Repair of a lower leg defect with an ipsilateral gracilis myocutaneous flap.

We report the use of a gracilis myocutaneous flap from the same thigh to repair a defect of the lower leg. This could be a useful alternative in well selected cases.     

The inferiorly based rectus abdominis myocutaneous flap for reconstruction of recurrent pressure sores.

Eight neurologically impaired patients underwent reconstruction of chronic perineal and ischial pressure sores utilizing an inferiorly based rectus abdominis myocutaneous flap. Other local and regional flap options had been previously used or were not feasible. In six patients, healing was uncomplicated. One patient required local debridement and flap readvancement. The second involved minor separation of a suture line and healed by secondary intention. All donor sites were closed directly and healed by primary intention. There was no evidence of hernia formation, and no functional deficit was detected from removal of the rectus muscle in any of the patients. In conclusion, it was felt that the inferiorly based rectus abdominis myocutaneous flap should be considered a reconstructive option in dealing with perineal and ischial pressure sores. Furthermore, for reasons discussed, we found distinct advantages to using this flap in spinal cord injury patients.     

Popliteal-based filleted lower leg musculocutaneous free-flap coverage of a hemipelvectomy defect.

A 33-year-old man suffered from locally recurrent malignant fibrous histiocytoma of his left thigh unresponsive to previous excision, radiation therapy, chemotherapy, and hyperthermic treatment. He underwent radical hemipelvectomy for cure. Because of extensive tumor involvement, a free flap consisting of his distal left leg based on the popliteal artery was utilized to close the defect. Both the tibia and fibula were removed from their periosteal sheaths, and the foot was excised from the flap. The popliteal artery and vein were anastomosed to the iliac vessels. The flap survived, and the patient was discharged home after physical rehabilitation. We suggest that uninvolved portions of the distal leg may be utilized as a free flap to successfully close hemipelvectomy defects in selected patients when conventional pedicle flaps are unavailable.     

Gluteus maximus myocutaneous flaps for repair of pressure sores.

Myocutaneous flaps based on the gluteus maximus muscle, and its blood supply, have many advantages for the surgical repair of pressure sores in paraplegics. These are described, as well as the techniques used in various areas.     

Latissimus dorsi free flaps for total repair of extensive lower leg injuries in children

A well-established belief is that with crushed and contaminated wounds closure should be delayed. However, an emergency procedure involving very thorough debridement, complete reconstruction of all injured tissues, and cover by a latissimus dorsi free flap in the same operation is evaluated in 15 children presenting with severe injuries to the lower limb. It is felt that the procedure is superior to the established method because it is a one-stage procedure that minimizes the danger of infection, prevents growth impairment, shortens hospitalization, and allows early mobilization, thus being, in some cases, a limb-saving procedure.     

Coverage of bilateral lower extremity calcaneal fractures with osteomyelitis using a single split free gracilis muscle transfer

A case is presented in which a single gracilis muscle was split and used for free-tissue coverage of two sites in a patient with bilateral calcaneal fractures and posttraumatic osteomyelitis. Muscle-flap coverage of osteomyelitis and the use of the gracilis muscle for free-tissue transfer are discussed.     

Coverage of wounds in the distal lower leg by advancement of an enlarged medial gastrocnemius skin flap

Advancement of a medial gastrocnemius flap is a new technique in treating skin defects of the lower third of the lower leg, including that at the anteromedial aspect of the distal portion of the lower leg. Satisfactory results have been obtained in two clinical cases using this technique. In this modified technique, the size of the flap is enlarged, the origin of the medial head of the gastrocnemius is severed so that the island myocutaneous flap may be advanced 8 to 9 cm distally, and good blood supply to the flap is also maintained. In the authors' opinion, this method is a new approach that is simple, easy, safe, and reliable in treating skin defects of the lower leg.     

Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery

The lower trapezius island myocutaneous flap is a useful flap in head and neck reconstruction. It is thin and pliable and can reach defects in most areas of the head and neck. Its usefulness in head and neck reconstruction has often been limited or discouraged by reports of significant failure rates. In this study, the vascular anatomy and clinical use of the extended lower trapezius myocutaneous flap based solely on the dorsal scapular artery system are elucidated, and experience gained performing 20 flaps over the past 5 years by using the extended lower trapezius myocutaneous flap is reported. The vascular anatomy of the dorsal scapular artery system is reviewed in 13 fresh cadaveric dissections by using methylene blue, latex injection studies, and radiologic examination.     

Staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts

The use of long vein grafts in the axilla adds a new dimension to the versatility of the latissimus dorsi myocutaneous flap. When suitable recipient vessels are not available for a microvascular anastomosis, long vein grafts can be used in the axilla to double the arc of rotation of the flap, allowing it to cover the buttocks, lower torso, and scalp (Fig. 8). A case is presented in which the latissimus dorsi myocutaneous flap was transferred in stages to cover a large radiation ulcer of the right buttock.     

The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg

Defects of the skin and soft tissue in the region of the lateral malleolus of the ankle and the Achilles tendon, resulting in exposed bone, tendons, or osteosynthetic material, cannot be covered with free skin transplants. Local or free flaps must be employed. The authors present the construction of a peroneus brevis muscle flap with a distal pedicle as a useful alternative. Between 1993 and 1999, distal pedicled peroneus brevis muscle flaps were used in 19 patients with various types of defects. During construction of the flap, both the long peroneal muscle and the peroneal artery remained intact. In the region of the distal third of the fibula, consistently arranged branches run from the artery into the muscle, and these form the distal pedicle. The proximal portion of the muscle can be transposed distally and easily extends to the tip of the fibula and the attachment of the Achilles tendon to the calcaneus. Primary healing occurred in 16 patients undergoing flap construction. Donor-site morbidity was mostly limited to the donor-site scar. The distally pedicled peroneus brevis muscle flap is a reliable means for covering defects in the lower leg. This form of muscle flap has not yet been described in the known literature. In the authors' opinion, this flap constitutes a logical and valuable extension of local flap procedures for plastic surgery in the distal leg region.     

Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap

To avoid a more proximal amputation at the distal part of the thigh, and when the knee joint is preserved, it is possible to lengthen short lower leg stumps. The authors report five cases in which the latissimus dorsi-rib flap was used to achieve a satisfactory functional prosthetic result. The bone segment is long enough to both lengthen the stump and allow its extremities to be firmly fixed to the tibia. Depending on the remaining tibia length, one or two ribs were included in the flap. The procedure allowed achievement of a 5-cm to 9-cm lengthening of the tibia. Bone healing time was 5 to 6 months and allowed prosthetic rehabilitation and ambulating 5 to 7 months after surgery. Final range of motion of the knee joint is compatible with normal ambulating, and the prosthesis is well tolerated. This procedure, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of short lower leg stumps.     

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores

The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation-advancement flap with V-Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V-Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation-advancement action was supported laterally with V-Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound-healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V-Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotation-advancement flap and bilateral rotation-advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow-up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome.     

Total mandibular and lower lip reconstruction with a prefabricated osteocutaneous free flap.

Large, complex bony defects can be a vexing problem for the reconstructive surgeon, especially when standard donor sites are not available or do not provide sufficient tissue. Using the concept of flap prefabrication, we demonstrated in a single patient that (1) iliac crest bone chips and bone morphogenic protein in an alloplastic mandibular tray can ossify in a heterotopic location and (2) neovascularization sufficient to support a large, custom-designed bone graft occurs within a convenient "carrier" flap. Ultimately, the fields of angiogenesis and osteogenesis research could significantly contribute to the ability of the plastic surgeon to construct the "ideal" composite prefabricated flap for complicated reconstruction.     

Modified hamstring musculocutaneous flap for the coverage of ischial pressure sores.

Ischial pressure sores can be efficiently covered with a modification of the traditional V-Y advancement flap, the musculocutaneous hatchet flap. Results of operations performed on 10 patients prove its reliability.