Axial Flap Research Articles

Use of Bilateral Groin Flaps in the Closure of Defects of the Perineum: A Case Report

Reconstruction of perineal and groin defects is a challenging problem. Commonly used methods of reconstruction include skin grafts and local flaps. The groin flap is a vascularized axial flap based on the superficial circumflex iliac artery arising from the femoral artery just below the inguinal ligament. Due to the location, the donor defect can usually be closed primarily, leaving an acceptable scar. The use of bilateral groin flaps for coverage of defects of the anterior perineum following excision of condylomas is reported.

The Evolution of Perforator Flaps

Perforator flaps have recently become ubiquitous in the field of plastic surgery. To understand and appreciate their unique nature, it is necessary to compare and contrast them with the development of other types of flaps. A complete yet abridged version of the history of flap surgery is presented in this article. Beginning with Sushruta’s Indian cheek flap method for nasal reconstruction, a trip through time and space is taken to highlight the milestones leading to the evolution of the perforator flap. Random pattern skin flaps, axial pattern skin flaps, and musculocutaneous flaps are all discussed. Finally, the future of perforator flaps is presented.

Peninsular Conchal Axial Flap to Reconstruct the Upper or Middle Third of the Auricle

The reconstruction of partial amputations of the auricle is a continuous subject of publications, in particular, the techniques of ear reconstruction with postauricular flaps. To present in detail the surgical procedure of a new peninsular conchal transposition flap. This new conchal transposition flap has been used since 1998 to reconstruct seven partial amputations of the upper or middle third of the auricle. If we compare the flap to a tennis racket, the head corresponds to a skin-cartilage-skin flap harvested from the concha and the shaft to a post- and supra-auricular cutaneous and subcutaneous pedicle based around the posterior auricular artery and the superior auricular branch of the superficial temporal artery. The blood supply is reliable because the superior branch of the posterior auricular artery anastomoses with the superior auricular branch of the superficial temporal artery. There have been no significant complications, except one case of partial rim necrosis, which responded well to wound healing by secondary intention. Our peninsular flap could be an alternative to more complex procedures involving costal cartilage harvesting, provided that auricle amputations are confined to the upper or middle third of the peripheral structures and spare the concha.

Oblique scapular flap

We report an axial transposition flap based on the anterior branch of the descending branch of the circumflex scapular artery. This has some advantages, including a hidden donor site, easy transfer with no abnormalities, no distortion of the structures, and much pliable tissue.

Reconstruction of the tip of the nose by an axial dorsonasal musculocutaneous rotation flap

The axial dorsonasal musculocutaneous rotation flap has been used successfully in a series of 21 patients to reconstruct defects (ranging in size from 10×12 to 25×30 mm) of the tip of the nose. This flap meets many of the demands of the ideal flap for reconstruction of these defects: the planning and dissection of the flap is an easy one-step procedure that can be performed under local anaesthesia on an outpatient base. The flap provides an ample amount of local tissue with the best possible colour and texture match, the scars are placed along the topographic anatomic subunits of the nose and the aesthetic outcome is good.

Hemodynamic enhancement in reconstructive surgery: Mathematical model and clinical findings

In this paper, a recent operating technique that consists of using perforator instead of axial flaps in reconstructive surgery is investigated from the hemodynamic point of view. By means of a mathematical modeling resting on the fluid dynamical aspects of the technique, we describe the hemodynamic enhancements with respects to the classical surgical method. Finally, we report some clinical data showing how the model projections meet the clinical findings.

Measurement of perfusion pressure of perforators and its correlation with their internal diameter

The aim of this study is to find out the correlation between the internal diameter of perforators to the deep fascia with their perfusion pressure.1–3 This is an important step towards understanding how much tissue is supplied by a perforator.4 In clinical practice, for a given defect, it is difficult to gauge the size and number of perforators that should be incorporated in the flap for security.5,6 In other words, it is difficult to assess the angiosome of the perforators. It is well established now that due to the rich inherent vascular network of the deep fascia, one can dissect a large flap of nonconventional dimension (beyond 1:2) safely and it behaves like an axial flap.

Pharyngo oesophageal strictures and its reconstruction by delto pectoral flaps

Delto pectoral flap is a thin and pliable cutaneous axial flap suitable for the reconstruction of pharynx and upper oesophagus. Corrosive stricture of the pharyngo oesophageal area can very well be reconstructed by deltopectoral flap. Oesophageal reconstruction by viscera like stomach or colon often produces anastomic stricture at the upper anastomic site with hypopharynx or upper oesophagus. Delto pectoral flap can also be used to reconstruct this anastomotic stricture. Postoperative swallowing is satisfactory when reconstruction is done with this flap.

Use of Axial Pattern Cervico-Occipital Flaps in Restoration of Beard Defects

Use of Axial Pattern Cervico-Occipital Flaps in Restoration of Beard Defects

Peninsular Conchal Axial Flap to Reconstruct the Upper or Middle Third of the Auricle

Peninsular Conchal Axial Flap to Reconstruct the Upper or Middle Third of the Auricle

Reconstruction of a complex intercanthal defect with triple advancement flaps

A complex intercanthal skin defect, created by resection of a squamous cell carcinoma localised in the nasal root of a 52-year-old man, was successfully reconstructed using three axial pattern advancement flaps raised from the nasal dorsum and paranasal areas.

Submammary flap for correction of severe sequelae from augmentation mammaplasty.

A submammary flap was used in 20 patients with severe cicatricial retractions and loss of the inferior pole of the breast caused by inadequately treated mammary implant infections. This axial flap can be used with a medial pedicle, based on the perforating branches of the epigastric artery or the distal part of the internal mammary artery, or laterally based, nourished by the intercostal perforators. After 6 months, reimplantation was performed in 15 patients. The authors' follow-up ranged between 8 months and 6 years. This transverse adipocutaneous flap procedure is very simple to perform, the donor site is sutured primarily without additional undermining, and the resultant scar lies hidden within the submammary fold. It provides tissue with similar skin texture and color match. Its versatility allows it to be used as a full-thickness tissue replacement or partially or totally de-epithelialized for soft-tissue reconstruction. It can also be used as an island flap. For all of these reasons, in emotionally distressed patients with low compliance with surgical treatments and additional scars, this flap is the authors' flap of choice for reconstruction.

Use of Groin Flap in the Closure of Through and Through Defect of a Forearm: A Case Report

The groin flap is a vascularized axial flap based on the superficial circumflex iliac artery arising from the femoral artery just below the inguinal ligament. It is used regularly by many reconstructive surgeons for covering soft tissue defects of the hand. Although the development of various fasciocutaneous free flaps during the 1980s decreased the attractiveness of the groin flap, these flaps can be used in reconstructing significant defects of the forearm and hand where free tissue transfer is not feasible.

A novel axial pattern skin flap based on the lateral thoracic artery in the dog

SummaryThe cutaneous distribution and anatomical landmarks of the lateral thoracic artery in the dog are reported. Perfusion studies in cadavers showed a variable distribution, but a skin flap capable of rotation through 90° could be created. The successful use of an axial pattern skin flap based on the lateral thoracic artery for reconstruction of a major skin deficit over the caudal elbow of a Greyhound is reported.

Interposition arthroplasty in temporomandibular joint ankylosis.

We report a series of 60 cases of post- traumatic temporomandibular joint ankylosis that were treated at our unit from 1992 to 2002 by temporalis fascia flap interposition arthopiasty. Majority of these patients (21 patients, 35%) were in the age group of 15-20 years, with 39 males (65%) and 21 females (35%). The duration of ankylosis varied from 6 months to more than 4 years with 32 patients (54.32%) having a duration of 6 months to 2 years. 44 patients (73.33%) had unilateral white 16 patients (26.67%) had bilateral involvement of temporomandibular joint. Pedicled temporalise fascia axial flap based on superficial temporal artery was used for interpositional arthopiasty. The advantage is that it is available at the operative site, easy to raise, well vascularized, reliable and with better long term results. Adequate mouth opening was achieved in all cases and a long follow up, of up to 10 years for the earlier operated cases, showed no recurrence of ankylosis in any of the patients.

Nine-year experience with extended use of the commissure-based buccal musculomucosal flap.

This study reports on the extended use of the commissure-based buccal musculomucosal (CBMM) flap. Large lip defects and medium-size intraoral defects have the general problem of being too large for primary closure to avoid a major functional and aesthetic impairment. Elaborate free flaps, such as axial flaps, although excellent in large defects, may not provide mucosa-equivalent sensitivity, motility, volume, and texture to replace lost tissue with a similar kind of tissue. A total of 60 flap procedures were performed with bilateral and unilateral flaps up to 7.5 x 4 cm in size. The partial and total upper and lower vermilion, gingivobuccal sulcus, floor of the mouth, lateral tongue margin, oropharynx, and hard and soft palates were reconstructed. Partial necrosis was seen in four flaps; all patients recovered with good oral function in speech and swallowing, good aesthetics, and prosthetic rehabilitation if necessary. The donor site could be closed primarily. In flaps with dorsal advancement, the mucosal excess above and below was closed, creating two small dog-ears. Facial expression and mouth opening returned to normal after less than 2 months. The parotid duct had to be marsupialized in large flap preparations, but this did never provoke stasis or infection. The two-point sensitivity of the flaps was, on average, equal to that of the nonoperated mucosa in intraindividual correlation, and the flaps lost, on average, 15 percent of their original size. In the authors' estimation, the results indicate a reliable and technically easy option for intraoral, medium-size defect reconstruction that yields sensitivity and facilitates the rehabilitation of oral function in speaking and ingestion.

Pre-fabricated lined axial flaps for reconstruction of extensive post-burn facial and forehead full-thickness composite defects

From January 1996 to February 1998, three patients who suffered extensive post-burn facial and forehead composite defects were treated successfully in our Burn Unit. The delto-pectoral flap and reverse radial forearm flap were pre-fabricated with lining of free split skin grafted onto the underside of the flap. The pre-fabricated flaps were sutured in situ for 2 ∼ 3 weeks. The pre-fabricated lined axial flaps were then transferred for the reconstruction of facial and forehead composite defects. The flap had good blood supply and the wounds healed by first intention. The three cases presented all achieved satisfactory functional and aesthetic results. The results show that pre-fabricated lined axial flaps for the reconstruction of extensive facial and forehead composite defects are safe, effective and relatively easy for clinical application.

A review of the experimental study and clinical application of the prefabricated flap

It is this paper’s intention to review the concept, research, clinical applications, and the advantages and disadvantages of prefabricated flaps. Prefabricating a flap is a technique that allows non-axial flaps to be connected to axial flaps. The usual adopted methods include transplanting the vascular axis into a donor site that does not have a defined vascular supply or transplanting the flap onto a richly vascularized area. The basic theories of prefabrication have been proven experimentally, and the clinical application of this concept has been satisfactory. Moreover, studies that focus on using allogenic vascular transplantation, alloplastic materials, bioengineering, as well as combinations of these methods have begun.

An experimental study of skin flap associated with muscle: is muscle nourishment possible through the musculocutaneous perforators?

An experimental study was planned to examine whether the blood supply of muscle would be maintained by reverse flow from the cutaneous arteriolar microcirculatory system via the musculocutaneous perforators. A flap model containing both muscle and skin based on the inferior superficial epigastric vessels was designed with the blood supplied directly from the cutaneous arteriolar microcirculatory system. A total of 154 male Wistar Albino rats were divided into three groups. Group I included the standard vertical rectus abdominis musculocutaneous flap based on the superior deep epigastric vessels (N = 48). Group II included the acute cutaneous muscle flap (N = 53). Group III contained the delayed cutaneous muscle flap (N = 53). Skin flap survival area, muscle scintigraphy with technetium-99m-methoxy-isobutyl-isonitrile, microangiography, and histopathological examination of the flaps were conducted. The mean percentage of surviving skin paddle area was 96.4 +/- 5.2%, 84.9 +/- 21.6%, and 91.0 +/- 16.8% in groups I, II, and III respectively. There was no significant difference between groups. Microangiography revealed the blood flow from skin to muscle through the musculocutaneous perforators. The radioisotope uptake of the muscle flap was expressed as A percentage of the intact contralateral muscle. Mean uptake in group I was 90.1 +/- 4.9% immediately after flap elevation, 62.5 +/- 13.5% on day 2, and 88.3 +/- 12.0% on day 7. These values were 53.7 +/- 7.1%, 63.6 +/- 14.1%, and 89.2 +/- 18.1% in group II, and 64 +/- 7.8%, 75.5 +/- 9.8%, and 92.8 +/- 40.1% in group III. Radioisotope uptake in group I was significantly higher than groups II and III immediately after flap elevation (p < 0.05, analysis of variance), whereas there was no significant difference on days 2 and 7. Histopathological examination revealed surviving muscle tissue without marked atrophy. There was no marked difference between groups histopathologically. These results indicate that muscle tissue may survive by reverse flow through the musculocutaneous perforators when elevated with an axial skin flap.

Delayed prefabricated arterial composite venous flaps: an experimental study in rabbits.

Prefabrication of composite arteriovenous flaps with implantation of an autologous graft (cartilage) or an alloplastic material (porous polyethylene) was studied in 40 rabbits. Abdominal flaps based on bilateral epigastric pedicles were elevated. An ear cartilage graft or a porous polyethylene implant was inserted under the flap. Two weeks after the operation, 10 flaps with cartilage graft and 10 flaps with porous polyethylene were raised, converted to arteriovenous flaps, and resutured in place in the experimental groups. In the other 20 rabbits of the control groups, the flaps (10 with cartilage graft and 10 with porous polyethylene) were raised and resutured in place as conventional axial flaps. At the end of the second and fourth week postoperatively, samples were obtained from the flap tissues (including a part of the graft or implantation material) and were prepared for histologic examination in all rabbits. The viable areas of all flaps were assessed at the end of fourth week after the second operation. The mean survival rates were 99.4%, 99.7%, 99.5%, and 99.8% in the arteriovenous and control flaps prefabricated with cartilage graft and the arteriovenous and control flaps prefabricated with porous polyethylene respectively. The features of wound healing in the experimental and control groups were similar. The study showed that arteriovenous perfusion can nourish a prefabricated flap containing an implanted material (autologous or alloplastic) and these 2-week delayed composite flaps have a similar survival rate to delayed prefabricated conventional axial flaps.