Axial Flap Research Articles

Repair of skin and soft tissue defects of the extremity by transplantation of a U-shaped trimmed ilioinguinal flap

Objective To explore the efficacy of transplantation of a U-shaped ilioinguinal flap in the repair of skin and soft tissue defects of the extremity. An axial flap based on the superficial iliac circumflex artery and trimmed to a subdermal vascular network flap was used for the procedures. Methods Seven patients with skin and soft tissue defects treated between June, 2009 and May, 2014 were studied. The patients were 22-45 years of age (mean, 32 years) , and included 5 males and 2 females. Four patients had punch-press injuries, 1 patient had a hot-crush injury, and the remaining 2 patients were injured in the accidents. The wound sizes were 14.0 cm × 10.0 cm to 6.0 cm × 5.0 cm, with a varying extent of exposed tendons and bones. Repairs were performed using free ilioinguinal flaps, which were 15.0 cm × 11.0 cm to 7.0 cm × 5.0 cm in size. The axial flap was trimmed to a U-shaped subdermal vascular network flap and transplanted to the recipient site with anastomosis of blood vessels. Results All transplanted flaps survived. Four patients were followed for 1-6 months, with a mean duration of follow-up of 4 months. The trimmed flaps showed gradual reddening immediately after surgery, and the capillaries were recovered with a flat surface. Re-examination 3 months after surgery showed that the flaps were thin and flexible and met the aesthetic demand. No obvious pigmentation occurred, and the donor site was sutured directly, leaving only linear scars. Conclusion Repair of skin and soft tissue defects of the extremity using a U-shaped trimmed ilioinguinal flap has the advantages of a hidden donor site, small scar, and conformity to aesthetic requirements. The trimmed flaps are preferred over untrimmed flaps in terms of color and texture. The former flap is thinner, meets the aesthetic demand, and achieves a better efficacy. Key words: Ilioinguinal flap; Subdermal vascular network flap; Extremity; Microsurgical operation

Preliminary Exploration: When Angiosome Meets Prefabricated Flaps.

Background The best known limitation to the use of prefabricated flaps is their limited survival area. One explanation for this is insufficient neovascularization. However, blood flow of prefabricated flaps is through their innate vascular network. This could lead one to conclude that angiosomes may impede blood perfusion. This study aims to settle this contradiction between theory and clinical practice. Methods We performed a two-stage operation of a prefabricated abdominal flap in a rat model. The rats were divided into five groups (n = 6/group). Group A: fixed pedicle at a horizontal angle; Group B: fixed pedicle at an oblique angle; Group C: fixed pedicle at a vertical angle; Group D: fixed pedicle in the same position as Group A; and Group E: axial flap. Groups A and B were prefabricated for 2 weeks and Groups C and D were prefabricated for 3 weeks. Macroscopic appearance was noted, and analysis of near-infrared fluorescence imaging and capillary density was performed. Results There was no significant difference in the flaps' survival area between Groups A and B. Group D had a significantly larger survival area when compared with Group C. The boundary between two angiosomes (medioventral line) seemed to limit the indocyanine green perfusion in Groups B, C, and E, while in Groups A and D, no such limitation was seen. Capillary density was positively correlated with neovascularization time. Conclusions Angiosomes impede blood perfusion in prefabricated flaps. Cross-bound neovascular vessels nourish the flap, thus overcoming the limitation of choke vessels.

Effect of the surgical treatment on the keloid of mons pubis with postoperative radiotherapy

Objective To explore an effective surgical treatment to the keloid of mons pubis. Methods From March 2008 to January 2015, local flap and adjacent flap (including ilioinguinal flap and rectus abdominal musculocutaneous flap) were performed, and used to repair the defect after surgical removal of the keloid in 25 patients, and all the patients were received postoperative local radiotherapy, and then chi square test was applied to evaluate the effect in the six aspects, including perineal form, skin color, pubic hair distribution, satisfactory effect, skin texture and sense. Results The local flap group was better than the adjacent flap group in perineal form, skin color, pubic hair distribution, satisfactory effect, but there was no significant difference in skin texture and sense. Conclusions For the keloid of mons pubis, the first choice is local flap graft, which can maintain the normal mons pubis formation as most as possible, while the wound is so large that the local flap cannot work, and therefore the vascular pedicle axial flap should be used. Key words: Flap; Flap graft; Keloid; Mons pubis; Radiotherapy

The Paramidline Forehead Flap: A Clinical and Microanatomic Study.

The traditional paramedian forehead flap (FHF) is an axial flap based on the supratrochlear artery (STA). Doppler examination is often used to ensure inclusion of the STA within the flap. The authors hypothesized that a FHF pedicle design could be simplified to extend from the midline of the glabella to 1.2 cm lateral to the midline without compromising outcomes. To compare clinical outcomes and vessel densities of 2 FHF designs. Two FHF designs were used to repair fifty nasal defects. One was based on Doppler identification of the STA; the other on clinical measurements from the glabellar midline (with no effort to identify the STA). Clinical outcomes, complication rates, and pedicle vasculature of both groups were compared. There was no significant difference in flap survival or complication rate. Forehead flaps designed on the paramidline glabella had more arteries within their pedicles than Doppler-based FHFs (p < .05). Small arteries predominated, whereas larger arteries were infrequent in both groups. Size and number of arteries were not related to flap survival. A paramidline FHF has equivalent clinical outcomes as a flap based on the STA. A simple and reproducible design of the FHF using only surface landmarks is described.

Prognostic significance of tissue oxygenation changes and early signaling responses in fasciocutaneous advancement flap healing

Regional axial flaps have become mainstays of reconstructive and plastic surgery aimed at restoring function, form and integrity of various body parts after traumatic injuries, burns, tumor resection or the repair of birth defects. Such flaps remain attached to the donor site via single intact vascular pedicle, which serves as a conduit for supplying nutrients and removing waste during wound healing process. Despite advances in surgical techniques, complications associated with partial or full flap loss remains a significant clinical problem, particularly in the angiopathic population. In addition to inducing debilitating patient stress, reconstructive failures inordinately contribute to health care costs due to prolonged hospitalization, readmission and revision surgery. The knowledge about the diagnostic biomarkers that may predict the fate of a flap can greatly improve the rate and quality of ischemic flap healing, as it permits early therapeutic interventions to reduce the risk of flap loss. Twenty three 10–12 months old Sprague‐Dawley rats underwent bilateral epigastric flap reconstruction surgery. Tissue oxygen saturation was measured in vivo by optical photoacoustic imaging between 24 and 48 hours post‐surgery and 0.75×2.5cm skin biopsies as well as wound fluid (if present) were taken from the distal part of each flap. Tissue oxygenation changes, intracellular and/or wound exudate levels of matrix metalloproteinases (MMPs), various growth factors/cytokines, as well as the activation of major cell signaling pathways (JAK/STATs, c‐Src/FAK, PI3‐kinase/Akt/eNOS, PLC‐γ/PKC/H3, HO‐1/COX‐2, Ras/ERK, SAPK/JNK, MKK/p38 MAPK, Rac/PAK) including the induction of key transcription factors (Fra‐1, c‐Myc, c‐Fos, CREB1, EGR1, Sp1) and wound healing‐associated heat shock proteins (HSP27, HSP90, HSP47), have been correlated to the degree of survival of 45 superficial inferior epigastric artery (SIEA)‐based fasciocutaneous advancement flaps as assessed by planimetry analysis, Western blotting and H&amp;E/Masson's Trichrome staining at 9th day after the surgery. Although the level of heme oxygenase‐1 (HO‐1), a cytoprotective enzyme, which inhibits leukocyte migration to inflammatory sites, and can be induced by hypoxia or various pro‐inflammatory stimuli, was uniformly increased on average by 2.77 fold in distal segments of all surviving and partially failed flaps, there was a significant correlation between the positive or negative changes in oxygen saturation percentage of middle‐to‐distal flap sections and functional flap outcomes. Impaired flap healing was significantly associated only with a loss of HSPs. Poor outcome, to a lesser extent, correlated with increased phosphorylation of p54 JNK isoform and expression of cyclooxygenase‐2 (COX‐2) as well as inducible, but not endothelial, nitric oxide synthase (NOS).Support or Funding InformationThis Research was supported by Department of Otolaryngology ‐ Head &amp; Neck Surgery at Thomas Jefferson University

The involvement of c-Jun N-terminal kinase signaling pathway in the protective effect of estrogen on attenuating ischemia reperfusion injury in a rat flap model

Objective To observe the protective effect of estrogen against ischemia reperfusion injury in axial flaps, and investigate the role of the c-Jun N-terminal kinase signaling pathway in estrogen′s protective effect. Methods An ischemia reperfusion injury model in the abdominal flap was created in 40 Wistar rats that were randomly divided into 4 groups: control (group A), ischemia reperfusion injury (group B), estrogen (group C) and JUN inhibitor (group D). Seven days postoperatively, gross observation of the flap, measurement of flap survival area and calculation of flap survival rate were carried out. The flap tissues were harvested for hematoxylin-eosin staining to observe histological changes, and for Western blot to quantify JNK, p-JNK and MKP-5 expression. The relationship between flap survival and JNK expression was analyzed. Results Flaps in groups C and D grew well. Flap survival rates in these two groups were significantly higher than that in group B, while pathological changes were milder. Expressions of JNK and p-JNK were significantly lower in flaps of groups C and D than in flaps of group B, while expression of JNK negative regulator MKP-5 was the opposite. Conclusion Estrogen can significantly improve the ischemia reperfusion injury in flaps and increase flap survival rate. The potential mechanism of estrogen′s protective effect can be through regulating Jun N-terminal kinase signaling pathway. Key words: Estrogens; Surgical flaps; Ischemia-reperfusion injury; c-Jun N-terminal kinase pathway

Utilização de plasma rico em plaquetas para estimulação da angiogênese em flape de padrão axial toracodorsal em coelhos (Oryctolagus cuniculus)

Resumo: Feridas de grandes extensões, com perda da viabilidade tecidual e retardo na cicatrização por segunda intenção são casos que se faz necessário o emprego de técnicas cirúrgicas reconstrutivas. O plasma rico em plaquetas (PRP) é um produto com maior concentração plaquetária, adjuvante no processo cicatricial de cirurgias reconstrutivas, auxiliando nos processos de hemostasia e estimulação da angiogênese. Dessa forma, delineou-se um estudo a fim de avaliar a eficácia do uso do gel produzido a partir do plasma rico em plaquetas (PRP) em flapes de avanço de padrão axial toracodorsal em coelhos, para avaliar a possibilidade de favorecer a integração do retalho no leito receptor. Utilizaram-se 30 coelhos da raça Nova Zelândia branco, separados em dois grupos de 15 animais, compreendendo os grupos plasma rico em plaquetas (GPRP), na qual empregou-se o gel antes da síntese da ferida cirúrgica, e controle (GC), na qual utilizou-se apenas solução fisiológica. Para obtenção do PRP, coletou-se sangue dos animais, e determinou-se a contagem plaquetária antes da preparação do gel. No início e término do experimento os animais foram pesados para posterior análise de ganho peso médio. Após o procedimento cirúrgico iniciou-se as avaliações macroscópicas no 3º, 7º e 14º dia, e avaliou-se presença ou ausência de exsudato, integridade da pele, edema, rubor e necrose. Após esta etapa, coletou-se o material da ferida cirúrgica para confecção das lâminas histológicas e posterior avaliação microscópica. Avaliou-se a proliferação vascular, presença de células mononucleares e polimorfonucleares, proliferação fibroblástica, colagenização, reepitelização e hemorragia. Os dados obtidos foram submetidos à análise estatística (Teste t Student, t emparalhado, e Kruskall Walis, sendo p&lt;0,05). O ganho de peso médio não foi significativo entre os grupos; a concentração plaquetária da amostra final do PRP foi significativamente maior quando comparada com a inicial; exsudato e necrose foram significativamente maior no grupo controle quando comparado ao grupo PRP; proliferação vascular e reepitelização foram significativamente maior no grupo PRP, enquanto que a presença de mononucleares, polimorfonucleares, proliferação de fibroblastos, colagenização e hemorragia não foram significativas entre os grupos. Obteve-se no terceiro dia, diferença significativamente maior quanto à variável exsudato no grupo controle quando comparado ao grupo PRP, no sétimo dia exsudato e rubor foram significativamente maior no grupo controle, e ao décimo quarto dia exsudato e integridade da pele foram significativamente maior no grupo controle. Os resultados obtidos neste estudo evidenciaram que a utilização do plasma rico em plaquetas na forma de gel em cirurgia reconstrutiva foi capaz de estimular a angiogênese na ferida favorecendo o processo de cicatrização.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

Surgical rehabilitation of patients with spinal neurotrophic decubitus

The greatest weight neurodystrophic process develops in traumatic spinal cord injury, appears as neurotrophic decubitus (bedsores). There is a high risk of wound infection in the event of pressure ulcers. Surgical repair of the skin integrity in spinal patients of 3 and 4 grade is a basic prerequisite for the further complex of the rehabilitation measures. Work objective: to develop the concept of innovative technologies of treatment of local physical impacts and to implement it in surgical system of rehabilitation of patients with spinal cord lesion with neurotrophic decubitus of 3 and 4 grade. Clinical studies subjected 49 (100%) patients with spinal cord lesions and neurotrophic decubitus of 3 and 4 grade. All patients were divided into two groups: 1– (study group 1) 29 patients; 2 – (control group 2) 20 patients. The managed negative pressure system S042 NPWT VivanoTec (Hartmann), a method of ultrasonic cavitation (Sonoca%180), the system for the hydro surgery Versajet Smith and Nephew were used in the 1%st group. Traditional dressings for the preparation of a plastic closure of the wound defect neurotrophic decubitus of the grade 3%4 were used in the 2nd group. Statistical analysis was performed using package of Microsoft Excel%97 Statistica for Windows 6.0, SPSS 10.0 for Windows. The study showed that the use of complex methods of vacuum therapy, ultrasound cavitation and hydro surgical in the 1st group significantly reduces the duration of treatment compared with conservative methods in the 2nd group. In group 1, the mean duration of treatment was 19.9±13.9 days, in group 2 (comparison group) – 40.0±28.2 days (p&lt;0.05). The usage of physical methods (managed negative pressure system, ultrasonic processing method, hydro surgical system) local treatment is a highly effective method of preparation neurotrophic decubitus grade 3 and 4 to the early recovery of the skin. Physical methods of local treatment have a positive effect on tissue regeneration and reduces periods of maturing granulation tissue. Axial flaps allow adequately perform the restoration of the skin in case of neurotrophic decubitus grade 3 and 4.

Complications of Head and Neck Reconstructive Surgery Using Axial Pedicled Flap

Objectives: Axial flap surgery is associated with numerous complications. The purpose of this study is to determine the frequency of these complications, and identify possible factors contributory to their occurrence.&#x0D; &#x0D; Methods:&#x0D; Study design: Cross-sectional study&#x0D; &#x0D; Setting: Tertiary public university hospital&#x0D; &#x0D; Subjects: Records of all patients who underwent axial pedicled flap reconstruction at the otorhinolaryngology ward of our tertiary public university hospital from January 2013 to July 2015 were retrospectively reviewed, and data consisting of age, sex, diagnosis, disease stage, smoking history, alcohol intake, co-morbidities, past operations, pre-operative hemoglobin and albumin, total operative time, total blood loss, location and total area of the surgical defect, and length of hospitalization were tabulated. All complications were listed. Data were analyzed for any potential trends.&#x0D; &#x0D; Results: A total of 38 patients underwent axial pedicled flap reconstruction in the study period. Nineteen out of 38 (50%) cases involved complications. The most common complication was infection. Most of the complications occurred in males with history of alcohol intake, advanced cancer stage, significant blood loss, recurrent tumors, low pre-operative hemoglobin and albumin levels, and a large area of surgical defect.&#x0D; &#x0D; Conclusions: The complication rate for axial flap surgery in our series was significant at 50%. Potential risk factors identified were male gender, advanced cancer stage, tumor recurrence, alcohol intake, low pre-operative hemoglobin and albumin levels, significant blood loss, longer operative time, and a larger surgical defect.&#x0D; &#x0D; Keywords: surgical flaps, myocutaneous flap, axial flap, complications, risk factors&#x0D; &#x0D;

The influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury

To study the influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury. 48 adult male Wistar rats aged 12-14 weeks old, were randomly divided into control group (group I), ischemia-reperfusion group (group II), saline group (group III), estradiol group (group IV). Superficial epigastric artery axial flap, 3 cm x 6 cm in size, was made in the left lower quadrant abdominal of each rat. Flap model with ischemia-reperfusion injury was established by using the nondestructive micro vascular clamp to clamp the superficial epigastric artery. The general condition of the flap was observed after operation. At 7 days after operation, the survival rate of the flap was detected, the flaps were harvested to receive histology and ultrastructural observation. The neutrophils level of the superficial epigastric vein were tested. 7 days after operation, the survival rate of the flap in group IV was significantly higher than that in group II, III (P < 0.05). The neutrophils level in group IV was lower than that in group II, III (P < 0.05). The histological observation showed that the degree of tissue swelling and inflammatory exudation in group IV was more slight than that in group II, III. Presence of high neutrophils density were observed in group II, III, while slight inflammation and necrosis were observed in group IV. In group I, collagen fibers in flap are regularly arranged with no significant necrosis. Oganelles structure disappeared and apoptotic bodies were shown in group II and group III, even the lysosome could be seen in the cell. Collagen fibers in flap are regularly arranged with slight swelling and no obvious ultrastructural necrocytosis was seen in the cell of group IV. The estradiol can significantly increase flap survival rate by inhibiting neutrophils infiltration and improving the pathological changes of organization structure in flap.

Heterodigital flaps for severe pulp defects

Heterodigital flaps for severe pulp defects

Use of an Axial Flap to Increase the Girth of Wassel IV Thumb Reconstructions

To investigate the use of a flap supplied by the radial collateral artery of the radial duplicate in Wassel type IV thumb duplications. We hypothesized that such a flap was viable and would make it possible to increase the girth of the reconstructed thumb. We operated on 17 thumbs in 16 children with type IV thumb duplication using a procedure that included the dissection of a long, narrow strip of skin and soft tissue harvested on the radial side of the radial duplicate. The girth of the reconstructed thumb was measured clinically and compared with that of the contralateral thumb. The width of the soft tissues and bony structures was also measured by x-ray and compared with the opposite side. Furthermore, children, caregivers, and the investigator assessed the overall cosmetic result using a visual analog scale score. All flaps fully survived. The average girth of the reconstructed thumb relative to the healthy contralateral thumb ranged from 92% to 103%, depending on the level of measurement. The mean visual analog scale score was 8.3 (children), 8.2 (caregivers), and 8.8 (investigator). An axial patterned flap proved to be viable and effective in improving the volume and contour of the reconstructed thumb. In radial polydactyly, each of the thumbs has a typically smaller girth than the contralateral thumb. Our clinical and radiological measurements showed the efficacy of this reconstruction in increasing the volume and girth of the reconstructed thumb, even though the skeleton of the ulnar duplicate remained thinner. Therapeutic IV.

Comparative analysis of results of early and late microsurgical reconstructive operations in patients with extensive posttraumatic tissue defects of lower extremities

Comparative analysis of patient treatment results with extensive and deep posttraumatic defects of different segments of lower limbs has been done in this article. Early (n=71) and late (n=127) microsurgical reconstructive operations with using island flaps and free axial skin flaps have been performed to all these patients. According to authors, early microsurgical reconstructive operations have significant opportunities due to similar but later done operations. In particular, operative treatment makes necessary conditions for reliably more frequent using of less difficult operations with island flaps and creates statistically reliable reduce of additional operations demand. This treatment also provides the best long-term results and a more complete functional recovery of the damaged lower extremities in terms from two to six years.

The impact of angiogenic and adipogenic microenvironment on adipose tissue regeneration in tissue engineering chamber

By observing the adipogenic and angiogenic microenvironment impact on the morphology of newly generated tissue for exploring the key factors which inducing mature adipose tissue regeneration in tissue engineering model. 24 healthy 6 months' New Zealand rabbits were picked and put into four groups according to different microenvironment. Every group has 6 rabbits and divided as follows: no axial-blood supply fat flap(0 ml), granular fat only(0.6 ml), axial blood vessel only (0.05 ml), axial vascularized fat flap ((0.6 ml). We separated or combined adipogenic and angiogenic environment within these groups. After 8 weeks, samples were harvested for histologic observation including macroscopic observation, volume analysis and HE testing. In granular fat group, its volume decreased by (0.25 ± 0.10) ml after 8 weeks as the shortage of blood supply and finally it could be enveloped. In axial blood vessel group, its volume increased by (0. 37 ± 0. 04) ml after 8 weeks with fibrous tissue formation as shortage of adipogenic microenvironment. The no axial-blood supply fat flap group grew into(0.12 ± 0.03) ml, which can' t support large volume adipose tissue formation because of lacking independent blood supply. Only axial vascularized fat flap model could generate mature adipose tissue in large volume(3.45 ± 0.48) ml. The number of new capillary in every group was different after 8 weeks. By counting the numbers in every single view, no axial-blood supply fat flap group 15 ± 3.5)and granular fat only group(5 ± 2.5)had a significant difference with axial vascularized fat flap group 22 ± 5) respectively. Only both adipogenic or angiogenic microenvironment exist could induce mature adipose tissue in large volume in tissue engineering chamber model.

Improved Random Component Viability of Axial Skin Flap through the Use of Human Adipose Derived Stem Cells

Improved Random Component Viability of Axial Skin Flap through the Use of Human Adipose Derived Stem Cells

Reverse-flow axial skin flap of the delay by minimal invasive surgery

Objective The mechanism of delaying flap with the minimal invasive surgery was approached to understand its effects on the whole delayed survival of skin flaps thoroughly so as to provide the rationale for its clinical use.Methods 80 male or female Wistar rats were randomly subdivided into two groups:delayed by the minimal invasive surgery,and immediately transfer without delay.Flaps in each group delayed were cut at 1,2,3 and 4 weeks,respectively.The flap was designed at the lower back of rat,with the size of 5 cm × 1 cm,crossing the middle area for 2.5 cm and including stem of iliac branch from iliolumbar artery.2 weeks after second operation,the survival area,capillary density and content of lactic acid of the flaps in each group were examined,and the survival of the falps delayed by the minimal invasive surgery was compared.Results The longer delaying time,and the higher survival rate were observed in the experimental group.Delaying for 3 weeks and 4 weeks,the survival rate was (86.13 ±1.13) ％,(93.49 ± 1.15) ％,respectively,in the experimental group.While in control group,the survival rate was no more than 63％.The longer delaying time,the higher the capillary density were noted in two groups,but 3 weeks delayed group equally matched to the 4 weeks delayed group.In the experimental group,the content of lactic acid increased peaked in 1 week delayed group,then fell-down gradually,but kept steady in 3 and 4 weeks delayed group.The content of lactic acid in the control group kept steady.Conclusions The experimental model is selected as cross-area axial flap on the lower back of rats.The minimal invasive surgery plays the same role as in delaying flaps,which causes vasoconstriction,resulting in disorder of internal environment,ischemia and hypoxia,finally vasodilatation.The more ramus anastomosis,the more survival rate of the flap. Key words: Minimal invasive surgery; Delay phenomenon; Reverse-flow axial skin flap

Colgajo gemelo axial de transposición para cobertura de defectos dorsales de los dedos de la mano: estudio anatómico

BackgroundDorsal skin defects of the middle phalanx and proximal interphalangeal joint (PIS) of the fingers are difficult to cover. However, a description is presented of novel flap called transposed twin axial flap. Transposition allows these defects to be covered. Material and methodsThis article discusses an anatomical study, performing dissections on 5 cadaveric models. Two of these dissections were performed by using colored acrylic with china blue dye. A dissection was also performed on a patient with severe hand trauma with vascular viability. ResultsThe anatomical bases of the flap were established, demonstrating the proper vascularization of the transposed twin axial flap. The patient who received the flap showed vascular viability with good clinical results. DiscussionThe twin axial transposition flap is presented as a valid alternative to cover the defects described. It is easy, fast and safe to perform compared to other local flaps. A prospective randomized clinical trial should be performed to determine the possibilities of its routine use.

Note technique : lambeau sous-mental super étendu ou sous-mental Combo

The author presents a technical variation of the sub-mental flap including in a conventional pedicled flap both sub-mental axes and their anastomoses on the midline. The assessment of the first flaps raised according to this method confirms the improvement of the distal blood supply. It allows the possibility to harvest "super extended" flaps reaching the contralateral auricular lobula. This variation can be considered as an axial flap which only the tip, located beyond the mandibular angle, is at random. The evolution of the sub-mental flap from its original description to this variation called "combo sub-mental flap" is then presented. Its reliability and the technical simplification it provides will have to be assessed in the future.

The median forehead flap reviewed: a histologic study on vascular anatomy.

Local skin flaps can be divided into two types: random flaps and axial flaps. An axial flap is defined as a flap containing a named artery in its pedicle. For the paramedian forehead flap (PMFF) a lot of surgeons insist on the point that the pedicle must contain the supratrochlear artery. To demonstrate that median forehead flaps (MFF) need not contain a named artery, we selected first 8 patients with a PMFF and further 12 patients who had undergone reconstructive surgery using a MFF. After division, we analysed the pedicle of the flap histologically and measured the diameter of the arteries or arterioles and compared them to anatomical descriptions of the frontal arteries. In none of the 12 cases could we find a functional artery of approximately 1 mm in diameter that could correspond to the supratrochlear artery. The MFF is an axial flap but not in accordance with the current definition of this term. In contrast to published literature, we show that only in a part of cases a named artery was present in the pedicle. Despite this fact, the MFF is a secure flap for full thickness defect repair on the nose.