Combined Flap Research Articles

Lambeau de muscle serratus anterior vascularisé par les pédicules mineurs du muscle latissimus dorsi. À propos de deux cas cliniques

The use of combined flap involving the distally based latissimus dorsi muscle pedicled on the lumber perforating arteries and prolonged by the last digitations of the serratus anterior flap muscle supplied by the thoracic branch of thoracodorsal vessels is uncommon but has ever been described. We describe the use of this flap in two original cases. The first case is for coverage of a controlateral dorsal radionecrosis. The second case describes its use in emergency following ballistic chest trauma.

Osteomyocutaneous peroneal artery–based combined flap for reconstruction of composite and en bloc mandibular defects

The osteomyocutaneous peroneal artery-based combined (OPAC) flap is a refinement of fibula osteoseptocutaneous flap, with the inclusion of partial soleus muscle based on an independent myocutaneous perforator. Seventeen men underwent composite oromandibular reconstruction using an OPAC flap. Flaps were raised with 1 or 2 skin paddles and 2 to 3 bone segments. In 8 cases, a portion of soleus muscle was included. All flaps survived, but partial failure occurred in 2 cases (11.7%). At a mean follow-up of 25.3 +/- 19.4 months, 6 of 12 patients tolerated a regular diet, 5 a soft diet, and 1 a liquid diet. Speech was normal in 2 patients, intelligible in 4, and slurred in 6. Advantages of the OPAC flap include a single donor site, 1 pair of recipient vessels, versatile 3-dimensional inset, adequate soft tissue augmentation, and better aesthetic and functional outcomes.

Résultats à long terme des reconstructions mammaires par lambeau de grand dorsal et prothèse

Breast reconstruction by latissimus dorsi myocutaneous flap in combination with prosthesis has been used for 30 years. Short- and medium-term evaluation after this procedure is well described in the literature, but there have been few evaluations of the late course published until now. In our retrospective study, we included 47 patients who had a breast reconstruction according to this technique, with a minimal follow-up of five years and a maximal follow-up of 11 years. We found that one third of the patients complained about the subjective donor-site morbidity of the latissimus dorsi myocutaneous flap and 37% of the patients needed a late reoperation for prosthesis exchange. Evolution of the reconstructed breast is different compared to the healthy side and getting a long-term symmetry seems difficult.

Coronally advanced flap in combination with acellular dermal matrix with or without enamel matrix derivatives for root coverage

Coverage of gingival recession defects has been considered as a subject of interest for dental practitioners. The present study was aimed to compare the clinical outcomes of root coverage (RC) procedures, using coronally advanced flap (CAF) in combination with acellular dermal matrix (ADM) with or without enamel matrix derivatives (EMD). A total of 36 Miller class I or II recession defects in 15 eligible patients were selected. The defects were randomly allocated to test (CAF+ADM+EMD) and control (CAF+ADM) groups. Recession depth (RD), recession width (RW), width of keratinized tissue (WKT), clinical attachment level (CAL), and the position of mucogingival junction (MGJ) were measured at baseline, two and six months after treatment. Data were analyzed using repeated measures ANOVA and paired sample t-test with the patients as statistical unit. At two-month follow-up, the mean RC for CAF+ADM+EMD and CAF+ADM was 82.75 +/- 22 and 88.89 +/- 22 percent, respectively. However, these values did not change significantly after six months. Both treatments led to significant RC (P < 0.001), whereas no significant differences were observed in WKT, CAL, and MGJ between the study groups. The application of EMD does not improve the clinical efficacy of ADM in combination with CAF in RC procedures.

Root Coverage Technique with Enamel Matrix Derivative

Various periodontal plastic surgical techniques are employed in obtaining root coverage. Recently, the use of an enamel matrix derivative (EMD) has been reported in such treatment. We report 2 cases of root coverage surgery with a coronally positioned flap in combination with EMD (CPF+EMD) and connective tissue graft in combination with EMD (CTG+EMD). Case 1: The patient was a 25-year-old woman referred to Suidobashi Hospital, Tokyo Dental College for root coverage surgery on the lower right first premolar. Gingival recession was classified as Miller Class II, as no alveolar bone loss or loss of attachment was observed in the interdental area, although recession had progressed to the mucogingival junction. The patient was diagnosed with local gingival recession caused by excessive tooth brushing. Primary conservative treatment failed to reduce the gingival recession. Subsequently, root coverage surgery with CPF+EMD was carried out. As observation at the 1-year follow-up revealed complete root coverage and no recurrence of root exposure or subjective symptoms, the postoperative course was considered to be favorable. Case 2: The patient was a 39-year-old woman referred to Suidobashi Hospital, Tokyo Dental College for root coverage surgery on the lower left canine. Gingival recession was classified as Miller Class II. Root coverage surgery with CTG+EMD was carried out. As observation at the 2-month follow-up revealed complete root coverage and no recurrence of root exposure, the postoperative course was considered to be favorable. These 2 cases indicate the effectiveness of root coverage surgery with CPF+EMD and CTG+EMD.

A three-dimensional virtual reality model for limb reconstruction in burned patients

Electrical burns are a common cause of injuries. Despite many developments in the treatment of high-tension electrical burns, this type of injury still shows high-morbidity rates. Recently, the use of free flaps for reconstruction in burned patients has increased due to advances in the field of microvascular free tissue transplantation [1]. Free flaps have reached a high level of sophistication. For instance, reexpanded flaps, composite tissue flaps, fascial flaps, multiple autologous flap transplantations and combined flaps (‘‘chimeric flaps’’) based on a single vascular pedicle have been performed in patients with severe burns and large defects in extremities [2]. Traditional methods of learning have helped generations of surgeons to familiarize themselves with flaps anatomy. Nevertheless, even texts with the highest level of accuracy and image quality are limited by the two-dimensional nature of printed material, which cannot impart three-dimensional (3D) views. Video material is similarly limited as to deliver a 3D experience. Another restriction of most traditional methods for the study of anatomy relates to the lack of interactivity and feedback. As a supplement to the knowledge gained from books and observation, cadaver dissections can play an

Surgical treatment of giant recurrent breast phyllodes tumor

In this study, a recurrent massive phyllodes tumor of the breast was surgically removed and the grafting was used to repair the local skin defects. A 29-y female patient had recurring breast phyllodes tumor of extremely large size in the chest wall after the excision of a previous tumor. The massive phyllodes tumor was eliminated by completely removing the layers of the skin and tissues above the costal bones with incisal margin being 2 cm away from the tumor lesion. The latissimus dorsi myocutaneous flap, lateral thoracic skin flap, and rectus abdominis myocutaneous flap were grafted to replace the lost tissues due to the surgery. Anti-infection and anticoagulation treatments were used after the surgery. The graft flaps had sufficient blood supply and good blood circulation, and the incisions mostly healed. The outcome of the surgery was acceptable. For the surgical treatment of the massive phyllodes tumor in the chest wall, it is an alternative of choice to use latissimus dorsi myocutaneous flap, lateral thoracic skin flap and rectus abdominis myocutaneous flap in combination for skin grafting.

An Introduction to the Chimeric Deep Inferior Epigastric Artery Perforator (DIEAP)—Rectus Abdominis Muscle Flap

A muscle perforator flap is a unique form of fasciocutaneous flap whose circulation is derived from musculocutaneous perforators, but without including any muscle. This anatomic relationship intuitively should readily allow the formation of branch-based chimeric or polyflaps consisting of a cutaneous perforator flap and its corresponding muscle as a combined flap, both ultimately supplied by a common source vessel. Many versions of the rectus abdominis musculocutaneous flap based on the deep inferior epigastric vessels are well known, but formation of a chimeric flap consisting of its component parts has heretofore not been reported. This treatise is intended primarily to provide an anatomic description that introduces the deep inferior epigastric artery perforator (DIEAP)-rectus abdominis muscle chimeric flap, with a clinical example that mainly demonstrated its usefulness to be the aesthetic advantage of a concomitant abdominoplasty.

Clinical outcome of dental implants placed in fibula-free flaps for orofacial reconstruction

Functional reconstruction of the jaw defect due to tumor resection poses a challenging problem in maxillofacial surgery. The osteocutaneous fibula free flap in combination with simultaneous or second stage insertion of dental implants has exhibited growing popularity for such reconstructions. This study was aimed at evaluating the clinical status and the success rates of dental implants inserted in fibula-free flaps for orofacial reconstruction following ablation of tumors. We conducted a clinical follow-up study based on 29 patients after oral tumor surgery, who received vascularized fibula bone grafts and endosseous implants for functional jaw reconstruction during a 5-year period. The follow-up protocol included clinical examination and radiological evaluation. The clinical records of the patients were reviewed retrospectively. Information on treatment modalities, dentition, implant parameters, and prostheses was collected and analyzed. In general, a high primary stability for implants placed into the free fibula grafts was achieved. The 1-year and 5-year cumulative survival rates of the implants were 96% and 91%, respectively, using the Kaplan-Meier method. The 1-year and 5-year cumulative success rates of implants placed into the fibula bone grafts were 95% and 87%, respectively. The main reasons for failure of the dental implants were infection, tumor recurrence and soft tissue proliferation. The fibula flap presents many advantages for implant placement, but its limited height sometimes makes implant-supported prosthetic rehabilitation difficult. Vascularized fibula bone grafts provide a firm basis for the placement of dental implants in jaw reconstruction. Implants placed in fibula bone grafts were shown to integrate normally. The double-barrel technique, or increasing the height of the fibula flap by vertical distraction osteogenesis before implant placement in the mandible, is desirable from a functional and esthetic point of view.

Vascularized Mastoid Bone Flap Cranioplasty after Translabyrinthine Vestibular Schwannoma Surgery

Objective: Cerebellospinal fluid (CSF) leak and postauricular deformity can be significant problems in patients after translabyrinthine excision of vestibular schwannomas (VS). We describe a novel technique of cranioplasty using a vascularized mastoid bone flap in combination with abdominal fat graft.

Chimeric Gastrocnemius Muscle and Sural Artery Perforator Local Flap

Under special circumstances, a chimeric form of combined flap can be advantageous. The formation of such a combination should be possible with any muscle perforator flap and its underlying muscle as a branch-based form of chimeric flap. In 2 patients with knee infections, this concept facilitated the use of local flaps only to simultaneously allow deep obliteration within the knee joint with the muscle portion while providing tension-free skin closure. Specifically, a chimeric gastrocnemius muscle and sural artery perforator flap, the latter based on either the medial or lateral sural source vessels, provided this reasonable solution. This is yet another new example of branch-based chimeric flaps, where the cutaneous component is a muscle perforator flap.

A New Composite Flap Model in the Rat

We introduce a new model of combined cremaster muscle and pubic bone flap based on a single pedicle consisting of the osseous branch of pubic bone and external spermatic vessels of cremaster muscle in continuity with the pudic-epigastric artery (PEA). Thirty male Sprague-Dawley rats weighing 200 to 250 g were used in this study. In 10 rats PEA, a branch of the iliac artery was dissected throughout its entire course for the anatomic study. We observed that after giving the external spermatic artery to the cremaster muscle and external pudendal branch to the penis, the PEA continued its course over the ipsilateral pubic bone that was thought to nourish the pubic bone. In 20 rats, the flap was raised on the PEA for the flap study. Five flaps were used for microangiographic study. Remaining 15 rats were used for scintigraphic assessment and dye injection and histologic study. Microangiographic evaluation revealed the vascularity of all components of the flap as provided by the pedicle. Bone scintigraphy performed at 7th postoperative day demonstrated radionuclide uptake by the bone segment of the flap, indicating the bone viability. In addition, the dye injection study revealed ink staining within blood vessels of the cortex and the marrow of the pubic bone. To the best of our knowledge, this is the first report describing the combined cremaster muscle and pubic bone flap model in the rat. It seems to have an important advantage over the other composite osteomuscular flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Besides being harvested from a small animal species, it is reliable, versatile, and relatively easy to dissect with quite long isolated vascular pedicle, which allows a greater range of flap displacement. It can be used for different applicability including microcirculatory, pharmacologic, physiological, biochemical, and immunologic studies, as well as for the transplantation studies.

Use of a prefabricated pectoralis major muscle flap and pedicled jejunal interposition graft for salvage esophageal reconstruction after failed gastric pull-up and colon interposition

Secondaryreconstruction after failedesophageal surgeryremains a challenging surgical problem. In circumstances when neither the stomach nor the small or large bowel is available or adequate as an esophageal replacement, skin or musculocutaneous flaps should be considered. We report a case of salvage esophageal reconstruction using a prefabricated muscle flap in combination with pedicled jejunum in a staged fashion that highlights some of the management issues in addressing this difficult clinical situation. Clinical Summary A 50-year-old man with a history of Barrett’s esophagus was found to have invasive adenocarcinoma in the distal third of his esophagus during surveillance endoscopy. He underwent en bloc esophagogastrectomy with 3-field lymph node dissection. On the fourth postoperative day ischemic necrosis of the gastric conduit developed, and the distal third of the conduit was resected. The left colic artery was sclerotic, so an isoperistaltic right colon interposition graft was used to connect the cervical esophagus to the gastric conduit remnant. Two weeks later, a right-sided empyema developed, and the colon interposition graft was found to be infarcted. The patient underwent decortication of the right lung and excision of the necrotic colon graft, and a cervical esophagostomy was created. Five months after the initial operation, the patient was referred to Massachusetts General Hospital/Harvard Medical School for an opinion on the options for esophageal reconstruction. Esophageal reconstruction was performed using a delayed, prelaminated, and tubularized pectoralis major muscle flap and pedicled jejunal interposition graft in a series of 3 staged procedures. Thefirst procedure was prelamination and delay of a right-sided pectoralis major muscle flap. A large fasciocutaneous flap was elevated to expose the entire pectoralis muscle. After the superior and lateral vascular bundles entering the pectoralis major were divided, a splitthickness skin graft from the right thigh was sutured over the entire muscle flap. The fasciocutaneous flap was then returned to the chest wall to cover the entire construct. One month later the pectoralis major flap was elevated, and the thoracoacromial vessels were divided, leaving the flap based on the internal thoracic artery perforators medially. The flap was tubularized by rolling it to create a skin-lined tube 22 cm in length. The proximal end of the tube was anastomosed to the distal cervical esophagus. The fasciocutaneous chest wall flap was advanced to cover the neoesophagus. At the distal end of the neoesophagus, the tube was sutured to the abdominal wall skin. This allowed salivary secretions to drain into an ostomy appliance affixed to the abdominal wall. Two months later a laparotomy was performed, and a Roux-en-Y jejunal segment was anastomosed to the distal end of the tubularized pectoralis major muscle flap (Figure 1). On postoperative day 7, the patient underwent a barium swallow that showed no anastomotic leaks with contrast flowing rapidly to the jejunum. The patient was able to discontinue enteral tube feedings and now is able to obtain 100% of his nutrition orally. Figure 2 shows the patient at the time of discharge from the hospital after the completed reconstruction.

Soft tissue dehiscence coverage around endosseous implants: a prospective cohort study

To evaluate the healing outcome of soft tissue dehiscence coverage at implant sites. Ten patients with one mucosal recession defect at an implant site and a contralateral unrestored clinical crown without recession were recruited. The soft tissue recessions were surgically covered using a coronally advanced flap in combination with a free connective tissue graft. Healing was studied at 1, 3 and 6 months post-operatively. Soft tissue dehiscences were covered with a coronal overcompensation of the flap margin up to 1.2 mm after the procedure. After 1 month, the coverage shrank to a mean of 75%, after 3 months to 70% and after 6 months to 66%. The implant sites revealed a substantial, clinically significant improvement following coronal mucosal displacement in combination with connective tissue grafting, but in none of the sites, a could complete implant soft tissue dehiscence coverage be achieved.

Combined Cremaster Muscle and Inner Thigh Skin Composite Flap: A Novel Experimental Flap Model in the Rat

Unlike the composite musculocutaneous flap models, the combined composite muscle-skin flap model allows evaluating muscle and skin viability independently, because it has an independent blood supply to the muscle and skin component. However, to our knowledge, only two combined muscle-skin flaps have been reported to date. During our cremaster dissection in our laboratory, we perceived a new vessel as a terminal continuation of the pudic-epigastric artery (PEA) on which the cremaster muscle flap is raised. Therefore, we designed this study to determine whether the scrotal and inner thigh skin can be harvested with the cremaster muscle as a combined cremaster muscle-skin composite flap. Thirty male Sprague-Dawley rats were used in this experiment. In five rats, ink study selective to the PEA marked a skin territory. In 15 rats, cremaster muscle and 4 x 3 cm ipsilateral scrotal and medial thigh skin flap was raised on the PEA. Fluorescein study after 4 hours showed fluorescein stain in the skin island. On postoperative day 7, both muscle and skin components of the flaps were viable. Microangiographic study after the flap elevation revealed the vascularity of all components of the flap and clearly identified the branch to the skin island. To the best of our knowledge, this is the first report describing the combined flap model including the cremaster muscle. Our flap seems to have an important advantage over the other combined muscle-skin flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Additionally, the two components of the flap have separate nutrient vessels with adequate length, which gives the flap flexibility in the placement of the skin component in a location distant from the muscle component. The flap may be also be raised as a skin flap without the cremaster muscle. It can be used for different applications, including microcirculatory, pharmacological, physiological, biochemical, and immunological studies as well as for transplantation studies.

Posterior tibial artery‐based multilobar combined flap free transfer for repair of complex soft tissue defects

In this report, the posterior tibial artery (PTA) based multilobar combined flap is introduced for the repair of complex soft tissue defects. The flap was designed based on the perforatoring branches of PTA in the anterior soleus muscle septum, which supply the skin over the medial side of the calf and the entire soleus muscle. The saphenous nerve was included in one perforator flap of the combined flap for reinnervation. The tibial artery was repaired with a vein graft after harvest of flap. From October 2005 to February 2007, eight patients (6 males, 2 females) underwent PTA-based multilobar combined flap transfer for coverage of soft tissue defects involving the foot (three cases), hand (two cases), and calf (three cases). Each combined flap composed of two to three perforator flaps, and the size of the perforator flaps ranged from 4 x 2 cm to 10 x 8 cm. With an average follow-up of 6 months, all flaps survived without complications and injured extremities showed a good functional recovery with restoration of the partial protective sensation on the flap with reinnervation. This clinical report has shown that a reliable multilobar combined flap can be designed based on the perforators of the posterior tibial artery and used for coverage of the complex wound.

Connective tissue graft for root coverage

Purpose: The treatment of gingival recessions is needed to reduce root sensitivity and improve esthetical satisfaction. Several surgical techniques have been proposed to achieve these goals. The use of connective tissue grafts has made esthetic root coverage a predictable procedure. Numerous clinical studies have represented that using connective tissue grafts to cover exposed root surface showed high success rates. This is a case report which demonstrates the technique to obtain root coverage of a buccal recession defect. Materials and Methods: A 35-year-old patient with a high level of oral hygiene was selected for the study. This patient had one Class Miller recession defect in the mandible. A coronally advanced flap in combination with the connective tissue Ⅰ graft was chosen for the treatment. After surgery, the patient was told to visit the hospital once a week for his oral management and professional prophylaxis. The depth of initial recession was 4.0 mm. Result: After three months, it reduced to 0.0 ㅤ mm, and the average recession reduction was 4.0 mm. The average root coverage was 100%. Conclusion: The connective tissue graft is both effective and predictable way to produce root coverage in increasing the width of CAL and KT of various adjacent gingival recessions. (J Korean Acad Periodontol 2008;38:231-236)

Hand reconstruction with lobulated combined flaps based on the circumflex scapular pedicle

Repair of multiple soft tissue defects on hand often pose a difficult problem to the reconstructive surgeons with employing a limited number of reliable flaps and recipient vessels. This report is to explore the feasibility and advantage of the treatment of multiple soft tissue defects on hand with combined island flaps based on branches of the circumflex scapular system. From 2002 to 2006, nine patients had transfer of the scapular lobulated combined flaps based on the transverse branch, ascending branch, and descending branch of the circumflex scapular vascular pedicle for coverage of soft-tissue defects over injured hands. Follow-up ranged from 6 months to 24 months with average 12.1 months' all of nine flaps completely survived without complications. Arterial insufficiency was found in one flap because of the pedicle compression in the subcutaneous tunnel. The blood supply to flap was restored after the compression was released. All transferred flaps showed good appearance without significantly swelling and congestion. Two flaps underwent secondary debulking surgery. At 6 months postoperatively, partial protective sensation (S1) was restored in the flaps. The donor sites were directly closed in six cases. Skin grafts were used to cover the donor sites in other three cases. All of donor sites healed without complications. Our report shows that the management of multiple soft tissue defects on hand in complex hand injuries with lobulated flaps of circumflex scapular system can obtain good results for its good appearance and low donor site complications. It is probably the optimal surgical intervention for these injuries.

The Combined Parascapular Fasciocutaneous and Latissimus Dorsi Muscle Conjoined Free Flap

A combined flap composed of at the least two otherwise distinct territories, each retaining its independent vascular pedicle yet joined together by a common interface, is by definition a conjoined flap. If the vascular pedicles are branches of a common source vessel, even more specifically this combination would be a "branch-based [common]" conjoined flap. The parascapular fasciocutaneous and latissimus dorsi muscle flaps can be raised together as a clinical example of a branch-based (common) conjoined flap. This combination allows the creation of an extremely large cutaneous flap from the dorsal thorax while ensuring survival of both the muscle and skin portions in their entirety. A series of eight parascapular fasciocutaneous and latissimus dorsi muscle conjoined free flaps in eight patients had total flap survival of all components. Major complications, none of which were related to flap viability, eventually occurred in two patients; that is, one patient had a persistent chronic tibial osteomyelitis and the other had the covered lower limb amputated. The parascapular fasciocutaneous and latissimus dorsi muscle conjoined free flap is an extremely large, yet reliable flap. The anatomy is fairly consistent and already well known. In favorable situations, only a single recipient site is needed for the requisite arterial and venous microanastomoses. This combination can replace the need for multiple conventional flaps, yet violates but a single donor site. This series is the first clinical example of the branch-based (common) conjoined free flap.

The Pectoralis Major Muscle Extended Island Flap for Complete Obliteration of the Median Sternotomy Wound

The sequence of adverse events initiated by a sternal wound infection today can typically be ameliorated by interposing a vascularized flap. The pectoralis major muscle due to its propinquity has universally been the workhorse flap for minimizing this dilemma, with our experience over the past 25 years being no exception as 123 of 156 patients so inflicted required this donor site in some format. However, a rectus abdominis muscle had to be used in combination in 22 patients, particularly for coverage of the xiphoid region, and this can add significant morbidity in an already compromised patient population. This conundrum provided the impetus starting in 2003 for the development of a pectoralis major muscle extended island flap, whereby skeletonizing its vascular pedicle back to near the origin of the thoracoacromial axis, the desired extended reach can be obtained. Since that time, 18 pectoralis major muscle extended island flaps have been successfully used, with only a single wound complication still requiring use of a rectus abdominis muscle flap. This has proven to be a reliable option that alone allows complete closure of the median sternotomy wound while avoiding the need for combined flaps with preservation of the rectus abdominis muscle.