Muscle-sparing latissimus dorsi myocutaneous flap with maintenance of muscle innervation,function, and aesthetic appearance of the donor site

In this report, the authors describe the application of a muscle-sparing technique to harvest a myocutaneous latissimus dorsi muscle flap, including only a tiny lateral muscle segment but carrying a large skin paddle, with the advantage of leaving intact innervation and function of the remaining latissimus dorsi muscle. According to the experiences and complications associated with the pure thoracodorsal artery perforator harvest at the authors' institution, the necessity of increasing the reliability of the vascular pedicle demands that a small muscle strip be left embedding the perforator vessels attached to the skin paddle. This procedure was applied in eight cases with only one minor complication, which was a distal flap tip necrosis in the largest flap used. The muscle function and aesthetic contour of the posterior axillary fold were preserved in every case. Harvesting a large skin paddle flap that is carried by a diminutive longitudinal segment of latissimus dorsi muscle circumvents thoracodorsal nerve damage and maintains muscle function. In contrast to a thoracodorsal artery perforator flap without muscle, the harvesting of which is a delicate procedure, this procedure is regarded as easier and safer.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Recurrence after surgical treatment of hidradenitis suppurativa.

From six to 89 months after surgery 82 patients who had been treated by radical surgery (118 excisions) for intractable hidradenitis suppurativa were reviewed. Local recurrence rates varied greatly with the disease site, being low after axillary (3%) and perianal surgery (0%) and high after inguinoperineal (37%) and submammary (50%) excision. Recurrence results from inadequate excision or an unusually wide distribution of apocrine glands, but physical factors such as obesity, local pressure, and skin maceration played a part in a few patients. Recurrence due to inadequate surgery tended to be the most troublesome. At follow up 75 (91%) of the patients were pleased with the results of their operation. A quarter of the patients developed disease at a new anatomical site after operation. Radical surgery gives good symptomatic control of severe hidradenitis suppurativa of the axilla, inguinoperineal, and perianal regions but is less satisfactory for submammary disease.     

The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques

The thoracodorsal artery perforator flap is a relatively new flap that has yet to find its niche in reconstructive surgery. At the authors' institution it has been used for limb salvage, head and neck reconstruction, and trunk reconstruction in cases related to trauma, burns, and malignancy. The authors have found the flap to be advantageous for cranial base reconstruction and for resurfacing the face and oral cavity. The flap has been used successfully for reconstruction of traumatic upper and lower extremity defects, and it can be used as a pedicled flap or as a free tissue transfer. The perforating branches of the thoracodorsal artery offer a robust blood supply to a skin-soft-tissue paddle of 10 to 12 cm x 25 cm, overlying the latissimus dorsi muscle. The average pedicle length is 20 cm (range, 16 to 23 cm), which allows for a safe anastomosis outside the zone of injury in traumatized extremities; the flap can be made sensate by neurorrhaphy with sensory branches of the intercostal nerves. Vascularized bone can be transferred with this flap by taking advantage of the inherent vascular anatomy of the subscapular artery. A total of 30 pedicled and free flap transfers were performed at the authors' institution with an overall complication rate of 23 percent and an overall flap survival rate of 97 percent. Major complications, such as vascular thrombosis, return to the operating room, fistula formation, recurrence of tumor, and flap loss, occurred in 17 percent of the patients. Despite these drawbacks, the authors have found the thoracodorsal artery perforator flap to be a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction cases.     

Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps

Two types of perforators, septocutaneous and musculocutaneous, are found in the same donor site of the flank area, and two perforator flaps based on each perforator are clinically available. Therefore, it is necessary to distinguish them from one another using different nomenclatures. Accordingly, the perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, the latissimus dorsi perforator flap, and the perforator flap based on a septocutaneous perforator, located between the serratus anterior and latissimus dorsi muscles, is named according to the name of the proximal vessel, the thoracodorsal perforator flap. In this series of 42 latissimus dorsi perforator flaps, flap size ranged from 5 x 3 cm to 20 x 15 cm, and two complications were observed: a marginal necrosis in an extremely large flap (26 x 12 cm) and a failure caused by infection. The thoracodorsal perforator flap was used in 14 cases, including two cases of chimeric composition. Flap size ranged from 4.5 x 3.5 to 18 x 15 cm, with no complications. In the two patterns of perforator flap that the author used, initial temporary flap congestion was observed in five latissimus dorsi perforator flap cases and two thoracodorsal perforator flap cases, when the flap was designed as a large flap or a less reliable perforator was selected. However, the congestion was not serious enough to cause flap necrosis. Several techniques, such as T anastomosis or inclusion of an additional perforator or a small portion of muscle, are recommended to prevent the initial flap congestion, especially when an unreliable perforator is inevitably used or when a flap larger than 20 cm long is required. A small portion of the muscle was included in six cases, when an unduly large or improperly long flap was planned. All of the flaps were successful and ranged from 22 x 7 to 15 x 28 cm, except for one case of distal flap necrosis in an extraordinarily large flap measuring 34 x 10 cm. Diverse selection of the perforator flap is one of the great advantages of the flank donor site, providing it with wider availability and more versatile composition for reconstruction or resurfacing.     

Bilateral autogenous breast reconstruction using perforator free flaps: a single center's experience

The authors present a single center's experience in bilateral breast reconstruction using perforator free flaps. The aim of this study was to show their indications, surgical technique, and results. A series of 53 patients underwent this procedure between February of 1996 and October of 2002. The surgical procedures were performed on patients with bilateral breast cancer (11 patients), patients with unilateral breast cancer and contralateral prophylactic mastectomy (22 patients), patients who had undergone bilateral prophylactic mastectomy (18 patients), a patient with Poland's syndrome, and a patient whose aesthetic breast augmentation had failed. Primary and secondary bilateral breast reconstructions were done in 18 and four patients, respectively. Eighteen patients who had earlier undergone breast reconstruction with implants had a tertiary breast reconstruction. Combined reconstruction (primary with secondary and primary with tertiary reconstruction) was done in 13 patients. Ninety-eight deep inferior epigastric perforator flaps and eight superior gluteal artery perforator flaps were used. The average operative time was 10 hours (range, 8 to 14.5 hours) for the simultaneous bilateral reconstruction. Total flap necrosis occurred in two cases (one deep inferior epigastric perforator flap and one superior gluteal artery perforator flap). Partial flap necrosis was not encountered, and fat necrosis was found in one deep inferior epigastric perforator flap (1 percent). Two pulmonary infections, one deep vein thrombosis, and one cardiac arrhythmia occurred as postoperative complications. The mean hospital stay was 9 days (range, 6 to 20 days). Abdominal bulging was reported in one patient. There were no recurrent disease or cancer manifestations, with an average follow-up of 3.5 years. This series clearly shows that perforator flaps are reliable and useful tools for bilateral breast reconstruction. This technique decreases the donor-site morbidity and offers an excellent aesthetic and long-term outcome and high patient satisfaction.     

Free dorsoulnar perforator flap transfers for the reconstruction of severely injured digits

The aim of this study was to investigate the feasibility of transferring the free dorsoulnar perforator flap nourished by the cutaneous perforator branched dorsoulnar artery to reconstruct severely injured fingers under upper arm anesthesia. Between April of 2001 and April of 2002, 13 free dorsoulnar perforator flaps were used in 13 patients. There were 11 men and two women ranging in age from 18 to 64 years, with an average age of 38 years. The affected fingers were one thumb, four index fingers, five middle fingers, two ring fingers, and one little finger. All cases were performed under upper arm anesthesia combined with intravenous local anesthesia. The operative time ranged from 103 to 140 minutes, with an average time of 120 minutes. The flap size ranged from 1 x 3 to 3 x 4 cm, and was transferred from the same forearm of the injured finger. All donor sites were closed primarily without a skin graft. The aim of reconstruction for fingers was to repair a traumatic defect (five cases), partial necrosis following replantation (two cases), and soft-tissue defects resulting from resection of a scar (three cases) and to revascularize ischemic fingers (three cases). All flaps survived completely. After repair of the flow-through circulation of the common digital artery and ischemic finger, a postoperative angiogram showed the vascular patency and hypervascularity of the reconstructed fingers, and the patients' complaints were reduced. The free dorsoulnar perforator flap under regional anesthesia is first reported; it may become one valuable option as a very small flap for the treatment of repairing intercalated or segmental defects as a flow-through flap for soft-tissue defects and ischemic fingers.     

A microdissected thin tensor fasciae latae perforator flap.

A new method, named "microdissection," has been introduced to create a thin flap by elevating the tensor fasciae latae perforator flap to serve as microdissected thin tensor fasciae latae perforator flap. In microdissection, perforators that run in the posterolateral direction in the adipose tissue after penetrating the deep fascia are dissected meticulously using an operative microscope, and a thin flap is elevated in a single process. The caliber of the perforator artery and vein in the tensor fasciae latae muscle measures approximately 0.7 mm and 0.9 mm, respectively. When transplanting the flap, an end-to-side anastomosis to the main artery measuring 1 to 2 mm is preferable to avoid the risk of arterial thrombosis. In contrast, an end-to-end anastomosis of the perforator vein to the comitans vein of the main artery can be performed safely. In the present study, 11 flaps were transplanted to the sites of skin defects of the neck, hand, axilla, knee, and foot. The author considers that the first clinical indication of this flap is reconstruction of hand skin defects.     

The superior thyroid artery perforator flap: anatomical study and clinical series

The redundant tissues of the anterior neck are well suited as a donor site for fasciocutaneous flaps in head and neck reconstruction, with similar skin quality and numerous underlying perforators. However, historic cadaveric research has limited the use of this as a donor site for the design of long and/or large flaps for fear of vascular compromise. The authors undertook an anatomical study to identify the vascular basis for such flaps and have modified previous designs to offer the versatile and reliable superior thyroid artery perforator (STAP) flap. Forty-five consecutive computed tomographic angiograms of the neck were reviewed, assessing the vascular supply of the anterior skin of the neck. Based on these findings, eight consecutive patients underwent head and neck reconstruction using a flap based on the dominant perforator of the region. In all cases, a perforator larger than 0.5 mm was identified within a 2-cm radius of the midpoint of the sternocleidomastoid muscle at its anterior border. This perforator was seen to emerge through the investing layer of deep cervical fascia as a fasciocutaneous perforator and to perforate the platysma on its ipsilateral side of the neck, proximal to the midline. This was seen to be a superior thyroid artery perforator in 89 of 90 sides and an inferior thyroid artery perforator in one case. Eight consecutive patients underwent preoperative imaging and successful flap planning and execution based on this dominant perforator. The superior thyroid artery perforator (STAP) flap demonstrates reliable vascular anatomy and is well suited to reconstruction of a broad range of head and neck defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Clinical applications of free soleus and peroneal perforator flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.     

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.     

A life-threatening multilocalized hidradenitis suppurativa case

The patient was a 38-year-old man. He had been suffering from hidradenitis suppurativa (HS) for approximately 20 years. He had active lesions at both axillas, hip, scrotum, and perineum, and inactive lesions located behind the ears, lower abdomen, and posterior neck. He was monitored and treated at different branches; he continuously used antibiotics and was given steroids at times. Antibiotic resistance developed subsequently. His general situation was bad; vital signs were poor; and he was in a state of sepsis and preshock, so this case was regarded as life-threatening. Total excision was performed first on the lesion at the right axilla, then on the lesion at the left axilla, and the parascapular fasciocutaneous flap was reversed. A skin graft was applied to the triangular defect on the scapula. No relapse occurred. Then the lesions at the hip were managed. Broad excision was used twice with the patient under general anesthesia; because the lesions spread to the retrococcygeal and gluteal muscles, coccyx resection and partial gluteal muscle resection were implemented. The defect was eliminated with a progressive flap. At the intergluteal sulcus, small lesions emerging at the median line were debrided with the patient under local anesthesia, and together with secondary recovery, the disease was completely managed. Lesions at the perineum and scrotum and at both inguinal areas were broadly excised and grafted. No lesion has relapsed so far. One year later, Hodgkin's lymphoma was diagnosed, and the patient was treated with chemoradiotherapy easily, because there was no infective focus. The disease is in remission now. The patient weighs 110 kg, is healthy, and is working again.     

The medial sural artery perforator free flap.

The medial sural artery supplies the medial gastrocnemius muscle and sends perforating branches to the skin. The possible use of these musculocutaneous perforators as the source of a perforator-based free flap was investigated in cadavers. Ten legs were dissected, and the topography of significant perforating musculocutaneous vessels on both the medial and the lateral gastrocnemius muscles was recorded. A mean of 2.2 perforators (range, 1 to 4) was noted over the medial gastrocnemius muscle, whereas in only 20 percent of the specimens was a perforator of moderate size noted over the lateral gastrocnemius muscle. The perforating vessels from the medial sural artery clustered about 9 to 18 cm from the popliteal crease. When two perforators were present (the most frequent case), the perforators were located at a mean of 11.8 cm (range, 8.5 to 15 cm) and 17 cm (range, 15 to 19 cm) from the popliteal crease. A series of six successful clinical cases is reported, including five free flaps and one pedicled flap for ipsilateral lower-leg and foot reconstruction. The dissection is somewhat tedious, but the vascular pedicle can be considerably long and of suitable caliber. Donor-site morbidity was minimal because the muscle was not included in the flap. Although the present series is short, it seems that the medial sural artery perforator flap can be a useful flap for free and pedicled transfer in lower-limb reconstruction.     

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.     

Technique and strategy in anterolateral thigh perforator flap surgery,based on an analysis of 15 complete and partial failures in 439 cases

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue defect reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients in Chang Gung Memorial Hospital. A total of 439 flaps were cutaneous or fasciocutaneous flaps based on musculocutaneous perforators. The analysis of the flap failures was done only in this perforator series. In six cases, no suitable skin vessel was found during the dissection of the flaps. The complete success rate was 96.58 percent (424 of 439). Of the 15 failure cases, eight were complete and seven were partial (10 percent to 60 percent of the flap). Thirty-four flaps were reexplored, and 19 (56 percent) were salvaged. In this study, some of the reasons for the flap failure, unique to the anterolateral thigh perforator flap, were identified. They include inadvertent division of perforator at the fascial plane as a result of inadequate knowledge of perforator anatomy, inadvertent injury to the perforator during intramuscular dissection (noted by the surgeon or ignored) as a result of inexperience, and twisting of the pedicle during inset of the flap at the recipient site. Technical pearls in the harvest of the anterolateral thigh perforator flap are as follows: mapping of the skin vessels with a Doppler probe before flap design, meticulous dissection of the perforator under surgical loupe or even lower-magnification microscope, inclusion of a small fascia cuff around the perforator, and intermittent topical use of Xylocaine during the intramuscular dissection of the perforators. During reexploration, one must search for twisting of the pedicle and small bleeders from the branches of the intramuscular perforators.     

Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction

This study presents the authors' experience using the anterolateral thigh fasciocutaneous flap for complex perineal and scrotal reconstruction. Anterolateral thigh fasciocutaneous island flaps were performed in seven patients between January and June of 2000 (six male, one female; mean age, 52 years; age range, 9 to 72 years). Four of the seven patients had scrotal or perineal defects after multiple debridements for Fournier's gangrene. Two of these four had exposed testicles. Three flaps were used for recurrent ischial ulcers. A true septocutaneous perforator (type 1) running between the rectus femoris and the vastus lateralis muscles was found in only two patients. In four patients, the cutaneous perforators were found to be intramuscular, originating from the descending branch (type 2). In the other patient, the musculocutaneous perforator originated from the lateral circumflex femoris artery independently (type 3). In these cases, intramuscular dissections were performed to follow each perforator to its main trunk. Mean follow-up was 8 months (range, 5 to 10 months), and all flaps survived. Three patients developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. Both wounds healed secondarily. Scrotal reconstruction with the anterolateral thigh flap gave an excellent aesthetic result. The authors conclude that the anterolateral thigh flap is a reliable flap for perineoscrotal reconstruction.     

Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.     

Hidradenitis suppurativa of the breast areolae. Case report.

A case of hidradenitis suppurativa of the areolae of the breasts is presented. The treatment was excision and split-skin grafting, and this was successful.     

A Comparative Study of Four Types of Free Flaps from the Ipsilateral Extremity for Finger Reconstruction

Aim

To compare the outcomes of finger reconstruction using arterialized venous flap (AVF), superficial palmar branch of the radial artery (SPBRA) flap, posterior interosseous perforator flap (PIPF), and ulnar artery perforator free (UAPF) flap harvested from the ipsilateral extremity.

Methods

We retrospectively reviewed the outcomes for 41 free flaps from the ipsilateral extremity in the reconstruction of finger defects in 41 patients with small/moderate skin defects, including 11 AVFs, 10 SPBRA flaps, 10 PIPFs, and 10 UAPF flaps. Standardized assessment of outcomes was performed, including duration of operation, objective sensory recovery, cold intolerance, time of returning to work, active total range of motion (ROM) of the injured fingers, and the cosmetic appearance of the donor/recipient sites.

Results

All flaps survived completely, and the follow-up duration was 13.5 months. The mean duration of the complete surgical procedure for AVFs was distinctly shorter than that of the other flaps (p<0.05). AVFs were employed to reconstruct skin defects and extensor tendon defects using a vascularized palmaris longus graft in 4 fingers. Digital blood supply was reestablished in 4 fingers by flow-through technique when using AVFs. Optimal sensory recovery was better with AVFs and SPBRA flaps as compared with UAPF flaps and PIPFs (p<0.05). No significant differences were noted in ROM or cold intolerance between the 4 groups. Optimal cosmetic satisfaction was noted for the recipient sites of AVFs and the donor sites of SPBRA flaps. The number of second-stage defatting operations required for AVFs was considerably lesser than that for the other flaps.

Conclusion

All 4 types of free flaps from the ipsilateral extremity are a practical choice in finger reconstruction for small/moderate-sized skin defects. AVFs play an important role in such operations due to the wider indications, and better sensory recovery and cosmetic appearance associated with this method.     

Eyelids and eye socket reconstruction using the expanded forehead flap and scapha composite grafting.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.