Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.     

From the "charretera" to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap

Wide tissue defects located on the face and neck area often require distant flaps or free flaps to achieve a tension-free reconstruction together with an acceptable aesthetic result. The supraclavicular island flap surely represents a versatile and useful flap that can be used in case of large tissue losses. Because of its wide arc of rotation, which ensures a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of the transverse cervical artery or, less frequently, of the suprascapular artery, though reliable, is not a very large vessel. In some particular cases, when too much tension or angles that are too tight are present, the vascular supply of the flap can be difficult and special care must be taken to avoid flap failure. To avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial pedicle, thin and resistant, which ensures good reliability; also, when a higher tension rate is present, it avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with various defects located on the head, neck, and thorax area were treated in the past 2 years using the modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there was marginal skin deepithelialization in only two cases, which only required minor surgery. Postoperative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed donor sites, except for one case, and tension-free scars. The authors show how the modified supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing such as smokers or patients with complex medical histories.     

Breast reconstruction with contralateral rectus abdominis myocutaneous flap

A transverse myocutaneous rectus abdominis flap from the contralateral side has been employed for breast reconstruction in 52 patients. This flap has the advantage of balancing the patient by utilizing skin from an area of relative excess. The blood supply to the flap is based on the superior epigastric vessel and its perforators. The scar of the donor area is acceptable because it falls in the submammary sulcus. The use of a silicone implant can be avoided in some patients because of the adequate bulk of skin, muscle, and fat that is available. Abdominoplasty of the superior abdomen can be obtained during the same operation and can enhance the overall aesthetic results. Breast reconstruction is now possible with either ipsilateral or contralateral upper-abdominal transfer flaps, and further refinement of operative technique using the contralateral upper-rectus abdominis myocutaneous island flap must await further experience.     

The dorsalis pedis myofascial flap

A modification of the dorsalis pedis artery island flap is presented. In this modification, the deep fascia of the dorsum of the foot with part or the whole of the extensor digitorum brevis muscle is used as a fascial or myofascial flap supplied by the dorsalis pedis artery and covered by a split-thickness skin graft. The purpose is to decrease the morbidity of the donor site, which is closed by direct sutures without skin grafting. Four cases are reported with minimal donor-site morbidity and full survival of the flaps. The mean follow-up period is 17 months.     

The trauma of suction-assisted lipectomy cannula on flap circulation in rats.

The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.     

Reappraisal of island modifications of lateral calcaneal artery skin flap

Reconstruction of soft-tissue defects of the calcaneal region and the heel is very demanding and necessitates, as a rule, a sensate and thin flap. The ideal characteristics of a sensate and thin layer of flap should be combined with a reliable blood supply and minimal morbidity at the donor site. The authors report an updated review of their experience with the use of island modifications of the lateral calcaneal artery skin flap-the lateral calcaneal island flap, the lateral calcaneal V-Y advancement flap, and the bilobed-shaped lateral calcaneal island advancement flap-for the reconstruction of small and medium-sized tissue defects over the exposed calcaneal tendons and calcaneal bones of 18 patients. All of the procedures were performed under spinal or epidural anesthesia. There were no problems associated with flap viability, but the authors have seen necrosis of undermined skin between the lateral malleolus and calcaneal tendon in two cases and a partial loss of skin graft in one case. In this article, the authors discuss some advantages and disadvantages of the use of a lateral calcaneal island flap and its modifications.     

An experimental neurovascular island skin flap for the study of the delay phenomenon.

We present an experimental neurovascular island skin flap. It is a consistent, reproducible model which produces a definite pattern of surviving skin flap area versus skin flap necrosis. There is a constant, anatomically definable nerve and vascular supply to the flap. This model permits independent experimental manipulation of the neural, arterial, and venous supply to the skin. It is useful, therefore, for the study of the vascular mechanisms of the skin microcirculation. We also demonstrated that increased flap survival can be produced by a delay involving denervation alone (leaving the vascular supply intact) or by devascularization alone (leaving the nerve supply intact). We conclude that both the adrenergic denervation and the ischemia contribute to the production of the delay phenomenon. We suggest that sustained vasodilation--vascular smooth muscle relaxation--is the vascular mechanism that accounts for the delay phenomenon.     

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 lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery

The pedicled lower trapezius musculocutaneous flap is a standard flap in head and neck reconstruction. A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels supplying this flap lead to confusion and technical problems when this flap is harvested. This article attempts to clarify the anatomical nomenclature, to describe exactly how the flap is planned and harvested, and to discuss the clinical relevance of this flap as an island or free flap. The authors dissected both sides of the neck in 124 cadavers to examine the variations of the subclavian artery and its branches, the vessel diameter at different levels, the course of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island muscle flap and once as a free flap. The anatomical findings and clinical applications proved that there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but possible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators. The lower trapezius flap is a thin and pliable musculocutaneous flap with a very long constant pedicle and minor donor-site morbidity, permitting safe flap elevation and the possibility of free-tissue transfer.     

Reconstruction of a socket using a retroauricular temporal flap

The reconstruction of a continent socket with a skin graft may be difficult because of varying degrees of contracture. In an effort to solve this problem, a retroauricular temporal flap was successfully transposed in a two-stage procedure. The one-stage transposition of a retroauricular island flap based on a temporal pedicle was a partial failure.     

Reliable assessment of skin flap viability using orthogonal polarization imaging

Intraoperative evaluation of skin flap viability has primarily been dependent on clinical judgment. The purpose of this study was to determine whether an orthogonal polarization spectral imaging device could be used to accurately predict viability of random-pattern skin flaps. Orthogonal polarization spectral imaging is a newly developed technique that visualizes the microcirculation using reflected light without the use of fluorescent dyes and allows for noninvasive real-time observation of functional microvascular networks. In Sprague-Dawley rats (n = 24), three types of random skin flaps were designed with unknown zones of viability (n = 8 per group). After flap elevation, the skin flaps were evaluated by both clinical examination and orthogonal polarization spectral imaging. Areas of the flap determined to be nonviable by clinical examination were measured and marked. Orthogonal polarization spectral imaging was subsequently performed, and areas of the skin flap with stasis (i.e., cessation of red blood cell movement) in the dermal microcirculation on orthogonal polarization spectral imaging were measured and marked. The skin flaps were then secured in place. Flaps were evaluated on a daily basis for clinical signs of ischemia and necrosis. On postoperative day 7, the total amount of random skin flap necrosis was measured and recorded. Clinical examination of the random skin flaps significantly underestimated the actual amount of eventual flap necrosis, and as result was a very poor predictor of flap necrosis. By contrast, assessment of microcirculatory stasis using the orthogonal polarization spectral imaging device correlated well with the subsequent development of necrosis in all groups. In the three groups, the average amount of flap necrosis predicted by clinical examination deviated from actual necrosis by approximately 2 to 4 cm. However, the amount that orthogonal polarization spectral imaging differed from actual necrosis was 0.1 to 0.3 cm. Therefore, orthogonal polarization spectral imaging was an excellent predictor of eventual flap necrosis and much more accurate than clinical observation (p < 0.001). Intraoperative evaluation of axial and random pattern flap viability has traditionally been based on clinical examination as no other reliable, convenient test currently exists. The authors demonstrated that an orthogonal polarization spectral imaging device accurately predicts zones of necrosis in random pattern flaps by directly visualizing cessation of microcirculatory flow. Intraoperative stasis in the dermal microcirculation correlated precisely with subsequent flap necrosis. Orthogonal polarization spectral imaging was significantly more accurate than clinical examination, which consistently underestimated flap necrosis. The orthogonal polarization spectral imaging technique may have value in the intraoperative assessment of skin flap perfusion such as that required after skin-sparing mastectomy.     

Thumb reconstruction with a sensory flap from the dorsum of the index finger.

The dorsal skin of the index ray is very useful (1) for a one-staged thumb lengthening procedure after amputation, (2) for covering the stump of an avulsed thumb with sensory skin, and (3) for expanding the first web space. The flap may be transferred as a rotation flap, or the dorsal vasculature and nerve supply to the index may be carefully dissected free as a pedicle to permit its use as a neurovascular island flap. We believe that considerably more sensory skin can be transferred by this flap than by the ring finger neurovascular island flap, and that the technical risks and surgical time are less with the index finger flap.     

Pulsed magnetic fields applied to a transferred arterial loop support the rat groin composite flap

Pulsed magnetic fields have been shown to stimulate neovascularization in the authors' laboratory. The rat groin composite flap was used to create a prospective randomized trial to test the effectiveness of these pulsed magnetic fields. The skin paddle to this flap is highly consistent, and the authors proposed using the flap to study how pulsed magnetic fields affect composite flap survival when the dominant vessel to the flap is divided and flap survival becomes dependent on a transferred vessel loop. Forty-three rats had the tail artery microsurgically anastomosed to the femoral artery and placed between the groin musculature and the abdominal skin. Pulsed magnetic energy of 1 gauss was applied for 8 (n = 14) or 12 (n = 8) weeks to the experimental groups. Control groups were treated in a comparable manner for 8 (n = 16) or 12 (n = 5) weeks. After the 8 or 12 weeks, all groups had an 8 x 4-cm skin flap raised, and the superficial epigastric artery, the main feeding vessel, was ligated. After 5 days, the total area of the flap and the area of necrosis were traced onto velum paper for each rat. The percent survival was calculated per rat, and a mean survival percentage was calculated per group. The experimental animals treated with pulsed magnetic fields for 8 weeks had statistically significant improved flap survival over the control animals. The study provides evidence that pulsed magnetic energy stimulates angiogenesis and suggests a possible use of this modality to create island vascular flaps in otherwise random vascular territories.     

Nonmicrosurgical use of the radial forearm flap for penile reconstruction

Although the era of microsurgical techniques has greatly expanded the number of possible solutions for penile reconstruction, additional options are still needed for some unusual situations when microsurgery is not available or not desired. This article describes the first nonmicrosurgical use of the radial forearm flap for penile reconstruction. With this technique, an osteocutaneous radial forearm flap 15 x 20 cm in size is elevated as a reverse-flow island flap and used to create a neopenis in the classic "tube within a tube" fashion. The neopenis is then transferred to the recipient site as a distant flap, without dividing its vascular connection with the forearm. Once a complete healing is ensured after the following 2 to 3 weeks, the pedicle is cut and the penile reconstruction is completed. Since 1995, this technique was used for total penile reconstruction in four patients: two with congenital penile agenesis, one with penile amputation as a result of a high-voltage electrical injury, and one with total loss of the external genitalia as a result of a shotgun injury. The patients have been followed up for 1 to 4 years. Good results were achieved in all patients. In conclusion, non-microsurgical use of the radial forearm flap seems to be a useful alternative to create an innervated functionally and aesthetically acceptable neopenis when microsurgery is not available or not desired. Although it is a multistage procedure, it is easy to perform. Moreover, this technique provides all well-known advantages of the radial forearm flap in penile reconstruction but does not require the sophisticated equipment and expertise of microsurgery. This is a great advantage that enables surgeons without microsurgical skill to use the radial forearm flap for phallic reconstruction. The author believes that the described technique will be extremely useful in developing countries that have limited resources and where microsurgery is difficult to obtain.     

Reverse-flow island sural flap

The reverse flow island sural flap is presented as an alternative to flaps currently used for reconstruction of small and medium substance losses in the distal third of the leg, ankle, and heel. This is a random type of flap, based on the reverse flow of the superficial sural artery, which mainly depends on the anatomy of the perforators of the peroneal artery system.The anatomic structures that constitute the pedicle are the superficial and deep fascias, the sural nerve, the short saphenous vein, and the superficial sural artery. The skin island and the subcutaneous cellular tissue complement the flap proper. This skin island was demarcated at any point of the median or distal thirds of the leg, having the short saphenous vein and the sural nerve on its central axis. The distal dissection limit of the pedicle is located 5 centimeters above the lateral malleolus. This limit is established so as to ensure the integrity of the perforators from the principal arteries of the leg, mainly the peroneal artery, responsible for the reverse flow nourishing the flap. These perforators will affect anastomoses with the superficial sural artery in charge of irrigating the structures compounding the flap.A total of 71 patients were operated on with this technique, some of them with basic pathologic abnormalities limiting the distal blood flow, such as diabetes mellitus, and some others having proven vascular insufficiency or displaying unstable areas attributable to problems such as pseudarthrosis and osteomyelitis, which needed to be covered. Fifteen flaps (21.1 percent) suffered partial necrosis, which did not compromise the final result, and another three (4.2 percent) showed total loss. The flap in question has great mobility and versatility, allowing the treatment of specific areas of the lower limb, without sacrificing important arteries or mobilizing structures that might bring about functional deficits.     

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.     

Island rat groin flaps with twisted pedicles

Clinical attempts are made to avoid rotating a flap and twisting the pedicle for fear of perfusion compromise. Torsion of an island rat groin flap pedicle is not a well-recognized experimental entity. The authors describe the results of island flap rotation with pedicle twisting in the rat groin flap model. Forty male Wistar rats were randomly divided into four groups of 10 animals each. In each group, bilateral groin flaps were elevated; one flap was sutured in place without rotation and the contralateral flap was subjected to 180, 270, 360, or 720 degrees of rotation. Blood flow within the flaps was assessed by laser Doppler flowmetry, and flap edema and necrosis were determined 10 days postoperatively. No differences were noted between control flaps and those subjected to 180 and 270 degrees of rotation. Although flaps subjected to 360 degrees of rotation demonstrated a large amount of postoperative edema and congestion of the subcutaneous tissue with some histologic changes, all flaps in this group survived. Measured flap weights at death were different from those of controls. All flaps subjected to 720 degrees of rotation underwent ischemic necrosis. Because of the differences between human skin architecture and rat skin architecture it cannot be concluded that similar results would be observed in any human skin flap. There might be three important points arising from this study of unknowingly twisted island groin flap pedicles in the rat model: (1) twisting of less than 360 degrees has no effect on flap survival; (2) twisting of 720 degrees is always associated with skin flap necrosis; (3) twisting of 360 degrees, although associated with some changes, does not cause skin flap necrosis.     

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.     

Reconstructing the breast mound employing a secondary island omental skin flap

We have shown in an initial animal study that omentum will adequately vascularize a skin flap and allow transfer of this tissue composite for use in surgical reconstruction of the breast. Based on this experimental procedure, a technique employing a two-stage operation has been developed and used in 21 female patients in reconstruction of the breast after radical mastectomy. In the first stage, the omentum, attached to one gastroepiploic artery and vein, is exteriorized to the subcutaneous tissue of the lower abdominal wall. In the second stage, the distal omentum, now vascularizing the overlying skin and soft tissue, is moved as a secondary island flap to the anterior chest wall to complete the breast reconstruction. In all but 1 of our 21 patients who have been followed for 1 to 8 years, reconstruction of large defects, including the chest wall, breast mound, and infraclavicular axillary fold depression, was performed without use of a prosthesis. In one patient, there was complete necrosis of the flap due to vascular impairment; there were three instances of delayed healing and a significant but partial loss of the flap in one patient. All complications were encountered in the first 10 patients of the series during the time the technique was being refined.     

A new technique of scarless expanded forehead flap for reconstructive surgery

The forehead flap is an ideal flap for reconstructive surgery, especially for that involving reconstruction of the face and neck. However, it is usually limited to use in nasal reconstruction, even when performed in conjunction with tissue expansion, because of the severe visible morbidity of the donor site. In this article, the author discusses his development of a new technique of forehead flap, performed in conjunction with tissue expansion, for reconstructive surgery without visible scarring at the donor site. The technique involved positioning a tissue expander in the forehead pocket under the occipitofrontal muscle and serially inflating the expander over a period of approximately 4 to 6 weeks. Thereafter, an expanded forehead flap was created from the frontal hairline area on the basis of the location of the superficial temporal vessels and transferred into 16 recipient sites in 13 patients as an island flap (n = 8), a free flap (n = 1), or a local random flap (n = 7). The donor site was closed directly into the frontal hairline, without any visible scar. With the author's experience in the use of the island flap for nasal, facial, and neck reconstruction and of the free flap for reconstruction in the extremities, the flap could be as large as 8 x 18 cm without inducing flap necrosis or problems with donor-site closure. All patients (n = 13) had acceptable donor-site aesthetic results, without visible scarring. The results indicate that the flap could be a safe, ample, and color-matched flap for reconstruction of the face and neck and could also diminish donor-site morbidity to a minimum, without an unsightly visible scar. Furthermore, the flap could be formed into a customized free flap, with the above-mentioned advantages, to be transferred to any part of the body.