Free-style Flap Research Articles

A Comprehensive Flap Classification: Beyond the Reconstructive Ladder.

Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.

Fasciocutaneous foreskin twin flaps in hypospadias repair: Reconstructing a functional penis with freestyle design

Hypospadias is the most common congenital urological deformity in males; however, there is still no perfect solution or surgical method for one-stage operations to fix proximal hypospadias with ventral penile curvature (VPC). We developed a fasciocutaneous foreskin twin flap technique that can provide freestyle flap designs in hypospadias repair. A retrospective study including 26 patients was performed between January 2017 and June 2020. The surgical procedures included VPC correction, skin flap design, transfer and reconstruction. The urethra and shaft were reconstructed by twin flaps in one stage. All patients were followed up until 12 months. All VPC cases were corrected after the operation. The fistula rate was 11.5% (3/26). No meatal stenosis, urethral diverticulum, or stricture was observed. A total of 92.3% (24/26) of patients were satisfied with their penis appearance. The fasciocutaneous foreskin twin flaps provide freestyle designs in hypospadias repair, which can achieve a one-stage operation for proximal hypospadias with low fistula rates.

Dual Reconstruction of Lumbar and Gluteal Defects with Freestyle Propeller Flap and Muscle Flap.

Background:The reconstruction of complex tissue defects in the lumbar and gluteal areas is a surgical challenge. The use of freestyle perforator-based flaps has gained popularity in the reconstruction of these defects due to several advantages: versatility, minimal donor-site morbidity, and tension-free closure. The present study reports the outcome of using a dual coverage of lumbar and gluteal defects with a gluteus maximus rotation flap as a deep layer and a freestyle propeller perforator-based flap as a superficial layer.Methods:A retrospective analysis of 18 patients who had a dual coverage of complex wounds of the lumbar and the gluteal areas was conducted. Different propeller flaps were used as superior gluteal artery perforator flap (SGAP), inferior gluteal artery perforator flap (IGAP), and posterior thigh perforator flap (PTP).Results:The study included 15 men and 3 women. The mean age was 26.3 years. The causes of the defects were: pressure ulcers in 14 patients and post-traumatic in 4 patients. A total of 28 freestyle flaps was used: 11 patients had 1 flap, 4 had 2 flaps, and 3 had 3 flaps. The mean postoperative follow-up was 12.2 months. The complications registered in the medical records were venous congestion in 2 patients, partial flap necrosis in 2 patients, and wound dehiscence in 1 patient.Conclusions:A freestyle propeller perforator-based flap combined with a gluteus maximus muscle flap is a solution that provides well-padding over bony prominence with a low complication rate. However, a long-term follow-up is needed to verify these results.

Using Freestyle Skin Flap in Closure of Defects in Upper Limb

Background: Defects in upper limb may result from primary open trauma, postoperative wound infection, raw area after burns or post burn scar excision, tumor excision, radiation injury. Some defects require skin flap for proper coverage and restoration of function. One of the methods recently used for reconstruction of defects in upper limb is local freestyle skin flap. This flap is based on a perforator which provides blood supply for flap and acts as pivot point when the flap is rotated. Objectives: To evaluate using freestyle flap for reconstruction of defects in upper limb and assess the post-operative results for restoring function and cosmoses. Patients and Methods: This is a prospective study carried out in Plastic & Reconstructive Surgery Department & Emergency Unit, Zagazig University Hospitals in the period from January to July 2018 including 12 patients with soft tissue loss in upper limb managed by freestyle skin flap. Results: 50% of the cases had soft tissue defect after contracture scar release, while 25% were due to traumatic cause and the remaining 25% were post malignancy resection. flap dimensions ranged from 6 - 96 cm². we had no complications in 58.3% of our cases, while minor complications like flap congestion and distal partial necrosis occurred in 33.4% which were resolved within 1 week. Unfortunately, we experienced 1 flap loss (8.3%) which managed later by debridement of necrotic tissue and skin grafting the remaining soft tissue. Conclusion: Freestyle skin flaps are a reliable option for coverage of small to moderate sized defects

Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity.

Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.

Duplex Ultrasonography-Assisted Freestyle Pedicled Perforator Flaps for the Repair of Myelomeningocele Defects.

Perforator flaps have unique advantages that may overcome the shortcomings of conventional approaches to myelomeningocele reconstruction. However, identifying and dissecting tiny perforators in neonates is arduous. We have overcome these obstacles with a freestyle flap approach that uses duplex ultrasonography to locate perforator vessels, allowing for limited superficial dissection. This report describes the duplex ultrasonography-assisted freestyle pedicled perforator flap technique for closure of myelomeningocele defects, with long-term clinical outcomes. The surgical technique is described in detail. Case records of surgeries between 2004 and 2017 were retrospectively reviewed, focusing on whether potential perforators for flap pedicle were identified by duplex ultrasonography and subsequently used. Among 18 neonates who underwent repair of thoraco-lumbo-sacral myelomeningocele, 8 had reconstruction of soft tissue defects with freestyle pedicled perforator flaps. Defect size ranged from 1.6 × 2.2 cm to 6.0 × 7.0 cm. Potential flap pedicle perforators were identified by intraoperative ultrasonography and used as the vascular supply of the flap. All perforator flaps survived intact. Complications were transient and uncommon. Over a median follow-up of 1.65 years (range, 0.3-12.8 years), there was 1 transient pressure sore due to severe kyphosis with some tenderness along the flap suture line. All other reconstructions were durable and well-padded without late sequelae. Cases with a corrected age of more than 12 months could walk, stand, and crawl without muscular dysfunction due to flap surgery. Freestyle pedicled perforator flaps combined with duplex ultrasonography delineates perforator anatomy and obviates the need for tiny perforator dissection during myelomeningocele reconstruction, achieving reliable closure with excellent long-term results.

A Systematic Review and Meta-analysis of Free-style Flaps: Risk Analysis of Complications.

Background:Free-style flaps allow surgeons to overcome anatomical variations and raise perforator flaps wherever a pulsatile signal can be detected. We performed a systematic review and meta-analysis to identify the risk factors for complications and indications for free-style flaps in soft-tissue defect reconstructions.Methods:This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The databases of MEDLINE, PubMed, ScienceDirect, and Cochrane Library were searched from January 1991 to January 2017 for original articles describing free-style flaps in soft-tissue defect reconstruction.Results:A total of 17 articles met the inclusion criteria, representing 453 free-style flaps. The percentage of free-style flaps conducted after primary oncologic resection was 54.4% (246/453). Free-style flaps were mostly used in the head and neck region (35.5%), and most of them were designed as pedicled perforator flaps (96.7%). Complete flap survival was accomplished in 91.8% of the free-style flaps. Complications were found in 13.5% of cases, and 2 risk factors were identified: extremity defects (risk ratio, 2.39; P = 0.006) and single perforator flaps (risk ratio, 4.93; P = 0.002). No significant differences were found among the criteria including patients aged greater than 60 years, female gender, chronic etiology, flap size over 100 cm2, flap rotation, or perforator skeletonization.Conclusions:Free-style flaps are both reliable and advanced forms of perforator flaps for use in soft-tissue defect reconstructions. Defects located on the extremities and flaps with single perforators are risk factors for flap failure and complications.

Advances and Innovations in Microsurgery.

After reading this article, the participant should be able to: 1. summarize the evolution of perforator, chimeric, and free style flaps; 2. define and give examples of supermicrosurgery as well as understand its application in treatment of lymphedema; and 3. appreciate the development and advancements of composite tissue allotransplantation. Although microsurgery may seem like a highly specialized niche within plastic surgery, it is more than just a discipline that focuses on small anastomoses. It is a tool and a way of thinking that allows us to embody the true tenets of plastic surgery, as quoted by Tagliocozzi. What began as a challenge of returning amputated tissue to the body and achieving wound closure has evolved into a refinement of technique and change in philosophy that empowers the plastic surgeon to work creatively to "restore, rebuild, and make whole."

Selection of ideal perforators and the use of a free-style free flap during dissection of an anterolateral thigh flap for reconstruction in the head and neck

The technique of raising an anterolateral thigh (ALT) perforator flap has been revolutionised by free-style retrograde intramuscular dissection of perforators to overcome anatomical variations, but choosing the appropriate perforator is still the key to success. We have shown this in a 41-year-old man with cancer of the buccal mucosa treated by wide excision and reconstruction with an ALT free flap that failed because of formation of microthrombi within the perforator. We identified only one tiny perforator that followed an 8cm, tortuous course within the vastus lateralis muscle. A long, narrow lumen in the perforator increases resistance proportionally to the length and four times the radius. Difficult dissection of the root makes the vessels prone to spasm. If no sizeable perforator is found, adjacent tissues on the medial or proximal thigh could be raised as alternative free-style flaps.

Upper Medial Tigh Perforator Flap in the Lower Extremity Reconstruction

INTRODUCTION: The medial circumflex femoral perforator flap was named according to the convention of the Gent consensus for perforator flap nomenclature1, on the basis of its customary source vessel. It is a true perforator flap, because intramuscular dissection of the gracilis musculocutaneous perforators is necessary to ensure inflow to the cutaneous flap2.In this report, we present upper medial tigh perforator flap (gracilis perforator flap) in a hori- zontal (transverse to the gracilis muscle) manner based on any reliable perforators from the upper medial thigh. MATERIALS AND METHODS: All of four patient have lower extremity soft tissue defects due to traumatic injuries. There were 1 female patients and 3 male patients. The average age of the patients was 23 years (range, 6 to 35 years). All flaps were raised subfascially in a free-style flap fashion. RESULTS: All perforators were originated from the medial circumflex femoral artery and the perforators were musculocutaneous. Mean flap diameter were 13x6,5cm. In one patient, gracilis muscle also included in flap design and upper medial tigh perforator based skin island also harvested. All flaps were survived and donor sites were closed primarily (Figure 1).Figure 1: Preoperative view of patient (A), the view of harvested upper medial tigh perforator flap (B;C), Postoperative view of patient (D).CONCLUSION: The major advantages of this flap were noted as its donor site that allowed surgeon concealing scar to gluteal creases. However, its major disadvantages was inconsistent perforator position and we believe that free style free flap approach can solve this advantages in experienced hands. The flap can obtain reasonable size, well-hidden scar, function, good pliability.

A novel combination flap of anterolateral thigh flap (ALT) and rectus femoris flap for perineal defects

The pedicled anterolateral thigh flap (ALT) has gained importance in perineal reconstruction. Especially, the combination with muscle tissue, in the form of a chimeric flap, has clearly increased its versatility and range of application. Thus, both the skin paddle and the muscle seal, filling the dead space within the small pelvis, can be used to exactly reconstruct the defect. Nevertheless, the lateral circumflex femoral artery system is known for its vascular variability. We report a case, where we planned to close a perineal defect with a combination flap of vastus lateralis muscle and ALT flap. However, the ALT was found perfused by vessels perforating the rectus femoris muscle instead of the vastus lateralis, which gained its main perfusion by the transverse branch of the lateral circumflex femoral artery. Thus, the defect was successfully reconstructed with a combination flap of ALT and rectus femoris muscle tissue. The variable anatomy of the lateral circumflex femoral artery system is one of the main challenges of the ALT flap, frequently demanding creativity and the usage of freestyle flap design. Therefore, it is possible to make a virtue out of necessity.

The clinical application of free-style cutaneous perforator flaps

Perforator flaps have become increasingly popular in reconstructive surgery. In theory, a flap can be based on any identified perforator, whether free or pedicled, based on the perforasome concept. In this study, we report our initial experience with free-style perforator flaps for reconstruction of complex soft tissue wounds. We present two cases of free-style cutaneous perforator flaps; one pedicled free-style perforator flap was designed and elevated adjacent to a complex hip wound and another free-style free perforator flap was elevated in the thigh based on a perforator identified within the flap territory, but no dominant perforator was present for a free anterolateral thigh (ALT) perforator flap. In this case, a free ALT flap was converted to a free-style free perforator flap for the anterior neck reconstruction. Two free-style perforator flaps, one pedicled and one free, were successfully performed to reconstruct complex wounds of the hip and anterior neck. During more than 12 months of follow-up, both reconstructions have healed adequately with optimal contour in the reconstructed areas. This series demonstrates some of the clinical applications available using both free and pedicled freestyle perforator flaps. These free-style flaps can be used successfully with good esthetic and functional results at various regions of the body if there is a detectable perforator that can be based on as a perforator flap.

The Internal Pudendal Artery Perforator Flap

Reconstruction of the vulva, vagina, and buttocks following cancer ablation is challenging. Restoring the shape, volume, and function is the key to the best reconstruction for these regions. Perineal reconstruction with a free-style flap based on skin perforators from the internal pudendal artery was evaluated. The internal pudendal artery perforator flap was designed based on information about the skin perforators. The flap base contained the arterial sounds, which were identified by a handheld Doppler device, on and around the ischiorectal fossa. Types of flaps used included propeller flaps, traditional transposition flaps, and V-Y advancement flaps. Seventy-one flaps were transplanted in 45 cases. The reconstructed regions included vulvar skin in 36 cases, buttock skin in 10 cases, vagina in nine cases, anus in six cases, and pelvic cavity in six cases. The flaps were transplanted in the lithotomy or prone position. Sixty-seven of these flaps survived completely. Four flaps showed partial necrosis, but no total flap failures occurred. Thinning of the fatty tissue of the flap was performed in all cases except pelvic cavity reconstruction. An additional operation to remove bulkiness of the flaps following the initial reconstruction was required in one case. Propeller flaps, transposition flaps, and V-Y flaps were used in 35, three, and seven cases, respectively. This study revealed that the blood circulation of this flap is reliable and that it offers suitable volume not only for vulvar, vaginal, and anal reconstruction, which requires a thin flap, but also for pelvic floor reconstruction, which requires flap volume. Therapeutic, IV.

Free-Style Dual Plane Recycling Tensor Fascia Lata Musculocutaneous Perforator Flap for Reconstruction of Recurrent Trochanteric Defects

Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a "free-style flap" has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site.

Freestyle propeller flaps from the lower abdomen: A valuable reconstructive option for proximal thigh defects

The concepts of freestyle flap design allows for flap creation from virtually every place in the body. Descriptions of named flaps based on their arterial origin are commonly described in the literature, allowing for predictable flap design. However, in certain cases, isolating a flap based on a Doppler signal and retrograde perforator dissection will allow for appropriate flap creation and wound coverage. We describe a 52-year-old female with a chronic open wound that failed wound care and local soft tissue rearrangement. This led to detection of a strong perforator signal in the lower lateral abdomen prompting the use of a freestyle propeller flap. The patient recovered without complication. Twelve-month follow-up demonstrated trunk and lower extremity mobility without impairment. We describe a successful and novel use of a rare, unnamed perforator from the lower, lateral abdomen by employing the freestyle propeller flap for coverage of a proximal thigh wound.

Clinical application of the thoracodorsal artery perforator flaps

Thoracodorsal artery perforator (TAP) flaps without latissimus dorsi muscle - have been used for reconstruction of the extremities, head and neck as free style flaps, and as pedicled flaps for reconstruction of the chest wall and axillary wounds. This retrospective study aimed to analyse the clinical applications and relevant anatomic findings of TAP flaps. From April 2007 to August 2011, 67 free or pedicled TAP flaps were transferred in 67 patients for reconstruction of wounds of the extremities, chest wall and axilla. Eight were used as free flaps for reconstruction of extremities, and 59 used as pedicled flaps for reconstruction of axillary or chest wounds. Patient ages ranged from 7 to 55 years (26.04±12.83). Perforator arteries were detected and identified with a hand-held Doppler. The size of flaps ranged from 6 by 9 to 14 by 18 cm ((8.66±2.05) by (12.62±2.03)). Flaps were designed with the perforator artery included, with all flaps based on one or two perforator arteries. All of the flaps survived. There were no problems with vascular spasm or occlusion. Significant venous congestion was not observed in any of the cases. Two cases developed minor wound dehiscence but healed with conservative therapy. None of the donor sites developed seromas. The thoracodorsal artery flap without associated latissimus dorsi muscle can provide a thin, large and reliable flap with robust blood supply. The TAP flap can significantly reduce donor site morbidity.

The clinical application of anterolateral thigh flap.

The anterolateral thigh flap can provide a large skin paddle nourished by a long and large-caliber pedicle and can be harvested by two-team work. Most importantly, the donor-site morbidity is minimal. However, the anatomic variations decreased its popularity. By adapting free-style flap concepts, such as preoperative mapping of the perforators and being familiar with retrograde perforator dissection, this disadvantage had been overcome gradually. Furthermore, several modifications widen its clinical applications: the fascia lata can be included for sling or tendon reconstruction, the bulkiness could be created by including vastus lateralis muscle or deepithelization of skin flap, the pliability could be increased by suprafascial dissection or primary thinning, the pedicle length could be lengthening by proximally eccentric placement of the perforator, and so forth. Combined with these technical and conceptual advancements, the anterolateral thigh flap has become the workhorse flap for soft-tissue reconstructions from head to toe.

Lower Back Defect Coverage Using a Free-Style Gluteal Perforator Flap

Lower back defects remain a major challenge for reconstructive surgeons. Advances in perforator flap techniques now make it possible to repair lower back defects using a gluteal perforator flap based on the free-style flap design. We used a free-style gluteal perforator flap in 10 patients with lower back defects due to skin cancer treatment (6 patients) or infection following spine surgery (4 patients). V-Y advancement flaps were used for defects <6 cm in length, and rotation flaps for defects >6 cm. Perforators were detected at the upper parasacral area, and the flap design was drawn on the skin of the upper gluteal region. Coverage was successful and donor sites were closed primarily in all cases. There were 4 complicated cases: 1 of partial flap loss that led to delay of the wound closure, 2 of initial venous congestion, and 1 of hematoma. These complications resolved, and there was no case of flap loss during a 12 to 62 months follow-up (mean, 32.4 months). The present series indicated that the free-style gluteal perforator flap provides a safe, effective, and relatively easy option for lower back defect reconstruction.

Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region

Perforator flaps from the lateral thoracic region have not been as popular as other donor sites because of the misconception that the vascular anatomy in this region is less than predictable. However, the skin over the lateral thoracic region is vascularised by three rows of perforators of varied vascular dominance. Two perforator flaps from this region based on the middle and the posterior row of perforators from the thoracodorsal artery have been described. The lateral thoracic perforator flap based on the anterior row of perforators is another useful option. Nine patients underwent reconstructions using the lateral thoracic perforator flap for various defects in the head and neck region and lower limbs as a result of tumour extirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in the supine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20×12 cm and the mean size was 106 cm2. All flaps survived without major complication. The lateral thoracic perforator flap is a reliable reconstructive option. It can be readily configured in terms of size, thickness and tissue composition. However, it is not the first-choice flap from this region because the resultant donor scar tends to extend visibly beyond the anterior axillary fold and the arterial and venous pedicles frequently have separate courses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.

Free-Style Flaps: A Further Step Forward for Perforator Flap Surgery

Technical advancements and increased experience with perforator flap techniques have allowed the harvest of flaps in a free-style manner. To perform free or local island pedicled flaps using the free-style concept, one requires mature skills in retrograde dissection of vascular pedicles and in using a hand-held Doppler device. To keep the technique safe, certain principles should be remembered and are detailed in this article. The free-style flap concept provides unparalleled freedom when choosing local or distant soft tissues for reconstructing a defect. Potential pitfalls during free-style flap harvest can be avoided if the presented principles are adhered to. Newer imaging modalities may prove useful for assessing vessels supplying any cutaneous territory.