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.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

The descending branch of the superficial circumflex artery supplying anteromedial thigh skin

This report presents an extended groin flap design that consists of a conventional skin paddle in the groin region and a vertical extension in the anteromedial thigh region, based on the superficial iliac circumflex artery and an unnamed descending branch, respectively. The inferior branch of the superficial iliac circumflex artery that supplies the thigh extension of the flap, spanning approximately the upper half of the thigh region, was found to originate approximately 2 cm from the origin of the superficial iliac circumflex artery. A total of six free and four local flaps were used in 10 patients with ages ranging from 10 to 60 years (average, 45 years). There were six male and four female patients. The free flaps were required for total facial resurfacing, through-and-through cheek defect, and burn scar contractures and traumatic defects of the lower extremity. The local flaps were used for reconstruction of scrotum defect, trochanteric decubitus ulcer, and lower abdominal skin and fascia defects. All 10 flaps survived completely. The groin flap with anteromedial thigh extension offers the following advantages: (1) it is very easy and quick to elevate; (2) a significantly increased volume of tissue is available for reconstruction, based on one axial vessel and being completely reliable; (3) the flap offers two skin paddles that are independently mobile; (4) there is no need for positional change and a two-team approach is possible; and (5) it can be raised as a vertical skin island only. The authors conclude that the groin flap with anteromedial thigh extension is a useful modification for reconstruction of both distant and local defects.     

The extended pectoralis major myocutaneous flap: uses and indications

The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.     

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.     

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.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.     

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.     

Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study

The vascularization of the skin paddle of 20 osteocutaneous fibula free flaps in 20 patients was studied. All skin paddles were designed over the proximal and middle third of the fibula. A parallel vascularization of the skin was found in 10 cases. In these cases, an axial (septo)musculocutaneous perforator was found to originate high in the peroneal artery or even in the popliteal artery. This branch runs parallel to the peroneal artery without any further connections with it. In 5 of these 10 cases, no other skin perforators were located within the boundaries of the skin paddle. Harvesting such a flap in the traditional way by blind inclusion of a muscle cuff results in ligation of the supplying vessel of the skin paddle and subsequent loss of the skin. In this series, this would have been the case in 5 of the 20 patients (25 percent). This might explain the bad reputation of the skin paddle of this flap. The high prevalence of the described vascular configuration in a proximally designed skin paddle justifies à vue dissection of all musculocutaneous perforators up to their origin, unless one or more septocutaneous perforators are found within the boundaries of the flap.     

Easy tissue expansion of prelaminated mucosa-lined flaps for cheek reconstruction in a canine model

In head and neck reconstruction, there is sometimes the need for a skin flap lined with mucosa. The object of this study was to determine whether small pieces of mucosa grafted onto the undersurface of a skin flap can be expanded in a reasonable time to provide the material required to reconstruct a full-thickness cheek defect as a free flap. The study consisted of two phases: prelamination and expansion of the flap, and vascularized free-tissue transfer of the flap. Six adult mongrel dogs were used. First, a 5 x 10-cm flap based on the saphenous vessels was elevated on the lower leg, and then four 1 x 2-cm pieces of mucosa harvested from the tongue were grafted onto the undersurface of the flap. A tissue expander (5 x 10 cm) was then placed under the flap, and the incision was closed primarily. The expanders were initially filled with just enough normal saline to obliterate dead space immediately after surgery. The expansion was continued twice weekly for 3 weeks until sufficient expansion was obtained. Two of six flaps were followed for an additional 6 weeks after the 3-week expansion period to observe whether additional mucosa could be obtained. After measurement of the mucosal area, each flap was transferred as free flap to reconstruct an iatrogenic cheek defect. The increase of mucosal surface area was compared with the original graft, and differences were analyzed using the paired t test. All flaps were successfully expanded without any complications. Histologic evaluation revealed that grafted mucosa took well without evidence of graft necrosis, and the intergraft area was covered with histiocytes. Angiography revealed well-defined vascular structures covering the entire area of the flap. The new mucosal area (23.5 +/- 2.4 cm2) was significantly larger than the original mucosal graft (8.7 +/- 0.9 cm2) (p < 0.001). The net increase of the mucosal area was 172.9 +/- 32.4 percent. The increase of mucosal area in two flaps, following a 6-week consolidation period after 3 weeks of expansion, was only slightly greater (25.9 +/- 1.3 cm2) than those without the consolidation period (22.3 +/- 1.8 cm2). This increase of the mucosal area appears to be related to the amount of expansion, and not to the length of the consolidation period. The flaps were successfully transferred as free flaps to reconstruct the full-thickness cheek defects without major complications. Although a staged operation to allow flaps to mature is needed, the present procedure has the advantages of providing a mucosa-lined flap and allowing primary closure of the donor site. The authors conclude that expansion of this flap has great potential in reconstructive surgery.     

Reconstruction of composite through-and-through mandibular defects with a double-skin paddle fibular osteocutaneous flap

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.     

Fasciocutaneous flaps: an experimental model in the pig

No experimental studies have substantiated the claim that fasciocutaneous flaps are superior to skin flaps. Using fasciocutaneous flaps designed in the pig, both flap survival and blood flow were assessed. The forelimb and hindlimb fasciocutaneous flaps survived to 8.2 +/- 0.3 cm and 7.9 +/- 0.3 cm, respectively, compared with 7.3 +/- 0.3 cm and 6.7 +/- 0.3 cm for the comparable cutaneous flaps, a statistically significant finding (p less than 0.01). Random fasciocutaneous flaps survive 12 to 18 percent longer than skin flaps. Using the radioactive microsphere technique, blood flow was measured after flap elevation, and flap survival was estimated using fluorescein. Again, a significant difference in flap survival was found, but there was no significant difference in measured blood flow. This can be explained by the relatively large interval between blood flow measurements (2 cm) compared with the observed difference in survival length (1.0 +/- 0.3 cm).     

The anterior tibial artery flap: anatomic study and clinical application

Satisfactory replacement of skin defects over the lower leg remains a difficult problem. Various forms of coverage, including, local rotation flaps, muscle flaps, and fascial and free flaps, have their specific indications and inherent disadvantages. In this work, a new axial skin flap based on perforating vessels in the territory of the anterior tibial artery is described. A series of 50 lower leg dissections was carried out in 25 fresh cadavers after latex injection into the femoral artery. Detailed studies of the cutaneous distribution of the anterior tibial artery showed that three main arteries perfuse the anterior lateral portion of the lower leg. The superior lateral peroneal artery and the inferior lateral peroneal artery interseptal cutaneous perforators arise at an average of 25.6 and 17.2 cm from the lateral malleolus, respectively. The superior lateral peroneal artery was present in 100 percent of the specimens, whereas the inferior lateral peroneal artery was present in 70 percent of the specimens. In their course, they give several muscular branches to the peroneus longus and brevis prior to perforating the fascia and arborizing in the subcutaneous tissues of the anterolateral portion of the leg. The average external diameter was 1.6 cm for the superior and 1.4 cm for the inferior lateral peroneal artery. The superficial peroneal nerve accessory artery is the third artery which contributes to the skin of the lower leg. It arises from the superior lateral peroneal artery in 30 percent of cases, from the inferior lateral peroneal artery in 40 percent, and from both in 30 percent. The artery runs along with the superficial peroneal nerve and gives several cutaneous perforators along its descending course. Several cutaneous axial flaps can be fashioned around this anatomy. The operative technique along with demonstrative clinical cases is presented followed by pertinent discussion.     

Anterolateral thigh flap for abdominal wall reconstruction

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

Perforator flaps from the lateral lower leg for intraoral reconstruction

Perforator flaps are based on cutaneous, small-diameter vessels that originate from a main pedicle and perforate fascia or muscle to reach the skin. Although these flaps have recently become popular for soft-tissue reconstructions in nearly all regions of the body, the systematic application of perforator flaps with short, small-caliber pedicles for intraoral reconstruction has not been reported. Experience with the use of 10 consecutive perforator flaps from the lateral lower leg for intraoral defect coverage is reported. In 10 cases, a 4- to 6-cm-long septocutaneous or myocutaneous perforating vessel from the peroneal artery, with a diameter of 1 to 2 mm, could be identified in the proximal one-half of the lateral lower leg. The thin, pliable skin paddles, measuring up to 6 x 8 cm, were used for defect coverage after resection of squamous cell carcinomas of the floor of the mouth (five cases), soft palate (one case), tongue (two cases), or buccal mucosa (two cases). Anastomoses were performed to the lingual artery and concomitant vein. Except for one case, all perforator flaps healed without complications and the functional results were satisfying. At the donor site, which was always closed directly, an approximately 15-cm-long scar resulted, without functional impairments. The peroneal artery was regularly preserved. Perforator flaps from the lateral lower leg might have many applications for intraoral soft-tissue reconstruction, especially because of their minimal donor-site morbidity.     

Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex facial paralysis

Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.     

Multipaddled Anterolateral Thigh Chimeric Flap for Reconstruction of Complex Defects in Head and Neck

The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge for reconstructive surgeries. Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14–23) cm and the mean width was 4.9 (range: 2.5–7) cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

The use of scapular and parascapular flaps for cheek reconstruction.

This is a retrospective review of our experience with microvascular transfer of scapular and parascapular flaps for the correction of lateral facial contour deficiencies. Twenty-eight patients with congenital (n = 8) and acquired (n = 20) defects were treated with 30 flaps; two patients had bilateral flaps. The etiology of the defects included hemifacial microsomia (n = 2), oblique facial cleft (n = 1), Romberg's hemifacial atrophy (n = 5), neoplasm (n = 4), irradiation (n = 8), trauma (n = 4), tumor excision (n = 4), facial lipodystrophy (n = 2), and silicone granuloma (n = 2). The follow-up evaluation was from 2 to 13 years, with an average of 6 years. Fabrication of a facial moulage was part of the preoperative planning for each patient. These were compound flaps, including skin, deepithelialized skin, fat, fascia, and bone, if necessary. All flaps were constructed with an intact skin paddle for postoperative monitoring. Based on dissections and anatomic findings at operation, several variations in the level of emergence of the circumflex scapular artery from the triangular space and its branching patterns were noted. All flaps survived; changes in the patients' weights were reflected in the flaps. Twelve patients required secondary procedures: excision of skin monitor islands, scar revisions, debulking, or flap resuspension to the malar region. Bone grafts or alloplastic implants were necessary in four patients in whom the malar eminence could not be adequately corrected by transfer of a flap. The deepithelialized scapular/parascapular flap is preferred for correction of large lateral facial defects.