The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.     

Prefabricated (expander) capsule-lined transposition and advancement flaps in reconstruction of lower eyelid and oral defects: an experimental study

In six pigs with prefabricated transposition flaps and six pigs with prefabricated advancement flaps, both flap types (lined with an expander capsule) were used to reconstruct wedge excisions of the lower eyelid or defects in the cheek/oral mucosa. The capsules replaced the conjunctiva in eyelid defects and the oral mucosa in cheek defects. Histopathologic studies were performed at 5 to 7 days, 9 to 10 days, 2 weeks, 3 to 4 weeks, and 2 and 3 months after flap reconstructions. Healing was rapid and uneventful, leading to restoration of the conjunctiva/eyelid and oral mucosa between 9 days and 2 weeks. The healing of the eyelid conjunctiva was somewhat faster than of the oral mucosa. The expander capsule acted as a conjunctival/ mucosal substitute, providing a temporary physical shield, an infectious barrier, and a matrix for epithelial regeneration. All reconstructions were successful except one oral reconstruction with early flap necrosis. Flaps lined with an expander capsule could improve and facilitate clinical reconstructions in the eyelid and oral cavity.     

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.     

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.     

Nine-year experience with extended use of the commissure-based buccal musculomucosal flap

This study reports on the extended use of the commissure-based buccal musculomucosal (CBMM) flap. Large lip defects and medium-size intraoral defects have the general problem of being too large for primary closure to avoid a major functional and aesthetic impairment. Elaborate free flaps, such as axial flaps, although excellent in large defects, may not provide mucosa-equivalent sensitivity, motility, volume, and texture to replace lost tissue with a similar kind of tissue. A total of 60 flap procedures were performed with bilateral and unilateral flaps up to 7.5 x 4 cm in size. The partial and total upper and lower vermilion, gingivobuccal sulcus, floor of the mouth, lateral tongue margin, oropharynx, and hard and soft palates were reconstructed. Partial necrosis was seen in four flaps; all patients recovered with good oral function in speech and swallowing, good aesthetics, and prosthetic rehabilitation if necessary. The donor site could be closed primarily. In flaps with dorsal advancement, the mucosal excess above and below was closed, creating two small dog-ears. Facial expression and mouth opening returned to normal after less than 2 months. The parotid duct had to be marsupialized in large flap preparations, but this did never provoke stasis or infection. The two-point sensitivity of the flaps was, on average, equal to that of the nonoperated mucosa in intraindividual correlation, and the flaps lost, on average, 15 percent of their original size. In the authors' estimation, the results indicate a reliable and technically easy option for intraoral, medium-size defect reconstruction that yields sensitivity and facilitates the rehabilitation of oral function in speaking and ingestion.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.     

Easy tissue expansion of prelaminated mucosa-lined flaps for cheek reconstruction in a canine model

In head and neck reconstruction, there is sometimes the need for a skin flap lined with mucosa. The object of this study was to determine whether small pieces of mucosa grafted onto the undersurface of a skin flap can be expanded in a reasonable time to provide the material required to reconstruct a full-thickness cheek defect as a free flap. The study consisted of two phases: prelamination and expansion of the flap, and vascularized free-tissue transfer of the flap. Six adult mongrel dogs were used. First, a 5 x 10-cm flap based on the saphenous vessels was elevated on the lower leg, and then four 1 x 2-cm pieces of mucosa harvested from the tongue were grafted onto the undersurface of the flap. A tissue expander (5 x 10 cm) was then placed under the flap, and the incision was closed primarily. The expanders were initially filled with just enough normal saline to obliterate dead space immediately after surgery. The expansion was continued twice weekly for 3 weeks until sufficient expansion was obtained. Two of six flaps were followed for an additional 6 weeks after the 3-week expansion period to observe whether additional mucosa could be obtained. After measurement of the mucosal area, each flap was transferred as free flap to reconstruct an iatrogenic cheek defect. The increase of mucosal surface area was compared with the original graft, and differences were analyzed using the paired t test. All flaps were successfully expanded without any complications. Histologic evaluation revealed that grafted mucosa took well without evidence of graft necrosis, and the intergraft area was covered with histiocytes. Angiography revealed well-defined vascular structures covering the entire area of the flap. The new mucosal area (23.5 +/- 2.4 cm2) was significantly larger than the original mucosal graft (8.7 +/- 0.9 cm2) (p < 0.001). The net increase of the mucosal area was 172.9 +/- 32.4 percent. The increase of mucosal area in two flaps, following a 6-week consolidation period after 3 weeks of expansion, was only slightly greater (25.9 +/- 1.3 cm2) than those without the consolidation period (22.3 +/- 1.8 cm2). This increase of the mucosal area appears to be related to the amount of expansion, and not to the length of the consolidation period. The flaps were successfully transferred as free flaps to reconstruct the full-thickness cheek defects without major complications. Although a staged operation to allow flaps to mature is needed, the present procedure has the advantages of providing a mucosa-lined flap and allowing primary closure of the donor site. The authors conclude that expansion of this flap has great potential in reconstructive surgery.     

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.     

Use of the free vastus lateralis flap in skull base reconstruction

Free flaps in skull base reconstruction are indicated for providing an effective separation of the intracranial cavity from the oronasal space, for eliminating a dead space, and for the treatment of established wound complications such as dural exposures and cerebrospinal fluid leaks. Seven patients with cranial base defects underwent reconstructions using a free vastus lateralis muscle flap. In two cases, a vastus lateralis flap was raised to incorporate the anterolateral thigh skin as a myocutaneous flap. In four cases, a free flap was indicated for reconstruction following tumor ablation, and in three cases, for the resolution of wound or cerebrospinal fluid leak complications following previous cranial base surgery. All flaps were successful, with no partial failures. In those patients undergoing tumor ablative surgery, the cranial cavity was effectively sealed from the oronasal cavity. Patients with established wound complications following previous cranial base surgery had a complete resolution of their symptoms. This report discusses the suitability of the vastus lateralis flap for skull base reconstruction in terms of the availability of adequate muscle volume to fill dead space, vascularized fascia to augment dural repairs, and the freedom to use skin if required for internal lining or external skin cover. This flap also provides an extremely long pedicle, allows simultaneous flap harvest, and has low donor site morbidity.     

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 prefabricated scapula flap consists of syngeneic bone, connective tissue, and a self-assembled epithelial coating.

The reconstruction of maxillary defects is a challenge in plastic surgery. The so-called prefabricated scapula flap consists of syngeneic bone covered with syngeneic dermis and is used to reconstruct maxillary defects. After placing these flaps into the oral cavity, they are reepithelialized within a short time period, raising the question of the cellular origin of the "neomucosa." We therefore obtained sequential biopsy samples of the prefabricated flap and of the flap after being placed into the oral cavity and analyzed the keratin expression profile of epithelial cells. We expected that after placing the prefabricated flap into the oral cavity, keratinocytes from adnexal structures of the dermal component of the graft would migrate onto the surface and reepithelialize the flap. Unexpectedly, reepithelialization occurred earlier. The flap had acquired a mucosa-like epithelium at the interface between the Gore-Tex coating and the dermis while still being positioned within the scapular region. The keratin expression profile of this epithelium was very similar to that of mucosal epithelium. Thus, the prefabricated scapula flap not only consisted of bone covered with connective tissue, but was also covered with epithelial cells derived from adnexal structures of the dermal graft. This seems to be the reason for the rapid restoration of an intact mucosa and the excellent outcome achieved with this surgical technique.     

Deepithelialized turnover flaps in burns

Acute and chronic burns leave behind a full-thickness defect that always requires a flap cover. Such defects are common in electrical burn injuries of the limbs. This paper deals with 35 patients with full-thickness defects following burns in whom deepithelialized turnover dermis flaps and deepithelialized turnover flaps with deep fascia have been used. This flap is an extension of Hynes's reversed dermis graft and Smahel's deepithelialized turnover flap where there is a larger area of blood supply on the deeper aspect of the dermis. If a good hinge is provided for safe blood supply, such a flap settles well in the defect, and cumbersome multistaged procedures can be avoided. If there is less fatty tissue in the area of flap used, then reversed dermis flaps are ideal because split-skin graft take is good. When there is a lot of fatty tissue on the undersurface of dermis, the fascia is also included to make it a reversed fasciocutaneous flap to augment the blood supply and for better split-skin graft survival. Advantages of the procedure and complications are elaborated.     

Free tensor fasciae latae perforator flap for the reconstruction of defects in the extremities

In the three cases presented in this study, free tensor fasciae latae perforator flaps were used successfully for the coverage of defects in the extremities. This flap has no muscle component and is nourished by muscle perforators of the transverse branch of the lateral circumflex femoral system. The area of skin that can by nourished by these perforators is larger than 15 x 12 cm. The advantages of this flap include minimal donor-site morbidity, the preservation of motor function of the tensor fasciae latae muscle and fascia lata, the ability to thin the flap by removing excess fatty tissue, and a donor scar that can be concealed. In cases that involve transection of the perforator above the deep fascia, the operation can be completed in a very short period of time. This flap is especially suitable as a free flap for young women and children who have scars in the proximal region of the lateral thigh or groin region that were caused by split-thickness skin grafting or full-thickness skin grafting during previous operations.     

Prefabricated buccal mucosa-lined flap in an animal model that could be used for vaginal reconstruction

Congenital vaginal aplasia, gynecological tumor excision, and male-to-female sex surgery are three clinical conditions in which the plastic surgeon is involved in vaginal reconstruction. Skin-lined or skin-grafted local flaps are currently used, but for many reasons, keratinized skin is not the ideal lining for such a moist cavity because it leads to dryness, desiccation, maceration of the skin, and even hair growth in the cavity. The purpose of this study was to create a subcutaneous cavity lined with mucosa in an area with a predictable blood supply. The abdominal area supplied by the deep circumflex iliac vessels was chosen. Six minipigs were used. Strips of tongue buccal mucosa formed the lining; if additional tissue was required, it was taken from the mucosal aspect of the cheek. The mucosa was expanded by using multiple stab incisions. The mucosa was sutured onto the fascia supplied by the deep circumflex iliac vessels, and the skin incision was closed over a silicone sheet to prevent adhesion to the underlying mucosa. This was left for 1 week to allow the mucosa to take. The prefabricated fascial flap was rolled over a silicone stent and was closed longitudinally to form a cylindrical shape. The flap was placed in a subcutaneous pocket in the right inguinal area. The caudal end was left open and was sutured to the surrounding skin. The silicone stent was used to keep the cavity patent and to prevent adhesions in the early stage of the healing process. Regular digital examination was performed to assess patency and contour; endoscopy allowed assessment of mucosa viability. This method of producing a mucosa-lined flap may provide a solution to the difficult problem of vaginal reconstruction.     

Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.     

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.     

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.     

Free anterolateral thigh adipofascial perforator flap

The anterolateral thigh adipofascial flap is a vascularized flap prepared from the adipofascial layer of the anterolateral thigh region. It is a perforator flap based on septocutaneous or musculocutaneous perforators of the lateral circumflex femoral system. With methods similar to those used for the free anterolateral thigh flap, only the deep fascia of the anterolateral thigh and a 2-mm-thick to 3-mm-thick layer of subcutaneous fatty tissue above the fascia were harvested. In 11 cases, this flap (length, 5 to 11 cm; width, 4 to 8 cm) was used for successful reconstruction of extremity defects. Split-thickness skin grafts were used to immediately resurface the adipofascial flaps for eight patients, and delayed skin grafting was performed for the other three patients. The advantage of the anterolateral thigh adipofascial flap is its ability to provide vascularized, thin, pliable, gliding coverage. In addition, the donor-site defect can be closed directly. Other advantages of this flap, such as safe elevation, a long wide vascular pedicle, a large flap territory, and flow-through properties that allow simultaneous reconstruction of major-vessel and soft-tissue defects, are the same as for the conventional anterolateral thigh flap. The main disadvantage of this procedure is the need for a skin graft, with the possible complications of subsequent skin graft loss or hyperpigmentation.     

Multipaddled Anterolateral Thigh Chimeric Flap for Reconstruction of Complex Defects in Head and Neck

The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge for reconstructive surgeries. Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14–23) cm and the mean width was 4.9 (range: 2.5–7) cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck.     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.