Prefabricated temporalis fascia pedicled flap for previously skin-grafted contracted eye socket

The use of free skin, mucous membrane, or dermis-fat grafts in eye socket reconstruction proved to be unsatisfactory in long-term follow-up because of the progressive contraction of the socket. For achieving eye socket expansion of proper size and shape and a good vascularized lining that can last despite eventual fibrosis, a prefabricated temporalis fascia flap pedicled on the superficial temporal bundle is described in this report. In this technique, a split-thickness skin graft is applied over the termporalis fascia to create a sort of prefabricated flap, on which the proper dimensions of the socket can be fabricated on the grafted temporalis fascia. This study was conducted on 17 patients who had previously undergone eye socket reconstruction with skin graft after posttraumatic enucleation. All patients presented with a contracted eye socket, which manifested clinically by extrusion and migration of the ocular prosthesis. The procedure was performed in two stages. The purpose of prefabrication was to provide the proper shape and size of the newly created socket after release of skin-graft contracture to get a proper fit of the prosthesis, because the flap is thin and can be shaped well. The follow-up period ranged between 1 and 5 years, and the results were good.     

Reducing morbidity in the radial forearm flap donor site

The radial forearm flap, although widely used, has been criticized for the poor quality of its donor site. To investigate the causes of morbidity, 100 radial artery free-flap donor sites have been reviewed. Sixty-seven patients required skin grafting (group 1), and the remaining 33 patients were closed directly (group 2). Seventeen patients in the series had compound osteocutaneous flaps (group 3). Wound healing proved to be a significant problem in groups 1 and 3, and fracture of the radius occurred in 4 of the 17 patients in group 3 and was the most significant cause of morbidity. The radial artery was reconstructed in 12 patients, but only 6 of the arteries (50 percent) were patent at the time of review. Subjective assessment on a scale of 0 to 10 demonstrated a relatively pain-free donor site with low pain scores (2.5 of 10). The cosmetic result was acceptable in men (1.5 of 10) but was less so in women (4 of 10). Angulated fracture of the radius produced an unacceptable cosmetic result (7 of 10). In light of this experience, we no longer reconstruct the radial artery as a matter of routine. The donor defect is closed directly wherever possible using an ulnar artery-based transposition flap when required. A "boat shaped" osteotomy is used in preference to right-angled bone cuts when harvesting a segment of radius to avoid the complications and sequelae of fracture. These changes in surgical technique have improved the acceptability and minimized the problems associated with this donor site.     

Successful bone grafting of fracture nonunion at the forearm radial flap donor site.

A case of donor-site fracture following a radial forearm flap was treated conservatively with plaster but failed to unite. Successful union was achieved with bone grafting, external fixation, and electrical stimulation. It is suggested that in similar cases of delayed union, or where a large amount of bone has been resected from the radius and there is a significant risk of fracture or where fracture has occurred intraoperatively, the possibility of primary bone grafting should be considered.     

The tensor fascia lata myocutaneous free flap.

The tensor fascia lata muscle and its overlying skin provide a reliable myocutaneous unit containing a large amount of soft tissue for a free flap transfer. Its anatomy is outlined, and the operative technique for transfer is detailed in a case of chronic stasis ulcer of the lower leg.     

Experiences with the tensor fascia lata flap.

Our experience with 60 TFL flaps is reviewed. The anatomy and the arcs of rotation of this flap are described. Our clinical experience--particularly in reconstruction of the groin and abdominal wall, and in free flap transfers--has been detailed, including the use of a free osteomyocutaneous sensory TFL flap for reconstruction of the heel.     

Refinement of the radial forearm flap donor site using skin expansion

The radial forearm flap has proven to be versatile for free vascularized composite tissue transfers as well as for ipsilateral upper extremity reconstructions that require no microsurgical expertise. The most common objection to this otherwise advantageous donor area has been the subsequent nonaesthetic donor-site deformity. In addition, skin grafts frequently fail over the flexor carpi radialis tendon leading to chronic skin breakdown or at best tendon adhesions. Both these concerns may be ameliorated by means of tissue expansion of the remaining dorsal forearm skin to then allow removal of the skin-grafted portion of the donor site. These problems should be anticipated at the time of initial flap elevation so that the same incisions can be used for immediate placement of expanders.     

Reverse anterior tibial artery flap for reconstruction of foot donor site

The foot offers numerous useful options for hand reconstruction. Hallux transfer, dorsalis pedis flap, second toe transfers, and toe joint transfers offer good functional results in reconstructed hands. However, when the donor site is repaired with skin grafts, delayed wound healing, scarring, and contractures often result. Poor cosmesis of the donor site and altered gait are the main drawbacks of the procedures. The authors propose a new concept of primary reconstruction of the donor foot using a reverse-flow anterior tibial flap from the same leg. Two flaps are raised from the same anterior tibial vessel system in continuity as a distal free flap for hand reconstruction and as a proximal reverse-flow pedicled flap to resurface the donor defect. This technique allows good flap reconstruction of the foot donor site, reducing morbidity and limiting the operation to the same limb. The authors report their experience of 33 cases. There were no failures. Primary wound healing was achieved in the foot donor site, with acceptable cosmesis and satisfactory function.     

Use of the temporalis muscule flap in blanking out orbits.

We report the use of the temporalis muscle as a transposition flap to obliterate the orbit in 5 patients. In 4 of the cases we split the muscle coronally and passed the anterior part through a window in the lateral orbital wall. In two of these patients, skin grafts were put on both sides of the temporalis muscle-fascia flap, to restore nasal lining and to cover the facial surface simultaneously. In the remaining patients, the muscle was split sagittally to provide a large surface for coverage. The temporalis muscle flap is a versatile one for filling orbits after exenteration.     

Skin-stretching device for intraoperative primary closure of radial forearm flap donor site

The use of a skin-stretching device to close radial forearm donor-site defects in patients being treated for intraoral cancer is described. Intraoperative application of the device achieved primary closure of the donor site during the time course of the reconstructive procedure with no requirement for additional operative time. The device was used successfully in seven patients with two instances of marginal skin necrosis and delayed healing but good long-term functional and cosmetic outcomes in all cases.     

The temporalis myo-osseous flap: an experimental study

The present paper investigates the anatomy and vascularization of the temporalis myo-osseous flap. This is a calvarial bone flap that employs temporalis muscle and its distal pericranial extension as a pedicle. In six human cadavers the flap was raised as an island on the anterior deep temporal artery after transecting the zygomatic arch and coronoid process. Maximal mobilization was thus obtained, allowing rotation of the flap into the mouth for intraoral reconstruction. The arc of rotation and potential surgical applications were noted. A comparative study of the temporalis myo-osseous flap and free calvarial bone graft was then conducted in a rabbit model. Vascularization of the calvarial bone flap was confirmed by technetium scintigraphy performed on the first postoperative day. The uptake of fluorochrome labels immediately after transfer verified the adequacy of the periosteal circulation in maintaining viability and new osteoid formation throughout the full thickness of calvarial bone. The transplantation of free calvarial bone grafts was followed by necrosis of most cellular elements. This was demonstrated by an absence of fluorochrome uptake up to 19 days postoperatively and a predominance of empty lacunae and nonviable marrow.