Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.     

7. The groin flap: a new technique to repair traumatic tissue defects.

Tissue loss from trauma, particularly in the hand and forearm, occasionally requires immediate skin-flap coverage to ensure optimal healing. A consistently safe technique of skin-flap coverage is use of a groin flap. Anatomic studies of this flap have revealed the reliability of blood supply by the superficial circumflex iliac vessels to an area of skin and subcutaneous tissue running paralle to the inguinal ligament lateral to the femoral artery, and the axial relation of the vessels to the flap allows the surgeon to take a longer flap than usual without fear of vascular embarassment. Three case reports illustrate the value of the groin flap in primary soft-tissue closure and in the treatment of acute traumatic injuries.     

Extended transverse rectus abdominis musculocutaneous flap

Blood circulation within the conventional TRAM flap is not generous, and the contralateral random portion of the flap may result in fat or skin necrosis. However, this random portion can be extended safely and used for reconstruction by including the superficial epigastric vessels and the superficial circumflex iliac vessels and by anastomosing either of these to the recipient vessels. We have experienced this extended TRAM flap in two patients without any complications.     

One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone.

The successful revascularized free transfer of a composite flap of groin skin with attached iliac bone is presented in two patients. The findings in the preliminary dissections and injection studies in cadavers are discussed, and the superficial circumflex iliac system is recommended as a stem for free flaps of groin skin and iliac bone. If iliac bone alone is required for a revascularized graft, then the deep circumflex iliac system would seem suitable for the stem. Further clinical cases are necessary to determine the indications for this procedure, and patients should be carefully selected. The need for preoperative preparation and planning on a sound anatomical background is emphasized, and preoperative angiography seems advisable. The ability to sew small vessels together reliably is one thing: the when and where is another.     

Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work.

In this paper we present 16 cases of free transfer of compound flaps from the groin, 11 using the deep circumflex iliac vessels as a stem and 5 using the superficial circumflex iliac vessels as a stem. We found the deep vessels superior in many ways to the superficial vessels for this purpose; they are larger, permitting greater ease in anastomoses and providing more reliable blood flow. We believe that larger osteocutaneous or myocutaneous flaps can be transferred on the deep vessels than on the superficial ones-and that the deep circumflex iliac flap may supplant the conventional free going flap in most situations. The method evolved in response to patient need, not for surgical éclat.     

Vaginal reconstruction with an axial subcutaneous pedicle flap from the inferior abdominal wall: a new method

A new method of vaginal reconstruction is reported. In the procedure, the left inferior abdominal wall flap with the subcutaneous pedicle containing epigastric superficial blood vessels and/or the circumflex iliac superficial vessel and the external pudendal vessel and their branches is raised and passed through an immediate extraperitoneal tunnel to be the artificial vagina. The operation is straightforward, quick, and safe. Thirty consecutive patients suffering from congenital absence of vagina have been treated. All flaps in the group, which were less bulky, survived completely. The follow-up survey was carried out from 6 months to more than 4 years postoperatively. There was no occurrence of hernia after surgery. The reconstructed vaginas in all patients were clean, soft, elastic, and expansible. Married patients indicated satisfaction with their sexual life.     

The vascular territories of the superior epigastric and the deep inferior epigastric systems

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.     

Functional oromandibular reconstruction with the microvascular composite groin flap

Ten patients were reconstructed with the microvascular osteocutaneous groin flap for oromandibular defects with the objective of improving function. The flap was based on the superficial and deep circumflex iliac vessels for optimal positioning of the bone and contouring of the skin. Patients with major glossectomies and arch resections had intelligible speech and were able to eat a soft diet without aspirating. Cineradiographic studies to evaluate swallowing in selected patients showed that the shape of the intraoral flap and the location of the bone graft played an important role in swallowing and prevention of aspiration.     

Guidelines for pharyngostome closure

The reconstructive procedure for pharyngostome closure includes single-stage restoration in three steps: lining, intermediate layer, and covering. The lining repair is the key factor to the successful outcome of the operation. Three clinical situations may be distinguished. First, the mucosa is sufficient to restore a new gullet. In this case, it is widely undermined and sutured along the midline without any tension. Second, the mucosa is only partially sufficient. The same procedure as above is adopted to close the lower two-thirds of the pharyngostome, while an advancement flap is outlined from the base of the tongue to restore the upper third. Third, the mucosa is not sufficient. A musculocutaneous flap solves the problem. Reconstruction of the intermediate layer involves rotation of one (or both) sternomastoid muscle(s), if present. The possibilities for coverage include a submandibular flap, a thoracoacromial flap, and/or musculocutaneous flaps. By following these guidelines, the authors have successfully closed 37 pharyngostomes.     

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.     

The free iliac flap: a lateral modification of the free groin flap.

A lateral modification of the free groin flap, called the free iliac flap, is presented. By moving the outline of the free groin flap laterally, so that the medial margin lies lateral to the underlying femoral triangle, a flap is obtained which is uniformly slender and which has a long vascular pedicle. The anatomical findings, a method for safe dissection of the superficial circumflex iliac vessels, and the results of 18 clinical cases are presented.     

The dermis-prelaminated scapula flap for reconstructions of the hard palate and the alveolar ridge: a clinical and histologic evaluation.

Ideal reconstructions of complex defects in the midface require the restitution not only of bone and soft tissue, but also of a thin and durable lining of the oral cavity. So far, split-thickness skin grafts, intestinal grafts, and in vitro cultured mucosal grafts have been used for the reconstruction of the oral lining. The use of skin as a substitute for oral mucosa is controversial because contraction, hair growth, maceration, and dysplastic changes can occur. This clinical and histologic study was performed to evaluate the suitability of dermis as a substitute for oral lining. Twelve complex defects of the midface were reconstructed with dermis-prelaminated scapula flaps. A bony flap from the lateral border of the scapula was prepared, and osseointegrated implants were placed. The bone flap was then prelaminated with dermis and covered with a Gore-Tex membrane to prevent adhesions. The composite flap was transferred to the midface 2 to 3 months later. The oral lining of the flap was evaluated clinically and histologically at 2, 4, and 6 weeks and at 3 to 41 months after the reconstruction. In all patients, the reconstructed bone was covered with a thin and lubricated surface without hair growth. None of the patients showed any signs of maceration. Histologically, these findings corresponded to a keratinized stratified squamous epithelium with highly developed connective-tissue papillae. These features closely resemble those of the normal mucosa of the hard palate and the gingiva. Thus, dermis prelamination is an effective method for reconstructing the mucosa of the alveolar ridge and the hard palate.     

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.     

Perforator-based flap in rats: a new experimental model.

A new type of flap, the perforator-based flap, has been described in the last decade. It has been used successfully as a pedicle or free flap by many plastic surgeons. There is no animal model for research, although these flaps have gained popularity in clinical use. We created a perforator-based flap model in the rat (a perforator-based flap group and two control groups; 10 rats in each group) and evaluated the survival characteristics of the new flap. The abdominal skin flap was elevated based on the second perforator of the right superior deep epigastric artery and then sutured to its original bed. In the first control group, the same flap was elevated with a subcutaneous pedicle without any perforator; in the second control group, a right-sided, random-pattern pedicle abdominal skin flap with the same dimensions and location was elevated and sutured to its original bed. Flap survival was studied, and microangiography and histologic studies were performed. The amount of viable skin in the three groups was compared 1 week later. The area of surviving skin paddles in the experimental group ranged from 74 to 83 percent; in the first control group, it was 0 percent; and in the second control group, it ranged from 29 to 44 percent (p < 0.001 and p < 0.001, respectively). There was a predictable and constant area of necrosis in the model.The results of this study demonstrate that most of the abdominal skin of the rat can survive on the basis of a single musculocutaneous perforator vessel. This flap can be easily elevated, and it can be used as a reliable model for flap research.     

Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection

To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.     

Reconstruction of composite through-and-through mandibular defects with a double-skin paddle fibular osteocutaneous flap

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.     

Groin flap design and versatility

The groin flap is a reliable and well-established reconstructive option for pedicled or free-tissue transfer. Concern regarding its variable vascular origin and caliber has limited its use. To overcome this, a simplified guideline based on the transverse diameter of the patient's index and long fingers at the distal interphalangeal level has been developed. Thus "rule of two finger widths" positions the origin of the vascular pedicle from the femoral vessels two finger widths below the inguinal ligament, the upper flap border two finger widths above the inguinal ligament, the lower flap border two finger widths below the vascular origin, and both parallel to the flap axis, which lies along a line from the vascular origin to the anterosuperior iliac spine. This new groin flap design provides the necessary guidelines for vascular identification, accommodates pediatric and adult stature, and ensures primary donor-site closure if flap dimensions are within the prescribed boundaries. In addition, a new sartorius-cutaneous groin flap is presented. This combines the cutaneous groin flap with the proximal sartorius muscle (up to 15 cm), which is supplied by the deep vessels of the superficial circumflex iliac system. The sartorius-cutaneous groin flap further emphasizes the concept of single-pedicle compound or combined flaps and additionally enhances the extensive reconstructive versatility of previously described groin flaps. Over 200 pedicled and free groin flaps have been performed according to the "rule of two finger widths" over the past 5 years. There have been no complications related to flap design, such as difficulty with flap elevation, marginal necrosis, or donor-site closure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prelaminating the fascial radial forearm flap by using tissue-engineered mucosa: improvement of donor and recipient sites.

In reconstructive surgery, prelamination of free flaps using split-thickness skin is an established technique to avoid the creation of a considerable defect at the donor site, for example, in the case of a radial forearm flap. For oral and maxillofacial surgery, this technique is less than optimal for the recipient site because the transferred skin is inadequate to form a lining in the oral cavity. To create mucosa-lined free flaps, prelamination using pieces of split-thickness mucosa has been performed. However, the availability of donor sites for harvesting mucosa is limited. The present study combines a tissue-engineering technique with free flap surgery to create mucosa-lined flaps with the intention of improving the tissue quality at the recipient site and decreasing donor-site morbidity. On five patients undergoing resection of squamous cell carcinoma of the oral cavity, the radial forearm flap was prelaminated with a tissue-engineered mucosa graft to reconstruct intraoral defects. Using 10 x 5 mm biopsies of healthy mucosa, keratinocytes were cultured for 12 days and seeded onto collagen membranes (4.5 x 9 cm). After 3 days, the mucosal keratinocyte collagen membrane was implanted subcutaneously at the left or right lower forearm to prelaminate the fascial radial forearm flap. One week later, resection of the squamous cell carcinoma was performed, and the free fascial radial forearm flap pre- laminated with tissue-engineered mucosa was transplanted into the defect and was microvascularly anastomosed. Resection defects up to a size of 5 x 8 cm were covered. In four patients, the graft healed without complications. In one patient, an abscess developed in the resection cavity without jeopardizing the flap. During the postoperative healing period, the membrane detached and a vulnerable pale-pink, glassy hyperproliferative wound surface was observed. This surface developed into normal-appearing healthy mucosa after 3 to 4 weeks. In the postoperative follow-up period, such functions as mouth opening and closing and speech attested to the success of the tissue-engineering technique for flap prelamination.     

Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.