The dorsalis pedis free flap: technique of elevation, foot closure, and flap application

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.     

Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

The free iliac flap: a lateral modification of the free groin flap.

A lateral modification of the free groin flap, called the free iliac flap, is presented. By moving the outline of the free groin flap laterally, so that the medial margin lies lateral to the underlying femoral triangle, a flap is obtained which is uniformly slender and which has a long vascular pedicle. The anatomical findings, a method for safe dissection of the superficial circumflex iliac vessels, and the results of 18 clinical cases are presented.     

The medial gastrocnemius muscle flap: a local free flap

A new application of the medial gastrocnemius muscle flap has been described. Lengthening of the sural vascular pedicle was obtained using interposition vein grafts. This allowed coverage of a larger defect than that which could have been obtained with the tethered muscle and without further insult to the already disturbed lower extremity anatomy. The principle of pedicle lengthening can be used to increase the arc of rotation of various other muscle, myocutaneous, skin, or bone flaps and thereby increase their usefulness.     

Deltopectoral skin flap as a free skin flap revisited: further refinement in flap design, fabrication, and clinical usage

The deltopectoral skin flap is an axial flap; therefore, it can be fashioned as a free skin flap. Although color and texture of the skin are well suited for facial resurfacing, the structural features of inconsistent thickness of the skin, a short vascular pedicle, a minute caliber of the nutrient vessel, and donor site morbidity often preclude the use of this flap for this purpose. The deltopectoral skin flap fabricated as a free skin flap transferred by means of a microsurgical technique was used in 27 patients between 1985 and 1998 at our hospital. The anterior perforating branches of the internal mammary vessels were the primary nutrient vessels of the flap in seven instances. The external caliber of this artery varied between 0.6 mm and 1.2 mm, with an average size of 0.9 mm. The size of the accompanying vein varied between 1.5 mm and 3.2 mm, with an average of 2.3 mm. Coaptation of these vessels with those in the recipient site was technically difficult. Thrombosis occurred at the anastomotic site in three patients, requiring reoperation. Two flaps were saved. The flap failure was drastically reduced in the remaining 20 patients by including a segment of the internal mammary vessel when fabricating the vascular pedicle. The size of the internal mammary arterial segment averaged 2.1 mm, and the average size of the accompanying vein was 2.9 mm. The problem of a bulky flap was managed by surgical defatting/thinning of the flap at the time of flap fabrication and transfer. A V-to-Y skin flap advancement technique of wound closure was used in eight individuals. The flap donor-site morbidities were minimized with this method of wound closure.     

The preexpanded radial free flap

The experimental basis for free-flap preexpansion is briefly discussed. Two cases are reported in which the ankle/heel area was resurfaced and reinnervated with a preexpanded radial flap. The size of the first flap was half the surface area of the entire forearm. Direct closure of the secondary defect was possible with a single scar and without functional deficit in both cases. The flaps were well-vascularized and consisted of the sensory distribution of one peripheral nerve division, which was anastomosed in the recipient site. This preparation proved to be finer and to have better contouring capacity and skin quality than existing alternatives. It is clear that hydraulic tissue expansion facilitates great additional use of the radial flap as well as a range of other modified free flaps when there is time available for the flap to be developed prior to transfer.     

The chondrocutaneous postauricular free flap

Use of the auriculomastoid region as a donor-site for a microvascular free flap is still not the general consensus. This report presents three patients with composite tissue defects of the face aesthetically reconstructed with a chondrocutaneous postauricular free flap. For its safe surgical application, additional anatomic knowledge was refined with cadaver study. Use of the chondrocutaneous postauricular free flap has some merits. Its dissection is straightforward and safer than when only the cutaneous unit is used. It also offers a more dependable vascularized composite tissue as a one-stage operation. With freedom of design, a variable combined facial defect can be delicately reconstructed. The final aesthetic results obtained were gratifying, and the donor-site deformity was minimal.     

The bipedicled osteocutaneous scapula flap: a new subscapular system free flap

Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.     

Rectus abdominis muscle free flap harvest by laparoscopic sheath-sparing technique

Previous reports of endoscopic rectus abdominis muscle harvest have described techniques that are hampered by the need for anterior rectus sheath division or mechanical devices to maintain the optical cavity. The authors report the first successful clinical case of a laparoscopic sheath-sparing rectus abdominis muscle harvest for free tissue transfer. It offers considerable advantages over the traditional open method and, with the help of an experienced laparoscopic surgeon, it should add little to operative time.     

The isolated perfused human skin flap: design, perfusion technique, metabolism, and vascular reactivity

The design, isolated perfusion technique, and reactivity of a novel human skin-flap model are described. A transverse paraumbilical skin flap based on perforator vessels from the deep epigastric system was designed utilizing the tissue usually discarded following abdominal dermolipectomy. Within 3 hours of devascularization, a gassed (95% O2, 5% CO2), 37 degrees C Krebs-Henseleit buffer containing albumin (65 gm/liter) was pumped into the cannulated arterial pedicle of the skin flap and subsequently collected from the venous pedicle. Vascular resistance was continuously monitored and remained stable throughout the 4-hour perfusion. Lactate release was maintained throughout perfusion and was markedly increased by addition of insulin to the perfusate. Addition of norepinephrine to the perfusate resulted in a significant (p less than 0.05) dose-response increase in vascular resistance, and acetylcholine significantly (p less than 0.05) attenuated resistance in flaps preconstricted with norepinephrine. The results of these studies indicate that the isolated perfused human skin flap remained metabolically active with functionally intact vascular endothelium and smooth muscle throughout the 4-hour perfusion. The availability of this technique will, for the first time, permit laboratory study of human skin-flap pathophysiology and pharmacology.     

A new flap design: neural-island flap

This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.     

The "cricket bat" flap: a one-stage free forearm flap phalloplasty

Total and subtotal penile reconstruction represents a major surgical challenge. We present a new method and two illustrative cases using a modified design of the radial forearm free-tissue transfer: the "cricket bat" flap.     

The tailored latissimus dorsi free flap

A technique is described for dissection of the latissimus dorsi free flap which yields musculocutaneous cover accurately tailored to the primary defect. It involves exposure high into the axilla, early transverse incision of the muscle to enhance visualization of the pedicle, and transection of the muscle close to the point at which the thoracodorsal artery enters. This last step eliminates the bulky portion of the muscle between this point of vascular supply and its insertion.     

The posterior calf fascial free flap

Six posterior calf fascial free flaps were employed to reconstruct defects of the upper and lower extremities. One flap failed due to a constricting dressing. Two flaps sustained partial loss secondary to bleeding and hematoma formation. One flap dehisced at the distal suture line due to mobility of an underlying fracture. All surviving flaps eventually healed and resulted in stable, thin coverage. Donor-site morbidity has been minimal. Shortcomings of this flap model have been defined in the peculiarities of its thinness, diffuse vascular oozing, the extent of the vascular territory, and in postoperative monitoring. These problems are analyzed and recommendations for their resolution are presented. Fascia represents a unique tissue which offers an exciting new dimension in the reconstruction of certain defects--particularly those in which thinness is a desirable option. In the posterior calf model, the inclusion of fat represents an alternative modification that allows the surgeon to tailor the design to a variety of problems where fascia alone is too thin and a cutaneous flap is too thick. This concept may find its greatest application in wounds involving the hand or foot. We believe that this and other fascial flap prototypes may offer an ideal solution for reconstruction of major wounds of the extremities.     

The lateral intercostal neurovascular free flap

The lateral intercostal flap is a new neurovascular flap that may be used as a free or island flap. It is based on the lateral cutaneous branch of a single posterior intercostal neurovascular bundle. The donor area of the flap is the anterolateral skin of the abdomen. The flap is large, thin, and has a long pedicle that contains the lateral cutaneous nerve. The donor pedicles of the flap are multiple, and its venous drainage is adequate. The detection and design of this flap were based on information gained from the dissection of 95 intercostal spaces in 40 fresh cadavers. The flap was then applied 12 times in 11 patients. Ten flaps were successful, one flap was partially lost, and one was completely lost. The flap was used as a noninnervated flap to resurface six defects in the neck and one facial defect, and it was used as an innervated flap to cover two hand defects and two heel defects.     

The posterior calf fasciocutaneous free flap

Four clinical cases are presented that represent our initial experience with a new fasciocutaneous free-flap unit. The territory of this flap incorporates the skin, fat, and fascia of the posterior calf region. Its design is based on the principle of the fasciocutaneous flap. Anatomic studies confirm that the blood supply to this flap is derived from a descending subfascial branch of the popliteal artery. The flap is well endowed with cutaneous sensory nerves, making it a potential neurosensory free flap. Our technique of flap design and elevation is presented, and potential advantages and disadvantages of this flap are discussed.