Thanks very much, Dr. Osei. Well, good morning, everybody. I'm going to provide for you a short, but I'm hoping somewhat thoughtful, introduction on how one goes about choosing, given today's really increased and in-depth understanding of the blood supply to the skin, how one chooses local versus non-local tissue to cover both lower and upper extremity wounds. The summary of what I'm going to say is that anatomical knowledge, some surgical curiosity, and really nimbleness in the operating room, as well as surgical technique and preoperative assessment, means that any capable hand surgeon, all of us really, with an interest in branching her or his practice out into doing these kinds of coverage procedures, can do interesting flaps based on an understanding of the blood supply to the skin. Now, I don't have to tell this audience what a flap is. It's a piece of vascularized tissue that is moved from one place of the body to another without a concomitant loss in its blood supply, as seen here. And a perforator is a blood vessel that comes out of the deep fascia, pierces that fascia, and enters the skin and subcutaneous tissue. Blood vessels can be seen here, such as the medial serral perforators coming out of the gastrocnemius muscle. Here we see perforators coming into the superficial tissue of the thigh after piercing the vastus lateralis muscle. And here, again, we see a different perforator, much less distinct, but no less important, coming through a space in the fascia. So a perforator is a vessel that supplies the skin after coming off, usually at right angles, but not necessarily, after coming off of a named, longitudinally running source vessel. Why are perforators important? I would suggest to you that number two and number five are the most important. How the blood gets to the skin will keep you out of trouble and will help you move tissue around. This knowledge, especially to this audience, is not new knowledge. Cormac and Lamberty, Ian Taylor, and even Monchaux, almost 100 years ago, have discussed the blood supply to the skin and have done independent investigation that documents the presence of these perforators in predictable locations. And not only that, but the blood supply to areas of skin that are predictable based on these perforators. And this is an illustration taken from Ian Taylor's book that shows the more well-known and well-described perforator, or perforasomes, as Mike Sancier will say. Here we see a dissection that Dr. Osei did for an anterolateral thigh flap that really shows what a perforator vessel is. Here the descending branch of the lateral femoral circumflex vessel between the rectus and the vastus lateralis that splits off into two and then three separate perforator vessels that supplies the flap. Again, the flap itself is not important. The concept of a named longitudinally running source vessel, in this case the lateral femoral circumflex descending branch, the perforators that come off of that vessel pierce the fascia and then supply the skin and the fascia cutaneum. The concept of the reconstructive ladder in 2016, I think, has been fairly supplanted by the reconstructive elevator. That is to say that we don't choose the most readily available tissue for coverage. And our friends will discuss their philosophy of this. But rather, the tissue that is the most suitable for coverage and certainly simplicity, as in Occam's razor, that the simplest solution really is the best has to be thought of in a different way. It's not the simplest operation that may be the best, but the simplest way of getting the patient from a non-covered to a healed covered status may be the best. In 2016, we replaced like with like, or at least make an effort to. Here we see a patient with a reverse serral artery flap. And here we see a patient with a very large propeller that was used to cover a distal tibia that perhaps 20 years ago might have been covered, and even today would be perfectly reasonably covered with a free tissue transfer, either with muscle or with skin. The information we seek that helps us make the decision are patient, limb factors, wound factors, as well as situational factors. Obviously, patient age is of relevance, patient's health status, that is their ability to heal wounds or their comorbidities, and their ability to withstand surgery and recovery obviously are relevant in terms of our choice of whether we're going to subject the patient to a free tissue transfer or not. These are five different cases of medial malleoli that are exposed that Dr. Osei and I have taken care of. Each particular patient is different in age, in comorbidities, in demand, and in underlying fracture. So the old solution of taking a distal third tibia and necessitating a soft tissue coverage with a free tissue transfer, a gracilis, or another muscle certainly is something that has been updated. Here we see a medial ankle wound, just as an illustration, a patient that's already had a free flap that failed and a rotation flap that we did, that we elected to cover with a propeller flap that ended up healing the wound quite successfully, as you can see in this particular slide. So understanding, and the final point I'll make is in addition to patient, limb, and wound factors, there's the hospital and location factors. We are blessed to be in a situation from a hospital point of view where we have the ability to take care of patients in an intensive care unit. We have fellow and resident and nursing staff that are well-versed in the treatment of these patients, but we also understand that in many centers, such as the ones perhaps talked about by Dr. Gumley yesterday, free tissue transfer may not be a reasonable option in that particular center, so added knowledge and in-depth knowledge and surgical nimbleness might be required to cover some of these particular wounds. And again, I show this is Chang-Gung Memorial Hospital where my partner, Dr. Osei, spent some time learning how to do flaps, and our own hospital to which Richard Gelberman recruited me, Wash U at Barnes, these are institutions that can support free tissue transfer, can support ICUs, but I would urge you that as you listen to the rest of the very experienced surgeons that are going to talk to you today about soft tissue cover, to try and think a little bit about soft tissue cover outside the free tissue transfer box, and with that, I guess I'll turn it over to our other speakers, thank you. Just a few minutes, Dr. Boyer. Understanding that there are many factors involved with the decision between free and rotational flap coverage, at the end of the day, for a practicing surgeon that may be comfortable with some of the rotational options, when would you say that person should start thinking about referral to a colleague that may have some of the free tissue techniques as part of their surgical armamentarium? You know, I think that it's going to be on a case-by-case basis, Dr. Osei. I think this year's Gelberman Scholar coming up, Lieutenant Commander Scott Tintle, is going to be evaluating soft tissue coverage as his academic activity for his scholarship this year, and so I'd be interested, perhaps, next year in his thoughts on how he might answer that question personally. I think starting with local tissue, seeing if that tissue is, first of all, available, second of all, supple, and third of all, appropriate, I personally would tend more towards local tissue, based solidly on an underpinning of an understanding of what the blood supply of that tissue is and how mobile that tissue is. Great, thank you.

flaps

vascularized tissue

perforators

free flap coverage

rotational flap coverage