Posterior interosseous free flap with extended pedicle for hand reconstruction

The anatomy of the posterior interosseous vessels makes them suitable as a donor area of free flap. The skin island can be designed on the perforating vessels of the distal third of the forearm, up to the dorsal wrist crease, to increase the pedicle length (7 to 9 cm). A series of nine flaps transferred to reconstruct hand defects is presented. All flaps were designed over the dorsal distal forearm, and dimensions permitted direct closure of the donor site (up to 4 to 5 cm wide). Apart from a linear scar, donor morbidity was negligible. All transfers were successful. Although its dissection is somewhat tedious, the anatomy of the vascular pedicle is suitable for microanastomosis and the skin island is thin, although hairy. The posterior interosseous free flap with extended pedicle may be a good choice when limited amounts of thin skin and a long vascular pedicle are needed.     

Late reconstruction of two total metacarpal bone defects using lengthening devices and a double-barrel osteocutaneous free parascapular flap

A case was presented in which the late reconstruction of left ring and little metacarpal bone defects was carried out using a lengthening device and a double-barrel osteocutaneous free parascapular flap. With this flap, up to 14 cm of nearly straight bone of a suitable width and length for the reconstruction of two metacarpal bones was raised safely. However, it required 3 months of lengthening to create enough space to insert the grafted bone because of the severe resistance of scar contracture and fibrous tissues.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap

Reconstruction of composite defects of the mandible is a challenging problem. Although the use of an osteocutaneous free flap, alone or in combination with another soft-tissue free flap, is generally accepted to be optimal, the bony reconstruction is sometimes undervalued, especially when the cancer is advanced. In such situations, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap. Between January of 1997 and July of 2000, 80 patients with composite or extensive composite oromandibular defects underwent treatment with a reconstruction plate and a soft-tissue free flap. All of the patients were male, and the ages of the patients at the time of treatment ranged from 32 to 78 years (mean, 51 years). Tumors were classified as stage IV in 56 patients (70 percent), whereas the remaining 24 patients (30 percent) had recurrent carcinomas. The titanium mandibular reconstruction system manufactured by Stryker (Freiburg, Germany) was used to bridge the mandibular defects. The soft-tissue free flaps used for wound and plate coverage were as follows: anterolateral thigh flap (n = 75), radial forearm flap (n = 3), transverse rectus abdominis myocutaneous flap (n = 1), and tensor fasciae latae flap (n = 1). Five patients with recurrent carcinomas and 10 with stage IV carcinomas (18.75 percent) died 2 to 6 months after the operation and were excluded from the study. The remaining 65 patients were monitored for an average follow-up period of 22 months (range, 6 to 40 months). During that period, one or more complications occurred for 45 patients (69.2 percent). Plate exposure was the most common complication and was observed for 30 patients (46.15 percent). Twenty of the 65 patients (30.8 percent) required secondary salvage reconstruction with a fibula osteoseptocutaneous flap. The decision to perform a secondary salvage procedure was based on the general health of the patient, the extent of local disease, and the severity of the complications. Patients underwent salvage operations after an average of 11.5 months (range, 6 to 26 months). The major reasons for the second operation were as follows: reconstruction plate exposure (n = 12), soft-tissue deficiency and mandibular contour deformation of the lateral face (n = 7), intraoral contracture and lack of a gingivobuccal sulcus (n = 6), trismus (n = 4), and osteoradionecrosis of the mandible (n = 2). The total flap survival rate was 90 percent (18 of 20 free flaps). In two cases, the skin paddles of the fibula osteoseptocutaneous flaps exhibited partial failure and were revised with pedicled pectoralis major and deltopectoral flaps. The reconstruction plate and free soft-tissue flap procedure for the reconstruction of composite defects of the oromandibular region has many late complications, which eventually necessitate reconstruction of the mandible with an osteocutaneous free flap.     

Extensor digitorum brevis as an island flap in the reconstruction of soft-tissue defects in the lower limb

The extensor digitorum brevis island flap is a versatile and robust flap able to provide adequate bulk and coverage in soft-tissue defects of the lower limb. The donor-site deformity is limited to the necessary scar needed to approach and rotate the muscle. An anatomic study was performed in 10 fresh cadavers and consisted of two parts: study of the muscle flap itself, and examination of skin vascularization. Methylene blue and Salmon's mass (radiopaque) were injected through the three main arteries of the leg. Muscle and cutaneous staining were noted. Clinical applications of this flap are reported. These resulted in successful healing of the defect with good aesthetic and functional results on both recipient and donor sites. Long-term follow-up was maintained for up to 21 months.     

Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs

Flow-through thin latissimus dorsi perforator flaps were used in six cases with complicated defects of the legs. This flap has a small amount of latissimus dorsi muscle with a considerable amount of fatty tissue removed to make a thin flap. In addition, the flap has several branches of the subscapular vessel, which are interposed to the recipient vessels of the legs. The advantages of this thin flap are: (1) flow-through vascular reconstruction can preserve the main vessels of the damaged legs; (2) the double arterial inflows and venous drainage systems of the flap ensure safe vascularization of the flap; (3) a flow-through venous drainage system from the distal extremities can also be established to prevent congestion of the affected legs; (4) this flap is versatile (it can be either thin or large); and (5) even in emergent ischemic legs, simultaneous elevation of the flap is possible with preparation of the legs. This flow-through flap is indicated for: (1) cases with a large skin defect and obstruction of the main vessels in the leg; (2) cases with a possibility of tumor recurrence in the legs; and (3) young women or girls with a large defect in the legs, rather than the rectus abdominis musculocutaneous flap.     

The free thoracoumbilical flap for resurfacing large soft-tissue defects of the lower extremity

Both cadavers and living patients were studied regarding a method to resolve large skin defects with bone exposure in the leg, with long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. Forty-six casting mold specimens of cadaveric legs were investigated. There were rich communication branches among the anterior tibial artery, posterior tibial artery, and fibular artery in the foot and ankle, which complemented each other well. Twenty-six patients with large skin defects with bone exposure in the proximal or middle segment of the leg were admitted to the authors' hospital. Among those patients, 19 demonstrated long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. During treatment, a thoracoumbilical flap based on the inferior epigastric vessels was anastomosed to the distal stump of the anterior tibial vessels or the posterior tibial vessels, with reversed flow. All defects were successfully repaired, with good color and texture matches of the flaps. This method can be used for patients with normal anterior tibial vessels or posterior tibial vessels, normal distal stumps of the injured blood vessels, and good reversed flow. The method has the advantages of dissecting blood vessels in the recipient area during the débridement, not affecting the blood circulation of the injured leg, not sacrificing blood vessels of the opposite leg, and not fixing the patient in a forced posture. The muscles are less bulky in the distal one-third of the leg, and the blood vessels are shallow and can be dissected and anastomosed easily. When the flap is used for reconstruction in the proximal two-thirds of the leg, the blood vessel pedicle of the free flap is at a straight angle, without kinking.