The use of free groin flaps in children

The free groin flap is a well-established method of skin coverage. Although its use in children has been reported, there have been no published series specifically in such cases. The authors report 33 consecutive cases of free groin flaps in children in their unit over a period of 9 years (1992 to 2001). Tissue transfer was performed to provide soft-tissue coverage during reconstruction of congenital defects and tumor resection and following trauma. Twenty-six cases (79 percent) involved the upper limb, six cases (18 percent) involved the lower limb, and one case involved the head. The complication rate compares favorably with similar series published for adults, with only two complete failures (6 percent), three (9 percent) minor donor-site complications (superficial wound infection, hypertrophic scarring, and dog-ears), and nine flaps requiring debulking. The reexploration rate was 24 percent, with seven of the eight flaps undergoing reexploration surviving. The groin flap is a reliable flap that can be used safely in children, with minimal morbidity.     

Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps

Early vascularized soft-tissue closure has long been recognized to be essential in achieving eventual infection-free union. The question of whether muscle or fasciocutaneous tissue is superior in terms of promoting fracture healing remains unresolved. In this article, the authors review the experimental and clinical evidence for the different tissue types and advocate that the biological role of flaps should be included as a key consideration during flap selection.     

Experimental use of free gastric flaps for the repair of pharyngoesophageal defects.

The repair of large pharyngoesophageal defects was accomplished experimentally in 16 dogs with revascularized free flaps from the greater curvature of the stomach. These flaps were based on the gastroepiploic vessels, and they were anastomosed to the carotid artery and external jugular vein in the neck. The procedure had a low mortality and did not lead to peptic ulceration or hyperchlorhydria in these animals.     

The no-reflow phenomenon in experimental free flaps.

The no-reflow phenomenon was studied following reconstitution of blood flow by microvascular anastomosis in an ischemic and denervated free epigastric flap in the rabbit. Microscopic, histological, angiographic, and hematological studies demonstrated the progressive nature of this obstruction to the peripheral blood flow after increasing periods of ischemia. This obstruction reached a point of irreversibility after 12 hours of ischemia, leading to ultimate death of these flaps. These results are consistent with the hypothesis that an ischemia-induced no-reflow phenomenon is caused by cellular swelling, intravascular aggregation, and the leakage of intravascular fluid into the interstitial space. Similarities between these experimental findings and human observations are made. The clinical importance of early diagnosis and treatment of ischemic tissues is emphasized.     

Late results of free-muscle flaps and delayed bone grafting in the secondary treatment of open distal tibial fractures

Since no current studies reflect the long-term function of patients accurately categorized and uniformly managed for the same degree and location of tibial injury, seven individuals with type IIIB open distal tibial fractures were studied prospectively for 2 to 4 years after debridement, free-muscle transfer, and delayed autologous bone grafting. Lymphedema, transient drainage, poor ankle motion, limb shortening, nonunion, and delayed union were all significant problems. On average, the patients endured over six operations, 2 months of hospitalization, and a year's course of physical rehabilitation. The study indicates that, although popular, such a regimen is not without important shortcomings. This experience has influenced our selection of and counseling for patients in whom we are contemplating such management.     

Angiography of the iliofemoral arteriovenous system supplying free groin flaps and free hypogastric flaps.

The circulatory anatomy of the iliofemoral region was elucidated by doing detailed angiography in 50 cases, and we classified the vessels into 4 types. In most cases, the s.c.i.a. predominated over the s.i.e.a. Therefore, it is probably better to plan free flaps supplied by this artery. This vessel usually arises approximately two or three fingerbreadths inferior to the intersection of the femoral artery and the inguinal ligament, and the skin flap should be designed in the area inferior and parallel to the inguinal ligament.     

Coverage of bilateral lower extremity calcaneal fractures with osteomyelitis using a single split free gracilis muscle transfer

A case is presented in which a single gracilis muscle was split and used for free-tissue coverage of two sites in a patient with bilateral calcaneal fractures and posttraumatic osteomyelitis. Muscle-flap coverage of osteomyelitis and the use of the gracilis muscle for free-tissue transfer are discussed.     

The simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps

The authors describe their experience with the use of distally based saphenous and sural neurofasciocutaneous flaps for the treatment of calcaneal osteomyelitis in nine cases. Aggressive débridement of all nonviable and poorly vascularized tissue and coverage with a distally based neurofasciocutaneous flap were coupled with a thorough antibiotic course in all cases. The deepithelized peripheral parts of all flaps were buried in the bone cavities after bone débridement. Follow-up periods ranged from 15 to 27 months. All flaps survived completely. All of the wounds except one healed completely. These flaps have adequate blood flow for the management of chronic bone infections. They also have many advantages, such as easy quick elevation, short operative time, and acceptable donor-site morbidity. Moreover, patients treated with neurocutaneous flaps do not require debulking procedures or special shoes. Reconstruction with neurocutaneous flaps after radical débridement is a versatile alternative to the use of local or distant muscle flaps and calcanectomy procedures for patients with osteomyelitis of the os calcis.     

Two new cutaneous free flaps: the medial and lateral thigh flaps

Two new cutaneous free-flap donor areas are described on the medial and lateral sides of the thigh. The medial thigh flap is supplied by an unnamed artery from the superficial femoral artery and is drained by the accompanying venae comitantes. Its nerve supply is from the medial femoral cutaneous nerve. The lateral thigh flap has its vascular pedicle from the third perforating artery of the profunda femoral artery and its accompanying vein. The lateral femoral cutaneous nerve provides sensation over the area. These flaps provide a large surface area of both skin and subcutaneous tissue without the usual bulk of subcutaneous fat and muscle. Their desirable features include long vascular pedicles with large vessel diameters and potential of being neurovascular flaps with specific sensory nerve supply and predictable anatomy. The principal disadvantage is that the donor site may leave a slight contour defect with primary closure or require grafting when a large flap is taken. We predict that these flaps will become important donor sites for reconstructive problems requiring resurfacing of cutaneous defects in various anatomic areas.     

Sensibility and cutaneous reinnervation in free flaps

Sensibility and sensory reinnervation were investigated in 19 free flaps, predominantly located on the lower extremities, between 2 months and 3 years after flap transfer. All patients showed deep pressure sensibility. In 10 of the patients, primarily those examined late after surgery, a heat pain threshold was obtained at about 50 degrees C. None of the patients had superficial sensibility of any other modality. No neurofilament-positive sensory nerve fibers were observed in the dermis or epidermis. In one patient nerve fibers were detected in the subcutaneous tissue. It is concluded that patients will have deep pressure sensibility of the flap area even early after the operation and that most patients will develop a heat pain sensitivity, probably due to subcutaneous reinnervation.