Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis.

PubMed

Thoma, Achilleas; Veltri, Karen; Khuthaila, Dana; Rockwell, Gloria; Duku, Eric

2004-05-01

This study compared the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap in postmastectomy reconstruction using a cost-effectiveness analysis. A decision analytic model was used. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits for 2002. Hospital costs were obtained from St. Joseph's Healthcare, a university teaching hospital in Hamilton, Ontario, Canada. The utilities of clinically important health states related to breast reconstruction were obtained from 32 "experts" across Canada and converted into quality-adjusted life years. The probabilities of these various clinically important health states being associated with the DIEP and free TRAM flaps were obtained after a thorough review of the literature. The DIEP flap was more costly than the free TRAM flap ($7026.47 versus $6508.29), but it provided more quality-adjusted life years than the free TRAM flap (28.88 years versus 28.53 years). The baseline incremental cost-utility ratio was $1464.30 per quality-adjusted life year, favoring adoption of the DIEP flap. Sensitivity analyses were performed by assuming that the probabilities of occurrence of hernia, abdominal bulging, total flap loss, operating room time, and hospital stay were identical with the DIEP and free TRAM techniques. By assuming that the probability of postoperative hernia for the DIEP flap increased from 0.008 to 0.054 (same as for TRAM flap), the incremental cost-utility ratio changed to $1435.00 per quality-adjusted life year. A sensitivity analysis was performed for the complication of hernia because the DIEP flap allegedly diminishes this complication. Increasing the probability of abdominal bulge from 0.041 to 0.103 for the DIEP flap changed the ratio to $2731.78 per quality-adjusted life year. When the probability of total flap failure was increased from 0.014 to 0.016, the ratio changed to $1384.01 per

Initial experience with laparoscopic inferior epigastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast reconstruction.

PubMed

Trus, Thadeus L; Collins, E Dale; Demas, Christopher; Kerrigan, Carolyn

2007-04-01

Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation. Prospective case series. Tertiary academic center. Female patients with breast cancer who chose pedicle TRAM reconstruction. Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin. Complications of surgery and subsequent flap viability. From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient. Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.

Supercharging the transverse rectus abdominis musculocutaneous flap: breast reconstruction for the overweight and obese population.

PubMed

Wu, Liza C; Iteld, Lawrence; Song, David H

2008-06-01

Autologous breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap is traditionally based on either the superior epigastric vessels (pedicled) or the deep inferior system (free). In the overweight and obese population, both techniques have been shown to have increased complications of the reconstructed breast. Another alternative is supercharging the flap by anastamosing the deep inferior epigastric vessels to either the internal mammary or thoracodorsal systems. We present a single surgeon's experience with unilateral TRAM reconstructions supercharged to either the thoracodorsal vessels, the internal mammary system, or in one case, perforator vessels in overweight and obese patients. Nineteen consecutive overweight or obese patients underwent delayed or immediate, unilateral autologous breast reconstruction with supercharged TRAM flaps between November 2000 and November 2004. The patients ranged in age from 28 to 66 years (average 49) and had an average body mass index (BMI) of 29.5 (24.9-38.3). Twelve patients had a BMI between 25 and 29.9 kg/m2; 7 patients had BMI > or =30 kg/m2. Left-sided reconstructions were 13; right-sided reconstructions were 6. Supercharging was performed by anastamosing the deep inferior epigastric artery and vein to the thoracodorsal vessels, internal mammary vessels, or perforator vessels. Follow-up ranged from 6 to 54 months. There was a qualitative increase in blood flow measured by audible Doppler signals in all patients after the arterial and venous anastamoses. There were no cases of partial or complete flap loss. One patient had a hematoma and subsequently developed minor fat necrosis. One patient had an infection of the reconstructed breast. There were no donor site complications. Supercharging the TRAM flap by means of microvascular augmentation of the deep inferior epigastric vessels provides a safe and effective breast reconstruction in the overweight and obese population with no additional

Technique and outcomes of laparoscopic bulge repair after abdominal free flap reconstruction.

PubMed

Lee, Johnson C; Whipple, Lauren A; Binetti, Brian; Singh, T Paul; Agag, Richard

2016-01-21

Bulges and hernias after abdominal free flap surgery are uncommon with rates ranging from as low as 0-36%. In the free flap breast reconstruction population, there are no clear guidelines or optimal strategies to treating postoperative bulges. We describe our minimally invasive technique and outcomes in managing bulge complications in abdominal free flap breast reconstruction patients. A retrospective review was performed on all abdominal free flap breast reconstruction patients at Albany Medical Center from 2011 to 2014. All patients with bulges on clinical exam underwent abdominal CT imaging prior to consultation with a minimally invasive surgeon. Confirmed symptomatic bulges were repaired laparoscopically and patients were monitored regularly in the outpatient setting. Sixty-two patients received a total of 80 abdominal free flap breast reconstructions. Flap types included 41 deep inferior epigastric perforator (DIEP), 36 muscle-sparing transverse rectus abdominus myocutaneous (msTRAM), 2 superficial inferior epigastric artery, and 1 transverse rectus abdominus myocutaneous flap. There were a total of 9 (14.5%) bulge complications, with the majority of patients having undergone msTRAM or DIEP reconstruction. There were no complications, revisions, or recurrences from laparoscopic bulge repair after an average follow-up of 181 days. Although uncommon, bulge formation after abdominal free flap reconstruction can create significant morbidity to patients. Laproscopic hernia repair using composite mesh underlay offers an alternative to traditional open hernia repair and can be successfully used to minimize scarring, infection, and pain to free flap patients who have already undergone significant reconstructive procedures. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016. © 2016 Wiley Periodicals, Inc.

Ventricular standstill: a complication of intrapleural anesthesia using bupivacaine in a patient with free transverse rectus abdominus myocutaneous flap breast reconstruction.

PubMed

Jagadeesan, Jagajeevan; Kannan, Ruben; Dujon, David

2007-10-01

Transverse rectus abdominus myocutaneous (TRAM) flap is one of the commonly used techniques for breast reconstruction. Postoperative pain relief is of paramount importance following TRAM flap breast reconstruction to avoid potentially preventable complications like chest infection. Several methods of pain control are available, including intrapleural anesthesia. Here we report a case of a patient who developed ventricular standstill as a complication of intrapleural bupivacaine.

Simultaneous bilateral breast reconstruction with the transverse rectus abdominus musculocutaneous free flap.

PubMed

Khouri, R K; Ahn, C Y; Salzhauer, M A; Scherff, D; Shaw, W W

1997-07-01

The purpose of the study was to assess the results and morbidity associated with simultaneous bilateral TRAM free flap breast reconstruction and describe refinements in its surgical technique. Bilateral prophylactic total mastectomies might be an agreeable option for those patients at highest risk for breast cancer if autogenous tissue breast reconstruction could be performed with reasonable technical ease and acceptable morbidity. However, some surgeons harbor reservations regarding the extensiveness of the surgery, the associated morbidity, and the aesthetic quality of the resulting outcome. A multicenter retrospective review of clinical experience with 120 consecutive patients who underwent 240 simultaneous bilateral TRAM free flap breast reconstructions was developed. The average operating time, including the time required for the breast ablative portion of the procedures, was 8.6 hours. The average length of hospitalization was 7.6 days. However, for the last 40 patients, these figures were reduced to 7.1 hours and 6.1 days, respectively. Nonautologous blood transfusions were needed in 33 cases (28%), but only 1 was required in the last 40 patients. Thromboses developed in six of 240 flaps (2.5%): 4 were arterial and 2 were venous. Re-exploration allowed us to restore circulation in five flaps, whereas one flap was unsalvageable and was replaced successfully with an alternate flap. An uncomplicated deep vein thromboses developed in one patient with a history of recurrent deep vein thromboses that had no adverse effect on her outcome. Minor complications developed in 18 patients (15%) (e.g., hematoma, partial wound necrosis, wound infection, or prolonged postoperative ileus) that did not affect the long-term outcome. Fourteen patients (11.6%) had abdominal wall weakness or hernias. Follow-up time averaged 37.2 months (range, 14-62 months). On last follow-up, patients' self-reported overall satisfaction with the procedure was 56% excellent, 40% good, and 4% fair

Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction

PubMed Central

Chirappapha, Prakasit; Trikunagonvong, Noppadol; Rongthong, Sasiprapa; Lertsithichai, Panuwat; Sukarayothin, Thongchai; Leesombatpaiboon, Monchai; Panawattanakul, Rujira; Thaweepworadej, Panya

2017-01-01

Background: Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes. Methods: We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications. Results: Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2. Conclusion: Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia. PMID:28740793

The sensate free superior gluteal artery perforator (S-GAP) flap: a valuable alternative in autologous breast reconstruction.

PubMed

Blondeel, P N

1999-04-01

The superior and inferior myocutaneous gluteal free flaps have been considered as valuable alternatives to the latissimus dorsi or TRAM flap since 1975. The superior gluteal artery perforator (S-GAP) flap is the ultimate refinement of this myocutaneous flap as no gluteus maximus muscle is harvested. The flap is vascularised by one single perforator originating from the superior gluteal artery. This study summarises the prospectively gathered data on 20 free S-GAP flaps used for breast reconstruction in 16 patients. Immediate reconstruction was performed in six breasts and delayed in 14 breasts. Mean follow-up was 11.1 months. Two risk factors, Raynaud's disease and radiotherapy, were the cause of flap revision in two different patients. Total flap loss occurred in one case. Partial flap loss was not observed and a small area of fat necrosis was diagnosed by mammography in one other patient. All flaps were anastomosed to the internal mammary vessels at the 3rd costochondral junction. The anatomy of the sensate nerves of the S-GAP flap is described. Two nervous repairs provided early sensory recovery. The free S-GAP flap has become my personal second choice for autologous breast reconstruction after the DIEP (deep inferior epigastric perforator) flap. The S-GAP flap is indicated in patients with an asthenic body habitus or with excessive abdominal scarring. The advantages are the abundance of adipose tissue in this area even in thin patients, a long vascular pedicle, a hidden scar, improved projection of the reconstructed breast compared to the DIEP and TRAM flaps and the preservation of the entire gluteus maximus muscle. The donor morbidity is extremely low.

Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction.

PubMed

Muller, C Y; Coleman, R L; Adams, W P

2000-07-01

We report our technique and experience performing laparoscopic pelvic surgery on four women after transverse abdominus rectus myocutaneous flap (TRAM). Examination under anesthesia is performed on all patients in the low lithotomy position parallel with the floor. The abdominal aorta is palpated and outlined. A pneumoperitoneum is created either by umbilical or left upper quadrant Veress placement. Patients with an acceptable umbilical location undergo port placement through the incision of the umbilical relocation. Other options include left upper quadrant or paramedian placement avoiding the ligamentum teres vessels. Lateral operative ports (5 mm) are placed with reference to the transverse incision present, the pelvic pathology, and the location of the umbilicus. Techniques of electrocautery, intra- and extracorporeal suturing and knot tying, and clips are preferred to minimize port size. Following unilateral or bilateral TRAM reconstruction, four consecutive breast cancer survivors underwent successful laparoscopic-assisted vaginal hysterectomy with oophorectomy using the periumbilical incision for trocar placement. The only complication was a superficial skin breakdown from an adhesive allergy that required 6 weeks for complete resolution. Laparoscopic pelvic surgery is feasible in women after TRAM reconstruction. Knowledge of anatomic and physiologic variations related to the TRAM procedure is necessary in planning a safe operation.

[Breast reconstruction: autologous tissue versus implant].

PubMed

Plogmeier, K; Handstein, S; Schneider, W

1998-01-01

Modified radical mastectomy remains the standard for treatment of breast cancer. Women faced with the diagnosis of breast cancer often find it difficult to cope with the arousing emotions. Fear of death or cancer recurrence and a perceived loss of femininity often coexists with the desire for a return to normality and wholeness. For women seeking breast reconstruction various techniques have been developed. Two different ways for breast reconstruction have become a standard. One way is the reconstruction by tissue expansion or transposing locally available tissue with the use of implants. The other way is the reconstruction of the breast without using any implants with the Latissimus dorsi flap or the TRAM flap. We performed 291 breast reconstructions. In 125 women available tissue and an implant was used. The Latissimus dorsi flap was used in 57 cases and 109 TRAM flaps either pedicled or as a microvascular flap were performed. Using expanders we found a perforation of the device in 2 cases. After using implants there were capsular contracture in 2 cases and in 1 case we had an infection. Using autologous tissue we had 2 partial flap necrosis, 4 hematomas, and 4 prolonged healings. There was no complete flap necrosis. Breast reconstruction using autologous tissue i.e. the TRAM flap is supposed to be a standard technique. Microsurgical transplantation of the TRAM flap shows almost no morbidity of the donor site area. Autologous tissue follows the changes of the body like weight gain or reduction to a certain extend and shows neither capsular contracture nor other implant associated side effects. Women get the impression that the TRAM flap is like soft tissue to the touch and not like a foreign body. The aesthetic results were in all cases superior sometimes needing minor secondary correction and mostly shaping of the nippel-areola complex. All patients were pleased with the result.

The economic viability of breast reconstruction in the UK: comparison of a single surgeon's experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients.

PubMed

Atherton, D D; Hills, A J; Moradi, P; Muirhead, N; Wood, S H

2011-06-01

A retrospective audit was performed of patients undergoing breast reconstruction under the care of the senior author from 2000 to 2007. We documented reconstruction type, length of stay and total number of revisions. Income to the trust based on the 2008/9 HRG codes along with any "top ups" was also recorded. This was compared to calculations of cost to the trust of performing each reconstruction. 274 patients had 278 primary reconstructions and a further 366 revisions. Only patients with a minimum one-year's follow-up were included (mean 3 years). This included 68 DIEPs'; 39 TRAMs'; 98 LDs'; and 73 implant reconstructions. The median length of stay for implant based reconstruction was 4 days; 9 for LD flaps; 11 for TRAMs' and 8 for DIEPs'. This was significantly shorter for the implant group compared to other reconstructions (P<0.001). The mean number of surgical revisions was 1.5 for implant reconstructions; 1.6 for LDs; 0.9 for TRAMs' and 0.8 for DIEPs'. There were significantly more revisions of implant reconstructions than DIEPs (P=0.037) and significantly more revisions of LDs compared to TRAM and DIEPs' (P=0.012 and 0.0023). In our study, the cost of an LD, TRAM or DIEP reconstruction including both primary surgery and any revisions was similar, and while at an average of three years, the implant reconstruction remains cheaper, that patient will still require more revisions, and if followed up enough will lose this small financial benefit. Furthermore, the difference is small (£8034 for implants vs. £10910 for DIEPs), and it could be argued this is justified by the increased patient satisfaction and cosmetic outcome. Finally we highlight several areas of financial inequality, including insufficient remuneration for providing individual operations, the lack of payment for performing more than one procedure at the same time and lack of payment for bilateral procedures. Copyright © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons

Funding analysis of bilateral autologous free-flap breast reconstructions in Australia.

PubMed

Sinha, Shiba; Ruskin, Olivia; McCombe, David; Morrison, Wayne; Webb, Angela

2015-08-01

Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Laparoscopic mesh repair of transverse rectus abdominus muscle and deep inferior epigastric flap harvest site hernias.

PubMed

Ravipati, Nagesh B; Pockaj, Barbara A; Harold, Kristi L

2007-08-01

The transverse rectus abdominus muscle (TRAM) flap is one of the treatment options for breast reconstruction. TRAM flap reconstruction donor site herniation rates range from 1% to 8.8%. Traditionally, these hernias were treated by an open primary repair with or without the addition of onlay mesh. We report laparoscopic approach to treat TRAM and deep inferior epigastric perforator flap (DIEP) harvest site hernias with mesh. We treated 5 patients, 4 from TRAM and 1 from DIEP flap harvest site hernias during the period of October 2003 to January 2006. Two of these patients underwent previous open mesh repair with recurrence. All of these patients underwent laparoscopic hernia repair using polytetrafluoroethylene dual mesh. Follow-up ranged 6 to 31 months without any recurrences. Laparoscopic mesh repair of ventral hernias located at TRAM and DIEP flap harvest sites can be performed safely and with a low rate of recurrence.

An international comparison of reimbursement for DIEAP flap breast reconstruction.

PubMed

Reid, A W N; Szpalski, C; Sheppard, N N; Morrison, C M; Blondeel, P N

2015-11-01

The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. Data were collected confidentially from the main international centres by an anonymous questionnaire. Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons

The Transverse Musculocutaneous Gracilis Flap for Breast Reconstruction Educational Illustration Series

NASA Astrophysics Data System (ADS)

Steenberg, Ryan

Advancements in medicine have allowed surgeons a menu of options in post-mastectomy breast reconstruction. A conundrum exists, however, in flap selection when faced with varying patient body types. In the case of the athletic patient who does not have the appropriate amount of donor site tissue to warrant a Transverse Rectus Abdominus Musculocutaneuos Flap (TRAM) the Transverse Musculocutaneous Gracilis Flap (TMG) is an appropriate alternative due to its functional and aesthetic benefits. An intricate and timely process, the TMG procedure can be difficult to understand for the layperson. Therefore, a need for a condensed and standardized description exists. By breaking the process down and illustrating the procedure one can effectively deliver the information for use across all realms of publication and education.

Analysis of effect isoxsuprine hydrochloride and nicotine in the Transverse Rectus Abdominis Myocutaneous flap (TRAM) in rats.

PubMed

Costa, Walder; Silva, Alcino Lázaro da; Costa, Gustavo Rocha; Vidigal, Paula Vieira Teixeira; Pereira, Fernando Henrique

2015-07-01

To evaluate the effects of isoxsuprine and nicotine on TRAM. Forty eight 48 Wistar rats distributed into four Groups (n=12). All rats received medication managed daily for 20 days: saline solution (SA), nicotine solution (NI), isoxsuprine solution (IS) and nicotine solution (NI) + isoxsuprine solution (IS). On day 21st the rats were submitted to the caudally based, right unipedicled TRAM flap and after 48 hours, made the macroscopic evaluation of the surface of the flap, photographic documentation and collection of material for histology. Data from macroscopic evaluation were analyzed by ANOVA and microscopic evaluation by Kruskal-Wallis test, with significance level of 5%. In the macroscopic evaluation of isoxsuprine Group retail presented absolute numbers: final area (p=0.001*) and viable area (p=0.006*) with the highest values; necrosis (p=0.001*) had the lowest value. Microscopic examination revealed no significant findings in the study of TRAM under the action of isoxsuprine and nicotine to the percentage of necrosis in the left and right cranial and caudal regions. There was significant improvement in viability of TRAM using the isoxsuprine solution alone. No influence using nicotine alone and in association with isoxsuprine.

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.

PubMed

Hwang, T G; Wilkins, E G; Lowery, J C; Gentile, J

2000-02-01

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of

Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.

PubMed

Kaartinen, Ilkka S; Vuento, Maarit H; Hyöty, Marja K; Kallio, Jukka; Kuokkanen, Hannu O

2015-01-01

Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. IV, therapeutic. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Four-flap Breast Reconstruction: Bilateral Stacked DIEP and PAP Flaps

PubMed Central

Mayo, James L.; Allen, Robert J.

2015-01-01

Background: In cases of bilateral breast reconstruction when the deep inferior epigastric perforator (DIEP) free flap alone does not provide sufficient volume for body-specific reconstruction, stacking each DIEP flap with a second free flap will deliver added volume and maintain a purely autologous reconstruction. Stacking the profunda artery perforator (PAP) flap with the DIEP flap offers favorable aesthetics and ideal operative efficiency. We present the indications, technique, and outcomes of our experience with 4-flap breast reconstruction using stacked DIEP/PAP flaps. Methods: The authors performed 4-flap DIEP/PAP breast reconstruction in 20 patients who required bilateral reconstruction without adequate single donor flap volume. The timing of reconstruction, average mastectomy/flap weights, and operative time are reported. Complications reviewed include fat necrosis, dehiscence, hematoma, seroma, mastectomy flap necrosis, and flap loss. Results: Twenty patients underwent 4-flap DIEP/PAP breast reconstruction. Surgical time averaged 7 hours and 20 minutes. The primary recipient vessels were the antegrade and retrograde internal mammary vessels. No flap losses occurred. Complications included 1 hematoma, 1 incidence of arterial and venous thrombosis successfully treated with anastomotic revision, 1 incidence of thigh donor site dehiscence, and 3 episodes of minor mastectomy skin flap necrosis. Conclusions: Four-flap breast reconstruction is a favorable autologous reconstructive option for patients requiring bilateral reconstruction without adequate single donor flap volume. Stacking DIEP/PAP flaps as described is both safe and efficient. Furthermore, this combination provides superior aesthetics mirroring the natural geometry of the breast. Bilateral stacked DIEP/PAP flaps represent our first choice for breast reconstruction in this patient population. PMID:26090273

Propeller flaps in eyelid reconstruction.

PubMed

Rajak, Saul N; Huilgol, Shyamala C; Murakami, Masahiro; Selva, Dinesh

2018-03-14

Propeller flaps are island flaps that reach the recipient site through an axial rotation. The flap has a subcutaneous pedicle on which it pivots, thereby resembling a helicopter propeller. We present our series of propeller flaps for the reconstruction of large eyelid defects. This is a retrospective review of the clinical case notes of eight patients that underwent tumour excision with reconstruction with a cutaneous propeller flap supplied by a non-perforator orbicularis pedicle between July and December 2016. Propeller flaps were used in the reconstruction of five lower lid defects (size range 19 × 5 mm to 25 × 8 mm), one medial canthus defect (13 mm diameter), one complete upper lid defect (42 × 19 mm diameter) and one lid sparing extenteration defect. The flaps were recruited from nasolabial, lateral canthal, temple or medial upper cheek skin. Post-operatively one case had 'trapdooring' which required flap revision at 4 months and one had persistent oedema that settled without intervention. The reconstruction of large eyelid defects is challenging in part because of the paucity of locally available skin. Propeller flaps are a paradigm shift in periocular reconstruction in which the subcutaneous pedicle enables the recruitment of large and highly mobile skin flaps from a wide area of regional tissue.

Breast reconstruction following mastectomy: an update.

PubMed

Elliott, L F; Beegle, P H; Hartrampf, C R; Bennett, G K

1991-11-01

Breast reconstruction today is a realistic and vital part of total breast cancer treatment. All physicians should be well informed on current methods of reconstruction so that they can present the facts to their patients in an encouraging, yet realistic manner. Recent developments in breast reconstruction after mastectomy have included the increase utilization of immediate breast reconstruction at the time of mastectomy, the improvement and refinement of the TRAM flap, the increased use of the "free" flap transfer of the TRAM flap which increases blood supply to the flap, texturing of implants which appears to increase their stability on the chest wall and reduce the incidence of capsular contracture or firmness, and the introduction of the newer autogenous tissue methods including the LTTF, gluteal, and latissimus dorsi flaps. Plastic surgeons are charged with the task of becoming proficient in breast reconstruction procedures in order to offer the mastectomy patient a safe, realistic facsimile breast that will be trouble free. Fortunately, there are several good options for restoring the breast after mastectomy. The method of reconstruction should be chosen by matching the desires of informed patients with the indications and contraindications in each case. In general, silicone reconstruction is expedient and satisfactory in most patients. However, it cannot compete with autogenous tissue transfer for severe chest wall defects, covering irradiated areas, creating a large, ptotic breast, or providing a natural appearing, soft breast mount.

[Preoperative CT angiography for planning free perforator flaps in breast reconstruction].

PubMed

Kuekrek, H; Müller, D; Paepke, S; Dobritz, M; Machens, H-G; Giunta, R E

2011-04-01

Preoperative Doppler ultrasonography for planning free perforator flaps is widely established to identify preoperatively perforators. The method allows one to localise the penetrating point of the perforator through the abdominal fascia. By this means it is not possible to see the intramuscular course or the position of the perforator in relation to the inferior epigastric artery. Lately the technique of computed tomographic angiography provides an opportunity for visualising the course of perforator vessels in these tissues. This paper summarises our experience with the preoperative CT angiography in our breast centre. Since spring 2009 we have reconstructed the breasts of 44 female patients by using free flaps from the lower abdominal wall. 6 of these were bilateral. In a total number of 50 breast reconstructions we used 23 deep inferior epigastric perforator (DIEP) flaps and 27 muscle-sparing transverse rectus abdominis muscle (TRAM) flaps. In addition to the preoperative ultrasonography, a CT angiography of the lower abdomen was conducted in 29 patients. On average they showed at least 2 perforators on the left as well as right abdominal sides, which could be used as flap vessels based on their signal intensity. Based on their estimated microsurgical dissection complexity, the perforator vessels could be classified into 3 groups: 1) direct perforators of category A with short intramuscular course (39%), 2) perforators with long intramuscular course of category B (50%) and 3) "turn around" perforators of category C, which pass medially around the rectus abdominis (11%). The technique of CT angiography permits a reliable preoperative visualisation of perforators in their entire course and facilitates the selection of the supplying perforator as well as the intraoperative procedure for the surgeon. The suggested classification of perforators into 3 groups simplifies the preoperative assessment of the microsurgical dissection effort. Compared to the commonly used

Lower-limb reconstruction with chimeric flaps: The quad flap.

PubMed

Azouz, Solomon M; Castel, Nikki A; Vijayasekaran, Aparna; Rebecca, Alanna M; Lettieri, Salvatore C

2018-05-07

Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity. © 2018 Wiley Periodicals, Inc.

Double Back Cut in Post-mastectomy Breast Skin (Fish-Shaped Skin Paddle) in Delayed Pedicled TRAM Flap Breast Reconstruction.

PubMed

Berezovsky, Alexander Bogdanov; Pagkalos, Vasileios A; Shoham, Yaron; Krieger, Yuval; Silberstein, Eldad

2015-08-01

Breast reconstruction has become standard of care for female patients with breast cancer. The transverse rectus abdominis musculo-cutaneous flap (TRAMf) is the most common method of immediate or delayed autologous breast reconstruction following mastectomy. We share our experience with modified, double back cut of post-mastectomy skin in delayed pedicled TRAMf breast reconstruction, resulting in fish-shaped skin paddle. This sort of back cut is a simple, reliable way to obtain a natural, esthetically pleasant breast mound with inconspicuous hidden scars.

Propeller thoracodorsal artery perforator flap for breast reconstruction.

PubMed

Angrigiani, Claudio; Rancati, Alberto; Escudero, Ezequiel; Artero, Guillermo; Gercovich, Gustavo; Deza, Ernesto Gil

2014-08-01

The thoracodorsal artery perforator (TDAP) flap has been described for breast reconstruction. This flap requires intramuscular dissection of the pedicle. A modification of the conventional TDAP surgical technique for breast reconstruction is described, utilizing instead a propeller TDAP flap. The authors present their clinical experience with the propeller TDAP flap in breast reconstruction alone or in combination with expanders or permanent implants. From January 2009 to February 2013, sixteen patients had breast reconstruction utilizing a propeller TDAP flap. Retrospective analysis of patient characteristics, clinical indications, procedure and outcomes were performed. The follow-up period ranged from 4 to 48 months. Sixteen patients had breast reconstruction using a TDAP flap with or without simultaneous insertion of an expander or implant. All flaps survived, while two cases required minimal resection due to distal flap necrosis, healing by second intention. There were not donor-site seromas, while minimal wound dehiscence was detected in two cases. The propeller TDAP flap appears to be safe and effective for breast reconstruction, resulting in minimal donor site morbidity. The use of this propeller flap emerges as a true alternative to the traditional TDAP flap.

Microsurgical free flaps: Controversies in maxillofacial reconstruction

PubMed Central

George, Rinku K.; Krishnamurthy, Arvind

2013-01-01

Reconstructive microsurgery for oral and maxillofacial (OMF) defects is considered as a niche specialty and is performed regularly only in a handful of centers. Till recently the pectoralis major myocutaneous flap (PMMC) was considered to be the benchmark for OMF reconstruction. This philosophy is changing fast with rapid advancement in reconstructive microsurgery. Due to improvement in instrumentation and the development of finer techniques of flap harvesting we can positively state that microsurgery has come of age. Better techniques, microscopes and micro instruments enable us to do things previously unimaginable. Supramicrosurgery and ultrathin flaps are a testimony to this. Years of innovation in reconstructive microsurgery have given us a reasonably good number of very excellent flaps. Tremendous work has been put into producing some exceptionally brilliant research articles, sometimes contradicting each other. This has led to the need for clarity in some areas in this field. This article will review some controversies in reconstructive microsurgery and analyze some of the most common microvascular free flaps (MFF) used in OMF reconstruction. It aims to buttress the fact that three flaps-the radial forearm free flap (RFFF), anterolateral thigh flap (ALT) and fibula are the ones most expedient in the surgeon's arsenal, since they can cater to almost all sizeable defects we come across after ablative surgery in the OMF region. They can thus aptly be titled as the workhorses of OMF reconstruction with regard to free flaps. PMID:23662264

Influence of Flap Thickness on Nipple Projection After Nipple Reconstruction Using a Modified Star Flap.

PubMed

Ishii, Naohiro; Ando, Jiro; Harao, Michiko; Takemae, Masaru; Kishi, Kazuo

2018-05-07

In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (β = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.

PubMed

Schoeller, Thomas; Huemer, Georg M; Wechselberger, Gottfried

2008-07-01

The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.

Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction: Bad Rap or Good Flap?

PubMed Central

Perdikis, Galen; Koonce, Stephanie; Collis, George; Eck, Dustin

2011-01-01

Objective: This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. Methods: A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. Results: There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. Conclusion: The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications. PMID:22031843

Latissimus dorsi myocutaneous flap for breast reconstruction: bad rap or good flap?

PubMed

Perdikis, Galen; Koonce, Stephanie; Collis, George; Eck, Dustin

2011-01-01

This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.

Boomerang flap reconstruction for the breast.

PubMed

Baumholtz, Michael A; Al-Shunnar, Buthainah M; Dabb, Richard W

2002-07-01

The boomerang-shaped latissimus dorsi musculocutaneous flap for breast reconstruction offers a stable platform for breast reconstruction. It allows for maximal aesthetic results with minimal complications. The authors describe a skin paddle to obtain a larger volume than either the traditional elliptical skin paddle or the extended latissimus flap. There are three specific advantages to the boomerang design: large volume, conical shape (often lacking in the traditional skin paddle), and an acceptable donor scar. Thirty-eight flaps were performed. No reconstruction interfered with patient's ongoing oncological regimen. The most common complication was seroma, which is consistent with other latissimus reconstructions.

Free flap reconstruction for diabetic foot limb salvage.

PubMed

Sato, Tomoya; Yana, Yuichiro; Ichioka, Shigeru

2017-12-01

Although free flap is gaining popularity for the reconstruction of diabetic foot ulcers, it is unclear whether free flap reconstruction increases the chances of postoperative independent ambulation. The aim of this study is to evaluate the relationship between free flap success and postoperative ambulation. This study reviewed 23 cases of free flap reconstruction for diabetic foot ulcers between January 2007 and March 2014. Free rectus abdominis, latissimus dorsi, and anterolateral thigh flaps were used in ten, eight, and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher's exact test. Two patients developed congestive heart failure with fatal consequences within 14 days postoperatively, resulting in an in-hospital mortality rate of 8.7%. Five patients lost their flaps (21.7%). Of the 16 patients who had flap success, 12 achieved independent ambulation. Five patients with flap loss did not achieve independent ambulation, except one patient who underwent secondary flap reconstruction using a distally based sural flap. Fisher's exact test revealed that independent ambulation was associated with free flap success (p = 0.047). The present study indicates that free flap reconstruction may increase the possibility of independent ambulation for patients with extensive tissue defects due to diabetic ulcers. Intermediate limb salvage rates and independent ambulation rates were favourable in patients with successful reconstruction. The use of foot orthoses and a team approach with pedorthists were effective to prevent recurrence.

Reconstruction Using Locoregional Flaps for Large Skull Base Defects.

PubMed

Hatano, Takaharu; Motomura, Hisashi; Ayabe, Shinobu

2015-06-01

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano's algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano's classification extends horizontally from the cribriform plate to the orbital roof. According to Yano's algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis.

PubMed

Forner, D; Phillips, T; Rigby, M; Hart, R; Taylor, M; Trites, J

2016-02-05

In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps. Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution. Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group. We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free

Perforator Peroneal Artery Flap for Tongue Reconstruction.

PubMed

Chauhan, Shubhra; Chavre, Sachin; Chandrashekar, Naveen Hedne; B S, Naveen

2017-03-01

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar. Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm. Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of

Pedicled Temporalis Muscle Flap for Craniofacial Reconstruction: A 35-Year Clinical Experience with 366 Flaps.

PubMed

Spanio di Spilimbergo, Stefano; Nordera, Paolo; Mardini, Samir; Castiglione, Giusy; Chim, Harvey; Pinna, Vittore; Brunello, Massimo; Cusino, Claudio; Roberto, Squaquara; Baciliero, Ugo

2017-02-01

In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction. Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent. The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy. Therapeutic, IV.

Latissimus Dorsi Flap in Breast Reconstruction

PubMed Central

Sood, Rachita; Easow, Jeena M.; Konopka, Geoffrey; Panthaki, Zubin J.

2018-01-01

Background: Surgeons employ the latissimus dorsi flap (LDF) for reconstruction of a large variety of breast cancer surgery defects, including quadrantectomy, lumpectomy, modified radical mastectomy, and others. The LDF may be used in delayed or immediate reconstruction, in combination with tissue expanders for a staged reconstruction, with implant-based immediate reconstruction, or alone as an autogenous flap. Methods: The authors discuss the historical uses and more recent developments in the LDF. More recent advancements, including the “scarless” approach and augmentation with the thoracodorsal artery perforator flap, are discussed. Results: The LDF is a reliable means for soft tissue coverage providing form and function during breast reconstruction with acceptable perioperative and long-term morbidities. Conclusions: When there is a paucity of tissue, the LDF can provide tissue volume in autologous reconstruction, as well as a reliable vascular pedicle for implant-based reconstruction as in the setting of irradiated tissue. PMID:29334788

Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores.

PubMed

Lin, Chin-Ta; Chen, Shih-Yi; Chen, Shyi-Gen; Tzeng, Yuan-Sheng; Chang, Shun-Cheng

2015-07-01

Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.

Single-stage interpolation flaps in facial reconstruction.

PubMed

Hollmig, S Tyler; Leach, Brian C; Cook, Joel

2014-09-01

Relatively deep and complex surgical defects, particularly when adjacent to or involving free margins, present significant reconstructive challenges. When the use of local flaps is precluded by native anatomic restrictions, interpolation flaps may be modified to address these difficult wounds in a single operative session. To provide a framework to approach difficult soft tissue defects arising near or involving free margins and to demonstrate appropriate design and execution of single-stage interpolation flaps for reconstruction of these wounds. Examination of our utilization of these flaps based on an anatomic region and surgical approach. A region-based demonstration of flap conceptualization, design, and execution is provided. Tunneled, transposed, and deepithelialized variations of single-stage interpolation flaps provide versatile options for reconstruction of a variety of defects encroaching on or involving free margins. The inherently robust vascularity of these flaps supports importation of necessary tissue bulk while allowing aggressive contouring to restore an intricate native topography. Critical flap design allows access to distant tissue reservoirs and placement of favorable incision lines while preserving the inherent advantages of a single operative procedure.

Reconstruction of Large Postburn Facial-Scalp Scars by Expanded Pedicled Deltopectoral Flap and Random Scalp Flap: Technique Improvements to Enlarge the Reconstructive Territory.

PubMed

Ma, Xianjie; Li, Yang; Li, Weiyang; Liu, Chaohua; Peng, Pai; Song, Baoqiang; Xia, Wensen; Yi, Chenggang; Lu, Kaihua; Su, Yingjun

2017-09-01

The scars of face and scalp caused by burning often show as 1 large facial-scalp scar. The deltopectoral flap was recognized as one of the first choices for the facial scar reconstruction. However, this flap cannot cross the level of zygomatic arch traditionally when it was transferred with pedicle. When the flap reconstructed the facial-scalp scars with expanded random scalp flap, another flap was often needed to reconstruct the remaining temple and forehead scars. The authors reviewed 24 patients of large facial-scalp scars reconstructed by expanded pedicled deltopectoral flap and scalp flap with several technique improvements. The seaming scar between the deltopectoral flap and scalp flap in the temple region formed the new hairline. The technique improvements included ligation of the perforating branches of the transverse cervical artery and thoracoacromial artery when dissecting the pocket, the partial bolster compressive dressing to the distal part of the flap and dividing the pedicle partly as a delaying procedure before dividing the pedicle completely. Good skin compliance, normal contours, and emotional expression were noted. There were complications including expander exposure in 3 patients, stretch marks in 5 patients, flap tip necrosis in 2 patients, and mild postoperative hypertrophic scars in 3 patients. In conclusion, the expanded pedicled deltopectoral flap can enlarge the reconstructive territory in face successfully with the technique improvements. The combination of the expanded pedicled deltopectoral flap and scalp flap is a reliable and excellent reconstructive option for large postburn facial-scalp scars.

Lower Extremity Reconstruction with Free Gracilis Flaps

PubMed Central

Nicoson, Michael C; Parikh, Rajiv P; Tung, Thomas H

2017-01-01

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon’s armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon’s series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was 7 days or less in 6 patients, 8–30 days in 11 patients, 31–90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30 month follow up. Conclusions This study demonstrates the utility of the free gracilis flap in reconstruction of small to medium sized defects of the lower extremity. This flap has a high success rate and low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures. PMID:28024305

Angiographic delay: a viable alternative to surgical delay.

PubMed

Aboutanos, Sharline Z; Spinos, Efstathios; Blanchet, Nadia P

2012-06-01

Selective embolization of the inferior epigastric arteries can serve as a method for transverse rectus abdominis musculocutaneous (TRAM) flap delay. The purpose of this study was to determine whether delay by selective arterial embolization is comparable to traditionally surgically delayed TRAM flaps as reported in the literature, in terms of skin and fat necrosis, and to examine whether certain risk factors play a role in TRAM flap fat necrosis despite angiographic delay. Retrospective chart review was performed for 88 consecutive patients who underwent unilateral TRAM flap breast reconstruction after selective embolization of bilateral inferior epigastric arteries. Between 1997 and 2009, 88 pedicled TRAM flaps were performed for breast reconstruction in women with a mean age of 49.7 years. No patients had flap skin necrosis or total flap loss. In all, 13.6% patients had TRAM flap fat necrosis. Two patients in the TRAM fat necrosis group (16.7%) had a positive history of smoking, which was a statistically significant risk factor for necrosis (P = 0.048). Outcomes of pedicled TRAM flaps delayed by selective arterial embolization are comparable to historical controls of those delayed by traditional surgical means (ligation of artery and vein) and better than nondelayed flaps. Smoking remains a significant risk factor for TRAM flap fat necrosis despite the benefit of delay.

Defining the Role of Free Flaps in Partial Breast Reconstruction.

PubMed

Smith, Mark L; Molina, Bianca J; Dayan, Erez; Jablonka, Eric M; Okwali, Michelle; Kim, Julie N; Dayan, Joseph H

2018-03-01

 Free flaps have a well-established role in breast reconstruction after mastectomy; however, their role in partial breast reconstruction remains poorly defined. We reviewed our experience with partial breast reconstruction to better understand indications for free tissue transfer.  A retrospective review was performed of all patients undergoing partial breast reconstruction at our center between February 2009 and October 2015. We evaluated the characteristics of patients who underwent volume displacement procedures versus volume replacement procedures and free versus pedicled flap reconstruction.  There were 78 partial breast reconstructions, with 52 reductions/tissue rearrangements (displacement group) and 26 flaps (replacement group). Bra cup size and body mass index (BMI) were significantly smaller in the replacement group. Fifteen pedicled and 11 free flaps were performed. Most pedicled flaps (80.0%) were used for lateral or upper pole defects. Most free flaps (72.7%) were used for medial and inferior defects or when there was inadequate donor tissue for a pedicled flap. Complications included hematoma, cellulitis, and one aborted pedicled flap.  Free and pedicled flaps are useful for partial breast reconstruction, particularly in breast cancer patients with small breasts undergoing breast-conserving treatment (BCT). Flap selection depends on defect size, location, and donor tissue availability. Medial defects are difficult to reconstruct using pedicled flaps due to arc of rotation and intervening breast tissue. Free tissue transfer can overcome these obstacles. Confirming negative margins before flap reconstruction ensures harvest of adequate volume and avoids later re-operation. Judicious use of free flaps for oncoplastic reconstruction expands the possibility for breast conservation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reconstruction of eyelids with Washio flap in anophthalmia.

PubMed

Tvrdek, M; Kozák, J

2014-01-01

The authors present a case report of a patient with anophthalmia in whom retroauriculo-temporal flap (Washio flap) was used for reconstruction of eyelids. This flap, which is mostly used for reconstructions of nasal defects, was not used in this way according to available literature.

Reconstruction of the vulva with sensate gluteal fold flaps.

PubMed

Kuokkanen, H; Mikkola, A; Nyberg, R H; Vuento, M H; Kaartinen, I; Kuoppala, T

2013-01-01

Soft-tissue reconstruction of the vulva following resection of malignancies is challenging. The function of perineal organs should be preserved and the reconstructed area should maintain an acceptable cosmetic appearance. Reconstruction with local flaps is usually sufficient in the primary phase after a radical vulvectomy. Numerous flaps have been designed for vulvar reconstruction usually based on circulation from the internal pudendal artery branches. In this paper we introduce our modification of the gluteal fold V-Y advancement flap as a primary reconstruction after a radical vulvectomy. Twenty-two patients were operated with a radical vulvectomy because of vulvar malignancies. The operation was primary in eight and secondary in 14 patients. The reconstruction of the vulva was performed in the same operation for each patient. All flaps survived completely. Wound complications were registered in three patients. Late problems with urinary stream were corrected in two patients. A local recurrence of the malignancy was observed in six patients during the follow-up period. Gluteal fold flap is easy to perform, has a low rate of complications and gives good functional results. Even a large defect can be reconstructed reliably with this method. A gluteal fold V-Y advancement flap is sensate and our modification allows the flap to be transposed with lesser dissection as presented before.

Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction.

PubMed

Vargo, James D; Przylecki, Wojciech; Camarata, Paul J; Andrews, Brian T

2018-05-18

 Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects.  A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed.  Eleven flaps in 10 subjects were identified and anatomic sites included: low ( n  = 5), middle ( n  = 3), and high ( n  = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) ( n  = 7) and fibula ( n  = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap ( n  = 1), latissimus myocutaneous flap ( n  = 1), and rectus abdominis myofascial flap ( n  = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak ( n  = 1) and pneumocephalus ( n  = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals.  In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area. Thieme Medical Publishers

Comparison of Dorsal Intercostal Artery Perforator Propeller Flaps and Bilateral Rotation Flaps in Reconstruction of Myelomeningocele Defects.

PubMed

Tenekeci, Goktekin; Basterzi, Yavuz; Unal, Sakir; Sari, Alper; Demir, Yavuz; Bagdatoglu, Celal; Tasdelen, Bahar

2018-04-09

Bilateral rotation flaps are considered the workhorse flaps in reconstruction of myelomeningocele defects. Since the introduction of perforator flaps in the field of reconstructive surgery, perforator flaps have been used increasingly in the reconstruction of various soft tissue defects all over the body because of their appreciated advantages. The aim of this study was to compare the complications and surgical outcomes between bilateral rotation flaps and dorsal intercostal artery perforator (DICAP) flaps in the soft tissue reconstruction of myelomeningocele defects. Between January 2005-February 2017, we studied 47 patients who underwent reconstruction of myelomeningocele defects. Patient demographics, operative data, and postoperative data were reviewed retrospectively and are included in the study. We found no statistically significant differences in patient demographics and surgical complications between these two groups; this may be due to small sample size. With regard to complications-partial flap necrosis, cerebrospinal fluid (CSF) leakage, necessity for reoperation, and wound infection-DICAP propeller flaps were clinically superior to rotation flaps. Partial flap necrosis was associated with CSF leakage and wound infection, and CSF leakage was associated with wound dehiscence. Although surgical outcomes obtained with DICAP propeller flaps were clinically superior to those obtained with rotation flaps, there was no statistically significant difference between the two patient groups. A well-designed comparative study with adequate sample size is needed. Nonetheless, we suggest using DICAP propeller flaps for reconstruction of large myelomeningocele defects.

Orbital Floor Reconstruction with Free Flaps after Maxillectomy

PubMed Central

Sampathirao, Leela Mohan C. S. R.; Thankappan, Krishnakumar; Duraisamy, Sriprakash; Hedne, Naveen; Sharma, Mohit; Mathew, Jimmy; Iyer, Subramania

2013-01-01

Background The purpose of this study is to evaluate the outcome of orbital floor reconstruction with free flaps after maxillectomy. Methods This was a retrospective analysis of 34 consecutive patients who underwent maxillectomy with orbital floor removal for malignancies, reconstructed with free flaps. A cross-sectional survey to assess the functional and esthetic outcome was done in 28 patients who were alive and disease-free, with a minimum of 6 months of follow-up. Results Twenty-six patients had bony reconstruction, and eight had soft tissue reconstruction. Free fibula flap was the commonest flap used (n = 14). Visual acuity was normal in 86%. Eye movements were normal in 92%. Abnormal globe position resulted in nine patients. Esthetic satisfaction was good in 19 patients (68%). Though there was no statistically significant difference in outcome of visual acuity, eye movement, and patient esthetic satisfaction between patients with bony and soft tissue reconstruction, more patients without bony reconstruction had abnormal globe position (p = 0.040). Conclusion Free tissue transfer has improved the results of orbital floor reconstruction after total maxillectomy, preserving the eye. Good functional and esthetic outcome was achieved. Though our study favors a bony orbital reconstruction, a larger study with adequate power and equal distribution of patients among the groups would be needed to determine this. Free fibula flap remains the commonest choice when a bony reconstruction is contemplated. PMID:24436744

Orbital floor reconstruction with free flaps after maxillectomy.

PubMed

Sampathirao, Leela Mohan C S R; Thankappan, Krishnakumar; Duraisamy, Sriprakash; Hedne, Naveen; Sharma, Mohit; Mathew, Jimmy; Iyer, Subramania

2013-06-01

Background The purpose of this study is to evaluate the outcome of orbital floor reconstruction with free flaps after maxillectomy. Methods This was a retrospective analysis of 34 consecutive patients who underwent maxillectomy with orbital floor removal for malignancies, reconstructed with free flaps. A cross-sectional survey to assess the functional and esthetic outcome was done in 28 patients who were alive and disease-free, with a minimum of 6 months of follow-up. Results Twenty-six patients had bony reconstruction, and eight had soft tissue reconstruction. Free fibula flap was the commonest flap used (n = 14). Visual acuity was normal in 86%. Eye movements were normal in 92%. Abnormal globe position resulted in nine patients. Esthetic satisfaction was good in 19 patients (68%). Though there was no statistically significant difference in outcome of visual acuity, eye movement, and patient esthetic satisfaction between patients with bony and soft tissue reconstruction, more patients without bony reconstruction had abnormal globe position (p = 0.040). Conclusion Free tissue transfer has improved the results of orbital floor reconstruction after total maxillectomy, preserving the eye. Good functional and esthetic outcome was achieved. Though our study favors a bony orbital reconstruction, a larger study with adequate power and equal distribution of patients among the groups would be needed to determine this. Free fibula flap remains the commonest choice when a bony reconstruction is contemplated.

Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction.

PubMed

Werdin, Frank; Haug, Daniel M; Amr, Amro; Schoeller, Thomas

2016-10-01

In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:539-545, 2016. © 2015 Wiley Periodicals, Inc.

Tachycardia in breast reconstructive microsurgery: Affirmation of the IMA tachycardia syndrome.

PubMed

Sachanandani, N S; Kale, S S; Skolnick, G B; Barbour, J R; Myckatyn, T M

2015-06-01

The internal mammary vessels are frequently chosen as recipient vessels for breast free flap reconstruction. We have noticed that when using the internal mammary recipients that these patients have a propensity for tachycardia that was not previously observed. Our aim was to investigate the factors related to perioperative tachycardia in the microsurgical breast reconstruction population and to address whether use of the internal mammary system is a causative factor in tachycardia. A retrospective chart review was conducted to identify patients who underwent abdominal-based microvascular breast reconstruction at the Washington University School of Medicine between 2002 and 2012 to identify the presence of tachycardia. After application of exclusion criteria, 76 microvascular abdominal-based free flap reconstructions were identified. The internal mammary (IM) TRAM group (n = 24) and the thoracodorsal (TD) TRAM group (n = 52) were compared. A binomial logistic regression was performed with the presence of tachycardia as the dependent variable. There was a higher incidence of tachycardia in the IM TRAM group when compared to the TD TRAM group (p = 0.004). The variables predictive of tachycardia in our logistic regression model were IMA recipient (p = 0.04), need for transfusion (p = 0.03), and presence of fever (p = 0.01). Our study reaffirms that there are several factors that are predictive of tachycardia in the setting of microvascular breast reconstruction. The IMA syndrome should be a recognized cause of tachycardia as using these recipient vessels are shown to be predictive of postoperative tachycardia as shown in our study. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

A new skin flap method for total auricular reconstruction in microtia patients with a reconstructed ear canal: extended scalp and extended mastoid postauricular skin flaps.

PubMed

Hwang, Euna; Kim, Young Soo; Chung, Seum

2014-06-01

Before visiting a plastic surgeon, some microtia patients may undergo canaloplasty for hearing improvement. In such cases, scarred tissues and the reconstructed external auditory canal in the postauricular area may cause a significant limitation in using the posterior auricular skin flap for ear reconstruction. In this article, we present a new method for auricular reconstruction in microtia patients with previous canaloplasty. By dividing a postauricular skin flap into an upper scalp extended skin flap and a lower mastoid extended skin flap at the level of a reconstructed external auditory canal, the entire anterior surface of the auricular framework can be covered with the two extended postauricular skin flaps. The reconstructed ear shows good color match and texture, with the entire anterior surface of the reconstructed ear being resurfaced with the skin flaps. Clinical question/level of evidence; therapeutic level IV. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The changing role of pectoralis major flap in head and neck reconstruction.

PubMed

Liu, Hin-Lun; Chan, Jimmy Yu-Wai; Wei, William Ignace

2010-11-01

Although pectoralis major flap (PM flap) has been used as the workhorse flap in head and neck reconstruction, its use in head and neck defects seems to fall out of favour in the era of free tissue transfer. The aim of this review is to find out the role of PM flap in modern head and neck surgery. Medical records of patients who underwent PM flap reconstruction for head and neck defect in our division were reviewed. The age, gender, flap type, indication and complication rate were described. Between January 1998 and December 2008, 202 PM flaps were used for head and neck reconstruction in 192 patients. In the early study period (1998-June 2003), out of the 119 PM flap reconstructions, 106 (89%) were performed for immediate reconstruction after resection of head and neck tumour, while 10 (8%) were performed as salvage procedures for complication after tumour resection e.g. failure of free flap, pharyngocutaneous fistula. In the late study period (July 2003-2008), out of the 83 PM flap reconstructions, 58 (70%) were performed for immediate reconstruction, while 24 (29%) were performed as salvage procedures. For immediate reconstruction after tumour extirpation, 51 flaps (48%) were performed for reconstruction of the tongue in the early study period, while only 14 (24%) were performed in the late study period. The number of PM flap used for immediate reconstruction for other head and neck defects remained relatively static throughout the two study periods. Over the study period, there were 10 (5%) cases of partial flap necrosis and 2 (1%) total flap loss, making the overall flap necrosis rate 6%. In the era of free tissue transfer, the role of PM flap in head and neck surgery has shifted from immediate reconstruction to salvage operation. However, PM flap still has an unique role in the repair of certain head and neck defects.

Lower Extremity Free Flaps for Breast Reconstruction.

PubMed

Dayan, Joseph H; Allen, Robert J

2017-11-01

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient's fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Reconstruction of Facial Defect Using Deltopectoral Flap.

PubMed

Aldelaimi, Tahrir N; Khalil, Afrah A

2015-11-01

Reconstruction of the head and neck is a challenge for otolarygology surgeons, maxillofacial surgeons as well as plastic surgeons. Defects caused by the resection and/or trauma should be closed with flaps which match in color, texture and hair bearing characteristics with the face. Deltopectoral flap is a one such flap from chest and neck skin mainly used to cover the facial defects. This study report a patient presenting with tragic Road Traffic Accident (RTA) admitted to maxillofacial surgery department at Ramadi Teaching Hospital, Anbar province, Iraq. An incision, medially based, was done and deltopectoral fascio-cutaneous flap was used for surgical exposure and closure of defects after RTA. There was no major complication. Good aesthetic and functional results were achieved. Deltopectoral flap is an excellent alternative for the reconstruction of head and neck. Harvesting and application of the flap is rapid and safe. Only a single incision is sufficient for dissection and flap elevation.

Innervated boomerang flap for finger pulp reconstruction.

PubMed

Chen, Shao-Liang; Chiou, Tai-Fung

2007-11-01

The boomerang flap originates from the dorsolateral aspect of the proximal phalanx of an adjacent digit and is supplied by the retrograde blood flow through the vascular arcades between the dorsal and palmar digital arteries. To provide sensation of the boomerang flap for finger pulp reconstruction, the dorsal sensory branch of the proper digital nerve and the superficial sensory branch of the corresponding radial or ulnar nerve are included within the skin flap. After transfer of the flap to the injured site, epineural neurorrhaphies are done between the digital nerves of the pulp and the sensory branches of the flap. We used this sensory flap in five patients, with more than 1 year follow-up, and all patients achieved measurable two-points discrimination. The boomerang flap not only preserves the proper palmar digital artery but also provides an extended and innervated skin paddle. It seems to be an alternative choice for one-stage reconstruction of major pulp defect.

The inferior turbinate flap in skull base reconstruction

PubMed Central

2013-01-01

Background As the indications for expanded endonasal approaches continue to evolve, alternative reconstructive techniques are needed to address increasingly complex surgical skull base defects. In the absence of the nasoseptal flap, we describe our experience with the posterior pedicle inferior turbinate flap (PPITF) in skull base reconstruction. Design Case series. Setting Academic tertiary care centre. Methods Patients who underwent reconstruction of the skull base with the PPITF were identified. Medical records were reviewed for demographic, presentation, treatment, follow-up, surgical and outcomes data. Main outcome measures Flap survival, adequacy of seal, and complications. Results Two patients with residual/recurrent pituitary adenomas met the inclusion criteria. The nasoseptal flap was unavailable in each case due to a prior septectomy. Salvage of the original nasoseptal flap was not possible, as it did not provide adequate coverage of the resultant defect due to contraction from healing. All PPITFs healed uneventfully and covered the entire defect. No complications were observed in the early post-operative period. Endoscopic techniques and limitations of the PPITF are also discussed. Conclusions Our clinical experience supports the PPITF to be a viable alternative for reconstruction of the skull base in the absence of the nasoseptal flap. PMID:23663897

Unit Advancement Flap for Lower Lip Reconstruction.

PubMed

Ogino, Akihiro; Onishi, Kiyoshi; Okada, Emi; Nakamichi, Miho

2018-05-01

Lower lip reconstruction requires consideration of esthetic and functional outcome in selecting a surgical procedure, and reconstruction with local tissue is useful. The authors reconstructed full-thickness defects with a unit advancement flap. Reconstruction was performed using this method in 4 patients with lower lip squamous cell carcinoma in whom tumor resection with preservation of the mouth angle was possible. The lower lip resection width was 30 to 45 mm, accounting for 50% to 68% of the entire width of the lower lip. The flap was prepared by lateral extension from above the mental unit and matched with the potential wrinkle line of the lower lip in order to design a unit morphology surrounded by the anterior margin of the depressor labii inferioris muscle. It was elevated as a full-thickness flap composed of the orbicularis oris muscle, skin, and mucosa of the residual lower lip from the bilateral sides, and advanced to the defect. Flap transfer was adjusted by small triangular resection of the skin on the lateral side of the mental unit. The postoperative scar was inconspicuous in all patients and there was no impairment of the mouth opening-closing or articulation functions. This was a relatively simple surgical procedure. A blood supply of the flap was stable, and continuity of the orbicularis oris muscle was reconstructed by transferred the residual lower lip advancement flap from the bilateral sides. The postoperative mouth opening-closing function was sufficient, and dentures could be placed from an early phase in elderly patients. The postoperative scar was consistent with the lip unit morphology, being esthetically superior. This procedure may be applicable for reconstruction of defects approximately 1/3 to 2/3 the width of the lower lip where the mouth angle is preserved.

Pedicled Extranasal Flaps in Skull Base Reconstruction

PubMed Central

Kim, Grace G.; Hang, Anna X.; Mitchell, Candace; Zanation, Adam M.

2013-01-01

Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1cm) can be repaired by multilayered free grafts. For large defects (>3cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options—inferior turbinate (IT) or middle turbinate (MT) flaps—as well as regional pedicled flaps: pericranial flap (PCF), temporoparietal fascial flap (TPFF), or palatal flap (PF). More recently, novel alternatives such as the pedicled facial buccinator flap (FAB) and the pedicled occipital galeopericranial flap (OGP) have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described. PMID:23257554

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions.

PubMed

Hummelink, S; Verhulst, Arico C; Maal, Thomas J J; Hoogeveen, Yvonne L; Schultze Kool, Leo J; Ulrich, Dietmar J O

2017-07-01

Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. In six patients (n = 9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. The measured breast volume using 3D stereophotogrammetry was 578 ± 127 cc; on CTA images, 527 ± 106 cc flap volumes were planned. The nine harvested flaps weighed 533 ± 109 g resulting in a planned versus harvested flap mean difference of 5 ± 27 g (flap density 1.0 g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of pressure sores with perforator-based propeller flaps.

PubMed

Jakubietz, Rafael G; Jakubietz, Danni F; Zahn, Robert; Schmidt, Karsten; Meffert, Rainer H; Jakubietz, Michael G

2011-03-01

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores. © Thieme Medical Publishers.

Transfer of free fillet lateral arm flap for facial reconstruction.

PubMed

Bayram, Fazli Cengiz; Dadaci, Mehmet; Ince, Bilsev; Altuntas, Zeynep

2014-07-01

We describe a 16-year-old male patient who had a major right facial degloving injury resulting in a soft-tissue defect with exposed zygoma as well as temporal and frontal bones. Multiple operations were undertaken in a staged manner for reconstruction. Lateral arm free fillet flap transfer was initially performed with fixation of bones with miniplates, which is followed by flap debulking, lateral canthopexy, scalp tissue expansion for hairline reconstruction, as well as ear reconstruction with costal cartilage and local flap techniques. After a follow-up period of 2 years, a good and impressive reconstructive result was achieved through the use of multiple contemporary reconstructive procedures after a successful free fillet flap transfer from an amputated part.

Posttraumatic eyebrow reconstruction with hair-bearing temporoparietal fascia flap

PubMed Central

Denadai, Rafael; Raposo-Amaral, Cassio Eduardo; Marques, Frederico Figueiredo; Raposo-Amaral, Cesar Augusto

2015-01-01

The temporoparietal fascia flap has been extensively used in craniofacial reconstructions. However, its use for eyebrow reconstruction has been sporadically reported. We describe a successfully repaired hair-bearing temporoparietal fascia flap after traumatic avulsion of eyebrow. Temporoparietal fascia flap is a versatile tool and should be considered as a therapeutic option by all plastic surgeons. PMID:25993077

Tracheal reconstruction with a pleuroperiosteal flap.

PubMed

Krespi, Y P; Biller, H F; Baek, S M

1983-12-01

Reconstruction of extensive tracheal defects remains a difficult surgical problem. In many experiments restoration of tracheal mucosa by autogenous or homologous soft tissue grafts has usually failed because of rejection or tracheal obstruction. This experimental work employed a two-stage surgical procedure that allowed reconstruction of extensive circumferential full-thickness defects of the trachea. Stage I involved the creation of a vascularized pleuroperiosteal flap that was formed into a rigid tube around a Silastic stent. Stage II consisted of creation of a full-thickness circumferential tracheal defect and repair with the flap in those animals in which a suitable rigid tube had been formed. The results of these experiments argue strongly that a vascularized composite pleuroperiosteal flap can produce an adequate tracheal replacement.

Early experience with the free lumbar artery perforator flap for breast reconstruction.

PubMed

Peters, Kevin T; Blondeel, Phillip N; Lobo, Fernando; van Landuyt, Koenraad

2015-08-01

Autologous breast reconstruction has become a progressively more popular method of breast reconstruction. A wide variety of perforator flaps have been described and subsequently refined to decrease donor-site morbidity. Recently, the lumbar artery perforator (LAP) flap has been reported as an option for autologous breast reconstruction. This study summarises the prospectively gathered data of 35 free LAP flaps for breast reconstruction in 28 patients. The mean follow-up was 18 months. The internal mammary artery and the venae comitantes were used as recipient vessels in all reconstructions. In 80% of the reconstructions (28 flaps), an interposition graft was used. Six flaps (17%) had to be revised for venous thrombosis. Two of the revised flaps (5.7%) could not be salvaged, and total flap necrosis occurred. The mean operating time was 6 h and 15 min, 6 h and 39 min when an interposition graft was used and 5 h and 23 min when no interposition graft was necessary. The LAP flap should be considered as a further alternative for breast reconstruction in patients in whom a deep inferior epigastric artery perforator (DIEAP) flap is not possible or not desirable. Shaping of this flap is easier compared to any other flaps due to the quality of the lumbar fat and the gluteal extension. An interposition graft is frequently used to facilitate anastomosis, either to lengthen the pedicle or to resolve size mismatch. This is a disadvantage of the LAP flap. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes.

PubMed

Paydarfar, Joseph A; Patel, Urjeet A

2011-01-01

To compare intraoperative, postoperative, and functional results of submental island pedicled flap (SIPF) against radial forearm free flap (RFFF) reconstruction for tongue and floor-of-mouth reconstruction. Multi-institutional retrospective review. Academic tertiary referral center. Consecutive patients from February 2003 to December 2009 undergoing resection of oral tongue or floor of mouth followed by reconstruction with SIPF or RFFF. Two groups: SIPF vs RFFF. Duration of operation, hospital stay, surgical complications, and speech and swallowing function. The study included 60 patients, 27 with SIPF reconstruction and 33 with RFFF reconstruction. Sex, age, and TNM stage were similar for both groups. Mean flap size was smaller for SIPF (36 cm²) than for RFFF (50 cm²) (P < .001). Patients undergoing SIPF reconstruction had shorter operations (mean, 8 hours 44 minutes vs 13 hours 00 minutes; P < .001) and shorter hospitalization (mean, 10.6 days vs 14.0 days; P < .008) compared with patients who underwent RFFF. Donor site, flap-related, and other surgical complications were comparable between groups, as was speech and swallowing function. Reconstruction of oral cavity defects with the SIPF results in shorter operative time and hospitalization without compromising functional outcomes. The SIPF may be a preferable option in reconstruction of oral cavity defects less than 40 cm².

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction.

PubMed

Molina, Alexandra R; Citron, Isabelle; Chinaka, Fungayi; Cascarini, Luke; Townley, William A

2017-02-01

Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction. In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps. The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence. Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity. Therapeutic, IV.

Free anterolateral thigh flap for reconstruction of major craniofacial defects.

PubMed

Amin, Ayman; Rifaat, Mohammed; Civantos, Francisco; Weed, Donald; Abu-Sedira, Mohammed; Bassiouny, Mahmoud

2006-02-01

Free-tissue transfer has revolutionized skull-base surgery by expanding the ability to perform cranial base resection and by improving the quality of reconstruction. The anterolateral thigh flap has come recently into use in the field of head and neck reconstruction. Its role in craniofacial and midface reconstruction has not been specifically defined. This study involved a total of 18 patients who were treated over a 5-year period from 1998 to 2003. Seventeen patients had locally advanced head and neck cancer, requiring craniofacial resection, and one patient had a complicated gun shot wound of the forehead. Thirteen patients were treated at the National Cancer Institute, Cairo University, Egypt, and five patients at the University of Miami, Florida. The patients presented with defects of the anterior skull base (5), lateral skull base (3), scalp and calvarium (3), and the midface (7). The anterolateral thigh flap was used as a myocutaneous flap in 11 cases and as a perforator fasciocutaneous flap in seven cases. Musculocutaneous perforators supplied the majority of flaps (17/18). Total flap survival occurred in 17 cases; one patient developed complete flap necrosis. The most commonly used recipient vessels were the facial vessels and the external jugular vein. Major complications included one case with meningitis; the patient died after failure of treatment. Another patient died 6 weeks postoperatively from pulmonary embolism. One patient developed CSF leak that stopped spontaneously. In addition, two patients developed minor wound dehiscence that healed spontaneously. The donor-site wound healed without problems except in two cases. One patient had an incomplete take of the skin graft; the other developed wound infection and superficial sloughing. Both wounds healed spontaneously. In addition to the feasibility of simultaneous flap harvesting with tumor resection, the flap's advantage in skull base reconstruction is its reliable blood supply, which can provide

Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation.

PubMed

Li, Bo-Han; Jung, Hun Jong; Choi, Sung-Won; Kim, Soung-Min; Kim, Myung-Jin; Lee, Jong-Ho

2012-12-01

The purpose of this study was to consider the indications and evaluate the clinical advantages and disadvantages including, results and complications, of immediate reconstruction using a latissimus dorsi (LD) free flap and reconstruction plate (R-plate) in advanced oro-mandibular tumour resection. Our cohort included 116 patients who underwent LD free flap and R-plate reconstruction. Flap survival, postoperative function, donor/recipient site complication and aesthetics were evaluated. Our series demonstrated a 99.1% flap survival rate. One case required a contralateral LD free flap reconstruction after the initial flap failed due to pedicle kinking. Twelve patients needed the plate to be removed and replaced (n=4, plate fracture; n=2, plate exposure) or definite reconstruction with free fibular flap and implant installation. Donor site complications included seroma accumulation, scarring, and discomfort of the shoulder girdle. The size of the skin paddle ranged from 6 × 10 cm to 12 × 18 cm (12 were double paddled).The facial contour was acceptable without sagging of the flap. The flap was tolerant to irradiation and was resistant to the exposure of the plate at the symphyseal arch. Our series of primary reconstruction with LD free flaps and R-plates showed the retention of mandibular function and the reconstruction of considerably large soft tissue can be achieved successfully. This reconstruction scheme can be indicated for large-volume defects in the oro-mandibular area when the area cannot be covered by a single osteocutaneous free flap, has undergone extensive oncologic resection for advanced or high recurrence rate malignancy and when immediate postoperative chemotherapy and/or irradiation is necessary. Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

[Perineal reconstruction: Salvage surgery with 2flaps technique].

PubMed

Jiménez Gómez, Marta; Navarro-Sánchez, Antonio; Lima Sánchez, Jaime; Hernández Hernández, Juan Ramón

2017-12-01

The principles of perineal reconstructive surgery comprise adequate filling of the defect along with stable and durable skin coverage, with a low morbidity rate. Two-flap perineal reconstruction is a simple, fast and reliable technique that uses a single donor site. This improves scar position with low morbidity. It is based in the use of 2flaps; one flap fills the defect with a «turn over» technique and the other is a rotation - advancement flap for skin coverage. A 52-year-old male diagnosed with Lynch syndrome who underwent laparoscopic abdominoperineal amputation for adenocarcinoma of the lower rectum and developed recurrence 2years later over the perineal scar that required radical resection and perineal reconstruction. The use of this approach facilitates perineal reconstruction and enables treatment of patients with large and complex defects in frequently irradiated tissues where wound dehiscence and infection are common. Copyright © 2017 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Comparison of morbidity-related seroma formation following conventional latissimus dorsi flap versus muscle-sparing latissimus dorsi flap breast reconstruction

PubMed Central

Numajiri, Toshiaki; Nakatsukasa, Katsuhiko; Sakaguchi, Koichi; Taguchi, Tetsuya

2017-01-01

Purpose The pedicled, descending-branch muscle-sparing latissimus dorsi (MSLD) flap has been widely used for breast reconstruction following total mastectomy. However, the superiority of the MSLD flap compared to the conventional latissimus dorsi (CLD) flap in preventing seroma formation has not been demonstrated. This study compares the morbidities related to seroma formation following pedicled MSLD flap and CLD flap breast reconstruction. Methods A total of 15 women who underwent partial mastectomy and immediate partial breast reconstruction with MSLD flaps were compared with 15 women under identical conditions with CLD flap breast reconstruction. The medical records were reviewed for both complications and demographic data. The authors compared morbidity, including donor-site seroma, total volume of drain discharge, indwelling period of drainage, and length of hospital stay following both MSLD flap and CLD flap breast reconstruction. Results The demographic data of the 2 groups were not significantly different. Donor-site seroma occurred in 2 MSLD patients (13.3%) and in 6 CLD patients (40.0%). The total volume of the drain discharge and the indwelling period of drainage at donor site were significantly lower in the MSLD group. The length of hospital stay was significantly shorter (by approximately a day and a half) for the MSLD group. Conclusion The MSLD flap, with its low complication rate and associated minimal functional and aesthetic deficits at the donor site, may be a useful option for small breast reconstruction if earlier discharge from hospital is demanded. PMID:28932726

Comparison of morbidity-related seroma formation following conventional latissimus dorsi flap versus muscle-sparing latissimus dorsi flap breast reconstruction.

PubMed

Sowa, Yoshihiro; Numajiri, Toshiaki; Nakatsukasa, Katsuhiko; Sakaguchi, Koichi; Taguchi, Tetsuya

2017-09-01

The pedicled, descending-branch muscle-sparing latissimus dorsi (MSLD) flap has been widely used for breast reconstruction following total mastectomy. However, the superiority of the MSLD flap compared to the conventional latissimus dorsi (CLD) flap in preventing seroma formation has not been demonstrated. This study compares the morbidities related to seroma formation following pedicled MSLD flap and CLD flap breast reconstruction. A total of 15 women who underwent partial mastectomy and immediate partial breast reconstruction with MSLD flaps were compared with 15 women under identical conditions with CLD flap breast reconstruction. The medical records were reviewed for both complications and demographic data. The authors compared morbidity, including donor-site seroma, total volume of drain discharge, indwelling period of drainage, and length of hospital stay following both MSLD flap and CLD flap breast reconstruction. The demographic data of the 2 groups were not significantly different. Donor-site seroma occurred in 2 MSLD patients (13.3%) and in 6 CLD patients (40.0%). The total volume of the drain discharge and the indwelling period of drainage at donor site were significantly lower in the MSLD group. The length of hospital stay was significantly shorter (by approximately a day and a half) for the MSLD group. The MSLD flap, with its low complication rate and associated minimal functional and aesthetic deficits at the donor site, may be a useful option for small breast reconstruction if earlier discharge from hospital is demanded.

Triple flap technique for vulvar reconstruction.

PubMed

Mercut, R; Sinna, R; Vaucher, R; Giroux, P A; Assaf, N; Lari, A; Dast, S

2018-04-09

Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Porcine experimental model for perforator flap raising in reconstructive microsurgery.

PubMed

González-García, José A; Chiesa-Estomba, Carlos M; Álvarez, Leire; Altuna, Xabier; García-Iza, Leire; Thomas, Izaskun; Sistiaga, Jon A; Larruscain, Ekhiñe

2018-07-01

Perforator free flap-based reconstruction of the head and neck is a challenging surgical procedure and needs a steep learning curve. A reproducible mammal large animal model with similarities to human anatomy is relevant for perforator flap raising and microanastomosis. The aim of this study was to assess the feasibility of a swine model for perforator-based free flaps in reconstructive microsurgery. Eleven procedures were performed under general anesthesia in a porcine model, elevating a skin flap vascularized by perforating musculocutaneous branches of the superior epigastric artery to evaluate the relevance of this model for head and neck reconstructive microsurgery. The anterior abdominal skin perforator-based free flap in a swine model irrigated by the superior epigastric artery was elevated in eleven procedures. In six of these procedures, we could perform an arterial and venous microanastomosis to the great vessels located in the base of the neck. The porcine experimental model of superior epigastric artery perforator-based free flap reconstruction offers relevant similarities to the human deep inferior epigastric artery perforator flap. We could demonstrate this model as acceptable for perforator free flap training due to the necessity of perforator and pedicle dissection and transfer to a distant area. Copyright © 2018 Elsevier Inc. All rights reserved.

Nasoseptal flap for palatal reconstruction after hemi-maxillectomy: case report.

PubMed

Alwashahi, M K; Battaglia, P; Turri-Zanoni, M; Castelnuovo, P

2018-01-01

Palatal reconstruction following maxillectomy is a surgical challenge, and a nasoseptal flap is a feasible approach. This paper reports the first known successful clinical case of a nasoseptal pedicle flap applied for the reconstruction of maxillary bone following hemi-maxillectomy. This report describes hemi-maxillectomy in a 60-year-old Italian male diagnosed with stage IV squamous cell carcinoma of the left maxilla. Endoscopic transnasal extended medial maxillectomy was performed, followed by a transoral modified midfacial degloving technique for removal of the maxillary bone. The contralateral nasoseptal pedicle flap was used to reconstruct the defect. The case was followed up prospectively for the assessment of flap reception and healing. The locally accessible nasoseptal flap is a viable alternative for palatal reconstruction; therefore, a second surgical procedure with its associated donor site morbidity can be avoided. Large-scale studies may help in establishing the cosmetic and functional outcomes.

The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction.

PubMed

Moro, Alessandro; Saponaro, Gianmarco; Doneddu, Piero; Cervelli, Daniele; Pelo, Sandro; Gasparini, Giulio; Garagiola, Umberto; D'Amato, Giuseppe; Todaro, Mattia

2018-05-15

In 1992, Pribaz described the facial artery musculomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects.The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle.

Prefabricated fibula free flap with dental implants for mandibular reconstruction.

PubMed

Pauchet, D; Pigot, J-L; Chabolle, F; Bach, C-A

2018-03-02

Free fibula transplant is routinely used for mandibular reconstruction in head and neck cancer. Dental rehabilitation, the objective of mandibular reconstruction, requires the use of dental implants as supports for fixed or removable dentures. Positioning of fibular bone grafts and implants determines implant osseointegration and the possibilities of dental rehabilitation. Prefabrication of a fibula free flap with dental implants prior to harvesting as a free flap can promote implant osseointegration. The position of the implants must then be precisely planned. Virtual surgery and computer-assisted design and prefabrication techniques are used to plan the reconstruction and then reproduce this planning by means of tailored fibula and mandible cutting guides, thereby ensuring correct positioning of fibular bone fragments and implants. The prefabricated fibula free flap technique requires two surgical procedures (prefabrication and flap transfer) and precise preoperative planning. Prefabricated fibula free flap with dental implants, by improving the quality of osseointegration of the implants before flap transfer, extends the possibilities of prosthetic rehabilitation in complex secondary mandibular reconstructions. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores.

PubMed

Chen, Yen-Chou; Huang, Eng-Yen; Lin, Pao-Yuan

2014-03-01

The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Mammographically detected recurrent nonpalpable carcinoma developing in a transverse rectus abdominus myocutaneous flap. A case report.

PubMed

Mund, D F; Wolfson, P; Gorczyca, D P; Fu, Y S; Love, S M; Bassett, L W

1994-11-15

Breast reconstruction is performed with increasing frequency and has become important in the treatment of mastectomy patients. The development of recurrent carcinoma after a mastectomy and transverse rectus abdominus myocutaneous (TRAM) flap procedure is described. The lesion was nonpalpable and was detected by mammography. This case raises questions about the practice of not performing postreconstruction mammography for detection of local recurrence after mastectomy.

The Impact of Perioperative Hormonal Therapy for Breast Cancer on Transverse Rectus Abdominis Myocutaneous Flap Abdominal Complications.

PubMed

Huber, Katherine M; Clayman, Eric; Kumar, Ambuj; Smith, Paul

2018-06-01

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is a reliable reconstructive option in breast cancer patients; however, it carries known risk of donor site hernia formation. Some hormonal therapy drugs have been associated with hernia formation in animal models. Minimal data exist concerning impact of hormonal therapy for breast cancer on abdominal donor site complications after breast reconstruction. Patients who underwent TRAM flap for breast cancer or high-risk status at a single institution by the senior author from 2003 to 2015 were identified. Charts were reviewed. Patient demographics, comorbidities, treatments, and abdominal complications were recorded. Patients were divided into groups based on use of hormonal therapy as well as exposure to specific drugs. Statistical analyses were performed. A total of 358 patients were included. Overall hernia rate was 5.9%. About 231 (64.5%) patients had hormonal therapy, whereas 127 (35.5%) did not. Difference in hernia formation was not statistically significant between the hormonal therapy group (6.9%) and the no hormonal therapy group (3.9%; P = 0.359). Patients exposed to tamoxifen and those exposed to anastrozole had no significant difference in complication rates compared with the no hormonal therapy group, whereas patients exposed to letrozole had increased rate of hernia (13.5%; P = 0.037) and infection (21.6%; P = 0.013) compared with the no hormonal therapy group (3.9% and 7.1%, respectively). Hormonal therapy is a useful adjunct for chemoprevention in breast cancer; however, use of letrozole in patients undergoing reconstruction with pedicled TRAM can lead to increase in certain complication rates.

A Novel Nipple Reconstruction Technique for Maintaining Nipple Projection: The Boomerang Flap

PubMed Central

Kim, Young-Eun; Hong, Ki Yong; Minn, Kyung Won

2016-01-01

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C–V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection. PMID:27689057

A Novel Nipple Reconstruction Technique for Maintaining Nipple Projection: The Boomerang Flap.

PubMed

Kim, Young-Eun; Hong, Ki Yong; Minn, Kyung Won; Jin, Ung Sik

2016-09-01

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C-V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection.

The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions.

PubMed

Can, Anil; Orgill, Dennis P; Dietmar Ulrich, J O; Mureau, Marc A M

2014-12-01

Because the vascular anatomy of the trapezius flap is highly variable, choosing the most appropriate flap type and design is essential to optimize outcomes and minimize postoperative complications. The aim of this study was to develop a surgical treatment algorithm for trapezius flap transfers. The medical files of all consecutive patients with a myocutaneous trapezius flap reconstruction of the head, neck, and upper back area treated at three different university medical centers between July 2001 and November 2012 were reviewed. There were 43 consecutive flaps performed in 38 patients with a mean follow-up time of 15 months (range, 1-48 months). Eleven patients had a mentosternal burn scar contracture (12 flaps), 12 patients (13 flaps) presented with cancer, and 15 patients (18 flaps) were suffering from chronic wounds due to failed previous reconstruction (n = 6), osteoradionecrosis (n = 1), chronic infection (n = 3), bronchopleural fistula (n = 3), and pressure sores (n = 2). The mean defect size was 152 cm(2). Sixteen flaps were based on the superficial cervical artery (SCA; type 2), 16 were based on the dorsal scapular artery (DSA; type 3), one was based on the intercostal arteries (type 4), and 10 flaps were based on both the DSA and SCA. Recipient-site complications requiring reoperation occurred in 16.3%, including one total flap failure (2.6%). The trapezius myocutaneous flap is a valuable option to reconstruct various head and neck and upper back defects. Based on our data, a surgical treatment algorithm was developed in an attempt to reduce variation in care and improve clinical outcomes. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Retroauricular skin: a flaps bank for ear reconstruction.

PubMed

Cordova, A; D'Arpa, S; Pirrello, R; Giambona, C; Moschella, F

2008-01-01

The retroauricular skin has always been given much attention by the reconstructive surgeon for ear and face reconstruction because it is richly vascularised, as many anatomical investigations show, it is hidden behind the ear, its skin is very similar to that of ear and face. All these reasons make it an ideal donor site for ear reconstruction. The authors propose their own algorithm for reconstruction of every kind of anterior defects of the auricle with different Retroauricular Island Flaps (RIFs) based on the location and size of the defect developed over a 16 years single institution's experience with a series of 216 consecutive cases. 216 patients have undergone ear reconstruction with RIFs from 1999 to 2006. In 52 a Superior Pedicle RIF (SP-RIF) was used for defects of the upper half of the auricle. In 68 cases a Perforator RIF (P-RIF) was used for conchal reconstruction. In 96 cases an Inferior Pedicle RIF (IP-RIF) was used for reconstruction of nonmarginal and superficial marginal defects of the auricle. No flap failure was recorded. Excellent morphological reconstruction was obtained with these flaps with no sequealae at the donor site in terms of form and function. Only in the case of P-RIFs the sulcus becomes flat in its central part, but this has never affected the possibility of wearing spectacles. The SP-RIFs may sometimes show some signs of venous stasis that invariably resolve in the first two postoperative days. The retroauricular skin may be considered a flaps bank for ear reconstruction. It offers in fact a great variety of island flaps that are suitable for every kind of loss of substance of the ear, have a safe vascularisation, skin of similar colour and texture, are easy to harvest under local anaesthesia on an outpatient basis and cause no relevant morbidity at the donor site. Location and size of the defects lead the choice between the different types of RIFs.

The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

PubMed Central

Brennan, Tara; Tham, Tristan M.; Costantino, Peter

2017-01-01

Introduction  The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalis myofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction. Objective  We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap. Methods  Retrospective chart review and review of the literature. Results  Fifteen patients underwent palate reconstruction with the TM flap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived. Conclusion  The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure. PMID:28680495

Reconstruction of lower face defect or deformity with submental artery perforator flaps.

PubMed

Shi, Cheng-li; Wang, Xian-cheng

2012-07-01

Reconstruction of lower face defects or deformity often presents as a challenge for plastic surgeons. Many methods, including skin graft, tissue expander, or free flap are introduced. Submental artery perforator flaps have been used in the reconstruction of defects or deformities of the lower face. Between August 2006 and December 2008, 22 patients with lower face defects or deformity underwent reconstruction with pedicled submental artery perforator flaps. Their age ranged between 14 and 36 years. The perforator arteries were detected and labeled with a hand-held Doppler flowmeter. The size of flaps ranged from 4 × 6 to 6 × 7 cm, and the designed flaps included the perforator artery. All the flaps survived well, except 1 flap which resulted in partial necrosis in distal region and healed after conservative therapy. No other complication occurred with satisfactory aesthetic appearance of the donor site. The submental artery perforator flap is a thin and reliable flap with robust blood supply. This flap can reduce donor-site morbidity significantly and is a good choice for reconstructive surgery of lower face.

Reconstruction of Complex Facial Defects Using Cervical Expanded Flap Prefabricated by Temporoparietal Fascia Flap.

PubMed

Zhang, Ling; Yang, Qinghua; Jiang, Haiyue; Liu, Ge; Huang, Wanlu; Dong, Weiwei

2015-09-01

Reconstruction of complex facial defects using cervical expanded flap prefabricated by temporoparietal fascia flap. Complex facial defects are required to restore not only function but also aesthetic appearance, so it is vital challenge for plastic surgeons. Skin grafts and traditional flap transfer cannot meet the reconstructive requirements of color and texture with recipient. The purpose of this sturdy is to create an expanded prefabricated temporoparietal fascia flap to repair complex facial defects. Two patients suffered severe burns on the face underwent complex facial resurfacing with prefabricated cervical flap. The vasculature of prefabricated flap, including the superficial temporal vessel and surrounding fascia, was used as the vascular carrier. The temporoparietal fascia flap was sutured underneath the cervical subcutaneous tissue, and expansion was begun in postoperative 1 week. After 4 to 6 months of expansion, the expander was removed, facial scars were excised, and cervical prefabricated flap was elevated and transferred to repair the complex facial defects. Two complex facial defects were repaired successfully by prefabricated temporoparietal fascia flap, and prefabricated flaps survived completely. On account of donor site's skin was thinner and expanded too fast, 1 expanded skin flap was rupture during expansion, but necrosis was not occurred after the 2nd operation. Venous congestion was observed in 1 patient, but after dressing, flap necrosis was not happened. Donor site was closed primarily. Postoperative follow-up 6 months, the color, texture of prefabricated flap was well-matched with facial skin. This method of expanded prefabricated flap may provide a reliable solution to the complex facial resurfacing.

An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction.

PubMed

Newman, Martin I; Samson, Michel C; Tamburrino, Joseph F; Swartz, Kimberly A; Brunworth, Louis

2011-01-01

Pedicle transverse rectus abdominus myocutaneous (pTRAM) flaps remain the most common method of autologous tissue breast reconstruction. Using pTRAM flaps, complications often arise postoperatively, secondary to inadequate circulation. Tissues from distant angiosomes are associated with poorer perfusion, but this differs among patients. Many modalities have been used to reduce the risk of complications, but none have achieved widespread application. The authors believe that laser-assisted indocyanine green fluorescent dye angiography (LA-ICGA) can potentially reduce the risk of complications. In two routine, single-pedicle, ipsilateral pTRAM flaps, LA-ICGA imaging was performed following the division of the distal rectus muscle and deep inferior epigastric pedicle. The resulting images were used to guide design of the flap and debridement. In case 1, good perfusion was observed in zone 1 and part of zone 2. In case 2, good perfusion was observed in zone 1 and 50% of zone 3, with little perfusion in zone 2. In both cases, tissues with poor perfusion were debrided before transfer and inset. In both patients, there were no issues with wound healing, tissue necrosis or fat necrosis. The variability of perfusion of the pTRAM flap among individuals is well appreciated. LA-ICGA helped to determine the limits of good perfusion and, therefore, the limits of tissue to be preserved for transfer and inset. This helped to avoid harvesting poorly perfused tissue that would have almost certainly experienced necrosis and, ultimately, would have reduced the risk of postoperative complications.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

PubMed

Park, Sung Woo; Oh, Tae Suk; Eom, Jin Sup; Sun, Yoon Chi; Suh, Hyun Suk; Hong, Joon Pio

2015-05-01

The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Intercostal artery perforator propeller flap for reconstruction of trunk defects following sarcoma resection.

PubMed

Zang, Mengqing; Yu, Shengji; Xu, Libin; Zhao, Zhenguo; Zhu, Shan; Ding, Qiang; Liu, Yuanbo

2015-06-01

Trunk defects following soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities and some trunk regions lack reliable recipient vessels. The intercostal arteries give off multiple perforators, which distribute widely over the trunk and can supply various pedicle flaps. Our purpose is to use various intercostal artery perforator propeller flaps for trunk oncologic reconstruction. Between November 2013 and July 2014, nine intercostal artery perforator propeller flaps were performed in seven patients to reconstruct the defects following sarcoma resection in different regions of the trunk, including the back, lumbar, chest, and abdomen. Two perforators from intercostal arteries were identified for each flap using Doppler ultrasound probe adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel. An elliptical flap was raised and rotated in a propeller fashion to repair the defects. There were one dorsal intercostal artery perforator flap, four dorsolateral intercostal artery perforator flaps, three lateral intercostal artery perforator flaps, and one anterior intercostal artery perforator flap. The mean skin paddle dimension was 9.38 cm in width (range 6-14 cm) and 21.22 cm in length (range 13-28 cm). All intercostal artery perforator flaps survived completely, except for marginal necrosis in one flap harvested close to the previous flap donor site. The intercostal artery perforator propeller flap provides various and valuable options in our reconstructive armamentarium for trunk oncologic reconstruction. To our knowledge, this is the first case series of using intercostal artery perforator propeller flaps for trunk oncologic reconstruction and clinical application of dorsolateral intercostal artery perforator flaps. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis.

PubMed

Allensworth, Jordan J; Troob, Scott H; Weaver, Tyler S; Gonzalez, Javier D; Petrisor, Daniel; Wax, Mark K

2017-04-01

Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis. Retrospective case series. Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed. Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive. Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates. 4. Laryngoscope, 127:815-819, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Breast oedema following free flap breast reconstruction.

PubMed

Greenhowe, Jennifer; Stephen, Christopher; McClymont, Liusaidh; Munnoch, D Alex

2017-08-01

Breast oedema causes significant morbidity and is historically difficult to quantify. The aim of this study was to identify changes in breast tissue water content from pre-operative levels in the native breast to post-operative levels in mastectomy skin flaps and free flaps in the reconstructed breast. One hundred patients undergoing unilateral mastectomy and immediate free flap breast reconstruction were examined pre-operatively and at three post-operative appointments. A validated moisture meter was used to record dermal water percentages of each breast quadrant and areola in both breasts pre-operatively, then four quadrants of both breasts plus the unaffected areola and free flap at each post-operative review. Native skin of the reconstructed breast showed significant, persistent increase in MWC from 45.6% ± 0.5% to 72.8% ± 0.9% at 1st follow up (p < 0.001), decreasing only to 67.6% ± 0.8% by 3rd follow up. There was a marked difference (p < 0.001) in the mean water content (MWC) of the initial free flap (39.7% ± 0.6%) compared to 61.8% ± 1.7% at 1st follow up, then 55.1% ± 1.4% at 2nd and 53.7% ± 1.3% at 3rd follow ups. The unaffected breast showed a small but significant increase in MWC of all quadrants at subsequent follow up (greatest difference 3.1% at 1st follow up). This patient group demonstrates significant, persistent oedema of the reconstructed breast, which can be monitored using a non-invasive moisture meter. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

[Modified pectoralis major myocutaneous flap in reconstruction of head and neck defects].

PubMed

Chen, Jie; Huang, Wenxiao; Li, Zan; Zhou, Xiao; Yu, Jianjun; Bao, Ronghua; Zhang, Hailin; Ling, Hang

2015-05-01

To report the experience of use of modified pectoralis major myocutaneous (PMMC) flaps in reconstruction of head and neck postoperative defects. A total of 107 patients who underwent head and neck defect reconstruction using modified PMMC flaps after tumor rescetion between Jan 2008 and Dec 2013 were analyzed retrospectively. The success rate of reconstruction with modified PMMC flaps was 94.4% (101/107). Five patients had partial flap necrosis and their wounds healed with dressing change. One patient (0.9%) had total flap necrosis, followed by the second reconstruction using contralateral PMMC flap. The modified falcate PMMC flap can obtain optimum quantity of the skin in the chest and decreasing the closing tension of the donnor site in favor of wound healing. The pedicle without muscle will not only maintain the partial function of the pectoralis major, but also help to avoid pressing the vascular pedicle within the subclavian tunnel. The muscular element the pedicled muscles of the PMMC flap can increase the ability of the flap to resist infection, which can use for covering an exposed carotid artery and improving the neck fibrosis of irradiated patients.

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

PubMed Central

Thankappan, Krishnakumar; Trivedi, Nirav P.; Sharma, Mohit; Kuriakose, Moni A.; Iyer, Subramania

2009-01-01

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome. PMID:19881028

Perforator-based propeller flaps for leg reconstruction in pediatric patients.

PubMed

Özalp, Burhan; Aydınol, Mustafa

2016-10-01

Perforator-based propeller flaps provide adequate soft tissue coverage for leg reconstruction. The aim of this study was to assess the versatility and reliability of the use of propeller flaps for leg reconstruction in pediatric patients. Seven male pediatric patients ranging in age from 2 to 13 years with a mean age of 6.7 underwent perforator-based propeller flap surgery over a four-year period. The defects resulted from burn injuries (n = 4) and traffic accidents (n = 3). The injuries were located on the ankles of four patients and on the knee, anterior lower tibia, and foot dorsum of the other three patients, respectively. The flap sizes ranged from 5 × 3 to 10 × 6 cm with a mean flap size of 7.6 × 4.3 cm. Flap harvesting time ranged from 38 to 56 m with a mean of 46 m. The rotation degree range of the flaps was from 90° to 180°. The propeller flaps were based on the posterior tibial artery (n = 4), anterior tibial artery (n = 2), and the descending branch of the lateral circumflex femoral artery (n = 1). All flaps survived completely without surgical complication; however, one patient developed disseminated intravascular coagulation syndrome two days post-surgery and died within four days. Perforator-based propeller flap reconstruction is a safe, reliable, and versatile method for lower extremities in pediatric patients; however, it requires meticulous surgical dissection and extreme patience during the surgical procedure. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Three-step orbitofacial reconstruction after extended total maxillectomy using free RAM flap and expanded cervicofacial flap with cartilage grafts.

PubMed

Kajikawa, Akiyoshi; Ueda, Kazuki; Katsuragi, Yoko; Hirose, Taro; Asai, Emiko

2010-10-01

Facial defect after an extended total maxillectomy is one of the most difficult deformities to reconstruct aesthetically, because the defect is not only large but also three-dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colour match and poor texture match are major problems. The contracture and displacement of the reconstructed eyelids and eye socket are also serious matters. To resolve these problems, we have performed a three-step reconstruction using a free rectus abdominis myocutaneous (RAM) flap and an expanded cervicofacial flap with cartilage grafts. In the first step, a free RAM flap was transplanted to the defect after extended total maxillectomy. In the second step, tissue expanders were placed under the skin of the cheek and neck a year after the RAM flap transplantation. After expansion of the cheek and neck skin, the third step was performed. The inferior part of the external skin island of the RAM flap was raised and sutured to the superior margin of the skin island to create a pouch for the eye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominence, and auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cervicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neo-eyelids were divided to form the lid fissure. We performed the three-step reconstruction on six cases after extended total maxillectomy. In all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids and cheek were natural in appearance with good colour and texture match without conspicuous scars. To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there are five points that should be formed; the eye socket, the groundwork of the eye socket, the orbital floor and malar prominence, the tarsal plates and the surface of the eyelids and cheek. We do not reconstruct the palate to set prosthetic

Fibular free flap reconstruction for the management of advanced bilateral mandibular osteoradionecrosis.

PubMed

Shan, Xiao-Feng; Li, Ru-Huang; Lu, Xu-Guang; Cai, Zhi-Gang; Zhang, Jie; Zhang, Jian-Guo

2015-03-01

Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis(ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction.Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN.

An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction

PubMed Central

Newman, Martin I; Samson, Michel C; Tamburrino, Joseph F; Swartz, Kimberly A; Brunworth, Louis

2011-01-01

BACKGROUND: Pedicle transverse rectus abdominus myocutaneous (pTRAM) flaps remain the most common method of autologous tissue breast reconstruction. Using pTRAM flaps, complications often arise postoperatively, secondary to inadequate circulation. Tissues from distant angiosomes are associated with poorer perfusion, but this differs among patients. Many modalities have been used to reduce the risk of complications, but none have achieved widespread application. The authors believe that laser-assisted indocyanine green fluorescent dye angiography (LA-ICGA) can potentially reduce the risk of complications. METHODS: In two routine, single-pedicle, ipsilateral pTRAM flaps, LA-ICGA imaging was performed following the division of the distal rectus muscle and deep inferior epigastric pedicle. The resulting images were used to guide design of the flap and debridement. RESULTS: In case 1, good perfusion was observed in zone 1 and part of zone 2. In case 2, good perfusion was observed in zone 1 and 50% of zone 3, with little perfusion in zone 2. In both cases, tissues with poor perfusion were debrided before transfer and inset. In both patients, there were no issues with wound healing, tissue necrosis or fat necrosis. CONCLUSIONS: The variability of perfusion of the pTRAM flap among individuals is well appreciated. LA-ICGA helped to determine the limits of good perfusion and, therefore, the limits of tissue to be preserved for transfer and inset. This helped to avoid harvesting poorly perfused tissue that would have almost certainly experienced necrosis and, ultimately, would have reduced the risk of postoperative complications. PMID:22379372

Facial artery musculomucosal flap for reconstruction of skull base defects: a cadaveric study.

PubMed

Xie, Liyue; Lavigne, François; Rahal, Akram; Moubayed, Sami Pierre; Ayad, Tareck

2013-08-01

Failure in skull base defects reconstruction following tumor resection can have serious consequences such as ascending meningitis and pneumocephaly. The nasoseptal flap showed a very low incidence of cerebrospinal fluid leak but is not always available. The superiorly pedicled facial artery musculomucosal (FAMM) flap has been successfully used for reconstruction of head and neck defects. Our objective is to show that the FAMM flap can be used as a new alternative in skull base reconstruction. Cadaveric study. Feasibility. Thirteen specimens underwent bilateral FAMM flap dissection. Two new modifications of the traditional FAMM flap have been developed. Feasibility in FAMM flap transfer to the skull base was investigated through endoscopic skull base dissection and maxillectomy in four specimens. Measurements were recorded for each harvested flap. The mean surface area of the modified FAMM flap efficient for reconstruction was 15.90 cm(2) . The flaps easily covered the simulated defects of the frontal sinus and the fovea ethmoidalis areas. Modifications of the traditional FAMM flap were necessary for a tension-free coverage of the planum sphenoidale and sella turcica. The FAMM flap holds high potential as a new alternative vascular flap in skull base reconstruction. However, it has not been used in patients yet and should be considered only when other options are not available. New modifications developed in this article can elongate the traditional FAMM flap, potentially contributing to a tighter seal of the skull base defect than FAMM flap alone. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

[Clinical experience with the supraclavicular flap to reconstruct head and neck defects].

PubMed

Zhang, Bin; Yan, Dangui; Zhang, Yabing; Zhang, Xiwei; Wan, Hanfeng

2015-06-01

To evaluate the efficacy of pedicled supraclavicular artery island flaps for head and neck reconstruction. Reconstructive surgeries for head and neck oncologic defects were performed with the pedicled supraclavicular artery island flaps in 10 patients from May 2013 to December 2014 and the cases were review. Among them, 6 were performed for hypopharyngeal cancer, 2 for oral tongue cancer, 1 for oral base cancer and 1 for cervical esophageal cancer. The size of the flaps was measured in (5-8) cm × (6-12) cm. Seven flaps survived, one flap failured and two flaps had partial necrosis. Donor sites were closed primarily without morbidity. The pedicled supraclavicular artery island flap is an easy harvesting and reliable for head and neck reconstruction, especially suitable for otolaryngo-head and neck surgeon and maxillofacial surgeon in the local hospital.

Reconstruction of Nasal Cleft Deformities Using Expanded Forehead Flaps: A Case Series.

PubMed

Ramanathan, Manikandhan; Sneha, Pendem; Parameswaran, Ananthnarayanan; Jayakumar, Naveen; Sailer, Hermann F

2014-12-01

Reconstruction of the nasal clefts is a challenging task considering the nasal anatomic complexity and their possible association with craniofacial defects. The reconstruction of these defects needs extensive amounts of soft tissue that warrant the use of forehead flaps. Often presence of cranial defects and low hairline compromise the amount of tissue available for reconstruction warrenting tissue expansion. To evaluate the efficacy of tissue expansion in reconstruction of congenital nasal clefts. 9 patients with congenital nasal clefts involving multiple sub units were taken up for nasal reconstruction with expanded forehead flaps. The average amount of expansion needed was 200 ml. The reconstruction was performed in 3 stages. Expanded forehead flaps proved to be best modality for reconstruction providing the skin cover needed for ala, columella and dorsum with minimal scarring at the donor site. Expansion of the forehead flap is a viable option for multiple sub unit reconstruction in congenital nasal cleft deformities.

"Reading man flap" design for reconstruction of circular infraorbital and malar skin defects.

PubMed

Seyhan, Tamer; Caglar, Baris

2008-11-01

Surgical complications such as lid retraction and ectropion from graft or flap scar contracture make reconstruction of skin defects in the malar and infraorbital regions challenging. A new flap design, the reading man flap, was used to overcome these problems. The Limberg and bilobed flap were compared with the reading man flap. The reading man flap consists mainly of a superiorly based quadrangular flap and an inferiorly based triangular flap. Malar and infraorbital circular skin defects measuring 14 x 14 to 40 x 40 mm were reconstructed with a reading man flap in 13 patients. The defects occurred after basal cell carcinoma in all patients. The Limberg flap, bilobed flap, and reading man flap were planned for same-sized defects on the abdominoplasty resection material. The results were compared in terms of total scar area, scar length, and total healthy skin area discarded. When comparing the 3 flap designs, the reading man flap was the most suitable flap in terms of total scar area and length. The reading man flap can be used to reconstruct malar and infraorbital circular defects with good cosmetic results and without creating any tractional forces to the eyelids.

Propeller Flap for Complex Distal Leg Reconstruction: A Versatile Alternative when Reverse Sural Artery Flap is Not Feasible.

PubMed

Ademola, Samuel A; Michael, Afieharo I; Oladeji, Femi J; Mbaya, Kefas M; Oyewole, O

2015-01-01

Reverse sural artery fasciocutaneous flap has become a workhorse for the reconstruction of distal leg soft tissue defects. When its use is not feasible, perforator-based propeller flap offers a better, easier, faster, and cheaper alternative to free flap. We present our experience with two men both aged 34 years who sustained Gustilo 3B injuries from gunshot. The donor area for reversed sural artery flap was involved in the injuries. They had early debridement, external fixation, and wound coverage with perforator-based propeller flaps. The donor sites were covered with skin graft. All flaps survived. There were minor wound edge ulcers due to the pressure of positioning that did not affect flap survival and the ulcers healed with conservative management. Perforator-based propeller flap is a versatile armamentarium for reconstruction of soft tissue defects of the distal leg in resource-constrained settings, especially when the donor area for a reverse flow sural flap artery is involved in the injury.

The Differential Use of Bilobed and Trilobed Transposition Flaps in Cutaneous Nasal Reconstructive Surgery.

PubMed

Knackstedt, Thomas; Lee, Kachiu; Jellinek, Nathaniel J

2018-05-22

Bilobed and trilobed transposition flaps are versatile random pattern transposition flaps which reliably restore nasal symmetry, topography, light reflex, contour and are frequently used in cutaneous nasal reconstructive surgery. We wish to compare the characteristics of bilobed and trilobed flaps in cutaneous reconstructive surgery and to identify scenarios for their differential use. A retrospective chart review over 7 years of consecutive patients reconstructed with a bilobed or trilobed flap after Mohs micrographic surgery was performed. Statistical analysis of patient and surgery characteristics, anatomic distribution, postprocedural events and need for revisions after both flap types was conducted. One hundred eleven patients with bilobed flaps and 74 patients with trilobed flaps were identified. Bilobed flaps are significantly more frequently used on the inferior nasal dorsum and on the sidewall whereas trilobed flaps are significantly more frequently used on the nasal tip and infratip. No significant difference in postprocedural events (complications, erythema, trapdoor, etc) was noted between the two flap types. Bilobed and trilobed transposition flaps are versatile repairs for nasal reconstruction. Trilobed flaps may be used to repair defects in a more distal nasal location than bilobed flaps. Regardless of flap type, complications are rare.

Reconstruction of the Foot and Ankle Using Pedicled or Free Flaps: Perioperative Flap Survival Analysis

PubMed Central

Li, Xiucun; Cui, Jianli; Maharjan, Suraj; Lu, Laijin; Gong, Xu

2016-01-01

Objective The purpose of this study is to determine the correlation between non-technical risk factors and the perioperative flap survival rate and to evaluate the choice of skin flap for the reconstruction of foot and ankle. Methods This was a clinical retrospective study. Nine variables were identified. The Kaplan-Meier method coupled with a log-rank test and a Cox regression model was used to predict the risk factors that influence the perioperative flap survival rate. The relationship between postoperative wound infection and risk factors was also analyzed using a logistic regression model. Results The overall flap survival rate was 85.42%. The necrosis rates of free flaps and pedicled flaps were 5.26% and 20.69%, respectively. According to the Cox regression model, flap type (hazard ratio [HR] = 2.592; 95% confidence interval [CI] (1.606, 4.184); P < 0.001) and postoperative wound infection (HR = 0.266; 95% CI (0.134, 0.529); P < 0.001) were found to be statistically significant risk factors associated with flap necrosis. Based on the logistic regression model, preoperative wound bed inflammation (odds ratio [OR] = 11.371,95% CI (3.117, 41.478), P < 0.001) was a statistically significant risk factor for postoperative wound infection. Conclusion Flap type and postoperative wound infection were both independent risk factors influencing the flap survival rate in the foot and ankle. However, postoperative wound infection was a risk factor for the pedicled flap but not for the free flap. Microvascular anastomosis is a major cause of free flap necrosis. To reconstruct complex or wide soft tissue defects of the foot or ankle, free flaps are safer and more reliable than pedicled flaps and should thus be the primary choice. PMID:27930679

Perforator chimerism for the reconstruction of complex defects: A new chimeric free flap classification system.

PubMed

Kim, Jeong Tae; Kim, Youn Hwan; Ghanem, Ali M

2015-11-01

Complex defects present structural and functional challenges to reconstructive surgeons. When compared to multiple free flaps or staged reconstruction, the use of chimeric flaps to reconstruct such defects have many advantages such as reduced number of operative procedures and donor site morbidity as well as preservation of recipient vessels. With increased popularity of perforator flaps, chimeric flaps' harvest and design has benefited from 'perforator concept' towards more versatile and better reconstruction solutions. This article discusses perforator based chimeric flaps and presents a practice based classification system that incorporates the perforator flap concept into "Perforator Chimerism". The authors analyzed a variety of chimeric patterns used in 31 consecutive cases to present illustrative case series and their new classification system. Accordingly, chimeric flaps are classified into four types. Type I: Classical Chimerism, Type II: Anastomotic Chimerism, Type III: Perforator Chimerism and Type IV Mixed Chimerism. Types I on specific source vessel anatomy whilst Type II requires microvascular anastomosis to create the chimeric reconstructive solution. Type III chimeric flaps utilizes the perforator concept to raise two components of tissues without microvascular anastomosis between them. Type IV chimeric flaps are mixed type flaps comprising any combination of Types I to III. Incorporation of the perforator concept in planning and designing chimeric flaps has allowed safe, effective and aesthetically superior reconstruction of complex defects. The new classification system aids reconstructive surgeons and trainees to understand chimeric flaps design, facilitating effective incorporation of this important reconstructive technique into the armamentarium of the reconstruction toolbox. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Scalp Free Flap Reconstruction Using Anterolateral Thigh Flap Pedicle for Interposition Artery and Vein Grafts

PubMed Central

Park, Jun Hyung; Eun, Suk Chan; Lee, Jong Hoon; Hong, Sung Hee; Kim, Chin Whan

2012-01-01

We experienced satisfactory outcomes by synchronously transplanting an artery and vein using an anterolateral thigh flap pedicle between the vascular pedicle and recipient vessel of a flap for scalp reconstruction. A 45-year-old man developed a subdural hemorrhage due to a fall injury. In this patient, the right temporal cranium was missing and the patient had 4×3 cm and 6×5 cm scalp defects. We planned a scalp reconstruction using a latissimus dorsi free flap. Intraoperatively, there was a severe injury to the right superficial temporal vessel because of previous neurosurgical operations. A 15 cm long pedicle defect was needed to reach the recipient facial vessels. For the vascular graft, the descending branch of the lateral circumflex femoral artery and two venae comitantes were harvested. The flap survived well and the skin graft was successful with no notable complications. When an interposition graft is needed in the reconstruction of the head and neck region for which mobility is mandatory to a greater extent, a sufficient length of graft from an anterolateral flap pedicle could easily be harvested. Thus, this could contribute to not only resolving the disadvantages of a venous graft but also to successfully performing a vascular anastomosis. PMID:22783493

Use of Pedicled Trapezius Myocutaneous Flap for Posterior Skull Reconstruction.

PubMed

Singh, Mansher; Rios Diaz, Arturo J; Cauley, Ryan; Smith, Timothy R; Caterson, E J

2015-09-01

Soft-tissue defects in posterior skull can be challenging for reconstruction. If related to tumor resection, these wound beds are generally irradiated and can be difficult from a recipient-vessel perspective for a free tissue transfer. Locoregional flaps might prove to be important reconstructive option in such patients. There is a very limited data on the usage of pedicled trapezius myocutaneous flaps for such defects. The authors reviewed existing study for usage of trapezius flap for posterior skull repair and used pedicled trapezius myocutaneous flaps based on the descending branch of superficial cervical artery (SCA) for reconstruction of posterior skull soft-tissue defect in an irradiated and infected wound. Two patients were operated for trapezius myocutaneous flap for posterior skull defects complicated by cerebrospinal fluid (CSF) leakage and epidural abscess. There was no recipient or donor-site complication at a mean follow-up of 12.5 months. Neither of the 2 patients had any functional deficits for the entire duration of the follow-up. Although this flap was able to help in controlling the CSF leakage in the first patient, it successfully healed the cavity generated from epidural abscess drainage in the second patient. The large angle of rotation coupled with the ability to complete the procedure without repositioning the patients makes trapezius myocutaneous flap an attractive option for posterior skull reconstruction. In our limited experience, the pedicled trapezius flaps are a reliable alternative as they are well vascularized and able to obliterate the soft-tissue defect completely. The recipient site healed completely in infected as well as irradiated wound beds. In addition, the donor site can be primarily closed with minimal donor-associated complication.

Fascial flap reconstruction of the hand: a single surgeon's 30-year experience.

PubMed

Carty, Matthew J; Taghinia, Amir; Upton, Joseph

2010-03-01

The reconstruction of complex hand wounds is challenging due to the requirements for thin and pliable coverage with a reliable vascular supply, potential for sensibility, and provision of a gliding surface. Fascial flaps represent an excellent option for the reconstruction of these complicated defects. A retrospective review of fascial flap reconstructive procedures to the hand undertaken by a single microsurgeon was performed for operations occurring between 1979 and 2009. Both pedicled and free tissue transfer procedures were included in both pediatric and adult patients. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs. Sixty fascial flap reconstructive procedures to the hand were analyzed in 60 patients from the defined 30-year period. The most common pathological process necessitating reconstruction was acute trauma (n = 32, 53 percent). Most of the soft-tissue injuries included in the study sample were located on the dorsal hand and wrist (n = 27, 45 percent). The most commonly utilized reconstructive modality was the temporoparietal fascial flap (n = 35, 58 percent). Most reconstructions were completed as free tissue transfers (n = 46, 77 percent). Perioperative complications were relatively minor; no flap losses were recorded. All cases studied demonstrated excellent long-term coverage with no evidence of underlying tendon adhesion or contracture. Fascial flaps represent an excellent option for coverage of soft-tissue defects of the hand that are not amenable to reconstruction with skin grafting alone, particularly for localized defects with denuded tendons or exposed joints.

Dorsal Intercostal Artery Perforator Propeller Flaps: A Reliable Option in Reconstruction of Large Meningomyelocele Defects.

PubMed

Basterzi, Yavuz; Tenekeci, Goktekin

2016-04-01

Several options have been reported for the reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects by using island propeller dorsal intercostal artery perforator (DIAP) flaps. Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were reconstructed with island propeller DIAP flaps. All flaps survived completely. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. Flap donor sites were closed primarily. Myelomeningocele defects with a diameter larger than 5 cm require reconstruction with flaps. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Use of perforator flaps provides 2 important advantages, namely, more predictability and also more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects.

Reverse-flow retroauricular island flap in facial reconstruction.

PubMed

Benlier, Erol; Top, Husamettin; Cinar, Can; Yazar, Sukru; Aygit, A Cemal; Cetinkale, Oguz

2007-12-01

Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap. Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years. Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period. This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.

[Free flap reconstruction in the head and neck. Indications, technical aspects and outcomes].

PubMed

Llorente, José Luis; López, Fernando; Suárez, Vanessa; Fueyo, Angel; Carnero, Susana; Martín, Clara; López, Victoria; Camporro, Daniel; Suárez, Carlos

2014-01-01

The use of microvascular free flaps (MFF) has become a common method of head and neck reconstruction because of its high success rates and better functional results. We report our experience in reconstructing complex defects with MFF. We analysed a series of 246 patients that underwent reconstruction using MFF in our Department from 1991 to 2013. There were 259 interventions performed in 246 patients. The most common reason for surgery was tumour recurrence (46%), followed by primary tumour resection (25%). The hypopharynx (52%) and the craniofacial region (22%) were the most frequently reconstructed sites. The free flaps most commonly used were the radial forearm free flap (41%) and the anterolateral thigh free flap (35%). Overall success and complication rates of 92% and 20% respectively were reported. The microvascular free flap is a reliable and useful tool for reconstructing complex head and neck defects and continues to be the reconstructive modality of choice for these defects. Copyright © 2013 Elsevier España, S.L. All rights reserved.

Reconstruction of Anterolateral Thigh Defects Using Perforator-Based Propeller Flaps.

PubMed

Iida, Takuya; Yoshimatsu, Hidehiko; Koshima, Isao

2017-10-01

Usually, anterolateral thigh (ALT) defects with width more than 8 cm cannot be closed directly. Although several methods of using local flaps exist, flap mobility of these methods is limited. We introduced a perforator-based propeller flap for such reconstruction. Their maximal mobility, which minimizes their size, is their greatest advantage. In addition, we present our technical refinements including double-axes propeller flap, the use of indocyanine green real-time angiography, and supercharged propeller flap for safer flap transfer. Seven patients underwent perforator-based propeller flap reconstruction of ALT defects. Flaps were designed cranial or caudal to the defect according to the perforator locations. To maximize mobility, flaps were designed so that the perforator was located at the periphery and closer to the defect. After rotating the flap to the defect, indocyanine green angiography was performed to determine the need for supercharge. In all cases, all flaps survived completely. Defect size ranged from 12 × 11 cm to 18 × 16 cm, and flap size ranged from 7 × 5 cm to 15 × 7 cm. The number of perforators in the flap was 1 in 3 cases and 2 in 4 cases. Supercharging was performed in 3 cases. Donor-site complications, including gait disturbance, were not observed. This method achieves ALT defect closure with minimal donor-site morbidity and can provide prompt and aesthetically acceptable results. Indocyanine green real-time angiography and supercharging technique are also useful for safer and reliable flap transfer.

Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy.

PubMed

Creagh, Terrence A; Dixon, Liane; Frizelle, Frank A

2012-06-01

Pelvic extenuative surgery produces good long term outcomes in advanced pelvic malignancies. We evaluate the use and clinical outcomes of the Vertical Rectus Abdominus Myocutaenous (VRAM) flap as a reconstruction technique in a heterogenic cohort of patients with advanced colorectal cancer in whom neo-adjuvant chemo-radiotherapy had been performed pre-operatively. Analysis of patients having VRAM flaps for pelvic reconstruction in a tertiary referral centre from 2001 to 2010 was conducted. 37 patients (23 female, 14 male) underwent pelvic extenuative surgery of which 22 (60%) had recurrent pelvic disease. All surgical and medical complications were analysed. Major flap complications were defined as 'requiring return to the operating theatre at any stage' and these occurred in 6 (16%) patients. There were 7 (19%) minor flap complications defined as 'requiring conservative non surgical treatment' The total global re-intervention rate of patients requiring return to theatre for re-operation as a result of their exenteration and reconstruction was 6 (16%). We highlight the merits and versatility of the VRAM flap in advanced pelvic malignancy in obtaining stable and supple reconstructive cover and the relative low morbidity in this difficult group confirms out strong support for immediate VRAM reconstruction in pelvic exenterative procedures. Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.

Supraclavicular artery perforator flap in management of post-burn neck reconstruction: clinical experience

PubMed Central

Ismail, H.; Elshobaky, A.

2016-01-01

Summary Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques, including chimeric flaps, supercharged flap, pre-expanded flaps, “superthin” flaps and perforator flaps. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Between January 2013 and March 2015, 20 patients suffering from postburn neck contracture underwent reconstruction with 20 unilateral supraclavicular artery perforator flaps. Nineteen patients had post-burn neck contractures (9 cases type Іc, 10 cases type Пc) while only one had post-burn granulation tissue in the neck. We harvested fifteen flaps from the right side and five from the left. Size of the reconstructed defect ranged from 23x10 to14x6, and flap size varied from 25/11 to 16/7cm. Period of follow up ranged from 27-2months (average 12.3). Nineteen flaps survived well (95% survival rate): only one was lost due to iatrogenic extensive dissection over the pedicle. Five cases showed distal superficial epidermolysis, and 2 cases showed 2 cm complete distal necrosis. All patients were managed conservatively. Our results coincide with other literature results confirming the efficacy and rich vascularity of this flap. In all cases with distal partial necrosis, flaps were 23 cm or more. We recommend that supraclavicular flaps of more than 22 cm in length are not harvested immediately and that flaps are expanded before harvesting. Expanding the supraclavicular flap increases its surface area and decreases donor site morbidity. PMID:28149252

Use of the pericranial flap in medial canthal reconstruction: another application for this versatile flap.

PubMed

Leatherbarrow, Brian; Watson, Adam; Wilcsek, Geoffrey

2006-01-01

To describe the use and outcomes of a versatile surgical technique in the reconstruction of deep soft tissue and bony defects of the medial canthus. A retrospective review of consecutive cases requiring reconstruction of medial canthal defects involving loss of periosteum or bone by a median forehead pericranial flap and full-thickness skin grafting in a tertiary referral hospital setting. Two techniques were used: an open technique, using a midline forehead incision; and an endoscopic technique, using 2 incisions behind the hairline. Twenty-one cases were identified: 19 open and 2 endoscopic. The average length of follow-up was 13 months (range, 6-50 months). Ten cases required additional oculoplastic procedures including local periosteal flaps and mucous membrane grafts. Two cases (10%) had complete flap failure; one of these was caused by infection. Five (24%) had partial (< 50%) skin graft necrosis. Two cases (10%) have required further surgery. Our experience shows the pericranial flap to be versatile, robust, and easy to manipulate, offering advantages over alternative techniques when used for the repair of deep medial canthal defects. It is a valuable reconstructive technique that can yield good cosmetic and functional results.

Paramuscular perforators in DIEAP flap for breast reconstruction.

PubMed

Pons, Gemma; Masia, Jaume; Sanchez-Porro, Lídia; Larrañaga, Jose; Clavero, Juan Angel

2014-12-01

One of the main steps in perforator flap surgery is to identify the dominant perforator. Using multidetector row computed tomography (MDCT) for the preoperative planning of deep inferior epigastric artery perforator (DIEAP) flap surgery, we identified a perforator with a large caliber, an excellent location in the middle abdominal region, and a totally extramuscular trajectory in a significant number of patients. We describe the frequency of this perforator and determine its characteristics. We conducted a retrospective study of 482 patients who underwent 526 DIEAP flaps for breast reconstruction from October 2003 to October 2011. Mean age at surgery was 51.3 years old. A preoperative MDCT of abdominal vascularization was performed in all patients. MDCT identified a dominant perforator with a paramuscular course in 12.4% of abdominal walls. In all cases, it was located in the midline and emerged directly from the deep inferior epigastric system. Its mean caliber was 1.9 mm. The flap was harvested based on this perforator in all these patients, and mean harvest time was 51 minutes. The characteristics of this perforator made dissection easier and reduced morbidity at the donor site. There were no flap losses and the only complications were minor. We located a paramuscular perforator in 12.4% of patients undergoing breast reconstruction with abdominal perforator flaps. Its morphological features and extramuscular course make it the perforator of choice in DIEAP flap surgery.

Gastrocnaemius-propeller extended miocutanous flap: a new chimaeric flap for soft tissue reconstruction of the knee.

PubMed

Innocenti, M; Cardin-Langlois, E; Menichini, G; Baldrighi, C

2014-02-01

Soft tissue defects involving the anterior aspect of the knee are a frequent finding in a number of pathological conditions. The aim of this article is to describe a new pedicled flap consisting of a conventional medial gastrocnaemius muscle flap associated with a propeller flap based on a perforator of the medial sural artery. Five males ranging in age between 26 and 72 years underwent a reconstruction of the soft tissue of the knee by means of the described procedure. Three patients sustained complex tissue loss subsequent to high-energy trauma; two losses were due to septic complications after elective knee surgery. Four flaps survived allowing adequate proximal tibial metaphysis and patella coverage. One patient underwent early above-the-knee amputation due to life-threatening septicaemia. The described chimaera flap consists of a medial gastrocnaemius flap with a skin paddle that is elevated on a perforator of the medial sural artery and then rotated according to the propeller flaps' principles. It provides effective coverage of large soft tissue defects of the knee. In the authors' experience, the propeller flap portion proved to be particularly useful to cover the patella, while the muscle flap was used to cover the proximal metaphysis of the tibia and fill the dead space if present. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of a traumatic plantar foot defect with a novel free flap: The medial triceps brachii free flap.

PubMed

Leclère, Franck Marie; Casoli, Vincent

2015-01-01

Lower extremity defects may account for 14.6% of the approximately 117 million visits to emergency departments in the U. S. in 2007. In this article, we present a reconstruction of a traumatic plantar foot defect with a medial triceps brachii (MTB) free flap. A 53-year-old man sustained an accidental gunshot wound to the right foot. The patient was admitted after the failure of a sural flap procedure performed in another hospital. He presented with a soft-tissue defect with calcaneal exposition and osteomyelitis. The defect was reconstructed with a MTB free flap anastomosed to his dorsalis pedis vessels. Flap raising time was 52 min. There were no intraoperative complications. The total flap surface was 38.5 cm². The pedicle length was 3 cm. The diameters of the artery and vein of the flap pedicle were 1.1 mm and 1.4 mm, respectively. Ischemia time was 28 min. His donor site healed uneventfully without any morbidity, and the scar was well concealed. The flaps survived and there was no partial flap necrosis. A split-thickness skin graft was performed 12 days postoperatively. Two months later, he had a completely healed wound with no contour abnormality. The total follow-up was 24 months. The patient was able to walk normally. MTB free flap appears to be an excellent option for plantar foot defects in patients with preserved vascularization of the foot. Due to the anatomical shape of the flap, the position of its pedicle, and the moldability of the muscle, we predict that the use of the MTB free flap will grow and develop rapidly for reconstruction of ankle and foot defects.

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

PubMed

Panse, Nikhil; Sahasrabudhe, Parag

2014-01-01

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent. We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series. 63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap. Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects. Therapeutic IV.

A simplified surgical algorithm for flap reconstruction of eyebrow defects.

PubMed

Liu, Hai-Peng; Shao, Ying; Yu, Xiao-Jie; Zhang, Duo

2017-04-01

Partial or total eyebrow defects after trauma or tumor excisions have been repaired by several surgical technique and algorithms. However, these algorithms are often complicated and difficult to apply clinically. We therefore established a simplified surgical algorithm for the treatment of eyebrow defects using flap reconstruction. During the period between January 2009 and December 2015, a total of 21 Chinese patients (12 males, 9 females) with eyebrow defects were treated with eyebrow flap reconstruction. The ages ranged from 12 to 51 years. The patients included 13 cases located on the left and 8 cases on the right eyebrow. These defects were caused by trauma (5 patients) and tumor excision (16 patients). Among them, 6 patients were treated using superficial temporal artery island flap, while 15 patients were treated using the V-Y advancement pedicle flap based on the orbicularis oculi muscle. The minimum defect area was 0.8 × 1.0 cm and maximum area was 2.3 × 4.3 cm. All patients were followed up for 6 months to 5 years postoperatively. The clinical effects of eyebrow reconstruction were evaluated using a designated scoring system. All 21 flaps survived without significant complications and the shapes of the reconstructed eyebrows were continuous, symmetrical and with good integrity. According to the rating scale, there were 13 excellent, 8 good reconstructions among all patients. After an average of 9 months of follow-up, all patients had no recurrence of tumors and no infection or scarring. Based upon our experience with 21 patients who underwent eyebrow reconstruction for various eyebrow defects, we believe that our simplified surgical algorithm can serve as a model for the treatment of patients with eyebrow defects. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Vulva reconstruction after pelvic exenteration, using a unique combination of two flaps

PubMed Central

van Bommel, Annelotte C M; Schreuder, Henk W R; Schellekens, Pascal P A

2011-01-01

A 64-year-old woman with recurrence of carcinoma of the vulva in an irradiated area received an en-bloc total pelvic exenteration. Reconstruction of the pelvic defect was performed with an anterolateral thigh (ALT) flap and a rectus abdominis muscle (RAM) flap (PM/RAM). This combination of flaps is unique, with excellent results. In a large defect, often irradiated in advance, well-vascularised tissue should be placed. Multiple flaps can be used to reconstruct these large pelvic defects, each with their own advantages and disadvantages. The combination of flaps used in this case uses the good properties of both flaps: the reliable and well-vascularised PM/RAM in combination with the ALT flap to provide much bulk in extreme large defects. PMID:22692483

Reconstruction of infected abdominal wall defects using latissimus dorsi free flap.

PubMed

Kim, Sang Wha; Han, Sang Chul; Hwang, Kyu Tae; Ahn, Byung Kyu; Kim, Jeong Tae; Kim, Youn Hwan

2013-12-01

Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus (MRSA). Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm(2) . The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient. There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results. Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.

Reconstruction of oral cavity defects with FAMM (facial artery musculomucosal) flaps. Our experience.

PubMed

Sumarroca, Anna; Rodríguez-Bauzà, Elena; Vega, Carmen; Fernández, Manuel; Masià, Jaume; Quer, Miquel; León, Xavier

2015-01-01

The facial artery musculomucosal (FAMM) flap is a good option for covering small and medium-sized defects in the oral cavity because of its similar tissue characteristics and easy implementation. We reviewed our results using this flap between 2006 and 2014. A total of 20 patients were included and 25 FAMM flaps were performed, 16 right (64%) and 9 left (36%) flaps. Five patients had simultaneous bilateral reconstructions. The indications for flap surgery were reconstruction after resection of tumours in the floor of the mouth (8 cases, 40%), tumours in other sites of the oral cavity (4 cases, 20%), mandibular osteoradionecrosis (4 cases, 20%), oroantral fistula (3 cases, 15%) and postoperative ankyloglossia (one case, 5%). Reconstruction was successful in 92% of cases (n=23). Total flap necrosis occurred in one case and dehiscence with exposure of bone in another. Oral function and ingestion were satisfactory in all patients. The facial artery musculomucosal flap is reliable and versatile for reconstruction of small and medium-sized intraoral defects. It allows functional reconstruction of the oral cavity with a low risk of complications. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Otorrinolaringología y Patología Cérvico-Facial. All rights reserved.

Flap Reconstruction for Pressure Ulcers: An Outcomes Analysis

PubMed Central

Madden, James J.; Hoffman, Ashley N.; Kim, Justine S.; Thayer, Wesley P.; Nanney, Lillian B.; Spear, Marcia E.

2017-01-01

Background: Historically, complication rates after pressure ulcer reconstruction utilizing flap coverage have been high. Patients undergoing operations for pressure ulcer coverage typically have multiple risk factors for postoperative complications. The purpose of this study was to examine a large patient series in the pressure ulcer population to uncover objective evidence of the linkage between risk factors and outcomes after flap coverage. Methods: This study was a retrospective chart review of patients who underwent flap reconstruction for a pressure ulcer between 1997 and 2015. The characteristics of patients were analyzed to determine those who had complications such as pressure ulcer recurrence, wound dehiscence, and wound infection. Results: All patients (N = 276) underwent flap coverage of their pressure ulcers. The overall complication rate was 58.7% (162 patients). Wound dehiscence was the most common complication (31.2%), and the pressure ulcer recurrence rate was 28.6%. Multivariate regression for pressure ulcer recurrence revealed that body mass index <18.5 [relative risk (RR) 3.13], active smoking (RR 2.33), and ischial pressure ulcers (RR 3.46) were independent risk factors for pressure ulcer recurrence. Ischial pressure ulcers (RR 2.27) and preoperative osteomyelitis (RR 2.78) were independent risk factors for wound dehiscence. Diabetes was an independent risk factor for wound infection (RR 4.34). Conclusions: Our retrospective analysis revealed numerous factors that are associated with high rates of major postoperative complications. Risk factors must be taken into account when offering flap coverage, and risk-reducing strategies must be implemented in patients before pressure ulcer reconstruction. PMID:28203494

Immediate reconstruction of palato-maxillary defect following tumor ablation using temporalis myofascial flap

PubMed Central

Yadav, Sunil; Dhupar, Anita; Dhupar, Vikas; Akkara, Francis; Mittal, Hitesh C.

2014-01-01

The resection of oral cavity tumor and malignancies often causes functional disabilities like deglutition and articulation. Maxillectomy is a very common surgical procedure carried out for the management of benign and malignant tumors of maxilla. Irrespective of the procedure, there is a common end result that is the defect. Several soft tissue flaps can be used for reconstruction of maxillectomy defect. Keeping the parameters of reconstruction in mind it is ideal to reconstruct the maxillary defect with either the free flaps or the regional flaps. Of all regional flaps, the temporalis myofascial flap (TMF) provides a high degree of reliability, vascularity, adequate bulk, and proximity to the defect in the oral and maxillofacial region. PMID:25937744

Venous coupler use for free-flap breast reconstructions: specific analyses of TMG and DIEP flaps.

PubMed

Bodin, Frédéric; Brunetti, Stefania; Dissaux, Caroline; Erik, A Sauleau; Facca, Sybille; Bruant-Rodier, Catherine; Liverneaux, Philippe

2015-05-01

The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap. Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series. The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P = 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P = 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P < 0.001). The mean size was also smaller when double venous anastomoses were required compared to single anastomosis (2.4 mm versus 2.9 mm) (P < 0.001). The double branching was more frequent with the TMG flap (28%) than with the DIEP flap (11%). The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number. © 2014 Wiley Periodicals, Inc.

Levator alae nasi muscle V-Y island flap for nasal tip reconstruction.

PubMed

La Padula, Simone; Abbate, Vincenzo; Di Monta, Gianluca; Schonauer, Fabrizio

2017-03-01

Nasal tip reconstruction can be very challenging. It requires close attention to skin texture, colour and thickness matching, with the respect of the nasal aesthetic units and symmetry. Flaps are usually preferred to skin grafts where possible. Based on different donor areas, various flaps have been described for reconstruction of this region. Here we present a new V-Y myocutaneous island flap based on the levator alae nasi muscle (LAN muscle) blood supply. This flap may represent an alternative to the nasalis myocutaneous sliding V-Y flap previously described by Rybka. As its pivot point it is located more cranially than the nasalis flap, and it can advance more medially than the Rybka flap, with the possibility of covering larger defects of the nasal tip area, up to 1.8 cm in diameter. Over the past 5 years, 24 patients received nasal tip reconstruction with this flap following the resection of basal cell carcinomas. Good tip projection was maintained, and the aesthetic outcome was satisfactory, with well healed scars. We recommend this technique as an alternative to other flaps for nasal tip defects, especially if paramedian. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Retention of a reconstructed nipple using a C-V flap with different layer thicknesses in the C-flap.

PubMed

Sowa, Yoshihiro; Itsukage, Sizu; Sakaguchi, Kouichi; Taguchi, Tetsuya; Numajiri, Toshiaki

2018-04-01

The C-V flap for nipple reconstruction is now one of standard surgical techniques. But decreased projection is still a problem. In recent years, it has been suggested that projection can be more easily maintained when raising of the C-flap is performed with a split thickness dermis. In this study, we examined whether decrease of projection can be prevented by raising of a C-flap with a split dermis rather than with full dermis. A total of 49 consecutive patients who underwent reconstruction of a nipple using the C-V flap technique were enrolled. The patients included 22 who underwent surgery using a C-flap with a full thickness dermis (Group F), and 27 who underwent surgery with raising of a flap with a split thickness dermis (Group S). The size of the reconstructed nipple was measured at 2 weeks, 6 months and 1 year postoperatively for comparison between Groups F and S. Partial necrosis of the C-flap end occurred in 4 subjects in only Group S. The decrease in projection after 1 year postoperatively in Group S was significantly lower than that in Group F. In contrast, the teat base size in Group F tended to be greater than that in Group S, suggesting a tendency for an expanded base using a flap with a full dermis. Our results indicated that it is recommended to use a C-flap with a split dermis for cases with high projection of the nipple on the contralateral side.

Predictable dental rehabilitation in maxillomandibular reconstruction with free flaps. The role of implant guided surgery

PubMed Central

Cebrian-Carretero, José L.; Sobrino, José A.; Yu, Tomás; Burgueño-García, Miguel

2014-01-01

The reconstruction of maxillomandibular defects secondary to oral cancer surgery, represent a great challenge for Maxillofacial surgeons. During the last decades the reconstructive surgery has experimented a big advance due to the development of the microsurgical techniques. At present, we are able to reconstruct complex defects using free flaps that provide both soft and bone tissue. Fibula, iliac crest and scapula free flaps have been the three classic options for the maxillomandibular reconstruction owing to the amount of bone that this flaps provide, allowing the posterior dental rehabilitation with implants. Today, our objective it is not only the aesthetic reconstruction, but also the functional reconstruction of the patients enhancing their life quality. Guided implant surgery in free flap reconstructed patients has become an essential tool, helping to define the exact position of the dental implant in the flap. In this way it is possible to look for the areas with better bone conditions, avoiding the osteosynthesis material used to fixate the flap with the native bone and deciding the best biomechanical option, in terms of number and situation of the implants, for the future dental prostheses. In summary, using the guided implant surgery, it is possible to design an exact and predictable dental implant rehabilitation in patients with oral cancer who are reconstructed with free microvascular flap, resulting in an optimal aesthetic and functional result. Key words:Oral cancer, mandibulectomy, maxillectomy, microvascular reconstruction, fibula flap, dental implant, guided surgery. PMID:25129241

Extending the use of the gracilis muscle flap in perineal reconstruction surgery.

PubMed

Goldie, Stephen J; Almasharqah, Riyadh; Fogg, Quentin A; Anderson, William

2016-08-01

Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7 cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4 cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The unique and valuable soft tissue free flap in head and neck reconstruction: Lateral arm.

PubMed

Kang, Stephen Y; Eskander, Antoine; Patel, Krupal; Teknos, Theodoros N; Old, Matthew O

2018-07-01

While the lateral arm free flap has been well described, there is a relative paucity in its use compared to other free flaps and regional flaps. The lateral arm free flap is a unique soft tissue free flap that provides several reconstructive advantages in head and neck reconstruction: excellent contour and color match to facial skin, well compartmentalized fat, donor nerves for nerve grafting, and the ability to two-team harvest and close the donor site without a skin graft. A detailed anatomic and harvest technique is described, along with indications and advantages of using lateral free flap for head and neck reconstruction. A scoping literature review was also conducted to tabulate indications, overall success and complications of the flap. The lateral arm flap is a primary option for defects requiring soft tissue reconstruction in the head and neck. Copyright © 2018 Elsevier Ltd. All rights reserved.

Biologic collagen cylinder with skate flap technique for nipple reconstruction.

PubMed

Tierney, Brian P; Hodde, Jason P; Changkuon, Daniela I

2014-01-01

A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3-5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging.

Temporalis myofascial flap for primary cranial base reconstruction after tumor resection.

PubMed

Eldaly, Ahmed; Magdy, Emad A; Nour, Yasser A; Gaafar, Alaa H

2008-07-01

To evaluate the use of the temporalis myofascial flap in primary cranial base reconstruction following surgical tumor ablation and to explain technical issues, potential complications, and donor site consequences along with their management. Retrospective case series. Tertiary referral center. Forty-one consecutive patients receiving primary temporalis myofascial flap reconstructions following cranial base tumor resections in a 4-year period. Flap survival, postoperative complications, and donor site morbidity. Patients included 37 males and 4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative radiation therapy. Patient follow-up ranged from 4 to 39 months. The whole temporalis muscle was used in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%). Nine patients had primary donor site reconstruction using a Medpor((R)) (Porex Surgical, Inc., Newnan, GA) temporal fossa implant; these had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was seen in six patients (14.6%); only two required surgical débridement. None of the patients developed cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent trismus. The temporalis myofascial flap was found to be an excellent reconstructive alternative for a wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is usually available in the operative field with relatively low donor site aesthetic and functional morbidity.

Reconstruction of trochanteric pressure sores with pedicled anterolateral thigh myocutaneous flaps.

PubMed

Wang, Chih-Hsin; Chen, Shih-Yi; Fu, Ju-Peng; Dai, Niann-Tzyy; Chen, Shao-Liang; Chen, Tim-Mo; Chen, Shyi-Gen

2011-05-01

To provide an alternative choice for covering trochanteric pressure sores, we report on a modified pedicle anterolateral thigh (ALT) myocutaneous flap based on the descending branch of the lateral circumflex femoral artery. From August 2007 to January 2010, 20 consecutive patients (10 men and 10 women) underwent 21 pedicled ALT myocutaneous flaps for reconstruction of trochanteric pressure sores. The flap was designed and elevated, resembling the ALT perforator flap including part of the vastus lateralis muscle but without skeletonisation of the perforators. The mean age of patients was 79.4 years (range: 46-103). The mean follow-up period was 13.9 months (range: 3-32). The flaps were 8-21 cm long and 5-11 cm wide. All flaps healed without major complications. All donor sites were closed primarily without skin grafting and showed good aesthetic results. No recurrence was observed. This modified design of pedicled ALT myocutaneous flap without skeletonisation of perforators is a reliable and easily harvested flap for reconstruction of trochanteric pressure sores with limited morbidity. Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.

[Reconstruction of facial soft tissue defects with pedicled expanded flaps].

PubMed

Yangqun, Li; Yong, Tang; Wen, Chen; Zhe, Yang; Muxin, Zhao; Lisi, Xu; Chunmei, Hu; Yuanyuan, Liu; Ning, Ma; Jun, Feng; Weixin, Wang

2014-09-01

To investigate the application of pedicled expanded flaps for the reconstruction of facial soft tissue defects. The expanded skin flaps, pedicled with orbicularis oculi muscle, submental artery, the branch of facial artery, superficial temporal artery, interior upper arm artery, had similar texture and color as facial soft tissue. The pedicled expanded flaps have repaired the facial soft tissue defects. Between Jan. 2003 to Dec. 2013, 157 cases with facial soft tissue defects were reconstructed by pedicled expanded flaps. Epidermal necrosis happened at the distal end of 8 expanded flaps, pedicled with interior upper arm artery(4 cases), orbicularis oculi muscle(3 cases) and submental artery(1 case), which healed spontaneously after dressing. All the other flaps survived completely with similar color and inconspicuous scar. 112 cases were followed up for 8 months to 8 years. Satisfactory results were achieved in 75 cases. 37 cases with hypertrophic scar at incisions need secondary operation. Island pedicled expanded flap with similar texture and color as facial soft tissue is suitable for facial soft tissue defects. The facial extra-incision and large dog-ear deformity could be avoided.

Brown class III maxillectomy defects reconstruction with prefabricated titanium mesh and soft tissue free flap.

PubMed

Dediol, Emil; Uglešić, Vedran; Zubčić, Vedran; Knežević, Predrag

2013-07-01

Midface reconstruction is one of the most challenging tasks for the reconstructive surgeon. We present a technique for the reconstruction of the midface after total maxillectomy with preservation of orbital contents. Skeletal reconstruction is achieved with a preoperatively bent titanium sheet mesh on a universal skeletal model. The alveolar ridge, the anterior wall of the maxillary sinus, the zygomatic prominence, the lower orbital rim, and the orbital floor are reconstructed with a titanium mesh. A soft tissue free flap, preferably anterolateral thigh free flap, is harvested as well. A part of the flap is deepithelized and put in front of the mesh to prevent exposure, and the other part is used for palatal reconstruction. Four male and 1 female patients were reconstructed with titanium mesh. Four free flaps were raised: 3 anterolateral thigh and 1 latissimus dorsi. All free flaps survived. All patients received postoperative irradiation with 64 Gy. Median follow-up was 12 months; no major complications occurred. Mesh was exposed in only 1 case, which was managed successfully with resuspension of the heavy latissimus dorsi myocutaneous flap. Midface projection and height, globe position, ocular movements, and vision where satisfactory in all cases. Midface reconstruction with titanium mesh and soft tissue free flap is a reliable and safe method for functional and aesthetic reconstruction after maxillectomy.

Flap reconstruction does not increase complication rates following surgical resection of extremity soft tissue sarcoma.

PubMed

Slump, Jelena; Hofer, Stefan O P; Ferguson, Peter C; Wunder, Jay S; Griffin, Anthony M; Hoekstra, Harald J; Bastiaannet, Esther; O'Neill, Anne C

2018-02-01

Flap reconstruction plays an essential role in the surgical management of extremity soft tissue sarcoma (ESTS) for many patients. But flaps increase the duration and complexity of the surgery and their contribution to overall morbidity is unclear. This study directly compares the complication rates in patients with ESTS undergoing either flap reconstruction or primary wound closure and explores contributing factors. Eight hundred and ninety-seven patients who underwent ESTS resection followed by primary closure (631) or flap reconstruction (266) were included in this study. Data on patient, tumour and treatment variables and post-operative medical and surgical complications were collected. Univariate and multivariate regression analyses were performed to identify independent predictors of complications. Post-operative complications occurred in 33% of patients. Flap patients were significantly older, had more advanced disease and were more likely to require neoadjuvant chemo- and radiotherapy. There was no significant difference in complication rates following flap reconstruction compared to primary closure on multivariate analysis (38 vs 30.9% OR 1.12, CI 0.77-1.64, p = 0.53). Pre-operative radiation and distal lower extremity tumour location were significant risk factors in patients who underwent primary wound closure but not in those who had flap reconstruction. Patients with comorbidities, increased BMI and systemic disease were at increased risk of complications following flap reconstruction. Flap reconstruction is not associated with increased post-operative complications following ESTS resection. Flaps may mitigate the effects of some risk factors in selected patients. Copyright © 2017. Published by Elsevier Ltd.

The superior gluteal artery perforator flap for reconstruction of sacral sores

PubMed Central

Chen, Weijian; Jiang, Bo; Zhao, Jiaju; Wang, Peiji

2016-01-01

This report describes our experiences using the superior gluteal artery perforator (SGAP) flaps for reconstruction of 2 sacral sore cases. A 47-year-old female patient and a 38-year-old man with sacral sores were treated in our unit. The size of the defects were approximately 5×6 cm2 and 8×9 cm2, the defects were repaired by SGAP flaps. The size of designed was SGAP flaps varied from 7×20 to 9×16 cm2. All flaps survived and healed primary, the texture, functions, and appearance of flaps were satisfactory, and also without region dysfunction of donor and recipient sites. The SGAP flap, which has reliable blood supply, preserves the gluteus maximus muscle and could be transferred simply and safely, is an ideal and reusable method to reconstruct sacral sores with low rate of postoperative recurrence and satisfactory appearance. PMID:27652367

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty.

PubMed

Lee, S I; Lee, H S; Hwang, K

2001-11-01

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.

Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects.

PubMed

Zhou, Renpeng; Wang, Chen; Qian, Yunliang; Wang, Danru

2015-09-01

Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The 'RITE' use of the Fricke flap in periorbital reconstruction.

PubMed

Wilcsek, G; Leatherbarrow, B; Halliwell, M; Francis, I

2005-08-01

To revisit an important but outmoded periorbital reconstructive technique. We present cases to illustrate the usefulness of the Fricke flap and describe a method of rapid intraoperative tissue expansion (RITE), which can enhance the applicability and effectiveness of the Fricke flap. A comparison between those cases performed with and without adjunctive RITE was not made due to the low numbers available. A retrospective review of clinical cases. A total of 20 cases in which the Fricke flap was used for periorbital reconstruction were reviewed. The mean patient age was 64.7 years; the male-to-female ratio was 1:1. The patient follow-up ranged from 1 to 8 years with a mean of 4.2 years. The most common cause (65%) of periorbital defect was excision of eyelid malignancy. Necrosis of the terminal segment of the flap requiring further surgical intervention occurred in 10% (2/20). In both of these cases, the surgeons were trainees, with the complications being due to poor surgical technique. In the first case, the flap base was too narrow and in the second case, the distal end of the flap was thinned excessively. The functional result was excellent in 10/20 (50%), good in 5/20 (25%), fair in 3/20 (15%), and poor in 2/20 (10%). The cosmetic result was excellent in 3/20 (15%), good in 12/20 (60%), fair in 3/20 (15%), and poor in 2/20 (10%). The Fricke flap is an important and, in selected cases, an indispensable technique in periorbital reconstruction.

Supraclavicular Artery Flap for Head and Neck Oncologic Reconstruction: An Emerging Alternative

PubMed Central

Shenoy, Ashok; Patil, Vijayraj S.; Prithvi, B. S.; Chavan, P.; Halkud, Rajshekar

2013-01-01

Aim. Head and Neck oncologic resections often leave complex defects which are challenging to reconstruct. The need of the hour is a versatile flap which has the advantages of both a regional flap (viz. reliable and easy to harvest) and a free flap (thin, pliable with good colour match). In this a study we assessed the usefulness of the supraclavicular artery flap in head and neck oncologic defects. Materials and Method. The flap was used as a pedicled fasciocutanous and was based on the transverse supraclavicular artery. We assessed this reconstructive option for complications as well as its and functional out comes. Results. Eleven cases underwent supraclavicular artery flap between 20011-2012 of which 5 were males and 6 females. Mean defect size was 5 cm × 6 cm. Nine donor sites were closed primarily and 1 required split skin grafting. We encountered one complete flap loss which was attributed to a band of constricting skin bridge over the vascular pedicle in a defect involving lateral third of midface. Two patient developed pharyngeocutaneous fistula (without flap loss) out of 3 patients who underwent augmentation pharyngoplasty post Near total laryngectomy. Conclusion. Supra clavicular artery flap is a thin versatile, reliable, easy to harvest, with good cosmetic and functional outcome at both ends (recipient and donor) for reconstructing head and neck oncologic defects. PMID:24490064

V-Y and rotation flap for reconstruction of the epicanthal fold.

PubMed

Shin, Yong Ho; Hwang, Pil Joong; Hwang, Kun

2012-07-01

Epicanthoplasty is commonly performed on Asian eyelids. Consequently, overcorrection may appear. The aim of this study was to introduce a method of reconstructing the epicanthal fold and to apply this method to the patients. A V flap with an extension (eagle beak shaped) was designed on the medial canthal area. The upper incision line started near the medial end of the double-fold line, and it followed its curvature inferomedially. For the lower incision, starting at the tip (medial end) of the flap, a curvilinear incision was designed first diagonally and then horizontally along the lower blepharoplasty line. The V flap was elevated as thin as possible. Then, the upper flap was deeply undermined to make it thick. The lower flap was made a little thinner than the upper flap. Then, the upper and lower flaps were approximated to form the anteromedial surface of the epicanthal fold in a fashion sufficient to cover the red caruncle. The V flap was rotated inferolaterally over the caruncle. The tip of the V flap was sutured to the medial one-third point of the lower margin. The inferior border of the V flap and the residual lower margin were approximated. Thereafter, the posterolateral surface of the epicanthal fold was made. From 1999 to 2011, 246 patients were operated on using this method. Among them, 62 patients were followed up. The mean intercanthal distance was increased from 31.7 to 33.8 mm postoperatively. Among the 246 patients operated on, reoperation was performed for 6 patients. Among the 6 patients reoperated on, 3 cases were due to epicanthus inversus, 1 case was due to insufficient reconstruction, 1 case was due to making an infold, and 1 case was due to reopening the epicanthal fold.This V-Y and rotation flap can be a useful method for reconstruction of the epicanthal fold.

Long-Term Follow-Up of Quality of Life following DIEP Flap Breast Reconstruction.

PubMed

Hunsinger, Vincent; Hivelin, Mikael; Derder, Mohamed; Klein, Delphine; Velten, Michel; Lantieri, Laurent

2016-05-01

Sequelae resulting from breast cancer negatively impact patients' quality of life. Although the deep inferior epigastric perforator (DIEP) flap has become a standard for autologous breast reconstruction, there are limited data regarding long-term quality of life. The authors studied patients' quality of life more than 5 years after DIEP flap breast reconstruction and compare it with two French reference samples. A cross-sectional study of quality of life was performed in women who underwent DIEP flap breast reconstruction between 1995 and 2007 using the Medical Outcomes Study 36-Item Health Survey (Short Form-36). The first reference sample included subjects from the French general population (n = 3308), and the second included cancer survivors who underwent mastectomy with (n = 70) or without (n = 135) breast reconstruction. One hundred eleven respondents were analyzed among 186 eligible women. The mean follow-up period after reconstruction was 8.6 years (range, 5 to 15 years). There were no statistically significant differences in the quality of life between women from 45 to 64 years old who underwent DIEP flap breast reconstruction and from the French general population. Five of the eight Short Form-36 dimensions were significantly better in the DIEP flap breast reconstruction group in the 65- to 74-year-old cohort. In addition, quality of life of our study population was significantly higher than that of women who underwent mastectomy with or without any type of breast reconstruction. These results indicate that DIEP flap breast reconstruction allows patients with breast cancer to maintain a good postoperative quality of life comparable to that of the general population. Therapeutic, III.

Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects.

PubMed

Boccola, Mark A; Rozen, Warren M; Ek, Edmund W; Teh, Bing M; Croxford, Matthew; Grinsell, Damien

2010-07-01

With the progressive use of more radical surgical resections and pre-operative chemo-radiotherapy for locally advanced anorectal cancers, there has become an increasing need for reconstructive options that import well-vascularised tissue of sufficient bulk to the perineum. We present our technique of inferior gluteal artery myocutaneous (IGAM) transposition flaps for reconstruction after extended abdomino-perineal excision (APE) for anorectal cancer. Six consecutive male patients with T2/T3 rectal carcinoma underwent neoadjuvant chemo-radiotherapy followed by extended APE and immediate reconstruction with an islanded IGAM transposition flap. The operative technique and surgical outcomes were assessed with follow-up ranging from 3 to 18 months (median 5 months). In all cases, there were clear histological margins with no flap failures or partial flap losses, and no post-operative hernias. There were no major wound complications, with only one superficial breakdown associated with high body mass index (BMI) and adhesive tape allergy, treated with dressings alone. There was no donor site morbidity evident following flap harvest. The IGAM island transposition flap provides excellent tissue bulk, a large reliable skin paddle and a long pedicle that permits flexible positioning with tension free closure. Our successful results and high patient satisfaction make it a favourable option that should be considered when faced with this reconstructive challenge. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Clinical Comparison of Scapular, Fibular, and Iliac Crest Osseal Free Flaps in Maxillofacial Reconstructions.

PubMed

Wilkman, T; Husso, A; Lassus, P

2018-05-01

This study compared the three most used composite flaps in maxillofacial reconstructions in our institute. Between 2000 and 2012, a total of 163 patients with mandibular, maxillary, and orbital defects received either scapular, fibular, or iliac crest osseal reconstructions in Helsinki University Hospital, Departments of Plastic Surgery and Maxillofacial Surgery. Data regarding the patient demographics, complications, and outcomes were analyzed. There were 92 deep circumflex iliac artery flaps (56%), followed by 42 scapular (26%) and 29 fibular flaps (18%). The rate of flap loss was the highest in the deep circumflex iliac artery group (p = 0.001). Reconstructions using fibula were fastest (p = 0.001) and had lowest perioperative blood loss (p = 0.013). There were no significant differences in the number of early or late complications between the flaps, but donor site complications were more severe in deep circumflex iliac artery. Osteotomies as well as dental implants were safely performed in all flaps with equal results. All three flaps of this study can be performed with awareness of the deep circumflex iliac artery flap being the least reliable alternative. The knowledge of the advantages and disadvantages of several osseal-free flap alternatives is beneficial in selecting the best suitable method for each individual patient requiring maxillofacial osseal reconstruction.

Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps.

PubMed

Deganello, A; Gitti, G; Parrinello, G; Muratori, E; Larotonda, G; Gallo, O

2013-12-01

Reconstructive surgery of the head and neck region has undergone tremendous advancement over the past three decades, and the success rate of free tissue transfers has risen to greater than 95%. It must always be considered that not all patients are ideal candidates for free flap reconstruction, and also that not every defect strictly requires a free flap transfer to achieve good functional results. At our institution, free flap reconstruction is first choice, although we use pedicled alternative flaps for most weak patients suffering from severe comorbidities, and for pretreated patients presenting a second primary or a recurrent cancer. From July 2006 to May 2010, 54 consecutive patients underwent soft tissue reconstruction of oral cavity and oropharyngeal defects. We divided the cohort in three groups: Group 1 (G1): 16 patients in good general conditions that received free radial forearm flap reconstruction; Group 2 (G2): 18 high-risk patients that received a reconstruction with infrahyoid flap; Group 3 (G3): 20 patients that received temporal flap (10 cases) or pectoral flap (10 cases) reconstruction. We must highlight that pedicled alternative flaps were used in elderly, unfavourable and weak patients, where usually the medical costs tend to rise rather than decrease. We compared the healthcare costs of the three groups, calculating real costs in each group from review of medical records and operating room registers, and calculating the corresponding DRG system reimbursement. For real costs, we found a statistically significant difference among groups: in G1 the average total cost per patient was € 22,924, in G2 it was € 18,037 and in G3 was € 19,872 (p = 0.043). The amount of the refund, based on the DRG system, was € 7,650 per patient, independently of the type of surgery. Our analysis shows that the use of alternative non-microvascular techniques, in high-risk patients, is functionally and oncologically sound, and can even produce a cost savings. In

Free anterolateral thigh flap for reconstruction of car tire injuries of children's feet.

PubMed

Demirtas, Yener; Neimetzade, Tale; Kelahmetoglu, Osman; Guneren, Ethem

2010-01-01

Grade IV and V car tire injuries occurring in children cause extensive soft tissue defects with exposure or loss of tendons and bone on the dorsum of the foot. Free tissue transfer is indicated for reconstruction of these defects because of the limited local tissue available. We describe our management of high-grade car tire foot injuries in children with free anterolateral thigh flap (ALT). Five pre-school children with car tire injuries (one grade IV and four grade V) were treated with free ALT flap in the last 4 years. The mean age was 4.8 years. In four patients, immediate flap coverage after initial debridement was performed and delayed reconstruction was used as a secondary procedure in one patient. One of the flaps was re-explored for hematoma evacuation and salvaged. All of the flaps survived completely and there were no donor site complications. None of the flaps required a debulking procedure and custom shoe wear has not been necessary in any of the patients. Minor gait abnormalities were detected in two of the patients. With minimal donor site morbidity, long vascular pedicle allowing anastomosis outside of the trauma zone, we believe free ALT flap provides the ideal soft tissue reconstruction for high grade car tire injuries of foot in children. ALT flap can be further thinned to adapt to the defect, contracts less than muscle flaps and contains a vascularized fascia which can be used for extensor tendon reconstruction.

Mandibular reconstruction in irradiated patients utilizing myosseous-cutaneous flaps

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pearlman, N.W.; Albin, R.E.; O'Donnell, R.S.

1983-10-01

Myosseous-cutaneous flaps were used for mandibular reconstruction in 16 irradiated patients. Three of six sternomastoid-clavicle flaps failed (all in conjunction with a neck dissection), as did one of 10 pectoralis major-anterior-fifth rib flaps. One trapezius-scapular flap was used and it succeeded. We found the blood supply of the sternomastoid-clavicle flap too tenuous for use in conjunction with a neck dissection. The trapezius-scapular flap had too short an arc of rotation to be used for defects other than those in the horizontal ramus. In addition, this flap required a change of position and created an undesirable functional deformity. The pectoralis major-fifthmore » rib flap, in contrast, could be used for a variety of defects, in conjunction with a neck dissection, and did not require a change of position during operation. We found it to be the most versatile and dependable of the flaps employed in this series.« less

Survival of a pedicled latissimus dorsi flap in breast reconstruction without a thoracodorsal pedicle.

PubMed

Hartmann, C E A; Branford, O A; Malhotra, A; Chana, J S

2013-07-01

The latissimus dorsi flap, first performed by Tansini in 1892, was popularised for use by Olivari in 1976. The successful transfer of a latissimus dorsi flap during breast reconstruction has previously been thought to be dependent on having an intact thoracodorsal pedicle to ensure flap survival. It is well documented that the flap may also survive on the serratus branch in thoracodorsal pedicle division. We report a case of a 52-year-old female patient who underwent successful delayed breast reconstruction with a latissimus dorsi flap following previous mastectomy and axillary node clearance. Intraoperatively, the thoracodorsal pedicle and serratus branch were found to have been previously divided. On postoperative computer tomographic angiography the thoracodorsal pedicle was shown to be divided together with the serratus branch. The flap was seen to be supplied by the lateral thoracic artery. To our knowledge survival of a pedicled latissimus dorsi flap in breast reconstruction with a vascular supply from this vessel following thoracodorsal pedicle division has not previously been described. Previous thoracodorsal pedicle and serratus branch division may not be an absolute contraindication for the use of the latissimus dorsi flap in breast reconstruction, depending on the results of preoperative Doppler or computer tomographic angiography studies. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Scalp Defect Reconstruction with Triple Rotation Flap: A Case Report.

PubMed

Shilpa, Kanathur; Divya, Gorur; Budamakuntla, Leelavathy; Lakshmi, Dammaningala Venkataramaiah

2018-01-01

Scalp surgeries are some of the surgeries frequently performed in dermatosurgery department. These surgical procedures may leave large defects, especially when performed for malignant condition in which wide margin has to be excised. Such large defects are difficult to close primarily when reconstruction with local flap is essential. Here we report a case of epithelioid angiosarcoma of the scalp in a 24-year-old man where excision and reconstruction were performed using triple rotation flap.

Biologic Collagen Cylinder with Skate Flap Technique for Nipple Reconstruction

PubMed Central

Tierney, Brian P.; Hodde, Jason P.; Changkuon, Daniela I.

2014-01-01

A surgical technique using local tissue skate flaps combined with cylinders made from a naturally derived biomaterial has been used effectively for nipple reconstruction. A retrospective review of patients who underwent nipple reconstruction using this technique was performed. Comorbidities and type of breast reconstruction were collected. Outcome evaluation included complications, surgical revisions, and nipple projection. There were 115 skate flap reconstructions performed in 83 patients between July 2009 and January 2013. Patients ranged from 32 to 73 years old. Average body mass index was 28.0. The most common comorbidities were hypertension (39.8%) and smoking (16.9%). After breast reconstruction, 68.7% of the patients underwent chemotherapy and 20.5% underwent radiation. Seventy-one patients had immediate breast reconstruction with expanders and 12 had delayed reconstruction. The only reported complications were extrusions (3.5%). Six nipples (5.2%) in 5 patients required surgical revision due to loss of projection; two patients had minor loss of projection but did not require surgical revision. Nipple projection at time of surgery ranged from 6 to 7 mm and average projection at 6 months was 3–5 mm. A surgical technique for nipple reconstruction using a skate flap with a graft material is described. Complications are infrequent and short-term projection measurements are encouraging. PMID:25114802

Latissimus dorsi flap for total autologous immediate breast reconstruction without implants.

PubMed

Santanelli di Pompeo, Fabio; Laporta, Rosaria; Sorotos, Michail; Pagnoni, Marco; Falesiedi, Federica; Longo, Benedetto

2014-12-01

The latissimus dorsi flap provides suitable recipient tissue for fat transfer, with a good blood supply and a reasonable volume of host tissue to inject into. The authors present their experience with use of the pedicled latissimus dorsi flap for fat grafting in total autologous immediate breast reconstruction without implants. From 2010 to 2013, 23 patients underwent breast reconstruction with primary fat augmented latissimus dorsi flaps (21 unilateral procedures and two bilateral procedures). Mean patient age was 52.3 years (range, 39 to 68 years); mean body mass index was 24.77 kg/m2 (range, 21.5 to 28.7 kg/m2). Fat was harvested using the Coleman technique with 10-ml syringes and injected into the adipose layer and muscle fascia of the latissimus dorsi flap skin paddle with 1-ml syringes. The mean size of the harvested skin paddle was 19.7 × 11.04 cm (range, 18 × 10 cm to 21 × 12 cm). Mean operative time was 2.62 hours (range, 2.10 to 3.20 hours) and 4.12 hours (range, 4.10 to 4.15 hours) for unilateral and bilateral reconstructions, respectively. Mean harvested fat volume was 126 ml (range, 90 to 180 ml), and mean injected fat volume was 101 ml (range, 60 to 150 ml). All flaps healed uneventfully, no seroma occurred at the flap donor-site, and no fat grafting-related complications were observed. To the best of the authors' knowledge, this is the first report in which fat transfer was used to achieve immediate latissimus dorsi flap volume augmentation as an alternative for total autologous reconstruction, avoiding implant-related complications.

The application of multilobed flap designs for anatomic and functional oropharyngeal reconstructions.

PubMed

Choi, Jong Woo; Lee, Min Young; Oh, Tae Suk

2013-11-01

The oropharynx has a variety of functions, such as mastication, deglutition, articulation, taste, and airway protection. Because of its many roles, recent goals in head and neck reconstruction have focused on anatomic and functional reconstructions to minimize functional deficits. Since chemoradiation has earned a good reputation in the management of head and neck cancer, the manifestation of oropharyngeal defects has changed. Although we could not control the anatomic defects that were known to be related to the oropharyngeal functions, we hypothesized that optimizing the flap designs would be helpful for minimizing the functional deficits.Two hundred fifty cases of the head and neck reconstruction using free flaps were carried out between March 2006 and December 2010, where modified flap designs were applied. Among these, 37 tongue and 15 tonsillar reconstructions were analyzed for functional outcomes. The patients were of Asian ethnic background, and the average age was 52 years, including 38 males and 17 females. The average follow-up period was 20.5 months. Based on previous studies, the flap designs were categorized into type I, unilobe; type II, bilobe; type III, trilobe; type IV, quadrilobe; type V, additional lobe for lateral and posterior pharyngeal wall; and type VI, additional lobe for tongue base. The functional outcomes of both tongue and tonsillar reconstructions were investigated.To quantify the outcome in terms of swallowing and pronunciation, we analyzed the patients' function based on the 7-scale parameter. In terms of swallowing, the tongue reconstruction group scored 5.70 on average, whereas the tonsillar reconstruction group showed an average score of 4.53. With regard to speech intelligibility, the tongue reconstruction group revealed an average score of 5.67, whereas the tonsillar reconstruction group scored 5.46 on average.Our findings indicate that specification of the flap designs is helpful for minimizing the functional deficits in head

Utility and versatility of the supraclavicular artery island flap in head and neck reconstruction.

PubMed

González-García, José A; Chiesa-Estomba, Carlos M; Sistiaga, Jon A; Larruscain, Ekhiñe; Álvarez, Leire; Altuna, Xabier

The supraclavicular island flap is a rotational pedicled flap and may have some advantages in head and neck reconstruction compared with free-tissue transfer when this kind of reconstruction is not affordable or recommended. We present our experience during the year 2016 in the application of the supraclavicular island flap in five cases as an alternative to microvascular reconstruction in several defects after resection of head and neck tumours. In two patients, the flap was used to close the surgical pharyngostoma after total laryngectomy with partial pharyngectomy. In one patient, it was used in lateral facial reconstruction after partial resection of the temporal bone. In one case, it was used to close a skin defect after total laryngectomy with prelaryngeal tissue extension. And in the last case to close a neck skin defect after primary closure of a pharyngo-cutaneous fistula. There were no flap complications, and the result was satisfactory in all cases. The supraclavicular artery island flap is useful and versatile in head and neck reconstruction. Operating room time in aged patients or those with comorbidities will be reduced compared to free flaps. The surgical technique is relatively easy and can be used for skin and mucosal coverage. The supraclavicular island flap could be a recommended option in head and neck reconstruction, its use seems to be increasing and provides a safe and time-saving option to free flaps in selected patients. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. All rights reserved.

Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction.

PubMed

Ono, Shimpei; Sebastin, Sandeep J; Yazaki, Naoya; Hyakusoku, Hiko; Chung, Kevin C

2011-05-01

A propeller flap is an island flap that moves from one orientation to another by rotating around its vascular axis. The vascular axis is stationary, and flap movement is achieved by revolving on this axis. Early propeller flaps relied on a thick, subcutaneous pedicle to maintain vascularity, and this limited the flap rotation to 90°. With increasing awareness of the location and the vascular territory perfused by cutaneous perforators, it is now possible to design propeller flaps based on a single perforator, so-called "perforator-based propeller flaps." These flaps permit flap rotation up to 180°. We present the results of upper limb soft tissue reconstruction using perforator-based propeller flaps. We constructed a treatment strategy based on the location of the soft tissue defect and the perforator anatomy for expedient wound coverage in 1 stage. All perforator-based propeller flaps derived from 3 institutions that were used for upper limb soft tissue reconstruction were retrospectively analyzed. The parameters studied included the size and location of the defect, the perforator that was used, the size and shape of the flap, the direction (ie, clockwise or counter-clockwise) of flap rotation, the degree of twisting of the perforator, the management of the donor site (ie, linear closure or skin grafting), and flap survival (recorded as the percentage of the flap area that survived). Twelve perforator-based propeller flaps were used to reconstruct upper limb soft tissue defects in 12 patients. Six different perforators were used as vascular pedicles. The donor defects of 11 flaps could be closed primarily. One flap was partially lost in a patient with electrical burns. Perforator-based propeller flaps provide a reliable option for covering small- to medium-size upper limb soft tissue defects. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Propeller facial artery perforator flap as first reconstructive option for nasolabial and perinasal complex defects.

PubMed

Ruiz-Moya, A; Lagares-Borrego, A; Infante-Cossío, P

2015-04-01

Facial cutaneous oncological pathology often involves more than one esthetic unit due to their close boundaries. The reconstruction of both the nasolabial and perinasal regions may be especially complex and challenging for the surgeon. Traditionally, these defects have been reconstructed with local random flaps based on the vascularization provided by the superficial musculoaponeurotic system. In this article, we present our experience in the reconstruction of the aforementioned defects using the propeller facial artery perforator (FAP) flap. A propeller FAP flap was performed for reconstruction in 12 patients with nasolabial or perinasal complex defects after tumoral resection between the years 2011 and 2013. The flap was designed parallel to the nasolabial fold in all cases for achieving direct closure and an aesthetically pleasing outcome. In one of the cases, a paramedian forehead flap was performed simultaneously. Nine patients healed uneventfully, with good functional and esthetic outcomes. One of the flaps developed partial necrosis of the distal end, and another developed temporary postoperative venous congestion, lymphedema, and, finally, trapdoor deformity. The latter complication also occurred in one more flap. The propeller FAP flap is reliable and versatile, with few complications, and it is especially useful when reconstructing complex defects that involve the nasolabial and perinasal regions; therefore, it should be considered as one of the first reconstructive options for the described defects. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Free flap reconstructions of tibial fractures complicated after internal fixation.

PubMed

Nieminen, H; Kuokkanen, H; Tukiainen, E; Asko-Seljavaara, S

1995-04-01

The cases of 15 patients are presented where microvascular soft-tissue reconstructions became necessary after internal fixation of tibial fractures. Primarily, seven of the fractures were closed. Eleven fractures had originally been treated by open reduction and internal fixation using plates and screws, and four by intramedullary nailing. All of the patients suffered from postoperative complications leading to exposure of the bone or fixation material. The internal fixation material was removed and radical revision of dead and infected tissue was carried out in all cases. Soft tissue reconstruction was performed using a free microvascular muscle flap (11 latissimus dorsi, three rectus abdominis, and one gracilis). In eight cases the nonunion of the fracture indicated external fixation. The microvascular reconstruction was successful in all 15 patients. In one case the recurrence of deep infection finally indicated a below-knee amputation. In another case, chronic infection with fistulation recurred postoperatively. After a mean follow-up of 26 months the soft tissue coverage was good in all the remaining 13 cases. All the fractures united. Microvascular free muscle flap reconstruction of the leg is regarded as a reliable method for salvaging legs with large soft-tissue defects or defects in the distal leg. If after internal fixation of the tibial fracture the osteosynthesis material or fracture is exposed, reconstruction of the soft-tissue can successfully be performed by free flap transfer. By radical revision, external fixation, bone grafting, and a free flap the healing of the fracture can be achieved.

Autologous breast reconstruction using the immediately lipofilled extended latissimus dorsi flap.

PubMed

Johns, N; Fairbairn, N; Trail, M; Ewing, A; Yong, L; Raine, C; Dixon, J M

2018-02-01

The latissimus dorsi flap is a popular choice for autologous breast reconstruction. To dramatically improve volume, we report our experience of using the immediately lipofilled extended latissimus dorsi (ELD) flap and show it as a valid option for autologous breast reconstruction. Patients undergoing the procedure between December 2013 and June 2016 were included. Demographic, clinical and operative factors were analysed, together with in-hospital morbidity and duration of postoperative hospital stay. A total of 71 ELD flaps with immediate lipofilling were performed. Forty-five reconstructions were immediate and the remaining 26 delayed. Median (range) volume of autologous fat injected immediately was 171 ml (40-630 ml). Contralateral reductions were performed in 25 patients with the median reduction volume 185 g (89-683 g). Median duration of admission was 6.5 (3-18) days and patients were followed up for 12 months (1-37). Three total flap failures occurred and had to be excised (4%). One haematoma occurred requiring drainage (1%). Signs of infection requiring intravenous antibiotics occurred in five patients (7%). In 5 patients wound dehiscence occurred, and only two of these required resuturing (3%). In total, 7 patients developed a seroma requiring repeated drainage (10%). Three reconstructions experienced mild mastectomy flap necrosis with no needing reoperation (4%). Our experience represents the largest series to date and shows that in carefully selected patients the technique is safe, can avoid the requirement for implants, and has the potential to streamline the reconstructive journey. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Perforator Propeller Flap for Oncologic Reconstruction of Soft Tissue Defects in Trunk and Extremities.

PubMed

Yu, Shengji; Zang, Mengqing; Xu, Libin; Zhao, Zhenguo; Zhang, Xinxin; Zhu, Shan; Chen, Bo; Ding, Qiang; Liu, Yuanbo

2016-10-01

Defects after soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities, and some regions lack reliable recipient vessel. Our purpose is to use various perforator propeller flaps for oncologic reconstruction. Between 2008 and 2014, 33 perforator propeller flaps were performed in 24 patients to reconstruct the defects after tumor resection in trunk and extremities. Fifteen patients underwent tumor resection previously. Thirteen patients underwent adjuvant radiotherapy or chemotherapy. Flaps based on perforators adjacent to the lesions were raised and rotated in propeller fashion to repair the defects. Twenty-seven flaps were based on perforators of known source vessels, and 6 were harvested in freestyle fashion. The defects were repaired with 2 flaps in 4 patients and 3 flaps in 2 patients. The mean skin paddle dimension was 8.36 cm in width and 20.42 cm in length. The mean degree of flap rotation was 158.79°. Complications include partial necrosis of 6 flaps in 5 cases and venous congestion of 1 flap. In these 6 patients, 3 underwent adjuvant radiotherapy. The donor sites were primarily closed in 21 patients and skin grafted in 3 patients. No functional loss related to flap harvesting was recognized. The perforator propeller flaps can be used to manage the medium defects in extremities and large defects in torso after soft tissue sarcoma resection. They avoid the sacrifice of the underlying muscle and eliminate the concerns of the unavailability of recipient vessels. The perforator propeller flaps provide flexible options for versatile oncologic reconstruction in trunk and extremities. However, the impact of radiotherapy on the viability of the flaps for local reconstruction needs further investigation.

Propeller flap reconstruction of abdominal defects: review of the literature and case report.

PubMed

Scaglioni, Mario F; Giuseppe, Alberto Di; Chang, Edward I

2015-01-01

The abdominal wall is perfused anteriorly by the superior and deep epigastric vessels with a smaller contribution from the superficial system. The lateral abdominal wall is perfused predominantly from perforators arising from the intercostal vessels. Reconstruction of soft tissue defects involving the abdomen presents a difficult challenge for reconstructive surgeons. Pedicle perforator propeller flaps can be used to reconstruct defects of the abdomen, and here we present a thorough review of the literature as well as a case illustrating the perforasome propeller flap concept. A patient underwent resection for dermatofibrosarcoma protuberans resulting in a large defect of the epigastric soft tissue. A propeller flap was designed based on a perforator arising from the superior deep epigastric vessels and was rotated 90° into the defect allowing primary closure of the donor site. The patient healed uneventfully and was without recurrent disease 37 months following reconstruction. Perforator propeller flaps can be used successfully in reconstruction of abdominal defects and should be incorporated into the armamentarium of reconstructive microsurgeons already facile with perforator dissections. © 2014 Wiley Periodicals, Inc.

Extradural myelomeningocele reconstruction using local turnover fascial flaps and midline linear skin closure.

PubMed

Patel, Kamlesh B; Taghinia, Amir H; Proctor, Mark R; Warf, Benjamin C; Greene, Arin K

2012-11-01

Myelomeningocele is the most common neural tube defect. Repair typically involves deep closure with regional muscle flaps (e.g. latissimus dorsi, gluteus maximus) and skin closure with rotation, bipedicle, or rhomboid flaps. We describe the reconstruction of large myelomeningocele defects using (1) local fascial turnover flaps with or without paraspinous muscle flaps for deep coverage of the dural repair followed by (2) linear, midline skin closure. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Vascularised free fibular flap in bone resection and reconstruction.

PubMed

Belt, P J; Dickinson, I C; Theile, D R B

2005-06-01

This paper compares allograft alone and in combination with vascularised free fibular flaps (FFF) to reconstruct long bone defects after tumour excision. We present 33 cases, 21 of these patients had reconstruction with an allograft alone as the initial procedure. Nine patients underwent reconstruction with FFF plus allograft plus iliac crest bone graft (ICG), two patients underwent reconstruction with a FFF and ICG and one patient underwent reconstruction with an allograft, a pedicled fibular flap and a FFF. The allograft was obtained from the Queensland Bone Bank and had been irradiated to 25 000Gy. In our experience (N=21) the complication rates with allograft alone were: delayed union 3, nonunion 7, fractured allograft 6, infection requiring resection of the allograft 3, other infections 2. The revision rate was 48% (10 cases of which five required a free fibular flap) and an average of 1.8 revision procedures were required. In the lower limb cases, the mean time to full weightbearing was 20 months and 40% were full weightbearing at 18 months. We felt that the high complication rate compared with other series may have been related to the irradiation of the graft. FFFs were used in 18 cases, 12 cases were primary reconstructions and six were revision reconstructions. The mean fibular length was 19.4 cm (range 10-29 cm). There were no flap losses and the FFF united at both ends of 11 of 12 primary reconstruction cases. One case had nonunion at one end, giving a union rate of 96% (23 of 24 junctions). When a FFF was used in combination with an allograft as a primary reconstruction, the allograft nonunion rate was 50% (five of 10 cases). The mean time to full weightbearing in the lower limb cases was 7.5 months and 100% were full weightbearing at 18 months. The FFF hastens time to full weightbearing but does not appear to affect the complication rates of allograft. The number of revision procedures required is reduced in the presence of a FFF and is the latter is a

Prelaminated extended temporoparietal fascia flap without tissue expansion for hemifacial reconstruction.

PubMed

Altındaş, Muzaffer; Arslan, Hakan; Bingöl, Uğur Anıl; Demiröz, Anıl

2017-10-01

Disfigurement of the face caused by postburn scars, resected congenital nevi and vascular malformations has both functional and psychological consequences. Ideal reconstruction of the facial components requires producing not only function but also the better appearance of the face. The skin of the neck, supraclavicular or cervicothoracic regions are the most commonly used and the most likely source of skin for facial reconstruction in those techniques which prefabrications with tissue expansion are used. This retrospective cohort study describes the two staged prelaminated temporoparietal fascia flap which eliminates the usage of tissue expansion by using skin graft harvested from the neck and occipital region and the application of this flap for the lower three-fourths of the face. 5 patients received prelaminated temporoparietal fascia flap without tissue expansion for facial resurfacing. The mean age at surgery was 39, 2 years (range, 17-60 years). The average follow up was 21.6 months (range, 10-48 months). The size of the raised prelaminated temporoparietal fascia flaps ranged from 9 × 8 cm to 14 × 10 cm. All flaps survived after second stage. Varied degrees of venous congestion were observed after flap insets in all cases but none required any further treatment for the congestion. The entire lesion could not be resected due to the large size of the lesion in all patients. Two stage prelaminated temporoparietal fascia flap with skin graft is an effective technique for the reconstruction of partial facial defects in selected patients. It is simple, quick, safe and reliable, and requires no expansion of skin or no microsurgery. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction.

PubMed

Yang, Hee Jun; Lee, Dong Hun; Kim, Yang Woo; Lee, Sang Gu; Cheon, Young Woo

2016-11-01

The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction.

[Breast reconstruction surgery with endoscopic assisted latissimus dorsi muscle flap].

PubMed

Bognár, Gábor; Novák, András; Ledniczky, György; István, Gábor

2017-06-01

The results obtaining with breast reconstruction surgery are not always satisfactory for the patients. Reconstruction with pure latissimus dorsi flap is useful option and due to endoscopic harvest large scar on the back can be avoided. The skin sparing mastectomy and even the sentinel lymph node biopsy or lymphadenectomy can be performed using a single incision in the axilla. Also the immediate reconstruction with endoscopically assisted harvest of the latissimus dorsi muscle flap in selective cases can be done using the same incision. The patient reported high satisfaction with the aesthetic and functional results due to preservation the breast shape and the absence of any scarring on the back.

[Fasciae latae perforator flap for breast reconstruction: An attractive alternative in case of DIEP contraindication].

PubMed

Lefèvre, M; Sarfati, B; Honart, J-F; Alkashnam, H; Rimareix, F; Leymarie, N; Kolb, F

2017-02-01

The musculocutaneous tensor fascia latae flap was one of the first free flaps described. It is possible to harvest a flap with the same skin paddle, vascularized by a septo-cutaneous perforator running through the tensor fascia lata muscle septum and coming from the ascending branch of the lateral circumflex femoral artery. The DIEP is currently the workhorse of autologous breast reconstruction, but there are some contraindications. The septo-cutaneous tensor fascia latae perforator flap may be an alternative for women with lateral upper thigh lipodystrophy. Between 2010 and 2014, three flaps have been performed in two patients for delayed breast reconstruction (one case of unilateral reconstruction, and one bilateral). Perforators were identified by preoperative angiography. The intervention was performed in a two-team approach, in only one operative position. Perforators were located in the horizontal axis of the upper rim of the pubis bone. One perforator artery was dissected for each flap. The mean caliber of the pedicle was 2.8mm, and the mean length was 6.4cm. The operative time was 240minutes for unilateral flap, 375minutes for bilateral flap. There was no case of total or partial necrosis, or complications on the donor site. Cosmetic results were considered satisfying by patients and surgeons with the reconstructed breast as well as the donor site. Septo-cutaneous fascia lata perforator flap is an attractive flap for breast reconstruction in patients with DIEP contraindication and lateral upper thigh lipodystrophy. It has many advantages: easy to harvest, length and calibre of the pedicle, double team approach, only one operating position, quality of reconstruction. It is necessary to carry out a larger series of cases to study the complication rate in the donor site. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Lower extremity soft tissue reconstruction with free flap based on subscapular artery.

PubMed

Karşıdağ, Semra; Akçal, Arzu; Turgut, Gürsel; Uğurlu, Kemal; Baş, Lütfü

2011-01-01

The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery. Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects. Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-to-end anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts. The subscapular vascular system based flaps have an optimal

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

PubMed

Frey, Jordan D; Stranix, John T; Chiodo, Michael V; Alperovich, Michael; Ahn, Christina Y; Allen, Robert J; Choi, Mihye; Karp, Nolan S; Levine, Jamie P

2018-05-01

Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. Therapeutic, III.

A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction.

PubMed

Lin, Pao-Yuan; Kuo, Yur-Ren; Tsai, Yun-Ta

2012-03-01

Perforator-based fasciocutaneous flaps for reconstructing pressure sores can achieve good functional results with acceptable donor site complications in the short-term. Recurrence is a difficult issue and a major concern in plastic surgery. In this study, we introduce a reusable perforator-preserving gluteal artery-based rotation flap for reconstruction of pressure sores, which can be also elevated from the same incision to accommodate pressure sore recurrence. The study included 23 men and 13 women with a mean age of 59.3 (range 24-89) years. There were 24 sacral ulcers, 11 ischial ulcers, and one trochanteric ulcer. The defects ranged in size from 4 × 3 to 12 × 10 cm(2) . Thirty-six consecutive pressure sore patients underwent gluteal artery-based rotation flap reconstruction. An inferior gluteal artery-based rotation fasciocutaneous flap was raised, and the superior gluteal artery perforator was preserved in sacral sores; alternatively, a superior gluteal artery-based rotation fasciocutaneous flap was elevated, and the inferior gluteal artery perforator was identified and dissected in ischial ulcers. The mean follow-up was 20.8 (range 0-30) months in this study. Complications included four cases of tip necrosis, three wound dehiscences, two recurrences reusing the same flap for pressure sore reconstruction, one seroma, and one patient who died on the fourth postoperative day. The complication rate was 20.8% for sacral ulcers, 54.5% for ischial wounds, and none for trochanteric ulcer. After secondary repair and reconstruction of the compromised wounds, all of the wounds healed uneventfully. The perforator-preserving gluteal artery-based rotation fasciocutaneous flap is a reliable, reusable flap that provides rich vascularity facilitating wound healing and accommodating the difficulties of pressure sore reconstruction. Copyright © 2011 Wiley Periodicals, Inc.

Workhorse Flaps in Chest Wall Reconstruction: The Pectoralis Major, Latissimus Dorsi, and Rectus Abdominis Flaps

PubMed Central

Bakri, Karim; Mardini, Samir; Evans, Karen K.; Carlsen, Brian T.; Arnold, Phillip G.

2011-01-01

Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction. PMID:22294942

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction

PubMed Central

Yang, Hee Jun; Kim, Yang Woo; Lee, Sang Gu

2016-01-01

Background The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. Methods A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. Results In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. Conclusions Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction. PMID:27896183

Reconstruction with different free flaps in oro-facial cancer patients.

PubMed

Bhathena, H M; Savant, D N; Kavarana, N M; Parikh, D M; Sanghvi, V D

1996-01-01

In 75 patients following ablative surgery of head and neck cancer, reconstruction was attempted with free tissue transfer techniques under magnification. It was possible to do free tissue transfers in 69 cases. In 6 cases it was not possible to harvest free flaps successfully and alternative reconstructive procedure was carried out due to unavoidable circumstances and various reasons: 1. unsuitable venous drainage, as in Anterior Rib Osteomyocutaneous Composite Flap, AROCF (2 cases), 2. injury to vessels during flap harvest, as in parascapular flap (1 case), 3. residual disease unable to excise (2 cases) and 4. unsuitable proposition (1 case), due to emergency curfew imposed suddenly. These 6 cases were not included in the study. Free tissue transfer was successful in 64 cases (92.7%) and there was a total failure in 5 cases where delayed secondary salvage surgery was performed. Out of 69 cases, in 65 cases reconstructions were carried out immediately, primarily as one-stage operative procedure. Their functional, cosmetic results and complications during the operative and post-operative period are analyzed and discussed. Inter-maxillary fixation was never used to maintain the bite alignment. All cases were given a bite guide prosthesis in the early post-operative period, to improve the bite alignment when it was necessary.

Three-dimensional model simulation and reconstruction of composite total maxillectomy defects with fibula osteomyocutaneous flap flow-through from radial forearm flap.

PubMed

He, Yue; Zhu, Han Guang; Zhang, Zhi Yuan; He, Jie; Sader, Robert

2009-12-01

A total maxillectomy always causes composite defects of maxilla, zygomatic bone, orbital floor or rim, and palatal and nasal mucosa lining. This leads to significant functional and cosmetic consequences after ablative surgery. The purpose of this clinical study was to preliminarily 3-dimensionally reconstruct the defect of total maxillectomy with sufficient bone support and soft tissue lining. Three-dimensional model simulation technique and free fibula osteomyocutaneous flap flow-through from radial forearm flap were used to reconstruct a total maxillectomy defect for a 21-year-old female patient. Preoperatively, the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies and bone segment replacement. At surgery, a 22-cm-length free fibula was divided into 4 segments to make 1 maxilla skeletal framework in the schedule of the preoperative model surgical planning with a radial forearm flap flow-through for the free fibula flap with skin paddle to repair the palatal and nasal region. Free fibula and radial forearm flap were alive, and the patient was satisfied with the results both esthetically and functionally after dental rehabilitation which was carried out 6 months after surgery. This preliminarily clinical study and case demonstrated that: the fibula osteomyocutaneous flap is an ideal donor site in 3D total maxillectomy defect reconstruction, because of its thickness, length, and bone uniformity which makes ideal support for dental rehabilitation; the flow-through forearm radial flap not only serves as the vascular bridge to midface reconstruction, but also provides sufficient soft tissue cover for the intraoral defect; and the 3D model simulation and preoperative surgical planning are effective methods to refine reconstruction surgery, shorten the surgical time, and predict the outcome after operation.

Free sural artery perforator flap: An occasional gift in oral cavity reconstruction.

PubMed

Pease, Natalie L; Davies, Andrew; Townley, William A

2016-07-01

The medial sural artery perforator (MSAP) flap is becoming a popular strategy for reconstructing intraoral defects. We present a case in which no MSAPs were present, however, a perforator-based calf flap was successfully raised on the sural artery and used for tongue reconstruction. A corresponding anatomic study was undertaken to establish if this finding was reproducible. A 58-year-old woman underwent left hemiglossectomy for a squamous cell carcinoma of the tongue. Subsequently, 6 fresh frozen cadaveric limbs were dissected examining the blood supply of the posterior calf skin. The sural artery perforator (SAP) flap successfully reconstructed the defect. Our cadaveric study similarly demonstrated a septocutaneous SAP supplying the posterior calf skin in 1 of 6 limbs. SAPs allow a favorable flap dissection, as opposed to the musculocutaneous course of MSAPs. Our findings provide further evidence of the versatility of the calf donor site. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2454-E2456, 2016. © 2016 Wiley Periodicals, Inc.

Meta-analysis of Timing for Microsurgical Free-Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles.

PubMed

Haykal, Siba; Roy, Mélissa; Patel, Ashit

2018-05-01

 In 1986, Marko Godina published his seminal work regarding the timing of free-flap reconstruction for traumatic extremity defects. Early reconstruction, compared with delayed and late reconstruction resulted in significant decreases in free-flap failure rate, post-operative infections, hospitalization time, bone healing time, and number of additional anesthesias. The objective of this manuscript was to evaluate whether these principles continue to apply.  A meta-analysis was performed analyzing articles from Medline, Embase, and Pubmed. Four hundred and ninety-two articles were screened, and 134 articles were assessed for eligibility. Following full-text review, 43 articles were included in this study.  The exact timing for free-flap reconstruction, free-flap failure rate, infection rate, and follow-up was defined in all 43 articles. Early free-flap reconstruction was found to have significantly lower rates of free-flap failure and infection in comparison to delayed reconstruction ( p  = 0.008; p  = 0.0004). Compared with late reconstruction, early reconstruction was found to have significantly lower infection rates only ( p  = 0.01) with no difference in free-flap failures rates. Early reconstruction was found to lead to fewer additional procedures ( p  = 0.03). No statistical significance was found for bone healing time or hospitalization time.  Early free-flap reconstruction performed within the first 72 hours resulted in a decreased rate of free-flap failures, infection, and additional procedures with no difference in other parameters. The largest majority of free flaps continue to be performed in a delayed time frame. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Risk factors for pedicled flap necrosis in hand soft tissue reconstruction: a multivariate logistic regression analysis.

PubMed

Gong, Xu; Cui, Jianli; Jiang, Ziping; Lu, Laijin; Li, Xiucun

2018-03-01

Few clinical retrospective studies have reported the risk factors of pedicled flap necrosis in hand soft tissue reconstruction. The aim of this study was to identify non-technical risk factors associated with pedicled flap perioperative necrosis in hand soft tissue reconstruction via a multivariate logistic regression analysis. For patients with hand soft tissue reconstruction, we carefully reviewed hospital records and identified 163 patients who met the inclusion criteria. The characteristics of these patients, flap transfer procedures and postoperative complications were recorded. Eleven predictors were identified. The correlations between pedicled flap necrosis and risk factors were analysed using a logistic regression model. Of 163 skin flaps, 125 flaps survived completely without any complications. The pedicled flap necrosis rate in hands was 11.04%, which included partial flap necrosis (7.36%) and total flap necrosis (3.68%). Soft tissue defects in fingers were noted in 68.10% of all cases. The logistic regression analysis indicated that the soft tissue defect site (P = 0.046, odds ratio (OR) = 0.079, confidence interval (CI) (0.006, 0.959)), flap size (P = 0.020, OR = 1.024, CI (1.004, 1.045)) and postoperative wound infection (P < 0.001, OR = 17.407, CI (3.821, 79.303)) were statistically significant risk factors for pedicled flap necrosis of the hand. Soft tissue defect site, flap size and postoperative wound infection were risk factors associated with pedicled flap necrosis in hand soft tissue defect reconstruction. © 2017 Royal Australasian College of Surgeons.

Distally Based Sural Artery Peroneus Flap (DBSPF) for Foot and Ankle Reconstruction

PubMed Central

Ebrahiem, Ahmed Ali; Manas, Raj Kumar

2017-01-01

Background: Reconstruction of soft-tissue defects in lower third of leg, ankle, and foot has been a challenge and reconstructive surgeons have been trying to innovate different flaps. To solve this issue, we propose a distally based sural artery peroneus flap (DBSPF) in which we include superficial portion of the peroneus brevis muscle and its blood supply with the peroneal artery distally. The aim of this study was to evaluate the functional outcome and its usefulness over conventional distal sural artery flap or other local options available. Methods: This is a case series of 20 patients that include a DBSPF that was done for defects around ankle, distal leg, and foot caused by trauma or tumor ablation within the period of June 2013 to March 2015 in Kasralainy Hospital, Cairo. All cases were evaluated according to flap vascularity, distal reach of flap, aesthetic outcome, and donor-site morbidity. Results: All flaps survived. One flap developed venous congestion that subsided spontaneously with limb elevation. The flap dimension ranged from 42 cm to 442 cm2, and it reached the midfoot easily. The pivot point was kept as low as 2–6 cm from lateral malleolus according to location of perforators. The ankle stability was maintained, and the desired aesthetic outcome was achieved. Conclusions: The DBSPF is an addition to the armamentarium in plastic surgery for defects around ankle, distal leg, and foot. It is an easy and swift procedure as compared with complex microsurgical reconstruction. PMID:28507850

Case Report Reconstruction of Exposed Ilium With Reverse Turnover Latissimus Dorsi Muscle Flap

PubMed Central

Hayashida, Kenji; Endo, Yoshie; Kamebuchi, Katsuhiko

2011-01-01

Objective: It is difficult to cover a large skin and soft tissue defect with exposure of the ilium. We therefore performed a new reconstruction technique, using a reverse latissimus dorsi muscle flap fed by perforating branches of only the 10th intercostal artery. Methods: A 45-year-old man had a large traumatic defect located on the hip with exposure of the iliac crest. After confirming and preserving perforating branches of the 10th intercostal artery, the latissimus dorsi muscle flap was turned over just proximal to the perforating branch, and a split-thickness skin graft was performed over the flap. Results: The skin graft took place well and there were no circulation problems. Conclusions: This flap covered a larger area on the hip than the musculocutaneous flap. Furthermore, this is easier to perform and is less invasive than a vascularized free flap. Skin and soft tissue defects that expose bones of the lumbar or hip region can be reconstructed with a local flap; however, the deficit is small for this coverage and usually there is little skin and soft tissue to cover the wound defect in the surrounding area. Thus, it is often difficult to deal with large defects. We performed a reconstruction, using a reverse latissimus dorsi flap fed by perforating branches of the 10th intercostal artery for a large skin and soft tissue defect of the hip with exposure of the iliac crest, resulting in a good outcome. This technique is thought to be useful for reconstruction when the ilium is exposed, and we report the case and surgical procedure. PMID:21559059

Transverse musculocutaneous gracilis flap for treatment of capsular contracture in tertiary breast reconstruction.

PubMed

Pülzl, Petra; Huemer, Georg M; Schoeller, Thomas

2015-02-01

Capsular contracture is a common complication associated with implant-based breast reconstruction and augmentation leading to pain, displacement, and rupture. After capsulectomy and implant exchange, the problem often reappears. We performed 52 deepithelialized free transverse musculocutaneous gracilis (TMG) flaps in 33 patients for tertiary breast reconstruction or augmentation of small- and medium-sized breasts. The indications for implant removal were unnatural feel and emotion of their breasts with foreign body feel, asymmetry, pain, and sensation of cold. Anyway, most of the patients did not have a severe capsular contracture deformity. The TMG flap is formed into a cone shape by bringing the tips of the ellipse together. Depending on the contralateral breast, the muscle can also be shaped in an S-form to get more projection if needed. The operating time for unilateral TMG flap breast reconstruction or augmentation was on average 3 hours and for bilateral procedure 5 hours. One patient had a secondary revision of the donor site due to disruption of the normal gluteal fold. Eighty percent of the unilateral TMG flap reconstructions had a lipofilling procedure afterward to correct small irregularities or asymmetry. The advantages of the TMG flap such as short harvesting time, inconspicuous donor site, and the possibility of having a natural breast shape make it our first choice to treat capsular contracture after breast reconstruction and augmentation.

Total Reconstruction of Lower Eyelid in a Post-traumatic Patient Using Modified Fricke's Cheek Flap.

PubMed

Sengupta, Subhabrata; Baruah, Binayak; Pal, Suvra; Tuli, Isha Preet

2013-07-01

Eyelids are very complex structure, reconstruction of which is a challenge to surgeons. Reconstruction of eyelids may be required in a variety of conditions like congenital anomalies, trauma, or postsurgical excision in malignant lesions involving the eyelids. There are numerous ways to reconstruct the eyelids; the best procedure depends on both the skill of the surgeon and the condition of the patient. Fricke' lateral temporal based flap was first described in 1829 for reconstruction of the eyelids and lateral canthal region. This flap had inherent problems regarding cosmetic appearance of the eyebrows. The modified Fricke's flap based on the cheek has the advantage of avoiding such complications. It is very easy and rapid outpatient department (OPD) based procedure with acceptable cosmetic and functional result. It can be done by all ear, nose, and throat (ENT) and head and neck surgeons without any reconstructive training. In this article we are presenting a case of total reconstruction of lower eyelid using the modified Fricke's cheek flap.

Superficial Circumflex Iliac Artery-Based Iliac Bone Flap Transfer for Reconstruction of Bony Defects.

PubMed

Yoshimatsu, Hidehiko; Iida, Takuya; Yamamoto, Takumi; Hayashi, Akitatsu

2018-05-12

 The superficial circumflex iliac artery (SCIA)-based iliac bone flap has yet to be widely used. The purpose of this article is to validate the feasibility of SCIA-based iliac bone flap transfers for reconstruction of small to moderate-sized bony defects. Retrospective outcome comparisons between SCIA-based iliac bone flaps and fibula flaps were made.  Twenty-six patients with bony tissue defects underwent reconstructions using either free SCIA-based iliac bone flaps (13) or fibula flaps (13). Outcomes were evaluated 9 months after the reconstruction on the following basis: bone length, pedicle length, skin paddle area, bone union, donor-site complications, skin paddle survival, and complications at the reconstructed site.  There was no statistically significant difference in pedicle length (iliac bone vs. fibula; 5.5 ± 1.8 vs. 4.1 ± 1.5 cm; p  = 0.181), in bone union rate (iliac bone vs. fibula; 100 vs 92.3%; p  = 0.308), in donor-site complication rate (iliac bone vs. fibula; 0 vs. 7.7%; p  = 0.308), or in skin paddle complete survival rate (iliac bone vs. fibula; 100 vs. 83.3%; p  = 0.125). Statistically significant differences were observed in bone flap length (iliac bone vs. fibula; 4.8 ± 2.2 vs. 11.1 ± 4.8 cm; p  = 0.0005), in skin paddle area (superficial circumflex iliac artery perforator flap vs. peroneal artery perforator flap; 58.8 ± 35.6 vs. 27.7 ± 17.5 cm 2 ; p  = 0.0343), and in reconstructed site complication rate (iliac bone vs. fibula; 0 vs. 30.8%; p  = 0.030).  In our series of SCIA-based iliac bone flap transfers, up to 8 × 3 cm could be procured along the iliac crest. When compared with fibula flap transfers, there were no significant statistical differences in pedicle length or in bone union rate; the SCIA-based iliac bone flap may be a feasible option for bony defects of small to moderate size. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Free-style puzzle flap: the concept of recycling a perforator flap.

PubMed

Feng, Kuan-Ming; Hsieh, Ching-Hua; Jeng, Seng-Feng

2013-02-01

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Prevention of perioperative limb neuropathies in abdominal free flap breast reconstruction.

PubMed

Blackburn, Adam; Taghizadeh, Rieka; Hughes, David; O'Donoghue, Joseph M

2016-01-01

Perioperative peripheral neuropathies are a significant cause of post-operative morbidity in patients undergoing prolonged procedures. The aims of this study were to determine the incidence and possible causes of peripheral neuropathy in patients undergoing abdominal free flap breast reconstruction and to develop methods of ameliorating this problem. A 4-year retrospective study of patients undergoing abdominal free flap breast reconstruction by a single surgeon and anaesthetist was undertaken to determine the incidence and potential causes of perioperative neuropathy. A new positioning protocol was introduced to minimise the stretch on the brachial plexus and to protect peripheral nerves from compression forces. In addition, regular intraoperative physiotherapy was introduced. A prospective study was then conducted on patients managed by the same team to evaluate the effect of this change in practice on the subsequent incidence of peripheral neuropathies. Over the 4-year retrospective period, 93 consecutive patients underwent abdominal free flap breast reconstruction, six of whom (6.5%) developed a peripheral neuropathy. Following the introduction of the new positioning protocol, prospective data collected on 65 consecutive patients showed no further occurrences of perioperative neuropathy (p = 0.04). There were no significant differences in the characteristics between the two cohorts. Perioperative peripheral neuropathy in abdominal free flap breast reconstruction is a preventable problem. This paper presents a peripheral neuropathy prevention protocol for managing these patients. Copyright © 2015. Published by Elsevier Ltd.

Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot.

PubMed

Kansal, Sandeep; Goil, Pradeep; Agarwal, Vijay; Agarwal, Swarnima; Mishra, Shashank; Agarwal, Deepak; Singh, Pranay

2014-01-01

Paucity of soft tissue available locally for reconstruction of defects in leg and foot presents a challenge for reconstructive surgeon. The use of reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap in reconstruction of lower leg and foot presents a viable alternative to free flap and cross-leg flap reconstruction. The vascular axis of the flap is formed by the vessels accompanying the saphenous nerve and the greater saphenous vein. We present here our experience with reverse saphenous neurocutaneous flap which provides a stable cover without the need to sacrifice any important vessel of leg. The study is conducted from March 2003 through Dec 2009 and included a total of 96 patients with defects in lower two-thirds of leg and foot. There are 74 males and 22 females. Distal pivot point was kept approximately 5-6 cm from tip of medial malleolus, thus preserving the distal most perforator, and the flap is turned and inserted into the defect. Donor site is covered with a split thickness skin graft. Postoperative follow-up period was 6 weeks to 6 months. The procedure is uneventful in 77 cases. Infection is observed in 14 cases. Partial flap necrosis occurs in 2 cases. Total flap necrosis is noted in 3 cases. Reverse pedicle saphenous flap can be used to reconstruct defects of lower one-third leg and foot with a reliable blood supply with a large arc of rotation while having minimal donor site morbidity.

Plastic Surgery Challenges in War Wounded I: Flap-Based Extremity Reconstruction

PubMed Central

Sabino, Jennifer M.; Slater, Julia; Valerio, Ian L.

2016-01-01

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war. PMID:27679751

An Alternative Posterosuperior Auricular Fascia Flap for Ear Elevation During Microtia Reconstruction.

PubMed

Li, Yiyuan; Zhang, Ruhong; Zhang, Qun; Xu, Zhicheng; Xu, Feng; Li, Datao

2017-02-01

Advances in staged total auricular reconstruction have resulted in improved anterior auricular appearance; however, satisfactory postreconstruction esthetics of the retroauricular fold remain challenging. The postauricular appearance of the reconstructed ear depends largely upon optimizing the covering material. When used as the covering soft tissue for ear elevation, a flap containing primarily the upper portion of the retroauricular fascia has potential advantages over the conventional book cover-type retroauricular fascia flap. We developed a geometrically designed, posterosuperior auricular fascia flap to replace the conventional retroauricular fascia flap for ear elevation. During the second-stage operation, the posterosuperior auricular fascia flap is rotated downward and turned over to wrap around the inner strut and entire posterior auricular surface. Compared to the conventional book cover-type retroauricular fascia flap, the novel posterosuperior auricular fascia flap was easier to harvest and the operative time significantly decreased (110.3 vs. 121.5 min, p < 0.01). The modified flap produced a thin and natural contour of the postauricular surface, as well as reduced the incidence of postauricular hypertrophic scarring (from 24.7 to 13.2%, p = 0.03) and partial skin graft necrosis (from 43.4 to 31.2%, p = 0.01). The geometrically designed posterosuperior auricular fascia flap improves ear elevation. Compared to the conventional book cover-type retroauricular fascia flap, this covering tissue is easier to perform so the surgical time is decreased. It was highly vascularized, well defined, thinner, and yields reliable results. Thus, favorable postauricular surface results can be achieved during auricular reconstruction by using the modified fascia flap. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and

DIEP Flap Breast Reconstruction in Patients with Breast Ptosis: 2-Stage Reconstruction Using 3-Dimensional Surface Imaging and a Printed Mold

PubMed Central

Yano, Kenji; Taminato, Mifue; Nomori, Michiko; Hosokawa, Ko

2017-01-01

Background: Autologous breast reconstruction can be performed for breasts with ptosis to a certain extent, but if patients desire to correct ptosis, mastopexy of the contralateral breast is indicated. However, accurate prediction of post-mastopexy breast shape is difficult to make, and symmetrical breast reconstruction requires certain experience. We have previously reported the use of three-dimensional (3D) imaging and printing technologies in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. In the present study, these technologies were applied to the reconstruction of breasts with ptosis. Methods: Eight breast cancer patients with ptotic breasts underwent two-stage unilateral DIEP flap breast reconstruction. In the initial surgery, tissue expander (TE) placement and contralateral mastopexy are performed simultaneously. Four to six months later, 3D bilateral breast imaging is performed after confirming that the shape of the contralateral breast (post-mastopexy) is somewhat stabilized, and a 3D-printed breast mold is created based on the mirror image of the shape of the contralateral breast acquired using analytical software. Then, DIEP flap surgery is performed, where the breast mold is used to determine the required flap volume and to shape the breast mound. Results: All flaps were engrafted without any major perioperative complications during both the initial and DIEP flap surgeries. Objective assessment of cosmetic outcome revealed that good breast symmetry was achieved in all cases. Conclusions: The method described here may allow even inexperienced surgeons to achieve reconstruction of symmetrical, non-ptotic breasts with ease and in a short time. While the requirement of two surgeries is a potential disadvantage, our method will be particularly useful in cases involving TEs, i.e., delayed reconstruction or immediate reconstruction involving significant skin resection. PMID:29184728

Quadratus lumborum catheters for breast reconstruction requiring transverse rectus abdominis myocutaneous flaps.

PubMed

Spence, Nicole Z; Olszynski, Patrycja; Lehan, Anne; Horn, Jean-Lois; Webb, Christopher A J

2016-06-01

Patients diagnosed with breast cancer may opt to undergo surgical reconstructive flaps at the time of or after mastectomies. These surgeries leave patients with significant postoperative pain and sometimes involve large surgical beds including graft sites from the abdomen to reconstruct the breast. Consequently, multimodal methods of pain management have become highly favored. Quadratus lumborum catheters offer an opioid-sparing technique that can be performed easily and safely. We present a case of a patient who underwent a breast flap reconstruction and had bilateral quadratus lumborum catheters placed for perioperative pain control.

Long-Term Follow-Up of Flap Prefabrication in Facial Reconstruction.

PubMed

Wang, Weixin; Zhao, Muxin; Tang, Yong; Chen, Wen; Yang, Zhe; Ma, Ning; Xu, Lisi; Feng, Jun; Li, Yangqun

2017-07-01

Flap prefabrication is to turn a random flap into an axial flap by transferring a vascular pedicle. In the past 13 years, we have prefabricated 20 flaps in 20 patients by the superficial temporal artery and its concomitant veins. Typically, a 50- to 800-mL tissue expander was implanted in the donor site. After flap maturation, the prefabricated flap was raised and transferred locally to cover the large defect on the face. All the cases were followed up regularly. The patients' age were between 3 and 27 years, the size of the flaps were between 3.5 × 5.5 cm and 13 × 15 cm, the superficial temporal artery length was between 10 and 15 cm. All flaps were transferred successfully: 10 of the flaps had venous congestion, partial epidermis exfoliation and flap necrosis occurred in 4 flaps. All cases were followed up for at least 1 year, the longest follow-up period was 9 years. Long-term follow-up results showed the prefabricated flap survived in good condition and had a satisfactory outcome. Because flap prefabrication is practical, and long-term follow-ups have proved its preferable characters and stability, it is a fine method for large area facial reconstructions.

Bilateral Breast Reconstruction with Extended Thoracodorsal Artery Perforator Propeller Flaps and Implants

PubMed Central

Gunnarsson, Gudjon L.; Børsen-Koch, Mikkel; Nielsen, Henrik T.; Salzberg, Andrew

2015-01-01

Summary: We present our experience of bilateral total breast reconstruction using a double-sided extended thoracodorsal artery perforator propeller flap in a case series of 10 patients. Reconstruction was successfully achieved in all cases with few complications. The median time for surgery was 275 minutes (200–330), and the average implant size used was 350 cm3 (195–650). We demonstrate how the extended thoracodorsal artery perforator propeller flap allows for a swift and reliable direct to implant bilateral total breast reconstruction in a simple setting and is a valuable adjunct to our armamentarium of techniques for single-stage bilateral breast reconstruction. PMID:26180736

A comparative study of tissue expansion and free parascapular flaps in extensive facial burn scar reconstruction

PubMed Central

Kalra, G S; Bedi, Mitesh; Barala, Vipin Kumar

2017-01-01

Background: Large post burn scars are a very difficult problem to treat. Available methods include skin grafts and tissue expansion. The reconstructive method used should be tailored according to individual patient rather than following a textbook approach in each. Patients and Methods: A retrospective analysis was done of cases with extensive facial burn scars in whom secondary reconstruction was done with either free parascapular flap cover or tissue expansion and flap advancement following facial burn scar excision by a single surgeon (GSK) in Department of Burns, Plastic and reconstructive surgery. Results: A total of 15 patients with free parascapular flap and 15 patients with tissue expansion followed by flap advancement were analyzed in the group. There were no free flap failures, but 2 patients required skin graft at donor site. In patients undergoing tissue expansion, minor complication was noted in 1 patient. Conclusion: Tissue expansion is a useful technique in reconstruction of post burn scars, but has its limitations, especially in patients with extensive burns in head and neck region with limited local tissue availability. Parascapular free flap may provide a good alternative option for reconstruction in such cases. PMID:28804686

Results of auricular helical rim reconstruction with post-auricular tube flap.

PubMed

Iljin, Aleksandra; Lewandowicz, Edward; Antoszewski, Bogusław; Zieliński, Tomasz

2016-01-01

The aim of the study was to present our experience with post-auricular tube flap (ptf) and clinical evaluation of the results following auricular helical rim reconstruction with this technique in patients after trauma. We analyzed the results in 12 patients who underwent three-staged auricular helical rim reconstruction with ptf following trauma in the Department of Plastic, Reconstructive and Aesthetic Surgery between 2005-2014. The patients were followed-up for at least 1 year. We evaluated early and long-term results after surgery including plastic surgeon's and patient's opinion. Postoperative results were satisfactory (very good) in 10 cases, both in the opinion of the plastic surgeon and patients. Transient venous congestion of the helix occurred in two cases (16.6%). This complication did not have any influence on estimation of the results after surgery. Delayed wound healing in the poles of the reconstructed helical edge, as well as non-aesthetic helical scars with imperfections of helical rim, were seen in another two patients (16.6%). 1. Post-auricular tube flap reconstructions after helical rim trauma allowed for complete restoration of contour, size and orientation of the helix and the whole operated ear, which confirms the efficiency of the applied technique. 2. Reconstructive surgery with post-auricular tube flap in patients with auricular helical rim defects contributed to postoperative satisfaction in both patients and doctors' estimations.

Propeller Flaps With Reduced Rotational Angles: Clinical Experience on 40 Consecutive Reconstructions Performed at Different Anatomical Sites.

PubMed

Brunetti, Beniamino; Tenna, Stefania; Poccia, Igor; Persichetti, Paolo

2017-02-01

Despite of the widespread use of 180-degree propeller flaps in the field of soft tissue reconstruction, less information are available in the current literature to standardize the use of propeller flaps with reduced degrees of rotation.The authors report their experience with propeller flaps with reduced rotational angles reviewing clinical applications and outcomes of the technique in a series of 40 consecutive reconstructions. Forty elective defects of various etiologies located in different regions of the body (head and neck, trunk, buttocks and perineum, extremities) were reconstructed with less than 180 degrees rotated propeller flaps. The technique was applied to patients presenting with a strong audible perforator detected in close proximity to the wound and the defect located in a position adjacent to the axis of the chosen perforasome. Defect size ranged from 2 × 2 to 15 × 9 cm. Flap dimensions ranged from 5 × 2 to 21 × 10 cm. The flaps were based on 1 (34) or 2 (6) perforators and were mobilized with an angle of rotation of 45, 90, and 135 degrees in 7, 24, and 9 patients, respectively. Mean operative time was 105 minutes. All flaps survived postoperatively. In only 4 cases (10%) partial flap necrosis was registered. All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. Propeller flaps with reduced rotational angles represent a safe and versatile option to reconstruct soft tissues defects at different anatomical sites.

Flap choice does not affect complication rates or functional outcomes following extremity soft tissue sarcoma reconstruction.

PubMed

Slump, Jelena; Hofer, Stefan O P; Ferguson, Peter C; Wunder, Jay S; Griffin, Anthony M; Hoekstra, Harald J; Bastiaannet, Esther; O'Neill, Anne C

2018-04-12

Flap reconstruction plays an essential role in facilitating limb preservation in patients with extremity soft tissue sarcoma (ESTS). However, the effect of flap choice on the rates of postoperative complications and functional outcomes has not been clearly established. This study directly compares the outcomes of free and pedicled flap reconstructions in patients with ESTS. Two hundred sixty-six patients who underwent flap reconstruction following ESTS resection were included. Associations between flap type and complications were determined using logistic regression analyses. Functional outcome was evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society Scales (MSTS). There was no significant difference between complication rates in the pedicled and free flap groups (32% vs. 38%, p = 0.38). In the lower limb, pedicled flaps had complication rates similar to those of free flaps on univariate analysis (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 0.56-2.26, p = 0.75). Conversely, in the upper limb, pedicled flaps were associated with fewer complications on univariate analysis (OR = 0.31, 95% CI = 0.11-0.86, p = 0.03), but this was not significant on multivariate analysis (OR = 0.45, 95% CI = 0.13-1.59, p = 0.22). Obesity was a strong predictor of complications in the upper limb group on multivariate analysis (body mass index [BMI] ≥ 30 kg/m 2 , OR = 7.01, 95% CI = 1.28-38.51, p = 0.03). There was no significant difference in functional outcomes between both flap groups in either upper or lower limbs. Postoperative complications and functional outcomes for patients undergoing free and pedicled flaps are similar in ESTS reconstruction. Selecting the most suitable reconstructive option in each individual case is paramount to preserving function while minimizing postoperative morbidity. Copyright © 2018 British Association of Plastic, Reconstructive and

[Breast reconstruction by latissimus dorsi flap: Towards an evolution of ideas].

PubMed

Niddam, J; Guihard, T; Cothier-Savey, I; Chaussard, H; Lemasurier, P

2015-12-01

Breast reconstruction with latissimus dorsi flap and fat grafting is a technique widely used in current practice. Some operators still complain at the lack of final results at the first intervention and the need for repeated lipofilling sessions. The objective of this study was to compare the number of reoperations in patients who underwent reconstruction with latissimus dorsi with prosthesis versus without prosthesis. We included all patients operated for breast reconstruction with latissimus dorsi flap, with or without prosthesis between 2008 and 2012 in our center. We noted the number of new surgical interventions in these patients on the reconstructed breast. We also noted the average weight of mastectomy in two groups each year. One hundred and eighty-six patients were included in this study. Ninety-one patients underwent reconstruction with latissimus dorsi and prosthesis, and 95 patients reconstruction by latissimus dorsi and fat graft. It has not been demonstrated significant differences in the number of new surgical procedures between the two groups. The average weight of mastectomies in the autologous group has steadily increased over the five years. There was no significant difference in the average weight of mastectomies between the two groups over the last two years. For breast reconstruction with latissimus dorsi flap, surgical indications changed in our center to the absence of prosthetic implant, whatever the volume of the breast. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Computer-assisted versus conventional free fibula flap technique for craniofacial reconstruction: an outcomes comparison.

PubMed

Seruya, Mitchel; Fisher, Mark; Rodriguez, Eduardo D

2013-11-01

There has been rising interest in computer-aided design/computer-aided manufacturing for preoperative planning and execution of osseous free flap reconstruction. The purpose of this study was to compare outcomes between computer-assisted and conventional fibula free flap techniques for craniofacial reconstruction. A two-center, retrospective review was carried out on patients who underwent fibula free flap surgery for craniofacial reconstruction from 2003 to 2012. Patients were categorized by the type of reconstructive technique: conventional (between 2003 and 2009) or computer-aided design/computer-aided manufacturing (from 2010 to 2012). Demographics, surgical factors, and perioperative and long-term outcomes were compared. A total of 68 patients underwent microsurgical craniofacial reconstruction: 58 conventional and 10 computer-aided design and manufacturing fibula free flaps. By demographics, patients undergoing the computer-aided design/computer-aided manufacturing method were significantly older and had a higher rate of radiotherapy exposure compared with conventional patients. Intraoperatively, the median number of osteotomies was significantly higher (2.0 versus 1.0, p=0.002) and the median ischemia time was significantly shorter (120 minutes versus 170 minutes, p=0.004) for the computer-aided design/computer-aided manufacturing technique compared with conventional techniques; operative times were shorter for patients undergoing the computer-aided design/computer-aided manufacturing technique, although this did not reach statistical significance. Perioperative and long-term outcomes were equivalent for the two groups, notably, hospital length of stay, recipient-site infection, partial and total flap loss, and rate of soft-tissue and bony tissue revisions. Microsurgical craniofacial reconstruction using a computer-assisted fibula flap technique yielded significantly shorter ischemia times amidst a higher number of osteotomies compared with conventional

Reconstruction of Heel With Propeller Flap in Postfasciotomy and Popliteal Artery Revascularization State.

PubMed

Kang, Jin Seok; Choi, Hwan Jun; Tak, Min Sung

2016-06-01

Free flaps are still the gold standard for large defects of the lower limb, but propeller perforator flaps have become a simpler and faster alternative to free flaps because of some advantages such as reliable vascular pedicle, wide mobilization and rotation, great freedom in design, low donor site morbidity, and easy harvest with no requirement for anastomosis. But when the vessels show insufficient findings in preoperative evaluation using a Doppler probe or the vessel is injured, the surgeon should avoid performing free flap surgery to prevent flap failure and should select a propeller perforator flap as an alternative method on the condition that more than one perforator is intact. In this study, we report reconstruction of soft tissue defects of the heel with a pedicled propeller flap in postfasciotomy and popliteal artery revascularization state by making an incision on the central portion above the Achilles tendon, which can be covered by the posterior tibial artery perforator or the peroneal artery perforator based flaps. In conclusion, we showed that although the popliteal artery was injured, the soft tissue defect can be reconstructed using a perforator propeller flap if intact distal flow in the anastomosis site was confirmed. © The Author(s) 2015.

Lower lip reconstruction with nasolabial flap--going back to basics.

PubMed

Coutinho, Inês; Ramos, Leonor; Gameiro, Ana Rita; Vieira, Ricardo; Figueiredo, Américo

2015-01-01

Squamous cell carcinoma of the lower lip is frequent, and radical excision sometimes leads to complex defects. Many lip repair techniques are aggressive requiring general anesthesia and a prolonged post-operative period. The nasolabial flap, while a common flap for the repair of other facial defects, is an under-recognized option for the reconstruction of the lower lip. We describe the use of nasolabial flap for the repair of a large defect of the lower lip in a ninety year-old male, with good functional results and acceptable cosmetic outcome. We believe the nasolabial flap is a good alternative for intermediate-to-large lower lip defects in patients with impaired general condition.

The 'double headed slug flap': a simple technique to reconstruct large helical rim defects.

PubMed

Masud, D; Tzafetta, K

2012-10-01

Reconstructing partial defects of the ear can be challenging, balancing the creation of the details of the ear with scarring, morbidity and number of surgical stages. Common causes of ear defects are human bites, tumour excision and burn injuries. Reconstructing defects of the ear with tube pedicled flaps and other local flaps requires an accurate measurement of size of the defect with little room for error, particularly under estimation. We present a simple method of reconstruction for partial defects of the ear using a two-stage technique with post auricular transposition flaps. This allows for under or over estimation of size defects permitting accurate tissue usage giving good aesthetic outcomes. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

31. LOOKING SOUTHEAST. AS THE TRAM ENTERED THE GRAVITY TRAM ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

31. LOOKING SOUTHEAST. AS THE TRAM ENTERED THE GRAVITY TRAM LINE, IT CROSSED THIS CUT-STONE BRIDGE AND WAS CONTROLLED BY THE SWITCHING PLATFORM IN THE BACKGROUND - Independent Coal & Coke Company, Kenilworth, Carbon County, UT

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes

PubMed Central

Rozen, Warren Matthew; Chowdhry, Muhammad; Patel, Nakul Gamanlal; Chow, Whitney T.H.; Griffiths, Matthew; Ramakrishnan, Venkat V.

2016-01-01

Background Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. Methods A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew’s Centre for Plastic Surgery & Burns from January 2009 to December 2014. Results Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). Conclusions The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits

The Type of Breast Reconstruction May Not Influence Patient Satisfaction in the Chinese Population: A Single Institutional Experience

PubMed Central

Chen, Jiaying; Chen, Ying; Hu, Zhen; Liu, Guangyu; Shen, Zhenzhou; Shao, Zhimin; Wu, Jiong

2015-01-01

Background The goal of this study was to evaluate patient satisfaction with four common types of breast reconstruction performed at our institution: latissimus dorsi myocutaneous (LDM) flap reconstruction with or without implants, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction, and free deep inferior epigastric perforator (DIEP) flap reconstruction. Methods A custom survey consisting of questions that assessed general and aesthetic satisfaction was sent to patients who had undergone breast reconstruction in the last 5 years. The clinical data and details of the surgery were also collected from the patients who returned the surveys. We compared satisfaction rates across the four breast reconstruction types and analyzed the effects of various factors on overall general and aesthetic satisfaction rates using a binary logistic regression model. Result A total of 207 (72%) patients completed the questionnaires. Overall, significant differences in general and aesthetic satisfaction among the four procedures were not observed. A multivariate analysis revealed that the factor “complications” (p = 0.001) played a significant role in general satisfaction and that the factors “> 2 years since reconstruction” (p = 0.043) and “age > 35 years” (p = 0.05) played significant roles in overall aesthetic satisfaction. Conclusion The present study demonstrated that the type of breast reconstruction might not influence satisfaction in Chinese patients. PMID:26562294

Use of the lateral circumflex femoral artery perforator flap in the reconstruction of gunshot wounds to the face.

PubMed

Fernandes, Rui; Lee, Jason

2007-10-01

The reconstruction of large avulsive tissue loss in the head and neck region is one of the most difficult tasks faced by reconstructive surgeons. The advent of free tissue transfer has improved our ability to predictably reconstruct these patients. One of the most recent advances in the field of microvascular surgery is the use of perforator flaps. We have used the lateral circumflex femoral artery perforator (LCFAP) flap for reconstructions in patients who have suffered severe gunshot wounds (GSWs) to the maxillofacial area. A retrospective chart review was conducted of patients treated with a LCFAP flap in our division for large defects of the face resulting from GSWs between July 2005 and July 2006. The patient's age and gender, site and size of defect, and degree of bone and soft tissue loss were recorded. Flap survival and donor site morbidity were noted as outcomes of the reconstruction. Four patients who met the inclusion criteria were identified. The success rate for the flaps was 100%. There was no partial necrosis of the flaps. The size of the defect ranged from 20 x 10 cm to 10 x 10 cm. None of the patients had donor site complications, and all donor sites were closed primarily. Use of the LCFAP flap for the reconstruction of large defects secondary to GSWs to the face is a reliable option for the immediate reconstruction of this patient population. The lateral circumflex femoral artery perforator (LCFAP) flap is at a site not involved in the immediate resuscitation of trauma patients, thus ensuring an intact vascular system. This fact makes the LCFAP flap a reliable source for small to large soft tissues for reconstructing avulsive soft tissue losses in the head and neck.

Immediate reconstruction using free medial circumflex femoral artery perforator flaps after breast-conserving surgery.

PubMed

Izumi, Ken; Fujikawa, Masakazu; Tashima, Hiroki; Saito, Takuya; Sotsuka, Yohei; Tomita, Koichi; Hosokawa, Ko

2013-11-01

Recent advances in perforator flap surgical techniques have allowed for safe and reliable autologous tissue transfer with minimal donor-site morbidity. Between April 2012 and January 2013, we performed immediate breast reconstruction using free medial circumflex femoral artery perforator (MCFAP) flaps in 15 patients after breast-conserving surgery. The flaps were harvested from patients in the lithotomy position, while a second surgical team simultaneously conducted tumour resection. Of the 15 procedures performed, three flaps were dissected as true perforator flaps, while 12 flaps were dissected as muscle-sparing perforator flaps. The mean flap weight was 138.5 g (range, 77-230 g) and the mean pedicle length was 5.7 cm (range, 3.0-9.0 cm). Recipient vessels for anastomosis were serratus branches in 10 patients, internal mammary vessels in three patients and thoracodorsal vessels in two patients. The mean duration of surgery was 6.74 h (range, 5.65-9.45 h). There were no major complications requiring surgical intervention. Researchers observed partial flap necrosis, which manifested as small firm lesions in two patients, as well as local wound infection and dehiscence in one patient, which resolved spontaneously. There were no instances of donor-site seroma formation or lymphoedema in any of the patients. An objective assessment of postoperative photographs showed that cosmetic results were mostly satisfactory. Donor-site scars along the medial groin crease were inconspicuous and readily concealed by clothing. Given its reliable vascularity and minimal donor-site morbidity, the free MCFAP flap can be a good alternative for partial breast reconstruction after breast-conserving surgery. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

THE NASOLABIAL FLAP: THE MOST VERSATILE METHOD IN FACIAL RECONSTRUCTION.

PubMed

Bayer, J; Schwarzmannová, K; Dušková, M; Novotná, K; Kníže, J; Sukop, A

2018-01-01

The nasolabial flap was described 170 years ago and still remains one of the most frequently used methods in facial reconstruction. This technically easy and maximally effective procedure has become a real workhorse and an integral instrument for every plastic surgeon. Over time multiple modifications of this technique have been described. In this article, authors present an overview of nasolabial flap modalities and discuss advantages and disadvantages of these techniques.

[Reconstruction of ankle and foot with combination of free perforator flaps and skin graft].

PubMed

Yin, Lu; Gong, Ketong; Yin, Zhonggang; Zhang, Bo; Xu, Jianhua

2017-03-01

To evaluate the clinical outcomes of free perforator flaps combined with skin graft for reconstruction of ankle and foot soft tissue defects. Between June 2014 and October 2015, 20 cases of ankle and foot soft tissue defects were treated. There were 16 males and 4 females, aged from 19 to 61 years (mean, 43.3 years). Injury was caused by traffic accident in 7 cases, by crashing in 9 cases, and machine twist in 4 cases. The locations were the ankle in 6 cases, the heel in 3 cases, the dorsum pedis in 4 cases, and the plantar forefoot in 7 cases of avulsion injury after toes amputation. The size of wound ranged from 15 cm×10 cm to 27 cm×18 cm. The time from injury to treatment was from 11 to 52 days (mean, 27 days). The anterolateral thigh perforator flap was used in 11 cases, thoracodorsal antery perforator flap in 3 cases, medial sural artery perforator flap in 4 cases, deep inferior epigastric perforator flap in 1 case, and anteromedial thigh perforator flap in 1 case, including 5 chimeric perforator flaps, 5 polyfoliate perforator flaps, 3 flow-through perforator flaps, and 3 conjoined perforator flaps. The size of the perforator flap ranged from 10.0 cm×6.5 cm to 36.0 cm×8.0 cm, the size of skin graft from 5 cm×3 cm to 18 cm×12 cm. Venous crisis occurred in 2 flaps which survived after symptomatic treatment; 18 flaps survived successfully and skin grafting healed well. The follow-up time ranged 4-18 months (mean, 8.3 months). The flaps had good appearance, texture and color, without infection. The patients could walk normally and do daily activities. Only linear scars were observed at the donor sites. Free perforator flap can be used to reconstruct defects in the ankle and foot, especially in the weight-bearing area of the plantar forefoot. A combination of free perforator flap and skin graft is ideal in reconstruction of great soft tissue defects in the ankle and foot.

A Nationwide Analysis of Cost Variation for Autologous Free Flap Breast Reconstruction.

PubMed

Billig, Jessica I; Lu, Yiwen; Momoh, Adeyiza O; Chung, Kevin C

2017-11-01

Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown. To investigate factors that influence cost variation for autologous free flap breast reconstruction. A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction. Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost. A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22 677 (interquartile range, $14 907-$33 391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24 360 vs $18 918, P < .001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[β], 1.06; 95% CI, 1.02-1.11; P = .003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P < .001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P < .001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28�

Reconstruction of posterior neck and skull with vertical trapezius musculocutaneous flap

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mathes, S.J.; Stevenson, T.R.

1988-10-01

The vertical trapezius musculocutaneous flap has been successfully utilized for reconstruction in 13 patients with complex posterior skull and neck defects. This flap based on its vascular pedicle, the descending branch of the transverse cervical artery, provides well-vascularized tissue for coverage of defects related to chronic osteomyelitis, tumor extirpation, osteoradionecrosis, and dehisced cervical laminectomy wounds. Emphasis on flap design, including the location of the skin island, allows adequate wound coverage, direct donor site closure, and muscle function preservation. With its large size and wide arc of rotation, the vertical trapezius musculocutaneous flap provides reliable coverage for posterior trunk, cervical, andmore » skull defects.« less

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment

PubMed Central

2012-01-01

Background Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue. Methods Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery. Results No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely. Conclusion This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled. PMID:22559860

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment.

PubMed

Mori, Stefano; Di Monta, Gianluca; Marone, Ugo; Chiofalo, Maria Grazia; Caracò, Corrado

2012-05-06

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue. Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery. No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely. This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled.

Immediate reconstruction of maxillectomy defects using anterolateral thigh free flap in patients from a low resource region.

PubMed

Liu, Wei Wei; Peng, Han Wei; Guo, Zhu Ming; Zhang, Quan; Yang, An Kui

2012-11-01

To report the reliability and reconstructive outcome of using anterolateral thigh (ALT) flap with or without titanium mesh to repair maxillectomy defects in a patient from a low resource region (LRR). Retrospective review. Clinical data of patients with oral-maxillofacial cancers who underwent maxillectomy and reconstruction using ALT flap in two tertiary cancer centers in southern China were retrospectively reviewed. Reconstructive techniques, flap survival, postoperative oral functions, and surgical complications were reported. Apart from one total flap loss, 18 of the 19 free ALT flaps survived. Titanium mesh was used in two patients with total maxillectomy defects. Eighteen of the 19 patients resumed a normal oral diet. Fourteen patients had good speech, except one patient with poor pronunciation, and four patients had average speech. One patient presented with postoperative palatal fistula. No other complications were observed. The application of ALT flaps with or without titanium mesh to repair maxillectomy defects is straightforward and reliable and has an acceptable reconstructive outcome. It might be a suitable procedure for patients from an LRR. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

The Medial Sural Artery Perforator Flap: The First Choice for Soft-Tissue Reconstruction About the Knee.

PubMed

Ling, Barbara M; Wettstein, Reto; Staub, Daniel; Schaefer, Dirk J; Kalbermatten, Daniel F

2018-02-07

The gastrocnemius muscle flap may be considered the first choice in many cases of soft-tissue reconstruction about the knee. Limited arc of rotation and reach of the flap as well as unsightly muscle bulk are major disadvantages and were the impetus to look for a local alternative. The aim of this study is to present a consecutive series of patients with a reconstruction about the knee involving the medial sural artery perforator flap (MSAPF). A consecutive series of 17 cases of defect reconstructions about the knee using the MSAPF is described, with an emphasis on early postoperative complications. No major flap-related complications occurred except 1 case of tip necrosis that healed uneventfully after excision and secondary suture. Two patients with direct donor-site closure had a minor complication that required no revision, and 2 had partial skin-graft loss. In summary, use of this pedicled perforator flap represents a reliable technique for soft-tissue reconstruction about the knee with an acceptable complication rate and optimal contour reconstruction without the need for a skin graft and secondary debulking procedures. The range of motion associated with the MSAPF in comparison to the range associated with the gastrocnemius muscle flap is increased so that more proximal and lateral defects can be covered. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients.

PubMed

Santanelli Di Pompeo, Fabio; Longo, Benedetto; Pagnoni, Marco; Laporta, Rosaria

2015-05-01

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh. © 2014 Wiley Periodicals, Inc.

Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap.

PubMed

Løve, Uffe S; Sjøgren, Pia; Rasmussen, Peter; Laurberg, Søren; Christensen, Henrik K

2013-02-01

The use of the vertical rectus abdominis myocutaneous flap in reconstruction after abdominoperineal resection or pelvic exenteration for neoplasia is well documented. However, functional outcomes after vaginal reconstruction, including sexual function, are poorly described. This study aimed to examine sexual function in women following extensive pelvic surgery with colpectomy and vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap. This study is a retrospective review of medical records in combination with patient questionnaires. Nonresponders were followed up with a second contact. This study was performed at a tertiary care university medical center (Colorectal Section, Department of Surgery P, Aarhus University Hospital, Denmark) All women undergoing pelvic surgery and simultaneous vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap between 2004 and 2010 at our department were identified from a patient database. Thirty women who were alive at the time of identification were included in the study. Sexual function before and after surgery was evaluated by the use of the Sexual function Vaginal changes Questionnaire. The main outcome end point was whether the patient was sexually active after vaginal reconstruction. Twenty-six participants (87%) answered the questionnaire. Fifty percent of patients reported an active sex life before surgery. In general, patients reported an unchanged desire for both physical and sexual contact after surgery. However, only 2 patients (14%) reported being sexually active after surgery. This was a retrospective study with a heterogeneous cohort involving several types of cancers and surgical procedures. Factors other than vertical rectus abdominis myocutaneous flap reconstruction itself may interfere with the sexual function. Extensive pelvic surgery with colpectomy leads to sexual dysfunction even when the vagina is reconstructed with a vertical rectus abdominis

Scalp Reconstruction With Free Latissimus Dorsi Flap in a Patient With Giant Cutis Verticis Gyrata.

PubMed

Mutlu, Ozay Ozkaya; Colak, Ozlem; Canli, Mert; Akcay, Ayberk

2016-09-01

Cutis verticis gyrata is a rare skin disorder characterized by formation of thick skin folds and grooves. Because of the risk of malignant transformation, these lesions must be surgically excised. In this study, the authors aimed to present a successful reconstruction of scalp with free latissimus dorsi musculocutaneous flap after total excision of giant cerebriform intradermal nevus that causes cutis verticis gyrata. An 18-year-old male patient attended to our clinic with a large tumor that covers almost 80% of his scalp. Lesion is diagnosed as cerebriform intradermal nevus. Excision of the tumor and scalp reconstruction with free latissimus dorsi musculocutaneous flap is planned and the patient is operated. Free tissue transfer is one of the best choices for full thickness defects that covers 80% of scalp with its excellent reconstructive and aesthetical results. Reconstruction with free flaps reduces the number of operations necessary to cover the defect unlike serial tissue expansion or staged excision methods. Free flaps are also a good alternative when the patient has not enough hair-bearing tissue to expand. Low donor site morbidity also makes free latissimus dorsi musculocutaneous flaps excellent choice. Cerebriform intradermal nevus is one of the most common causes of cutis verticis gyrata and has an importance due to the current risk of malign transformation. Latissimus dorsi musculocutaneous free flap is a reliable and aesthetically acceptable reconstruction option in the patients of giant cutis verticis gyrata due to sufficient pedicle length, reliable vascularized tissue volume, and large surface area.

Magnitude of Myocutaneous Flaps and Factors Associated With Loss of Volume in Oral Cancer Reconstructive Surgery.

PubMed

Sakamoto, Yuki; Yanamoto, Souichi; Ota, Yoshihide; Furudoi, Shungo; Komori, Takahide; Umeda, Masahiro

2016-03-01

Myocutaneous flaps are often used to repair oral and maxillofacial defects after surgery for oral cancer; however, their volume decreases during the postoperative period. To facilitate treatment planning, the authors measured the extent of such postoperative flap volume loss and identified associated factors in patients who underwent oral reconstruction with myocutaneous flaps. The authors designed and performed a retrospective observational study of patients who underwent reconstructive procedures involving rectus abdominal myocutaneous (RAM) or pectoralis major myocutaneous (PMMC) flaps at Tokai University Hospital, Kobe University Hospital, or Nagasaki University Hospital from April 2009 through March 2013. Flap type and other clinical variables were examined as potential predictors of flap loss. The primary outcome was flap loss at 6 months postoperatively. Correlations between each potential predictor and the primary outcome were examined using multiple regression analysis. The subjects were 75 patients whose oral defects were reconstructed with RAM flaps (n = 57) or PMMC flaps (n = 18). RAM flaps exhibited a mean volume shrinkage of 22% at 6 months postoperatively, which was less than the 27.5% displayed by the PMMC flaps, but the difference was not important. Renal failure, previous surgery of the oral region, postoperative radiotherapy, and postoperative serum albumin level were found to be meaningful risk factors for postoperative flap volume loss. The results of this study suggest that larger flaps should be used in patients who possess these risk factors or are scheduled to undergo postoperative radiotherapy. Future studies should examine the utility of postoperative nutritional management for preventing flap volume loss. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

The Extended Nasoseptal Flap for Skull Base Reconstruction of the Clival Region: An Anatomical and Radiological Study

PubMed Central

Peris-Celda, Maria; Pinheiro-Neto, Carlos Diogenes; Funaki, Takeshi; Fernandez-Miranda, Juan C.; Gardner, Paul; Snyderman, Carl; Rhoton, Albert L.

2013-01-01

Objective Reconstruction of large clival defects after an endoscopic endonasal procedure is challenging. The objective is to analyze the morphology, indications, and limitations of the extended nasoseptal flap, which adds the nasal floor and inferior meatus mucosa, compared with the standard nasoseptal flap, for clival reconstruction. Design Twenty-seven sides of formalin-fixed anatomical specimens and 13 computed tomography (CT) scans were used. Under 0-degree endoscopic visualization, a standard flap on one side and an extended flap on the other side were performed, as well as exposure of the sella, cavernous sinus, and clival dura mater. Coverage of both flaps was assessed, and they were incised and extracted for measurements. Results The extended flap has two parts: septal and inferior meatal. The extended flaps are 20 mm longer and add 774 mm2 of mucosal area. They cover a clival defect from tuberculum to foramen magnum in 66.6% cases and from below the sella in 91.6%. They cover both parasellar and paraclival segments of the internal carotid arteries. The lateral inferior limits are the medial aspect of the hypoglossal canals and Eustachian tubes. CT scans can predict the need or limitation of an extended nasoseptal flap. Conclusions The nasal floor and inferior meatus mucosa adds a significant area for reconstruction of the clivus. A defect laterally beyond the hypoglossal canals is not likely covered with this variation of the flap. Preoperative CT scans are useful to guide the reconstruction techniques. PMID:24436940

Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP).

PubMed

Chaput, B; Gandolfi, S; Ho Quoc, C; Chavoin, J-P; Garrido, I; Grolleau, J-L

2014-02-01

In recent years, perforator flaps have become an indispensable tool for the reconstruction process. Most recently, "propeller" perforator flaps allow each perforator vessels to become a flap donor site. Once the perforator of interest is identified by acoustic Doppler, the cutaneous or fascio-cutaneous island is designed and then customized according to the principle of "perforasome". So, the flap can be rotated such a propeller, up to 180°. Ideally the donor site is self-closing, otherwise it can be grafted at the same time. Through a skin necrosis secondary to a contrast medium extravasation of the cubital fossa in a 47-year-old man, we describe the use of propeller perforator flap based on a perforator of the radial collateral artery (RCAP). The perforator was identified preoperatively by acoustic Doppler then the flap was adapted bespoke to cover the loss of substance. Ultimately, the result was very satisfying. Well experienced for lower-extremity reconstruction, perforator-based propeller flap are still few reported for upper limb. It is likely that in the future, propeller flap supersede in many indication not only free flaps and locoregional flaps but also, leaving no room for uncertainties of the vascular network, the classic random flaps. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap.

PubMed

Santanelli, Fabio; Longo, Benedetto; Angelini, Matteo; Laporta, Rosaria; Paolini, Guido

2011-05-01

The deep inferior epigastric perforator (DIEP) flap is considered the definitive standard for autologous breast reconstruction because of its ability to restore shape, its consistency, and its static and dynamic symmetry, but the degree of spontaneous sensory recovery is still widely discussed. To clarify the real need for sensitive nerve coaptation, return of sensibility in DIEP flaps was investigated using a pressure-specifying sensory device. Thirty consecutive patients with breast cancer scheduled for modified radical mastectomy, axillary node dissection, and immediate reconstruction with cutaneous-adipose DIEP flaps without nerve repair were enrolled in the study. Sensibility for one and two points, static and moving, was tested preoperatively on the breasts and abdomen, and postoperatively at 6 and 12 months on the DIEP flaps. A t test was used for comparison of paired data and to investigate which factors affected sensory recovery. Preoperative healthy breast and abdomen pressure thresholds were lower for two-point than one-point discrimination and for moving discriminations compared with static ones at 6 and 12 months. Although they were significantly higher than those for contralateral healthy breasts (p < 0.05), pressure thresholds in DIEP flaps at 12 months were lower than at 6 months, showing a significant progressive sensory recovery (p < 0.05). At 12 months postoperatively, the best sensibility recovery was found at the inferior lateral quadrant, the worst at the superior medial quadrant. Age and flap weight were factors related to the performance of sensory recovery. DIEP flap transfer for immediate breast reconstruction undergoes satisfactory progressive spontaneous sensitive recovery at 6 and 12 months after surgery, and operative time spent dissecting sensitive perforator branches and their coaptation in recipient site could be spared.

Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps.

PubMed

Koshima, Isao; Nanba, Yuzaburo; Nagai, Atsushi; Nakatsuka, Mikiya; Sato, Toshiki; Kuroda, Shigetosi

2006-04-01

The free radial forearm flap is a very common material for penile reconstruction. Its major problems are donor-site morbidity with large depressive scar after skin grafting, urethral fistula due to insufficiency of suture line for the urethra, and need for microvascular anastomosis. A new method using combined bilateral island SCIP flaps for the urethra and penis is developed for gender identity disorder (GID) patients. The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.

Zygomatico-maxillary Reconstruction with Computer-aided Manufacturing of a Free DCIA Osseous Flap and Intraoral Anastomoses.

PubMed

Roy, Andrée-Anne; Efanov, Johnny I; Mercier-Couture, Geneviève; Chollet, André; Borsuk, Daniel E

2017-02-01

Craniomaxillofacial reconstruction using virtual surgical planning, computer-aided manufacturing, and new microsurgical techniques optimizes patient-specific and defect-directed reconstruction. A 3D customized free deep circumflex iliac artery (DCIA) flap with intraoral anastomoses was performed on a 23-year-old man with a posttraumatic right zygomatico-maxillary defect with failure of alloplastic implant reconstruction. An osseous iliac crest flap was sculpted based on a customized 3D model of the mirror image of the patient's unaffected side to allow for perfect fit to the zygomatico-maxillary defect. An intraoral dissection of the facial artery and vein was performed within the right cheek mucosa and allowed for end-to-end microvascular anastomoses. 3D preoperative planning and customized free DCIA osseous flap combined with an intraoral microsurgical technique provided restoration of facial esthetics and function without visible scars. In cases where zygomatico-malar reconstruction by alloplastic material fails, a customized free DCIA osseous flap can be designed by virtual surgical planning to restore facial appearance and function.

Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note.

PubMed

Dolci, Ricardo Landini Lutaif; Todeschini, Alexandre Bossi; Santos, Américo Rubens Leite Dos; Lazarini, Paulo Roberto

2018-04-19

One of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. Describe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. Step by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. Both patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. This endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches. Copyright © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Reliability of extended dorsal intercostal artery perforator propeller flaps for reconstruction of large myelomeningocele defects.

PubMed

Tenekeci, Goktekin; Basterzi, Yavuz

2017-01-01

Reconstruction of large myelomeningocele defects using extended (elongated beyond the lateral margin of the latissimus dorsi muscle) dorsal intercostal artery perforator (DICAP) propeller flaps is not recommended by previous studies. However, to provide tension-free and successful closure of a defect, the DICAP propeller flaps must sometimes be elongated beyond this margin. Our experience and results in this issue are discussed. In this article, reconstruction of 11 consecutive cases, with large myelomeningocele defects in which standard DICAP propeller flaps were incapable to close the defect, was achieved using extended DICAP propeller flaps between June 2013 and November 2015. At least two reliable perforators of the neighboring intervertebral spaces are included to supply the flap. Intramuscular dissection of perforators is performed to free the perforators from the surrounding muscle and to gain pedicle length as much as possible to prevent twisting and vascular compromise. All the flaps survived completely except for one patient who had superficial skin necrosis on the most distal part of the flap and had severe accompanying systemic disorders and died on postoperative 14th day. In 7 of 11 patients, venous congestion was noted, which resolved spontaneously. No hematoma or seroma formation was observed during the postoperative follow-up period. Dissection of multiple DICAPs supplying flaps enable us to harvest larger DICAP flaps possibly by providing better arterial supply and venous drainage. We use microsurgical instruments and 4.3× loupe magnification for pedicle dissection in this newborn population. This study shows the reliability of extended DICAP propeller flaps when multiple perforators at sixth or more cranial adjacent intercostal spaces are included in DICAP propeller flaps. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The trapezius perforator flap: an underused but versatile option in the reconstruction of local and distant soft-tissue defects.

PubMed

Sadigh, Parviz L; Chang, Li-Ren; Hsieh, Ching-Hua; Feng, Wen-Jui; Jeng, Seng-Feng

2014-09-01

The trapezius myocutaneous flap is an established reconstructive option in head and neck cases The authors present their experience with 10 trapezius perforator flaps, all raised using a freestyle technique of perforator dissection, to successfully reconstruct both local and distant soft-tissue defects. Ten patients underwent soft-tissue reconstruction using trapezius perforator flaps. After mapping the perforator with a handheld Doppler device at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back, perforator flaps were raised in a freestyle fashion, with complete preservation of the trapezius muscle. The flap can be pedicled into local defects or transferred as a free flap. Six flaps were elevated as pedicled flaps and four were transferred as free flaps. Flap size ranged from 6 × 4 cm to 25 × 15 cm. The pedicle length ranged from 4 to 14 cm. The pedicle originated from the dorsal scapular artery. In one case, the authors converted from a pedicled flap to a free flap secondary to insufficient pedicle length. All donor sites were closed directly. The follow-up period ranged from 4 months to 4 years. All of the flaps survived completely with no major complications, and no patients developed any shoulder dysfunction. The trapezius perforator flap is a reliable and versatile reconstructive option that can be used to repair both local and distant soft-tissue defects. The donor-site morbidity is minimal. Therapeutic, IV.

The midline-based nasolabial transposition (MNT) flap: an original single-stage technique for nasal tip reconstruction.

PubMed

Beustes-Stefanelli, Matthieu; O'Toole, Greg; Schertenleib, Pierre

2015-04-01

Nasolabial flaps based on the lateral side of the nose for the reconstruction of lateral nasal defects in a single-stage procedure have been described. Similarly, in midline defects, nasolabial flaps can be used but a 2-stage procedure is classically required. The Midline-based Nasolabial Transposition (MNT) flap is presented as a new single-stage procedure for nasal tip reconstruction. Between 2009 and 2011, an MNT flap was used as a single-stage procedure in 3 cases of large nasal defects of the tip where the forehead flap was either contraindicated or rejected as an option by the patient. There were no complications and a satisfactory aesthetic result was achieved in all cases. The MNT flap is a new single-stage procedure for large nasal tip defects and as such represents an interesting alternative to the classical 2-stage forehead and nasolabial flaps, especially in elderly patients.

Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation.

PubMed

Santanelli, Fabio; Tenna, Stefania; Pace, Andrea; Scuderi, Nicolò

2002-06-01

The authors present a retrospective study on major plantar foot reconstruction to evaluate the role of the free fasciocutaneous flap and the importance of sensory nerve reconstruction in improving long-term results. Between 1995 and 1999, 20 patients with major defects of the sole of the foot underwent free forearm flap reconstruction performed by the senior author (F.S.). Sensory nerve reconstruction was added to this technique in 1997. The age and sex of the patients and the cause, location, and dimensions of their defects were recorded. The patients were clinically and neurophysiologically evaluated at 3, 6, and 12 months after the procedure for the following parameters: flap contour, flap stability, load capacity, walking ability, touch sensation, pain sensation, static two-point discrimination, and thermal sensibility. Dermatomic somatosensory-evoked potentials were also tested at 12 months. Follow-up ranged from 1 to 5 years. Patients were divided into two groups according to sensory nerve reconstruction. Group A consisted of 11 patients with nerve repair, and group B consisted of nine patients without nerve repair. One patient from group A who had an idiopathic neuropathy was excluded from the study because of interference with the reinnervation process. Five more patients (three from group A and two from group B) were lost at follow-up and excluded from the study. The final sample size in each group was seven. Data from both groups were compared and statistically analyzed with the Mann-Whitney test and the Fisher exact test. Long-term results confirmed in all reconstructions long-lasting stability. During the first postoperative year, patients with sensory nerve reconstruction showed better sensibility. The statistical analyses confirmed significant differences between the two groups to be dependent upon surgical technique at 3 and 6 months. Two-point discrimination and dermatomic somatosensory-evoked potentials were recorded. After 12 months, flaps without

The scarless latissimus dorsi flap provides effective lower pole prosthetic coverage in breast reconstruction.

PubMed

Lee, Mark A; Miteff, Kirstin G

2014-05-01

The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis. A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions. Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0). Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices.

Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for reconstruction in recurrent oral and oropharyngeal cancer.

PubMed

Chen, Wei-Liang; Wang, You-Yuan; Zhang, Da-Ming; Fan, Song; Lin, Zhao-Yu

2016-04-01

The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF). A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs. The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group. Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconstruction of major defects. © 2015 Wiley Periodicals, Inc. Head Neck 38: E159-E164, 2016. © 2015 Wiley Periodicals, Inc.

Reconstruction of Knee Defects Using Pedicled Gastrocnemius Muscle Flap with Split-Thickness Skin Grafting: A Single Surgeon's Experience with 21 Patients.

PubMed

Kilic, Ali; Denney, Brad; de la Torre, Jorge

2018-05-31

Generally, reconstruction of knee defects with exposed bone, joint, tendon, and/or hardware requires a vascularized muscle flap for coverage. Although there are several surgical options for a knee defect reconstruction, the pedicled gastrocnemius muscle still remains the workhorse flap. Although this flap is commonly used for knee defect reconstruction and the technique is described very well, there is an absence of information in the literature detailing the technique of harvesting and insetting of the gastrocnemius flap step by step with illustrations. The purpose of this article is to describe in detail the technique to reconstruct defects of the knee with pedicled gastrocnemius muscle flap as well as to present demographics and surgical results of 21 patients who had knee reconstruction with a pedicled gastrocnemius muscle flap and split-thickness skin grafting. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Optimization of breast reconstruction results using TMG flap in 30 cases: Evaluation of several refinements addressing flap design, shaping techniques, and reduction of donor site morbidity.

PubMed

Nickl, Stefanie; Nedomansky, Jakob; Radtke, Christine; Haslik, Werner; Schroegendorfer, Klaus F

2018-01-31

The transverse myocutaneous gracilis (TMG) flap is a widely used alternative to abdominal flaps in autologous breast reconstruction. However, secondary procedures for aesthetic refinement are frequently necessary. Herein, we present our experience with an optimized approach in TMG breast reconstruction to enhance aesthetic outcome and to reduce the need for secondary refinements. We retrospectively analyzed 37 immediate or delayed reconstructions with TMG flaps in 34 women, performed between 2009 and 2015. Four patients (5 flaps) constituted the conventional group (non-optimized approach). Thirty patients (32 flaps; modified group) underwent an optimized procedure consisting of modified flap harvesting and shaping techniques and methods utilized to reduce denting after rib resection and to diminish donor site morbidity. Statistically significant fewer secondary procedures (0.6 ± 0.9 versus 4.8 ± 2.2; P < .001) and fewer trips to the OR (0.4 ± 0.7 versus 2.3 ± 1.0 times; P = .001) for aesthetic refinement were needed in the modified group as compared to the conventional group. In the modified group, 4 patients (13.3%) required refinement of the reconstructed breast, 7 patients (23.3%) underwent mastopexy/mammoplasty or lipofilling of the contralateral breast, and 4 patients (13.3%) required refinement of the contralateral thigh. Total flap loss did not occur in any patient. Revision surgery was needed once. Compared to the conventional group, enhanced aesthetic results with consecutive reduction of secondary refinements could be achieved when using our modified flap harvesting and shaping techniques, as well as our methods for reducing contour deformities after rib resection and for overcoming donor site morbidities. © 2017 Wiley Periodicals, Inc.

Bilateral Distraction Osteogenesis of Vascularized Iliac Crest Free Flaps Used in Mandibular Reconstruction

PubMed Central

Subramaniam, Shiva S.; Vujcich, Nathan J.; Nastri, Alf L.

2016-01-01

Summary: Vascularized free flaps have become the gold standard in reconstructing large segmental mandibular defects; however, even when bony union and soft-tissue coverage is achieved, insufficient bone stock and altered facial contour can create functional and cosmetic problems for the patient. There have been limited case reports on the use of secondary distraction osteogenesis to address these issues. The authors report a case of bilateral mandibular distraction of deep circumflex iliac artery free flaps, used for mandibular reconstruction after total mandibulectomy for treatment of osteosarcoma. Performed for reasons of retrognathia and facilitation of dental prosthetic rehabilitation, this is the first case of bilateral horizontal distraction osteogenesis of deep circumflex iliac artery free flaps reported in the literature. PMID:27257565

Lateral orbital propeller flap technique for reconstruction of the lower eyelid defect.

PubMed

Ding, J-P; Chen, B; Yao, J

2018-05-01

The lower eyelid, which has a unique anatomy and esthetic importance, is a common site of basal cell carcinoma. The reconstruction of the defect after the wide excision of the tumour is a special concern of many plastic surgeons. How to achieve the most satisfying effect through minimal invasive is important for patients. We successfully applied the lateral orbital propeller flap for one-stage reconstruction of a large lower eyelid defect after tumour resection. We consider that this flap can achieve better tissue mobilisation as it provides effective coverage of soft tissue defects and thus is especially useful for repairing facial defects.

The Use of Harmonic Scalpel for Free Flap Dissection in Head and Neck Reconstructive Surgery

PubMed Central

Albert, Sebastien; Guedon, Charles; Halimi, Caroline; Cristofari, Jean Pierre; Barry, Beatrix

2012-01-01

Surgeons conventionally use electrocautery dissection and surgical clip appliers to harvest free flaps. The ultrasonic Harmonic Scalpel is a new surgical instrument that provides high-quality dissection and hemostasis and minimizes tissue injury. The aim of this study was to evaluate the effectiveness and advantages of the ultrasonic Harmonic Scalpel compared to conventional surgical instruments in free flap surgery. This prospective study included 20 patients who underwent head and neck reconstructive surgery between March 2009 and May 2010. A forearm free flap was used for reconstruction in 12 patients, and a fibular flap was used in 8 patients. In half of the patients, electrocautery and surgical clips were used for free flap harvesting (the EC group), and in the other half of the patients, ultrasonic dissection was performed using the Harmonic Scalpel (the HS group). The following parameters were significantly lower in the HS group compared to the EC group: the operative time of flap dissection (35% lower in the HS group), blood loss, number of surgical clips and cost of surgical materials. This study demonstrated the effectiveness of the Harmonic Scalpel in forearm and fibular free flap dissections that may be extended to other free flaps. PMID:22693666

Long-term outcomes of patients with breast cancer after nipple-sparing mastectomy/skin-sparing mastectomy followed by immediate transverse rectus abdominis musculocutaneous flap reconstruction: Comparison with conventional mastectomy in a single center study.

PubMed

Lee, Sae Byul; Lee, Jong Won; Kim, Hee Jeong; Ko, Beom Seok; Son, Byung Ho; Eom, Jin Sup; Lee, Taik Jong; Ahn, Sei-Hyun

2018-05-01

To evaluate the oncological outcomes of patients with breast cancer after nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM), followed by immediate reconstruction, as compared to conventional mastectomy (CM).SSM/NSM has been increasingly used to treat women with breast cancer who wish to preserve the overlying breast skin, but concern exist regarding its oncological safety due to the potential for residual breast tissue. We report our experience performing SSM/NSM for breast cancer treatment compared to CM with a long follow-up period.All consecutive patients who underwent mastectomy for breast cancer at Asan Medical Center between January 1993 and December 2008 were identified by retrospective medical chart review. The patients who underwent NSM/SSM, followed by immediate breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap (TRAM), were compared to the patients who underwent CM in terms of breast-cancer specific survival (BCSS) rate, distant metastasis-free survival (DMFS) rate, and local recurrence (LR) rate.During the study period, 6028 patients underwent mastectomy for breast cancer. Of these, 1032 and 4996 underwent NSM/SSM with TRAM and CM, respectively. Their median follow-up durations were 94.4 (range, 8.1-220.2) and 110.8 (range, 6.1-262.0) months, respectively. Their 5 year BCSS rates were 95.4% and 88.1%, respectively (log-rank, P < .001). Their 5 year DMFS rates were 93.0% and 85.6%, respectively (log-rank, P < .001).Relative to CM, NSM/SSM, followed by immediate breast reconstruction, may be a viable and oncologically safe surgical treatment in selected patients with breast cancer.

Tissue Expander versus Tissue Expander and Latissimus Flap in Morbidly Obese Breast Reconstruction Patients

PubMed Central

Adams, Robert L.; Chandler, Robert G.; Parks, Joseph

2015-01-01

Background: Immediate postmastectomy breast reconstruction in morbidly obese patients represents a challenge because neither prosthetic nor abdominal-based options may be suitable. Methods: This study compared a previously published cohort of immediate prosthetic reconstruction of 346 patients (511 breasts) of whom 49 patients (67 breasts) were morbidly obese (defined as a body mass index > 35) with a morbidly obese patient population whose breasts were reconstructed immediately following postmastectomy with latissimus flap and tissue expander (21 patients and 22 breasts) in the same time period. The preoperative risk factors of mastectomy such as tobacco use, diabetes, and prior radiation and the postoperative complications of mastectomy such as skin necrosis, seroma, and prosthesis loss were examined. The explantation of the tissue expander provided a defined endpoint of reconstruction failure. Results: The average body mass index in the tissue expander/implant group and in the latissimus flap plus tissue expander/implant group was 40.9 and 40.1, respectively. The risk profile of diabetes and tobacco use was similar in both groups. Fifteen of the 67 breasts (22.3%) of the tissue expander/implant group and 15 of the 23 breasts (65.2%) of the latissimus flap group had received prior radiation. The prosthesis loss was 13 of 67 breasts (19.4%) that had tissue-expander–alone reconstruction and 1 of 22 (4.8%) in the latissimus group that had tissue expander reconstruction. Modification of donor-site incision and skin-island location in the latissimus group of patients can minimize scar deformity. Conclusion: The loss rate in immediate postmastectomy reconstruction in morbidly obese patients with latissimus flap plus tissue expander was substantially lower than the loss rate in those with breast reconstructed with tissue expander alone. PMID:25878934

Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator Flap.

PubMed

Hunsinger, Vincent; Lhuaire, Martin; Haddad, Kevin; Wirz, Francesco-Saverio; Abedalthaqafi, Samah; Obadia, Déborah; Derder, Mohamed; Marchac, Alexandre; Benjoar, Marc David; Hivelin, Mikael; Lantieri, Laurent

2018-06-02

 The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small- and medium-sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience.  In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those ( n  = 17) of a bra cup greater than or equal to C who underwent 21 fleur-de-lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups.  The average flap weight was 480 g (range: 340-735 g) for the fleur-de-lys PAP flap group compared with 222 g (range: 187-325 g) for the horizontal PAP flap procedure ( p  < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur-de-lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur-de-lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group ( NS ). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group ( NS ).  The fleur-de-lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium- or large-sized breasts, the fleur-de-lys PAP flap seems to be ideal when a DIEP flap

Tram-related trauma in Melbourne, Victoria.

PubMed

Mitra, Biswadev; Al Jubair, Jubair; Cameron, Peter A; Gabbe, Belinda J

2010-08-01

To establish the incidence and pattern of injuries in patients presenting to hospital with tram-related injuries. Data on tram-related injury pertaining to 2001-2008 calendar years were extracted from three datasets: the population-based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram-related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P = 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P = 0.006) with pedestrians accounting for most major trauma cases. Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.

Flap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures.

PubMed

Ovaska, Mikko T; Madanat, Rami; Tukiainen, Erkki; Pulliainen, Lea; Sintonen, Harri; Mäkinen, Tatu J

2014-12-01

The aim of the present study was to determine the outcome for patients treated with flap reconstruction following deep ankle fracture infection with exposed hardware. Out of 3041 consecutive ankle fracture operations in 3030 patients from 2006 to 2011, we identified 56 patients requiring flap reconstruction following deep infection. Thirty-two of these patients could be examined at a follow-up visit. Olerud-Molander Ankle (OMA) score, 15D score, Numeric Rating Scale (NRS), and clinical examination were used to assess the outcome. A total of 58 flap reconstructions were performed in 56 patients with a mean age of 57 years (range 25–93 years) and mean follow-up time of 52 months. The most commonly used reconstruction was a distally based peroneus brevis muscle flap with a split-thickness skin graft. A microvascular free flap was required in only one patient. 22 (39%) patients required subsequent surgical interventions because of a flap-related complication. With flap reconstruction, hardware could eventually be salvaged in 53% of patients with a non-consolidated fracture. The mean OMA score was fair or poor in 53% of the patients, and only 56% had recovered their pre-injury level of function. Half of the patients had shoe wear limitations. The 15D score showed a significantly poorer health-related quality of life compared to an age-standardised sample of the general population. The mean pain NRS was 2.1 (range 0–6), and the mean satisfaction NRS was 6.6 (range 0–10). Our study showed that successful treatment of a soft-tissue defect with exposed hardware following ankle fracture infections can be achieved with local flaps. Despite eventual reconstructive success, complications are common. Patients perceive a poorer health-related quality of life, have shoe wear limitations, and only half of them achieve their pre-injury level of function.

[Muscle-sparing latissimus dorsi flap. Vascular anatomy and indications in breast reconstruction].

PubMed

Mojallal, A; Saint-Cyr, M; Wong, C; Veber, M; Braye, F; Rohrich, R

2010-04-01

The muscle-sparing latissimus dorsi flap pedicled on descending branch presents distinct advantages in breast reconstruction, specially when there is a transversely oriented skin paddle, including reduced donor site morbidity, sparing muscle function and greater freedom of orientation of the skin paddle. This study reports the anatomical basis, surgical technique, advantages and complications of this technique. Four clinical cases illustrate surgical indications in breast reconstructive surgery. An anatomical cadaveric study underwent to University of Texas Southwestern Medical Center, Dallas. The goal was performed to determine the location of the bifurcation of the thoracodorsal artery and the course of its descending branch compare to the anterior side of latissimus dorsi muscle. Four clinical cases illustrated indications of muscle-sparing latissimus dorsi flap pedicled on descending branch in breast reconstruction. These cases showed advantages and complications of the technique, and impact on donor site. Fifteen descending branch muscle-sparing latissimus dorsi flaps were harvested. All flaps had a bifurcation of the thoracodorsal artery. The average was located at 5,1cm from posterior axillary side (from 2,1 to 7,5 cm) and average of 2,2 cm from the anterior side of latissimus dorsi muscle (from 1,3 to 3,1cm). To 5, 10 and 15 cm from posterior axillary side, the descending branch was located at respectively an average of 2,0 cm (from 1,4 to 2,5), 2,4 cm (from 1,3 to 3,3), and 2,9 cm (from 2,0 to 3,8) behind the anterior side of latissimus dorsi muscle. The average length of descending branch was measured at 15,2 cm (from 13,2 to 19,0). None clinical cases paddle suffering was observed. Donor site morbidity was less than classical or extended adipomuscular technique. Latissimus dorsi muscle function is spared. The muscle-sparing latissimus dorsi flap, pedicled on descending branch, is versatile and reproducible. It results in minimal functional deficit of the

Long-term follow-up study of radial forearm free flap reconstruction after hemiglossectomy.

PubMed

Akashi, Masaya; Hashikawa, Kazunobu; Sakakibara, Akiko; Komori, Takahide; Terashi, Hiroto

2015-01-01

Previous studies on postoperative long-term results in patients who underwent reconstructive free flap transfer following hemiglossectomy had some issues, including the heterogeneity of the patient population and the observation period. The present study aimed to evaluate changes of reconstructed tongues in patients who underwent radial forearm free flap (RFFF) after hemiglossectomy with long-term follow-up. We enrolled 23 patients who underwent RFFF after hemiglossectomy with a postoperative follow-up of 5 years or more. Postoperative status (eating, speech, sensation function) was assessed by concise medical inquiries. Morphological changes of flaps were evaluated by reviewing clinical photographs. Hemiglossectomy involving the base of the tongue was performed in 4 cases (17.4%) and was limited to the mobile tongue in 19 cases (82.6%). The mean follow-up was 85.4 months (range, 60-122 months). All patients experienced gradually improved postoperative status. The most significant improvement was found between 1 and 5 years after surgery (P = 0.007), but not between 1 and 3 years (P = 0.075) or between 3 and 5 years (P = 0.530). In almost all of the flaps, there were few morphological changes throughout the follow-up period. Postoperative status in patients who underwent reconstructive RFFF following hemiglossectomy improved sequentially.

Rethinking the superficial inferior epigastric artery flap in breast reconstruction: Video demonstration of a rapid, reliable harvest technique.

PubMed

Buchel, Edward W; Dalke, Kimberly R; Hayakawa, Thomas Ej

2013-01-01

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.

Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions

PubMed Central

Broome, Martin; Juilland, Naline; Litzistorf, Yann; Monnier, Yan; Sandu, Kishore; Pasche, Philippe; Plinkert, Peter K.; Federspil, Philippe A.

2016-01-01

Background: Complications after head and neck free-flap reconstructions are detrimental and prolong hospital stay. In an effort to identify related variables in a tertiary regional head and neck unit, the microvascular reconstruction activity over the last 5 years was captured in a database along with patient-, provider-, and volume-outcome–related parameters. Methods: Retrospective cohort study (level of evidence 3), a modified Clavien-Dindo classification, was used to assess severe complications. Results: A database of 217 patients was created with consecutively reconstructed patients from 2009 to 2014. In the univariate analysis of severe complications, we found significant associations (P < 0.05) between type of flap used, American Society of Anesthesiologists classification, T-stage, microscope use, surgeon, flap frequency, and surgeon volume. Within a binomial logistic regression model, less frequently versus frequently performed flap (odds ratio [OR] = 3.2; confidence interval [CI] = 2.9–3.5; P = 0.000), high-volume versus low-volume surgeon (OR = 0.52; CI = −0.22 to 0.82; P = 0.007), and ASA classification (OR = 2.9; CI = 2.4–3.4; P = 0.033) were retained as independent predictors of severe complications. In a Cox-regression model, surgeon (P = 0.011), site of reconstruction (P = 0.000), T-stage (P = 0.001), and presence of severe complications (P = 0.015) correlated with a prolonged hospitalization. Conclusions: In this study, we identified a correlation of patient-related factors with severe complications (ASA score) and prolonged hospital stay (T-stage, site). More importantly, we identified several provider- (surgeon) and volume-related (frequency with which a flap was performed and high-volume surgeon) factors as predictors of severe complications. Our data indicate that provider- and volume-related parameters play an important role in the outcome of microvascular free-flap procedures in the head and neck region. PMID:27826458

A propeller flap based on the thoracoacromial artery for reconstruction of a skin defect in the cervical region: a case report.

PubMed

Okada, Mitsuhiro; Ikeda, Mikinori; Uemura, Takuya; Takada, Jun; Nakamura, Hiroaki

2013-05-01

A propeller flap is useful for coverage of an adjacent skin defect without dissection back to source vessels and harvesting muscle tissues. The thoracoacromial artery is one of the vascular pedicles of the flaps for reconstruction in the cervical region. Use of a propeller flap based on the thoracoacromial artery has not previously been reported for reconstruction in the cervical region. We report a case in which a propeller flap based on the thoracoacromial artery was used for skin coverage after tumour resection in the cervical region together with an anatomical investigation. The propeller flap based on the thoracoacromial artery was harvested in the supine position, requiring no change in position after tumour resection. The skin defect was successfully reconstructed using the propeller flap based on the thoracoacromial artery with linear closure of the donor site. The propeller flap based on the thoracoacromial artery offers an alternative for reconstruction in the cervical region. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The Scarless Latissimus Dorsi Flap Provides Effective Lower Pole Prosthetic Coverage in Breast Reconstruction

PubMed Central

Miteff, Kirstin G.

2014-01-01

Background: The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis. Methods: A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions. Results: Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0). Conclusions: Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices. PMID:25289340

Tissue-engineered oral mucosa grafts for intraoral lining reconstruction of the maxilla and mandible with a fibula flap.

PubMed

Sieira Gil, Ramón; Pagés, Carles Martí; Díez, Eloy García; Llames, Sara; Fuertes, Ada Ferrer; Vilagran, Jesús Lopez

2015-01-01

Many types of soft tissue grafts have been used for grafting or prelaminating bone flaps for intraoral lining reconstruction. The best results are achieved when prelaminating free flaps with mucosal grafts. We suggest a new approach to obtain keratinized mucosa over a fibula flap using full-thickness, engineered, autologous oral mucosa. We report on a pilot study for grafting fibula flaps for mandibular and maxilla reconstruction with full-thickness tissue-engineered autologous oral mucosa. We describe 2 different techniques: prelaminating the fibula flap and second-stage grafting of the fibula after mandibular reconstruction. Preparation of the full-thickness tissue-engineered oral mucosa is also described. The clinical outcome of the tissue-engineered intraoral lining reconstruction and response after implant placement are reported. A peri-implant granulation tissue response was not observed when prelaminating the fibula, and little response was observed when intraoral grafting was performed. Tissue engineering represents an alternative method by which to obtain sufficient autologous tissue for reconstructing mucosal oral defects. The full-thickness engineered autologous oral mucosa offers definite advantages in terms of reconstruction planning, donor site morbidity, and quality of the intraoral soft tissue reconstruction, thereby restoring native tissue and avoiding peri-implant tissue complications. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Scapular flap for maxillectomy defect reconstruction and preliminary results using three-dimensional modeling.

PubMed

Modest, Mara C; Moore, Eric J; Abel, Kathryn M Van; Janus, Jeffrey R; Sims, John R; Price, Daniel L; Olsen, Kerry D

2017-01-01

Discuss current techniques utilizing the scapular tip and subscapular system for free tissue reconstruction of maxillary defects and highlight the impact of medical modeling on these techniques with a case series. Case review series at an academic hospital of patients undergoing maxillectomy + thoracodorsal scapula composite free flap (TSCF) reconstruction. Three-dimensional (3D) models were used in the last five cases. 3D modeling, surgical, functional, and aesthetic outcomes were reviewed. Nine patients underwent TSCF reconstruction for maxillectomy defects (median age = 43 years; range, 19-66 years). Five patients (55%) had a total maxillectomy (TM) ± orbital exenteration, whereas four patients (44%) underwent subtotal palatal maxillectomy. For TM, the contralateral scapula tip was positioned with its natural concavity recreating facial contour. The laterally based vascular pedicle was ideally positioned for facial vessel anastomosis. For subtotal-palatal defect, an ipsilateral flap was harvested, but inset with the convex surface facing superiorly. Once 3D models were available from our anatomic modeling lab, they were used for intraoperative planning of the last five patients. Use of the model intraoperatively improved efficiency and allowed for better contouring/plating of the TSCF. At last follow-up, all patients had good functional outcomes. Aesthetic outcomes were more successful in patients where 3D-modeling was used (100% vs. 50%). There were no flap failures. Median follow-up >1 month was 5.2 months (range, 1-32.7 months). Reconstruction of maxillectomy defects is complex. Successful aesthetic and functional outcomes are critical to patient satisfaction. The TSCF is a versatile flap. Based on defect type, choosing laterality is crucial for proper vessel orientation and outcomes. The use of internally produced 3D models has helped refine intraoperative contouring and flap inset, leading to more successful outcomes. 4. Laryngoscope, 127:E8-E14

Relationship between BMI and Postoperative Complications with Free Flap in Anterolateral Craniofacial Reconstruction

PubMed Central

Yagi, Shunjiro; Toriyama, Kazuhiro; Takanari, Keisuke; Fujimoto, Yasushi; Nishio, Naoki; Fujii, Masazumi; Saito, Kiyoshi; Takahashi, Masakatsu; Kamei, Yuzuru

2016-01-01

Background: Although we have seen tremendous advancement in microsurgery over the last 2 decades and free tissue transfer has become standard for head and neck reconstruction, surgeons still struggle to prevent postoperative complications. We examined the relationship between body mass index (BMI) and postoperative complications in patients undergoing rectus abdominis free flap transfer after anterolateral craniofacial resection. Methods: This was a retrospective review of reconstructive surgery using rectus abdominis musculocutaneous free flap in patients with locally advanced maxillary sinus carcinoma from 2003 to 2014 (n = 35, 27 men and 8 women; average age, 60.9 ± 7.8 years). All patients underwent craniofacial reconstruction after anterior and middle cranial fossa skull base resection and maxillectomy (class IV, subtype a) with palatal resection. Patients were categorized based on sex, BMI, and other parameters. Results: Recipient-site infection occurred in 11 patients (31.4%), cerebrospinal fluid leakage in 6 (17.1%), partial flap necrosis in 2 (5.7%), total flap necrosis in 1 (2.9%), and facial fistula in 4 (11.4%). Women showed partial flap necrosis significantly more frequently (P = 0.047), probably owing to poor vascular supply of the subcutaneous fat layer. Patients with low BMI (<20 kg/m2) showed recipient-site infection (P = 0.02) and facial fistula (P = 0.01) significantly more frequently owing to insufficient tissue volume and poor vascular supply. Conclusion: Postoperative recipient-site infection and facial fistula occurred mainly in low-BMI patients. Surgeons should take care to achieve sufficient donor tissue on low-BMI patients. Using a prosthetic obturator in low-BMI patients for craniofacial reconstruction can be a good alternative option to reduce postoperative complications due to insufficient donor tissue volume. PMID:27257566

Effects of nitroglycerin ointment on mastectomy flap necrosis in immediate breast reconstruction: a randomized controlled trial.

PubMed

Gdalevitch, Perry; Van Laeken, Nancy; Bahng, Seokjae; Ho, Adelyn; Bovill, Esta; Lennox, Peter; Brasher, Penelope; Macadam, Sheina

2015-06-01

Mastectomy flap necrosis is a common complication of immediate breast reconstruction that impacts recovery time and reconstructive success. Nitroglycerin ointment is a topical vasodilator that has been shown to improve skin flap survival in an animal model. The objective of this study was to evaluate whether the application of nitroglycerin ointment to the breast skin after mastectomy and immediate reconstruction causes a decrease in the rate of mastectomy flap necrosis compared with placebo. This study was conducted as a randomized controlled trial and included patients aged 21 to 69 years undergoing mastectomy and immediate breast reconstruction at the University of British Columbia-affiliated hospitals (Vancouver, British Columbia, Canada). Patients with a medical history that precluded the administration of nitroglycerin were excluded from the study. The target sample size was 400 patients. Nitroglycerin ointment (45 mg) or a placebo was applied to the mastectomy skin at the time of surgical dressing. The trial was stopped at the first interim analysis after 165 patients had been randomized (85 to the treatment group and 80 to the placebo group). Mastectomy flap necrosis developed in 27 patients (33.8 percent) receiving placebo and in 13 patients (15.3 percent) receiving nitroglycerin ointment; the between-group difference was 18.5 percent (p = 0.006; 95 percent CI, 5.3 to 31.0 percent). Postoperative complications were similar in both groups [nitroglycerin, 22.4 percent (19 of 85); placebo, 28.8 percent (23 of 80)]. In patients undergoing mastectomy and immediate reconstruction, there was a marked reduction in mastectomy flap necrosis in patients who received nitroglycerin ointment. Nitroglycerin ointment application is a simple, safe, and effective way to help prevent mastectomy flap necrosis. Therapeutic, I.

The transverse musculo-cutaneous gracilis flap for breast reconstruction: How to avoid complications.

PubMed

Bodin, Frédéric; Dissaux, Caroline; Dupret-Bories, Agnes; Schohn, Thomas; Fiquet, Caroline; Bruant-Rodier, Catherine

2016-01-01

The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension. Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared. Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip. Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation. © 2015 Wiley Periodicals, Inc.

Reconstruction of two separate defects in the upper extremity using anterolateral thigh chimeric flap.

PubMed

Peng, Feng; Chen, Lin; Han, Dong; Xiao, Chenwei; Bao, Qiyuan; Wang, Tao

2013-11-01

We presented our experience on the use of anterolateral thigh (ALT) chimeric flap to reconstruct two separate defects in upper extremity. From December 2009 to August 2012, we used this ALT chimeric flap to reconstruct two separate defects in upper extremity on five patients (mean age: 36.6 years; range: 15 ∼ 47 years). The locations of defect were palm and fingers in four patients and forearm in the other patient. The sizes of defect ranged from 4.5 × 1.5 cm to 20 × 10 cm. A minimum of two separate perforator vessels in the flap were identified. The skin paddle was then split between the two perforators to shape two separate paddles with a common vascular supply. There were no cases of flap failure or re-exploration. Four donor sites were directly closed and one was covered by a skin graft. Donor-site morbidity was negligible. The ALT chimeric flap provides customized cover for two separate defects in upper extremity. Copyright © 2013 Wiley Periodicals, Inc.

The lobular transposition flap: a useful adjunct to reconstruct helical defects.

PubMed

Saleh, D B; Tan, J; Mohammed, P; Majumder, S

2012-07-01

We detail our adjunct to Antia and Buch's chondrocutaneous advancement flap for helical reconstruction. It is simple, reliable and negates the need for transfer of the defect to the lobule and/or V-Y advancement of the helical crus. Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Mandibular reconstruction using fibula free flap harvested using a customised cutting guide: how we do it.

PubMed

Tarsitano, A; Ciocca, L; Cipriani, R; Scotti, R; Marchetti, C

2015-06-01

Free fibula flap is routinely used for mandibular reconstructions. For contouring the flap, multiple osteotomies should be shaped to reproduce the native mandibular contour. The bone segments should be fixed using a reconstructive plate. This plate is usually manually bent by the surgeon during surgery. This method is efficient, but during reconstruction it is complicated to reproduce the complex 3D conformation of the mandible and recreate a normal morphology with a mandibular profile as similar as possible to the original; any aberration in its structural alignment may lead to aesthetic and function alterations due to malocclusion or temporomandibular disorders. In order to achieve better morphological and functional outcomes, we have performed a customised flap harvest using cutting guides. This study demonstrates how we have performed customised mandibular reconstruction using CAD-CAM fibular cutting guides in 20 patients undergoing oncological segmental resection.

Immediate Breast Reconstruction with Abdominal Free Flap and Adjuvant Radiotherapy: Evaluation of Quality of Life and Outcomes.

PubMed

Pont, Luis Parra; Marcelli, Stefano; Robustillo, Manuel; Song, Dajiang; Grandes, Daniel; Martin, Marcos; Iglesias, Israel; Aso, Jorge; Laloumet, Iñaki; Díaz, Antonio J

2017-10-01

The effects of postoperative radiotherapy on free flap-based breast reconstruction are still controversial. Poor outcomes, breast distortion, and fat necrosis have been traditionally documented. The aim of this study was to evaluate whether adjuvant radiotherapy affects the quality of life, satisfaction, and cosmetic result in patients undergoing immediate breast reconstruction with autologous free flap. Between January of 2013 and December of 2016, 230 patients underwent mastectomy with immediate free flap reconstruction at the authors' institution. Patients were divided into two groups depending on whether they received postmastectomy radiotherapy. Quality of life measured with the BREAST-Q questionnaire, self-reported aesthetic outcomes, and general satisfaction were assessed and compared. Fat necrosis of the flap and its severity were also analyzed as the main surgical outcomes. Mean follow-up time after reconstruction was 23 months (range, 6 to 48 months). No significant difference in quality of life or satisfaction scores were found between patients that underwent postmastectomy radiotherapy and patients who did not receive adjuvant radiotherapy. There were no significant differences in rates of fat necrosis between the groups (11.1 percent versus 13.76 percent; p = 0.75). Postmastectomy radiotherapy in patients undergoing immediate breast reconstruction with free flaps does not seem to affect quality of life, satisfaction with the outcome, or the cosmetic result as perceived by the patients. The potential need for postoperative radiotherapy should not hinder women from the benefits of autologous immediate breast reconstruction. Therapeutic, III.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period.

PubMed

McKelvie, James; Ferguson, Reid; Ng, Stephen G J

2017-08-01

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

Nasolabial Perforator Flap for One-stage Reconstruction of Nasal Defects

PubMed Central

Prakash, Siddharth; Panda, Ritesh; Kumar, Vivek; Saha, Shiv Shankar; Choudhary, Lalit; Pandey, Anurag; Reddy, J. Sasidhar

2017-01-01

Background: The excellent freedom of movement and range of this flap when based on a the nasolabial perforator flap have not been sufficiently explored. In this study, along with demonstrating the other key advantages of this flap over its traditional counterpart, we will endeavour to fill these lacunae in the available literature. Materials and Methods: From February 2009 to February 2012, twenty patients with nasal defects were repaired with a nasolabial perforator flap in the Department of Plastic and Cosmetic Surgery at Sir Ganga Ram Hospital, New Delhi. Of these, two patients (10%) underwent the procedure bilaterally. Thus, a total of 22 nasolabial perforator flap procedures were carried out. Prospectively, collected clinical records and data of each patient were retrospectively retrieved and reviewed to study the nasal defect and surgery done. Results: All the twenty (100%) patients had good functional and aesthetic outcome. All patients who had nasal stenosis preoperatively had very good improvement in the patency of the nasal passages, breathing and nasal blockage with complete recovery of symptoms. The patients were entirely satisfied with the functional recovery. Conclusions: The reliability and versatility of the nasolabial perforator flap exceed its recognised application in reconstruction of nasal defects and it must form a part of every plastic surgeon's armamentarium. PMID:28529417

Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity.

PubMed

Nelson, Jonas A; Kim, Elizabeth M; Eftekhari, Kian; Eftakhari, Kian; Low, David W; Kovach, Stephen J; Wu, Liza C; Serletti, Joseph M

2012-01-01

Microvascular free-tissue transfer is a reliable pillar of reconstructive surgery, yet pedicle thrombosis remains a challenge. The authors examined the phenomenon of late venous thrombosis (after postoperative day 3) and detail a method of flap salvage that can be utilized following this microvascular insult. A retrospective review was performed of all free flap breast reconstructions performed by the senior author (J.M.S.) from 1991 to 2008, utilizing a prospectively maintained database. All cases of postoperative thromboses were evaluated. Late venous thrombosis was defined as a thrombosis occurring after postoperative day 3. A total of 1277 free flap breast reconstructions were performed over the 17-year period. Nineteen flaps had venous thromboses (1.5 percent), and 10 of these occurred after postoperative day 3 (average, 5.67 days; range, 4 to 12 days). Operative exploration was employed in seven of 10 cases, with the remaining patients presenting too late or too advanced for operative intervention. Sixty percent of flaps were fully salvaged, and two were partially saved, with some subsequent volume loss. Earlier late venous thrombosis presentation led to better outcomes overall. Late venous thrombosis is a rare phenomenon that, although occurring late in the postoperative course, is an acute event. Early recognition and urgent treatment are key to flap salvage, with clinical judgment dictating the treatment choice. In the absence of extenuating circumstances, the authors prefer urgent exploration in the operating room, as flap survival following late venous thrombosis is a race against time but with a high probability of salvage if the proper steps are taken. Therapeutic, IV.

Functional reconstruction of complex tendo Achilles defect by free latissimus dorsi muscle flap

PubMed Central

Upadhyaya, Divya N.; Khanna, Vaibhav; Kohli, Romesh; Tulsi, Satendar P. S.; Garg, Sandeep

2012-01-01

Managing the complex tendo Achilles defect involves reconstructing the Achilles tendon as well as providing soft tissue cover to the heel area. The advent of microsurgery has revolutionised the reconstruction of this difficult defect providing a number of options to the reconstructive surgeon. We present a case of complex tendo Achilles defect reconstructed by the latissimus dorsi free flap. PMID:23450740

Versatility of Subscapular Chimeric Free Flaps in the Secondary Reconstruction of Composite Posttraumatic Defects of the Upper Face

PubMed Central

Stalder, Mark Winston; Wise, Matthew Whitten; Dupin, Charles L.; St Hilaire, Hugo

2014-01-01

High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts. PMID:25709752

Complex posterior thoracic wall reconstruction using a crossover combined latissimus dorsi and serratus anterior free flap.

PubMed

Bodin, Frédéric; Dissaux, Caroline; Steib, Jean-Paul; Massard, Gilbert

2016-03-01

Radical resection of an extended malignant sarcoma of the chest wall requires full-thickness thoracic chest wall reconstruction. Reconstruction is tedious in the case of posteriorly located tumours, because the ipsilateral pedicled myocutaneous latissimus dorsi flap is involved and hence not usable for soft tissue coverage. We report an original case of a left giant dorsal chondrosarcoma originating from the 11th costovertebral joint. After extended resection and skeletal reconstruction, soft tissue coverage was achieved with an original contralateral free flap encompassing both latissimus dorsi and serratus anterior muscles. The flap pedicle was anastomosed to the ipsilateral thoracodorsal vessels. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Systematic review: Early versus late dangling after free flap reconstruction of the lower limb.

PubMed

McGhee, J T; Cooper, L; Orkar, K; Harry, L; Cubison, T

2017-08-01

Dangling regimes after free flap surgery to the lower limb vary between centres and clinicians. There is currently no accepted gold standard. This review examines the evidence for early versus late post-operative dangling after free flap reconstruction of the lower limb. The secondary aim is to evaluate the regimes used. Medline, Embase and the Cochrane library were searched for all studies on dangling or rehabilitation after free flap reconstruction in the lower limb (December 2015). All studies outlining a clear dangling regime were included. Data were extracted by two authors independently and analysed using the software package Review Manager (RevMan 5). All authors were contacted for further information. 197 patients were included from 8 studies: 1 randomized, 6 cohort and 1 case-series. Although some studies did not state the aetiology, of those that did; 42% were trauma, 31% oncology, 20% complex wounds and 7% infection. The majority of flaps were latissimus dorsi, 18% parascapular, 15% anterolateral thigh and the remainder was mixed. Forty-eight percent of patients dangled on post-operative day (POD) 7, 29% on day 6, 4% on day 5 and 18% on day 3, with varying regimes. A meta-analysis of comparable studies showed circulatory benefit after 4 days of dangling using tissue oxygen saturation as a measure. Four flap failures (2.0%) were reported. There is physiological benefit in post-operative dangling. A 3-day flap training regime is sufficient for physiological training. However, the optimal flap training regime remains unclear. It may be appropriate to start dangling as early as POD 3. More research is needed to determine the optimal time to start dangling and the regime. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Management of Unfavorable Outcomes in Head and Neck Free Flap Reconstruction: Experience-Based Lessons from the MD Anderson Cancer Center.

PubMed

Chang, Edward I; Hanasono, Matthew M; Butler, Charles E

2016-10-01

Complex head and neck reconstruction often mandates free tissue transfer to achieve the most optimal outcomes. Unfortunately, such challenging cases are not without risks of complications, the most dreaded of which is loss of the free flap. Aside from loss of the free flap, there are several other potential complications that can result following head and neck reconstruction. Certain complications are avoided with careful planning, others require significant revisions and in certain cases another free flap. This article presents the experience managing a series of unique complications following free flap head and neck reconstruction. Published by Elsevier Inc.

Free Boomerang-shaped Extended Rectus Abdominis Myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities.

PubMed

Koul, Ashok R; Nahar, Sushil; Prabhu, Jagdish; Kale, Subhash M; Kumar, Praveen H P

2011-09-01

A soft tissue defect requiring flap cover which is longer than that provided by the conventional "long" free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free "Boomerang-shaped" Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and "free" version of a similar flap described by Ian Taylor in 1983. This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings. Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line. BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.

Reconstruction of maxillary defect with musculo-adipose rectus free flap.

PubMed

Low, Tsu-Hui Hubert; Lindsay, Andrew; Clark, Jonathan; Chai, Francis; Lewis, Richard

2017-02-01

The rectus myocutaneous free flap (RMFF) is used for medium to large maxillectomy defects. However, in patients with central obesity the inset could be difficult due to the bulk from excessive layer of adipose tissue. We describe a modification of the RMFF for patients with excessive central obesity with a flap consisting of adipose tissue with minimal rectus muscle; the musculo-adipose rectus free flap (MARF). Five cases of MARF reconstruction were performed between 2003 and 2013, with patients' body mass indexes ranging from 29.0 to 41.2 kg/m 2 . All patients had sinonasal tumor, of which three were adenoid cystic carcinoma, one squamous cell carcinoma, and one melanoma. Four patients had Codeiro IIIb defects and one had Codeiro II defect. Using the MARF technique, the maxillectomy defect was obliterated with vascularized adipose tissue overlying the rectus muscle and was trimmed to fit the maxillectomy defect. The adipose tissue was allowed to granulate and mucosalize. The volume of adipose tissue harvested was between 120 and 160 mL. All flaps survived with no requirement for re-exploration. Complete oro-nasal separation was achieved in all patients. The time to commencement of oral intake ranges from 5 to 15 days. One patient developed seroma and one developed wound breakdown on the donor site. The length of stay at the hospital ranges from 9 to 22 days. On follow-up ranging 7.5-32.8 months, two patients died from their malignancies. The other three patients were able to tolerate oral soft diet. The MARF may be considered as an alternative to myocutaneous rectus free flap particularly for the reconstruction of maxillary defects in patients with central obesity. © 2015 Wiley Periodicals, Inc. Microsurgery 37:137-141, 2017. © 2015 Wiley Periodicals, Inc.

Outcomes of Fat-Augmented Latissimus Dorsi (FALD) Flap Versus Implant-Based Latissimus Dorsi Flap for Delayed Post-radiation Breast Reconstruction.

PubMed

Demiri, Efterpi C; Dionyssiou, Dimitrios D; Tsimponis, Antonios; Goula, Christina-Olga; Pavlidis, Leonidas C; Spyropoulou, Georgia-Alexandra

2018-06-01

Although free abdominal flaps constitute the gold standard in post-radiation delayed breast reconstruction, latissimus dorsi-based methods offer alternative reconstructive options. This retrospective study aims to compare outcomes of delayed breast reconstruction using the fat-augmented latissimus dorsi (FALD) autologous reconstruction and the latissimus dorsi-plus-implant reconstruction in irradiated women. We reviewed the files of 47 post-mastectomy irradiated patients (aged 29-73 years), who underwent delayed latissimus dorsi-based breast reconstruction between 2010 and 2016. Twenty-three patients (Group A) had an extended FALD flap and twenty-four patients (Group B) an implant-based latissimus dorsi reconstruction. Patients' age, BMI, pregnancies, volume of injected fat, implant size, postoperative complications, and secondary surgical procedures were recorded and analyzed. Age, BMI, pregnancies, and donor-site complications were similar in both groups (p > 0.05). Mean fat volume injected initially was 254 cc (ranged 130-380 cc/session); mean implant volume was 323 cc (ranged 225-420 cc). Breast complications were significantly fewer in Group A (one wound dehiscence, two oily cysts) compared to Group B (three cases with wound dehiscence, two extrusions, thirteen severe capsular contractions). Non-statistically significant difference was documented for secondary procedures between groups; although the mean number of additional surgeries/patient was higher in Group A, they referred to secondary lipofilling, whereas in Group B they were revision surgeries for complications. The FALD flap constitutes an alternative method for delayed autologous reconstruction after post-mastectomy irradiation, avoiding implant-related complications. Although additional fat graft sessions might be required, it provides an ideal autogenous reconstructive option for thin nulliparous women, with a small opposite breast and adequate fat donor sites. This journal requires that

Extended lateral thoracic fasciocutaneous biosynthetic flap for reconstruction of full-thickness partial external ear defects: an experimental study.

PubMed

Kuvat, Samet Vasfi; Taşkın, Ümit; Yücebaş, Kadir; Tansuker, Hasan Deniz; Oktay, Mehmet Faruk; Kozanoğlu, Erol; Aydın, Salih

2017-01-01

External ear reconstruction is a controversial topic in reconstructive plastic surgery. Here, we prepared a pedicled biosynthetic flap for full-thickness, partial ear defects in rabbits. We operated on six adult female New Zealand rabbits weighing 3-4 kg. The dimensions of the lateral thoracic fasciocutaneous flap were 7 × 6 cm. The flap was elevated based on one of the bilaterally located internal thoracic arteries, which were dissected proximally. The pedicled flap was folded in two, and polypropylene mesh was sandwiched in the middle. The flap was adapted to a defect of 3.5 × 3 cm in diameter. In fact, the defect was created before elevation of the flap. Rabbits were followed up for 4 weeks, at the end of which they were killed and their ears were evaluated histopathologically. The survival rate of the rabbits was 100 %. All pedicled biosynthetic flaps were viable, but one showed partial (20 %) necrosis (1/6) and one was partially detached (1/6). Macroscopic (color, thickness, texture) and histological (polymorphonuclear leukocyte invasion in the skin, subcutaneous tissue, and at the junction between the polypropylene mesh and the flap) features of the flap were compared to the ipsilateral ear. A new technique was developed for partial external ear reconstruction with sufficient inner skeletal support and outer skin lining. Level of evidence Level NA.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection.

PubMed

Cherubino, Mario; Turri-Zanoni, Mario; Battaglia, Paolo; Giudice, Marco; Pellegatta, Igor; Tamborini, Federico; Maggiulli, Francesca; Guzzetti, Luca; Di Giovanna, Danilo; Bignami, Maurizio; Calati, Carolina; Castelnuovo, Paolo; Valdatta, Luigi

2017-01-01

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

The temporalis muscle flap and temporoparietal fascial flap.

PubMed

Lam, Din; Carlson, Eric R

2014-08-01

The temporal arterial system provides reliable vascular anatomy for the temporalis muscle flap and temporoparietal fascial flap that can support multiple reconstructive needs of the oral and maxillofacial region. The minimal donor site morbidity and ease of development of these flaps result in their predictable and successful transfer for reconstructive surgery of the oral and maxillofacial region. Copyright © 2014 Elsevier Inc. All rights reserved.

EAST ELEVATION OF LOWER TRAM TERMINAL, LOOKING NORTHWEST. TRAM CARS ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

EAST ELEVATION OF LOWER TRAM TERMINAL, LOOKING NORTHWEST. TRAM CARS ENTERED AND EXITED FROM RIGHT,AND DUMPED INTO THE ORE BIN SEEN AT LOWER LEFT. BELOW THE ORE BIN IS A JAW CRUSHER FOUNDATION. THE WOODEN BOX AT CENTER IS FILLED WITH ROCKS, PROVIDING THE COUNTERWEIGHT TO THE TRAMWAY CABLE, WHICH KEEPS IT TAUGHT. - Keane Wonder Mine, Park Route 4 (Daylight Pass Cutoff), Death Valley Junction, Inyo County, CA

Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects.

PubMed

Balakrishnan, Thalaivirithan Margabandu; Ramkumar, Jayagosh; Jaganmohan, Janardhanan

2017-01-01

Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region.

Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects

PubMed Central

Balakrishnan, Thalaivirithan Margabandu; Ramkumar, Jayagosh; Jaganmohan, Janardhanan

2017-01-01

Introduction: Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. Aim: This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. Patients and Methods: 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. Results: All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. Conclusion: With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region. PMID:29618863

Outcomes of microvascular flap reconstruction of the head and neck in patients receiving systemic immunosuppressive therapy for organ transplantation.

PubMed

Schaverien, Mark V; Dean, Riley A; Myers, Jeffrey N; Fang, Lin; Largo, Rene D; Yu, Peirong

2018-05-03

For organ transplant recipients, cancer secondary to immunosuppressive therapy threatens long-term survival. The associated multiple comorbidities make major free flap reconstruction following cancer surgery a complicated event. This study evaluates the outcomes of free flap reconstruction in this population. A retrospective chart review of all head and neck free flap cases in patients with a history of organ transplantation receiving systemic immunosuppressive therapy between 2005 and 2017 at a single-institution was conducted. Of 57 organ transplant patients, 25 patients (28 flaps) were included. Flaps used included the anterolateral thigh (n = 17), radial forearm (n = 4), latissimus dorsi (n = 3), fibula (n = 2), lateral arm (n = 1), and thoracodorsal artery perforator (n = 1) flaps. The most common organ transplant was kidney, then lung, liver, and heart. Mean inpatient stay was 8.2 days (range, 4-28). Complications occurred in 15 patients, with no total or partial flap losses. Major head and neck free flap reconstructive surgery can be performed safely in organ transplant patients receiving immunosuppressive therapy. Meticulous multidisciplinary care is required to achieve consistently successful outcomes. © 2018 Wiley Periodicals, Inc.

Inferiorly based buccinator myomucosal island flap in oral and pharyngeal reconstruction. Four techniques to increase its application

PubMed Central

Rahpeyma, Amin; khajehahmadi, Saeedeh

2015-01-01

Introduction Reconstruction of oral and pharyngeal defects after pathologic resections with the same tissue is an optimal and ideal target. Islanded variety of inferiorly pedicled facial artery musculomucosal flap, in which facial artery and vein are skeletonized (referred to as inferiorly based BUMIF), is suitable for reconstruction of medium-sized mucosal defects. Presentation of cases In this article, with four cases, modifications of this flap are demonstrated in reconstruction of large intraoral and oropharyngeal defects and coverage of alveolar ridge in the mandible. Discussion In some situations, there is a need for more mucosal paddle, longer vascular pedicle and more adaptation to the recipient bed. Conclusion Relocating Stensen’s duct increases the mucosal paddle with cranial extension of superior limit while differential incision of the mucosa and buccinator muscle in mandibular vestibule extend the lower limit of this flap. Bone suture is a good complementary technique when this flap is used for coverage of mandibular alveolar ridge. Inferiorly based BUMIF with added length is indicated for oropharyngeal and contralateral mouth floor reconstructions. PMID:26218177

Free Vastus Intermedius Muscle Flap: A Successful Alternative for Complex Reconstruction of the Neurocranium in Preoperated Patients.

PubMed

Horn, Dominik; Freudlsperger, Christian; Berger, Moritz; Freier, Kolja; Ristow, Oliver; Hoffmann, Jürgen; Sakowitz, Oliver; Engel, Michael

2017-07-01

The reconstruction of large cranial and scalp defects is a surgical and esthetic challenge. Single autologous tissue transfer can be insufficient due to the defect size and the anatomic complexity of the recipient site. Alloplastic patient-specific preformed implants can be used to recover hard tissue defects of the neurocranium. Nevertheless, for long-term success adequate soft tissue support is required. In this brief clinical study, the authors describe calvarian reconstruction in a 33-year-old patient with wound healing disorder after an initial resection of ependymoma. The patient suffered from osteonecrosis and wound breakdown in the fronto-parietal region. An alloplastic polymethylmethacrylate implant for hard tissue support was manufactured based on 3-dimensional visualization of a computed tomography scan. After the resection of remaining pathologic bone from earlier surgical procedures, the alloplastic implant was inserted to achieve functional coverage of the brain. Due to anatomic variation of donor site vessels during anterolateral thigh flap preparation, the authors performed a vastus intermedius free flap as a new muscular flap for craniofacial reconstruction. The authors achieved excellent functional and esthetic results. The muscular vastus intermedius free flap in combination with a split skin graft proves to be a new alternative to the anterolateral thigh flap for soft tissue reconstruction of the neurocranium.

Postburn Neck Reconstruction With Preexpanded Upper Back Perforator Flaps: Free-Style Design and An Update of Treatment Strategies.

PubMed

Li, Haizhou; Wang, Zi; Gu, Bin; Gao, Yashan; Xie, Feng; Zhu, Hainan; Li, Qingfeng; Zan, Tao

2018-05-14

For extensive postburn neck deformities, the preexpanded flaps in the upper back region were used and gained a uniform skin appearance and esthetic contours. Free-style perforator-based free-tissue transfer that represents the most recent advance in reconstructive surgery may provide more versatility of these flaps. We retrospectively reviewed 31 patients treated at our institution for postburn neck contracture from March 2010 to May 2016. Various upper back flaps were designed according to the dominant perforators and the shape of the defect after fully releasing the neck contracture. Thirty-one patients received neck reconstructions with the versatile applications of the preexpanded upper back perforator flaps. Tip necrosis was observed in one case, and the others survived completely. The donor sites were all primarily closed. No incision dehiscence was observed. The free-style design has significantly increased the potential and versatility of the upper back flaps in reconstruction of severe neck scar contracture.

OVERVIEW OF UPPER TRAM TERMINAL, TRAM TRESTLE, AND PRIMARY ORE ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

OVERVIEW OF UPPER TRAM TERMINAL, TRAM TRESTLE, AND PRIMARY ORE BIN, LOOKING NORTHEAST. REMAINS OF A BLACKSMITH'S FORGE AND WORK CAN BE SEEN JUST BELOW THE ORE BIN (SEE CA-291-32 FOR DETAIL). ROCK FOUNDATIONS LOCATED JUST ABOVE THE ORE BIN AND ALONG THE FIRST RIDGELINE ARE TENT PADS. SEE CA-291-24 FOR IDENTICAL B&W NEGATIVE. - Keane Wonder Mine, Park Route 4 (Daylight Pass Cutoff), Death Valley Junction, Inyo County, CA

OVERVIEW OF UPPER TRAM TERMINAL, TRAM TRESTLE, AND PRIMARY ORE ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

OVERVIEW OF UPPER TRAM TERMINAL, TRAM TRESTLE, AND PRIMARY ORE BIN, LOOKING NORTHEAST. REMAINS OF A BLACKSMITH'S FORGE AND WORK CAN BE SEEN JUST BELOW THE ORE BIN (SEE CA-291-32 FOR DETAIL). ROCK FOUNDATIONS LOCATED JUST ABOVE THE ORE BIN AND ALONG THE FIRST RIDGELINE ARE TENT PADS. SEE CA-291-49 (CT) FOR IDENTICAL COLOR TRANSPARENCY. - Keane Wonder Mine, Park Route 4 (Daylight Pass Cutoff), Death Valley Junction, Inyo County, CA

Posterior trunk reconstruction with the dorsal intercostal artery perforator based flap: Clinical experience on 20 consecutive oncological cases.

PubMed

Brunetti, Beniamino; Tenna, Stefania; Aveta, Achille; Poccia, Igor; Segreto, Francesco; Cerbone, Vincenzo; Persichetti, Paolo

2016-10-01

Few studies in the recent literature have investigated the reliability of dorsal intercostal artery perforator (DICAP) flap in posterior trunk reconstruction. The purpose of this report is to describe our clinical experience with the use of DICAP flaps in a cohort of oncological patients. Twenty patients underwent posterior trunk reconstruction with DICAP based flaps. Patients age ranged from 45 to 76 years. All defects resulted from skin cancer ablation. Defect sizes ranged from 4 × 4 to 6 × 8 cm. The flaps were mobilized in V-Y or propeller fashion. The flaps were islanded on 1 (12 cases), 2 (6 cases), or 3 (2 cases) perforators. Donor sites were always closed primarily. Eleven V-Y advancement flaps were performed; one of these was converted to a perforator-plus peninsular flap design, which retained an additional source of blood supply from the opposite skin bridge. Nine flaps were mobilized in propeller fashion. Flap dimensions ranged from 4 × 6 to 6 × 14 cm. Mean operative time was 70 min. One V-Y flap complicated with marginal necrosis that healed with no need for reintervention. All the other flaps survived uneventfully. No other complications were observed at recipient and donor sites. Follow-up ranged from 3 months to 2 years. All the patients were satisfied with the surgical outcome. DICAP based flaps proved to be a reliable option to resurface posterior trunk defects following oncological resection, allowing to achieve like-with-like reconstruction with excellent contour and minimal donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:546-551, 2016. © 2015 Wiley Periodicals, Inc.

Free Boomerang-shaped Extended Rectus Abdominis Myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities

PubMed Central

Koul, Ashok R.; Nahar, Sushil; Prabhu, Jagdish; Kale, Subhash M.; Kumar, Praveen H. P.

2011-01-01

Background: A soft tissue defect requiring flap cover which is longer than that provided by the conventional “long” free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free “Boomerang-shaped” Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and “free” version of a similar flap described by Ian Taylor in 1983. Materials and Methods: This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings. Results: Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line. Conclusion: BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs. PMID:22279271

One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps.

PubMed

Heidekrueger, Paul I; Ehrl, Denis; Heine-Geldern, Albrecht; Ninkovic, Milomir; Broer, P Niclas

2016-12-01

Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients' demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p>0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p>0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible. Copyright © 2016 Elsevier Ltd. All rights reserved.

Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft.

PubMed

Chi, Zhenglin; Chen, Yiheng; Chu, Tinggang; Gao, Weiyang; Li, Zhijie; Yan, Hede; Song, Yonghuan

2018-02-01

The conventional procedure of the sural neuro-fasciocutaneous flap enables the supply of blood and venous drainage by increasing the width of the adipofascial tissue and preserving tiny venous return routes. Moreover, skin graft is a common method for donor site closure, which may lead to some complications and influence the aesthetic appearance. We report modifications for a distally based sural neuro-fasciocutaneous perforator flap and a relaying flap for donor site closure without skin graft. Twelve patients undergoing the modified flap for foot and ankle reconstruction were included in this study between 2014 and 2016. A peroneal-based perforator, a superficial vein, and the vascular axis of the sural nerve were included in the pedicle. A Z-shape skin incision was performed to explore the perforator vessels and a relaying island perforator flap was used to close the donor site. All flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 15 cm. The diameter width of the pedicle ranged from 1.0 to 2.0 cm. A relaying perforator island flap was used in 10 cases for donor site closure and no skin graft was performed. There were no serious donor site complications. All patients were satisfied with the aesthetic outcome postoperatively at the final follow-up. The distally based sural neuro-fasciocutaneous perforator flap is considered a reliable method for foot and ankle reconstruction. The modification for flap pedicle and donor site closure method without skin graft should be recommended. Copyright © 2017. Published by Elsevier Ltd.

[Reconstruction of zygomatic-facial massive defect using modified bilobed flap after resection of skin cancer].

PubMed

Ling, Bin; Abass, Keremu; Hu, Mei; Yin, Xiaopeng; Hu, Lulu; Lin, Zhaoquan; Gong, Zhongcheng

2013-01-01

To investigate the clinical application of the modified bilobed flap in the reconstruction of zygomatic-facial massive defect after resection of skin cancer. Between August 2009 and October 2011, 15 patients with skin cancer in the zygomatic-facial region underwent defect reconstruction using modified bilobed flaps after surgical removal. There were 12 males and 3 females, aged 52-78 years (mean, 64.1 years). The disease duration was 1-14 months (mean, 4.6 months). Among the patients, there were 11 cases of basal cell carcinoma and 4 cases of squamous cell carcinoma; 1 patient had infection and the others had no skin ulceration; and tumor involved the skin layer in all patients. According to TNM staging, 13 cases were rated as T2N0M2 and 2 cases as T3N0M3. The defect size ranged from 4.0 cm x 2.5 cm to 6.5 cm x 4.0 cm after cancer resection. The modified bilobed flaps consisting of pre-auricular flap and post-auricular flap was used to repair the defect after cancer resection. The size ranged from 4.0 cm x 2.5 cm to 6.5 cm x 4.0 cm of the first flap and from 3.0 cm x 2.0 cm to 5.0 cm x 3.0 cm of the second flap. Partial incision dehiscence occurred in 1 case, and was cured after dressing change; the flaps survived and incision healed primarily in the other cases. Fourteen patients were followed up 12-24 months (mean, 18.7 months). No recurrence was found, and the patients had no obvious face asymmetry or skin scar with normal closure of eyelid and facial nerve function. At last follow-up, the results were very satisfactory in 5 cases, satisfactory in 7 cases, generally satisfactory in 1 case, and dissatisfactory in 1 case. The pre- and post-auricular bilobed flaps could be used to reconstruct the massive defects in the zygomatic-facial region after resection of skin cancer.

Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction.

PubMed

Bendon, Charlotte L; Giele, Henk P

2016-07-01

Traditionally, in free flap cover of lower limb injuries, every attempt is made to perform anastomoses proximal to the zone of injury. We report on the success of anastomoses within the zone of trauma, at the level of the fracture, avoiding further dissection and exposure. The records of free flap reconstructions for fractures of the lower extremity at a tertiary trauma centre between 2004 and 2010 were retrospectively reviewed. A total of 48 lower limb fractures required free flap reconstruction, performed at 28 days post injury (0-275 days). Anastomoses were proximal (21), distal (5) or within the zone of trauma (22). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between groups. Of the 22 performed within the zone of injury, five returned to theatre but only two for revision of anastomosis and 20 (91%) of these flaps survived. Of the 48 free flaps, arterial anastomoses were end to end in 34 (71%) and end to side in 14 (30%). There was no significant difference (p > 0.05) in return to theatre, revision of anastomosis or flap survival between the end-to-end and end-to-side groups. There was a tendency for arterial anastomoses to be performed end to end outside the zone of trauma (23/26) compared to within the zone of trauma (11/22). Our data suggest that free flap anastomoses can be performed safely in the zone of trauma in lower limb injuries. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Post chemotherapy extravasation injuries: Hypogastric flap for reconstruction of wounds over dorsum of hand.

PubMed

Salunke, Abhijeet Ashok; Nambi, G I; Sudhakar, N

2015-01-01

Management of extravasation injuries over the dorsum of hand after administration of chemotherapeutic agents. To study the results of hypogastric flap reconstruction in chemotherapy extravasation wounds over dorsum of hand. Retrospective study. At our center over 3-years period, 32 patients were treated for chemotherapy extravasation wounds. Out of these 32 patients, seven had wound over dorsum of hand. There were five males and two females, and their mean age was 45 years (range, 19 - 64 years). These patients with wound over the dorsum of hand were treated with multiple debridements and hypogastric flap reconstruction. The mean interval between extravasation wound and surgical treatment was 6.28 days (range, 4 - 10). The mean size of extravasation wound defect was 14 × 8 (range, 12 × 7 to 18 × 8). Non-dominant hand was involved in six patients and dominant hand in one patient. In four patients, the hypogastric flap was supplemented with skin graft. The hypogastric flap settled well in all patients and enabled a good wound cover. Complete division of the flap and final insetting was done under local anesthesia after 3 weeks; this was followed by limb mobilization exercises. Contour difference over the dorsum of hand was present in all the cases. The range of movement of the hand was functionally restricted in one patient. No patient in current series developed wound infection. Hypogastric flap is a reliable flap to cover wound over dorsum of hand after extravasation of chemotherapeutic agents.

Versatility of the Angularis Oris Axial Pattern Flap for Facial Reconstruction.

PubMed

Losinski, Sara L; Stanley, Bryden J; Schallberger, Sandra P; Nelson, Laura L; Towle Millard, Heather A M

2015-11-01

To describe the versatility of the axial pattern flap based on the cutaneous perforating branch of the angularis oris artery for reconstruction of large facial defects in dogs, including complications and clinical outcomes. Retrospective clinical case series. Client-owned dogs (n = 8). Facial flaps (n = 9) based at the commissure of the lip with a caudodorsal orientation were utilized, with established anatomical borders. Flaps were elevated deep to the panniculus carnosus in a caudal to rostral direction, preserving the angularis oris artery, its cutaneous perforator, and surrounding cutaneous vasculature. Flaps were rotated dorsally or ventrally to cover the defect. Primary closure of the donor site was by direct apposition in all cases. Angularis oris axial pattern flaps were most commonly used to close large defects of the nasomaxillary area rostral to the eyes (6 dogs), followed by orbital (2) and intermandibular (1) defects. Defects occurred because of tumor resection (6 dogs), trauma (2), and a chronic, non-healing wounding (1). All flaps healed with acceptable functional and cosmetic outcomes without major complications. Followup ranged from 10 days to 16 months. Minor postoperative complications included flap edema (8 dogs), partial incisional dehiscence (3), distal tip necrosis (2), and oroantral fistula recurrence (1). Angularis oris axial pattern flaps provided hirsute, full-thickness skin coverage of a variety of large facial defects with minor complications, and should be considered when restructuring large defects of the rostral face or chin. © Copyright 2015 by The American College of Veterinary Surgeons.

Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects.

PubMed

Delikonstantinou, Iraklis P; Gravvanis, Andreas I; Dimitriou, Vasilios; Zogogiannis, Ioannis; Douma, Amalia; Tsoutsos, Dimosthenis A

2011-08-01

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Syndactyly Web Space Reconstruction Using the Tapered M-to-V Flap: A Single-Surgeon, 30-Year Experience.

PubMed

Mericli, Alexander F; Black, Jonathan S; Morgan, Raymond F

2015-09-01

To describe the technique and results of the tapered M-to-V flap for syndactyly web space construction. We reviewed a single-surgeon, single-institution experience of all syndactyly reconstructions performed between 1982 and 2013. Demographic data and patient characteristics were recorded. Complications included flap loss, graft loss, web creep, infection, restricted range of motion, and digit deviation. A total of 138 web spaces were reconstructed in 93 patients. There were 89 primary congenital hand and 32 foot syndactylies. Four patients had an acquired simple incomplete syndactyly and 13 patients had secondary reconstructions. The complication rate was 14%. The most common complication was web creep resulting from partial skin graft loss (12 web spaces; 9%). There were no total flap losses. Univariate analysis revealed no factor to be predictive of an elevated complication rate. Average follow-up was 2.6 years (range, 6 mo to 26 y). The tapered M-to-V flap proved to be a reliable and versatile technique for web space reconstruction, offering several advantages over the standard rectangular flap method of repair, such as ease of intraoperative adjustment, a z-plasty at the palmodigital crease to minimize scar contracture, and better color match. Therapeutic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft.

PubMed

Heo, Jae-Woo; Park, Seong Oh; Jin, Ung Sik

2018-06-13

Nipple-areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola. From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple-areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12 months postoperatively. At the final visit, the patient's subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale. Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12 months postoperatively, respectively. Patients' overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a 'good' satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be 'poor' and 'disappointing' each accounted for 1 and 3 patients. The combination of nipple-areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www

[Antegrade extended peroneal artery perforator flap for knee reconstruction].

PubMed

Ruan, Hongjiang; Cai, Peihua; Fan, Cunyi; Chai, Yimin; Liu, Shenghe

2009-03-01

To investigate the operative technique and clinical results of repairing the soft tissue defects of knee with antegrade extended peroneal artery perforator flap. From October 2007 to January 2008, 3 patients (2 men and 1 woman) with the soft tissue defects of knee were treated, with the ages of 18, 31 and 42 years, respectively. The first case sustained femur and pelvis fractures and soft tissue defect over his right popliteal fossa, which were treated with open reduction and internal fixation (ORIF) and debridement of knee joint 2 weeks ago. The second case was necrosis of skin 3 weeks after ORIF for fracture of tibial plateau. The third case suffered from open fracture of tibial plateau and soft tissue defect, which were treated with external fixation and debridement 3 weeks ago. The defect sizes were 16 cm x 9 cm, 11 cm x 6 cm and 14 cm x 7 cm. The flap was raised by dividing the peroneal artery and veins distally and elevating them proximally, which covered for the defects of knee. The flaps were designed with the size of 18 cm x 10 cm, 12 cm 7 cm and 15 cm x 8 cm. The pure vascular pedicle of the flap was 10 cm to 17 cm in length, including the peroneal vessels and one or two perforator branches. The donor site is covered by a split thickness skin graft. All flaps survived after surgery. The donor sites healed by first intention and the skin grafts survived. After following up for 6, 8 and 11 months, the appearance and function of the flaps were all satisfactory. Based on the modified HSS knee performance system, post-operative knee functional outcomes of three patients were excellent. The antegrade extended peroneal artery perforator flap supplied by a pure vascular pedicle can be a good alternative for reconstruction of knee. The flap, with a long and thin pure vascular pedicle, could provide good texture and contour matching the recipient area.

Reconstruction of the lower vermilion with a musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects.

PubMed

Rong, Li; Lan, Shi-Jie; Zhang, Duo; Wang, Wang-Shu; Liu, Chao; Peng, Wei-Hai

2014-09-01

In the repair of extensive lower lip and chin defects, the reconstruction of vermilion at the same time is a great challenge to plastic surgeons. We describe a novel method for the reconstruction of lower vermilion with musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects. Two patients underwent extensive lower lip and chin reconstruction together with vermilion reconstruction. This technique used 3 basic components: musculomucosal flap from the upper lip, buccal mucosal advancement flap, and cutaneous rotational flap from the neck. All the flaps survived without significant complications. Labial function in the motions of expression and speaking was maintained. The patients could basically close their mouths completely, and there were no drooping or small-mouth deformities postoperatively. Functional and cosmetically acceptable lower-lip and chin reconstructions in both patients were achieved.

Better anatomical and cosmetic results using tunneled lotus petal flap for plastic reconstruction after demolitive surgery for vulvar malignancy.

PubMed

Buda, Alessandro; Confalonieri, Pier Luigi; Rovati, Luca Carlo Vittorio; Fruscio, Robert; Giuliani, Daniela; Signorelli, Mauro; Dell'Anna, Tiziana; Pirovano, Cecilia; Milani, Rodolfo

2012-06-01

To evaluate the efficacy of tunneled lotus petal flap in terms of anatomical and cosmetic results in patients who underwent vulvoperineal reconstruction for vulvar malignancy. Between March 2010 and July 2011, 22 women underwent vulvoperineal reconstruction using tunneled lotus petal flap for primary or recurrent disease at San Gerardo Hospital, Monza. In 16 cases, lotus flaps were bilateral, whereas in 6 cases, they were monolateral. The median age was 72 years (range, 53-87 years). The mean operating time was 85 minutes. The mean length of follow-up was 10 months (range, 2-16 months). Postoperative complications occurred in 2 patients, including one case of partial flap necrosis and one case of donor site breakdown. Tunneled lotus petal flap is safe, easy and fast to perform, has a low rate of complications, and good functional and cosmetic results. This technique represents an optimal solution for plastic reconstruction in case of primary or recurrent vulvar disease, or in case of introital stenosis after primary inadequate closure.

Medial sural artery perforator flap: a challenging free flap.