Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot.

The use of free flaps to repair defects of the leg or foot is a viable alternative to cross-leg flaps because (1) the total time of immobilization and hospitalization is less, (2) the total number of general anesthetics is less, and (3) the morbidity and cost are less. Increased experience will enhance the survival statistics for free flaps, making their use the method of choice for the reconstruction of defects in the distal part of the lower extremity.     

Perforator flaps from the lateral lower leg for intraoral reconstruction

Perforator flaps are based on cutaneous, small-diameter vessels that originate from a main pedicle and perforate fascia or muscle to reach the skin. Although these flaps have recently become popular for soft-tissue reconstructions in nearly all regions of the body, the systematic application of perforator flaps with short, small-caliber pedicles for intraoral reconstruction has not been reported. Experience with the use of 10 consecutive perforator flaps from the lateral lower leg for intraoral defect coverage is reported. In 10 cases, a 4- to 6-cm-long septocutaneous or myocutaneous perforating vessel from the peroneal artery, with a diameter of 1 to 2 mm, could be identified in the proximal one-half of the lateral lower leg. The thin, pliable skin paddles, measuring up to 6 x 8 cm, were used for defect coverage after resection of squamous cell carcinomas of the floor of the mouth (five cases), soft palate (one case), tongue (two cases), or buccal mucosa (two cases). Anastomoses were performed to the lingual artery and concomitant vein. Except for one case, all perforator flaps healed without complications and the functional results were satisfying. At the donor site, which was always closed directly, an approximately 15-cm-long scar resulted, without functional impairments. The peroneal artery was regularly preserved. Perforator flaps from the lateral lower leg might have many applications for intraoral soft-tissue reconstruction, especially because of their minimal donor-site morbidity.     

Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures

Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 x 2 cm to 26 x 5 cm (mean, 19.7 x 3.3 cm). The size of flaps ranged from 11 x 5 cm to 26 x 8 cm (mean, 21.3 x 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split-thickness skin graft in two cases. At a mean follow-up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one-stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor-site morbidity.     

Widely split latissimus dorsi muscle flaps for reconstruction of long soft-tissue defects in lower extremities

Although the latissimus dorsi is one of the largest and longest muscles in the human body, it is still sometimes inadequate for reconstruction of a soft-tissue defect of extensive length and dimension. Eight patients with such lower limb defects were treated with latissimus dorsi muscles split into two hemiflaps sequentially linked, one after the other like a chain. Six transfers were completely successful, one required reexploration for arterial occlusion, and two hemiflaps had a partial loss that could be managed by touching up the skin graft. The average split sequential-link muscle was 42 cm in length. Although two patients had a partial loss, we consider that the widely split single latissimus dorsi muscle can still be used reliably to reconstruct a long slender defect, or two separate, longitudinally located, medium-sized defects in the same leg.     

Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study

Over the past 4 years at the Massachusetts General Hospital 18 patients have been treated for extensive defects (mean size 130 cm2) of the foot at or below the medial and lateral malleoli. These patients have been treated with free muscle flaps covered with thick split-thickness skin grafts. Full muscle flap survival has been seen in each patient, and all patients are currently ambulatory. A subgroup of nine patients are weight-bearing directly upon their skin grafts covering transferred muscle. All patients are walking without chronic breakdown over a mean follow-up of over 19 months with the exception of a single patient who has had breakdown in a region of redundant improperly tailored muscle flap. None of the skin grafted muscles has significant cutaneous sensibility. Detailed gait analysis of these patients has confirmed the weight-bearing capabilities of free muscle flaps with skin grafts and has proven to be an excellent method of foot reconstruction evaluation. It would appear from this study that cutaneous sensibility may not be necessary for successful reconstruction of the weight-bearing surface of the foot. This method of reconstruction should be considered when local tissues are not suitable for plantar foot reconstruction.     

Lower extremity muscle perforator flaps for lower extremity reconstruction

A true muscle perforator flap is distinguished by the requisite intramuscular dissection of its musculocutaneous perforator to capture the same musculocutaneous territory but with total exclusion of the muscle, and thereby results in minimal functional impairment. Adhering to this definition, several lower extremity donor sites now are available, each with specific attributes especially useful for consideration in the treatment of lower extremity defects. In this author's experience over the past two decades, 20 lower extremity muscle perforator flaps using multiple donor sites proved advantageous for lower extremity coverage problems as either a local pedicled flap or as a microsurgical tissue transfer. Significant complications occurred in 30 percent of flaps (six of 20) in that further intervention was required. Venous insufficiency and bulkiness were found to be the major inherent shortcomings. However, giant flaps, lengthy and large-caliber vascular pedicles, and the possibility for combined flaps were important assets. The choice of a lower extremity muscle perforator flap for lower extremity reconstruction limited the surgical intervention and morbidity to a single body region.