The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath.

Harvesting the rectus abdominis myocutaneous flap results in defects in both the rectus abdominis muscle and the anterior rectus sheath, which may be circumvented by dissecting a perforator flap (DIEP flap) instead. However, the latter is associated with a reduction in the number of myocutaneous perforators nourishing the flap, which has been hypothesised to lead to an increased risk of partial flap failure. We present a technical modification that maintains all the feeding perforators within the flap while fully preserving the anterior rectus sheath. The anterior rectus sheath is incised along a line connecting the perforators. A muscle cuff including all the feeding perforators was raised with the flap. This technique was used in 20 consecutive patients. Nine patients underwent free TRAM flap transfers for breast reconstruction (10 flaps), and 11 patients underwent thoracic-wall reconstruction with a superiorly based pedicled flap. The median follow-up was 11 months. One patient with a pedicled flap developed a partial failure that required surgical revision; all other flaps healed spontaneously. One patient in each subset had preoperative abdominal-wall laxity that was partly corrected after surgery; no abdominal bulging or hernia occurred in the other patients. Our results suggest that the technical modification presented here may enable the surgeon to dissect a rectus abdominis myocutaneous flap with maximal perforator-related flap perfusion and minimal donor-site morbidity. An advantage over the DIEP flap is that this technique is applicable to both free and pedicled flaps.     

Breast reconstruction with the free TRAM flap after breast cancer surgery.

The authors' experiences with 34 free lower TRAM flap transfers, in which 19 primary reconstructions and 15 secondary reconstructions were successfully achieved, are reviewed. The free TRAM flap yielded better results than the pedicled TRAM flap in cases where reconstruction of the infraclavicular and anterior axillary areas, as well as of the breast mound itself, was required.     

Upper extremity salvage using the tensor fascia lata flap: report of two cases

The tensor fascia lata pedicled flap was successfully used to salvage 3 severely injured upper extremities in 2 patients. Both patients had undergone 3 prior free tissue transfers without complete closure of their wounds. All 3 tensor fascia lata flaps (2 myocutaneous, 1 myofascial) survived entirely. We believe this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required.     

The Evolution of the Pedicled Radial Forearm Flap

Because of the thin skin envelope of the hand, especially at the dorsum, flaps are frequently required for defect reconstruction in the hand. The pedicled radial forearm flap is a time proven procedure that offers reliable coverage in this area without the need of advanced microsurgical expertise. Despite several alternatives and an increasing acceptance of free tissue transfers, the pedicled radial forearm flap can still be the procedure of choice under special circumstances. Variations of the original technique address the two main disadvantages, the conspicuous donor site and the sacrifice of the radial artery. Indications, anatomy, surgical technique, and limitations of this classic workhorse flap are presented.     

口腔口咽肿瘤切除术后较大缺损修复的研究

目的总结口腔口咽肿瘤切除后较大缺损的修复方法，讨论影响组织瓣相关并发症的因素。方法回顾性分析2004年12月～2006年4月我院头颈外科收治的部分口腔口咽肿瘤患者64例，肿瘤切除后出现较大缺损，使用组织瓣66块进行修复，其中带蒂组织瓣39块，游离组织瓣27块。结果27例游离组织瓣中，2例前臂皮瓣坏死，成功率92．6％；39例带蒂组织瓣中，4例胸大肌肌皮瓣出现部分坏死。成功率90％。64例患者中，除1例死亡外，全部恢复经口进食。带蒂或游离组织瓣的选择及术前放疗与否不影响组织瓣相关并发症的发生。结论对口腔口咽部肿瘤切除后的较大缺损，应视缺损的范围、大小及患者的一般情况、术前放疗、颈部手术史等综合考虑，选择最合适的组织瓣进行修复。如果出现皮瓣相关井发症，尤其对术前放疗者应积极处理。     

Free-tissue transfers for reconstruction of oromandibular area in children

Introduction: Currently, free‐tissue transfers are commonly used for various reconstructive purposes in adults. However, there is a lack of large series of free flap reconstruction in children, especially for reconstruction of oromandibular defects. Our study aims to share our experience in free‐flap reconstruction of some challenging pediatric cases. Materials and methods: Pediatric free‐flap interventions (<18‐year‐old) that were performed between 2000 and 2006 in our clinic were retrospectively evaluated. Eighteen free‐tissue transfers were performed in 17 pediatric cases. Epidemiologic data, etiology, defects, preferred free flaps, and results have been compared and analyzed. Results: A total of 17 patients (18 free flaps) were analyzed. Mean age was 10.4 years. The etiology was tumor in 11 cases, traffic accident in 5 cases, and gunshot in 1 case. Double‐flap transfer was performed to one patient with a devastating shotgun wound and single flap transfers to others. A total of 8 osseous flaps, 7 osteocutaneous flaps, and 3 septocutaneous flaps were transferred. Total superficial flap necrosis was encountered in one flap (5.8%) while partial superficial necrosis was seen on two flaps (11.7%). Sixteen of the 17 cases reconstructed, including the three cases with complications, resulted in good functional and cosmetic outcome. One case was lost in the sixth postoperative month due to septisemia during chemotherapy. All the surviving 16 cases acquired bony fusion, mastication, and speech in addition to good cosmetic results. Conclusion: Pediatric free‐tissue transfers are increasing due to the development of better equipment, finer surgical technique, and a better understanding of the unique characteristics of pediatric cases. In our opinion, high success rates with good cosmetic and functional results can be obtained if the specific requirements of the pediatric procedures are met. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Measurement of blood flow and oxygen tension in adjacent tissues in pedicled and free flap head and neck reconstruction.

The purpose of this study was to evaluate blood flow and transcutaneous partial oxygen pressure (TcPO(2)) in adjacent tissues to free and pedicled flaps following reconstructive procedures used in conjunction with radical surgery for head and neck cancers. Fifty patients were included. Fourteen patients had reconstruction with pedicled flaps and 36 with free flaps. For each patient, TcPO(2) and laser Doppler flow measurements were taken at the center of the flap, in adjacent tissue, and in a corresponding contralateral site. Three laser Doppler measurements were performed at each site and a mean value recorded. All patients had undergone reconstruction up to 6 months prior to the time of the measurements. The collected data were analyzed using a Wilcoxon signed rank test. There were no statistically significant differences in partial oxygen tension or laser Doppler values between tissues adjacent to free compared to pedicled flaps. Although there is strong evidence to support that free flaps have improved blood flow and partial oxygen tension over pedicled flaps, further study is required to evaluate adjacent tissues. Flap choice may assist with alteration in blood flow in less favorable defects such as those in previously irradiated fields and those resulting from burn scars or chronic infections.     

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.     

A buried reversed radial forearm flap in pharyngeal reconstruction: refinements and monitoring

Pharyngeal reconstruction can be accomplished in a variety of ways, from pedicled to free revascularized tissue transfers. The use of an extra skin paddle combined with a buried radial forearm flap, which permits long-term postoperative monitoring under direct vision, has been described before. In this study, we monitored nine patients who had undergone pharyngeal reconstruction with a buried reversed radial forearm flap. Our modified technique gave better coverage of the large vessels and a better postoperative neck contour, prevented esophageal leakage and facilitated continuous postoperative patient monitoring, without any significant additional donor site morbidity. Received: 18 January 2000 / Accepted: 14 February 2000     

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction

Background: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT. Methods: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result. Results: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence. Conclusions: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.     

Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound. The authors' experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version.     

The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening.

The vascularised scapular bone free flap is popular in mandible reconstruction, but it is less commonly used as a pedicled flap to reconstruct the upper humerus. We analysed our experience with pedicled scapular crest flaps in humerus reconstruction and compared our results with cases reported in the literature. We considered the age at surgery, the time elapsed before reconstruction, the time required to obtain solid bony union, the operative indication, the osteosynthesis procedure used and whether circumflex scapular vessels or angular vessels were used. There were eight patients (seven men and one woman, mean age=33): four humerus stump lengthenings, two upper-third humerus bone and soft tissue defects and two multioperated established humerus non-unions. Flaps were pedicled either on circumflex scapular vessels (three) or angular vessels (five). The mean size of the scapular bone used was 9.4 cm (range 7-11 cm). We associated a covering flap for seven patients. All the flaps survived and bone healed in a 3.75 month mean delay (range three to six months), and there was one accidental secondary fracture one year after reconstruction. For a vascularised reconstruction of the upper humerus, the pedicled scapular bone flap is a valuable option especially if a composite reconstruction is needed. For short humerus stump lengthening, this flap seems to provide a very satisfactory solution.     

Factors predicting free flap complications in head and neck reconstruction.

In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.     

Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries

The benefits of free flap transfers in the acute burn injury are early wound closure, early mobility, reduced hospitalization, and possibly limb salvage. This retrospective study will attempt to provide principles to the use of free fasciocutaneous flap for the reconstruction of acute burned-hand injuries. Between 1995 and 2004, 5521 patients were admitted to the burn unit at Linkou Chang Gung Memorial Hospital. Of these, 38 patients (0.7%) patients received free fasciocutaneous flap transfers. Each patient's chart was reviewed the following data: age, gender, burn injury type, percentage of the burned area to total body surface area, flap type, operations prior to free flap coverage, the size and location of recipient area, timing of free flap coverage, operative time, duration of hospital stay, complications, flap survival and returning to work. All 38 free flaps survived and healed well. Three flaps with partial necrosis due to wound infections required subsequent debridement and skin grafting. Arterial thrombosis occurred in one patient and was salvaged successfully. Minimal donor-site morbidity with no intraoperative mortality was observed. Free fasciocutaneous flap transfer is a safe, efficacious one-stage reconstruction for acute burned-hands with satisfactory aesthetic and functional outcomes. Flap survival is not affected neither by the etiologies of burn nor the timing of free flap coverage.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

Renaissance gestielter Fernlappen in der Mund-Kiefer-Gesichts-Chirurgie

A retrospective analysis in the period 2007 to 2011 included 71 surgically treated patients for carcinoma of the head and neck region and subsequent reconstruction with 36 pedicled distant flaps and 47 free flaps. Patient specific parameters of data collection with SPSS 17.0 were age and sex distribution, TNM stage and treatment. The specific type of flap reconstruction, duration of surgery, complications, intensive care and inpatient treatment were recorded. The results showed that the healing process was uneventful in 26 (72.2?%) pedicled flaps, 14 (38.9?%) pedicled flaps were transplanted in a preoperatively irradiated area of the head and neck region and in 86.0?% with a positive healing process. Tumor stage, general physical condition of the patient and type of therapy are the key parameters for the choice of reconstruction.     

A Case of Postmastectomy Defect Reconstructed Using a Laterothoracic Bilaterally Pedicled V-Y Advancement Flap

BACKGROUND: The reconstruction of major defects of the trunk is generally achieved by means of pedicled or free musculocutaneous flaps, but for less extensive defects, local flaps or skin grafts are currently used. The bilaterally pedicled V-Y advancement flap differs from the traditional V-Y advancement flap and was described for soft tissue reconstruction in the face. In our unit, the bilaterally pedicled V-Y advancement flap is the most used local flap for face reconstruction, and our aim was to use it in a different location. METHODS: In this case report we present a postmastectomy defect reconstructed with good results using the bilaterally pedicled V-Y advancement flap. RESULTS: The flap healed without further problems, and a good aesthetic result was obtained. CONCLUSION: The bilaterally pedicled V-Y advancement flap is reliable and easy to harvest, and not only for face reconstruction. Its versatility and plasticity allow its use for the reconstruction of many defects at varying locations.     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

Sternumosteomyelitis – chirurgische Behandlungskonzepte

Sternal osteomyelitis is a potentially fatal condition following cardiac surgery. Sternal osteomyelitis should be diagnosed as early as possible followed by an interdisciplinary radical debridement. Subsequently plastic reconstructive surgery is necessary for defect reconstruction. This can be achieved by a number of established pedicled and free flap plastic surgery procedures. The choice of flap procedures is based on defect geometry and the individual patient situation, including potential flap donor sites. Smaller defects can generally be reconstructed by pedicled flap transfer. For extensive sternal defects, free flap transplantation is now a well-established therapeutic option. In some patients lacking sufficient recipient vessels, the creation of an arteriovenous (AV) loop as recipient vessel is necessary. In summary, successful therapy of sternal osteomyelitis is based on early interdisciplinary treatment by the various surgical subspecialties.     

Changes in the peroneal flap and its use in reconstructive surgery of the lower limb. Apropos of an experience of 10 cases]

A peroneal fasciocutaneous flap supplied by the peroneal septocutaneous vessels and raised from the lateral side of the lower leg was reported by Yoshimura in 1983. This flap which can be used as a proximally or distally pedicled or free flap is very useful for leg skin coverage. This flap has a great potential for skin cover and composite reconstruction of the lower limb due to its multiple structural facets (cutaneo-aponevrotic or composite flap), its possible extensions to other vascular territories and the variable geometry of its mode of transfer. 8 reconstructions have been performed. Their indications are described: 4 proximally pedicled flaps (3 with the fibula), 4 reverse-flow island flaps (1 with Soleus and Peroneus longus muscles). The authors stress the importance of preoperative assessment of the feasibility of a given flap which may be limited by post-traumatic, surgical or anatomic modifications. In particular, the uppermost septocutaneous artery which corresponds inconstantly to the "circumflex peroneal artery" can only be visualized by preoperative arteriography. This artery supplies a proximal peroneal flap which can be used as an island or a free flap. We have used this new variety as a free flap in 2 cases and were satisfied with the results. These various clinical applications without any significant complication or flap failure confirm the biological performance and the safe procedure of peroneal flaps.