Bowel preparation before microvascular free colon transfer for head and neck reconstruction: is it necessary?

Mechanical bowel preparation before any intestinal operation, especially when the large intestine is involved, is routine practice for most surgeons. This practice has been questioned by many colorectal surgeons, with convincing data showing the lack of benefit of preoperative mechanical bowel preparation. Free microvascular transfer of the large intestine is occasionally performed for reconstruction of the upper esophagus, as it provides a better size match for the oropharynx than other visceral organs. Nine patients underwent reconstruction of the cervical esophagus and voice tube using a segment of ileocolon. In all patients, the cervical esophagus was reconstructed using the ascending colon and the voice tube was reconstructed using the ileal segment. Both were transferred as one free flap. All patients underwent the procedure without any form of preoperative mechanical bowel preparation. The patients were able to tolerate a solid diet at the end of the mean follow-up period of 7 months, and all esophagograms showed no evidence of stricture formation. One patient developed a fistula at the recipient site that was treated with a regional flap, one patient developed a superficial wound infection of the abdominal wall, and one patient developed a postoperative abdominal wound dehiscence after several episodes of excessive coughing. Microvascular transfer of a large intestinal segment without preoperative mechanical bowel preparation for the reconstruction of the esophagus is a safe procedure. It can avoid the discomfort and complications associated with mechanical bowel preparation. If preoperative mechanical bowel preparation is preferred, the results of this study, which are based on nine patients, demonstrate the safety of this practice in cases where the patient did not follow proper instructions or in cases where the use of the colon was not anticipated preoperatively.     

Microsurgical reconstruction of the esophagus using supercharged pedicled jejunum flaps: special indications and pitfalls

This report outlines a microsurgical technique for total esophageal reconstruction in situations in which conventional methods using stomach or colon are not available. Eleven patients with corrosive injury and one patient following tumor resection underwent total esophageal reconstruction in a two-stage procedure. In the first stage, skin flaps or free jejunal transfers were used for the cervical reconstruction. In the second stage, supercharged pedicled jejunum flaps placed subcutaneously were used for thoracic esophageal replacement. The study included one male and 10 female patients, with a mean age of 38.4 years. The mean follow-up period was 78.9 months. All patients had one or more complications that required revisional surgery. Pedicled myocutaneous flaps were used to close fistulas or chronic wounds in four patients. The cervical skin tube in two patients and the jejunum in another two patients required shortening because of redundancy. Four patients had dysphagia caused by neck contractures, which were released. Two patients developed pharyngoesophageal strictures that required further free skin flaps for release. Two patients had reflux because of blind pouches arising from the original esophagus and required thoracotomy for removal. At long-term follow-up, all patients are fully rehabilitated and have resumed an oral diet with significant weight gain. Compared with lifelong jejunostomy feeding and its associated psychosocial disadvantages, the authors' experience demonstrates that the application of microsurgical techniques to fully reconstruct the esophagus is of considerable benefit to this difficult patient group.     

Reconstructing the breast mound employing a secondary island omental skin flap

We have shown in an initial animal study that omentum will adequately vascularize a skin flap and allow transfer of this tissue composite for use in surgical reconstruction of the breast. Based on this experimental procedure, a technique employing a two-stage operation has been developed and used in 21 female patients in reconstruction of the breast after radical mastectomy. In the first stage, the omentum, attached to one gastroepiploic artery and vein, is exteriorized to the subcutaneous tissue of the lower abdominal wall. In the second stage, the distal omentum, now vascularizing the overlying skin and soft tissue, is moved as a secondary island flap to the anterior chest wall to complete the breast reconstruction. In all but 1 of our 21 patients who have been followed for 1 to 8 years, reconstruction of large defects, including the chest wall, breast mound, and infraclavicular axillary fold depression, was performed without use of a prosthesis. In one patient, there was complete necrosis of the flap due to vascular impairment; there were three instances of delayed healing and a significant but partial loss of the flap in one patient. All complications were encountered in the first 10 patients of the series during the time the technique was being refined.     

Assessment of long-term nipple projection: a comparison of three techniques

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.     

Pharyngoesophageal reconstruction using a fabricated forearm free flap

A new microsurgical alternative in reconstruction of the pharynx and cervical esophagus is reported. A trapezoidal forearm flap is fabricated into an inverted skin tube and placed in the pharyngoesophageal defect. Although microvascular anastomoses are required to revascularize the transferred forearm flap, the long and large nutrient vessels of the flap make anastomoses easy and reliable. None of our 12 patients demonstrated any necrosis of the transferred flap. This one-stage, less invasive operation for pharyngoesophageal reconstruction greatly benefits older persons, who are the more likely to be involved with pharyngoesophageal carcinomas.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.     

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.     

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)     

V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle

A V-Y advancement pedicle flap including fascia has been used for reconstruction of soft-tissue defects of the posterior heel and ankle region. This flap has been used to cover 17 defects in 16 patients ranging in age from 4 to 58 years, and results have been good. We limited this application to patients without systemic disease and under 60 years of age and did not apply it to the elderly, debilitated, or systemic vascular damaged patients. There were no complications or loss of overlying skin, with the exception of one superficial tip necrosis of the flap. The results indicate the reliability and usefulness of this procedure in coverage of the posterior heel and ankle regions. It is a relatively quick and simple procedure that is without a free skin graft, and it involves only one stage that adequately corrects the skin defect at the posterior heel and ankle without prolonged splintings and results in negligible deformity of the donor site.     

Nonmicrosurgical use of the radial forearm flap for penile reconstruction

Although the era of microsurgical techniques has greatly expanded the number of possible solutions for penile reconstruction, additional options are still needed for some unusual situations when microsurgery is not available or not desired. This article describes the first nonmicrosurgical use of the radial forearm flap for penile reconstruction. With this technique, an osteocutaneous radial forearm flap 15 x 20 cm in size is elevated as a reverse-flow island flap and used to create a neopenis in the classic "tube within a tube" fashion. The neopenis is then transferred to the recipient site as a distant flap, without dividing its vascular connection with the forearm. Once a complete healing is ensured after the following 2 to 3 weeks, the pedicle is cut and the penile reconstruction is completed. Since 1995, this technique was used for total penile reconstruction in four patients: two with congenital penile agenesis, one with penile amputation as a result of a high-voltage electrical injury, and one with total loss of the external genitalia as a result of a shotgun injury. The patients have been followed up for 1 to 4 years. Good results were achieved in all patients. In conclusion, non-microsurgical use of the radial forearm flap seems to be a useful alternative to create an innervated functionally and aesthetically acceptable neopenis when microsurgery is not available or not desired. Although it is a multistage procedure, it is easy to perform. Moreover, this technique provides all well-known advantages of the radial forearm flap in penile reconstruction but does not require the sophisticated equipment and expertise of microsurgery. This is a great advantage that enables surgeons without microsurgical skill to use the radial forearm flap for phallic reconstruction. The author believes that the described technique will be extremely useful in developing countries that have limited resources and where microsurgery is difficult to obtain.     

Medial canthal reconstruction using a medially based upper eyelid myocutaneous flap

Periorbital reconstruction following skin cancer ablation represents a challenging problem. A thorough understanding of the complex periorbital anatomy is necessary to preserve lid function and protect the ocular surface. The medial canthal region represents the most difficult periorbital zone to reconstruct. This area has a complex anatomy involving both the medial canthus itself and the lacrimal apparatus. The authors present their experience with a versatile technique for reconstruction of the medial canthal periorbital region, namely, a medially based upper eyelid myocutaneous flap. In the 10 patients in whom this procedure was used, there was one partial and no complete flap losses. The authors believe that the medially based upper lid myocutaneous flap offers an excellent solution to the difficult problem of medial canthal periorbital reconstruction.     

Management of the hairline using a local flap in total reconstruction for microtia

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flap's position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.     

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.     

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.     

Patch esophagoplasty with free forearm flap for focal stricture of the pharyngoesophageal junction and the cervical esophagus.

Focal stricture of the cervical esophagus can be caused by corrosive injury or irradiation or following esophageal reconstruction. For severe stricture that cannot be relieved by bougie dilatation, surgical correction should be done. Among the operations performed, the myocutaneous flap is considered the first choice. Patch esophagoplasty with a free flap is indicated in the following situations: (1) when the patient is a young woman, (2) when the patient is obese, and (3) following irradiation that renders myocutaneous flaps unreliable. For correction of focal stricture of the cervical esophagus, six patients underwent esophagoplasty with a patch of free forearm flap. In comparison with other methods, this approach is associated with less morbidity and a better aesthetic result. The patients started oral intake at 1 month. Only one patient had minor leakage, and this healed after conservative treatment. The skin patch inserted in the esophageal wall caused no problem in motility, and the patients could eat smoothly after surgery.     

Single-stage, autologous breast restoration

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.     

Use of the free dorsalis pedis flap in head and neck repairs.

Many defects of the head and neck can be readily repaired with a free dorsalis pedis flap, and we report success with these flaps in 9 of 12 cases. A precise knowledge of the anatomy of the arterial supply of the flap is necessary. Preoperative arteriography is recommended if the dorsalis pedis artery is not easily palpable, or if an anomalous distribution of the artery along the dorsum of the foot is sus pected. However, the transfer of the flap should be delayed for two weeks after preoperative arteriography is performed. The one-stage soft tissue reconstruction with a free dorsalis pedis flap has been associated with minimal morbidity and good acceptance by patients. A delay procedure for the flap seems to enhance the chances of complete survival which is so necessary in the repair of intraoral and pharyngeal defects. Careful attention to details and close monitoring of the flap will minimize morbidity. In case of an early failure of a flap, a secondary reconstruction by a different flap can be done in the first 48 to 72 hours. Early postoperative radiotherapy has been well tolerated over these free flaps.     

A new surgical procedure for phallic reconstruction: Istanbul flap

A new surgical procedure is described for phallic reconstruction, which still remains a great challenge in reconstructive surgery. In this procedure, an osteocutaneous radial forearm flap is combined with a radial recurrent fasciocutaneous flap from the anterolateral aspect of the upper arm. While keeping a fasciovascular connection between them, both flaps are elevated as a combined free flap based on the radial artery. The forearm skin island is used solely to construct the outer skin cover of the phallic shaft, and the neourethra is created by using the radial recurrent flap. Over the past 4 years, this surgical procedure, termed the Istanbul flap, has been used successfully for complete phallic reconstruction in five patients. Although more clinical experience with this new technique is needed, it seems to be a useful alternative in phallic reconstruction. It remarkably minimizes the donor-site scar without sacrificing the length of the neopenis. In addition, this technique reduces the risk of a hairy urethra.     

Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle

Soft-tissue reconstruction of the dorsum of the foot and ankle has long been a challenge for reconstructive surgeons. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these difficult problems, the authors have begun to use a distally based lateral supramalleolar adipofascial flap. This report presents the authors' early experience with seven patients treated with this flap. The patients' ages ranged from 5 to 26 years; four of the patients were male and three were female. The cause of the soft-tissue defects involved acute trauma and chronic scar contracture. The flap and the adjoining raw area were covered with a full-thickness skin graft, and the donor site at the lateral aspect of the leg was closed primarily without grafting. A skin graft was taken from the groin area, which was closed primarily. Compared with the other flaps, this adipofascial flap was thinner and produced less bulkiness to the recipient site and minor aesthetic sequelae to the donor site. It is believed that this flap is versatile and effective and is a good addition to the available techniques used by reconstructive surgeons for coverage of the dorsum of the foot and ankle.     

The radial forearm skin graft-fascial flap

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.