Appearance Of Donor Site Research Articles

The submental artery island flap for head and neck reconstruction.

Following excisional surgery for head and neck cancer, most complex defects are reconstructed using microvascular free tissue transfer. These methods offer many advantages; however, they are of increasing complexity with attendant risks of flap loss and donor site problems. The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity, and offers the advantages of simplicity, reliability and excellent cosmesis. We have been using this flap as an alternative to free tissue transfer, and in this paper we present our series of 11 cases, after a review of the recent literature, anatomy and surgical technique. The advantages and limitations of the use of this flap are presented. A consecutive series of 11 patients in which this reconstruction was performed was reviewed retrospectively, and the results studied. Advantages and disadvantages of this reconstructive method were determined to define appropriate indications and contra-indications for its use. We have used this flap in 11 patients for post-excisional soft tissue reconstruction of the head and neck, both as skin and as a mucosal replacement. In all but two patients the results were satisfactory, with excellent cosmesis when used as skin replacement. One patient required secondary debulking and one had complete flap loss. In all, the donor site was satisfactory. The Submenal Artery Island Flap is a useful addition to the reconstructive surgeon's options and has definite advantages over distant flaps in terms of ease of dissection, final cosmetic appearance and donor site appearance.

Tissue expansion using osmotically active hydrogel systems for direct closure of the donor defect of the radial forearm flap.

Although widely used, the radial forearm flap has been criticized for the poor quality of its donor site. Attempts to avoid donor-site problems have concentrated on the elaboration of the split-thickness and full-thickness skin graft methods of reconstruction. Skin grafts frequently fail over the flexor carpi radialis tendon, leading to chronic skin breakdown or, at best, tendon adhesion. Tissue expansion appears to be a good alternative that allows the use of local tissues to ultimately improve the forearm donor-site appearance. To avoid the disadvantages of traditional silicone balloon expanders (such as pressure peaks, infection, the valve at a distance from the expander, postoperative fillings), an osmotically active system was used. In an 18-month prospective study, 10 osmotically active hydrogel tissue expanders were placed on the forearms of 10 patients. The radial forearm flap was performed for intraoral reconstruction after surgical resection of oral cavity malignancies. The study showed that, in nine out of 10 patients, the expanded skin achieved was sufficient to cover the donor site after raising the forearm flap. Additionally, the expansion-related swelling pressure was well tolerated by the patients, the cosmetic results were very satisfactory, and the incidence of complications was very low. By using osmotically active hydrogel tissue expanders, there is no postoperative filling and no risk of complications arising from defective balloon expanders, filling valves, or missing ports.

Anterolateral thigh flap donor-site complications and morbidity.

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.

Anterolateral Thigh Flap Donor-Site Complications and Morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of longterm morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site. (Plast. Reconstr. Surg. 106: 584, 2000.)

Reliability of the venae comitantes in venous drainage of the free radial forearm flaps.

The radial venae comitantes are usually considered as an accessory venous outflow tract in the free radial forearm flap because of their smaller size and thinner structure when compared with those of the cephalic vein. To evaluate the reliability of the deep venous system, a single radial vena comitans anastomosis was performed to serve as the sole venous outflow tract in 94 consecutive radial forearm free flap transfers. The suprafascial dissection technique was used in flap elevation, which allowed preservation of the cephalic vein and the dorsal branch of the radial nerve. In all cases, the external diameter of at least one vena comitans was adequate (< or = 1.5 mm) to perform a smooth microvascular anastomosis; in none of the cases was a venous anastomosis failure detected. Preselected use of a single vena comitans for the venous drainage of radial forearm free flaps was proven to be reliable and was preferred because of the ease of flap dissection and better donor site appearance.

The distally planned lateral arm flap in hand reconstruction

The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2-6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 x 5.5 cm to 23 x 7 cm (average 15 x 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.

Aesthetic refinements in toe-to-hand transfer surgery.

Techniques for aesthetic refinement are as important as those for functional improvement in toe-to-hand transfer. The appearance of the thumb reconstructed using various types of great toe transfer can be improved by reduction of the soft tissue, bone, interphalangeal joint, and nail and by secondary pulp reduction and contouring procedures. Finger and thumb reconstructions using lesser toes can be improved aesthetically by minimal inclusion of adipofibrous tissue under the plantar skin flap especially at the metatarsophalangeal joint region, thus decreasing the anterior-posterior bulkiness. Tight extensor repair, temporary K-pin fixation of the proximal and distal interphalangeal joint in extension, followed by prolonged use of a nighttime extension splint and secondary pulp reduction help to avoid the claw and drumstick appearances of the transferred lesser toe. Adequate soft-tissue coverage, cruciate skin incisions, extensive mobilization, and thinning and trimming of the skin flaps of the digital amputation stump lead to a smooth junction between the amputated digit and the transferred toe. In the distal digital reconstruction, skeletonization of medial and lateral neurovascular bundles of the harvested toe helps primary closure of the digital wound, thus avoiding the unsightly skin graft on the sides of the reconstructed digit. Regarding the donor foot, preservation of the proximal 0.5 to 1 cm of the proximal phalangeal stump of the great toe maintains the span of the foot, thus improving donor site appearance. In single lesser toe or combined second and third toe transfer, the proximal phalanx should not be preserved but an optimal web space should be reconstructed. Primary closure without skin graft is essential for aesthetic appearance of the donor foot.

Reduction of Complication Rate at Radial Forearm Flap Donor Sites

The radial forearm flap has become a versatile tissue transfer in head and neck surgery, especially in the reconstruction of the pharynx and oral cavity. Still, many surgeons avoid its application because of the possible donor site complications. In 29 of 51 patients who were operated between July 1987 and April 1990 at the Department of Otorhinolaryngology in Tübingen, we evaluated the function and aesthetic appearance of the radial forearm donor site after surgery. We found a much lower complication rate compared to some reports in the literature. With a questionnaire, the patients were asked how they judged the function and appearance of the forearm donor site. Further tests were made to detect a possible reduced mobility of the hand, and to measure the strength of the hand. Postoperative complications and their management as well as our concept of dealing with the radial forearm flap donor site to minimize complications are discussed.

The free fascial forearm flap

The unpleasant appearance of the donor site after harvesting a forearm flap limits its use in many centers. In this paper, the author records his experience with a modification of the standard fasciocutaneous forearm flap. Such modification involves the utilization of the fascial component of the flap sparing the skin of the forearm, which is closed as a longitudinal line. This fascial forearm flap (FFF) was used as a free flap in eight cases. All the flaps survived well, and the donor site appearance was excellent. The fascial forearm flap advantages and limitations are discussed with recommendations for further utilization of other fascial flaps.

Two new free flaps developed from aesthetic surgery II. The inferior gluteal flap

A new vascular musculocutaneous flap from the lower buttock is described that is based on the inferior gluteal vessels and includes skin from the gluteal fold and a part of the gluteus maximus muscle. The inferior gluteal flap has been clinically used either as an island flap for sacral repair or as a free flap. The results of 6 clinical cases are presented and the features of the flap are exposed. The minimum residual deformity of the buttock contour and, even in some cases of trochanteric lipodystrophy, the cosmetic improvement of the donor site appearance are emphasized.