Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects

New flow-through perforator flaps with a large, short vascular pedicle are proposed because of their clinical significance and a high success rate for reconstruction of the lower legs. Of 13 consecutive cases, the authors describe two cases of successful transfer of a new short-pedicle anterolateral or anteromedial thigh flow-through flap for coverage of soft-tissue defects in the legs. This new flap has a thin fatty layer and a small fascial component, and is vascularized with a perforator originating from a short segment of the descending branch of the lateral circumflex femoral system. The advantages of this flap are as follows: flow-through anastomosis ensures a high success rate for free flaps and preserves the recipient arterial flow; there is no need for dissecting throughout the lateral circumflex femoral system as the pedicle vessel; minimal time is required for flap elevation; there is minimal donor-site morbidity; and the flap is obtained from a thin portion of the thigh. Even in obese patients, thinning of the flap with primary defatting is possible, and the donor scar is concealed. This flap is suitable for coverage of defects in legs where a single arterial flow remains. It is also suitable for chronic lower leg ulcers, osteomyelitis, and plantar coverage.     

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

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

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

Leg length preservation with pedicled fillet of foot flaps after traumatic amputations

Six patients with insufficient soft-tissue coverage after lower limb trauma were treated with pedicled fillet of foot flaps to achieve primary stump closure and to preserve leg length. The flaps used were all based on either the posterior tibial neurovascular pedicle, the anterior tibial neurovascular pedicle, or both. Five flaps survived; one patient required conversion of a through-knee to an above-knee amputation and debridement of the flap because of venous thrombosis of the pedicle. In three of the cases, a functional knee joint was preserved. The patients ranged in age from 21 to 54 years, the mean hospital stay was 55.5 days (range, 28 to 76 days), and the mean follow-up time was 14.5 months. Despite an average of 4.3 procedures from initial admission to first discharge and an average of 2.0 postamputation procedures to achieve primary stump healing, all patients have achieved independent mobility with their prosthesis. The advantages of preserving leg length and, where possible, preserving a functional knee joint compensate for repeated procedures on these patients. When planned well, a pedicled fillet of foot flap therefore achieves the aims of amputation, namely, providing primary healing of a sensate, durable, cylindrical stump that is pain-free and preserves maximal leg length. This is achieved with no donor-site morbidity and with no need for microvascular reconstruction.     

Experimental use of free gastric flaps for the repair of pharyngoesophageal defects.

The repair of large pharyngoesophageal defects was accomplished experimentally in 16 dogs with revascularized free flaps from the greater curvature of the stomach. These flaps were based on the gastroepiploic vessels, and they were anastomosed to the carotid artery and external jugular vein in the neck. The procedure had a low mortality and did not lead to peptic ulceration or hyperchlorhydria in these animals.     

Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps

Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.     

Transiliac and retroperitoneal approach for coverage of sacrogluteal defects with inferiorly based rectus abdominis musculocutaneous flaps.

An inferiorly based rectus abdominis musculocutaneous flap is transferred to the sacrogluteal region through a transiliac approach. This technique is a simple and safe alternative to obtain a short pathway from the anterior abdomen to the sacral area.     

A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution.

Several reports concluded that free tissue transfer of the transverse rectus abdominis muscle (TRAM) flap for breast reconstruction is superior to pedicled transfer of the flap. In an effort to compare the various parameters of both techniques, the authors took advantage of a unique experience at one hospital where one surgeon (D.L.L.) used only the pedicled method and the other (N.J.Y.) used only free tissue transfer. Additionally, the authors compared the findings of the study with the experiences of other surgeons by surveying active members of the American Association of Plastic Surgeons. The records of 119 patients who underwent TRAM flap reconstruction between January of 1988 and July of 1997 were reviewed. Of these, 33 patients received free TRAM flaps, and 86 received pedicled TRAM flaps. To provide an adequate number of patients for statistical analysis, only those with unilateral, single-muscle reconstructions were considered (immediate or delayed). This provided 61 patients in the pedicled flap group and 26 in the free tissue group. Parameters examined included length of operation and of hospitalization, amount of pain medication used, amount of blood lost and received, and complications. A small subset of the patients had hospital records available to compare hospital charges; the comparison of 17 pedicled and 12 free TRAM flaps showed a mean difference of $15,637 (p < 0.001) in favor of the pedicled flap. On the basis of the findings from this study, it seems that the pedicled TRAM flap has significant economic and clinical advantages over the free TRAM flap. There is less need for blood, a shorter operating time and hospital stay, and a need for less pain medication. However, both methods of transfer have indications and contraindications in certain clinical settings. It will always remain the responsibility of the surgeon to evaluate all issues and select a method that is economically responsible and within the abilities of the surgeon, while producing a satisfactory outcome that best serves the patient. The information provided in this report should aid in accomplishing this goal.     

Distally based sural fasciomuscular flap: anatomic study and application for filling leg or foot defects

Since 1995, the authors have created 32 distally based superficial sural artery flaps based on the vascular axis of the sural nerve. The creation of the first 18 flaps permitted the authors to view perforators that issued from the gastrocnemius muscles to the vascular axis of the sural nerve. This led to the development of an anatomic study involving 25 cadaveric dissections to establish a relationship between the gastrocnemius muscles and the vascular axis of the sural nerve, with two to three constant and direct perforators from the gastrocnemius to the neurovascular axis. In this article, the technique for harvesting this new muscular flap is described. Between June of 1997 and March of 1998, three patients underwent flap operations. Two fasciomyocutaneous flaps and one fasciomuscular flap were created and were followed by uncomplicated postoperative courses in terms of flap viability and donor sites. In all cases, the flap created was designed to fill bone defects of the leg (one case) or of the foot (two cases). The results were considered to be excellent and stable over time, with follow-up periods ranging from 9 months to 18 months in duration.     

Free medial plantar perforator flaps for the resurfacing of finger and foot defects

In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.     

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

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.     

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.     

The cross-groin flap for coverage of foot and ankle defects in children. Case reports.

The cross-groin flap is useful for covering soft tissue defects of the distal portion of the lower limb in a child.     

Treatment of late ulceration in free muscle flaps to the foot

One of the preferred methods for the repair of large defects of the foot has been the use of free muscle flaps covered with skin grafts. Although this method has served well, some patients will experience ulceration in the weight-bearing surface. Three cases are reported in which small ulcerations developed in the heel after reconstruction of traumatic defects with muscle free flaps. All three patients were treated with a neurovascular island flap from the side of the great toe. All three patients are active young males, and all three patients have subsequently maintained intact skin for an average of 6.8 years (range, 5.1 to 9.1 years).