Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps

The skin fascial flap is now recognized as a reliable flap for use in reconstructive surgery. The fasciocutaneous flap has been advocated for coverage of chronic infected wounds after debridement as an alternative to the musculocutaneous flap. Previous experimental and clinical studies have demonstrated the superior resistance of the musculocutaneous flap as compared to the random-pattern flap to bacterial inoculation. A canine model is presented for comparison of the effect of bacterial inoculation in fasciocutaneous and musculocutaneous flaps of similar dimensions. The area of skin necrosis secondary to bacterial inoculation was similar in these two flap types despite greater blood flow and skin oxygen in the fasciocutaneous flap. In a study of closed wound spaces formed by the deep surface of these two flap types, a greater degree of inhibition and elimination of bacterial growth and more collagen deposition are observed in the musculocutaneous wound space than in the fasciocutaneous flap.     

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.     

Thumb reconstruction with a sensory flap from the dorsum of the index finger.

The dorsal skin of the index ray is very useful (1) for a one-staged thumb lengthening procedure after amputation, (2) for covering the stump of an avulsed thumb with sensory skin, and (3) for expanding the first web space. The flap may be transferred as a rotation flap, or the dorsal vasculature and nerve supply to the index may be carefully dissected free as a pedicle to permit its use as a neurovascular island flap. We believe that considerably more sensory skin can be transferred by this flap than by the ring finger neurovascular island flap, and that the technical risks and surgical time are less with the index finger flap.     

The great potential of the intercostal flap for torso reconstruction.

The intercostal flap has many uses for torso reconstruction, whether employed as an island flap or a free flap. With modifications, it can be used as a sensory skin flap, or as a compound osteocutaneous flap to restore stability in a chest wall construction, or as a skin flap with a permanent blood supply to provide stable cover after excision of radiation ulcers.     

Suitability of the scapular flap for reconstructions of the foot

Eighteen patients with mainly a traumatic soft-tissue defect of the foot underwent reconstruction with a microvascular free scapular flap. Of the 17 successful transfers, 13 were to the weight-bearing parts of the foot. The stability and contour of the flaps were assessed after an average follow-up time of 3 years (range 1 to 5 years). The thicknesses of the scapular donor site and flap and the recipient site were measured by an ultrasound technique. The resistance of the flap to shear was measured with a dynamometer. The ultrasound measurements aided in refining our operative technique. In early cases, the flap thickness after transfer could be more than double what it was in the donor area. With proper tightening, the thickness could be reduced, with improvement in contour but no increase in soft-tissue stability or shear resistance of the flap. Without proper tightening, the scapular flap tended to be redundant when transferred to the foot. For good results, the patient should be lean, since the optimal thickness of the scapular donor site was less than 6 mm and the maximum thickness should not exceed 8 to 10 mm. The differences in shear resistance between the flaps were not associated with the soft-tissue stability of the reconstruction. The relative laxity of the flap on the plantar surface was found by several patients to be subjectively unpleasant. Although good contour could be achieved when covering the plantar heel, the tendency of the flap to develop abrasions and superficial breakdowns made it unsatisfactory for covering this area.(ABSTRACT TRUNCATED AT 250 WORDS)     

吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果分析

摘要 目的：探讨与分析吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果。方法：选择2018年12月到2021年12月在本院创伤造成的四肢皮肤软组织缺损60例患者作为研究对象,将其随机分为吻合皮下静脉带蒂皮瓣组与传统带蒂皮瓣组各30例。吻合皮下静脉带蒂皮瓣组给予吻合皮下静脉的带蒂皮瓣修复治疗,传统带蒂皮瓣组给予常规直接覆盖创面修复治疗。结果：所有患者都顺利完成手术,吻合皮下静脉带蒂皮瓣组围手术指标时间均较传统带蒂皮瓣组少（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的总有效率为96.7 %,高于传统带蒂皮瓣组的76.7 %（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的并发症发生率较传统带蒂皮瓣组低（P<0.05）。吻合皮下静脉带蒂皮瓣组术后6个月的感觉功能恢复情况好于传统带蒂皮瓣组（P<0.05）。结论：吻合皮下静脉的带蒂皮瓣能促进患者的创面愈合,提高治疗效果,减少并发症,加快恢复患者的四肢皮肤软组织缺损。     

Geometric considerations in the design of rotation flaps in the scalp and forehead region

The classical transposition and rotation flaps are well known. Cosmetic considerations in the scalp and forehead region limit the use of a flap design that requires a skin graft for a donor defect. On sound geometric principles, the classical flap designs are suitably modified here to have a somewhat equal proportion of transposition and rotation. This "modified rotation flap" design works to a maximum advantage in the inextensible region of the scalp and forehead by providing single-stage primary closure of moderate to large defects. No backcuts are ever necessary with this flap design. Use of this principle to modify the rotation flap design for closure of an extended midline forehead defect following rhinoplasty allows a still wider (up to 6.5 cm) midline forehead flap to be available for rhinoplasty with primary closure of the donor defect.     

Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds

The distally based sural nerve flap is an excellent option for covering defects of the lower third of the leg. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. The flap can be elevated under a tourniquet in relatively bloodless fashion without sacrificing a major vessel to the foot. Its use is described in a variety of defects in 11 patients, ranging in age from 3 to 64 years. The flap was used bilaterally in one case and in cross-leg fashion in another. All defects were covered with no major complications, and none of the patients required a blood transfusion. One flap experienced a small amount of distal marginal necrosis, which was excised and closed primarily. The technical aspects of flap elevation are emphasized.     

Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity

The radial forearm flap is commonly used for reconstruction of tongue defects following tumor extirpation. This flap is easy to harvest and offers thin tissue with large-caliber vessels. However, its use leaves behind a conspicuous aesthetic deformity in the forearm and requires the sacrifice of a major artery of that limb, the radial artery. The anterolateral thigh cutaneous flap has found clinical applications in the reconstruction of soft-tissue defects requiring thin tissue. More recently, in a thinned form, the anterolateral thigh flap has been used for reconstructing defects of the tongue with functional results equivalent to that of the radial forearm flap. For the reconstruction of tongue defects, these two flaps could provide similar soft-tissue coverage, but they seem to result in different donor-site appearances. The donor site is closed primarily, leaving only a linear scar that is inconspicuous with normal clothing, and no functional deficit is left behind in the thigh. Thus, for the supply of flaps for tongue defects, a comparison between the radial forearm flap and the anterolateral thigh flap donor sites is provided in this study. Between December of 2000 and August of 2002, 41 patients who underwent reconstruction of defects of the tongue using either a radial forearm flap or an anterolateral thigh flap were evaluated. The focus was on the evaluation of the functional and aesthetic outcome of the donor site after harvesting these flaps for the purpose of reconstructing either total or partial tongue defects. Finally, a comparison was performed between the donor sites of the two flaps. The disadvantages of the radial forearm flap include the conspicuous unattractive scar in the forearm region, pain, numbness, and the sacrifice of a major artery of the limb. In some patients, the donor-site scar of the forearm acted as a social stigma, preventing these patients from leading a normal life. In contrast, the anterolateral thigh cutaneous flap, after thinning, achieved the same results in reconstructing defects of the tongue without the associated donor-site morbidity. Most importantly, the donor site in the thigh could be closed primarily in almost all patients without any functional deficit. The thinned anterolateral thigh cutaneous flap is a viable substitute for the radial forearm flap when reconstructing defects of the tongue. The results achieved are similar to those of the radial forearm flap, and the donor-site morbidity is significantly decreased.     

The vascular anatomy of the galeal flap in the interparietal and midline regions.

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.     

Free flap coverage of bilateral frostbite of the feet

The indications, principles of management, and outcomes of free flap transfer for limb salvage in four patients with bilateral frostbite of their feet are presented. A fasciocutaneous flap was used for coverage when the wound involved a single surface of the foot. When multiple surfaces of the foot required free flap coverage, a muscle flap was used because it could more easily improve the shape and contour of the defect. Successful coverage was achieved in all four patients.     

Multiple and repetitive uses of the extended hamstring V-Y myocutaneous flap

An extended hamstring V-Y myocutaneous advancement flap is described that may be used to cover unusually large defects in the ischial region. Technical points that allow a large amount of flap advancement are discussed. Because of its large size, the flap can be raised and used on repeated occasions to repair defects from recurrent ischial pressure sores. Two patients are presented in whom the same flap was used repeatedly on multiple occasions, demonstrating the potential for preservation of future options in such patients when this flap is used.     

Extending the reach of the heterodigital arterialized flap by vein division and repair

The heterodigital arterialized flap is ideal for nonsensory reconstruction of sizable soft-tissue defects in the proximal fingers, web spaces, and the hand. The inclusion of a dorsal vein augments the venous drainage of this digital island flap and avoids the problem of postoperative venous congestion, which is a common problem in digital island flaps. However, the presence of a dorsal vein pedicle inhibits flap mobility somewhat, and the reach of the flap is mainly limited to adjacent fingers. In situations that demand a transfer from a nonadjacent donor finger or when the reach from the adjacent donor finger is inadequate, the dorsal vein pedicle can be temporarily divided and then anastomosed microsurgically after flap transfer is performed. This enables the reach of the flap to be extended up to two fingers from the donor finger. The authors performed this "partially free" heterodigital arterialized flap in 11 consecutive patients between 1991 and 2001. The average size of the defects was 4.4 x 2.3 cm. All of the flaps survived completely, without any evidence of postoperative flap congestion. Healing of all of the flaps was primary and did not result in any scarring. All of the donor fingers had "normal" two-point discrimination of 3 to 5 mm. All of the donor fingers retained excellent or good total active motion, as graded by the criteria of Strickland and Glogovac.     

The groin flap in reparative surgery of the hand

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.     

Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap.

The latissimus dorsi myocutaneous flap is a remarkably durable and versatile flap. Flap necrosis did not occur in any of our patients. One can safely carry with it skin segments as narrow as 3 cm, or as wide as 30 cm. In addition to the 5 cases presented, we have used the flap to repair axillary burn contractures, for breast reconstruction after a transverse incision, and for coverage of the upper arm and shoulder. The applications of this flap challenge the creative imagination of the surgeon and allow a simplified reconstruction, compared to other good methods. The newly described posterior advancement of a latissimus dorsi myocutaneous flap is suggested as the preferred method to repair meningomyelocele defects.     

Simple approach to harvest of the anterolateral thigh flap

The free anterolateral thigh flap has proven to be invaluable for many types of reconstruction, ranging from upper and lower extremity trauma to head and neck reconstruction. There exist some controversies relating to certain difficulties in flap harvest because of the intramuscular route of its major perforator, which can exceed 80 percent and create a longer, more tedious dissection. Strategies to expedite flap harvest and minimize technical challenges have been proposed. The authors propose a simplified approach to harvest the anterolateral thigh flap founded on topographic surface anatomy and the intrinsic vascular anatomy of the flap. No Doppler imaging or angiography is used for preoperative perforator mapping.     

The medial adiposofascial flap of the leg: anatomical basis and clinical applications

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.     

The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction

The Hughes tarsoconjunctival flap was initially described in 1937. This flap is best used for reconstructing full-thickness defects involving the central portion of the lower eyelid. The evolution of this flap over the last 60 years is outlined. Several important modifications are presented; these modifications lead to decreased donor-site morbidity and improved recipient site outcome.     

Pericranial healing and the temporalis myo-osseous flap in the rabbit model.

The purpose of this animal study was to determine the rate of revascularization of a temporalis myo-osseous (TMO) flap after pericranial elevation. In 24 rabbits, the right pericranium was raised in entirety through a bicoronal flap at the first operation. The pericranium was then reapproximated in situ. The pericranium was allowed to heal for 1 to 28 days before the second operation. At the second operation, through the same bicoronal flap, right and left temporalis myo-osseous flaps were raised. The left temporalis myo-osseous flap served as a control. Revascularization and viability of the temporalis myo-osseous flaps were studied by using technetium bone scans, india ink injection studies, and histologic study. Results demonstrated that 4 days following pericranial elevation, the temporalis myo-osseous flap is viable and revascularized by the pericranium. Immediate bone scanning and india ink injection showed patent pericranial circulation to the osseous portion of the temporalis myo-osseous flap at 4 days. Histologic study confirmed the viability of the temporalis myo-osseous flap. In conclusion, after pericranial elevation, pericranial healing and revascularization were complete at 4 days. This allowed a viable temporalis myo-osseous flap to be raised successfully at this time.