Local Pedicled Flaps Research Articles

Olecranon Fractures With Sagittal Splits Treated With Dual Fixation

To assess the results of olecranon fractures with an intra-articular sagittal plane fracture managed by orthogonal fixation constructs. A retrospective chart review was performed and 14 proximal ulna fractures with intra-articular comminution resulting in separate medial and lateral fragments were identified. All fractures were classified according to the Schatzker, Mayo, and AO classification systems. Postoperative functional assessment, Disabilities of the Arm, Shoulder, and Hand (DASH) score, time to union, and complications were recorded. Eleven patients were treated with both dorsal and lateral plates. Three patients were managed with a single dorsal plate and cerclage wires. All fractures healed. Mean length of follow-up was 15 months (range, 4-72 mo). Mean range of motion at final follow-up was a flexion-extension arc of 24° to 129° with 89° and 79° of pronation and supination, respectively. The most common complication was symptomatic hardware, leading to removal of hardware in 5 of 14 (36%) patients. Average postoperative Disabilities of the Arm, Shoulder, and Hand score was 7. Two patients developed heterotopic ossification and 1 patient required a local pedicled flap for soft-tissue coverage. Identification of this subset of fractures is critical to successful management. A supplemental lateral plate or cerclage wires can successfully manage these difficult fractures and achieve good outcomes. Therapeutic IV.

Healing septal perforations by secondary intention using acellular dermis as a bioscaffold.

Several techniques are described in the literature for nasal septal perforation repair. Most of these involve interposition grafts in conjunction with local pedicled mucosal flaps. The following article describes our experience using acellular dermis as a bioscaffold to support the regrowth of nasal septal mucosa by secondary intention. Retrospective chart review of all patients who underwent repair of nasal septal perforations by the senior author using acellular dermis placed between the 2 sides of the perforation and covered with silastic splints to allow for mucosalization. Thirteen patients underwent nasal septal perforation repair using this technique. All perforations repaired were under 2 cm in greatest dimension. Two-thirds of patients had complete closure of the perforation upon initial use of bioscaffolding technique. The remaining third achieved near-total closure with bioscaffolding technique and were able to be completely closed with a single additional procedure. Acellular dermis offers an alternative to most currently described complex flaps. The method can be used in patients with defects less than 2 cm, but initial data suggest caution when using in those with wound healing impediments. This technique is also an excellent choice for patients with multiple small septal perforations.

The Freestyle Facial Perforator Flap

BACKGROUND: Since 2008 we are increasingly using island perforator flaps instead of local pedicle flaps in the reconstruction of moderate size skin defects of the face. We want to present the simplicity and reliability of our method and emphasize key steps in flap dissection and planning. METHODS: Initially we carried out a careful dissection with loop magnification looking for a perforator in a planned local flap that subsequently was turned into an island flap based only on the nearest available perforator. Plan B was a full thickness skin graft. We published our initial experience of facial artery perforator flaps to establish the safety of the method for the reconstruction of moderate-sized facial defects.1 A retrospective case series of 19 patients with moderate size oncologic skin defects reconstructed in a single operation using 21 local island perforator flaps. RESULTS: In every case we located a sufficient perforator where expected by careful exploration and designed an island flap accordingly. The pedicle can usually be “felt” as a resistance with the dissecting instrument indicating to slow down the dissection and establish what it contains. Once the perforator is noted the flap can be released around it to allow mobilization, transposition or advancement. Three out of four flaps were transposed on the perforator pedicle in a propeller fashion 90-180 degrees and the remaining flaps were advanced. Two minor complications occurred early on in our series representing a learning curve and a corrective procedure was performed in four patients. Reconstruction was successfully achieved in all cases. CONCLUSIONS: The freestyle facial perforator flap is a good option for the reconstruction of facial subunits combining the freedom of the island design and increased angle of rotation of the perforator pedicle. With a careful planning and basic anatomical understanding a pleasing result can be achieved in one operation with minimal donor site morbidity and a low rate of complications.

Application of the Orthoplastic Reconstructive Ladder to Preserve Lower Extremity Amputation Length

A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

Lower Extremity Ulcers

Acknowledging and addressing common features of lower extremity ulcers will allow the surgeon to heal the vast majority of leg ulcers, either surgically or nonsurgically. The involvement of a surgeon interested in lower extremity preservation ensures the patient is offered a comprehensive set of management options. The authors discuss chronic and problem wounds, incidence and epidemiology, anatomic considerations, clinical evaluation and investigative studies, and general and specific management of the main types of leg ulcer (arterial, diabetic, venous, and inflammatory). Tables describe types and causes of lower extremity ulcers, common characteristics, members of the multidisciplinary team, conditions that interfere with healing, angiosomes of the foot, components of a leg ulcer that must be removed by débridement, benefits of hyperbaric oxygen and well-performed débridement, commonly used local pedicled flaps, staging systems for diabetic foot ulcer, and classes of compression stockings. Figures illustrate angiosomes of the anterior tibial, dorsalis pedis, peroneal, posterior tibial, lateral plantar, and medial plantar arteries; interplay between bacterial levels; types of wound dressing; ulcer locations as an indication of etiology; and management of arterial insufficiency ulcers, diabetic foot ulcers, and venous stasis ulcers. This review contains 11 figures, 11 tables, and 138 references.

Lower Extremity Ulcers

Acknowledging and addressing common features of lower extremity ulcers will allow the surgeon to heal the vast majority of leg ulcers, either surgically or nonsurgically. The involvement of a surgeon interested in lower extremity preservation ensures the patient is offered a comprehensive set of management options. The authors discuss chronic and problem wounds, incidence and epidemiology, anatomic considerations, clinical evaluation and investigative studies, and general and specific management of the main types of leg ulcer (arterial, diabetic, venous, and inflammatory). Tables describe types and causes of lower extremity ulcers, common characteristics, members of the multidisciplinary team, conditions that interfere with healing, angiosomes of the foot, components of a leg ulcer that must be removed by débridement, benefits of hyperbaric oxygen and well-performed débridement, commonly used local pedicled flaps, staging systems for diabetic foot ulcer, and classes of compression stockings. Figures illustrate angiosomes of the anterior tibial, dorsalis pedis, peroneal, posterior tibial, lateral plantar, and medial plantar arteries; interplay between bacterial levels; types of wound dressing; ulcer locations as an indication of etiology; and management of arterial insufficiency ulcers, diabetic foot ulcers, and venous stasis ulcers. This review contains 11 figures, 11 tables, and 138 references.

Treatment of Painful Median Nerve Neuromas With Radial and Ulnar Artery Perforator Adipofascial Flaps

To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps. Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel's sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18-84 mo). Preoperative and postoperative pain was measured with a visual analog scale. Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site. Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve. Therapeutic IV.

Application of Local Axial Flaps to Scalp Reconstruction

BackgroundScalp defects may be caused by various etiological factors, and they represent a significant surgical and aesthetic concern. Various surgical techniques can be applied for reconstructive work such as primary closure, skin grafting, pedicled or free flaps. In this article, the authors share their clinical experience with scalp operations using the technique of local flaps and discuss the application of this method from the perspective of not only the size of the defect, but also in relation to the anatomical area, quality of surrounding tissue, and patient's condition.MethodsDuring the period from December 2007 to December 2012, 13 patients with various scalp defects, aged 11 to 86 years, underwent reconstruction with local pedicle flaps. The indications were based on the patients' condition (age, sex, quality of surrounding tissue, and comorbidities) and wound parameters. Depending on the size of the defects, they were classified into three groups as follows: large, 20 to 50 cm2; very large, 50 to 100 cm2; extremely large, 100 cm2. The location was defined as peripheral (frontal, temporal, occipital), central, or combined (more than one area). We performed reconstruction with 11 single transposition flaps and 1 bipedicle with a skin graft on the donor area, and 2 advancement flaps in 1 patient.ResultsIn all of the patients, complete tissue coverage was achieved. The recovery was relatively quick, without hematoma, seroma, or infections. The flaps survived entirely.ConclusionsLocal flaps are widely used in scalp reconstruction since they provide healthy, stable, hair-bearing tissue and require a short healing time for the patients.

Colgajo perforante en hélice basado en arteria peronea para reconstrucción distal de extremidad inferior

Resumen en: Introduction: Propeller flaps are local pedicle flaps, based on a perforator vessel, which acts as the pivot point for the skin island that can be rotate...

Muscle Flaps and their Role in Limb Salvage

Muscle flaps have proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salvage infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion following compartment syndrome. Free flap pedicles have also been used in a flow-through fashion to create a distal arterial bypass. This article explores the multipurpose role of muscle flaps in limb salvage surgery and their beneficial physiologic characteristics in hostile wound environments.

The Distally Based Adipofascial Sural Artery Flap

Complex wounds of the distal third of the leg are challenging to treat. Despite free tissue transfer, local pedicled flaps such as the distally pedicled sural artery flap remain a valuable option. The authors conducted a retrospective comparison of the classical harvesting technique of the sural artery flap with a simplified method without a skin island. We report on 148 patients who were treated with 104 adipofascial flaps and 44 fasciocutaneus flaps from 1997 to 2010. The adipofascial group showed a shorter operative time and a better aesthetic outcome. Complications did not differ in this multimorbid patient group. With a simple modification, the distally based sural artery flap is easier and faster to perform. The study shows that the adipofascial flap is as safe as the classic version, with the advantage of an improved donor-site appearance. Therefore, the described technique is a valuable tool in cases where free tissue transfer is not suitable. Therapeutic, III.

Meta-Analysis of CSF Leak Rate Following Skull Base Reconstruction with and without Vascularized Local Pedicled Flaps

Meta-Analysis of CSF Leak Rate Following Skull Base Reconstruction with and without Vascularized Local Pedicled Flaps

A “Sling Swing Transposition” Technique With Pedicled Dural Flap for Microvascular Decompression in Hemifacial Spasm

The key to successful microvascular decompression of the neurovascular compression syndrome is maintaining the separation between the nerve and the offending vessel. We describe a transposition technique in which a local pedicled dural flap, fashioned from the petrous posterior surface, is used to retract the offending vessel away from the root exit zone of the facial nerve in hemifacial spasm cases. We conducted a retrospective review of microvascular decompression operations in which the offending vessel was transposed and then retained by a local pedicled dural flap made from the dura of the petrous posterior surface. This technique was used in 7 consecutive cases of the most recently operated series. Postoperatively, complete symptom relief was achieved in 100% of the patients without any significant surgical complications. To our knowledge, this is the first report in which an autologous anatomic structure in the cerebellopontine angle, such as petrous dura mater, is used in the microvascular decompression of the facial nerve. This is a simple yet robust method and can be considered an option for the treatment of hemifacial spasm caused by arterial compression.

Local and regional pedicled flaps in head neck reconstruction

Local and regional pedicled flaps in head neck reconstruction

Phalloplasty in Complete Aphallia and Ambiguous Genitalia

The most common indications for phalloplasty in children include aphallia, micropenis/severe penile inadequacy, ambiguous genitalia, phallic inadequacy associated with epispadias/bladder exstrophy and female to male gender reassignment in adolescents. There are many surgical options for phalloplasty; both local pedicled tissue as well as free tissue transfer. The advantages of local tissue include a more concealed donor site, less complex operation and potentially faster recovery. However, pedicled options are generally less sensate, making placement of a penile prosthesis more risky and many children with bladder exstrophy have been previously operated upon making the blood supply for local pedicled flaps less reliable. This Here the authors discuss free tissue transfer, including the radial forearm, the anterolateral thigh, the scapula and latissimus, and the fibula free flaps, as well as local rotational flaps from the abdomen, groin, and thigh. The goal of reconstruction should be an aesthetic and functional (ability to penetrate) phallus, which provides tactile and erogenous sensation, and the ability to urinate standing. Ideally, the operation should be completed in one to two operations with minimal donor site morbidity. There are advantages and disadvantages of each of flap and thus the choice of donor site should be a combination of the patient's preference and surgeon's ability to produce a consistent result.

Outcome of local anconeus flap transfer to cover soft tissue defects over the posterior aspect of the elbow

To report the outcome of using local pedicled anconeus flap (LPAF) to cover soft tissue defects over the posterior aspect of the elbow. Twenty elbows in 20 patients who had chronic soft tissue defects over the posterior aspect of the elbow that were managed with the use of LPAF were included in this study. The mean soft tissue defect size averaged 4 × 3 cm (range, 2 × 3 cm to 7 × 4 cm). The mean duration of symptoms was 11 months (range, 4-96), and the mean number of debridement and attempt at closure of the wound defect before the flap was performed was 3 (range, 2-7). Wound healing occurred in all elbows at an average 3 weeks (range, 2-5) after surgery. No flap complication either at the time of the surgery or postoperatively was recorded. At the final follow-up that averaged 17 months (range, 15-20) after surgery, there were significant improvements in the subjective elbow value (SEV) and Mayo Elbow Performance Score (MEPS) from average 70% (range, 50-80%) and 74% (range, 65-80%) to an average 95% (80-100%) and 90% (range, 85-100%), respectively (P = .001). All patients had full range of motion of the elbow, and all were satisfied with the surgery and would do it again. The LAPF is a reliable flap that could be used to cover chronic soft tissue defect around the posterior aspect of the elbow, with expected wound healing in all patients at an average of 3 weeks after surgery.

Plastic Surgical Techniques for the Foot and Ankle

Random advancement or rotational flaps, split-thickness skin grafts, and local muscle and pedicle flaps are commonly used for closing a complicated foot and ankle wound. Local flaps are typically based on the geometric designs, the mobility and condition of the surrounding soft tissues, the nature of their movement, and the angiosomes of the foot. Local flaps can be advanced, transposed, or rotated to provide soft tissue coverage of the defect. Split-thickness skin grafts can be used in wounds with exposed granulation tissue, dermis, fascia, muscle, peritenon, paratenon, and periosteum. A split-thickness skin graft may not be used in wounds with greater than 5 mm of exposed bone or tendon, over adipose tissue, and over weight-bearing areas. The main prerequisites for splitthickness skin grafting are the presence of a granular wound bed with no drainage, malodor, periwound erythema, edema, and no systemic signs of infection. Granulation tissue is an indicator of skin graft readiness and survival. Granulation tissue is absent if the wound bed is not well perfused or if infection remains. The pedicle flap is used predominately for durable soft tissue closure of the weightbearing aspect of the foot and is useful when performed in conjunction with a skeletal reconstruction of themidfoot and for closure of calcaneal defects. Themain advantage of a pedicle flap is that extensive soft tissue coverage to the plantar aspect of the foot can be provided without the microvascular anastomosis that is required of a free tissue transfer (Fig. 1). Absolute contraindications to surgical wound closure via plastic surgical techniques include vascular insufficiency despite endovascular or vascular surgery, complicated

Pedicled vertical myocutaneous gracilis (VMG) flap for reconstruction of a large composite lower abdominal defect

Management of the complex abdominal wall defect after tumour extipiration represents a challenge and requires careful planning. We report a case of a 76-year-old gentleman treated initially for a T4N0M0 Dukes B sigmoid cancer with anterior resection in 2008. He re-presented 6 months after chemotherapy with a histopathologically proven anterior abdominal wall adenocarcinoma of colonic origin with involvement of the underlying parietal wall and rectus muscle. En bloc resection was undertaken with the harvesting of a vertical myocutaneous gracilis, VMG, pedicled flap (11 × 22 cm) to fill the abdominal soft tissue defect. A concurrent supraumbilical incisional hernia, poor coverage from other local pedicle flap options and multiple co-morbidities made the pedicled VMG the only viable option. We report its success as a valuable option in the reconstructive armamentarium for complex abdominal defects.

The Reconstructive Clockwork of the Twenty-First Century: An Extension of the Concept of the Reconstructive Ladder and Reconstructive Elevator

Sir: The conventional reconstructive ladder addressing tissue defects begins with primary and secondary closure of wounds followed by autologous skin grafting, regional and local pedicled flaps, tissue expansion, and free tissue transfer.1 Conceptionally different, the reconstructive elevator allows one to ascend directly to the chosen level of reconstructive complexity.2 Another Plastic and Reconstructive Surgery commentary is entitled, “Why Climb a Ladder When You Can Take the Elevator?”3 Despite enormous achievements and refinements in the aforementioned reconstructive techniques, clinical situations and problems occur beyond the scope of these conventional reconstructive measures. As such, composite tissue allotransplantation of partial faces (unilateral or bilateral) has been introduced as a juvenile part of transplantation medicine with encouraging early and midterm clinical results.4 However, short- and long-term problems such as potential tumor induction by immunosuppression and chronic rejection are to be considered. Given the fact that patients undergoing composite tissue allotransplantation have undergone various reconstructive procedures before, the patients often gain tremendous improvement in quality of life. A further evolving field is robotics, such as the da Vinci Surgical System for surgeons and the Penelope assistant robot, which found their way into the clinical operating room. Although even microsurgical anastomosis has been performed using the da Vinci system, the total amount of time and resources spent is beyond being practical today. Regeneration and tissue engineering are of distinct and genuine interest in reconstructive surgery. Adipose-derived stem cell transfer is able not only to improve contour but also to improve overlying skin,5 with potential widespread future application in reconstructive surgery. Comprehensive care is usually achieved best using a team approach. A given reconstructive problem is reasonably addressed by a combination of various reconstructive techniques if one alone is not able to do so. Having said that the combination of reconstructive procedures is feasible and clinically relevant, the aforementioned evolving fields of composite tissue allotransplantation, robotics, and regeneration/tissue engineering will be and sometimes are already integral parts of daily reconstructive procedures. Although the above-mentioned metaphors of the reconstructive ladder and the reconstructive elevator do not allow one to intuitively combine various reconstructive measures from different echelons, we would like to propose a novel thought on this issue. We consider these novel techniques—composite tissue allotransplantation, robotics, and regeneration/tissue engineering—as potential future integral parts of a reconstructive sequence that is not necessarily consecutive but simultaneous (Fig. 1). Given the integral nature of the procedures, we would propose the term “reconstructive clockwork” for reconstructive surgery of the twenty-first century. The idea of the reconstructive clockwork is to mirror the integral parts of various reconstructive echelons serving the one goal of addressing the defect, the function, the deformity, or all of them in combination. The reconstructive clockwork metaphor bears the precision of microsurgical procedures and complexity of reconstructive approaches in a natural fashion.Fig. 1.: A reconstructive clockwork as a refinement of the conventional reconstructive ladder. CTA, composite tissue allotransplantation.DISCLOSURE The authors have no financial interest to disclose. Karsten Knobloch, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Hannover Medical School Hannover, Germany

P74 Resurfacing the penoscrotum with local pedicle flaps at large defects after ablation of penoscrotal extramammary Paget's disease

Purpose Penoscrotal extramammary Paget's disease is a rare cutaneous malignancy that primarily affects the elderly. To prevent local recurrence, adequate surgical excision with an intraoperative frozen section, proper reconstruction, and a long-term period of follow-up are required. The present study describes the treatment of patients with penoscrotal extramammary Paget's disease, with a focus on post-oncologic reconstruction. Methods Eleven patients who had undergone a local pedicle flap procedure due to the large body defects after ablation of extramammary Paget's disease of the penoscrotal area, during the period of 1999–2009. Local wide excision with intraoperative frozen sectioning was performed, and the penoscrotal wound was reconstructed with a local skin flap. Various flaps were chosen depending on the site and the defected size. If the defect size was small and scrotal tissue was adequate, only a scrotal flap (n=5) was completed for the reconstruction. Large defects with insufficient remnant scrotal tissue as well as cases in which the pubic or inguinal area was involved went through a groin flap (n=2) or an anterolateral thigh flap (n=4) among the local pedicle flaps. Results There were no complications with the postoperative wound. Furthermore, no local recurrence was noted during two to six years of follow-up (mean average 3.5 years). Conclusion For the resurfacing the penoscrotum at large defects after ablation of extramammary Paget's disease, we performed reconstruction with a local pedicle flap. In cases where the remnant tissue was sufficient, a scrotum flap was primarily used, and if additional tissue was needed a local pedicle flap; groin flap or anterolateral thigh flap, etc was applied for reconstruction. In terms of both function and cosmetic concerns, the results were satisfactory. Key Words: Penoscrotal extramammary Paget's disease, Scrotal flap, Groin flap, Anterolateral thigh flap