Andreas Jokuszies

Use of spider silk fibres as an innovative material in a biocompatible artificial nerve conduit.

Defects of peripheral nerves still represent a challenge for surgical nerve reconstruction. Recent studies concentrated on replacement by artificial nerve conduits from different synthetic or biological materials. In our study, we describe for the first time the use of spider silk fibres as a new material in nerve tissue engineering. Schwann cells (SC) were cultivated on spider silk fibres. Cells adhered quickly on the fibres compared to polydioxanone monofilaments (PDS). SC survival and proliferation was normal in Live/Dead assays. The silk fibres were ensheathed completely with cells. We developed composite nerve grafts of acellularized veins, spider silk fibres and SC diluted in matrigel. These artificial nerve grafts could be cultivated in vitro for one week. Histological analysis showed that the cells were vital and formed distinct columns along the silk fibres. In conclusion, our results show that artificial nerve grafts can be constructed successfully from spider silk, acellularized veins and SC mixed with matrigel.

Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels.

Background: Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. Methods: Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). Results: Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher’s exact test did not indicate a significant difference between a simultaneous or staged flap transfer. Conclusions: Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.

Burn-induced organ dysfunction: Vagus nerve stimulation attenuates organ and serum cytokine levels

INTRODUCTIONnThe interaction of the CNS and the immune system is well known. A parasympathetic anti-inflammatory pathway has recently been described. Both electrical and pharmacological parasympathetic stimulation attenuate proinflammatory mediator generation. Burn induces abacterial cytokine generation and we sought to evaluate whether parasympathetic stimulation after experimental burn decreases cardiodepressive mediator generation.nnnMATERIAL AND METHODSnA 30% TBSA full-thickness rat burn model was used. After microsurgical preparation of the cervical portion of the vagus nerve, we performed electric vagus nerve stimulation. Serum was harvested and organ samples of heart and liver were homogenized. Samples were subjected to sandwich-ELISA specific for TNF-alpha, IL-1beta and IL-6. Heart rate measurements were done using left ventricular microcatheterization. Statistical analysis was done using Students t-tests and analysis of variance (ANOVA).nnnRESULTSnBurn induced a significant rise of TNF-alpha, IL-1beta and IL-6 in organ homogenates and serum. After cervical vagal electrostimulation, serum and organ homogenate levels of proinflammatory cytokines were markedly reduced compared to burn controls. Left ventricular microcatheter assessment demonstrated no cardiodepressive effect of the vagal stimulation itself.nnnCONCLUSIONnOur results encourage further research regarding the neuroimmunologic background of burn, possibly leading to the development of a novel therapeutic approach to burn-induced organ dysfunction and immunodysregulation.

In Vivo Transformation of Neural Stem Cells Following Transplantation in the Injured Nervous System

Johnson et al report tumor formation following murine neural precursor cell transplantation in a rat peripheral nerve injury model, emphasizing the importance of full in vitro characterization of cells prior to transplantation. Cell lines can change during expansion and subclones which may become tumerogenic may be selected in the process of expansion. Cell transplantation studies with committed cells that have been minimally manipulated and expanded in culture such as olfactory ensheathing cells and Schwann cells may pose less risk of tumerogenicity, but have the disadvantage of limited cell harvest yields. The balance between in vitro transformation of expanded cell lines and the limitation of cell harvest yields from preparation of more stable committed cells must be considered in selection of cells for therapeutic intervention for nerve repair.

Is there an association between comorbidities and the outcome of microvascular free tissue transfer

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.

[One-stage defect closure of deperiosted bone and exposed tendons with MATRIDERM® and skin transplantation. Possibilities and limitations].

ZusammenfassungHintergrundVollschichtige Hautdefekte über funktionellen Strukturen (Sehnen, Gefäße) oder denudiertem Knochen an den Extremitäten machen in der Regel aufwändige Weichteilplastiken zur Defektdeckung notwendig. Als neue Option bei der Defektdeckung steht die bovine Kollagen-Elastin-Matrix MATRIDERM® zur Verwendung als Neodermis unter Hauttransplantaten zur Verfügung. Kann die einzeitige Transplantation mit MATRIDERM® und ausgedünnter Vollhaut oder Spalthaut über denudierten Knochen oder freiliegenden Sehnen eine suffiziente Defektdeckung erreichen?Patienten und MethodenBei insgesamt 10xa0Patienten wurde anstatt plastisch-chirurgischer Defektdeckungen, MATRIDERM® in Kombination mit Spalthaut/Vollhaut in einem einzeitigen Deckungsverfahren angewandt. Es wurde die Einheilungsrate der einzeitig und kombiniert verwandten Transplantate auf einem generell mit großen Hauttransplantatverlusten verbundenem Wundgrund (denudierter Knochen und Sehnen ohne Paratenon) ermittelt.ErgebnisseBei 9 von 10xa0Patienten konnte mit dem kombinierten Verfahren durch MATRIDERM® und Hauttransplantation eine vollständige Defektdeckung erzielt werden. Dabei war ein einzeitiger Wundverschluss über freiliegenden Sehnen ohne Paratenon in 4 von 5 Lokalisationen unter Erhalt der Funktion zu erreichen gewesen. Über deperiostierten knöchernen Defekten war ein einzeitiger komplikationsfreier Verschluss jedoch nur in 2 von 6 Lokalisationen erfolgreich gewesen. Insgesamt konnte jedoch mit einer zweiten Spalthauttransplantation bei vaskularisiertem MATRIDERM® ein vollständiger Wundverschluss an der Wunde mit freiliegender Sehne und in 3 der 4 knöchernen Lokalisationen erzielt werden. Bei einem Patienten mit freiliegendem Olecranon konnte eine lokale Transpositionslappenplastik zum abschließenden Verschluss angewendet werden.SchlussfolgerungDurch die ein- bzw. zweizeitige Verwendung von MATRIDERM® über frei liegenden Sehnen sowie Knochen kann ein effektiver Defektverschluss ohne die Notwendigkeit eines komplizierteren plastisch-rekonstruktiven Verfahrens erzielt werden. Einen Ersatz für Lappenplastiken in Bezug auf ihre Funktionalität kann dieses Verfahren nicht darstellen. Durch die Verwendung von MATRIDERM® besteht aber in ausgewählten Fällen eine erweiterte Indikationsmöglichkeit für Spalthauttransplantationen bei plastisch-rekonstruktiven Eingriffen.AbstractBackgroundFull-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM®, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?Patients and methodsWe performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined. ResultsIn nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.ConclusionAs a one- or two-stage procedure, MATRIDERM® application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM® is an interesting and successful method in plastic reconstructive surgery.BACKGROUNDnFull-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM®, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?nnnPATIENTS AND METHODSnWe performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined.nnnRESULTSnIn nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.nnnCONCLUSIONnAs a one- or two-stage procedure, MATRIDERM® application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM® is an interesting and successful method in plastic reconstructive surgery.

Einzeitige Defektdeckung von denudiertem Knochen und freiliegenden Sehnen mittels MATRIDERM® und Spalthaut

ZusammenfassungHintergrundVollschichtige Hautdefekte über funktionellen Strukturen (Sehnen, Gefäße) oder denudiertem Knochen an den Extremitäten machen in der Regel aufwändige Weichteilplastiken zur Defektdeckung notwendig. Als neue Option bei der Defektdeckung steht die bovine Kollagen-Elastin-Matrix MATRIDERM® zur Verwendung als Neodermis unter Hauttransplantaten zur Verfügung. Kann die einzeitige Transplantation mit MATRIDERM® und ausgedünnter Vollhaut oder Spalthaut über denudierten Knochen oder freiliegenden Sehnen eine suffiziente Defektdeckung erreichen?Patienten und MethodenBei insgesamt 10xa0Patienten wurde anstatt plastisch-chirurgischer Defektdeckungen, MATRIDERM® in Kombination mit Spalthaut/Vollhaut in einem einzeitigen Deckungsverfahren angewandt. Es wurde die Einheilungsrate der einzeitig und kombiniert verwandten Transplantate auf einem generell mit großen Hauttransplantatverlusten verbundenem Wundgrund (denudierter Knochen und Sehnen ohne Paratenon) ermittelt.ErgebnisseBei 9 von 10xa0Patienten konnte mit dem kombinierten Verfahren durch MATRIDERM® und Hauttransplantation eine vollständige Defektdeckung erzielt werden. Dabei war ein einzeitiger Wundverschluss über freiliegenden Sehnen ohne Paratenon in 4 von 5 Lokalisationen unter Erhalt der Funktion zu erreichen gewesen. Über deperiostierten knöchernen Defekten war ein einzeitiger komplikationsfreier Verschluss jedoch nur in 2 von 6 Lokalisationen erfolgreich gewesen. Insgesamt konnte jedoch mit einer zweiten Spalthauttransplantation bei vaskularisiertem MATRIDERM® ein vollständiger Wundverschluss an der Wunde mit freiliegender Sehne und in 3 der 4 knöchernen Lokalisationen erzielt werden. Bei einem Patienten mit freiliegendem Olecranon konnte eine lokale Transpositionslappenplastik zum abschließenden Verschluss angewendet werden.SchlussfolgerungDurch die ein- bzw. zweizeitige Verwendung von MATRIDERM® über frei liegenden Sehnen sowie Knochen kann ein effektiver Defektverschluss ohne die Notwendigkeit eines komplizierteren plastisch-rekonstruktiven Verfahrens erzielt werden. Einen Ersatz für Lappenplastiken in Bezug auf ihre Funktionalität kann dieses Verfahren nicht darstellen. Durch die Verwendung von MATRIDERM® besteht aber in ausgewählten Fällen eine erweiterte Indikationsmöglichkeit für Spalthauttransplantationen bei plastisch-rekonstruktiven Eingriffen.AbstractBackgroundFull-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM®, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?Patients and methodsWe performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined. ResultsIn nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.ConclusionAs a one- or two-stage procedure, MATRIDERM® application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM® is an interesting and successful method in plastic reconstructive surgery.BACKGROUNDnFull-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM®, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?nnnPATIENTS AND METHODSnWe performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined.nnnRESULTSnIn nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.nnnCONCLUSIONnAs a one- or two-stage procedure, MATRIDERM® application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM® is an interesting and successful method in plastic reconstructive surgery.

Anticoagulative strategies in reconstructive surgery – clinical significance and applicability

Advanced strategies in reconstructive microsurgery and especially free tissue transfer with advanced microvascular techniques have been routinely applied and continously refined for more than three decades in day-to-day clinical work. Bearing in mind the success rates of more than 95%, the value of these techniques in patient care and comfort (one-step reconstruction of even the most complex tissue defects) cannot be underestimated. However, anticoagulative protocols and practices are far from general acceptance and – most importantly – lack the benchmark of evidence basis while the reconstructive and microsurgical methods are mostly standardized. Therefore, the aim of our work was to review the actual literature and synoptically lay out the mechanisms of action of the plethora of anticoagulative substances. The pharmacologic prevention and the surgical intervention of thrombembolic events represent an established and essential part of microsurgery. The high success rates of microvascular free tissue transfer as of today are due to treatment of patients in reconstructive centers where proper patient selection, excellent microsurgical technique, tissue transfer to adequate recipient vessels, and early anastomotic revision in case of thrombosis is provided. Whether the choice of antithrombotic agents is a factor of success remains still unclear. Undoubtedly however the lack of microsurgical experience and bad technique can never be compensated by any regimen of antithrombotic therapy. All the more, the development of consistent standards and algorithms in reconstructive microsurgery is absolutely essential to optimize clinical outcomes and increase multicentric and international comparability of postoperative results and complications.

Die aktuelle S3-Leitlinie zur Prophylaxe der venösen Thromboembolie und ihre Implikation für die Plastische Chirurgie

INTRODUCTIONnIn Germany, clinically and experimentally proven, evidence-based guidelines for the perioperative prophylaxis of thromboembolism in plastic surgery have not yet been developed. The ever-expanding complexity of microsurgical reconstructive procedures associated with the immense technical progress in the medical field have once more highlighted the urgent need for evidence-based guidelines. Moreover, this urgency is underlined by more and more complex reconstructive procedures needing to be performed in elderly patients presenting with grave comorbidities and the related high risk for thromboembolic events. These facts prompted us to review and discuss the relevance of the updated S3-guidelines on prophylaxis of venous thromboembolic events for the field of plastic and reconstructive surgery .nnnMATERIAL AND METHODSnThe existing S3-guidelines represent the result of a consensus between 27 medical societies and organisations. Delegates of the German Society of Plastic, Reconstructive and Aesthetic Surgery (DGPRAEC) also participated in this consensus process and the development of the guidelines, which provide evidence-based and clinically oriented recommendations for the prophylaxis of venous thromboembolism for operative and non-operative as well as outpatient and inpatient settings. In the results section of this paper, general and specific recommendations with regard to plastic and reconstructive surgery are outlined.nnnRESULTSnIndications for the pharmacological prophylaxis of thromboembolic events are oriented on the specific risk categories for surgical interventions with regard to the dispositional individual risk factors. Furthermore, the recommendations for the field of plastic and reconstructive surgery are subdivided into the various regions of the body.nnnDISCUSSIONnEvidence-based recommendations for perioperative prophylaxis of venous thromboembolism in plastic surgery are not available yet. The establishment of an algorithm to screen and estimate the procedure-associated risks for thromboembolism is needed. The discussed S3-guidelines of the AWMF Society on the prophylaxis of venous thromboembolism meet these formal requirements. Gathering of evidence-based data and the generation of recommendations leading to a reduction of the perioperative risk of thromboembolic events is a pivotal element to improve patient outcomes and safety in microsurgery.

Der gestielte Leistenlappen zur Defektdeckung an der Hand

ZusammenfassungOperationszielDefektdeckung des beuge- und streckseitigen Hand- undnUnterarmbereichs bis zu einer maximalen Defektgrößenvon 10 × 25 cm.IndikationenWeichteildefekte des beuge- und streckseitigen Hand-nund Unterarmbereichs bis zu einer maximalen Defektgrößenvon 10 × 25 cm.KontraindikationenPolytraumatisierte Patienten mit lebensbedrohlichen Begleitverletzungen.nIn diesen Fällen sollte die definitivenWeichteildeckung spätprimär oder sekundär nach Kreislaufstabilisierungnerfolgen.nSchlecht vaskularisiertes Empfängergebiet (z.B. nachnRadiatio).nFloride Infekte im Empfänger- und/oder Spendergebietnsowie Nekrosen.nVoroperationen der Leistenregion mit Kompromittierungnder Gefäße.nNicht kooperativer Patient.OperationstechnikOrientierungspunkte zur Lappenumschneidung sind derntastbare Puls der Arteria femoralis, das Leistenband, dienSpina iliaca anterior superior und der Musculus sartorius.nEinzeichnung des Lappenober- und -unterrandes parallelnzum Leistenband, wobei die Längsachse des Lappens demnVerlauf der Arteria circumflexa ilium superficialis entspricht,ndie anteilig oberhalb des Leistenbandes verläuft.nEin Drittel des Lappens sollte oberhalb und zwei Drittelnsollten unterhalb des Leistenbandes zu liegen kommen.nDie Lappenpräparation beginnt im lateralen Abschnitt ohnenEinschluss der Faszie. Um eine Verletzung des Gefäßstiels zunvermeiden, erfolgt die vorsichtige Identifikation des lateralennSartoriusrandes, dessen Faszie eingeschnitten und in dennLappen miteinbezogen wird. Ein langer Rundstiel erfordertnunter Umständen, die Präparation der A. circumflexa iliumnsuperficialis bis zu ihrem Ursprung fortzusetzen. NachnHebung des Lappens Einschwenken des Lappens in dennDefektbereich und Einnaht mit Rundstielbildung. Der Rundstielnschützt die Lappengefäße und erleichtert die ischämischenKonditionierung des Lappens in der postoperativennPhase. Je nach Lappengröße spannungsfreier Primärverschlussndes Hebedefekts oder Spalthautdeckung.nDie durchschnittliche Operationszeit in einer Ausbildungskliniknbeträgt 120 min (Daten aus dem eigenen Pa-tientengut).Weiterbehandlung3-wöchige Stielung des Lappentransplantats und sofortigenMobilisierung des Patienten. Vermeidung von Abknickungenndes Lappenstiels; hierzu ggf. Unterpolsterung desnArms und Lagerung in angepasster Schulterabduktion.nTägliche Verbandswechsel und Lappenmonitoring zur Vitalitätsprüfung.nAb dem 10.–14. postoperativen Tag Lappentrainingnmit Abklemmen des Lappenstiels mit einernDarmklemme. Steigerung der Abklemmzeit um täglichn5–10 min von initial 3 × 5 min/d auf 3 × 1 h/d. Lappenstieldurchtrennungnnach Erreichen der maximalen Abklemmzeitnnach 3 Wochen unter Belassung eines ausreichendnlangen Lappenstiels im Empfängergebiet und Sekundärverschlussnder Leiste. Nach Demarkierung des Lappenstielendesnendgültige Einpassung des Leistenlappens.ErgebnisseIn einem 3-Jahres-Zeitraum wurde bei insgesamt 14 Patientenneine Defektdeckung mit dem gestielten Leistenlappenndurchgeführt. Indikationen für das Verfahren warenndie Daumenrekonstruktion nach Avulsionsamputationnzum Längenerhalt und zur Defektdeckung, die spätsekundärenWiederherstellung der Daumenlänge durch eine Beckenkammspaninterposition,ndie Rekonstruktion der Daumenweichteilennach radikalem Débridement einer tiefennzweitgradigen Verbrennung, Hautweichteildefekte im Bereichndes Handrückens nach traumatischer Kontusion undnInfekt, ausgedehnte Hautweichteildefekte nach Kombinationsverletzungndes distalen Unterarms, Handgelenks undnder Hohlhand sowie ein plastisch-rekonstruktiver Langfingererhaltnmit nachfolgender Phalangealisierung bzw. Syndaktylietrennung.nDie Anwendung des Leistenlappens führte in allen Fällennzur vollständigen Defektdeckung. In keinem der Fälle kamnes zu einem Lappenverlust, und bei sämtlichen Patientennkonnte ein zufriedenstellendes funktionelles und ästhetischesnErgebnis erzielt werden.AbstractObjectiveSoft-tissue defect closure of the volar and dorsal aspect ofnthe hand and lower arm with a maximum defect size ofn10 × 25 cm.IndicationsSoft-tissue defects of the entire palm and dorsum of thenhand and lower arm with a maximum defect size ofn10 × 25 cm.ContraindicationsPolytraumatized patients presenting with concomitantnlife-threatening injuries. In these cases one should performnthe definite defect closure secondary after cardiovascularnstabilization. Scars and vascular injury at the donor site.nLack of vascularity and necrosis of implantation site.nPoorly vascularized recipient site (e.g. after radiation)nInfection and necrosis at the donor and/or recipient site.nPrior operations of the groin with impairment of the vasculature.nNoncompliant patient.Surgical TechniqueLandmarks are the femoral artery, inguinal ligament, anteriornsuperior iliac spine, and sartorius muscle.nThe superior and inferior border of the flap should be orientatednparallel to the inguinal ligament. The longitudinalnaxis of the flap is parallel to the superficial circumflex iliacnartery, which is partially located superior to the inguinalnligament. One third of the flap is located superior, and twonthirds inferior, to the inguinal ligament.nFlap dissection starts at the lateral border without includingnthe fascia. Identification of the lateral border of the sartoriusnmuscle, incision of its fascia and inclusion of the fascianinto flap dissection in order to preserve the vessel.nIf a long flap pedicle is favored, flap dissection is continuednto the source of the superficial circumflex iliac artery.nPrimary closure of the donor site and, finally, inset of thenflap. A tubed pedicle protects the vessels and simplifies thenischemic preconditioning during the postoperative phase.nAccording to the flap size, the donor site closure is eithernprimary or split-thickness skin grafting is necessary at thenlateral aspect of the donor site.nThe mean duration of the procedure is 120 min in a teachingnhospital (own data).Postoperative ManagementThe patient should be mobilized as early as possible. Dressingsnand flap monitoring should be performed daily. Ischemicnpreconditioning by applying a tourniquet starts aftern10–14 days. The ischemic period is increased continuouslynfrom 3 × 5 min/d in the beginning to 3 × 1 h/d before flapndissection. Flap dissection of the pedicle is performed aftern3 weeks. The residual donor site is closed, while the distalnpedicle is left untrimmed and closed secondarily a few daysnlater to allow for sufficient venous drainage. Finally, defectnclosure can be completed after demarcation of the pedicle.ResultsIn a 3-year period, defect closure with a pedicled groin flapnwas performed in 14 patients. Indications for this procedurenwere the following: thumb reconstruction for lengtheningnand defect closure after amputation and burn injury,nsoft-tissue reconstruction of the dorsum of the hand afterndecollement and infection, soft-tissue reconstruction of thendistal part of the lower arm, wrist and palm after complexnand combined trauma, and plastic reconstructive preservationnof multiple fingers with subsequent phalangealizationnand syndactyly release, respectively.nIn all patients, complete soft-tissue coverage and flap survivalncould be achieved. The functional and aesthetic resultnwas satisfactory in all cases.OBJECTIVEnSoft-tissue defect closure of the volar and dorsal aspect of the hand and lower arm with a maximum defect size of 10 × 25 cm.nnnINDICATIONSnSoft-tissue defects of the entire palm and dorsum of the hand and lower arm with a maximum defect size of 10 × 25 cm.nnnCONTRAINDICATIONSnPolytraumatized patients presenting with concomitant life-threatening injuries. In these cases one should perform the definite defect closure secondary after cardiovascular stabilization. Scars and vascular injury at the donor site. Lack of vascularity and necrosis of implantation site. Poorly vascularized recipient site (e.g. after radiation) Infection and necrosis at the donor and/or recipient site. Prior operations of the groin with impairment of the vasculature. Noncompliant patient.nnnSURGICAL TECHNIQUEnLandmarks are the femoral artery, inguinal ligament, anterior superior iliac spine, and sartorius muscle. The superior and inferior border of the flap should be orientated parallel to the inguinal ligament. The longitudinal axis of the flap is parallel to the superficial circumflex iliac artery, which is partially located superior to the inguinal ligament. One third of the flap is located superior, and two thirds inferior, to the inguinal ligament. Flap dissection starts at the lateral border without including the fascia. Identification of the lateral border of the sartorius muscle, incision of its fascia and inclusion of the fascia into flap dissection in order to preserve the vessel. If a long flap pedicle is favored, flap dissection is continued to the source of the superficial circumflex iliac artery. Primary closure of the donor site and, finally, inset of the flap. A tubed pedicle protects the vessels and simplifies the ischemic preconditioning during the postoperative phase. According to the flap size, the donor site closure is either primary or split-thickness skin grafting is necessary at the lateral aspect of the donor site. The mean duration of the procedure is 120 min in a teaching hospital (own data).nnnPOSTOPERATIVE MANAGEMENTnThe patient should be mobilized as early as possible. Dressings and flap monitoring should be performed daily. Ischemic preconditioning by applying a tourniquet starts after 10-14 days. The ischemic period is increased continuously from 3 × 5 min/d in the beginning to 3 × 1 h/d before flap dissection. Flap dissection of the pedicle is performed after 3 weeks. The residual donor site is closed, while the distal pedicle is left untrimmed and closed secondarily a few days later to allow for sufficient venous drainage. Finally, defect closure can be completed after demarcation of the pedicle.nnnRESULTSnIn a 3-year period, defect closure with a pedicled groin flap was performed in 14 patients. Indications for this procedure were the following: thumb reconstruction for lengthening and defect closure after amputation and burn injury, soft-tissue reconstruction of the dorsum of the hand after decollement and infection, soft-tissue reconstruction of the distal part of the lower arm, wrist and palm after complex and combined trauma, and plastic reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly release, respectively. In all patients, complete soft-tissue coverage and flap survival could be achieved. The functional and aesthetic result was satisfactory in all cases.