Closure of large spina bifida cystica defects with bilateral bipedicled musculocutaneous flaps

A report of 19 cases of large spina bifida cystica defects closed with bilateral bipedicled latissimus dorsi musculocutaneous flaps is presented. This procedure offers a distinct advantage over other procedures used currently: (1) any large defect in the thoracic, lumbar, and sacral area can be repaired without tension; (2) the flaps have good blood supply; (3) they require no delay, and operative time and blood loss are minimized; and (4) excellent results have been obtained using this safe, predictable technique with a minimum of complications.     

Scalp expansion in the treatment of male pattern baldness

Tissue expansion has been extremely valuable in the treatment of traumatic scalp defects. We have recently used expansion techniques in the treatment of male pattern baldness. Expansion has been used in conjunction with scalp-reduction procedures and pedicled hair-bearing flaps. Flaps have been designed as Juri flaps, and in one patient, a new posteriorly based flap was used. This design gives the advantage of a more natural-appearing hairline and forward-growing hair. The major advantage of tissue expansion in the treatment of male pattern baldness is that it generates new hair-bearing scalp. The increase in vascularity which occurs during expansion allows for large, safe, and predictable flaps. Donor sites are also relatively easily closed. The disadvantages of expansion include the need for two or more surgical procedures and multiple office visits. There is also some discomfort following expansion and a cosmetic defect as the expanders become larger. Complications include infection, exposure or extrusion, deflation, and hair loss. Tissue expansion combined with scalp reduction and pedicled hair-bearing flaps have proved to be a valuable technique in the treatment of male pattern baldness with a high degree of patient satisfaction.     

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.     

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.     

The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects

Stable wound coverage after extensive soft-tissue loss of the upper extremity remains a difficult problem in the management of large defects of the upper limb. To prevent further tissue loss owing to infection or inadequate cover when important structures such as vessels, tendons, nerves, joints, and bones are exposed, various free flaps have been introduced into the therapeutic armamentarium of acute plastic surgical management options. Emergency or delayed early reconstruction has been proposed to prevent chronic infection and further tissue loss. We report a series of 12 emergency and delayed early reconstructions of the forearm, wrist, carpus, metacarpus, and hand using the free rectus abdominis muscle flap with split-skin coverage, demonstrating the versatility of this flap within this special context. Emergency free rectus muscle flap transfer is safe, technically easy, and expandable.     

Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee-four cases in the posterior region and three cases in the anterior region-were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects.     

Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses

Six cases of large defects of the scalp, skull, and dura following tumor ablation and radiation are presented. Each was accompanied by chronic infection in the irradiated defect. Efforts to reconstruct the resulting defects with local flaps were not successful. One-stage reconstruction was then accomplished in each case utilizing a latissimus dorsi musculocutaneous or myo-osteocutaneous free flap transferred by microvascular anastomoses. The versatility of the latissimus dorsi musculocutaneous and/or osseous flap allows single-stage reconstruction of these complex defects.     

Microsurgical scalp reconstruction in the patient with cancer

The literature regarding reconstruction of large scalp wounds with free tissue transfer consists mostly of case reports and small series, and none of the published reports focus on the particular problems of the oncology patient. Here the authors describe their experience with 37 flaps in 32 patients, all of whom required scalp reconstruction with free tissue transfer after tumor extirpation. Twenty-seven free flaps were performed at the time of the initial surgery and 10 were performed after a prior reconstruction failed. The authors describe the characteristics of the patients and procedures, including tumor type, wound size and complexity, flaps and recipient vessels used, preoperative and postoperative radiation therapy, and complications. Most (72 percent) of the tumors were recurrent or persistent. The free tissue transfer was successful in all patients. There was a 59 percent overall complication rate with 32 percent of patients requiring a secondary surgical procedure. Most of the complications were wound-healing complications. Although there were two cases of vein thrombosis, these were salvaged by revision, and no flaps were lost. Nine patients underwent postoperative radiation therapy that was well tolerated. Only four patients underwent cranioplasty at the time of the initial operation, and no secondary cranial reconstructions were performed. The authors conclude that preoperative and postoperative radiation therapies as well as the need for expedient tumor resection and immediate flap coverage are issues that make free tissue transfer attractive for the oncology patient who needs scalp reconstruction. Although the complication rate is relatively high and a significant percentage of patients require a secondary procedure, free flap coverage was efficacious for all patients in this group. Cranioplasty is not usually required but, if needed, alloplastic or autologous cranial reconstruction does not appreciably increase morbidity in the selected patient.     

Split nails

Photographic documentation of successful surgical correction of two major vertical-type and one horizontal-type split nail is presented. The developmental mechanism of the horizontal-type split nail is discussed. Treatment of the vertical-type split nail with bipedicled subperiosteal nailbed-matrix flaps is described in detail.     

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

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

The versatile temporoparietal fascial flap: adaptability to a variety of composite defects

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.     

Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.     

Metabolic adaptations in delayed skin flaps. Glucose utilization and hexokinase activity.

The distribution of glucose and hexokinase activity was determined in the epithelial tissue of delayed bipedicled skin flaps in guinea pigs. The periods of "delay" were 1, 3, 7, 14, or 21 days. The flap survival was maximal (100% of the flap) when the flap elevation was performed either 7 or 14 days following the "delay" procedure. When the flap elevation was performed 1, 3, or 21 days following the "delay" procedure, the result was partial necrosis. A differential distribution of epithelial glucose was found within the bipedicled flaps. The lowest glucose level (30% of normal) was at a distance of 2 to 3.5 cm from the end of the caudal pedicle during the first day after the "delay" procedure. This decreased glucose content recovered toward normal levels during the later part of the "delay" period. The bipedicled flaps exhibited increased hexokinase activity during the 3-week period of the "delay," and the responses of hexokinase activity and tissue glucose levels to the "delay" procedure were reciprocal in the caudal half of the flaps.     

A new surgical approach to closure of large lumbosacral meningomyelocele defects

A new method for the reconstruction of large thoracolumbar and lumbosacral meningomyelocele defects is described in which latissimus dorsi and gluteus maximus myocutaneous units are advanced medially and reapproximated in the midline, permitting primary closure of the defect in three layers. The flaps are based on the thoracodorsal and superior gluteal vessels and the intervening thoracolumbar fascia, providing tension-free, durable, and viable soft-tissue coverage over the dural repair. No lateral relaxing incisions, delays, or skin grafts are necessary. This technique has been used successfully in the repair of nine large meningomyelocele defects, and uncomplicated wound closure was achieved in all cases. The anatomic basis, technique, advantages, and functional implications of our approach are described. The flaps described do not alter the nerve supply of the muscles and merely redefine the muscle origins; therefore, no functional deficit from the reconstructive surgery is anticipated.     

Versatile fasciocutaneous flaps based on the medial septocutaneous vessels of the arm

Dissections in cadavers injected with latex confirm that direct septocutaneous branches from the brachial artery are the main source of irrigation for the fascial plexus of the inner arm. They are arranged in a vertical row from the level of the pectoralis major insertion down to a few centimeters above the medial epicondyle. Multiple fasciocutaneous flaps can be outlined utilizing these vessels, with either pedicled or island designs, proximally or distally based. Twelve clinical cases are reported. Axillary and elbow-crease contractures can be released with island flaps, and thumb and hand defects can be covered in a cross-arm fashion. Other clinical applications are suggested as well. The special quality of the skin transposed in this way, the simplicity of the surgical technique, and the circulatory reliability are the main advantages of these versatile flaps.     

Perforator-preserving chondrocutaneous rotation flap reconstruction of auricular defects

A technique of chondrocutaneous flap reconstruction of the ear that preserves the perforating branches of the posterior auricular artery is described. Preservation of the perforators offers improved safety in high-risk patients because it maintains the blood supply to the anterior surface of the ear. This perforator-preserving technique also emphasizes simplicity of flap design, concealment of scars, and preservation of ear shape. It is best suited for reconstructing defects of the scapha, antihelix, or triangular fossa up to approximately 2 cm in diameter. A variety of chondrocutaneous rotation flaps have been developed for reconstructing helical and nonhelical defects. These flaps have been designed on the basis of the size and location of the surgical defect. Although previously described techniques are usually reliable, extensive dissection and mobilization can injure perforators, leading to vascular compromise. When flap reconstruction is used in high-risk patients, it is necessary to protect the blood supply, and perforator-preserving flap reconstruction offers improved safety. The perforator-preserving technique was used in six consecutive high-risk patients during a 2-year period. Good results were obtained in all cases, including in patients who smoked cigarettes or had extensive medical problems.     

Treating Cutis Verticis Gyrata Using Skin Expansion Method

The objective of this study was to evaluate the feasibility and clinical effect of repairing scalp defect after the excision of cutis verticis gyrata using expanded scalp skin flaps. For this purpose, 8 patients with cutis verticis gyrata were subjected to scalp skin expander implantation under the skin. After saline injection and scalp expansion for 2–3 months, the cutis verticis gyrata was excised and the expanded scalp flaps were applied to recover the skin defect. As a result, the flaps and hair grew well without contractures and significant scarring, suggesting that this method is useful for surgical correction of cutis verticis gyrata.     

Clamp delay: an effective new method of nonsurgical delay

This study introduces an effective new method of nonsurgical delay. In this new method, a special clamp that compressed a bipedicled skin fold along the sides of a proposed flap was glued to rat dorsa. The study also used a control group of untreated flaps and a group of flaps delayed by the conventional surgical procedure involving conventional parallel incisions. Eight days later, 1 x 6 cm reverse McFarlane flaps were isolated from the wound and raised. After 5 days, the survival length of the flaps was measured. Viability of the flaps delayed by the clamps [40.5 +/- 2.0 mm (mean +/- standard error); n = 10] did not differ from that of surgically delayed flaps (41.3 +/- 3.6 mm; n = 8) and was significantly higher (p < 0.001) than the survival of control flaps (26.3 +/- 0.6 mm; n = 10). Clamp delay can be useful in flap research that explores the relative significance of the vessel obstruction and biochemical processes that follow the surgical delay procedure. This method also offers a new perspective by introducing the concept of nonsurgical delay into clinical practice.     

The expanded supraclavicular flap, prefabricated with thoracoacromial vessels, for reconstruction of postburn anterior cervical contractures

Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. These contractures may cause severe deformities that are both functionally and aesthetically crippling. Reconstruction of the neck requires the transfer of large flaps of thin, pliable skin to optimally match the texture and color of the recipient region. With the introduction of free tissue transfer, the availability of flaps for reconstruction of large neck defects has greatly increased. Unfortunately, many of these flaps are bulky and are not well matched to the thin and pliable skin of the neck. This article introduces the expanded supraclavicular flap prefabricated with the thoracoacromial vessels for reconstruction of anterior cervical contractures. Their anatomic location, length, and arc of rotation make the thoracoacromial vessels an excellent choice for prefabricating the supraclavicular skin for its subsequent interpolation into the anterior neck. Skin expansion in the donor region not only allows coverage of the larger unit of the anterior neck but also modifies the morphologic characteristics of the transferred flap through capsule formation and fatty tissue atrophy, which is beneficial for obtaining an optimal neck reconstruction.