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.     

Reconstruction of mandibular and floor of mouth defects using the trapezius osteomyocutaneous flap

The trapezius osteomyocutaneous island flap has evolved in postablative head and neck reconstruction as a versatile and hardy local flap which can provide intraoral lining, well-vascularized bone, and muscle bulk for the reconstruction of a complex defect. This investigative study examines the anatomy of 20 osteomyocutaneous flaps in 10 fresh cadavers and in 8 clinical patients. In our series, 80 percent (type I) of the major vascular pedicle arose from the thyrocervical trunk. In 20 percent (type II), the major pedicle arose separately from the subclavian artery. The regions perfused by the vascular trunk were further examined with microopaque and Prussian blue injections through the transverse cervical artery. Consistent areas of cutaneous staining as well as bony staining were noted over the shoulder, arm, and back and into the scapula itself. Experience with eight clinical applications of this osteomyocutaneous flap resulted in successful healing with an excellent aesthetic and functional result. Long-term follow-up was maintained on the patients for up to 36 months. Panorex radiographs and biopsies of the grafted bone were obtained on several patients. These disclosed evidence of bony remodeling and viable bone tissue. Tetracycline labeling also revealed evidence of active bony turnover.     

Oropharyngeal reconstruction using the supraclavicular artery island flap: a new flap alternative

Oropharyngeal reconstruction following head and neck oncologic resection has utilized local, regional, and free tissue transfer flap options. The modality utilized is often guided by the type of defect created as well as the surgeon's preference. In this article, the authors introduce the application of the supraclavicular artery island flap as a reconstructive modality following oropharyngeal oncologic ablation. Five patients underwent head and neck oncologic resection for oropharyngeal squamous cell carcinoma followed by single-stage reconstruction with an ipsilateral supraclavicular artery island flap. There were no flap failures and only one postoperative complication consisting of a postoperative oral-cutaneous fistula that resolved without surgical intervention. There were no donor-site complications. The supraclavicular artery island flap is a viable alternative for oropharyngeal reconstruction following head and neck oncologic resection. It is a regional flap that can be harvested without microsurgical expertise and yields reliable postoperative results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

The expanded supraclavicular flap, prefabricated with thoracoacromial vessels, for reconstruction of postburn anterior cervical contractures

Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. These contractures may cause severe deformities that are both functionally and aesthetically crippling. Reconstruction of the neck requires the transfer of large flaps of thin, pliable skin to optimally match the texture and color of the recipient region. With the introduction of free tissue transfer, the availability of flaps for reconstruction of large neck defects has greatly increased. Unfortunately, many of these flaps are bulky and are not well matched to the thin and pliable skin of the neck. This article introduces the expanded supraclavicular flap prefabricated with the thoracoacromial vessels for reconstruction of anterior cervical contractures. Their anatomic location, length, and arc of rotation make the thoracoacromial vessels an excellent choice for prefabricating the supraclavicular skin for its subsequent interpolation into the anterior neck. Skin expansion in the donor region not only allows coverage of the larger unit of the anterior neck but also modifies the morphologic characteristics of the transferred flap through capsule formation and fatty tissue atrophy, which is beneficial for obtaining an optimal neck reconstruction.     

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.     

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 temporal island scalp flap for management of facial burn scars

Facial burn scars are difficult to conceal and often preclude an aesthetic rehabilitation of the patient. Multistaged scalp and neck flaps have been described to provide hair-bearing skin to resurface burn scars in men. We have been resurfacing the upper lip and cheek in a one-stage procedure using a temporal artery island scalp flap. The temporoparietal fascia has been well described in recent years, and the understanding of this anatomy has facilitated the use of the island scalp flap for more distal transfers.     

A new flap design: neural-island flap

This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.     

Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.     

Island rat groin flaps with twisted pedicles

Clinical attempts are made to avoid rotating a flap and twisting the pedicle for fear of perfusion compromise. Torsion of an island rat groin flap pedicle is not a well-recognized experimental entity. The authors describe the results of island flap rotation with pedicle twisting in the rat groin flap model. Forty male Wistar rats were randomly divided into four groups of 10 animals each. In each group, bilateral groin flaps were elevated; one flap was sutured in place without rotation and the contralateral flap was subjected to 180, 270, 360, or 720 degrees of rotation. Blood flow within the flaps was assessed by laser Doppler flowmetry, and flap edema and necrosis were determined 10 days postoperatively. No differences were noted between control flaps and those subjected to 180 and 270 degrees of rotation. Although flaps subjected to 360 degrees of rotation demonstrated a large amount of postoperative edema and congestion of the subcutaneous tissue with some histologic changes, all flaps in this group survived. Measured flap weights at death were different from those of controls. All flaps subjected to 720 degrees of rotation underwent ischemic necrosis. Because of the differences between human skin architecture and rat skin architecture it cannot be concluded that similar results would be observed in any human skin flap. There might be three important points arising from this study of unknowingly twisted island groin flap pedicles in the rat model: (1) twisting of less than 360 degrees has no effect on flap survival; (2) twisting of 720 degrees is always associated with skin flap necrosis; (3) twisting of 360 degrees, although associated with some changes, does not cause skin flap necrosis.     

The free vastus lateralis flap: an anatomic study with case reports.

The suitability of the thigh as a donor site for a new free flap was examined in 100 cadavers. It was found that the vastus lateralis muscle can be used to form a myocutaneous or fasciomuscular flap, the raising of which causes no technical problems and leads to no functional and only minor aesthetic impairments. Depending on the muscle segment from which the flap is raised, a neurovascular pedicle measuring between 8 and 20 cm with a diameter of 2 to 2.5 mm (artery) or 2.5 to 4 mm (vein) can be formed. The skin island in the myocutaneous flap measures on average 8 x 16 cm and is located above the middle portion of the muscle. The diameter of the supplying perforator vessel is between 0.7 and 1.2 mm. The flap can be raised parallel to head and neck surgery and applied as a myocutaneous flap for coverage of extensive or perforating defects or intraorally as a fasciomuscular flap.     

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.     

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 distally pedicled peroneus brevis muscle flap: a new flap for the lower leg

Defects of the skin and soft tissue in the region of the lateral malleolus of the ankle and the Achilles tendon, resulting in exposed bone, tendons, or osteosynthetic material, cannot be covered with free skin transplants. Local or free flaps must be employed. The authors present the construction of a peroneus brevis muscle flap with a distal pedicle as a useful alternative. Between 1993 and 1999, distal pedicled peroneus brevis muscle flaps were used in 19 patients with various types of defects. During construction of the flap, both the long peroneal muscle and the peroneal artery remained intact. In the region of the distal third of the fibula, consistently arranged branches run from the artery into the muscle, and these form the distal pedicle. The proximal portion of the muscle can be transposed distally and easily extends to the tip of the fibula and the attachment of the Achilles tendon to the calcaneus. Primary healing occurred in 16 patients undergoing flap construction. Donor-site morbidity was mostly limited to the donor-site scar. The distally pedicled peroneus brevis muscle flap is a reliable means for covering defects in the lower leg. This form of muscle flap has not yet been described in the known literature. In the authors' opinion, this flap constitutes a logical and valuable extension of local flap procedures for plastic surgery in the distal leg region.     

The dorsal scapular island flap: an alternative for head,neck, and chest reconstruction

The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free-tissue transfer for the reconstruction of defects in the head, neck, and anterior chest.     

Reverse-flow island sural flap

The reverse flow island sural flap is presented as an alternative to flaps currently used for reconstruction of small and medium substance losses in the distal third of the leg, ankle, and heel. This is a random type of flap, based on the reverse flow of the superficial sural artery, which mainly depends on the anatomy of the perforators of the peroneal artery system.The anatomic structures that constitute the pedicle are the superficial and deep fascias, the sural nerve, the short saphenous vein, and the superficial sural artery. The skin island and the subcutaneous cellular tissue complement the flap proper. This skin island was demarcated at any point of the median or distal thirds of the leg, having the short saphenous vein and the sural nerve on its central axis. The distal dissection limit of the pedicle is located 5 centimeters above the lateral malleolus. This limit is established so as to ensure the integrity of the perforators from the principal arteries of the leg, mainly the peroneal artery, responsible for the reverse flow nourishing the flap. These perforators will affect anastomoses with the superficial sural artery in charge of irrigating the structures compounding the flap.A total of 71 patients were operated on with this technique, some of them with basic pathologic abnormalities limiting the distal blood flow, such as diabetes mellitus, and some others having proven vascular insufficiency or displaying unstable areas attributable to problems such as pseudarthrosis and osteomyelitis, which needed to be covered. Fifteen flaps (21.1 percent) suffered partial necrosis, which did not compromise the final result, and another three (4.2 percent) showed total loss. The flap in question has great mobility and versatility, allowing the treatment of specific areas of the lower limb, without sacrificing important arteries or mobilizing structures that might bring about functional deficits.     

Experimental use of a gastric flap on an omental pedicle to close defects in the trachea, pharynx, or cervical esophagus.

The use of local or regional skin flaps for repairs after head and neck cancer surgery often increases the deformity of the patient. We present a new procedure using a gastric flap on an omental pedicle. It has been successful in dog experiments where we transferred it to the head and neck region, to serve as a substitute for the standard skin flaps.     

Elbow joint salvage with the transverse rectus island flap: a new application

The transverse rectus island flap has gained wide acceptance in breast reconstruction. We introduce its use in reconstruction of extensive wounds of the elbow region. Three cases are presented. Its principal advantages over other methods are size, pedicle length, reliability, acceptable donor defect, and potential prevention of elbow and shoulder stiffness. Its disadvantages are bulk, weight, and required staged procedures.     

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.     

Reconstruction of facial defects with superficial temporal artery island flaps: a donor site with various alternatives

Color and texture match is crucial in reconstruction of facial tissue defects. Between March of 1997 and July of 2000, island flaps based on the parietal, anterofrontal, centrofrontal, posterofrontal, and superior auricular branches of the superficial temporal artery were used in the reconstruction of tissue defects localized on different regions of the face in 28 patients. According to the size and the location of the defect, the flap was selected. There were 15 male patients and 13 female patients, with ages ranging between 19 and 74 years. In six of the flaps, venous congestion was observed. Because of the elevation of the eyebrow on the flap side, three patients required a sling to the opposite eyebrow. Excellent color and tissue match and transfer of hair-bearing tissue to the eyebrow and beard areas were achieved with no other complications. Satisfactory aesthetic results were gained.