The free deltoid flap: microscopic anatomy studies and clinical application to oral cavity reconstruction

The deltoid free flap is a fasciocutaneous flap that should be thin, hairless, of an adequate size, and capable of sensory reinnervation. Because of its excellent color-matching and texture-matching characteristics, it has recently been widely used for the reconstruction of soft-tissue defects during oral and maxillofacial surgery. Furthermore, a characteristic of oral and maxillofacial soft-tissue defects is that they are not large; therefore, flap size will be small, allowing the donor site to be directly closed. Because of natural variation in parts of the anatomy, there has sometimes been great difficulty in clinical application. The authors decided to study this by performing anatomical studies of the deltoid region on 21 cadavers. The result indicates that the pedicle of the deltoid free flap penetrates the "quadrangular space" in 90 percent of cases but passes and does not penetrate the quadrangular space in the remaining cases. The authors also confirmed that the skin has a vascular network comprising five layers and, furthermore, that the vascular network of the deep fascia is dense. The authors also report six cases of its clinical use complicated by anatomic variation and local infection in which the deltoid flap showed a completely successful outcome.     

A new classification for the standardization of nomenclature in free flap wound closure

A profusion of terms are currently used to describe free flap wound closure. It is important to broadly standardize nomenclature when embarking on a comparison of functional outcomes between institutions. Therefore, a series of 68 "emergency" (within 24 hours) free flaps performed by a single surgeon were reviewed with respect to a total experience of 188 free tissue transfers to formulate a consistent nomenclature applicable to free flap wound closure in general. The nomenclature presented divides free flap closure into three categories: "primary free flap closure" (12 to 24 hours), "delayed primary free flap closure" (2 to 7 days), and "secondary free flap closure" (after 7 days). This system is analogous to the standard terms "primary," "delayed primary," and "secondary wound closure." It is consistent with known biologic and microbiologic principles of wound closure in general and should provide a simple basis for classifying free flap wound closure. Illustrative examples are presented to highlight the classification scheme.     

Geometric considerations in the design of rotation flaps in the scalp and forehead region

The classical transposition and rotation flaps are well known. Cosmetic considerations in the scalp and forehead region limit the use of a flap design that requires a skin graft for a donor defect. On sound geometric principles, the classical flap designs are suitably modified here to have a somewhat equal proportion of transposition and rotation. This "modified rotation flap" design works to a maximum advantage in the inextensible region of the scalp and forehead by providing single-stage primary closure of moderate to large defects. No backcuts are ever necessary with this flap design. Use of this principle to modify the rotation flap design for closure of an extended midline forehead defect following rhinoplasty allows a still wider (up to 6.5 cm) midline forehead flap to be available for rhinoplasty with primary closure of the donor defect.     

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time-consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon-assisted advancement flap technique (n = 10 each). The balloon-assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloon-assisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds.     

Further refinements on the triangular flap closure of the cleft lip

Refinements in the triangular flap closure of the unilateral cleft lip are presented. Randall's mathematical interpretation of the Tennison repair has been extended by using a series of arcs to determine the crucial points which form the triangular flap. Using this easily taught method, an isosceles triangular flap can be plotted which will interdigitate into the noncleft side of the lip. Two symmetrical vertical distances on either side of the cleft are thus formed. This allows for a standardized repair which may be more readily taught than the rotation-advancement technique. In addition, flaps are created which are turned medically toward the cleft and are used to accentuate the philtral pout, close the nostril floor, and reinforce the lip repair, allowing closure of even extremely wide clefts in one stage. These refinements in using the triangular flap closure for the repair of the unilateral cleft lip are diagrammatically presented. We believe that these refinements enhance the results of this closure.     

Does velopharyngeal closure pattern affect the success of pharyngeal flap pharyngoplasty?

Historically at The Hospital for Sick Children in Toronto, pharyngeal flap pharyngoplasty has been the treatment of choice for treatment of velopharyngeal insufficiency, regardless of velopharyngeal closure pattern. The authors hypothesize that pharyngeal flap pharyngoplasty is more effective in treating velopharyngeal insufficiency in patients with circular or sagittal velopharyngeal closure and less effective in treating the coronal closure pattern. Ninety-three patients who underwent superiorly based pharyngeal flap surgery for velopharyngeal insufficiency were evaluated in a retrospective chart review. Closure pattern was determined preoperatively by nasopharyngoscopy or multiview videofluoroscopy. Nasalance was assessed preoperatively and at 6 weeks and 1 year postoperatively. Nasalance during nonnasal speech was decreased on average, for all closure patterns, postoperatively. However, a significantly higher percentage of patients were corrected to normal nasalance scores in thenoncoronal group than in the coronal group (57 percent versus 35 percent, respectively) at 1 year postoperatively (p < 0.05). Surgical overcorrection, as determined by postoperative hyponasality, occurred at a rate of 13 percent in the coronal group versus 7 percent in the noncoronal group (not statistically significant). The results demonstrate that hypernasality in patients with a coronal velopharyngeal closure pattern can be improved by pharyngeal flap pharyngoplasty. This procedure, however, is more frequently effective in correcting noncoronal closure pattern velopharyngeal insufficiency than coronal pattern velopharyngeal insufficiency. The authors are now more selective in their approach to the management of velopharyngeal insufficiency and are more inclined to treat coronal pattern velopharyngeal insufficiency with sphincter pharyngoplasty.     

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores

The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation-advancement flap with V-Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V-Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation-advancement action was supported laterally with V-Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound-healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V-Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotation-advancement flap and bilateral rotation-advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow-up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome.     

Closure of hemicorporectomy with bilateral subtotal thigh flaps

Hemicorporectomy is typically performed with a circumferential truncal incision, and the wound is closed primarily. Wound disruption is a common complication, especially at the base of the wound closure and posteriorly at the lumbar vertebral level. We report a case of the use of bilateral subtotal thigh flaps for the closure of a hemicorporectomy wound in a patient with a defect extending up to the high lumbar region. The subtotal thigh flap is a well-vascularized thick flap that provides a firm support for the abdominal viscera and is a large flap that can be used to close even a high lumbar defect.     

Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases

Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.     

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.     

A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications

Forty-eight patients who suffered sternal wound infections following coronary artery bypass grafting were retrospectively reviewed over a 5-year period. All patients in this study had clinical signs of major infection including redness, pain, and purulence at the time of mediastinal drainage and debridement. One patient died 11 days postoperatively because of heart failure, leaving 47 patients available for long-term follow-up. All muscle flaps (pectoralis and rectus abdominis) survived completely. All wound complications were related to chest wall skin flap dehiscence or continued infection. Seventeen of 22 patients (77 percent) undergoing flap closure 4 days or less after sternal debridement and irrigation suffered wound complications. Five of these 22 patients (23 percent) had major wound complications, meaning that the wound required more than 2 months of care before healing was complete. No major wound complications and only three minor complications (12 percent) occurred in 25 patients undergoing sternal flap closure 5 days or more after mediastinal debridement and irrigation. The frequency and severity of wound complications were significantly decreased in the group of patients undergoing sternal flap closure 5 or more days after sternal drainage and debridement (p < 0.00005). In the majority of cases [29 of 47 (62 percent)], secure sternal wound closure was obtained with a single, split, medially based, right pectoralis major muscle flap.     

The inhibition of skeletal changes in a rat burn model with a local muscle flap

The effects of early wound closure using a local muscle flap on the development of periosteal new bone formation in a rat burn model were studied. Following a full-thickness burn to one hind limb, periosteal new bone formation along the tibial diaphysis was measured by the use of the fluorochrome agent calcein and an image-analysis system. Prostaglandin E levels, a known inflammatory mediator, from the bone beneath the burn also were measured. Periosteal new bone formation was inhibited by 50 percent in animals that had debridement and wound closure with a gastrocnemius muscle flap and skin graft on postburn day 2 compared to untreated controls or animals closed with skin grafts only. There was a trend toward reduced prostaglandin E measurements from tibial sections in the early closure group compared to untreated controls. This study demonstrates that early wound closure using a local muscle flap inhibits the periosteal new bone formation which is possibly associated with the inflammation in a rat burn model.     

Deltopectoral skin flap as a free skin flap revisited: further refinement in flap design, fabrication, and clinical usage

The deltopectoral skin flap is an axial flap; therefore, it can be fashioned as a free skin flap. Although color and texture of the skin are well suited for facial resurfacing, the structural features of inconsistent thickness of the skin, a short vascular pedicle, a minute caliber of the nutrient vessel, and donor site morbidity often preclude the use of this flap for this purpose. The deltopectoral skin flap fabricated as a free skin flap transferred by means of a microsurgical technique was used in 27 patients between 1985 and 1998 at our hospital. The anterior perforating branches of the internal mammary vessels were the primary nutrient vessels of the flap in seven instances. The external caliber of this artery varied between 0.6 mm and 1.2 mm, with an average size of 0.9 mm. The size of the accompanying vein varied between 1.5 mm and 3.2 mm, with an average of 2.3 mm. Coaptation of these vessels with those in the recipient site was technically difficult. Thrombosis occurred at the anastomotic site in three patients, requiring reoperation. Two flaps were saved. The flap failure was drastically reduced in the remaining 20 patients by including a segment of the internal mammary vessel when fabricating the vascular pedicle. The size of the internal mammary arterial segment averaged 2.1 mm, and the average size of the accompanying vein was 2.9 mm. The problem of a bulky flap was managed by surgical defatting/thinning of the flap at the time of flap fabrication and transfer. A V-to-Y skin flap advancement technique of wound closure was used in eight individuals. The flap donor-site morbidities were minimized with this method of wound closure.     

Repair of pharyngocutaneous fistulas with the submental artery island flap

Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, debridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 x 3 cm and the minimum size was 4 x 2 cm (average, 4.8 x 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donor-site morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed.     

Sideburn reconstruction with an arterial V-Y hair-bearing scalp flap after the excision of basal cell carcinoma

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.     

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)     

A transverse thoracoabdominal skin flap for closure after radical mastectomy.

For closure of radical mastectomy defects, we present a new rotation flap using thoracoabdominal skin which crosses the midline of the trunk. This allows a rapid closure without the necessity of a delay.     

Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

A systematic approach for improvement of the donor sites of fasciocutaneous flaps

Fasciocutaneous flaps as a group have been maligned more often for fear of potential donor-site morbidity than any concern for reliability. Typically, this is related to limitations imposed by the skin graft necessary to close most such donor sites, as admittedly has been required for the majority (52 percent) of our 313 flaps over the past 2 decades. Nevertheless, 48 percent did not require skin grafts, reflecting the adoption of strategies that evolved to minimize this shortcoming. These included use of fascia-only flaps, primary closure with small composite flaps, direct closure possible by use of rotation or advancement flaps or a second flap, or a delayed closure utilizing either pretransfer or posttransfer tissue expansion. Donor-site complications were actually fewest when a skin graft or primary closure was possible and occurred at the same rate regardless of body region. However, because the skin-grafted donor site was always a cosmetic compromise, a systematic approach to circumvent its use whenever possible is emphasized as a valuable tool to enhance the role of fasciocutaneous flaps as a vascularized flap alternative.     

Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction

Patients presenting advanced breast tumors are usually subject to major resections of the anterior chest wall tissue. Flaps taken from the abdominal wall, such as the TRAM, the external oblique flap, and the thoracoabdominal flap are frequently used for closure of this type of lesion. In this study, a different shape was planned for the skin island from the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall after mastectomies occasioned by advanced breast cancer. The technique was used on eight female patients, between November of 1998 and July of 1999, victims of advanced breast cancer, who had been submitted to radical mastectomies with major resections of the cutaneous tegument. It was possible to make primary closure of lesions in the anterior chest wall, the preoperative areas of which varied between 15 x 15 and 29 x 14 cm (vertical x horizontal). This technical variant permitted use of the flap without the need to create tunnels for its advancement and rotation. It also proved to be easy to perform and presented a low morbidity rate, with three patients presenting minor complications that did not require correction through any further surgical intervention. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. According to the authors, this procedure is a viable alternative in repairing large defects in the anterior chest wall.