The lateral intercostal neurovascular free flap

The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.     

Multiple and repetitive uses of the extended hamstring V-Y myocutaneous flap

An extended hamstring V-Y myocutaneous advancement flap is described that may be used to cover unusually large defects in the ischial region. Technical points that allow a large amount of flap advancement are discussed. Because of its large size, the flap can be raised and used on repeated occasions to repair defects from recurrent ischial pressure sores. Two patients are presented in whom the same flap was used repeatedly on multiple occasions, demonstrating the potential for preservation of future options in such patients when this flap is used.     

Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps

Two types of perforators, septocutaneous and musculocutaneous, are found in the same donor site of the flank area, and two perforator flaps based on each perforator are clinically available. Therefore, it is necessary to distinguish them from one another using different nomenclatures. Accordingly, the perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, the latissimus dorsi perforator flap, and the perforator flap based on a septocutaneous perforator, located between the serratus anterior and latissimus dorsi muscles, is named according to the name of the proximal vessel, the thoracodorsal perforator flap. In this series of 42 latissimus dorsi perforator flaps, flap size ranged from 5 x 3 cm to 20 x 15 cm, and two complications were observed: a marginal necrosis in an extremely large flap (26 x 12 cm) and a failure caused by infection. The thoracodorsal perforator flap was used in 14 cases, including two cases of chimeric composition. Flap size ranged from 4.5 x 3.5 to 18 x 15 cm, with no complications. In the two patterns of perforator flap that the author used, initial temporary flap congestion was observed in five latissimus dorsi perforator flap cases and two thoracodorsal perforator flap cases, when the flap was designed as a large flap or a less reliable perforator was selected. However, the congestion was not serious enough to cause flap necrosis. Several techniques, such as T anastomosis or inclusion of an additional perforator or a small portion of muscle, are recommended to prevent the initial flap congestion, especially when an unreliable perforator is inevitably used or when a flap larger than 20 cm long is required. A small portion of the muscle was included in six cases, when an unduly large or improperly long flap was planned. All of the flaps were successful and ranged from 22 x 7 to 15 x 28 cm, except for one case of distal flap necrosis in an extraordinarily large flap measuring 34 x 10 cm. Diverse selection of the perforator flap is one of the great advantages of the flank donor site, providing it with wider availability and more versatile composition for reconstruction or resurfacing.     

Temporoparietal fascial flap for orbital and eyelid reconstruction.

The temporoparietal fascial flap is a recognized technique for the transfer of vascularized tissue in the craniofacial region. The flap has a predictable axial vessel, provides thin vascularized tissue, and can be harvested with minimal donor-site morbidity. The temporoparietal fascial flap is well suited for orbital or eyelid reconstruction because of its proximity to the orbit. The flap is useful for reconstruction of anatomic barriers between the orbit, intracranial cavity, and paranasal sinus spaces. We present four patients in whom the temporoparietal fascial flap was used for orbital reconstruction following extirpative surgery for orbital neoplasm and two patients in whom the flap was used for lower eyelid and malar reconstruction.     

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.     

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.     

Frontalis musculocutaneous island flap for coverage of forehead defect

The use of the frontalis musculocutaneous flap as a pedicle island flap offers some advantages in frontal reconstruction. It can be used for immediate reconstruction following the ablation of a small or moderate area, even after harvesting of the frontal flap for nasal reconstruction. Because of its intact lateral bundle, it has the potential to carry some sensory innervation, albeit minimal, to the reconstructed area. We have found the frontalis musculocutaneous flap, when used as a pedicle island flap, to be an adaptable and dependable alternative flap for repairs after small or moderate resections in the frontal region. This flap could be performed immediately and in one stage, have a low morbidity rate, and allow a rapid aesthetic restoration; and, it is easy to perform. In two cases, we have observed some degree of venous congestion in the island during the early postoperative period but with success in final healing. The experience demonstrates that this flap should be considered as another valuable tool in reconstructive efforts directed at the forehead. We propose a novel method for the forehead reconstruction using the frontalis musculocutaneous island flap. A case is presented that demonstrates the use of this flap for repair in a depressed frontal defect.     

A newly defined conchal floor arterial flap for auricular reconstruction

A conchal floor composite flap pedicled by skin of the helical crus has been well described in the literature. Here the flap is elevated based on the supply by an upper auricular branch of the superficial temporal artery. In this article, a newly defined conchal floor arterial flap is proposed. The flap is based on the main stem of the posterior auricular artery and its venae comitantes. Two types of conchal floor arterial flaps were elevated: a proximally based chondral arterial flap and a distally based chondrocutaneous arterial flap. The proximally based flap was used for earlobe reconstruction, whereas the distally based flap was useful in the reconstruction of the upper auricle. Nine congenital auricular malformations were successfully corrected with this newly defined conchal floor flap procedure. This type of flap is easier to elevate, more reliable, and more versatile than the one currently in use.     

Free-flap free flap

We present a patient who sustained bilateral below-knee amputations that were treated with skin grafts as initial coverage. A latissimus dorsi free flap was later used as definitive coverage of one stump. Then at a subsequent operation a portion of the same latissimus dorsi free flap was reharvested, again as a free flap, and transplanted to cover the contralateral stump. Thus one latissimus dorsi free flap was used twice as a free flap (free-flap free flap) to cover bilateral amputation stumps in sequential operations.     

Submammary flap for correction of severe sequelae from augmentation mammaplasty

A submammary flap was used in 20 patients with severe cicatricial retractions and loss of the inferior pole of the breast caused by inadequately treated mammary implant infections. This axial flap can be used with a medial pedicle, based on the perforating branches of the epigastric artery or the distal part of the internal mammary artery, or laterally based, nourished by the intercostal perforators. After 6 months, reimplantation was performed in 15 patients. The authors' follow-up ranged between 8 months and 6 years. This transverse adipocutaneous flap procedure is very simple to perform, the donor site is sutured primarily without additional undermining, and the resultant scar lies hidden within the submammary fold. It provides tissue with similar skin texture and color match. Its versatility allows it to be used as a full-thickness tissue replacement or partially or totally de-epithelialized for soft-tissue reconstruction. It can also be used as an island flap. For all of these reasons, in emotionally distressed patients with low compliance with surgical treatments and additional scars, this flap is the authors' flap of choice for reconstruction.     

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

Retroauricular island flap for eye socket reconstruction

This paper describes the use of a flap which is the random portion of an island flap based on superficial temporal vessels. The flap has three distinct anatomic portions: the cutaneous portion, which includes the postauricular skin, the triangular deepithelialized scalp and fascia above the ear, which augments random-pattern blood circulation to the cutaneous portion, and the superficial temporal fascia encompassing the vascular pedicle, which is dissected down to the upper pole of the parotid gland and unfolded using a cutback incision between the vascular pedicle and the second portion of the flap in order to increase the reach of the cutaneous portion. The flap has been successfully used in eight patients for reconstruction of missing or contracted eye sockets. In two patients, inconsequential superficial loss of the distal portion of the distal flap was observed. This flap can also be used for reconstruction of the external face, eyelid, and palate as well as soft-tissue augmentation.     

A versatile one-stage neurovascular flap for fingertip reconstruction: the dorsal middle phalangeal finger flap.

The dorsal middle phalangeal finger flap is an extremely reliable flap that is indicated for fingertip injuries which require sensory reconstruction. This flap originates from the dorsum of the middle phalanx of the finger and is elevated with a vascular pedicle of the digital artery and the dorsal branch of the digital nerve. After transfer of the flap to the injured site, epineural neurorrhaphy is done between the digital nerve and the dorsal sensory branch of the flap. This flap can be thought of as an island flap of the innervated cross-finger flap that provides excellent sensory recovery and aesthetic improvement. We used this flap in a series of eight consecutive patients and were able to follow up seven patients for longer than 6 months (mean follow-up time 10.7 months). All patients achieved measurable two-point discrimination, with an average of 4.9 mm in the moving two-point discrimination. In this study, we report our consecutive series of the dorsal middle phalangeal finger flap and its versatile utility.     

Reconstruction of soft-tissue defect of the posterior heel with a lateral calcaneal artery island flap

We obtained most favorable results in 11 patients with a lateral calcaneal artery island flap. It is a simple, stable, sensate, and yet safe and versatile flap to repair defects around the ankle and heel. We have also used this flap to cover defects around the medial malleolus without any delay (extended lateral calcaneal artery island flap).     

The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume.

The ideal skin-flap reconstruction provides functional preservation and a good cosmetic outcome in both the reconstructed site and the donor site. Although various flaps are used for reconstruction of the vulvar and buttock region, there are disadvantages associated with each. In 1996, Yii and Niranjan reported the gluteal-fold flap for vulvar reconstruction. As presently used, this flap is bulky, particularly in obese patients or when used for hemilateral reconstruction. Thinning the flap has been considered impossible because of the obscurity of the blood supply. In the study presented here, the pedicle vessels of this flap were studied in eight cadavers; the authors found that the flap is nourished by a direct cutaneous system of the internal pudendal artery and vein. Accordingly, adjustment of the flap volume was believed to be possible, with the exception of the adipose tissue containing the pedicle vessels. The authors have since used 14 thinned flaps for seven vulvar, one vaginal, and two buttock defects in 10 patients. All flaps survived completely. Good functional and cosmetic results were achieved with hemilateral or bilateral flaps in vulvar or buttock reconstruction. In the buttock in particular, the usefulness of this flap for anal and pelvic-floor reconstruction was demonstrated. The scar at the donor site, concealed in the gluteal fold, was acceptable. The gluteal-fold flap is very useful for various vulvar and buttock reconstructions because it can be adjusted to the required volume.     

The extended V-Y flap.

The extended V-Y flap is a modification of the V-Y advancement flap, which is very useful in closing defects following excision of facial lesions. The modification involves the addition of an extension limb onto the advancing edge of the standard flap. This limb is located adjacent to the area requiring reconstruction and is hinged down as a transposition flap on the end of the V-Y advancement flap to close the most distal portion of the defect. The extended V-Y flap has been found to be very effective in closing large defects in areas that typically have inadequate subcutaneous tissue to allow extensive mobilization of the standard V-Y advancement flap. It has been used effectively with excellent cosmetic results in the temporal, scalp, forehead, and nasal areas, providing a well-contoured and aesthetically pleasing reconstruction.     

The VY tensor fasciae latae musculocutaneous flap

When first introduced in 1978, the tensor fasciae latae flap was used both as a free-tissue transfer and as a local rotational flap. Its use as a free flap has diminished as other more appropriate flaps for free-tissue transfer have been described. The tensor fasciae latae flap has remained, however, an instrumental flap in the coverage of anterior and posterior soft-tissue defects around the hip region. The purpose of this paper is to present a new design of the tensor fasciae latae flap in the coverage of trochanteric pressure sores. By essentially creating a VY advancement flap into the trochanteric defect with the tensor fasciae latae, one can cover the trochanteric defect with the best-vascularized portion of the flap and avoid the dog-ear deformity.     

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.     

The lateral thoracodorsal flap in breast reconstruction

A fasciocutaneous transposition flap, the lateral thoracodorsal flap, has been used in 114 cases of breast reconstruction. This flap is raised from the lateral and dorsal aspects of the thoracic wall at the level of the submammary crease, and the size may be varied from 12 to 22 cm in length and 6 to 12 cm in width. The lateral thoracodorsal flap is used with an implant and forms the lateral part of the reconstructed breast. A natural ptotic breast shape is achieved in a single-stage procedure. Complications such as partial necrosis and infection have occurred in 3.5 and 2.5 percent of cases, respectively. The procedure is simple and has at our unit largely replaced the use of the latissimus dorsi musculocutaneous flap in extensive postmastectomy defects. In less disfiguring defects, the lateral thoracodorsal flap has taken the place of direct implantation because the reconstructed breast obtains a more pleasing shape by augmentation of the lower lateral pole.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.