The role of microsurgery in reconstruction of oncologic chest wall defects.

Regional pedicled myocutaneous flaps are usually the best choice for soft-tissue coverage of full-thickness chest wall defects. As defects increase in size, microsurgical techniques are necessary to augment blood flow to pedicled flaps or to provide free flap coverage from distant sites. This study retrospectively reviews all microsurgical procedures performed at one institution for the coverage of full-thickness chest wall defects. Twenty-five cases of full-thickness chest wall reconstruction are reviewed. There were 20 free flaps and five supercharged pedicled flaps. A rectus abdominis myocutaneous flap (free or supercharged) was used in 20 cases, and a filet free flap following forequarter amputation was used in five patients. Large skeletal defects were repaired with a Marlex mesh/methylmethacrylate sandwich prosthesis. There was 100 percent flap survival and one case of minor, partial flap loss. The prosthesis remained effectively covered in all cases. Five patients required ventilatory support for up to 10 days postoperatively. There were three perioperative deaths due to multisystem failure. Microsurgical techniques are extremely useful for reconstruction of complicated, composite chest wall defects. They are indicated when regional pedicled flap options are unavailable or inadequate. These flaps have a 100 percent success rate and uniformly result in stable soft-tissue coverage.     

Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.     

Reconstructive management of cranial base defects after tumor ablation

Successful reconstruction after cranial base tumor ablation is paramount in preventing potentially life-threatening complications. The purpose of this study was to evaluate experiences of cranial base reconstruction and to identify reconstructive management principles that may assist in achieving successful cranial base reconstruction. All cranial base reconstructions performed by the Department of Plastic Surgery at the University of Texas M. D. Anderson Cancer Center between January of 1993 and September of 1999 were reviewed. Analyses were performed to assess the impact of location of defect, type of reconstruction, type of dural repair, and history of preoperative radiation and chemotherapy on rates of complications, and patient survival. The 77 patients who underwent cranial base reconstruction after tumor ablation during the study period had a mean age of 52 years (6 to 84 years). The mean follow-up period was 28.7 months (1 to 76 months). Squamous cell carcinoma, the most common histopathologic type, was present in 24 patients (31 percent), and 35 patients (45 percent) presented with recurrent disease. Location of defects involved region I (anterior) in 31 patients (40 percent), region II (anterior-lateral) in 18 (23 percent), region III (lateral-posterior) in six (8 percent), and more than one region in 22 (29 percent). Reconstructive methods included free flaps in 52 patients (68 percent), temporalis muscle flaps in 14 (18 percent), pericranial flaps in eight (10 percent), and other local flaps (two galeal, one scalp) in three (4 percent). Of the 52 free flaps, 18 (35 percent) were used in region I, 14 (27 percent) in region II, six (12 percent) in region III, and 14 (27 percent) in defects involving more than one region. Of the 14 temporalis muscle flaps, 13 (93 percent) were used for defects involving regions I or II and one (7 percent) was used for a defect involving region III. Of the 11 pericranial and other local flaps, nine (82 percent) were used in region I, one (9 percent) in region II, and one (9 percent) in a combination of regions II and III. Complications occurred in 21 patients (27 percent): three total flap losses (4 percent), three partial flap losses (4 percent), two cerebrospinal fluid leaks (3 percent), two cases of meningitis (3 percent), two abscesses (3 percent), five cases of delayed wound healing (6 percent), two hematomas (3 percent), one wound infection (1 percent), and one cerebrovascular accident (1 percent). Overall survival was 77 percent at 2 years and 58 percent at 4 years. The type of reconstruction, location of defect, type of dural repair, and history of preoperative radiation and chemotherapy had no significant association with the incidence of complications. Neither the type of reconstruction nor the location of defect showed a significant effect on patient survival. In this experience, local flaps, such as pericranial or temporalis muscle flaps, are good choices for reconstruction of smaller anterior or lateral cranial base defects. For defects that require larger amounts of soft tissue, free flaps are appropriate. With proper patient selection, successful cranial base reconstruction can be performed with either local or free flaps with a low incidence of complications.     

Anterolateral thigh flap for abdominal wall reconstruction

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.     

Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses

Six cases of large defects of the scalp, skull, and dura following tumor ablation and radiation are presented. Each was accompanied by chronic infection in the irradiated defect. Efforts to reconstruct the resulting defects with local flaps were not successful. One-stage reconstruction was then accomplished in each case utilizing a latissimus dorsi musculocutaneous or myo-osteocutaneous free flap transferred by microvascular anastomoses. The versatility of the latissimus dorsi musculocutaneous and/or osseous flap allows single-stage reconstruction of these complex defects.     

Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient

Primary microsurgical reconstruction is the treatment of choice for ablative defects of oral carcinoma. As a result of this trend, more and more patients with recurrent oral carcinoma who have been initially treated with surgical excision and reconstructed with free flaps are being seen. However, a second microsurgical reconstruction attempt in these cases raises questions about the flap choices, availability of recipient vessels, and effects of previous treatment modalities. Herein, 35 patients with perioral carcinoma who had two successive tumor resections and reconstruction with free flaps on each occasion are presented. A total of 75 free tissue transfers were carried out for the first and second reconstructions. After the first tumor resection, 28 radial forearm fasciocutaneous flaps, 7 fibula osteoseptocutaneous flaps, 1 iliac osteomyocutaneous flap, and 2 rectus abdominis myocutaneous flaps were used. For reconstruction after the recurrence, 17 radial forearm fasciocutaneous flaps, 13 fibula osteoseptocutaneous flaps, 3 rectus abdominis myocutaneous flaps, 2 anterolateral thigh flaps, 1 jejunum flap, and 1 tensor fasciae latae flap were used. More vascularized bone transfers were performed during the second reconstruction since the excision for the recurrence frequently required segmental mandibulectomy. The complete flap survival rate was 97.3 percent and 94.6 percent with a reexploration rate of 7.9 percent and 13.5 percent for the first and second free tissue transfers, respectively. The mean follow-up time throughout the procedures was 37.5 months. Disease-free interval between reconstructions was 20.8 months. At the time of evaluation, 54.3 percent of the patients were surviving an average of 19 months since the second reconstruction. The results suggest that free flaps represent an important option in reconstruction of recurrent perioral carcinoma cases undergoing reexcision. When used in this indication they are as safe and effective as the initial procedure.     

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.     

Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.     

Microvascular reconstruction of the hypopharynx: defect classification,treatment algorithm,and functional outcome based on 165 consecutive cases

The objectives of this study were three-fold: to develop a scheme for classification of hypopharyngeal defects, to establish a reconstructive algorithm based on this system, and to assess the functional outcome of such reconstruction. This study is a retrospective review of a 14-year experience with 165 consecutive microvascular reconstructions of the hypopharynx in 160 patients. The average patient age was 59 years (95 percent CI, 37 to 81). Thirty-four patients were operated on for recurrent disease; 71 had preoperative radiotherapy. Partial defects were reconstructed with radial forearm flaps (n = 52); circumferential defects were reconstructed with jejunum (n = 90); and extensive, noncircumferential longitudinal defects were reconstructed with rectus abdominis flaps (n = 23). The overall free flap success rate was 98 percent. Six flaps required reexploration, two of which were salvaged. The incidence of fistula was 7 percent and stricture, 4 percent. Preoperative radiotherapy was significantly associated with risk of recipient site complications (OR, 2.3; 95 percent CI, 1.0 to 5.0). Follow-up data were available on 95 percent of patients: 53 percent were able to tolerate an unrestricted diet, 23 percent a soft diet, 12 percent liquids only, and 12 percent were limited to tube feedings. The treatment algorithm for microvascular hypopharyngeal reconstruction is based on the type of defect with partial defects with radial forearm flaps, circumferential defects reconstructed with free jejunal flaps, and extensive, multilevel defects reconstructed with rectus abdominis myocutaneous flaps. Microvascular reconstruction of pharyngeal defects is highly successful with few postoperative complications. With appropriate flap selection, functional outcome can be optimized.     

Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap

Reconstruction of composite defects of the mandible is a challenging problem. Although the use of an osteocutaneous free flap, alone or in combination with another soft-tissue free flap, is generally accepted to be optimal, the bony reconstruction is sometimes undervalued, especially when the cancer is advanced. In such situations, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap. Between January of 1997 and July of 2000, 80 patients with composite or extensive composite oromandibular defects underwent treatment with a reconstruction plate and a soft-tissue free flap. All of the patients were male, and the ages of the patients at the time of treatment ranged from 32 to 78 years (mean, 51 years). Tumors were classified as stage IV in 56 patients (70 percent), whereas the remaining 24 patients (30 percent) had recurrent carcinomas. The titanium mandibular reconstruction system manufactured by Stryker (Freiburg, Germany) was used to bridge the mandibular defects. The soft-tissue free flaps used for wound and plate coverage were as follows: anterolateral thigh flap (n = 75), radial forearm flap (n = 3), transverse rectus abdominis myocutaneous flap (n = 1), and tensor fasciae latae flap (n = 1). Five patients with recurrent carcinomas and 10 with stage IV carcinomas (18.75 percent) died 2 to 6 months after the operation and were excluded from the study. The remaining 65 patients were monitored for an average follow-up period of 22 months (range, 6 to 40 months). During that period, one or more complications occurred for 45 patients (69.2 percent). Plate exposure was the most common complication and was observed for 30 patients (46.15 percent). Twenty of the 65 patients (30.8 percent) required secondary salvage reconstruction with a fibula osteoseptocutaneous flap. The decision to perform a secondary salvage procedure was based on the general health of the patient, the extent of local disease, and the severity of the complications. Patients underwent salvage operations after an average of 11.5 months (range, 6 to 26 months). The major reasons for the second operation were as follows: reconstruction plate exposure (n = 12), soft-tissue deficiency and mandibular contour deformation of the lateral face (n = 7), intraoral contracture and lack of a gingivobuccal sulcus (n = 6), trismus (n = 4), and osteoradionecrosis of the mandible (n = 2). The total flap survival rate was 90 percent (18 of 20 free flaps). In two cases, the skin paddles of the fibula osteoseptocutaneous flaps exhibited partial failure and were revised with pedicled pectoralis major and deltopectoral flaps. The reconstruction plate and free soft-tissue flap procedure for the reconstruction of composite defects of the oromandibular region has many late complications, which eventually necessitate reconstruction of the mandible with an osteocutaneous free flap.     

Island scalp flap for superior forehead reconstruction

An island scalp fasciocutaneous flap, based on the posterior superficial temporal vessels, is described for single-stage reconstruction of full-thickness forehead and scalp defects. The hairline can be precisely determined and tailored to restore symmetry. By removing the hair-bearing dermis of the forehead portion of the flap and placing a full-thickness skin graft, aesthetic reconstitution of the forehead skin is achieved. This flap is especially useful when exposed calvarium limits other techniques.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.     

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.     

The Tagliacozzi flap as a method of nasal and palatal reconstruction

A random flap of upper arm skin has been successfully used to reconstruct large nasal (seven patients) and palatal (three patients) defects. This method is an attractive alternative for nasal reconstruction in patients whose foreheads cannot be used. Problems of color match can be managed by subsequent resurfacing of the nose with a single-piece full-thickness graft taken from the supraclavicular area. Pedicle flaps can be transected 9 to 12 days after inset, thus shortening the immobilization period.     

Reconstruction of through-and-through cheek defects involving the oral commissure, using chimeric flaps from the thigh lateral femoral circumflex system

Repairing full-thickness cheek defects involving the oral commissure in the head and neck regions after tumor resection is a challenge for reconstructive surgeons. First, they are usually relatively large defects. Second, the axes of the cheek and intraoral lining are different from each other. Third, the shape and volume of the defect and the oral sphincter should be considered individually. Lateral femoral circumflex perforator flaps with at least two independent cutaneous perforators are suitable for reconstruction of such a defect in one stage. In this study, between January and December of 1999, a total of nine patients underwent reconstruction with chimeric lateral femoral circumflex perforator flaps immediately after resection of their oral cancers. The average age of the patients was 61 years (range, 42 to 74 years). The oral lining defects were between 5 x 5 cm and 6 x 12 cm in size, whereas the cheek defects were between 5 x 6 and 8 x 12 cm. Fifteen flaps were supplied by one perforator, and three flaps were supplied by two perforators. There were nine single arterial anastomoses, eight single venous anastomoses, and one double venous anastomosis. There were no total flap failures. One case of postoperative venous congestion was successfully treated by a second venous anastomosis. The average duration of hospitalization was 31.8 days (range, 18 to 49 days). The median follow-up time was 8.6 months, and all patients were alive at the time of evaluation. Six of nine patients had satisfactory or good contours of the cheek. Five of nine patients had normal deglutition. Six of nine patients had adequate oral continence. Compared with other free flaps, use of the combined (chimeric) lateral femoral circumflex perforator flaps for the reconstruction of cheek through-and-through defects involving the oral commissure has several advantages: (1) easy three-dimensional insetting, (2) a unique character suitable for the requirements of the oral lining and cheek skin to achieve good aesthetic appearance, (3) functional preservation of the oral sphincter and the resistance of gravity by use of the tensor fasciae latae, (4) minimal donor-site morbidity, (5) economic design, and (6) no need for microsurgical fabrication, because major vascular branches such as the transverse branch, the ascending branch, and the feeding branch to the rectus femoris muscle are not sacrificed in the procedure. The disadvantages of these flaps include (1) the complicated anatomy of the perforators, (2) the learning-curve requirement for their use, and (3) the occasional need for secondary venous drainage and shifts to double flaps. Although there are some difficulties, it was concluded that use of the chimeric lateral femoral circumflex perforator flaps in the selected cases is one of the good options available for the reconstruction of cheek through-and-through defects involving the oral commissure.     

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.     

Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.

Osseous free flaps have become the preferred method for reconstructing segmental mandibular defects. Of 457 head and neck free flaps, 150 osseous mandible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 79 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 percent), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. Aesthetic and functional results were evaluated a minimum of 6 months postoperatively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were placed in 20 patients. A return to an unrestricted diet was achieved in 45 percent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to maintain weight. Speech was assessed as normal (36 percent), near normal (27 percent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic outcome was judged as excellent (32 percent), good (27 percent), fair (27 percent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent functional and aesthetic results using osseous free flaps for primary mandible reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of alternative donor sites (i.e., radius and scapula) is best reserved for cases with large soft-tissue and minimal bone requirements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.