Free groin flap revisited

Reported herein are 130 consecutive cases of free groin flap transfer performed by one surgeon over a 19-year period. Transplantation was performed for soft-tissue cover or augmentation of contour defects involving the head and neck (68 cases), trunk (4 cases), upper limb (14 cases), and lower limb (44 cases). Indications for flap coverage/augmentation were classified broadly into tumor, trauma, radiation induced, and miscellaneous. Specific reconstructive problems included augmentation for Romberg's hemifacial atrophy, external ear canal reconstruction after tumor ablation, and coverage of lower limb defects. There were nine failures (total flap loss), seven cases of partial flap loss, and two cases were abandoned intraoperatively. Of 15 cases that were urgently re-explored, 9 flaps were salvaged. The failure rate for the groin flap series (130 cases) was 8.5 percent compared with the failure rate of 4.2 percent for the other 517 cases of microvascular transfer performed over the same period by the same surgeon. Donor-site complications occurred in 24 cases and included hematoma or seroma formation, hypertrophic scars, nerve paresthesiae, infection, and dehiscence. Secondary debulking procedures were performed in 26 cases. The free groin flap, contrary to some reports, is a reliable flap that provides relatively thin pliable soft-tissue cover or augmentation, with minimal donor-site morbidity. The specific indications for its use have undergone an evolution since first described in 1973.     

The effectiveness of muscle flaps for the treatment of prosthetic graft sepsis.

The objective of this study was to assess the efficacy and reliability of muscle flaps in the treatment of prosthetic graft sepsis. A retrospective analysis was performed to assess the outcome of all patients with prosthetic graft sepsis who were treated with a muscle flap at Groote Schuur Hospital between January of 1991 and July of 2000. The specific end points studied were flap survival, limb salvage rate, and mortality. A total of 27 muscle flaps were raised to cover 24 sites of graft sepsis in 21 patients. Twenty-five flaps were performed primarily and two secondarily. The mortality rate was zero. Limb salvage was achieved in 15 of 21 patients (71 percent), with no recurrent sepsis after an average follow-up period of 36 months. The groin was the most common site of infection, with an 86 percent incidence. Eighteen sartorius flaps were raised in the groin. Seventeen of the 18 sartorius flaps survived (94 percent), and a 71 percent limb salvage was achieved with no recurrent sepsis after 36 months of follow-up. This series supports the use of muscle flaps for the treatment of prosthetic graft sepsis. The sartorius flap has been shown to be reliable as a flap in the groin, with successful limb salvage in the majority of patients.     

Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction

Limb salvage after extremity tumor ablation may include the use of allograft bone. The primary complication of this method is infection of the allograft, which can lead to limb loss in up to 50 percent of cases. The purpose of this study is to evaluate the efficacy of primary muscle flap coverage in the setting of allograft bone limb salvage surgery. This study is a prospective review of all patients with flap coverage of extremity allografts over the 10-year period 1991 to 2001. There were 20 patients (11 male and nine female patients) with an average age of 28 years (range, 6 to 72 years). Flap coverage was primary in 16 patients and delayed in four. Delayed coverage was performed for failed wounds that did not have a primary soft-tissue flap. Pathologic findings included osteosarcoma in nine patients, Ewing sarcoma in five patients, malignant fibrohistiocytoma in two patients, chondrosarcoma in two patients, synovial sarcoma in one patient, and leiomyosarcoma in one patient. Allograft reconstruction was performed for the upper extremity in 12 patients and for the lower extremity in eight patients. Flap reconstruction was accomplished with 20 pedicle flaps in 17 patients (latissimus dorsi, 12; gastrocnemius, four; soleus, three; and fasciocutaneous flap, one) and four free flaps (rectus abdominis, three; latissimus dorsi, one) in four patients. All pedicled flaps survived. There was one flap failure in the entire series, which was a free rectus abdominis flap. This case resulted in the only limb loss noted. The follow-up period ranged from 1 to 50 months (average, 12.35 months). At the time of final follow-up, three patients were dead of disease and 17 were alive with intact extremities. The overall limb salvage rate in the setting of bone allograft and soft-tissue flap coverage was 95 percent (19 of 20). Reoperation for bone-related complications was required in 50 percent (two of four) of cases receiving delayed flap coverage compared with 19 percent (three of 16) of patients with primary flap coverage (statistically not significant). The results of this study support the use of soft-tissue flap coverage for allograft limb reconstruction. In this series, no limb was lost in the setting of a viable flap. Reoperation was markedly reduced in the setting of primary flap coverage. Pedicled or microvascular transfer of well-vascularized muscle can be used to wrap the allograft and minimize devastating wound complications potentially leading to loss of allograft and limb.     

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.     

Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases

Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography, surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with an external component. Buried free flaps lack an external component; thus, conventional monitoring is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identification and salvage of failing flaps. The purpose of this study was to compare the salvage rate and final outcomes of buried versus nonburied flaps monitored by conventional techniques. This study is a retrospective review of 750 free flaps performed between 1986 and 1997 for reconstruction of oncologic surgical defects. There were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional techniques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction. Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included jejunum (n = 50), fibula (n = 16), forearm (n = 8), rectus abdominis (n = 2), and temporalis fascia (n = 1). Overall flap loss for 750 free flaps was 2.3 percent. Of the 77 buried flaps, 5 flaps were lost, yielding a loss rate of 6.5 percent. The loss rate for nonburied flaps (1.8 percent) was significantly lower than for buried flaps (p = 0.02, Fisher's exact test). Fifty-seven (8.5 percent) of the nonburied flaps were reexplored for either change in monitoring status or a wound complication. Reexploration occurred between 2 and 400 hours postoperatively (mean, 95 hours). All 44 of the salvaged flaps were nonburied; these were usually reexplored early (<48 hours) for a change in the monitoring status. Flap compromise in buried flaps usually presented late (>7 days) as a wound complication (infection, fistula). None of five buried flaps were salvageable at the time of reexploration. The overall salvage rate of nonburied flaps (77 percent) was significantly higher than that of buried flaps (0 percent, p<0.001, chi-square test). Conventional monitoring of nonburied free flaps has been highly effective in this series. These techniques have contributed to rapid identification of failing flaps and subsequent salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration. Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier identification of flap compromise in buried free flaps, alternative monitoring techniques such as implantable Doppler probes or exteriorization of flap segments are recommended.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.     

The thigh flap: an osteomyocutaneous free-flap model in the rat

A new experimental model for free-flap transfer has been developed in the rat. This "thigh flap" is an osteomyocutaneous free flap of bone (femur), muscle (thigh), and skin (groin) based on the femoral vessels. The flap is harvested from the left groin and thigh of an inbred female rat and is transferred to a subcutaneous pocket in the left groin of a male rat of the same inbred strain. The femoral vessels supplying the flap are anastomosed end-to-end with the femoral vessels of the recipient. Thirty flaps have been transferred, with 5 technical failures. Three of the remaining 25 flaps developed necrosis within 24 hours. The other 22 flaps remained viable until the rat was sacrificed at 7 days. The survival rate of the thigh flap was thus 88 percent. The model is suitable for use in metabolic, vascular, and immunologic studies of composite free flaps.     

Upper extremity limb salvage with microvascular reconstruction in patients with advanced sarcoma

Limb salvage is a viable alternative to amputation in many cases of advanced sarcoma. The authors examined their experience with microvascular reconstruction of upper extremity defects after sarcoma resection, focusing on oncologic and functional outcomes. A retrospective analysis yielded 17 patients who underwent 18 free flap procedures and met the inclusion criteria. Most patients (71 percent, n = 12) had recurrent sarcoma at presentation to the authors' institution. Malignant fibrous histiocytoma was the most common pathologic subtype (n = 6). High-grade tumors were present in 94 percent of patients (n = 16). The free flap survival rate was 100 percent. The rectus abdominis flap was the most common free flap used (39 percent; n = 7). Local recurrence occurred in nine flaps (50 percent), and five patients ultimately required amputations. Six patients (35 percent) had distant recurrence. The mean Enneking score for limb function was 73 percent of the maximum (21.9 of 30). The 5-year disease-specific survival rate was 61.3 percent. In select patients with advanced upper extremity sarcoma undergoing limb salvage, microvascular flap reconstruction can provide reliable, safe coverage with reasonable preservation of function.     

Technique and strategy in anterolateral thigh perforator flap surgery,based on an analysis of 15 complete and partial failures in 439 cases

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue defect reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients in Chang Gung Memorial Hospital. A total of 439 flaps were cutaneous or fasciocutaneous flaps based on musculocutaneous perforators. The analysis of the flap failures was done only in this perforator series. In six cases, no suitable skin vessel was found during the dissection of the flaps. The complete success rate was 96.58 percent (424 of 439). Of the 15 failure cases, eight were complete and seven were partial (10 percent to 60 percent of the flap). Thirty-four flaps were reexplored, and 19 (56 percent) were salvaged. In this study, some of the reasons for the flap failure, unique to the anterolateral thigh perforator flap, were identified. They include inadvertent division of perforator at the fascial plane as a result of inadequate knowledge of perforator anatomy, inadvertent injury to the perforator during intramuscular dissection (noted by the surgeon or ignored) as a result of inexperience, and twisting of the pedicle during inset of the flap at the recipient site. Technical pearls in the harvest of the anterolateral thigh perforator flap are as follows: mapping of the skin vessels with a Doppler probe before flap design, meticulous dissection of the perforator under surgical loupe or even lower-magnification microscope, inclusion of a small fascia cuff around the perforator, and intermittent topical use of Xylocaine during the intramuscular dissection of the perforators. During reexploration, one must search for twisting of the pedicle and small bleeders from the branches of the intramuscular perforators.     

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

The serratus anterior free-muscle flap: experience with 100 consecutive cases

We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.     

The role of microsurgery in reconstruction of oncologic chest wall defects.

Regional pedicled myocutaneous flaps are usually the best choice for soft-tissue coverage of full-thickness chest wall defects. As defects increase in size, microsurgical techniques are necessary to augment blood flow to pedicled flaps or to provide free flap coverage from distant sites. This study retrospectively reviews all microsurgical procedures performed at one institution for the coverage of full-thickness chest wall defects. Twenty-five cases of full-thickness chest wall reconstruction are reviewed. There were 20 free flaps and five supercharged pedicled flaps. A rectus abdominis myocutaneous flap (free or supercharged) was used in 20 cases, and a filet free flap following forequarter amputation was used in five patients. Large skeletal defects were repaired with a Marlex mesh/methylmethacrylate sandwich prosthesis. There was 100 percent flap survival and one case of minor, partial flap loss. The prosthesis remained effectively covered in all cases. Five patients required ventilatory support for up to 10 days postoperatively. There were three perioperative deaths due to multisystem failure. Microsurgical techniques are extremely useful for reconstruction of complicated, composite chest wall defects. They are indicated when regional pedicled flap options are unavailable or inadequate. These flaps have a 100 percent success rate and uniformly result in stable soft-tissue coverage.     

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.     

Complications and vascular salvage of free-tissue transfers to the extremities

Complications were examined in 122 free flaps to lower and upper extremities in 104 patients, and vascular salvage was examined in 182 free flaps to lower and upper extremities in 158 patients. All patients were treated by the same surgeon. The overall survival rate of flaps was 96 percent. Complications occurred in 22 percent of the flaps. Complication rates were lower in patients with one free flap than in patients with two. Flaps had more vascular complications than nonvascular. Accompanying skin islands were found to be necessary to monitor vascularized bone transfers in order to avoid flap failure. Flow in the pedicle was reestablished in all flaps, but a higher percentage of flaps with longer ischemic times were lost. Although vascular compromise occurred frequently (15 percent), prompt surgical exploration and reexploration were thought to have greatly increased free-flap survival.     

Free flaps to preserve below-knee amputation stumps: long-term evaluation

Five patients with insufficient soft-tissue coverage on below-knee amputation stumps have been treated with free-tissue transfer surgery to preserve a functional below-knee prosthetic level. The flaps employed include one latissimus dorsi myocutaneous flap, two latissimus dorsi muscle-skin graft flaps, one groin flap, and one foot-fillet flap. All five flaps survived; one patient required early venous anastomosis reexploration and revision. The patients have been followed for a mean duration of 5.5 years (range 3 to 8 years). The mean duration to first ambulation with a prosthesis was 3.6 months (range 2 to 7 months). Four of the five patients developed ulcerations on or adjacent to their flaps which required surgical revision. The patients required a mean of 1.28 prosthesis changes annually since surgery. The functional motion (mean active knee motion is 100 degrees) and ligamentous stability of the knee joints were well preserved in all patients. Five patients wear patella tendon-bearing prostheses, with one requiring an additional thigh corset. In two of the patients, nerve anastomoses to their flaps were performed. Both patients developed true cutaneous sensibility, but nevertheless experienced flap ulceration. All the patients are fully ambulatory on their free flaps. Free-tissue transfer can assist in preserving traumatic below-knee amputations so that patients can benefit from the functional advantage of a below-knee prosthetic device.     

Microsurgical scalp reconstruction in the patient with cancer

The literature regarding reconstruction of large scalp wounds with free tissue transfer consists mostly of case reports and small series, and none of the published reports focus on the particular problems of the oncology patient. Here the authors describe their experience with 37 flaps in 32 patients, all of whom required scalp reconstruction with free tissue transfer after tumor extirpation. Twenty-seven free flaps were performed at the time of the initial surgery and 10 were performed after a prior reconstruction failed. The authors describe the characteristics of the patients and procedures, including tumor type, wound size and complexity, flaps and recipient vessels used, preoperative and postoperative radiation therapy, and complications. Most (72 percent) of the tumors were recurrent or persistent. The free tissue transfer was successful in all patients. There was a 59 percent overall complication rate with 32 percent of patients requiring a secondary surgical procedure. Most of the complications were wound-healing complications. Although there were two cases of vein thrombosis, these were salvaged by revision, and no flaps were lost. Nine patients underwent postoperative radiation therapy that was well tolerated. Only four patients underwent cranioplasty at the time of the initial operation, and no secondary cranial reconstructions were performed. The authors conclude that preoperative and postoperative radiation therapies as well as the need for expedient tumor resection and immediate flap coverage are issues that make free tissue transfer attractive for the oncology patient who needs scalp reconstruction. Although the complication rate is relatively high and a significant percentage of patients require a secondary procedure, free flap coverage was efficacious for all patients in this group. Cranioplasty is not usually required but, if needed, alloplastic or autologous cranial reconstruction does not appreciably increase morbidity in the selected patient.     

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.     

The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?

The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.     

Management of complex groin wounds: preferred use of the rectus femoris muscle flap

This study reviews our experience with the rectus femoris muscle flap for complex groin wound reconstruction. Over the past 5 years, the rectus femoris has become our routine method of groin wound reconstruction. The rectus femoris is harvested through a midanterior incision extending over the distal two-thirds of the thigh. The muscle is elevated on its pedicle and transposed into the groin wound defect either directly or through an intervening skin bridge. Hospital and outpatient records were reviewed for all patients undergoing groin wound reconstruction with this technique from 1999 through 2003. Thirty-seven rectus femoris muscle flaps were performed in 33 patients. The mean patient age was 65.3 years (range, 25 to 88 years). Thirty groin wounds (81.1 percent) occurred after infrainguinal revascularization, 23 (76.7 percent) of which contained prosthetic material. Five (21.7 percent) of these wounds had their prosthetic material removed at the time of reconstruction. The remaining seven groin wounds (18.9 percent) occurred after femoral vessel cannulation for either cardiac or transplant surgery. There were no intraoperative mortalities and no anastomotic hemorrhages. There were no flap losses. Thirty-five of the 37 treated wounds healed (94.6 percent), 26 primarily (70.3 percent) and nine (24.3 percent) after delayed healing and contracture. Reoperation was performed in one patient for flap readvancement and in three patients for prosthetic graft removal after initial flap reconstruction. Two patients (6.1 percent) died during their hospitalization with persistent open groin wounds after flap reconstruction. All muscle flap donor incisions healed, with only two (5.4 percent) experiencing minimal delayed healing. There were no donor-site wound infections and no donor sites required reoperation. Thirty-three groin wounds (89.2 percent) demonstrated culture-positive microbial infection, 15 (45.5 percent) of which were polymicrobial. The 30-day mortality rate was 15.2 percent and the 6-month mortality rate increased to 27.2 percent, with multisystem organ failure as the most common cause. The rectus femoris muscle flap is an effective and reliable means of complex groin wound reconstruction. The muscle flap is dependable and the donor site is not problematic, even in the presence of peripheral vascular disease. On the basis of our clinical results, we believe that the rectus femoris muscle flap is the flap of choice for groin wound reconstruction.