Local Pedicled Flaps Research Articles

Management of Large Scalp Defects with Local Pedicle Flaps

Recent reports have emphasized free-flap reconstruction for large defects of the scalp and calvarium following resection of tumors, infection, or trauma. In most cases, however, a carefully planned local transposition or rotation flap may be equally effective, and the technical difficulties and donor-site problems associated with microsurgical tissue transfer are then avoided. We present 10 patients whose full-thickness scalp defects covered an average area of 241 cm2, or 27 percent, of the skull surface. Although this series included defects as large as 450 cm2, or 50 percent, of the skull surface area, each was easily managed with a local pedicle flap transfer. Four patients were reconstructed with parietal scalp transfer, four with an occipital scalp flap, and two with temporal scalp transfer. The technique and results are discussed.

Acute Management of Traumatic Forequarter Amputations

Traumatic forequarter amputation is a rare and very devastating injury. The arm, including the scapula, clavicle, and pectoral muscle, is torn from the body by a tremendous traction force, usually combined with a counteracting force from the body. The cases of three patients are presented. One patient was caught by the axle of a harvesting machine, resulting in a forequarter amputation of his right extremity and amputation of his left arm at the level of the upper arm. The other two patients had their arms caught in conveyer belts. All patients survived. Closure of the defect was performed acutely using a local pedicled musculocutaneous flap in one case and free vascularized musculocutaneous flaps from the amputated limbs in the two other cases.

Injuries of the External Ear

Ear injuries occur in people of all ages but predominate in active people such as wrestlers, boxers, and bike riders. The types and extent of injury are a function of the force causing the injury. Shearing forces of moderate intensity cause hematoma formation, whereas greater force causes lacerations or even amputation. Sharp objects cause lacerations determined by the force, direction, and point of impact. The high ratio of surface area to mass makes the auricle vulnerable to extremes of temperature. People participating in high-risk activities should wear protective headgear. The goal of treatment is to restore the normal contours while preventing infection. Hematoma results in disfigurement by organization or chondritis. Evacuation and pressure dressings using sterile technique correct the condition. Second-degree burns are treated by regular cleansing and application of topical antimicrobials. Deeper burns require debridement, biologic dressings, or burying the cartilage subcutaneously for later reconstruction. Simple lacerations are closed under aseptic technique using either skin-to-skin sutures only or sutures of the skin combined with intercartilage sutures. Extensive and complex lacerations require meticulous care to match all fragments and prevent infection or loss of tissue. Bare cartilage must be covered with vascularized tissue. The treatment of total amputation is controversial. Some advocate reattachment as a composite graft using intravenous low molecular weight dextrans and heparin as adjuvants. Mladick dermabrades the amputated pinna, reattaches it with sutures, and then slips it into a pocket of elevated postauricular skin for 2 weeks. Others urge microvascular reanastomosis of the small nutrient vessels. Brent and Byrd separate the cartilage from its overlying skin and envelope it first with vascularized temporoparietal fascia and then a split-thickness skin graft. Chondritis is the most feared complication of injury or surgery of the pinna. It is an aggressive process, and prompt removal of pus and necrotic cartilage is required. Exteriorization and removal of all cartilage is effective but disfiguring. Removal of only affected cartilage and constant irrigation with antibiotic solutions is effective but requires prolonged hospitalization. Iontophoresis of antibiotics into the auricle may be effective and conserve tissue. Traumatic deformities are corrected with composite grafts from the opposite ear, costal cartilage, and local pedicled flaps.(ABSTRACT TRUNCATED AT 400 WORDS)

Reconstruction of Late Craniofacial Deformities after Irradiation of the Head and Face During Childhood

Little is known about the results of surgical management of late craniofacial abnormalities arising after irradiation of the head and face for treatment of childhood cancers. The clinical records of 10 children (4 males and 6 females) who received 4500 to 6500 rads (mean 5160 rads) of craniofacial radiation between birth and 8 years of age (mean 5 years) and who subsequently had reconstructive surgery were reviewed. Six of the 10 patients received orbital radiation, 3 received maxillary-midfacial radiation, and 1 patient underwent radiation to the frontal bone. Histologic tumor types included retinoblastoma (4), rhabdomyosarcoma (3), Ewing's sarcoma (2), and neurofibrosarcoma (1). In addition to radiation, 7 of the 10 patients underwent surgical resection or debulking of their tumors and 6 received adjuvant chemotherapy. All patients presented from 4 to 20 years after treatment (mean 10 years) with varying, but severe degrees of soft-tissue and bony hypoplasia of the irradiated territories. Onlay bone grafting with soft-tissue reconstruction by a combination of local pedicle flaps and dermal-fat grafts was initially performed in 9 patients, and an occipitoparietal bone-flap switch procedure was done in 1 patient. Late follow-up ranged from 11 months to 7.5 years (mean 34 months). A total of 8 secondary procedures were necessary in 4 of the 10 patients (40 percent). Of these 4 patients, major revisions were performed in 3 and minor adjustments in 1. In addition, 2 patients in whom secondary procedures had not been done would benefit from further reconstruction. Therapy for cancer of the head and face during childhood has profound and ongoing effects on the growth of soft tissue and bone.(ABSTRACT TRUNCATED AT 250 WORDS)

Wound Healing of Canine Vocal Folds after Phonosurgery

To develop phonosurgical techniques, the authors investigated the healing mechanisms of wounds on the vocal folds of canine larynges, and devised a method to cover the raw surfaces of such wounds. To restore the normal physiologic properties of the vocal folds, the normal mucosa should be removed as little as possible in phonosurgery. When the mucosa of the vocal folds is extensively removed by surgical intervention and the raw surface cannot be covered with the local pedicle flap, it should be covered with a free mucosal flap. We found an activated human fibrinogen concentrate, which is a biologic tissue adhesive, to be suitable for adhering a free mucosal flap to the raw surface by a laryngomicrosurgical approach.

Bipedicled lingual flap forlip reconstruction

Full-thickness loss of the lower lip due to trauma or malignancy presents a difficult reconstructive problem. Numerous reconstructive techniques, including distant flaps, local pedicle flaps, advancements and skin-muscle composite transfers, have been described. The bipedicled lingual flap is a relatively simple procedure that offers many advantages over other techniques since it results in excellent cosmesis without donor site deformity. It causes negligible loss of labial and lingual function. Although it is performed in two stages, its simplicity of execution requires less operative time than many other techniques, and it allows satisfactory reconstruction of unusually large defects.

A free dorsalis pedis flap from the other foot combined with a dorsalis pedis pedicle flap from the same foot to close foot ulcers

The dorsalis pedis flap has several advantages: the skin is thin and hairless, a long vascular pedicle with relatively large diameter vessels is available, and a cutaneous nerve supply is also available if needed. It may be used as a free flap or as a local pedicle flap; we have combined both methods in 2 patients.

Epidermal lining in the capsule of a breast prosthesis

THE patient presented herself in 1969 when she was 29 years old, with multiple painful indurations of the left breast. Repeated biopsies confirmed the diagnosis of chronic cystic mastitis. Upon the indication of the referring physician a subcutaneous mastectomy was carried out, with simultaneous insertion of a silicone gel breast implant with 4 Dacron patches (Dow Corning), The patient was warned that there might be asymmetry in the position of the left nipple as well as in the position and size of the other breast, but having had multiple biopsies, she wanted minimal surgery only. Postoperative progress was uncomplicated. Seven years postoperatively she complained of a painful area in the anterior aspect of the breast. On examination, the breast was found to be distorted and firm. In the anterior skin segment of the breast there was a protruding area 3 cm in diameter at the centre which showed bluish discolouration (Fig. I). Multiple dilated vessels were visible and on palpation the skin was found to be thinned in this area. Because a “blow-out” of the skin seemed to be imminent, the implant was removed together with its capsule. A local de-epithelialised pedicle flap from the medial breast quadrant was rotated beneath the thinned skin area and a smaller soft round silicone gel breast implant inserted. Postoperative progress was uneventful. On histological examination, the capsule was I to 2 mm thick and consisted of dense collagenous tissue. Marked fibrosis was noted in the posterior wall of the capsule, in the area of the Dacron patches. Bundles of Dacron fibres were surrounded by a foreign body reaction. The most significant finding consisted in an epithelial lining within the anterior segment of the cavsule. corresvondina to the area where the skin was found to be thinned. The structure of this lining varied from’ simple cuboidal to stratified squamous epithelium (Fig. 2). The cells

Surgery of Repair as Applied to Hand Injuries

In its first two editions this book firmly established itself as an important contribution to the literature on primary reparative surgery of the hand. The new third edition reports progress made in the field and develops seasoned thoughts and conclusions of the senior authors, after a decade and a half of experience since the first edition. It adds a new scholarly and imaginative author, J. T. Hueston. The book has not lost its unique flavor as a volume with which one may spend hours and feel that he has conversed with the authors. The emphasis on primary care of hand injuries is unique to the volume, and I find little disagreement with the principles and most of the techniques described. Although I might disagree in some of the details on such things as donor sites for split grafts (the forearm), local pedicle flaps (the radial side of the index digit

Operative treatment of deep burns of the scalp

Summary Experience of the operative treatment of 40 patients with deep burns of the scalp and skull is described and a classification has been recommended. The surgical methods used depend on the extent and depth of the defect. Free skin grafts, local pedicle flaps and, in most cases, a combination of both procedures have been used.

Surgery for cerebrospinal fluid rhinorrhea and otorrhea.

CEREBROSPINAL FLUID leakage into the nasal and ear spaces can be repaired with a resultant lower morbidity and mortality by using extracranial rather than intracranial surgery. Techniques for repair of spinal fluid leakage which cause rhinorrhea, otorrhea, and otorhinorrhea are presented in this paper. The connection of the subarachnoid space with the intranasal space may be via the frontal sinus, sphenoid sinus, cribriform plate, ethmoid sinuses, or from the mastoid and middle ear by way of the eustachian tube. Spinal fluid otorrhea or otorhinorrhea from the middle or posterior fossae by way of the mastoid can be treated by obliteration, using either a local pedicled connective tissue flap or an adipose autograft. If the spinal fluid leakage is subsequent to a radical mastoidectomy, it may be necessary to use a fascia lata graft. A nasal septal mucoperichondrial pedicled flap is used to repair spinal fluid leakage through the cribriform plate,

Resurfacing of the Thumb Following Major Skin Loss

The repair of areas of skin loss on the hand and in particular on the thumb demands a careful appraisal of the type of tissue used to close the wound. In this report on the closure of avulsed wounds of the thumb, emphasis is placed on the superiority of local pedicle tissue, as compared with pedicle flaps obtained from a distance. Abundant pedicle skin is available on the dorsum of the hand of close partial or complete circumferential defects of the thumb from the level of the metacarpophalangeal joint distally.The main advantage of a local pedicle flap is that the tissue more closely simulates the physical characteristics of volar skin. Neither local nor distant pedicle flaps regain functional sensation. If sensation is essential for satisfactory function it must be supplied by normally innervated volar skin added to the thumb by means of a neurovascular island flap.

Local pedicle flaps in traumatic amputations of the finger tip

Twenty-four consecutive cases of traumatic amputation in the distal phalanx treated with local hand flaps are reported. The patients all had significant loss of substance involving bone. The results in this series have been very satisfactory. The only serious complication encountered was stiffness of the proximal interphalangeal joint which persisted in one patient. X-finger and palmar flap pedicles, carefully planned and executed, are an excellent method of conservation of the length of the finger and offer the most expedient approach to achieve an esthetic and useful finger.

The use of local pedicle flaps for reconstruction of the breast after subtotal or total extirpation of the mammary gland and for the correction of distortion and atrophy of the breast due to excessive scar.

The use of local pedicle flaps for reconstruction of the breast after subtotal or total extirpation of the mammary gland and for the correction of distortion and atrophy of the breast due to excessive scar.

Reconstruction of the œsophagus

Summary Reconstruction of the damaged œsophagus is briefly discussed with the following conclusions:— 1.That repair of the œsophagus by suture in the posterior mediastinum by the thoracic surgeon is the method of choice when practicable. 2.Failing this, a Yudin jejunal loop should be employed if the blood supply to the mobilised loop seems unimpeachable. 3.If neither of these methods can be completed the upper œsophageal stump should be brought out on to the chest wall and the jejunal loop carried upwards subcutaneously as far as it will safely go; subsequent completion to be carried out later by skin tube. 4.The more widespread application of methods in current use by plastic surgeons to skin-tube construction and anastomosis will lessen the frequency of disruption, fistula formation, and stenosis of the tube. 5.Cases are reported in which reconstruction was carried out: (a) By local pedicled skin flaps and tubed pedicle cover; (b) by a method in which both lining and cover were supplied from a distance. The indications for the latter method are few.