The reverse-flow posterior tibial artery island flap: anatomic study and 72 clinical cases

Based on anatomic, dye injection, and angiography observations since 1984, 72 patients with tissue defects of the foot (due to injury or surgery) have been reconstructed using a reverse-flow posterior tibial artery island flap. In the 72 patients, etiology has included extensive crushing (40 patients), burn scars (10 patients), and tissue loss following tumor or chronic ulcer resection (22 patients). Only two flaps developed necrosis. The survival rate was 97.2 percent, including seven cases of distal marginal necrosis. This procedure, therefore, offers a useful alternative in the repair and reconstruction of extensive tissue defects in the foot, whether caused by accidental injury or surgery.     

Island scalp flap for superior forehead reconstruction

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.     

The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp

Hair transplantation by use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session was initially described for the treatment of male pattern baldness. More recently, the author has found many other applications, particularly in facial and scalp reconstruction. The most common causes for aesthetic hair restoration of those areas in the author's experience include hair loss resulting from aesthetic facial rejuvenation surgery, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, and hair loss after oncologic resections. The basic technique is described in detail, with variations given for each of the challenging anatomic areas, including the sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Special attention is given to the direction of hair growth, hair texture, aesthetic planning, and absence of detectable scars, in order to mimic nature and to result in a minimal number of procedures. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable, and has provided a high level of patient satisfaction.     

Innervated island flaps in morphofunctional vulvar reconstruction

In this article, the authors present their own experience in vulvar reconstruction following vulvectomy using two different innervated island flaps according to the size and site of the defect. Island-flap mobilization is possible thanks to the rich blood supply of the perineal region. The methods described are a "V-Y amplified sliding flap from the pubis" and a "fasciocutaneous island flap" raised from one or both gluteal folds. The V-Y amplified sliding flap from the pubis is indicated when the defect is symmetric and located anteriorly. This flap is harvested from the pubis and vascularized by the deep arterial network of the pubis. Sensory innervation is provided by branches of the ileo-inguinal nerve. The fasciocutaneous island flap, raised from one or both gluteal folds, can be used following hemivulvectomy or radical vulvectomy, respectively, to cover posteriorly located defects. Vascularization is provided by the musculocutaneous perforating branches of the pudendal artery, whereas sensory innervation is maintained through the perineal branches of the pudendal nerve. Twenty-two patients have undergone reconstructive surgery of the vulvar region from 1989 to date. On 14 patients, a V-Y amplified sliding flap was used; on 7 patients, reconstruction was carried out by island flaps raised from the gluteal fold. Both techniques are compatible with inguino-femoral lymphadenectomy, and they allow for a correct morphofunctional reconstruction and provide good local sensibility. The final result is aesthetically satisfactory, as all final scars are hidden in natural folds.     

A simple method for alar rim reconstruction

A one-stage repair procedure is described for the reconstruction of small to medium-sized full-thickness alar rim defects with a hinged medially based nasolabial island flap. The operation is performed under local anesthesia as an office procedure and is indicated particularly in older patients. The hinged flap provides both the inner and outer layers of the alar rim. The donor site is closed primarily with no need to mobilize a large skin flap. The procedure leaves no conspicuous scars on the face. This method was found to be simple and safe, providing excellent tissue viability and yielding good color and texture match.     

The gluteus maximus musculocutaneous island flap: refinements in design and application

The gluteus maximus island musculocutaneous flap has been described using a variety of designs. We employ an island whose long axis is directed toward the pressure sore, minimizing tension in wound closure. Skin overlying the greater trochanter is avoided. Previously undermined skin can be included in the flap. Fifty patients with ischial or sacral pressure sores have been managed by this technique. Superficial dehiscence occurred in 13 percent of patients, and deep dehiscence occurred in 10 percent. The dehiscence closed spontaneously in all but one patient. Forty-nine of the 50 patients experienced complete wound healing at the pressure sore site. The patients have been observed for an average of 20 months (range 3 to 38 months), with one recurrent pressure sore seen at 28 months postoperatively. The gluteus maximus musculocutaneous island flap has proven to be both reliable in healing and durable over the observed interval.     

Lateral cervical advancement flaps for the correction of webbed-neck deformity

In the webbed-neck deformity, a horizontal excess of cervical skin creates bilateral and often asymmetrical skin webs from the mastoid to the acromion. Hair extends laterally to the free edge on the posterior web surface, creating a wide nuchal hairline. A technique of correction is presented. Through an incision along or within the hairline, the glabrous anterior web surface is undermined with the platysma muscle into the anterior cervical triangle until posterosuperior traction will obliterate the web. The posterior hair-bearing web surface is also elevated, and an excess of scalp is excised anterior to the new hairline position determined by the surgeon. The anterior glabrous flap is advanced posteriorly to resurface the scalp defect and recreate a normal neck contour and symmetrical hairline. A Szymanowski triangle of scalp is excised to equalize wound margins creating two "lazy" Y incisions that join in the scalp midline on completion of the opposite neck web. All scars lie within or along the hairline or extend onto the posterolateral shoulder. The method allows precise control of bilateral neck contour and hairline position without intraoperative repositioning and avoids scars on the exposed anterolateral cervical surface. There has been no recurrence of the neck deformity after 2 years.     

Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach.

Different techniques can be used to repair contracture of burn scars on the elbow, including local or distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders. Among these, a pedicled adipofascial flap based on the most proximal two to four perforators of the ulnar artery (located 1 to 5 cm from the origin of the artery) can be anastomosed to form a sort of axially patterned blood supply within the fascia and subcutaneous fat. Therefore, no major vessel in the forearm need ever be severed. In addition, use of this type of flap preserves muscle function. The pedicled adipofascial flap described in this article allows for early rehabilitation because the flap is thin and pliable. Additional advantages are the easy and quick dissection and completion of the procedure in one stage. A detailed anatomic dissection of the flap was performed on 16 upper extremities from fresh cadavers; an injection study was also performed to determine the location and dimensions of the pedicle flap and its area of reach around the elbow. In the past 3 years, 14 flaps were used in 13 patients to repair elbow defects after release of burn scar contractures. Flap dimensions ranged from 4 x 7 cm to 6 x 14 cm (mean flap size, 74 cm). The results were very satisfactory.     

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.     

Dermal suspension flap in vertical-scar reduction mammaplasty

Reduction mammaplasty has the following goals: appropriate reduction of breast size, symmetric and youthful breast shape, minimal and inconspicuous scars, and stable, long-term results. Although the first two parameters can be obtained by various reduction techniques, vertical-scar mammaplasty eliminates the horizontal inframammary scar, thereby reducing total scar length. Dermal flaps have been described in various types of reduction mammaplasty. The refinement of the authors' method is the incorporation of a superiorly pedicled dermal flap for better and longer-lasting support in vertical-scar reduction mammaplasty. A total of 73 vertical breast reductions in 38 patients were performed with this technique from May of 1996 to November of 1999. Vertical-scar reduction mammaplasty with a dermal suspension flap combines minimal scars with an internal support for long-term stability of the breast shape.     

The internal oblique muscle flap: an anatomic and clinical study

A new muscle flap based on the ascending branch of the deep circumflex iliac artery is described. Twenty internal oblique muscle flaps have been dissected and studied in 10 fresh cadavers. This muscle flap has been used successfully as a free-tissue transfer in seven lower extremity defects. There was one loss of flap due to venous thrombosis. Other complications included a local wound abscess (one case), partial loss of skin graft (two cases), and arterial thrombosis (one case). There has been no donor-site morbidity. The donor scars are well concealed and no hernias have been observed, the longest follow-up being 9 months. The additional advantages of this flap include its thin, flat shape, excellent vascularity, and ease of application to areas about the ankle, with good aesthetic results. The disadvantages are (1) bloody and tedious dissection and (2) potential for abdominal weakness or hernia in the long run. This muscle flap appears to be excellent as a free flap for coverage of small- to moderate-sized defects of the distal lower extremity and as a pedicle flap for coverage of soft-tissue defects of the groin and anterior perineum.     

Clinical applications of the subgaleal fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.     

Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap

Postburn skin contracture of the inframammary sulcus is a commonly encountered problem, especially in pubescent girls. Release of these contractures is commonly performed by split-thickness skin grafts, which necessitate further operations as the child grows. If the contracture of the inframammary sulcus is only one-sided, then the inframammary tissues of the contralateral breast can be used for reconstruction with the fasciocutaneous island flap. The donor site can be closed primarily without disrupting the appearance of the healthy breast, and the skin incision is hidden in the inframammary sulcus. The flap described here is a fasciocutaneous island flap based on the internal mammary artery and the perforating branches to the skin and subcutaneous tissues that the artery gives off as it leaves the thoracic cavity through the seventh intercostal space. After being supported by fresh cadaver and angiographic studies, the flap was applied to seven female patients (four of whom were pubescent) with burn contracture of the breast; satisfactory results were obtained. In defects of the mammary region that required volume or for which repair by skin grafting was planned, in sternal defects, or in young patients, this flap seems to be the best choice.     

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.     

Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique

Scarring eyebrow loss is usually repaired with a hair-bearing island scalp flap or scalp strip grafting technique. The results, however, are usually not desirable with regard to appearance. In this article, a one- or two-hair graft with a dense-packing technique was developed for cicatricial eyebrow reconstruction. It was carried out by harvesting a scalp strip close to the hairline of the back, then dividing it into a series of one- or two-hair grafts, and finally implanting the grafts into the prepared recipient holes of the eyebrow with a desired hair direction. With the authors' experience in treating 96 patients (154 eyebrows) in cases of burn, skin grafting, traumatic scarring, and chemical peeling scar after tattoo removal, the eyebrows could be restored in only one session. In general, 150 to 200 grafts with 200 to 250 hairs were needed for a complete male eyebrow reconstruction and 100 to 150 grafts with 150 to 200 hairs were needed for a complete female eyebrow reconstruction. The maximal hair density was 91.5 hairs/cm per session. Over a 6-month follow-up period, the mean graft survival rate reached 98.1 percent. All of the patients achieved satisfactory results, with a very natural appearance. These results indicate that the above-mentioned technique could be a practical, effective, and probably ideal method for cicatricial eyebrow reconstruction.     

Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

The functional pectoralis major musculocutaneous island flap in head and neck reconstruction

We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.     

The zygomatic flap: a further possibility in reconstructing soft-tissue defects of the nose and upper lip

Through the dissection and localization of the cutaneous zygomatic branch, as previously described by the authors, a vessel is available that plays an important role in reconstructive surgery. The performance of this anatomical study has enabled designing of the so-called zygomatic flap, which can be considered as a further possibility in the reconstruction of soft-tissue defects of the upper lip and nose. This new island axial pattern flap provides a reliable source of skin, with color match for facial resurfacing, and leaves a well-hidden donor site similar to that of the nasolabial flap. The flap must be carefully raised, and when properly designed, it can follow naturally existing contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal surgical deformity. In this article, the authors report the clinical application of the zygomatic flap and the outcome of 10 cases. In a follow-up period from 1998 to the end of 2002, there was no flap loss, and in all cases, the aesthetic results were excellent and highly acceptable to the patients. The authors' experience with this new island axial pattern flap has been good, and they recommend this technique.     

A simple method for forehead unit reconstruction

The supratrochlear and supraorbital vessel-based island flap was used to avoid excessive scarring during reconstruction of the unilateral forehead defects after surgical excision of a malignant tumor. This method had a number of advantages: operation time was short, it was a one-stage procedure, the technique was relatively simple, a good match of the texture and color could be achieved, and scars were inconspicuous.