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General Anesthesia

Synopsis Delivery of general anesthesia requires a trained anesthesia provider; the availability of functioning, safe anesthetic equipment and patient monitors; and the essential anesthetic and resuscitative medications. Anesthesia is an essential component of surgery, and when anesthesia services are inadequate, difficulties are experienced. Maintaining the safety of patients while treating them in areas with limited resources is a continuing challenge. Minimum requirements for general anesthesia in…

Operating Room Requirements and Setup

Synopsis The purpose of this chapter is to help experienced perioperative registered nurses prepare for their first international surgical trip by familiarizing them with the process of establishing and running a successful operating room (OR) in an unfamiliar facility in a foreign country. This will be accomplished through discussions of pre-trip preparations, setting up the OR with limited supplies and resources, establishing professional working relationships with…

Pre-Operative Screening

Synopsis Elective surgery in resource-limited countries is often performed by mobile surgical teams, either as an outreach within the country itself, or as a volunteer group from another country. These teams provide a needed service; however, they are often operating in unfamiliar settings and with limited ancillary support. Careful screening of the patients with respect to overall health and post-operative requirements is necessary to ensure maximum…

Peripheral Nerve Allotransplantation

Introduction Peripheral nerve injuries are common and can be functionally devastating. Improved understanding of nerve topography, injury, and regeneration has led to advances in peripheral nerve surgery and increased treatment options for our patients. Traditionally, when a tensionless repair cannot be performed, a nerve autograft is employed to bridge the defect. However, autografts can be associated with additional surgical sites, increased operative time for harvesting, and…

Immunology and Research in Reconstructive Transplantation

Introduction More than 89 upper extremities and 30 face transplants have been performed worldwide since 1998, proving that vascularized composite allotransplantation (VCA) is technically feasible and guarantees long-term survival under currently available immunosuppressive regimens. VCA is not a lifesaving procedure, thus minimization or withdrawal of the systemic immunosuppression is imperative to avoid the long-term deleterious complications related to the chronic use of the immunosuppressive treatment. When…

Laryngeal, Abdominal Wall, and Uterus Transplantation

Introduction Composite tissue allotransplantation (CTA) involves transplantation of various complex tissues embryologically derived from different layers that can include musculoskeletal structures (nerve, bone, muscle, etc.), skin and mucosa, and their adnexal extensions. These differ from well-known solid organ allotransplantations, which are lifesaving procedures, intended to improve quality of life. These have benefited from the introduction of more specific immunosuppressive agents, with fewer adverse effects and greater…

Hand and Upper Extremity Transplantation

Introduction Hand and upper extremity transplantation is the most common form of vascularized composite allotransplantation (VCA) or reconstructive transplantation and has evolved from a procedure only performed at the distal forearm level to a procedure now being performed above the elbow more proximally. At the time of writing this chapter, the authors can count 107 hand and upper limb transplants performed throughout the world. The “modern…

Face Transplantation

Introduction The notion of drastically improving the treatment of catastrophic facial injuries, regardless of the cause, has motivated surgeons to pursue the development of facial transplantation in addition to other types of vascularized composite allotransplantation (VCA) over the past few decades. Historically, the reconstruction of such daunting facial defects has been demanding, often requiring numerous procedures and often yielding less than ideal results. Conventional techniques have…

Starting a Reconstructive Transplantation Program

Introduction The purpose of this chapter is to discuss the general principles, challenges, and opportunities in establishing a reconstructive transplant program. The authors bring the experience of two centers in two different countries with significantly differing healthcare systems: the United States and France. The authors provide their own perspectives and experiences. L. Lantieri is a plastic and reconstructive surgeon who established a face transplant program in…

Free-style Flaps

Introduction Reconstructive surgery has, as its premise, the principle of restoring form and function utilizing surrounding or distant tissues while minimizing morbidity at the donor site. While muscle flaps remain a viable option for reconstructive surgery, their use has become less important in recent years with the advent of perforator flap surgery. No longer is it necessary to take muscle as a carrier of blood supply…

Posterior Tibial Artery Perforator Flap

Figure 61.1 Posterior tibial artery perforator flap. Open full size image Introduction In the field of reconstructive surgery, not a day goes by without a skin flap being used. The earliest description of skin flaps was by Sushruta in 600 bc and this was, in fact, a local flap, of axial type. The flap described by Tagliacozzi in 1597 was a random pattern flap from the…

Tensor Fascia Lata Flap

Figure 60.1 Tensor fascia lata perforator flap. Open full size image Introduction The tensor fascia lata (TFL) flap is one of the well-known flaps with a reliable and constant pedicle. This flap has served as a workhorse flap for a variety of indications such as trochanteric pressure ulcers. The TFL muscle has a single dominant pedicle (Mathes-Nahai type I muscle), which sends musculocutaneous perforators to supply…

Anterolateral and Anteromedial Thigh Flaps

Figure 59.1 (Left) Anterolateral thigh flap; (Right) Anteromedial thigh flap. Open full size image Introduction In 1984, Song and colleagues introduced the anterolateral thigh flap based on septocutaneous branches of the descending branch of the lateral circumflex femoral artery. Since that time, the anterolateral thigh flap has gained popularity for use as a soft tissue flap for reconstruction of regional as well as distant defects. This…

Superior and Inferior Gluteal Artery Perforator Flaps

Introduction The superior gluteal myocutaneous free flap was first described by Fujino in 1975 for breast reconstruction. In 1978, Le Quang performed the first breast reconstruction with an inferior gluteal myocutaneous free flap. Shaw popularized the myocutaneous superior gluteal artery free flap; however, a short vascular pedicle often led to additional vein grafting, thus decreasing enthusiasm. The inferior gluteal myocutaneous flap championed by Paletta et al. was…

Deep and Superficial Inferior Epigastric Artery Perforator Flaps

Figure 57.1 Deep and superficial inferior epigastric artery perforator flap. Open full size image Introduction Since the dawn of plastic surgery, the lower abdominal region has always been a loyal provider of abundant well-perfused tissue. First used in pedicled and tubed flaps for distant transfers, the lower abdomen skin and fat was discovered to be an ideal material for breast reconstruction. That specific use of the…

Perforator Flaps in the Lateral Thoracic Region

Figure 56.1 Perforator flaps in the lateral thoracic region. Open full size image Introduction The conventional latissimus dorsi muscle or myocutaneous flap has undoubtedly served an important role as one of the most common flaps in reconstructive microsurgery. However, its bulkiness and the sacrifice of donor structures often preclude its use. In this respect, the reduction in volume and complete preservation of the muscle and its…

Medial Femoral Condyle and Descending Genicular Artery Perforator Flaps

Figure 55.1 Medial Femoral Condyle and Descending Genicular Artery Perforator Flaps. Open full size image Introduction Increasing knowledge of the blood supply to the distal femur has resulted in the development of a variety of composite flaps designed to include bone from the medial femoral condyle. Flaps from this area can be designed to include not only bone but also articular cartilage, skin, muscle, and tendon.…

Toe Flaps and Toe Transplantation

Introduction It is thanks to the illustrious Austrian surgeon, Carl Nicoladoni that the foot began to be considered as a precious warehouse for all requirements of thumb and digital reconstruction. In his three papers (1897, 1900, 1903), he described the use of pedicled toe transplantation as a valid option for reconstruction of missing digits, rather than sacrificing viable tissue in an already injured hand. The obvious…

Glabrous Skin Flaps

Introduction The word glabrous is defined as “smooth, having a surface without hairs or projections.” Anatomically, glabrous skin is present on the palms of the hands and volar fingers, as well as the plantar surface of the feet and toes. Replacing glabrous skin on the hand and fingers is best accomplished by microneurovascular transplantation of similar skin from the foot, most often from the great toe.…

Fibula Flap

Figure 52.1 Fibula flap. Open full size image Introduction With an outstanding length available for harvest, a solid and sizable bone stock, a reliable blood supply, an allowance for manipulation of the components of the flap while maintaining adequate blood supply, and the ability to carry bone, skin, muscle, and fascia, the fibula flap has become one of the most commonly used vascularized osseous and osteocutaneous…