Distant Pedicle Flaps Research Articles

Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach.

Different techniques can be used to repair contracture of burn scars on the elbow, including local or distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders. Among these, a pedicled adipofascial flap based on the most proximal two to four perforators of the ulnar artery (located 1 to 5 cm from the origin of the artery) can be anastomosed to form a sort of axially patterned blood supply within the fascia and subcutaneous fat. Therefore, no major vessel in the forearm need ever be severed. In addition, use of this type of flap preserves muscle function. The pedicled adipofascial flap described in this article allows for early rehabilitation because the flap is thin and pliable. Additional advantages are the easy and quick dissection and completion of the procedure in one stage. A detailed anatomic dissection of the flap was performed on 16 upper extremities from fresh cadavers; an injection study was also performed to determine the location and dimensions of the pedicle flap and its area of reach around the elbow. In the past 3 years, 14 flaps were used in 13 patients to repair elbow defects after release of burn scar contractures. Flap dimensions ranged from 4 x 7 cm to 6 x 14 cm (mean flap size, 74 cm). The results were very satisfactory.

Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.

SOFT-TISSUE COVERAGE FOR THE ELBOW

Coverage of soft-tissue defects about the elbow ranges from direct wound closure to free tissue transfer. Early split thickness skin grafting is vital to preserving range of motion in burn patients. Useful regional flaps include the flexor carpi ulnaris, brachioradialis, lateral arm, and radial forearm. The latissimus dorsi is the primary distant pedicled flap with great potential for use as a functionalized transfer. Other often used free flaps include the parascapular and scapular flaps, rectus flap, and gracilis flap.

Early division of pedicled flaps using a simple device: a new technique

A simple occlusion clamp with screws used to achieve early division of two-staged, distant pedicled flaps is presented. The device is applied to the bridge of a distant flap on the 5th postoperative day and is gradually tightened. It was used on 20 consecutive pedicled flaps in 20 patients: 5 abdominal flaps, 4 superficial external pudendal artery (SEPA) flaps, 9 cross leg flaps, 1 groin flap and 1 medial arm flap. In 17 patients, the flaps were divided successfully between the 9th to the 14th day (Mean: 10 days). The device was removed in 3 patients when ischaemic changes became apparent; their flaps however survived completely and were divided after a longer interval. The principles on which the device works, the technique, feasibility, and advantages of using the device for early flap division are discussed.

Single-stage treatment of sternal wound complications in heart transplant recipients in whom pectoralis major myocutaneous advancement flaps were used

Treatment of sternal wound complications is controversial, particularly in immunosuppressed heart transplant recipients. Regardless of the severity of infection, we combine immediate, aggressive débridement with bilateral pectoralis major myocutaneous advancement flaps in a single procedure. Compared with management with pectoralis major turnover flaps or distant pedicled muscle flaps, treatment of these sternal wounds with pectoralis major myocutaneous advancement flaps is simpler and quicker and provides better aesthetic results. Furthermore, because pectoralis major myocutaneous flaps are based on the thoracoacromial arteries, whether or not the internal mammary arteries have previously been harvested for coronary grafts is irrelevant. Twenty consecutive heart transplant recipients with sternal wound complications were treated with this technique. No intraoperative or perioperative deaths occurred. The morbidity rate was 30%, with seroma treated by needle aspiration in four patients (20%) being the most common complication. Only one patient had a postoperative wound infection. All patients had excellent functional and aesthetic results.

Single-Stage Management of 74 Consecutive Sternal Wound Complications with Pectoralis Major Myocutaneous Advancement Flaps

The optimal management of sternal wound complications remains controversial. Since 1985, we have utilized a combination of immediate, aggressive debridement with simultaneous repair using bilateral pectoralis major myocutaneous advancement flaps, regardless of the degree of infection. As compared with the use of distant pedicled muscle flaps or pectoralis major turnover flaps, the management of complicated sternal wounds with immediate pectoralis major myocutaneous advancement flaps provides an effective yet simpler, quicker method of management with improved aesthetic results. In addition, basing the pectoralis major myocutaneous flaps on the thoracoacromial arteries eliminates the need for intact internal mammary arteries, valuable since the latter are increasingly used for coronary grafts. Seventy-four consecutive patients, 17 (23 percent) of whom were immunosuppressed heart transplant recipients, have been managed with this procedure. There were no intraoperative deaths. The 30-day perioperative mortality rate was 9 percent (7 of 74), with only 1 death related to persistent sepsis. The morbidity rate was 39 percent, with the most common complication being seroma managed by needle aspiration (18 of 74, 24 percent). The aesthetic and functional results have been uniformly excellent.

The random fasciocutaneous flap for upper extremity coverage

Rapid and appropriate healing of any upper extremity wound is essential for preservation of normal hand function. If vascularized tissue must be used, local cutaneous flaps nourished by the multiple perforators to the fasciocutaneous plexus avoid the complexity of microsurgical tissue transfers or prolonged immobilization required for distant pedicled flaps. For small or moderate-sized defects, assuming that adequate adjacent deep fascia has remained intact, these simple, rapidly elevated, so-called random fasciocutaneous flaps deserve initial consideration, as demonstrated in all 11 cases in this reported series.

The pros and cons of distant pedicled flaps for upper extremity trauma reconstruction in the era of microvascular surgery

Nineteen distant pedicled flaps, performed during 1989 for posttraumatic upper extremity soft tissue defect cover were reviewed. The pros and cons of distant pedicled flaps were examined with respect to the alternative treatment; namely, free microvascular tissue transfer. The main points considered were the traumatic defect, the donor site and particular problems of each patient. The conclusion was that pedicled flaps are useful in this type of reconstruction in spite of the availability of microvascular techniques.

Local Random Fasciocutaneous Flaps for Repair of the Burned Elbow

Wound management of the burned elbow is not always possible with a skin graft alone. Rather than resort to distant pedicle flaps or the complexity of microsurgical tissue transfers, local fasciocutaneous flaps may provide a better source for vascularized tissue. "Random" fasciocutaneous flaps do not require isolation of any discrete vessel, but must be designed to parallel the longitudinal axis of perifascial circulation in the upper extremity. Therefore no vessel in the major extremity need ever be violated, and muscle function is always preserved. Excision-to-fascia techniques for burn escharectomy should probably be minimized in the elbow region, because if the fascia remains intact, the overlying skin-grafted subcutaneous fat will survive flap transposition as a fasciocutaneous flap. Local flaps allow for earlier rehabilitation, and the donor defect is restricted to the already deformed ipsilateral extremity.

An Update on Tissue Expansion in Head and Neck Surgery

Tissue expansion is a surgical option that has to be considered by the facial plastic surgeon when confronted with skin defects of the head and neck. This modality is now categorized with local flaps, distant pedicle flaps, free flaps, and skin grafts as a proven and efficacious reconstructive surgical technique. Tissue expansion is the stretching of skin adjacent to a defect by the implantation of Silastic balloons that are gradually filled over a period of weeks or months (chronic tissue expansion), or at the time of the initial surgery (acute or intraoperative tissue expansion). The expanded tissue usually has characteristics that match the missing skin. At the Fifth International Symposium of Plastic and Reconstructive Surgery of the Head and Neck, sponsored by the American Academy of Facial Plastic and Reconstructive Surgery in Toronto (June 25 through 29, 1989), a number of scientific papers, discussions, and courses on tissue expansion were presented.

Hand reconstruction following avulsion of all dorsal soft tissues: A cutaneo-tendinous free tissue transfer

Restoration of function following mutilating injuries to the extensor surface of the hand has traditionally involved staged reconstruction with distant pedicle flaps, followed by tendon grafting. Advances in microsurgery now permit the transfer, in one operation, of vascularized composite tissues such as skin and muscle, or skin and bone. For dorsal hand reconstruction a composite flap of skin, tendons and nerves from the dorsum of the foot was transferred in one stage soon after injury, avoiding unnecessary disabling scar formation, prolonged hospitalization and resulting in the rapid restoration of near normal function and appearance of the hand. Donor site morbidity was minimal.

Single-stage repair of complex scalp and cranial defects with the free radial forearm flap.

The free radial forearm flap provides a reliable single-stage method to cover difficult scalp and forehead defects where other local methods are unsuitable. Six patients have been successfully reconstructed utilizing seven free radial forearm flaps. A description of our surgical technique along with illustrative cases demonstrate the indications and advantages of this flap. Cranial soft-tissue deficits are primarily cutaneous; therefore, a more predictable reconstruction can be obtained utilizing a cutaneous flap with similar characteristics. Restoration of bony defects should be considered separately utilizing autogenous bone and/or alloplastic materials and not merely obliterated with a bulky soft-tissue flap. Therefore, if the local factors of a cranial wound require the utilization of a distant tissue transfer, we prefer the thin coverage of a well-vascularized free fasciocutaneous radial forearm flap over two-stage distant pedicle flaps or skin-grafted free flaps.

食道，下いん頭‐皮膚ろうの再建手術

The management and reconstruction of pharyngo-cutaneous, and esophago-cutaneous fistulae after head and neck cancer surgery are most important and difficult problems. Various kinds of flaps, such as local flaps, distant pedicled flaps and myocutaneous flaps have been used in primary and staged pharyngo-esophageal reconstructions.In most cases of head and neck cancer, preoperative and postoperative irradiation therapy is required. It is well known that reconstructive surgery is very difficult after full dose irradiation, which leads to postoperative complications.We use delto-pectral flaps and free skin grafts in two cases of esophago-cutaneous fistula, and the postoperative course was satisfactory. These patients are described, and the technical aspects and the results of treatment are discussed.

Platysma myocutaneous flap for intraoral defects.

The use of myocutaneous flaps has resulted in improved methods for reconstruction involving the head and neck area. The platysma myocutaneous flap offers an excellent alternative for reconstructing appropriate oral cavity defects resulting from tumor ablation. It has certain advantages over other local or distant pedicled flaps and has been proved to be a reliable alternative for single-stage repair of these defects. The technique of this flap is described and a review of its use in six cases, including complications, is discussed.

Free groin flaps in children.

We report two successful transfers of free groin flaps to the lower legs of children. We believe this method can be safely applied and can often take the place of distant pedicled flap transfers in children.

Skin coverage in common hand injuries.

The indications for the various methods of skin coverage in hand injuries are outlined. While the function of many badly injured hands can be saved by using distant pedicle flaps in repair, sensory loss is a notable drawback. Sometimes the answer to this deficiency can be found in transfer of a neurovascular island of skin and subcutaneous tissue.

Resurfacing of the Thumb Following Major Skin Loss

The repair of areas of skin loss on the hand and in particular on the thumb demands a careful appraisal of the type of tissue used to close the wound. In this report on the closure of avulsed wounds of the thumb, emphasis is placed on the superiority of local pedicle tissue, as compared with pedicle flaps obtained from a distance. Abundant pedicle skin is available on the dorsum of the hand of close partial or complete circumferential defects of the thumb from the level of the metacarpophalangeal joint distally.The main advantage of a local pedicle flap is that the tissue more closely simulates the physical characteristics of volar skin. Neither local nor distant pedicle flaps regain functional sensation. If sensation is essential for satisfactory function it must be supplied by normally innervated volar skin added to the thumb by means of a neurovascular island flap.