A two-team approach is used. One team commences on the arm with a 40 cm medial incision through the subcutaneous tissue and superficial fascia raising anterior and posterior skin flaps exposing the deep fascia of the forearm and arm for approximately 50% of the circumference of the limb. The brachial vascular bundle is exposed and a superior profunda branch and/or the interior profunda branch are isolated. The main brachial vein is prepared circumferentially for an end-to-side anastomosis. Multiple longitudinal fasciotomies are performed in the deep fascia of the arm and forearm.

Simultaneously, the other team harvests the omentum through an upper midline or transverse incision. It is carefully separated from its attachments to both the transverse colon and the greater curvature of the stomach, ligating the multiple gastroepiploic vessels and collateral branches to the stomach and transverse colon. The right gastroepiploic vascular pedicle is identified and a 3 cm to 4 cm segment carefully cleared under Loupe magnification. When the recipient site is prepared, this pedicle is ligated and the omentum transferred immediately to the arm and forearm, where it is stabilized with multiple tacking sutures to the wound bed. The proximal microvascular anastomosis in the arm is completed in an end-to-end manner with a profunda arterial branch and an end-to-side manner with the vein. The omentum is then spread out over the entire wound bed in contact with the split fascia and muscles on the deeper surface and the superficial fascia and subcutaneous tissue on the under surface of the skin flaps. The skin wound is closed and drains brought out proximally. The extremity is bandaged loosely with a bulky circumferential bandage and kept in an elevated position for 9 days. Postoperatively, broad-spectrum antibiotics are given for 10 days, low molecular dextran, 500 mg daily continuously for 5 days, and aspirin, 250 mg for 5 weeks. The same dose of aspirin is given daily for 1 week preoperatively on elective cases.

When there is extensive axillary scarring and poor venous runoff, the omental vessels can be anastomosed to healthy vessels proximal to the axilla such as the transverse cervical vessels, or inferior thyroid vessels. The ultimate combination would include hand and arm lymphatic vessel anastomoses to lymphatics or veins in the distal omentum.

Clinical Cases

CASE 1

Experimental ear reconstruction is shown, using omentum silicone rubber frame and a skin graft in a dog. (From Buncke, H. J.; Experimental Omental Transplantation by Microvascular Anastomosis. Sixth International Congress of Plastic Surgery. Paris, Masson, pp. 58-60, 1975.)

FIG. 26-01. The dog's omentum has been isolated in the lower central area of the photograph. The positive silicone mold of the ear in the center with negative clam-shell molds on either side and split-thickness skin graft taken with Reese dermatome are visible in the upper field.

FIG. 26-02. The positive ear mold has been placed on the omentum with the vascular pedicle coming out in the region of the new tragus.

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