Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.     

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.     

Refinements in abdominoplasty with emphasis on reimplantation of the umbilicus

First, the author describes the suprapubic deepithelialized triangular flap to eliminate the dead space that can result when the abdominal flap, elevated from the periumbilical zone, meager in fatty tissue, is sutured to the thick pubic region. Second, because of the frequently poor quality of circular periumbilical scars, the author proposes a superiorly based, round-shaped flap taken from the future umbilical location and then defatted. The umbilical cylinder is divided vertically down to its aponeurotic attachment to permit insertion of this round skin flap, which is then anchored to the aponeurosis and to the edge of the triangular gap. This method prevents retracted periumbilical scars. Finally, in secondary corrections after abdominoplasty, satisfactory results can be obtained only if the umbilicus is detached from either the skin or the aponeurosis. The author's technique for covering the hole at the old umbilical location makes use of a round flap from the new umbilical site.     

Sideburn reconstruction with an arterial V-Y hair-bearing scalp flap after the excision of basal cell carcinoma

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.     

Pharyngoesophageal reconstruction using a fabricated forearm free flap

A new microsurgical alternative in reconstruction of the pharynx and cervical esophagus is reported. A trapezoidal forearm flap is fabricated into an inverted skin tube and placed in the pharyngoesophageal defect. Although microvascular anastomoses are required to revascularize the transferred forearm flap, the long and large nutrient vessels of the flap make anastomoses easy and reliable. None of our 12 patients demonstrated any necrosis of the transferred flap. This one-stage, less invasive operation for pharyngoesophageal reconstruction greatly benefits older persons, who are the more likely to be involved with pharyngoesophageal carcinomas.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Free omental flap for partial breast reconstruction after breast-conserving surgery

Recent advances in endoscopic surgery have allowed laparoscopic harvesting of the omental flap with reduced donor-site morbidity and deformity. Between August of 2004 and May of 2010, the authors performed immediate breast reconstruction with the free omental flap in 10 breast cancer patients, employing it either as a pedicle flap or as a free flap for volume replacement. Only one complication occurred during the follow-up. Cosmetic results were mostly satisfactory. The free omental flap is a safe procedure with minimal donor-site morbidity and deformity and can be an additional option for immediate partial breast reconstruction after breast-conserving surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Breast reconstruction after a radical mastectomy.

Breast reconstruction after a radical mastectomy remains a complex problem. We describe the use of a latissimus dorsi myocutaneous flap, a transverse abdominal flap, or a pedicled flap of the greater omentum to obtain satisfactory cover for the implant and enable us to correct the deformity in one operation.     

Reverse anterior tibial artery flap for reconstruction of foot donor site

The foot offers numerous useful options for hand reconstruction. Hallux transfer, dorsalis pedis flap, second toe transfers, and toe joint transfers offer good functional results in reconstructed hands. However, when the donor site is repaired with skin grafts, delayed wound healing, scarring, and contractures often result. Poor cosmesis of the donor site and altered gait are the main drawbacks of the procedures. The authors propose a new concept of primary reconstruction of the donor foot using a reverse-flow anterior tibial flap from the same leg. Two flaps are raised from the same anterior tibial vessel system in continuity as a distal free flap for hand reconstruction and as a proximal reverse-flow pedicled flap to resurface the donor defect. This technique allows good flap reconstruction of the foot donor site, reducing morbidity and limiting the operation to the same limb. The authors report their experience of 33 cases. There were no failures. Primary wound healing was achieved in the foot donor site, with acceptable cosmesis and satisfactory function.     

Optimizing autologous breast reconstruction in thin patients

Breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap plus an implant has been proposed as an option for women with a thin body habitus who do not have sufficient abdominal tissue to permit reconstruction with a TRAM flap alone. The standard autologous tissue reconstructive procedure in these women is a combined latissimus dorsi myocutaneous flap and breast implant. We reviewed our experience performing TRAM flap/implant and latissimus dorsi flap/implant breast reconstruction to compare complication rates and aesthetic outcomes between these two types of reconstruction. Between 1992 and 1999, 88 breasts were reconstructed at our institution using an autologous tissue flap combined with a breast implant (44 with a TRAM flap/implant and 44 with a latissimus dorsi flap/implant). Recipient-site and donor-site complications for the two procedures were compared using Fisher's exact test; a panel of unbiased, blinded judges compared the aesthetic outcomes. The recipient-site complication rate was lower for the TRAM flap/implant group than for the latissimus dorsi flap/implant group (18 percent versus 34 percent, p = 0.09). Most recipient-site complications in the TRAM flap/implant group were related to fluid collection around the implant. In the TRAM flap/implant group, complications occurred in 37 percent of the reconstructions that had immediate implant placement and in none of the reconstructions with delayed implant placement (p = 0.01). In the TRAM flap/implant reconstructions with immediate implant placement, the recipient-site complication rate was 50 percent when implants were completely filled with saline, but no complications occurred with incompletely filled, postoperatively adjustable implants (p = 0.03). No microvascular complications occurred with immediate placement of breast implants under TRAM flaps. Donor-site complications included a hematoma, a seroma, and an umbilical necrosis in the TRAM flap/implant group and six cases of seroma formation in the latissimus dorsi flap/implant group. The comparison of aesthetic outcome was statistically significant for the TRAM flap/implant group, which had a higher overall mean score than the latissimus dorsi flap/implant group did (3.29 versus 2.85, p = 0.01). The results of this study suggest that the TRAM flap/implant breast reconstruction should be considered as an alternative to the latissimus dorsi flap/implant breast reconstruction in women with a thin body habitus.     

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.     

The midabdominal TRAM flap for breast reconstruction in morbidly obese patients

The transverse rectus abdominis myocutaneous (TRAM) flap is ideal for postmastectomy reconstruction but is tenuous in morbidly obese patients. Because of their relatively high incidence of postoperative complications, morbidly obese patients are often not considered candidates for autogenous reconstruction. The midabdominal TRAM flap has a more favorable anatomy and may represent an alternative technique in this patient population. The records of 18 morbidly obese patients who underwent postmastectomy reconstruction using a mid-abdominal TRAM flap from 1998 through 2002 were retrospectively reviewed. The mid-abdominal TRAM flap territory includes more of the supraumbilical region than the traditional TRAM flap, corresponding to an area with more abundant musculocutaneous perforators and greater dependence on the superior epigastric vascular system. All patients underwent unipedicled mid-abdominal TRAM flap surgery. Four patients with previous subumbilical midline incisions had a delay procedure with ligation of the inferior epigastric vessels. Complications investigated were flap necrosis greater than 10 percent or sufficient to require surgical revision, abdominal donor-site breakdown, seroma formation, umbilical necrosis, abdominal wall bulging or hernia, deep vein thrombosis, infected mesh, surgical revisions, fat necrosis, and extended hospital stay. At a mean follow-up time of 15.6 months (range, 12 to 24 months), three patients had postoperative complications requiring surgical revision. Two of these patients had previous midline abdominal incisions. One patient had both partial flap necrosis and a donor-site complication. The second patient had partial flap necrosis, and the third had an abdominal donor-site complication. No occurrences of abdominal wall hernia, total flap loss, deep vein thrombosis, infected mesh, extensive surgical revision, or extended hospitalization were noted in this series. The mid-abdominal TRAM flap represents an alternative method for postmastectomy breast reconstruction in morbidly obese patients. Autologous reconstruction using a midabdominal TRAM flap may be considered in this patient population; however, additional research is required to conclusively demonstrate an improved outcome when compared with traditional reconstructive methods.     

Vaginal reconstruction after extended radical pelvic surgery for cancer: comparison of two techniques

An immediate partial or total vaginal reconstruction is frequently proposed in cases of exenterative or extended radical pelvic surgery for cancer treatment. One of the main complications after this reconstruction is the vagina obliteration caused by the healing process. This study compares the results of two different reconstructive techniques, particularly focusing on general complications and the risk of vaginal occlusion. A transversus rectus abdominis musculoperitoneal (TRAMP) composite flap has been performed in five cases, and an inverted inferior transverse rectus abdominis musculocutaneous flap (TRAM) has been used in another five cases. Recovery was uneventful in eight cases. One patient (case 5) developed an aortofemoral embolism requiring a bilateral transfemoral embolectomy and heparin administration. Another patient (case 9) experienced severe peritonitis because of the partial leak of the rectal anastomosis, and therefore a Mikulicz's colostomy was performed. Four patients who underwent the TRAMP flap developed a complete closure of the neovagina. In one patient with a TRAMP flap, a severe shortening (2 cm) of the neovagina occurred. Five patients out of five who underwent a reconstruction with a TRAM flap had a stable length of the neovagina (6 to 12 cm) and no shrinkage in diameter occurred, even though a vaginal stent was not used. The conventional inferior TRAM flap with a skin paddle seems to better maintain a stable length of the neovagina than the TRAMP composite flap with peritoneum.     

Eyelids and eye socket reconstruction using the expanded forehead flap and scapha composite grafting.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.     

Technique of foot lengthening and shaping with free vascularized iliac osteocutaneous flap.

The iliac osteocutaneous flap has been used widely to replace bony defects of the mandible and the extremities. We report a further application of this flap in foot reconstruction. The iliac osteocutaneous flap proved to be of value to augment both soft tissue and bone in a transmetatarsally amputated foot. This resulted in satisfactory function and an appealing cosmetic result, allowing the patient to wear normal shoes. Flap design and secondary contouring procedures are described for the success of this reconstruction.     

A free arterialized venous loop flap.

An arterialized venous loop flap measuring 6 x 16 cm was transferred from the left forearm to the right lower leg for reconstruction of an unstable skin graft on the tibia. The transferred flap became softer and thinner, as intended, after ligation of the afferent artery, which was performed 50 days after the first operation. The operative results were satisfactory.     

Bilobed fasciocutaneous flap for reconstruction of the posterior neck after necrotizing fasciitis

Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with necrosis of overlying skin. Eleven cases of necrotizing fasciitis of the posterior neck are reviewed to demonstrate the advantage of using a bilobed fasciocutaneous flap for repair following surgical debridement. Nine men and two women aged 40 to 65 years (mean age, 54.8 years) presented for reconstruction from April of 1999 to March of 2003. The blood supply of the bilobed fasciocutaneous flap originates from a constant row of musculocutaneous perforators of posterior intercostal arteries. The technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results.     

Versatility of the medial plantar flap: our clinical experience

The medial plantar flap presents an ideal tissue reserve, particularly for the reconstruction of the plantar and palmar areas, which require a sensate and unique form of skin. In the past 5 years, the authors performed 16 free flaps, 10 locally pedicled flaps, and five cross-leg flaps on 31 patients for the reconstruction of palmar and plantar defects. All flaps transferred to the palmar area survived, providing good color match and sufficient bulkiness. The overall results were satisfactory in terms of function and sensation, and no complications related to flap survival in the plantar area were observed. All flaps used to cover defects in the heel and ankle region adapted well to their recipient areas, and all lower extremities remained functional. Because the medial plantar flap presents glabrous, sensate skin with proper bulkiness and permits the movement of underlying structures, the authors advocate its use and view this procedure as an excellent alternative in the reconstruction of palmar and plantar weight-bearing areas.     

Functional reconstruction after a total maxillectomy using a fibula osteocutaneous flap with osseointegrated implants

The fibula osteocutaneous flap with osseointegrated implants was used for reconstruction of a total maxillectomy defect. We have achieved satisfactory reconstruction of three-dimensional facial structure, orbit support, and a functional prosthesis. Our procedure restored the patient's masticatory function of the maxilla and enabled good speech and a natural facial appearance. A very high quality of function was obtained without any complications, but long-term follow-up is necessary for maintenance of the implants.     

Difficult reconstruction of an extensive injury in the lower extremity with a large cross-leg microvascular composite-tissue flap containing fibula

In the absence of proper recipient vessels, a large microvascular composite-tissue flap was transferred successfully for reconstruction of a leg with an extensive crush injury. This was accomplished by using vessels of the normal leg. The microvascular flap containing skin, muscle, and 15 cm of fibula survived well after division of the pedicle. To achieve good bone healing, the leg was protected by a brace while gradually increasing weight bearing. The functional result is satisfactory.