Donor Area Morbidity Research Articles

Cobertura de defecto lateral del brazo con colgajo de perforantes de la arteria toracodorsal. Reporte de caso

Reconstructive plastic surgery continues to achieve a number of outstanding results aimed at greater functionality with reduced donor area morbidity. The literature of anatomical studies provides multiple descriptions on the uses of perforator flaps, which are currently one of the fundamental options available to reconstructive surgeons. In this report, we describe the case in which a lateral arm defect was successfully reconstructed following resection of a neoplastic lesion by using a thoracodorsal artery perforator flap

Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction

Background Breast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity. Methods The investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy. Results Five patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed. Conclusions For selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.

Dorsalis pedis free flap in oromandibular reconstruction

This paper reports the free dorsalis pedis flap as a fasciocutaneous and osteocutaneous flap in oromandibular reconstruction. The authors present a 7-year series of nine patients with squamous cell carcinoma of oral cavity with extensive soft tissue/soft tissue and bone defect in whom this flap was used for intraoral reconstruction. The free fasciocutaneous flap (two neurosensate) was used in eight patients, and in one patient, a free osteocutaneous flap was required. The follow-up period ranged from 2 and 7 years. No ischemic flap complications occurred and a good anatomical and functional reconstruction was achieved in the majority of patients. There was no significant donor area functional disability. One death occurred in the early post-operative period due to multi-organic failure and four deaths in the follow-up period due to recurrence of the oncological disease. The dorsalis pedis free flap was found to be a good alternative tool for reconstruction of the anterior floor of mouth defects (including marginal mandibular defects). This was also used for anterolateral intraoral soft tissue defects. The donor area morbidity is not problem-free, but with good planning and careful flap dissection, it is possible to minimize the sequelae to a very acceptable level.

Superior gluteal artery perforator flap in the reconstruction of pilonidal sinus

Pilonidal sinus is a difficult disease to treat. Many treatment modalities from secondary-intention healing to various types of flaps have been used with each having different rates of success. A perforator flap based on the superior gluteal artery perforators was designed at 45( degrees )-angle to the defect created by the excision of the pilonidal sinus and was transposed in 15 male patients with un-operated chronic pilonidal sinus. Defect and flap size, length of surgery, blood loss, time to mobilisation, hospital stay, time of return to work and rate of complications were evaluated. The average defect size in length, width and depth were 6.9 cm, 3 cm and 3 cm, respectively. The cutaneous part of the flaps was exactly the same size as the defect. The average length of surgery was 45 min (sinus excision 10 min, flap harvest 15 min and closure 20 min) with blood loss being less than 25 cm(3). Patients were mobilised and discharged home the morning after surgery (less than 24h). The patients were able to return to normal daily activities after 3 days and to work 10 days after the surgery. There were no complications and no recurrences at an average of a 10-month follow-up. The superior gluteal artery perforator flap (SGAP) offers many advantages over random (better vascularity and flap safety) or larger flaps (decreased operating time and donor-area morbidity) in the treatment of pilonidal sinus disease. We present our results with the use of the SGAP flap, which is designed at a 45( degrees )-angle to the defect created by the excision of the pilonidal sinus. Compared to the previously described techniques, it has the advantage of closing defects of any size within a short surgical time and minimal blood loss. The hospital stay, time to mobilisation and return to daily activities and work are shortened, in addition to zero complications and recurrence rates.

A Novel Approach for the Reconstruction of Medial Canthal and Nasal Dorsal Defects

Medial canthal and dorsal nasal defects after surgery have been a challenging problem for surgeons and patients. The main purpose in reconstruction is not solely covering the defects with similar skin and soft tissue, but also causing minimal donor-area morbidity. The authors described an elliptical fashioned frontal island flap at the level of the frontal hairline, nourished by the vascular network composed of supraorbital and supratrochlear arteries, then carried subcutaneously to the defect area at medial canthus and upper nose. Any extra incisions above the eyebrow to control the pedicles were not necessary. Donor region was closed primarily; thus, scarring was hidden at the hairline. We present our frontal hairline island flap design and results in our series of 10 patients.In our study, we aimed to reduce scarring at donor area by planning a forehead island flap in an elliptical fashion at the frontal hairline. There are no more incisions than the elliptical incision over the hairline. Primary closure of skin flaps at the donor ensures a final scar that is hidden at the frontal hairline border. Forehead hairline island flap is an important flap for small- and medium-size defects as an alternative to conventional paramedian forehead flap.

Skin Perforators of Back Region

Despite widespread studies that have been commonly performed recently on skin perforators and perforator flaps of various regions of the body, investigations on the back region of the body are still insufficient. This study investigates the anatomical characteristics and clinical applications of perforating vessels in the back region. The skin on the back region between the right and left, 7th to 11th thoracic vertebrae of 10 fresh cadavers were raised as flaps. Perforating vessels perfusing the skin with pedicle diameters of over 1 mm were included in the study. The anatomical localization, diameter, pedicle size, and the supplying vessels of these pedicles were determined. Utilizing this information, the defects of 8 patients with large meningomyeloceles included in the study were closed with prepared intercostal artery perforating flap. Perforators of the back region were seen to originate from the posterior intercostal vessels. There were a higher number of perforators on the right side of the body. The most commonly observed perforators were the 7th and 9th posterior intercostal perforators, and their diameters were larger. All flaps were viable following perforator flap closure for defects in 8 patients with large meningomyelocele included in the clinical study. No problems were encountered in the postoperative 3-month follow-up of cases. Owing to the low donor area morbidity and wide motion capabilities, the perforator flap is a new choice of flap for the back region. Perforator pedicle flaps supplied by the posterior intercostal vessels may be safely used in congenital tissue defects, such as meningomyelocele, tumors, and traumatic defects.

The Use of a Deep Inferior Epigastric Perforator Flap (DIEP) in a Case of Severe Breast Asymmetry Secondary to Radiation Therapy during Childhood

Breast radiotherapy during childhood may cause unpredictable outcomes in soft tissue growth and may be responsible for most iatrogenic-related breast hypoplasias. Poor local skin quality and subcutaneous atrophy poses a difficult problem for the use of alloplastic tissues. Clinical use of a deep inferior epigastric perforator flap (DIEP) in oncological breast surgery is a common practice; however few studies have described its application in benign situations and no previous report addressed this subject. The authors indicate the use of the DIEP flap to correct severe hypomastia after previous childhood radiotherapy for hemangioma treatment, followed by unsuccessful alloplastic tissue reconstruction. For selected patients the DIEP flap may constitute a new alternative for complications of radiotherapy treatment due to the possibility of large tissue transfer with minimal donor area morbidity. The quantity of flap tissue necessary to restore the breast mound, the perforator vessel size, and the quality of suitable recipient vessels should be carefully evaluated. However, the need for microsurgical training as well as the extended surgical time are the main limiting factors for the use of this flap.

Pedicled thoracodorsal arterial perforator flap for reconstruction of a large defect post-burn in posterior side of the arm

Recently the efforts made to diminish the morbidity of the flap donor area, as well as thickness, have promoted the study and description of perforator flaps. The latissimus dorsi musculocutaneous flap has been for many years a fundamental weapon in the reconstruction of major local defects (including breast surgery) and at a distance in its free transferred state. Undoubtedly, the sacrifice of a muscle as important as the lattissimus dorsi, as well as the resulting thickness of the above mentioned flap, has made us reflect on its use because of the associated morbidity. Variations on design with the objective of diminishing thickness have lessened considerably sequelae of the donor area. From the original description by Angrigiani et al. [1] and subsequently by Spinelli et al. [2], the thoracodorsal artery perforator flap (TAP) has meant a radical change in the morbidity of the donor area, with a series of additional advantages, that include an especially large vascular pedicle, a homogeneous thinning of the flap and the conservation of the functions of the subjacent muscle [3]. Additionally, the possibility of raising up flaps of large dimensions for the reconstruction of great defects and the need to avoid deformity of the posterior axillary fold (in keeping with preservation of the innervation of the dorsal muscle), has made the TAP flap process of reconstruction far superior to other fasciocutaneous or cutaneous flaps of the same region, such as the scapular and the parascapular flaps. We illustrate a case of traumatic entrapment of the arm resulting in the loss of a considerable volume of tissue in the posterior face (21 cm × 8 cm in size), reconstructed using a TAP pedicle flap. The results as well as regularization and

Distally based sural neuro-fasciocutaneous island flap to cover tissue loss in the distal third of the leg

The distally based sural neurofasciocutaneous flap is based on the vascular contribution furnished by the arterial network that accompanies the sural nerve and on its neurocutaneous perforating branches. This flap provides a solution that can be effectively used for various reconstructions in the distal third of the lower extremity, thus offering a valid alternative to solutions involving microsurgical repair. The main advantages of this flap are the need for a single operation, limited donor area morbidity, and the structural characteristics of the soft tissue of the flap, which makes it ideal for covering defects in this region. The authors present their clinical experience using this technique.

Reinnervation of denervated muscle in a split-nerve transfer model.

This study was performed to quantify the reinnervation of denervated muscle in a split-nerve transfer model and to determine any possible downgrading effects on the donor nerve and its end organ. Fifty-four adult Wistar rats weighing 200 to 250 g were used. The experimental design consisted of two groups. The motor nerve branch to the anterior tibial muscle and gastrocnemius muscle of the right hind limb were dissected in all rats. In the experimental group (N = 36), the motor nerve branch of the tibial nerve to the gastrocnemius muscle was exposed, cut, and ligated. The motor nerve branch to the anterior tibial muscle was split and transected longitudinally, and the medial half was routed posteriorly. End-to-end neural anastomosis was performed between this medial half of the split nerve and the distal stump of the gastrocnemius nerve. In the control group (N = 18), while the same surgical preparation was performed, the motor nerve branch to the anterior tibial muscle and gastrocnemius nerve were exposed and transected, and the nerve endings were ligated, but neural anastomosis was not performed between these nerves. The left hind limb of all rats served as a normal comparison side without any surgical intervention. Both of the groups were divided into three subgroups (12 rats each for the experimental groups and 6 rats each for the control group) to evaluate the results after periods of 1, 3, and 6 months. Electromyography, light microscopic and morphometric examination, and muscle weight measurements were used to document the results. Although stimulation of the peroneal and tibial nerves did not produce any compound muscle action potential (CMAP) recordings from either the anterior tibial or the gastrocnemius muscle in the control group, the normalized CMAP areas of the tibial nerve were (mean +/- standard deviation) 16.2 +/- 30.8% in the 1-month group, 63.4 +/- 34.7% in the 3-month group, and 72.4 +/- 16.3% in the 6-month group. For the peroneal nerve, the normalized CMAP areas were 17.0 +/- 32.2%, 53.4 +/- 29.4%, and 54.4 +/- 14.5% for the 1-, 3-, and 6-month groups in the experimental groups respectively. A high number of regenerating myelinated nerve fibers was identified in the distal part of the coapted motor nerve branch to the gastrocnemius muscle. The average number of myelinated fibers in the lateral half of the split nerve in the experimental group was 15,108 fibers per square millimeter, 14,167 fibers per square millimeter, and 19,830 fibers per square millimeter at months 1, 3, and 6 respectively. The average number of fibers proximal to the nerve anastomotic site was 15,423 fibers per square millimeter, 19,200 fibers per square millimeter, and 20,774 fibers per square millimeter. Distal to the nerve anastomotic site, the number of myelinated fibers was 17,941 fibers per square millimeter, 18,885 fibers per square millimeter, and 18,895 fibers per square millimeter at 1, 3, and 6 months respectively. There were no myelinated fibers in the control group sections. There were significant differences in muscle weight between the experimental and control groups at the end of month 6. The difference between the experimental side and the untouched normal healthy side was not significant in the weight measurements of both muscles. The results show acceptable reinnervation by split-nerve transfer with minimal functional impairment of the donor muscle. This study confirms that split-nerve transfer is a reliable method of reconstruction for paralyzed muscle with minimal donor area morbidity.

The preputium: an overlooked skin graft donor site.

Plastic surgeons often encounter tissue defects consisting of the superficial layer of the skin. Fortunately, many of these defects are reconstructed easily with skin grafts. The authors have used the preputium as a skin graft for the reconstruction of skin defects of various sizes and locations in children. The defect size ranged from 2.3 x 4.0 cm to 4.8 x 6.5 cm. The average defect size was 3.5 x 5.5 cm. The defects were caused from trauma, acute burn, and release of burn contractures, and were located in the lower extremity, upper extremity, and scalp. All patients were treated successfully. No complications of the donor area or recipient area were seen. The prepuce should be included as an additional tool in the reconstructive surgeons armamentarium because of its many advantages, including easy harvest, high viability and elasticity, and low donor area morbidity.

Donor area morbidity after flaps: clinical applications of the superficial temporal fascial flap

Ten cases of the superficial temporal fascial flap (STFF) are presented. The indications for the STFF were ear reconstruction, maxillofacial injuries and malformations, and a chronic ulcer above the Achilles tendon. Nine pedicled and one free STFF were used. The flap size was up to a maximum of 12 cm in length and 8 cm in width. There was little aesthetic and no functional impairment at the donor site. There is no doubt that too little attention has been paid to the STFF in the past.

L-shaped scalp flap for moustache reconstruction in a patient with an acid burn of the face

An L-shaped scalp flap based on the parietal branch of the superficial temporal artery is described to reconstruct the moustache in a young male patient who suffered from nitric acid burns of the face. This provides a simple technique as an alternative to microvascular technique for moustache reconstruction. The donor area morbidity was minimal.

Clinical Applications of Micro-Skin Grafting For Skin Defect Coverage

Microskin graft is a technique of skin defect closure using a minimum of STSG donors to cover the large defect. Some considerations were taken, which includes the general status of the patient, donor area morbidity, and patient refusal to act is one of the reasons for the use microskin graft. History STSG failure with previous defect closure and lack of donor area would to bene!t from microskin graft. Case of boy 12 years old with extensive defects in the forearm due to burns. Consideration of the lack of donor area made us deciding to use microskin graft as main option to close the defect. We did one-week post operative evaluation. Epithelialization occurs at day 7, while complete epithelialization occurred at 14th day. Three month during follow-up control, the scar are minimal. We conclude that microskin graft is one technic that can be used in skin defect closure with minimal donor.