Rectus abdominis myocutaneous flaps]

The free transverse rectus abdominis myocutaneous (TRAM) flap is vascularized by the inferior epigastric pedicle. There are many techniques according to the indication. We describe the technique for breast reconstruction after mastectomy for cancer. The rectus muscle is taken between the umbilicus and the arcuate line. The skin paddle, was taken transversely like an abdominoplasty. The incision extends from 1 cm above the umbilicus to include the perforators around it. The mean length of the vascular epigastric pedicle is 6 cm. This study was performed from one hundred dissections.     

Anatomical study of the cutaneous perforator arteries and vascularisation of the biceps femoris muscle

We present an anatomical study that describes the distribution of the cutaneous perforators (CP) of both heads of the biceps femoris muscle.

Material and methods

In this study, we dissected 18 legs from nine cadavers. The study was centered on the biceps femoris muscle and musculocutaneous perforator arteries from both muscular heads. Only perforator arteries with comitant vein diameters of over 0.5 mm were selected. The vascular origin and length were also studied. In all cases, measurements were taken from the bicondyle line.

Results

The measurements taken from the muscle bellies of the biceps gave the following results; for the long head 33.91 cm as medium length (SD=2.70) and for the short head 23.85 cm as medium length (SD=2.96).The total number of perforator arteries obtained from the two muscle bellies was 139, with the greatest percentage located in the lower half of the thigh. The majority follow an intramuscular route (80.48%) and less frequently they are septals (19.52%).The lengths of perforator arteries from its origin in the axial vessel of the muscle to the subcutaneous fat were, for the short head 5.01±1.33 (3.0–10.0), whereas the same measurement, in the long head was 4.54±1.36 (2.5–9.0).The principal vascular origin of the perforator arteries was the popliteal artery in both muscle bellies, whilst the second arterial vessel in importance was the first and second profunda perforator artery.

Conclusion

From the results obtained in our work, we can deduce that it is always possible to locate perforator arteries in both muscle bellies; most frequently they have intramuscular distribution and are located in the proximity of the vascular septum. Their most common origins are the popliteal artery and first and second profunda perforator artery. Finally, it is possible to design pedicle and free flaps, with less morbidity and more versatility than musculocutaneous flaps.     

Superior gluteal artery perforator free flap for breast reconstruction

The purpose of this paper is to present a new method of breast reconstruction utilizing skin and fat from the buttock without muscle sacrifice. Cadaver dissections were done to study the musculocutaneous perforators of the superior gluteal artery and vein. Eleven breasts were reconstructed successfully with skin/fat flaps based on the superior gluteal artery with its proximal perforators. Long flap vascular pedicles allow the internal mammary or thoracodorsal vessels to be used as recipient vessels. This new technique has several advantages over the previously described gluteus maximus myocutaneous flaps, including long vascular pedicle and no muscle sacrifice.     

The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects

Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL–ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180°; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm². Mean muscle part size of the MC-ALT flaps was 268 cm³. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.     

Alterations of lymphocyte subsets in patients with recurrent fetal wastage positive for antiphospholipid antibodies treated with Chinese herbal medicine

The delay technique is an established method of enhancing flap survival. This investigation attempts to determine which of two delay techniques results in the best delay effect by measuring their relative abilities to capture adjacent vascular territories in a rat model. A dorsal flap based on the iliac branch of the iliolumbar artery with a captured random zone corresponding to the axial territory of the lateral thoracic artery was used in the evaluation. Sprague-Dawley rats (350-400 g) were randomly assigned into three groups. Group I was the control group. In group II, the circumferential borders of the animal's dorsum were incised without undermining and the dominant pedicle of the lateral thoracic flap was divided. In group III, the medial and lateral borders of the flap were incised and undermined as a bipedicled flap, violating the musculocutaneous perforators. The dominant pedicle of the lateral thoracic artery was also divided. Group III had the greatest survival with only 9% of flap area necrosis compared to 28% and 21% for groups I and II, respectively. These differences were statistically significant. The results suggest that musculocutaneous perforators provide a substantial vascular source to the tissue at risk and should be considered in selecting a delay technique.     

Comparative pathogenesis of human WA1 and Babesia microti isolates in a Syrian hamster model

The medial thigh flap is a perforator-based flap nourished with septocutaneous or muscle perforators originating from the femoral vessels. To date, 8 patients have been repaired with this flap and extended or connected flaps including this flap: 4 patients with lower leg defects and 4 patients with intraoral and neck defects. The advantages of this flap are (1) several pedicle perforators exist for this flap, which makes possible duplicated vascular anastomoses to establish reliable circulation of the transferred flap; (2) the flap can be extended or connected to other neighboring flaps in the anterior thigh, so that extensively wide defects can be closed in one stage; (3) the great saphenous vein can be simultaneously used as a vein graft or for venous drainage for the flap; (4) the anterior branch of the femoral nerve can be used for sensory potential; and (5) there is minimum morbidity of the donor defect and a large dominant vessel for the leg can be preserved. The suitable indications for this flap are defects after removal of skin cancer in the foot or lower leg and wide defects after resection of head and neck cancer, which can be reconstructed with the flap connected to neighboring skin flaps. The disadvantages of this flap are that it has a small, short vascular pedicle and the bulkiness of the flap's fatty tissue often requires thinning.     

The early days of the British Journal of Nutrition

Twenty patients were treated for intraoral epidermoid carcinoma with a single-stage reconstructive technique using a myocutaneous flap based on the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The superior vascular pedicle, the submental branch of the facial artery, was used. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. Only three minor complications were seen and healed spontaneously. The flap has proved to be highly reliable and has significant benefits over many other techniques commonly used for head and neck reconstruction.     

MRI of the intracerebral lesions at 0.5 Tesla: comparison of fast spin-echo and conventional spin-echo sequences

The purpose of this study was to identify the angiosome of the medial saphenous artery and vein and to evaluate the use of this cutaneous angiosome as a free skin flap in the dog. In phase 1 of this study, selective angiography of the medial saphenous artery performed in six canine cadavers showed that the skin covering the entire medial femorotibial area, the distal half of the caudal head of the sartorius muscle, and the gracilis muscle were perfused by the medial saphenous artery. In phase 2, a medial saphenous fasciocutaneous island flap was raised and sutured back to the skin edges of the donor wound in three dogs. One hundred percent survival of all of the flaps occurred. In phase 3, a medial saphenous fasciocutaneous microvascular free flap was transferred to a wound that was created over the dorsal metacarpal (n = 3) or metatarsal region (n = 3). The mean length +/- SD of the medial saphenous vascular pedicle was 80 +/- 13 mm (n = 5); the mean diameter +/- SD of the medial saphenous artery was 2.8 +/- 0.2 mm (n = 5) and the mean diameter +/- SD of the medial saphenous vein was 4.2 +/- 0.2 mm (n = 5). One hundred percent of all flaps survived (n = 6). Selective angiography or the distal cranial tibial artery (metatarsal wounds, n = 3) and the median artery (metacarpal wound, n = 3) was performed 3 weeks after surgery. All of the vascular anastomoses were patent and neovascularization of the wound beds was present. This free flap was found to be acceptable for cosmetic reconstruction of wounds located on the distal extremity.     

The anatomical basis of the vascularized pronator quadratus pedicled bone graft

The vascular supply of the pronator quadratus was studied in 25 cadaveric dissections following coloured latex injections. This showed that the main blood supply of the pronator quadratus came from the anterior interosseous artery. There was, however, a rich anastomosis between the branches of the anterior interosseous artery and those of the radial and ulnar arteries. It was possible to raise a corticocancellous bone graft from the anterior surface of the radial styloid on a pedicle of the lower fibres of the pronator quadratus muscle. This muscle pedicle had a constant branch of the anterior interosseous artery which vascularized the bone graft. Such a vascularized pedicled bone graft may be useful in the treatment of non-union of the scaphoid and Kienb?ck's disease.     

Clinical anatomy of the interosseous arteries of the forearm

In recent years, several local flaps have been developed, based on the anterior and posterior interosseous arteries and their anastomoses at the wrist (e.g. posterior interosseous flap, pronator quadratus flap etc.). The anatomy of the arterial network supplying the flap is well established in both clinical and anatomical literature. Most authors agree in the constancy of the anastomoses between the interosseous arteries at the wrist and the absence of major anatomical variations excluding the use of the flap. In the present study, which is based on cadaver dissections of 60 preserved specimens, several gross vascular variations of the interosseous arteries have been found. The most frequent types were an additional anastomosis between the posterior interosseous artery and a perforating branch of the anterior interosseous artery in the middle third of the forearm, which was found in 20%. Ring-formations of the palmar and the dorsal branch of the anterior interosseous artery occurred in 5%. The point of perforation of the interosseous membrane by the dorsal branch of the anterior interosseous artery was found to vary in a larger extent, as described previously.     

Galeal pedicle flap of the occipital region for pharynx reconstruction: anatomic and clinical considerations

Surgeons are still searching for the ideal method for pharynx reconstruction after tumor ablation. The objective of this study was to prove the anatomic and clinical viability of an occipital galeal pedicle flap for hypopharynx reconstruction. We studied anatomic details in 50 fresh adult cadavers. The dissections were performed after posterior galea exposure, silicone injection in occipital vessels, and mobilization of the galeal flap with an 8 x 8 cm square of galea. We also used the proposed flap in three clinical cases after laryngopharyngectomy. The surgical technique and its problems are described. Some of the anatomic data obtained are as follows: occipital artery diameter, 2.69 mm (mean); occipital artery length, 134.25 mm; area of occipital vessels network on galea, 148.77 cm2; pedicle length, 116.63 mm; and success in rotation to pharynx region (100 percent). The flap showed good functional and cosmetic results when used in three patients. A partial necrosis occurred in one case. The pedicled galeal occipital flap has favorable anatomic characteristics for use in head and neck reconstruction. Additional studies are necessary to provide more substantial information about its clinical viability.     

Assessment of ischaemia of the distal part of the gracilis muscle during transposition for anal dynamic graciloplasty

BACKGROUND: Dynamic graciloplasty is used to create a neosphincter in patients with intractable faecal incontinence. When mobilizing the distal gracilis muscle from the upper leg, the minor vascular pedicles have to be ligated. This can interfere with the vascular supply in this part of the muscle. METHODS: The arterial anatomy within the muscle was visualized by means of angiography of 11 postmortem specimens. To quantify potential acute ischaemia, blood flow in the distal gracilis muscle was measured in ten patients with laser Doppler flowmetry during mobilization of the muscle. RESULTS: Angiography showed that the main vascular pedicle and all minor pedicles drain into one and the same arterial system. After clamping of the minor vascular pedicles, blood flow (mean 25.8 (range 6.5-74.3) perfusion units) did not differ from values obtained before clamping (mean 25.4 (range 7.5-68.7) perfusion units). After a mean of 1.8 years, all muscles were vital. No correlation existed between the change in muscle blood flow and either squeeze pressure (r = -0.2) or functional outcome (r = 0.31). CONCLUSION: This study provides direct anatomical and physiological evidence of one arterial system within the gracilis muscle. It is therefore questionable whether ligation of the minor vascular pedicles is the bottleneck in human dynamic graciloplasty. An additional operation for vascular delay may be redundant. A prospective randomized clinical study should be performed to compare the functional outcome in patients with and without a delay procedure.     

Modifications of the paraspinous muscle flap: anatomy and clinical application

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.     

The second dorsal metacarpal flap with vascular pedicle composed of the second dorsal metacarpal artery and the dorsal carpal branch of radial artery

A pedicle second dorsal metacarpal flap, comprising the second dorsal metacarpal artery, the partial carpal arterial arch of the dorsal hand, and the dorsal carpal branch of radial artery, was designed. The flap may be rotated through two axes of rotation, one at the entry of carpal branch of radial artery into the first dorsal interosseous muscle and one at the entry of the recurrent cutaneous branch arising from the second dorsal metacarpal artery into the skin. The method introduced can increase as much as possible the length of the vascular pedicle of the second dorsal metacarpal flap. Thus, it can cover a small defect at a more distant area. If the width of this flap is not more than 3 cm, the donor site can be closed directly. The flap had been used in five cases with no necrosis of the flap or complication of the donor site. In further investigation of the postoperative patients, no stiffness and tightness have been observed through a short period of rehabilitation of the hand. The results are satisfactory. The anatomy, the operative technique, and three selective cases are described here.     

Internal mammary artery and vein supercharge in TRAM flap breast reconstruction

To improve the blood supply of the pedicled flap we have performed an additional microvascular augmentation to this type of breast reconstruction procedure since 1991. The ipsilateral deep inferior epigastric pedicle is anastomosed to the internal mammary artery and vein (IMAV supercharge). In 19 of 20 patients this technique proved to be feasible. For the venous anastomoses the 3M microvascular anastomosis system facilitated the procedure. In one patient the venous anastomosis failed due to the small calibre of two internal mammary veins. In a majority of the cases rapid improvement of flap perfusion could be observed as the direct result of the supercharging. The IMAV supercharged flap is quite comparable with the free flap as regards to the operative procedure. Disadvantages are a slightly more extensive dissection and less freedom in positioning the flap due to the presence of the superior muscular pedicle. The main advantage is that the supercharge procedure minimises the risk of total flap loss. Further technical improvement may be obtained by the use of a contralateral vascular pedicle dissected with muscle-sparing techniques.     

Free split and segmental latissimus dorsi muscle transfer in one stage for facial reanimation

The authors report the experience in facial reanimation using free innervated split and segmental latissimus dorsi muscle flap one-stage transfer in 86 patients with longstanding facial palsy. The segmental latissimus dorsi was taken from the distal part of the muscle so that the muscle flap had an ultra-long neurovascular pedicle of 13 to 17.5 cm in length. The muscle flap was made thinner by splitting the segmental muscle. The split segmental muscle flap was transferred to the paralyzed side of the face with its ultra-long neurovascular pedicle passing through a tunnel in the upper lip to the normal side of the face. The neurovascular pedicle of the muscle flap was anastomosed with the facial nerve, artery, and veins, respectively, on the normal side of the face. The operation was designed without the cross-facial nerve graft stage. From 1986 to October of 1997, 86 patients with long-standing facial paralysis were treated in our department. The duration of facial palsy in this series ranged from 1.5 to 51 years. A satisfactory result was obtained in 80 cases, evaluated at 8 months to 2 years postoperatively. The expression movement of the soft tissues of the face can be seen not only over transferred muscle but also on the paralyzed muscle covered by the splitting muscle flap. It is supposed that this is the result of muscle-muscle neurolization. Study of 66 specimens of latissimus dorsi muscle in the cadavers is discussed.     

''Low-risk'' myelodysplastic syndrome is associated with excessive apoptosis and an increased ratio of pro- versus anti-apoptotic bcl-2-related proteins

The aim of this study was to develop a free flap of the male prepuce. First, a dissection feasibility study was performed in eight male cadavers. Dissection proved feasible, and the mean surface area of the prepuce, when folded out, was 46.7 cm2. The mean pedicle length was 15 cm, with a mean diameter of the inferior external pudendal artery at its origin of 1.2 mm and a mean diameter of the inferior external pudendal vein at its origin of 1.9 mm. Next, a viability study was performed by isolating a prepuce free flap during male-to-female sex reassignment procedures. The flap as well as the residual skin of the penis shaft remained well perfused. Thereafter, the new prepuce free flap was successfully applied for the reconstruction of defects of the floor of the mouth, tongue, and oropharynx in two patients. The thinness and pliability of the flap, its large surface area, the long vascular pedicle, and the limited donor-site morbidity are the major advantages of this new flap. The possibility to raise the flap simultaneously with the tumor resection is an additional advantage. The small caliber of the flap artery seems to be the only drawback.     

Clinical application of rhombotrapezious island musculocutaneous flap for skull base and/or craniomaxillary operation with malignant tumor

Regional pedicled musculocutaneous flaps are the mainstay of the head and neck reconstruction. They provide a rapid, highly reliable and single-staged technique that is applicable in most cases. The rhombotrapezious island musculocutaneous flap is valuable in the base and craniomaxilloface reconstruction. In this study we updated our experience with the rhombotrapezious island musculocutaneous flap (RTIMF) in 6 cases from 1989 to 1993. Dissections were performed on 9 cadavers, 4 preserved and 5 fresh, yielding 18 pairs or dorsal scapular and transverse cervical artery for evaluation. In the five fresh cadavers, the arteries were selectively cannulated and injected with colored latex. 67% with dorsal scapular and transverse cervical artery commonly arose from the thyro-cervical trunk. 33% with the dorsal scapular artery directly arose from the second part of the subclavian artery. In the period of 1989-1993, 6 rhombotrapezious island musculocutaneous flaps with vascularized pedicle were used for immediate repair in the skull base or craniomaxillary cancer operations. There was no complication of the flaps. Donor site complications were relatively minor. The disturbance in shoulder function was well tolerated. We advocated the incorporation of both the greater and lesser rhomboid muscle to form the compound rhombotrapezious flaps to enhance the vascular supply to the overlying skin. The major advantage of the RTIMF are that it provides a long paddle of thin pliant, hairless skin and muscle that can be rotated as far as the craniomaxilloface and scalp in a single stage. It offers the longest arc of rotation and thus the greatest versatility for the skull base or craniomaxillary reconstruction.     

Comparison of two different delay procedures in a rat skin flap model

The overall objective of this study was to investigate how a strategic delay procedure could generate large flaps survival. On the basis of the vascular anatomy in 10 rats, a long three-territory skin flap spanning the length of the rat dorsum was designed. This flap was distally based on the deep circumflex iliac artery. The adjacent territories consisted of a large perforator of the posterior intercostal artery and the lateral thoracic artery in sequence. Two different vascular delay procedures were used and compared in nine animals. One dorsal midline incision was used to perform the two different delay procedures. The limited delay technique was performed by ligating a large cutaneous perforator of the posterior intercostal artery on one side of the rat. The extensive delay procedure was completed by ligating the cutaneous perforators of the posterior intercostal artery and the lateral thoracic artery on the other side of the rat. After a delay period of 10 days, the paired flaps were elevated, respectively, and sutured back in place. Seven days later, the area of viable skin flap was measured by the paper template technique. The animals were then killed, and the dorsal skin arteriograms were obtained by injecting a lead oxide mixture. Vascular changes of the paired flaps were assessed. In the extensive delay group, 100-percent survival was seen in four animals and distal partial necrosis was observed in five animals. The average survival area in the extensive delay group was 85.5 +/- 14.2 percent (mean +/- SD), whereas the flaps in limited delay group showed 100-percent survival in all animals (p < 0.05). In flaps that survived completely, the choke vessels among three vascular territories anastomosed throughout the flap. In the partially necrotic flaps, some choke and true anastomoses existed between the deep circumflex iliac and the posterior intercostal artery territories and the flap necrosis occurred in the third territory. This study suggests that the limited delay technique (ligation of one artery in the territory adjacent to the base of the flap) was the more effective delay procedure in the rat dorsal skin flap model.     

TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.