Free-style Free Flap Research Articles

Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution.

Soft tissue reconstruction of the upper extremity requires consideration of wound bed status, varied anatomic composition, future function and tissue match, whether in thickness, pliability or involvement of other tissue components. Of the options available, microvascular free tissue flaps allow maximal customizability with the avoidance of long-term donor site morbidity. Free tissue transfers have evolved, given increased surgical proficiency, from direct vessel-based flaps to septocutaneous vessel-based flaps, to musculocutaneous perforator flaps, and most recently to free-style free flaps. With increases in technical complexity come limitless alternatives. We documented the progression of free flap upper extremity reconstruction in recreating form and function of the upper extremity. The foundations laid should allow surgeons the freedom and versatility to choose the most faithful restoration of the defect and produce the best functional and aesthetic results.

A Practical Tip for Intraoperative Perforator Vessel Selection

In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (<0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.

Best New Flaps and Tips for Success in Microsurgery.

After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes. Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.

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.

Perforator Flaps: Anatomy, Technique and Clinical Applications

This extensive and highly detailed work comprises two volumes and provides a comprehensive account of perforator flaps and their use in reconstructive surgery. Perforator flaps have gained popularity in recent years in many aspects of reconstruction and the Initial chapter of the book provides a brief history of flap surgery, describing the relatively recent appreciation of the fact that perforating vessels were capable of sustaining a large variety of flaps. The first volume gives detailed accounts of flap types, anatomy and physiology and overall provides an excellent account of the basic principles underlying perforator flaps. This volume also includes chapters on planning and complications. The latter of these gives a very clear account of the main ‘golden rules’ for complication avoidance in this type of surgery. The remainder of this volume is divided into three sections dealing with flaps of the head and neck, upper extremity and trunk. The first section of the second volume deals with flaps of the lower extremity followed by a good account of the clinical applications of a wide range of perforator flaps for reconstruction in various sites of the body. The final part of the second volume is, in my view, one of the most interesting sections of the entire book. Entitled ‘Controversies and Future Directions’, this explores a number of newer concepts, including that of the ‘freestyle free flap’ (a flap harvested from any region of the body, based on a vessel identified by Doppler), ‘supermicrosurgery’ (vessels of 0.5–0.8 mm) and neurocutaneous perforator flaps. The quality of the presentation and illustration is high throughout. As with most multi-author texts there is invariably some overlap in the various chapters, but this is a minor criticism. I have no doubt that this two-volume set would be a significant asset to any individual or department involved in reconstructive surgery and I recommend it highly.

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.

Free descending genicular artery perforator flap harvested with the free-style approach: A case report

The descending genicular artery perforator flap, also known as the saphenous flap, has rarely been used as a free flap. We report the successful use of a free descending genicular artery perforator flap to reconstruct a defect of the medial calf region in a 13-year-old boy with Ewing sarcoma. A dominant perforator from the descending genicular artery was detected preoperatively with computed tomographic angiography and colour Doppler ultrasonography. This flap provides a perfect texture match to the medial calf region, and its donor-site scars are better hidden than those on the lateral thigh. We believe that this flap is a versatile 'free-style free flap' for patients in whom a sizable perforator can be found with preoperative imaging.

Learning From Our International Colleagues

With growing contribution to plastic surgery by our international colleagues, one may be wondering about what US plastic surgeons have learned from them. The purpose of this study was to evaluate a single surgeon's experience to identify any specific areas of plastic surgery that one has learned substantially from our international colleagues. All plastic surgical procedures performed by a single US plastic surgeon at an academic medical center with an active plastic surgery residency training program during the past 10 years were reviewed. More frequently performed procedures by the author were identified. In each identified procedure, critical references used by the author were examined to find out whether these references were from domestic or international sources. More frequently performed procedures by the author were (1) free anterolateral thigh perforator flap and free-style free flap, (2) deep inferior epigastric perforator flap breast reconstruction, (3) implant-based breast reconstruction, (4) oncoplastic breast reduction or mastopexy for breast reconstruction, (5) vertical scar breast reduction, and (6) fat grafting for correction of contour deformity after breast reconstruction. Much more innovative procedures that the author had learned after his residency were published primarily by our international colleagues. The author has learned substantially from our international colleagues because many new procedures may be either first described by them or they have more extensive clinical experience. It is important to fully appreciate the significance of international scientific exchange in plastic surgery and its impact on a US plastic surgeon's clinical practice.

Couverture du talon par lambeaux libres perforants de type « freestyle »

Heel coverage requires the surgeon to considerate of multiple parameters: the type of defect, the exposed tissues, the weight-bearing requirements, the donor site morbidity, and the shape of the reconstructed heel allowing at best normal footwear. Although many methods of coverage exist, they are often chosen at the cost of a compromise between all the parameters described. In recent years, perforator freestyle free flaps offer plastic surgeons an unparalleled freedom that can adapt the constraints of the reconstruction while minimizing the functional and scar donor site morbidity. We present four cases of heel defect of different origins treated by three types of tailored perforator freestyle free flaps (ALT, TAP and SCIP Flaps). End-to-side anastomosis to the posterior tibial vessels was used in three flaps while one flap was anastomosed to the internal plantar artery in an end-to-end fashion. No postoperative complication occurred. This approach allowed, in all patients, a reconstruction of excellent quality with minimal cicatricial morbidity. All patients were walking effectively at 21 days postoperatively. Perforator freestyle free flaps offer a solution of first choice for heel reconstruction. At the price of a linear hidden scar, they offer a functional, aesthetic and durable coverage.

Role of Microsurgery in Lower Extremity Reconstruction

Developments in reconstructive microsurgery have heralded a new phase of limb-saving procedures. Although pedicled local fasciocutaneous or muscle flaps continue their useful role, microsurgical free tissue transfer is usually required for larger defects and also for areas without locoregional options. As this treatment modality has become more established, innovation and technical refinements have resulted in an evolution of flap surgery, including perforator and free-style free flaps, that has been applied to lower limb surgery. Effective outcome measures, bioelectronic prostheses, and composite tissue allotransplantation are the three major trends leading into a new era of lower limb reconstruction. This article outlines the role of microsurgical free tissue transfer for lower limb salvage and reconstruction.

Perforator Flaps in Head and Neck Reconstruction

Free tissue transfer has revolutionized the management of complex head and neck defects. Perforator flaps represent the most recent advance in the development of free flap surgery. These flaps are based on perforating vessels and can be harvested without significant damage to associated muscles, thereby reducing the postoperative morbidity associated with muscle-based flaps. Elevation of perforator flaps requires meticulous technique and can be more challenging than raising muscle-based flaps. Use of a Doppler device enables reliable identification of the perforating vessels and aids in the design of free-style free flaps, where the flaps are designed purely according to the perforator located. The major advantage of free-style free flaps is that an unlimited number of flaps can potentially be designed on much shorter pedicles. The anterolateral thigh flap is the most commonly used perforator flap in head and neck reconstruction. Its use is described in detail, as is use of other less common perforator flaps. This article also describes head and neck reconstruction in a region-specific manner and gives a short-list of suitable flaps based on the location of the defect.

Free-style free flap

Advancements in microsurgical techniques as applied to perforator flaps have made harvesting flaps in a free-style manner a practical reality. A hand-held Doppler identifies sizable perforators on which flaps can be based. In free-style free flap harvesting, any region of the body can be chosen as a donor site as long as there is an audible pulsatile Doppler signal. The value of the free-style free flap concept lies in its ability to overcome anatomical variations. The clinical application of raising flaps in a free-style manner has been demonstrated in the thigh where flaps have been raised safety and reliably in spite of the many anatomical uncertainties in this area. Flaps can, thus, be designed and raised in any region of the body to suite the unique requirements of individual cases. However, limitations to the clinical application of the free-style free flap should be noted; the course of the perforator may be unpredictable. Small and long perforators may be difficult to harvest and inset. Furthermore, the skin territory and intra-operative flap thinning should more conservative compared with conventional flaps. These shortcomings can however be overcome by clinical experience and improvement in surgical techniques.

Perforator Flaps

Worldwide interest in perforator flaps was reignited when Koshima published his description of a flap based upon a single paraumbilical perforator vessel in 1989. Building upon the earlier work of visionaries such as Manchot, Milton, and Ponten, a new group of visionaries set out to discover the endless possibilities in the “perforator” world. In this issue of Seminars in Plastic Surgery, we are fortunate to have authors from such an innovative and creative group. Authors such as Robert Allen, Phillip Blondeel, and Moustapha Hamdi, who have all made countless contributions to the field of breast reconstruction using perforator flaps. And authors such as Geoffrey Hallock and Peter Neligan, who have helped pioneer and advance the fields of lower extremity and head and neck reconstruction, respectively. This impressive group also includes Fu-Chan Wei, who single-handedly expanded our repertoire of donor sites by demonstrating the use of freestyle free flaps. Perhaps what is most admirable about this group, however, is their unwavering dedication to challenging some of our most deeply held beliefs to further our specialty. This journal is dedicated to all those who dream of not only following in the footsteps of such revolutionary leaders, but charting new territories themselves.

Free-Style Free Flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.