De Jong JP, et al. Clin Orthop Surg. 2014 Jun;6(2):196-202. https://doi.org/10.4055/cios.2014.6.2.196

Rationale: With over seven million infections and $25 billion treatment cost, chronic ischemic wounds are one of the most serious complications in the United States. The controlled release of bioactive factor enriched exosome from finbrin gel was a promising strategy to promote wound healing.

The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Recently, the internal mammary vessels have been recommended as the first-choice recipient vessels for microvascular breast reconstruction. This approach requires a shorter pedicle length, allows for central placement of flap tissue, and avoids axillary scarring. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction. The authors performed a prospective trial examining the differences in operative and aesthetic outcomes between each recipient site. A prospective trial of 108 consecutive free-tissue transfers was conducted in 100 patients. The first 60 TRAM flap patients were randomized so that 30 flaps were anastomosed to the internal mammary vessels and 30 were anastomosed to the thoracodorsal vessels, whereas the recipient vessels for the remaining 40 patients were left to the discretion of the surgeon. Of the 10 nonrandomized patients, 10 patients underwent reconstruction using the internal mammary vessels and 30 patients underwent reconstruction using the thoracodorsal vessels. The patients' medical history and hospital course were noted. To evaluate aesthetic outcome, a group of five blinded nonmedical observers and three blinded plastic surgeons graded the reconstructions in the 60 TRAM flap patients for symmetry and overall aesthetic result on a scale of 1 to 5. Blinded practitioners administered postoperative questionnaires to patients regarding recovery time and satisfaction with the aesthetic result. Forty-three flaps were transferred to the internal mammary vessels and 65 were transferred to the thoracodorsal vessels. No significant differences existed between groups with regard to age of preoperative risk factors. Average operative time was 6 hours in each group. Average hospital stay was 5.8 days in each group. Conversion from initial recipient vessel to a secondary recipient site occurred in 12.5 percent of internal mammary reconstructions and 7 percent of thoracodorsal reconstructions. All converted internal mammary cases occurred in left-sided reconstructions and were attributable to problems with the veins. Overall, 20 percent of left-sided internal mammary reconstructions were found to have an inadequate recipient vein. Unusable thoracodorsal vessels were found only in delayed reconstructions, at a rate of 15 percent in the delayed setting. All flaps from converted procedures survived without complications. Average follow-up was 20 months, during which time there was one flap loss in the thoracodorsal group. There were no significant differences in complication rates between groups. Average aesthetic grade was 3.6 in each group. Postoperative recovery time and overall patient satisfaction were not significantly different between groups. Either recipient site can provide for a safe and acceptable result; however, surgeons should be aware of conversion rates and plan appropriately if recipient vessels appear unusable for free-tissue transfer. (Plast. Reconstr. Surg. 111: 1876, 2003.)

Background: Long segmental bony defects after tumor extirpation can pose difficult problems for the reconstructive surgeon. Capanna and colleagues have described a technique that places a free fibular flap within the intramedullary canal of an allograft for reconstruction of large intercalary bony defects. This article describes the authors' long-term follow-up with this technique for the treatment of large segmental bone defects in a pediatric population. Methods: Over a 6-year period, seven patients underwent bony reconstruction with an allograft and vascularized fibular construct. All reconstructions were performed for lower extremity salvage after tumor extirpation. Grafts were evaluated for viability with bone scans 10 days postoperatively. Radiologic and clinical evaluations were performed on all patients. Time to union was recorded through evaluation of plain radiographs. Patients' charts were evaluated for postoperative complications. Results: There were two female and five male patients with an average age of 10.5 years. The average follow-up time was 36 months (range, up to 72 months). Limb salvage was 100 percent, with all bone scans positive at 10 days. Two nonunions at the allograft interface were treated successfully with a secondary bone graft. The average time to complete bony union of the fibula and allograft to the native bone was 9 months. There were no allograft fractures and no infections. One patient developed nonunion at the donor leg syndesmosis site. Average final knee motion was 110 degrees. All patients returned to ambulation. Conclusion: Intramedullary free fibular flaps in combination with massive bony allografts provide an excellent option in the pediatric population for reconstruction of large bony defects after tumor extirpation.