Axial Pattern Flap Research Articles

Greater Palatine Island Axial Pattern Flap for Repair of Oronasal Fistula Related to Eosinophilic Granuloma

A Greyhound presented with eosinophilic granuloma lesions of the soft palate and oronasal fistula. Since other siblings had been known to also have oral eosinophilic granuloma, it was suspected that the dog reported here had a familial predisposition to develop the disease. Preoperative medical management consisting of anti-inflammatory and immunosuppressive therapy was required before surgical repair of the oronasal fistula. Multiple surgical techniques, including a greater palatine island axial pattern flap, were used to repair the oronasal fistula.

Perforator Flaps for Perineal Reconstructions

Whenever there is soft tissue loss from the perineum there are many options for reconstruction. These include allowing the wound to heal by secondary intention and the use of local random or axial pattern flaps, regional flaps, or free flaps. The axial skin flap can be defined as a flap based on known constant vessels of the subcutaneous tissue and its vena comitantes. The perforator flap on the other hand is a randomly selected perforator consisting of an artery with vena comitantes, which perforate the deep fascia to supply the subcutaneous vascular networks. The perineum has a rich blood supply with multiple perforating vessels, and the vascular network of the perineum is similar to that of the head and neck. Anatomically, there exist circles of anastomosis around any orifice or joint. The perineum has two outlets: the urogenital and the anal. The arterial network of the perineum is supplied by the vessels of the lower abdomen, medial thigh, and gluteal region. Knowledge of the rich blood supply of the perineum can be applied to harvest the various types of perforator flaps in perineal reconstruction.

The protective effect of melatonin on ischemia–reperfusion injury in the groin (inferior epigastric) flap model in rats

Inadequate blood perfusion and ischemia-reperfusion (I/R) injury in the surgical skin flap are believed to be the major factors that cause harmful changes within the tissue and vasculature, resulting in flap necrosis. Reactive oxygen radical species (ROS), in part, are believed to play an important role in this injury. Melatonin, in many physiological conditions, has been shown to have direct and indirect antioxidative effects and free-radical-scavenging properties. Therefore, it may have a beneficial effect on I/R-induced flap injury. In this study, the possible protective effects of melatonin were investigated in I/R injury of rat epigastric (axial pattern) flaps. Ischemia was achieved for 12 h by occlusion of inferior epigastric artery. Melatonin or vehicle was administered 1 h before flap elevation and was continued for 6 days after ischemia. I/R injury elevated malondialdehyde (MDA), an end product of lipid peroxidation, and nitric oxide (NO) levels while the glutathione (GSH) content was reduced. Myeloperoxidase (MPO) activity, which is known to be related to tissue neutrophil accumulation, was found to be statistically higher in the I/R group when compared with the sham group. Administration of melatonin significantly decreased MDA, NO and MPO levels and elevated the GSH content. Moreover, melatonin reduced the flap necrosis area, which was determined using a planimetric method. In conclusion, melatonin, a potent scavenger of free radicals, plays a major role in preventing the inferior epigastric arterial I/R-induced flap necrosis, based on planimetric flap survival and biochemical results. The beneficial effects of melatonin in I/R injury implies the involvement of free radicals in flap damage.

Effect of caffeic acid phenethyl ester on survival of axial pattern flaps in rats with ischaemia–reperfusion injuries

Oxygen-derived free radicals have been implicated in the pathogenesis of tissue injury after ischaemia-reperfusion. Caffeic acid phenethyl ester (CAPE), an active ingredient of honeybee propolis, has been identified as having potent antioxidant and anti-inflammatory properties. We evaluated the ability of CAPE applied intraperitoneally in reducing tissue injury after ischaemia-reperfusion. To investigate whether treatment with CAPE modifies the concentrations of the endogenous indices of oxidant stress, we examined its effects on a model of flap ischaemia-reperfusion injury in rats. CAPE (10 micromol/kg) was given through the peritoneum before reperfusion. CAPE given intraperitoneally had an inhibitory effect on tissue injury after ischaemia-reperfusion comparable to that of a control group. The anti-inflammatory and antioxidant properties of CAPE may contribute to its suppression of tissue injury.

Chronic axillary wound repair in a cat with omentalisation and omocervical skin flap

A mature, neutered male domestic cat was presented with a chronic axillary wound of unknown origin and at least three years' duration. The diagnostic investigation included screening tests for feline leukaemia virus and feline immunodeficiency virus, tissue culture and histological examination. No underlying aetiology or perpetuating cause could be identified. An omental flap was created, passed via a subcutaneous tunnel, and packed into the wound site after excision of all chronic granulation tissue. The skin defect was closed using an omocervical axial pattern skin flap. A small area of the distal edge of the flap became necrotic but the defect healed by second intention. To the author's knowledge, this is the first clinical report of the use of an omocervical skin flap for repair of a chronic axillary wound in a cat. This flap offers a useful alternative where the use of a thoracodorsal axial pattern flap is not possible due to the extent of the lesion.

Axial Pattern Flap Based on the Lateral Caudal Arteries of the Tail in the Dog: An Experimental Study

To determine applicability and size limits of an axial pattern flap based on the lateral caudal arteries in dogs to reconstruct caudodorsal trunk skin defects. Experimental study. Ten mature, mixed breed dogs. The lateral caudal vessels of the tail were incorporated in the flaps of the treatment group (n=5) and were ligated in the control group (n=5). Flaps were rotated and placed into experimentally created caudodorsal skin defects on the trunk. The length and area of tissue that remained viable in each flap were determined. Mean (+/-SD) survival area (222.8+/-32.9 cm2) and length (25.1+/-4.5 cm) of vascularized flaps were significantly greater (P<.05) compared with control flaps (94.9+/-13.4 cm2 and 14.61+/-4.7 cm). Necrosis occurred in all control flaps, resulting in lower percentage flap area (48.8%) and length (47.1%) survival compared with vascularized flaps (78.1%, 77.5%). Axial pattern flap based on lateral caudal arteries of the tail was successfully elevated and transferred in a single procedure, with 78% survival for closure of large experimentally created caudodorsal trunk defects in dogs. Large cutaneous defects of the caudodorsal trunk area in dog could be reconstructed with tail axial pattern flap. Limitations in terms of size and changes in animal appearance have to be considered before flap elevation.

Necrotising fasciitis associated with Escherichia coli in a dog

CASE HISTORY: Lameness and limb pain associated with a laceration in the inner thigh of a Border Collie dog progressed over 4 days to extensive necrosis of the full-thickness of skin and subcutaneous (S/C) tissue. A successful outcome was achieved using surgical debridement and intensive supportive care, followed by limited local closure, axial pattern flap development, and free skin grafting. CLINICAL FINDINGS: Clinical findings included severe pain, depression, pyrexia and hypoalbuminaemia, and full-thickness loss of skin from the caudal thigh to the hock. Histopathologically, debrided tissue showed extensive necrosis of the dermis, adipose and muscle tissues, and the presence of numerous Gram-negative rods. Escherichia coli was cultured from deep tissue samples. DIAGNOSIS: Necrotising fasciitis (NF) associated with E. coli infection. CLINICAL RELEVANCE: NF associated with E. coli has not been previously reported in dogs. The importance of early diagnosis and surgical debridement is noted and the relevant medical literature is reviewed.

Clinical Evaluation of Caudal Superficial Epigastric Axial Pattern Flap Reconstruction of Skin Defects in 10 Dogs (1989–2001)

Ten dogs with caudal superficial epigastric axial pattern flap reconstruction of extensive skin defects were reviewed. Nine dogs had complete survival of the flap. In one dog, a small area of necrosis occurred near the flap tip. Other complications included seroma formation (n=3), partial incisional dehiscence (n=3), flap edema (n=9), and bruising (n=7). Use of the caudal superficial epigastric axial pattern flap provided full-thickness skin coverage of extensive skin defects of the rear limb and inguinal region, with relatively minor complications that were amenable to conservative management.

Clinical application of transcutaneus blood gas monitoring on axial pattern flaps

目的 探讨经皮氧及二氧化碳分压在动态监测皮瓣血供中的应用意义方法 2001年8月至2003年11月,应用经皮血气分析技术,对56例复合组织皮瓣进行动态血供监测. 结果 56例皮瓣中,6例在术后监测4～10 h发生血管栓塞,再手术成活5例,抢救成功率83.33%. 结论该方法能够敏感、客观、连续定量的反映皮瓣的灌注状况,是移植术后早期理想的血运监测手段。

Clinical Evaluation of Random Skin Flaps Based on the Subdermal Plexus Secured with Sutures or Sutures and Cyanoacrylate Adhesive for Reconstructive Surgery in Dogs

To evaluate the use of subdermal plexus skin flaps for closing defects after excision of cutaneous and subcutaneous tumors in dogs and to compare outcome of flaps secured with sutures and those secured with butyl-cyanoacrylate and intermittent sutures. Clinical study. Fifteen dogs. After excision of cutaneous or subcutaneous tumors the skin defect was reconstructed by random flaps based on the subdermal plexus. Flap skin edges were apposed with simple interrupted 4-0 monofilament nylon sutures (group 1; 5 dogs) or nylon sutures alternated with butyl-cyanoacrylate adhesive (group 2; 10 dogs). Flaps were evaluated every 48 hours when bandages were changed, until complete healing. Random flaps based on the subdermal plexus were effectively used to close wound defects; mean flap survival was 89%. Partial flap necrosis occurred in 4 dogs. Wound margins apposed with butyl-cyanoacrylate had thinner and more esthetic scars than sutured margins. Random flaps based on the subdermal plexus proved to be versatile for covering limb wounds after excision of cutaneous or subcutaneous tumors. Mean survival rate was comparable to that reported for axial pattern flaps. Butyl-cyanoacrylate adhesive was easy to apply, allowed accurate margin apposition with good cosmetic outcome and reduced sutures needed. Cyanoacrylate adhesive should be considered in lieu of suture closure to secure random skin flaps based on the subdermal plexus in dogs.

La mammoplastie, comme première étape de la chirurgie prothétique du coude traumatique : à propos d’un cas

A 45-year old polytraumatized female patient presented with an ankylosed elbow two years after a traffic accident. A skin graft adherent to the proximal radius was painful and precluded any attempt at total elbow arthroplasty. Local muscular, cutaneous and vascular sequelae contraindicated the usual local regional flaps or made risky elbow coverage with free flaps. The patient’s breast hypertrophy, an obstacle to a random-pattern flap on the torso, offered enough tissue to cover the injured elbow with an axial-pattern flap of the left breast lower-outer quadrant. Six months later the patient had a total elbow arthroplasty with pain suppression and improvement of the range of motion.

Nasal Reconstruction???Beyond Aesthetic Subunits: A 15-Year Review of 1334 Cases

A retrospective analysis was performed on 1334 patients who underwent nasal reconstruction between 1986 and 2001. The senior author performed all reconstructions in this series after Mohs' histographic excisions. Only secondary reconstructions were performed without a preceding Mohs' excision. Methods of reconstruction, number of operations per patient, locations of defects, and complications were recorded. Using preoperative and postoperative photographs, aesthetic results were reviewed. Basal cell carcinoma was the most common lesion, followed by squamous cancer and melanoma. The average age of the patients was 51 years. Cancers most commonly arose on the dorsum, ala, and tip. Of 1334 cases, a 1.9 percent recurrence rate was documented. The average time between surgery and clinical recognition of recurrence was 39 months. All recurrent lesions were reexcised by the Mohs' technique. Eighty-one percent of reconstructions were completed in three or fewer stages. Seventy-five percent of reconstructions were completed in two stages. Primary dermabrasion or primary laserbrasion using carbon dioxide or erbium lasers was used in nearly every case. Early secondary dermabrasion or laserbrasion was used in a few cases where indicated. A 1.2 percent revision rate was noted (16 patients). Thirteen partial flap necroses required revision. Three patients experienced dehiscence at the donor site of paramedian forehead flaps. A preferred philosophy toward nasal reconstruction is described. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue. Six core principles are advocated that guide efficient and successful nasal reconstruction: (1) maximal conservation of native tissue is advised; (2) reconstruction of the defect, not the subunit, is advised; (3) complementary ablative procedures, such as primary dermabrasion, enhance the final result and decrease the number of revisionary procedures; (4) primary defatting also decreases the number of revisionary procedures; (5) when possible, the use of axial pattern flaps is preferred; and (6) good contour is the aesthetic endpoint.

Defocused diode laser therapy (830 nm) in the treatment of unresponsive skin ulcers: a preliminary trial

BACKGROUND: Skin ulcers with compromised healing remain a major problem for plastic and dermatological surgeons. Low incident levels of laser energy have been shown to increase the blood flow rate and volume and to accelerate the wound healing process, thus raising the possibility in augmenting treatment for skin ulcers.METHODS: Preliminary controlled experiments with a 830 nm GaAlAs diode laser in axial pattern flap survival in the rat model showed statistically significant improvement in survival for the irradiated versus unirradiated control animals. In the present study, a newly developed defocused GaAlAs diode laser (830 nm, continuous wave, 669 mW/cm2) was applied once or twice per week in an uncontrolled study of five patients (aged between 5 and 81 years old, average 46.6 years old, doses from 6.3 J/cm2 to 21 J/cm2) with previously unresponsive ulcers of various aetiologies.RESULTS: In all five patients, the ulcers healed completely between 3 weeks and 7 months (22.8±19.3 weeks), without recurrence during a minimum 12‐month follow‐up.CONCLUSIONS: Defocused 830 nm diode laser therapy was well tolerated, and was very effective in the treatment of this small number of compromised skin ulcers of different aetiologies and in a large range of patient ages. Further controlled studies in larger populations are required. Defocused diode laser therapy nonetheless appears to be a very useful adjunctive method in the treatment of slow‐to‐heal and non‐healing skin ulcers.

Role of free-tissue transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palates.

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.

A symmetrical dorsal island double flap in the mouse

The mouse is currently recognized as the most advantageous experimental animal amongst the muridae because of its small size, universal availability, and the large variety of lines available including disease models. We propose a new axial-pattern double flap model which allows symmetrical preparation of two flaps, reducing difficulties regarding inter-animal variation. Two symmetrical island flaps were harvested based on the bilateral deep circumflex iliac arteries (DCIAs) and subjected to ischaemia followed by reperfusion. On postoperative day 7, the flap survival area was measured. Comparison between the right and left flap in each animal showed an almost identical survival area. The model provides a reliable experimental means for research in flap pathophysiology. It could be especially useful for estimating effects of topical therapeutic manipulation to individual flaps including local application of agents and cell and/or gene transplantation.

A medially based cervical transposition flap for soft tissue coverage of the cheek

A new flap for cheek reconstruction is presented. It is a medially based axial pattern flap that is elevated on the SMAS or including the SMAS and thus is of good thickness and stability for coverage of even large defects of the cheek without significant contour irregularities. It is planned like a traditional transposition flap and harvested in such a way that the scar of the secondary defect lies under the edge of the mandible and, thus, on the border between two aesthetic units and along the relaxed tension lines. The donor site scar is aesthetically acceptable.

Reliable assessment of skin flap viability using orthogonal polarization imaging.

Intraoperative evaluation of skin flap viability has primarily been dependent on clinical judgment. The purpose of this study was to determine whether an orthogonal polarization spectral imaging device could be used to accurately predict viability of random-pattern skin flaps. Orthogonal polarization spectral imaging is a newly developed technique that visualizes the microcirculation using reflected light without the use of fluorescent dyes and allows for noninvasive real-time observation of functional microvascular networks. In Sprague-Dawley rats (n = 24), three types of random skin flaps were designed with unknown zones of viability (n = 8 per group). After flap elevation, the skin flaps were evaluated by both clinical examination and orthogonal polarization spectral imaging. Areas of the flap determined to be nonviable by clinical examination were measured and marked. Orthogonal polarization spectral imaging was subsequently performed, and areas of the skin flap with stasis (i.e., cessation of red blood cell movement) in the dermal microcirculation on orthogonal polarization spectral imaging were measured and marked. The skin flaps were then secured in place. Flaps were evaluated on a daily basis for clinical signs of ischemia and necrosis. On postoperative day 7, the total amount of random skin flap necrosis was measured and recorded. Clinical examination of the random skin flaps significantly underestimated the actual amount of eventual flap necrosis, and as result was a very poor predictor of flap necrosis. By contrast, assessment of microcirculatory stasis using the orthogonal polarization spectral imaging device correlated well with the subsequent development of necrosis in all groups. In the three groups, the average amount of flap necrosis predicted by clinical examination deviated from actual necrosis by approximately 2 to 4 cm. However, the amount that orthogonal polarization spectral imaging differed from actual necrosis was 0.1 to 0.3 cm. Therefore, orthogonal polarization spectral imaging was an excellent predictor of eventual flap necrosis and much more accurate than clinical observation (p < 0.001). Intraoperative evaluation of axial and random pattern flap viability has traditionally been based on clinical examination as no other reliable, convenient test currently exists. The authors demonstrated that an orthogonal polarization spectral imaging device accurately predicts zones of necrosis in random pattern flaps by directly visualizing cessation of microcirculatory flow. Intraoperative stasis in the dermal microcirculation correlated precisely with subsequent flap necrosis. Orthogonal polarization spectral imaging was significantly more accurate than clinical examination, which consistently underestimated flap necrosis. The orthogonal polarization spectral imaging technique may have value in the intraoperative assessment of skin flap perfusion such as that required after skin-sparing mastectomy.

Central hemimaxillectomy and reconstruction using a superficial temporal artery axial pattern flap in a domestic short hair cat

A 2-year old, neutered male domestic short hair cat presented with a large mass involving the right upper lip and underlying gingiva. A previous attempt at mass excision had failed, and the histopathological diagnosis was reported to be a fibrosarcoma. The cat was otherwise in good health. A central hemimaxillectomy was performed with extensive soft-tissue dissection and maxillofacial reconstruction achieved using an axial pattern flap based on the superficial temporal artery. This is the first reported clinical case of the use of the superficial temporal artery axial pattern flap in the cat. Histopathology identified a periodontal fibromatous epulis.

Laser-induced fluorescence of indocyanine green: plastic surgical applications

The objective assessment of tissue perfusion is of utmost importance to plastic surgeons. Nevertheless, clinical observation remains the accepted gold standard for assessment of microcirculation. Dynamic laser fluo- rescence videography is a new technique for objective assessment of blood flow. We describe our clinical expe- rience using this technique in plastic surgical patients. Possible implementations include evaluation of pedicle (random and axial pattern) flaps, monitoring of free tis- sue transfer and replants, and the objective determination of burn depth. Compared with standard clinical assess- ment techniques indocyanine green imaging provides significant additional information which allows a ratio- nal and evidence-based planning of surgery.

Effects of diode laser therapy on blood flow in axial pattern flaps in the rat model.

Axial pattern skin flaps are a very important reparative tool for the plastic and reconstructive surgeon in the reconstruction of tissue defects. From whatever unfortunate reason, part or all of such flaps occasionally suffers from irreversible ischaemia with loss of the flap. Infrared diode laser therapy has been shown to improve local and systemic circulation. The present study was designed to assess the effect of an 830 nm diode laser (power density, 18.5 W/cm(2), energy density 185 J/cm(2)) on the blood flow of axial pattern flaps in the rat model and their survival, compared with unirradiated controls. The flaps were raised in all animals ( n=40), and blood flow assessed with laser speckle flowmetry (LSF). In the experimental groups (3 groups, n=10 per group), the flaps were irradiated either directly over the dominant feeder vessel (iliolumbar artery), at the proximal end or at the distal end of the flap itself and blood flow assessed during irradiation. Flowmetry was performed again in all animals at 5 and 10 min postirradiation, and the flaps sutured back in position. The unirradiated controls were handled in exactly the same way, but the laser was not activated. The survival rate of the flaps was assessed on the fifth postoperative day. LSF demonstrated significant increased blood flow in the flaps at 5 and 10 min postirradiation in all experimental groups compared with the control animals. At five days postirradiation, there was significantly better survival of the flaps in all the experimental groups compared with the controls ( p<0.01), but no significant difference was seen between any of the experimental groups. We conclude that laser therapy increases the blood flow and perfusion of transferred flaps, and that this has significant effects on the survival of the flaps. One possible mechanism of modulation of the autonomic nervous system is discussed.