Male baldness: immediate single-stage rotation of very long arterialized temporo-parieto-occipital flaps

Over a period of 5 years we have performed 62 rotations of long temporo-parieto-occipital flaps in a single stage without delay for both frontal and occipital male baldness. The technique and indications are reported and discussed. The good results obtained permit us to affirm that this surgical technique is safe, simple to perform, and rapidly effective. It has clear advantages over techniques involving delay, including guaranteed survival and vitality of the rotated flap, speedier execution, and few, if not minimal, complications.     

Scalp expansion in the treatment of male pattern baldness

Tissue expansion has been extremely valuable in the treatment of traumatic scalp defects. We have recently used expansion techniques in the treatment of male pattern baldness. Expansion has been used in conjunction with scalp-reduction procedures and pedicled hair-bearing flaps. Flaps have been designed as Juri flaps, and in one patient, a new posteriorly based flap was used. This design gives the advantage of a more natural-appearing hairline and forward-growing hair. The major advantage of tissue expansion in the treatment of male pattern baldness is that it generates new hair-bearing scalp. The increase in vascularity which occurs during expansion allows for large, safe, and predictable flaps. Donor sites are also relatively easily closed. The disadvantages of expansion include the need for two or more surgical procedures and multiple office visits. There is also some discomfort following expansion and a cosmetic defect as the expanders become larger. Complications include infection, exposure or extrusion, deflation, and hair loss. Tissue expansion combined with scalp reduction and pedicled hair-bearing flaps have proved to be a valuable technique in the treatment of male pattern baldness with a high degree of patient satisfaction.     

An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction.

This article presents an updated review of our experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in total auricular reconstructions. Our indications for use of the temporoparietal fascial flap are presented. Partial flap necrosis occurred in 5 cases, total necrosis in 2 of 14 microsurgically transplanted cases, cartilage infection in 2 cases, and paralysis of the frontal branch of facial nerve in 1 case. Prospective observations of vascular anatomy were carried out in the last 93 temporoparietal fascial flaps during flap elevations. Only 59 flaps (63.4 percent) showed a typical pattern, distributed mainly by the superficial temporal artery and vein. Others (36.6 percent) were distributed mainly by various combinations of the posterior auricular artery or vein, occipital artery or vein, diploic vein, and the superficial temporal artery or vein. At the upper margin of the imaginary reconstructed auricle, the mean diameters of the artery and vein were 1.7 mm and 2.2 mm, respectively. There were no significant differences of vascular patterns and their diameters between the temporoparietal fascial flap of microtia sides and of nonmicrotia sides (sides with acquired ear deformities or free-flap donor sides). We are presenting our technical evolution in using the temporoparietal fascial flap for total auricular reconstruction with the goal of reducing surgical complications and improving aesthetic results.     

Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels

The authors have carried out a clinical study of all the patients who underwent reconstructions with occipito-cervico-dorsal flaps in their department between 1994 and 2003 and analyzed the outcomes of the surgery. The reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight cases underwent reconstruction with microvascular augmented occipito-cervico-dorsal flaps, and four were reconstructed with single pedicle occipito-cervico-dorsal flaps. In five cases, distal partial necrosis was observed. The largest flap size was 43 x 23 cm (5 x 5-cm pedicle). In the microvascular augmented occipito-cervico-dorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal perforators were used together with circumflex scapular artery and veins in five cases. The follow-up term was between 1 and 8 years. Neck scar contractures were released in all cases, and good results were obtained not only functionally but also aesthetically. In an anatomical study, the authors used 20 preserved cadavers and took angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of the vessels that have close relations to the occipito-cervico-dorsal flap (the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomical territory was clearly seen and its area identified.     

One-stage reconstruction for defects of the mouth using a sternomastoid myocutaneous flap.

The sternomastoid muscle has 3 blood supplies: the occipital artery superiorly, the superior thyroid artery in the middle, and the thyrocervical trunk below. We report the use of a myocutaneous flap consisting of a "paddle" of skin on the end of a pedicle of sternomastoid muscle--with the latter based either on its superior or inferior blood supply. Fourteen such flaps have been used successfully in 13 consecutive patients for one-stage reconstructions of defects of the oral cavity and oropharynx. Although there was partial epithelial loss of the skin "paddle" in 7 cases, in each case the surviving dermis became resurfaced with epithelium.     

Bipedicled fronto-occipital flap for reconstruction of postoncologic defects of the lateral scalp

Presented here are two clinical cases of extensive defects of the scalp secondary to surgical resection of invasive basal cell carcinoma on the parietal region, successfully treated by means of very large, bipedicled fronto-occipital flaps, based anteriorly on the supratrochlear-supraorbital vessels and posteriorly on the occipital and posterior auricular vessels. Considering both the location and the large size of the scalp defects, different surgical techniques are discussed and the potential use of bipedicled scalp flaps is considered, designed either sagittally or coronally as fronto-occipital or temporo-temporal flaps. The bipedicled fronto-occipital scalp flap is believed to represent a simple, secure, and useful reconstructive procedure for cutaneous coverage of extensive defects located on the lateral scalp.     

Scalp reconstruction with a prefabricated abdominal flap carried by the radial artery.

Custom prefabrication of free flaps provides an unlimited variety of applications, since flaps can be created with expendable tissues and without restriction to naturally occurring vascular territories. These principles also can be used to customize flaps that could not be completed by conventional means. We report a case of scalp reconstruction using a random-pattern abdominal flap in which a radial artery fascial flap was induced to serve as the vascular carrier. In addition to providing durable scalp coverage, the prefabricated free flap enabled salvage of an abdominal flap that would otherwise have been aborted after intermediate transfer to the forearm.     

The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery

The clinical role of the lower trapezius musculocutaneous flap varies within the literature. Many describe its use in the reconstruction of the lateral neck and facial regions, but very few refer to its use in the posterior cervical and occipital regions. Different vascular pedicles have also been described and effectively used. A retrospective analysis was conducted, reviewing the authors' experience with 13 patients who suffered complex open wounds to the posterior cervical and occipital regions that were treated with a lower trapezius muscle or musculocutaneous flap. All flaps were based on the deep branch of the transverse cervical artery. This pedicle was used to support a relatively large skin segment over the distal portion of the lower trapezius muscle, a margin that, in the authors' experience, extends at least 1 cm beyond the muscular margin. Postoperatively, patients were evaluated based on complications, residual shoulder function, and aesthetic outcome. In addition to the clinical study, cadaveric dissection of the trapezius muscle was conducted on 22 specimens, and the vascular anatomy was confirmed by direct visualization. The authors' experience indicates that the lower trapezius musculocutaneous flap, when based on the deep branch of the transverse cervical artery, provides a reliable alternative for the reconstruction of complicated wounds in the posterior cervical and occipital regions, with the added capability of providing richly vascularized tissue to compromised wounds as far cephalad as the vertex of the skull.     

Opercular Flaps as Sexual Ornaments for Male Longear Sunfish (Lepomis megalotis): Male Condition and Male-Male Competition

Male longear sunfish, Lepomis megalotis , have longer opercular flaps than females, and females are known to prefer males with longer flaps, suggesting that these exaggerated structures serve as sexual ornaments. We tested the hypothesis that opercular flap length is associated with body condition and is therefore potentially an honest indicator of male quality. Opercular flaps grew significantly faster than pelvic fin spines, a non-sexually selected trait, regardless of diet treatment, suggesting an advantage to having fast-growing opercular flaps. Growth indices (opercular flap growth divided by pelvic fin spine growth) of males fed a larger ration were greater than those of males fed a smaller ration, although the difference was marginally non-significant. We also tested for an effect of opercular flap length on resource holding power by manipulating flap length on pairs of males matched for body length. In an experiment where opercular flaps were clipped to different lengths, only longer original (unmanipulated) flap length was associated with a significantly greater frequency of dominance. In a corollary experiment where opercular flaps were artificially lengthened, the abnormally long-flapped males were dominant significantly more often than the 'normal' males given transparent extensions. These results indicate that the opercular flap length of male longear sunfish may serve as an honest indicator of male quality and may be used to assess the resource holding power of rival males.     

Total breast reconstruction with either of two abdominal flaps.

We describe our experience with 15 cases of total breast reconstruction, using open abdominal flaps. Of these, 13 were mid-abdominal flaps. We believe the latter, an arterial flap(axial pattern flap), is safer.     

Development of a Mouse Model of Abdominal Cutaneous Flaps for Breast Reconstruction

Autologous tissue transfer, in addition to replacing tissue that was lost during injury or surgery, offers women an excellent option to improve cosmetic appearance and self-confidence following mastectomy due to breast cancer. However, flap necrosis is a complication in obese patients undergoing this procedure. We created a mouse model to study the flap-related complications that leads to decreased flap survival in autologous breast reconstruction.

Methods

Left superficial inferior epigastric (SIE) pedicle abdominal-cutaneous flaps were elevated in 8 week-old, obese ob/ob male mice and their lean littermates. Flaps were followed by serial photography. Area of flap necrosis was measured at 7 days. Statistical analysis was performed.

Results

Necrosis was observed at the distal margin of the flaps, in both lean and obese groups. Lean left SIE flaps (n = 8) had a total area flap necrosis of 9.1% at 7 days whereas obese left SIE flaps (n = 8) had a total area flap necrosis of 45.5% at 7 days. Obese flaps had a statistically significant increase in necrosis compared to the lean flaps, p = 0.001.

Conclusions

There was a significant difference between flap survival in lean and obese SIE pedicle flaps in our mouse model. We have developed the first flap model of obesity utilizing the superficial epigastric pedicle in the mouse. This model is optimal for future studies to dissect out mechanisms that lead to the complications related to flap survival for breast reconstruction, especially in obese subjects.     

Monitoring acute skin-flap failure

Reliable and repeatable means for the objective postoperative monitoring of skin flaps is a necessity. If a failing free flap can be recognized early, it can be salvaged by revision of the appropriate anastomoses. For the threatened distal portion of a conventional flap, external factors, such as kinking or hematoma, may be corrected or drug therapy instituted. We have analyzed blood from stab wounds in experimental pig flaps for pO2, pCO2, pH, and hematocrit. The results were compared with fluorescein penetration and flap surface temperature. The most significant finding was hematocrit readings of threatened flaps (54 percent) elevated above those of control flaps (35 percent). pH readings in the jeopardized flaps were 0.4 units below control. These two measures proved to be more reliable than intermittent temperature readings. In contrast to the fluorescein test, which can be used only once, stab wound analysis is repeatable at any time in the postoperative period. It can be effectively used to follow dynamic changes within a skin flap.     

Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.     

Reverse-flow island flap: clinical report and venous drainage

Twenty-two reverse-flow island flaps were transferred. These included peroneal, forearm, anterior tibial, and temporal flaps. Sixteen of 22 flaps survived completely. We encountered partial necrosis in 4 flaps and total necrosis in only 2 flaps. We credit this success to the reliability and availability of the peroneal, forearm, and temporal flaps; but we do not encourage use of the anterior tibial flap. The flaps that survived well did not show any signs of venous congestion. The advantage of the reverse-flow island flap is that it can be transferred from a proximal to a distal location. Using cadavers and fresh amputated limbs, studies on venous drainage of the reverse-flow island flap were performed. The venae comitantes had numerous venous valves and communicating branches, but more than sufficient reflux of the venous blood occurred through the valves at pressures of 90 to 105 cmH2O. We believe that the venous drainage of the reverse-flow island flap occurs as a result of reflux actions at the valve, communicating branches between the venae comitantes, and bypass vessels around the valves.     

Free-style free flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.     

Comparison of three different supercharging procedures in a rat skin flap model

A significant clinical problem in reconstructive surgery is partial loss of a pedicled flap. To resolve this problem, various methods of vascular augmentation have been developed; "supercharging" is one of those techniques. A new rat flap model was developed for investigation of the supercharging procedure, and the efficacy of the arterial supercharging method was examined. The purpose of this study was to investigate how an arterial supercharging procedure could generate large flap survival areas with different supercharging positions in rats. On the basis of the vascular anatomical features of rats, a circumferential skin flap from the lower abdomen to the back, measuring 4 x 12 cm, was marked. The flap was divided along the dorsal midline. Forty rats were divided into four experimental groups, as follows: group 1 (control), flaps based only on the deep circumflex iliac artery and vein; group 2, flaps supercharged with the ipsilateral superficial inferior epigastric artery; group 3, flaps supercharged with the contralateral superficial inferior epigastric artery; group 4, flaps supercharged with the contralateral deep circumflex iliac artery. On the fourth postoperative day, the flaps were evaluated with measurements of necrosis and survival areas. Microfil (Flow Tech, Inc., Carver, Mass.) was then injected manually throughout the body, and the vascular changes produced by supercharging were angiographically evaluated. Compared with group 1 (control), the flap survival areas were significantly greater in distally supercharged flaps in groups 3 and 4 (mean flap survival, 91.2 +/- 5.2 percent and 90.5 +/- 10.6 percent, respectively; p < 0.001) and in proximally supercharged flaps in group 2 (45.9 +/- 4.1 percent, p < 0.05). Angiographic assessment of the flaps that survived completely revealed marked dilation of the choke veins among the territories and reorientation of dilated veins along the axes of the flaps. This study suggests that distal arterial supercharging (contralateral superficial inferior epigastric artery or contralateral deep circumflex iliac artery) is more effective than proximal arterial supercharging (ipsilateral superficial inferior epigastric artery) in increasing flap survival. Although the rat skin flap may not be analogous to human flaps, distal arterial supercharging might have useful therapeutic potential in increasing flap survival in clinical practice.     

Further experience with the lateral arm free flap

Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.     

Effect of capsulectomy on the hemodynamics and viability of random-pattern skin flaps raised on expanded skin in the pig

Skin flaps constructed on expanded skin usually include the underlying capsular tissue. It has been hypothesized that capsulectomy may jeopardize the viability of the expanded skin flap. The experiments reported herein were designed to test this hypothesis. Specifically, we studied the hemodynamics and viability of random-pattern skin flaps (8 X 20 cm) raised on delayed bipedicle flaps (group A) and on expanded skin pockets with capsulectomy at the time of flap elevation (group B) or with intact underlying capsular tissue (group C). Each group was randomly assigned to each flank in 16 pigs. Skin pockets were expanded by inflation of subcutaneous silicone tissue expanders with sterile saline (299 +/- 7 ml; X +/- SEM) over a period of 3 weeks. At the end of this period, the bipedicle flaps were constructed. Eight days later, random-pattern skin flaps were raised on bipedicle flaps and skin pockets. The length and area of skin flap viability, judged by the fluorescein dye test performed 1 day postoperatively, were not significantly different (p greater than 0.05) among groups A, B, and C (n = 31 to 32). There also were no significant differences (p greater than 0.05) in total skin capillary blood flow measured 1 day postoperatively (A = 2.6 +/- 0.4, B = 2.4 +/- 0.4, and C = 2.7 +/- 0.6 ml/min per flap; n = 15 to 16) and in skin viability assessed 7 days postoperatively (A = 74 +/- 2, B = 75 +/- 2, and C = 76 +/- 2 percent; n = 16) among delayed skin flaps and skin flaps raised on expanded skin pockets with or without capsulectomy. The results of this flap viability study were confirmed in 5 minipigs in a separate experiment. We conclude that capsulectomy did not have a detrimental effect on the hemodynamics and viability of random-pattern skin flaps raised on expanded skin. Furthermore, we hypothesize that skin flaps raised on expanded skin are similar to delayed skin flaps in that the skin blood flow is optimally augmented; therefore, the capsular tissue does not add significant blood supply to the overlying skin.     

Fasciocutaneous flaps: an experimental model in the pig

No experimental studies have substantiated the claim that fasciocutaneous flaps are superior to skin flaps. Using fasciocutaneous flaps designed in the pig, both flap survival and blood flow were assessed. The forelimb and hindlimb fasciocutaneous flaps survived to 8.2 +/- 0.3 cm and 7.9 +/- 0.3 cm, respectively, compared with 7.3 +/- 0.3 cm and 6.7 +/- 0.3 cm for the comparable cutaneous flaps, a statistically significant finding (p less than 0.01). Random fasciocutaneous flaps survive 12 to 18 percent longer than skin flaps. Using the radioactive microsphere technique, blood flow was measured after flap elevation, and flap survival was estimated using fluorescein. Again, a significant difference in flap survival was found, but there was no significant difference in measured blood flow. This can be explained by the relatively large interval between blood flow measurements (2 cm) compared with the observed difference in survival length (1.0 +/- 0.3 cm).     

The value of fluorescein in predicting the viability of arterialized flaps.

We recommend routine fluorescein examination whenever a major flap is manipulated. It will depict those flaps which are dead at elevation, and it will allow us to critically evaluate the other factors which might have affected flap viability. The examination is safe when precautionary measures are taken.