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.     

The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery

The pedicled lower trapezius musculocutaneous flap is a standard flap in head and neck reconstruction. A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels supplying this flap lead to confusion and technical problems when this flap is harvested. This article attempts to clarify the anatomical nomenclature, to describe exactly how the flap is planned and harvested, and to discuss the clinical relevance of this flap as an island or free flap. The authors dissected both sides of the neck in 124 cadavers to examine the variations of the subclavian artery and its branches, the vessel diameter at different levels, the course of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island muscle flap and once as a free flap. The anatomical findings and clinical applications proved that there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but possible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators. The lower trapezius flap is a thin and pliable musculocutaneous flap with a very long constant pedicle and minor donor-site morbidity, permitting safe flap elevation and the possibility of free-tissue transfer.     

The nerve supply to the clavicular part of the pectoralis major muscle: an anatomical study and clinical application of the function-preserving pectoralis major island flap

The purpose of this study was to investigate the nerve supply to the clavicular part of the pectoralis major muscle so that the innervation to this part can be maintained in the muscle-preserving pectoralis major island-flap transfer. Although methods have been described that include a limited portion of the muscle while leaving the upper parts undisturbed with an intact motor innervation, reports on anatomical studies of this nerve supply are brief. The distal distribution of the nerves, the spatial relationship to the main vascular pedicle, and the ways to preserve them during surgical procedures remain unclear. Surgically relevant features of the clavicular part of the pectoralis major muscle were studied by dissection. The nerve supply to this part was examined on 11 sides of eight formalin-fixed cadavers. Two fresh cadavers were used for dissection, intraarterial polymer injection, and application of a nerve-preserving surgical technique. In all subjects, a separate nerve innervated the clavicular and upper medial sternocostal portions of the pectoralis major muscle. This nerve arises craniomedial to the main vascular pedicle of the flap and divides into several branches. These branches run in a fascia on the deep surface of the pectoralis major muscle, superficial to the origin and distal course of the vascular pedicle. Most branches to the clavicular part end medial to the coracoid process. The course of the branches to the upper sternocostal part is more medial. Based on their anatomical findings, the authors propose a surgical technique for transfer of the pectoralis major island flap to the head and neck area through a tunnel in the deltopectoral groove, lateral to the origin of the vascular pedicle. Head and neck reconstruction was performed using this technique. The presented method is a muscle-preserving procedure that maintains maximal donor-site function and morphology.     

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.     

Frontalis musculocutaneous island flap for coverage of forehead defect

The use of the frontalis musculocutaneous flap as a pedicle island flap offers some advantages in frontal reconstruction. It can be used for immediate reconstruction following the ablation of a small or moderate area, even after harvesting of the frontal flap for nasal reconstruction. Because of its intact lateral bundle, it has the potential to carry some sensory innervation, albeit minimal, to the reconstructed area. We have found the frontalis musculocutaneous flap, when used as a pedicle island flap, to be an adaptable and dependable alternative flap for repairs after small or moderate resections in the frontal region. This flap could be performed immediately and in one stage, have a low morbidity rate, and allow a rapid aesthetic restoration; and, it is easy to perform. In two cases, we have observed some degree of venous congestion in the island during the early postoperative period but with success in final healing. The experience demonstrates that this flap should be considered as another valuable tool in reconstructive efforts directed at the forehead. We propose a novel method for the forehead reconstruction using the frontalis musculocutaneous island flap. A case is presented that demonstrates the use of this flap for repair in a depressed frontal defect.     

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.     

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time-consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon-assisted advancement flap technique (n = 10 each). The balloon-assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloon-assisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds.     

The extended pectoralis major myocutaneous flap: uses and indications

The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

The lateral pectoral composite flap in one-stage reconstruction of the irradiated mandible

We present a composite flap based on the musculature of the anterolateral thorax that allows immediate reconstruction of the mandible through the interposition of vascularized bony fifth rib. While the vascular pedicle remains the pectoral branch of the thoracoacromial artery, the pectoralis major muscle can be spared largely intact. The lateral position of the composite rib segment ensures a purely bony composition, while the lateral skin island remains largely hairless. Despite the unfavorable conditions of massive tumor size and prior irradiation attending the clinical cases presented, the complication rate was acceptable, with only one flap loss, and this followed technical error.     

Distally based anterolateral thigh flap: an anatomic and clinical study

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Shoulder defect correction with the island latissimus dorsi flap

Reconstruction of normal shoulder contour is possible utilizing a latissimus dorsi musculocutaneous flap at the end of a long neurovascular pedicle. The thoracodorsal vessels and their lateral divisions form the basis of the pedicle. The nerve in the pedicle is left intact if maintenance of muscle bulk is desired and sectioned if atrophy is preferred. The amount of muscle taken in conjunction with the skin island is determined by the nature of the defect to be corrected. The twin goals of a single-stage reconstruction and a satisfactory aesthetic result are achieved with this method.     

The tunneled supraclavicular island flap: an optimized technique for head and neck reconstruction

Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure. The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps. To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always essential. Moreover, the donor-site defect needs to be reduced, with no resulting functional or aesthetic impairment. We have found that the shoulder is a region providing an optimum skin texture match to the neck and face. In cadaver dissection, a vascular pedicle extending from the transversal cervical artery with two accompanying veins was found to vascularize a defined region around the shoulder cap. In line with these findings, the previously described fasciocutaneous island flap, nourished by the supraclavicular artery, was developed further and used purely as a subcutaneously tunneled island flap. The tunneling maneuver significantly improves the donor site by reducing scarring. The flap is characterized by a long subcutaneous pedicle of up to 20 cm. The pivot point is in the supraclavicular region and allows the flap to be used in the upper chest, neck, chin, and cheek. In this article, we introduce the anatomic features and present clinical cases underlining the surgical possibilities of the flap in reconstructive procedures with expanded indications.     

The pectoralis major for single-stage reconstruction of the difficult wounds of the orbit and pharyngoesophagus

This paper reports the results of reconstructions of difficult wounds in the head and neck area with musculocutaneous flaps in 20 patients. Twelve patients had reconstructions following cranial and orbital resections, and eight patients had reconstructions of the pharyngoesophagus. There were four wound complications, all of which healed without further surgical procedures. The pectoralis major musculocutaneous flap continues to be the most versatile flap for reconstructions at a variety of sites in the head and neck area. Contrary to other reports, it has not been bulky, it has been used without previous delays of the skin paddle, it has not required skin grafts to close the donor sites, and it has been used without difficulty in five female patients.     

Free anterolateral thigh adipofascial perforator flap

The anterolateral thigh adipofascial flap is a vascularized flap prepared from the adipofascial layer of the anterolateral thigh region. It is a perforator flap based on septocutaneous or musculocutaneous perforators of the lateral circumflex femoral system. With methods similar to those used for the free anterolateral thigh flap, only the deep fascia of the anterolateral thigh and a 2-mm-thick to 3-mm-thick layer of subcutaneous fatty tissue above the fascia were harvested. In 11 cases, this flap (length, 5 to 11 cm; width, 4 to 8 cm) was used for successful reconstruction of extremity defects. Split-thickness skin grafts were used to immediately resurface the adipofascial flaps for eight patients, and delayed skin grafting was performed for the other three patients. The advantage of the anterolateral thigh adipofascial flap is its ability to provide vascularized, thin, pliable, gliding coverage. In addition, the donor-site defect can be closed directly. Other advantages of this flap, such as safe elevation, a long wide vascular pedicle, a large flap territory, and flow-through properties that allow simultaneous reconstruction of major-vessel and soft-tissue defects, are the same as for the conventional anterolateral thigh flap. The main disadvantage of this procedure is the need for a skin graft, with the possible complications of subsequent skin graft loss or hyperpigmentation.     

The prepuce free flap in 10 patients: modifications in flap design and surgical technique

The prepuce free flap was used in 10 oral and oropharyngeal reconstructions. During the course of this study, various modifications took place. Residual penile skin necrosis and skin island necrosis early in the series led to modification of flap design. This solved the donor-site problem by placing the skin island more proximally, to consist of the outer layer of the prepuce and an equidimensional area of penile skin proximal to the prepuce. Identification of the vascular pedicle was greatly facilitated by changing to retrograde dissection, making skin incision in the mons veneris superfluous. Incongruence between donor and recipient artery, together with microsurgical arrogance, resulted in (resolvable) inflow problems in four patients. One flap was lost. After modification, marginal necrosis still occurred in one flap, most likely because of an episode of venous congestion. Although much care was taken to not harvest more skin than in a regular circumcision, penile skin shortage, especially during erection, appeared to be the major long-term shortcoming of this flap. Flap thinness and pliability, both expected strongholds of the flap, were evident during flap inset, but less apparent during follow-up because of postoperative radiotherapy in the majority of the cases. The best indications for this flap include defects in the tonsillar area extending into the soft palate, tongue, lateral oropharynx, retromolar trigonum, gums, and vallecula.     

The gluteus maximus musculocutaneous island flap: refinements in design and application

The gluteus maximus island musculocutaneous flap has been described using a variety of designs. We employ an island whose long axis is directed toward the pressure sore, minimizing tension in wound closure. Skin overlying the greater trochanter is avoided. Previously undermined skin can be included in the flap. Fifty patients with ischial or sacral pressure sores have been managed by this technique. Superficial dehiscence occurred in 13 percent of patients, and deep dehiscence occurred in 10 percent. The dehiscence closed spontaneously in all but one patient. Forty-nine of the 50 patients experienced complete wound healing at the pressure sore site. The patients have been observed for an average of 20 months (range 3 to 38 months), with one recurrent pressure sore seen at 28 months postoperatively. The gluteus maximus musculocutaneous island flap has proven to be both reliable in healing and durable over the observed interval.     

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.     

Free omental flap for partial breast reconstruction after breast-conserving surgery

Recent advances in endoscopic surgery have allowed laparoscopic harvesting of the omental flap with reduced donor-site morbidity and deformity. Between August of 2004 and May of 2010, the authors performed immediate breast reconstruction with the free omental flap in 10 breast cancer patients, employing it either as a pedicle flap or as a free flap for volume replacement. Only one complication occurred during the follow-up. Cosmetic results were mostly satisfactory. The free omental flap is a safe procedure with minimal donor-site morbidity and deformity and can be an additional option for immediate partial breast reconstruction after breast-conserving surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.