A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores

The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation-advancement flap with V-Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V-Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation-advancement action was supported laterally with V-Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound-healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V-Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotation-advancement flap and bilateral rotation-advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow-up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome.     

The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume.

The ideal skin-flap reconstruction provides functional preservation and a good cosmetic outcome in both the reconstructed site and the donor site. Although various flaps are used for reconstruction of the vulvar and buttock region, there are disadvantages associated with each. In 1996, Yii and Niranjan reported the gluteal-fold flap for vulvar reconstruction. As presently used, this flap is bulky, particularly in obese patients or when used for hemilateral reconstruction. Thinning the flap has been considered impossible because of the obscurity of the blood supply. In the study presented here, the pedicle vessels of this flap were studied in eight cadavers; the authors found that the flap is nourished by a direct cutaneous system of the internal pudendal artery and vein. Accordingly, adjustment of the flap volume was believed to be possible, with the exception of the adipose tissue containing the pedicle vessels. The authors have since used 14 thinned flaps for seven vulvar, one vaginal, and two buttock defects in 10 patients. All flaps survived completely. Good functional and cosmetic results were achieved with hemilateral or bilateral flaps in vulvar or buttock reconstruction. In the buttock in particular, the usefulness of this flap for anal and pelvic-floor reconstruction was demonstrated. The scar at the donor site, concealed in the gluteal fold, was acceptable. The gluteal-fold flap is very useful for various vulvar and buttock reconstructions because it can be adjusted to the required volume.     

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar.The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum.All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps.This article discusses the expanding indications of this versatile flap and the refinements in operative technique.     

Male perineogenital anatomy and clinical applications in genital reconstructions and male-to-female sex reassignment surgery

To determine the possibility of providing alternative surgical techniques for male genital reconstruction and for male-to-female sex reassignment surgery, the authors undertook an anatomic investigation of the perineogenital region in male cadavers. Anatomic dissection was performed on 14 male adult human cadavers (fresh and formalin-preserved) studying the main afferent vessels to the anterior perineal region and their mean internal diameters: deep external pudendal artery (0.60 mm), superficial perineal artery (0.50 mm), and funicular artery (0.37 mm). We established their exact topography, together with vascular anatomic variations, main vascular anastomosis circuits (base of the penis, scrotal septum, and perineal fat and lateral spermatic-scrotal fascia), angiosomes, anatomy of the rectovesical septum cavity, and their "critical" key points of dissection. The authors discuss the clinical possibility of elevation of a "tree" of previously described paragenital-genital flaps including mainly those based on the terminal branches of the internal pudendal vascular system, the erectile tissue pedicled flaps, and finally, flaps of the external pudendal system. The authors indicate the concrete vascularization system for each flap.     

Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction

This study presents the authors' experience using the anterolateral thigh fasciocutaneous flap for complex perineal and scrotal reconstruction. Anterolateral thigh fasciocutaneous island flaps were performed in seven patients between January and June of 2000 (six male, one female; mean age, 52 years; age range, 9 to 72 years). Four of the seven patients had scrotal or perineal defects after multiple debridements for Fournier's gangrene. Two of these four had exposed testicles. Three flaps were used for recurrent ischial ulcers. A true septocutaneous perforator (type 1) running between the rectus femoris and the vastus lateralis muscles was found in only two patients. In four patients, the cutaneous perforators were found to be intramuscular, originating from the descending branch (type 2). In the other patient, the musculocutaneous perforator originated from the lateral circumflex femoris artery independently (type 3). In these cases, intramuscular dissections were performed to follow each perforator to its main trunk. Mean follow-up was 8 months (range, 5 to 10 months), and all flaps survived. Three patients developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. Both wounds healed secondarily. Scrotal reconstruction with the anterolateral thigh flap gave an excellent aesthetic result. The authors conclude that the anterolateral thigh flap is a reliable flap for perineoscrotal reconstruction.     

The new bilaterally pedicled V-Y advancement flap for face reconstruction

A new bilaterally pedicled V-Y advancement flap based on two subcutaneous pedicles that vascularize the skin island through subdermal plexus lateral bridges is described for face reconstruction. It differs from traditional V-Y advancement flaps in that it does not rely on the classic subcutaneous "vertical" pedicle that is sectioned from top to bottom to improve advancement of the skin island. This technique had predictable results for 12 years in 425 consecutive patients, with infection occurring in 2.8 percent of the cases and complete necrosis in less than 1 percent of the flaps.     

Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers

Although the gluteal V-Y advancement flap has been recognized as the most reliable method for management of sacral pressure ulcers, its limited mobility has been a challenging problem. The authors present a new modification of the V-Y advancement flap to overcome the problem. After débridement, a large triangle is designed to create a V-Yadvancement flap on the unilateral buttock and the medial half is elevated as a fasciocutaneous flap, preserving the distal perforators in the muscular attachment. Then an arc-shaped incision is made in the gluteus maximus muscle along with the lateral edge of the triangular flap. The split muscle is elevated at a depth above the deeper fascia until sufficient advancement of the flap is obtained. This full-thickness elevation of the gluteus maximus muscle from the distal (lateral) side avoids the impairment of perforators or their mother vessels and achieves great advancement. Thirty-one patients with sacral pressure defects larger than 8 cm in diameter were treated using this surgical procedure. Overall, 93.5 percent of the flaps (29 of 31) healed primarily. The largest defect that was closed with a unilateral flap was 16 cm in diameter. The present technique accomplishes remarkable excursion of the unilateral V-Y fasciocutaneous flap, with high flap reliability and preservation of the contralateral buttock as well as gluteus maximus muscle function.     

The nontypical gluteus maximus flap

Since 1984, 42 patients have been treated with gluteus maximus myocutaneous flaps. In 37 patients, a "classical" gluteus maximus myocutaneous flap was used to cover a sacral-gluteal defect. In 5 patients, a "nontypical" gluteus maximus myocutaneous flap was used: two flaps were advanced from caudal to cranial to close defects over the lumbar spinal area, two flaps were advanced from cranial to caudal to close defects in the perineal region, and one flap was advanced from medial to lateral to close a trochanteric defect. All defects could be closed. There was no flap necrosis. In 12 patients (out of 42) there were minor wound infections, and in 6 patients there were minor wound dehiscences. The average blood loss never exceeded 500 cc, the average time of hospitalization (postoperatively) was 17 days, and mobilization (walking) was started 3 to 4 days postoperatively. The average distance of flap advancement was 10 cm. The maximum defect closed by a bilateral V-Y gluteus maximus myocutaneous flap was 24 x 20 cm.     

Our experience with combined procedures in aesthetic plastic surgery

The instep flap needs neither muscle nor a transposition base for survival or innervation. It can be transposed as an island fasciocutaneous flap either on the medial or lateral plantar neurovascular bundles or both, and it can be transferred also as a free flap from the opposite foot. Four cases demonstrating the use of the flap as an island and free flap are presented with follow-up ranging from 1 to 2 years. The absence of muscle in the flap provides greater stability of the heel reconstruction and results in a lesser secondary defect. Sensation in the flaps is diminished but adequate for long-term function, but hyperkeratotic reaction remains an unpredictable problem. The ability to transfer the flap as a free transfer widens the scope of the flap to reconstruct both heel and forefoot defects where local instep tissue or vascularity are inadequate for local reconstruction. The secondary defect, particularly when no muscle is included in the flap, has been minimal.     

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.     

Treatment of ischial pressure ulcers with a posteromedial thigh fasciocutaneous flap.

This study describes the use of the posteromedial thigh fasciocutaneous flap for the treatment of ischial pressure sores. The authors prefer this flap because it is the fasciocutaneous flap nearest to the ischial region, it is easy to raise, and it causes no donor-site morbidity. In this study, 11 ischial pressure sores in 10 paraplegic patients were closed using the posteromedial thigh fasciocutaneous flaps. All flaps survived, although two caused distal necrosis; after these same two flaps were readvanced, they survived. After an average follow-up time of 77 months, seven of the 10 patients have had no recurrence of ulcers.This fasciocutaneous flap was previously described by Wang et al. However, this study revealed that the arrangement of the vascular pedicle was different from that described by Wang et al. To reveal the vascular supply of this flap, anatomic dissections were conducted. The source of circulation to this flap was the suprafascial vascular plexus, in addition to the musculocutaneous perforator. The dominant pedicle was the musculocutaneous perforator from either the adductor magnus muscle or the gracilis muscle. The key to safe elevation of this flap was the accurate outlining of the skin island directly over the vascular pedicle and the preservation of the proximal fascial continuity. Of the 11 flaps, two viability problems occurred. These partial flap losses resulted from the failure to properly include the perforator. It is the authors' conclusion that the width of the flap should be greater than 5 cm. In addition, it is safe to make a flap within a 1:3 base-to-length ratio in a fatty, diabetic patient. This posteromedial thigh fasciocutaneous flap was found to be a valuable alternative for reconstruction of primary or recurrent ischial pressure ulcers.     

Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.     

The fasciocutaneous flap: a conservative approach to the exposed knee joint

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.     

The expansive gluteus maximus flap

The rich vascular network of the gluteal and posterior thigh region provides for a larger range of flaps for reconstructive surgery than previously described. Facility with these flaps requires an appreciation of relevant anatomy, embryology, and anthropology. Structural changes in the gluteus maximus muscle are critical to the evolutionary advance toward an upright stance during walking. The superficial and deep segmentation of the gluteus maximus are best appreciated by phylogenic and ontogenetic study. Femoral arterial and gluteal arterial anastomotic hemodynamics are affected by the relative involution of the gluteal system in late embryogenesis. The gluteal thigh flap should include contributions from the femoral system when the cutaneous branch of the inferior gluteal artery cannot be identified. Huge sacral wounds can be closed with gluteus maximus myocutaneous flaps with maintenance of muscular function by detaching the entire origin, sliding the muscle medially, and reconstructing these attachments. By dissection between the divergent inserting fibers of the gluteus maximus, a long, superficial portion of the muscle can be raised that forms the basis of the extended gluteus maximus flap. The pedicle of the flap is at the level of the piriformis muscle and the skin paddle can be placed over the midportion of the posterior thigh. Finally, the first deep femoral perforating artery forms the basis of a posterolateral fasciae latae flap that is well suited for coverage of defects over the trochanter.     

Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

Bilateral gluteal thigh flaps for closure of large defects in the lumbosacral region and perineal region

Large defects in the lumbosacral and perineal regions were reconstructed with bilateral gluteal thigh flaps. These two patients demonstrate the versatility of the flap, which also was used as a sensory flap in one patient.     

The descending branch of the superficial circumflex artery supplying anteromedial thigh skin

This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.