modified and left upper neck dissections. An 8 x 6 cm
forearm flap was designed on the left side and trans-
ferred to the defect (Fig. la). The vascular pedicle was
anastomosed with the right superior thyroid artery and
facial vein. The donor site defect was covered with a
split-thickness skin graft from the left thigh. The flap
survived completely, and the postoperative course was
uneventful. Seven months after surgery, the patient was
well satisfied with the result (Fig. Ib and c).
Case 2
A 52-year-old man presented with T4NOMO squamous
cell carcinoma of the tongue (Fig. 2a). He underwent a
subtotal glossectomy involving the tongue base, the
floor of the mouth, and the suprahyoid muscles down to
the hyoid bone, following bilateral modified radical
neck dissections. A rectus abdominis myocutaneous flap
was designed on the left side and elevated on the deep
inferior epigastric vessels (Fig. 2b). The vascular pedicle
was anastomosed with the right superior thyroid artery
and internal jugular vein. The postoperative course was
uneventful, with no incidence of flap necrosis. Three
years postoperatively, the bulk of the reconstructed
tongue was well maintained, and the patient was able to
eat a regular diet (Fig. 2c).
510
Reconstruction of the Hypopharanx
and Cervical Esophagus
Case 3
A 67-year-old man had had a laryngeal cancer
(T4N2bMO) and received a total dose of 40Gy of
radiotherapy. One month later, total laryngectomy,
including the anterior wall of the hypopharynx and the
cervical esophagus, as well as right radical and left
functional neck dissections, was carried out (Fig. 3a).
The radial forearm free flap was scheduled to be used
as a patch for the pharyngoesophageal defect (Fig. 3b).
The radial artery was anastomosed to the left facial
artery, and one accompanying and one cephalic veins
were anastomosed to the left internal jugular vein in an
end-to-side fashion. The postoperative course was very
smooth, without any fistula formation. A 2-week post-
operative esophagogram showed good barium flow
(Fig.3c).
Case 4
A 62-year-old man presented with a squamous cell
carcinoma of the hypopharynx. Following 40 Gy of
radiotherapy, the patient underwent laryngopharyngoe-
sophagectomy and right modified and left radical neck
dissections. A segment of jejunum on the second jejunal
vascular system was harvested and transferred. After
microvascular anastomoses had been performed be-
tween the jejunal vessels and the left transverse cervi-
cal artery and external jugular vein, the jejunal graft was
inset to be matched with the pharyngoesophageal
defect (Fig. 4a). A radiographic examination on the
9th postoperative day showed no leakage and good
swallowing (Fig. 4b).
 3.17. Reconstruction of the Oral Cavity and Esophagus 511

Fig. 1. Case 1. a The left forearm flap was designed. b Seven-month postoperative appearance
of the reconstructed tongue. c At deglutition. The lateral and inferior sites of the tongue and
oral floor were well reconstructed

Fig. 2. Case 2. a Preoperative appearance. b The rectus abdominis myocutaneous flap

was harvested. (See Color Plates) c Three-year post-operative appearance of the recon-
structed tongue
512 E. Clinical Reconstructive Microsurgery

a C

Fig. 3. Case 3. a Intraoperative view showing a defect of the anterior wall of the hypopharynx and cervical esoph-
agus. (See Color Plates) b The forearm flap was harvested on the radial vascular system and one cephalic vein. c
Two-week postoperative esophagogram

Fig. 4. Case 4. a Free jejunal transfer after

completion of the microvascular and intestinal
anastomoses. (See Color Plates) b Postopera-
tive esophagogram showing smooth barium
a b
flow

Reconstruction of the Cervical and
Thoracic Esophagus
Case 5
A 72-year-old man presented with partial necrosis of the
conventional gastric pedicle and fistulous tract forma-
tion after a thoracic esophagectomy. The necrotic
stomach was d.ebrided, and a temporal esophagostoma
was created at the left supraclavicular region. To re-
construct cervical and thoracic esophageal continuity, a
32-cm-Iong segment of jejunum based on the second
jejunal vascular system was transferred. The vascular
pedicle was anastomosed to the right transverse cervi-
cal artery in an end-to-end fashion, and the right inter-
nal jugular vein was anastomosed in an end-to side
fashion (Fig. 5a). The mesenteric flap connected with the
revascularized jejunum [1] was placed to cover the area
of the vascular anastomoses (Fig. 5b). The area of the
esophagojejunal anastomoses was covered with the
platysma myocutaneous flap, and the area of the jejuno-
gastric anastomoses was covered with the pectoral fas-
ciocutaneous flap [2]. Finally, the flap donor sites were
covered by skin grafting. Six months postoperatively,
the patient was able to eat a normal diet without reflux
and stasis (Fig. 5c).
 3.17. Reconstruction of the Oral Cavity and Esophagus
Fig. 6. Case 6. Intraoperative view of the microvascularly
augmented (MVA) elongated gastric pedicle. (See Color
Plates)
Case 6
A 59-year-old man presented with carcinomas of the
hypopharynx and the cervical and thoracic esophagus.
Following pharyngolaryngectomy and total esophagec-
tomy, the patient underwent reconstruction of alimen-
513
Fig. 5. Case 5. a A long segment of
jejunum was transferred to the eso-
phageal defect between the cervical eso-
phagus and previously pulled-up gastric
pedicle. (See Color Plates) b The jejunal
graft was inset, and the mesenteric flap
connected with the revascularized
jejunum was placed on the vascular anas-
tomosis area. c Six-month postoperative
appearance
b
Fig. 7. Case 7. Intraoperative view of the MVA jejunal
pedicle. (See Color Plates)
tary continuity with the microvascularly augmented
elongated gastric pedicle (MVA elongated gastric
pedicle) [3] (see the chapter by Y. Yamamoto et aI.,
this volume). The left gastric vessels were anastomosed
with the left superior thyroid artery and internal jugular
vein (Fig. 6).
 514 E. Clinical Reconstructive Microsurgery
a b
Case 7
A 72-year-old man presented with carcinomas of the
thoracic esophagus and the cardiac part of the stomach.
Following en bloc esophagogastrectomy, the patient
underwent reconstruction of digestive continuity with
the microvascularly augmented jejunal pedicle (MVA
jejunal pedicle) [4] (see the chapter by Y. Yamamoto
et al., this volume). The second jejunal vessels were
anastomosed with the right internal thoracic vessels
(Fig. 7).
Case 8
A 62-year-old man who had previously undergone a
gastrectomy presented with carcinoma of the thoracic
esophagus. Following subtotal esophagectomy, the
patient underwent reconstruction of alimentary con-
tinuity with the microvascularly augmented right-
side colonic pedicle (MVA right-side colonic pedicle)
including the distal end of the ileum [5] (see the chapter
by Y. Yamamoto et al., this volume). The ileocolic artery
and vein were anastomosed with the right internal tho-
racic artery and vein at the second to third intercostal
Fig.8. Case 8. a Intraoperative view of the MVA right-
side colonic pedicle. b Following partial resection of
the third costal cartilage, the right internal thoracic
vessels were used as the recipient vessels. (See Color
Plates)
space (Fig. Sa and b). Finally, the cervical esophagoileos-
tomy procedure was performed.
References
1. Yamamoto Y, Nohira K, Shintomi Y, Yoshida T, Minakawa
H, Okushiba S, Fukuda S, Inuyama Y, Hosokawa M (1995)
Mesenteric flap in free jejunal transfers: A versatile tech-
nique for head and neck reconstruction. Head Neck
17:213-218
2. Yamamoto Y, Minakawa H, Okushiba S, Motohara T
(1997) Surgical salvage of failed esophageal reconstruction
attempted with gastric pedicle. J Reconstr Microsurg
13:285-289
3. Matsubara T, Ueda M, Nakajima T, Kamata S, Kawabata K
(1995) Elongated stomach roll with vascular microanasto-
mosis for reconstruction of the esophagus after pharyngo-
laryngoesophagectomy. J Am Col Surg 180:613-615
4. Hirabayashi S, Miyata M, Shouzi M, Shibusawa H (1993)
Reconstruction of the thoracic esophagus, with extended
jejunum used as a substitute, with the aid of microvascular
anastomosis. Surgery 113:515-519
5. Nagawa H, Seto Y, Nakatsuka T, Kaizaki S, Muto T (1997)
Microvascular anastomosis for additional blood flow in
reconstruction after intrathoracic esophageal carcinoma
surgery. Am J Surg 173:131-133
3.18 Breast Reconstruction
KUNIHIKO NOHIRA, YUHEI YAMAMOTO, and YOSHIHISA
In 1982, Hartrampf and colleagues introduced a rev-
olutionary breast reconstruction technique using
redundant soft tissue from the lower abdomen sup-
plied through the rectus abdominis muscle [1]. About
two decades later, their technique, which has been called
the transverse rectus abdominis myocutaneous
(TRAM) flap, has proved, with various technical modi-
fications, to be one of the world's standard autogenous
breast reconstruction techniques [2-14]. In this chapter,
several varieties of TRAM flap breast reconstruction
are described.
Single-Pedicled TRAM Flap
Case 1
A 31-year-old woman who had undergone a modi-
fied radical mastectomy underwent secondary breast
reconstruction with a single pedicled TRAM flap. The
left rectus abdominis muscle was used as a carrier of
the flap. The postoperative course was uneventful.
A skate flap and medical tattooing procedure were
performed for nipple and areola reconstruction (Fig.
la--c).
Free TRAM Flap
Case 2
A 35-year-old woman who had undergone a modified
radical mastectomy underwent secondary breast recon-
struction with a free TRAM flap. The flap was isolated
on the left deep inferior epigastric vascular system with
a small muscle belly [4,7]. The vascular pedicle was an-
astomosed with the right internal thoracic artery and
vein at the third to fourth intercostal space. The post-
operative course was uneventful. A skate flap and med-
ical tattooing procedure were carried out for nipple
and areola reconstruction (Fig. 2a-d).
SHINTOMI
Single-Pedicled TRAM Flap and
Ipsilateral Microvascularly Augmented
(MVA) TRAM Flap
Case 3
A 40-year-old woman who had undergone a modified
radical mastectomy on the right side and a radical
mastectomy on the left side underwent secondary
breast reconstruction. A single-pedicled TRAM flap
based on the left rectus abdominis muscle was used
for right breast reconstruction, and the ipsilateral
MVA TRAM flap was used for left breast reconstruc-
tion. The ipsilateral MVA TRAM flap is a single-
pedicled TRAM flap with microvascular anastomosis
between the ipsilateral deep inferior epigastric
vascular system and the superiorly pedicled muscle
and available vessels close to the defect [12]. In
this case, the ipsilateral MVA TRAM flap was raised
on the right rectus abdominis muscle, and the right
deep inferior epigastric vascular system was anasto-
mosed with the left thoracodorsal artery and axillary
vein. The postoperative course was uneventful. A
skate flap and medical tattooing procedure were
performed for nipple and areola reconstruction
(Fig. 3a-e).
Contralateral Microvascularly
Augmented (MVA) TRAM Flap
Case 4
A 43-year-old woman who had undergone a radical
mastectomy underwent secondary breast reconstruc-
tion with the contralateral MVA TRAM flap. The con-
tralateral MVA TRAM flap is a single-pedicled TRAM
flap with microvascular anastomosis between the con-
tralateral deep inferior epigastric vascular system and
515
516 E. Clinical Reconstructive Microsurgery

Fig.t. Case 1. a Preoperative view. b Postoperative appearance at 3 years. c A single-pedicled transverse rectus abdo-
minis myocutaneous (TRAM) flap

Fig. 2. Case 2. a Preoperative view. b Postoperative appearance at 2 years. c A free TRAM flap. d View of microvas-
cular anastomoses. (See Color Plates)

the superiorly pedicled muscle and available vessels
close to the defect [12]. In this case, the contralateral
MVA TRAM flap was raised on the right rectus abdo-
minis muscle, and the left deep inferior epigastric vas-
cular system was anastomosed with the left axillary
vessels in an end-to-side fashion. At the donor site, the
anterior rectus sheath was directly closed without diffi-
culty, because the fascia-sparing technique was applied
for the left side. The postoperative course was unevent-
ful. A skate flap and medical tattooing procedure
were performed for nipple and areola reconstruction
(Fig.4a-f).
 3.18. Breast Reconstruction 517

c d,e

Fig. 3. Case 3. a Preoperative view. b Postoperative appearance at 3 years. c The TRAM flap was
divided for bilateral breast reconstruction. d A single-pedicled TRAM flap on the left side and the
ipsilateral microvascularly augmented (MVA) TRAM flap on the right side. e Both flaps were trans-
ferred to bilateral defects through an upper abdominal subcutaneous tunnel. (c-e See Color Plates)

References 5. Hartrampf CR Jr, Bennett GK (1987) Autogenous tissue

1. Hartrampf CR, Scheflan M, Black, PW (1982) Breast
reconstruction with a transverse abdominal island flap.
Plast Reconstr Surg 69:216-224
2. Georgiade GS, Voci VE, Riefkohl R, Scheflan M (1984)
Potential problems with the transverse rectus abdominis
myocutaneous flap in breast reconstruction and how to
avoid them. Br J Plast Surg 37:121-125
3. Ishii CH, Bostwick J III, Raine TJ, Coleman JJ, Hester
TR (1985) Double pedicle transverse rectus abdominis
myocutaneous flap for unilateral breast and chest wall
reconstruction. Plast Reconstr Surg 76:901-907
4. Friedman RJ, Argenta LC, Andersen R (1985) Deep in-
ferior epigastric artery free flap for breast reconstruction
after radical mastectomy. Plast Reconstr Surg 76:455-458
reconstruction in the mastectomy patient: A critical re-
view of 300 patients. Ann Surg 205:508-518
6. Harashina T, Sone K, Inoue T, Fukuzumi S, Enomoto K
(1987) Augmentation of circulation of pedicled transverse
rectus abdominis musculocutaneous flaps by micro-
vascular surgery. Br J Plast Surg 40:367-370
7. Grotting JC, Urist MM, Maddox WA, Vasconez LO (1989)
Conventional TRAM flap versus free microvascular
TRAM flap for immediate breast reconstruction. Plast
Reconstr Surg 83:828-841
8. Takayanagi S, Ohtsuka M (1989) Extended transverse
rectus abdominis musculocutaneous flap. Plast Reconstr
Surg 83:1051-1060
9. Pennington DG, Nettle WJS, Lam P (1993) Microvascular
augmentation of the blood supply of the contralateral side
518 E. Clinical Reconstructive Microsurgery

Fig. 4. Case 4. a Preoperative view. b Postoperative appearance at 1 year. c The contralateral MVA TRAM flap. d The fascia-
sparing technique on the left side. e Primary closure of the anterior rectus sheath. f View of microvascular anastomoses. (c-f
See Color Plates)

of the free transverse rectus abdominis musculocutaneous
flap. Ann Plast Surg 31:123-127
10. Volpe AG, Rothkopf DM, Walton RL (1994) The versa-
tile superficial inferior epigastric flap for breast recon-
struction. Ann Plast Surg 32:113-117
11. Jensen JA, Handel N, Silverstein MJ, Waisman J, Gierson
ED (1995) Extended skin island delay of the unipedicle
TRAM flap: Experience in 35 patients. Plast Reconstr
Surg 96:1341-1345
12. Yamamoto Y, Nohira K, Sugihara T, Shintomi Y, Ohura T
(1996) Superiority of the microvasculariy augmented flap:
Analysis of 50 transverse rectus abdominis myocutaneous
flaps for breast reconstruction. Plast Reconstr Surg 97:
79-83
13. Hamdi M, Weiler-Mithoff EM, Webster MHC (1999)
Deep inferior epigastric flap in breast reconstruction:
Experience with the first 50 flaps. Plast Reconstr Surg
103:86-95
14. Yanaga H, Tai Y, Kiyokawa K, Inoue Y, Rikimaru H
(1999) An ipsilateral superdrainaged transverse rectus
abdominis myocutaneous flap for breast reconstruction.
Plast Reconstr Surg 103:465-472
3.19 Soft Tissue Defect Reconstruction Using
Omentum or Fascial Flap
KUNIHIRO ISHIDA, KEN ARASHIRO, and HISASHI OHTSUKA
Soft Tissue Defect Reconstruction
Using Omentum
A free omental transfer by microvascular anastomosis
was first used by McLean and Buncke [1] for the recon-
struction of a scalp defect. After their report, autoge-
nous omentum was also microsurgically transferred
and utilized in various treatments, including the corre-
ction of progressive hemifacial atrophy [2], chronic
osteomyelitis of a long bone [3,4], chronic lymphedema
of the extremity [3], revascularization of an ischemic
lower extremity [5], and reconstruction of the soft tissue
cover in the lower limb in difficult situations [6].
The omental flap has several advantages. The tissue
is thin and soft, it can take various forms, and a long
vascular pedicle is easily isolated and is ideal for mic-
rovascular anastomosis. The omentum is also highly
vascularized and therefore is extremely useful even in
moderately infected wounds. It can also be covered by
intermediate to thick split-thickness or full-thickness
skin grafts. For these reasons, the omental flap and
skin graft can be adapted to various parts of the body
for soft tissue defect reconstruction and is able to tol-
erate considerable trauma, stress, and pressure in the
scalp and extremities, although the indications for free
omental transfers have been markedly reduced with the
development of free cutaneous or musculocutaneous
flaps.
Case 1
A 4-year-old boy sustained a severe injury of the dorsal
region of the right lower leg and foot in an automobile
accident. Six days after the trauma, he was referred
to our hospital. At that time, the distal end of the tibia,
the dorsal surface of the ankle joint, tarsal bones, tar-
sometatarsal joint, and the first metatarsal bone were
exposed and severely infected. Preliminary debride-
ment was performed two days later, prior to the radical
operation, due to the presence of particles of foreign
material and slough in and around the exposed joint
(Fig. la). The extensor digitorum longus, extensor hal-
lucis longus, and tibialis anterior muscles were avulsed
with large gaps.
For reconstruction of the soft tissues and the skin
defect, a free omental transfer with a split-skin graft
was performed, anastomosing the right gastroepiploic
vessels to the anterior tibial vessels (Fig. Ib). A suction
drain was inserted into the ankle joint.
The postoperative course was uneventful. One year
later, the distal third of the area covered with a mesh skin
graft was replaced by a sheet of thick split -skin graft.
In spite of the absence of the extensor digitorum,
extensor hallucis longus, and tibialis anterior tendons,
the range of active movement of the ankle joint was rel-
atively good, although there was a slight tendency to
medial deviation (Fig. lc). The area of the transferred
tissue with the skin graft had tolerated the stresses
of daily activities very well 6 years and 5 months
postoperatively.
Case 2
Following a severe thermal injury 29 years earlier, a
52-year-old man developed a chronic intractable ulcer
and scar contracture in his right leg, ankle, and foot.
Although biopsies taken from several parts of the ulcer-
ated area showed no malignant change, a wide excision
of this area was considered advisable (Fig. 2a). The pos-
terior part of the lower leg, having an unstable scar,
was also involved and was included in the scar excision.
Thus, the area needing soft tissue replacement was
circumferential.
After complete excision of the involved area, a free
omental transfer was performed, anastomosing the right
gastroepiploic vessels to the anterior tibial vessels (Fig.
2b). During the operation, circulation to the foot was
checked when the anterior tibial artery was clamped
temporarily to demonstrate the safety of using this as
the recipient vessel. A sheet graft was used on the
omentum.
The postoperative course was uneventful. The grafted
area showed good tolerance of shoes and boots 5 years
and 11 months postoperatively (Fig. 2c).
519
520 E. Clinical Reconstructive Microsurgery

Fig.I. Case 1. a Five days after debridement. b A free omental tibial vessels to the donor right gastroepiploic vessels. c 6 years
transfer accomplished by anastomosing the recipient anterior and 5 months postoperatively

Fig. 2. Case 2. a A long-standing, unstable burn scar contrac- vessels to the donor right gastroepiploic vessels. c 5 years and
ture of the right lower leg and foot. b A free omental transfer 11 months postoperatively
accomplished by anastomosing the recipient anterior tibial
 3.19. Soft Tissue Defect Reconstruction Using Omentum or Fascial Flap
Fig.3. Case 3. a A long-standing, unstable scar contracture of
the right knee and lower leg. b A free omental transfer accom-
plished by anastomosing the recipient vessels of the right thigh
Case 3
A 55-year-old man was referred to our department for
treatment of a chronic incurable ulcer and scar con-
tracture in his right knee to lower leg (Fig. 3a), which
originated from a severe automobile injury at 8 years
of age. He had undergone skin grafts 16 times after
the accident, but the wound was never corrected com-
pletely. Mild cerebral infarction at the age of 49 resulted
in right incomplete facial paralysis and right mild hemi-
paresis. Mild diabetes mellitus, viral hepatitis, and aortic
valve stenosis were also noted.
After subtotal excision of the involved area, a free
omental transfer was performed, with anastomosis of
the right gastroepiploic artery to one of the perforating
branches of the deep femoral artery, and the right gas-
troepiploic vein to the lateral femoral cutaneous vein,
respectively (Fig. 3b). A mesh skin graft was used on the
omentum.
The postoperative course was uneventful, although a
small local flap and skin graft was added 4 weeks later
521
to the donor right gastroepiploic vessels. (See Color Plates)
c 4 years and 9 months postoperatively
for a small area of poor graft take. The range of active
motion of the right knee joint demonstrated significant
improvement 5 years and 9 months postoperatively
(Fig.3c).
Soft Tissue Defect Reconstruction
Using Fascial Flap
Free fascia transfer has distinct advantages over muscle,
myocutaneous, and skin flap in that it provides a thin
pliable vascularized tissue without bulk, supplies a
gliding surface for tendon excursion, and conforms to
any three-dimensional cavities or surfaces.
Various free fascia transfers have been described,
including the temporoparietal fascial flap, scapular
adipofascial flap, dorsal thoracic fascial flap, serratus
anterior adipofascial flap, lateral arm fascial flap, and
radial forearm adipofascial flap. Among these, the
temporoparietal fascial flap has been one of the most
versatile flaps [7,8], giving a thin, broad sheet of
522 E. Clinical Reconstructive Microsurgery
Fig.4. Case 4. a A full-thickness skin defect of the dorsum of
the left foot with exposed extensor tendons and bones. b A
free temporoparietal fascial flap anastomosed end-to-end with
well-vascularized tissue with consistent, long and wide
caliber vascular pedicle. The donor site can be hidden
with a strategically placed zigzag incision so that hair
grows at angles over the scalp incision.
It has been successfully used for reconstruction of the
upper extremity [9], hand [10], digit [11,12], non-weight-
bearing surface of the foot [13], and intranasal lining
[14,15] and for coverage of the auricular cartilaginous
framework [16,17] where local skin coverage is not
available.
Case 4
A 3-year-old boy had his left foot caught under the front
tire of an automobile. He sustained a full-thickness skin
defect of the dorsum of the left foot, with exposed
extensor tendons and bones (Fig. 4a). The wound was
initially treated by irrigation and wet dressing. Two
days later, the defect was reconstructed by a free tem-
poroparietal fascial flap harvested from the right tem-
poral area through a zigzag incision. The superficial
temporal artery and vein were anastomosed end-to-end
with the dorsalis pedis artery and the greater saphenous
vein. The transferred fascia was immediately covered by
a split-thickness skin graft from the back (Fig. 4b). The
patient was discharged on the 27th postoperative
day without complications. At 9-month postoperative
the dorsalis pedis artery and vein, immediately covered by a
split-thickness skin graft. c 9-month postoperative result, with
a very thin pliable skin and no limitation of ankle joint motion
follow-up, he wore regular shoes, and the reconstructed
foot had a very thin, pliable skin, with no limitation of
motion at the ankle joint (Fig. 4c).
Case 5
A 5-year-old boy was run over by an automobile and
sustained a closed left tibial shaft fracture with deglov-
ing injury of the dorsum of the big toe to the third
toe. Progressive necrosis of the soft tissue necessi-
tated debridement in the operating room on the 15th
postinjury day (Fig. 5a). The interphalangeal joint of
the big toe was exposed, with loss of the overlying
joint capsule and the extensor tendon (Fig. 5b and c).
The extensor tendon to the second toe was also
exposed. The defect was temporarily covered by a
dermal substitute (Terudermis, Terumo Co., Tokyo,
Japan) for 4 days and was then reconstructed by a free
temporoparietal fascial flap with a split-thickness skin
graft from the back (Fig. 5d and e). The flap was har-
vested from the right temporal scalp through a zigzag
incision. Microvascular anastomosis was end-to-end
with the dorsalis pedis artery and the dorsal cutaneous
vein. The patient was discharged after bony union of the
tibial fracture. He developed cicatricial syndactyly of
the big to the third toe and a hypertrophic scar on the
dorsum of the left foot. After correction of the syn-
 3.19. Soft Tissue Defect Reconstruction Using Omentum or Fascial Flap
Fig. 5. Case 5. a Degloving injury of the dorsum of the big
toe to the third toe with progressive soft tissue necrosis. 15th
postinjury day before debridement. b 15th postinjury day after
debridement. The interphalangeal joint of the big toe was
exposed, with loss of overlying joint capsule and the extensor
tendon. c Lateral view after debridement. d A free tem-
poroparietal fascial flap was transplanted anastomosing the
dactyly and scar revision by Z-plasty (Fig. 5f), he was
able to wear normal shoes. The donor site scar was
inconspicuous, with hair growing over the zigzag inci-
sion scar.
Case 6
A 26-year-old man visited the plastic surgery clinic for
correction of a depressed scar on the anterior aspect of
the left ankle (Fig. 6a). He had sustained an open crush
injury to his left ankle joint with transection of the tib-
ialis anterior muscle, which was treated elsewhere 2
523
dorsalis pedis artery and the dorsal cutaneous vein end-to-
end. e The free temporoparietal fascial flap was covered by
a split-thickness skin graft. A Penrose drain in place under
the free temporoparietal fascial flap. f 6-month postoperative
result, after correction of cicatricial syndactyly and scar revi-
sion by Z-plasty
years prior to this clinic visit. After major arterial injury
to the foot had been ruled out by angiography, the
contour deformity was reconstructed by free tem-
poroparietal fascial flap with a split-thickness skin graft
from the right buttock. The temporoparietal fascial
flap was harvested through a zigzag incision on the right
temporal scalp. The donor vessels were anastomosed
end-to-side with the posterior tibial artery and its
accompanying vein (Fig. 6b). The patient was discharged
with marginal flap necrosis, which resolved with con-
servative treatment. Transient alopecia at the donor site
resolved in three months, and the contour deformity
was satisfactorily corrected (Fig. 6c).
524 E. Clinical Reconstructive Microsurgery
Fig. 6. Case 6. a A depressed scar on the anterior aspect of the
left ankle after open crush injury to the left ankle joint. b The
temporoparietal fascial flap was transplanted anastomosing
the posterior tibial artery and its com it ant vein end-to-side.
References
1. McLean DH, Buncke HJ (1972) Autotransplant of
omentum to a large scalp defect, with microsurgical rev as-
cularization. Plast Reconstr Surg 49:268-274
2. Harii K (1976) Free omental transfer. In: Marchac D (ed)
Transactions of the Sixth International Congress of Plastic
and Reconstructive Surgery. Masson, Paris, pp 61--64
3. Harii K (1978) Clinical application of free omental flap
transfer. Clin Plast Surg 5:273-281
4. Azuma H, Kondo T, Mikami M, Harii K (1976) Treatment
of chronic osteomyelitis by transplantation of autogenous
omentum with microvascular anastomosis. Acta Orthop
Scand 47:271-275
5. Nishimura A, Sano F, Nakanishi M, Koshino I, Kasai Y
(1974) Revascularization of the leg by subfascial trans-
plantation of autogenous omentum with vascular anasto-
mosis. J Jpn Coll AngioI14:15-19
6. Ohtsuka H, Torikai K, Ito M (1980) Free omental trans-
fer to the lower limbs. Ann Plast Surg 4:70-78
7. Brent B, Upton J, Acland RD, Shaw WW, Finseth FJ,
Rogers C, Pearl RM, Hentz VR (1985) Experience with
the temporoparietal fascial free flap. Plast Reconstr Surg
76:177-188
8. Rose EH, Norris MS (1990) The versatile temporoparietal
fascial flap: Adaptability to a variety of composite defects.
Plast Reconstr Surg 85:224-232
The flap was immediately covered with a split-thickness skin
graft. c 3-month postoperative result with the contour defor-
mity satisfactorily corrected
9. Hing DN, Buncke HJ, Alpert BS (1988) Use of the tem-
poroparietal free fascial flap in the upper extremity. Plast
Reconstr Surg 81:534-544
10. Upton J, Rogers C, Durham-Smith G, Swartz WM (1986)
Clinical applications of free temporoparietal flaps in hand
reconstruction. J Hand Surg [Am] 11:475-483
11. Hirase Y, Kojima T, Bang HH (1990) Secondary recon-
struction by temporoparietal free fascial flap for ring avul-
sion injury. Ann Plast Surg 25:312-316
12. Chowdary RP (1989) Use of temporoparietal fascia free
flap in digital reconstruction. Ann Plast Surg 23:543-546
13. Woods JM IV, Shack RB, Hagan KF (1995) Free tem-
poroparietal fascia flap in reconstruction of the lower
extremity. Ann Plast Surg 34:501-506
14. Upton J, Ferraro N, Healy G, Khouri R, Merrell C (1994)
The use of prefabricated fascial flaps for lining of the oral
and nasal cavities. Plast Reconstr Surg 94:573-579
15. Hirase Y, Kojima T, Takeishi M, Hayashi H, Shinoda A
(1994) Nasal reconstruction using free temporoparietal
fascial flap transfer (Upton's method). Ann Plast Surg 33:
629-632
16. Brent B, Byrd HS (1983) Secondary ear reconstruction
with cartilage grafts covered by axial, random, and free
flaps of temporoparietal fascia. Plast Reconstr Surg 72:
141-152
17. Bhandari PS (1998) Total ear reconstruction in post burn
deformity. Burns 24:661--670
3.20 Treatment of Lymphedema:
Lymphaticovenous Anastomosis
ISAO KOSHIMA and T AKAHIKO MORIGUCHI
The treatment of obstructive lymphedema is a difficult
and challenging problem, and the search continues for
the best operative procedure for this condition [1-7]. To
date, there is very little information, especilly concern-
ing the pathology of lymphedema of the lymphatics and
treatment in the human extremities. Several authors
have indicated that microsurgical lymphaticovenous
anastomosis is a suitable method of treating lym-
phedema of the extremities, but there is some contro-
versy because this method has been ineffective with
many patients. Instead of lymphaticonvenous anasto-
mosis, we have treated lymphedema in the extremities
with ultramicrosurgicallymphaticovenous anastomosis,
using subdermal precise venules (not using the sub-
cutaneous vein), and have biopsied affected lymphatic
vessels. The present investigation was carried out to
evaluate lymphaticovenous anastomosis for the
improvement of lymphedema in the extremities.
Materials and Methods
Microvascular lymphaticovenous anastomoses were
performed on a total of 14 patients. Operations were
carried out six upper extremities in six women (average
age, 56.5 years) and were followed up for 17 months or
more after surgery (average, 25.5 months). Edema was
of the severe type in all these cases and could not be
improved by any conservative treatment. The duration
of edema until surgical operation ranged from 11 to 137
months (average, 70.8 months). The maximum excess
circumference of the affected arms compared with the
contralateral normal arms ranged from 6 to 11 cm
(average,7.9cm).
Operations were performed on 12 legs of eight
patients (average age, 44.6 years) who were followed up
for 12 months or more after surgery (average, 23.4
months). Edema was moderate or severe and resisted
conservative treatment. The duration of the edema
ranged from 4 to 288 months (average, 114.5 months).
The maximum excess circumference of the legs ranged
from 2 to 15.5 cm (average, 9.9cm), but that of bilateral
leg edema could not be measured.
In these patients, lymphedemas were due mainly to
surgical resection of malignant tumors, with or with-
out lymph node dissection, followed by radiotherapy
and lymphadenitis. There were two cases of primary
lymphedema.
Operative Techniques
Lymphaticovenous anastomoses were performed on
patients whose edema had lasted for more than 6
months after treatment with conservative methods.
Under general anesthesia, anastomoses are begun after
a tourniquet has been applied to the extremities. To
facilitate preparation for lymphatics, a small amount of
indigocarmine is injected intradermally below the skin
incision. After short incisions have been made on the
medial and lateral aspects, the lymphatics and subder-
mal venules (0.3-0.6mm of each diameter) are exposed
using a loupe. Lymphatics with a strong lymphatic
drainage function should be selected to establish pow-
erfullymphovenous shunting. Small subdermal venules
0.5 mm in calibre are used for drainage of congestive
lymphatic fluid. The direction of venular flow must be
confirmed with by the milking test under an operating
microscope. End-to-end lymphaticovenous anasto-
moses are carried out using 50-micron needle suture
with 11-0 nylon with a fine needle holder under high
magnification (x20 to x30). Two to five anastomoses can
usually be established simultaneously for 3 to 5 h. Post-
operatively, the extremity is continuously elevated at
night, and a pressure bandage is applied for 2 weeks
after surgery. Later, elastic stockings are used for at least
half a year.
Results
Improvement of Edema with Surgery
Seventeen months or more after surgery, the circumfer-
ence of the arms had decreased by an average of 5.3 cm
(range, 2 to 9cm). After operation, the percentage
525
 526 E. Clinical Reconstructive Microsurgery
excess circumference of the arms decreased by an
average of 65.7% (range, 25% to 94.7%). Half of the
legs showed improvement 12 months or more after
surgery. Two patients showed remarkable volume loss
of edema and two showed moderate improvement, but
three showed no improvement. An accurate rate of
improvement could not be calculated, because half of
the patients had edema in both legs. In summary, the
postoperative results showed no correlation with the
type of edema (primary versus secondary), the preop-
erative duration of edema, or the excess circumference
of the extremities in either the upper or the lower
extremities.
Case 1 (Upper Extremity with Moderate
Improvement after Surgery)
The patient was a 65-year-old woman with progressive
lymphedema with frequent phlegmon of the left arm 15
years after radical mastectomy. Eleven months after the
initial edema appeared, a total of six lymphaticovenous
anastomoses were performed. Two and a half years after
surgery, the rate of preoperative/postoperative excess
circumference at the mid-forearm was 58.3% (moder-
ate improvement). There was a postoperative occur-
rence of phlegmon in the upper extremity (Fig. 1).
Case 2 (Upper Extremity with
Excellent Improvement)
The patient was a 61-year-old woman who suffered
from progressive lymphedema of the left arm for 11
a,b
Fig. 1. a Case 1 with 11 months of arm edema. Preoperative
appearance. b Thirty months after surgery with moderate
improvement
years after mastectomy. A total of seven lymphati-
covenous anastomoses were performed 12 years and 5
months after the initial edema. Postoperatively, there
was no occurrence of phlegmon. Twenty-five months
after surgery, the rate of improvement at mid-forearm
was 70% (Fig. 2).
Case 3 (Bilateral Legs with Slight
Improvement)
The patient was a 58-year-old woman who suffered
from progressive lymphedema with frequent phlegmon
of both legs 6 years after hysterectomy and following
radiotherapy. Four months after the appearance of
edema, lymphaticovenous anastomoses (four anasto-
moses in the right leg and two in the left leg) were
performed. The patient had a few recurrences of
postoperative phlegmon. Twenty-five months after
surgery, although the exact rate of improvement could
not be calculated, slight improvement (4.5-cm decrease
in circumference) was obtained (Fig. 3).
Case 4 (Bilateral Legs with Excellent
Improvement)
The patient was a 42-year-old woman who had suffered
from progressive lymphedema with frequent occur-
rence of phlegmon in both legs without any particular
cause. She had been operated on several times, in-
cluding operation by Thompson's method. Twenty-four
years after the initial edema, lymphaticovenous anasto-
moses (five anastomoses in the right lower leg, groin
a,b
Fig. 2. a Case 2 with 137 months of arm edema. Preoperative
appearance. b Twenty-five months after surgery with satisfac-
tory improvement
 3.20. Treatment of Lymphedema: Lymphaticovenous Anastomosis 527

a,b a,b
Fig. 3. a Case 3 with 4 months of leg edema. Preoperative Fig. 4. a Case 4 with more than 20 years of bilateral leg
appearance. b Twenty-five months after surgery edema. Preoperative appearance. b Nineteen months after
surgery with satisfactory improvement

dermal-fat flap transfer in the left leg) were performed.

Postoperatively, the patient had no recurrence of phleg-
mon. Nineteen months after surgery, excellent im-
provement (13.5-cm decrease in circumference) was
obtained (Fig. 4).

Discussion
According to our histologic observation of biopsied
lymphatics, the occlusion of the lymphatic trunks and
degeneration of the smooth muscle cells may start from
the proximal ends of the extremities, and the timing of
the occlusions and degeneration of smooth muscle cells
may not correspond to the duration of edema in the
lymphatic trunks.
In cases with a short duration of edema, a few smooth Fig. 5. Histologic finding of biopsied lymphatic channel in
muscle cells of the trunk existed at the elbow and lower-leg edema for over 20 years. A considerable number of
mid-calf levels, respectively, and the effects on them of smooth muscle cells (R) and thick collagen fibrills (S) exists.
N, Normal endothelial cell
surgery for edema were not good. In cases with a long
duration of edema and a considerable number of exist-
ing smooth muscle cells at the elbow and mid-calf levels,
the postoperative improvement of edema was satisfac- proximal level of the extremities. Therefore, it is sug-
tory. It is well known that the drainage of lymphatic fluid gested that the remaining lymphatic drainage function
is determined by the interstitial pressure in the extra- related to the smooth muscle cells may correlate with
cellular spaces, which, in turn, is influenced by contrac- the postoperative improvement of edema (Fig. 5).
tion of the subjacent skeletal muscles, particularly Finally, many surgical methods for the treatment of
during exercise, by arterial pulsation near the lymphat- lymphedema have been reported to date, but the most
ics, and by the contraction of smooth muscle cells in the suitable one has yet to be found [1--4]. The search for
lymphatic trunk wall stimulated by the sympathetic such a method has been difficult, because accurate eval-
nervous system [1]. Therefore, clinically it is considered uation of lymph-transport capacity in human limb lym-
that because of this degeneration of the smooth muscle phedema has been difficult to estimate, since there are
cells, the lymph-drainage capacity of the lymphatic no reliable methods for evaluating it. Based on our
trunks may be remarkably weakened, especially at the results, it is suggested that the lymph-drainage capacity
528 E. Clinical Reconstructive Microsurgery
may be evaluated by ultrastructural observations of the
lymphatics. This method may be the most reliable as a
preoperative examination for evaluation of the level of
functioning lymphatics and for operative indication for
lymphaticovenous anastomosis.
References
1. O'Brien BM, Chait LA, Hurwitz PI (1977) Microlymphatic
surgery. Orthop Clin North Am 8:405-424
2. O'Brien BM, Sykes PI, Threlfall GN, Browning FSC (1977)
Micro-lymphaticovenous anastomoses for obstructive lym-
phedema. Plast Reconstr Surg 60:197-211
3. Huang GK, Hsin YP (1983) An experimental model for
lymphedema in rabbit ear. Microsurgery 4:236
4. Huang GK, Hu RQ, Liu ZZ, Shen YL, Lan TD, Pan GP
(1985) Microlymphaticovenous anastomosis in the treat-
ment of lower limb obstructive lymphedema: analysis of 91
cases. Plast Reconstr Surg 76:671-677
5. O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar
V, Pederson WC (1990) Long-term results after micro-
lymphaticovenous anastomoses for the treatment of
obstructive lymphedema. Plast Reconstr Surg 85:562-
572
6. Koshima I, Kawada S, Moriguchi T, Kajiwara Y (1996)
Ultrastructural observation of lymphatic vessels in lym-
phedema in human extremities. Plast Reconstr Surg
97:397-405
7. Koshima I, Inagawa K, Urushibara K, Moriguchi T (2000)
Supermicrosurgicallymphaticovenular anastomosis for the
treatment of lymphedema in the upper extremities. Recon-
str Microsurg 16:437-442
Subject Index

A avascular necrosis of femoral head 485

abdominal muscle 360 avascular necrosis of talus 364
absolute indication for amputation 229 avulsion amputation 203
acetylthiocholine 84 axial pattern flap 247
acidosis 107 axial plexus flap 248
Achilles tendon 335 azathioprine 97
active oxygen intermediate 88
acute rejection 96
acute respiratory distress 203 B
adaptive hypertrophy 127 bacteria load 444
adduction contracture of thumb 181 barrier effect 125
alcohol-methyl salicylate clearing 59 Batson No.17 anatomical corrosion compound 57
alkaline phosphatase (ALP) 70 biceps muscle 433
Allen radial compression test 258 blood pool image 65
allogeneic tissue transfer 120 bone blood flow 137
allogeneic hand transplantation 93 bone dynamics 642
allograft 93, 149,501 bone formation rate 131
amputation 210 bone grafting 342
amputated extremity 209 bone hypertrophy 137
amputated hand 197 bone image 65
anatomical variation 292 bone tumor 347
anconeus 433 bony union on roentgenogram 123
anterior radial collateral artery (ARCA) 254 brachial plexus injury 426
anterior tibial artery 160,287 brachioradialis tendon 335
anterobrachiallateral cutaneous nerve 259 buoy flap 175
anterograde bone reconstruction 452 bum scar contracture of neck 285
anterolateral thigh flap 446
antibiotic-formulated bone cement 459
anticoagulant 166, 169, 180 C
anticoagulant therapy 163, 204 calcium channel blocker 91
antigen-presenting cell 94 calcium ion 88
antiplatelet aggregation 167 cambium 363
arm replantation 187 cancello-corticoperiosteal graft 363
arterial anastomosis 35 cancellous bone graft 143
arterial scleorotic change 175 ' 4 C-antipyrine 77

arterial thrombi 171 capillary refill 162

arterial variation in groin 282 catheterization 176
arterial venous fistula 118 caudal artery 143
arterial venous neovascularization 118 causalgic pain 188
arterialized flow-through venous flap 312 Celsior solution 207
arteriovenous flow-through venous flap 312 cephalic vein 160
arthrodesis 473 ceramic 72
aseptic necrosis of the femoral head (ANFH) 481 chain-linked combined flap 448
autogenous joint transfer 373 choline acetyltransferase 84
autogenous vein graft 40 choline acetyltransferase (ChAT) activity 81

529
530 Subject Index

cholinesterase 84 D
Chopart joint 220 Daumenplastik 386
chordoma 468 debridement 444
chronic osteomyelitis 451 decompression fasciotomy 190
chronic rejection 96 deep circumflex iliac artery 359,481
chuck pinch function 206 deep circumflex iliac vein 481
circulatory disorder 162 deep femoral artery 160
circumflex scapular artery (CSA) 251,324,355 deep inferior epigastric vessel 305
clamp flap 116 delayed areriovenous flow-through venous flap 313
claw nail deformity 385 delayed primary reconstruction 448
cold intolerance 219 delayed secondary reconstruction 448
cold tolerance test 260 descending genicular artery 366
collapse of fibular head 473 descending genicular vessel 363
combined lateral arm and posterior interosseous artery desensitization exercise 181
flap 446 digital artery island flap 266
combined second and third toe transfer 367,414 digital replantation 177
combined toe transfer 371 direct observation of microcirculation 78
common plantar digital artery 297 disadvantage 339
compass PIP joint hinge (CPJH) 212 disk graft 146
composite graft 231 divided vascularized fibula 437
composite scapular flap 251 donor harvesting technique 268
composite tissue 149 donor-specific transfusion 98
compound flap 257 Doppler examination 452
compound injury 445 Doppler flowmeter 287
concomitant vein 351 Doppler stethoscope 174
congenital proximal radioulnar synostosis 432 dorsal branch of ulnar nerve 277
congenital pseudarthrosis 437 dorsal middle phalangeal flap 266
congenital pseudarthrosis of forearm 440 dorsalis pedis artery 161
congenital pseudarthrosis of tibia 435 dorsalis pedis cutaneotendinous flap 334
congenitally stiff elbow 497 dorsalis pedis flap 158,292,333,446
contaminated devitalized tissue 444 double-barrel fibular graft 504
continuous intraarterial infusion 212 double-level amputation 203
continuous local heparinization (CLH) 169 double second toe transfer 414
continuous local intraarterial infusion 169 double vascularized fibula graft 463
continuous local intravenous infusion 169 drift phenomenon 124
contractility of vascular smooth muscle 90 dual bone graft 347
contralateral microvascularly augmented TRAM flap 515 dynamic MR study 486
conventional muscle vascularized pedicle flap 388
cooling 104
corrosion 57 E
corticocancellous bone graft 145 ear replantation 237
corticoperiosteal graft 365 early coverage 444
creeping substitution 342 early vascular reconstruction 445
criteria for successful replantation 187 early weight-bearing 127
cross-foot method 296 edema 104
cross-sectional bone area 131 elbow arthroplasty 496
cross-toe flap 379,385 elbow prostheses 50 I
Crouzon disease 496 eiectrophysiological method 86
crush and contusion injury 203 elevation of groin flap 282
cryopreservation 90 113, 120 emergency free flap 444, 490
cryopreserved vessel and nerve 113 end-to-end anastomosis 35
cutaneotendinous flap 258, 333 epigastric flap 111
cutaneous branch 288 epineurial repair 47
cutaneous branch from peroneal artery 349 epineurial suture 44
Cybex 11 220 epiphyseal growth 222
cyclosporine 97 epiphyseal plate 349
evaluation of vascular system 157
 Subject Index 531

expanded flap 389 free temporoparietal fascial flap 522

expanded muscle vascularized pedicle flap 389 free tissue transfer 164,388
extensor tendon arcade (ETA) 270 free tissue transplantation 318
external fixation of bone 135 free toe transfer 159
external jugular vein 160 free vascularized bone graft 159,359
free vascularized fibular graft (FVFG) 349,468
free vascularized fibular head graft (FVFHG) 468
F free vascularized nail graft 386
fascial flap 260, 519 freezing 89
fascicutaneous flap 247 frozen section 85
fasciotomy 194 function after arm replantation 187
fat flap 117 functional muscle transplantation 330
feeding artery 427 functional position of the hand 179
femoral head 476 functional reconstruction 330
femoral profunda artery 464 functional score 473
fibula 344 funicular pattern 44
fibular graft 503 funicular repair 48
filet flap 491 funiculus 44
filet graft 472
fileted flap 470
fine network of artery 361 G
finger reconstruction 414 gas (H 2) clearance 77
finger-to-finger transfer 418 glycerin clearing 60
fingertip 385 gracilis muscle 319, 330, 428
first dorsal metatarsal artery 301, 380 graft under non-weight-bearing condition 126
first metacarpal flap 272 grasping power 192
first plantar metatarsal artery 301, 380 great saphenous vein 160, 438
first web flap 158, 301 groin flap 158, 281, 446
flap success rate 445 growth of replanted arm 189
flexor carpi radialis tendon 335 growth retardation 222
flexor hallucis longus 289 guillotine amputation 203
flow-through-type tissue 176 Gustilo typing of open fracture 225
fluorocarbon 107
fluorochrome bone labeling 129
fluorochrome bone marker 122 H
fluorochrome bone study 124 hair growth 243
fluorochrome labeling 61, 143 hallux-to-hand transfer 386
fluorometric assessment 77 hand allotransplantation 193
fluoromicroscopy 62 Hannover fracture scale (HFS) 228
fluosol-43 107 Hannover fracture scale-97 (HFS-97) 225
focal curettage 463 harvesting a fibula graft with flap 350
folded vascularized fibula graft 349 harvesting of omentum 397
foot 219 harvesting technique of vascularized fibula graft 349
forearm flap 158,257,510 hemipump flap 301
forearm replantation 193 heparin 164, 166, 169, 176, 212
fracture of the grafted fibula 349 heparinization 176
free TRAM flap 515 hind limb replantation 111
free deep inferior epigastric perforator (DIEP) flap 335 hindquarter amputation 472
free digital transfer 386 histochemical method 86
free fascia transfer 521 histomorphological measurement 129
free flap 158 history of microsurgery 3
free gracilis muscle graft 470 Hoffman-type external fixator 499
free jejunal transfer 392 human leukocyte antigen 93
free muscle graft 318,426,470 hydrogen-clearance method 78
free muscle transplantation 318, 428 hydroxyapatite 70
free omental transfer 396, 519 hyperacute rejection 95
free rectus abdominis myocutaneous flap 327 hyperkalemia 104
532 Subject Index

hyperpotassemia 104 joint transfer 373

hypertrophy ]29,342,466
hypertrophy of bone 138
hypertrophy of graft 473 K
hypertrophy of vascularized fibular graft 455 Karnovsky staining 84
hypertrophy rate 131 KienbSck disease 115,347
hypothermia 88, 104

L
I lactate 106
ibprofen 91 lactate production 104
ice water 104 lamellar bone formation 124
ileocolic vessel 394 large bone defect 451
iliac bone 48] laser Doppler flowmetry (LDF) 78
iliac crest 344, 355 laser Doppler perfusion imager 78
iliacus fascia 361 late reconstruction and closure 445
iliacus muscle 361 lateral arm flap 254, 446
Ilizarov external fixator 437 lateral circumflex femoral artery 160
immunological tolerance 96 lateral displacement of scapula 224
immunosuppression 94 lateral femoral cutaneous nerve 281
incurable nonunion 451 lateral plantar artery 297
indication for free omental transfer 519 lateral upper arm flap 433
indication for replantation 209 latissimus dorsi flap 158,446,470
indication of groin flap 282 latissimus dorsi muscle 356
infected nonunion 343, 458, 462 latissimus dorsi muscle flap III
inferior epigastric artery 360 latissimus dorsi musculocutanelus flap 407,452,493
infraclavicular region 160 L-Cath 170
inlay graft 438 lidocaine 166
intercostal nerve 319,426 limb amputation 100
intercostal nerve crossing 426 limb replantation 100, 1] 2
interfascicular suture 44 limb salvage 224
intermuscular septum 287 limb salvage index (LSI) 225
internal thoracic artery 514 limb salvage index scoring system 226
internal thoracic vein 514 limb-sparing surgery 468
interosseous recurrent vessel 432 lipo-prostaglandin E, 167
interpositional anastomosis 452 living disk 148
intertubercular sulcus of humerus 325 local heparinization 164
intervertebral fusion 146 low-molecular-weight dextran 320
intramedullary artery 122 low-molecular-weight dextran solution 212, 219
intramedullary rod 437 lower extremity replantation 219
intravenous infusion 2] 2 lower leg 219
intrinsic minus contracture 18] lumber artery 325
intrinsic plus contracture 181 lymph-drainage capacity 527
intrinsic plus position 179 lymph-transport capacity 527
ipsilateral microvascularly augmented TRAM flap 515 Iymphaticovenous anastomosis 525
ipsilateral pedicled vascularized fibula graft 349 lymphedema 525
ischemia 88, 104
ischemia-reperfusion injury 88
ischemia time 203 M
ischemic time 188, 219 major limb amputation 193
ischial weight-bearing orthosis 465 mandibular reconstruction 502
island flap 305 mangled extremity severity score (MESS) 225
ISOLA system 468 mangled extremity syndrome (MES) 225
mangled extremity syndrome grading system 228
manometer 55
J marginal hyperkeratosis 296
JMHW classification 476 Marlex mesh 474
 Subject Index 533

marrow cell 72 mRNA 70

mechanical loading 126, 138 MRS A infection 459
mechanical stress 145 99m-technetium (99m-Tc) methylene diphosphonate
mechanical stress load 129 (MDP) bone scan 65
medial arm flap 446 multilevel amputation 203
medial descending genicular artery 160 multistrand suture technique 211
medial femoral condyle 363 muscle pedicle bone graft 342
medial plantar artery 296 muscle pedicle bone grafting 476
medial plantar cleft 296 muscle perforator 307
medial plantar flap 296 muscle transplantation 426
medial plantar island flap 297 muscle vascularized pedicle flap 388
medical leech 177, 211 muscle vascularized pedicle iliac bone flap 390
mesenteric flap 512 muscle-perforating artery 307
metabolic acidosis 104 musclocutaneous flap 287,319,323,474
metacarpal artery island flap 266 musculocutaneous branch 288
metacarpal flap 271 mycophenolic acid 97
metastatic bone tumor 474 myocutaneous flap 116, 390
metatarsophalangeal (MTP) joint 407, 496
metatarsophalangeal (MTP) joint transfer 373,423
methicillin-resistant Staphylococcus aureus (MRS A) 457 N
microangiography 57 neovascularization 115
microcorrosion casting 58 neovasvularized muscle flap 115
microfil 59 nerve graft 192
micropaque 57 nerve grafting 86
microsurgery 3, 174 nerve injury, ischemia, soft-tissue injury, skeletal injury,
microsurgical free compound toe transfer 386 shock, and age of patient (NISSSA) 225
microsurgical instrument 25 nerve recovery 222
microsurgicallymphaticovenous anastomosis 525 nerve repair 81
microsurgical replantation of an amputated penis 231 nerve viability 81
microsurgical technique 35 neuroadipofascial (NAF) flap 248
microvascularly augmented colonic pedicle 392 neurofasciocutaneous flap 265
microvascularly augmented elongated gastric pedicle neurotropism 46, 50
393,513 neurovascular anastomosis 428
microvascularly augmented gastric pedicle 392 nonradioactive colored-microsphere (NRACM) technique
microvascularly augmented gastrointestinal pedicle 392 76
microvascularly augmented jejunal pedicle 392, 514 nonunion 364,474
microvascularly augmented left-side colonic pedicle 394 normograde anastomosis 453
microvascularly augmented microvascular augmentation northern blot analysis 71
392
microvascularly augmented rectus abdominis
myocutaneous flap 327 o
microvascularly augmented right-side colonic pedicle orthofix apparatus 194
394,514 obstructive lymphedema 525
mid-sole plantar skin 296 omentum 396, 519
minimal shortening 197 omentum volume 397
misalignment 83 one-bone forearm 129
mobilization 432 one-stage reconstruction 343
modified Enneking method 470 operating microscope 25
monitoring 174 orthodromic anastomosis 453
monitoring buoy flap 498 osseointegrated dental implant 504
monitoring flap 438, 451, 463, 477 osteoblastic activity 70
monitoring of blood circulation 162 osteocalcin 70
motor fascicle 84 osteochrome bone stain 123
motor nerve 82, 330, 427 osteocutaneous flap 258,265,294,345,360,457,463
motor supply 427 osteocutaneous scapular flap 251
motor-to-motor fascicle 86 osteomyelitis 343,457
MRL 484 osteomyocutaneous flap 116
534 Subject Index

osteonecrosis 347,476 preoperative angiography 157

osteoonychocutaneous flap 384 preoperative planning 157
osteotendocutaneous flap 294 preoperative simulation 157
osteotomy 476 preservation of digital artery 270
oxygen radical scavenger 90 primary amputation 224
primary microsurgical reconstruction 403
primary reconstruction 403,445,471
p primary repair 445
palmaris longus tendon 335 profunda humeri vessel 433
paralytic hand 428 progressive hemifacial atrophy 286, 398
parascapular flap 158, 252 progressive lymphedema 526
paraumbilical perforator-based flap 306 proper digital artery 160
patient's health status 157 prostaglandin 164
pectoral fasciocutaneous flap 512 prostaglandin E, (PGE,) 167,169,176,194
pedicled vascularized fibular graft (PVFG) 468 proximal phalangeal island flap 266
pedicled venous flap 309 pseudarthrosis 364, 452, 465
pelvic ring 474 pseudarthrosis of forearm 437
pentobarbital 55 pseudarthrosis of radius 442
perforating branch 287 pseudarthrotic region 463
perforator flap 249 psychological care 188
periosteal artery 359
periosteum 71,361,363
peroneal arery 291, 287, 349 Q
peroneal flap 159,287,457 quantitative culture 444
peroneal island flap 287
peroneal vascular bundle 479
peroneal vessel 288 R
peroneus brevis muscle 287 rabbit metatarsal bone 134
peroneus longus muscle 288 radial artery 160,257, 335
peroneus longus tendon 335 radial collateral artery 160
peroneus vessel 336 radial forearm flap 159,257,334,445
pH 105 radial forearm flap with hemiradius 503 .
pH monitoring 113 radial forearm free flap 510
phlegmon 526 radial nerve palsy 434
pinching power 192 radial recurrent artery 160
PIP joint transfer 421 radial thenar flap 275
plasminogen activator 167 radical debridement 457
platysma myocutaneous flap 512 radioactive microsphere method 135
point system for predictive salvage index (PSI) 226 radioactive microsphere (RAM) technique 73
popliteal artery 160 radioisotopic 86
posterior cutaneous nerve of arm (PCNA) 254 radius osteotomy 432
posterior intercostals artery 325 random pattern flap 247
posterior interosseous artery flap 445 rat 149
posterior interosseous flap 265 rat cremaster model 78
posterior radial collateral artery (PRCA) 254 reactive change 132
posterior septum 287 reactive hypertrophy 127
posterior tibial artery 161, 287 reattachment of amputated penis 234
posterior tibial vein 160 reconstructive microsurgery 388
postoperative care 204 reconstructive surgery 192
postoperative graft hypertrophy 121 rectus abdominis muscle 390
postoperative management 162, 179, 194, 212 rectus abdominis myocutaneous flap 510
postoperative monitoring 162 rectus femoris muscle 319,428
postoperative viability 463 recurrent radial vessel 433
posttraumatic vessel disease 160 reexploration 479
predictive salvage index (PSI) 225 reflex sympathetic dystrophy 197
prefabricated flap 388 refracture of the graft 437
prefabrication 115 rehabilitation 180, 204
 Subject Index 535

remodeling 123 spinal accessory nerve 319

replantation 164,203,209,219,237,241 35S-sulfate 146
replantation model 100 sterilized leech 164
replantation of limb 187 subdermal plexus 305
replantation toxemia 104, 203 subdermal precise venule 525
resorption drift 127 subscapular artery 323,355
retrograde anastomosis 452 subscapular flap 158
reverse digital artery island flap 268 subzero 89
reverse digital flag flap 266 superficial circumflex iliac artery (SCIA) 281, 359
reverse flap 265 superficial circumflex iliac vein (SCIV) 281
reverse metacarpal flap 272 superficial epigastric artery (SEA) 281
reverse peroneal island flap 287 superficial epigastric vein (SEV) 281
reverse radial forearm flap 257 superficial peroneal nerve 288
reverse-flow proximal phalangeal island flap 270 superficial radial nerve 275
reversed bone reconstruction 453 superficial temporal artery (STA) 340
root avulsion injury 426 superficial temporal vein (STV) 340
rotation flap 298 superficial temporal vessel 237
rotation osteotomy 435 superficial tibial plantar artery 297
superomedial genicular vessel 363
supraclavicular region 160
S sural nerve neurosensory flap 446
sacroiliac joint 468 surgical delay 390
sacrum 469 survival rate 187,473
salvage technique 174 suture material 29
scalp avulsion 242 suture "a distance" method 44
scapula 344,355 system of Enneking 472
scapular flap 252, 406
scapulothoracic dissociation (SD) 224
second toe transfer 367,412 T
secondary vascularization 389 tacrolimus 97
secondary vascularized flap 388 Tarnai's zone 210
segment of jejunum 510 T-cell receptor 94
Semmes-Weinstein test 199, 206 temporoparietal fascia 339
sensate instep flap 296 temporoparietal fascial flap 524
sensory fascicle 84 temporoparietal flap 339
sensory flap 259 tendocutaneous flap 294, 406
sensory nerve 82 tendon grafting 333
sensory reeducation program 181 tenolysis 181
sensory-to-sensory fascicle 86 tension band wiring 498
septocutaneous branch 288 tension of grafted muscle 320
serratus anterior 324 teres major muscle 325, 357
serratus anterior muscle 356 teres minor muscle 357
serratus muscle flap III thermography 239,243
sharp-cut amputation 203 thermometer 179
shortening osteotomy 434 thin deep inferior epigastric perforator (DIEP) flap 305
silicone rubber 59 thin osteoonychocutaneous flap 384
single toe transfer 367,415 third toe transfer 367
skin graft 190 Thompson method 526
skin temperature 162 thoracoacromial artery 160
sling procedure 470 thoracodorsal artery 323
small saphenous vein 160 thoracodorsal nerve 324
soft tissue defect reconstruction 519 thoracodorsal neurovascular bundle 324
soft tissue tumor 468 thoracodorsalis artery 355
soft-tissue defect 343 three-phase bone imaging 65
soleus muscle 288 thrombectomy 164
Spalteholz cleared specimen 59 thrombogenesis 176
spare surgery 491 thrombolitic activity 172
536 Subject Index

thrombosis 166, 169, 174,462 vascularized bone graft (VBG) 121, 143,342,355,359,
thumb opposition 190 457
thumb reconstruction 410 vascularized bone grafting 476
tibialis posterior muscle 289 vascularized fascia lata 335
tibiofibular metaphyseal synostosis 438 vascularized fascio-fat graft 432
timing of the wound coverage 444 vascularized fibula graft 66, 134, 163,287, 366, 451,457
tissue expander 389 vascularized fibula grafting 458
tissue plasminogen activator (t-PA) 172 vascularized iliac bone 359
tissue transfer 174 vascularized iliac bone graft 66
tissue typing 96 vascularized iliac crest graft 366
toe joint transfer 159,421 vascularized intervertebral disk 146
toe proximal interphalangeal joint transfer 377 vascularized metatarsal bone graft 366
toe transfer 371,410 vascularized nail graft 384
topography 84 vascularized pedicled bone graft 481
total scalp avulsion 241 vascularized periosteal graft 361
transplanted muscle 427 vascularized periosteum 71
transverse cervical artery 160 vascularized proximal interphalangeal joint transfer 373
transverse facia 361 vascularized scapular bone graft 485
transverse rectus abdominis myocutaneous (TRAM) flap vascularized tendon graft 333
327,515 vascularized thin corticoperiosteal graft 345, 363
traumatic bony defect 451 vascularized tibiofibular graft 121
triangular space 355 vascularized toe joint transfer 496
trimmed second toetip 385 vascularized whole nail graft 384
trimmed second toetip transfer 385 vascularly augmented random flap 250
twin barrel graft 452 vein graft 176, 188
twin-barrelled fibula 343 venoadipofascial (VAF) flap 248
twisted-toe flap 383 venous anastomosis 39
two-point discrimination 199 venous congestion 265, 315
type lII-C fracture 458 venous drainage 211, 258
venous flap 309,405,491
venous network 315
U venous pressure 315
ulnar artery 160 venous thrombi 171
ulnar collateral artery 160 venous thrombosis 162
ulnar hypothenar flap 277 venovenous flow-through venous flap 309
ultramicrosurgicallymphaticovenous anastomosis 525 viability 484
undecalcified section 61 Villanueva bone stain 62
undecalcified specimen 123, 131 Villanueva osteochrome bone stain 131
unstable radiation ulcer 396 Volkmann contracture 318
urokinase(UK) 166,169,176,194,212,221,320
utilization of discarded tissue 404
utilization of normal tissue 404 W
Wallerian degeneration 86
watershed area 298
V wound closure using free flap 444
vascular anastomosis 194, 459 woven bone 124
vascular anatomy in the bone 121 wrap-around flap (WAF) 259,379,386,410
vascular compliance 90 W/V chlorhexizin Maskin 220
vascular corrosion cast 57
vascular pedicle 482
vascular tension 175 X
vascular thrombosis 194 xylenol orange 61
vascularization 70