Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele

Reconstruction of a large meningomyelocele defect with bilateral latissimus dorsi V-Y musculocutaneous flaps is reported. This procedure provides a reliable, well-vascularized soft-tissue coverage over the neural repair with minimum donor-site morbidity.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

Immediate and long-term management of gunshot wounds to the lower face

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

Improved technique for a one-stage repair of significant defects of the ear

An improved technique for repair of severe acquired partial defects of the auricle in one stage is described. The common postauricular flap with its base on the margin of the auricular defect is usually unable to repair a severe partial auricular defect in one stage because of the limited length of the flap. The authors developed this technique by means of lengthening the flap with a piece of subcutaneous tissue of the scalp, so that the ear framework can be covered completely in one stage. All flaps in this group survived totally. Seven patients with severe acquired partial defects of the auricle underwent this procedure, and good results were obtained.     

Upper extremity microsurgery

Learning objectives: After studying this article, the participant should be able to: 1. Understand the indications for free flap coverage of the upper extremity. 2. Know the advantages and disadvantages of the flaps discussed. 3. Have a basic understanding of the anatomy of the flaps discussed. 4. Have a variety of options for free tissue transfer.The application of microsurgical tissue transfer to reconstruction of the upper extremity allows repair of significant bone and soft-tissue defects. Through the years the approach has changed from one of simply getting the wound covered to primary reconstruction to preserve or regain function. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the arm and hand. Vascularized bone transfer can be utilized to repair large bony defects, while innervated free muscle transfer can replace missing muscle function. The total array of flaps and their indications is beyond the scope of a single discussion, but this article focuses on a few flaps that have found application for coverage and functional restoration in the hand and upper extremity.     

A simple technique for closure of a palatal fistula using a conchal cartilage graft.

A simple technique for closure of a palatal fistula using a conchal cartilage graft as a substitute for nasal lining flaps is reported. This graft simplifies the repair of the palatal fistula and protects the suture line of the oral covering flaps from recurrence.     

Geometric limit of multiple local Limberg flaps: a flap design.

The Limberg rhombic flap is a reliable and widely used technique in head and neck surgery. Since Limberg introduced his original design in 1946, several modifications of the technique have been described. Although a single Limberg flap is frequently used at the face to close small to medium defects, multi-Limberg flap techniques can help the surgeon to cover moderate to large defects of the extremities, trunk, and back. In this study, a design of four neighboring local Limberg flaps to cover a moderate to large defect without using a skin graft is introduced. It is believed that this design is the geometric limit of multiple Limberg flaps that can entirely cover a single large rhombic defect, because one Limberg flap unit can only be adjoined by three others, one from the tip and two from the sides. This flap design of four local Limberg flaps is also the only geometrically possible design that can keep all the bases of these four flaps free of incisions if one attempts to prepare four small Limberg flaps around a large rhombic defect.     

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.     

Nail lengthening and fingertip amputations

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult. In the period between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be used with different flaps for pulp reconstruction.     

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.     

Split-thickness skin grafting of the myelomeningocele defect: a subset at risk for late ulceration

The appropriate method and timing of the management of the myelomeningocele defect have prompted considerable discussion. Use of split-thickness skin grafts acutely has accomplished wound closure with low morbidity and mortality. This study was designed to address the question of long-term suitability of the technique of split-thickness skin grafting of the myelomeningocele patient. The incidence of late and/or severe skin ulceration and the presence of gibbus deformity were correlated with the method of skin closure. Long-term follow-up revealed a higher incidence of chronic skin ulceration in the split-thickness skin graft group as compared with the primary closure group. All skin breakdowns appeared in the presence of a gibbus deformity, and gibbus deformity was more prevalent in the split-thickness skin graft group. The incidence of skin ulceration and gibbus deformity was site-dependent. A thoracic or thoracolumbar myelomeningocele repair with split-thickness skin graft was significantly more likely to be complicated by skin problems than the defect in the lumbar, lumbosacral, or sacral region. This relationship was secondary to the frequency of gibbus deformity in the more cephalad defects than defects caudad. A treatment plan is outlined that is based on the primary variable of the location of the myelomeningocele and secondarily by defect size.     

The external oblique flap for reconstruction of the rectus sheath.

Despite the availability of synthetic materials and distant fascial flaps, primary closure of ventral abdominal defects with contiguous tissues remains the preferred solution. Increased experience with such defects in the lower abdomen, particularly at the time of bilateral rectus muscle transposition, led in 1985 to the investigation of an external oblique abdominis flap for closure of the anterior rectus sheath. From October of 1985 to October of 1990, 33 patients underwent repair of bilateral lower rectus abdominis defects with the help of bilateral external oblique flaps. Each of the patients had undergone synchronous chest or breast reconstruction using a transverse rectus abdominis musculocutaneous flap including bilateral rectus muscle pedicles. Although all patients in this study had undergone double-pedicle rectus muscle procedures, not all patients having had double-pedicle rectus muscle procedures required this maneuver. External oblique flaps were performed at the time of rectus sheath repair only if fascia could not be approximated without tearing. After closure of the bilateral paramedian defect, synthetic mesh overlay was added only if the direct closure still appeared excessively tight. At the time of advancement of the external oblique muscle and fascia, the internal oblique abdominis muscle and lateral cutaneous nerve of the thigh were preserved. Of the 33 patients who underwent this procedure, 7 required the addition of mesh overlay. Thirty-two patients healed uneventfully with a remarkably solid ventral abdominal wall. One patient developed an early postoperative hernia subsequent to a major and prolonged abdominal-wall infection and abscess. Patient follow-up ranged from 1 to 36 months, with a mean of 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

The fasciocutaneous flap: a conservative approach to the exposed knee joint

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.     

Experience with the Furlow double-reversing Z-plasty for cleft palate repair

One-hundred and six cases of soft palate closure using the Furlow double-reversing Z-plasty technique have been reported. Most of these patients have been done in the past 2 years. There seem to be a number of worthwhile advantages to this procedure, with few disadvantages or complications. The operation is adaptable for use in early soft palate closure (3 to 6 months) as well as late closure (12 to 14 months), in submucosal clefts, as well as in secondary palatal repair where lengthening and repositioning of the levator muscle is desired. With this type of palatoplasty, the need for raising or shifting large mucoperiosteal flaps from the hard palate has been completely avoided. The operation can be combined with a primary posterior pharyngeal flap if desired, although this is not advised if early palatal closure (3 to 6 months) is used because of a high incidence of sleep apnea. Preliminary speech results are very encouraging.     

Advances in plastic surgery

The influence of the war period has been reflected in an active trend toward the conservation of time in the execution of reconstructive operations. The myriad improvements in the technique of tissue transplantation and the use of large flaps rather than tubed pedicles have been in keeping with this trend. The goal of the complete restoration of function and appearance applies not only to the correction of post-traumatic defects but also to the cosmetic repair of defects created by the surgical excision of malignant tumors and to correction of congenital anomalies.     

ADVANCES IN PLASTIC SURGERY

The influence of the war period has been reflected in an active trend toward the conservation of time in the execution of reconstructive operations. The myriad improvements in the technique of tissue transplantation and the use of large flaps rather than tubed pedicles have been in keeping with this trend. The goal of the complete restoration of function and appearance applies not only to the correction of post-traumatic defects but also to the cosmetic repair of defects created by the surgical excision of malignant tumors and to correction of congenital anomalies.     

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.     

Double-Z rhombic technique for reconstruction of facial wounds

The double-Z rhombic technique of repair of excisional defects is characterized by borrowing the required tissue from two nonadjacent opposite sides of the defect. Most other flaps borrow the required tissue from a single adjacent region or all adjacent directions. The "sharing" of tissue from two opposite regions minimizes tension in that direction, while not borrowing from the remaining regions prevents the distortion of anatomic landmarks located along that direction. The orientation of the final scar and direction of tissue tension can be controlled by rotating the rhombic defect about its central axis. This study was undertaken to assess the utility of the double-Z rhombic technique in terms of cosmesis and avoidance of displacement of mobile anatomic landmarks such as eyelids, eyebrows, nasal alae, and lips. Excisional defects resulting from removal of skin neoplasms in 30 patients in whom primary closure or reconstruction with direct tissue advancement was not feasible and displacement of facial landmarks was undesirable were reconstructed using the double-Z rhombic technique. No considerable asymmetry or facial anatomic landmark deformity was observed in any of the 30 patients. Our results are presented along with representative illustrations.