The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap

A new island fasciocutaneous flap raised on the inner medial surface of the upper arm has been used for reconstruction of soft-tissue defects of the elbow. The blood supply to this flap comes from the fasciocutaneous perforators of the ulnar recurrent vessels. This unique vascular arrangement allows for safe transference of the upper medial skin to the elbow region. This flap has been used to cover nine defects in eight patients, and results have been good. Except for one case of sensory disturbance, there were no complications or loss of overlying skin. It is a relatively quick and simple procedure involving only one stage that adequately corrects the skin defect around the elbow region and does not require prolonged splinting.     

Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps

The skin fascial flap is now recognized as a reliable flap for use in reconstructive surgery. The fasciocutaneous flap has been advocated for coverage of chronic infected wounds after debridement as an alternative to the musculocutaneous flap. Previous experimental and clinical studies have demonstrated the superior resistance of the musculocutaneous flap as compared to the random-pattern flap to bacterial inoculation. A canine model is presented for comparison of the effect of bacterial inoculation in fasciocutaneous and musculocutaneous flaps of similar dimensions. The area of skin necrosis secondary to bacterial inoculation was similar in these two flap types despite greater blood flow and skin oxygen in the fasciocutaneous flap. In a study of closed wound spaces formed by the deep surface of these two flap types, a greater degree of inhibition and elimination of bacterial growth and more collagen deposition are observed in the musculocutaneous wound space than in the fasciocutaneous flap.     

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.     

Reconstruction of microtia with a contour-accentuated framework and supplemental coverage

A new method of assembling the framework of the ear with overaccentuated auricular contour is presented. In order to achieve the primary objective of the contour-accentuated framework, any shortage of skin coverage resulting from the increased surface area of the framework is supplied by the resurfaced temporoparietal fascial flap. This is done in 7 cases of microtia reconstruction. The procedure is beneficial for restoring clearly defined auricular relief in ear reconstruction.     

Development of interfollicular epidermis on the surface of collagen framework of the dermis in experimental animals]

The fate of interfollicular epidermis keratinocytes which filled the hair follicles bursas of collagen dermis framework was investigated in the autotransplantation experiment. Collagen dermis framework was prepared from the skin flap. Interfollicular epidermis was detached with the help of suction method and transferred to the collagen dermis framework surface which was placed previously on the full thickness skin defect surface. It was established that in this environment keratinocytes not only developed, but some of them migrated into the hair follicle bursas cavities. It resulted in the follicular-like structures formation, cell elements of which differentiated in the manner characteristic of interfollicular epidermis. However, in spite of the fact that the epidermal cells partially retained their proliferating ability, ingrowing would completely disappear by the 15th to 20th day after the transplantation.     

Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study

Over the past 4 years at the Massachusetts General Hospital 18 patients have been treated for extensive defects (mean size 130 cm2) of the foot at or below the medial and lateral malleoli. These patients have been treated with free muscle flaps covered with thick split-thickness skin grafts. Full muscle flap survival has been seen in each patient, and all patients are currently ambulatory. A subgroup of nine patients are weight-bearing directly upon their skin grafts covering transferred muscle. All patients are walking without chronic breakdown over a mean follow-up of over 19 months with the exception of a single patient who has had breakdown in a region of redundant improperly tailored muscle flap. None of the skin grafted muscles has significant cutaneous sensibility. Detailed gait analysis of these patients has confirmed the weight-bearing capabilities of free muscle flaps with skin grafts and has proven to be an excellent method of foot reconstruction evaluation. It would appear from this study that cutaneous sensibility may not be necessary for successful reconstruction of the weight-bearing surface of the foot. This method of reconstruction should be considered when local tissues are not suitable for plantar foot reconstruction.     

The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle

The extensor digitorum brevis muscle flap, which has already been suggested as a local flap for the foot, has been applied by us in 2 cases with excellent results. This flap, as with other muscle flaps, provides an excellent bed for the skin graft. Furthermore, because of its width, it allows for covering an area of skin loss 5 X 7 cm in size in areas that are difficult to cover by other reconstructive means. The arch of rotation of this flap allows for coverage of the lateromedial and posterior surfaces of the ankle with no functional loss at the donor site. The relative ease of elevating this flap presents a reasonable justification for its wider application as a single local procedure for skin problems around the ankle.     

Glucose metabolism in experimental skin flaps

The metabolism of glucose by rat abdominal skin flaps has been investigated at various times after flap elevation. Biopsies of flap skin taken during the first 3 days after flap elevation and incubated in vitro show a marked increase in glucose consumption and lactate production compared with normal skin. At the same time, flap tissue reserves of glucose and glycogen are lower than those of normal skin. Providing that some circulation persists, the magnitude of the changes in glucose metabolism is proportional to the degree of ischemia experienced by the flap tissue in vivo. In most cases, glucose consumption and lactate production return to normal by the end of the first week after flap elevation. These experiments thus further define a major ischemia-induced shift to anaerobic metabolism (glycolysis) that occurs in skin flaps.     

Perforator-based flap in rats: a new experimental model.

A new type of flap, the perforator-based flap, has been described in the last decade. It has been used successfully as a pedicle or free flap by many plastic surgeons. There is no animal model for research, although these flaps have gained popularity in clinical use. We created a perforator-based flap model in the rat (a perforator-based flap group and two control groups; 10 rats in each group) and evaluated the survival characteristics of the new flap. The abdominal skin flap was elevated based on the second perforator of the right superior deep epigastric artery and then sutured to its original bed. In the first control group, the same flap was elevated with a subcutaneous pedicle without any perforator; in the second control group, a right-sided, random-pattern pedicle abdominal skin flap with the same dimensions and location was elevated and sutured to its original bed. Flap survival was studied, and microangiography and histologic studies were performed. The amount of viable skin in the three groups was compared 1 week later. The area of surviving skin paddles in the experimental group ranged from 74 to 83 percent; in the first control group, it was 0 percent; and in the second control group, it ranged from 29 to 44 percent (p < 0.001 and p < 0.001, respectively). There was a predictable and constant area of necrosis in the model.The results of this study demonstrate that most of the abdominal skin of the rat can survive on the basis of a single musculocutaneous perforator vessel. This flap can be easily elevated, and it can be used as a reliable model for flap research.     

Skin recycling following neovascularization using the rat musculocutaneous flap model.

The recycling of a skin territory as part of a musculocutaneous flap despite prior division of existing musculocutaneous perforators or vice versa within an axial cutaneous flap using skin from a previous musculocutaneous flap may sometimes be done safely if an adequate time period has been allotted to permit sufficient neovascularization from adjacent tissues. In order to test this clinically observed phenomenon, a musculocutaneous flap model based on perforators from the rat rectus abdominis muscle was developed and observed to have complete reliability. Groups of five Sprague-Dawley rats each were sequentially utilized to prove that by a single week following creation of a rectus abdominis musculocutaneous flap adequate peripheral neovascularization would evolve to permit total viability of secondary axial epigastric cutaneous flaps incorporating the same skin that initially was the cutaneous portion of the muscle flap. The converse was also confirmed possible, again using sequential groups of five rats each, in that by 2 weeks the skin of an initial abdominal cutaneous flap could instead be safely transposed and nourished as part of a rectus abdominis musculocutaneous flap. The proposition concerning the reliable reuse of identical skin territories as part of disparate metachronous flap configurations appears to be valid.     

The basic types of scar contractures after burns and methods of eliminating them with trapezeplasty flaps

The study of postburn scar contractures in various locations has revealed four contracture variables: edge, medial, strip, and total. Following the surgical treatment of more than 2000 patients with such contractures, a trapezeplasty flap method has been worked out and applied since 1979. This method allows one to make up for deficient scar tissue of the same shape. Flaps are cut out of sheets of a fold with the maximum use of undamaged skin in adjacent sections. They move toward each other and merge with adjacent sides into a state of tension. This surgery is based on use of the reserve on the width of the surface of a fold and the high tension of skin with pressure on underlying tissue. The extended skin grows quickly, the tension disappears, and the scars dissolve. For each contracture type, there are trapeze-flap variables either in pure form or in combination with the transposition of split-thickness skin with a flap to create a flexible joint zone. The trapezeplasty flap method can be used to treat all edge, medial, strip, and total contractures of joints whose natural position is adduction, the shoulder joint, and contractures between fingers. Skin-fat or skin-fascia trapeze flaps prevent the relapse of contracture and make the weakened scars softer, which, as a rule, ensures a good functional and aesthetic result.     

The effect of nifedipine on skin-flap survival

Nifedipine, a calcium-channel blocker, is a peripheral vasodilator and has been shown to increase blood flow to skin. The hypothesis that nifedipine would thereby improve skin-flap viability was tested by comparing the extent of necrosis of long pedicle flaps in control and nifedipine-treated rats. Thirty male Sprague-Dawley rats were randomized to receive either 2.5 mg/kg nifedipine in chocolate PO t.i.d. or plain chocolate according to protocols. Serum nifedipine levels were determined by gas chromatography. Dorsal cephalad-based random vascular pedicle flaps (2 X 6 cm) were elevated, sutured to their beds, and photographed for computer-aided surface area determinations. The extent of distal flap necrosis was expressed as a percentage of the total flap area, and differences were studied by one-way analysis of variance. The differences between the mean percentages of necrosis at 1 and 2 weeks for the groups were not statistically significant. We conclude that nifedipine has no effect on the extent of necrosis of the random skin flap in the rat.     

Fibular osteoseptocutaneous flap: anatomic study and clinical application

The vascularized fibular graft has been expanded to an osteoseptocutaneous flap by including a cutaneous flap on the lateral aspect of the lower leg. The cutaneous flap can serve not only for postoperative monitoring of the grafted fibula, but also as extra skin coverage to replace substantial skin defects or prevent tight closure of the wound. From anatomic studies of 20 cadaver legs and 15 clinical cases, it has been possible to demonstrate adequate circulation to the skin of the lateral aspect of the lower leg from the septocutaneous branches of the peroneal artery alone. This finding has allowed the development of a new concept and technique to elevate the fibula as an osteoseptocutaneous flap for reconstruction which provides the following advantages: Elevation of the fibular osteoseptocutaneous unit is easy and fast. The cutaneous flap of the fibular osteoseptocutaneous unit can slide almost freely while attached to the paper-thin posterior crural septum without being tethered by a bulky muscle cuff, facilitating the setting of the fibular osteocutaneous flap when the bone and skin are widely separated. Intraoperatively, in a situation in which it is necessary to change from originally selected recipient vessels to ones more suitable, the thin posterior crural septum can be folded around the fibula allowing more flexibility in choice of recipient vessels. The fibular osteoseptocutaneous flap meets the criteria outlined for composite tissue reconstruction of defects of the extremities.(ABSTRACT TRUNCATED AT 250 WORDS)     

The supply of blood in the skin territory above the lower part of the serratus anterior muscle

At present, the putative clinical use of the musculocutaneous and ostomusculocutaneous serratus anterior flaps has been compromised by the risk of partial or total necrosis of the skin overlying the lower part of the serratus anterior muscle. Therefore, the aim of this study was to delineate a skin area vascularized by perforant musculocutaneous branches of arteries stemming from the lower segment of the anterior serrated muscle. Black ink was injected in thoracodorsal artery branches for the serratus anterior muscle in 50 human cadavers before the autopsies (the study was approved by the Institutional Review Board). The surface area of the labeled skin was determined and its borders delineated by means of transparent millimeter grid. Planimetry data were subsequently analyzed with the aid of PC computer program. The results show that the calculated mean surface area (143.79 +/- 2.68 x 2.077; range 138.22-149.36 cm2) of the skin vascularized by perforant musculocuaneous branches stemming from the lower segment of the anterior serrated muscle, can serve as a reliable guide for taking serratus anterior flap in any patient. Therefore, appropriately sized musculocutaneous or osteomusculocutaneous serratus anterior flap can be safely and efficiently used in plastic and reconstructive surgery.     

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

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

The use of a fascial flap in ear reconstruction.

We describe the use of a fascial flap for covering the framework in ear reconstruction. When covered in turn with a skin graft, this fascial flap provides an abundant amount of a thin, tough, vascular, hairless cover of good quality in all cases except those where injuries in the auricular area have been deep enough to damage this fascia. This method of ear reconstruction is particularly useful in secondary ear reconstructions useful in secondary ear reconstructions and in reconstruction after traumatic losses. The procedure described can often be performed in one stage, requiring two to 4 hours, with minimal complications.     

Reliable assessment of skin flap viability using orthogonal polarization imaging

Intraoperative evaluation of skin flap viability has primarily been dependent on clinical judgment. The purpose of this study was to determine whether an orthogonal polarization spectral imaging device could be used to accurately predict viability of random-pattern skin flaps. Orthogonal polarization spectral imaging is a newly developed technique that visualizes the microcirculation using reflected light without the use of fluorescent dyes and allows for noninvasive real-time observation of functional microvascular networks. In Sprague-Dawley rats (n = 24), three types of random skin flaps were designed with unknown zones of viability (n = 8 per group). After flap elevation, the skin flaps were evaluated by both clinical examination and orthogonal polarization spectral imaging. Areas of the flap determined to be nonviable by clinical examination were measured and marked. Orthogonal polarization spectral imaging was subsequently performed, and areas of the skin flap with stasis (i.e., cessation of red blood cell movement) in the dermal microcirculation on orthogonal polarization spectral imaging were measured and marked. The skin flaps were then secured in place. Flaps were evaluated on a daily basis for clinical signs of ischemia and necrosis. On postoperative day 7, the total amount of random skin flap necrosis was measured and recorded. Clinical examination of the random skin flaps significantly underestimated the actual amount of eventual flap necrosis, and as result was a very poor predictor of flap necrosis. By contrast, assessment of microcirculatory stasis using the orthogonal polarization spectral imaging device correlated well with the subsequent development of necrosis in all groups. In the three groups, the average amount of flap necrosis predicted by clinical examination deviated from actual necrosis by approximately 2 to 4 cm. However, the amount that orthogonal polarization spectral imaging differed from actual necrosis was 0.1 to 0.3 cm. Therefore, orthogonal polarization spectral imaging was an excellent predictor of eventual flap necrosis and much more accurate than clinical observation (p < 0.001). Intraoperative evaluation of axial and random pattern flap viability has traditionally been based on clinical examination as no other reliable, convenient test currently exists. The authors demonstrated that an orthogonal polarization spectral imaging device accurately predicts zones of necrosis in random pattern flaps by directly visualizing cessation of microcirculatory flow. Intraoperative stasis in the dermal microcirculation correlated precisely with subsequent flap necrosis. Orthogonal polarization spectral imaging was significantly more accurate than clinical examination, which consistently underestimated flap necrosis. The orthogonal polarization spectral imaging technique may have value in the intraoperative assessment of skin flap perfusion such as that required after skin-sparing mastectomy.     

Sensory restoration of the skin graft on a free muscle flap: experimental rabbit study.

Transplantation of a muscle flap with free skin graft for wound coverage is a common procedure in reconstructive microsurgery. However, the grafted skin has little or no sensation. Restoration of the sensibility of the grafted skin on the transferred muscle is critically important, especially in palmar hand, plantar foot, heel, and oral cavity reconstruction. The purpose of this study was to investigate the possibility of sensory restoration of the grafted skin on a trimmed muscle surface that has been sensory neurotized after sensory nerve-to-motor nerve transfer, using the rabbit gracilis muscle as an animal model. The ipsilateral saphenous nerve (sensory) was transferred to the motor nerve of the gracilis muscle for sensory neurotization. A 4 x 4-cm2 area of skin island over the midportion of the gracilis muscle was harvested as a full-thickness skin graft. The upper half of the gracilis muscle was then excised, becoming a rough surface. The harvested skin was reapplied on the trimmed rough surface of the muscle. After 6 months, retrograde and antegrade horseradish peroxidase labeling studies were performed through skin and muscle injection. The group with a free skin graft was compared with the group with an intact surface of the gracilis muscle. This study clearly shows that sensory nerves can regenerate and penetrate into the trimmed muscle surface and grow into the overlying grafted skin. However, if the muscle surface is intact as with the compared group, sensory reinnervation of the grafted skin is not possible.     

The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck.

A compound flap is described that utilizes skin from the anterior chest on a narrow segment of pectoralis major muscle, with its underlying axial neurovascular bundle. This flap has been used successfully to reconstruct large defects in 4 consecutive patients. Our experience with this flap suggests that it may be more versatile than the deltopectoral flap.     

A study of the pharmacologic control of blood flow to acute skin flaps using xenon washout. Part I

This study was undertaken to understand the control mechanisms differentiating circulation to normal skin and acute skin flaps. The approach was to compare the effects of systemic vasoactive drugs on skin blood flow in rats in acute skin flaps and identical areas of control skin. With this model it was felt that systemic changes would affect both areas equally and any difference in response would be due to vascular control mechanisms unique to the flap. Xenon washout by percutaneous injection was chosen to measure blood flow. The results of over 8000 observations in these studies were: 1. Vasodilation enhances blood flow and flap survival. 2. Vasoconstriction decreases blood flow. 3. Depletion of sympathetic nerve terminals enhances blood flow and flap survival. 4. The acute flap is less sensitive to systemic alpha-agonists than control skin. 5. The acute flap is less sensitive to vasodilators acting at the receptor-site level than control skin. 6. Total sympathetic denervation does not occur. 7. Biologic increases in area of flap survival did occur in drug dose ranges predicted by xenon washout measurements in this model. These findings indicate that the vessels in an acutely raised skin flap have a greater vasospastic tone than is optimal for maximum nutrient blood flow. One explanation consistent with these findings is offered in which the mechanism responsible for this tone is the release of catecholamines from the sympathetic nerve terminals after the flap has been raised.