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.     

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.     

Free flaps to preserve below-knee amputation stumps: long-term evaluation

Five patients with insufficient soft-tissue coverage on below-knee amputation stumps have been treated with free-tissue transfer surgery to preserve a functional below-knee prosthetic level. The flaps employed include one latissimus dorsi myocutaneous flap, two latissimus dorsi muscle-skin graft flaps, one groin flap, and one foot-fillet flap. All five flaps survived; one patient required early venous anastomosis reexploration and revision. The patients have been followed for a mean duration of 5.5 years (range 3 to 8 years). The mean duration to first ambulation with a prosthesis was 3.6 months (range 2 to 7 months). Four of the five patients developed ulcerations on or adjacent to their flaps which required surgical revision. The patients required a mean of 1.28 prosthesis changes annually since surgery. The functional motion (mean active knee motion is 100 degrees) and ligamentous stability of the knee joints were well preserved in all patients. Five patients wear patella tendon-bearing prostheses, with one requiring an additional thigh corset. In two of the patients, nerve anastomoses to their flaps were performed. Both patients developed true cutaneous sensibility, but nevertheless experienced flap ulceration. All the patients are fully ambulatory on their free flaps. Free-tissue transfer can assist in preserving traumatic below-knee amputations so that patients can benefit from the functional advantage of a below-knee prosthetic device.     

The coincidence of TRAM flaps and prostheses in the setting of breast reconstruction

It is well known that transverse rectus abdominis myocutaneous (TRAM) flaps can be used to replace unsatisfactory prosthetic breast reconstructions; however, little has been written about the scope of breast implant use in TRAM flap patients. In this study, to ascertain the range of such therapeutic options, their frequency, and their clinical outcomes, the authors retrospectively reviewed the senior author's breast reconstruction experience from 1989 to 2000 with patients in whom both a TRAM flap and an implant were used for breast reconstruction. The authors examined the surgical indications, body habitus, bra size, chest wall irradiation history, flap type, implant type, complications, and outcomes for those patients with TRAM flap and breast implant combinations.Thirty-two women who had 50 (various) combinations of a TRAM flap and a breast implant were identified. There were more clinical scenarios than patients because many of the women had multiple scenarios. The 50 combination scenarios were then divided into six groups. Group I consisted of 14 patients who had elective prostheses placed beneath simultaneous TRAM flaps; group II consisted of 10 patients who had TRAM flaps with contralateral prosthetic reconstruction (in which two implants were received before the TRAM flaps, five implants were received simultaneously with the TRAM flaps, and three implants were received after the TRAM flaps); group III consisted of eight patients who had contralateral augmentation in addition to their TRAM flaps; group IV consisted of 11 patients who had TRAM flaps that were used to cover or replace previous prosthetic reconstructions; group V consisted of four patients in whom prostheses were used to augment or improve previous TRAM flap reconstructions; and group VI consisted of three patients who required prostheses to either reconstruct or salvage total or near-total TRAM flap failures. A broad range of implant types was used, although anatomic saline implants predominated. Forty-one percent of the patients in the review had undergone irradiation during the course of their treatment for breast cancer. Eight of the 32 patients experienced a total of twelve complications, four of which were related to the implants and eight of which involved the TRAM flaps and abdominal donor sites.Although complex, the wide variety of potential TRAM flap/breast implant combinations can be useful for patients with challenging reconstructive scenarios, particularly those that involve radiation therapy. In the group of patients reviewed by the authors, TRAM flaps were most often used in successful partnership either on the same side as or opposite to an implant reconstruction. A TRAM flap was used to salvage or replace an unsatisfactory implant reconstruction in less than a third of the patients. From a risk point of view, implants used opposite a TRAM flap reconstruction had a lower incidence of complication than did implants used beneath TRAM flaps.     

Free-flap free flap

We present a patient who sustained bilateral below-knee amputations that were treated with skin grafts as initial coverage. A latissimus dorsi free flap was later used as definitive coverage of one stump. Then at a subsequent operation a portion of the same latissimus dorsi free flap was reharvested, again as a free flap, and transplanted to cover the contralateral stump. Thus one latissimus dorsi free flap was used twice as a free flap (free-flap free flap) to cover bilateral amputation stumps in sequential operations.     

Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants

The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.     

Pectoralis major myocutaneous flap for hypopharyngeal reconstruction

The reconstruction of total or subtotal defects after surgical treatment for hypopharyngeal cancer is a challenging problem in head and neck surgery. The authors discuss reconstructive surgery performed in 37 patients affected by advanced hypopharyngeal cancer using the pectoralis major myocutaneous flap. In 22 cases of total pharyngolaryngectomy, the reconstructive procedure originally proposed by the authors was based on the use of a pectoralis major myocutaneous flap directly sutured to the pharyngeal and esophageal stumps and the prevertebral fascia, which eventually represented the posterior wall of the neohypopharynx. In 15 cases of subtotal pharyngolaryngectomy, the posterior wall of the neohypopharynx consisted of a residual strip of pharyngeal mucosa. In each patient, removal of the tumor and reconstruction were performed during the same operation, with only a few complications. Neither flap necrosis nor strictures were encountered; five patients had pharyngeal fistula and one patient died because of massive pneumonia. Although the use of microvascular free flaps is a reliable procedure, the pectoralis major myocutaneous flap is still applicable for hypopharyngeal reconstruction, thanks to its feasibility and low complication rate. The other reconstructive options require surgical transgression of the abdomen and/or thorax in patients affected by malnutrition and other chronic systemic disorders.     

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.     

Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap

To avoid a more proximal amputation at the distal part of the thigh, and when the knee joint is preserved, it is possible to lengthen short lower leg stumps. The authors report five cases in which the latissimus dorsi-rib flap was used to achieve a satisfactory functional prosthetic result. The bone segment is long enough to both lengthen the stump and allow its extremities to be firmly fixed to the tibia. Depending on the remaining tibia length, one or two ribs were included in the flap. The procedure allowed achievement of a 5-cm to 9-cm lengthening of the tibia. Bone healing time was 5 to 6 months and allowed prosthetic rehabilitation and ambulating 5 to 7 months after surgery. Final range of motion of the knee joint is compatible with normal ambulating, and the prosthesis is well tolerated. This procedure, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of short lower leg stumps.     

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.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

Alternative venous outflow vessels in microvascular breast reconstruction

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.     

Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

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.     

Breast Reconstruction with the free TRAM or DIEP flap: patient selection,choice of flap,and outcome

Recent reports of breast reconstruction with the deep inferior epigastric perforator (DIEP) flap indicate increased fat necrosis and venous congestion as compared with the free transverse rectus abdominis muscle (TRAM) flap. Although the benefits of the DIEP flap regarding the abdominal wall are well documented, its reconstructive advantage remains uncertain. The main objective of this study was to address selection criteria for the free TRAM and DIEP flaps on the basis of patient characteristics and vascular anatomy of the flap that might minimize flap morbidity. A total of 163 free TRAM or DIEP flap breast reconstructions were performed on 135 women between 1997 and 2000. Four levels of muscle sparing related to the rectus abdominis muscle were used. The free TRAM flap was performed on 118 women, of whom 93 were unilateral and 25 were bilateral, totaling 143 flaps. The DIEP flap procedure was performed on 17 women, of whom 14 were unilateral and three were bilateral, totaling 20 flaps. Morbidities related to the 143 free TRAM flaps included return to the operating room for 11 flaps (7.7 percent), total necrosis in five flaps (3.5 percent), mild fat necrosis in 14 flaps (9.8 percent), mild venous congestion in two flaps (1.4 percent), and lower abdominal bulge in eight women (6.8 percent). Partial flap necrosis did not occur. Morbidities related to the 20 DIEP flaps included return to the operating room for three flaps (15 percent), total necrosis in one flap (5 percent), and mild fat necrosis in two flaps (10 percent). Partial flap necrosis, venous congestion, and a lower abdominal bulge were not observed. Selection of the free TRAM or DIEP flap should be made on the basis of patient weight, quantity of abdominal fat, and breast volume requirement, and on the number, caliber, and location of the perforating vessels. Occurrence of venous congestion and total flap loss in the free TRAM and DIEP flaps appears to be independent of the patient age, weight, degree of muscle sparing, and tobacco use. The occurrence of fat necrosis is related to patient weight (p < 0.001) but not related to patient age or preservation of the rectus abdominis muscle. The ability to perform a sit-up is related to patient weight (p < 0.001) and patient age (p < 0.001) but not related to preservation of the muscle or intercostal nerves. The incidence of lower abdominal bulge is reduced after DIEP flap reconstruction (p < 0.001). The DIEP flap can be an excellent option for properly selected women.     

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.     

Surgical method for treatment of syndactyly with osseous fusion of the distal phalanges.

For the interdigital space plasty to correct a syndactyly with fusion of the distal phalanges, we adopted a new operative procedure, covering the exposed distal bone with local rectangular flaps designed transversely on both dorsal and volar surfaces. A full-thickness skin graft from the groin region covers the remaining raw surface. The procedure was performed in six patients, and the flaps measured 6 mm (width) x 12 to 16 mm (length) in four patients, 5 x 15 mm in one patient, and 5 x 18 mm in one patient. Partial necrosis was observed in only one patient, in whom a narrow flap of 5 x 18 mm was used. In the other five patients, however, the results were satisfactory on both external appearance and function during the follow-up period of 3 to 6 years.     

Intraarterial chemotherapy: the effects on free-tissue transfer

Multimodal therapy including intraarterial chemotherapy is recognized as state-of-the art therapy for soft-tissue cancer. Multimodal therapy often involves regional limb perfusion followed by sarcoma surgery with reconstruction of the resulting defect. This study was performed in an effort to evaluate the potential of free flap reconstruction after intraarterial therapy. A retrospective chart review of 52 patients who had undergone limb perfusion between 1988 and 1998 at the University of Texas M. D. Anderson Cancer Center and the Division of Plastic Surgery, University of Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion that was then followed by surgical resection and free flap reconstruction. There were seven women and nine men, with an average age of 37.9 years. All sixteen patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor recipient anastomosis had been previously perfused. A vein graft was used in one case. Split-thickness skin grafting over the free flaps was used in four cases. The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis. Three patients developed partial split-thickness skin graft loss and one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The overall surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation on the basis of both the patient self-evaluation and the physical therapy evaluation. Seven patients had recurrence of their disease. The overall mean survival time after surgery was 20.6 months. Currently, 10 patients are alive and six have died from their disease. The results of this study indicate that preoperative intraarterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although our numbers are small, we believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be performed to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free flap reconstruction.     

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.     

Resource cost comparison of implant-based breast reconstruction versus TRAM flap breast reconstruction

Relatively little has been published to date comparing the resource costs of transverse rectus abdominis musculocutaneous (TRAM) flap and prosthetic breast reconstruction. The data that have been published reflect the experience at just one medical center with a previously known clear preference for autologous breast reconstruction. The goal of this study was to compare the resource costs of TRAM flap and prosthetic reconstruction in an institution where both procedures continue to be performed using modern techniques and at a relatively equivalent frequency. All available medical records were reviewed for patients who had completed their breast reconstruction between 1987 and 1997. Records of patients who had undergone TRAM flap or prosthetic reconstruction were reviewed to compare resource costs, including hospital stay, operating room time, anesthesia time, prosthetic devices, and physician's fees. Of 835 patients reviewed who had completed breast reconstruction, a total of 140 suitable patients were identified who had all the necessary financial information available. The patient population comprised 64 patients who received TRAM flaps and 76 patients who had undergone prosthetic reconstruction. The length of stay for the TRAM flap group, including all subsequent admissions for each patient, ranged from 2 to 24 days (mean, 6.25 days), and that for the prosthetic reconstruction group ranged from 0 to 20 days (mean, 4.36 days). Operating room time for the complete multistage reconstructive process for a TRAM flap ranged from 5 hours, 20 minutes to 12 hours, 25 minutes (mean, 7 hours, 34 minutes); with implant-based reconstruction, operating time ranged from 1 hour, 45 minutes to 8 hours, 56 minutes (mean, 4 hours, 6 minutes). With prostheses costing from $600 to $1200, a surgeon's fee of $160/hour, and an assistant's fee of $45/hour, the average cost of TRAM flap reconstructions was $19,607 (range, $11,948 to $49,402), compared with $15,497 for prosthetic reconstructions (range, $6422 to $40,015). The results were statistically significant (p < 0.001). Several factors weigh into the decision as to which reconstructive operation best suits the patient's needs. These factors include surgical risk, potential morbidity, and aesthetic results. On the basis of this review of autologous and prosthetic breast reconstruction in an institution where both are performed frequently, during a 10-year period with a mean time elapsed since reconstruction of 7.45 years, prosthetic reconstruction was significantly less expensive.