De novo induction of island capsule flap by using two silastic sheets: Part 1. Generation

A new experimental model for de novo generation of an axial pattern island flap has been designed in a rat model. The purpose of this study was to make a sufficient vascular carrier, as an island capsule flap, with only vascular pedicles and addition of collagen fibers induced by foreign-body reaction. The femoral arteriovenous bundle was isolated and sandwiched between two 2.5 x 1.5 cm Silastic sheets. Eight weeks later, as a delay procedure, femoral vessels were ligated at the distal end of the Silastic sheets and the four margins of the sheets were divided except for the vascular pedicle. This capsule flap was raised as a secondary island flap connected only by its vascular pedicle, then it was sutured back in place. Ten days after the delay procedure, the upper Silastic sheet was removed and a full-thickness skin graft was performed on the capsular island flap. Animals were killed at 80 days. A total of 40 axial pattern capsulocutaneous flaps from 20 Sprague-Dawley rats were successfully achieved. Pathologic study revealed neovascularization, and abundantly impregnated vascular structures near the pedicle were observed with randomly developed collagen fibers. The skin graft took 100 percent on this newly formed capsular flap; therefore, the capsule structure was able to survive on its own and support skin grafts. This experiment, by using an isolated femoral artery and vein as the main pedicle, led to the formation of a capsule flap through a normal foreign body reaction between two Silastic sheet implants. This new flap can be used as a reliable vascular carrier for various needs with minimal donor morbidity.     

Hair-bearing submental artery island flap for reconstruction of mustache and beard

Loss of mustache and beard in the adult male caused by severe burn, trauma, or tumor resection may cause cosmetic and psychological problems for these patients. Reconstruction of the elements of the face presents difficult and often daunting problems for plastic surgeons. The tissue that will be used for this purpose should have the same characteristics as the facial area, consisting of thin, pliable, hair-bearing tissue with a good color match. There is a very limited amount of donor area that has these characteristics. A hair-bearing submental island flap was used successfully for mustache and beard reconstruction in 11 male patients during the last 5 years. The scar was on the mentum in four cases, right cheek in two cases, right half of the upper lip in two cases, left cheek in one case, left half of the upper lip in one case, and both sides of the upper lip in one case. The submental island flap is supplied by the submental artery, a branch of the facial artery. The maximum flap size was 13 x 6 cm and the minimum size was 6 x 3 cm (average, 10 x 4 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed up for 6 months to 5 years. No major complication was noted other than one case of temporary palsy of the marginal mandibular branch of the facial nerve. The mean postoperative stay was 7 days. Color and texture match were good. Hair growth on the flap was normal, and characteristics of the hair were the same as the intact side of the face in all patients. The submental island flap is safe, rapid, and simple to raise and leaves a well-hidden donor-site scar. The authors believe that the submental artery island flap surpasses the other flaps in reconstruction of the mustache and beard in male patients. Application of the technique and results are discussed in this article.     

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.     

The dorsal scapular island flap: an alternative for head,neck, and chest reconstruction

The back has become an increasingly popular donor site for flaps because it can provide thin, pliable tissue, with minimal bulk, and the scar can be easily hidden under clothing. The authors performed a cadaveric and clinical study to evaluate the anatomy of the dorsal scapular vessels and their vascular contribution to the skin, fascia, and muscles of the back. On the basis of anatomical studies in 28 cadavers and clinical experience with 32 cases, it was concluded that the dorsal scapular vessels provide a reliable blood supply to the skin of the medial back, making it a versatile flap to use as an island flap. A flap raised on the dorsal scapular vessels can be harvested with a long pedicle and can be rotated to reach as far as the anterior regions of the head, neck, and chest wall. Delaying and expanding the flap may help to facilitate venous drainage. The authors recommend the use of this versatile island pedicle flap as an alternative to microvascular free-tissue transfer for the reconstruction of defects in the head, neck, and anterior chest.     

Reappraisal of island modifications of lateral calcaneal artery skin flap

Reconstruction of soft-tissue defects of the calcaneal region and the heel is very demanding and necessitates, as a rule, a sensate and thin flap. The ideal characteristics of a sensate and thin layer of flap should be combined with a reliable blood supply and minimal morbidity at the donor site. The authors report an updated review of their experience with the use of island modifications of the lateral calcaneal artery skin flap-the lateral calcaneal island flap, the lateral calcaneal V-Y advancement flap, and the bilobed-shaped lateral calcaneal island advancement flap-for the reconstruction of small and medium-sized tissue defects over the exposed calcaneal tendons and calcaneal bones of 18 patients. All of the procedures were performed under spinal or epidural anesthesia. There were no problems associated with flap viability, but the authors have seen necrosis of undermined skin between the lateral malleolus and calcaneal tendon in two cases and a partial loss of skin graft in one case. In this article, the authors discuss some advantages and disadvantages of the use of a lateral calcaneal island flap and its modifications.     

The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities

Collapse of the zygomatic arch following trauma results in inadequate anteroposterior projection of the zygomatic body and an increase in facial width. Accurate assessment of the position of the zygomatic arch in relation to the cranial base posteriorly and the midface anteriorly is the key to the acute repair of complex midfacial fractures and the secondary reconstruction of posttraumatic deformities of the orbitozygomaticomaxillary complex. Loss of projection of the zygomatic arch may occur with injuries confined to the orbitozygomaticomaxillary region or in association with complex midfacial fractures. A safe anatomic approach to the zygomatic arch allows exact anatomic restoration of the zygomatic arch using miniplates and screws and results in the reconstruction of an outer facial frame with a correct anteroposterior projection and facial width. The zygomatic arch injury is diagnosed using axial CT scanning. Three-hundred and seventeen arches have been exposed through a coronal incision following acute trauma and 47 arches have been exposed in patients requiring late correction of a posttraumatic orbitozygomaticomaxillary deformity. Permanent palsy to the frontal branch of the facial nerve has occurred in one patient following the exact definition of the anatomy of this region.     

New buccinator myomucosal island flap: anatomic study and clinical application

The authors studied the vascular anatomy of the buccinator muscle by dissecting fresh cadavers. The anatomy of the buccal branches of the facial artery consistently confirmed the existence of a posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator. The buccal artery and posterior buccal branch anastomose to each other and ramify over the muscle. Several veins originate from the lateral aspect of the muscle, converge into the buccal venous plexus, and drain into the facial vein (from two to four tributaries) or into the pterygoid plexus and the internal maxillary vein (from the buccal vein). These vessels and nerves enter the posterior half of the buccinator posterolaterally. The facial artery and vein are located at variable distances from each other around the oral commissure and the nasal base. Two patterns of buccinator musculomucosal island flaps supplied by these buccal arterial branches are proposed in this article. The buccal musculomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery, its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the pterygomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and the floor of the mouth. The buccal musculomucosal reversed-flow arterial island flap (superiorly based), supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum, lip, and orbit. The authors have used the flaps in 12 patients. There has been no flap necrosis, and results have been satisfactory, both aesthetically and functionally.     

Anatomic study of the vasculature of the submental artery flap

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.     

Oropharyngeal reconstruction using the supraclavicular artery island flap: a new flap alternative

Oropharyngeal reconstruction following head and neck oncologic resection has utilized local, regional, and free tissue transfer flap options. The modality utilized is often guided by the type of defect created as well as the surgeon's preference. In this article, the authors introduce the application of the supraclavicular artery island flap as a reconstructive modality following oropharyngeal oncologic ablation. Five patients underwent head and neck oncologic resection for oropharyngeal squamous cell carcinoma followed by single-stage reconstruction with an ipsilateral supraclavicular artery island flap. There were no flap failures and only one postoperative complication consisting of a postoperative oral-cutaneous fistula that resolved without surgical intervention. There were no donor-site complications. The supraclavicular artery island flap is a viable alternative for oropharyngeal reconstruction following head and neck oncologic resection. It is a regional flap that can be harvested without microsurgical expertise and yields reliable postoperative results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Repair of pharyngocutaneous fistulas with the submental artery island flap

Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, debridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 x 3 cm and the minimum size was 4 x 2 cm (average, 4.8 x 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donor-site morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed.     

The reverse ulnar artery forearm island flap in hand surgery: 54 cases

The authors discuss their experience with the ulnar artery forearm island flap in 54 cases of hand surgery. They discuss its advantages over the radial island forearm flap and examine further technical possibilities in hand reconstruction, such as the compound flap. Although these reconstructive techniques do not have any sequelae, they involve the sacrifice of a major artery and should thus be used only in complex cases with very clear indications and as a last resort.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

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.     

Endoscopically assisted malarplasty: one incision and two dissection planes

Asian society is uniquely concerned about the distinctive facial features associated with malar prominence. Various methods of reduction malarplasty have been developed and are currently being applied. In this study, a new approach to malarplasty was experimentally assessed between December of 1999 and August of 2001. After having received careful observations of their facial features and full counseling sessions, 32 patients were selected. These patients had three distinctive characteristics: (1) severe zygomatic arch prominence and normal zygomatic body prominence, (2) desire for only a reduction of the lateral prominence, and (3) desire for a less invasive surgery. Through a short incision in the temporal area, the authors performed the dissection as two different planes. Endoscopic dissection between the superficial layer of deep temporal fascia and the temporoparietal fascia to the zygomatic body and blunt dissection under the deep layer of the deep temporal fascia to the zygomatic arch were performed. Complete osteotomy of the zygomatic arch and an incomplete osteotomy of the zygomatic body were then performed with a reciprocating saw. Finally, the zygomatic arch for the zygoma infraction was pressed manually. The major advantages of this procedure are its simplicity and the short operation and recovery time, with little bleeding and edema.     

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar.The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum.All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps.This article discusses the expanding indications of this versatile flap and the refinements in operative technique.     

A new intraoral flap: facial artery musculomucosal (FAMM) flap.

By combining the principles of nasolabial and buccal mucosal flaps, we have designed a new axial musculomucosal flap based on the facial artery. This flap has been designated the facial artery musculomucosal (FAMM) flap. The flap has proven to be reliable either superiorly based (retrograde flow) or inferiorly based (antegrade flow). It is versatile and has been used 18 times in 15 patients, with one failure and two partial losses. It has been used successfully to reconstruct a wide variety of difficult oronasal mucosal defects, including defects of the palate, alveolus, nasal septum, antrum, upper and lower lips, floor of the mouth, and soft palate.     

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.     

Reduction malarplasty through an intraoral incision: a new method

Until recently, osteotomies and surgeries to reposition prominent zygoma have been performed by means of a coronal incision or intraoral and preauricular incisions. Such incisions have penalties such as scars, the possibility of facial nerve injury, and long operative times. After reflecting on their past experiences with facial bone surgery, the authors developed an alternative approach. In this method, the cheekbone protrusion is corrected by performing an osteotomy and repositioning through an intraoral incision only. During the past 3 years, the authors have operated on 23 patients with malar prominences. The amount of bone to be removed is determined by preoperative interviews, physical examinations, and x-rays. Intraoral incisions provide access to the zygomatic body and lateral orbital rim. After L-shaped osteotomies (two parallel vertical and one transverse osteotomy at the medial part of the zygomatic body), the midsegment is removed. The posterior portion of the zygomatic arch was approached through the medial aspect and was outfractured using a curved osteotome. After completing the triple osteotomy, the movable zygomatic complex was reduced medially and fixed with miniplates and screws on the zygomaticomaxillary buttress. The patients were followed for 9.5 months, with acceptable results and few complications. The authors conclude that this technique is an effective and safe method of reduction malarplasty.     

Surgical anatomy and blood supply of the fascial layers of the temporal region

In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.