Avendano-Peza, Héctor; Novitsky, Yuri W.
Summary: Breast reconstruction with a pedicled transverse rectus abdominis muscle (TRAM) flap can result in significant abdominal wall donor-site morbidity. Although the pedicled TRAM flap donor area reinforced with mesh results in decreased rates of postoperative abdominal bulging and hernias, the best technique to accomplish that is yet to be elucidated. We present our novel technique of posterior components separation with transversus abdominis muscle release and retromuscular mesh reinforcement for donor-area closure during pedicled TRAM flap breast reconstruction.
Nelson Alfred Smith
Full Text Available The authors detail the experimental development of a technique for the reconstruction of the ureter using a tubular shape, muscle flap of the abdominal wall. the preliminary results indicate the feasibility of this surgical technique.
Nelson Alfred Smith; Paulo Cesar Silva; Manoel Luiz Ferreira; Alberto Schanaider
The authors detail the experimental development of a technique for the reconstruction of the ureter using a tubular shape, muscle flap of the abdominal wall. the preliminary results indicate the feasibility of this surgical technique.
Conclusion: The use of a subscapularis muscle flap to repair chest wall defect is a simple and safe technique that can be conducted in the same surgical field as the initial reconstruction surgery and does not require plastic surgery support.
Goldberg, J A; Trabulsy, P; Lineaweaver, W C; Buncke, H J
A retrospective study was performed to measure sensibility in sensory-to-motor innervated microvascular muscle transplants to the foot. Seven transplants were on the weight-bearing surface of the foot. Five of seven flaps had light-touch sensation. Mean vibrometer readings of the innervated transplants were 15.7 (range: 5 to 40) vs. 5.3 (range 2 to 9) on the contralateral foot. Semmes-Weinstein scores of the innervated flaps were 3.84 (one), 4.74 (one), 5.46 (two), and 6.45 (three) vs. 3.22 (one), 3.84 (one), 4.08 (one), and 4.17 (four) on the contralateral foot. This study documents that sensory-to-motor innervated free muscle flaps may regain measurable sensibility.
Ozçelik, Derya; Uğurlu, Kemal; Turan, Tuğrul
Reconstruction with the latissimus dorsi muscle flap, combined with the serratus anterior fascia flap, was performed to cover two large and separate palmar and dorsal forearm skin defects in a patient, whose hand had been replanted 20 days earlier after traumatic amputation at the distal forearm level. As a result, a total forearm amputation was salvaged by microsurgical replantation and a free combined flap of the subscapular system. This new application of the combined flap allowed the reconstruction of large and separate wounds of the replanted hand, and provided gliding surfaces for tendons.
Full Text Available Objective: Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle. Patients and Methods: A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles. Results: Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients. Conclusion: This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.
Kun Liu; Guanghui Wang; Hong Zhang; Yuping Wu; Yangcheng Lv; Jingsong Liu; Jieke Ma; Cheng Li; Jiang Zhu
Objective: The aim of our study was to reconstruct soft and hard tissue perforating defects of the anterior skull base in a 1-stage surgical procedure with a combined craniofacial approach. Methods: Soft and hard tissue defects of the anterior skull base were successfully reconstructed in 43 patients during a 1-stage surgery through the use of frontalis muscle galea aponeurotica skull flaps with 1 or 2 vascularized pedicles. The skull flap areas were up approximately 7 cm × 14 cm. Results: Intracranial infection and cerebrospinal fluid leakage were not observed in the 43 patients, and all incisions healed. Of 33 malignant tumor patients, 25 patients received follow-up examinations for longer than 2 years, and 18 patients survived for 2 years. Conclusion: Frontalis muscle galea aponeurotica skull pedicle flaps provided a constant blood supply and resulted in soft and thin tissue. The pedicle flaps, together with the external cranial bone plate, strengthened the support, but still allowed for bending and shaping. In addition, the flap harvesting approach was consistent with surgery approach, without aesthetic compromises.
Chae Eun Yang
Full Text Available BackgroundCurrently, breast conservation therapy is commonly performed for the treatment of early breast cancer. Depending on the volume excised, patients may require volume replacement, even in cases of partial mastectomy. The use of the latissimus dorsi muscle is the standard method, but this procedure leaves an unfavorable scar on the donor site. We used an endoscope for latissimus dorsi harvesting to minimize the incision, thus reducing postoperative scars.MethodsTen patients who underwent partial mastectomy and immediate partial breast reconstruction with endoscopic latissimus dorsi muscle flap harvest were reviewed retrospectively. The total operation time, hospital stay, and complications were reviewed. Postoperative scarring, overall shape of the reconstructed breast, and donor site deformity were assessed using a 10-point scale.ResultsIn the mean follow-up of 11 weeks, no tumor recurrence was reported. The mean operation time was 294.5 (±38.2 minutes. The postoperative hospital stay was 11.4 days. Donor site seroma was reported in four cases and managed by office aspiration and compressive dressing. Postoperative scarring, donor site deformity, and the overall shape of the neobreast were acceptable, scoring above 7.ConclusionsReplacement of 20% to 40% of breast volume in the upper and the lower outer quadrants with a latissimus dorsi muscle flap by using endoscopic harvesting is a good alternative reconstruction technique after partial mastectomy. Short incision benefits from a very acceptable postoperative scar, less pain, and early upper extremity movement.
Lin, Ying-Sheng; Liu, Wen-Chung; Lin, Yaoh-Shiang; Chen, Lee-Wei; Yang, Kuo-Chung
Background For large tongue defects, reconstructive surgeons have devised a variety of feasible options, such as radial forearm free flap and anterolateral thigh (ALT) flap. In our institution, peroneal flap has been the workhorse flap for the soft tissue defect in head and neck reconstruction. We present our experience using peroneal flap in tongue reconstruction. Patients and Methods The study included 47 patients who had undergone tongue reconstructions with peroneal flaps after tumor resection. The size and location of the defect after tumor resection determined whether the peroneal flaps could be harvested as pure septocutaneous flaps to solely reconstruct the neotongue or to carry an additional muscle bulk to fill the adjacent defect. Retrospective chart review was used to look for postoperative complications and to perform functional assessments (which were also performed through telephone inquiry). Results Of the 47 patients, 3 (6%) had flap failure and 1 (2.1%) had partial flap necrosis. The hemiglossectomy group had better results than the total glossectomy group with respect to speech and diet, but neither of these results reached statistical significance (p = 1.0 for speech and p = 0.06 for diet). The results of the subtotal glossectomy group were better than those of the total glossectomy group with respect to diet (p = 0.03). No statistically significant differences were noted among the three groups with respect to cosmetic aspect (p = 0.64). Conclusions Considering its reasonable postoperative complication rates and functional results, peroneal flap can be considered a feasible option for tongue reconstruction. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Objective To assess clinical effectiveness of using bilateral pectoralis major or plus rectus abdominis muscle flaps in treating deep sternal wound infection (DSWI) following median sternotomy. Methods Between January 2009 and December 2013, 19 patients with DSWI after median sternotomy for cardiac surgery were admitted to our hospital, including 14 males (73.7%) and 5 females (26.3%), aged 55±13 (18-78) years. According to the Pairolero classification of infected median sternotomies, 3 (15.8%) patients were type II, and the other 16 (84.2%) were type III. Surgical procedure consisted of adequate debridement of infected sternum, costal cartilage, granulation, steel wires, suture residues and other foreign substances. Sternal reconstruction used the bilateral pectoralis major or plus rectus abdominis muscle flaps to obliterate dead space. The drainage tubes were placed and connected to a negative pressure generator for adequate drainage. Results There were no intraoperative deaths. In 15 patients (78.9%), bilateral pectoral muscle flaps were mobilized sufficiently to cover and stabilize the defect created by wound debridement. 4 patients (21.0%) needed bilateral pectoral muscle flaps plus rectus abdominis muscle flaps because their pectoralis major muscle flaps could not reach the lowest portion of the wound. 2 patients (10.5%) presented with subcutaneous infection, and 3 patients (15.8%) had hematoma. They recovered following local debridement and medication. 17 patients (89.5%) were examined at follow-up 12 months later, all healed and having stable sternum. No patients showed infection recurrence during the follow-up period over 12 months. Conclusion DSWI following median sternotomy may be effectively managed with adequate debridement of infected tissues and reconstruction with bilateral pectoralis major muscle or plus rectus abdominis muscle flap transposition.
Divya N Upadhyaya
Full Text Available 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.
Breast reconstruction with flap surgery Overview By Mayo Clinic Staff Breast reconstruction is a surgical procedure that restores shape to ... breast tissue to treat or prevent breast cancer. Breast reconstruction with flap surgery is a type of breast ...
Tuhar; Zamfirescu, D; Gheorghiță, C; Slăvescu, D; Frunză, A; Lascăr, I
.... The anterior lateral thigh flap sensitive myocutaneous (ALTF) with vastus lateralis muscle was used to reconstruct the oral defect in a patient undergoing total glossectomy with laryngeal preservation for T4 tongue cancer...
Serra-Renom, José M; Serra-Mestre, José M; Martinez, Lourdes; D'Andrea, Francesco
Results obtained with breast-conserving therapy are not always satisfactory. Reconstruction with a pure latissimus dorsi muscle flap is a useful option. The techniques described for endoscopic dissection of the flap create several scars on the back. As a result, they do not improve on the open approach, which causes a horizontal scar at the level of the bra strap. The authors' technique avoids all scars on the back using a single incision in the highest folds of the axilla, which also is used for the sentinel node biopsy or lymphadectomy and quadrantectomy. The study was performed with 23 patients. The tumor was extracted via a clockwise downward periareolar incision and via another incision in a fold of the axilla. Through this axillary incision, the sentinel lymph node biopsy or lymphadectomy was performed, and the external part of the latissimus dorsi muscle was harvested endoscopically for the reconstruction. Both the medical team and the patients reported high satisfaction with the aesthetic and functional results due to the preservation of the breast shape and the absence of any scarring on the back. Endoscopy-assisted techniques make either three small scars on the back or one long scar, with the muscle sectioned distally, or a vertical incision in the midaxillary line, which may form a hypertrophic or keloid scar. The authors' approach avoids the creation of these scars on the back because the endoscopy and the distal sectioning of the muscle flap are performed through the single axillary incision.
Yamamoto, Etsuhide; Kumagai, Shigehiro (Kanazawa Univ. (Japan). School of Medicine); Kohama, Gen-iku; Nagai, Itaru; Hiratsuka, Hiroyoshi; Miyakawa, Akira
A case of mandibular reconstruction with clavicle is presented. A 54-year old woman, who received irradiation for therapy of buccal cancer, visited our clinic complaining of exposed bone at premolar area. This lesion has become oro-cutaneous fistula with bone necrosis within a few years in spite of minor sequestrectomies. Necrosed mandibular body was, therefore, resected about 5 cm in length. Seven months after this treatment, split-thickness of clavicle was used with sternocleidomastoid muscle as an osteomascular flap. Skin graft vestibuloplasty was done one year after success of mandibular reconstruction. Denture is well-fitted and stable on improved alveolar rigde. (author).
Selber, Jesse C; Nelson, Jonas; Fosnot, Joshua; Goldstein, Jesse; Bergey, Meredith; Sonnad, Seema S; Serletti, Joseph M
The purpose of this two-part study was to demonstrate the impact of free flap breast reconstruction on the abdominal wall. In Part I, the authors present the results for unilateral techniques. A blinded, prospective, cohort study was performed involving 234 free flap breast reconstruction patients. Patients were evaluated preoperatively, and followed for 1 year. At each encounter, patients underwent abdominal strength testing using the Upper and Lower Rectus Abdominis Manual Muscle Function Test, the Functional Independence Measure, and psychometric testing using the 36-Item Short-Form Health Survey. Patients also completed a satisfaction questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. Two-hundred thirty-four patients were enrolled. Of these, 157 underwent reconstruction (75 of which were unilateral), completed follow-up, and were included in the analysis. There was a significantly greater decline in upper abdominal strength in patients undergoing muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap surgery compared with deep inferior epigastric perforator (DIEP) flap surgery at early (p = 0.01) and late follow-up (p = 0.02). Unilateral superficial inferior epigastric artery flap procedures (n = 3) were too few for a meaningful conclusion to be reached. Lower abdominal and Functional Independence Measure scores showed no significant differences. Psychometric testing showed that there was a significant decline in physical health within the free TRAM flap group. No significant difference among groups was appreciable. In unilateral cases, the impact of the muscle-sparing free TRAM flap versus the DIEP flap follows theoretical predictions based on the degree of muscle sacrifice: the muscle-sparing free TRAM flap demonstrated a greater decline than the DIEP flap in certain measurable parameters.
Selber, Jesse C; Fosnot, Joshua; Nelson, Jonas; Goldstein, Jesse; Bergey, Meredith; Sonnad, Seema; Serletti, Joseph M
The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on the abdominal wall. This is the second installation of a two-part series. Presented here are bilateral combinations of three techniques: the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. A blinded prospective cohort study was performed involving 234 patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each encounter, patients underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional Independence Measure and psychometric testing using the Short Form 36 questionnaire. At postoperative visits, patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. A total of 234 patients were enrolled. Of these, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in upper (p=0.02) and lower (p=0.05) abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP flaps. Likewise, there was a significant decline in upper (p=0.055) and lower (p=0.04) abdominal strength from bilateral free TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA, and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing showed trends, there was no significant difference among treatment groups. Abdominal wall strength following various combinations of bilateral free flap breast reconstruction techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.
Sasaki, Kaoru; Adachi, Koji; Sekido, Mitsuru
Large full-thickness oral defects involving the oral commissure continue to be a challenge for reconstructive surgeons. Although local flaps are the best option for full-thickness lip reconstruction, they are unavailable for large defects. In particular, recent advances in microsurgery have extended the available surgical options using free flaps, but for full-thickness large oral defects involving the oral commissure, it is still difficult to obtain good function and competence. The major disadvantages are the drooping and loosening of the reconstructed lip and the difficulty in restoring a natural oral commissure. We present two cases of lip reconstruction for full-thickness large defects involving the oral commissure in which free flaps with the muscle bow traction method were used to overcome these problems. In case 1, the lip was reconstructed with a free radial forearm-palmaris longus tendon composite flap. The tendon was sutured onto the orbicularis oris stumps. In case 2, the lip was reconstructed with a free anterolateral thigh flap including the fascia lata. A fascial strip in the flap was sutured to the residual orbicularis muscles. In each case, additional nonvascularised fascia lata was harvested and suspended the reconstructed lip in transverse direction as a muscle bow traction method. Both patients achieved good oral competence without medial deviation of the oral commissure and were able to resume a regular diet without drooping and loosening of the reconstructed lip. For large full-thickness oral defects involving the oral commissure, transverse fascial suspension with muscle bow traction is useful for functional and cosmetic reconstruction.
disgusting defect crated in the donor site. So we have created a variety: instead of taking half of the muscle, we took just a quarter, which survived with only one dominant vessel. The other quarter improved de defect in the donor site. The 3 patients were successful and they are happy with the results. We present an innovative surgical variant in muscle Soleous flap that can be useful in lower limb reconstruction, and that we have denominated So flap.
Zhong, Toni; Novak, Christine B.; Bagher, Shaghayegh; Maass, Saskia W. M. C.; Zhang, Jing; Arad, Udi; O'Neill, Anne C.; Metcalfe, Kelly A.; Hofer, Stefan O. P.
BACKGROUND: Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative f
Nofal, Ahmad Abdel-Fattah; Mohamed, Morsi
Introduction Most patients after either superficial or total parotidectomy develop facial deformity and Frey syndrome, which leads to a significant degree of patient dissatisfaction. Objective Assess the functional outcome and esthetic results of the superiorly based sternocleidomastoid muscle (SCM) flap after superficial or total parotidectomy. Methods A prospective cohort study for 11 patients subjected to parotidectomy using a partial-thickness superiorly based SCM flap. The functional outcome (Frey syndrome, facial nerve involvement, and ear lobule sensation) and the esthetic results were evaluated subjectively and objectively. Results Facial nerve palsy occurred in 5 cases (45%), and all of them recovered completely within 6 months. The Minor starch iodine test was positive in 3 patients (27%), although only 1 (9%) subjectively complained of gustatory sweating. The designed visual analog score completed by the patients themselves ranged from 0 to 3 with a mean of 1.55 ± 0.93; the scores from the blinded evaluators ranged from 1 to 3 with a mean 1.64 ± 0.67. Conclusion The partial-thickness superiorly based SCM flap offers a reasonable cosmetic option for reconstruction following either superficial or total parotidectomy by improving the facial deformity. The flap also lowers the incidence of Frey syndrome objectively and subjectively with no reported hazard of the spinal accessory nerve.
Nofal, Ahmad Abdel-Fattah
Full Text Available Introduction Most patients after either superficial or total parotidectomy develop facial deformity and Frey syndrome, which leads to a significant degree of patient dissatisfaction. Objective Assess the functional outcome and esthetic results of the superiorly based sternocleidomastoid muscle (SCM flap after superficial or total parotidectomy. Methods A prospective cohort study for 11 patients subjected to parotidectomy using a partial-thickness superiorly based SCM flap. The functional outcome (Frey syndrome, facial nerve involvement, and ear lobule sensation and the esthetic results were evaluated subjectively and objectively. Results Facial nerve palsy occurred in 5 cases (45%, and all of them recovered completely within 6 months. The Minor starch iodine test was positive in 3 patients (27%, although only 1 (9% subjectively complained of gustatory sweating. The designed visual analog score completed by the patients themselves ranged from 0 to 3 with a mean of 1.55 ± 0.93; the scores from the blinded evaluators ranged from 1 to 3 with a mean 1.64 ± 0.67. Conclusion The partial-thickness superiorly based SCM flap offers a reasonable cosmetic option for reconstruction following either superficial or total parotidectomy by improving the facial deformity. The flap also lowers the incidence of Frey syndrome objectively and subjectively with no reported hazard of the spinal accessory nerve.
Fox, Paige; Endress, Ryan; Sen, Subhro; Chang, James
The ability to use the anterolateral thigh (ALT) flap as a vascularized fascial flap, without skin or muscle, was first documented by Koshima et al in 1989. The authors mention the possibility of using the fascia alone for dural reconstruction. Despite its description more than 20 years ago, little literature exists on the application of the ALT flap as a vascularized fascial flap. In our experience, the ALT flap can be used as a fascia-only flap for thin, pliable coverage in extremity reconstruction. After approval from the institutional review board, the medical records and photographs of patients who had undergone fascia-only ALT free flaps for extremity reconstruction were reviewed. Photographic images of patients were then matched to patients who had undergone either a muscle-only or a fasciocutaneous free flap reconstruction of an extremity. Photographs of the final reconstruction were then given to medical and nonmedical personnel for analysis, focusing on aesthetics including color and contour. Review of cases performed over a 2-year period demonstrated similar ease of harvest for fascia-only ALT flaps compared to standard fasciocutaneous ALT flaps. Fascia-only flaps were used for thin, pliable coverage in the upper and lower extremities. There was no need for secondary procedures for debulking or aesthetic flap revision. In contrast to muscle flaps, which require muscle atrophy over time to achieve their final appearance, there was a similar flap contour from approximately 1 month postoperatively throughout the duration of follow-up. When a large flap is required, the fascia-only ALT has the advantage of a single-line donor-site scar. Photograph comparison to muscle flaps with skin grafts and fasciocutaneous flaps demonstrated improved color, contour, and overall aesthetic appearance of the fascia-only ALT over muscle and fasciocutaneous flaps. The fascia-only ALT flap provides reliable, thin, and pliable coverage with improved contour and color over
Background The pectoralis major flap is frequently being applied as a pedicled flap for head and neck reconstruction. To reduce donor-site morbidity, muscle-preserving methods using only a segment of this muscle for transplantation, were described. The nerve supply to the clavicular part of the pect
Lanfrey, E; Grolleau, J L; Glock, Y; Chavoin, J P; Costagliola, M
Reconstruction of the chest wall after balistic or other trauma requires good and muscle cover and creation of a new, stable and airtight wall. The authors present a case of balistic trauma of the right anterolateral chest wall which was urgently debrided and subsequently reconstructed by sandwich combination of a latissimus dorsi muscle flap and synthetic material composed of a sheet of PTFE and creation of two methylmethylacrylate ribs. The advantage of this technique is that it avoids the use of autologous tissue from an already weakened chest wall and confers a new chest stability in several sites corresponding to the wall defect with easily available and easy-to-use materials.
defects can usu- ally be obtained with a rotational flap , larger size defects commonly require free tissue transfer. A number of techni- ques have...feasible.21,22 Because limb salvage situations occur in which rota- tional muscle coverage is inadequate and free flap coverage is less desirable, we...larger defects which previously would have required free tissue transfer. Surgical Technique The GEM flap for large soft tissue defects of the leg requires
Kuo, Pao-Jen; Chew, Khong-Yik; Kuo, Yur-Ren; Lin, Pao-Yuan
Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted. © 2014 Wiley Periodicals, Inc.
Galla, T J; Lukas, B; Feller, A M
In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.
Breton, P; Henry, J F; Crezoit, E; Souchere, B; Freidel, M
The serrato-costal free flap provides a large costal flap vascularized by a digitation of the serratus anterior muscle supplied by the dorsal thoracic artery. The flap is easy and rapid to raise with low morbidity. The repair obtained is functionally very satisfactory, but does not allow insertion of an implant. Six cases are reported. The indications of this technique of mandibular reconstruction are discussed.
In reconstructive surgery, occasional free flap failures occur despite the clinical and technical advances in microsurgery of the past few years. To minimize these losses a better understanding of basic flap physiology must be achieved. The objectives of this work were the investigation of the haemodynamic characteristics of skin and muscle flaps in normal and compromised circumstances, the viability of skin and muscle flaps after pedicle ligation or ischaemia, and the possible interrelationship of haemodynamics and viability. A Wistar rat groin island skin flap model was used to assess flap survival following vascular compromise produced by vessel ligation. Survival was seen earliest following loss of the artery and was not dependent on circulation through the vascular pedicle after 5 days. A study using free groin flaps in rats gave similar results. Normal free groin flaps were then transferred to irradiated Fischer F344 rats. Delayed neovascularization was shown at a time corresponding to the onset of the late phase of the response to skin radiation. A canine inferior epigastric free skin flap model was established to determine the normal haemodynamic parameters during free flap transfer. A canine gracilis free muscle flap model was developed. Normal haemodynamic parameters are given. These parameters were examined after ischaemia. Survival of the muscle followed ischaemia of 4 hours or less. Flap survival is not dependent solely on arterial input or venous drainage. More complex phenomena such as the reactive hyperaemia following ischaemia are implicated in survival.
Chae Eun Yang; Tai Suk Roh; In Sik Yun; Young Seok Kim; Dae Hyun Lew
Background Currently, breast conservation therapy is commonly performed for the treatment of early breast cancer. Depending on the volume excised, patients may require volume replacement, even in cases of partial mastectomy. The use of the latissimus dorsi muscle is the standard method, but this procedure leaves an unfavorable scar on the donor site. We used an endoscope for latissimus dorsi harvesting to minimize the incision, thus reducing postoperative scars. Methods Ten patients who under...
Zhu, Yue-Liang; He, Xiao-Qing; Wang, Yi; Lv, Qian; Fan, Xin-Yv; Xu, Yong-Qing
The forefoot is critical to normal walking; thus, any reconstruction of forefoot defects, including the soft tissues, must be carefully done. The free perforator flap, with its physiologic circulation, lower donor site morbidity, and minimal thickness is the most popular technique in plastic and microsurgery, and is theoretically the most suitable for such forefoot reconstruction. However, these flaps are generally recognized as more difficult and time-consuming to create than other flaps. In 41 patients with traumatic forefoot defects, we reconstructed the forefoot integument using 5 types of free perforator flaps. The overall functional and cosmetic outcomes were excellent. Three flaps required repeat exploration; one survived. The most common complications were insufficient perfusion and the need for second debulking. The key to our success was thoroughly debriding devitalized bone and soft tissue before attaching the flap. Forefoot reconstruction with a free perforator flap provides better function, better cosmesis, better weightbearing, and better gait than the other flaps we have used.
Sowa, Yoshihiro; Morihara, Toru; Kushida, Rie; Sakaguchi, Koichi; Taguchi, Tetsuya; Numajiri, Toshiaki
Several investigators have evaluated the impaired function of the shoulder after removal of the latissimus dorsi muscle for breast reconstruction. However, a few investigators have studied whether including radiotherapy has a negative effect on functional recovery of the shoulder by a long-term follow-up after surgery. In this study, we compared objective measurements of shoulder function preoperatively and postoperatively for 3 years after latissimus dorsi muscle (LDM) flap transfer and postoperative radiotherapy (PRT). Eighteen patients who underwent unilateral transfer of a pedicled LDM flap and PRT within 2 months of breast-conserving surgery were enrolled in this study. Range of motion (ROM) and muscle strength in exhaustive shoulder movements were measured before surgery, and at 3 and 6 months, and 1 and 3 years. The results of ROM measurements at 3months postsurgery showed significant decreases in both flexion and abduction by 7.1 and 9.2 % and at 3 years postsurgery by 4.7 and 5.7 %. The muscle strength measurements at 3 months postsurgery showed statistically significant decreases both in adduction and in the 2nd medial rotation by 30.7 and 25.9 % and at 3 years postsurgery by 36.4 and 20.4 %. A significant improvement in these impairments was not observed for 3 years after surgery compared with that at 3 months after surgery. A combination of the LDM flap procedure and PRT could be associated with a higher incidence of tissue adhesions in both flexion and abduction and muscle deficit both in adduction and in the 2nd medial rotation.
Full Text Available The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18% suffered complications.
Full Text Available [english] Background: A tremendous number of free flaps have been developed in the past. As the surgical result depends not only on a successful flap transfer but also on the harvest, this paper details the procedures for undertaking the first total endoscopic harvest of a serratus fascia flap for free flap transplantation to the lower leg. Patient and methods: In September 2012 we performed the first total endoscopic serratus anterior fascia free flap harvest. The incision of 2.5 cm length was made 10 cm in front of anterior muscle border of the latissimus dorsi at level with the midthorax. After insertion of a flexible laparoscopic single port system we started CO gas insufflation. We used this setting to meticulously prepare a neo cavity between atissimus dorsi and M. serratus anterior. The vessels were dissected and the thoraco-dorsal nerve was separated. With a second auxiliary incision we used a clamp to support the raising of the fascia flap from the underlying muscle. Finally we clipped the vessels to the latissimus dorsi muscle and the flap vessels at the Arteria and Vena axillaris. The flap was extracted via the 2.5 cm incision.Results: We were able to perform a total endoscopic harvest of a serratus fascia flap for free flap reconstruction of soft tissues. With this new operative technique we were able to avoid a long skin incision, which in our view lowers the morbidity at the harvest area.Conclusion: We describe a new method for the total endoscopic harvest of the serratus fascia flap for free flap transfer. The flap was harvested within reasonable time and following surgery leaves the patient with minimal donor site morbidity compared to the open technique.
Min Jae Lee
Full Text Available BackgroundThe anterolateral thigh (ALT perforator flap has become a popular option for treating soft tissue defects of lower extremity reconstruction and can be combined with a segment of the vastus lateralis muscle. We present a comparison of the use of the ALT fasciocutaneous (ALT-FC and myocutaneous flaps.MethodsWe retrospectively reviewed patients in whom free-tissue transfer was performed between 2005 and 2011 for the reconstruction of lower extremity soft-tissue defects. Twenty-four patients were divided into two groups: reconstruction using an ALT-FC flap (12 cases and reconstruction using a vastus lateralis myocutaneous (VL-MC flap (12 cases. Postoperative complications, functional results, cosmetic results, and donor-site morbidities were studied.ResultsComplete flap survival was 100% in both groups. A flap complication was noted in one case (marginal dehiscence of the ALT-FC group, and no complications were noted in the VL-MC group. In both groups, one case of partial skin graft loss occurred at the donor site, and debulking surgeries were needed for two cases. There were no significant differences in the mean scores for either functional or cosmetic outcomes in either group.ConclusionsThe VL-MC flap is able to fill occasional dead space and has comparable survival rates to ALT-FC with minimal donor-site morbidity. Additionally, the VL-MC flap is easily elevated without myocutaneous perforator injury.
Liao, Gui-Qing; Su, Yu-Xiong; Liu, Hai-Chao; Li, Jin; Fahmha, Numan; Ou, De-Ming; Wang, Qin
To investigate the clinical application of free forearm flap in the functional hemitongue reconstruction. From July 2002 to November 2006, 40 patients with tongue cancer underwent hemiglossectomy and primary hemitongue reconstruction with free forearm flaps. In some cases, the lateral antebrachial cutaneous nerves of the flaps were anastomosed with the lingual nerve to restore the flap sensation. All patients recovered uneventfully after surgery with no morbidity in the donor site. All free flaps survived. The average follow-up period was 2 years and 6 months. The aesthetic and functional results were both satisfactory. The swallowing and speech function were almost normal. The flap sensation was partially restored. Good functional hemitongue reconstruction can be achieved with free forearm flaps.
Min Jae Lee
Full Text Available Background The anterolateral thigh (ALT perforator flap has become a popular option fortreating soft tissue defects of lower extremity reconstruction and can be combined witha segment of the vastus lateralis muscle. We present a comparison of the use of the ALTfasciocutaneous (ALT-FC and myocutaneous flaps.Methods We retrospectively reviewed patients in whom free-tissue transfer was performedbetween 2005 and 2011 for the reconstruction of lower extremity soft-tissue defects. Twentyfourpatients were divided into two groups: reconstruction using an ALT-FC flap (12 cases andreconstruction using a vastus lateralis myocutaneous (VL-MC flap (12 cases. Postoperativecomplications, functional results, cosmetic results, and donor-site morbidities were studied.Results Complete flap survival was 100% in both groups. A flap complication was noted inone case (marginal dehiscence of the ALT-FC group, and no complications were noted in theVL-MC group. In both groups, one case of partial skin graft loss occurred at the donor site,and debulking surgeries were needed for two cases. There were no significant differences inthe mean scores for either functional or cosmetic outcomes in either group.Conclusions The VL-MC flap is able to fill occasional dead space and has comparable survivalrates to ALT-FC with minimal donor-site morbidity. Additionally, the VL-MC flap is easily elevatedwithout myocutaneous perforator injury.
Kim, Jeong Tae; Kim, Sang Wha; Youn, Seungki; Kim, Youn Hwan
Microsurgical free tissue transfer is regarded as the best available method of tissue reconstruction for intractable defects. The ideal soft tissue flap is thought to be the anterolateral thigh flap. On the basis of 334 procedures involving the latissimus dorsi (LD) flap, we discuss the advantages of the LD flap over the current universal option, and we aimed to establish whether the LD could also gain universal status in all reconstructive fields.Three hundred thirty-four reconstructive procedures using the LD flap were performed in 322 patients between September 2002 and July 2012. In accordance with defect characteristics, we performed 334 procedures using flaps, which included the LD muscle flap with skin graft, the myocutaneous flap, the muscle-sparing flap, the perforator flap, the chimeric flap, and the 2-flap technique using the serratus anterior branch.Flap-related complications occurred in 21 patients (6.3%), including total and partial flap failure. In 253 cases, the donor site was closed primarily, and in the remaining cases, we used split-thickness skin grafts. Donor-site complications occurred in 20 cases (6%). In 11 of the 182 cases, no suitable perforators were identified during surgery.The advantages of the LD as a donor site include the possibility of various harvesting positions without position change, versatility of components, availability of muscle to fill extensive defects, and presence of thick fascia to enable full abdominal reconstruction. On the basis of our experience, we concluded that this flap has the potential to be used as widely as, or in preference to, the anterolateral thigh flap in most reconstructive areas.
Jun Yong Lee
Full Text Available For the successful reconstruction of facial defects, various perforator flaps have been used in single-stage surgery, where tissues are moved to adjacent defect sites. Our group successfully performed perforator flap surgery on 17 patients with small to moderate facial defects that affected the functional and aesthetic features of their faces. Of four complicated cases, three developed venous congestion, which resolved in the subacute postoperative period, and one patient with partial necrosis underwent minor revision. We reviewed the literature on freestyle perforator flaps for facial defect reconstruction and focused on English articles published in the last five years. With the advance of knowledge regarding the vascular anatomy of pedicled perforator flaps in the face, we found that some perforator flaps can improve functional and aesthetic reconstruction for the facial defects. We suggest that freestyle facial perforator flaps can serve as alternative, safe, and versatile treatment modalities for covering small to moderate facial defects.
Lee, Jun Yong; Kim, Ji Min; Kwon, Ho; Jung, Sung-No; Shim, Hyung Sup; Kim, Sang Wha
For the successful reconstruction of facial defects, various perforator flaps have been used in single-stage surgery, where tissues are moved to adjacent defect sites. Our group successfully performed perforator flap surgery on 17 patients with small to moderate facial defects that affected the functional and aesthetic features of their faces. Of four complicated cases, three developed venous congestion, which resolved in the subacute postoperative period, and one patient with partial necrosis underwent minor revision. We reviewed the literature on freestyle perforator flaps for facial defect reconstruction and focused on English articles published in the last five years. With the advance of knowledge regarding the vascular anatomy of pedicled perforator flaps in the face, we found that some perforator flaps can improve functional and aesthetic reconstruction for the facial defects. We suggest that freestyle facial perforator flaps can serve as alternative, safe, and versatile treatment modalities for covering small to moderate facial defects.
Jonathan Bank, MD
Conclusions: Patients who underwent irradiation before TDAP flap did not have a higher complication rate when compared with patients who had a full LD flap following radiation. By integrating well-vascularized, nonradiated tissue of a TDAP flap in reconstruction, overall complication rate may be minimized and the results are comparable to the generally accepted method of utilizing the entire latissimus dorsi muscle.
Full Text Available Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection.
Pavlov, V N; Bakirov, A A; Kabirov, I R; Izmajlov, A A; Kutlijarov, L M; Safiullin, R L; Urmancev, M F; Sultanov, I M; Abdrahimov, R V
Evisceration of the pelvic organs (EPO) is a fairly uncommon surgical treatment that removes all organs from a patient's pelvic cavity. We use gracilis musculocutaneous flap to repair pelvic floor after EPO. Over the period from November 2013 to December 2014 we carried out EPO with reconstructive repair of the pelvic floor with gracilis musculocutaneous flap in 10 patients with locally advanced pelvic tumors. We describe the surgical procedure and surgical outcomes in these patients. Mean age of the patients was 55 years. Mean duration of EPO with the pelvic floor repair was 285 min., mean blood loss--595 mL and the average length of hospital stay--19 days. Gracilis musculocutaneous flap has a sufficient arterial supply and mobility for pelvic floor reconstruction. Necrosis of flap's distal edge occurred in one of the 10 clinical cases, while the remaining flaps were fully preserved. Complete healing of wounds with no signs of weakening of the pelvic floor muscles was observed in all cases. Pelvic floor reconstruction is an essential procedure in order to reduce complications associated with the evisceration of the pelvic organs. The Gracilis musculocutaneous flap is the logical alternative to repair pelvic floor defect. It does not contribute to complications like functional deficiency of the lower limbs, complications of stoma formation or weakening of the muscles of the anterior abdominal wall.
Kim, Chae Min; Yun, In Sik; Lee, Dong Won; Lew, Dae Hyun; Rah, Dong Kyun
Background Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores. Methods We retrospectively analyzed data from 14 patients (16 ischial sores) whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course. Results All flaps survived the entire follow-up period. Seven patients (50%) had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years). The mean follow-up period was 27.9 months (range, 3-57 months). In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%), wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%), but resolved with conservative treatment. Among 16 cases, there was only one (6%) recurrence at 34 months. Conclusions The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores. PMID:25075362
Chae Min Kim
Full Text Available Background Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores. Methods We retrospectively analyzed data from 14 patients (16 ischial sores whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course. Results All flaps survived the entire follow-up period. Seven patients (50% had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years. The mean follow-up period was 27.9 months (range, 3-57 months. In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%, wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%, but resolved with conservative treatment. Among 16 cases, there was only one (6% recurrence at 34 months. Conclusions The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores.
YAN Xiao-qing; YANG Hong-yan; ZHAO Yu-ming; YOU Lei; XU Jun
Background In the past decade, there has been increasing breast reconstructions after mastectomy. The ideal material for reconstruction of a breast is fat and skin. The transverse rectus abdominis myocutaneous (TRAM) flap has been the gold standard for breast reconstruction until recently. Abdominal wall function is a major concern for plastic surgeons in breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore preserves adequate abdominal wall competence. The aim of this study was to summarize our experience in breast reconstruction with DIEP flap.Methods Between March 2000 and August 2005, a total of 43 breast reconstructions were performed on 40 patients by our surgeons using DIEP flap (3 patients had bilateral procedures), 14 of them were immediate surgeries and 26 were delayed. Abdominal function, satisfaction with the donor site and reconstructed breast, and the sensation recovery was assessed respectively during follow-up.Results The mean age of the patients was 38.6 years (range, 28-50). The size of the flaps was 11 cm×26 cm in average (height 10-12 cm, width 15-33 cm). The mean length of the vascular pedicles was 9.3 cm (range, 7-12). The patients were followed up for a mean of 16 months (range, 6-30 months). During the follow-up, 2 (5%) patients had total flap loss, 2 (5%) had partial necrosis, 4 (9%) had wound edge necrosis in the abdomen, and 1 had axillary seroma. None of the patients had hernia, and all of them were able to resume their daily activities after the operation. Patient satisfaction with the reconstructed breast rated high, 95% of the patients achieved spontaneous return of sensation in the reconstructed breast, but none of them had a sensation equivalent or approximate to the normal.Conclusions The DIEP flap has the same benefits as the TRAM flap without destroying the continuity of the rectus muscle. It can reduce
Zgonis, Thomas; Ramanujam, Crystal L.; Facaros, Zacharia
Complicated soft tissue defects of the diabetic foot often call for alternative methods to traditional primary closure. Despite the popularity of microvascular free flaps, local muscle flaps can offer reliable reconstruction for these challenging wounds with shorter surgical times and reduced complication rates. In this article, the authors describe the successful use of the abductor hallucis muscle flap and external fixation for soft tissue reconstruction of a chronic Charcot foot wound and ...
Crystal L. Ramanujam
Full Text Available Complicated soft tissue defects of the diabetic foot often call for alternative methods to traditional primary closure. Despite the popularity of microvascular free flaps, local muscle flaps can offer reliable reconstruction for these challenging wounds with shorter surgical times and reduced complication rates. In this article, the authors describe the successful use of the abductor hallucis muscle flap and external fixation for soft tissue reconstruction of a chronic Charcot foot wound and osteomyelitis in a diabetic patient.
Rausky, Jonathan; Binder, Jean-Philippe; Mazouz-Dorval, Sarra; Hamou, Cynthia; Revol, Marc
The reconstruction of severe defects of the ankle and foot is a challenge. The ideal solution should combine a thin skin flap on the dorsum to allow shoe fitting and a muscle flap with a split-thickness skin graft on the weight-bearing area. Perforator-based thoracodorsal chimaeric flaps allow us to achieve these two goals with minimal donor-site morbidity. We present a reconstruction of an extended circumferential defect of the ankle with an exposed heel using a chimaeric thoracodorsal perforator flap with a serratus muscle flap. The skin flap was transferred on the dorsal foot, whereas the serratus anterior muscle was transferred on the exposed heel. Postoperative recovery was uneventful and the patient began full weight bearing after 3 months. Twelve months after reconstruction, natural shape and walking function were successfully achieved.
Wang, Qianwen; Wang, Jiaqi
Various types of anterior chest flaps can be recruited in the reconstruction of faciocervical region. Most of them were created based on the internal mammary artery and the lateral thoracic artery, and the thoracoacromial artery (TAA) is usually used in pectoralis major musculocutaneous flap. An anterior chest flap with TAA perforator (TAAP) will have no sacrifice of the pectoralis major muscle, but less reports, especially expanded pedicled one, can be reviewed. Here, we reported a case using expanded pedicled TAAP flap to reconstruct the perioral scar contracture. In this technique, expanded TAAP flap could be easily harvested without the sophisticated microsurgical technology. Acceptable esthetic and functional results were achieved.
Clark, Jonathan R; Gilbert, Ralph; Irish, Jonathan; Brown, Dale; Neligan, Peter; Gullane, Patrick J
Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal functional results. The primary aim of this study is to determine whether complications can be predicted on the basis of reconstruction in patients undergoing pharyngectomy for tumors involving the hypopharynx. In addition, we detail a reconstructive algorithm for management of partial and total laryngopharyngectomy defects. A retrospective review was performed of 153 patients undergoing flap reconstruction for 85 partial and 68 circumferential pharyngectomies at a single institution over a 10-year period. There were 118 males and 35 females, the median age was 62 years, and mean follow up was 3.1 years. Pharyngectomy was performed for recurrence after radiotherapy in 80 patients and as primary surgery in 73. Free flap reconstruction was used in 42%, with 30 jejunal, 15 radial forearm, 11 anterolateral thigh, five rectus abdominis, and three gastro-omental flaps. Gastric transposition and pectoralis major pedicle flap was used in 14% and 44% of patients, respectively. Morbidity was analyzed according to extent of defect, regional versus free flap, enteric versus fasciocutaneous free flap reconstruction, and the effect of laparotomy. The total operative morbidity and mortality rate was 71% and 3%, respectively. The most common complications were hypocalcemia in 45%, pharyngocutaneous fistula in 33%, and wound complications in 25%. The late complication and stricture rate was 26% and 15%, respectively. On univariate analysis, circumferential defects were associated with increased total (P=.046) and flap-related morbidity (P=.037), hypocalcemia (Pspeech was the method of voice restoration in 44% of patients. Oral diet was achieved in 93% of patients; however, 16% required gastrostomy tube feeds for either total or supplemental nutrition. The operative morbidity associated with pharyngeal reconstruction is substantial in terms of early and late complications. We were
Chevray, Pierre M.
Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data ...
Zang, Mengqing; Yu, Shengji; Xu, Libin; Zhao, Zhenguo; Zhu, Shan; Ding, Qiang; Liu, Yuanbo
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
Conclusion: Nasolabial flap is an old flap for reconstructive purposes. Over time different modifications have been introduced to expand its usage. Clear definition of the terms used with this flap is given.
Pompei, S; Caravelli, G; Vigili, M G; Ducci, M; Marzetti, F
In modern multi-disciplinary cancer treatment, rehabilitation and functional results represent utmost intent in reconstructive surgery of the oral cavity. Even in cases where the stage of disease is advanced) and the perspective of survival is limited, it is possible to achieve an acceptable quality of life. The authors report, in this study, the morpho-functional results and the morbidity observed in glossectomies in which the reconstruction was performed using three different methods. In a total of 264 reconstructive flaps of the head and neck regions, the authors considered three groups of 15 patients that had had reconstruction after the demolitive procedure. Respectively these groups were divided by the followed methods: free forearm flap, pectoralis major myocutaneous flap and nasolabial flap. The morbidity showed an extremely low rate of flap loss in all the groups, but "minor" complications, such as fistulas and leakages, were significantly more frequent in the myocutaneous flaps group. Functional evaluation for speech and deglutition showed good results in most patients. Extremely severe postoperative conditions as a permanent NG tube or incomprehensible speech had been observed in less than 15% of the cases. Particularly, the pectoralis major flap, showed its best functional performances in the total or subtotal glossectomies with a sacrifice of the muscles of the oral floor. The free forearm flap is reliable and safe with its low thickness and pliability, especially for partial glossectomies. The nasolabial flap was confirmed to be the first reconstructive choice for selected limited resections of the tongue and of the antero-lateral floor. With this experience it is possible, even in more complex free flaps, to reduce the time consumption and the complication rate. Free flaps do not substitute routinely myocutaneous and conventional flaps, but they represent the "ideal" reconstructive alternatives for specific and selected indications.
Healy, Claragh; Allen, Robert J
It is over 20 years since the inaugural deep inferior epigastric perforator (DIEP) flap breast reconstruction. We review the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66%), followed by the superior gluteal artery perforator flap (12%), superficial inferior epigastric artery perforator flap (9%), inferior gluteal artery perforator flap (6%), profunda artery perforator flap (3%), and transverse upper gracilis flap (3%). Primary reconstruction accounted for 1,430 flaps (50%), secondary 992 (35%), and tertiary 425 (15%). As simultaneous bilateral reconstructions, 59% flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Mulvey, Carolyn L; Cooney, Carisa M; Daily, Francis F; Colantuoni, Elizabeth; Ogbuago, Onyebuchi U; Cooney, Damon S; Rad, Ariel N; Manahan, Michele A; Rosson, Gedge D; Sacks, Justin M
Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept. Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis. One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P fat necrosis, compared to 14.3% of large multiple perforator flaps. Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.
Jun Yong Lee; Ji Min Kim; Ho Kwon; Sung-No Jung; Hyung Sup Shim; Sang Wha Kim
For the successful reconstruction of facial defects, various perforator flaps have been used in single-stage surgery, where tissues are moved to adjacent defect sites. Our group successfully performed perforator flap surgery on 17 patients with small to moderate facial defects that affected the functional and aesthetic features of their faces. Of four complicated cases, three developed venous congestion, which resolved in the subacute postoperative period, and one patient with partial necrosi...
Azizzadeh, B; Yafai, S; Rawnsley, J D; Abemayor, E; Sercarz, J A; Calcaterra, T C; Berke, G S; Blackwell, K E
This study evaluates the outcome of pharyngoesophageal reconstruction using radial forearm free flaps with regard to primary wound healing, speech, and swallowing in patients requiring laryngopharyngectomy. Retrospective review in the setting of a tertiary, referral, and academic center. Twenty patients underwent reconstruction of the pharyngoesophageal segment using fasciocutaneous radial forearm free flaps. All free flap transfers were successful. An oral diet was resumed in 85% of the patients after surgery. Postoperative pharyngocutaneous fistulas occurred in 4 patients (20%) with 3 resolving spontaneously. Distal strictures also occurred in 20% of the patients. Five patients who underwent tracheoesophageal puncture achieved useful speech. Advantages of radial forearm free flaps for microvascular pharyngoesophageal function include high flap reliability, limited donor site morbidity, larger vascular pedicle caliber, and the ability to achieve good quality tracheoesophageal speech. The swallowing outcome is similar to that achieved after jejunal flap pharyngoesophageal reconstruction. The main disadvantage of this technique relates to a moderately high incidence of pharyngocutaneous fistulas, which contributes to delayed oral intake in affected patients.
Wong, Wendy W; Hiersche, Matthew A; Martin, Mark C
Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.
Posch, N A S; Mureau, M A M; Flood, S J; Hofer, S O P
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 degrees ; 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
Full Text Available Background It can be difficult to select an appropriate flap for various defects on the hand. Although defects of the hand usually must be covered with a skin flap, some defects require a flap with rich blood supply and adequate additive soft tissue volume. The authors present their experience with the anconeus muscle free flap in the reconstruction of various defects and the release of scar contractures of the hand. Methods Ten patients underwent reconstruction of the finger or release of the first web space using the anconeus muscle free flap from May 1998 to October 2013. Adequate bed preparations with thorough debridement or contracture release were performed. The entire anconeus muscle, located at the elbow superficially, was harvested, with the posterior recurrent interosseous artery as a pedicle. The defects were covered with a uniformly trimmed anconeus muscle free flap. Additional debulking of the flap and skin coverage using a split-thickness skin graft were performed 3 weeks after the first operation. Results The average flap size was 18.7 cm2 (range, 13.5–30 cm2. All flaps survived without significant complications. Vein grafts for overcoming a short pedicle were necessary in 4 cases. Conclusions The anconeus muscle free flap can be considered a reliable reconstructive option for small defects on the hand or contracture release of the web space, because it has relatively consistent anatomy, provides robust blood supply within the same operative field, and leads to no functional loss at the donor site.
Kim, Ji-Wan; Hwang, Jong-Hyun; Ahn, Kang-Min
Background Osteoradionecrosis is the most dreadful complication after head and neck irradiation. Orocutaneous fistula makes patients difficult to eat food. Fibular free flap is the choice of the flap for mandibular reconstruction. Osteocutaneous flap can reconstruct both hard and soft tissues simultaneously. This study was to investigate the success rate and results of the free fibular flap for osteoradionecrosis of the mandible and which side of the flap should be harvested for better recons...
Camporro, Daniel; Fueyo, Angel; Martín, Clara; Carnero, Susana; Llorente, José L
We present a 10-year retrospective study at a tertiary center designed to evaluate the advantages, complications, and comparative results using lateral circumflex femoral artery (LCFA) system free flaps for cranial base reconstruction. In this study, a cranial base defect refers to exposed intracranial contents to the skin, paranasal sinuses, nasopharynx, oropharynx, or oral cavity. These defects resulted from resections of primary or recurrent neoplasms or from secondary problems after cranial base surgery. We performed 20 flaps in 20 patients. The selection of flap was as follows: 8 combinations of anterolateral/anteromedial thigh flaps with vastus lateralis muscle or tensor fascia lata flaps, 6 ALT fasciocutaneous flaps, and 6 muscle/myocutaneous flaps. The flap's success rate was 95% (19/20). Early major complications included 1 perioperative death, and there was 1 myocardial infarction. Minor complications included 1 partial (12%) flap loss, 2 temporal cerebrospinal fluid leak, 2 donor-site hematoma, 2 minor wound breakdown, 3 facial nerve weakness, and 4 donor-site numbness. Among 20 patients undergoing LCFA system flap reconstruction, 12 are alive and disease free. Local recurrence occurred in 1 patient. She underwent ablative surgery and a new successful free flap (forearm flap); after 2 years, the patient is disease free. The LCFA system flaps in skull base reconstruction provide versatility in flap design and availability of adequate tissues to fill dead space, and it offers vascularized fascia to augment dural repairs. It also provides a very long pedicle and allows simultaneous flap harvest with low donor-site morbidity.
Denadai, Rafael; Raposo-Amaral, Cassio Eduardo; Marques, Frederico Figueiredo; Raposo-Amaral, Cesar Augusto
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.
Denadai, Rafael; Raposo-Amaral, Cassio Eduardo; Marques, Frederico Figueiredo; Raposo-Amaral, Cesar Augusto
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
This animal was presented with a large-sized infiltrative lipoma in the abdominal wall that had been noted for 4 years. This lipoma was confirmed by histological examination from a previous biopsy, and the infiltrative features were identified by a computerized tomography scan. The surgical removal created a large-sized abdominal defect that was closed by a combination of latissimus dorsi and external abdominal oblique muscle flaps in a pedicle pattern. A small dehiscence at the most distal e...
S. Gallana Álvarez
Full Text Available Presentamos tres pacientes con defectos genianos complejos, que fueron reconstruidos mediante tres combinaciones diferentes de colgajos cutáneos y suspensiones dinámicas de músculo temporal. Los defectos comprendían amplias pérdidas de piel y musculatura facial, pudiendo incluir o no la mucosa geniana. En dos de los casos se trataba de una lesión indurada a nivel geniano con histología compatible con dermatofibrosarcoma protuberans, que no habían recibido ningún tratamiento previo. En el otro paciente se trataba de un carcinoma epidermoide, intervenido en dos ocasiones y que había recibido radioterapia. Para la reconstrucción del defecto cutáneo usamos el colgajo libre compuesto radial, un colgajo de rotación cervicofacial y un colgajo de músculo temporal. Todos los pacientes curaron sin complicaciones y los resultados estéticos y funcionales fueron buenos.We present three patients whose genian complex defects were reconstructed with several cutaneous flaps and dynamic suspension of the temporal muscle. Complex genian defects are those that involve major skin and facial muscle loss, which can also include genian mucous or not. Two cases involved a nodular lesion in the genian region with biopsy reports that indicated dermatofibrosarcoma protuberans, without previous treatment; the other patient had an epidermoide carcinoma, which had been operated twice, and she had received radiotherapy. For the cutaneous reconstruction a composite free radial forearm flap, a cervicofacial flap and a temporal muscle flap were used. Primary healing with no complications was achieved in all patients together with good aesthetic and functional results.
Utilización del colgajo de músculo temporal en cirugía reconstructiva maxilofacial: Revisión de 104 casos Use of the temporalis muscle flap in maxillofacial reconstruction surgery: A review of 104 cases
I. Zubillaga Rodríguez
. Aims: To show our indications and results using the temporalis flap in craniofacial reconstruction. Material and methods: A retrospective analysis of our experience with temporalis flap along the last decade. Results: A total of 108 flaps have been used in the following situations: postmaxillectomy defect reconstruction (44; cranial base (25 including anterior, middle and posterior cranial fossas; oral cavity and oropharynx (23; orbital exenteration (6; Temporomandibular joint ankylosis (6; others (2 with an overall success rate (no partial or total flap failure over 94 %. Conclussions: Temporalis muscle flap is one of the «first choice» elections in reconstructive craniofacial surgery, for midfacial and cranial base indications. Non-careful surgical dissection and flap suture under tension predispose to complications such as flap necrosis (commonly partial and wound dehiscence.
Colletti, Giacomo; Tewfik, Karim; Bardazzi, Alessandro; Allevi, Fabiana; Chiapasco, Matteo; Mandalà, Marco; Rabbiosi, Dimitri
Starting from our experience with 45 consecutive cases of regional pedicled flaps, we have underlined the effectiveness and reliability of a variety of flaps. The marketing laws as applied to surgical innovations are reviewed to help in the understanding of why regional flaps are regaining wide popularity in head and neck reconstruction. From January 2009 to January 2014, 45 regional flaps were harvested at San Paolo Hospital to reconstruct head and neck defects. These included 35 pectoralis major muscular and myocutaneous flaps, 4 lower trapezius island or pedicled flaps, 3 supraclavicular flaps, 2 latissimus dorsi pedicled flaps, and 1 fasciocutaneous temporal flap. The basic literature of marketing regarding the diffusion of new products was also reviewed. Two myocutaneous pectoralis major flaps were complicated by necrosis of the cutaneous paddle (one complete and one partial). No complete loss of any of the 45 flaps was observed. At 6 months of follow-up, 2 patients had died of multiple organ failure after prolonged sepsis. The 43 remaining patients had acceptable morphologic and functional results. Regional and free flaps appear to compete in many cases for the same indications. From the results of the present case series, regional flaps can be considered reliable reconstructive choices that are less expensive than their free flap alternatives. The "resurrection" of regional flaps can be partially justified by the changes in the global economy and the required adaptation of developed and developing countries. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Full Text Available Reconstruction of the amputated breast in female patients after surgical management of breast carcinoma is possible with the use of autologous tissue, synthetic implants, or by combining autologous tissue and synthetic materials. Autologous tissue provides soft and sufficiently elastic tissue which is usable for breast reconstruction and eventually obtains original characteristics of the surrounding tissue on the chest wall. The use of the TRAM flap for breast reconstruction was introduced in 1982 by Hartrampf Scheflan, and Black. The amount of the TRAM flap tissue allows breast reconstruction in the shape most adequate to the remaining breast. The possibilities of using the TRAM flap as pedicled myocutaneous flap or as free TRAM flap make this flap a superior choice for breast reconstruction in comparison with other flaps.
Windfuhr, Jochen P; Remmert, Stephan
For selected cases, reconstruction of the tongue may be required after tumor removal. This study was undertaken to demonstrate a simplified concept of tongue reconstruction with emphasis on infrahyoid myofascial flaps (IMF). The defects of the tongue were classified in 23 patients according to the extent of tumor growth, functional and surgical aspects. The oral tongue (OT; n = 1), base of tongue (BT; n = 12) or both areas (OT and BT; n = 10) were involved, with (n = 14) or without (n = 9) infiltration of adjacent tissues. Minor defects (extent (1/4) or less) required no reconstructive procedure at any area. Major defect closure (extent (1/2)-3/4) was accomplished with a combination of IMF covered by a radial forearm flap (RFF). A complete reconstruction of the OT was achieved with a combination of a bilateral IMF covered by a RFF. Whenever the complete BT has to be removed, interposition of a vein graft to establish a sufficient arterial blood supply to the remaining OT is mandatory. Moreover, a larynx lift to prevent aspiration is recommendable. Resection of adjacent soft tissues requires a larger RFF (OT; BT) or flaps from the shoulder-back region (BT and OT). Whenever the integrity of the mandible has to be sacrificed, a free fibula graft serves as an excellent tool for reconstruction. IMF serves as a reliable tool for minor or major reconstructive procedures of the tongue. Reliability and versatility of IMF may contribute to a reduced time required for surgery since harvesting is performed in the neck area immediately after neck dissection. Moreover, harvesting of the IMF does not result in an increased postoperative morbidity. Hence, functional restoration can be achieved with a more cost-effective procedure.
Reiter, M; Harréus, U; Kisser, U; Betz, C S; Baumeister, Ph
Thrombosis of the pedicle is central to free flap failure, and early revision of a compromised flap is the key to successfully salvage a flap. Therefore, the majority of free flaps in reconstructive head and neck surgery are used with the ability to visually examine the flap. Sometimes, due to intra-operative circumstances, it is necessary to use a flap that cannot be monitored externally. These flaps are called buried flaps and have the reputation of being put at risk. The current literature provides only limited data to support or disprove this position. A single institution retrospective review of patient charts between 2007 and 2015 was performed. Flap monitoring was carried out with hand-held Doppler of the pedicle hourly for the first 72 h in all cases. Additional duplex ultrasound was performed in the majority of buried flaps. A total of 437 flaps were included into the study. 37 flaps (7.8 %) were identified to fulfill the criteria of a buried free flap. In total, four patients had complications, three of which required operative reexploration. All interventions were successful, resulting in no flap loss in our series. An accurate operation technique combined with meticulous monitoring protocols supported by duplex ultrasound can result in satisfactory outcome of buried flaps. No enhanced risk of flap loss of buried flaps was found in our cohort.
McCulley, Stephen J; Schaverien, Mark V; Tan, Veronique K M; Macmillan, R Douglas
Partial breast reconstruction using pedicled perforator flaps from the thoracodorsal (TDAP) and lateral intercostal arteries (LICAP) is well described. The article introduces the lateral thoracic artery perforator (LTAP) flap as an additional valuable option from the lateral chest wall and reports clinical experience and outcomes. The anatomy of the LTAP flap is reviewed and the results of a consecutive series are reported. In a series of 75 consecutive cases of lateral chest wall perforator flaps used for reconstruction of partial breast defects, 12 (17%) were raised as pure LTAP flaps, and a further 19 (27%) as combined LTAP/LICAP flaps. The LTAP was therefore used in 44% of flaps overall. One LTAP flap (delayed case) had early venous compromise that settled spontaneously. The LTAP flap is a reliable option for partial breast reconstruction from the lateral chest wall, particularly in the immediate setting. It allows comparable flap size to be harvested compared to LICAP flaps. The LTAP flap can be raised on its own pedicle allowing greater mobilization or it can be incorporated into the more commonly used LICAP flap to augment perfusion. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Güven, Erdem; Uğurlu, Alper Mete; Başaran, Karaca; Basat, Salih Onur; Yiğit, Bariş; Hafiz, Günter; Kuvat, Samet Vasfi
In this article, we present the use of the superior labial artery musculo-mucosal (SLAMM) flap for intraoral reconstruction. The study included five patients (2 females, 3 males; mean age 36 years; range 11 to 56 years) who consulted at our clinic between October 2008 and January 2010. Five oral defects were reconstructed with the SLAMM flap. Three patients underwent reconstruction with SLAMM flap following oncologic resection. The other two patients had traumatic defects in the oral cavity which necessitated flap application. First, the distal end of the flap was incised and the superior labial artery was identified after dissection. After ligation of the artery, the mucosa, submucosa and the cuff of orbicularis oris muscle were elevated. The dissection was extended laterally and anteriorly, depending on the necessary flap size. None of the patients had partial or total flap necrosis. During the follow-up period, contracture developed in only one patient. Successful reconstruction was observed in all patients. The superior labial artery musculo-mucosal flap is a simple and feasible technique which can be used for reconstruction of intraoral defects.
Waheeb, Aliaa M
Large oroantronasal fistulas have a detrimental effect on patient nutrition and speech, not to mention its moral effect when combined with devastating deformity associated with high-energy gunshot injuries to the face. Despite the fact that temporalis muscle flap was first described nearly 116 years ago, it still represents a useful tool in craniofacial and oral reconstruction. The aim of this article was to describe the utilization of temporalis muscle flap for reconstructing large oroantronasal fistula residual after gunshot injuries. Three clinical cases were described with emphasis on surgical technique. The flap was reliable because of its rich blood supply and close proximity to the oral cavity. Major complications were not observed. In hospitals lacking facilities for extensive reconstructive procedure, temporalis muscle flap should be taken into consideration when tackling difficult oral defects.
Kekatpure, V D; Trivedi, N P; Manjula, B V; Mathan Mohan, A; Shetkar, G; Kuriakose, M A
The aim of this study was to evaluate factors affecting the selection of pectoralis major flap in the era of free tissue reconstruction for post ablative head and neck defects and flap associated complications. The records of patients who underwent various reconstructive procedures between July 2009 and December 2010 were retrospectively analysed. 147 reconstructive procedures including 79 free flaps and 58 pectoralis major flaps were performed. Pectoralis major flap was selected for reconstruction in 21 patients (36%) due to resource constrains, in 12 (20%) patients for associated medical comorbidities, in 11 (19%) undergoing extended/salvage neck dissections, and in 5 patients with vessel depleted neck and free flap failure salvage surgery. None of the flaps was lost, 41% of patients had flap related complications. Most complications were self-limiting and were managed conservatively. Data from this study suggest that pectoralis major flap is a reliable option for head and neck reconstruction and has a major role even in this era of free flaps. The selection of pectoralis major flap over free flap was influenced by patient factors in most cases. Resource constraints remain a major deciding factor in a developing country setting.
Objective: Penile syringomas are rare lesions usually occurring in isolation. We report the excision and reconstruction of multiple synchronous penile shaft syringomas with local scrotal flaps. Methods: We report a rare case of excision of multiple penile syringomas and reconstruction with scrotal flaps in a 29-year-old man. Results: Penile syringomas were excised and reconstructed with scrotal flaps in a single-stage procedure. Conclusions: In addition to providing wound coverage, this recon...
Berrone, M.; Crosetti, E.; Succo, G
SUMMARY Oral malignancies involving the mandibular bone require a complex reconstructive plan. Mandibular reconstruction with a fibular free flap is currently considered the best choice for functional and aesthetic rehabilitation after oncological surgery. This flap can be modelled with multiple osteotomies and can provide bone, muscle and skin for composite reconstruction. One of the most delicate aspects of mandibular reconstruction is the technique of bone modelling; the risk of prolonging...
Alvarez Jorge, A; Martelo Villar, F
Soft-tissue injuries of the hand frequently require flap coverage to preserve structures damaged at the time of injury or to facilitate later reconstruction. The radial forearm flap makes local tissue readily available and offers a simple method of reconstruction. Secondary augmentation of the skin flap by means of tissue expansion appears to be a useful alternative to improve the possibilities of reconstruction. This case report describes a primary reconstruction of a hand with multiple finger amputations using both techniques: Forearm flap and tissue expansion.
Zhang, Senlin; Chen, Wei; Cao, Gang; Dong, Zhen
This study investigated the tongue function and donor-site morbidity of patients with malignant tumors who had undergone immediate flap reconstruction surgery. Twenty-seven patients who had undergone immediate reconstruction after hemiglossectomy were observed. Twelve patients were reconstructed using the pedicled supraclavicular artery island flap (PSAIF) and 15 patients using the free radial forearm flap (FRFF). Flap survival, speech and swallowing function, and donor-site morbidity at the 6-month follow-up were evaluated. All the flaps were successfully transferred. No obvious complications were found in either the transferred flaps or donor regions. Age, sex, defect extent, speech and swallowing function were comparable between the 2 groups. Donor-site complications were less frequent with PSAIF reconstruction than FRFF reconstruction. The PSAIF is reliable and well suited for hemiglossectomy defect. It has few significant complications, and allows preservation of oral function.
Mahieu, R.; Colletti, G.; Bonomo, P.; Parrinello, G.; Iavarone, A.; Dolivet, G.; Livi, L.; Deganello, A.
Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results.
Gilman, Kaitlyn; Ipaktchi, Kyros; Moore, Ernest E; Barnett, Carlton; Gurunluoglu, Raffi
An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.
Full Text Available Abstract An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.
Bibhuti B Nayak
Full Text Available Even though free tissue transfers are a routine in many centres, pedicle flaps still have a huge roll to play in our country. There are many centres in the country where pedicle flaps are in use because of logistic problems. Deltopectoral and pectoralis muscle flaps are usually preferred for composite cheek defects. When both these flaps are used in combination it is a two-staged procedure. We describe a single-stage procedure to reconstruct a composite cheek defect with pectoralis major myocutaneous flap for lining and single-stage deltopectoral flap for cover. In the available literature search, single-stage DP and PMMC have not been described for management of composite cheek defect.
Fujioka, Masaki; Hayashida, Kenji; Senju, Chikako
Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects.
Israeli, Ron; Hazani, Ron; Feingold, Randall S; DeNoto, George; Scheiner, Marc S
Many patients undergoing reconstructive surgery after mastectomy opt for reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Among the morbidities related to TRAM flap reconstruction is the development of abdominal wall contour abnormalities, including bulges or hernias. Several repair techniques at the flap abdominal wall donor site have been described for use at the time of flap harvest in an attempt to reduce the risk of such abdominal wall complications. For patients that develop abdominal wall contour abnormalities, numerous reconstructive options have been reported, with mixed results. Ten patients were identified as having abdominal wall contour abnormalities after a TRAM flap and underwent an extended mesh repair with external oblique muscle reinforcement. The mesh was secured to the bony landmarks of the lower abdomen and the abdominal wall fascia. All patients achieved complete resolution of abdominal wall bulging. In the follow-up period, no recurrences, infections, or seromas were noted. One patient, who failed an earlier repair at the inferior abdominal wall, reported symptoms consistent with a scar neuroma. Symptoms were treated successfully with gabapentin and a nonsteroidal anti-inflammatory drug. We propose a novel and reliable method of lower abdominal wall reconstruction for patients with post-TRAM flap abdominal wall contour abnormalities. This technique incorporates the use of a large Marlex mesh reinforced with bilateral external oblique muscle flaps. We report a series of 10 patients who have achieved resolution of their symptoms and have regained a natural, flat-appearing abdominal wall contour.
Dabernig, Jörg; Shelley, Odhran P; Schaff, Jürgen
Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.
Ebrahiem, Ahmed Ali; Manas, Raj Kumar; Vinagre, Gustavo
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. 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. All flaps survived. One flap developed venous congestion that subsided spontaneously with limb elevation. The flap dimension ranged from 42 cm to 442 cm(2), 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. 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.
Lin, Chih-Hsun; Ma, Hsu
Pressure sore reconstruction is always a challenge for plastic surgeons due to its high recurrence rate. In addition to the myocutaneous flap, the perforator-based fasciocutaneous flap has become a new entity used for pressure sore reconstruction. This study presents a series of 26 perforator-based fasciocutaneous flaps for pressure sore reconstruction, with good outcomes in 21 patients from July 2008 to April 2011. The flaps were advanced, transposed, or rotated to obliterate the defects. Twenty of 26 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, one had partial flap necrosis (flap rotated 180° in the above two cases), one had infection and healed by a secondary flap, one had minor wound dehiscence, one died of pneumonia 1 week postoperatively, and recurrence developed in one patient. The perforator-based fasciocutaneous flap is a reliable method and produced good results in this series. These flaps are well vascularised, have enough soft tissue bulk, and have a high degree of mobilisation freedom.
Geiger, Erik J; Basques, Bryce A; Chang, Christopher C; Son, Yung; Sasaki, Clarence T; McGregor, Andrew; Ariyan, Stephan; Narayan, Deepak
Introduction This study compared complication rates between pedicle flaps and free flaps used for resurfacing of intraoperative brachytherapy (IOBT) implants placed following head and neck tumour extirpation to help clarify the ideal reconstructive procedure for this scenario. Patients and methods A retrospective review of reconstructions with IOBT at our institution was conducted. Patient and treatment details were recorded, as were the number and type of flap complications, including re-operations. Logistic regressions compared complications between flap groups. Results Fifty free flaps and 55 pedicle flaps were included. On multivariate analysis, free flap reconstruction with IOBT was significantly associated with both an increased risk of having any flap complication (OR = 2.9, p = 0.037) and with need for operative revision (OR = 3.5, p = 0.048) compared to pedicle flap reconstruction. Conclusions In the setting of IOBT, free flaps are associated with an increased risk of having complications and requiring operative revisions.
Chen, Yongfeng; Zhang, Kai; Li, Jiancheng; Xu, Jingcheng; Liao, Shengkai; Xu, Tao
To investigate the method of combining radial forearm free flap and adjacent tissue flap in reconstruction of palatomaxillary defects and its effectiveness. Between March 2005 and May 2010, 17 patients with palatomaxillary defects were treated. There were 11 males and 6 females with an age range of 45-74 years (mean, 62.5 years), including 1 case of benign tumor and 16 cases of malignant tumors (7 cases of squamous cell carcinoma of palate, 1 case of recurring squamous cell carcinoma of palate, 1 case of malignant melanoma of palate, 1 case of adenoid cystic carcinoma of palate, 1 case of malignant melanoma of maxilla, 1 case of ductal carcinoma of maxilla, and 4 cases of squamous cell carcinoma of maxilla). The maxillectomy defect ranged from 7.0 cm x 5.5 cm to 10.0 cm x 7.5 cm. According to Brown's classification for the maxillectomy defect, there were type II in 15 cases, type III in 2 cases. Palatomaxillary defects were repaired with radial forearm free flap and buccal fat pad in 11 cases, and with radial forearm free flap, buccal fat pad, and mandibular osteomuscular flap pedicled with temporal muscle in 6 cases. The effectiveness was evaluated after operation by observing the vitality of the flap, the functions of speech, swallowing, breath, and the facial appearance. All cases were followed up 6-12 months without tumor recurrence. All flaps and skin grafts at donor sites survived. The functions of speech, swallowing, and breath were normal without obvious opening limitation. The facial appearance was satisfactory without obvious maxillofacial deformity. No enophthalmos occurred in patients with orbital floor and infraorbital rim defects. The patients had no oronasal fistula with satisfactory oral and nasal functions. According to the type of palatomaxillary defects, it can have good early effectiveness to select combining radial forearm free flap and buccal fat pad or combining radial forearm free flap, buccal fat pad, and mandibular osteomuscular flap for
Monticciolo, D L; Ross, D; Bostwick, J; Eaves, F; Styblo, T
The objective of this study was to define and evaluate mammographic changes in patients treated with breast-conserving therapy and a new reconstructive technique that uses autologous tissue from a latissimus dorsi musculosubcutaneous flap. Of 20 patients who underwent either immediate or delayed endoscopic latissimus dorsi muscle flap reconstruction after lumpectomy, 13 also had postsurgery mammograms available for review. Radiographic findings assessed included skin thickening, density or radiolucency at the reconstruction site, density around the flap, fat necrosis, calcifications, and the presence of surgical clips. Mammograms for three patients (23%) revealed thickening that we believed was attributable to radiation therapy. No patient had increased density in the flap itself; all flaps were relatively radiolucent centrally (13/13; 100%). Mammograms revealed density around the rim of the flap in four patients (31%). This density was most likely secondary to latissimus dorsi muscle fibers and did not limit radiographic evaluation. One patient had calcifications, probably secondary to fat necrosis. No oil cysts were seen. In the majority of patients (11/13; 85%), surgical clips were visible. Endoscopic latissimus dorsi muscle flap reconstruction, previously used only for mastectomy patients, is now being used for improved esthetic outcome in selected patients who desire breast conservation. Our results indicate that the mammographic findings are predictable. The most common findings are relative radiolucency centrally, with or without density from muscle fibers around the edges of the area of tissue transfer. The transplanted musculosubcutaneous flap does not interfere with mammographic evaluation.
Hsiao, Hung-Tao; Leu, Yi-Shing; Tung, Kwang-Yi
A bilobed free radial forearm flap was designed to reconstruct a defect in the epiglottis and tongue base in 2 patients who underwent supraglottic laryngectomy. The flap was initially sutured in the shape of the epiglottis to prevent aspiration during deglutition. Six months after surgery, after a full course of radiation therapy, the flap had flattened and underwent atrophy, but the patients still had good voice production and were able to swallow well without any aspiration. Regardless of the final shape of the reconstructed epiglottis, it will suffice to prevent aspiration if the flap is large enough to occlude the tracheal outlet.
Ma, Xianjie; Li, Yang; Wang, Lu; Li, Weiyang; Dong, Liwei; Xia, Wei; Su, Yingjun
Cervical scar contracture causes both physical and psychological distress for burn patients. Many pedicle flaps or skin grafting have been suggested for reconstruction of cervical scar contracture with variable results in the literature. The authors present the axial thoracic flap based on the thoracic branch of the supraclavicular artery (TBSA) for reconstruction of cervical scar contracture. Postburn scar contractures in anterior neck region of 66 patients had been reconstructed with the axial pattern thoracic flaps based on the TBSA, including 1 expanded and 10 nonexpanded pedicle flaps, and 9 expanded and 46 nonexpanded island pedicle flaps, during 1988 through 2012. After removing and releasing the cervical scar contracture, the flap was designed in the thoracic region. The axial artery of the flap is the TBSA bifurcating from the intersection point of sternocleidomastoid muscle and omohyoid muscle with several concomitant veins as the axial veins. The flap can be designed in a large area within the borders of the anterior border of the trapezius muscle superiorly, the middle part of the deltoid muscle laterally, the midsternal line medially, and the level 3 to 4 cm below nipples inferiorly. After incisions were made along the medial, inferior, and lateral border, dissection was performed toward the pedicle. Donor site was closed directly in expanded cases and with skin grafting in nonexpanded cases. Cervical scar contractures were repaired with good functional and cosmetic results in 64 cases among this cohort. Flap tip necrosis in other 2 cases, caused by postoperative hematoma, was repaired by skin grafting. The color and texture of all flaps were fitted with those of the surrounding skin. The donor sites all healed primarily. The flap sensation in the thoracic region regained in the early stage postoperatively and that in cervical area recovered completely after 6 months according to the report of the patients. With reliable blood supply based on the
Ogawa, Tomoko; Yamakawa, Tomomi
Prosthetic-based breast reconstruction can be used in combination with autologous flaps such as a latissimus dorsi (LD) flap or a thoracodorsal artery perforator (TDAP) flap to achieve symmetry. However, the LD and TDAP flaps require a different skin incision from that which is used for the mastectomy. As a new autologous flap for use in combination with prosthetic-based breast reconstruction after nipple-sparing mastectomy (NSM), we used an inframammary adipofascial flap. The patient was a 27-year-old female with moderate ptotic breasts, who had ductal carcinoma in situ in the lower outer quadrant of her left breast. After NSM through the inframammary fold (IMF) incision, the subcutaneous fat of the intended inframammary area was undermined, and the tongue shaped adipofascial flap was pulled up in the intended area. After inserting a tissue expander under the major pectoral muscle, this adipofascial flap was reflected back to the inferior portion of the breast area. After modeling the breast mound with this flap, the inframammary skin incision was sutured. Eleven months later, the patient underwent surgery to replace the expander with a permanent implant. Eight months after the replacement with an implant, the cosmetic result is good. This procedure can be performed through the same skin incision on the IMF as NSM. Total breast reconstruction using the inframammary adipofascial flap with an implant can be an alternative approach to achieving symmetry in some patients. This method is useful for breast reconstruction after NSM for young patients with moderate-ptotic breasts. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.
Lu, Mingxing; Sun, Guowen; Hu, Qingang; Tang, Enyi; Wang, Yujia
To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap...
TARSITANO, A.; VIETTI, M.V.; Cipriani, R; MARCHETTI, C.
SUMMARY The aim of the present study is to assess functional outcomes after hemiglossectomy and microvascular reconstruction. Twenty-six patients underwent primary tongue microvascular reconstruction after hemiglossectomy. Twelve patients were reconstructed using a free radial forearm flap and 14 with an anterolateral thigh flap. Speech intelligibility, swallowing capacity and quality of life scores were assessed. Factors such as tumour extension, surgical resection and adjuvant radiotherapy ...
Full Text Available Background:The transverse rectus abdominis musculocutaneous TRAM flap remains the gold standard for postmastectomy reconstruction either immediate or delayed.However,transfer of TRAM flap can be associated with donor site morbidities and complications in flap.A successful reconstruction consists of careful patient selection, surgical technique and meticulous preoperative planning.This study was designed to evaluate outcome and complications of breast reconstruction with TRAM flap in association with patient conditions and risk factors, prospectively. Methods: Breast reconstruction was performed in 44 women consecutively,using the TRAM flap during a 3-year period, 1999–2002. Modified radical mastectomy accompanying immediate reconstructions with TRAM flap was performed for 12 patients and delayed reconstruction was used for other patients with previous mastectomy. Results: The mean age of the patients was 40.41±4.43 years. Thirty (68.18% patients had comorbidities, consisting of radiation therapy, obesity, hypertension, diabetes mellitus, smoking and abdominal scar. Contralateral and ipsilateral TRAM flaps were used in 26(59.09% and 14(31.81% reconstructions, respectively. The abdominal defect was repaired in layers with the use of synthetic mesh in 30(68.18% patients. The overall complication rate was 31.82%, such as fat necrosis (15.91%, partial flap loss (13.64%, etc. Satisfaction rates were excellent in 10 (22.72%, good in 25 (56.82%, moderate in five (11.36%, and poor in four (9.09% patients. The mean of postoperative inpatient hospital days were 15.18±4.89 and 14.28±6.52 in patients with contralateral and ipsilateral flaps,respectively (p>0.05.A significant association was observed between overall complications and comorbidities. Partial flap loss and fat necrosis was associated with smoking, and abdominal hernia was associated with obesity marginally.Conclusions:The outcome of breast reconstruction using TRAM flap is similar by
Parys, Simon P.; Leman, Thea; Gurfinkel, Reuven
Objective: Herpes simplex virus 1 (HSV1) is a widespread virus that primarily causes orofacial infection. Methods: We present a case of HSV1 infection on a free radial forearm flap used to reconstruct a palate defect. Initially, the free flap appeared healthy; however, after 48 hours the free flap appeared in distress, with dark red colour and fast capillary refill. Venous congestion was suspected, and the patient underwent a second operation where no vascular compromise was found. Vesicles w...
Sheeja Rajan T. M
Full Text Available BACKGROUND Pressure ulcers can significantly contribute to morbidity and mortality by chronic infections. Radical debridement of all devitalised and infected tissues followed by a reconstructive algorithm for soft tissue padding over bony prominences to prevent recurrent breakdown are the mainstay of surgical management of pressure ulcers. Choice of the soft tissue flap for reconstruction is influenced by the dimensions of ulcers, local tissue availability and surgeon’s preferences. MATERIALS AND METHODS This retrospective study includes 140 patients with spinal injuries having pressure ulcers of NPUAP grade III and IV treated surgically over a period of four years. The demographics of pressure ulcers, the workhorse flap options as well as the outcome were analysed. RESULTS The pressure ulcers were seen predominantly in males (93.6% of 40-49 years’ age group (42.8%. Ischial pressure ulcers (n=104 constituted 74.2% followed by sacral pressure ulcers (n=24 that is 17.1% and trochanteric pressure ulcers (n=12 in 8.6%. Debridement and direct closure of wound were possible only in 10 cases. Majority (92.8% of patients needed additional tissues for wound coverage. Our workhorse fasciocutaneous flaps were rotation flaps from the gluteal region or posterior thigh with medial or lateral based designs (34.2%. Local muscle tissue was used in 64 cases (46% either as gluteal, tensor fascia lata and biceps femoris myocutaneous flaps or gluteus maximus, hamstring or gracilis muscle fillers in myoplasty. CONCLUSIONS Rotation flap along with myoplasty were our workhorse flap options in majority of the pressure ulcers. But, our future perspective is to spare muscle and use more fasciocutaneous perforator flaps for reconstruction according to evidence-based clinical practice.
Zhu, Yue-Liang; Wang, Yi; He, Xiao-Qing; Zhu, Min; Li, Fu-Bin; Xu, Yong-Qing
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
Zhang, Ling; Yang, Qinghua; Jiang, Haiyue; Liu, Ge; Huang, Wanlu; Dong, Weiwei
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.
Tarsitano, A; Vietti, M V; Cipriani, R; Marchetti, C
The aim of the present study is to assess functional outcomes after hemiglossectomy and microvascular reconstruction. Twenty-six patients underwent primary tongue microvascular reconstruction after hemiglossectomy. Twelve patients were reconstructed using a free radial forearm flap and 14 with an anterolateral thigh flap. Speech intelligibility, swallowing capacity and quality of life scores were assessed. Factors such as tumour extension, surgical resection and adjuvant radiotherapy appeared to be fundamental to predict post-treatment functional outcomes. The data obtained in the present study indicate that swallowing capacity after hemiglossectomy is better when an anterolateral thigh flap is used. No significant differences were seen for speech intelligibility or quality of life between free radial forearm flap and anterolateral thigh flap.
Patients with head and neck cancer are seeking improved surgical procedures to avoid severe defects that result from head and neck cancer resection. Free flap reconstruction provides vascularized tissue that has been transferred from a distant donor site on a patient's body to a recipient site, markedly improving wound closure and protecting structures of the head and neck. This article discusses free flap procedures for reconstruction after head and neck cancer resection, including the following procedure phases: airway protection and neck dissections, tumor resection, flap harvest, microvascular anastomosis of the flap, and reconstruction and closure. The article also explains specific risk factors for patients undergoing free flap procedures that have been identified in the literature and include procedure length, hypothermia, and pressure injuries. Each of these factors is discussed regarding its specific effect on this patient population, and the nursing interventions to reduce these risks are identified.
Macía, G; Picón, M; Nuñez, J; Almeida, F; Alvarez, I; Acero, J
Skull base tumours are rare, comprising less than 1% of all tumours of the head and neck. Surgical treatment of these tumours involves the approach, the resection, and the reconstruction of the defect, which present a challenge due to the technical difficulty and anatomical complexity. A retrospective study of 17 patients with tumours involving the skull base, treated by resection and immediate reconstruction using microsurgical free flaps, is presented; 11 were men and six were women. The following types of flap were used: osteocutaneous fibula flaps, fasciocutaneous anterolateral thigh flaps, and myocutaneous latissimus dorsi flaps. The most common histology of the tumours was squamous cell carcinoma. The most frequent point of origin was the paranasal sinuses (58.8%). All of the free flaps used for reconstruction were viable. A cerebrospinal fluid fistula occurred in two patients, and in one of these cases, meningoencephalitis led to death. In conclusion, the reconstruction of large defects of the skull base after ablation requires a viable tissue that in many cases can be obtained only through the use of microvascular free flaps. The type of flap to be selected depends on the anatomical structures and size of the defect to be restored.
Belli, E; Cicconetti, A; Matteini, C
The concentration in a restricted area such as the oral cavity of the essential anatomic structures for mastication, deglutition, speech, salivary drainage and respiration makes it indispensable to ensure not only the structural reconstruction of the region but also, and above all, a functional reconstruction of the anatomic unit affected by resection. The use of revascularised flaps has extended both the quantity and quality of reconstructive methods available. In the context of the oral cavity the most widely used flaps are the radial forearm free flap and jejunum free flap. In this paper the authors report their personal experience in a group of 13 patients (6 radial forearm and 7 jejunum) undergoing oral cavity reconstruction using free flap. For each flap the authors describe the microsurgical procedure, the clinical characteristics of the post-operative period, the locoregional complications, the donor site and lastly the long-term clinical, anatomopathological and functional modifications 6-12 months after primary treatment. Moreover, they highlight the varying characteristics of the two flaps and make a critical assessment of the advantages and disadvantages of using one or other method. Lastly, in the light of their experience and a review of international literature, the authors underline the importance of making a careful choice and personalized reconstruction, and finally outline their own criteria of choice.
Di Candia, Michele; Asfoor, Ahmed Al; Jessop, Zita M.; Kumiponjera, Devor; Hsieh, Frank; Malata, Charles M.
Presented in part at the following Academic Meetings: 57th Meeting of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery, September 24-27, 2008, Naples, Italy.45th Congress of the European Society for Surgical Research (ESSR), June 9-12, 2010, Geneva, Switzerland.British Association of Plastic Reconstructive and Aesthetic Surgeons Summer Scientific Meeting, June 30-July 2, 2010, Sheffield Hallam University, Sheffield, UK. Background: Patients with previous multiple abdominal surgeries are often denied abdominal free flap breast reconstruction because of concerns about flap viability and abdominal wall integrity. We therefore studied their flap and donor site outcomes and compared them to patients with no previous abdominal surgery to find out whether this is a valid contraindication to the use of abdominal tissue. Patients and Methods: Twenty patients with multiple previous abdominal operations who underwent abdominal free flap breast reconstruction by a single surgeon (C.M.M., 2000-2009) were identified and retrospectively compared with a cohort of similar patients without previous abdominal surgery (sequential allocation control group, n = 20). Results: The index and control groups were comparable in age, body mass index, comorbidities, previous chemotherapy, and RT exposure. The index patients had a mean age of 54 years (r, 42-63) and an average body mass index of 27.5 kg/m2 (r, 22-38). The main previous surgeries were Caesarean sections (19), hysterectomies (8), and cholecystectomies (6). They underwent immediate (n = 9) or delayed (n = 11) reconstructions either unilaterally (n = 18) or bilaterally (n = 2) and comprising 9 muscle-sparing free transverse rectus abdominis muscle and 13 deep inferior epigastric perforator flaps. All flaps were successful, and there were no significant differences in flap and donor site outcomes between the 2 groups after an average follow up of 26 months (r, 10-36). Conclusion: Multiple previous abdominal
Departments of Oral and Maxillofacial Surgery, MGV's K.B.H. Dental College, Nashik, Maharashtra, ... free radial forearm flap techniques for oral floor reconstruction, the ... status do not permit a lengthy anesthetic and surgical procedure,.
Jeong, Jae Hoon; Hong, Jin Myung; Imanishi, Nobuaki; Lee, Yoonho; Chang, Hak
The aim of this study was to determine the efficacy of lateral intercostal artery perforator-based adipofascial free flaps for facial reconstruction in patients with facial soft tissue deficiency. We conducted a retrospective study of five consecutive patients diagnosed with facial soft tissue deficiency who underwent operations between July 2006 and November 2011. Flap design included the area containing the perforators. A linear incision was made along the rib, which had the main intercostal pedicle. First, we dissected below Scarpa's fascia as the dorsal limit of the flap. Then, the adipofascial flap was elevated from the medial to the lateral side, including the perforator that pierces the serratus anterior muscle after emerging from the lateral intercostal artery. After confirming the location of the perforator, pedicle dissection was performed dorsally. Dominant perforators were located on the sixth to eighth intercostal space, and more than four perforators were found in fresh-cadaver angiography. In the clinical case series, the seventh or eighth intercostal artery perforators were used for the free flaps. The mean diameter of the pedicle artery was 1.36 mm, and the mean pedicle length was 61.4 mm. There was one case of partial fat necrosis. No severe complications occurred. This is the first study of facial contour reconstruction using lateral intercostal artery perforator-based adipofascial free flaps. The use of this type of flap was effective and can be considered a good alternative for restoring facial symmetry in patients with severe facial soft tissue deficiency.
Liu, Lifeng; Cao, Xuecheng; Cai, Jinfang
Reconstruction of a defect of the weightbearing forefoot region remains a challenging problem owing to the limited alternatives available. The digital artery flap can be used for coverage of defects in the weightbearing forefoot. The present study reports our results using a digital artery flap for reconstruction of soft tissue defects of the weightbearing forefoot in 8 patients. The mean patient age was 35 ± 11.3 years. The etiology of the soft tissue defects included 4 (50%) traumatic events, 2 (25%) dysfunctional scars, and 2 (25%) neuropathic ulcerations. The mean postoperative follow-up duration was 22 ± 11.1 months (range 12 months to 4 years). All 8 flaps survived successfully. The complications included 1 case of delayed healing of a neuropathic ulceration. The digital artery flap is a good alternative for soft tissue defects of the weightbearing forefoot. The surgical techniques for harvesting the flaps are easy to manage.
Chen, Z; Chen, C; Chen, M; Zhang, J; Wu, N; Wang, J
A technique of vaginal reconstruction using bilateral, perineal-thigh flaps with subcutaneous pedicle is described. In this procedure, the flaps were raised bilaterally and introduced into an artificial space between the urinary bladder and rectum. The blood supply for the flaps flows from the perineal artery through anastomotic branches to the external pudendal artery. The authors used the technique on four patients, and all the flaps survived entirely. There was no complication. According to a more than two-year follow-up survey, the reconstructed vaginas are expansible and contract little. No stent is needed. There is good sensitivity in the wall of the artificial vagina because sensory nerves run through the flaps.
Izumi, Ken; Fujikawa, Masakazu; Tashima, Hiroki; Saito, Takuya; Sotsuka, Yohei; Tomita, Koichi; Hosokawa, Ko
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.
Amin, Kavit; Darhouse, Nagham; Sivakumar, Bran; Floyd, David
Summary: We present an interesting method of shaping a vascularized medial femoral condyle (MFC) flap into a “neophalanx” for phalangeal reconstruction. Our patient presented with limited strength and function secondary to fracture nonunion of the proximal phalanx of the dominant thumb. Following excision of the pseudarthrosis, an MFC corticoperiosteal flap was harvested, sculpted into a prism shape and inset. The superomedial genicular pedicle was anastomosed to the princeps pollicis artery and a cephalic tributary. On follow-up, new bone growth was seen on radiographs and the patient had substantially improved function, with full metacarpophalangeal extension, a Kapandji score of 9, and a markedly reduced Disabilities of the Arm, Shoulder and Hand score of 2.68. The MFC flap is useful for reconstruction of bony defects, with minimal donor morbidity. This versatile vascularized flap can be crafted to requisite shapes and is useful for small defects in the hand, including phalangeal reconstruction. PMID:26495205
Tashiro, Kensuke; Yamashita, Shuji
Reconstruction of dorsalis pedis with soft tissue is challenging because it needs to preserve thin structure to ensure that the patient will be able to wear shoes. Here, we report the use of a thin superficial circumflex iliac artery perforator (SCIP) flap in dorsalis pedis reconstruction. A 67-year-old man presented with a third-degree burn, which exposed his extensor tendons. A thin SCIP flap from the left inguinal region measuring 15 × 4 cm was transferred to the dorsalis pedis region. Postoperatively, no major cosmetic or functional problems were observed. Because the invasiveness of the donor site is nearly same between SCIP flap and skin graft from inguinal region, SCIP flap is better solution in point of textural qualities for dorsalis pedis reconstruction.
LI Jun-hui; XING Xin; OUYANG Tian-xiang; LI Ping; XU Jie; GUO En-tan
Objective:To investigate the outcomes of subcutaneous island pedicle flap for reconstruction of the medium-sized facial skin defects. Methods: Eighty nine cases of facial defects within one cosmetic unit following removal of skin tumors or scars were reconstructed with advancement or transposition island pedicle flaps. Patient records and postoperative photographs were reviewed retrospectively. Both patients and other surgeons were asked to assess outcome variables. Results: All flaps survived with primary healing postoperatively. Patients and surgeons judged excellent or good overall outcomes in 95.5% and 92.7%of all evaluated cases, respectively. Conclusion: The subcutaneous island pedicle flap may be an extremely versatile and reliable method for aesthetic reconstruction of medium-sized facial defects in the patients of all time of life.
Zhang, Qingguo; Quan, Yuzhu; Su, Yuanda; Shi, Lei; Xie, Yangchun; Liu, Xinhai
The aim of this article is to report the application of expanding retroauricular skin fascia flap, and autogenous costal cartilage for congenital microtia reconstruction. Microtia reconstruction was generally completed in 3 surgical stages. In the first surgical stage, a 50 or 80 mL kidney-shaped tissue expander was inserted subcutaneously in the retroauricular mastoid region. Inflation of saline volume increased up to 60 to 80 mL, and skin flap was expanded for 2 to 3 months postoperatively. In the second surgical stage, removal of tissue expander, formation of retroauricular skin flap, elevation of retroauricular fascia flap, and pedicles of both flaps in remnant ear side were performed. Costal cartilage was harvested from ipsilateral side chest to the ear for reconstruction. The 3D ear framework was sculpted with stabilization of structure, contour and erection. Simultaneously, intermediate full thickness skin graft of 4 x 8 cm was obtained from previous incision site from where costal cartilage was harvested. Cartilage ear framework was anchored between skin flap and fascia flap, and fixed it symmetrically to the opposite normal ear, inferior portion of the ear framework was wrapped by remnant ear lobule, expanded skin flap covered the anterior portion of the framework, fascial flap was draped to the posterior side of framework and helical rim, then fascial flap was surfaced by intermediate full thickness skin graft. Suction drain was inserted and coated between skin flap and framework, drain was removed fifth postoperative day. Tragus construction and conchal excavation with skin graft was performed in the third stage of microtia reconstruction. Between October 2000 and October 2007, 426 cases were diagnosed as unilateral microtia patients and 22 cases were bilateral microtia patients. Therefore, 448 microtia ears were treated with tissue expander and autogenous costal cartilage. In 262 cases, structure of the helix, tragus, conchal excavation
Full Text Available The pedicled partial latissimus dorsi myocutaneous flap based on the transverse branch of the thoracodorsal artery is described as it offers several advantages for reconstruction of radiated partial mastectomy defects. It maintains bulk and vascularity while having a favorable morbidity profile compared to the total flap. Specifically, seroma rates and length of drain use should be reduced. The anatomical location of the transverse branch allows creation of the flap outside the radiated field. Further, the flap preserves the lateral and inferior portions of the latissimus dorsi and the muscle is not detached from its insertion allowing preservation of the posterior axillary fold. Finally, the transversely oriented skin paddle offers favorable scar healing.
Nuri, Takashi; Ueda, Koichi; Yamada, Akira; Okada, Masashi; Hara, Mai
We attempted to reconstruct dynamic palatal function using a radial forearm-palmaris longus tenocutaneous free flap in conjunction with a pharyngeal flap for a postoncologic total-palate defect in a 67-year-old male patient. This reconstruction involved 3 important tasks, namely, separating the oral and nasal cavities, preserving the velopharyngeal space to avoid sleep apnea, and maintaining velopharyngeal closure to avoid nasal regurgitation during swallowing. In our technique, the radial forearm flap separates the oral and nasal cavities with an open rhinopharyngeal space, and a superiorly based pharyngeal flap, which is sutured to the posterior end of the forearm flap, limits the rhinopharyngeal space, and forms the bilateral velopharyngeal port. Furthermore, the palmaris longus tendon, which is attached to the forearm flap, is secured to the superior constrictor muscle to create a horizontal muscle sling. Contraction of the superior constrictor muscle leads to shrinkage of the sling, resulting in velopharyngeal closure. Swallowing therapy was started 4 weeks after the surgery. The patient could resume oral intake without any difficulties 6 months after the surgery. Speech intelligibility changed from severe to minimal hypernasality.
CONCLUSION: Surgeons and cardiologists should be aware of this cerebrovascular complication secondary to PFO following major reconstructive surgery such as microvascular breast reconstruction. It also serves to challenge microvascular surgeons to reconsider routine use of central venous pressure lines in free flap patients who might otherwise have good peripheral vessels for postoperative fluid and antibiotic administration.
Højvig, Jens B; Bonde, Christian Torsten
INTRODUCTION: The latissimus dorsi (LD) myocutaneous flap has long been regarded as the second choice flap for autologous breast reconstruction following a mastectomy in our department. Despite uncertainty about donor-site morbidity, it is regarded as a relatively safe procedure; moreover......, in contrast to our first choice, the deep inferior epigastric perforator flap, no microsurgical expertise is needed. METHODS: This is a systematic review of patient files for all LD breast reconstructions performed in the 2004-2013 period, at Rigshospitalet, Copenhagen, Denmark. RESULTS: A total of 135...... unilateral LD breast reconstructions were performed in 126 women during the ten-year period. The median age of the women was 48.5 years, and they mainly had secondary reconstruction (90%). The average time to removal of the last drain was 6.3 days, and the average time to discharge was 6.9 days. A total...
van Wijk, MP; Damen, A; Nauta, JM; Lichtendahl, DHE; Dhar, BK
The results of reconstruction of the anterior floor of the mouth, using 105 nasolabial flaps in 79 patients were reviewed in a retrospective study. Of those flaps, 82% healed uneventfully; flap survival was 95%. Considerable flap loss occurred in 5%. Primary dehiscence was observed in 5% of all flap
Lee, Sanglim; Kim, Min Bom; Lee, Young Ho; Baek, Jeong Kook; Baek, Goo Hyun
Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based adipomuscular abductor hallucis flap for the treatment of 7 patients with soft tissue defect on the plantar forefoot after diabetic ulcer (n = 2), excision of melanoma at the medial forefoot (n = 3), and posttraumatic defects of the plantar forefoot (n = 2). The size of the defects ranged from 6 to 36 cm. All defects were covered successfully without major complications. The distally based adipomuscular flap from the abductor hallucis muscle provides a reliable coverage for small and moderate defects of the plantar and medial forefoot. This flap is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.
Whiteside, Leo A; Nayfeh, Tariq; Katerberg, Brian J
We evaluated the results of an operative technique used in five patients (five hips) to reconstruct the greater trochanter with a gluteus maximus flap transfer during revision total hip arthroplasty. We exposed the hip through a posterior approach that split the gluteus maximus in its midsubstance. We then raised a flap from the posterior portion of the gluteus muscle that was elevated proximally to create a triangular muscle flap. The flap was sewn into the gap between the greater trochanter and lateral cortex of the femur and secured to the inner surface of the anterior capsule of the hip. With the hip abducted 10 degrees to 15 degrees, the edges of the gluteus maximus were closed over the flap and the greater trochanter. We compared the results of these patients with those of five patients (five hips) who had the trochanter left unrepaired and those of four patients (four hips) who had excision of the greater trochanter and suture closure of the intervening gap. The flap group had less pain, lower incidence of limp and Trendelenburg sign, and less need for support than the other two groups, but range of motion decreased.
Objective: To evaluate the speech function on repairing defects of maxilla and palate with temporalis muscle flap after benign or malignant turmor resection. Methods: The lateral cephalogram and speech intelligibility were detected in 19 cases with the operations of repairing defects of maxilla and palate by temporalis muscle flap, and their recovery of the speech function were analyzed.Results: Among the 19 patients, there were 15 cases (78.00％) with complete velopharynx, 3 cases (15.80 ％ ) with mariginal velopharynx, and 1 case (5.26％) with insufficient velopharynx. The average speech intelligibility was 94.3％, close to the normal speech intelligibility. Conclusion: The operation of repairing defects of maxilla and palate with temporalis muscle flap can reconstruct the phonatory structure, preserve the palate function and restore the speech function after operation.
En-Qi Guo; Qing-Ping Xie
Management of defects on the hand and foot with exposed tendons remains a major challenge for plastic surgeons.Here,we present a case of hand reconstruction with a totally laparoscopic peritoneal flap.The anterior rectus sheath was preserved in situ.The peritoneal free flap supplied by peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover the soft tissue defect of the hand.The defect of the dorsal hand was 17 cm × 12 cm.The peritoneal flap measuring 22 cm × 15 cm survived completely without any complications.A following split-thickness skin graft offered the successful wound closure.Motor and sensory function improved gradually within the first year follow-up.The totally laparoscopic peritoneal free flap is a good choice for reconstruction of the soft tissue defects accompanied by exposed tendons on the hand and foot.
Gabr, E M; Kobayashi, M R; Salibian, A H; Armstrong, W B; Sundine, M; Calvert, J W; Evans, G R D
The ulnar forearm flap is not frequently utilized for oromandibular reconstruction. This study evaluated the usefulness of the ulnar free flap for reconstruction. A retrospective study of 32 patients was conducted. The ulnar forearm flap was combined with an osseous flap in 24 patients. Nine females and 23 males with a mean age of 58.15 years comprised our study population. Squamous-cell carcinoma was the diagnosis in 93.75% of cases (56.25% T4), of which 20% were recurrent. Functional evaluation of swallowing was based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8 days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was the main recipient vein. Overall flap survival was 96.8%. One flap was lost due to unsalvageable venous thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, hematoma, and an orocutaneous fistula. At the time of this study, 21 patients were available for functional evaluation. Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is available when the radial artery is the dominant artery of the hand. Being more hidden, it may be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular defects, and can be used as a second choice after other free-flap failures. Copyright 2004 Wiley-Liss, Inc.
Belli, E; Cicconetti, A
The reconstruction of postoperative or post-radiotherapeutic losses of substance in the oral cavity must respond to a number of basic requirements, such as lingual motility, the conservation of the labiogingival groove and adequate drainage of saliva towards the pharynx. This study reports the authors' experience of the reconstruction of the oral cavity using a pectoralis major myocutaneous flap. The identification of anatomic structures, such as the interpectoral compartment which separates the deep folium of the pectoralis major muscle from the clavi-coraco-axillary fascia covering the smaller pectoral muscle. Is indispensable for the correct preparation of the flap. Using an oblique incision along the lateral margin of the pectoralis major muscle the edge of the muscle is revealed and the muscle is separated from the pectoralis minor and from the costosternal structure. The cutaneous island is formed using the deep level of the muscle, and after tunnelling into the subcutaneous plane of the superficial fascia in the deltopectoral region, the flap is overturned to reach the part of the surgical reconstruction. The transposed tissue is sutured at various levels so as to reduce traction on a single component of the flap and to preserve the integrity of the perforating vessels. A total of 16 reconstructions of the oral cavity were performed by the authors using a pedunculated flap from the pectoralis major muscle. Fourteen of these cases were advanced stages of cancer and two were the outcome of radiotherapy. A myofascial flap was used in one case due to the excessive thickness of the subcutaneous panniculus of fat, whereas in the other cases it was not necessary to involve the cutaneous component which guarantees better functional adaptation. The following results were obtained: the metaplasia of the cutaneous surfaces of the flap into a multi-stratified non-keratinized epithelium and the contemporary reduction of cutaneous adnexa. The best functional recovery was
Yoon, Chi Sun; Yim, Ji Hong; Kim, Min Ho; Ha, Won; Kim, Kyu Nam
Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used. Between May 2009 and April 2014, 51 patients underwent gluteal pressure sore reconstructions with gluteal (n = 39) or modified lumbar artery (n = 12) perforator flaps. Patients in the modified lumbar artery perforator group had scar tissue from trauma or previous surgery. In this retrospective review, we analyzed patient age and sex, defect size and location, operative time, follow-up duration, immediate postoperative issues, flap necrosis, dehiscence, re-operation, donor-site morbidity and recurrence. Complications and clinical outcomes were compared between groups. We found no significant differences in patient demographics, surgical complications or clinical outcomes. There were eight cases of temporary congestion (20.51%) and four of partial flap necrosis (10.25%) in the gluteal perforator group. In the modified lumbar artery perforator group, there were three cases of temporary congestion (25%) and one of partial flap necrosis (8.33%). No pressure sores recurred during follow-up in either group. GPFs are the gold standards for gluteal pressure sores, but modified lumbar artery perforator flaps are relatively easy and useful when GPFs cannot be used due to scar tissue. © 2016 Royal Australasian College of Surgeons.
Sapountzis, Stamatis; Park, Hyoung Joon; Kim, Ji Hoon; Chantes, Achilleas; Beak, Rong Min; Heo, Chan Yeong
The treatment of pressure sores represents a significant challenge to health care professionals. Although, pressure wound management demands a multidisciplinary approach, soft tissue defects requiring reconstruction are often considered for surgical management. Myocutaneous and fasciocutaneous flaps can provide stable coverage of pressure sores. Here, we describe our experience using a recent fasciocutaneous flap, which is named 'reading man' flap, in sacral, ischial, and trochanteric pressure sores. During a period of 1 year the authors operated 16 patients, 11 men, and 5 women, using the reading man flap. The ages of the patients ranged from 24 to 78 years. The location of pressure sores was 8 sacral, 5 ischial, and 3 trochanteric pressure sores. The mean size of pressure sores was 8 cm × 9 cm. All pressure sores covered bt the Reading Man flap healed asymptomatically. After follow-up of 2-8 months, no recurrences were encountered and no further surgical intervention was required. The reading man flap was found to be a useful technique for the closure of pressure sore in different anatomic locations. The advantage of tension-free closure and the minimal additional healthy skin excision made this flap a useful tool in pressure sore reconstructions.
YU Guang; LEI Hong-yu; GUO Shuang; HUANG Jian-hua; YU Hao
Objective:To report the results of repair of skin defects in the extremities with arterialized venous flap harvested from the lateral aspect of the dorsum of the foot.Methods:Six cases of skin and soft tissue defects over the foot and hands were resurfaced by free arterialized venous flaps,including five patients with skin defects of the hands,and one with defects at the dorsum of the foot.The flaps were harvested from the lateral aspect of the dorsum of the foot with the sizes ranging from 2 cm×5.5 cm to 6 cm×11 cm.Two veins at the proximal margin of the flap were retained,one of which was anastomosed to a recipient bed artery to provide arterial inflow and the other was anastomosed to a recipient bed vein for venous outflow.Results:All flaps demonstrated mild edema and survived completely.Blisters appeared on four flaps.Using this technique,we achieved good functional and cosmetic results in this series.Conclusions:Dorsalis pedis arterialized venous flap with rich vascular communications could enhance peripheral perfusion and decrease congestion of venous flaps,thereby improves reliability and utility for extremity reconstruction.
Huizhuang Xie; Malata, Charles M.
INTRODUCTION: Abdominal free flap breast reconstruction is regarded as the gold standard method of post-mastectomy breast reconstruction by many. It is a major surgery which can be associated with varied systemic complications. To date, there have been no reports of cerebrovascular complications in the literature which examine the possible relation between thromboembolism and patent foramen ovale (PFO) in patients undergoing microvascular breast reconstruction. PRESENTATION OF CASE: A 54-y...
Haughey, B H; Fredrickson, J M; Sessions, D G; Fuller, D
Reconstructive options following total laryngopharyngectomy include thin, pliable free tissue segments, approximating the natural thickness of the pharyngeal wall. The authors have investigated outcomes in the following clinical series, emphasizing speech and swallowing. Twelve cancer patients underwent laryngopharyngectomy with or without glossectomy. Eight jejunal, 1 radial forearm, and 3 innervated latissimus dorsi flaps were used for vibratory segment (VS) reconstruction, and all 12 patients underwent tracheoesophageal puncture (TEP). Eleven patients achieved intelligible speech, with a median intelligibility of 93%. The vibrating segments showed fluttering of the free flap tissue when studied by videopharyngography. Vocal quality was lower pitched and softer than "conventional" TEP speech. All patients achieved oral intake as their primary mode of nutrition. Free flaps are a successful option for VS reconstruction in patients undergoing laryngopharyngectomy or glossopharyngolaryngectomy, obviating the need for written or electrolarynx communication.
@@ The radial forearm free flap is a useful reconstructive method of surgical defects after oral and oropharyngeal tumor resection. We evaluated the swallowing and speech outcomes of radial forearm free flap reconstruction for oral and oropharyngeal cancers.
A. D. Zikiryakhodzhaev
Full Text Available The treatment of breast cancer (BC is a relevant problem. Surgery is a key treatment method for BC. The volume of its operations varies from radical mastectomies to lumpectomies and, in the areas of regional metastases, from three-level lymphadenectomy to sentinel lymph node biopsy. Objective: to assess whether a displaced TRAM flap may be used for reconstructive operations for BC. The paper presents some experience in treating 11 BC patients in whom a displaced TRAMP flap was employed for reconstruction. At this time, the displaced TRAM flap was applied for delayed reconstruction in 3 patients. The mean age of the patients was 45.5 ± 15.7 years. In 8 BC patients undergoing one-stage reconstruction with a displaced TRAM flap, the treatment schedule was as follows: surgical treatment in 1 patient, combined treatment in 2 patients, and multimodality treatment in 5. The patients received targeted therapy in 3 cases or hormone therapy in 6. A lower abdominal skin-and-fat flap on one vascular pedicle was used in all the 11 patients.Indications for using a displaced TRAM flap were determined; complications were analyzed. The percentage of complications due to the use of a displaced TRAM flap was 9.1 % in our study.To reduce the rate of complications after breast reconstruction with a displaced TRAM flap, we carefully selected patients for this choiceof a plastic component. The displaced TRAM flap is one of the variants for delayed breast reconstruction despite its duration and complexity. Corrective surgery is further used to achieve breast symmetry. Corrective operations, namely, breast liposuction and submammary fold formation, were performed in 2 patients. For full breast recovery, the nipple-areolar complex is to be formed following skin-sparing mastectomies and delayed breast reconstructions. The cosmetic effect was evaluated in 11 patients as excellent in 4 (36.4 % cases, good in 7 (63.6 %. Neither local recurrences nor distant
Full Text Available Introduction. Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. Patients and Methods. This procedure was used in 5 patients with 80–100% lip defect resulting from Squamous cell carcinoma. Patients’ age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. Results. All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. Conclusion. We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.
Full Text Available INTRODUCTION : Face represents complete personality of human being. Cosmetically it is very important part of a person especially for woman. There are many situations when due to disease or trauma, facial defect arises, which requires reconstruction by either local or distant surgical flaps . METHODS AND MATERIALS : In rural places, we come across many patients suffering from trauma and skin malignancy of face. These patients require reconstruction done esthetically with local flaps. Objective of this study is to share our exper ience of providing esthetically good results at our secondary referral care center. Hereby, we present case series of 14 patients operated at our institute. These patients were analyzed according to the age, sex, nature of injury and anatomical location of lesion on the face. All these patients were operated and reconstruction of defect was done with various local flaps best suited for respective lesion, under local anesthesia or sedation. Post - operative nature of wound was analyzed for flap viability or fl ap necrosis . RESULTS : Amongst them were 7 male and 7 female, ages ranging from 4 to 80 years. 7out of 14 patients were of basal cell carcinoma, 4 were due to trauma, 2 were due to dog bite and 1 case of recurrent pleomorphic adenoma at root of nose. All patients had excellent flap viability at end of 6 months and flap achieving almost similar color and contour as that of surrounding skin. CONCLUSION : Reconstruction of facial defects by local flaps is very easy and cost effective technique. This can be don e even at secondary referral care centre with minimal availability of facilities
Krishna Gopal Bhuju; Shuzhong Xing; Hualian Liu
Objective: To evaluates mandible reconstruction by free vascularized fibular flap with special emphasis on the immediate complications. Methods:The clinical data of 63 patients were reviewed, 35 male and 28 female(age range l6 to 73 years). Aesthetic and functional outcomes were evaluated by follow-up and/or telephone conversation. Results:Among the 63 fibular flaps, 29 were osteocutaneous flaps with one or two skin islands. All the flaps were surviving well and the success rate was 100%. Long term donor site disability was not recorded for any patient. Thirty-one patients responded for aesthetic and functional evaluation, 20 cases(64.5%) reported their facial appearance as excellent or good, 11 (35.48%) felt fair; 14 cases (45%) could eat unrestricted diet, 17(55%) could eat soft diet; 21 cases were(67.67%) speech normal, 10(22.33%) speech intelligible. Conclusion:Free fibular flap reflects good functional and esthetic results with a high degree of consistency, and acceptable level of complications, and we strongly believe the vascularized fibular flap is the first choice for mandibular reconstruction.
Magerkurth, Olaf [Dept. of Radiology, Hospital Baden, Baden (Switzerland); Girish, Gandikota; Jacobson, Jon A.; Kim, Sung Moon; Brigido, Monica; Dong, Qian; Jamadar, David A. [Dept. of Radiology, University of Michigan Hospitals, Ann Arbor (United States)
MR imaging appearances of different types of reconstructive muscle flaps following reconstructive surgery of the lower extremity with associated post-surgical changes due to altered anatomy, radiation, and potential complications, can be challenging. A multidisciplinary therapeutic approach to tumors allows for limb salvage therapy in a majority of the patients. Decision-making for specific types of soft tissue reconstruction is based on the body region affected, as well as the size and complexity of the defect. Hematomas and infections are early complications that can jeopardize flap viability. The local recurrence of a tumor within six months after a complete resection with confirmed tumor-free margins and adjuvant radiation therapy is rare. Identification of a new lesion similar to the initial tumor favors a finding of tumor recurrence.
Franco, Diogo; Rocha, Diógenes; Arnaut, Marcio; Freitas, Renato; Alonso, Nivaldo
Initially described for the treatment of cleft palate, the anatomical bases of the buccinator myomucosal flap were described by Bozola et al. (1989). A meticulous search found several reports of its use for the correction of post-palatoplasty oronasal fistulas, with only a few reports of its use for other palate-related pathologies. A retrospective analysis was undertaken of patients treated by the Plastic Surgery Units at the Rio de Janeiro Federal University Hospital (HU-UFRJ) and the São Paulo University Hospital (HC-USP), suffering from palatal lesions not associated with a cleft palate and treated through the use of buccinator myomucosal flaps. The average age was 47 years, with 70% of the patients being male. Assorted aetiologies were noted for palatal defects. When there was significant damage to the soft palate, a superior base pharyngeal flap was used. Of this total, in 71% of the cases only the buccinator myomucosal flap was used. In all cases, the flaps were unilateral, adequately covering the defects in question. The buccinator myomucosal flap is a good option for reconstructing medium to large palate defects, as it is a flap with good vascularization and dimension, in addition to an ample arc of rotation, with primary closure of the donor site, without adding significant morbidity.
Harenberg, P S; Jakubietz, R G; Jakubietz, M G; Schmidt, K; Meffert, R H
Reconstruction of the tip of the thumb using a neurovascular flap. Transverse defects of the thumb's tip or large defects of the palmar pulp (max. 2.0-2.5 cm) with exposure of bone and/or tendons. Extensive crush injury, heavy wound contamination, circulatory disorders, acute infection, very large defects (> 2.0-2.5 cm finger length), circumferential soft tissue defects, and previous defects/operations (relative). Supine position, hand supinated, tourniquet, loupe magnification. Mid-lateral incisions along both sides of the finger running from the defect to the interphalangeal joint (small defect) or proceeding further proximally. Careful elevation of the flap including both neurovascular bundles leaving dorsal branches of the bundles (long fingers only) and the flexor tendon sheath intact. Suture of the flap in either flexion position (i.e., advancement flap) (Moberg) or by creating an island-flap through an additional transverse skin incision along the flap's base (O'Brien). Finally, closure of the defect at the flap's base using a full thickness skin graft, Z plasty, or V-Y plasty. Plaster cast (finger slightly flexed) for 2 weeks. Reliable method. Good functional results with good sensibility and only minor reduction in range of motion.
黄平; 秦旭; 廖琳迪; 黄梅靖; 邵乐南; 陈卫民
目的:总结应用嚼肌瓣修复口腔癌术后软组织缺损的临床效果.方法:收集2例口腔癌病例,利用嚼肌瓣修复术后软组织缺损,并对相关文献进行回顾.结果:口腔癌术后软组织缺损严重影响患者的口腔功能,应用嚼肌瓣以及生物膜整复可获得较为满意的功能及美学效果.结论:应用嚼肌瓣修复口腔癌术后软组织缺损可以获得较为满意的临床效果好.%Objective:To investigare feasibility the postoperative result of using masseter flap as a postoperative soft tissue defect of oral carcinoma reconstruction regional flap. Method: We choosed two cases of oral carcinoma patient, performing oral soft tissue defect reconstruction with masseter muscle flap, then make a briefly literature review. Result: Oral carcinoma is a kind of common head and neck cancer, and its postoperative soft tissue defect have severe impact on the oral function,such as eating, pronunciation, swallowing and so on. The using of split masseter muscle combined with oral biofilm could obtain satisfactory function and aesthetic effect in reconstruction of large area defect caused by the ablation of oral cancer. Conclusion: The masseter muscle can be used as a useful flap to reconstruct targe area oral cancer postoperative defect.
A. D. Zikiryakhodzhayev,
Full Text Available Reconstructive surgery for breast cancer are an integral method of rehabilitation of cancer patients. Breast reconstruction may be delayed and instantaneous. The article presents a description of the thoraco-epigastric flap for breast reconstruction in cancer. The operation involves the replacement of the remote volume (after radical resection of the breast and the breast skin adjacent tissues adjacent to the inframammary crease from the side of the anterior abdominal wall. Surgery is indicated when the tumor in the lower parts of the breast, closest to the skin, in combination with small size breast cancer. The article presents a clinical example of this operation. Described in detail the operation, received a good cosmetic result. The advantage of the application of thoraco-epigastric flap is in the simplicity of the technique of its execution, good blood supply, donor wound is easily sutured due to the possible wide separating cellular adjacent skin and subcutaneous tissue. The disadvantage of this method is limited and the need for careful monitoring of perforating branches of the upper epigastric artery. Thus, thoraco-epigastric flap, can be applicable when performing reconstructive operations for breast cancer in compliance with the necessary requirements for the formation of the flap and the correct attitude to feeding the flap vessels, and virtually eliminates possible complications with the healing of the flap. Undoubtedly, reconstructive plastic surgery for breast cancer, during the testimony and technical capabilities, are an essential component of surgical treatment.
Jeremić Jelena V.
Full Text Available Introduction. The radial forearm free flap has an important role in reconstruction of the oncologic defects in the region of head and neck. Objective. The aim was to present and evaluate clinical experience and results in the radial forearm free transfer for intraoral reconstructions after resections due to malignancies. Methods. This article illustrates the versatility and reliability of forearm single donor site in 21 patients with a variety of intraoral oncologic defects who underwent immediate (19 patients, 90.5% or delayed (2 patients, 9.5% reconstruction using free flaps from the radial forearm. Fascio-cutaneous flaps were used in patients with floor of the mouth (6 cases, buccal mucosa (5 cases, lip (1 case and a retromolar triangle (2 cases defects, or after hemiglossectomy (7 cases. In addition, the palmaris longus tendon was included with the flap in 2 patients that required oral sphincter reconstruction. Results. An overall success rate was 90.5%. Flap failures were detected in two (9.5% patients, in one patient due to late ischemic necrosis, which appeared one week after the surgery, and in another patient due to venous congestion, which could not be salvaged after immediate re-exploration. Two patients required re-exploration due to vein thrombosis. The donor site healed uneventfully in all patients, except one, who had partial loss of skin graft. Conclusion. The radial forearm free flap is, due to multiple advantages, an acceptable method for reconstructions after resection of intraoral malignancies. [Projekat Ministarstva nauke Republike Srbije, br. 41006
Sun, Guowen; Yang, Xudong; Tang, Enyi; Wen, Jianmin; Lu, Mingxing; Hu, Qingang
The purpose of this study was to assess the treatment and prognosis of the palatomaxillary reconstruction with titanium mesh and the free radial forearm flap. This is a retrospective study of 19 patients with palatomaxillary defects who underwent immediate reconstruction using titanium mesh and a radial forearm flap during the 4-year period from 2004 to 2008. Intraoperatively, the titanium mesh was fixed to the residual bones for the reconstruction of hard-tissue defect after the tumor resection; then the free radial forearm flap was harvested to repair the soft-tissue defect, serving as the intraoral lining and titanium mesh covering. Postoperative esthetic appearance and function were followed-up. All of the patients achieved a satisfactory facial appearance. The speech assessment was good, and the oronasal reflux did not occur in all patients. Only 3 patients had titanium mesh exposure during the follow-up period. The free radial forearm flap with folded titanium mesh is a reliable option for reconstruction of palatomaxillary defects. It is highly effective for swallowing and speech rehabilitation as well as esthetic reconstruction.
Theodoros Stathas; Georgios Tsinias; Dimitra Tsiliboti; Aris Tsiros; Nicholas Mastronikolis; Panos Goumas
Reconstruction after resection of large tumors of the lower lip requires the use of free flaps in order to restore the shape and the function of the lip, with the free radial forearm flap being the most popular. In this study we describe our experience in using the dorsalis pedis free flap as a salvage option in reconstruction of total lower lip defect in a patient with an extended lower lip carcinoma after failure of the radial forearm free flap, that was initially used. The flap was integra...
Wade, Ryckie G; Marongiu, Francesco; Sassoon, Elaine M; Haywood, Richard M; Ali, Rozina S; Figus, Andrea
Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery. Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis. During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation. Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier
Full Text Available Hand burn scar contractures affect patients in aesthetic and functional aspects. After releasing these scars, the defects should be repaired. The reconstruction methods include primary suturation, Z plasty, skin grafting, local or free flaps, etc. All methods have their own advantages and disadvantages. One of the most useful flaps is the reverse ulnar perforator flap. We performed a two-staged procedure for repairing a post-burn contracture release defect in a 40-year-old male. In the first stage we applied reverse ulnar perforator flap for the hand defect, and ulnar artery and vein repair in the second stage. In conclusion, this two-staged procedure is a non-primary but useful option for hand and finger defects and prevents major vascular structure damage of the forearm. [Hand Microsurg 2016; 5(1.000: 40-43
Bamba, Ravinder; Madden, James J; Hoffman, Ashley N; Kim, Justine S; Thayer, Wesley P; Nanney, Lillian B; Spear, Marcia E
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. 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. 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 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). 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.
Hwang, Euna; Kim, Young Soo; Chung, Seum
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.
Calli, Caglar; Teknos, Theodoros N; Agrawal, Amit; Schuller, David E; Ozer, Enver; Songu, Murat
The aim of our study was to investigate the effect of patient-related factors, such as the body mass index (BMI) and tumor size, in selecting the flap type for the reconstruction of pharyngeal defects. This retrospective review included 182 patients with pharyngeal defect reconstructions with free and pedicled flaps at the Ohio State University from January 2005 to December 2008. We conducted a retrospective comparison of variety of different flap reconstruction techniques. We compared different flap reconstruction with BMI and tumor size without functional outcome such as swallowing and speech data. Although there was no statistically significant correlation (P > 0.05) when comparing the free flaps with pedicled flaps according to the BMI and tumor size, there was an obvious tendency to prefer radial forearm free flap over anterolateral thigh free flap in patients who are overweight and those with obesity with a ratio of 32:3. In the same group of patients, a similar tendency was observed to prefer fibular free flap over iliac crest free flap with a ratio of 14:5, whereas the ratio was becoming 3:5 in favor of iliac crest free flap over fibular free flap in patients with BMI of 24 or lower. Despite the fact that surgeons' experience with a certain flap type is one of the most important factors while determining which flap to reconstruct, BMI might have a significant impact while selecting the free flap types for the reconstruction of pharyngeal defects.
Zhang, Yi Xin; Xi, Wenjing; Lazzeri, Davide; Zhou, Xiao; Li, Zan; Nicoli, Fabio; Zenn, Michael R; Torresetti, Matteo; Grassetti, Luca; Spinelli, Giuseppe
Although the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. The authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the "perforator-pedicle propeller flap method" allow for the changing of the flap shape according to the shape of the recipient site defect. From 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. The bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence
Zhang, C; Sun, J; Zhu, H; Xu, L; Ji, T; He, Y; Yang, W; Hu, Y; Yang, X; Zhang, Z
This study represents the surgical experience of 4481 microvascular free flap cases performed at the authors' institution in China, between 1979 and 2013. Four thousand four hundred and eighty-one patients underwent reconstruction with 4640 flaps: 56% radial forearm flaps, 8% iliac crest flaps, 13% fibula flaps, 10% anterolateral thigh flaps, and other flaps. In the overwhelming majority of cases, the flap transfer was required following tumour resection (97.5%). Three hundred and twenty minor complications (6.9%) occurred. One hundred and eighteen major complications (2.5%) were encountered: 114 cases of failure (2.4%) and four deaths. Among the 118 cases with major complications, 26 - 22.0% - had received radiotherapy; this proportion was higher than the 6.9% in the minor complications group and 8.1% in the non-intervention group. Venous thrombosis was the most common complication at the recipient site and was the main cause of flap failure. When a compromised flap is identified, surgical re-exploration should not be delayed. This study confirms that free flaps are reliable in achieving successful reconstruction in the head and neck region; however this technique requires extensive clinical experience. Owing to the large number of flap options, microsurgeons should always pay attention to the details of the different surgical defects and choose the most appropriate flap.
Jacobs, Jordan; Børsen-Koch, Mikkel; Gunnarsson, Gudjon Leifur;
BACKGROUND: The thoracodorsal artery perforator (TAP) flap is a versatile tool that can be used to reconstruct the breast. The authors use preoperative perforator mapping using color Doppler ultrasonography and present a safe, efficient harvesting technique to demonstrate reliable use of the TAP...
Jiménez Gómez, Marta; Navarro-Sánchez, Antonio; Lima Sánchez, Jaime; Hernández Hernández, Juan Ramón
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.
Antonella Giugno, M.D.
Conclusions: Reparation of CSF fistulas that arise after meningioma surgery can require a complex reconstructive surgery of the superficial layers; when cranioplasty is not feasible or indicated, a meticulous reconstruction of the extracranial soft tissues is possible also by using vascularized autologous distal muscular tissue, with close interdisciplinary cooperation.
Full Text Available Abstract Background Local flaps are widely used in reconstructive surgery. Tri-lobed skin flap is a relatively new flap and there has been no experimental model of this flap. This flap can be used for repair of full thickness defects in the face, ears and alar region. Based on the size of ears in a rabbit, we designed a model of ear reconstruction using expanded tri-lobed flap. Local flaps are more advantageous in that they provide excellent color and texture matching up with those of the face, adequately restore ear contour, place scars in a favorable location and ideally accomplish these goals in a single stage with minimal donor site morbidity. Methods Eight adult New Zealand rabbits were divided into two groups. 50 ml round tissue expander were implanted to four rabbits. After completion of the expansion, a superiorly based tri-lobed flap was elevated and a new ear was created from the superior dorsal skin of each rabbit. Scintigraphy with Technetium-99m pertecnetate was performed to evaluate flap viability. Results Subtotal flap necrosis was seen in all animals in non-expanded group. New ear in dimensions of the original ear was created in expanded group without complication. Perfusion and viability of the flaps were proved by Technetium-99m pertecnetate scintigraphy. Conclusion According to our knowledge this study is the first to demonstrate animal model in tri-lobed flap. Also, our technique is the first application of the trilobed flap to the possible ear reconstruction. We speculated that this flap may be used mastoid based without hair, in human. Also, tri-lobed flap may be an alternative in reconstruction of cylindrical organs such as penis or finger.
Keith S. Hansen
Full Text Available Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.
Carolyn L. Mulvey, BS
Conclusions: Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.
Seidenstuecker, Katrin; van Waes, Carl; Munder, Beatrix I; Claes, Karel E Y; Witzel, Christian; Roche, Nathalie; Stillaert, Filip; Mahajan, Ajay L; Andree, Christoph; Blondeel, Phillip N
Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. 1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Düsseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. Overall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). The DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result. Copyright © 2015 Elsevier Ltd. All rights reserved.
Szychta, Pawel; Butterworth, Mark; Dixon, Mike; Kulkarni, Dhananjay; Stewart, Ken; Raine, Cameron
To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. The reconstructed and healthy breasts decreased in volume in group 1 (-45.85 cm(3) ± 48.41 cm(3), p = 0.0004; -29.13 cm(3) ± 14.98 cm(3), p = 0.0009) and in group 2 (-31.5 cm(3) ± 25.35 cm(3), p = 0.0001; -15.4 cm(3) ± 21.96 cm(3), p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p reconstructed breast (p = 0.0001). We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast. Copyright © 2013 Elsevier Ltd. All rights reserved.
Peng, Weihai; Rong, Li; Wang, Wangshu; Liu, Chao; Zhang, Duo
To investigate the technique and its effect of combined nasolabial flap and free auricular composite flap for full-thickness nasal alar defect. From March 2010 to March 2013, 9 patients with full-thickness nasal alar defects were treated with combined nasolabial flaps and free auricular composite flaps. Composite auricular flap was used as inner lining and cartilage framework. The nasolabial flap at the same side was used as outer lining. All the patients were followed up for 6-18 months (average, 12 months). All the 9 composite auricular flaps survived completely. Epidermal necrosis happened at the distal end of 1 nasolabial flap. Alar rim was almost normal and symmetric nose was achieved in 6 cases. The arc and the thickness of the alar rim was not enough in 3 cases, resulting in asymmetric appearance. The survival area of auricular composite flap can be enlarged with nasolabial flap. The auricular helix edge can be reserved to reconstruct nasal alar rim with smooth and natural arc. Large full-thickness nasal alar defedts can be reconstructed with combined nasolabial flaps and free auricular composite flaps.
Mücke, Thomas; Loeffelbein, Denys J; Kolk, Andreas; Wagenpfeil, Stefan; Kanatas, Anastasios; Wolff, Klaus-Dietrich; Mitchell, David A; Kesting, Marco R
Several microvascular free flaps are available for reconstruction of the osseous components after resections for head and neck cancer. We have prospectively evaluated patients treated by bony microsurgical reconstruction to identify predictors of adverse outcomes for delayed wound healing and failure of free flaps. All patients from July 2007 to June 2011 who had reconstructions with microvascular fibular or iliac crest flaps immediately after resection of the tumour were evaluated. There were a total of 156 bony free flaps: 120 (77%) fibular and 36 (23%) iliac crest flaps. A total of 133 (85%) were successful. Delayed wound healing was more common with the iliac crest flap (p=0.01) at the intraoral site (p=0.04). Significantly more iliac crest free flaps failed (p=0.02). Anastomosis to the facial artery (p=0.05) and facial vein (p=0.04), and duration of overall operating time were associated with a significantly higher risk of failure of the flap. Patients with cancer of the head and neck who require microsurgical bony reconstruction are at increased risk of postoperative complications. Significantly more complications were found with the iliac crest flap, whereas the fibular flap was associated with a significantly longer operating time.
Højvig, Jens B; Bonde, Christian Torsten
, in contrast to our first choice, the deep inferior epigastric perforator flap, no microsurgical expertise is needed. METHODS: This is a systematic review of patient files for all LD breast reconstructions performed in the 2004-2013 period, at Rigshospitalet, Copenhagen, Denmark. RESULTS: A total of 135...... of 13 patients (10%) had local complications and were re-operated within the first 30 days. We observed one flap loss and only one systemic complication; a urinary tract infection. In all, 38 patients (28%) received antibiotic treatment after the operations and 27 (20%) developed a seroma at the donor...
Alfio José Tincani
Full Text Available CONTEXT AND OBJECTIVE: The use of pedicled myocutaneous flaps in head and neck reconstruction is widely accepted. Here we describe our experience with infrahyoid flaps (IHFs employed to cover surgical defects in the oral cavity and oropharynx in patients with benign and malignant tumors. The aim was to evaluate the success rate for infrahyoid myocutaneous flap procedures performed at a single institution. DESIGN AND SETTING: Retrospective study, at the Head and Neck Surgery Service, Unicamp. METHODS: Fourteen IHFs were used to reconstruct surgical defects in eleven men (78.5% and three women (21.5% with a mean age of 66.4 years. The anterior floor of the mouth was reconstructed in nine patients (64.2%, the base of tongue in three (21.4%, the lateral floor in one (7.1%, and the retromolar area (7.1% in one. Thirteen patients (92.8% had squamous cell carcinoma (SCC and one (7.2% ameloblastoma. The disease stage was T3 in eight (61.5% of the SCC cases and T4 in five (38.5%. RESULTS: No patient presented total flap loss or fistula. The most common complication was epidermolysis, which delayed the beginning of oral ingestion. The patients with SCC received postoperative radiotherapy without major consequences to the flap. CONCLUSION: IHF is a safe and reliable procedure for reconstructing head and neck surgical defects. Due to its thinness and malleability, its use for oral cavity and oropharynx defects provides favorable cosmetic and functional outcomes. Complications, when present, are easy to manage.
Anthony, J P; Foster, R D; Kaplan, M J; Singer, M I; Pogrel, M A
The purpose of this study was to determine the role of the fibular free flap in reconstructing lateral segmental defects of the mandible. Over the past 5 1/2 years, 17 consecutive patients underwent reconstruction of their lateral mandible with the fibular free flap. Patients included 12 men and 5 women, the mean age was 54 years (range, 29-76 years), and the mean length of the mandibular defect was 6.3 cm (range, 2.5-9 cm). The majority of patients with tumors (54%) were treated for recurrence and 92% received radiation to the operative field. The mean operative time to perform the microsurgery and bone plating was 4 hours. Postoperative morbidity occurred in 3 patients (18%) (plate fracture, malocclusion, orocutaneous fistula). Five patients (29%) required leg donor site skin grafting. Donor site morbidity included a minor cellulitis, a transient neuropraxia, and one case of leg swelling. None required additional surgery for donor complications. Thus far, 71% of the patients have received dental rehabilitation and 35% had osseointegrated implants placed in their bone flap. Eighty-two percent of the patients achieved both good or excellent aesthetic and functional results. Sixteen patients (94%) tolerate at least a soft diet and 65% are on a regular diet. Five patients developed tumor recurrence an average of 9 months postoperatively with a mean survival of 21 months. This study demonstrates that the fibular free flap is highly reliable for reconstructing the lateral mandible in a single stage, with low overall morbidity, and provides for excellent dental and speech rehabilitation. For most patients, the fibular free flap should be considered for lateral mandibular reconstruction even in those patients with a limited life expectancy.
Lee, Su-Shin; Huang, Shu-Hung; Chen, Meng-Chum; Chang, Kao-Ping; Lai, Chung-Sheng; Lin, Sin-Daw
Inappropriate seating has been implicated as a major contributing factor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Despite a wide variety of flap reconstruction options being described, the ischium remains the most difficult pressure-sore site to treat. From June 1998 to July 2006, there were 253 pressure-sore patients operated upon at Kaohsiung Medical University Hospital. Ten patients (eight men and two women) suffered from recurrent ischial pressure sores, and all of them received more than one flap reconstruction for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilis muscle flap and readvancement of the V-Y profunda femoris artery perforator-based flap were used to fill the dead space as well as cover the defect. Among these 10 recurrent ischial pressure-sore patients, six of them had suffered bilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap reconstruction procedures were performed on these 10 patients. Unfortunately, one patient had recurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. The other nine patients had no recurrence noted, and enjoyed their lives with an average 27.2 months ulcer-free period (range 9-53 months). The fasciocutaneous flap provides a higher mechanical resistance than the detached and transposed muscle. However, for the recurrent ischial ulcer patients, readvancement of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to obliterate the 'dead space' after debridement of the bursa and the surrounding necrotic tissue. By combining the readvancement of V-Y profunda femoris artery perforator-based fasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal without complication. Recurrence of ulceration often develops despite successful flap closure
Hamahata, Atsumori; Saitou, Takashi; Beppu, Takeshi; Shirakura, Satoshi; Hatanaka, Akio; Yamaki, Takashi; Sakurai, Hiroyuki
When advanced mandibular carcinoma is resected, the defect may include lip and oral commissure. Free flap insertion is commonly used to reconstruct the lip defect. Although improvements in the oral reconstructive method via free flap use have been reported, functional and aesthetic results of the oral sphincter remain limited. This case report describes two individuals presenting with massive lower face defects, including a lower lip defect and a mandibular bone defect. Reconstruction was accomplished using the Estlander flap and free subscapular system of flaps. In both cases, the free subscapular artery system flap was elevated from the mandibular bone defect and other mucosal defect. The lower lip and oral commissure defect was reconstructed via Estlander flap. Free flaps survived 100% and both cases healed without complication. Patients regained good oral sphincter function with no reports of drooling. Thus, in cases involving massive lower face resection, including that of the lower lip and mandibular bone, this method of reconstruction when combined with lip-switch flap and subscapular artery system flap can prove to be useful.
Van Genechten, M L V; Batstone, M D
Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap.
Sasaki, K; Nozaki, M; Morioka, K; Huang, T T
The use of a radial forearm flap has become the most popular method to reconstruct a phallus in recent years. This method of reconstruction, however, is plagued with problems such as urethral fistula and loss of phallic girth as a result of tissue atrophy, rendering a phallic contour that is cosmetically unsatisfactory. We had the opportunity of modifying the technique of penile reconstruction using a forearm osteocutaneous flap to minimize these problems. Specifically, a segment of the big toe pulp is used to reconstruct a glans penis. Sensory restoration in the "glans" and "penile shaft" is restored by coapting the digital and the antebrachial nerves to the penile nerve remnants. A segment of flexor carpi radialis muscle is included in the design of a forearm flap to reinforce the coaptation site of the urethral tract. An arteriovenous shunt is incorporated in the shaft as a mechanism to elicit erection of the penis by compressing the root of the neophallus. We had used these technical modifications in a 51-year-old man who had undergone penile amputation because of cancer. The cosmetic appearance and erotic and tactile sensation in the shaft and glans were proper and satisfactory at the end of fourth year after the surgery. The coital function was also satisfactory.
George V. Patrut
Conclusion: Although ischemic complications associated with VA-ECMO are accepted by intensivists under the slogan “leg for life”, for the repair of the femoral artery in the presence of groin infection the sartorius muscle remains an efficient solution for limb salvage.
Su, Wan-Fu; Chen, Shyi-Gen; Sheng, Hwa
The tongue plays a more significant role in English than in Mandarin, both in apical-palatal consonant production and tense-lax distinction. Theoretically, the same surgical intervention may produce a less significant impact on postoperative Mandarin production. The impact of tongue reconstruction on Mandarin articulation has not been reported. This study compared the tongue function outcome obtained using two methods of tongue reconstruction, radial forearm free flap transfer and pectoralis major flap transfer. Twenty-five patients with carcinoma of the tongue underwent tumor resection. The surgical defects were reconstructed using a pectoralis major flap in six patients and a radial forearm flap in 19 patients. Swallowing and speech function were evaluated 6 months to 5 years after the reconstruction. Speech intelligibility and a Mandarin articulation test were used to evaluate the articulation proficiency before and after surgery. Clinical evaluation of deglutition included a questionnaire on dietary habits and a swallowing rating of 1 to 7. Clinical evaluation showed that patients with free flap reconstruction had more intelligible speech (p = 0.014) even after total glossectomy. Assessment of data obtained by clinical questionnaire showed no significant difference between the two groups in swallowing function. Motility due to flap pliability increased speech intelligibility but had little effect on swallowing function. Our results suggest that radial forearm flap transfer is better than pectoralis major flap transfer in preserving speech function and that there is no significant difference between the two methods of reconstruction in their impact on swallowing function.
Yamamoto, Takumi; Saito, Takafumi; Ishiura, Ryohei; Iida, Takuya
Total ankle arthroplasty (TAA) is becoming popular in patients with rheumatoid arthritis (RA)-associated ankle joint degeneration. However, ankle wound complications can occur after TAA, which sometimes requires challenging reconstruction due to anatomical complexity of the ankle. Superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has been reported to be useful for various reconstructions, but no case has been reported regarding a chimeric SCIP flap for complex ankle reconstruction. We report a case of complex ankle defect successfully reconstructed with a free quadruple-component chimeric SCIP flap. A 73-year-old female patient with RA underwent TAA, and suffered from an extensive ankle soft tissue defect (13 × 5 cm) with exposure of the implanted artificial joint and the extensor tendons. A chimeric SCIP flap was raised based on the deep branch and the superficial branch of the SCIA, which included chimeric portions of the sartorius muscle, the deep fascia, the inguinal lymph node (ILN), and the skin/fat. The flap was transferred to the recipient ankle. The sartorius muscle was used to cover the artificial joint, the deep fascia to reconstruct the extensor retinaculum, the ILN to prevent postoperative lymphedema, and the adiposal tissue to put around the extensor tendons for prevention of postoperative adhesion. Postoperatively, the patient could walk by herself without persistent leg edema or bowstringing of the extensor tendons, and was satisfied with the concealable donor scar. Although further studies are required to confirm efficacy, multicomponent chimeric SCIP has a potential to be a useful option for complex defects of the ankle.
Germain, M A; Hartl, D M; Marandas, P; Juliéron, M; Demers, G
To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results. Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability. Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech. Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.
Full Text Available Background Scalp defects may be caused by various etiological factors, and they representa significant surgical and aesthetic concern. Various surgical techniques can be applied forreconstructive work such as primary closure, skin grafting, pedicled or free flaps. In this article,the authors share their clinical experience with scalp operations using the technique of localflaps and discuss the application of this method from the perspective of not only the sizeof the defect, but also in relation to the anatomical area, quality of surrounding tissue, andpatient’s condition.Methods During the period from December 2007 to December 2012, 13 patients with variousscalp defects, aged 11 to 86 years, underwent reconstruction with local pedicle flaps. Theindicationswere based on the patients’ condition (age, sex, quality of surrounding tissue, andcomorbidities and wound parameters. Depending on the size of the defects, they wereclassified into three groups as follows: large, 20 to 50 cm2; very large, 50 to 100 cm2; extremelylarge, 100 cm2. The location was defined as peripheral (frontal, temporal, occipital, central,or combined (more than one area. We performed reconstruction with 11 single transpositionflaps and 1 bipedicle with a skin graft on the donor area, and 2 advancement flaps in 1 patient.Results In all of the patients, complete tissue coverage was achieved. The recovery was relativelyquick, without hematoma, seroma, or infections. The flaps survived entirely.Conclusions Local flaps are widely used in scalp reconstruction since they provide healthy,stable, hair-bearing tissue and require a short healing time for the patients.
Masoomi, Hossein; Clark, Emily G; Paydar, Keyianoosh Z; Evans, Gregory R D; Nguyen, Audrey; Kobayashi, Mark R; Wirth, Garrett A
Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage.
Funk, Duane; Bohn, James; Mutch, WAC; Hayakawa, Tom; Buchel, Edward W
Fluid replacement is an important aspect of surgery and is particularly challenging in patients undergoing microvascular free flap reconstruction. The use of vasopressors can compromise blood flow to the flap, a problem also encountered with inadequate volume replacement, which can lead to ischemia and flap loss. However, excessive perioperative fluid administration may lead to flap loss resulting from venous engorgement and flap edema. This uncertainty, in part, prompted the authors of this ...
Low, Tsu-Hui Hubert; Lindsay, Andrew; Clark, Jonathan; Chai, Francis; Lewis, Richard
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.
Xie, Huizhuang; Malata, Charles M.
INTRODUCTION Abdominal free flap breast reconstruction is regarded as the gold standard method of post-mastectomy breast reconstruction by many. It is a major surgery which can be associated with varied systemic complications. To date, there have been no reports of cerebrovascular complications in the literature which examine the possible relation between thromboembolism and patent foramen ovale (PFO) in patients undergoing microvascular breast reconstruction. PRESENTATION OF CASE A 54-year old female with a pre-existing PFO developed a stroke following bilateral mastectomies and immediate free flap breast reconstruction on postoperative day 5. This was attributed to an air embolus caused by central venous pressure line removal. After uneventful intra and early postoperative periods, the patient had collapsed suddenly on day 5 and become unresponsive immediately following the removal of a central venous line. Brain magnetic resonance imaging confirmed a cerebrovascular accident. This resolved within 48 h following therapeutic heparinisation. A clinical diagnosis of paradoxical embolism was made and she was subsequently referred to the cardiologists for angiographic closure of the PFO. DISCUSSION The case study herein reported gives an account that PFO can have considerable health implications in the early postoperative period and conceivably intraoperatively in patients undergoing major reconstructive surgeries. CONCLUSION Surgeons and cardiologists should be aware of this cerebrovascular complication secondary to PFO following major reconstructive surgery such as microvascular breast reconstruction. It also serves to challenge microvascular surgeons to reconsider routine use of central venous pressure lines in free flap patients who might otherwise have good peripheral vessels for postoperative fluid and antibiotic administration. PMID:25437687
Kim, Heejin; Jeong, Woo-Jin; Ahn, Soon-Hyun
Objectives Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap do...
Miyazaki, Yuko; Fukuda, Kenji; Fujita, Kazutoshi; Nishimoto, Soh; Terada, Tomonori; Wada, Ryu; Sotsuka, Yohei; Kawai, Kenichiro; Kakibuchi, Masao
Malignant oral cancers do not commonly occur in pregnant women. But when they do, the presence of a foetus and maternal physiological changes complicate and limit the treatment options. Risk benefit assessment and balancing of them are always important. A 33-year-old woman, who was 25 weeks pregnant, presented with a squamous cell carcinoma on her tongue. She was clinically staged II (T2, N0 and M0). Discussions between the patient, surgical teams and obstetricians agreed to continue her pregnancy while managing the tumour. Hemi-glossectomy and ipsilateral neck dissection was performed. Free antero-lateral thigh flap was transferred to reconstruct the tongue defect, successfully. The patient gave birth to a healthy baby afterward. She is tumour free for 6 years. Free flap reconstruction can be an option, even if the patient is pregnant.
Siew Cheng Chai
Full Text Available A transverse rectus abdominis myocutaneous (TRAM flap is a popular choice for breast reconstruction. Pregnancies in women following a TRAM flap present concerns regarding both safety and the integrity of the abdominal wall. We report a case of a patient who was pregnant during immediate breast reconstruction with pedicled TRAM flap and had a successful spontaneous vaginal delivery. We also conducted a literature review using PubMed on pregnancy post TRAM flap, type of reconstruction, timing of pregnancy after TRAM flap, complication, and mode of delivery, which are summarised in this report. We concluded that patients may have safe pregnancies and normal deliveries following TRAM flap breast reconstruction regardless of the time frame of pregnancy after the procedure. Therefore, TRAM flaps can continue to be a reconstruction option, even in women of childbearing age.
Lu, Mingxing; Sun, Guowen; Hu, Qingang; Tang, Enyi; Wang, Yujia
To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery. Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P > 0.05). Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity.
Economides, James M.; DeFazio, Michael V.; Golshani, Kayvon; Cinque, Mark; Anghel, Ersilia L.; Attinger, Christopher E.
Background In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. Methods A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. Results A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. Conclusions Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes. PMID:28352601
James M. Economides
Full Text Available BackgroundIn cases of total knee arthroplasty (TKA threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA.MethodsA systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis.ResultsA total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05 and limb salvage (89.8% vs. 100%, P=0.14 were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78, the rates of persistent infection (16.4% vs. 0%, P=0.14 and recurrent infection (9.1% vs. 4%, P=0.94 tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported.ConclusionsRates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.
Su, Wan-Fu; Hsia, Yi-Jan; Chang, Yen-Chine; Chen, Shyi-Gen; Sheng, Hwa
Numerous patients in Taiwan with tongue carcinoma require tongue reconstruction. We compared the abilities of 2 methods of tongue reconstruction to reserve tongue function. Sixty patients underwent resection of the tumors and reconstruction with a pectoralis major flap or a radial forearm flap. The Chinese articulation test was used to evaluate the place and manner of error production, and a questionnaire on dietary habits was used to evaluate deglutition 6 months to 10 years after reconstruction. Patients with the free flap had more intelligible speech. The questionnaire study showed no significant difference between the 2 groups in swallowing rating. Motility caused by flap pliability increased speech intelligibility more than it did on swallowing function. Our experience in a few selected patients shows that the functional outcome of tongue surgery is related to the reconstruction methods used (for speech) and to the extent of tongue resection (for swallowing).
Sung Kyu Bae
Full Text Available BackgroundIf a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect.MethodsFrom 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction.ResultsUpon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery.ConclusionsUsing a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.
Lewin, Jan S; Barringer, Denise A; May, Annette H; Gillenwater, Ann M; Arnold, Katherine A; Roberts, Dianna B; Yu, Peirong
We examined speech and swallowing outcomes and complications in patients with anterolateral thigh (ALT) flap reconstruction of cervical esophageal defects. We retrospectively reviewed 29 patients treated with laryngopharyngectomy and ALT flap reconstruction at The University of Texas M. D. Anderson Cancer Center from March 2002 to July 2004. We compared complication rates, nutritional intake, number of tracheoesophageal punctures (TEPs), speech fluency and use, operative defects, and radiotherapy effects. Twenty-two patients had circumferential defects, and seven had partial defects. Twenty-four patients had radiotherapy. Eleven patients underwent TEP. Higher complication rates in patients after TEP compared with those without TEP were not statistically significant (p = .268). Ninety percent of patients with TEP spoke fluently. Ninety percent of all patients returned to oral alimentation without significant effect from TEP (p = 1.00), complications (p = 1.00), radiation therapy (p = 1.00), or surgical defect (p = .56). The ALT flap successfully reconstructs laryngopharyngeal defects with excellent speech and swallowing results. Copyright 2005 Wiley Periodicals, Inc.
Lin, Wentao; Qing, Yong; Liu, Jia; Cen, Ying
The nasal ala plays an important role in the aesthetic appearance of the nose. Repairing the nasal alar defect, especially full-thickness alar defect, is one of the difficulties of plastic surgeons. In this article, a new surgical method is introduced about repairing full-thickness alar defect with free auricular composite flaps and local nasal alar rotation and advancement tissue flaps. We retrospectively reviewed 6 patients with a diagnosis of full-thickness alar defect between 2010 and 2013. All of them accepted this new surgical method. The patients were followed up for 6 to 12 months. The method used local nasal alar rotation and advancement tissue flap to form new nasal rim and made the defect of nasal rim shift to alar groove region. After that, we harvested free auricular composite flap to repair the new defect. All patients attained relatively symmetrical nostrils with a natural, smooth, integrated alar rim and inconspicuous scars. All the reconstructed nasal alae were aesthetically satisfactory. Slight atrophy of grafts was observed in all patients. The shape of the donor ear changed a little. Two patients experienced hyperpigmentation change and one patient presented slight hypertrophic scar in the suture site. No other complications were observed. This simple method not only reconstructed almost normal nasal alar rims and alar grooves but also improved the survival rate of the composite grafts without any free edges. This method also changed the traditional free auricular tissue flap location from the nasal alar rim to the upper alar groove region, which would help achieve more aesthetic appearance. This new method is a creative and useful technique for the repair of full-thickness alar defect.
O'Neill, J P
BACKGROUND: With the advent of microsurgery the pedicled flap is considered by many to be an outdated surgical option. AIMS: To explore the relationship between flap survival and pre-morbid risk factors, conduct a comparative analysis of flap and systemic morbidities and complete a cosmesis and functionality assessment for oral and oropharyngeal reconstruction patients. METHODS: 114 patients, over a 13-year period, who had a one-stage reconstructive procedure employing the pectoralis major myocutaneous flap (PMMF) or radial forearm-free flap (RFFF). RESULTS: Variables, including age, smoking and radiation exposure were not statistically significant predictors of flap survival probability. Atelectasis was a significant post-op finding of RFFF patients. Flap dehiscence of >50% was a significant morbidity of PMMF. No statistical difference in cosmetic deformity, diet and socialisation was noted. CONCLUSIONS: Pectoralis major myocutaneous flap remains an enduring and safe flap; however, the RFFF has markedly improved speech performance over the PMMF.
Locke, Michelle B; Zhong, Toni; Mureau, Marc A M; Hofer, Stefan O P
Autologous tissue microsurgical breast reconstruction is increasingly requested by women following mastectomy. While the abdomen is the most frequently used donor site, not all women have enough abdominal tissue excess for a unilateral or bilateral breast reconstruction. A secondary choice in such women may be the transverse upper gracilis (TUG) myocutaneous flap. This study reviews our experience with TUG flap breast reconstruction looking specifically at reconstructive success rate and the requirement for secondary surgery. A total of 16 free TUG flaps were performed to reconstruct 15 breasts in eight patients over a period of five years. Data were collected retrospectively by chart review. Follow up ranged from 14 to 41 months. During the follow up period, there was one (6.3%) complete flap loss in an immediate breast reconstruction patient. Four further flaps (25%) failed in their primary aim of breast reconstruction, as they required additional significant reconstruction with either deep inferior epigastric perforator (DIEP) flaps (two flaps (12.5%), one patient) or augmentation with silicone breast implants (two flaps (12.5%), one patient), giving a successful breast reconstruction rate with the TUG flap of only 66.7%. In all of the remaining reconstructed breasts, deficient flap volume or breast contour was seen. Eight flaps were augmented by lipofilling. A total of 62.5% of the donor sites had complications, namely sensory disturbance of the medial thigh (25%) and poor scar (37.5%) requiring revision. This series demonstrates a high rate of reconstructive failure and unsatisfactory outcomes from TUG flap breast reconstruction. We feel this reinforces the necessity of adequate pre-operative patient assessment and counselling, including discussion regarding the likelihood of subsequent revisional surgery, before embarking on this form of autologous breast reconstruction.
Satoh, K; Sakai, M; Hiromatsu, N; Ohsumi, N
Island flaps supplied by the intermuscular cutaneous perforator (IMCP) from a deep vessel, such as the peroneal flap pedicled by IMCP from the peroneal vessel or the anterior tibial flap supplied by IMCP from the anterior tibial vessel, are reported to be useful in reconstructive procedures for soft-tissue defects of the lower leg. However, the posterior tibial flap, pedicled by IMCP from the posterior tibial vessel, has not yet been fully described. The posterior tibial flap can be used either as a normal-flow or as a reverse-flow flap. It is particularly versatile as a reverse-flow flap for reconstruction of soft-tissue defects of the heel and foot. Three reverse-flow posterior tibial flaps were clinically applied, without venous anastomosis, to reconstruct heel and foot defects, and all three survived completely. The operative procedure and its characteristics are described.
Ma, Sunxiang; Cheng, Kaixiang; Liu, Yang; Chen, Fuguo
To introduce a new surgical procedure for penile reconstruction, emphasizing both the aesthetic appearance and the function by combined free radial forearm flap and dorsalis pedis flap. In this procedure, the penis was subdivided into 2 anatomic subunits: the penile shaft and the glans penis. A sequential innervated radial forearm free flap was combined with a dorsalis pedis free flap to reconstruct the penile shaft and the glans, separately. Cartilage prosthesis was implanted at the same time. Since May 2011, 14 biologically male patients with total penile losses by various reasons were treated with this procedure. Patient satisfaction was evaluated by questionnaire, and sensory testing was performed. The ages of the patients ranged between 21 and 53 years (mean, 35.2 years). The average follow-up period was 38.1 months (range, 25.5-56 months). Twenty-five flaps in 11 patients were 100% viable. One dorsalis pedis flap in a patient underwent partial necrosis. There were no cases of urethral fistula or urethral stenosis, but 1 case of prosthesis infection and 1 case of abdominal hernia were recorded. The sensation of the neophallus recovered 3-6 months after surgery, and the patient satisfaction rate was quite high. The new surgical procedure of combined free radial forearm flap and dorsalis pedis flap for penile reconstruction achieves both satisfactory aesthetic and functional results. We recommend this procedure as an alternative ideal method for total penile reconstruction. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF or the pedicled anterolateral thigh flap (ALTF has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy. Methods. Eleven males (age 15 to 42 years were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months. Aesthetic and functional results were evaluated. Results. There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula. Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion. Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.
Hughes, Tom; Yu, Jonathan T.S.; Wong, Kai Yuen; Malata, Charles M.
INTRODUCTION Necrotising fasciitis (NF) is a rare, severe, rapidly progressing and life-threatening synergistic infection primarily affecting the superficial fascia. A novel method of definitive and aesthetic reconstruction of NF thigh defects by using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap without recourse to temporising skin grafts is presented. PRESENTATION OF CASE A 30-year-old parous woman presented in extremis with fulminant NF of her left anteromedial thigh. Following emergency radical debridement and intensive care stabilisation she was reconstructed 48 h later in a single stage with a pedicled TRAM flap islanded on the ipsilateral deep inferior epigastric vessels. There was excellent contour restoration of her thigh and coverage of the exposed femoral vessels. DISCUSSION Pedicled flaps based on the rectus abdominis muscle provide a large, readily available reconstructive option for correction of substantial regional defects as herein illustrated. They are robust when based on dominant inferior vascular pedicle with a long reach and wide arc of rotation when designed transversely (as a TRAM flap). CONCLUSION This case also illustrates that definitive flap reconstruction of NF can be successfully undertaken in the emergent setting, thereby negating the need for large areas of skin grafting which can lead to contractures with consequent functional impairment and suboptimal aesthetic results. PMID:23548707
Yang, Ching-Hsiang; Kuo, Yur-Ren; Jeng, Seng-Feng; Lin, Pao-Yuan
Pressure sore reconstruction is quite difficult for plastic surgeons because of long-term high recurrence rates. We designed a freestyle perforator-based flap for pressure sore reconstruction considering pressure sore recurrence and further reconstruction. We used a handheld Doppler device to locate a perforator position just adjacent to the pressure ulcer. In a series of 34 patients, we used 37 perforator-based flaps to reconstruct 25 sacral, 5 ischial, and 4 trochanteric ulcers. Twenty-eight of 37 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, 3 had partial flap necrosis, 3 had wound dehiscence, 1 died 3 days postoperatively, and recurrence developed in 1 patient. We used the freestyle perforator-based fasciocutaneous flap for pressure sore management with good success. These flaps are easy to design and provide good versatility for coverage. Cooperation of surgical skills and good postoperative care also contributed to the lower recurrence rates and satisfactory results.
Berrone, M; Crosetti, E; Succo, G
Oral malignancies involving the mandibular bone require a complex reconstructive plan. Mandibular reconstruction with a fibular free flap is currently considered the best choice for functional and aesthetic rehabilitation after oncological surgery. This flap can be modelled with multiple osteotomies and can provide bone, muscle and skin for composite reconstruction. One of the most delicate aspects of mandibular reconstruction is the technique of bone modelling; the risk of prolonging the period of ischaemia and not restoring the correct maxillomandibular and occlusal relationships can ultimately lead to a higher rate of complications as well as poor aesthetic and functional results. Recently, there has been rising interest in virtual surgical planning and computer-assisted mandibular reconstruction in pre-operative planning; however, this is not always possible because of the costs involved and the set-up time for the entire procedure. In this paper, we present a simple and inexpensive technique for fibular free flap modelling and repositioning after segmental resection of the mandible; the technique entails the pre-operative preparation of a resin repositioning template on a stereolithographic model. This technique has been successfully applied in four cases: two cases underwent resection involving only the mandibular body, one case involving the mandibular body and symphysis and one case in which a ramus to ramus resection was performed. In this preliminary report, we show that the resin repositioning template is an easy, safe and useful tool for mandibular reconstruction with a fibular free flap.
Shpitzer, T; Gullane, P J; Neligan, P C; Irish, J C; Freeman, J E; Van den Brekel, M; Gur, E
Reconstruction of the mandible and oral cavity after segmental resection is a challenging surgical problem. Although osteocutaneous free flaps are generally accepted to be optimal for reconstruction of anterior defects, the need for bony reconstruction for a pure lateral mandibular defect remains controversial. A retrospective study. A retrospective comparative study of short- and long-term outcomes of three different reconstruction techniques for lateral defects was performed. In total, 57 patients were included, of whom 27 had a plate and pedicled pectoralis major myocutaneous flap (PMMF group), 16 had a plate and free radial forearm flap (FRFF group), and 14 had an osteocutaneous free flap. Functionality, flap failure, and complications were scored. Plates had to be removed in 7 of the 27 patients in the PMMF group and 2 of the 16 in the FRFF group; none of the 14 osteocutaneous free flaps failed. The difference was of borderline statistical significance (P = .055). Longterm functional outcome revealed no statistically significant difference in oral deglutition (P = .76) or in facial contour (P = .36). Oral continence was significantly better in patients in the FRFF group (88%) as compared with the PMMF group (52%) or the osteocutaneous free flap group (43%) (P = .02). On the other hand, the results for speech favored the osteocutaneous free flap group; 13 of 14 patients (92.9%) had a normal score compared with 12 of 16 patients (75%) in the FRFF group and 17 of 27 (63%) in the PMMF group. However, this represented a borderline statistically significant result (P = .06). For lateral mandibular defects, the osteocutaneous free flap is reliable and durable in the long term. However, in a selected group of patients either of the two flap-plate options is a viable reconstructive option.
Iain S Whitaker
Full Text Available BACKGROUND: Mastectomies are one of the most common surgical procedures in women of the developed world. The gracilis myocutaneous flap is favoured by many reconstructive surgeons due to the donor site profile and speed of dissection. The distal component of the longitudinal skin paddle of the gracilis myocutaneous flap is unreliable. This study quantifies the fasciocutaneous vascular territories of the gracilis flap and offers the potential to reconstruct breasts of all sizes. METHODS: Twenty-seven human cadaver dissections were performed and injected using lead oxide into the gracilis vascular pedicles, followed by radiographic studies to identify the muscular and fasciocutaneous perforator patterns. The vascular territories and choke zones were characterized quantitatively using the 'Lymphatic Vessel Analysis Protocol' (LVAP plug-in for Image J® software. RESULTS: We found a step-wise decrease in the average vessel density from the upper to middle and lower thirds of both the gracilis muscle and the overlying skin paddle with a significantly higher average vessel density in the skin compared to the muscle. The average vessel width was greater in the muscle. Distal to the main pedicle, there were either one (7/27 cases, two (14/27 cases or three (6/27 cases minor pedicles. The gracilis angiosome was T-shaped and the maximum cutaneous vascular territory for the main and first minor pedicle was 35 × 19 cm and 34 × 10 cm, respectively. CONCLUSION: Our findings support the concept that small volume breast reconstructions can be performed on suitable patients, based on septocutaneous perforators from the minor pedicle without the need to harvest any muscle, further reducing donor site morbidity. For large reconstructions, if a 'T' or tri-lobed flap with an extended vertical component is needed, it is important to establish if three territories are present. Flap reliability and size may be optimized following computed tomographic angiography and
Kuvat, Samet Vasfi; Keklik, Barş; Özden, Burcu Celet; Uçar, Adem; Cizmeci, Orhan
The popularity of the fibular free flap in mandibular reconstructions is persisting, and major donor area complications rarely occur after fibular free flap operations. Still, we have observed a pseudo-compartment syndrome in a 52-year-old patient on the 12th postoperative day after a mandibular reconstruction with a fibular free flap. When an obstruction in the deep venous system (deep vein thrombosis) was observed in the Doppler ultrasound-guided imaging, the patient has been taken to the operating room for an emergency surgery and the donor area has been completely reopened (in the manner of a fasciotomy). After this procedure, the circulation in the foot appeared to return to normal. The exposed muscles of the patient, who was started on a low-molecular-weight heparin treatment for the deep vein thrombosis, have been closed with skin grafts on the 10th day. No functional loss was observed during the 2-month follow-up period.
Higgins, Kristen S; Gillis, Joshua; Williams, Jason G; LeBlanc, Martin; Bezuhly, Michael; Chorney, Jill M
Clinical experience suggests that flap failure after autologous breast reconstruction can be a devastating experience for women. Previous research has examined women's experiences with autologous breast reconstruction with and without complications, and patients' experiences with suboptimal outcomes from other medical procedures. The authors aimed to examine the psychosocial experience of flap failure from the patient's perspective. Seven women who had experienced unilateral flap failure after deep inferior epigastric perforator flap surgery in the past 12 years completed semistructured interviews about their breast cancer treatments, their experiences with flap failure, the impact of flap failure on their lives, and the coping strategies they used. Interpretive phenomenological analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences and their meanings, was used to analyze the interview data. From these data, patient-derived recommendations were developed for surgeons caring for women who have experienced flap failure. Three main themes (6 subthemes) emerged: coming to terms with flap failure (coping with emotions, body dissatisfaction); making meaning of flap failure experience (questioning, relationship with surgeon); and care providers acknowledging the emotional experience of flap failure (experience of being treated "mechanically," suggestions for improvement). In conclusion, flap failure in breast reconstruction is an emotionally difficult experience for women. Although there are similarities to other populations of patients experiencing suboptimal outcomes from medical procedures, there are also unique aspects of the flap failure experience. A better understanding of women's experiences with flap failure will assist in providing more appropriate supports.
Nthumba, Peter M
The gold standard for mandibular defect reconstruction is the fibular free flap. Nevertheless, the pedicled osteomuscular dorsal scapular flap as a reconstructive tool offers promise for mandibular defect reconstruction and could be the first choice in certain circumstances. Its use in resource-limited settings offers an excellent solution to otherwise difficult reconstructive problems of the mandible. In 8 patients, mandibular defects resulting from the excision of benign tumors (6), trauma (1), and chronic osteomyelitis (1) were reconstructed using the pedicled osteomuscular dorsal scapular flap; these defects included the central segment of the mandible. The pedicled osteomuscular dorsal scapular flap is an excellent choice for mandibular reconstruction; it may serve as the primary choice in patients with vascular pathology that precludes free tissue transfer, as well as in resource-limited environments, as a secondary choice after a failed free flap reconstruction.
Bellidenty, L; Chastel, R; Pluvy, I; Pauchot, J; Tropet, Y
Authors analyzed 89 cases (86 patients) of lower limb extensive soft tissue defects reconstruction during 1978 to 2013. The mean age is 37 years and 2 months old (range: 5-84 years old). A total of 71 males and 15 female were included. Free flaps were used in emergency in 23 cases for principally covering Gustilo 3B open lower limb fracture and in a later stage for 66 cases all referred from their center for coverage of exposed bone, with frequently osteomyelitis. About the selection of free flaps, in 47 cases we used a latissimus dorsi flaps, 12 cases of epiploon free transfer (in septic area), 10 cases of gracilis transfer and 10 serratus anterior flaps. There are one medial gastrocnemius flap, 2 composite soleus and fibular free flap, 2 antebrachial flap, one inguinal myoosteocutaneous flap, 1 transferred from the other lower limb and one inguinal cutaneous flap. There are 18 free flap losses: one in emergency and 17 after delayed reconstruction. Authors retrospectively analyzed the results (complications, osteomyelitis) according to the timing for lower extremity reconstruction. They found a low infection and flap failure rates (4%) when the coverage is made in the same operating time than initial fracture fixation, they increase to 60% for osteomyelitis and to 23% for flap failure when the reconstruction is delayed.
Full Text Available BackgroundThe aim of unilateral breast reconstruction after mastectomy is to craft a natural-looking breast with symmetry. The latissimus dorsi (LD flap with implant is an established technique for this purpose. However, it is challenging to obtain adequate volume and satisfactory aesthetic results using a one-stage operation when considering factors such as muscle atrophy, wound dehiscence and excessive scarring. The two-stage reconstruction addresses these difficulties by using a tissue expander to gradually enlarge the skin pocket which eventually holds an appropriately sized implant.MethodsWe analyzed nine patients who underwent unilateral two-stage LD reconstruction. In the first stage, an expander was placed along with the LD flap to reconstruct the mastectomy defect, followed by gradual tissue expansion to achieve overexpansion of the skin pocket. The final implant volume was determined by measuring the residual expander volume after aspirating the excess saline. Finally, the expander was replaced with the chosen implant.ResultsThe average volume of tissue expansion was 460 mL. The resultant expansion allowed an implant ranging in volume from 255 to 420 mL to be placed alongside the LD muscle. Seven patients scored less than six on the relative breast retraction assessment formula for breast symmetry, indicating excellent breast symmetry. The remaining two patients scored between six and eight, indicating good symmetry.ConclusionsThis approach allows the size of the eventual implant to be estimated after the skin pocket has healed completely and the LD muscle has undergone natural atrophy. Optimal reconstruction results were achieved using this approach.
Lampert, Joshua A; Harmaty, Marco; Thompson, Elizabeth Chabner; Sett, Suvro; Koch, R Michael
Ectopia cordis is a rare congenital defect characterized by complete or partial displacement of the heart outside the thoracic cavity. Repair of ectopia cordis can present a reconstructive challenge often requiring a staged approach. Ideally, structural integrity and protection of the heart are restored using autologous tissues capable of growth. In addition, reconstruction of the thorax must proceed without compromise to pulmonary or cardiovascular stability. The following article describes repair of thoracoabdominal ectopia cordis in a patient with pentalogy of Cantrell. Reconstruction of the chest wall was accomplished using a musculoosseus composite flap involving segments of the 9th and 10th ribs and overlying pedicled latissimus dorsi muscle. This is the first report known to the authors of such a repair.
Bibhuti Bhusan Nayak
Full Text Available Gracilis is a commonly used muscle for free tissue transfer. It is also split into two based on its pedicles and used as two units. Use of distal part as a free flap in isolation has never been described in literature. We describe a technique of harvesting a small unit of gracilis based on its minor pedicle and maintaining the continuity and conserving the major bulk of muscle. Thus, the function of the muscle is preserved and the same is also available for transfer on its major pedicle later, if required.
Gunnarsson, Gudjon Leifur; Tei, Troels; Thomsen, Jørn Bo
Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap reconstruction throughout the body. The CDU was used to identify the largest and best-located perforator adjacent to the defect to target the reconstruction. The cutaneous or fasciocutaneous flaps were raised, mobilized, and designed according to the reconstructive needs as rotation, advancement, or turnover flaps. We performed 148 reconstructions in 130 patients. Eleven facial reconstructions, 118 reconstructions in the body, 7 in the upper limbs, and 12 in the lower limbs. The propeller flap was used in 135 of 148 (91%) cases followed by the turnover design in 10 (7%) and the V to Y flap in 3 (2%) cases. The flaps were raised on 1 perforator in 98 (67%), 2 perforators in 48 (33%), and 3 perforators in 2 (1%) flaps. The reconstructive goal was achieved in 143 of 148 reconstructions (97%). In 5 cases, surgical revision was needed. No flaps were totally lost indicating a patent pedicle in all cases. We had 10 (7%) cases of major complications and 22 (15%) minor complications. The CDU-targeted perforator mapping and angiosome-based flap reconstruction are simple to perform, and we recommended its use for freestyle perforator flap reconstruction. All perforators selected by CDU was identified during surgery and used for reconstruction. The safe boundaries of angiosomes remain to be established.
Hurbungs, A; Ramkalawan, H
To report the use of the pedicled superior gluteal artery perforator (SGAP) fasciocutaneous flap as a reliable surgical option for sacral pressure sore reconstruction. A prospective study was conducted between September 2008 and September 2010 of 10 patients with stage 3 or 4 sacral pressure sores treated with a unilateral pedicled SGAP flap. All flaps survived completely with no complications in 9 patients. One patient had a haematoma below the flap that was easily drained. No recurrence of the bedsore occurred during follow-up. We suggest that the pedicled SGAP fasciocutaneous flap is a reliable surgical option for sacral pressure sore reconstruction.
Full Text Available 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.
Rosich-Medina, Anais; Bouloumpasis, Serafeim; Di Candia, Michele; Malata, Charles M.
Introduction The total ‘rib’-preservation method of dissecting out the internal mammary vessels (IMV) during microvascular breast reconstruction aims to reduce free flap morbidity at the recipient site. We review our five-year experience with this technique. Patients & methods An analysis of a prospectively collected free flap data cohort was undertaken to determine the indications, operative details and reconstructive outcomes in all breast reconstruction patients undergoing IMV exposure using the total ‘rib’-preservation method by a single surgeon. Results 178 consecutive breast free flaps (156 unilateral, 11 bilateral) were performed from 1st June 2008 to 31st May 2013 in 167 patients with a median age of 50 years (range 28–71). There were 154 DIEP flaps, 14 SIEA flaps, 7 muscle-sparing free TRAMs, 2 IGAP flaps and one free latissimus dorsi flap. 75% of the reconstructions (133/178) were immediate, 25% (45/178) were delayed. The mean inter-costal space distance was 20.9 mm (range 9–29). The mean time taken to expose and prepare the recipient IMV's was 54 min (range 17–131). The mean flap ischaemia time was 95 min (range 38–190). Free flap survival was 100%, although 2.2% (4 flaps) required a return to theatre for exploration and flap salvage. No patients complained of localised chest pain or tenderness at the recipient site and no chest wall contour deformity has been observed. Discussion & conclusion The total ‘rib’-preservation technique of IMV exposure is a safe, reliable and versatile method for microvascular breast reconstruction and should be considered as a valid alternative to the ‘rib’-sacrificing techniques. PMID:26468373
Open window thoracostomy for thoracic empyema: Open window thoracostomy is a simple, certain and final drainage procedure for thoracic empyema. It is most useful to drain purulent effusion from empyema space, especially for cases with broncho-pleural fistulas, and to clean up purulent necrotic debris on surface of empyema sac. For changing of packing gauzes in empyema space through a window once or twice every day after this procedure, thoracostomy will have to be made on the suitable position to empyema space. Usually skin incision will be layed along the costal bone just at the most expanded position of empyema. Following muscle splitting to thoracic wall, a costal bone just under the incision will be removed as 8-10 cm as long, and opened the empyema space through a costal bed. After the extension of empyema space will be preliminarily examined through a primary window by a finger or a long forceps, it will be decided costal bones must be removed how many (usually 2 or 3 totally) and how long (6-8 cm) to make a window up to 5 cm in diameter. Thickened empyema wall will be cut out just according to a window size, and finally skin edge and empyema wall will be sutured roughly along circular edge. Muscle flap transposition for empyema space: Pediclued muscle flap transposition is one of space-reducing operations for (chronic) empyema Usually this will be co-performed with other several procedures as curettages on empyema surface, closure of bronchopleural fistula and thoracoplasty. This is radically curable for primarily non fistulous empyema or secondarily empyema after open window thoracostomy done for fistula. Furthermore this is less invasive than other radical operations as like pleuro-pneumonectomy, decortication or air-plombage for empyema. There are 2 important points to do this technique. One is a volume of muscle flap and another is good blood flow in flap. The former suitable muscle volume is need to impact empyema space or to close fistula, and the
V. S. Mel'nikov
Full Text Available Objective: to determine the capabilities and perspectives of island and perforator flaps for soft tissue reconstruction of the hand. Material and methods. Results of treatment of 41 patients with defects of the soft tissue of the hand, treated at the in the period from 2010 to 2013 and operated using the island flaps and perforator flaps (DAP flap. Results and conclusion. In all cases the authors have received positive functional and cosmetic results, which were evaluated using a questionnaire DASH, the average score was 12.3. Digital artery perforator flaps allow close defect covering tissue any surface fingers. The use of perforator flaps allows reconstructing soft tissue defect with the skin of the same anatomical region as identical morphologically lost. The second important advantage is that the DAP flap is not included in the magisterial arteries, allows its use as a recipient for subsequent microsurgical reconstructions.
Wang, L; Liu, K; Shao, Z; Shang, Z-J
The current study was undertaken to evaluate a novel approach to tongue and mouth floor reconstruction using the myofascial vastus lateralis free flap (MVLF). The surgical techniques, benefits, complication rate, and the aesthetic and functional results are described. A series of six patients underwent functional tongue reconstruction between July 2013 and November 2014. The myofascial vastus lateralis flap was obtained as follows: the vastus lateralis muscle was exposed, the neurovascular pedicle was identified, and the myofascial flap was raised. Postoperatively, the neotongue appeared plump and was able to maintain palatal contact. Moreover, no obvious decrease in flap volume was observed during the follow-up period. Most patients experienced good tongue mobility. Further use of the MVLF should confirm whether the mucous membrane on the surface of the flap becomes part of the tongue mucosa in the true sense, whether and how well the patients will recover their sense of taste, and the degree to which quality of life is improved after nerve anastomosis. So far, it appears to be a suitable approach to tongue and mouth floor reconstruction.
Khafagy, M; Fakhr, I; Hamed, A; Youssef, O
Breast conserving therapy is the gold standard treatment of early breast cancer. However, a balance between good cosmetic outcome and limiting the risk of locoregional recurrence remains the key of success. The aim of this work was to evaluate the outcome of partial breast reconstruction using pedicled dermo-glandular flap from the upper outer quadrant, for central quadrantectomy BCS. Thirty patients underwent wide excision of carcinoma of retroareolar or periareolar regions of the breast, from July 2008 to August 2011. Excisions included the nipple/areola complex down to the pectoralis fascia with a wide safety margin, and complete axillary dissection. Breast reconstruction was done by means of pedicled dermoglandular flap. Mean age of patients was 51.86 years (range from 30 to 70 years). Tumor size ranged from 1 to 4.2 cm. Postoperative pathological results came out with 21 (70.0%) patients mean (range) of the tumor safety margin 2.01 (0.5-2.8). Seventeen (56.7%) patients had positive axillary lymph nodes. All patients received postoperative radiation therapy to the breast, while 17/30 (56.67%) and 6/30 (20%) received endocrine therapy or adjuvant chemotherapy, respectively, and only 7/30 (23.34%) patients received both therapies. During a median follow-up period of 24 months, neither local nor distant metastasis, were detected. The postoperative cosmetic result was excellent in 80% patients, good in 13.3% patients, acceptable in 6.7% with no poor result. Following central quadrantectomy BCS for small centrally located breast cancer, a pedicled dermoglandular flap from the upper outer quadrant is a good reconstructive option. Copyright © 2012 National Cancer Institute, Cairo University. Published by Elsevier B.V. All rights reserved.
Full Text Available Background: Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip. Materials and Methods: Six cases (six fingers of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site. Results: Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale and the two point discrimination was 3-8 mm. Conclusion: Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.
Shi, Ye; Zhang, Tao; Chen, Yong-Ning; Zhao, Ji-Zhi; Yu, Li-Jiang; Shi, Tian-Yin; Ma, Chao
To discuss the feasibility of using free tissue flap for simultaneous tongue reconstruction after tongue cancer resection. Radial forearm flaps and anterolateral thigh flaps were used for simultaneous reconstruction of different defects after tongue cancer resection in 47 cases. The functional evaluation was assessed during the follow-up period of 3 months to 9 years. Only one flap failed,giving a success rate of 97.7%. The 36 patient available for postoperative follow-up were all able to communicate in basic languages and eat normally. Among them, normal speech was found in 34, while slurred speech was found in two. 31 patients could eat normal diet ,while eight could eat soft diet and two could eat liquid diet. Simultaneous tongue reconstruction with free tissue flap is a reliable method with high successful rate. Flaps selection based on different tongue defects is the key point to achieve good functional and cosmetic results for the reconstruction tongue.
Sung Kyu Bae
Full Text Available Background If a chronically infected abdominal wound develops, complications such asperitonitis and an abdominal wall defect could occur. This could prolong the patient’s hospitalstay and increase the possibility of re-operation or another infection as well. For this reason,a solution for infection control is necessary. In this study, surgery using a rectus abdominismuscle myofascial splitting flap was performed on an abdominal wall defect.Methods From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture,cesarean section, or uterine myoma were chosen. In each case, during the first week afteroperation, the wound showed signs of infection. Surgery was chosen because the wounds didnot resolve with dressing. Debridement was performed along the previous operation woundand dissection of the skin was performed to separate the skin and subcutaneous tissue fromthe attenuated rectus muscle and Scarpa’s fascial layers. Once the anterior rectus sheath andmuscle were adequately mobilized, the fascia and muscle flap were advanced medially sothat the skin defect could be covered for reconstruction.Results Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation,no major complication occurred. In addition, all of the patients showed satisfaction in termsof function and esthetics at 3 to 6 months post-surgery.Conclusions Using a rectus abdominis myofascial splitting flap has many esthetic andfunctional benefits over previous methods of abdominal defect treatment, and notably, itenabled infection control by reconstruction using muscle.
Gabert, Pierre-Elliott; Bodin, Frederic; Aljudaibi, Nawaf; Duquennoy-Martinot, Veronique; Guerreschi, Pierre
The transverse musculocutaneous gracilis free flap is a valuable choice for autologous tissue, unilateral or bilateral breast reconstruction. This procedure is an excellent and customized option for immediate or delayed breast reconstruction in patients with small to moderate size breasts. Few descriptions of flap dissection and breast mound shaping are available. In this first educational video, the authors report the original dissection of the transverse musculocutaneous gracilis free flap used for breast reconstruction. Virtual animations insist on surgical key points and relevant details of the harvesting of the flap.
Cornejo, Agustin; Rodriguez, Thomas; Steigelman, Megan; Stephenson, Stacy; Sahar, David; Cohn, Stephen M; Michalek, Joel E; Wang, Howard T
The loss of a free flap is a feared complication for both the surgeon and the patient. Early recognition of vascular compromise has been shown to provide the best chance for flap salvage. The ideal monitoring technique for perioperative free flap ischemia would be noninvasive, continuous, and reliable. Visible light spectroscopy (VLS) was evaluated as a new method for predicting ischemia in microvascular cutaneous soft tissue free flaps. In an Institutional Review Board-approved prospective trial, 12 patients were monitored after free flap reconstructions. The tissue hemoglobin oxygen saturation (StO (2)) and total hemoglobin concentration (THB) of 12 flaps were continuously monitored using VLS for 72 hours postoperatively. Out of these 12 flaps 11 were transplanted successfully and 1 flap loss occurred. The StO (2 )was 48.99% and the THB was 46.74% for the 12 flaps. There was no significant difference in these values among the flaps. For the single flap loss, the device accurately reflected the ischemic drop in StO (2) indicating drastic tissue ischemia at 6 hours postoperatively before the disappearance of implantable Doppler signals or clinical signs of flap compromise. VLS, a continuous, noninvasive, and localized method to monitor oxygenation, appeared to predict early ischemic complications after free flap reconstruction.
Thomsen, Jørn Bo; Bille, Camilla; Wamberg, Peter
The aim of this study was to examine if a propeller thoracodorsal artery perforator (TAP) flap can be used for breast reconstruction. Fifteen women were reconstructed using a propeller TAP flap, an implant, and an ADM. Preoperative colour Doppler ultrasonography was used for patient selection...... major complications needing additional surgery. One flap was lost due to a vascular problem. Breast reconstruction can be performed by a propeller TAP flap without cutting the descending branch of the thoracodorsal vessels. However, the authors would recommend that a small cuff of muscle is left around...
Kwon, Soo-Ha; Tsai, Chia-Hsuan; Chang, Kai-Ping; Kao, Huang-Kai
Introduction Oncological resection of the tongue can be reconstructed using a multitude of free flaps. The medial sural artery perforator (MSAP) flap has been well described in the literature in terms of its anatomy and harvest. However, functional outcome studies of post-reconstruction tongue defects using the MSAP flap have not been reported. This study represents the largest outcome study of patients with tongue reconstructions using MSAP flaps and a comprehensive review of its use. Materials and methods From December of 2010 to October of 2015, 579 patients with subtotal glossectomy and free flap reconstructions in Chang Gung Memorial Hospital were retrospectively reviewed. 27 patients were reconstructed with MSAP flap. The pre- and intra-operative factors, as well as flap-related factors were analyzed. Post-operative complications and functional outcomes were evaluated. Donor site assessment were also conducted. Results A 96.3% flap survival rate was found with an average total operating time of 6 hours and 18 minutes. 84.6% of patients had primary closure of the donor site with and the remaining either had skin grafts or delayed closure. Donor site closure can be achieved primarily with no functional deficit. Speech intelligibility remained for most patients. 100% of patients resumed normal oral feeding. Conclusion The MSAP flap is a small to medium sized flap most suited for subtotal glossectomy defects where optimal outcomes can be achieved in terms of speech clarity and restoration of oral intake. PMID:28182639
Lu, Mingxing; Sun, Guowen; Hu, Qingang; Tang, Enyi; Wang, Yujia
Background To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. Material and Methods The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for ...
Full Text Available Objective: To evaluate the use of the medial gastrocnemius muscle and/or soleus muscle flaps as surgical treatment of the leg bone exposure.Methods: We retrospectively analyzed the medical records of patients undergoing transposition of the medial gastrocnemius and / or soleus for treating exposed bone in the leg, from January 1976 to July 2009, gathering information on epidemiological data, the etiology the lesion, the time between the initial injury and muscle transposition, the muscle used to cover the lesion, the healing evolution of the skin coverage and the function of the gastrocnemius-soleus unit.Results: 53 patients were operated, the ages varying between nine and 84 years (mean age 41; 42 were male and 11 female. The main initial injury was trauma (84.8%, consisting of tibia and / or fibula fracture. The most frequently used muscle was the soleus, in 40 cases (75.5%. The rank of 49 patients (92.5% was excellent or good outcome, of three (5.6% as regular and of one (1.9% as unsatisfactory.Conclusion: the treatment of bone exposure with local muscle flaps (gastrocnemius and/or soleus enables obtaining satisfactory results in covering of exposed structures, favoring local vascularization and improving the initial injury. It offers the advantage of providing a treatment in only one surgical procedure, an earlier recovery and reduced hospital stay.
We present a case of leiomyosarcoma in a patient who underwent mastectomy followed by radiotherapy for invasive ductal carcinoma. A delayed TRAM flap reconstruction was performed 10 years after and a rapid growing mass under the reconstructed flap appeared, on routine follow-up, twenty years later. This report analyzes the diagnostic and therapeutic approach of patients with RIS.
Benlloch-Gonzalez, Manuel; Lafarge, Stéphanie; Bouvy, Bernard; Poncet, Cyrill
Upper-lip reconstruction after mast-cell tumor-resection in a French bulldog was achieved by using a transposition flap from the nasal-skin-fold and an oral mucosal flap. The new technique is an alternative for reconstruction of extensive upper-lip defects in brachycephalic dogs and achieves satisfactory functional and cosmetic results.
Karabeg, Reuf; Dujso, Vanis; Jakirlić, Malik
Tensor fascia lata pedicled flap is one of the most useful flaps for reconstruction pressure sore defects on trochanteric region. Debate exists on the safe dimension of the flap, as distal tip necrosis can be encountered. The aim of the current study is to report experience of Clinic for Plastic and Reconstructive Surgery, Clinical University Center of Sarajevo, with tensor fascia lata pedicled flap in reconstructing trochanteric pressure sore defects. From January 1993 to December 2007, 39 pedicled TFL flaps were used for reconstruction trochanteric pressure sore defects in 34 patients. We used 3 local flaps for reconstruction of small trochanteric defects and one direct suture. In our study we had 43 trochanteric pressure sores and in 9 patients pressure sores were bilateral. The age ranged from 9 to 65, with average age 41,2. The resulting trochanteric defects in this study were due to debridement of pressure sore. The size of the flaps used ranged from 15 x 6 cm to 30 x 15 cm. All flaps survived. Distal tip necrosis occurred in 4 cases. All 4 cases developed in a very large flap beyond the safe limits. Wound dehiscence occurs in 3 cases. There was minimal donor side morbidity in the form of partial skin loss in 1 case. The average follow up period in this study ranged from 6 months to 15 years. Tensor fascia lata flap is reliable flap. Donor site morbidity is minimal. Problem with the flap can be encountered if the flap is not harvested with the safe limits and properly designed. Proper preoperative preparations must be taken into consideration. Chronic skin ulcers, such as pressure sores, that are refractory to conventional local wound therapies, are good examples of potential beneficiaries of the TFL musculocutaneous flap.
Roostaeian, Jason; Yoon, Alfred P; Ordon, Shannon; Gold, Chris; Crisera, Christopher; Festekjian, Jaco; Da Lio, Andrew; Lipa, Joan E
Implant-based breast reconstructions can result in unsatisfactory results requiring surgical revision or salvage reconstructive surgery with autologous tissue. This study compares the outcomes and complications of salvage (tertiary) flap reconstruction after failed prosthesis placement to those of primary/secondary flap reconstruction. All patients undergoing free flap breast reconstruction after failed prosthesis between July 1, 2005, and June 30, 2014, were identified. A matched number of patients who underwent a de novo free flap breast reconstruction were selected randomly for review. The indication for prosthesis removal, demographic and operative data, flap type and inset, and complication rates were evaluated. Eighty-nine women with a history of failed implant-based reconstruction required free flap reconstruction for salvage in 121 breasts. Capsular contracture was the most common indication for prosthesis removal (62.0 percent). Recipient vessel scarring was 5.23 times more likely to occur in the prior prosthesis group (p breast reconstruction with autologous tissue after failed prosthesis can be safely performed, with success rates similar to those of primary free flap breast reconstruction. However, these procedures may have increased complexity because of recipient vessel scarring, higher rates of prior radiation therapy, and major complications, which may warrant appropriate preoperative planning and patient counseling. Therapeutic, III.
Zelken, Jonathan A; AlDeek, Nidal F; Hsu, Chung-Chen; Chang, Nai-Jen; Lin, Chih-Hung; Lin, Cheng-Hung
Lower abdominal, perineal, and groin (LAPG) reconstruction may be performed in a single stage. Anterolateral thigh (ALT) flaps are preferred here and taken as fasciocutaneous (ALT-FC), myocutaneous (ALT-MC), or vastus lateralis myocutaneous (VL-MC) flaps. We aim to present the results of reconstruction from a series of patients and guide flap selection with an algorithmic approach to LAPG reconstruction that optimizes outcomes and minimizes morbidity. Lower abdomen, groin, perineum, vulva, vagina, scrotum, and bladder wounds reconstructed in 22 patients using ALT flaps between 2000 and 2013 were retrospectively studied. Five ALT-FC, eight ALT-MC, and nine VL-MC flaps were performed. All flaps survived. Venous congestion occurred in three VL-MC flaps from mechanical cause. Wound infection occurred in six cases. Urinary leak occurred in three cases of bladder reconstruction. One patient died from congestive heart failure. The ALT flap is time tested and dependably addresses most LAPG defects; flap variations are suited for niche defects. We propose a novel algorithm to guide reconstructive decision-making.
Daniel John Womac
Full Text Available UNLABELLED: Autologous tissue transfer, in addition to replacing tissue that was lost during injury or surgery, offers women an excellent option to improve cosmetic appearance and self-confidence following mastectomy due to breast cancer. However, flap necrosis is a complication in obese patients undergoing this procedure. We created a mouse model to study the flap-related complications that leads to decreased flap survival in autologous breast reconstruction. METHODS: Left superficial inferior epigastric (SIE pedicle abdominal-cutaneous flaps were elevated in 8 week-old, obese ob/ob male mice and their lean littermates. Flaps were followed by serial photography. Area of flap necrosis was measured at 7 days. Statistical analysis was performed. RESULTS: Necrosis was observed at the distal margin of the flaps, in both lean and obese groups. Lean left SIE flaps (n = 8 had a total area flap necrosis of 9.1% at 7 days whereas obese left SIE flaps (n = 8 had a total area flap necrosis of 45.5% at 7 days. Obese flaps had a statistically significant increase in necrosis compared to the lean flaps, p = 0.001. CONCLUSIONS: There was a significant difference between flap survival in lean and obese SIE pedicle flaps in our mouse model. We have developed the first flap model of obesity utilizing the superficial epigastric pedicle in the mouse. This model is optimal for future studies to dissect out mechanisms that lead to the complications related to flap survival for breast reconstruction, especially in obese subjects.
Zeitani, Jacob; Russo, Marco; Pompeo, Eugenio; Sergiacomi, Gian Luigi; Chiariello, Luigi
Background The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up. Methods In a propensity score matching analysis, out of 94 patients who underwent sternal reconstruction, 20 patients were selected: 10 patients underwent sternal reconstruction with bilateral pectoralis muscle flaps (group 1) and 10 underwent sternal rewiring (group 2). Eligibility criteria included the presence of hemisternum diastases associated with multiple (≥3) bone fractures and radiologic evidence of synchronous chest wall motion (CWSM). We compared radiologically assessed (volumetric computed tomography) ventilatory mechanic indices such as single lung and global vital capacity (VC), diaphragm excursion, synchronous and paradoxical chest wall motion. Results Follow-up was 100% complete (mean 85±24 months). CWPM was inversely correlated with single lung VC (Spearman R=−0.72, p=0.0003), global VC (R=−0.51, p=0.02) and diaphragm excursion (R=−0.80, p=0.0003), whereas it proved directly correlated with dyspnea grade (Spearman R=0.51, p=0.02) and pain (R=0.59, p=0.005). Mean CWPM and single lung VC were both better in group 1, whereas there was no difference in CWSM, diaphragm excursion and global VC. Conclusion Our study suggests that in patients with complex chronic sternal dehiscence, pectoralis muscle flap reconstruction guarantees lower CWPM and greater single-lung VC when compared with sternal rewiring and it is associated with better clinical outcomes with less pain and dyspnea. PMID:27733997
Spiegel, Aldona J; Eldor, Liron
In this study, partial breast reconstruction was undertaken after breast conservation therapy using mini abdominal free flaps on both an immediate and delayed basis.Patient demographics, oncologic status, reconstructive data, and complications were collected from medical records.Twelve patients (age range 39-60) were included in this study with a mean follow-up time of 5 years. Ten mini superficial inferior epigastric artery flaps and 2 mini deep inferior epigastric perforator flaps were used (7 immediate and 5 delayed reconstructions). No flap lost, 1 minor abdominal wound dehiscence, and no local or distant recurrences were noted. Good to excellent results were reported by 91% of the women.In properly selected patients with high motivation toward breast conservation, tailored abdominal mini-free flaps can safely and satisfactorily be implemented for the reconstruction of partial mastectomy defects. Patients should be comprehensively educated on the potential future implications of using the abdominal donor site for partial breast reconstruction.
Duflo, S; Lief, F; Paris, J; Giovanni, A; Thibeault, S; Zanaret, M
To report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure. During the period 1990-2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction. RFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3-18 months. Patients self assessed their quality of life on a scale of 0-2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet. RFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.
Hartman, Ed H M; Van Damme, Philip A; Sauter, Hartwig; Suominen, Sinikka H H
Three noma patients with large unilateral facial defects were reconstructed using the pedicled supraclavicular flap technique in the Noma Children Hospital in Sokoto, Nigeria. The results are-although not completely perfect-encouraging enough to report and to repeat the technique in future reconstructive noma surgery after moderate modifications. It is advised not to tunnel the pedicle in the neck, but instead to open the neck. Then, the flap can be inset in a Z-plasty fashion to close the neck without the chance of compression of the pedicle of the flap. In this way flap necrosis can be prevented, without the risk of a scar contracture of the neck. Another technique, which can prevent partial flap necrosis and loss of tissue, with the need for secondary stage interventions, is a delay procedure of the flap. Incorporation of the fascia in the pedicled supraclavicular flap can be another option to fulfil the abovementioned requirements.
G I Nambi
Full Text Available We present a case of composite oromandibular reconstruction with fibula free flap in which the vascularity to the flap was established in a retrograde direction through the distal end of the peroneal pedicle vessels. The flap was initially designed in such a way so as to anastomose with superior thyroid artery. However after initial good flow, the superior thyroid artery flow became insufficient. Therefore, an attempt was made to vascularise the flap by anastomosing the distal end of peroneal vessels with the facial artery and a tributary of the internal jugular vein so that the flap was perfused in a retrograde direction. This was successful and the retrograde flow was adequate to ensure flap survival. We believe this to be the first successful case of reverse vascular flow reported for composite oromandibular reconstruction with the fibula free flap.
HUANG Dong; WANG Hai-wen; WANG Hong-gang; WU Wei-zhi; ZHAO Cheng-yi
Background The perforator flap has become a very useful reconstructive means of soft tissue defect of extremities.The perforator flap from the inguinal region has advantages that include the ability to cover a large area with little donor site morbidity and provision of suitable thickness for reconstruction.Methods From July 1, 2005 to June 30, 2007, 10 patients with various types of soft tissue defect underwent reconstruction with 10 perforator flaps from the inguinal region. Six flaps were applied to the upper extremities and four flaps to the lower extremities. The dimensions of the transferred flaps ranged from 7-30 cm in length and 4-10 cm in width.Results The postoperative course of all 10 flaps was uneventful and all flaps survived. Distal small partial necrosis was observed in one case due to arterial insufficiency of the distal part of the flap. All patients were satisfied with the functional and esthetic resurfacing outcome.Conclusion Use of perforator flap from the inguinal region could overcome the disadvantages of the traditional free groin flap, and represents a safe and useful tool for coverage of soft tissue defects.
Yang, X; Li, S; Wu, K; Hu, L; Liu, W; Ji, T; Hu, Y; Xu, L; Sun, J; Zhang, Z; Zhang, C
The medical records of patients who had undergone a free flap reconstruction after radical resection of oral cancer between January 2009 and December 2013 at the study hospital in China were reviewed retrospectively. Of the 1550 patients who underwent free flap reconstructions, 71 were explored for suspected flap compromise caused by postoperative thrombosis. Patient demographic data, clinicopathological data of the tumour, details of the free flaps, and operative findings were assessed, and the medical records were analyzed to identify the reasons for intervention and the outcomes. Of the 71 flaps in crisis, 47 (66.2%) were salvaged. Free flap failure was 6.2-times more likely to develop in patients undergoing surgical exploration after 72 h (95% confidence interval 2.090-18.197, P=0.001). Of the 19 flaps identified as subject to delayed exploration, 14 failed and three had partial necrosis. Free flap failure was 3.4-times more likely to develop in patients with perforator flaps (95% confidence interval 1.222-9.719, P=0.019). The early detection of free flap failure is critical to flap salvage. The salvage success rate decreases significantly at >72 h after the initial operation. It appears to be more difficult to salvage a perforator flap.
Wu, Hao; Sheng, Jia-Gen
Background: Although there are many surgical treatments for covering the skin defect of the fore–mid foot, how to reconstruct the weight-bearing region remains a challenge. The weight-bearing region of the sole needs to withstand the pressure and shearing stresses of walking, so the plantar skin is anatomically different from other skins in the areas of texture, thickness, subcutaneous tissue, etc. Medial plantar flaps that are harvested from the instep region are regarded as the first choice for weight-bearing region reconstruction because of their excellent functional and aesthetic long-term result. However, when facing an extensive skin defect on a weight-bearing area such as a fore–mid foot avulsion, the application of this flap is limited because if we put the flap in a weight-bearing area of the forefoot, the set of vessels will be exposed to outside. Methods: We suggest 2 connected free flaps (posterior tibial artery flap and medial plantar flap) pedicled with 1 set of vessels. The medial plantar flap was used to cover the skin defect of the weight-bearing area in the forefoot. The dorsal skin defect of the injured foot was covered with a posterior tibial artery flap and supplied the medial plantar flap with the posterior tibial vessel. The midfoot skin defect was repaired by a full-skin grafting. Results: Long-term follow-up results showed that the shape and function of the injured limbs recovered almost entirely. Conclusion: This method of connected flaps is suitable for repairing large skin defects of the fore–mid foot. PMID:27975013
Full Text Available Background: 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. Materials and Methods: 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. Results: 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. Conclusion: Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects. Level of Evidence: Therapeutic IV.
Michiel A. J. van de Sande
Full Text Available The surgical repair of an extensive anterior glenohumeral soft tissue defect is complicated by glenohumeral instability and subsequent significant functional deficit. This surgical note offers a relatively simple reconstruction of the anterior capsule and subscapularis muscle using a pectoralis minor pedicle flap. This reconstruction is supplemented with functional reconstruction of the anterior glenohumeral joint. A conventional deltopectoral approach is utilized and pectoralis minor is freed from its coracoid insertion, released, and mobilized without compromising the pedicle entering from the dorsum and inferior one-third of the muscle. The mobilized pectoralis minor vascular pedicle has sufficient length for the pectoralis minor to be transferred to provide coverage of the anterior shoulder joint even in full external rotation, providing anterior stability. To further improve glenohumeral stability and shoulder function, the pectoralis major muscle can be split with the clavicular part reinserted lateral to the bicipital groove onto the lesser tuberosity replacing subscapularis function while stabilising the glenohumeral joint.
Gunnarsson, Gudjon Leifur; Tei, Troels; Thomsen, Jørn Bo
Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap reconstr......Knowledge about perforators and angiosomes has inspired new and innovative flap designs for reconstruction of defects throughout the body. The purpose of this article is to share our experience using color Doppler ultrasonography (CDU)-targeted perforator mapping and angiosome-based flap...
Ying, B; Ye, W; Li, Z
With the idea of "replacing lost tissure with similar tissure in kind", vessel-pedicled palate mucosal flap, pedicled buccal musculomucosal flap and adjacent tongue musculomucosal flap could be the ideal approaches to soft palate reconstruction. To assess the adjacent tongue musculomucosal flap for soft palate reconstruction. From August 2010 to July 2011, we applied tongue musculomucosal flap for soft palate reconstruction in three patients with Obstructive Sleep Apnoea/Hypopnoes Syndrome (OSAHS) in order to release OSAHS symptom by glossal volume reduction. All patients recovered from intraoral operations with good objective as subjective speech and swallowing. Suffice it to say that OSAHS symptom was released for these patients. Here we provide a case to deal with problems related to OSAHS symptom when one works on oral surgery or reconstructing oral structure.
Vermassen, F E; van Landuyt, K
Gangrenous lesions of the foot or lower leg due to severe diabetic arterial disease resulting in extensive soft tissue defects with exposed bones or tendons often result, even after successful revascularisation, in staged or primary amputation. We present our experience with 45 such patients treated with combined arterial reconstruction and free tissue transfer for limb-salvage. All presented with peripheral vascular disease of diabetic origin, and extensive gangrenous lesions that could not be treated by simple wound closure or skin-grafting without major amputation. A total of 53 arterial reconstructions and 47 free-flap transfers were performed. In the majority of patients, the distal anastomosis was on a pedal or tibial vessel. These bypass grafts or a native revascularized artery served as the inflow tract for the free flap which was anastomosed using microsurgical techniques. Venous anastomoses were preferentially performed on the deep venous system. Donor muscles were Musculus rectus abdominis (n=37), Musculus latissimus dorsi (n=5), Musculus serratus anterior (n=3), and a perforator flap (n=2) tailored to the size of the defect and covered with a split thickness graft (STG). The operation was set up as a combined procedure in 39/45 patients, two teams working simultaneously, limiting the mean operative time to 6 h. Early reinterventions had to be performed in 14 patients resulting in five flap losses of which two could be treated with a new free flap transfer and three were amputated. Three other patients died in the postoperative period, leaving us with a total of 39/45 patients leaving the hospital with a full-length limb. Independent ambulation was achieved in 32 of these 39 patients. During late follow-up (mean 26 months) eight bypasses occluded resulting in two amputations and two new vascular reconstructions. Combined survival and limb-salvage rate was 84% after 1 year, 77% after 2 years and 65% after 3 years. The advantages of this combined technique
Las, David E; de Jong, Tim; Zuidam, J Michiel; Verweij, Norbert M; Hovius, Steven E R; Mureau, Marc A M
Reconstructive microsurgery is a powerful method of treating various complex defects. However, flap loss remains a possibility, leading to additional surgery, hospitalisation and costs. Consequently, it is important to know which factors lead to an increased risk of flap failure, so that measures can be undertaken to reduce this risk. Therefore, we analysed our results over a 20-year period to identify risk factors for flap failure after breast, head and neck and extremity reconstruction. The medical files of all patients treated between 1992 and 2012 were reviewed. Patient characteristics, surgical data and post-operative complications were scored, and independent risk factors for flap loss were identified. Reconstruction with a total of 1530 free flaps was performed in 1247 patients. Partial and total flap loss occurred in 5.5% and 4.4% of all free flaps, respectively. In all flaps, signs of compromised flap circulation were a risk factor for flap failure. More specifically, the risk factors for flap failure in breast reconstruction were previous radiotherapy, venous anastomosis revision, gluteal artery perforator (GAP) flap choice and post-operative bleeding. In head and neck reconstruction, pulmonary co-morbidity and anastomosis to the lingual vein or superficial temporal artery were risk factors, whereas a radial forearm flap reduced the risk. In extremity reconstruction, diabetes, prolonged anaesthesia time and post-operative wound infection were risk factors. Independent pre-, intra- and post-operative risk factors for flap failure after microvascular breast, head and neck and extremity reconstruction were identified. These results may be used to improve patient counselling and to adjust treatment algorithms to further reduce the chance of flap failure.
Kalfarentzos, Evagelos; Ma, Chunyue; Tian, Zhuowei; Zhu, Hanguang; He, Yue
The purposes of this study were to evaluate the clinical application and efficacy of the dorsalis pedis fasciocutaneous flap in the reconstruction of oral cavity defects and to assess the associated donor-site morbidity. From September 2009 to December 2012, 7 patients with associated oral cavity defects resulting from tumor resection underwent reconstruction with a dorsalis pedis fasciocutaneous flap. Surgical anatomy and harvesting procedure of the dorsalis pedis flap are described. Special consideration was given to the associated donor-site morbidity. All flaps survived without any complications. All 7 flaps were based on the dorsalis pedis artery and the greater saphenous vein for perfusion and drainage respectively. In all 7 cases, the donor site was closed with a full-thickness skin graft, with no associated healing complications or functional deficit of the foot. The resulting scar was well hidden in the lower extremity. The dorsalis pedis fasciocutaneous flap is a thin and pliable flap sharing many similarities with the radial forearm flap, thus making it ideal for intraoral reconstruction. Proper intraoperative and postoperative care of the donor site can result in minimal morbidity, as shown in this study. This flap may provide an ideal alternative to the radial forearm free flap, with the added advantages of a well-hidden scar and a high level of patient satisfaction. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Dornseifer, Ulf; Kleeberger, Charlotte; Ehrl, Denis; Herter, Frank; Ninkovic, Milomir; Iesalnieks, Igors
Background Sternal defects following deep wound infections are predominantly reconstructed using local and regional flaps. The lack of appropriate recipient vessels after cardiac surgery may explain the minor role of free flaps. To date, arteriovenous loops have been the leading solution to enable microsurgical closure of these defects. However, the related surgical effort and the risk of flap failure are increased. We reviewed our experiences with the right gastroepiploic vessels as alternative recipient vessels for free flap reconstructions. Methods Between September 2010 and July 2015, 12 patients suffering deep wound infection after cardiac surgery underwent sternal reconstruction with free flaps anastomosed to the right gastroepiploic vessels. Gracilis flaps (n = 8) and anterolateral thigh perforator flaps (n = 4) were used for sternal reconstruction. Recipient vessels were harvested by laparoscopic dissection in five patients. Half of the free flaps were variably combined with omental flow-through flaps. Results Healing of all flaps was uneventful with no partial or total flap loss. Simultaneous interdisciplinary harvesting of recipient vessels by laparoscopy significantly shortened mean operative time from 313 to 216 minutes (p = 0.018). One incisional hernia was observed in the laparotomy group. Revision of a gracilis donor site was necessary in another patient due to postoperative bleeding. No recurrent sternal infection occurred during a mean follow-up of 20 months (range, 3-59 months). Conclusions The concept of gastroepiploic recipient vessels allows reliable free flap reconstructions of sternal defects in such high-risk patients without the need for arteriovenous loops.
Ji Hong Yim
Full Text Available BackgroundMicrovascular complications after free-flap breast reconstructions are potentially devastating problems that can increase patient morbidity and lead to flap loss. To date, no comprehensive study has examined the rates of salvage and the methods of microvascular revision in breast reconstruction. We reviewed the treatment of microvascular complications of free-flap breast reconstruction procedures over a seven-year period.MethodsA retrospective review of all patients who underwent microvascular breast reconstruction at our institution between April 2006 and December 2013 was conducted. Based on their surgical records, all patients who required emergency re-exploration were identified, the rate of flap salvage was determined, the factors associated with flap salvage were evaluated, and the causes and methods of revision were reviewed.ResultsDuring the review period, 605 breast reconstruction procedures with a free lower abdominal flap were performed. Seventeen of these flaps were compromised by microvascular complications, and three flaps were lost. The overall salvage rate was 82.35%. No significant differences between the salvaged group and the failed group were observed with regard to age, BMI, axillary dissection, number of anastomotic arteries and veins, recipient vessel types, or use of the superficial inferior epigastric vein in the revision operation. Successful salvage of the flap was associated with a shorter time period between recognizing the signs of flap compromise and the take-back operation.ConclusionsThe salvage rate of compromised lower abdominal flaps was high enough to warrant attempting re-exploration. Immediate intervention after the onset of flap compromise signs is as important as vigilant postoperative monitoring.
Full Text Available BackgroundPostmastectomy adjuvant therapy is used to prevent locoregional recurrence and improve overall breast cancer specific survival rates. However, it can adversely affect the cosmetic results of reconstruction. Therefore, the authors examined flap stability and patients' satisfaction with immediate breast reconstruction after adjuvant therapy.MethodsWe retrospectively reviewed the medical records of 204 patients from January 2006 to November 2011. For complication rates, the authors categorized the patients who underwent the immediate breast reconstruction into 4 groups: adjuvant chemotherapy and radiotherapy group, adjuvant chemotherapy only group, adjuvant radiotherapy only group, and the group that did not undergo adjuvant therapy. For comparison of patients' satisfaction, the study was performed with an additional 16 patients who had undergone delayed breast reconstruction.ResultsRegarding complication rates, the group that had undergone adjuvant therapy showed no significant difference compared to the group that did not undergo adjuvant therapy. In evaluating the patients' satisfaction, there was no significant difference.ConclusionsEven after adjuvant therapy, immediate breast reconstruction showed good results with respect to flap stability and patients' satisfaction. Immediate breast reconstruction and adjuvant therapy is a safe and useful option for breast cancer patients.
Zhang, Bin; Li, Ke-Yi; Jiang, Li-Cheng; Meng, Zhen; Wang, Xiu-Mei; Cui, Fu-Zhai; Zhu, Ying-Nan; Wu, Ya-Ping
The purpose of this study was to present the outcome and discuss the feasibility of rib composite flap with intercostal nerve and internal thoracic vessels for reconstructing mandibular defect. Rib composite flaps have been used in 82 patients for reconstructing benign tumor-caused large mandibular defects: 66 of the 82 patients were reconstructed using rib composite flap with intercostal nerve and internal thoracic vessels, whereas the other 16 patients were reconstructed using rib composite flap with internal thoracic vessels, without intercostal nerve. After operation, clinical observation, imageological examination, and sensory detection were used to evaluate the effect of reconstruction. All rib composite flaps with intercostal nerve and internal thoracic vessels were successfully harvested and transplanted. Both immediate and long-term examination showed good appearance reconstruction. All followed-up patients conveyed good satisfaction degree with function and appearance reconstruction. Postoperative panoramic x-ray examination showed new bone formation between the transplanted rib and mandibular stump. Good recoveries of mandibular nerve sensory were observed when followed up after reconstruction surgery. Rib composite flap with intercostal nerve and internal thoracic vessels could be a promising method for reconstruction of mandibular defects.
Figus, Andrea; Canu, Vanessa; Iwuagwu, Fortune C; Ramakrishnan, Venkat
Recent advances in breast reconstruction allow for high expectations regarding long-term symmetry and aesthetic appearance. The DIEP flap is currently considered as an ideal autologous reconstruction. However, there are situations in which the amount of tissue from a DIEP flap is not enough to achieve adequate symmetry. Indications and outcomes for a combined use of DIEP flap and implants are discussed in order to describe and examine a further scenario in optimising breast reconstruction. Between January 2004 and January 2006, all patients who underwent combined DIEP/implant breast reconstruction have been collected and followed prospectively. When clinical assessment demonstrated inadequate amount of tissue in the abdominal region to achieve a suitable unilateral or bilateral reconstruction with DIEP flaps, the patients were counselled about the opportunity of primary augmentation of the DIEP flaps. In cases where DIEP breast reconstruction has been done previously and there is a considerable asymmetry, delayed flap augmentation was considered. Patient's age, indication for surgery, preoperative and postoperative radiotherapy (RT), operative procedure, implant size, location and timing of insertion, complications, outcomes, and follow-up have been gathered. In all cases, textured round silicone gel implants have been used. After 12 months, four-point scales were used to analyse patients' satisfaction and aesthetic outcome. During the study period, 156 patients underwent breast reconstruction with 174 DIEP flaps. Fourteen patients (8.9%) had breast reconstruction with 19 DIEP flaps and 18 implants. The mean follow-up was 20.6 months (range 12-32 months). Fourteen implants were placed primarily at the time of DIEP reconstruction. The average implant weight was 167.2g with range between 100 and 230 g. Implant/flap weight ratio is about 1:5 corresponding to 20%. In six flaps, the patients had RT before the reconstruction, whilst in three cases of delayed DIEP flap
Raab, Edward L; Ackert, Jessica M; Ostrovsky, Ann
Most published cases of rectus muscle flap tear have been associated with orbital trauma of various degrees of severity. When they accompany an orbital fracture, however, it is difficult to determine whether the flap tear is merely an incidental additional finding or a major contributing cause of the resulting restriction. How to treat the flap itself remains an open question. We report a 24-year-old man with an inferior rectus muscle flap tear caused by direct laceration of the muscle. The major finding was a "reverse leash" vertical restriction. Discarding the flap instead of reattaching it did not prevent a successful result. Our case supports the proposition that rectus muscle flap tear can be a restriction-producing entity. Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.
Elo, Jeffrey A; Tandon, Rahul; Allen, Chad N; Murray, Matthew D
Ameloblastoma is one of the most common odontogenic tumors encountered, occurring more frequently than all other tumors combined, if one excludes the keratocystic odontogenic tumor. These tumors can cause severe expansion of the cortical bones and gross anatomic deformities. They can affect the dentition, causing tooth mobility and displacement. Fortunately, morbidity can be minimized with recognition on routine radiographic examination. The tissue may be unilocular or multilocular and has been described as having a "soap-bubble" appearance. Nevertheless, its radiographic appearance is insufficient to make a definitive diagnosis, because other tumors have similar appearance. Although the anatomic distribution and progression of ameloblastoma remain fairly consistent, alternative manifestations follow an atypical clinical course. One such variant is the desmoplastic ameloblastoma. We present a case of maxillary desmoplastic ameloblastoma treated with hemimaxillectomy and immediate reconstruction with temporalis flap that was recurrence-free at 36 months. Copyright © 2014 Elsevier Inc. All rights reserved.
Li, C; Cai, Y C; Wang, W; He, Y X; Lan, X J; Li, Q L; Zhou, Y Q; Liu, J F; Zhu, G Q; Liu, K; Wang, S X; Wang, K; Fan, J C; Sun, R H
Application of free flap is one of the important repair means in head and neck surgery. A variety of free flaps, such as anterolateral thigh flap, have showed unique advantages in repair for tissue defects after resection of head and neck tumor, and have became increasing popularity. Lateral arm flee flap is an important repair means in plastic surgery, which has developed more than 30 years, but the application of this flap for reconstruction in head and neck surgery is relatively backward, with few reports. This review focuses on the creativity and innovation, the relationship between anatomy and clinical application, and the application status and prospects for lateral arm flee flap in individual head and neck reconstruction surgery.
Brandtner, Christian; Hachleitner, Johannes; Bottini, Gian Battista; Buerger, Heinz; Gaggl, Alexander
We have assessed the role of the medial femoral condylar flap in 107 patients who had reconstructions of the head and neck. We retrospectively reviewed their medical records for indications, complications, and outcomes. The flap was primarily used for coverage of alveolar ridge defects (n=67), secondly for defects of the facial bone, calvaria, or skull base (n=35), and thirdly for partial laryngeal defects (n=5). Two flaps were lost. One patient fractured a femur 5 weeks postoperatively. The duration of follow up ranged from 6 months to 12 years. The medial femoral condylar flap is well-suited to individual reconstructions of the alveolar ridge, midface, calvaria, skull base, and part of the larynx with poor recipient sites. The flap does not replace other wellknown flaps, but offers new solutions for solving special problems in head and neck surgery.
Full Text Available Introduction: Reconstruction of intraoral soft tissue defects is important in restoring function and esthetic. In large defects, there will be demand for regional pedicle flaps or free flaps. Hard palate separates nasal and oral cavities. Due to the small surface area between flap and remaining palate after surgical resections, optimal blood supply of the flaps for hard palate reconstructions are needed. This article demonstrates immediate reconstruction of two edentulous hemimaxillectomy patients with submental artery Island flap and brief review of this flap discussed.
Full Text Available Background Perforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP flap survival and flap-related complications. Methods A retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4 and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI categorization. Results Three hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009. The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (40=42.9%, P<0.001 in the DIEP flaps, but no increase in fat necrosis. Conclusions This study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.
BACKGROUND: The facial artery myomucosal (FAMM) island flap is a cheek flap, pedicled on the facial artery and suitable for small to medium-sized reconstructions of the oral cavity and neighboring areas. A novel transposition of the flap to the hypopharynx after laryngectomy is presented...... donor-site morbidity, and recipient tissue similarity count among the advantages. © 2016 Wiley Periodicals, Inc. Head Neck 39: E29-E33, 2017....
Full Text Available Background Postmastectomy adjuvant therapy is used to prevent locoregional recurrenceand improve overall breast cancer specific survival rates. However, it can adversely affectthe cosmetic results of reconstruction. Therefore, the authors examined flap stability andpatients’ satisfaction with immediate breast reconstruction after adjuvant therapy.Methods We retrospectively reviewed the medical records of 204 patients from January2006 to November 2011. For complication rates, the authors categorized the patients whounderwent the immediate breast reconstruction into 4 groups: adjuvant chemotherapyand radiotherapy group, adjuvant chemotherapy only group, adjuvant radiotherapy onlygroup, and the group that did not undergo adjuvant therapy. For comparison of patients’satisfaction, the study was performed with an additional 16 patients who had undergonedelayed breast reconstruction.Results Regarding complication rates, the group that had undergone adjuvant therapyshowed no significant difference compared to the group that did not undergo adjuvanttherapy. In evaluating the patients’ satisfaction, there was no significant difference.Conclusions Even after adjuvant therapy, immediate breast reconstruction showed goodresults with respect to flap stability and patients’ satisfaction. Immediate breast reconstructionand adjuvant therapy is a safe and useful option for breast cancer patients.
Full Text Available Background: Despite advances in reconstruction techniques, sacral sores continue to present a challenge to the plastic surgeon. The superior gluteal artery perforator (SGAP 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. However, the dissection of the perforator is tedious and carries a risk of compromising the perforator vessels. Patients and Methods: During the period between April 2003 and March 2013, 30 patients presented to our section with sacral wounds causing by pressure sores or infected pilonidal cysts. Of a total of 30 patients, 13 were female and 17 were male. Their ages ranged from 22 to 92 years old (mean 79.8 years old. Surgical intervention was performed electively with immediate or delayed reconstruction using a SGAP flap. The characteristics of patients′ age, and sex, and cause of sacral defect, co-morbidities, wound culture, flap size, perforator number, hospital stay, and outcome were reviewed. Results: For all operations, the length of the pedicle dissection will not exceed 1 cm because of the vascular anatomy of the SGAP, which lies adjacent to the sacral region. Due to short pedicle dissection, all SGAP flap were elevated around an hour. All flaps survived except two, which had partial flap necrosis and were finally treated by contralateral V-Y advancement flaps coverage. The mean follow-up period was 14.8 months (range 3-24. No flap surgery-related mortality was found. Conclusion: Perforator-based flaps have become popular in modern reconstructive surgery because of low donor site morbidity and good preservation of muscle. Our study shows that deep pedicle dissection is unnecessary when the surgery involves an accurate indicating perforator, adequate flap size design, and correct selection of flap utilization between tunnel and rotation. The
Pauchot, J; Feuvrier, D; Pluvy, I; Floret, F; Mauvais, O
Reconstruction of the soft palate after oncologic resection remains a surgical challenge. Speech and swallowing problems are the consequences of velopharyngeal incompetence following soft palate resection. Free tissue transfer like radial forearm flaps can be used in larger defects for complex reconstruction. The conformation of the flap in order to be closer to the shape of the soft palate improves the functional outcome. In the same way, we describe an original "double-arched" flap design. A double arch of the exact length of the soft palate tumor resection is designed. After suturing, the flap spontaneously formed a double arch of the exact dimensions of the resected piece. The patient achieved good functional recovery without any surgical complications. The original "double-arched" forearm flap design allows a tailored reconstruction with exactly the same shape and dimensions, preserving the functional requirements of speech and deglutition. Copyright Â© 2016 Elsevier Masson SAS. All rights reserved.
Full Text Available The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge for reconstructive surgeries. Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14-23 cm and the mean width was 4.9 (range: 2.5-7 cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck.
Oh, S J; Koh, S H; Chung, C H
Degloved mutilated hand injury results in severe contracture of palmar surfaces after avulsion defects of soft tissue and insensate scarring of amputated digits at the proximal interphalangeal level. In an effort to restore the basic function of such hands, we simultaneously used a sensate in-step free flap for re-surfacing the first web space and sensate twin digital free flaps for re-surfacing the palmar defects of the thumb and index finger. Three male patients sustained degloved mutilated hand injury from a machine in a factory. The average age of the patients was 26 years. These injuries were reconstructed by concomitant twin digital neurovascularised free flaps harvested on the contralateral hands and the in-step neurovascularised free flaps harvested on the feet. The lateral plantar vascular pedicle of the in-step flaps was anastomosed to the vascular pedicle of the twin digital flaps by a flow-through fashion. All flaps survived. These flaps provided durable sensate coverage and improved pinch and grasp. The morbidity of donor fingers and feet was minimal. These described flaps supply durable glabrous sensate skin of prehensile function in degloved mutilated hands. Our method is useful in the reconstruction of degloved mutilated hands with amputated stumps of the thumb and counter digit more than 3 cm in length required for pinch and grip. Copyright © 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Chih-Hsun, Lin; Ma, Hsu
A perforator-based fasciocutaneous flap is an alternative type of flap for pressure sore reconstruction. The aim of the present study was to determine whether a single-perforator-based flap or a multiple-perforator-based flap is better for pressure sore reconstruction. We reviewed the general data and postoperative complications in patients who received single-perforator-based or multiple-perforator-based fasciocutaneous flaps for pressure sore reconstruction between July 2009 and July 2012. No differences in general data, comorbidities, wound locations, flap sizes (73.9 vs. 67.0 cm(2), P = 0.455), and operative times were noted between the single-perforator-based and multiple-perforator-based flap groups. The flap rotation arc was larger in the single-perforator-based flap group than in the multiple-perforator-based flap group; however, the difference in the rotation arc was not significant (99.2° vs. 55.5°, respectively; P = 0.199). Two patients had total flap necrosis and one had partial flap necrosis in the single-perforator-based flap group. None of flap necrosis was noted in the multiple-perforator-based flap group; however, no significant differences in major complications were noted between the two groups. All donor sites underwent primary closure. This is the first clinical patient-matched research that considered the number of perforators and the rotation arc in applying perforator-based fasciocutaneous flaps in wound reconstruction. The results showed that the number of perforators is not the determinant factor of surgical outcome of the use of perforator-based fasciocutaneous flaps in pressure sore reconstruction. Thus, whether a single- or a multiple-perforator-based fasciocutaneous flap is used for flap perfusion does not jeopardize the operation. These results emphasize the reliability and convenience of using freestyle design of perforator-based flaps for pressure sore reconstruction. The design and clinical utility of the flaps have the
Shinji Matsuo, MD
Conclusions: The procedure for raising an extended hair-bearing lateral orbital flap is relatively easy, although attention must be paid to the temporal facial nerve. This flap is useful for simultaneously reconstructing defects of the upper eyelid and lateral eyebrow.
Fujiwara, Toshihiro; Kawai, Kenichiro; Nishimoto, Soh; Kakibuchi, Masao
Summary: Recent reports have shown successful transfer of vascularized fibular flap in bisphosphonate-induced mandibular osteonecrosis. We present a case of a 50-year-old patient who presented with bisphosphonate-related osteonecrosis of bilateral maxilla, which is reconstructed using a fibular flap.
This study sought to determine the efficacy of interpositional arthroplasty with temporalis muscle and fascia flap in the treatment of unilateral temporomandibular joint (TMJ) ankylosis in adults. This retrospective study of seven cases evaluated the postoperative results of interpositional arthroplasty on temporalis muscle and fascia flap in adults. The operative protocol for unilateral TMJ ankylosis entailed, (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy, (3) contralateral coronoidectomy when necessary, (4) interpositional tissue transfer to the TMJ with temporalis muscle and fascia flap, (5) maxillomandibular fixation (MMF), and (6) early mobilization and aggressive physiotherapy. The results of this protocol were encouraging, while the functional results of interpositional arthroplasty on temporalis muscle and fascia flap were satisfactory. The findings of this study support the use of temporalis muscle and fascia flap in adult patients with unilateral TMJ ankylosis. Early postoperative initial exercise, physiotherapy, and strict follow-up play an important role in preventing postoperative adhesions.
Shan, Xiao-Feng; Li, Ru-Huang; Lu, Xu-Guang; Cai, Zhi-Gang; Zhang, Jie; Zhang, Jian-Guo
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.
Jeng, Seng-Feng; Kuo, Yur-Ren; Wei, Fu-Chan; Su, Chih-Ying; Chien, Chih-Yen
Large, full-thickness lip defects after head and neck surgery continue to be a challenge for reconstructive surgeons. The reconstructive aims are to restore the oral lining, the external cheek, oral competence, and function (i.e., articulation, speech, and mastication). The authors' refinement of the composite radial forearm-palmaris longus free flap technique meets these criteria and allows a functional reconstruction of extensive lip and cheek defects in one stage. A composite radial forearm flap including the palmaris longus tendon was designed. The skin flap for the reconstruction of the intraoral lining and the skin defect was folded over the palmaris longus tendon. Both ends of the vascularized tendon were laid through the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of the upper lip. This procedure was used in 12 patients. Six patients had cancer of the lower lip, five patients had a buccal cancer involving the lip, and one patient had a primary gum cancer that extended to the lower lip. Total to near-total resection (more than 80 percent) of the lower lip was indicated in six patients. In two other patients, the cancer ablation included more than 80 percent of the lower lip and up to 40 percent of the upper lip. A radial forearm palmaris longus free flap was used in all cases for reconstruction of the defect. Free flap survival was 100 percent. At the time of final evaluation, which was 1 year after the operation, all patients had good oral continence at rest (static suspension) and had achieved sufficient oral competence when eating. Ten patients were able to resume a regular diet, and two patients could eat a soft diet. All patients regained normal or near-normal speech and had an acceptable appearance. The described refinement of the composite radial palmaris longus free flap technique allows the reconstruction of the lower lip with a functioning oral sphincter; the technique can be recommended for patients who
Soo Kwang Yoon
Full Text Available Background Recent literature has indicated that free flaps are currently considered thepreferred choice for head and neck reconstruction. However, head and neck cancer patients arefrequently treated with chemoradiotherapy, which is often associated with a poor general andlocal condition, and thus, such patients are ineligible for free flap reconstruction. Therefore,other reconstruction modalities should be considered.Methods We used lower trapezius musculocutaneous (LTMC flap based on the dorsal scapularartery to reconstruct head and neck defects that arose from head and neck cancer in 8 patients.All of the patients had undergone preoperative chemoradiotherapy.Results There were no complications except one case of partial flap necrosis; it was treatedwith secondary intention. Healing in the remaining patients was uneventful without hematoma,seroma, or infection. The donor sites were closed primarily.Conclusions The LTMC flap is the preferred flap for a simple, reliable, large flap with a widearc of rotation and minor donor-site morbidity. The authors recommend this versatile islandflap as an alternative to microvascular free tissue transfer for the reconstruction of defects inthe head and neck region, for patients that have undergone preoperative chemoradiotherapy.
Jyoshid R Balan
Full Text Available Background: Fingertip injury requiring flap cover is very common in the modern era. The ideal cover should fulfill both functional and aesthetic improvement. Materials and Methods: From June 2015 to April 2016, we performed seven free toe pulp flaps for finger defect reconstruction. All patients were males. Five flaps were done in emergency post-traumatic cases, and two were done in elective set up. The cases included reconstruction of three thumbs, one index and one ring finger in an emergency set up and two ring fingers in the elective. Thumb reconstruction was done with great toe lateral pulp and the other digits reconstructed with second toe pulp flap. Follow-up evaluation included both functional and aesthetic assessment. Results: Five flaps survived completely, one suffered partial loss, and one flap failed completely. The median follow-up period was 9 months. The median duration of surgery was 255 min (range 210 to 300 min. The median two-point discrimination was 6.5 mm (range 4–8 mm. There was the return of temperature sensation in all patients; two had cold intolerance. The Semmes-Weinstein monofilament score varied from 3.61 to 5.07 (median filament index value 4.31/pressure value of 2 g/mm2. Three patients had delayed donor site wound healing. Conclusions: The free toe pulp flap is an efficient choice for fingertip and volar finger defects reconstruction with an excellent tissue match.
Objective: To explore new surgical procedure for repairing and reconstructing medial malleolus and soft tissue defect.Methods: According to the size of medial malleolus and composite soft tissue defect, vascular fibular head composite tendon bone flap free grafting using anterior tibial recurrent vessel as the perforating branch was designed to reconstruct the medial malleolar saddle and triangular ligament, and composite back broadest muscle flap free grafting was designed to repair the medical malleolar wound surface. From January 2000 to December 2006, the technique was used in 5 male patients who were injured by machine or in traffic accidents, causing bone and soft tissue defect. The size of wound surface ranged from 19 cm×12 cm to 24 cm×12 cm.Results: The wound surface was healed at the first stage in 4 cases, and the other case had infection and was cured in 6 months with anti infection therapy. Postoperative follow-ups from 6 months to 6 years showed that grafted bones and free cutaneous flaps were healed well, malleolar joints were stable, joint movement was normal, and the appearance was satisfactory. The overall outcome was good.Conclusion: Fibular head composite tendon bone flap free grafting is effective for repairing medical malleolar defect.
Background. With greater experience in microsurgical reconstruction, free tissue transfer has become common and reliable. However, total flap necrosis after microsurgical reconstruction is sometimes seen in patients who have undergone radical ablation of head and neck malignancies. We investigated factors predicting free flap loss in head and neck reconstruction. Methods. We reviewed the records of 111 free flap reconstructions carried out among 107 patients with head and neck cancer who requ...
Full Text Available The aim of the study was clinical evaluation of the results following reconstruction with the Indian flap in patients with partial nasal defects, and estimation of their postoperative life quality in functional and aesthetic aspects.
Ko, Alvin B; Lavertu, Pierre; Rezaee, Rod P
We describe what is, to the best of our knowledge, the first use of a double bilobed radial forearm free flap in reconstructive surgery of the tongue and floor of the mouth following bilateral tumor resection...
Al Qattan, M M; Boyd, J B
The use of a "mini" skin paddle to monitor the fibular free flap for mandibular reconstruction is described. The paddle is easy to inset, can be excised later under local anesthesia, and yet is adequate for postoperative monitoring.
Longo, Benedetto; Laporta, Rosaria; Pagnoni, Marco; Campanale, Antonella; Grippaudo, Francesca Romana; Santanelli Di Pompeo, Fabio
Reconstruction of large defects of the lateral region of the face is rather challenging due to the unique color, texture, and thickness of soft tissues in this area. Microsurgical free flaps represent the gold standard, providing superior functional and aesthetic restoration. Purpose of this study was to assess reliability of skin-grafted latissimus dorsi (LD) flap, for a pleasant and symmetric reconstruction of the lateral aesthetic units of the face compared to a control group of patients addressed to perforator flaps. From November 2008 to June 2012, 5 patients underwent skin-grafted LD flap reconstruction of defects involving the lateral aesthetic units of the face, with 8.1 ± 0.5 × 9.7 ± 1.3 cm mean size. A 1-to-4 Likert scale was used to assess skin color, texture, shape, and bulkiness. Using the Pressure-Specified Sensory Device epicritic, proprioceptive, and protopathic sensitivities were tested. Outcomes were compared with those of a control group of 5 patients addressed to reconstruction with perforator flaps (3 anterolateral thigh flap, 2 vertical deep inferior perforator flap). At mean 21-month follow-up all flaps healed uneventfully without need for revisions, all developing more satisfactory results in terms of skin color (P = 0.028) and texture (P = 0.021) match, shape (P = 0.047) and bulkiness (P = 0.012) compared with perforator flaps. No differences in epicritic, proprioceptive, and protopathic sensitivities were observed (P > 0.05) between the two groups. Skin-grafted LD flap may be a suitable option for reconstruction of wide defects of the lateral aesthetic units of the face.
张树标; 潘广嗣; 刘江峰; 易晓辉
Objective In search of a way of simple and less hurting immediate reconstruction of tougue . Methods The levator scapula flap and the medial scalene flap were applied in 13 cases with cancer of tougue after neck dissection for the immediate reconstruction of ora bottom and tongue muscle defect , Then the buccinator musculomucosal flap was applied for the immediate reconstruction of ora- bottom and tongue mucous membrane defect . Results There were not flap necrosis and ora- bottom fistala in all cases. The swallowing and speech rehabilitations following surgical treatment for tongue cancer were acceptable. Conclusions This surgical procedure of reconstruction of tongue and ora- bottom is successful and simple, easy to perform.
Hugo St. Hilaire, MD, DDS
Full Text Available Summary: Craniofacial reconstruction remains the main application for virtual surgical planning (VSP. We present a case in which this technology was applied to reconstruct a bony defect of the first metatarsal bone from a gunshot injury. VSP was used to facilitate a 1-stage reconstruction with a fibular osteocutaneous flap. A template of the reconstructed bone was designed based on the virtual mirror-image, noninjured bone. Prefabricated cutting guides facilitated precise shaping of the vascularized bone accounting for location of perforators. Successful reconstruction of the metatarsal bone was achieved with excellent functional outcomes. We believe that VSP can be a valuable tool in reconstruction of metatarsal bones by facilitating precise intraoperative shaping and anatomic orientation of the vascularized flap and reducing flap ischemia and operative time.
Zhao, Yang; Xiang, Jing-Zhou; Liu, Fa-Yu
The aim of this study was to evaluate operation-related factors and quality of life (QOL) for patients after tongue reconstruction with radial forearm free flap (RFFF), anterolateral thigh perforator flap (ALT) or submental island flap (SIF). Totally 59 patients, diagnosed as tongue carcinoma, received glossectomy and simultaneous reconstruction with free flaps including RFFF, ALT or SIF in the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, China Medical University from October 2004 to October 2014. All patients were followed up for 6 months and completed the University of Washington Quality of Life scale Version 4 questionnaires. The postoperative QOL was compared among the three groups. The data were analyzed using SPSS 21.0 software package. The operation duration of SIF group was significantly shorter than those of RFFF group or ALT group (Pspeech and postoperative pain among the 3 groups. In summary, there may be functional disability for patients after glossectomy and simultaneous reconstruction. The quality of life would be acceptable after tongue reconstruction with RFFF, ALT and SIF.
Kim, N K; Nam, W; Kim, H J
Miniplates and reconstruction plates are usually used to fix a fibular free flap, the gold standard in reconstruction of large segmental mandibular defects. Though biodegradable plates are used in orthognathic operations and repair of fractures nowadays, we know of no studies of the use of biodegradable plates in the reconstruction of segmental mandibular defects including a fibular free flap. We retrospectively reviewed 47 patients who had reconstruction of segmental mandibular defects with fibular free flaps during the past 10 years, and recorded clinical data and morbidity. We compared patients who had reconstruction of such defects with fibular free flaps and miniplates (n=26) with those in whom biodegradable plates had been used (n=21). There was no significant difference between miniplates and biodegradable plates with regard to overall complications (p=0.45) and failure of flaps (p=0.59). After confounding factors had been adjusted for with Cox's proportional hazards regression, there was no significant difference in the proportion of patients who developed a complication between the two groups (p=0.4). The type of plate does not seem to affect overall morbidity in reconstruction of the mandible with a fibular free flap.
Koichi Tomita, MD, PhD
Full Text Available Summary: Recent advances in 3-dimensional (3D surface imaging technologies allow for digital quantification of complex breast tissue. We performed 11 unilateral breast reconstructions with deep inferior epigastric artery perforator (DIEP flaps (5 immediate, 6 delayed using 3D surface imaging for easier surgery planning and 3D-printed molds for shaping the breast neoparenchyma. A single- or double-pedicle flap was preoperatively planned according to the estimated tissue volume required and estimated total flap volume. The DIEP flap was then intraoperatively shaped with a 3D-printed mold that was based on a horizontally inverted shape of the contralateral breast. Cosmetic outcomes were assessed as satisfactory, as confirmed by the postoperative 3D measurements of bilateral breasts. We believe that DIEP flap reconstruction assisted with 3D surface imaging and a 3D-printed mold is a simple and quick method for rebuilding a symmetric breast.
Full Text Available PURPOSE: To review the role of Mustarde’s flap for post basal cell carcinoma excision lower eyelid reconstruction , its clinical outcomes and complications. METHODS: The Mustarde’s rotational cheek flap has been used to reconstruct the lower eyelids of 16 patients from 2008 to 2015 in proven cases of bcc. RESULT S: Mustarde’s flaps have very high functionally as well as cosmetic acceptability with minimum patient morbidity. The most frequent complications were downward contraction and sagging of the flap and ectropion of the lid margin. To prevent them, the zygomatico - cheek flap must be carefully designed, rotated, and sutured as high as possible so that immediately postoperatively, t he palpebral fissure is only a narrow slit.
Khansa, Ibrahim; Colakoglu, Salih; Tomich, David C; Nguyen, Minh-Doan; Lee, Bernard T
Two cases are reported of flap loss following microsurgical perforator flap breast reconstruction in patients diagnosed with a factor V Leiden mutation. Factor V Leiden is the most common inherited cause of hypercoagulability, leading to an increased risk of thrombotic events. The first patient underwent a deep inferior epigastric artery perforator flap and then had recurrent arterial thrombosis both intraoperatively and postoperatively. This patient was subsequently diagnosed with a factor V Leiden mutation. The second patient had a known factor V Leiden mutation and underwent a superior gluteal artery perforator flap, which developed thrombosis and flap loss 2 days later. Preoperative assessment of a personal or family history of unexplained venous or arterial thrombosis should prompt suspicion of a factor V Leiden mutation. This mutation places patients at high risk for thromboembolic events in microvascular breast reconstruction, particularly when oral contraceptives or tamoxifen are used in conjunction. Copyright © 2011 Wiley-Liss, Inc.
Wei Wei Liu, MD
Full Text Available Summary: Wide-apart double defect in head and neck region is rare and difficult to reconstruct at one time. Double free flaps are normally used for this scenario and often tedious and technically complicated. This study presented a technique using branch-based anterolateral thigh free flap to simultaneously reconstruct the 2 defects separated wide apart. The concept, indications, surgical technique, and anatomical variations are discussed. Branch-based anterolateral thigh flap is a safe technique and the dissection will be easy when the oblique branch is present.
Lin, Chih-Hung; Liao, Chun-Ta; Lin, Cheng-Hung; Tan, Bien-Keem; Lee, Chun-Ta
It is not uncommon that after using a fibular flap for lower gum cancer reconstruction, nonunion, chronic osteomyelitis, or fibular bone exposure occurs, which requires a composite bone and soft tissue reconstruction. Radial forearm osteocutaneous flap possesses the risk of stress fracture. Ulnar forearm osteocutaneous flap can be another option for small bone defect reconstruction. Six patients who had undergone fibular flap for mandible reconstructions and sustained either bone exposure (3 patients), chronic osteomyelitis (1 patient), malocclusion (1 patient), or osteoradionecrosis (1 patient) underwent ulnar forearm osteocutaneous flap with 3-cm ulnar bone for touch-up procedure. The distal radioulnar joints were fused with a screw. Six ulnar forearm osteocutaneous flap dissections were also performed on 4 fresh frozen cadavers to clarify the anatomic distribution of the distal ulnar artery. All 6 ulnar forearm osteocutaneous flaps survived with one re-exploration for venous occlusion. All presented bone union. Comparable to the clinical dissection, the cadaveric distal ulnar artery demonstrates a periosteal branch that runs between the proper ulnar nerve and dorsal sensory nerve. This periosteal branch comes out of an ulnar artery approximately 3 cm proximal to the wrist joint. Ulnar forearm osteocutaneous flap can provide a secondary flap of wide skin paddle and small segment bone for specific mandibular defect after a fibular flap transfer.
Bodin, Frédéric; Dissaux, Caroline; Dupret-Bories, Agnes; Schohn, Thomas; Fiquet, Caroline; Bruant-Rodier, Catherine
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.
Patel, A J K
Autologous breast reconstruction following mastectomy is commonly achieved using the free Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Since its first description, refinements and modifications have resulted in improved operative techniques and more aesthetically pleasing reconstructions. Pre-operative flap design, however, is a relatively new concept that has not received much attention in the literature. Patients who undergo breast reconstruction may have large, ptotic contralateral breasts. In these patients there is a tendency to raise a large abdominal flap in an attempt to achieve symmetry, or simply a larger breast. This has the potential to lead to tight closure of the abdomen and the risk of subsequent wound problems. Reconstructions that are too small or have inadequate ptosis commit the patient to contralateral breast surgery to achieve symmetry. Pre-operatively designing the flap, using a template created from the opposite breast, can help achieve a good match, often reducing the need for contralateral breast surgery. Even when contralateral breast reduction surgery is planned in advance, many of these patients still require, and prefer, a large reconstruction in order to achieve a well-proportioned result. We present a design template that addresses these particular issues and in the senior author\\'s hands has proved to be a very effective technique. Our technique allows raising an abdominal flap of less vertical height than traditionally used (thus reducing the risk of tight abdominal closure) and incorporates an inverted V-shaped flap of skin from the inferior mastectomy skin flap into the reconstruction. This allows more flap tissue to be available to fill the upper poles of the reconstructed breast and at the same time produces good ptosis.
Smith, Benjamin D.; Liu, Jun; Robb, Geoffrey L.; Kronowitz, Steven J.; Garvey, Patrick B.
Background: The most commonly chosen flaps for delayed breast reconstruction after postmastectomy radiation therapy (PMRT) are abdominal-based free flaps (ABFFs) and pedicled latissimus dorsi (LD) musculocutaneous flaps. The short-and long-term advantages and disadvantages of delayed ABFFs versus LD flaps after PMRT remain unclear. We hypothesized that after PMRT, ABFFs would result in fewer postoperative complications and a lower incidence of revision surgery than LD flaps. Methods: We retrospectively reviewed a prospectively maintained database of consecutive patients who underwent unilateral, delayed breast reconstruction after PMRT using ABFFs or pedicled LD flaps with implants at the MD Anderson Cancer Center between January 1, 2001, and December 31, 2011. We compared outcomes and additional surgeries required between the 2 groups. Univariate and multivariate logistic regression modeling analyzed the relationships between patient and reconstruction characteristics and postoperative outcomes. Results: A total of 139 consecutive patients’ breast reconstructions were evaluated: 101 ABFFs (72.7%) versus 38 LDs (27.3%). Average follow-up was similar for ABFF and LD reconstructions. Although ABFF and LD reconstructions experienced similar rates of overall (30.7% vs 23.7%, respectively; P = 0.53), donor-site (8.91% vs 5.13%, respectively; P = 0.48), and flap (20.7% vs 17.9%, respectively; P = 0.37) complications, the LD reconstructions required more additional surgeries (92.1% vs 67.3%; P surgeries more than 1 year after reconstruction (37.1% vs 14.7%; P = 0.02). Conclusion: Although early complication rates were similar for both types of reconstructions, ABFFs seem to have the advantage of providing a more durable result that required fewer revision surgeries in the long term.
Sailon, Alexander M; Schachar, Jeffrey S; Levine, Jamie P
Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps represent increasingly popular options for breast reconstruction. Although several retrospective, small-scale studies comparing these flaps have been published, most have failed to find a significant difference in flap complication rates or donor-site morbidity. We systematically reviewed the current literature, and subsequently pooled and analyzed data from included studies. Included studies reported flap complications and/or donor site morbidities for both flap types. Eight studies met the inclusionary criteria. For flap complications, there was a statistically significant difference between deep inferior epigastric perforator and free transverse rectus abdominis myocutaneous flaps in fat necrosis rates (25.5 +/- 0.49 vs. 11.3% +/- 0.41%, P flap options.
Gunnarsson, Gudjon L; Børsen-Koch, Mikkel; Nielsen, Henrik Toft
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 cm(3) (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....
Firriolo, Joseph M; Ganske, Ingrid M; Pike, Carolyn M; Caillouette, Catherine; Faulkner, Heather R; Upton, Joseph; Labow, Brian I
Pressure ulcers refractory to nonoperative management may undergo flap reconstruction. This study aims to evaluate the long-term outcomes and recurrence rates of flap reconstruction for pediatric pressure ulcers. We reviewed the records of patients who underwent flap reconstruction for pressure ulcer(s) from 1995 to 2013. Twenty-four patients with 30 pressure ulcers, requiring 52 flaps were included. Ulcers were stages III and IV and mostly involved either the ischia (15/30) or sacrum (8/30). Flaps were followed for a median of 4.9 years. Twenty-three patients were wheelchair dependent, and 20 had sensory impairment at their ulcer site(s). Ten patients had a history of noncompliance with preoperative management, 8 of whom experienced ulcer recurrence. Twenty-one ulcers had underlying osteomyelitis, associated with increased admissions (P = 0.019) and cumulative length of stay (P = 0.031). Overall, there was a 42% recurrence rate in ulceration after flap reconstruction. Recurrence was associated with a preoperative history of noncompliance with nonoperative therapy (P = 0.030), but not with flap type or location, age, sex, body mass index, osteomyelitis, or urinary/fecal incontinence (P > 0.05, all). Flap reconstruction can be beneficial in the management of pediatric pressure ulcers. Although high rates of long-term success with this intervention have been reported in children, we found rates of ulcer recurrence similar to that seen in adults. Poor compliance with nonoperative care and failure to modify the biopsychosocial perpetuators of pressure ulcers will likely eventuate in postoperative recurrence. Despite the many comorbidities observed in our patient sample, compliance was the best indicator of long-term skin integrity and flap success.
William HC Tiong
Full Text Available Reverse abdominoplasty was originally described for epigastric lift. Since the work by Baroudi and Huger in the 1970s, it has become clear that reverse abdominoplasty application can be extended beyond just aesthetic procedure. Through the knowledge of anterior abdominal wall vascularity, its application had included reconstructive prospect in the coverage of various chest wall defects. To date, reverse abdominoplasty flap has been used to reconstruct unilateral anterior chest wall defect or for larger defect but only in combination with other reconstructive techniques. Here, we presented a case where it is used as a standalone flap to reconstruct bilateral anterior chest wall soft tissue defect post-bilateral mastectomies in oncological resection. In conclusion, reverse abdominoplasty flap provided us with a simple, faster, and satisfactory reconstructive outcome.
Full Text Available A 77-year-old woman presented with a 1-year history of a right medial canthal tumor, which was histopathologically diagnosed as a basal cell carcinoma. After removal of the tumor with a 4-mm safety margin, the defect occupied the areas superior and inferior to the medial canthal tendon. We first reconstructed the lower part of the defect using a nasolabial V-Y advancement flap to make an elliptic defect in the upper part. We then created a glabellar subcutaneous pedicled flap to match the residual upper elliptic defect with the major axis set along a relaxed skin tension line. The pedicled glabellar flap was passed through a subcutaneous tunnel to the upper residual defect. At 6 months postoperatively, the patient showed no tumor recurrence and a good cosmetic outcome.
Anthony, J P; Singer, M I; Deschler, D G; Dougherty, E T; Reed, C G; Kaplan, M J
For recovery to be deemed adequate, the laryngectomized patient requires restoration of both the ability to swallow and to speak. Immediate results and long-term functional recovery after pharyngoesophageal (PE) reconstruction with the radial forearm free flap were studied in 22 consecutive patients who had undergone primary (n = 3) or secondary (n = 19) reconstructions after total laryngectomy. Circumferential reconstructions were done in 13 patients (mean length 10 cm, range 6 to 16) and patch reconstructions in 9 patients (defect size range 4 x 4 cm to 8 x 7 cm). Flap leakage was evaluated for all patients, and postoperative diet and ability to swallow were evaluated for 16 patients with an intact tongue base. Voice was evaluated for 6 patients with circumferential reconstructions who had later undergone tracheoesophageal puncture with placement of a Blom-Singer voice prosthesis, and the results compared with those of a control group of 5 voice-restored patients who had undergone laryngectomy with primary closure of the pharyngoesophagus. All 22 flaps survived and none of the patients died. Although 7 (32%) reconstructions leaked, all but 1 closed spontaneously. Fourteen (88%) of the patients with an intact tongue base have no dysphagia and are on a regular diet, and 2 remain on an oral liquid diet. Compared with controls, patients with a radial free-flap reconstruction had similar loudness with soft speech (43 dB for controls versus 52 dB for radial patients) and loud speech (61 dB versus 63 dB), comparable fundamental frequencies (136 Hz versus 125 Hz), and increased jitter (2% versus 5%). Speech intelligibility was judged by untrained listeners as excellent for 4 of the patients with radial flaps and good for the other 2. The radial free flap offers the advantages of rapid harvest, high flap reliability, and minimal donor-site and patient morbidity. Leakage rate and deglutition restoration were similar to those of other reconstructions, including the free
Cerci, Felipe Bochnia; Dellatorre, Gerson
The paramedian forehead flap is a great option for restoration of complex nasal defects. For full-thickness defects, it may be used alone or in combination with other methods. We present a patient with a basal cell carcinoma on the distal nose treated by Mohs micrographic surgery, and a resulting full-thickness defect repaired with paramedian forehead flap combined with a hinge flap. For optimal results with the paramedian forehead flap, adequate surgical planning, patient orientation and meticulous surgical technique are imperative.
Allensworth, Jordan J; Troob, Scott H; Weaver, Tyler S; Gonzalez, Javier D; Petrisor, Daniel; Wax, Mark K
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.
Cerci, Felipe Bochnia
Staged retroauricular flap is a great option for full-thickness defects along the helical rim and antihelix. Donor site consists of the posterior ear, postauricular sulcus and mastoid area. The advantages of this flap include hidden donor scar, donor tissue similarity and rich vascularity. We present a case of collision tumor on the left helix treated with Mohs micrographic surgery and the resulting full-thickness defect repaired with a staged retroauricular flap. This flap is an effective technique for full-thickness helical defect repair with relatively little operative morbidity. High esthetic and functional results may be obtained restoring the ear size and shape.
Alani, Harith A; Balalaa, Nahed
Immediate breast reconstruction with tissue expander has become an increasingly popular procedure. Complete coverage of the expander by a musculofascial layer provides an additional well-vascularised layer, reducing the rate of possible complications of skin necrosis, prosthesis displacement, and the late capsular contracture. Complete expander coverage can be achieved by a combination of pectoralis major muscle and adjacent thoracic fascia in selected patients. Seventy-five breast mounds in 59 patients were reconstructed, in the first stage a temporary tissue expander inserted immediately after mastectomy and a musculofascial layer composed of the pectoralis major muscle, the serratus anterior fascia, and the superficial pectoral fascia were created to cover the expander. The first stage was followed months later by implant insertion. Minor and major complications were reported in a period of follow-up ranging from 24-42 months (mean 31 months). Complete musculofascial coverage of the tissue expander was a simple and easy to learn technique providing that the patient has a well-formed and intact superficial pectoral and serratus anterior fascia. From a total of 75 breast mounds reconstructed, major complications rate was 4% (overall rate of 19.8%), including major seroma (n = 4), haematoma (n = 1), partial skin loss (n = 3), wound dehiscence (n = 1), major infection (n = 2), severe capsule contracture (n = 1), and expander displacement (n = 3). The serratus anterior fascia and the superficial pectoral fascia flaps can be effectively used as an autologous tissue layer to cover the lower and the lateral aspect of tissue expanders in immediate breast reconstruction after mastectomy.
Lin, Pao-Yuan; Kuo, Yur-Ren; Tsai, Yun-Ta
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.
Minn, Kyung Won; Hong, Ki Yong; Lee, Sang Woo
To obtain pleasing symmetry in breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) free flap, a large amount of abdominal flap is elevated and remnant tissue is trimmed in most cases. However, elevation of abundant abdominal flap can cause excessive tension in donor site closure and increase the possibility of hypertrophic scarring especially in lean patients. The TRAM flap was divided into 4 zones in routine manner; the depth and dimension of the 4 zones were obtained using ultrasound and AutoCAD (Autodesk Inc., San Rafael, CA), respectively. The acquired numbers were then multiplied to obtain an estimate of volume of each zone and the each zone volume was added. To confirm the relation between the estimated volume and the actual volume, authors compared intraoperative actual TRAM flap volumes with preoperative estimated volumes in 30 consecutive TRAM free flap breast reconstructions. The estimated volumes and the actual elevated volumes of flap were found to be correlated by regression analysis (r = 0.9258, P AutoCAD (Autodesk Inc.) allow the authors to attain the precise volume desired for elevation. This method provides advantages in terms of minimal flap trimming, easier closure of donor sites, reduced scar widening and symmetry, especially in lean patients.
Berenguer, B; Simal, I; Marín, M C; E de Tomás; Riquelme, O; García Martín, A; González, J L
Children have much lower incidence of pressure sores (PS) than adults and furthermore, they are diagnosed in earlier stages. Therefore, the reported experience with surgical treatment of advanced pediatric PS is scarce. We present the surgical treatment of 2 chronic PS stage IV in children aged 11 and 14 years, by means of perforator flaps based on the gluteal arteries: in the first case we used a free-style flap based on a left medial gluteal perforator and in the second a large reusable rotation-advancement flap based on both right superior and inferior gluteal artery perforators. In both patients we achieved a rapid cure with 100% survival of the flaps and a stable cover over a 6 month and 1 year follow-up respectively. Gluteal artery perforator flaps can produce excellent and durable results in the reconstructive treatment of sacral pressure sores in children. These flaps carry lower morbidity than musculocutaneous flaps and are more reliable than traditional fasciocutaneous flaps. Furthermore they preserve more reconstructive options in case of recurrence during the children's lifetime.
Full Text Available 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.
Albert, Sebastien; Guedon, Charles; Halimi, Caroline; Cristofari, Jean Pierre; Barry, Beatrix
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.
Krijgh, David D; Mureau, Marc A M
During the past 40 years, free vascularized flaps have become the golden standard in the reconstruction of postoncologic head and neck defects. When there is a need for an osteofasciocutaneous free flap, the free fibula flap is the first choice because of the advantages of its long bone structure, high reliability, and minimal donor-site morbidity. However, most of these patients receive adjuvant radiation therapy, which sometimes causes symptomatic fibrosis, contractures, and (osteo)radionecrosis. In case of these late complications, locoregional reconstructive options are often limited, and complex secondary free flap procedures are not always feasible or preferred by the patient. The present paper discusses regional and free flap reconstructive options and demonstrates with 3 cases that the delayed deltopectoral flap remains a very safe, reliable, and easy flap, which still has a place in the management of these complex reconstructive challenges.
Full Text Available The anterolateral thigh (ALT flap is now widely established as a versatile flap which can provide ample amounts of skin, muscle and fascia to construct a variety of defects following major head and neck surgery. However, its use remains cautious due to well documented variations in its vascular anatomy for which this flap is notorious. What is less well known is the effect of variations in quadriceps muscle anatomy on the success of flap harvest. Here, we report a unique case in which fusion of the vastus intermedius (V.I and vastus lateralis (V.L muscles precluded ALT flap harvest. We also advise on appropriate management should similar cases be encountered. To our knowledge this is the first reported case of its kind in the English language literature.
Descripción anatómico-quirúrgica del colgajo dorsoepigástrico: una opción diferente en reconstrucción mamaria Anatomical and surgical description of a new concept in breast reconstruction: muscle sparing dorsoepigastric flap of latissimus dorsi
J.L. Haddad Tame
Full Text Available La importancia de las mamas para el equilibrio biopsico-social de la mujer es evidente. Las secuelas físicas y psíquicas de la mastectomía pueden ser tratadas mediante cirugía de reconstrucción mamaria; la búsqueda de nuevas opciones reconstructivas con menor incidencia de complicaciones y que permitan obtener mejores resultados estéticos, sigue vigente en nuestros días. En un estudio piloto realizado en 3 cadáveres frescos identificamos la anatomía neurovascular del músculo dorsal ancho, que fue constante en los hallazgos, por lo que en una segunda etapa procedimos a realizar reconstrucción mamaría mediante un colgajo dorsoepigástrico conservador de músculo dorsal ancho en 9 pacientes. El diseño del colgajo permite tomar una tira de 5 a 7cms del borde lateral del dorsal ancho, que incluye la rama descendente de la arteria tóracodorsal. La tasa global de complicaciones fue del 0.63 %, por lo que la morbilidad del sitio donante fue menor que la que se presenta con otro tipo de colgajos, y el resultado estético fue muy satisfactorio. Consideramos que el colgajo dorsoepigástrico conservador de músculo dorsal ancho es una excelente opción reconstructiva para las pacientes mastectomizadas, si bien se trata de un estudio piloto y necesitamos ampliar la muestra de pacientes para validar los resultados.Breast importance is evident for women quality of life. The physical and psychological trauma of mastectomy can be treated by breast reconstruction, so it´s important to search for new reconstructive options decreasing complications and improving the cosmetic results. By an anatomical study in 3 fresh cadavers we observed the neurovascular anatomy of the latissimus dorsi and we founded a constant anatomy; then we realized the dorsoepigastric muscle sparing of latissimus dorsi flap taking a strip of 5 to 7cm from lateral edge of the muscle including the descending branch of the thoracodorsal artery in 9 patients meeting inclusion
Ludwig, Irene H; Brown, Mark S
To present an avulsion injury of the rectus muscle after orbital trauma, usually the inferior rectus, and detail its diagnosis and operative repair. Forty-three patients underwent repair of flap tears of 62 rectus muscles. During surgery, we found the muscle abnormality was often subtle, with narrowing or thinning of the remaining attached global layer of muscle. The detached flap of external (orbital) muscle was found embedded in surrounding orbital fat and connective tissue. Retrieval and repair were performed in each case. The causes of orbital trauma were as follows: orbital fractures (15 patients), blunt trauma with no fracture (11 patients), suspected trauma but did not undergo computerized tomographic scan (12 patients), and status after retinal detachment repair (5 patients). Of note, 15 of the 43 patients (35%) underwent repair of the flap tear alone, without any additional orbital or strabismus surgery. Diagnostically, the predominant motility defect in 45 muscles was limitation toward the field of action of the muscle, presumably as a result of a tether created by the torn flap; these tethers simulated muscle palsy. Seventeen muscles were restricted away from their field of action, simulating entrapment. The direction taken by the flap during healing determined the resultant strabismus pattern. All patients with gaze limitation toward an orbital fracture had flap tears. The worst results after flap tear repair were seen in patients (1) who had undergone orbital fracture repair before presentation, (2) who had undergone previous attempts at strabismus repair, and (3) who had the longest intervals between the precipitating event and the repair. The best results were obtained in patients who underwent simultaneous fracture and strabismus repair or early strabismus repair alone. Avulsion-type flap tears of the extraocular muscles are a common cause of posttraumatic strabismus. Early repair produces the best results, but improvement is possible despite long
Zhu, L; Zhang, J; Song, X; Hou, W; Wu, S; Chen, W; Svensson, P; Wang, K
The aims of this study were to assess sensory recovery and impact on life quality after tongue reconstruction of oncological defects using different flap types. Thirty-two patients who underwent tongue reconstruction for oncological defects 9·3 months after surgery with non-innervated radial forearm free flaps (RFFFs) (N = 16), non-innervated anterolateral thigh free flaps (ALTFFs) (N = 8) and nasolabial island flaps (NLIFs) (N = 8), and 20 age- and gender-matched healthy controls participated in the study. The modalities assessed were cold detection threshold, warm detection threshold (WDT), cold pain threshold, heat pain threshold (HPT), mechanical detection threshold (MDT), mechanical pain threshold (MPT) and the Chinese version of Oral Health Impact Profile-49. ALTFFs was significantly more sensitive than RFFFs (P = 0·005) and NLIFs (P = 0·014) for WDT, and showed a better sensory recovery than RFFFs for HPT (P = 0·011). ALTFFs and NLIFs showed significantly better sensory recovery than RFFFs for MDT (P sensory recovery for MPT, followed by ALTFFs and lastly RFFFs (P = 0·004). NLIFs also showed the least impact on quality of life measures related to psychological discomfort compared to RFFFs and ALTFFs (P sensory recovery in RFFFs did not depend on gender and post-operative radiotherapy (P > 0·05). Different flaps for tongue reconstruction of oncological defects appear to have different patterns of sensory recovery and impact on quality of life measures. A longer follow-up period and larger number of participants will be needed in future studies. © 2017 John Wiley & Sons Ltd.
Full Text Available We present our experience with the use of local fasciocutaneous V-Y advancement flaps in the reconstruction of 10 axillae in 6 patients for large defects following wide excision of long-standing Hidradenitis suppurativa of the axilla. The defects were closed with local V-Y subcutaneous island flaps. A single flap from the chest wall was sufficient for moderate defects. However, for larger defects, an additional flap was taken from the medial side of the ipsilateral arm. The donor defects could be closed primarily in all the patients. The local areas of the lateral chest wall and the medial side of the arm have a plentiful supply of cutaneous perforators and the flaps can be designed in a V-Y fashion without resorting to preoperative marking of the perforator. The flaps were freed sufficiently to allow adequate movement for closure of the defects. Although no attempt was made to identify the perforators specifically, many perforators were seen entering the flap. Some perforators can be safely divided to increase reach of the flap. All the flaps survived completely. A follow up of 2.5 years is presented.
Abdominoperineal resection (APR) of anorectal cancers after neoadjuvant chemoradiotherapy may incur significant perineal morbidity. While vertical rectus abdominis muscle (V-RAM) flaps can fill the pelvic resection space with health tissue, their use has previously been described predominantly in association with laparotomy. Here, we describe a means of combination laparoscopic APR with V-RAM flap reconstruction that allows structural preservation of the entire abdominal wall throughout the oncological resection and of the deep parietal layers after V-RAM donation. Furthermore, a single port access device used at the end colostomy site allows a second senior surgeon assist with an additional two working instruments for the purpose of improved pelvic tissue retraction, especially useful in obese patients.
Conclusion: Omental flap is safe, easy and effective technique in management of mediastinitis with DSWI following open heart surgery in CABG patients either this procedure was followed by reclosure of the sternum or bilateral pectoral flap. However, reclosure of the sternum is more physiological and less invasive than doing bilateral pectoral flap leaving the sternum unclosed.
Andree, Christoph; Munder, Beatrix; Seidenstuecker, Katrin; Richrath, Philipp; Behrendt, Philipp; Köppe, Tobias; Hagouan, Mazen; Audretsch, Werner; Nestle-Krämling, Carolin; Witzel, Christian
Summary Background Currently about 70% of women who suffer from breast cancer undergo breast-conserving therapy (BCT) without removing the entire breast. Thus, this surgical approach is the standard therapy for primary breast cancer. If corrections are necessary, the breast surgeon is faced with irritated skin and higher risks of complications in wound healing. After radiation, an implant-based reconstruction is only recommended in selected cases. Correction of a poor BCT outcome is often only solved with an additional extended operation using autologous reconstruction. Material/Methods In our plastic surgery unit, which focuses on breast reconstruction, we offer a skin-sparing or subcutaneous mastectomy, followed by primary breast reconstruction based on free autologous tissue transfer to correct poor BCT outcomes. Between July 2004 and May 2011 we performed 1068 deep inferior epigastric artery perforator (DIEP) flaps for breast reconstruction, including 64 skin-sparing or subcutaneous mastectomies, followed by primary DIEP breast reconstruction procedures after BCT procedures. Results In all free flap-based breast reconstruction procedures, we had a total flap loss in 0.8% (9 cases). Within the group of patients after BCT, we performed 41 DIEP flaps and 23 ms-2 TRAM flaps after skin-sparing or subcutaneous mastectomies to reconstruct the breast. Among this group we had of a total flap loss in 1.6% (1 case). Conclusions In cases of large tumour sizes and/or difficult tumour locations, the initial oncologic breast surgeon should inform the patients of a possibly poor cosmetic result after BCT and radiation. In our opinion a skin-sparing mastectomy with primary breast reconstruction should be discussed as a valid alternative. PMID:23197233
Hunsinger, Vincent; Hivelin, Mikael; Derder, Mohamed; Klein, Delphine; Velten, Michel; Lantieri, Laurent
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.
d'Alcontres, F Stagno; Cuccia, G; Lupo, F; Delia, G; Romeo, M
The management of lagophthalmos in patients with long-standing facial palsy is difficult, since the immobility and scleral show have to be corrected to protect the vision. In this article, the authors describe the treatment of paralytic eye with a static technique using a medially based orbicularis oculi muscle flap (OOMF) from the upper eyelid in patients with lagophthalmos. From April 2006 to May 2008, five Caucasian patients with ages ranging from 45 to 71 years (mean, 61 years) were treated at the Plastic Surgery Unit of Messina University. All patients underwent orbicularis oculi muscle (OOM) transposition flap to support the lower orbicularis oculi and create a suspension of the eyelid. To validate the anatomical features of the OOM transposition flap, four fresh cadaver heads (eight eyelids) were dissected to demonstrate flap viability, feasibility and suspension effect. We achieved resolution of the lagophthalmos and good cosmetic appearance in all cases. The distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced postoperatively on the paralysed side compared to the contralateral healthy side. Follow-up time ranged from 3 to 25 months (mean, 12 months). All patients healed well with no complications of the flaps. There was no flap contraction, recurrent deformity or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible. The authors believe that the switching of upper blepharoplasty technique from the upper eyelid to the paralysed and scarred lower lid can be used as a tool to treat lagophthalmos. (c) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Full Text Available Objectives: Free fibula flap remains the flap of choice for reconstruction of mandibular defects. If free fibula flap is not possible, the subscapular system of flaps is a valid option. In this study, we evaluated the possibility of dental implant placement in patients receiving a scapular free flap for oromandibular reconstruction. Material and Methods: We retrospectively reviewed 10 patients undergoing mandible reconstruction with a subscapular system free-tissue (lateral border of the scapula transfer at the University Hospital Zürich between January 1, 2010 and January 1, 2013. Bone density in cortical and cancellous bone was measured in Hounsfield units (HU. Changes of bone density, height and width were analysed using IBM SPSS Statistics 22. Comparisons of bone dimensions as well as bone density were performed using a chi-square test. Results: Ten patients were included. Implantation was conducted in 50%. However, all patients could have received dental implants considering bone stock. Loss of bone height and width were significant (P < 0.001. There was a statistical significant increase in bone density in cortical (P < 0.001 and cancellous (P = 0.004 bone. Conclusions: Dental implants are possible after scapular free flap reconstruction of oromandibular defects. Bone height and width were reduced, while bone density increased with time.
Pitak-Arnnop, P; Hemprich, A; Dhanuthai, K; Pausch, N C
Fibular free flap is considered as an "old dog" in reconstructive surgery because it was first described by Taylor and his colleagues in 1975, and was then introduced for mandibular reconstruction by Hidalgo in 1989. There are some "tricks" for fibular free flap that have been used and recognized in many European maxillofacial surgical units over the past decade. These include: 1) harvesting the distal fibula when recipient vessels are distant; 2) flap selection based on the anatomy of perforators; 3) use of the skin paddle for postoperative flap monitoring; 4) protection of the flap's soft-tissue cuff; 5) preventing venous thrombosis which is essential to reduce flap complications; 6) aligning fibular struts and protecting the vascular pedicle when the double-barrel technique is used; 7) minimizing the gap between the double-barrel struts and implementing a long-term follow-up of dental implants; 8) selecting osteosynthesis materials; and 9) learning curve and clinical competence in microvascular reconstruction. We also reviewed current data from the literature, which would be useful for maxillofacial reconstructive surgeons. With these tricks, one can teach an "old dog" "old tricks".
Tan, Bien-Keem; Joethy, Janna; Ong, Yee-Siang; Ho, Gay-Hui; Pribaz, Julian J
Recent experience with the ipsilateral TRAM flap has shown that it has the advantage of a longer functional pedicle length, which allows tension-free inset of well-vascularized tissue into the breast pocket. This leads to better positioning and shaping of the reconstructed breast with minimal disruption of the inframammary fold. The purpose of this article was to provide an illustrated approach to the ipsilateral TRAM flap and to clarify the technique when applied in the context of immediate breast reconstruction following cancer extirpation. A prospective evaluation of 89 patients who underwent immediate breast reconstruction following skin-sparing mastectomy for breast cancer was performed. All patients underwent ipsilateral TRAM reconstruction. The innate insetting advantage of the ipsilateral TRAM flap is illustrated in the article. The key steps of the technique were as follows: (1) The ipsilateral corner of the flap was used as the axillary tail, leaving the more bulky part to form the main body of the breast; (2) To avoid undesirable twists, a right TRAM was rotated clockwise so that its apex points superiorly; (3) This flap was subsequently tunneled into the breast pocket while preserving the inframammary fold. The opposite maneuvers were done for the left side; (4) If the flap was congested, venous augmentation was performed where the tributary of the axillary vein or the thoracodorsal vein was anastomosed with the inferior epigastric vein from the flap with an interposed vein graft (17% of cases). All flaps survived and flap-related complications included partial necrosis of tissue across the midline (2.2%), palpable fat necrosis (22%), and hematoma requiring drainage (2.2%). All flaps were raised concurrent with the resection, and the combined operative time ranged from 3.5 to 6 h, with a mean hospital stay of 7 days. The ipsilateral TRAM flap was a reliable flap with low complication rates and short surgery time. It was our preferred choice for
Bouhassira, J; Hersant, B; Noel, W; Aguilar, P; Niddam, J; Meningaud, J-P
Reconstruction of an entire alar wing is a frequently encountered reconstructive challenge in onco-dermatologic surgery. The aim of this technical note was to describe a surgical technique total for reconstruction of the alar wing, with a modified nasolabial flap with an inferior pedicle associated with a cartilaginous graft. This rapid procedure seems to be a well alternative for elderly people and patients who do not want a forehead flap. The aesthetic and functional outcomes of the donor and recipient sites were satisfactory. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Spence, Nicole Z; Olszynski, Patrycja; Lehan, Anne; Horn, Jean-Lois; Webb, Christopher A J
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.
Anthony, J P; Foster, R D; Sharma, A B; Kearns, G J; Hoffman, W Y; Pogrel, M A
Refinements in microsurgical techniques, plate fixation, and osseointegration have changed the conceptual approach to midface reconstruction. Free tissue transfer has emerged as the ideal method of reconstructing complex midfacial defects. Single-stage bony restoration of the palate and orbital rim using the folded fibular osteocutaneous free flap is described. The fibular free flap is our first choice for reconstructing complex midfacial defects. The thin, soft, pliable tissue is ideal for intraoral and palatal reconstructions. The bone can be tailored precisely to fit any desired shape, and forms a sturdy support for both orbital and dental prostheses. With a single flap, rapid and reliable restoration of midfacial appearance, orbital support, and palatal function can be achieved.
Robert M. Whitfield
Full Text Available A 47-year-old female with a locally advanced urologic malignancy previously managed with resection, diversion, and postoperative radiation therapy presented for management of her recurrent cancer that had eroded through the soft tissues of the left inner thigh and vulva. On all staging studies the tumor involved the left common femoral artery, and vein, both above and below the inguinal ligament. The difficulty with such tumors is the availability of tissue to reconstruct the defect. The patient had a history of deep venous thrombosis in the femoral venous system. A local flap was the most logical type of reconstruction. The patient had a right lower quadrant ureterostomy with a large parastomal hernia which further limited the local flap options. An anterolateral thigh flap from the opposite thigh was used to reconstruct the soft tissue deficit in this patient. This resurfaced the defect and provided coverage for the vascular reconstruction.
Mureau, Marc A M; Hofer, Stefan O P
Reconstruction of large-sized lumbosacral or sacral defects often is not possible using local or regional flaps, making the use of free flaps necessary. However, the difficulty of any microsurgical procedure in this region is complicated by the need to search for potential recipient vessels to revascularize the flap. In the present case, a free musculocutaneous anterolateral thigh flap to cover a large-sized and deep lumbosacral defect was used. Arterial anastomosis was performed, connecting the cutaneous anterolateral thigh (ALT) perforator to the perforator of the second lumbar artery. In this fashion, the arterial circulation through the flap was flowing reversely through the muscle. The concomitant vein of the descending branch of the lateral circumflex femoral artery was hooked up to the thoracodorsal vein using a long interposition vein graft because the perforator of the second lumbar vein was too small. Postoperative healing was uneventful. In conclusion, a successful reconstruction of a lumbar defect has shown that local perforators in the lumbar area may be accessible for easier perforator-to-perforator anastomoses and that the muscular part of the musculocutaneous ALT flap can survive on retrograde arterial perfusion from a perforator of the skin island.
Young Sun You
Full Text Available BackgroundA pectoralis major flap is one of the standard tools for the reconstruction of defects of the head and neck. Despite the technical advancement in free tissue transfer in head and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked. The purpose of this study is to evaluate our 17 years of experience in reconstructing defects of the head and neck region using the pectoralis major flap.MethodsWe retrospectively reviewed the medical records of 112 patients (120 cases who underwent pectoralis major flap operations for head and neck reconstruction during a period ranging from 1994 to 2010.ResultsIn our series, no total necrosis of the flap occurred. Of the total cases, 30.8% presented with flap-related complications. Major complications occurred in 20% of all of the cases but were then all successfully treated. The male sex was correlated with the occurrence of overall complications (P=0.020 and major complications (P=0.007. Preoperative albumin levels of <3.8 g/dL were correlated with the formation of fistula (P=0.030. Defects of the hypopharynx were correlated with the occurrence of major complications (P=0.019 and the formation of fistula (P=0.012. Secondary reconstructions were correlated with the occurrence of overall complications (P=0.013 and the formation of fistula (P=0.030.ConclusionsA pectoralis major flap is still considered to be a safe, versatile one-stage reconstruction procedure in the management of the defects of head and neck and the protection of the carotid artery.
DI Gen-hong; YU Ke-da; WU Jiong; QI Fa-zhi; LU Jin-song; SHEN Zhen-zhou; SHAO Zhi-min
Objective: To discuss the suitable immediate breast reconstruction modalities for Chinese patients by comparing thepedicled transverse rectus abdominis myocytaneous flap (TRAM) reconstruction with latissimus dorsi myocytaneous flap (LTD) reconstruction plus implants or not after mastectomy due to breast cancer. Methods: From Jan. 2000 to Jul. 2005, 74staged 0-Ⅱ patients (mean age 39) were performed immediate breast reconstruction with autologous tissue either using LTD flaps or pedicled TRAM flaps with supplemental implants when necessary after mastectomy due to breast cancer and the charts were reviewed. Results: The age, marriage and menses status did not affect the selection of modalities and the need of implants. In 74 patients, 62 cases (83.8%) were performed LTD reconstruction with 13 implants and 12 cases received TRAM with 1 implant. The difference in need of implants or not between the two modalities had no statistical significance (P=0.442,Fisher' exact test). Aesthetic results judged as good or fair were in 88% patients and the cosmetic effects between LTD and TRAM groups or implant and non-implant groups had no differences. All reconstructions were successful, with 4.1%cumulative locoregional recurrence and 100% overall survival by following up to 66 months (median 9 months). The DFS and RFS between the two modalities had no significant differences by log rank test. Conclusion: Immediate autologous tissue reconstruction makes it possible to regain the natural and symmetric contour of breast without increased local recurrence. The LTD flap reconstruction is a suitable option for most Chinese women as well as the pedicled TRAM flap.
Hsiao, Hung-Tao; Leu, Yi-Shing; Lin, Chang-Ching
The authors compared the postoperative speech and swallowing function of six patients who underwent free radial forearm flap reconstruction after hemiglossectomy with that of six control patients who underwent primary closure of the defect. Clinical speech pathologic evaluations included the Fletcher time-to-time maximum repetition rate of syllables, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included the duration of deglutition, bolus volume, and ingestion rate. Speech quality, including intelligibility and articulation, was better in patients with primary closure. However, the bolus volume and ingestion rate in deglutition were better in those with flap reconstruction. These results suggest that the flap adds bulk, thus improving pharyngeal clearance by maintaining the tongue-to-mouth roof contact that is necessary in the swallowing process. The nonfunctional flap, however, hinders articulation by restricting the mobility of the remaining portion of the normal tongue.
Chien, C Y; Su, C Y; Hwang, C F; Chuang, H C; Jeng, S F; Chen, Y C
To evaluate the functional outcomes of patients who underwent total or nearly total glossectomy for advanced tongue or base of tongue cancer. We used the radial forearm free flap (RFFF), anterior lateral thigh flap (ALTF) or fibular osteocutaneous flap (FOCF) to reconstruct the oral defect after radical resection in 39 patients undergoing total or nearly total glossectomy with laryngeal preservation. Good functional outcomes, measured by independent feeding, speech and swallowing were achieved in 35, 36 and 35 patients, respectively. The cumulative 4-year survival rates were 63.8% for tongue cancer and 42.9% for base of tongue cancer. Reconstruction with free flaps is a feasible method to restore the functional outcomes in speech and deglutition among patients who undergo total or nearly total glossectomy with laryngeal preservation.
Leite, A K N; de Matos, L L; Belli, M; Kulcsar, M A V; Cernea, C R; Garcia Brandão, L; Pinto, F R
The pectoralis major myocutaneous flap (PMMF) is a safe and versatile flap used widely for head and neck cancer reconstructions, but one of the major and most feared complications is oro- or pharyngocutaneous fistula. Herein, we attempt to establish risk factors for fistula formation in reconstructions of mucosal defects in the head and neck using PMMF through retrospective analysis of PMMF performed during 3 years at a single institution, with a total of 84 procedures. There were 69 men and 15 women, with a mean age of 59.5 years. There were 15 cases of partial flap loss, two total flap losses and 31 fistulas. The independent risk factors for fistula formation were preoperative serum hemoglobin analysis analysing risk factors for fistula formation. These findings are helpful in selecting patients with elevated risk of fistula formation, and therefore preventive measures can be undertaken to avoid potentially serious complications.
Just, Maren; Chalopin, Claire; Unger, Michael; Halama, Dirk; Neumuth, Thomas; Dietz, Andreas; Fischer, Miloš
The aim of this study is to investigate static and dynamic infrared (IR) thermography for intra- and postoperative free-flap monitoring following oropharyngeal reconstruction. Sixteen patients with oropharyngeal reconstruction by free radial forearm flap were included in this prospective, clinical study (05/2013-08/2014). Prior ("intraop_pre") and following ("intraop_post") completion of the microvascular anastomoses, IR thermography was performed for intraoperative flap monitoring. Further IR images were acquired one day ("postop_1") and 10 days ("postop_10") after surgery for postoperative flap monitoring. Of the 16, 15 transferred free radial forearm flaps did not show any perfusion failure. A significant decreasing mean temperature difference (∆T: temperature difference between the flap surface and the surrounding tissue in Kelvin) was measured at all investigation points in comparison with the temperature difference at "intraop_pre" (mean values on all patients: ∆T intraop_pre = -2.64 K; ∆T intraop_post = -1.22 K, p < 0.0015; ∆T postop_1 = -0.54 K, p < 0.0001; ∆T postop_10 = -0.58 K, p < 0.0001). Intraoperative dynamic IR thermography showed typical pattern of non-pathological rewarming due to re-established flap perfusion after completion of the microvascular anastomoses. Static and dynamic IR thermography is a promising, objective method for intraoperative and postoperative monitoring of free-flap reconstructions in head and neck surgery and to detect perfusion failure, before macroscopic changes in the tissue surface are obvious. A lack of significant decrease of the temperature difference compared to surrounding tissue following completion of microvascular anastomoses and an atypical rewarming following a thermal challenge are suggestive of flap perfusion failure.
Ghazali, Naseem; Hanna, Todd C; Dyalram, Donita; Lubek, Joshua E
The tubed, buried anterolateral thigh (ALT) flap is a popular reconstruction method for total pharyngolaryngectomy defects. The "papillon"-designed ALT flap, described by Hayden et al, offers an alternative method of using the ALT flap in this situation. We report our early experience with the papillon ALT flap in a patient cohort. On retrospective review, all patients who underwent reconstruction of circumferential total pharyngolaryngectomy defects with the papillon ALT flap from February 2012 to February 2015 were identified from our departmental database. Demographic and clinical data, operative details, and complications were analyzed from the records. Seven patients were included in this study. The mean length of hospital stay was 15 days (range, 10 to 32 days). Acute complications occurred in 5 of 7 patients, namely, partial flap loss managed by a pectoralis flap (1 of 7 [14%]); an early pharyngocutaneous fistula (4 of 7 [57%]) managed by simple repair, wound packing, or delayed repair; and a donor-site hematoma (1 of 7 [14%]). At follow-up (range, 2 to 24 months), there was 1 stricture formation, but no chronic fistula. All patients were able to swallow orally. Early results using the papillon ALT flap suggest that this technique is a viable alternative to the standard tubed ALT flap design. The advantages of this design include the following: 1) it offers simultaneous vascularized skin to resurface anterior neck skin deficiency without resorting to additional tissue elsewhere; 2) direct monitoring of the ALT flap is possible; and 3) any pharyngocutaneous fistula is exteriorized to the surface without compromising the internal neck structures and can be easily identified and repaired directly in the office. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Salunke, Abhijeet Ashok; Nambi, G I; Sudhakar, N
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.
Li, Yiyuan; Zhang, Ruhong; Zhang, Qun; Xu, Zhicheng; Xu, Feng; Li, Datao
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 Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.
Full Text Available Background: Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases. Materials and Methods: Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF over a period of 7 years. The mean age of these patients was 41.2 years. Results: Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management. Conclusions: RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.
Hsiao, Hung-Tao; Leu, Yi-Shing; Liu, Chung-Ji; Tung, Kwang-Yi; Lin, Chang-Ching
The authors retrospectively compared the results of postoperative speech and swallowing in patients who had undergone hemiglossectomy for carcinoma of the anterior tongue. Immediate reconstruction in 16 patients was with a free radial forearm flap and in another 16 with an anterolateral thigh flap. Clinical speech pathology evaluation included the Fletcher time-to-time maximum syllable repetition rate, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included deglutition duration, bolus volume, and ingestion rate. The functional results with both flaps were adequate, and the two groups did not differ significantly between each other for either speech or swallowing.
Minetti, C; Colson, T; Gisquet, H; Pujo, J; Brix, M; Simon, E
Perforator flaps represent a new approach in reconstructive surgery including the thoracodorsal perforator flap. It can be used as a free or pedicled tissue transfer. By exposing two clinical cases, we demonstrate that this flap is an interesting option for children and adolescents chest wall skin coverage with less morbidity compared to myocutaneous latissimus dorsi flap. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Bertelli, J A; Pereira Filho, O J; Ely, J B
Sensory reconstruction has recently been stressed in breast reconstruction. However, there are no reports concerning the reconstruction of a sensitive areola. The bilateral reconstruction of a sensitive areola using a neurocutaneous flap based on the medial antebrachial cutaneous nerve is reported. The flap was harvested from the distal third of the forearm as an island flap and tunneled to reach the apex of the new breast, which was previously reconstructed using a 135-cc, gel-filled, silicone prosthesis covered by a latissimus dorsi myocutaneous flap. Six months later, fine sensibility in the reconstructed areola was demonstrated. The patient could perceive light touch, pain, and 14 mm two-point discrimination. At 2 months after surgery, 50 percent of cutaneous faulty stimulus location was observed. However, at 4 and 6 months after surgery, faulty location disappeared. Six months after harvesting the medial antebrachial cutaneous nerve, the sensory deficit was minimal; it included a hypoesthesic zone of 4 to 7 cm and an anesthesic zone of 2.5 to 5 cm on the middle third of the forearm. Fifteen months after the procedure, no hypoesthesic zone was observed; only a 2 to 3 cm anesthesic zone on the proximal medial side of the forearm existed. This sensory deficit passed unnoticed by the patient. The technique developed here is a refinement in breast reconstruction, and we think it should be used in selected patients.
Niitsuma, Katsunori; Hatoko, Mitsuo; Kuwahara, Masamitsu; Tanaka, Aya; Iioka, Hiroshi; Fukuda, Takehiko; Yane, Katsunari
With the extension of the average life span and the development of surgical technique, anesthesia, and pre- and postoperative management, operations for elderly patients have become more widely accepted. In the field of plastic surgery, free-flap transfers using microvascular techniques have become a common surgical procedure in reconstruction of the head and neck region after surgical removal of a cancer. There have been several reports of free-flap transfer in patients older than 90 years, but the authors know of no reports of free osteocutaneous flap transfer for mandibular reconstruction, which is a very invasive free-flap surgery, for such patients. The mandible plays a significant role in various kinds of dynamic functions, such as mastication, deglutition, and articulation. Disorder of these functions causes a deterioration in the patient's quality of life. The authors have performed a mandibular reconstruction using an osteocutaneous scapular free flap after resection of a gingival cancer invading the mandibular bone in a 93-year-old Japanese woman. In our case, an osteocutaneous scapular free flap, which permits the patient rapid rehabilitation of the lower leg, is thought to be a good choice because it allows the patient to get out of bed as quickly as possible in the postoperative period to minimize additional complications.
Wechselberger, Gottfried; Traintinger, Heike; Larcher, Lorenz; Russe, Elisabeth; Edelbauer, Monika; Ensat, Florian
In secondary autologous breast reconstruction, the current standard is a flap derived from the lower abdomen or the back. If these donor sites are not available because of lack of tissue, prior operations, or simply the patient's desire to avoid these donor sites, the authors use the transverse musculocutaneous gracilis flap if feasible. The authors retrospectively evaluated only patients where secondary autologous breast reconstruction was performed with a transverse musculocutaneous gracilis flap because of the prior mentioned reasons. Indications, limitations, advantages, and technique are discussed by sharing the authors' experience in 23 patients using 26 transverse musculocutaneous gracilis flaps. No flap loss could be observed in this series. In four patients, minimal lateral skin necrosis could easily be managed by débridement and primary wound closure. In 12 cases, subsequent lipofilling was performed for a better breast shape. On average, patient satisfaction was high. Secondary reconstruction after simple mastectomy using the transverse musculocutaneous gracilis flap requires a little more experience than after skin-sparing mastectomy but, especially combined with later lipofilling, can lead to an optimally shaped breast in selected patients with substantial skin laxity and fat distribution at the inner thigh. Therapeutic, IV.
Jeong, Euicheol C; Jung, Young Ho; Shin, Jin-yong
A 67-year-old-male patient visited our hospital for a mass on the soft palate of approximately 5.0 × 6.0 cm in size. He was diagnosed with adenoid cystic carcinoma and reconstruction after total palate resection was planned. After ablative surgery, a radial forearm free flap procedure was successfully performed to cover the hard and soft palates. However, wound disruption occurred twice during the postoperative period. When a palate defect is reconstructed using a soft tissue free flap, flap drooping by gravitation and the flap itself can generate irregularity in the lower contour of the palate and, in the long-term, insufficiencies of velopharyngeal function, speech, and mastication. To complement such functional and aesthetic problems caused by flap drooping, conventional prosthetics and new operative techniques have been discussed. However, overcoming wound disruption caused by flap drooping in the acute postoperative period has not been discussed. In this case, the temporary use of a palatal obturator during the postoperative period was beneficial after soft tissue reconstruction of the palate.
the costs of free and regional flap surgery, the reality in limited. Table 5: Variables ... tissue bulk, limited pedicle length and arc of rotation, as well as reduced shoulder ... Acknowledgment. Nursing Staff of the Department of OMFS, LASUTH.
Lindford, A J; Jahkola, T A; Tukiainen, E
Locally extensive recurrent breast cancer usually portends a poor prognosis but certain cases can be treated surgically by wide soft-tissue resection as well as full-thickness chest wall resection (FTCWR). The resulting defect usually necessitates immediate flap coverage. The aim of this study was to assess local control, morbidity, choice of flap reconstruction, patient selection and overall long-term survival following surgical salvage of patients with chest wall recurrent breast cancer. Forty patients were treated with wide soft-tissue resection and immediate flap reconstruction from 1984 to 2011 in a single institution. Demographic, treatment and mortality data were obtained from patients' files. Mean age at surgery was 54 years. FTCWR was performed in 19 cases including three extended forequarter amputations. Chest wall stabilisation involved a synthetic mesh in 12 patients, fascia lata in two patients, free rib grafts in one patient and synthetic mesh and free rib graft in one patient. Soft-tissue reconstruction consisted of microvascular free flaps in seven patients and pedicled flaps in 33 patients. In-hospital mortality was 0%, 30-day mortality was 5%; there were two re-operations, six minor wound complications and one pulmonary embolism. There were no flap losses. In patients operated on with curative intent (n=31) median disease-free interval was 31 months and median survival was 52 months. In selected cases wide resections for extensive chest wall recurrent breast cancer can result in reasonable local control and survival. Several flap options exist for soft-tissue reconstruction. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Young Sun You
Full Text Available Background A pectoralis major flap is one of the standard tools for the reconstruction ofdefects of the head and neck. Despite the technical advancement in free tissue transfer inhead and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked.The purpose of this study is to evaluate our 17 years of experience in reconstructing defectsof the head and neck region using the pectoralis major flap.Methods We retrospectively reviewed the medical records of 112 patients (120 cases whounderwent pectoralis major flap operations for head and neck reconstruction during a periodranging from 1994 to 2010.Results In our series, no total necrosis of the flap occurred. Of the total cases, 30.8% presentedwith flap-related complications. Major complications occurred in 20% of all of the casesbut were then all successfully treated. The male sex was correlated with the occurrence ofoverall complications (P=0.020 and major complications (P=0.007. Preoperative albuminlevels of <3.8 g/dL were correlated with the formation of fistula (P=0.030. Defects of thehypopharynx were correlated with the occurrence of major complications (P=0.019 and theformation of fistula (P=0.012. Secondary reconstructions were correlated with the occurrenceof overall complications (P=0.013 and the formation of fistula (P=0.030.Conclusions A pectoralis major flap is still considered to be a safe, versatile one-stagereconstruction procedure in the management of the defects of head and neck and theprotection of the carotid artery.
Victor Diniz de Pochat
Full Text Available Due to the complex three-dimensional structure of the nose, the repair of the nasal defect requires reconstruction of three different layers: skin envelope, osteocartilaginous framework and nasal lining. Before nasal reconstruction can be accomplished, the nose must rest on a stable platform to avoid late nasal obstructions, and septal deviations resulting from scar contraction. We present three cases of nasal reconstruction using a forehead flap in which we performed a preliminary stage to increase reliability of outcomes.
Børsen-Koch, Mikkel; Gunnarsson, Gudjon L; Udesen, Ann;
BACKGROUND: The latissimus dorsi (LD) flap is considered one of the working horses within the field of breast reconstruction and it offers several advantages. However, donor-site morbidity may pose a problem. This article describes a new and modified technique for delayed breast reconstruction co...... there is a learning curve, this simple modified technique does not demand any perforator or other vessel dissection. Any trained plastic surgeon should be able to adopt the technique into the growing armamentarium of breast reconstruction possibilities....
Chen, H; Zhou, N; Huang, X; Song, S
Currently the radial forearm fasciocutaneous flap and the anterolateral thigh flap are among the most popular free flaps used for reconstruction of oral soft tissue. However, there is controversy about their efficacy after reconstruction of tongue defects because of their respective intrinsic properties, so we have compared them in reconstruction of tongue defects using meta-analysis. We conducted a search in Pubmed, EMBASE, OVID, Science Direct, the Cochrane Library, and Chinese National Knowledge Infrastructure, which covered all papers published before January 2015. Twelve clinical papers, that included 366 patients with 198 radial forearm flaps and 168 anterolateral flaps, met the criteria. Relevant data were extracted and analysed using systematic meta-analyses. The results showed that the incidence of localised numbness at the donor site of the radial forearm flap postoperatively was significantly higher and satisfaction with the appearance of the donor site significantly lower than in the anterolateral thigh group. There were no differences in flap survival, incidence of vascular crises in the flap, complications, satisfaction with the appearance of the tongue, or the postoperative clarity of speech and swallowing ability. Results suggested that the anterolateral thigh flap is the ideal soft tissue flap for reconstructing defects in the tongue, as there was minimal numbness at the donor site and patients were much more satisfied. Further research is needed to address details of the site and the extent of surgical defects as well as the relations between dissection of the radial flap and repair of the skin graft. Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Mohamed Makboul; Mohamed Abdel-Rahim
Objective:To analyze the management of high-voltage electrical burn injury of the scalp in our hospital.Methods:This study involved 10 patients who suffered from high-voltage electrical burn injury of the scalp.Scalp reconstruction was done by different modalities according to the size and location of the defect.Results:Complete flap viability was achieved in all the cases.We had one case of gapped wound which was managed only by dressing.Widening of the scar was found in 2 cases.Conclusion:Rotation,advancement and transposition scalp flaps are used for reconstructing scalp defects caused by electrical burn.The choice of ideal flaps for reconstruction depends upon the size and site of scalp defect.
Yamamoto, Y; Minakawa, H; Kokubu, I; Kawashima, K; Sugihara, T; Satoh, N; Fukuda, S
The efficacy of osteocutaneous or vascularized bone flaps for reconstruction of massive skeletal and soft-tissue defects has been supported by recent descriptions in the literature. In this article we presented an alternative technique, which is the rectus abdominis myocutaneous flap combined with vascularized eighth and ninth costal cartilages, for reconstruction of midfacial composite defects. The vascular pedicle of the composite flap is the deep inferior epigastric artery and vein. The costal cartilages are supplied by the perichondrial vascular network through the anterior intercostal vessels connecting with the deep epigastric vascular system. Vascularized costal cartilages are considered to reduce the incidence of postoperative complications and resorption of this material. This technique is a useful tool for restoration of craniofacial contour in reconstructive head and neck surgery.
Biraima, A M; Käch, K P; Calcagni, M
Reconstruction of fingertip amputations, especially if they involve more than half of the fingernail require the surgeon to determine whether the fingernail should be removed. However, aside from aesthetic aspects the fingernail has functional purposes - stabilisation of the pulp and enhancement of sensibility - and should therefore be preserved. Since November 2004 we have been using the technique of combining palmar finger flaps with dorsal eponychial plasty in reconstructing complex distal fingertip defects in 12 patients. All flaps had an uneventful healing. One patient with insufficient bone support after a failed operation developed an onychogryphosis. The remaining patients were satisfied with the result. With a simple technique augmenting the palmar reconstruction of complex fingertip defects by the dorsal eponychial flap plasty we can achieve a better support for the pulpa and also a better cosmetic result.
Full Text Available A male cynomolgus monkey experienced extensive soft tissue trauma to the right caudal calf area. Some weeks after complete healing of the original wounds, the monkey developed a chronic pressure sore on plantar surface of the heel of its right foot. A loss of sensitivity in the sole of the foot was hypothesized. The skin defect was closed by a medial sensate pedicled instep flap followed by counter transplantation of a full thickness graft from the interdigital webspace. The integrity of the tibial nerve was revised and reconstructed by means of the turnover flap technique. Both procedures were successful. This is an uncommon case in an exotic veterinary patient as it demonstrates a reconstructive skin flap procedure for the treatment of a chronic, denervated wound in combination with the successful reconstruction of 2.5 cm gap in the tibial nerve.
Nektarios Sinis; Androniki Lamia; Helml Gudrun; Thomas Schoeller; Frank Werdin
There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons.The principle of connecting not only the vascular supply,but also sensitive nerves,in free tissue transfer is attractive.However,increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves "untreated".Nevertheless,in special cases such as breast reconstruction or extremity reconstruction,the question about sensory nerve coaptation of the flaps remains open.We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.
Ebrahimi, Ali; Motamedi, Mohammad Hosein Kalantar; Nejadsarvari, Nasrin; Ebrahimi, Azin; Rasouli, Hamid Reza
Objective: A variety of nasal skin reconstruction methods are available to meet the esthetic patient's needs. In this article, we review some of modifications of these procedures and share our experience in reconstruction of different parts of the nasal skin following skin tumor ablation. Patients and Methods: From January 2010 to January 2014, 171 patients underwent nasal skin reconstruction after excising cancerous lesions of the involved nasal skin. The patient's history, pre- and post-operation photographs, and the surgery data were collected and assessed. Demographic data related to the type of cancer, defect size and location, type of reconstruction were collected. Results: A variety of local flaps were used based on location and defect features. Nearly all flaps healed primarily without postsurgical significant complications. Conclusion: According to the results and the outcomes of the operations, we concluded that a certain flaps are more effective than others in nasal skin reconstruction. Local flap reconstruction of the nose has good esthetic result with low complication rate.
Extensive pulp (zone 4) defects of the thumb, with the exposure of tendon or bone, are challenging reconstructive problems. Surgical treatment includes the use of local, regional, and free flaps. The first dorsal metacarpal artery flap has been used successfully for defects of the thumb. The innerved first dorsal metacarpal artery flap from the dorsum of the index finger was first described by Hilgenfeldt and refined by Holevich. An island flap carried on a neurovascular pedicle consisting of the first dorsal metacarpal artery was first demonstrated by Foucher and Braun. Seven innervated FDMCA island flaps were performed from May 2005 until July 2007 for thumb reconstruction. There were three women and four men with an average age of 54.9 years (range 28–89 years). The mean follow-up period was 15.4 months (range 4–29 months). The dominant hand was involved in six (85.7%) patients. In a retrospective clinical study, the following criteria were evaluated: (1) etiology of the defect, (2) time of reconstruction (primary vs. delayed), (3) survival rate of flap, (4) sensory function (Semmes–Weinstein monofilaments, static 2-PD, pain, cortical reorientation), (5) TAM measured with the Kapandji index, and (6) subjective patient satisfaction (SF 36). Four patients presented with trauma, two patients with defects after tumor resection and one with infection of the thumb. The flap was used for immediate reconstruction in three (42.9%) patients and for delayed reconstruction in four (57.1%) patients. Delayed reconstruction was performed 4.75 (1–12) months after initial trauma or first surgery. The donor area was grafted with full-thickness skin grafts in all cases. All flaps survived. The mean SWMF was 3.31 g and average statis 2-PD over the flap was 10.57 mm. Pain at the flap scored 3.71 over 10 and at the donor site 2.17 over 10. Paresthesia at the flap scored 0.57 over 4 and at the donor site 0.33 over 4. Complete cortical reorientation was only seen in one
Fansa, H; Meric, C
Femoral nerve palsy, mostly of iatrogen cause, leads to paresis of quadriceps muscle with complete loss of knee extension. Therapeutical options include neurolysis, nerve reconstruction or functional muscle transplantations. Another concept is the transfer of hamstring muscles as described in post polio surgery. We describe our experience of biceps femoris and semitendinosus muscle transfer for reconstruction of knee extension. From 2003 to 2007 seven patients (mean age 43) with complete loss of knee extension after femoral nerve lesion were treated. Nerve palsy was caused by direct lesion, traction, hematoma after collapse, lesion of lumbosacral plexus and an unclear muscle dystrophy. Indication for muscle transfer was due to long standing muscle paresis. All patients received a transfer of biceps femoris and semitendinosus muscle/tendon into the quadriceps tendon. Patients were immobilised in a cast for 6 weeks in extended knee position. Weight bearing started after 8 weeks. Operations went uneventfully. All patients were able to extend the knee postoperatively against gravity and were able to climb stairs without help. 4 Patients had complete knee extension, 2 had a lack of 20 degrees , one of 30 degrees. Daily routine was possible in all cases. No instability of knee joints occurred postoperatively. In a nerve lesion close to the muscle a nerve reconstruction should be aimed. If not performed or with unsuccessful outcome, muscle transfer is a good option to restore function. All recent studies describe good to excellent results with stable knees, allowing the patient to manage daily routine without assistance and to climb stairs up and down. Long term complications such as dislocation of patella or genu recurvatum were not observed in our patients. The latter results as typical complication in polio from weakening knee flexion through biceps femoris transfer, if the gastrocnemius muscle is not forceful enough. However in an isolated femoral nerve lesion this
G.I.Nambi; Abhijeet Ashok Salunke; Szeryn Chung; K.S.Raj Kumar; Vikram Anil Chaudhari; Anant Dattaray Dhanwate
Descending branch of the lateral circumflex femoral artery (LCFA) is commonly used pedicle for anterolateral thigh (ALT) flap.Oblique branch of LCFA is an alternative pedicle that can be used in microvascular surgery.According to review of literature and to the best of our knowledge we could not find the use of oblique branch of LCFA as a pedicle of the ALT flap in regional soft tissue reconstruction.Here we presented a case of a 55-year-old man sustaining soft tissue injury and wound over the left trochanteric and gluteal region following a road traffic accident,who was treated by the use of extended ALT pedicle flap with oblique branch of LCFA as the pedicle for reconstruction of soft tissue defect in trochanteric and gluteal regions with successful outcome.
Full Text Available Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result.
Sato, Tomoya; Ichioka, Shigeru
Charcot foot is a serious complication of diabetes, characterized by deformity and overlying ulceration. The condition most commonly affects the midfoot. However, little information is available on the use of a medial plantar artery flap to treat diabetic midfoot ulceration. The purpose of the present study was to evaluate the versatility of ostectomy and medial plantar flap reconstruction for midfoot plantar ulceration associated with rocker-bottom deformity secondary to Charcot foot. Four patients underwent ostectomy and medial plantar flap reconstruction. Before flap reconstruction, the devitalized soft tissues and bone were radically resected. After the infection had been controlled, the ulcerated portion was minimally excised, and the bony prominence underlying the ulcer was removed. A medial plantar artery flap was applied to the ulcer. The donor site was covered with a split-thickness skin graft or artificial dermis. In all patients, the ulcers healed and independent ambulation was achieved. However, 1 patient experienced ulcer recurrence, and subsequent infection necessitated a major amputation. Limb salvage is challenging in the setting of deformity and intractable plantar ulceration. The advantages of medial plantar artery flap reconstruction are that tissues with a rich blood supply are used to cover the exposed bone, and the flap can withstand the pressure and shear stress of the patient's body weight. However, a dominant artery in the foot is sacrificed. Therefore, the patency of the dorsalis pedis artery must be confirmed in every patient. The results of the present study have demonstrated that a medial plantar artery can be an effective alternative for diabetic patients with a plantar ulcer secondary to Charcot foot.
Altındaş, Muzaffer; Arslan, Hakan; Bingöl, Uğur Anıl; Demiröz, Anıl
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.
Stillaert, F B; Casaer, B; Roche, N; Van Landuyt, K; Hamdi, M; Blondeel, P N; Monstrey, S
Release and reconstruction of axillary scar contractures can be challenging due to the specific anatomic site and contouring of the axillary region. Pliable and unscarred skin coverage of resulting defects after scar release is needed which enhances the postoperative recovery and revalidation. When traditional donor regions of fasciocutaneous flaps are involved in the scarred area, options are few. We describe the design and versatility of an inframammary extended lateral intercostal artery perforator (LICAP) flap to reconstruct an axillary defect after wide scar release and debridement. The postoperative recovery was uneventful with restoration of the range of motion of the shoulder joint.
Full Text Available It is difficult to reconstruct an alar defect with cartilage involvement. Here in the authors report a case of traumatic alar loss during childhood in which an alar reconstruction was carried out with a composite auricular graft put over the pedicle buccal flap which was rotated and passed through the intraoral side. The lining skin and auricular cartilage for the flap was obtained from the auricular region which was acceptable for the patient. All procedures were performed under general anesthesia. One year follow up revealed satisfactory results with minimal contracture of the graft.
Pourdanesh, F.; Khojasteh, A.
It is difficult to reconstruct an alar defect with cartilage involvement. Here in the authors report a case of traumatic alar loss during childhood in which an alar reconstruction was carried out with a composite auricular graft put over the pedicle buccal flap which was rotated and passed through the intraoral side. The lining skin and auricular cartilage for the flap was obtained from the auricular region which was acceptable for the patient. All procedures were performed under general anesthesia. One year follow up revealed satisfactory results with minimal contracture of the graft. PMID:22509460
Jes Christian Rødgaard
Full Text Available Coverage of large soft tissue defects at the hip region constitutes a challenge for plastic surgeons. We report the case of a 43-year-old female with necrotizing fasciitis of the right thigh, necessitating hip exarticulation and substantial debridement of necrotic tissue. An ipsilateral horizontal rectus abdominis myocutaneous (HRAM flap was used to cover the defect. The reconstruction was carried out after the attempt of local tissue rearrangement. In light of the successful outcome, we propose that this flap be considered in the future planning of soft tissue reconstruction at the hip region.
Albert H. Chao
Full Text Available Sarcomas of the gluteal region often result in sizable defects following resection that are challenging to reconstruct due to their location, particularly in patients who have received radiation therapy. Reconstruction of these defects has been seldom discussed in the literature. We present two patients with large radiated gluteal defects following sarcoma resection, of which one patient received neoadjuvant radiation and the other received intraoperative radiation therapy. As a result of the resection and radiation, local tissues and recipient vessels were unsuitable for use in reconstruction. A pedicled tensor fascia lata (TFL flap was therefore performed in both cases, which resulted in durable sensate reconstruction with good functional outcomes and no complications. We believe the pedicled TFL flap represents an important option for the reconstruction of oncologic gluteal defects that provides well-vascularized and sensate tissue from outside the zone of radiation without the need for microsurgical techniques.
Hara, I; Gellrich, N-C; Duker, J; Schön, R; Fakler, O; Smelzeisen, R; Honda, T; Satoru, O
Swallowing, speech, and morbidity were assessed postoperatively in 25 patients, 18 of whom had had intraoral defects reconstructed by lateral upper arm free flaps (LUFF) and 7 by radial forearm free flaps (RFFF). Video fluoroscopy was used to assess swallowing, the Freiburger audiometric test to assess speech; and measurement of arm circumference to assess donor site morbidity. A questionnaire was used to evaluate swallowing, speech, and donor site morbidity subjectively. The degree of impairment in swallowing depended on the site of resection. Anterior and posterior resections affected swallowing more than lateral resections. Anterior resection and the use of LUFFs reduced intelligibility. There was no significant difference in impairment between LUFF and RFFF. We conclude that the LUFFs are superior to RFFFs because they can be closed primary and the incidence of donor site morbidity is slight.
Qi, W; Chen, K J
Amputation or degloving injuries of the thumb or index finger are highly disabling. We describe the use of twin dorsal middle finger flaps harvested from the dorsal aspects of the middle and ring fingers, and based on one palmar proper digital artery, its venae comitantes, and the dorsal branches of the palmar digital nerves of the middle and ring fingers, respectively. These flaps offer advantages when large soft tissue defects of the thumb or index finger are present. In this study, twin dorsal middle finger flaps were used in nine patients (six thumbs, three index fingers). All flaps completely survived. At the mean follow-up of 20 months, the appearance of the reconstructed thumbs or index fingers was acceptable, the length was maintained, and the mean static 2-point discrimination values were 10 mm in the palmar flap and 13 mm in the dorsal flap of the reconstructed digit. All patients were satisfied with the appearance and mobility of the donor fingers. All but one donor finger showed normal finger pulp sensibility, with a static 2-point discrimination between 3 and 6 mm.
Vikas Deep Goyal
Full Text Available A 50-year-old male patient, a known case of chronic obstructive pulmonary disease (COPD, presented with the features of bronchopleural fistula (BPF on the right side for 1 month. The patient was a chronic smoker and did not give any history suggestive of pulmonary Koch′s. The patient had sudden-onset breathlessness and chest pain 1 month before, which was diagnosed to be due to spontaneous pneumothorax. An intercostal drain was inserted but even after 1 month of all conservative measures, the lung remained collapsed and there was large air leak in the intercostal drain. Computed tomogram (CT of the chest revealed collapsed and entrapped lung with surgical emphysema of the subcutaneous tissues due to rupture of the emphysematous bulla on the right side along with the presence of emphysematous bullae on the left upper lobe also. Surgical intervention in the form of decortication of entrapped lung and repair of the BPF with intercostal muscle flap was performed. The patient recovered well and was discharged after 10 days.
Gdalevitch, Perry; Van Laeken, Nancy; Bahng, Seokjae; Ho, Adelyn; Bovill, Esta; Lennox, Peter; Brasher, Penelope; Macadam, Sheina
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.
Chahine, Karim A; Chaffanjon, Philippe; Bettega, Georges; Lebeau, Jacques; Reyt, Emile; Righini, Christian A
Reconstruction flaps following major head and neck cancer surgery should consider the state of tissue at the recipient site. This study presents the cumulative experience of the use of the gastro-omental free flap (GOFF) for pharyngeal reconstruction in cases with unfavourable recipient site conditions. The GOFF reconstruction procedure and postoperative follow-up are described in details, and the functional results are analysed retrospectively. Fifteen patients underwent GOFF reconstruction. Previous treatments included radiotherapy, chemotherapy and surgery. Postoperatively, two patients (13%) developed partial flap necrosis, and four (27%) patients developed fistula and flap stenosis. On the functional level, eight (53%) patients developed oesophageal speech at different levels of audibility, and all patients developed oral alimentation ranging from a mixed diet with supplements to a regular oral diet. The GOFF is characterised by multiple survival advantages that favour its use in the presence of inhospitable recipient site conditions. (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Girish Rao, S; Aditya, T N; Gopinath, K S; Anand, Krishna
The defects secondary to surgical ablation of the mandible have far reaching consequences. Speech, respiration, mastication, deglutition and cosmesis are severely affected. Restoring these functions is a challenging task. Till the late eighties, myocutaneous flaps were the rule for mandibular reconstruction and free bone was used to restore bony continuity.In spite of the result being predictable the outcome left much to be desired. There was also a fairly regular crop of complications. Acceptable dental rehabilitation was almost non-existent. With the introduction of free flaps as a consequence of the development of the operating microscope, the field of reconstruction was revolutionized.The fibular free flap is especially suited for mandibular reconstruction. It provides adequate bone to re-establish bony continuity and also allows for the placement of osseointegrated implants.Here we present six of our cases, which underwent mandibular reconstruction with free fibula flaps and the current thoughts in literature on the reconstruction of the mandible with this technique.
de Pochat, Victor Diniz; Alonso, Nivaldo; Ribeiro, Emilie Barreto; Figueiredo, Bruno Suffredini; de Magaldi, Eduarda Nilo; Cunha, Marcelo Sacramento; Meneses, José Valber Lima
Reconstruction of nasal defects is challenging because it requires covering skin, supporting framework, and lining. Traditionally, the forehead flaps are transferred in 2 stages; however, it can be accomplished in a single stage or in 3 stages. Few published studies are available about the paramedian forehead flap using the intermediate stage (3-stage) and the aesthetic subunits principle. The purpose of this study is to evaluate the use of the paramedian forehead flap in 2 and 3 stages for nasal reconstructions, highlighting the indications, complications, and technical details and evaluating the patient's satisfaction through a questionnaire about the quality of life (Derriford Appearance Scale 24). A retrospective review was performed between 2011 and 2013 for a consecutive series of 11 patients who underwent nasal reconstructions using the paramedian forehead flap in 2 or 3 stages. All preoperative and postoperative data were collected, and outcomes were also assessed through a questionnaire about the patients' postoperative quality of life. The causes of nasal lesions varied among skin cancer, trauma, and infection. Two-stage paramedian forehead flap reconstruction was performed upon 4 patients, whereas the 3-stage reconstruction was performed for 7 patients. Of the 10 survey respondents, 6 were highly satisfied (score of 11-27), and 4 were moderately satisfied (score of 28-44), whereas no one was dissatisfied after his/her surgical nasal reconstruction procedure. Whether the approach is accomplished in 2 or 3 stages, all areas of the reconstructed nose must be firmly supported. Applying the nasal subunits principle seems to contribute to an overall satisfied population in our study, according to the score obtained by the questionnaire about quality of life.
Lin, Huang; Tang, Ping-zhang; Li, Sen-kai
To reconstruct tracheal defect after tumor excision, we used the contralateral musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum. The contralateral musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum was used to reconstruct the tracheal defect when the blood supply to the ipsilateral sternocleidomastoideus was destroyed because of lymphonode clearing or radiotherapy. The pedicle of the musculo-periosteum flap was dissected adequately and the blood supply was protected carefully. All flaps survived with epithelization and osteogenesis. The endotracheal tubes were pulled out safely without trachea stenosis in all the patients. The contralateral musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum could reconstruct the tracheal defect when the ipsilateral blood supply was damaged. This method extends the application of the musculo-periosteum flap.
Langer, Martin F.; Roldán, J. Camilo
Background: The ala of the nose is vascularized by a dense net of perforators originating from the lateral nasal artery or the angular artery. These vessels reach the ala in a cascade fashion from the alar groove/lateral nasal wall. Based on these vessels, a V/Y flap can be dissected with a wide range of mobility. Materials and Methods: Nineteen patients underwent reconstruction of the nose by means of a V/Y-alar-perforator flap alone or in combination with a myocutaneous rotation flap from the lateral nasal wall and/or from the nasal dorsum for reconstruction of defects at the nasal tip, ala of the nose, and/or lateral nasal wall. All patients were followed up 8 months after surgery in average. Results: There was no prolonged congestion or any tissue loss. All patients presented postoperatively with excellent aesthetic results, and no nasal distortion was observed. Conclusion: The V/Y-alar-perforator flap alone or in combination with a myocutaneous rotation flap proved to be a reliable tool in the armamentarium for reconstruction of nasal tip and alar defects providing good aesthetic results. PMID:28203497
Feinendegen, Dominik L; Langer, Martin F; Roldán, J Camilo
The ala of the nose is vascularized by a dense net of perforators originating from the lateral nasal artery or the angular artery. These vessels reach the ala in a cascade fashion from the alar groove/lateral nasal wall. Based on these vessels, a V/Y flap can be dissected with a wide range of mobility. Nineteen patients underwent reconstruction of the nose by means of a V/Y-alar-perforator flap alone or in combination with a myocutaneous rotation flap from the lateral nasal wall and/or from the nasal dorsum for reconstruction of defects at the nasal tip, ala of the nose, and/or lateral nasal wall. All patients were followed up 8 months after surgery in average. There was no prolonged congestion or any tissue loss. All patients presented postoperatively with excellent aesthetic results, and no nasal distortion was observed. The V/Y-alar-perforator flap alone or in combination with a myocutaneous rotation flap proved to be a reliable tool in the armamentarium for reconstruction of nasal tip and alar defects providing good aesthetic results.
Daniel L. Ching
Full Text Available BackgroundHidradenitis suppurativa (HS is a chronic skin condition that can affect any area with apocrine sweat glands and has the potential to involve multiple sites concurrently. Commonly affected sites include the axilla, groin, perineum and perianal areas. In this study we performed a literature review on the surgical methods for HS and describe an innovative technique for reconstructing axilla HS using an inner-arm transposition flap.MethodsWe reviewed all cases (5 cases from 4 patients of transposition flap reconstruction performed by the senior author at a single London tertiary hospital from 2008–2013. Patient related outcome measures were collected using the Derriford appearance scale (DAS 24 and a study specific questionnaire.ResultsAll patients were satisfied with their final result. One out of five cases had a complication but did not result in flap failure. There is no disease recurrence to date. DAS 24 scores collected demonstrated acceptable postoperative distress that did not deviate far from the norm tables while study specific questionnaire reveal desirable outcomes.ConclusionsWe have managed to achieve our aim through the use of the innovative inner-arm transposition flap. Our study hopes to provide an additional technique for axillary reconstruction. This technique offers the effective concealment of scars with the benefit of tightening of the arm tissue producing ‘brachioplasty like’ effects. All things considered it would be reasonable to conclude the innovative flap technique is a reliable, effective, and simple method that results in multiple benefits.
Namin, Arya W; Varvares, Mark A
The purposes of this article were to review the literature regarding subjective outcomes, objective functional outcomes, and objective sensation return after sensate and/or insensate free flap reconstruction of the oral cavity and oropharynx. Sensate radial forearm and anterolateral thigh free flaps tend to have better static 2-point discrimination and pressure threshold sensitivity than insensate flaps. There is insufficient evidence to draw conclusions on whether sensate flaps improve functional speech and swallowing outcomes measured by videofluoroscopic swallowing studies and percentage of word intelligibility by a listener blinded to the study. These data highlight the complexity and number of variables affecting functional outcomes in patients who have undergone reconstructive surgery after oral and oropharyngeal cancer ablative operations. A prospective randomized multicenter study that properly and rigidly stratifies patients by defect, flap and recipient nerve choice, adjuvant therapies, and uses widely agreed upon pretreatment and posttreatment evaluation tools could help to answer this important question. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016. © 2016 Wiley Periodicals, Inc.
Maciejewski, Adam; Ulczok, Rafał; Dobrut, Mirosław; Szumniak, Ryszard; Półtorak, Stanisław
The extended latissimus dorsi flap (LD) is used in breast reconstruction since the 70's. LD flap is often used in corrective surgery in cases of unsatisfactory cosmetic results after breast-conserving therapy. In our department LD flap has several uses. In addition to free microvascular flaps - which applies in breast reconstructive surgery is routine, there are clinical situations where the use of pedicled LD flap is justified. The main indications for its use are: the inability to apply microvascular flap, the general condition (diabetes, advanced atherosclerosis), smoking, previous surgery of abdominal wall, abdominal obesity, patient preferences. Approximately 30% of patients after breast reconstruction require corrective procedures. Group which uses extended LD flap account for 24 patients. In 16 cases it was used for elective breast reconstruction. In the remaining eight cases it was used in the corrective procedures symmetry and shape of the previously reconstructed breast. Based on our own experience it can be concluded that the LD flap with an alternative to microvascular techniques. Complication rate when using the LD flap is relatively low and includes: seroma and slight motor disability of the shoulder girdle.
Smith, G I; Brennan, P A; Scott, P J; Ilankovan, V
We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech. The selection of free flap did not correlate with speech function (P=0.44), swallowing (P=0.68), or management of saliva (P=0.59). No significant difference was found between the patients' outcome and the site of resection of the tumour. There were more complications after gastro-omental flaps and this may influence the choice of reconstruction.
Hsiao, Hung-Tao; Leu, Yi-Shing; Lin, Chang-Ching
Thirty-three patients with squamous cell carcinoma of the anteriolateral part of the tongue underwent a 50 percent resection of the tongue. The surgical defect was reconstructed with a microvascular radial forearm flap. All the flaps were especially designed to have a narrow waist, shaped like an omega in cross-section, thus allowing for a free tongue tip, and avoiding suturing the edge of the flap to the soft palate and tongue base. Sixteen patients were evaluated for swallowing and speech function at least 6 months following reconstruction. With this technique, the majority of the patients had nearly normal deglutition, although their speech was still unsatisfactory. However, the speech function in this series was better than that in other reported series.
Full Text Available Reconstruction of the neck following a burn injury poses a significant challenge to reconstructive burn surgeons. Here, we report a case of successful application of pre-expanded occipito-dorsal flaps in the reconstruction of postburn scars and contractures in the neck. The patient was a 10-year-old boy who sustained scars and contractures secondary to a burn injury 4 years ago. "Super-thin" flaps were obtained through pre-expansion in the occipito-dorsal area and then transferred to the recipient site. This approach resulted in an esthetic satisfaction and a significant functional improvement, thereby having significant clinical implications in the reconstruction of soft tissue damage secondary to burn injuries in the neck.
钱云良; 章一新; 张余光; 王丹茹; 关文祥
Objective To introduce a one stage technique in the reconstruction of mutilated hand with loss of thumb and eventual digits. Methods Tibialis anterior pediculated triple flaps (TAPTF) including distal lateral leg, dorsalis pedis flaps for skin defect covering and trimmed hallux for thumb reconstruction were presented.Results Mutilated hands in five patients were repaired by the technique with acceptable cosmetic and functional success. A three to twelve months follow-up in three patients resulted in the recovery of protective thermal sensation and pinch action of the reconstructed thumb. The donor sites were free from major disability. Conclusion TAPTF is ideal for one stage reconstruction of the mutilated hand with loss of digits.
Posch, Nicole A S; Mureau, Marc A M; Dumans, Antoine G; Hofer, Stefan O P
Extensive composite defects in the head and neck area may require the use of double free flap reconstructions. These reconstructions are not only surgically challenging but also challenging to patients. A realistic perspective on general outcome for the patient seems important. From January of 2002 to August of 2003, double free flap reconstructions were used in 12 patients with extensive composite head and neck defects following malignant tumor (n = 7) and osteoradionecrosis (n = 5) resection. Six patients had a standardized interview, physical examination, and clinical photographs. All reconstructions were performed using an osteocutaneous fibula flap in combination with an anterolateral thigh flap (n = 8), a radial forearm flap (n = 1), or a lateral thigh flap (n = 1). The total flap survival rate was 96 percent. Mean mandibular bone defects were 10 cm. Mean skin island sizes of osteocutaneous fibula flaps were 67 cm. Mean external skin reconstruction flap sizes were 117 cm. Mean overall survival time was 20 months in patients with malignant tumors. Patients with osteoradionecrosis reconstruction survived free of disease for an average period of 38 months. Three patients (50 percent) were very satisfied, one was neutral, and two were very dissatisfied with their functional and aesthetic results. Objective evaluation of function showed mainly deteriorated speech (83 percent) and oral incontinence (67 percent). Objective evaluation of aesthetics showed mainly color mismatch (67 percent) and flap contracture of external flaps (50 percent). Reconstruction of these major composite through-and-through defects will often result in a modest functional and aesthetic outcome. Because selected patients require these procedures, the authors give information that matches with realistic expectations.
David, Sylvain; Balaguer, Thierry; Baque, Patrick; Peretti, Fernand de; Valla, Maxime; Lebreton, Elisabeth; Chignon-Sicard, Berengere
In many plastic surgeries, a detailed understanding of the pectoral nerve anatomy is often required. However, the information available on the anatomy of pectoral nerves is sparse and unclear. The purpose of this study is to provide detailed anatomical information on the pectoral nerves to allow for their easy intra-operative localisation and to improve the understanding of the pectoral muscle innervation. We dissected 26 brachial plexuses from 15 fresh cadavers. The origins, locations, courses and branches of the pectoral nerves were recorded. We found three constant branches of the pectoral nerve. The superior branch travelled in a straight course to the pectoralis major to innervate the clavicular aspect. The middle branch coursed on the under-surface of the pectoralis major near the pectoral branch of the thoraco-acromial artery to innervate the muscle's sternal aspect. The inferior branch passed beneath the pectoralis minor muscle to innervate the pectoralis minor muscle and the costal aspect of the pectoralis major muscle. Knowing the pectoral nerves' origins, courses and connections, in addition to understanding the functional consequences of iatrogenically severing these nerves, leads to a better understanding of the pectoral muscle's innervation. Precise anatomical data on the pectoral nerve allow for its easy localisation during axillary breast augmentation, axillary dissection, removal of the pectoralis minor muscle and harvesting the pectoralis major muscle island flap. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Yang, Zengjie; Fan, Jincai; Tian, Jia; Liu, Liqiang; Gan, Cheng; Chen, Wenlin; Yin, Zhuming
The sideburn is an important feature of the facial profile in both women and men. Scars in the area around the sideburn and temple are difficult to conceal. Sideburn reconstruction is an especially challenging procedure for plastic surgeons because of the difficulty involved in acquiring high-quality tissue and achieving proper hair direction for a satisfactory appearance. This article describes how to utilize an expanded temporoparieto-occipital scalp flap for sideburn reconstruction, which results in satisfactory hair direction, inconspicuous scars in both the donor and recipient areas, and few complications. From August 2011 to April 2012, 11 patients underwent sideburn reconstruction treatments that involved the use of an expanded temporoparieto-occipital scalp flap. The likeness of hair color and density in the sideburn area was achieved, and the scars at the donor site were hidden in the post-auricular hairline. All of the patients were shown a satisfactory appearance, with few complications both on the recipient and donor site. An expanded temporoparieto-occipital scalp flap is an ideal flap to utilize in sideburn reconstructions because it results in satisfactory hair direction, inconspicuous scars at both the donor and recipient areas, and few complications.
Ueda, Koichi; Nuri, Takashi; Shigemura, Yuka
The Treacher Collins syndrome is characterized by both soft and hard tissue deficiencies. To reconstruct malar hypoplasia with both soft and hard tissues, we designed a new method using cartilage grafts, Y-V advancement flaps, and Z plasty with tissue expansion.
Mark A. Lee, MBBS, FRACS
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.
Hartman, E.H.M.; Damme, P.A. van; Sauter, H.; Suominen, S.H.
Three noma patients with large unilateral facial defects were reconstructed using the pedicled supraclavicular flap technique in the Noma Children Hospital in Sokoto, Nigeria. The results are-although not completely perfect-encouraging enough to report and to repeat the technique in future reconstru
Kang, Hyun Gu; Park, Myong Chul; Lim, Hyoseob; Kim, Joo Hyoung; Lee, Il Jae
Wide excision of cancer arising from the tonsillar fossa and soft palate has several functional sequelae (e.g., speech, swallowing, chewing, and breathing) that require surgical restoration of the pharyngeo-palatal structure and optimal velopharyngeal function. For this purpose, several kinds of surgical procedures have been introduced. Our method to reconstruct the tonsillar fossa and soft palate entails folding the flaps and reconstructions at the same time as the oral and nasal planes, with some modifications.Patient 1 was a 64-year-old man with left soft palate cancer. After wide excision of the tumor, the defect size of the nasal floor was 3 × 3 cm, and that of soft palate and tonsillar fossa was 8 × 5 cm. Patient 2 was a 49-year-old man with left tonsil cancer. The defect size of the nasal floor was 3 × 3 cm, and that of left lateral wall of the tonsillar fossa was 8 × 3 cm. For reconstruction of oral, nasal, and tonsillar plane, we designed the flap fit to the defect site, especially cutting of the edge of the square plane of the flap to a round shape.Both patients achieved good functional recovery without surgical complications. The average speech intelligibility score in the 2 patients was 10. Swallowing functional score was 4 in both patients. Creative reconstruction with modified radial forearm free flap for tonsillar and soft palate area makes it possible to restore velopharyngeal function to levels close to the preoperative condition.
Lodders, J.N.; Parmar, S.; Stienen, N.L.M.; Martin, T.J.; Karagozoglu, K.H.; Heymans, M.W.; Nandra, B.; Forouzanfar, T.
BACKGROUND: The aims of the study were 1) to evaluate the incidence and types of postoperative complications after ablative oral cancer surgery with primary free flap reconstruction and 2) identify prognostic variables for postoperative complications. MATERIAL AND METHODS: Desired data was retrieved
Lodders, J.N.; Parmar, S.; Stienen, N.L.M.; Martin, T.J.; Karagozoglu, K.H.; Heymans, M.W.; Nandra, B.; Forouzanfar, T.
BACKGROUND: The aims of the study were 1) to evaluate the incidence and types of postoperative complications after ablative oral cancer surgery with primary free flap reconstruction and 2) identify prognostic variables for postoperative complications. MATERIAL AND METHODS: Desired data was retrieved
Full Text Available In this report we present a case of blast injury to hand, including multiple metacarpal bone defect. Bone defects were reconstructed using fibular flap. Structural integrity of metacarpal bones was preserved with good functional results. [Hand Microsurg 2014; 3(1.000: 29-32
Meek, MF; Vermey, A; Robinson, PH; Lichtendahl, DHE; Roodenburg, JLN
The success rate of 56 free radial forearm flaps used between 1987 and 1995 in the University Hospital Groningen, The Netherlands for oral and oropharyngeal reconstructions in cancer patients, was evaluated. There were 36 men and 20 women. The most prevalent neoplasm was squamous cell carcinoma (n=5
Rahmi Evinc; Can Kopal; Dogan Bek; Muzaffer Durmus
In this report we present a case of blast injury to hand, including multiple metacarpal bone defect. Bone defects were reconstructed using fibular flap. Structural integrity of metacarpal bones was preserved with good functional results. [Hand Microsurg 2014; 3(1.000): 29-32
Full Text Available Abstract 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.
Kim, Jin-Hwan; Chu, Hyung-Ro; Kang, Jeong-Min; Bae, Woo-Jin; Oh, So-Jung; Rho, Young-Soo; Ahn, Hwoe-Young; Jung, Chul-Hoon
Objectives To compare the velopharyngeal function, swallowing and speech of the conventional and modified radial forearm free flap (RFFF) for soft palate reconstruction. Methods Retrospective clinical study. Twenty-eight patients who underwent oropharyngeal reconstruction with RFFF were divided into two groups: 10 patients had conventional folded RFFF and 18 patients underwent modified method. Results The average speech intelligibility score in modified RFFF group was 8.0?2.4, and 6.2?2.2 in ...
Jagdeep K Rao
Full Text Available Context: The most common malignant tumours of the face are basal cell carcinoma, squamous cell carcinoma and melanoma. While the results of skin graft are less than satisfactory for large areas to cover, distant flaps are bulky with a poor colour match. Local fasciocutaneous flaps provide reasonable option for reconstruction of facial defects with good colour and texture match and good success rate. Aims: This study aimed to analyse the various modalities of reconstruction after resection of facial malignancies and their advantages and disadvantages. Settings and Design: This was a retrospective study. Materials and Methods: Of 70 patients, 34 were managed with V-Y advancement flap, 24 with nasolabial flap, 8 with median forehead flap and 4 with standard forehead flap cover. The duration of follow-up ranged from 6 months to 2 years. Statistical Analysis Used: Nil. Results: Of 34 V-Y advancement flaps, 2 showed suture dehiscence at the apex of triangle which was allowed to heal secondarily with regular dressings. All the 24 nasolabial flaps were healthy without any complication. All patients had satisfactory functional and cosmetic outcomes. Conclusions: In our experience, local flaps give the best results and are the first choice for reconstruction of the face. Most defects can be best closed by nasolabial, V-Y advancement and forehead flap. Outstanding functional and cosmetic results can be achieved. Proper execution requires considerable technical skill and experience.
Ascioti, Anthony J; Hofstetter, Wayne L; Miller, Michael J; Rice, David C; Swisher, Stephen G; Vaporciyan, Ara A; Roth, Jack A; Putnam, J B; Smythe, W Roy; Feig, Barry W; Mansfield, Paul F; Pisters, Peter W T; Torres, Marla T; Walsh, Garrett L
Many patients with cancer have limited esophageal reconstruction options when the stomach is unavailable as a replacement conduit or when long-segment discontinuity exists. Jejunum has been used as an alternative conduit, both as a pedicled or free flap interposition; however, reports of this are usually limited to short-segment repairs. Microvascular augmentation of a pedicled jejunal flap allows creation of a longer conduit, making it possible to replace the entire esophagus with jejunum. Few reports describe this technique in patients with cancer. We report our initial experience with "supercharged" pedicled jejunum as an alternative conduit for total esophageal reconstruction. Review of a prospectively collected departmental database was performed to identify those patients who underwent total esophageal reconstruction with supercharged pedicled jejunum. Data regarding their perioperative course and postoperative function were gathered from the prospectively collected clinical data, review of hospital records, and patient interviews. Total esophageal reconstruction with supercharged pedicled jejunum was attempted in 26 patients (age range, 37-74 years) between March 2000 and April 2004. Twenty-four of 26 patients were ultimately discharged with an intact supercharged pedicled jejunum flap, for an overall success rate of 92.3%. One patient experienced intraoperative flap loss caused by technical difficulties harvesting the flap and never had the flap interposed. One other flap loss occurred in the early postoperative period in a patient who had multisystem organ failure after a prolonged reconstruction. Cervical anastomotic leaks occurred in 19.2% (5/26) of the patients. Two midconduit leaks occurred that were suspicious for iatrogenic perforation from nasogastric tube placement; one required reoperation. One additional early reoperation was performed for cecal ischemia. There were no mortalities. Functional results were available in 95.4% (21/22) of the
Figus, Andrea; Mazzocchi, Marco; Dessy, Luca Andrea; Curinga, Giuseppe; Scuderi, Nicolò
Unusual and probably underestimated complications following breast reconstruction with a latissimus dorsi (LD) flap and sub-pectoral implant are the LD muscle twitching and the breast contour deformities from pectoralis major (PM) muscle contraction. Surgical muscle denervation is usually indicated for these complications. Botulinum toxin A (BTX-A) infiltration has been described in reducing breast contour deformity in sub-pectoral implant after breast augmentation or reconstruction. Between January 2002 and April 2006, 71 consecutive patients underwent delayed unilateral breast reconstructions with LD flap and sub-pectoral implant after mastectomy. All patients reporting discomforting signs and symptoms from muscle contraction in the reconstructed breast were included in this prospective study. Thirteen patients (18.3%) were selected and treated with BTX-A percutaneous local injections. Signs and symptoms were evaluated, after 4, 8 and 12 months, by the patients and by a panel of three physicians not involved in the study, using a five-point scale. During the study period all patients reported a decrease or disappearance of the signs and symptoms. After 12 months, 11 patients received three BTX-A infiltrations, demonstrating considerable improvements compared to the pre-treatment status. Wilcoxon matched pairs rank sum test showed a statistical difference between pre-treatment and post-treatment scores after 14 days (P<0.01) and 12 months (P<0.001). Our experience shows that muscular contraction deformities after breast reconstruction with a LD flap plus implant are not uncommon complications. The use of BTX-A infiltrations is an effective, not surgical, low cost and low risk procedure to treat these complications. It is an easy procedure to be performed on an outpatient basis with a temporary effect but safely repeatable and reproducible; it avoids hospitalisation or further surgical procedures and demonstrates tolerable latency with satisfactory outcomes.
de Vicente, Juan Carlos; de Villalaín, Lucas; Torre, Aintzane; Peña, Ignacio
The purpose of this study was to evaluate tongue function and donor site morbidity in patients with oral cancer surgically treated and reconstructed with radial or anterolateral thigh free flaps. Twenty patients underwent primary reconstruction after hemiglossectomy between January 2002 and June 2004. Ten patients were reconstructed using a free forearm flap and the remaining with an anterolateral thigh flap. Eight patients on each group underwent postoperative radiotherapy (average, 60 Gy). All of them were followed postoperatively to determine after 6 months their functional outcome as it related to speech, deglutition, tongue mobility, and donor site morbidity. The intelligibility, deglutition, and tongue mobility were each scored on a scale ranging from 1 to 7 by an independent investigator. Data were analyzed by the 2-tail Mann-Whitney U test. No differences in mean speech intelligibility, tongue mobility, or deglutition mean scores were seen between radial forearm flap and anterolateral thigh flap (P > .05). In all anterolateral thigh flap-treated cases, the donor site was closed directly and no complications were seen. However, in all forearm flaps donor site closure was carried out with skin grafts and dorsal forearm splinting was applied for 1 week postoperatively. In 4 cases a partial skin graft failure was observed and donor sites healed for second intention. Anterolateral thigh flap, with its versatility in design, long pedicle with a suitable vessel diameter, and low donor site morbidity, could be the ideal flap for hemiglossectomy defect reconstruction.
Maeda, T; Oyama, A; Funayama, E; Yamamoto, Y
Treacher Collins syndrome (TCS) is a rare genetic disorder leading to congenital craniofacial malformations. Although this syndrome presents with various symptoms, corrective surgery for bilateral microtia with low hairline is one of the most challenging operations given the complex contours of the external ear. In this technical note, a novel, simple procedure for dealing with the low hairline by using a hinged mastoid fascial flap simultaneously with costal cartilage grafting is described. Several techniques for the reconstruction of low hairline microtia have been reported previously, such as skin graft, skin flap, and tissue expander, but the high number of repeat operations and residual scars remain problematic. As a simultaneous procedure with framework grafting, the use of a temporoparietal flap with skin grafting is popular; however, its drawbacks include the operative scar, decreased hair growth, and hair thinning. Patients with TCS show anatomical variations of the superficial temporal vessels supplying the temporoparietal flap. In contrast, due to the high vascularity of the mastoid fascia, the mastoid fascial flap can be elevated safely and easily as an anteriorly, posteriorly, superiorly, or inferiorly based flap.
LU Yao-jun; HONG Guang-xiang; XU Nan-wei; HU Zhi-yong; SHAO Lei
Objective: To investigate the clinical curative effect of reconstruction of finger pulp defect by anastomosis of reversed fasciocutaneous island flap with dorsal branch of the digital nerve of the same finger. Methods: The restoration of finger pulp defect with fasciocutaneous island flap from the same finger was conducted in 25 cases (30 fingers) from January 2002 to June 2003. Nine patients (11 fingers) whose flaps with dorsal branch of the digital nerve anastomosed with the digital inherent nerve around the surface of the wound were Group A and the others were Group B. The follow-up was carried out at 3 and 9 months after the operation to observe the shape of finger pulp and the sense restoration between two groups.Results: All flaps of 25 cases (30 fingers) survived. Three months after operation, the patients had fully grown finger pulps and recovered the superficial sensation and tactile sense of finger pulps. The two point discrimination on average was 5.00 mm ± 0.23 mm in Group A and 6.00 mm ± 0.30 mm in Group B. The difference between two groups was highly significant. Nine months later, their senses of finger pulps between two groups were recovered basically. Conclusions:The reversed fasciocutaneous island flap from the same finger is the first choice to reconstruct the finger pulp defect, and the anastomosis of dorsal branch of the digital nerve shall be determined according to the specific condition.
Lee, Sang Hyun; An, Sung Jin; Kim, Nu Ri; Kim, Um Ji; Kim, Jeung Il
Severe forefoot deformities, particularly those involving the dorsum of the foot, cause inconvenience in daily activities of living including moderate pain on the dorsal aspect of the contracted foot while walking and difficulty in wearing nonsupportive shoes due to toe contractures. This paper presents clinical results of reconstruction of severe forefoot deformity using the anterolateral thigh (ALT) free flap. Severe forefoot deformities were reconstructed using ALT flaps in 7 patients (8 cases) between March 2012 and December 2015. The mean contracture duration was 28.6 years. All the flaps survived completely. The size of the flaps ranged from 8 cm × 5 cm to 19 cm × 8 cm. The mean follow-up period was 10 months (range, 7 to 15 months). There was no specific complication at both the recipient and donor sites. There was one case where the toe contracture could not be completely treated after surgery. All of the patients were able to wear shoes and walk without pain. Also, the patients were highly satisfied with cosmetic results. The ALT flap may be considered ideal for the treatment of severe forefoot deformity.
Jian-Xia; Cheng; Lan; Zuo; Xin-Yu; Huang; Ji-Zhe; Cui; Shuai; Wu; Yuan-Yuan; Du
· AIM: To reconstruct the extensive full-thickness defects of eyelids is a challenge for the plastic surgeon because of their complex anatomy and special functions.This article presents and discusses an improved surgical technique in which the orbicularis oculi myocutaneous flap is rotated through a "subcutaneous tunnel" in conjunction with a palatal mucosal graft employed for lining.·METHODS: Data from 22 eyes with extensive full-thickness eyelid defects from various causes between2009 and 2013 were analyzed in this study. After the different layers of eyelid were separated completely, a temporally based orbicularis oculi myocutaneous flap was designed following fishtail lines and was mobilized,leaving the base of the pedicle intact with a submuscular tissue attachment. The flap was then rotated through a "subcutaneous tunnel" to the defect, and the donor site was closed primarily. Posterior lamellar reconstruction was performed with a mucosal graft harvested from the hard palate.·RESULTS: All the flaps were survived without any healing problems. There was no corneal irritation, flap contraction, or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible.The defects were repaired completely, and the evaluations showed satisfactory function and appearance.·CONCLUSION: This technique is an improved singlestage operation and can be applied to repair large, full-thickness eyelid defects from various causes. With our method, the functional and aesthetic results can be obtained in either the upper or lower eyelids.
Patel, Urjeet A; Hartig, Gregory K; Hanasono, Matthew M; Lin, Derrick T; Richmon, Jeremy D
Objective To review state-of-the-art modifications and advances in soft tissue local and regional flap reconstruction of the oral cavity and to determine the role these techniques play in current practice. Data Sources Review of the literature regarding oral cavity reconstruction. Review Methods The authors describe advances in locoregional reconstructive options and assimilate data from the literature that compare recent advances to the historic standards. Conclusions Modern advances in regional reconstruction of the oral cavity offer outstanding results and demonstrate potential advance over free tissue transfer. These modifications demonstrate the prominent role that regional reconstruction can play in oral cavity reconstruction. Implications for Practice With a more complete understanding of these options, the surgeon is better able to tailor the reconstruction to the needs of the patient to provide high-quality cost-effective care.
O. G. Oseni
Full Text Available Lip reconstruction following resection for tumour or following extensive trauma may pose a challenge. This is more so when the resection is total and a complete lip has to be constructed. We present a case of lip reconstruction following a total resection of the upper lip. The procedure used in this case was a combination of bilateral nasolabial flaps with a submental flap and buccal mucosal graft lining. We believe that this provides an alternative method of total upper lip reconstruction with minimal disruption of the facial aesthesis.
Full Text Available To compare the long-term clinical outcomes of postmastectomy radiotherapy (PMRT between breast cancer patients with and without immediate transverse rectus abdominis myocutaneous (TRAM flap reconstruction.The study included 492 patients with stage II or III breast cancer who underwent modified radical mastectomy (MRM and chemotherapy followed by PMRT between 1997 and 2011. Cox regression model and Kaplan-Meier curves were calculated, and the log-rank test was used to evaluate the differences between overall and disease-free survival rates in the 2 groups.Among 492 patients, 213 patients had immediate TRAM flap reconstruction. The mean follow-up was 7.2 years (range, 11-191 months. The 5-year and 10-year disease free survival rates were 81% and 76% for the TRAM flap group and 78% and 73% for the non-flap group. The 5-year and 10-year overall survival rates were 89% and 73% for the TRAM flap group and 83% and 74% for the non-flap group.There exists no statistically significant difference in the rates of local recurrence, distant metastasis, disease-free and overall survival when comparing immediate TRAM flap reconstruction with no reconstruction. Our results suggest that immediate TRAM flap reconstruction does not compromise long term clinical outcomes in breast cancer patients requiring PMRT.
Bi, Hongda; Xing, Xin; Li, Junhui
Nasolabial flaps have been widely used for nasal reconstruction. However, transposition of the nasolabial flap to lower nasal defects may be challenging because of functional and aesthetic concerns. The upper part of the alar crease joins with the nasolabial fold seamlessly, forming the nasolabial-alar crease line, which provides a natural strategy for easy concealment of the surgical scar. In this article, we would like to introduce a method for transferring a nasolabial flap along the nasolabial-alar crease to reconstruct lower nasal defects. Incision was made along the nasolabial-alar crease, and the nasolabial flap was transferred for lower nasal reconstruction in 9 patients. Subcutaneously based nasolabial flaps were designed, and undermining of the superolateral skin was made along the nasolabial-alar crease to obtain a robust subcutaneously based pedicle, so as to readily achieve flap transposition without tension and concealment of the subcutaneous pedicle. The nasolabial fold could be reproduced by closing the donor site. Lower nasal defects were successfully repaired with nasolabial flap in 9 patients. Good nasal contour and appropriate symmetry of the reconstructed nasolabial fold were achieved, and there were no conspicuous scars in the 9 cases. The natural nasolabial-alar crease can serve as a useful incision line to facilitate the nasolabial flap transposition for lower nasal reconstruction while minimizing the scar.
Ling, Bin; Abass, Keremu; Hu, Mei; Yin, Xiaopeng; Hu, Lulu; Lin, Zhaoquan; Gong, Zhongcheng
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.
Full Text Available Fistulae between an ileal pouch and the vagina are an uncommon complication of ileal pouch-anal anastomosis following proctocolectomy and mucosectomy in patients with familial adenomatous polyposis coli. Several reports describe the successful use of muscle flaps to close recurrent pouch-vaginal-fistulae (PVF. However, series only contain small numbers and an optimal management has not yet been determined. We report the case of a 26-year old woman with a third recurrence of a PVF after proctocolectomy for treatment of familial adenomatous polyposis in October 2005. Because local approaches failed, definitive closure of the fistula was achieved by interposition of a gracilis muscle flap between the pouch-anal anastomosis and the vagina. The postoperative course was uneventful; the patient was discharged 7 days after surgery and remained free of recurrence and symptomatic complaints for 22 months now. The gracilis muscle flap proved to be an effective method in the treatment of recurrent PVF.
Malata, Charles M.; Nicholas Grant Rabey
Introduction The deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed ou...
Nikolaos Papadogeorgakis, Vlasios Oktseloglou, Eleni Pappa, Petros Spyriounis
Full Text Available Large defects of the maxilla, following ablative surgery, significantly affect functions such as chewing, swallowing, speech and also the aesthetics. Reconstruction of soft tissues and bone defects can be achieved, either with the use of an obturator, or with free flaps. In the literature there is no sufficient evidence on the primacy of the one or the other method. The choice depends on the judgment, the experience and the ability of the surgical team. In recent years, the use of anterolateral thigh (ALTfree flap for reconstruction of large defects of the maxillary region, has gained a lot of popularity. The vastuslateralis free flap (VL is a variation of ALT. VL’s advantages include long pedicle, easier harvesting, and fewer anatomical variations. We present a case of a 75 year old male with recurrent squamous cell carcinoma of the medial canthal region, invading the maxillary bone, the medial wall and the floor of the orbit. The patient underwent a total maxillectomy, orbital exenteration, and reconstruction with vastus lateralis free flap.
Deschler, D G; Doherty, E T; Reed, C G; Anthony, J P; Singer, M I
Tracheoesophageal voice restoration after laryngectomy is possible with a variety of neopharyngeal reconstructions. We have used the tubed radial forearm free flap for neopharyngeal reconstruction since 1991. Six patients have undergone voice restoration with the Blom-Singer prosthesis and were available for quantitative and qualitative speech analysis. These patients were compared to five laryngectomy patients with standard pharyngeal closures and similar voice restorations. The free flap patients produced similar loudness levels compared to the standards with soft speech (52.06 dB and 47.19 dB, respectively) and loud speech (62.66 dB and 60.91 dB, respectively). The free flap patients demonstrated adequate intelligibility, with fundamental frequencies comparable to standards (124.82 Hz and 135.66 Hz, respectively), although with increased jitter (5.00% versus 1.96%). No differences were statistically significant, but evaluation by trained and naive listeners demonstrated significant differences in voice quality. This quantitative and qualitative and qualitative analysis of tracheoesophageal speech after radial forearm free flap reconstruction of the neopharynx demonstrates that acceptable voice can be achieved, but with limitations.
Akashi, Masaya; Hashikawa, Kazunobu; Sakakibara, Akiko; Komori, Takahide; Terashi, Hiroto
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.
Weitz, J; Bauer, F J M; Hapfelmeier, A; Rohleder, N H; Wolff, K-D; Kesting, M R
Mandibular reconstruction with a fibular free flap has become standard in specialised centres for head and neck reconstruction, particularly for defects with more than one osteotomy that are challenging even for experienced surgeons. Virtual surgical planning is a potential tool to facilitate harvesting of the fibula and the osteostomy. The purpose of this study was to compare the two methods of mandibular reconstruction - conventionally planned (conventional group) and "virtually" planned (virtual group) - with regard to accuracy, bony consolidation, complications, and operating time. Fifty patients who required mandibular reconstruction after segmental mandibulectomy were evaluated retrospectively, 24 virtually planned and 26 conventionally planned. The overall survival of flaps was 92% (46/50). The bony consolidation rate in the virtual group was significantly better than that in the conventional group (p=0.002). The difference between the angle of the mandible before and after was highly significant with a median of 11.5° (range 2°-75°) in the conventional group and 4.5° (range 0-18°) in the virtual group (p=0.0001). Operations were mean (SD) of 34 (21.2) minutes shorter in virtually-planned cases (p=0.12). The overall morbidity did not differ significantly between the groups. The use of virtual surgical planning in mandibular reconstruction by fibular free flap is beneficial for optimising accuracy, consolidation of bony segments, and operating time, while increasing the predictability of results for the surgeon. However, additional costs have to be carefully weighed against the benefits.
Zhang, Peipei; Li, Rui; Liu, Yiming; Kan, Quancheng
Background This study investigated the quality of life of Chinese patients with tongue cancer who had undergone immediate flap reconstruction surgery. In addition, we compared 2 groups of patients: those who had received radial forearm free flap (RFFF) surgery and others who had received pectoralis major myocutaneous flap (PMMF) surgery. Material and Methods Patients who received RFFF or PMMF reconstruction after primary tongue cancer treated with total and subtotal tongue resection were eligible for the current study. The patients’ demographic data, medical history, and quality of life scores (14-item Oral Health Impact Profile (OHIP-14) and the University of Washington Quality of Life (UW-QOL) questionnaires) were collected. Results A total of 41 of 63 questionnaires were returned (65.08%). There were significant differences between the 2 groups in the gender (p< .05). Patients reconstructed with RFFF performed better in the shoulder domains, in addition to worse appearance domains. Conclusions Using either RFFF or PMMF for reconstruction of defects after tongue cancer resection significantly influences a patient’s quality of life. Data from this study provide useful information for physicians and patients during their discussion of reconstruction modalities for tongue cancers. Key words:Quality of life, radial forearm free flaps, pectoralis major myocutaneous flap, tongue cancer, oral function. PMID:27694786
Varvares, M A; Cheney, M L; Gliklich, R E; Boyd, J M; Goldsmith, T; Lazor, J; Baron, J C; Montgomery, W W
Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.
Khan, K; Hinckley, V; Cassell, O; Silva, P; Winter, S; Potter, M
The buccinator musculo-mucosal island or Zhao flap can be used to reconstruct a wide range of intra-oral defects including floor of mouth, tonsillar fossa and lateral tongue. We describe our experience with the inferiorly based facial artery buccinator musculo-mucosal flap for a novel use in the reconstruction of oropharyngeal tumours at the tongue base and lateral pharyngeal wall. We prospectively reviewed all patients who underwent buccinator musculo-mucosal island flap reconstruction examining indication, operative details, and post-operative outcomes. We describe our technique for its novel use in lateral pharynx/tongue base reconstruction through neck dissection access. Deeper flaps were adequately visualised and monitored using flexible nasoendoscopy. There were no flap failures with all patients achieving primary healing with minimal complications. All donor sites closed directly with minimal scarring. Two patients reported mild tightness on mouth opening and two patients reported transient weakness of the mandibular branch of the facial nerve. In our experience the buccinator musculo-mucosal island flap is an extremely versatile 'like for like' local flap option due to its long arc of rotation. As inset can be achieved via neck dissection access, this avoids lip/jaw split as per conventional oropharyngeal surgical management further minimising morbidity. We present the first series of its effective use in oropharyngeal reconstruction. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Nirav P Trivedi
Full Text Available Introduction: Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India. Materials and Methods: This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed. Results: We performed 22 cases of free flaps in a six-month period (2008-2009. Majority (17 of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9 and anterolateral thigh flap (ALT: 9 were the most commonly used flaps. A fibula flap (1 was done for an anterior mandible defect, whereas a jejunum free flap (1 was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps. Conclusion: Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.
C. Márquez Zevallos
Full Text Available Los traumatismos de miembros inferior representan un reto importante para el cirujano plástico en cuanto a su reconstrucción cuando no se dispone de técnicas microquirúrgicas. En el presente trabajo se presentan 2 casos de reconstrucción de rodilla con doble colgajo muscular de gemelo, en los que se demuestra que se pueden utilizar simultáneamente los dos gemelos sin dejar ninguna secuela estética importante ni funcional en la deambulación de los pacientes. Hasta donde podemos conocer, no existe en la literatura nacional ni internacional un reporte de casos con esta aplicación, ya que siempre se ha empelado un solo músculo precisamente por el temor a alterar la función de flexo-extensión del pie.Lower limb traumatism has always been a problem for plastic surgeon when in the moment of the surgical reconstruction we have not microsurgical techniques. In this paper, we present 2 cases of knee reconstruction using a double gemelar muscular flap, showing how is possible the simultaneous use of the two muscles without aesthetic or functional sequels. As we know, there is no national or international report of cases with this muscular reconstruction; it has been usual to use only one muscle, in order to avoid problems in the flexo-extension movements of the foot.
Koreyuki Kurosawa, MD
Full Text Available Summary:. Reconstruction following total laryngopharyngectomy with total glossectomy (TLPTG is challenging. To reconstruct this extended range of mucosal defect, it is necessary to overcome the remarkable discrepancy of apertures of oral and esophageal sides. We report a case of reconstruction surgery for total laryngopharyngectomy with total glossectomy with a funnel-shaped rectus abdominis musclocutaneous flap. The patient recovered without major complications and could keep a relatively good swallowing function. We believe this simple method should contribute to cases with complicated ablation.
Li, Wenlu; Xu, Zhongfei; Liu, Fayu; Huang, Shaohui; Dai, Wei; Sun, Changfu
This study investigated the quality of life of Chinese patients with malignant tumors who had undergone immediate free flap reconstruction surgery. In addition, we compared 2 groups of patients: those who had received radial forearm free flap surgery and others who had received free anterolateral thigh perforator flap surgery. Quality of life was assessed using the Medical Outcomes Study-Short Form-36 (MOS SF-36) and the University of Washington Quality of Life (UW-QOL) questionnaires 12 months after reconstruction. A total of 121 of 163 questionnaires were returned (74.2%). There were significant differences between the 2 groups in the T classification (p free anterolateral thigh perforator flaps performed better in the appearance and shoulder domains, and the role emotion and social functioning domains. Using either radial forearm free flaps or free anterolateral thigh perforator flaps for reconstruction of head and neck defects after cancer resection significantly influences a patient's quality of life. Copyright © 2013 Wiley Periodicals, Inc., A Wiley Company.
Bonde, Christian; Khorasani, Hoda; Højvig, Jens
because of the well-known side effects of NSAID treatment (bleeding/gastrointestinal ulcers). However, COX-2 inhibitors have been suggested to increase flap failure rates. We report our experience in using COX-2 inhibitors as part of our post-operative MOSA after ABR using free flaps. MATERIALS......BACKGROUND: A key component of modern analgesics is the use of multimodal opioid-sparing analgesia (MOSA). In the past, our analgesic regime after autologous breast reconstruction (ABR) included either NSAID or a selective cyclooxygenase-2 (COX-2) inhibitor. COX-2 inhibitors are superior to NSAIDs...... focus on reoperations due to bleeding/haematomas and flap thrombosis/failure. Comparisons between the COX-2 inhibitor and NSAID were made. RESULTS: Median age, ischaemia time, blood loss and operating time were similar in the two periods. Significantly, more patients were re-operated because of post...
Ogawa, Rei; Ono, Shimpei; Akaishi, Satoshi; Dohi, Teruyuki; Iimura, Takeshi; Nakao, Junichi
Background: It is difficult to completely resect huge anterior chest wall keloids and then close the wound directly. We report here our retrospective analysis of our case series of patients with such keloids who underwent reconstruction with internal mammary artery perforator (IMAP) pedicled propeller flaps and then received postoperative high-dose-rate superficial brachytherapy. Methods: All consecutive patients with large/severe keloids on the anterior chest wall who underwent keloid resection followed by reconstruction with IMAP-pedicled propeller flaps and then high-dose-rate superficial brachytherapy in our academic hospital were identified. All cases were followed for >18 months. Donor site position, perforator pedicle, flap size, angle of flap rotation, complications, and recurrence were documented. Results: There were nine men and one woman. The average age was 37.9 years. The average follow-up duration was 28.7 months. The largest flap was 16 × 4 cm. The dominant perforators of the internal mammary artery were located in the sixth (n = 2), seventh (n = 5), eighth (n = 1), and ninth (n = 2) intercostal spaces. Twelve months after surgery, patients reported marked relief from keloid-associated pain and itching, except in two patients who underwent partial keloid resection; their remaining keloids were still troublesome but after conservative therapies, including steroid ointments/plasters, the keloids gradually ameliorated. Eighteen months after surgery, there was no keloid recurrence or new development of keloids on the donor site. Conclusions: IMAP-pedicled propeller flaps transfer skin tension from the anterior chest wall to the abdomen. Our series suggests that this approach combined with radiation therapy can control keloid recurrence.
Kyeong Tae Lee
Full Text Available Lymphedema is a common complication after mastectomy in breast cancer patients. Manytreatment options are available, but no treatment results in a complete cure. We report acase of lymphedema that occurred after modified radical mastectomy in a breast cancerpatient who showed objective improvement after delayed breast reconstruction with anlatissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer hadundergone modified radical mastectomy with axillary lymph node dissection and postoperativeradiotherapy 12 years previously. Four years after surgery, lymphedema developed andincreased in aggravation despite conservative treatment. Eight years after the first operation,the patient underwent delayed breast reconstruction using the extended latissimus dorsimyocutaneous flap method. After reconstruction, the patient’s lymphedema symptomsshowed dramatic improvement by subjective measures including tissue softness and feeling oflightness, and by objective measures of about 7 mL per a week, resulting in near normal rangesof volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayedbreast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful topatients with lymphedema after mastectomy. This may be a good option for patients who areworried about the possibility of the occurrence or aggravation of secondary lymphedema.
Kyeong Tae Lee
Full Text Available Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.
Yuanzhi ZHANG; Jianwei LI; Yanbing LI; Dan JIN; Jionghao CHEN; Shizhen ZHONG; Guoxian PEI
Developments of digital technology and three-dimensional (3D) reconstruction allowed a precise description of anatomic structures. With the introduction of Visible Human Project and Virtual Chinese Human (VCH) techniques, more detailed anatomic images could be obtained. Digitized visible models of these structures can be applied as a useful tool in clinical training. The aim of this study was to reconstruct the normal structures of thoracodorsal artery in 3D images and to establish the digitized visible models of latissimus dorsi myocutaneous (LDM) flap. The cross-sectional images from the four VCH datasets were reviewed to study LDM and thoraco-dorsal artery structures on a section-by-section basis. Next, two adult fresh cadaver specimens were perfused with lead oxide-gelatine mixture and subject to radio-graphic CT scanning on their torsos. The cross-sectional images from the CT images were reviewed to study thor-acodorsal artery structures. Three-dimensional computer-ized reconstructions of LDM flap structures were conducted from these datasets by using Amira 3.1 (TGS) software respectively. The 3D reconstructed visible models established from these datasets perfectly displayed the anatomic characteristics of LDM flap.
Alessandro Guido Actis
Full Text Available Purpose: To describe a reconstructive technique of the superior eyelid with flaps and free grafts after excision of a basal cell carcinoma. Methods: Single case report of a 79-year-old woman who presented to our hospital with a basal cell carcinoma of the upper eyelid margin with initial erosion. Results: A large and full-thickness excision of the carcinoma was performed. The reconstruction technique should be customized to the individual patient. In this case, the use of a full-thickness tarsal graft from the contralateral upper eyelid, followed by an ipsilateral bipedicled flap and finally by a skin graft, was an effective surgical procedure, performed in one stage, without complications, and with good functional and esthetic results. Conclusions: Malignant neoplasms represent the leading cause of plastic reconstruction in the orbital region. Surgical techniques must be individualized for each patient and for each type of carcinoma. Reconstructive techniques with free grafts and flaps yield excellent results in the orbital region, particularly when some advice and a few fundamental rules are followed, namely accurate hemostasis of the receiving graft bed by moderate use of diathermy, careful suturing of the edges, and application of a compressive dressing for at least 4 days. Postoperative complications are very rare.
WU Yi-qun; HUANG Wei; ZHANG Zhi-yong; ZHANG Zhi-yuan; ZHANG Chen-ping; SUN Jian
Background Functional reconstruction of the jaw defect due to tumor resection poses a challenging problem in maxillofacial surgery. The osteocutaneous fibula free flap in combination with simultaneous or second stage insertion of dental implants has exhibited growing popularity for such reconstructions. This study was aimed at evaluating the clinical status and the success rates of dental implants inserted in fibula-free flaps for orofacial reconstruction following ablation of tumors. Methods We conducted a clinical follow-up study based on 29 patients after oral tumor surgery, who received vascularized fibula bone grafts and endosseous implants for functional jaw reconstruction during a 5-year period. The follow-up protocol included clinical examination and radiological evaluation. The clinical records of the patients were reviewed retrospectively. Information on treatment modalities, dentition, implant parameters, and prostheses was collected and analyzed. Results In general, a high primary stability for implants placed into the free fibula grafts was achieved. The 1-year and 5-year cumulative survival rates of the implants were 96% and 91%, respectively, using the Kaplan-Meier method. The 1-year and 5-year cumulative success rates of implants placed into the fibula bone grafts were 95% and 87%,respectively. The main reasons for failure of the dental implants were infection, tumor recurrence and soft tissue proliferation. The fibula flap presents many advantages for implant placement, but its limited height sometimes makes implant-supported prosthetic rehabilitation difficult. Conclusions Vascularized fibula bone grafts provide a firm basis for the placement of dental implants in jaw reconstruction. Implants placed in fibula bone grafts were shown to integrate normally. The double-barrel technique, or increasing the height of the fibula flap by vertical distraction osteogenesis before implant placement in the mandible, is desirable from a functional and esthetic
Lam, Lisetta; Samman, Nabil
This was a systematic review of the current research on speech and swallowing outcomes and the factors affecting these outcomes after primary resection of tongue cancer and free flap reconstruction. A structured search in various electronic databases and relevant journals was performed. Retrieved articles were critically appraised in three rounds according to the level of evidence, the methodological quality, and the specific domain of speech and swallowing. A total of 21 articles were in the final review and the findings were categorized according to the area of tongue resection. For patients with resection and free flap reconstruction limited to either the oral tongue or the base of tongue (BOT), significant decline in speech and swallowing function was evident in the early postoperative phase, but the majority recovered close to preoperative level after 1 year. Poorer speech and swallowing outcomes were found following resections involving both oral and base of tongue (OBOT) regardless of the type of free flap reconstruction. Results overall were influenced by multiple factors including tumor size, area of resection, method of reconstruction and the use of adjuvant therapy. The use of free flaps in the immediate reconstruction of the tongue after tumor resection should aim at the maintenance of the mobility of the residual tongue and restoration of tongue bulk in order to optimize the recovery of speech and swallowing function. Future research in this field should employ standardized and reliable evaluation of speech and swallowing outcomes using multiple modalities in well-designed cohort studies with longer follow-up. Copyright © 2013 Elsevier Ltd. All rights reserved.
Full Text Available Background: Thumb is with a special role in hand function. Therefore, in addition to the significance of using thin, pliable, color-matched, and hairless cover in resurfacing the lesion in this area, recovery of sensation should also be taken into consideration. Materials and Methods: Thirteen patients with thumb degloving injuries were candidates for sensate reverse island radial forearm surgery. After transferring the flap, forearm lateral sensory nerve was sewn to the thumb digital nerve. At least for two years, these patients received regular diagnosis, and monofilament, static two point discrimination (S-2PD, and moving two point discrimination (M-2PD tests were taken from them.Results: Monofilament test did not show normal sensation recovery, at protective sensation threshold, in the parents. The difference between monofilament test and normal thumb was statistically significant (p<0.0001. In spite of this, the protective sensation was restored in all flaps after two years. According to the results from S-2PD and M-2PD tests, the restored sensation was at protective threshold or reduced, and the difference was statistically significant (p<0.0001.Conclusion: Given difficulties of performing free flaps, and also deficiencies of pedicle flaps, the forearm radial island flap is known as one of the primary choices in most of the thumb soft tissue and hand defects reconstruction, due to its advantages, especially restoring the sensation of the injured site.
Joo, Young-Hoon; Hwang, Se-Hwan; Park, Jun-Ook; Cho, Kwang-Jae; Kim, Min-Sik
The purpose of this study was to investigate the relationship between the radial forearm free flap (RFFF) volume changes and speech and swallowing outcomes. The study included 18 subjects with squamous cell carcinoma of the oral tongue. Average percentage changes in flap volume between 3 and 12 months was 19.2%. Postoperative free flap volume changes were significantly and negatively correlated with the word and sentence intelligibility (Y=-0.338X+43.641, r(2)=0.383, p=0.006 and Y=-0.246X+34.322, r(2)=0.321, p=0.014, respectively). A significant positive correlation was also found between word and sentence intelligibility and floor of mouth resected, postoperative irradiation. Postoperative flap volume changes between 3 and 12 months were correlated with reduced posterior bolus movement by tongue (p=0.002), reduced tongue base to posterior pharyngeal wall contact (p=0.002), reduced laryngeal elevation (p=0.005), increased aspiration (p=0.005), delayed oral (p=0.010) and pharyngeal transit time (p=0.011). Floor of mouth resected, tongue base resected, and postoperative irradiation also influenced the swallowing outcomes. This study shows that postoperative flap volume changes are significantly related to speech and swallowing outcomes in patients undergoing partial glossectomy reconstructed with RFFF. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Momeni, A; Krischak, S; Bannasch, H
High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.
Full Text Available The autors present a case of bilateral vulvar defects after abrasion of malignant skin neoplasm, reconstructed with a gluteal-fold perforator flap, resulting in a successful outcome.
van Gemert, Johannes; Holtslag, Irene; van der Bilt, Andries; Merkx, Matthias; Koole, Ron; Van Cann, Ellen
Segmental resection of the mandible causes functional, aesthetic and social problems affecting health-related quality of life (HRQoL). It is often assumed that reconstruction with composite free flaps guarantees better function and aesthetics than bridging the defect with reconstruction plates. Using the European Organization for Research and Treatment of Cancer questionnaires (EORTC QLQ-C30 version 3.0 and EORTC QLQ-H&N35), we compared HRQoL in patients who received free fibula flaps versus reconstruction plates after segmental resection of the lateral mandible. Thirty-seven completed questionnaires (18 fibula reconstructions and 19 patients with reconstruction plates) were available. Reconstruction with a free fibula flap did not provide clear additional benefit to bridging the defect with a reconstruction plate after segmental resection of the lateral mandible. In particular aspects known to have the most impact on HRQoL like swallowing, speech and chewing were not influenced by the type of reconstruction. Reconstruction of segmental defects of the lateral mandible with free fibula flap and reconstruction plate resulted in comparable HRQoL. If dental rehabilitation by means of dental implants is not anticipated in the fibula, then plate reconstruction with adequate soft tissue remains a suitable technique for the reconstruction of segmental defects of the lateral mandible. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Full Text Available Background Fingertip injuries involving subtotal or total loss of the digital pulp are commontypes of hand injuries and require reconstruction that is able to provide stable padding andsensory recovery. There are various techniques used for reconstruction of fingertip injuries,but the most effective method is functionally and aesthetically controversial. Despite somedisadvantages, cross-finger pulp flap is a relatively simple procedure without significantcomplications or requiring special techniques.Methods This study included 90 patients with fingertip defects who underwent cross-fingerpulp flap between September 1998 and March 2010. In 69 cases, neurorrhaphy was performedbetween the pulp branch from the proper digital nerve and the recipient’s sensory nerve forgood sensibility of the injured fingertip. In order to evaluate the outcome of our surgicalmethod, we observed two-point discrimination in the early (3 months and late (12 to 40months postoperative periods.Results Most of the cases had cosmetically and functionally acceptable outcomes. The averagedefect size was 1.7×1.5 cm. Sensory return began 3 months after flap application. The twopointdiscrimination was measured at 4.6 mm (range, 3 to 6 mm in our method and 7.2 mm(range, 4 to 9 mm in non-innervated cross-finger pulp flaps.Conclusions The innervated cross-finger pulp flap is a safe and reliable procedure for lateraloblique, volar oblique, and transverse fingertip amputations. Our procedure is simple to performunder local anesthesia, and is able to provide both mechanical stability and sensory recovery.We recommend this method for reconstruction of fingertip injuries.
Schiefer, Jennifer Lynn; Schaller, Hans-Eberhard; Rahmanian-Schwarz, Afshin
Distally based dorsal metacarpal artery (DMCA) flaps are an established technique for the reconstruction of extensive finger defects. In many cases, such defects also include an injury of the extension tendon over the proximal and distal finger joint, which can lead to a reduced range of motion or finger deformation such as boutonniére deformity. To prevent this, operative techniques are necessary that allow complete defect coverage while simultaneously stabilizing the extension apparatus. In two cases, DMCA flaps were combined with vascularized extensor indices tendons for the reconstruction of extensive dorsal finger skin and soft tissue defects, particularly when tendon and bone are exposed. After three weeks of postoperative immobilization, physiotherapy could be intensified. In a six months' follow-up, the results obtained from the standpoint of both function and appearance were excellent, the flaps remained viable at all times and full-finger length and sensory function were maintained. Regarding operation time, pain and finger appearance, both patients stated satisfaction. The vascularized tendon incorporated in DMCA flaps provides a sufficient method to restore a satisfactory finger function and prevent finger deformity, arthrodesis, or amputation, especially in cases with severe injuries of the extension apparatus.
J. A. Lozano
Full Text Available La reconstrucción mamaria autógena se realiza frecuentemente con tejido abdominal, ya que se obtiene el mejor resultado estético perdurable en el tiempo, con una nueva mama muy similar en textura, consistencia y ptosis a la contralateral. La secuela a nivel de la zona donante abdominal es el principal problema que plantea este tipo de reconstrucciones. Los colgajos de perforantes se desarrollan como el gran recurso para solventar dicho problema, ya que apenas dañan el músculo y su fascia. El colgajo DIEP (Deep Inferior Epigastric Perforator ha demostrado ser una alternativa reconstructiva destinada a gran cantidad de mujeres, con bajas tasas de complicaciones locales, debido a la falta de sacrificio del músculo recto abdominal, e importante grado de satisfacción por el resultado obtenido. Como inconveniente presenta su mayor dificultad técnica y la necesidad de un equipo quirúrgico que domine la microcirugía vascular. No obstante, el colgajo DIEP se presenta como una técnica quirúrgica con una demanda en importante ascenso.Autogenous breast reconstruction is frequently carried out with abdominal tissue, since a better and lasting aesthetic result is obtained, providing a new breast that is very similar in texture, consistency and ptosis to the contralateral breast. The main problem presented by this type of reconstruction is the sequel at the level of the donor abdominal area. Perforator flaps are being developed as the main resource for solving this problem, as they hardly damage the muscle and its fascia. The DIEP flap (deep inferior epigastric perforator has proved itself to be an alternative for reconstruction for many women, with low rates of local complications, due to the absence of any sacrifice of the abdominis rectus muscle, and a significant level of satisfaction with the result obtained. One drawback is its greater technical difficulty and the need for a surgical team that is expert in vascular microsurgery. However, the
Baas, Martijn; Duraku, Liron S; Corten, Eveline M L; Mureau, Marc A M
Tongue reconstruction after (hemi)glossectomy including sensory recovery is challenging. Although sensory recovery could improve functional outcome, no consensus on the need for reinnervation of the neo-tongue exists. Therefore, a systematic review was performed to determine if sensory reinnervation of free flaps in tongue reconstruction is better than no sensory reinnervation. The secondary study aim was to assess the effect of sensory reinnervation on overall functional outcome, such as speech and deglutition. Seven databases (Embase, Medline, Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar) were searched. Studies that reported the effect of sensory reinnervation on overall functional outcome were identified. Fourteen articles were included in the systematic review, concerning a total of 271 tongue reconstructions. Free flaps that were used were the radial forearm (RF) flap (n = 137), the anterolateral thigh (ALT) flap (n = 65), the rectus abdominis (RA) flap (n = 20), and the tensor fascia latae (TFL) flap (n = 5). Seven out of seven articles directly comparing sensory reinnervation with no sensory reinnervation revealed superior sensibility in the reinnervated group. Moreover, the innervated RF and ALT flaps showed superior recovery of sensibility compared to other flaps used for the reconstruction of hemiglossectomy as well as total glossectomy defects. There are indications that sensory reinnervation may have a beneficial effect on overall tongue function. Age, smoking, and sex did not affect sensory recovery. Four out of five articles showed that postoperative radiotherapy does not have a long-term adverse effect on sensory recovery. Sensory reinnervation of free flaps in the reconstruction of (hemi)glossectomy defects improves sensory recovery; however, evidence for beneficial effects on function is poor. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights
Bello, Seidu Adebayo
The case of a 65-year-old noma patient with a defect involving her upper lip is presented. The defect also included missing teeth numbers eleven, twelve, 21, and 22 and the adjoining alveolus. One-stage lip reconstruction was carried out with Gillies fan flap followed by vestibuloplasty and commissuroplasty. An acrylic partial denture was subsequently fabricated to replace the missing teeth and thereby restore function. Even though the incidence of cancrum oris has reduced worldwide, cases are still being reported in Africa and can leave behind a significant facial defect. Whereas most cases of lip defects reported from the Western world are due to cancer, cancrum oris could be the cause of lip defects in sub-Saharan Africa. Gillies fan flap could be employed for the reconstruction of a relatively large defect of the lip and the disadvantage of microstomia could be minimized for the restoration of articulation, speech, and masticatory functions of the lip. PMID:23674921
Bater, M C; Brennan, P A; Mellor, T K; Tilley, E
An unsuspected severely stenosed common carotid artery that compromised a free flap for mandibular reconstruction is described. To our knowledge no one has advocated the assessment of the carotid tree before transfer of free tissue. We suggest that patients with several risk factors for peripheral vascular disease should have colour flow duplex imaging of the carotid system if transfer of free tissue is being considered.
Kim, Min Gyun; Lee, Seung Tae; Park, Joo Yong; Choi, Sung Weon
Background Osteoradionecrosis is a delayed complication from radiation therapy which causes chronic pain, infection and constant deformity after necrosis. Most of the osteoradionecrosis occurs spontaneously or after the primary oncologic surgery, dental extraction or by trauma of prosthesis. The treatment of osteoradionecrosis relies on both conservative measures and surgical measures. The fibular osteocutaneous free flap has become more popular choice for reconstruction of maxillofacial defe...
Huanlong, Liu; Zengtao, Wang; Wenlong, Zhang; Youmao, Zheng
To investigate the application of the dorsal metacarpal perforator sliding flap for web-space reconstruction in congenital syndactyly. According to the size and shape of skin defect at the web space after division operation of syndactyly, the corresponding intermetacarpal perforator sliding flap was designed. The edge of the flap was cut off, but its underlying tissue was not dissected. From May 2007 to November 2012, 28 web-spaces in 15 patients with syndactyly (10 male and 5 female) were reconstructed. All the 28 flaps survived completely. The flap size ranged from 3 cm x 2 cm to 1.5 cm x 1.0 cm. 14 cases with 26 flaps were followed up for 10-22 months (average, 14.5 month). The reconstructed web spaces had normal appearance and movement range. The 2-point discrimination distance was 9-13 mm (average, 11 mm). According to the Swanson Standard, 18 fingers were graded as excellent, 8 as good and 2 as fair (excellent and good, 92.6%, 26/28). Reconstruction of web-space in syndactyly with the dorsal metacarpal perforator flap has the advantages of easy handling, good cosmetic and functional results.
Goulão, João; Alves, João
An 86-year-old woman was referred for treatment of a lentigo maligna melanoma on the left earlobe, confirmed by cutaneous biopsy. The resulting surgical defect involved the earlobe's full thickness. The authors outline a simple method for reconstructing the entire lobe in one stage, without grafts, whilst offering a pleasant appearance. Earlobe deformity may be congenital or, more often, acquired due to trauma, burns or surgery. Ear lobules are an important reference point for facial symmetry and they serve decorative purposes like wearing earrings. Losing them represents an obvious aesthetic abnormality. Several methods developed to reconstruct this deformity have presented various advantages and disadvantages. PMID:27438210
Yin, Danhui; Tang, Qinglai; Wang, Shuang; Li, Shisheng; He, Xiangbo; Liu, Jiajia; Liu, Bingbing; Yang, Mi; Yang, Xinming
The aim of this study was to explore xenogeneic acellular dermal matrix (ADM) in combination with pectoralis major myocutaneous flap in hypopharynx and cervical esophagus reconstruction. A total of five patients were treated with this surgical method to reconstruct hypopharynx and cervical esophagus in Second Xiangya Hospital between January 2012 and April 2013. Four of them had hypopharyngeal carcinoma with laryngeal and cervical esophageal invasion, while the fifth patient with hypopharyngeal cancer had developed scars and atresia after postoperative radiotherapy. The defect length after hypopharyngeal and cervical esophageal resection was 6-8 cm, and was repaired by a combination of ADM and pectoralis major myocutaneous flap by our team. Interestingly, the four patients had primary healing and regained their eating function about 2-3 weeks after surgery, the fifth individual suffered from pharyngeal fistula, but recovered after dressing change about 2 months. Postoperative esophageal barium meals revealed that the pharynx and esophagus were unobstructed in all five patients. Xenogeneic ADM in combination with pectoralis major myocutaneous flap for hypopharynx and cervical esophagus reconstruction is a simple, safe and effective method with fewer complications. Nevertheless, according to the defect length of the cervical esophagus, the patients need to strictly follow the medical advice.
Full Text Available Seidu Adebayo BelloDepartment of Dental and Maxillofacial Surgery, State House Medical Center, Asokoro, Abuja, NigeriaAbstract: The case of a 65-year-old noma patient with a defect involving her upper lip is presented. The defect also included missing teeth numbers eleven, twelve, 21, and 22 and the adjoining alveolus. One-stage lip reconstruction was carried out with Gillies fan flap followed by vestibuloplasty and commissuroplasty. An acrylic partial denture was subsequently fabricated to replace the missing teeth and thereby restore function. Even though the incidence of cancrum oris has reduced worldwide, cases are still being reported in Africa and can leave behind a significant facial defect. Whereas most cases of lip defects reported from the Western world are due to cancer, cancrum oris could be the cause of lip defects in sub-Saharan Africa. Gillies fan flap could be employed for the reconstruction of a relatively large defect of the lip and the disadvantage of microstomia could be minimized for the restoration of articulation, speech, and masticatory functions of the lip.Keywords: Gillies fan flap, reconstruction, upper lip, noma
Full Text Available Background: The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to "abdominal wall friendly" techniques. This study has been undertaken to assess the abdominal wall function in patients with pedicled TRAM flap breast reconstruction. The entire width of the muscle and the overlying wide disk of anterior rectus sheath were harvested with the TRAM flap in all our patients and the anterior rectus sheath defect was repaired by a Proline mesh. Materials and Methods: Abdominal wall function was studied in 21 patients who underwent simultaneous primary unipedicled TRAM flap reconstruction after mastectomy for cancer. In all the patients, the abdominal wall defect was repaired using wide sheet of Proline mesh both as inlay and onlay. The assessment tools included straight and rotational curl ups and a subjective questionnaire. The abdominal wall was also examined for any asymmetry, bulge, or hernia. The minimal follow-up was 6 months postoperative. The objective results were compared with normal unoperated volunteers. Results and Conclusions: The harvesting the TRAM flap certainly results in changes to the anterior abdominal wall that can express themselves to a variable degree. A relatively high incidence of asymptomatic asymmetry of the abdomen was seen. There was total absence of hernia in our series even after a mean follow-up period of 15.5 months. A few patients were only able to partially initiate the sit up movement and suffered an important loss of strength. In most patients, synergists took over the functional movement but as the load increased, flexion and rotation performances decreased. The lack of correlation between exercise tests and the results of the questionnaire suggests that this statistically
Dmytro Unukovych, MD, PhD
Conclusion:. Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography may be advocated in patients with abdominal scars.
Kim, Raymond H; Randolph, Amanda H; Tirre, Conrad J; Morrey, Matthew; Jennings, Jason M
Cryogenic thermal necrosis after knee surgery is rare. We describe a patient who presented with an anterior knee soft tissue defect in conjunction with an extensor mechanism deficiency secondary to a cold thermal injury after an anterior cruciate ligament reconstruction. We treated the patient with a single stage surgical procedure combining patellar tendon reconstruction and soft tissue coverage utilizing the superficial portion of the patient's vascularized Achilles tendon attached to a medial gastrocnemius flap. The patient returned to unrestricted activities and has demonstrated this through a five year follow-up. Copyright © 2017 Elsevier B.V. All rights reserved.
Full Text Available Restoration of adequate cosmesis and preservation of sexual and urinary function are the main goals of penile reconstructive surgery following amputation for carcinoma. Split thickness skin grafts and oral mucosa grafts have been widely used for the creation of a pseudoglans with excellent cosmetic and functional results. The main drawbacks associated with the use of grafts are donor site morbidity, the lack of engorgement of the pseudoglans and the risk of poor graft take, which may lead to contracture and poor cosmetic results. In the present series the long term cosmetic and functional outcomes of glans reconstruction with an inverted distal urethral flap are described.
Kim, Jin-Hwan; Chu, Hyung-Ro; Kang, Jeong-Min; Bae, Woo-Jin; Oh, So-Jung; Rho, Young-Soo; Ahn, Hwoe-Young; Jung, Chul-Hoon
To compare the velopharyngeal function, swallowing and speech of the conventional and modified radial forearm free flap (RFFF) for soft palate reconstruction. Retrospective clinical study. Twenty-eight patients who underwent oropharyngeal reconstruction with RFFF were divided into two groups: 10 patients had conventional folded RFFF and 18 patients underwent modified method. The average speech intelligibility score in modified RFFF group was 8.0+/-2.4, and 6.2+/-2.2 in conventional RFFF group (Pspeech assessment and nasalance demonstrate a more favorable outcome in modified group than conventional group.
Funayama, Emi; Yamamoto, Yuhei; Furukawa, Hiroshi; Murao, Naoki; Shichinohe, Ryuji; Yamao, Takeshi; Hayashi, Toshihiko; Oyama, Akihiko
Full-thickness defects of the entire nasal ala, including the rim, can be challenging to reconstruct. A forehead flap may provide a more imperceptible and natural-appearing reconstructed nasal ala. Previously, many authors have insisted adding cartilaginous infrastructural support for an entire, full-thickness defect to keep the postoperative alar structure symmetrical. They finally use a forehead flap after thinning of the distal covering portion subcutaneously, possibly for a Caucasian-type nasal ala. However, Asian skin has a thicker and more compact dermis than that of Caucasian skin, and the Asian ala is rounder and thicker. There may be another approach for an Asian-type nasal ala. The authors propose the possibility of nasal alar reconstruction for an entire, full-thickness defect in Asians using a forehead flap without structural support. Six patients with entire full-thickness nasal alar defects treated with full-thickness forehead flaps above the periosteum without structural support were reviewed. Five patients demonstrated esthetically good to excellent outcomes in color, texture, and symmetry. Their nasal linings were reconstructed using mucoperiosteal flaps or mucosal grafts. One patient treated with a nasal lining using a local flap showed a fair result esthetically. Asians forehead above the periosteum has adequate thickness and supportability to reconstruct the entire full-thickness nasal ala in Asians. No cartilage support is necessary.
Di Rienzo, Alessandro; Iacoangeli, Maurizio; Alvaro, Lorenzo; Colasanti, Roberto; Nocchi, Niccolo; Di Somma, Lucia Giovanna Maria; Scerrati, Massimo
Temporalis muscle reconstruction is a necessary step during frontotemporal cranioplasty ensuing decompressive craniectomy (DC). During this procedure, scarring between the temporalis muscle and the dural layer may lead to complicated muscle dissection, which carries an increased risk of dura and muscle damage. At time of DC, temporalis muscle wrapping by an autologous vascularized dural flap can later on facilitate dissection and rebuilding during the subsequent cranioplasty. In a span of 2 years, we performed 57 DCs for different etiologies. In 30 cases, the temporalis muscle was isolated by wrapping its inner surface using the autologous dura. At cranioplasty, the muscle could easily be dissected from the duraplasty. The inner surface was easily freed from the autologous dural envelope, and reconstruction achieved in an almost physiological position. Follow-up examinations were held at regular intervals to disclose signs of temporalis muscle depletion. Twenty-five patients survived to undergo cranioplasty. Muscle dissection could always be performed with no injury to the dural layer. No complications related to temporalis muscle wrapping were recorded. Face asymmetry developed in four cases but it was always with bone resorption. None of the patients with a good neurological recovery reported functional or aesthetic complaints. In our experience, temporalis muscle wrapping by vascularized autologous dura proved to be effective in preserving its bulk and reducing its adhesion to duraplasty, thereby improving muscle dissection and reconstruction during cranioplasty. Functional and aesthetic results were satisfying, except in cases of bone resorption. PMID:24067769
Full Text Available Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014. A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM. Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years] had bilateral breast reconstruction. The majority (41, 74.5% underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5% occasions. Major surgical complications occurred in 6 (10.9% patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5% occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m2 and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P60 years were associated with higher complication rates.
Herman, Charles K; Benacquista, Teresa; Brindzei, Nelya; Berdichevsky, Max; Baum, Thomas; Strauch, Berish
Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic
Kim, Soung Min; Amponsah, Emmanuel K; Kim, Hui Young; Kwon, Ik Jae; Myoung, Hoon; Lee, Jong Ho
Ameloblastoma is the most common benign odontogenic tumor of the jaw, and expansional growth of a huge untreated ameloblastoma can result in disturbances in facial aesthetics and function, such as difficulty with mouth opening, swallowing, chewing, breathing, neurologic deficits, and pathologic fractures. Radical wide resection with safety margins and subsequent reconstruction is generally recommended. A fibular free flap (FFF) is commonly used to reconstruct the mandible in order to adequately restore both aesthetic appearance and function. The aim of this brief clinical report is to present a case of huge ameloblastoma after wide resection with free safety margins, and describe the immediate one-step mandibular reconstruction using a vascularized composite FFF. The sterolithographic( rapid prototype, RP) model, a wax pattern of the resected mandible, and a surgical fibular stent made from the wax pattern were constructed preoperatively. We suggest a standardized surgical protocol for mandibular reconstruction with FFF.
Agrawal, Mukta D; Thimmappa, Nanda Deepa; Vasile, Julie V; Levine, Joshua L; Allen, Robert J; Greenspun, David T; Ahn, Christina Y; Chen, Constance M; Hedgire, Sandeep S; Prince, Martin R
Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Elsherbiny, Magdy; Mebed, Ali; Mebed, Hassan
The aim of this study is to report on the patient's quality of life and outcomes after reconstruction of palatomaxillary defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and dental obturator. During the period between 2005-2007, 10 patients who had palato maxillary defects were immediately reconstructed using RFFF to restore physiologic oronasal separation. All patients were treated for malignant tumors of hard palate or maxilla and all had preservation of orbital floor. Vascular anastomoses were done with the facial vessels in the neck. All the patients underwent a lateral thigh split-thickness skin graft for closure of the donor site. Outcome measurements included post-operative assessment of flap survival and healing, speech, swallowing and diet evaluation and quality of life. Dental rehabilitation was done 3 months postoperatively for all patients. Flap survival was successful in all cases. In the first 2 weeks post operatively, 80% of patients had very good swallowing, speech and diet ability in the form of soft chewable foods and by the end of 6 months, all patients had very good swallowing and speech function and were able to eat all types of foods. Dental rehabilitation with obturator was easily applied and the presence of the flap did not interfere with its application. The technique improved chewing ability and cosmosis. Complications included, small oronasal fistula in 2 patients (20%) who required secondary sutures and delayed wound healing of donor site in one patient. RFFF for soft tissue reconstruction after maxillectomy is a reliable technique that provides a definitive physiologic separation between oral and nasal cavity. This allows very early improvement of speech and swallowing without being totally dependent on obturator. Dental rehabilitation to improve chewing and cosmoses can be done easily with minimal home care. Subsequently, the quality of life is markedly improved.
Hekner, D.D.; Roeling, TAP; van Cann, EM
The aim of this study was to investigate the vascular anatomy of the distal forearm in order to optimize the choice between the radial forearm free flap and the ulnar forearm free flap and to select the best site to harvest the flap. The radial and ulnar arteries of seven fresh cadavers were injecte
Moubayed, S P; L'Heureux-Lebeau, B; Christopoulos, A; Sampalis, J S; Letourneau-Guillon, L; Bissada, E; Guertin, L; Harris, P G; Danino, A M; Ayad, T
To determine whether the fibula free flap is the most frequently used osteocutaneous flap for mandible reconstruction, and whether it provides quality of life, depression and anxiety advantages. A systematic review of the public Medline database was conducted. Thirteen patients who underwent mandibular reconstruction at our hospital centre completed questionnaires to evaluate quality of life, depression and anxiety outcomes. The most frequently used free flaps are those of the fibula (n = 982), radial forearm (n = 201), iliac crest (n = 113), subscapular system (n = 50) and rib-serratus (n = 7). In our patient population, there was a trend towards a better quality of life in those with a fibula free flap. However, patients in this group were significantly younger than patients with other flap types (p = 0.025). Patients with a subscapular system free flap were more depressed (p = 0.031); however, they had large through-and-through defects. The flap used most frequently in the literature is the fibula free flap. Comparative quality of life data are lacking, and homogeneous populations should be used to reach significant conclusions.
Atiyeh, B S; Sfeir, R E; Hussein, M M; Husami, T
We present our experience at the American University of Beirut Medical Center with two diabetic patients suffering from large necrotic and infected foot ulcers. Both patients were ambulatory at the time of presentation despite their extensive wounds and were believed to have a useful limb with adequate protective sensation worth saving. Below-knee amputation was prevented in both cases by successful soft-tissue coverage of the ulcers using microvascular composite-tissue transfer a few days after performing a preliminary arteriovenous fistula with a long vein graft loop. The flap vessels were anastomosed end-to-end to the arterial and venous limbs of the divided arteriovenous loop. This reconstructive technique of difficult diabetic wounds of the lower extremity, though in two stages, may be safer than one long procedure in a high-risk patient. It is technically easier than long interpositional vein grafts at the same time as free-flap transfer or microvascular anastomoses with small and diseased vessels. It definitely provides more chance of success as larger vessels are used to supply the flap. It permits distension of the vein graft at normotensive physiologic pressures and allows testing the arterial anastomosis as well as the venous flow before final flap transfer. Above all, it allows extreme freedom in performing tension-free anastomoses away from the infected wound.
... It also does not involve cutting of the abdominal muscle and is a free flap. This type of ... NCI fact sheet Mammograms . What are some new developments in breast reconstruction after mastectomy? Oncoplastic surgery. In ...
Villarreal, P M; Monje, F; Gañán, Y; Junquera, L M; Morillo, A J
This anatomical study was carried out in order to discover the etiology of partial necrosis of the peroneus longus and brevis muscles after fibular osteocutaneous flap harvest. The vascular supply to the lateral compartment peroneal muscles was investigated in 10 fresh cadaveric lower limbs. The peroneal muscles are supplied by two principal sources arteries, the anterior tibial artery (ATA) and the peroneal artery (PA). The ATA is the dominant artery and supplies the proximal and middle thirds of these muscles. The PA is considered to be a supplementary vascular source and supplies the distal thirds of these muscles. After harvesting the PA in a fibular flap, regions of the peroneal muscles preoperatively vascularized by its branches become supplied through the anastomotic "choke" vessels between the ATA and the PA. Primary closure of the cutaneous defect increases the possibility of developing a pseudo-compartment syndrome with necrosis of the more precariously vascularized portions of the peroneal muscles. This complication is difficult to diagnosis early and the reason why we advocate that direct skin closure following composite harvest must be avoided. Moreover, conservation of the inferior and superior lateral branches of the ATA is imperative in order to preserve the peroneal muscles vascularization.
Charles M Malata
Full Text Available Introduction: The deep inferior epigastric artery perforator (DIEP free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. Methods: All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR by a single surgeon (CMM over 40 months were reviewed from a prospectively collected database. Results: Of the 112 consecutive breast free flaps performed, 25 (22% utilised two vascular pedicles. The mean patient age was 45 years (range=27-54. All flaps but one (which used the thoracodorsal system were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 minutes (range=468-690 mins. The median flap weight was 618g (range=432-1275g and the mastectomy weight was 445g (range=220-896g. All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.Conclusion: Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.
Liu, Zhi; Chen, Wenxian; Cui, Pengcheng; Gao, Penfei; Lou, Jiasheng; Zhong, Limei
To investigate the effect of the musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum on the reconstruction of extensiveness laryngotracheal defect. Retrospectively studied 49 patients, who admitted in our department from 1996 to 2005 years for severe laryngotracheal defect. There were 28 males and 21 females aged from 15 to 69 years old (mean age was 47 years old). The causes of laryngotracheal defect were laryngotracheal stenosis (31 cases) and surgery for thyroid carcinoma invading trachea (18 cases). All of 49 cases were treated with the graft of musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum and placed a silicon T-tube stenting for 3 to 6 months. All of 49 cases were successfully decannulated with recuperative normal airway patency and effective phonation. The follow up ranged from 2 to 10 years, and the effect of operation was steady. The musculo-periosteum flap of the sternocleidomastoideus with clavicular periosteum is an ideal graft for the reconstruction of cervical extensiveness tracheal defect.
Jeong, Euicheol C; Yoon, Sehoon; Jung, Young Ho
The radial forearm free flap is beneficial for reconstruction of large palatal defect with oronasal fistula.A 51-year-old male patient who had anterior palate defect including alveolus after the radiation therapy of malignant cancer on the nasopharyngeal area undertook the radial forearm osteocutaneous free flap to close the oronasal fisula and restore the alveolar arch. The small radial bone segment was fixed in the alveolar defect and vascular anastomoses were performed with facial vessels in neck. The donor site was closed with split thickness skin graft. All suture wounds in the oral and nasal side had healed primarily with no complication within 1 month. The patient was able to swallow soluble foods in the 3 weeks postoperatively without the leakage phenomena in the nose and decreased hypernasality nature in his speech. Grafted bone union at alveolus was confirmed by follow-up computed tomography scan. There was no complication at left forearm donor site with intact musculoskeletal function.Radial forearm osteocutaneous free flap is a versatile option for its capability of reconstruction in complicated defect of soft and hard plate with alveolar defect.
Pont, Luis Parra; Marcelli, Stefano; Robustillo, Manuel; Song, Dajiang; Grandes, Daniel; Martin, Marcos; Iglesias, Israel; Aso, Jorge; Laloumet, Iñaki; Díaz, Antonio J
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.
Alam, Daniel S; Vivek, Prashant P; Kmiecik, Joann
Laryngectomy with primary closure and tracheoesophageal prosthesis (TEP) voice rehabilitation has been the mainstay of the management of patients with advanced laryngeal malignancy. When adequate mucosal tissue is not available, pharyngeal reconstruction with free flaps can be utilized. The speech outcomes of these patients have been traditionally considered inferior based on the findings of a limited number of studies. We report the results of a review of our experience with radial forearm free flap (RFFF) reconstruction of extensive laryngopharyngectomy defects vs our institutional outcomes seen with primary closure. Retrospective review. All patients treated with laryngectomy procedures with either primary closure (28 patients) or RFFF (20 patients) reconstructions at the Cleveland Clinic from 2002 through 2007 were included. Blinded evaluation with statistical analysis of standard speech outcomes measures (maximal sustained phonation, fluent count) as well as qualitative variables are reported. Based on our data collection, the two groups are statistically indistinguishable. These findings support the utility and effectiveness of the RFFF in pharyngeal reconstruction in achieving good voice outcomes.
García-Rozado, Alvaro; Martín Sastre, Roberto J; López Cedrún, José L
The fibular free flap is seen as one of the foremost technical options in mandibular reconstruction, especially in those defects where long bone is required. Cases with squamous-cell carcinoma of the floor of the mouth with mandibular spread and subsequent segmentary mandibular removal are the cornerstone examples. A case of squamous-cell carcinoma of the whole floor of the mouth with mandibular invasion is reported. Radical resection of the floor of the mouth and bilateral mandibular horizontal ramus was performed, with a bony defect extending from angle to angle. The patient revealed an achondroplastic condition, with remarkable dwarfism and long-bone morphological alterations, that minimized the potential fibular length to transfer. A microsurgical reconstruction with an osteocutaneous fibular free flap was undertaken. The flap design was technically compromised by the forward bowing of the fibula and the ossification of the interosseous membrane. Specific intraoperative strategies for dealing with anatomic variations are discussed. The fibular free flap is an excellent technique for mandibular reconstruction. Morphological deviations can modify the design of the flap. Achondroplasia is not a deterrent in successful use of the free fibula flap for reconstruction of the head and neck in adequately selected cases.
Sirasanagandla, Srinivasa Rao; Nayak, Satheesha B.; Somayaji, Nagabhooshana S.; Rao, Mohandas K. G.; Bhat, Kumar M. R.
The extensor digitorum brevis muscle (EDB) is a practical option for use as an island flap or free flap when reconstructing soft tissue defects in the ankle as well as in the entire lower limb. It is frequently used to correct crossover toe deformity and other painful toe disorders. We evaluated the morphometry of the EDB in 44 formalin-fixed limbs. Length and width of the muscles were measured. Surface area was calculated as the product of length and width of the muscle. The length of each tendon was also measured from its origin to the point of distal attachment. Presence of any additional tendons was noted. Mean length, width, and surface area of the muscle were 7.39±0.71 cm, 4.1±0.37 cm, and 30.5±4.78 cm2 on the right side and 7.2±0.84 cm, 3.9±0.37 cm, and 28.4±5.35 cm2 on the left side, respectively. Morphometry of the tendons revealed that the tendon of the great toe had the highest mean length (9.5 cm) and the tendon of the fourth toe had the lowest mean length (6.3 cm). Four of the limbs studied (9.09%) had only three tendons. Three of the limbs studied (6.81%) had five tendons, and in one exceptional case (2.27%), six tendons were detected. These observations have significant value and are applicable to plastic and orthopedic surgery. PMID:24179695
Chang, Yang-Ming; Deek, Nidal Farhan Al; Wei, Fu-Chan
This article addresses trismus following head and neck cancer ablation and free flap reconstruction whether or not radiotherapy has been utilized. The focus is to achieve durable and favorable outcomes and avoid untoward results. To aid surgeons in fulfilling these goals, key factors, including adequate release surgery, optimal free flap selection and reconstruction, long-lasting results, and the untoward outcomes specific to trismus release and reconstruction surgery and how to avoid them have been investigated and discussed based on the authors' experience in this surgery. Copyright © 2016 Elsevier Inc. All rights reserved.
Okay, Devin; Al Shetawi, Al Haitham; Moubayed, Sami P; Mourad, Moustafa; Buchbinder, Daniel; Urken, Mark L
The purpose of this study was to describe the trends pertaining to the use of the fibula free flap for mandibular reconstruction during the past 10 years. A systematic review for publications on the fibula free flap in mandibular reconstruction in the PubMed and Scopus databases was performed from January 1, 2005 until December 31, 2014. Publications were classified by topic, number of patients, and country of origin. The study period was split into 2 periods. The first 5-year period was compared with the second 5-year period. Eighty-five publications were identified. There was an increase in publications regarding restorative decision making (11 vs 9), surgical techniques (13 vs 6), outcomes (20 vs 10), and computer-aided design and computer-aided manufacturing (CAD-CAM; 8 vs 2) in the second 5-year period. The number of patients reported also increased in publications on surgical techniques (1,085 vs 59), outcomes (777 vs 254), bisphosphonate-related osteonecrosis of the jaw and osteoradionecrosis (165 vs 28), and CAD-CAM (65 vs 15) in the second 5-year period. The United States, India, China, and Europe produced most of the publications. In the past 10 years, there was a surge in publications on the use of the fibula free flap for mandibular reconstruction. There was a 1.8-fold increase in the number of publications and a 3.4-fold increase in the number of patients undergoing this method of mandibular reconstruction in the second 5-year period. Publications from the United States, India, and China contributed to a large increase in the number of patients in the second 5-year period. More interest in CAD-CAM technology was seen in the second 5-year period that was not seen in the first 5-year period. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Magdy, Emad A
Reconstruction of intraoral mucosal defects following tumor ablative surgery can be a challenging problem. The objective of this study was to evaluate the use of the palatal island mucoperiosteal flap (PIMPF) in reconstructing intraoral defects resulting from ablative tumor resections. The study included eight consecutive patients who underwent primary reconstruction using the PIMPF following intraoral tumor resections in a 5-year period by a single surgeon at a tertiary referral institute. Patients included five men and three women ranging in age from 32 to 69 years. Four patients were smokers (averaging 40 pack-years). None had received prior irradiation therapy. Resultant surgical defects ranged in size from 6 to 16.5 cm(2) (mean 12.3 ± 3.9) and included areas of soft/hard palate, lateral pharyngeal wall, retromolar trigone and inner cheek. Final pathological findings revealed three benign and five malignant tumors, mostly from minor salivary gland origin. All patients began oral diet between postoperative days 1 and 4 (mean 2 days). All flaps survived well with good postoperative wound healing except one minor flap dehiscence that eventually healed by granulation tissue with no further surgery needed. All donor sites were completely healed by remucosalization within 5-13 weeks. No patients manifested permanent velopharyngeal insufficiency, speech impairment, or airway compromise after a follow-up period ranging from 13 to 56 months (mean 31.3 ± 15.9). The PIMPF was found to be an attractive single-staged versatile and reliable reconstructive option for postero-lateral oral cavity/oropharyngeal defects that provides well-vascularized, sensate mucosa with minimal morbidity.
Seikaly, Hadi; Rieger, Jana; Wolfaardt, John; Moysa, Gerald; Harris, Jeffery; Jha, Naresh
To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. Prospective cohort study. Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.
Laaksonen, Juha-Pertti; Rieger, Jana; Happonen, Risto-Pekka; Harris, Jeffrey; Seikaly, Hadi
The purpose of this study was to use acoustic analyses to describe speech outcomes over the course of 1 year after radial forearm free flap (RFFF) reconstruction of the tongue. Eighteen Canadian English-speaking females and males with reconstruction for oral cancer had speech samples recorded (pre-operative, and 1 month, 6 months, and 1 year…
Laaksonen, Juha-Pertti; Rieger, Jana; Happonen, Risto-Pekka; Harris, Jeffrey; Seikaly, Hadi
The purpose of this study was to use acoustic analyses to describe speech outcomes over the course of 1 year after radial forearm free flap (RFFF) reconstruction of the tongue. Eighteen Canadian English-speaking females and males with reconstruction for oral cancer had speech samples recorded (pre-operative, and 1 month, 6 months, and 1 year…
The radial forearm free flap with palmaris longus tendon provides a good functional lip with a reasonable aesthetics in our patient. The patient was satisfied with the result and there were no functional complaints such as drooling reported by him. We think that this flap could be a flap of choice for reconstruction of the large, full thickness lip defects.
León, X; Quer, M; Orus, C; Martínez, V; Serret, P; Burgues, Y J
The complications of the pectoralis major myocutaneous flap (PMMF) placed at cervical level, carried out in oncologic patients during the period 1984-1992 are reviewed. A total of 33 PMMF for reconstruction at the cervical level were carried out in 30 patients. Data referred to the age, sex, indication, technics, complications and evolution of the patients were analysed. The global rate of patients affected by complications was 67%, with a 17% of failures. Considering the 33 PPMF carried out, in 15 occasions there appeared fistulas (45%) and in other 8 cases dehiscence or partial necrosis (24%). In only one case a total necrosis of the flap appeared (3%). The appearance of complications significatively increased the hospital stay.
Li, X J; Tong, J; Wang, Y
To repair a complexly injured hand with composite loss of the thumb and the thumb web space in one stage, the combined transfer of a free second toe and a free deep inferior epigastric perforator flap was designed. It was used to simultaneously reconstruct the thumb and thumb web space of the injured hand in five cases. All flaps survived and there were no complications at any donor site after the reconstructions. In follow-up averaging 35.6 months, the final functional and cosmetic outcomes of the reconstructed thumbs and thumb web spaces were satisfactory. Results demonstrated that the combined transfer of a free second toe and a free deep inferior epigastric perforator flap is a valid method for simultaneous reconstruction of the thumb and the thumb web space of the injured hand.
Nikhil S. Panse
Full Text Available We make an attempt to define the safe extent of local perforator flap for lower limb reconstruction by comparing it with the limb length of the patient. The maximum flap length from the perforator was compared to the limb length in 35 patients using EPI info 6.04 D software. On comparison of flaps that were less than one-third of limb length to those which were more than one-third of limb length, the statistical values were significant. The odds ratio calculated was 6, which means that there is a six times more chance that a local perforator flap will necrose if it is more than one-third of the limb length as compared to a flap which is less than one-third of the limb length.
Han Gyu Cha
Full Text Available Background The most common complication of latissimus dorsi myocutaneous flap in breastreconstruction is seroma formation in the back. Many clinical studies have shown that fibrinsealant reduces seroma formation. We investigated any statistically significant differences inpostoperative drainage and seroma formation when utilizing the fibrin sealant on the site ofthe latissimus dorsi myocutaneous flap harvested for immediate breast reconstruction afterskin-sparing partial mastectomy.Methods A total of 46 patients underwent immediate breast reconstruction utilizing alatissimus dorsi myocutaneous island flap. Of those, 23 patients underwent the procedurewithout fibrin sealant and the other 23 were administered the fibrin sealant. All flaps wereelevated with manual dissection by the same surgeon and were analyzed to evaluate thepotential benefits of the fibrin sealant. The correlation analysis and Mann-Whitney U testwere used for analyzing the drainage volume according to age, weight of the breast specimen,and body mass index.Results Although not statistically significant, the cumulative drainage fluid volume was higherin the control group until postoperative day 2 (530.1 mL compared to 502.3 mL, but thefibrin sealant group showed more drainage beginning on postoperative day 3. The donor sitecomparisons showed the fibrin sealant group had more drainage beginning on postoperativeday 3 and the d