Donor Site Defect Research Articles

A Case of Harvesting Anterolateral Thigh Flaps Twice from the Ipsilateral Thigh of a Single Patient in Separate Operations

Until now, harvesting of flap elevations from the ipsilateral thigh twice in the same patient in two operations has not been reported. We harvested thigh flaps twice from the ipsilateral thigh of a single patient in separate operations. A 44-year-old man had skin defects of the right thumb and the left middle finger. In the first operation, his right thumb was reconstructed by the hemi-pulp flap. The anterolateral thigh flap harvested from the left thigh transferred to the donor site defect of the hemi-pulp flap. Sixteen days after the first operation, another anterolateral thigh flap harvested from the left thigh transferred to the defect of the left middle finger. This operative procedure is very useful for cases requiring multi-flap transfer.

The assessment of the clinical applications of propeller flaps of the lower leg

Objective The aim of the present study was to assess the clinical applications of the various propeller perforator flaps for the leg in an attempt to evaluate the results and propose an algorithm for the management of various defects of the lower-third of the leg. Background The ideal method for the soft-tissue reconstruction of the leg should be reliable, relatively easy to perform, offer viable tissues similar in skin texture and thickness to the lost ones (replace like with like), leave the most inconspicuous donor-site defect possible, and be performed without compromising other body parts. The perforator-based propeller flaps have all these advantages. Patients and methods This study included 34 patients who presented with moderate-sized leg defects from August 2013 to June 2015. Out of the 34 patients, 24 were males and 10 were females. Their ages varied from 5 to 50 years with an average age of 27 years. There were 19 posterior tibial artery perforator flaps. There were 12 flaps based on perforators of the peroneal artery. Lastly, there were three anterior tibial artery perforator flaps. Duplex ultrasonography was carried out for 25 patients preoperatively. Results All flaps were based on a single perforator except three cases in which the flaps were based on two adjacent perforators. Fourteen of the flaps were proximally based and 20 were distally based. All flaps were designed as propeller flaps and were rotated from 70° to 180°. The donor site was closed by using split-thickness grafts in all except three cases in which the donor site was closed primarily. Out of the 19 flaps of the posterior tibial artery, 11 (57.5%) healed uneventfully and eight (42.5%) cases were complicated. Out of the 12 peroneal artery propeller flaps, nine (75%) flaps healed uneventfully and three (25%) cases were complicated. Lastly, out of the three cases of the anterior tibial artery propeller flaps, one (33%) healed uneventfully and two (66%) were complicated. Conclusion Propeller flaps based on perforator vessels are raising interest in the reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows the reconstruction of soft-tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of propeller perforator flaps in the treatment of various lower-leg defects.

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

ObjectiveTo explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity. MethodsSix patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps. Afterwards, a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure. ResultsAll six free scapular flaps survived without signs of infection. Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex, which resolved after six weeks with only conservative therapy. All the incisions healed without other complications. At six-month follow-up, the patients regained full shoulder function. ConclusionWith the assistance of an adjacent pedicled flap, the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar. It can achieve positive outcomes in both reconstructive and aesthetic aspects.

Modifying the keystone island perforator flap (KIPF) to close osteocutaneous free fibula flap donor site defects

Modifying the keystone island perforator flap (KIPF) to close osteocutaneous free fibula flap donor site defects

Novel Local Full-Thickness Skin Grafts for Closure of Free Fibular Osteocutaneous Flap Donor Sites

The fibular flap donor site after skin paddle harvest is usually covered with abdominal full-thickness skin grafts. However, this kind of skin graft creates an inevitable third operative area and additional esthetic damage. The aim of this report was to present a novel approach to manage fibular donor site defects using a full-thickness skin graft from the adjacent area and avoid further esthetic damage in a third area. Seventeen patients underwent mandibular and maxillary defect reconstruction using free fibular osteocutaneous flaps and the fibular donor-site defects were covered with full-thickness skin grafts from the adjacent area. The skin harvesting sites were closed primarily. The skin donor sites were closed without dehiscence in all cases. Fifteen full-thickness skin grafts survived completely, whereas 2 grafts were partial failures. There were no complete skin graft losses. All fibular osteocutaneous flaps were viable, and the recipient sites had no complications. This study shows that adjacent full-thickness skin grafts provide a straightforward and reliable technique for closure of the free fibular osteocutaneous flap donor site. The primary advantage of this technique is the avoidance of a third surgical site, an additional surgical scar, and subsequent additional esthetic impairment.

Use of Polymethyl Methacrylate-Based Cement for Cosmetic Correction of Donor-Site Defect following Transposition of Temporalis Myofascial Flap and Evaluation of Results after Adjuvant Radiotherapy.

Temporalis myofascial flap is a versatile flap for reconstruction of the oral cavity defects, but results in an esthetically compromised deformity at the donor site. We used polymethyl methacrylate (PMMA) cement to correct the volume loss defect caused by temporalis myofascial flap and evaluated its results before and after adjuvant radiotherapy. We discuss our experience of using PMMA cement to augment donor-site deformity in 25 patients (17 males, 8 females) between years 2005 and 2009. The primary defect was a result of the ablative surgery for squamous cell carcinoma of the upper alveolar and the buccoalveolar sulcus. A modified curved hemicoronal incision was used as an access for better cosmetic outcome. The volume of cement required was decided during the surgery. All patients are in regular follow-up, alive and free of complications at implant site, except one patient who developed wound dehiscence. The condition of the implant was evaluated by postoperative computed tomographic scan, repeated after adjuvant radiotherapy in cases required. There were no radiation-induced changes in the contour and volume of the implants. Cosmetic result of the implant was reported satisfactory by the patients postoperatively. Restoration of the temporal area defect after the temporalis myofascial flap harvest with the use of PMMA cement is an easy and safe method, with excellent esthetic results. The implant is stable and resistant to any changes in contour and loss of volume even after adjuvant radiotherapy, with no added morbidity to the patients.

Closure of the Radial Forearm Free Flap Donor Site Using the Combined Local Triangular Full-Thickness Skin Graft

Traditional donor-site closure has been associated with serious esthetic and functional morbidity. The purpose of this study was to assess morbidity in esthetics and function and measure the postoperative complications of the radial forearm free flap (RFFF) donor site after using combined local triangular full-thickness skin grafting. This prospective study of patients who underwent reconstruction of head and neck defects using an RFFF was conducted from July 2008 through December 2014. The donor site was repaired with a combined local triangular full-thickness skin graft. Quality of the scar, color match, tendon exposure, presence of necrosis, dehiscence of the suture, and presence of dysesthesia were recorded and analyzed using SPSS 21.0 software. One hundred consecutive patients (71 male and 29 female) underwent RFFF harvesting. RFFF donor-site defects ranged from 15 to 70 cm2; partial skin graft loss occurred in 7% of patients. Five patients (5%) had small dehiscences of the forearm skin graft, and 2 cases (2%) presented tendon exposure. In all cases, these sites healed secondarily by conservative management, with no final impairment of function. Esthetic results were considered excellent in 87%, good in 11%, and suboptimal in 2% of the cases. The combined local triangular full-thickness skin graft is a reliable method for closing RFFF donor-site defects because it obviates a second surgical site, it provides excellent color match and pliability, and it can be used for covering large defects of the donor site.

Abductor Hallucis: Anatomical Variation and Its Clinical Implications in the Reconstruction of Chronic Nonhealing Ulcers and Defects of Foot.

Abductor hallucis (AH) is an intrinsic muscle of sole of the foot. It is commonly used in the coverage of ankle and heel defects and chronic nonhealing ulcers of the foot; its use is reported to have a favorable long-term outcome. The muscle's apt bulk and size, its simple surgical isolation, absence of donor-site defect, unvaried anatomy, and long neurovascular pedicle are some of the advantages that make it a promising muscle flap. During routine cadaver dissection in the Department of Anatomy of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India, we identified an anatomical variation in AH in both feet of a 45-year-old embalmed male Indian cadaver. The variant muscle had innumerable proximal attachments, a majority of them arising atypically in the form of tough tendinous slips from the medial intermuscular septum at the junction of central and tibial components of plantar aponeurosis, the medial surface of first metatarsal and the intermuscular septum separating AH from the flexor hallucis brevis. The tendon: muscle ratio was 1.76, higher than the normal reported ratio of 0.56±0.07. This article highlights the variation noted and its implication for clinicians. On Internet search, we did not come across the variations described in our article. Findings of the anatomical variation reported in this article could benefit surgeons who decide to use AH flaps in the future.

Local full-thickness skin graft of the donor arm—a novel technique for the reduction of donor site morbidity in radial forearm free flap

A novel technique to reduce donor site morbidity after radial forearm free flap (RFFF) harvest, using a local full-thickness skin graft (FTSG), is described. Thirty consecutive patients undergoing RFFF for head and neck reconstruction were enrolled in a prospective study. Donor site defect closure was performed with spindle-shaped FTSGs excised from the wavelike skin incision made for the vascular pedicle. Both the removal site of the FTSG on the volar forearm and the covered RFFF donor site healed uneventfully in 29 cases, with no impairment of function related to the skin graft. No skin graft failure and no exposure, tenting, or adherence of the flexor tendons occurred. All patients expressed satisfaction with postoperative pain, the functional outcome, and cosmetic appearance. Primary donor site defect closure could be achieved in all cases with the use of a local FTSG. This graft can be gained at the access incision for the vascular pedicle, avoids expansion of the incision for a local flap technique, and does not prolong wound healing, and thus reduces both donor site and graft site morbidity of the RFFF. This technique leads to an inconspicuous aesthetic result with no apparent relevant functional deficits and avoids the need for a second donor site.

Use of a double-layer polypropylene mesh in the donor area of a TRAM flap for breast reconstruction: evaluation of the incidence of hernia and abdominal bulging

■ ABSTRACT Introduction: The transverse rectus abdominis myocutaneous flap is a well stablished surgery for breast reconstruction. Its main disadvantage is a large defect in its donor site, leading to weakness in the abdominal wall. Many surgical tactics has been described to address the donor site defect, including direct closure of the muscular aponeurotic and use of polypropylene mesh. The purpose of this study was to assess abdominal hernia and bulge after TRAM flap breast reconstruction using two layers of polypropylene mesh in the donor site defect. Methods: Prospective study in 24 patients who had unilateral TRAM flap breast reconstruction with two layers of polypropylene mesh to close the donor site defect. The patients were evaluated in 3.6 and 12 months of postoperative time for incidence of abdominal hernia and bulge. Results: It was observed one case of abdominal bulge (4.16%) and no case of abdominal hernia. There were no cases of mesh infection or extrusion. Conclusion: The use of two layers of polypropylene mesh in the donor site defect of TRAM flap breast reconstruction resulted in low incidence of abdominal hernia and bulge.

Experience of adult-onset velopharyngeal insufficiency after tuberculosis of the soft palate.

Experience of adult-onset velopharyngeal insufficiency after tuberculosis of the soft palate.

Coverage of donor site defects on dorsum of the foot after dorsalis pedis flap transfer with pedicled lateral supramalleolar artery flaps

Objective To investigate the clinical application of pedicled for coverage of donor site defects resulted from dorsalis pedis flap transfer.Methods From October 2008 to September 2012,the flap pedicled on the lateral supramalleolar artery was reverse transferred to cover the defect on the dorsum of the foot resulted from dorsalis pedis flap harvest in 11 cases.Among these cases 6 had second toe combined with dorsalis pedis flap transfer and 5 had dorsalis pedis flap transfer.Postoperatively the appearance of the flaps,pain and touch sensation,temperature perception and two-point discrimination were evaluated.AOFAS assessment of donor foot function was performed.Results Flaps of the 11 cases all completely survived.Primary wound healing was achieved at the flap donor site.Nine cases were follow-up for 12 to 24 months while 2 were lost to follow-up.The flaps had good appearance.There were no excessive scar,pain or ulcer.The patients were satisfied with the aesthetic results.Perception of pain,temperature and touch was restored.At 12 months postoperatively,twopoint discrimination was (10.1 ± 2.2) mm on average.Sensory recovery was S3+,while the mean foot and ankle AOFAS score was 90.7.Conclusion Reverse transfer of pedicled lateral supramalleolar artery flap is a good option for coverage of dorsum foot soft tissue defect.It reduces donor site morbidity and restores good appearance and function of the donor foot. Key words: Surgical flaps; Transplantation; Donor site; Repair

Computer-aided Maxillofacial ablation and reconstruction Surgery

Computer-aided surgery is popular and useful in the field of oral and maxillofacial surgery, because of the possibility of simulation with a high accuracy. In all aspects of surgery, proper planning facilitates more predictable operative results, however before the use of virtual planning, much of this relied on 2-dimensional (2-D) imaging for treatment planning on a 3-dimensional (3-D) object and surgical trial and error. With real-time instrument positioning and clear anatomic identification, a computer-assisted navigation system (CANS) is exceptionally helpful in maxillofacial surgery. These techniques enable performing precise bony ablation and reconstruction, and also decrease surgical time and donor site defect.

Treatment of the Radial Forearm Flap Donor Site with Single-Stage Integra™ Artificial Dermal Matrix and Autograft

INTRODUCTION: Optimal treatment of the radial forearm flap donor site remains a difficult clinical problem, with complications including unsightly scarring, tendon exposure, and impaired range of motion and strength. Integra™ artificial dermal matrix has been described as an alternative to autograft alone for the reconstruction of these donor site defects using a two-stage process.1,2 This study is a retrospective review of a consecutive series of radial forearm flap donor sites that have been treated with monolayer Integra™ artificial dermal matrix and autograft in a single stage. METHODS: Fourteen consecutive cases of radial forearm free flaps performed between June 2011 and June 2013 were reviewed. In each case, the donor site was reconstructed using monolayer Integra™ artificial dermal matrix and autograft in a single stage. After routine harvest of the flap, monolayer Integra artificial dermal matrix was meshed and applied to the wound. A split-thickness skin graft was then harvested and either meshed or pie-crusted prior to application over the Integra™. A negative pressure wound dressing was applied over the grafts for 5-7 days. The donor site was evaluated with regards to skin graft take, scar appearance, strength and range of motion, paresthesias, infection, and the need for secondary interventions. RESULTS: The fourteen patients had a mean age of 53 years old (range 20-68) and radial forearm donor site defect area of 65 cm2 (range 30-110 cm2). Follow up time ranged from four to 18 months. All defects had >98% skin graft take. There were no infections, and no patients required secondary intervention. Hypertrophic scarring was not seen in any patient, although 2/14 patients had some degree of scar hypopigmentation. 2/14 patients had FCR tendon exposure of <0.5 cm2. 2/14 had diminished grip strength as compared with the normal contralateral side. 4/14 patients had paresthesias in the early postoperative period, all of which resolved by 4 weeks. CONCLUSIONS: Treatment of the radial forearm flap donor site using Integra™ artificial dermal matrix and autograft is a promising alternative to autograft alone and is possible in a single stage.

Use of Integra Artificial Dermis to Reduce Donor Site Morbidity After Pedicle Flaps in Hand Surgery

To assess the results obtained with Integra artificial dermis to cover donor site following the harvesting of pedicle flaps for hand reconstruction. Between April 2010 and August 2013, 11 patients (8 men and 3 women; mean age, 37y) were treated with Integra Dermal Regeneration Template (Integra LifeSciences, Inc., Plainsboro, NY) to cover donor defects after raising pedicle flaps for hand and finger reconstruction: radial forearm flap (4 cases), ulnar artery perforator flap (2 cases), and heterodigital island flap (5 cases). After neodermis formation the silicone layer of the artificial dermis was removed (on average after 22 days) and a split- or full-thickness epidermal autograft placed. No infections, hematoma, or bleeding were recorded during the entire phase in which the artificial skin was applied. Two patients experienced a partial skin graft loss. Median follow-up was 20 months, and results included an average Vancouver Scar Scale rating of 2.7 and an average DASH score of 39. There were no cases of graft adherence to the underlying tendons or muscles. Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity. Therapeutic IV.

Reconstruction of large vermilion defects with buccinator myomucosal flap

To investigate a novel method for the reconstruction of large vermilion defects. Based on the size and shape of the defects, a buccinator myomucosal flap pedicled with the junction of buccinator and orbicularis oris in the oral commisure was designed and rotated to reconstruct the large vermilion defects. The upper bound of the flap is at least 1 cm away from the stensen's duct. The width is about 2.5-3.0 cm, and the length is as far as to arrive the raphe pterygomancibularis. The donate site is directly closed primarily. There is no need for secondary pedicle division. From July 2003 to April 2013, 14 cases with large vermilion defects was reconstructed with this method. No flap necrosis occurred with primary healing. 5 cases were followed up with an average follow up period of 1 year (0.5-3 years). The apprearance and function of the reconstructed vermilion were satisfactory without any apparent donor site defect. The patients were satisfied with both the functional and cosmetic results. The buccinator myomucosal flap is a simple and ideal method for reconstruction of large vermilion defects, especially for the defects closed to the commisure.

The Use of Adipose Stem Cells in Cranial Facial Surgery

Craniofacial malformations, have devastating psychosocial implications for many adults and children and causes huge socioeconomic burden. Currently craniofacial defects require soft tissue transfer, bone grafting techniques or difficult procedures such as microvascular free flaps. Such tissues are often limited in quantity, their harvest causes secondary large donor site defects and they lack the capability to fully restore previous form and function. Stem cell technology is being utilised for various tissue and organs of the body and consequently surgeons are eager to transfer these principles for craniofacial surgery. Adipose derived stem cells (ADSCs) are an exciting stem cell source for craniofacial surgeons due to their easy and painless isolation, relatively large abundance and familiarity with the harvesting procedure. ADSCs also have multiple desirable properties including adipogenic, osteogenic and chondrogenic potential, enhancement of angiogenesis and immunodulatory function. Due to these advantageous characteristics, ASDCs have been explored to repair craniofacial bone, soft tissue and cartilage. The desirable characteristics of ADSCs for craniofacial surgical applications will be explained. We report the experimental and clinical studies that have explored the use of ADSCs for bone, cartilage and soft tissue craniofacial defects. We conclude by establishing the key questions that are preventing the clinical application of ADSCs for craniofacial surgery.

Evaluation of computer-assisted mandibular reconstruction with vascularized iliac crest bone graft compared to conventional surgery: a randomized prospective clinical trial

BackgroundComputer-assisted surgery plays an increasingly important role in mandibular reconstruction, ensuring the best possible masticatory function and aesthetic outcome.MethodsTwenty patients were randomly assigned to computer-assisted or conventional mandibular reconstruction with vascularized iliac crest bone graft in a prospective study design.Virtual surgical planning was based on preoperative CT-data using specific surgical planning software. A rapid prototyping guide transferred the virtual surgery plan to the operation site. During surgery the transplant ischemic time, reconstruction time, time for shaping the transplant and amount of bone removed were measured. Additionally, the difference in the intercondylar distance before and after surgery was calculated.ResultsComputer-assisted surgery shortened the time of transplant ischemia (P < 0.005) and defect reconstruction (P < 0.001) compared to conventional surgery. The time to saw and shape the transplant at the donor site was shorter using conventional surgery (P < 0.005); therefore, the overall time for surgery didn’t change (P = 0.527). In the computer-assisted group, the amount of bone harvested equaled the defect size, whereas the transplant size in the conventional group exceeded the defect site by 16.8 ± 5.6 mm (P < 0.001) on average. The intercondylar distance before compared to after surgery was less affected in the computer-assisted than in the conventional group (P < 0.001).ConclusionsThe presented study shows that computer-assisted surgery can help reduce the time for mandibular defect reconstruction and consequently the transplant ischemic time. In the computer-assisted group, the iliac crest donor site defect was downsized and the postoperative condyle position was less altered, reducing possible risks of postoperative complications and donor site morbidity.Trial RegistrationDRKS00005181.

Fate of large donor site defects in osteochondral transfer procedures in the knee joint with and without TruFit Plugs

Because of the potential donor site morbidity, cartilage lesions of more than 3cm(2) in size are considered to be critical regarding autologous osteochondral transplantation (OCT). In this study, the potential donor site morbidity for large defects should be reduced by means of OBI TruFit Plugs. An autologous OCT was carried out on 37 patients and the cylinders were received from the dorsal medial femoral condyle. The donor site defects of 21 patients (average defect size 5.5cm(2)) were filled with artificial TruFit cylinders (study group); the donor site defects (average defect size 4.6cm(2)) were left untreated for 16 patients. In the study group, the Tegner, Western Ontario and McMaster Universities (WOMAC), knee society score, and visual analogue scale pain scores improved from preoperatively 3.2 (±0.8), 60.9 (±41.6), 133.6 (±27.1), and 4.8 (±2.3) points, respectively, to 3.9 (±0.6), 35.5 (±27.1), 177.8 (±16.6), and 3.3 (±2.9) points, respectively, at the time of the second follow-up; the control group's preoperative score values came to 2.8 (±0.9), 73.3 (±50.2), 123.8 (±41.5), and 5.3 (±2.7) points, respectively, and changed to 3.6 (±0.8), 41.4 (±28.8), 179.3 (±17.5), and 3.1 (±2.0) points, respectively, at the time of the second follow-up. The smaller the initial chondral defect was in the study group, the better the WOMAC score values became (p<0.05). The modified Henderson score at the study group's donor sites improved from 19.2 (±3.3) to 13.7 (±2.1) points (p<0.001); the control group's score values for the donor sites were 18.3 (±3.4) and 15.4 (±4.4) points (p=0.0015). OCT is an effective therapy even for large chondral defects >3cm(2). By filling the defects with TruFit implants, no clinical improvements could be found since the donor site morbidity was already low anyway. However, the regeneration of defects filled with TruFit implants took more than 2years.

Lappenplastiken zur Defektdeckung am distalen Unterschenkel

Soft tissue defects in the distal lower leg region are challenging to treat, especially in trauma cases. To achieve early closure of the defect, pediculated adipofascial or muscle flaps can be used as well as free flaps. The pediculated adipofascial suralis flap has a reliable blood supply and a broad radius so this flap can be used for almost every defect location on the distal lower leg except for defects larger than 10 × 10cm. The donor site defect does not lead to major problems and is well tolerated. The soleus flap can cover defects in the middle third and proximal distal third of the lower leg with its muscle. The donor site defect is occasionally associated with reduced calf functioning but is tolerated well most of the time. Because of these advantages, the pediculated adipofacial suralis flap and the soleus muscle flap can be used instead a microvascular free flap for the closure of defects in the distal lower leg region.