Average Flap Thickness Research Articles

Extreme Limb Salvage: The Thin SCIP Flap for Distal Amputation Coverage in Highly Comorbid Patients.

Limb length preservation is correlated with overall survival. Successful free flap coverage of forefoot, midfoot, and hindfoot amputations can prevent more proximal below-knee amputations but is challenging in patients with multiple comorbidities. The thin superficial circumflex iliac artery perforator (SCIP) flap is well-suited for these patients, as it provides thin, pliable tissue from a favorable donor site. A retrospective review of all patients with distal amputations requiring coverage with a thin SCIP flap between 2016 to 2022 was performed. Patient demographics, amputation levels, and wound characteristics in addition to flap and microsurgery details were analyzed. The primary outcome was limb salvage. Secondary outcomes included partial flap necrosis, flap revision rate, and additional postoperative complications. Thirty-two patients (mean age, 57.3 years) underwent reconstruction of forefoot, midfoot, and hindfoot amputations with thin SCIP flaps (mean follow-up, 36 months). Twenty-eight patients (87.5%) had diabetes, 27 (84.4%) had peripheral artery disease, and 15 (46.9%) were dialysis-dependent. Average flap size was 59.5 cm 2 and average flap thickness was 5.7 mm. Successful limb salvage was achieved in 27 patients (84.3%). Three cases (9.4%) had total flap loss. Twenty-one flaps (65.6%) had partial necrosis, of which 12 (57.1%) healed with conservative management and 7 (33.3 %) healed after late revision. The thin SCIP flap is a useful option for coverage of distal pedal amputations in patients with significant comorbidities. Despite higher rates of partial flap necrosis, free flap reconstruction allowed for high rates of limb salvage in a challenging patient population. Therapeutic, IV.

Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane.

Although many efforts have been made to create thinner anterolateral thigh (ALT) flaps, their thickness varies among patients, and the flap may be still too thick to match shallow defects. The authors successfully harvested an ALT flap through the most superficial elevation plane, the superficial fat layer, which was useful to match the shallow defects. All patients who underwent ALT free flap reconstruction for upper and lower distal extremity defects were divided retrospectively into groups by ALT flap elevation plane: thin, above the deep fascia; superthin, at the superficial fascia; and ultrathin, through the superficial fat. Preoperative computed tomographic angiography and duplex ultrasonography planning were used for all patients. Anatomical characteristics of donor subcutaneous tissue and surgical details, including flap thickness, flap size, and incidence of flap necrosis were compared among the groups and between sexes. The average deep and superficial fascial depths were 16.7 and 10.8 mm, 12.5 and 8.2 mm, and 9.1 and 5.6 mm ( P < 0.05), and the average flap thickness was 5.8 mm, 7.9 mm, and 7.8 mm ( P = 0.29) in the ultrathin, superthin, and thin ALT groups, respectively. No significant intergroup differences existed in flap size or complications. The deep and superficial fascia were located significantly deeper in female patients (9.4 and 6.0 mm in male patients and 14.9 and 9.6 mm in female patients, respectively). With precise preoperative planning, the most superficially elevated, ultrathin ALT flap can achieve optimal reconstructions of thin body areas. Female patients with thicker thighs and patients with a high body mass index would benefit from this flap. Therapeutic, IV.

Management of Post-LASIK Ectasia.

Corneal ectasia is a sight-threatening complication of corneal refractive surgery characterized by progressive steepening and thinning of the cornea and subsequent loss of best-corrected visual acuity. To report the clinical outcomes following treatment of post-laser in situ keratomileusis (LASIK) induced ectasia. This is a retrospective case series of 7 patients (10 eyes) which developed post-LASIK ectasia. In these cases of postoperative ectasia, the presented clinical signs were either forme fruste keratoconus, thin cornea, posterior elevation map value > +15.0µm, or residual stromal bed < 300µm. All cases were treated with either collagen crosslinking (CXL) alone or combined with PRK or CXL and phakic intraocular implant using the Dresden protocol and a slight modification thereof. In all cases, the flap was created using the Moria M2 mechanical microkeratome (average flap thickness 118.15±12.88µm), and refractive error was corrected using the Wavelight Allegretto excimer laser. Average preoperative corrected visual acuity (CDVA) was 0.75 (±0.26) Snellen. Postoperative CDVA significantly increased to 0.86 (±0.13) Snellen (p=0.04, paired t-test). One eye lost three lines of its baseline CDVA (before ectasia), while all other eyes regained lines of CDVA. All cases remained stable during the follow-up. Several surgical procedures are used for the management of corneal ectasia. However, the best surgical approach should be determined based on the state of progression of the disease. Although ectasia remains a potentially devastating complication after refractive surgery, most patients can regain functional visual acuity with appropriate management, and corneal transplantation is infrequently indicated.

Adipofascial anterolateral thigh free flap in hypopharyngeal and oropharyngeal reconstruction

The anterolateral thigh (ALT) flap is a popular choice for head and neck reconstruction surgery, but its ungainly thickness makes it of limited value in some intracavitary reconstructions. The ALT adipofascial flap is an improved flap without skin or muscle. Here, we seek to further illustrate the ALT adipofascial flap as an alternate method of hypopharyngeal and oropharyngeal reconstruction in head and neck. A retrospective review of 9 patients (7 men, 2 women) ranging from 28 to 67 years (mean age, 53.1 years) who underwent reconstruction with the ALT adipofascial flap after hypopharyngeal carcinoma (4 patients) or oropharyngeal carcinoma (5 patients) resections from August 2018 to December 2019 was performed. Surgical outcomes and functional resoration were assessed. The size of the flaps ranged from 6 × 4cm2 to 6 × 12 cm2 . The average flap thickness was 0.14 cm (range, 0.1-0.2cm) and the average pedicle length was 9.8cm (range, 7-12 cm). The postoperative course was uneventful in eight patients. Reconstruction was successful in all cases during 7-23 months of follow-up (mean time, 14.3months). All patients resumed oral feeding for 2-8 weeks (mean time, 4.9 weeks) and the tracheal cannula was successfully removed 0.5-4months postsurgery (mean time, 2.4months). The ALT adipofascial flap is a viable choice for hypopharyngeal and oropharyngeal reconstructions and is thinner than the ALT flap. It could be harvested as a single-pedicled double-island flap for complex defect reconstruction.

Modified anterior intercostal artery perforator flap (AICAP) for autologous breast volume restoration after explantation

Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31-67 years (mean, 52.4 years) with body mass index (BMI) between 24.43 and 29.34 (mean, 27.32) kg/m2 underwent this procedure. All patients had implant-related problems, such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0-3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Pre- and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a 4-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by BREAST-Q data was >90%. This new design, AICAP flap (with a lateral thoracic extension), can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.

Clinical outcome of femtosecond laser flap formation versus mechanical microkeratome in laser in situ keratomileusis for treatment of myopia

Purpose The aim of this study was to evaluate and to compare the thickness and morphology of femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and mechanical microkeratome flaps using anterior segment optical coherence tomography (AS-OCT).Patients and methods This prospective, interventional, comparative clinical study was performed on 60 eyes of 30 patients. Flaps were created in 30 eyes using the WaveLight FS200 FS laser and in 30 eyes using the Moria M2 microkeratome. AS-OCT was used at 1 month postoperatively to evaluate the thickness of each flap at four points, which were 1 and 2 mm from the corneal vertex on the horizontal meridian.Results At the sixth month postoperatively, the uncorrected visual acuity was 0.98±0.10 in the FS-LASIK group and 0.98±0.11 in the microkeratome group, which denotes the efficacy of both procedures. No vision-threatening complications occurred in either group. The average flap thickness at 1 mm was 114.93±3.04 µm in the FS-LASIK group compared with 128.57±3.98 µm in the microkeratome group, with a statistically significant difference (P=0.000). The difference between the achieved and intended flap thickness at 1 mm (accuracy) was 4.93±3.04 µm in the FS-LASIK group compared with 18.57±3.98 µm in the microkeratome group, with a statistically significant difference (P=0.000). At 2 mm, the average flap thickness was 115.22±3.34 µm in the FS-LASIK group compared with 139.00±4.75 µm in the microkeratome group (P=0.000). The flap accuracy at 2 mm was 5.22±3.34 µm and 29.00±4.75 µm in the FS-LASIK group and the microkeratome group, respectively (P=0.000). Flap morphology showed a planar shape (uniform) in the FS-LASIK group and a meniscus shape in the microkeratome group.Conclusion Both FS-LASIK and microkeratome techniques were safe and efficient in correcting myopia and myopic astigmatism, achieving good visual outcome. AS-OCT showed that flaps created by the FS laser were more accurate and uniform than those created by the Moria M2 microkeratome.

Direct and Indirect Flap Measurements in Femtosecond Laser-Assisted In Situ Keratomileusis.

To compare direct and indirect LASIK flap thickness measurements using ultrasound and Scheimpflug technology. Eighty-two eyes treated with laser-assisted in situ keratomileusis refractive surgery using a femtosecond laser (IntraLase FS150) were prospectively included in the study. Flap thickness was set to 115 μm. Corneal flap thickness was measured using the direct method-ie, ultrasound pachymetry immediately after flap construction in the presence of cavitation bubbles-and indirect methods, with subtraction of intraoperative post-lift corneal thickness measured using ultrasound pachymetry (intrastroma) from preoperative central corneal thickness using ultrasound (Indirect-US) or Scheimpflug thinnest pachymetry (Indirect-Scheimpflug). Mean flap thickness was overestimated using the indirect methods, Indirect-US and Indirect-Scheimpflug (122.6 ± 24.5 μm and 128.1 ± 26.1 μm, respectively; P < 0.0060 and P < 0.0001, respectively). There were no significant correlations between the direct and indirect methods. Indirect-Scheimpflug was significantly higher (P = 0.0122) than Indirect-US. The closest average flap thickness compared with the set parameter of 115 μm was that of the direct method (115.6 ± 8.6 μm; 95% confidence interval: -1.3 to 2.5; P = 0.5163). The direct method provided the lowest SD of all groups (SD: 8.64). The direct method of flap thickness measurement was the most comparable to the set parameter compared with the indirect subtraction methods. Additional studies are needed to determine which method allows for the most accurate measurement of flap thickness.

Incidence and Clinical Characteristics of Post LASIK Ectasia: A Review of over 30,000 LASIK Cases

ABSTRACTPurpose: To report the incidence of postoperative ectasia after laser in situ keratomileusis (LASIK). Methods: A retrospective case review of 30,167 eyes (16,732 patients) was conducted following LASIK between August 2007 and August 2015. The follow-up was between 2 and 8 years. Tomography was performed after 2 years postop. After identifying cases of ectasia, the charts of these patients were examined to identify any common factors that may have predisposed them to develop ectasia. Results: Ten eyes of seven patients developed post-LASIK ectasia. Eight eyes had been treated for myopia and myopic astigmatism, two eyes for mixed astigmatism. There were no cases of ectasia after LASIK for hyperopia. All 10 cases of ectasia had a flap that was created using the Moria M2 mechanical microkeratome (average flap thickness 118.15 ± 12.88 µm) and refractive error corrected using the Wavelight Allegretto excimer laser. Retrospectively, most prevalent risk factors were thin cornea (≤ 500 µm, 50% of cases), anterior topographic map irregularities (e.g., asymmetric bow tie, 40% of cases), Ectasia Risk Score > 3 (40% of cases), percent tissue thickness alteration ≥ 40% (20% of cases) and low residual stromal bed (≤ 300 µm, 30% of cases). One eye had no identifiable risk factors. In the retrospective chart review 14.97% (4,506) of all the eyes had similar risk factors to the cases that went on to develop ectasia. Conclusion: The incidence of ectasia was 0.033% over 8 years. The incidence could be higher as some cases may destabilize beyond this period and some patients were lost to follow-up asymptomatic of any clinical signs. Other intrinsic factors may trigger the development of post LASIK ectasia. The current widely accepted risk factors are not sufficiently rigorous for screening out potential ectasia from developing after LASIK. There is a need to augment accuracy with higher sensitivity and specificity.

Association Between Radiographic Mastectomy Flap Thickness and Risk of Post-Radiation Therapy Breast Reconstruction Complication

Breast reconstruction after mastectomy is an important component of holistic care for many women with breast cancer. Post-mastectomy radiotherapy yields a large survival advantage for well-selected patients, and is a vital component of cancer care, however, it can raise the risk of reconstruction complications. Several risk factors, such as smoking and diabetes, have been implicated in complication risk. This study sought to assess the relationship between reconstruction complication risk and mastectomy flap thickness as measured radiographically at CT simulation. Women with breast cancer who had undergone mastectomy and immediate tissue expander (TE) placement and received post mastectomy radiation therapy at a single institution were identified. Those patients with available digital CT-simulation records were included. Flap thickness was measured using both 2D and 3D methods. In a 2D method fashion, flap thickness was measured as the linear distance between the TE and the skin at the top, bottom and center of the TE. For a 3D estimation, the entire flap as defined as the tissue between TE and the skin-air interface was contoured and its volume calculated. Demographic and health variables and all reconstruction complications were recorded during stage I (after TE placement) and stage II (after permanent implant) including: flap necrosis, TE or implant migration, TE or implant rupture, infection, seroma, TE or implant removal, exposure and/or dehiscence, contracture, and capsulotomy. Flap thickness was correlated to risk of complications using Cox regression. Receiver operating characteristic curves were created to identify threshold values for flap thickness. A total of 87 patients met the inclusion criteria. A total of 132 breasts with implants were studied. The incidence of flap necrosis was 12.1% during phase I and 2.7% during phase II of reconstruction. The rates of TE removal was 9% and the rates of permanent implant removal was 7%. On UVA, lower 2D flap thickness and lower 3D flap volume were associated with significantly higher combined complications during both phases of reconstructions with hazard ratio (HR) of 0.43 (p=0.04) and HR 0.9 (p=0.03), respectively. Threshold values were identified: average flap thickness less than 8.9 mm and flap volume less than 259cc were correlated to worse outcomes HR 0.3 (p=0.04) and HR 0.35 (p=0.02). These data support the notion that lower flap thickness is associated with a higher risk of reconstruction complications. This series represents the only analysis of the relationship between radiographic mastectomy flap thickness and reconstruction risk known to the authors. These data raise the possibility that the risk of reconstruction toxicity could be estimated more accurately after CT simulation, potentially facilitating prophylactic intervention for women at high risk.

Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma.

Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.

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

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

Popliteal fossa reconstruction with a medial sural artery perforator free flap using the medial sural vessel as the recipient

Background: Reconstruction of the popliteal fossa using a free flap is challenging. Therefore, to facilitate easier free flap reconstruction of the popliteal fossa, we use a medial sural artery perforator (MSAP) free flap with a medial sural vessel as the recipient vessel, as it provides several advantages based on many reports.Methods: This report describes the authors’ experience and outcomes with this technique. Between October 2010 and January 2015, 10 patients with medium-sized defects in their popliteal fossa underwent MSAP free flap reconstruction using the medial sural vessel as the recipient vessel. The flap size and thickness were evaluated, as well as the pedicle length, for each case.Results: The skin flap sizes ranged from 60–112 cm2. The average flap thickness was 6 mm (range = 4–8 mm), and the average pedicle length was 7.5 cm (range = 6–9 cm). Full flap survival was observed in nine cases, and flap tip necrosis was observed in one case during a mean follow-up of 15 months (range = 3–36 months). MSAP free flap reconstruction was performed for moderate-sized defects in the popliteal fossa, using the medial sural vessel as the recipient vessel.Conclusion: The obvious advantages of this technique included simple vascular anastomosis (minimal size discrepancy), no intraoperative position changes, and good aesthetic outcomes (replacing like with like).

Reconstruction of foot and ankle defects with a superthin innervated anterolateral thigh perforator flap

Background: An anterolateral thigh (ALT) perforator flap can be thinned to an extent to which it is vascularised only by the subdermal plexus. This study presents an innervated flap thinning technique and its application for dorsal foot and ankle resurfacing.Methods: A superthin innervated ALT perforator flap was used to repair the dorsal foot and ankle of 12 patients. The perforators were classified according to their variations in the adipose layer, and the corresponding microdissection technique was then applied. The branch of the lateral femoral cutaneous nerve and its accompanying vessels were adopted to construct a sensory flap.Results: The flap thickness before defatting, which was measured immediately after flap elevation, ranged from 25–45 mm. The average flap thickness after defatting was 4.55 mm (range = 3–6 mm). A total of 11 flaps completely survived, and one flap presented superficial necrosis within a small area (2 cm ×2 cm) in the distal part of the flap. No further flap revision or defatting procedures were required for these patients during an average follow-up period of 16.5 months (range = 10–24 months). In the transferred flap, protective sensibility existed in all cases, and the static two-point discrimination was 13–16 mm.Conclusions: The superthin innervated ALT perforator flap may be considered as an ideal strategy for foot and ankle reconstruction.

Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction.

Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.

Aesthetic and functional outcomes of the innervated and thinned anterolateral thigh flap in reconstruction of upper limb defects.

Background. The anterolateral thigh (ALT) flap has been widely described in reconstruction of the upper extremity. However, some details require refinement to improve both functional and aesthetic results. Methods. After reconstruction of upper extremity defects using thinned and innervated ALT flaps, functional and aesthetic outcomes were evaluated with the QuickDASH scale and a Likert scale for aesthetic assessment of free flaps, respectively. Results. Seven patients with a mean follow-up of 11.57 months and average flap thickness of 5 mm underwent innervation by an end-to-end neurorrhaphy. The average percentage of disability (QuickDASH) was 21.88% with tenderness, pain, temperature, and two-point discrimination present in 100% of cases, and the aesthetic result gave an overall result of 15.40 (good) with the best scores in color and texture. Conclusions. Simultaneous thinning and innervation of the ALT flap lead to a good cosmetic result and functional outcome with a low percentage of disability, which could result in minor surgical procedures and better recovery of motor and sensory function. Level of Evidence. IV.

Reconstruction of the Oropharynx With Free Posterior Tibial Flap After Tonsillar Cancer Extirpation

Oropharyngeal reconstruction after tonsillar tumor resection is a great challenge for head and neck surgeons. The aim of the present study was to explore the reconstruction efficacy of the free posterior tibial flap in the primary reconstruction of oropharynx defects after tonsillar squamous cell carcinoma (SCC) ablation. From August 2009 to March 2012, 12 patients with tonsillar SCC underwent oropharynx reconstruction with a free posterior tibial flap at the Department of Otolaryngology Head and Neck Surgery, West China Hospital of Sichuan University. Their clinical and surgical data were retrospectively collected and analyzed. Of the 12 patients, 8 were male and 4 were female (age range 41 to 66 years, mean 55.1). The average size of the free posterior tibial flap was 9.2 × 6.3 cm (range 7 × 5 to 12 × 7), the average flap thickness was 1.1 cm (range 0.9 to 1.3), and the average pedicle length was 10 cm (range 7 to 12). Despite the multistep and time-consuming procedure, all patients tolerated oropharynx reconstruction with the free posterior tibial flap. The transferred free posterior tibial flaps survived well. No donor site complications were observed during the follow-up period. All 12 patients acquired satisfactory swallowing and speech function preservation. Satisfactory reconstruction results were achieved for all 12 patients, indicating the free posterior tibial flap should be considered a potential treatment option for reconstruction of oropharynx defects. However, additional prospective studies with a larger sample size are required to validate our results.

The Thin Gluteal Artery Perforator Free Flap to Resurface the Posterior Aspect of the Leg and Foot

The authors evaluated the clinical application of the gluteal artery perforator free flap harvested above the superficial fascia as a new approach to reconstruct soft-tissue defects of the posterior aspect of the lower limb. Between September of 2010 and August of 2013, 27 thin flaps were used to reconstruct lower extremity defects in 27 patients. All flaps were elevated on the superficial fascia plane and based on a single perforator from either the superior or inferior gluteal artery. With the exception of two flaps that healed secondarily after partial loss, all flaps survived completely. Average flap thickness was 8.5 mm (range, 5 to 11 mm). The average flap size was 125 cm (range, 9 × 4 cm to 25 × 12 cm). The average pedicle length was 5.5 cm (range, 3 to 8 cm.). The average artery diameter was 0.65 mm (range, 0.4 to 1.3 mm). During the average follow-up of 13 months (range, 2 to 35 months), all flaps showed good contour and did not require any secondary revisions. The gluteal artery perforator free flap provides a thin flap for ideal contour, minimizes the operative risks of changing the patient's position intraoperatively, and conceals the donor site with minimal morbidity. However, the pedicle can be short and supermicrosurgery skills may be needed to accommodate the short pedicle. Overall, this new approach of using a thin gluteal artery perforator free flap to reconstruct the posterior aspect of the leg and foot can be considered a feasible option. Therapeutic, IV.

Predictability of the corneal flap creation with the femtosecond laser in LASIK

To observe the predictability of corneal flap creation with the FEMTO LDV femtosecond laser and analyze preliminarily the factors correlating to the thickness and diameter of the flap . It was a study of serial cases. 260 eyes of 130 consecutive patients were treated with the FEMTO LDV. The eyes were assigned to two groups according to intended flap thickness, 110 µm (208 eyes) and 90 µm (52 eyes). Intended flap diameter varied from 8.5 to 9.5 mm. Difference analysis of flap diameter and intended diameter as well as flap thickness and intended thickness were made. The data was analyzed with SPSS to sum up a multiple stepwise regression formula that could express their quantitative relationship. The 90 µm flap group had a average flap thickness of (95.12 ± 7.65) µm, while for the 110 µm group the average flap thickness was (104.81 ± 3.09) µm. The difference between right and left eyes was not statistically significant (t(110 µm) = -1.223, t(90 µm) = -1.343, P > 0.05). Corneal flap thickness was inversely correlated with flap diameter (r(110 µm) = -0.143, r(90 µm) = -0.315, P < 0.05), but was not related to preoperative patient age, corneal thickness, keratometric value K or intraocular pressure (r(110 µm) = -0.160, 0.054, -0.011, -0.363; r(90 µm) = 0.024, 0.074, -0.212, -0.434, all P > 0.05). Corneal flap diameter was positively correlated with preoperative corneal keratometric value K and thickness (P < 0.001, P < 0.05). Multiple stepwise regression analysis showed flap diameter was an influencing factor for flap thickness. Preoperative corneal keratometric value K and thickness were influencing factors for flap diameter. The LASIK flap creation with the FEMTO LDV laser has relatively good predictability. Flap diameter is an influencing factor for flap thickness.

A Method of Preoperatively Assessing the Volume of Abdominal Tissue Available for an Autologous Breast Reconstruction

Sir:FigureWe have developed an office-based method of assessing the volume of abdominal tissue available for breast reconstruction that has proved to be accurate, reproducible, and noninvasive, yet relatively simple, quick, cost-effective, and of no inconvenience to our patients. We prospectively evaluated 30 sequential immediate deep inferior epigastric artery perforator flap breast reconstructions (25 unilateral and five bilateral). For assessment of breast weight, we used Bostwick's graph1 to preoperatively calculate the patient's breast weight based on their cup size and chest wall circumference. We validated this by weighing the mastectomy specimen (actual breast weight). For assessment of flap volume, standard flap markings were used and the elliptical flap was considered as two identical triangles. The area of each triangle was calculated using the standard formula: area of triangle = height × width × ½. The following measurements were obtained: width was measured by dropping a vertical line from the umbilicus to the suprapubic region, and height was measured from this line to the apex of the triangle (Fig. 1).Fig. 1: The marked elliptical flap area is considered as two identical triangles, with each triangle's area being calculated using the formula width (W) × height (H) × ½.To calculate the volume of the flap, the thickness of the abdominal skin and fat were measured using a metal calliper while the abdominal panniculus was grasped by the assistant (Fig. 2). Three measurements were taken and the average of these was used. This measurement was divided by 2 (as the abdominal wall is folded onto itself during the measurement) and multiplied by the area of the flap. Therefore, the final formula for calculation of the flap volume is as follows: calculated flap volume = (height × width × ½) × 2 × (flap thickness × ½).Fig. 2: The thickness of the flap is measured using a metal calliper while the abdominal panniculus is grasped by the assistant.These calculations were validated by measuring the thickness and weight of the flap (actual flap weight) once harvested. The average calculated breast weight was 585 g (range, 345 to 1560 g) and the average actual breast weight was 505 g (range, 295 to 1510 g), giving an average percentage error of 16 percent. The average calculated flap volume was 1306.6 ml (range, 468 to 2758.5 ml) and the average actual flap volume was 1371 g (range, 480 to 2880 g), giving an average percentage error of 4.74 percent. The average flap thickness as measured with calipers was 3.15 cm (range, 2 to 4.7 cm) and the average flap thickness measured perioperatively was 3.85 cm (range, 2.5 to 5.4 cm). We have developed a reliable method for the preoperative assessment of flap volume using simple mathematical principles that has proved to be an invaluable tool during our first consultation, both in managing patient expectations and in constructing an operative plan. It has been particularly useful (1) to confidently inform patients of the size of the reconstructed breast; (2) in bilateral reconstructions, to assess whether a sufficient volume of flap is available; and (3) to determine whether a contralateral reduction will be required. In these highly litigious times, such a comprehensive consultation is vital for the purposes of both informed consent and ensuring that the patient's expectations mirror our own. In addition, perioperative decisions can be facilitated.1 If a hemiflap provides sufficient volume, the superficial inferior epigastric artery pedicle can be used.2,3 In the case of large-volume (>1000 ml) breast reconstructions, the consideration of whether to raise a free transverse rectus abdominis musculocutaneous or a deep inferior epigastric artery perforator flap and in the latter how many perforators are required can be facilitated.4 We have described a validated method of calculating the abdominal flap volume available to patients undergoing autologous breast reconstruction. This technique is simple, consistently reliable, and cost effective, and has allowed us to refine our practice. Pari-Naz Mohanna, F.R.C.S.(Plast.) Jian Farhadi, F.M.H. GKT Cancer Reconstruction Service, St. Thomas' Hospital, London, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Comparison of laser in situ keratomileusis reoperation outcomes with the Moria M2 head 90 and 130 following previous photorefractive keratectomy or laser in situ keratomileusis

To compare the Moria Model Two (M2) automated microkeratome with the head 90 (intended to create a 120-microm flap) to the head 130 (intended to create a 160-microm flap) in reoperations following previous photorefractive keratectomy (PRK) or laser-assisted in situ keratomileusis (LASIK) in terms of accuracy, predictability, safety and complications of the procedure. Eighty-five eyes of 70 consecutive patients received LASIK with the Moria M2 microkeratome. Nine previously PRK-operated eyes were reoperated with the head 90 and 37 eyes were reoperated with the head 130. Repeated LASIK was performed on 16 eyes with the head 90 and on 23 eyes with head the 130. Flap dimensions were measured and correlated to preoperative parameters. The average flap thickness in the previously PRK-operated eyes was 115.1 microm [range 82-137 microm, standard deviation (SD) 17.9] with the head 90 and 131.2 microm (range 105-171 microm, SD 19.8) with the head 130. In the previously LASIK-operated eyes, the mean flap thickness was 139.2 microm (range 92-182 microm, SD 23.8) with the head 90 and 141.9 microm (range 109-179 microm, SD 15.2) with the head 130. There were no free or incomplete flaps or flaps with buttonholes in the study. There was no statistically significant difference in postoperative uncorrected visual acuity (UCVA) between the groups. In eyes with previous PRK or LASIK, LASIK reoperation offers a safe alternative for improving refractive outcomes. The Moria M2 head 90, especially in LASIK-operated eyes, does not cut thinner flaps compared to the head 130.