Composite Free Flap Research Articles

Use of the AO Plate for Immediate Mandibular Reconstruction in Cancer Patients

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.

One-Stage Repair of Both Skin and Tendon Digital Defects Using the Arterialized Venous Flap with Palmaris Longus Tendon

A novel technique of composite free-flap and tendon transfer is introduced and used in four patients to repair complicated finger injuries involving loss of skin and tendon. This is a one-stage procedure, providing unbulky, high-quality tissue. Although the final range of motion was disappointing, with an average of 10 degrees, there is justification for further clinical trials in patients with loss of skin and tendon in the digits.

Osteosynthetic titanium mini-plate fixation of composite radial forearm flaps in mandibular reconstruction

This paper describes the evolution and refinement, over a four-year period, of a simple technique for shaping and stabilising the bony component of a composite radial forearm free flap to reconstruct the mandible following segmental resection for neoplastic disease. The results of reconstruction in 30 consecutive patients are reported. The current method of adapting and stabilising the radial bony strut using a specially designed 32 hole osteosynthetic miniplate is described.

Reconstruction of the Lower Lip and Chin with the Composite Radial Forearm—Palmaris Longus Free Flap

Four cases of total lip and chin reconstruction are presented. In three, the composite radial forearm-palmaris longus free flap was used for reconstruction. In the fourth case, the palmaris longus was separated from the flap but still used as a lower lip sling. In all cases, the entire lower lip and the soft tissue of the chin were reconstructed in one stage. All patients healed primarily, and the three who underwent radiotherapy tolerated it without complications. Lip seal and speech were good, and there was no problem with drooling. Postoperative results emphasize the importance of respecting the aesthetic unit of the lower lip and chin.

Composite Free Flaps in Oromandibular Reconstruction: Review of the Literature

The transfer of vascularized bone containing free flaps is the most effective method of achieving a functional oromandibular reconstruction in the primary setting. All of the reported series on mandibular reconstruction using microvascular free flaps, totaling 513 cases, are reviewed. The collective success rates of free flap transfers compiled from these series have steadily increased to 96% during the latter portion of this review. The experimental studies demonstrating the viability of vascularized bone following an ischemic insult are presented. The issues regarding primary and secondary mandible reconstruction are reviewed. Each of the eight donor sites for vascularized bone are discussed and rated with respect to the ideal qualities of the bone and soft-tissue components of a composite free flap to achieve an optimal oromandibular reconstruction.

Oromandibular Reconstruction Using Microvascular Composite Free Flaps: Report of 71 Cases and a New Classification Scheme for Bony, Soft-Tissue, and Neurologic Defects

We describe 71 cases of oromandibular reconstruction using microvascular composite free flaps. There was an overall flap success rate of 94%, while 97% of the patients in this series had their mandibles reconstructed with free vascularized bone flaps. Fifteen patients were rehabilitated with implant-borne dental prostheses. Primary repair of discontinuity defects of the inferior-alveolar nerve using a variety of nerve grafts was performed in 16 patients. A new classification scheme for composite defects of the oral cavity involving bone, soft tissue, and neurologic defects is proposed and applied in the description of each of the patients in this series.

Composite Reconstruction for Chest Wall and Scalp Using Multiple Ribs—Latissimus Dorsi Osteomyocutaneous Flaps as Pedicled and Free Flaps

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.

Reconstruction of an avulsed ear by constructing a composite free flap

A completely avulsed ear cartilage was successfully replanted after being buried under the volar forearm skin as a radial forearm composite free flap.

Prefabrication of Composite Free Flaps Through Staged Microvascular Transfer

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.

Transplantation of free composite flaps to the foot. (Russian)

Transplantation of free composite flaps to the foot. (Russian)

The Thigh Flap

A new experimental model for free-flap transfer has been developed in the rat. This "thigh flap" is an osteomyocutaneous free flap of bone (femur), muscle (thigh), and skin (groin) based on the femoral vessels. The flap is harvested from the left groin and thigh of an inbred female rat and is transferred to a subcutaneous pocket in the left groin of a male rat of the same inbred strain. The femoral vessels supplying the flap are anastomosed end-to-end with the femoral vessels of the recipient. Thirty flaps have been transferred, with 5 technical failures. Three of the remaining 25 flaps developed necrosis within 24 hours. The other 22 flaps remained viable until the rat was sacrificed at 7 days. The survival rate of the thigh flap was thus 88 percent. The model is suitable for use in metabolic, vascular, and immunologic studies of composite free flaps.

Reconstruction of the ala of the nose using a composite free flap from the pinna

A new method of reconstruction of the nasal ala is described using a composite free flap taken from the anterior part of the pinna, based upon the superficial temporal vessels. Forty cadaver dissections have been performed to assess variations in vascular anatomy and a direct branch of the superficial temporal artery was found in 90% of subjects. The flap has been used successfully in two cases.

Immediate free vascularized joint transfer from second toe to index finger proximal interphalangeal joint: A case report

The results of treatment of severe injuries to the proximal interphalangeal joint are unsatisfactory. The methods of joint reconstruction are discussed, including fusion, implant arthroplasty, perichondrial grafting and vascularized joint transfer. A patient is presented with a severe crush injury to the dorsum of the index finger with loss of skin and extensor tendon and proximal interphalangeal joint disruption. Immediate reconstruction of the finger is described using a composite free flap of skin, extensor tendon and proximal interphalangeal joint from the second toe. Follow-up at two years is described, demonstrating proximal interphalangeal motion and finger function.

One-stage composite reconstruction using the latissimus myoosteocutaneous free flap

Head and neck reconstruction using a free flap composed of latissimus dorsi muscle and overlying skin and attached to vascularized posterior rib based on the thoracodorsal vessel was recently developed in our laboratory. Further clinical experience in the use of this flap is presented, along with a detailed explanation of the surgical technique. This flap provides internal lining, structural support, bulk, and external coverage for head and neck defects in one stage. Herein alternative composite free flaps have been compared with this flap.

A new method of oral reconstruction using a free composite foot flap

A new method of oral reconstruction using a free composite foot flap

Microvascular segmental thumb reconstruction: A case report

The great toe provides an ideal source of tissue for both functional and aesthetic reconstruction of segmental defects in the thumb and can be used without mutilation of the foot. A successful case is presented of a 1-stage primary reconstruction of a segmental defect of the thumb using a composite free flap transfer from the great toe containing pulp, tissue, nail and bone, with neurovascular anastomosis. The donor defect on the great toe was repaired at the same time.

Composite free flap and tendon transfer: An anatomical study and a clinical technique

Composite free flap and tendon transfer: An anatomical study and a clinical technique

A rib-containing free flap to reconstruct mandibular defects

A composite free flap based on intercostal vessels may be used to reconstruct in one stage defects around the mandible in which skin, soft tissue and bone are missing. A delay procedure is recommended one week prior to transfer.

Experimental transfer of composite free flaps with microvascular anastomoses.

The transfer of composite island flaps with microvascular anastomoses in rabbits from one iliac fossa to the other is described. Twenty‐seven out of 20 flaps had total survival, with mild necrosis in the remaining two. All five control flaps without microvascular anastomoses necrosed quickly. No measures such as perfusion, anticoagulants or antibiotics were used. Cadaver dissections are described, and it is suggested that suitable donor sites for clinical use include the groin flap, the deltopectoral flap and possibly the dorsum of the foot