A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

The free iliac flap: a lateral modification of the free groin flap.

A lateral modification of the free groin flap, called the free iliac flap, is presented. By moving the outline of the free groin flap laterally, so that the medial margin lies lateral to the underlying femoral triangle, a flap is obtained which is uniformly slender and which has a long vascular pedicle. The anatomical findings, a method for safe dissection of the superficial circumflex iliac vessels, and the results of 18 clinical cases are presented.     

The groin flap in reparative surgery of the hand

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.     

The thigh flap: an osteomyocutaneous free-flap model in the rat

A new experimental model for free-flap transfer has been developed in the rat. This "thigh flap" is an osteomyocutaneous free flap of bone (femur), muscle (thigh), and skin (groin) based on the femoral vessels. The flap is harvested from the left groin and thigh of an inbred female rat and is transferred to a subcutaneous pocket in the left groin of a male rat of the same inbred strain. The femoral vessels supplying the flap are anastomosed end-to-end with the femoral vessels of the recipient. Thirty flaps have been transferred, with 5 technical failures. Three of the remaining 25 flaps developed necrosis within 24 hours. The other 22 flaps remained viable until the rat was sacrificed at 7 days. The survival rate of the thigh flap was thus 88 percent. The model is suitable for use in metabolic, vascular, and immunologic studies of composite free flaps.     

Prefabricated thin flap using the transversalis fascia as a carrier.

To harvest a thin flap from the groin and hypogastric area, the authors developed a new prefabricated flap using the transversalis fascia as a carrier. The transversalis fascia is a very thin and abundantly vascularized tissue nourished by the deep inferior epigastric vessels. Flap prefabrication was performed by inserting the transversalis fascia between the thinly undermined skin flap and the tissue expander placed beneath the skin flap, followed by a pretransfer delay procedure around the flap. After a 3-week interval, the flap was transplanted with no complications, such as congestion and thrombus of anastomosis. By using this technique, it was possible to elevate an equally thin flap from the groin and hypogastric area while avoiding morbidity of the donor site.     

Groin flap design and versatility

The groin flap is a reliable and well-established reconstructive option for pedicled or free-tissue transfer. Concern regarding its variable vascular origin and caliber has limited its use. To overcome this, a simplified guideline based on the transverse diameter of the patient's index and long fingers at the distal interphalangeal level has been developed. Thus "rule of two finger widths" positions the origin of the vascular pedicle from the femoral vessels two finger widths below the inguinal ligament, the upper flap border two finger widths above the inguinal ligament, the lower flap border two finger widths below the vascular origin, and both parallel to the flap axis, which lies along a line from the vascular origin to the anterosuperior iliac spine. This new groin flap design provides the necessary guidelines for vascular identification, accommodates pediatric and adult stature, and ensures primary donor-site closure if flap dimensions are within the prescribed boundaries. In addition, a new sartorius-cutaneous groin flap is presented. This combines the cutaneous groin flap with the proximal sartorius muscle (up to 15 cm), which is supplied by the deep vessels of the superficial circumflex iliac system. The sartorius-cutaneous groin flap further emphasizes the concept of single-pedicle compound or combined flaps and additionally enhances the extensive reconstructive versatility of previously described groin flaps. Over 200 pedicled and free groin flaps have been performed according to the "rule of two finger widths" over the past 5 years. There have been no complications related to flap design, such as difficulty with flap elevation, marginal necrosis, or donor-site closure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work.

In this paper we present 16 cases of free transfer of compound flaps from the groin, 11 using the deep circumflex iliac vessels as a stem and 5 using the superficial circumflex iliac vessels as a stem. We found the deep vessels superior in many ways to the superficial vessels for this purpose; they are larger, permitting greater ease in anastomoses and providing more reliable blood flow. We believe that larger osteocutaneous or myocutaneous flaps can be transferred on the deep vessels than on the superficial ones-and that the deep circumflex iliac flap may supplant the conventional free going flap in most situations. The method evolved in response to patient need, not for surgical éclat.     

Experimental esophageal reconstruction in rats, with a free groin flap.

The reconstruction of a functioning esophagus with a free groin flap was performed successfully in 10 rats. A technique is described for the experimental anastomosis of vessels with a diameter of 0.5 mm or less. We also describe a modification of a method to convert a hairy flap before transfer into a hairless one.     

Superficial circumflex iliac artery perforator flap for reconstruction of limb defects

The superficial circumflex iliac artery perforator (SCIP) flap differs from the established groin flap in that it is nourished by only a perforator of the superficial circumflex iliac system and has a short segment (3 to 4 cm in length) of this vascular system. Three cases in which free superficial circumflex iliac artery perforator flaps were successfully transferred for coverage of soft-tissue defects in the limb are described in this article. The advantages of this flap are as follows: no need for deeper and longer dissection for the pedicle vessel, a shorter flap elevation time, possible thinning of the flap with primary defatting, the possibility of an adiposal flap with customized thickness for tissue augmentation, a concealed donor site, minimal donor-site morbidity, and the availability of a large cutaneous vein as a venous drainage system. The disadvantages are the need for dissection for a smaller perforator and an anastomosing technique for small-caliber vessels of less than 1.0 mm.     

The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume.

The ideal skin-flap reconstruction provides functional preservation and a good cosmetic outcome in both the reconstructed site and the donor site. Although various flaps are used for reconstruction of the vulvar and buttock region, there are disadvantages associated with each. In 1996, Yii and Niranjan reported the gluteal-fold flap for vulvar reconstruction. As presently used, this flap is bulky, particularly in obese patients or when used for hemilateral reconstruction. Thinning the flap has been considered impossible because of the obscurity of the blood supply. In the study presented here, the pedicle vessels of this flap were studied in eight cadavers; the authors found that the flap is nourished by a direct cutaneous system of the internal pudendal artery and vein. Accordingly, adjustment of the flap volume was believed to be possible, with the exception of the adipose tissue containing the pedicle vessels. The authors have since used 14 thinned flaps for seven vulvar, one vaginal, and two buttock defects in 10 patients. All flaps survived completely. Good functional and cosmetic results were achieved with hemilateral or bilateral flaps in vulvar or buttock reconstruction. In the buttock in particular, the usefulness of this flap for anal and pelvic-floor reconstruction was demonstrated. The scar at the donor site, concealed in the gluteal fold, was acceptable. The gluteal-fold flap is very useful for various vulvar and buttock reconstructions because it can be adjusted to the required volume.     

The isolated perfused human skin flap: design, perfusion technique, metabolism, and vascular reactivity

The design, isolated perfusion technique, and reactivity of a novel human skin-flap model are described. A transverse paraumbilical skin flap based on perforator vessels from the deep epigastric system was designed utilizing the tissue usually discarded following abdominal dermolipectomy. Within 3 hours of devascularization, a gassed (95% O2, 5% CO2), 37 degrees C Krebs-Henseleit buffer containing albumin (65 gm/liter) was pumped into the cannulated arterial pedicle of the skin flap and subsequently collected from the venous pedicle. Vascular resistance was continuously monitored and remained stable throughout the 4-hour perfusion. Lactate release was maintained throughout perfusion and was markedly increased by addition of insulin to the perfusate. Addition of norepinephrine to the perfusate resulted in a significant (p less than 0.05) dose-response increase in vascular resistance, and acetylcholine significantly (p less than 0.05) attenuated resistance in flaps preconstricted with norepinephrine. The results of these studies indicate that the isolated perfused human skin flap remained metabolically active with functionally intact vascular endothelium and smooth muscle throughout the 4-hour perfusion. The availability of this technique will, for the first time, permit laboratory study of human skin-flap pathophysiology and pharmacology.     

The use of free groin flaps in children

The free groin flap is a well-established method of skin coverage. Although its use in children has been reported, there have been no published series specifically in such cases. The authors report 33 consecutive cases of free groin flaps in children in their unit over a period of 9 years (1992 to 2001). Tissue transfer was performed to provide soft-tissue coverage during reconstruction of congenital defects and tumor resection and following trauma. Twenty-six cases (79 percent) involved the upper limb, six cases (18 percent) involved the lower limb, and one case involved the head. The complication rate compares favorably with similar series published for adults, with only two complete failures (6 percent), three (9 percent) minor donor-site complications (superficial wound infection, hypertrophic scarring, and dog-ears), and nine flaps requiring debulking. The reexploration rate was 24 percent, with seven of the eight flaps undergoing reexploration surviving. The groin flap is a reliable flap that can be used safely in children, with minimal morbidity.     

Free groin flap revisited

Reported herein are 130 consecutive cases of free groin flap transfer performed by one surgeon over a 19-year period. Transplantation was performed for soft-tissue cover or augmentation of contour defects involving the head and neck (68 cases), trunk (4 cases), upper limb (14 cases), and lower limb (44 cases). Indications for flap coverage/augmentation were classified broadly into tumor, trauma, radiation induced, and miscellaneous. Specific reconstructive problems included augmentation for Romberg's hemifacial atrophy, external ear canal reconstruction after tumor ablation, and coverage of lower limb defects. There were nine failures (total flap loss), seven cases of partial flap loss, and two cases were abandoned intraoperatively. Of 15 cases that were urgently re-explored, 9 flaps were salvaged. The failure rate for the groin flap series (130 cases) was 8.5 percent compared with the failure rate of 4.2 percent for the other 517 cases of microvascular transfer performed over the same period by the same surgeon. Donor-site complications occurred in 24 cases and included hematoma or seroma formation, hypertrophic scars, nerve paresthesiae, infection, and dehiscence. Secondary debulking procedures were performed in 26 cases. The free groin flap, contrary to some reports, is a reliable flap that provides relatively thin pliable soft-tissue cover or augmentation, with minimal donor-site morbidity. The specific indications for its use have undergone an evolution since first described in 1973.     

The trauma of suction-assisted lipectomy cannula on flap circulation in rats.

The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.     

Fluorometric analysis of an attempt to reclaim ischemic flaps in rats with Fluosol

An experiment was designed to answer two questions as they apply to random skin-flap survival: Is there a therapy that can improve random skin-flap survival when given postoperatively? And if so, when does one start such a therapy? Fluosol-DA 20% (Fluosol) has increased random skin-flap survival when given preoperatively in our laboratory. An experiment was devised to see if it could rescue failing flaps. One-hundred Sprague-Dawley rats were divided into a control (N = 25) and five experimental groups (N = 15). All had 10 X 13 cm reverse McFarlane random flaps raised and reinset. The experimental groups underwent hemodilution with either Ringer's lactate or Fluosol at 4, 8, and 12 hours after flap elevation. All were kept in 50% oxygen for 72 hours postoperatively. The flaps and their corresponding necrotic areas were measured on day 7. As to when to institute a therapy, we simultaneously evaluated the use of a microfluorometer as a monitor of flap survival. Analysis of flap survival showed little difference between control and experimental Ringer's lactate or Fluosol groups. Analysis of the microfluorometric data led to the following points. First, as a monitor of flap viability, it is limited by a lack of specificity and sensitivity. Second, comparison of the data from portions of the flap destined to live with those destined to die suggests that it may not be failure of circulatory inflow that leads to flap death.     

Functional oromandibular reconstruction with the microvascular composite groin flap

Ten patients were reconstructed with the microvascular osteocutaneous groin flap for oromandibular defects with the objective of improving function. The flap was based on the superficial and deep circumflex iliac vessels for optimal positioning of the bone and contouring of the skin. Patients with major glossectomies and arch resections had intelligible speech and were able to eat a soft diet without aspirating. Cineradiographic studies to evaluate swallowing in selected patients showed that the shape of the intraoral flap and the location of the bone graft played an important role in swallowing and prevention of aspiration.     

One-stage repair of compound leg defects with free, revascularized flaps of groin skin and iliac bone.

The successful revascularized free transfer of a composite flap of groin skin with attached iliac bone is presented in two patients. The findings in the preliminary dissections and injection studies in cadavers are discussed, and the superficial circumflex iliac system is recommended as a stem for free flaps of groin skin and iliac bone. If iliac bone alone is required for a revascularized graft, then the deep circumflex iliac system would seem suitable for the stem. Further clinical cases are necessary to determine the indications for this procedure, and patients should be carefully selected. The need for preoperative preparation and planning on a sound anatomical background is emphasized, and preoperative angiography seems advisable. The ability to sew small vessels together reliably is one thing: the when and where is another.     

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.     

On the mechanism by which antiadrenergic drugs increase survival of critical skin flaps

In order to asses the possibility that degeneration release of noradrenaline influences the survival of critical skin flaps, we studied the effect of various antiadrenergic drugs on skin-flap levels of noradrenaline, ATP, and cyclic AMP. Reserpine treatment depleted the skin flaps of noradrenaline and counteracted the fall in ATP and the cyclic AMP accumulation. Guanethidine had similar but less pronounced effects. Propranolol did not affect noradrenaline levels or depletion rate, but reduced the metabolic stimulation, as assessed by cyclic AMP levels in the flap. Phentolamine had no effect on basal noradrenaline levels, but tended to accelerate its disappearance and reduce lactate accumulation, a measure of hypoxia. All these drugs are known to increase skin-flap survival. It is suggested that they do so by, respectively, depleting the flap of its content of noradrenaline prior to operation or preventing the vasoconstriction and metabolic stimulation caused by released noradrenaline.     

Controlled tissue expansion of a groin flap for upper extremity reconstruction

A large upper extremity defect in an 8-year-old girl was resurfaced with an expanded groin flap. Tissue expansion allowed complete coverage of the defect while minimizing the donor deformity. Pretransfer expansion of pedicled flaps offers an alternative to free-flap reconstruction of complex upper extremity defects. This is especially valuable in the pediatric patient, in whom donor-site morbidity can be significant.