Use of the temporalis muscule flap in blanking out orbits.

We report the use of the temporalis muscle as a transposition flap to obliterate the orbit in 5 patients. In 4 of the cases we split the muscle coronally and passed the anterior part through a window in the lateral orbital wall. In two of these patients, skin grafts were put on both sides of the temporalis muscle-fascia flap, to restore nasal lining and to cover the facial surface simultaneously. In the remaining patients, the muscle was split sagittally to provide a large surface for coverage. The temporalis muscle flap is a versatile one for filling orbits after exenteration.     

Further experience with the lateral arm free flap

Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.     

Buccal flap reconstruction of oropharyngeal defects

AIM: Introduction of a safe and reliable method for reconstruction of soft tissue defects after excision of T1-T2 and borderline carcinomas of the posterior part of the oral cavity and mesopharynx. METHOD: Operation of two male patients suffering from tonsillolingual carcinoma, one with recurrent tumour after irradiation, the other with untreated primary and neck metastasis. After excision of the tumour with mandibular splitting method only a random buccal transposition flap was applied for reconstruction. The flap was adapted anatomically into the defect. It is a modification of previously described methods. RESULTS: Both patients healed primarily with undisturbed blood circulation of the flap. The functional rehabilitation period was short, the flap tolerated the postoperative irradiation, a moderate trismus remained after completion of the treatment, but it was not attributable to the flap. CONCLUSION: The use of the single buccal transposition flap for reconstruction of smaller defects of the posterior part of the oral cavity seems to be a simple, reliable and safe method even after irradiation. The key of the acceptable functional results is the correct adaptation of the flap     

Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients

In this retrospective study, 31 reconstructions using thin anterolateral thigh flaps and six cadaveric dissections of the thigh were investigated in consideration of the anatomic variations of the perforator vessels in the adipose layer, the safe area of flap circulation, and the clinical indications.Three variations of the perforator vessel course in the adipose layer were predicted correctly. The safe radius of a thin anterolateral thigh flap with a thickness of 3 to 4 mm was determined to be approximately 9 cm from the point where the perforator met the skin. The use of a thin anterolateral thigh flap for reconstruction of the neck, axilla, anterior tibial area, dorsum of the foot, circumference on the ankle, forearm, and dorsum of the hand was therefore recommended.     

A new technique of scarless expanded forehead flap for reconstructive surgery

The forehead flap is an ideal flap for reconstructive surgery, especially for that involving reconstruction of the face and neck. However, it is usually limited to use in nasal reconstruction, even when performed in conjunction with tissue expansion, because of the severe visible morbidity of the donor site. In this article, the author discusses his development of a new technique of forehead flap, performed in conjunction with tissue expansion, for reconstructive surgery without visible scarring at the donor site. The technique involved positioning a tissue expander in the forehead pocket under the occipitofrontal muscle and serially inflating the expander over a period of approximately 4 to 6 weeks. Thereafter, an expanded forehead flap was created from the frontal hairline area on the basis of the location of the superficial temporal vessels and transferred into 16 recipient sites in 13 patients as an island flap (n = 8), a free flap (n = 1), or a local random flap (n = 7). The donor site was closed directly into the frontal hairline, without any visible scar. With the author's experience in the use of the island flap for nasal, facial, and neck reconstruction and of the free flap for reconstruction in the extremities, the flap could be as large as 8 x 18 cm without inducing flap necrosis or problems with donor-site closure. All patients (n = 13) had acceptable donor-site aesthetic results, without visible scarring. The results indicate that the flap could be a safe, ample, and color-matched flap for reconstruction of the face and neck and could also diminish donor-site morbidity to a minimum, without an unsightly visible scar. Furthermore, the flap could be formed into a customized free flap, with the above-mentioned advantages, to be transferred to any part of the body.     

Regional intravascular sympathetic blockade for better results in flap surgery: an experimental study of free flaps, island flaps, and pedicle flaps in the rabbit ear

Flap survival is still a major problem in reconstructive surgery. Increased flap survival after systemic administration of drugs inhibiting the adrenergic system has been reported in experimental studies. The clinical use, however, is restricted by systemic side effects. It has been demonstrated that, using guanethidine, an effective regional intravascular sympathetic (RIS) block can be obtained without systemic effects. Using this type of block, an experimental study was made on the survival and quality of different types of flaps in the rabbit ear. The results obtained in 72 flaps created in the ears of 36 rabbits were assessed by the extent of flap edema, peripheral neovascularization, flap temperature, and flap surviving area. The RIS block reduced edema and scab formation, caused higher flap temperatures, better neovascularization, and increased surviving flap area, as compared with equal flaps in the untreated contralateral ear of the same animal. The effect of RIS block may be considered as a "pharmacological delay" procedure. From the experiments as well as clinical experience, it may be concluded that this technique is a safe and effective procedure. Therefore, the RIS block method is recommended for clinical use in flap techniques in extremities of man.     

Treatment of ischial pressure ulcers with a posteromedial thigh fasciocutaneous flap.

This study describes the use of the posteromedial thigh fasciocutaneous flap for the treatment of ischial pressure sores. The authors prefer this flap because it is the fasciocutaneous flap nearest to the ischial region, it is easy to raise, and it causes no donor-site morbidity. In this study, 11 ischial pressure sores in 10 paraplegic patients were closed using the posteromedial thigh fasciocutaneous flaps. All flaps survived, although two caused distal necrosis; after these same two flaps were readvanced, they survived. After an average follow-up time of 77 months, seven of the 10 patients have had no recurrence of ulcers.This fasciocutaneous flap was previously described by Wang et al. However, this study revealed that the arrangement of the vascular pedicle was different from that described by Wang et al. To reveal the vascular supply of this flap, anatomic dissections were conducted. The source of circulation to this flap was the suprafascial vascular plexus, in addition to the musculocutaneous perforator. The dominant pedicle was the musculocutaneous perforator from either the adductor magnus muscle or the gracilis muscle. The key to safe elevation of this flap was the accurate outlining of the skin island directly over the vascular pedicle and the preservation of the proximal fascial continuity. Of the 11 flaps, two viability problems occurred. These partial flap losses resulted from the failure to properly include the perforator. It is the authors' conclusion that the width of the flap should be greater than 5 cm. In addition, it is safe to make a flap within a 1:3 base-to-length ratio in a fatty, diabetic patient. This posteromedial thigh fasciocutaneous flap was found to be a valuable alternative for reconstruction of primary or recurrent ischial pressure ulcers.     

7. The groin flap: a new technique to repair traumatic tissue defects.

Tissue loss from trauma, particularly in the hand and forearm, occasionally requires immediate skin-flap coverage to ensure optimal healing. A consistently safe technique of skin-flap coverage is use of a groin flap. Anatomic studies of this flap have revealed the reliability of blood supply by the superficial circumflex iliac vessels to an area of skin and subcutaneous tissue running paralle to the inguinal ligament lateral to the femoral artery, and the axial relation of the vessels to the flap allows the surgeon to take a longer flap than usual without fear of vascular embarassment. Three case reports illustrate the value of the groin flap in primary soft-tissue closure and in the treatment of acute traumatic injuries.     

Extensor digitorum brevis free flap: anatomic study and further clinical applications

The extensor digitorum brevis muscle flap is reliable, safe, and can be used either as a pedicle or as a free flap with minimal donor site morbidity. To increase the existing knowledge of this flap and to establish further anatomic basis for the design and elevation of the extensor digitorum brevis flap, 26 specimens from 13 fresh cadavers were dissected under 3.5x loupes. The lateral tarsal artery was found to be the main blood supply to the muscle. It has an average diameter of 1.83+/-0.35 mm and a length of 1.89+/-0.69 cm. The dorsalis pedis artery has, at the level of the lateral tarsal artery takeoff, a diameter of 3.25+/-0.62 mm. From this point to the origin of the deep plantar branch, the dorsalis pedis artery has minimal branching, and the surgeon has available an artery homogeneous in diameter that is 6.77+/-0.99 cm in length. Related neurovascular structures (anterior tibial artery and the venae comitantes, dorsalis pedis and first dorsal metatarsal artery, and deep peroneal nerve) were also studied. A safe and reliable harvesting technique and the "T interposed extensor digitorum brevis" technique for sparing the anterior tibial artery are presented, as are clinical case examples on the use of this flap as a flow-through, extensor digitorum brevis-vascularized nerve graft, a combined extensor digitorum brevis-deep peroneal nerve graft, and a bilobed extensor digitorum brevis-dorsalis pedis fasciosubcutaneous free flap.     

Clinical applications of the subgaleal fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.     

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.     

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 thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques

The thoracodorsal artery perforator flap is a relatively new flap that has yet to find its niche in reconstructive surgery. At the authors' institution it has been used for limb salvage, head and neck reconstruction, and trunk reconstruction in cases related to trauma, burns, and malignancy. The authors have found the flap to be advantageous for cranial base reconstruction and for resurfacing the face and oral cavity. The flap has been used successfully for reconstruction of traumatic upper and lower extremity defects, and it can be used as a pedicled flap or as a free tissue transfer. The perforating branches of the thoracodorsal artery offer a robust blood supply to a skin-soft-tissue paddle of 10 to 12 cm x 25 cm, overlying the latissimus dorsi muscle. The average pedicle length is 20 cm (range, 16 to 23 cm), which allows for a safe anastomosis outside the zone of injury in traumatized extremities; the flap can be made sensate by neurorrhaphy with sensory branches of the intercostal nerves. Vascularized bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular artery. A total of 30 pedicled and free flap transfers were performed at the authors' institution with an overall complication rate of 23 percent and an overall flap survival rate of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula formation, recurrence of tumor, and flap loss, occurred in 17 percent of the patients. Despite these drawbacks, the authors have found the thoracodorsal artery perforator flap to be a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction cases.     

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar.The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum.All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps.This article discusses the expanding indications of this versatile flap and the refinements in operative technique.     

Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers

Although the gluteal V-Y advancement flap has been recognized as the most reliable method for management of sacral pressure ulcers, its limited mobility has been a challenging problem. The authors present a new modification of the V-Y advancement flap to overcome the problem. After débridement, a large triangle is designed to create a V-Yadvancement flap on the unilateral buttock and the medial half is elevated as a fasciocutaneous flap, preserving the distal perforators in the muscular attachment. Then an arc-shaped incision is made in the gluteus maximus muscle along with the lateral edge of the triangular flap. The split muscle is elevated at a depth above the deeper fascia until sufficient advancement of the flap is obtained. This full-thickness elevation of the gluteus maximus muscle from the distal (lateral) side avoids the impairment of perforators or their mother vessels and achieves great advancement. Thirty-one patients with sacral pressure defects larger than 8 cm in diameter were treated using this surgical procedure. Overall, 93.5 percent of the flaps (29 of 31) healed primarily. The largest defect that was closed with a unilateral flap was 16 cm in diameter. The present technique accomplishes remarkable excursion of the unilateral V-Y fasciocutaneous flap, with high flap reliability and preservation of the contralateral buttock as well as gluteus maximus muscle function.     

Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction

Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.     

Breast augmentation with bilateral deepithelialized TRAM flaps: an alternative approach to breast augmentation with autologous tissue

Since the 1980s, many patients have benefited from the use of the transverse rectus abdominis musculocutaneous (TRAM) flap for postmastectomy reconstruction. In addition to cancer reconstruction, this technique has recently been used to treat patients with breast implant intolerance and for reconstruction after siliconoma resection. However, physicians and patients alike believe that such an extensive procedure should not be used for aesthetic purposes, and to the authors' knowledge, no study has been reported on the use of pedicled TRAM flaps for aesthetic augmentation mammaplasty. In the past several years, a number of the authors' patients have requested simultaneous breast augmentation and abdominoplasty. These patients objected to the use of prosthetic implants because of potential complications such as implant failure, capsular contracture, wrinkling, and palpability. Therefore, from 1995 to 2000, the authors performed 14 cases of bilateral breast augmentation with deepithelialized, pedicled TRAM flaps. In this series, the donor-site complication rate was similar to that of the traditional TRAM flap. Surprisingly, no cases of complete or partial flap loss were clinically detected. The only complaints were pedicle bulges at the costal margins. These patients were all extremely satisfied with the results. It was concluded that the TRAM flap is safe for augmentation in a subset of carefully selected women with hypoplastic or atrophic breasts. The authors discuss patient selection, technique, and their experience with this method of breast augmentation.     

The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps

The midabdominal rectus abdominis myocutaneous flap is described in this review of 236 flaps in 223 patients. This flap is safe, reliable, and extremely well vascularized. It has been our flap of choice for purposes of reconstructing the moderate- or large-sized breast. In particular, the midabdominal flap permits restoration of fascial continuity over the entirety of the abdominal wall without the necessity for synthetic materials. A 2.2 percent incidence of hernias has been observed over a 4-year period. The flap is well suited to immediate reconstruction of the breast, particularly among the growing number of patients with antecedent radiation therapy.     

Scapular free-flap dissection made easier

An improved technique for the dissection of the scapular free flap is presented. It includes identification of the triangular space by palpation and delivery and deep dissection of the proximal flap pedicle by means of a counterincision in the axilla. This technique allows for a rapid, safe, and easy dissection of the transverse scapular 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.