Flap Donor Site Research Articles

Cervical Defect Reconstruction Using Preexpanded Neck Flaps Transferred in a Scarf-wrapping Manner.

Cervical burn scar contractures can be repaired using many modalities, including skin grafts, pedicled and free flaps. Although preexpanded cervical flaps can provide a like-with-like reconstruction, a simple advancement transfer of the flaps often fails to achieve ideal outcomes. The authors aimed to introduce a method using the preexpanded cervical flaps transferred in a scarf-wrapping manner to repair neck defects. The surgery was divided into 2 stages. In the first stage of the surgery, an expander was implanted above the platysma muscle on each side of the neck. After adequate inflation of the expanders, second-stage operations commenced. Following the expander removal, one flap was rotated upward to repair the neck defect, whereas the other flap was rotated downward to repair the neck defect and close the donor site of the first flap. Data on patient demographics, clinical characteristics, and outcomes were also collected. Between July 2004 and May 2024, 24 patients underwent neck reconstructions using this method. Four patients had grade I cervical contractures, and 20 had grade II. The mean size of the defects was 15.62×5.75cm (range: 6×6-18×10cm). The average dimension of the neck flap was 15.02×7.65cm (range: 9×6-20×10cm). All the flaps survived with no perfusion-related complications. The average improvement in the cervico-mental angle was 29.25 degrees (range: 10-45 degrees). Postsurgery follow-up ranged from 4 to 155 months (mean: 22mo). All patients and their families were satisfied with the outcomes. Preexpanded cervical flaps transferred in a scarf-wrapping manner can be used to reconstruct grade I and II cervical scar contractures and provide a like-with-like reconstruction of the neck.

Effective Management Strategies for Primary Lymphedema of the Lower Extremities: Integrating Conservative and Surgical Therapies in Early and Late Stages.

Lymphedema, a debilitating characterized by localized fluid retention and tissue swelling, results from abnormalities in the lymphatic system. In the case of primary lymphedema, this condition is attributed to malformations in lymphatic vessels or nodes, and it is marked by a relentless progression leading to irreversible tissue fibrosis after repetitive inflammation. Many questions regarding its treatment, such as the choice of the type of intervention and the timing, still remain unanswered. This study aims to present our comprehensive approach to treat this challenging condition. To elucidate our approach, we conducted a retrospective chart review of 42 patients treated for primary lymphedema at 3 hospitals between July 2010 and December 2022. The study included two patient groups, those with early-stage disease (20) and those in the advanced stages (22). We outline our algorithm, based on our clinical experience in Taiwan. Patients were followed for at least 12 months post-treatment, and assessments were made, including photographic evidence. A total of 42 patients participated in our study: 20 in the early stage and 22 in the late stage. Our approach yielded significant functional improvements and symptom regression in both groups. In the early-stage cohort, all 20 patients underwent VLNT procedures and SAL, with 15 (75%) undergoing unilateral procedures and 5 (25%) bilateral. Among the advanced-stage patients, 12 (54.5%) were treated with the modified Charles' procedure, and 10 (45.5%) with RRPP. The outcomes showed an average circumference reduction of 4.1 cm (2.9-5.3) after VLNT and liposuction. Reductions were noted at various levels: 5.7 cm (4.6-6.8) at mid-thigh, 4.3 cm (2.5-6.1) at mid-calf, 3.5 cm (2.7-4.3) at the ankle, and 1.4 cm (0.7-2.1) at mid-foot. Tonicity decreased by 5.9% (5.2-6.6), indicating significant tissue softening. Tissue removal averaged 3.7 kg (2.9-4.5) after the modified Charles' procedure and 2.6 kg (2.3-2.9) after RRPP. Patients experienced a mean of 3 (2-4) episodes of cellulitis per year, with no cellulitis in early-stage treated limbs during the follow-up period. Complications were minimal, including 4 partial skin graft losses that healed with conservative treatment and 3 postoperative infections after the modified Charles' procedure, treated successfully with antibiotics. No major complications were reported at the lymph node flap donor site. Primary lymphedema poses a considerable challenge, primarily due to its relentless progression if left untreated. The existing literature offers limited guidance on its management. Our algorithm, developed over years of experience, aims to fill this gap. By integrating surgical and conservative interventions, as well as individualized patient follow-up, we provide a comprehensive framework for managing both early and late- stage cases.

Assessment of Post-Operative Complications after Radial Recurrent Artery Flap for Management of Wound Coverage in and Around the Elbow Region

Complex elbow wound management is a common issue of reconstructive surgery which deals with burns (electric and flame burn), road traffic accidents (RTA), machineries and industrial accidents, tumor excision, the release of post-burn scar contracture, complications related to orthopedic reconstruction etc. A stable soft tissue cover is required for reconstructive purposes for such wounds management and for that reason surgeons apply suitable procedure and consider wound aetiologies to meet better outcome. Surgeons also permit the early elbow mobilization to preserve a range of motion after complex elbow wound management. Radial recurrent artery flap, in particular, provides durable coverage for medium-sized elbow defects as well as an early range of motion of the elbow joint. Some complications like marginal and partial flap necrosis are observed in some of the cases. The aim of the study was to assess the clinical outcome and complications after radial recurrent artery flap for the management of wound coverage in and around the elbow region. This is a prospective type of observational study conducted in the Department of Plastic Surgery, Dhaka Medical College and Hospital (DMCH), Dhaka. Twenty patients were selected according to inclusion and exclusion criteria over 17 months from October 2016 to February 2018. The patients were kept under follow-up of at least 2 months postoperatively. Findings of observation were recorded in a preformed data collection sheet and all data were compiled in a master table first. Statistical analysis of the results was obtained by using statistical package for social science (SPSS), version- 17. In this study, the mean age of the patients was 25.4 years. The age range was 05 years to 50 years. Maximum patients (40%) were in age group 16 to 25 years. Of the injured patients, male – female ratio was 4:1. More than half of the injuries (55%) were caused by electric burn; other injuries were trauma (15%), flame burn (10%), contact burn (05%), and 15% by different causes. Radial recurrent artery flap was used to cover the cubital fossa in 13 patients (65%), the posterior aspect of the elbow in 5 patients (25%), and amputation stump in 02 patients (10%). The cubital fossa was the most used site in 13 patients. Here, the mean dimension of the wound was 80.28 cm2 and the mean dimension of the flap was 70.43cm2. Among 20 patients, 16 patients showed no complication, marginal flap loss in one patient, partial flap necrosis in two patients, and total flap loss in one patient was observed. No history of graft loss and the donor site of the skin graft healed well. One case showed marginal flap loss, which is managed conservatively and healed by secondary intention. Two cases showed partial flap loss and another case showed total flap loss which is managed by excision of non-viable part followed by STSG. In 17 (85%) cases donor sites of flaps are closed primarily. One patient (05%) needed primary closure and STSG. Two patients (10%) needed STSG to cover the donor site. In most of the cases, about 80% showed excellent outcomes. Good outcomes in three cases (distal marginal and partial flap loss) and poor outcomes in one case (total flap loss) were observed. This study showed that Radial Recurrent Artery Flap is a good option for coverage of soft tissue defects in and around the elbow joint. It is a single-stage procedure allowing early mobilization and thereby preventing stiffness of the elbow joint. It also showed the rise of some complications that might be uncomfortable for patients. Bangladesh Med J. 2023 Sept; 52(3): 41-46

An "Expanded Zone" Concept for Soft Tissue Coverage of the Upper Extremity: Upper Extremity "Expanded Zones".

Vascularized soft tissue coverage of open wounds of the lower extremity has long been predicated on the zone of injury and the available local flap donor site options found therein. A hypothesis was presented decades ago in this journal that attempted to extend a similar approach to simplify upper extremity coverage as well, but appears to have long been forgotten. However, with the emergence of the fasciocutaneous flap and its offspring the perforator flap, now a plethora of additional local flap options within the upper extremity may justify this idea being further considered. Indeed, the upper extremity can arbitrarily be divided into distinct anatomical regions that each has unique characteristics. However, soft tissue requirements that must be restored cannot so simply be restricted by anatomical boundaries, so instead an "expanded zone" concept is more appropriate where comparable regions can be treated in a similar as long as functional fashion. All this must be with the realization that if a suitable local flap option does not exist, the selection of a free tissue transfer with the same preferable composition should instead be chosen, just as would be done in the lower extremity.

Evaluating Donor Morbidity in ALT and TDAP Flaps With Drainless Closure Compared to Conventional Drain Placement

ABSTRACTPurposeRecent trends in reconstructive surgery focus on rapid recovery, questioning the necessity of postoperative drains. Although harvesting perforator flaps causes minimal injury to anatomical structures at donor sites, attempts to omit drains have been limited. This study aimed to assess the safety of not using drains after harvesting the anterolateral thigh (ALT) perforators and the thoracodorsal artery perforator (TDAP) flaps.MethodsAll consecutive patients who underwent free ALT or TDAP flap‐based reconstruction between 2020 and 2022 did not have drains placed at the donor site. Their donor morbidities were evaluated, and compared with those who underwent the same operation between 2016 and 2019 with donor drains placed.ResultsThe drainless cohort consisting of 202 cases (159 ALT and 43 TDAP flaps) and the control cohort comprising 119 (52 ALT and 67 TDAP flaps) were analyzed. In ALT flap cases, the drainless cohort, apart from a larger flap dimension, exhibited comparable baseline characteristics to the control. The rates of overall donor complications were comparable between the two cohorts (10.1% vs. 11.5%, p = 0.795), as were rates for specific complications including wound dehiscence (p = 0.751) and seroma (p = 0.999). Multivariable analysis revealed no significant association between omitting drains and increased donor complications. Consistent results were obtained in the analysis for cases using TDAP flaps, with no significant difference between drainless and drain‐using groups (p = 0.297).ConclusionsOmitting drains in the donor site of ALT and TDAP flaps might be safe, not escalading the risks of donor morbidity.

Reconstruction de l’aponévrose musculaire de la zone donneuse du lambeau antérolatéral de cuisse par plaque synthétique : technique et bénéfice

The anterolateral thigh flap is sometimes harvested with a portion of the quadriceps muscle fascia, which can lead to muscle hernias or adhesions at the donor site. Studies report an 11 to 32% incidence of muscle hernias and an 8 to 26% incidence of persistent weakness at the donor site. There is no data in the scientific literature presenting a surgical technique for the prevention of muscle hernias at the donor site of the anterolateral thigh flap. The objective of our study is to describe our technique for placing a synthetic mesh when closure of the fascia is not possible during the harvesting of an anterolateral thigh flap, in order to reduce the risk of postoperative muscle hernias and to analyze its benefits. As part of a prospective study, we present here our technique for reconstructing the fascia by placing a non-resorbable synthetic mesh. Twenty-two patients underwent the placement of a mesh for the reconstruction of the fascial defect, which averaged 9.6cm. One year after the procedure, none of the patients presented with a muscle hernia or adhesions at the donor site. According to studies, muscle hernias and scar adhesions occur in 11 to 32% of cases and are both unsightly and disabling for patients. Although it is difficult to quantify the benefit in terms of muscle strength, fascia reconstruction effectively prevents this type of complication. When the defect is greater than 8cm, we believe it is essential to reconstruct the fascia during harvesting to prevent the occurrence of hernia or adhesion at the donor site. While not affecting limb function, muscle hernia is at least aesthetically bothersome and should be systematically prevented. Reconstruction of the muscle fascia at the donor site of the anterolateral thigh flap with a non-resorbable synthetic mesh, in cases of a defect greater than 8cm, prevents the occurrence of muscle hernias and adhesions, which can lead to aesthetic and functional complications.

Effect of different degrees of wound eversion sutures on scar formation at donor site of anterolateral thigh flaps: A prospective randomized controlled study

To investigate the effect of different degrees of wound eversion on scar formation at the donor site of anterolateral thigh flaps by a prospective clinical randomized controlled study. According to the degree of wound eversion, the clinical trial was designed with groups of non-eversion (group A), eversion of 0.5 cm (group B), and eversion of 1.0 cm (group C). Patients who underwent anterolateral femoral flap transplantation between September 2021 and March 2023 were collected as study subjects, and a total of 36 patients were included according to the selection criteria. After resected the anterolateral thigh flaps during operation, the wound at donor site of each patient was divided into two equal incisions, and the random number table method was used to group them ( n=24) and perform corresponding treatments. Thirty of these patients completed follow-up and were included in the final study (group A n=18, group B n=23, and group C n=29). There were 26 males and 4 females with a median age of 53 years (range, 35-62 years). The body mass index was 17.88-29.18 kg/m 2 (mean, 23.09 kg/m 2). There was no significant difference in the age and body mass index between groups ( P>0.05). The incision healing and scar quality of three groups were compared, as well as the Patient and Observer Scar Assessment Scale (POSAS) score [including the observer component of the POSAS (OSAS) and the patient component of the POSAS (PSAS)], Vancouver Scar Scale (VSS) score, scar width, and patient satisfaction score [visual analogue scale (VAS) score]. In group C, 1 case had poor healing of the incision after operation, which healed after debridement and dressing change; 1 case had incision necrosis at 3 months after operation, which healed by second intention after active dressing change and suturing again. The other incisions in all groups healed by first intention. At 6 months after operation, the PSAS, OSAS, and patient satisfaction scores were the lowest in group B, followed by group A, and the highest in group C. The differences between the groups were significant ( P<0.05). There was no significant difference between the groups in the VSS scores and scar widths ( P>0.05). Moderate everted closure may reduce the formation of hypertrophic scars at the incision site of the anterior lateral thigh flap to a certain extent.

Vascularized Bone Reconstruction for Recalcitrant Clavicular Nonunion: A Systematic Review of the Literature.

Clavicular nonunion is an uncommon complication with a significant impact on quality of life and can be difficult to manage. In recalcitrant cases, or situations unfavorable for take of nonvascularized grafts, vascularized osseous reconstruction may be utilized. Several donor sites for such flaps have been described, with each associated with unique benefits and drawbacks. A systematic review utilizing MEDLINE and Embase databases was performed for cases of vascularized bone reconstruction for clavicle nonunion. Twenty-six papers met inclusion, comprising 67 patients. Mean age was 43.1 years, across 32 male and 35 female patients. Mean period of nonunion was 43.2 months in the fibular group, 42.0 months in the medial femoral condyle (MFC), and 12 months in the rib flap group.Patients had undergone a mean of 2.67 prior operations at the time of vascularized osseous flap; a proportion of patients had undergone prior locoregional radiotherapy (9/26) or been complicated by infection (12/22). Radiological union was achieved in 95.2% (20/21) of fibular flaps, 95.6% (25/27) of MFC flaps, and 66.7% (2/3) of rib flaps. Mean time to union was 10.6 months for the fibular group, 7.8 months for the MFCs, and 4.0 months for the rib flaps. Complications occurred in 55.6% (20/36) of patients having fibular flaps, 26.1% (6/23) of MFC flaps, and 50% (2/4) of rib flaps. All osseous flaps yielded similar and consistent rates of union when used to reconstruct defects of the clavicle. Higher complication rates, particularly donor site morbidity, were noted with fibula and rib flaps when compared to the MFC.Level of evidence 3a.

Closure of the Osteocutaneous Fibula Flap Donor Site with a Tonearm (Propeller) Flap: Anatomic Considerations and Surgical Indications

BackgroundSkin graft is frequently used for donor site closure after osteocutaneous fibula free flap (OCFFF) harvest when primary closure is not possible. Partial skin graft loss requiring wound care is a common complication. The purposes of this prospective study were to investigate the perforator anatomy for local propeller/tonearm flap closure and compare outcomes to skin graft closure. MethodsAll patients undergoing OCFFF for head and neck reconstruction from February 2022 to October 2023 were considered for the tonearm flap. Intraoperative perforator anatomy was prospectively recorded. Surgical techniques and criteria for tonearm flap reconstruction were described. A minimum 6-month follow-up was required. Outcome measures included the rate of flap success and wound complications. Results40 consecutive patients were included. The tonearm flap was not possible in 16 patients (40%) due to unfavorable perforator anatomy and 2 patients underwent primary closure. All successful tonearm flaps were eccentrically designed on a proximal lower leg perforator, located 13.5±1.99cm from the fibular head. Most proximal perforators were musculocutaneous through the soleus muscle (n=20, 90.9%), while the rest were septocutaneous (n=2, 9.1%) originating from the peroneal artery. Three patients experienced distal partial flap loss; one required an additional skin graft. Only half of the skin graft cohort (n=99, 50.8%) achieved complete skin graft take. The average skin graft loss was 34.3% and wound care was required for an average 51.6±52.8 days. ConclusionsThe study findings demonstrate that local tonearm flaps, when anatomically feasible, can be successfully performed with superior outcomes compared to skin graft closures.

The Effect of Leg Dominance in Patients on Perforator-Based Flaps Elevated From the Lower Extremities.

The lower extremities are the largest donor sites in the body for perforator flap reconstruction. Multislice row computed tomography angiography allows for a multiplanar assessment of perforators using a large number of three-dimensional images with high resolution. In this study, the effect of leg dominance on perforator flap donor site preference was investigated radiologically to increase preoperative perforator mapping precision and surgical success. The study included 40 patients. Superior gluteal artery perforator (SGAP) flap, inferior gluteal artery perforator (IGAP) flap, superficial circumflex iliac artery perforator flap, anterolateral thigh (ALT) flap, profunda artery perforator (PAP) flap, medial sural artery perforator (MSAP) flap, peroneal artery perforator (PP) flap, and posterior tibial artery perforator (PTAP) flap were analyzed according to their number of perforators (> 0.8-mm perforators counted, number of larger perforators [nLP]), dominant perforator diameter (DPD), related muscle thickness (RMT), and related subcutaneous tissue thickness (RSTT) in each leg. Of these 40 patients, 35 (87.5%) were right-leg dominant and 5 (12.5%) were left-leg dominant. The dominant leg had higher DPD for MSAP, PTAP, and PP than the nondominant leg (p = 0.08, p = 0.06, and p = 0.06, respectively). The dominant leg had a significantly higher nLP (> 0.8 mm) in MSAP, PTAP, and PP flaps than the nondominant leg (p < 0.05). Except for the PAP flap (adductor magnus muscle; p > 0.05), RMT of all other perforator flaps (SGAP, IGAP, ALT, MSAP, PTAP, and PP) was statistically higher in the dominant leg (p < 0.05). There was no statistically significant difference in RSTT between any of the two groups (p > 0.05). According to findings, the dominant leg could be considered a donor site preference to improve surgical outcomes and reduce microsurgical complications due to an increased nLP, perforator diameter, and RMT.

Systematic Review of the Profunda Artery Perforator Free Flap for Head and Neck Reconstruction.

The profunda artery perforator (PAP) flap has gained popularity in head and neck reconstruction with a favorable donor site providing a relatively hidden scar and the ability to harvest a large amount of pliable tissue with consistent vascular anatomy. The primary aim of this study is to evaluate the safety and efficacy of this PAP flap in head and neck reconstruction. PUBMED, EMBASE, Web of Science, Google Scholar (January 1948-February 2022). A systematic review of the English language literature was conducted for studies with at least 3 patients 18 years or older undergoing head and neck reconstruction utilizing the PAP. Study quality and risk of bias were evaluated using the MINORS scoring system. Main analysis endpoints were flap failure rate, donor site morbidity, and complication rate. Nine articles and 206 total PAP flaps were included. The rate of flap-related and medical complications was 33%, with only 2 (0.97%) instances of complete flap failure. Other complications included partial flap failure (10, 4.86%) and donor site wound complications (12, 5.83%). A total of 16 flaps (7.77%) required subsequent revision in the operating room. Average MINORS score of the studies suggested a moderate to high risk of bias. Based on limited quality evidence, this review suggests that the PAP flap is a safe and feasible tool for head and neck reconstruction, with comparable complication and success rates as other free flaps. Further large-scale studies are warranted.

Preparation of vascularized forearm dermal fat flap and repairing of donor site

Objective:This study prepared vascularized dermal fat flaps and introduced a local split-thickness skin graft from an in situ cutaneous area cutaneous area to manage forearm flap donor sites and evaluated the esthetic and functional outcomes post-operatively. From July 2020 to June 2023, 13 patients with soft tissue defects in Oral and Maxillary Area were repaired with tvascular forearm dermal fat flap. There were 8 males and 5 females, aged from 42-71 years. The flaps ranged from 8 cm×7 cm to 7 cm×5 cm in size. The donor site defects were covered by local split-thickness skin graft from the in situ skins. The color matching degree, surgical scars, ranges of wrist movement and hand sensations in donor forearms were assessed at 6 months after surgery. Results:The tvascular forearm dermal fat flaps for 15 cases all survived. All the local split-thickness skin grafts transplanted with this technique showed primary healing. The follow-up period for 6 months, Donor site exhibited suitabler color matching and there was not severe complications. Conclusion:The vascularized dermal fat flap provides an alternative to conventional forearm flap harvest, which enables primary donor site closure with reduced rates of delayed donor site healing. The vascularized dermal fat flap is a relatively reliable repair method for soft defects in Oral and Maxillary Area.

Comparing the Outcomes of Osteocutaneous Radial Forearm and Fibula Free Flaps in the Reconstruction of Mandibular Osteoradionecrosis.

This study compares the outcomes of osteocutaneous radial forearm free flap (OC-RFFF) and fibula free flap (FFF) reconstruction of mandibular osteoradionecrosis (ORN). Retrospective review of patients undergoing OC-RFFF/FFF reconstruction for mandible ORN between 2005 and 2020 at a tertiary center. Patient characteristics, postoperative complications, and functional outcomes were evaluated using chi-squared and logistic regression analysis. Fifty-six patients were included (OC-RFFF: 38; FFF: 18). Significantly more OC-RFFF patients had lateral mandible defects (94% vs. 61%, p = 0.0014). There were significantly more patients with exposed intraoral bone in the OC-RFFF group (23% vs. 0% p = 0.02), but no significant differences in hardware complications or flap failure. Donor site partial skin graft loss was more common in the FFF group (22% vs. 2.6%, p = 0.016), but no other significant differences in donor site morbidity were seen. Bivariable analysis showed no impact of flap type, tobacco/alcohol use, diabetes, or hypothyroidism on postoperative complications. Sixty percent of OC-RFFF, and 67% of FFF, patients resumed an oral diet after surgery. Oral diet was not impacted by flap type (OR = 0.769, 95% CI = 0.201-2.706, p = 0.688). The OC-RFFF is an acceptable option in the reconstruction of ORN involving the lateral mandible, though there is increased risk of bone exposure. These findings can help guide surgeon selection of microvascular free flap donor sites and appropriate patient counseling.

Thoracoabdominal Flap Closure for Large Post Pectoralis Major Myocutaneous Flap Donor Site in Advanced Oral Cancer: An Innovative Approach in Resource Constraint Setting.

Oral cancer often presents in advanced stages, requiring complex surgical interventions. The bipedal pectoralis major myocutaneous (PMMC) flap is a commonly used alternative to the gold standard free flaps for reconstruction in resource-constrained settings. However, large donor sites may necessitate split-thickness skin grafting (STSG), leading to aesthetic challenges. This study explores using the thoracoabdominal flap (TA) for a large donor site closure following PMMC flap harvest in advanced oral cancer reconstruction. A retrospective analysis was conducted on twelve patients with advanced oral cancer with extensive skin involvement. The TA flap was utilised to achieve tension-free closure of the donor site. Patient demographics, clinical features, treatment stage, operative details, and postoperative complications were meticulously recorded. All patients had advanced oral cancer, with seven having left-sided disease and five having right-sided disease. The TA flap closure resulted in minimal complications, with two patients developing seromas and one experiencing marginal necrosis during the postoperative period. The innovative TA flap technique is useful in closing extensive donor sites following PMMC flap harvest for advanced oral cancer cases. It offers advantages such as improved cosmetic outcomes and fewer complications than split-thickness skin grafting.

Free vastus lateralis flap combined with skin grafting for repairing small- and medium-sized lacunar defects in non-weight-bearing area of diabetic foot

To explore the feasibility and effectiveness of free vastus lateralis flap combined with skin grafting for repairing small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot. Between January 2022 and October 2023, 8 patients (8 feet) with small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot were admitted. There were 6 males and 2 females, with an average age of 64.3 years (range, 58-76 years). The duration of the diabetic foot ulcer ranged from 2 to 7 weeks (mean, 4.3 weeks). The wound was located between the metatarsal bones in 4 cases, on the medial side of the foot in 2 cases, on the lateral side of the foot in 1 case, and on the dorsal and lateral sides of the foot in 1 case. The length of wound was 4.0-12.0 cm, the width was 3.0-5.0 cm, and the depth was 1.2-2.0 cm. The free vastus lateralis flaps were designed to repair the wounds, and skin grafting covered the vastus lateralis flaps. The length of the vastus lateralis flap was 5.0-14.0 cm, the width was 3.5-6.0 cm, and the thickness was 1.0-1.5 cm. The donor sites of the muscle flaps were directly sutured. The time for vastus lateralis flaps harvested ranged from 30 to 80 minutes (mean, 55.0 minutes), and the total operation time ranged from 125 to 170 minutes (mean, 147.5 minutes). All muscle flaps and skin grafts survived successfully, and the wounds and the incisions at the donor sites healed by first intention. All patients were followed up 6-24 months, with an average of 12.8 months. The appearances of 3 patients who did not follow the doctor's instructions for pressure treatment of the muscle flaps were a little bloated, and the rest had a good appearance. The texture of the muscle flaps was soft. There were linear scars at the donor sites. There was no recurrence of ulcers during follow-up. All patients could walk independently without limitation of daily activities at last follow-up. The application of free vastus lateralis flap combined with skin grafting to repair small- and medium-sized lacunar defects in the non-weight-bearing area of diabetic foot has the advantages of simple operation and time-saving as well as small damage to the donor site, with good repair effect, especially for the elderly patients who are not suitable for prolonged anesthesia.

Free Latissimus Dorsi Flaps in Head and Neck Reconstruction at a Modern High-Volume Microsurgery Center.

Over the past two decades, with the introduction of the perforator flap concept and advances in flap dissections, lower extremities have emerged as the preferred soft tissue flap donor sites. As a modern and high-volume microsurgical center, and the senior author being one of the pioneers and advocates for the use of lower extremity flap donor sites, we aim to investigate the role of latissimus dorsi (LD) free flap in head and neck reconstruction within our current practice. All free LD flaps used for head and neck reconstruction performed by a single surgeon between January 2010 and June 2023 were reviewed for their indications and immediate and short-term outcomes. A total of 1,586 head and neck free flap reconstructions were performed, and 33 free LD flaps were identified. The patients' median age was 53 (interquartile range [IQR] 48.5-63.5) years. Twenty-nine (87.9%) flaps were used to reconstruct oro-maxillo-facial and four (12.1%) flaps were used to reconstruct scalp defects. Most patients had prior radiation (n = 28, 84.8%), neck dissection (n = 24, 72.7%), and multiple previous head and neck flap reconstructions with a median of 3.0 (IQR 3.0-3.5) previous flaps. Six (18.2%) LD flaps were used to replace failed flaps from other donor sites. No major complications such as total flap failure or takebacks, and no need for vein grafts but three (9.1%) had flap marginal necrosis. Other complications included one flap dehiscence (3.0%), one orocutaneous fistula (3.0%), two wound infections (6.1%), three plate exposures (9.1%), and three patients who developed local recurrence (9.1%). The median patient follow-up time was 16 (IQR 5-27) months. This retrospective study demonstrates the role of LD free flap in head and neck reconstruction as a reliable and versatile backup soft tissue flap when workhorse flaps from lower extremity donor sites are either unavailable or unsuitable.

Combination of secondary intention healing and primary closure to reconstruct large facial defects.

Secondary intention healing has been a well-established method to close wounds for more than 200 years. Indeed, it represents the easiest technique in the ladder of plastic reconstruction. Primary wound closure (side-to-side closure, direct wound closure) is the second easiest method. The combination of these two techniques is already an integral aspect of specific surgical procedures, e.g. the reconstruction of the donor site of a paramedian forehead flap. This minireview will show that the combination is also a suitable alternative to classic flaps in reconstruction of different aesthetic subunits of the face. These are the scalp, the lateral cheek, the upper nasal sidewall/medial canthus and the retroauricular region. The advantages and disadvantages will be discussed and illustrated with clinical examples.

Perspectives in Using Multiple Flaps Reconstructions for Advanced Head and Neck Tumors (Scoping Review).

Background and Objectives: Patients with advanced head and neck tumors require salvage surgery as a last resort. These extensive surgeries pose the challenge of complex reconstructions. The head and neck surgeon undertaking such complex cases needs to master different flaps. The team managing these patients needs input from various specialists, along with otorhinolaryngologists, plastic surgeons, maxillofacial surgeons, vascular surgeons, experienced radiologists, dedicated pathologists, oncologists and radiation therapists. We focus on the optimum solution between oncologic resections and the future quality of life of patients and overall survival. Each complex case requires a personalized medicine approach. This scoping review aims to assess the efficacy and outcomes of complex reconstructions using various flaps for head and neck tumors, with a focus on free flaps and emerging techniques. Materials and Methods: A systematic search of the literature was conducted following PRISMA guidelines, resulting in the inclusion of 44 articles that met the predefined criteria in the last 10 years. Results: The included studies encompassed diverse patient populations and evaluated various surgical techniques, outcomes, complications, and advancements in head and neck reconstruction. The review identified a variety of flaps utilized in head and neck tumor reconstruction, including free flaps such as the radial forearm, anterolateral thigh, scapular tip, and myocutaneous flaps, among others. The success rates for free flap reconstructions ranged from 85% to 100%, with notable variations attributed to patient selection, tumor characteristics, and surgical expertise. Conclusions: Complications such as flap necrosis, infection, hematoma, and donor site morbidity were documented across studies, highlighting the importance of meticulous surgical planning and postoperative care. Furthermore, the review revealed emerging techniques such as computer-aided design, virtual surgery, stereolithographic models, customized implants, tissue engineering, and allotransplants, offering promising reconstructive armamentarium. Advances in surgical techniques and emerging technologies hold promise for further enhancing reconstructive outcomes, minimizing morbidity, and improving patient quality of life.

Clinical study on anterolateral femoral interregional flap with turbocharge technique in the repair of large limb wounds.

To compare the clinical outcomes of anterolateral femoral interregional flap with turbocharge technique and traditional anterolateral femoral flap in repair of large limb wounds. Clinical data of 38 patients with large limb surface wound (11 cm×39 cm-16 cm×65 cm) admitted to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from May 2018 to May 2022 were retrospectively analyzed. Eighteen patients were treated by anterolateral thigh perforator flap combined with superficial circumflex iliac artery flap (ALTP-SCIAP) with turbocharge technique (interregional flap group); while 20 patients were treated with unilateral or bilateral anterolateral femoral flaps, combined with skin grafting if necessary (traditional anterolateral femoral flap group). The survival of skin flap, repair of donor area, complications and patient satisfaction were compared between the two groups. In interregional flap group, 18 flaps were harvested and transplanted, the flap width, length and the viable area were (9.9±2.0) cm, (44.2±3.5) cm and (343.2±79.9) cm2, respectively. In traditional anterolateral femoral flap group, 29 flaps were harvested and transplanted, the flap width, length and the viable area were (11.0±2.8) cm, (21.7±3.2) cm and (186.4±49.2) cm2, respectively. There were significant differences in the flap length and the viable area between the two groups (t=22.365 and 8.345, both P<0.05). In the interregional flap group, the donor site of flap was closed by direct suture in 11 flaps, by skin retractor assisted suture in 6 flaps, and by skin grafting in one flap. In traditional anterolateral femoral flap group, the donor site of flap was closed by direct suture in 12 flaps, by skin retractor assisted suture in 11 flaps, and by skin grafting in 6 flaps. The skin graft rates of the two groups were 5.6% (1/18) and 20.7% (6/29), respectively (χ2=2.007, P>0.05). The interregional flap group had lower postoperative complications rate (5.6% vs. 35.0%, χ2=4.942, P<0.05) and higher patient satisfaction rate (94.4% vs. 70.0%, χ2=4.448, P<0.05) than traditional anterolateral femoral flap group. Compared with the traditional anterolateral femoral flap, the anterolateral femoral interregional flap with turbocharge technique has a larger flap area, most of the donor areas of the flap can be sutured directly without skin grafting and with less complications and a higher patient satisfaction rate.

Abdominal Mesh Use in Pedicled Rectus Abdominis Flaps for Pelvic Reconstruction.

Rectus abdominis flap coverage of high-risk perineal wounds following extirpative pelvic procedures can result in improved perineal outcomes. However, rectus abdominis flap harvest has morbidity associated with the donor site, including hernia or bulge development. The risk-benefit profile of mesh use in this scenario is not well-defined in the literature. We performed a retrospective chart review of all patients who underwent rectus abdominis flap coverage of pelvic defects at our institution during July 2012-January 2021. Patient characteristics and postoperative outcomes were assessed. Patients were stratified into groups based on whether mesh was used and whether primary fascial closure was achieved. Donor site outcomes were analyzed between groups. One hundred consecutive patients were included. When considering all patients in whom primary fascial closure was achieved, the use of mesh did not significantly decrease rates of hernia development. Mesh use in this setting was associated with significantly greater rates of infection, requiring procedural intervention (12% versus 0%, P = 0.044). When considering all patients in whom mesh was used, primary fascial closure was associated with decreased rates of hernia development, and this trended toward significance (16.1% versus 0.0%, P = 0.058). When closing a pedicled rectus abdominis flap donor site, if primary fascial closure is achievable, the addition of mesh to reinforce the repair does not have an added benefit. Mesh use in this setting was not shown to prevent hernia or bulge development, and was found to be associated with significantly greater rates of infection, requiring procedural intervention.