Microsurgical Flap Research Articles

The tunneld supracla vicular island flap - a fasciocutaneous flap for head and neck reconstructions

Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure. The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps. To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always essential. Moreover, the donor-site defect needs to be reduced, with no resulting functional or aesthetic impairment. We have found that the shoulder is a region providing an optimum skin texture match to the neck and face. Fasciocutaneous island flap, nourished by the supraclavicular artery is used purely as a subcutaneously tunneled island flap. The tunneling maneuver significantly improves the donor site by reducing scarring. The flap is characterized by a long subcutaneous pedicle of up to 20 cm. The pivot point is in the supraclavicular region and allows the flap to be used in the upper chest, neck, chin, and cheek. In this article we present clinical cases in reconstructive procedures with supraclavicular flap and its expanded indications.

Simultaneous reconstructive surgery for radical mastectomy

Breast reconstruction following radical mastectomy, if desired, is considered vital to the patient's rehabilitation and is an intrinsic part of her breast cancer treatment. Immediate reconstruction – especially immediate reconstruction using autologous tissues – has become more established since the introduction of the skin-sparing mastectomy in the early 1990s. Now, as the more current therapeutic armamentarium has been expanded to feature preoperative tumor shrinking with chemotherapy, accelerated or partial breast radiotherapy, and, in particular, the increased use of breast conservation surgery for larger tumors, immediate breast reconstruction techniques have also further evolved to address the radical mastectomy defect with newer micro-surgical techniques and autologous flap tissues, such as the IGAP, gracilis [1], and SIEA flaps, as well as improved silicone and anatomic saline implant designs [2] with post-operative adjustment capabilities designed to facilitate longer term symmetrical breast reconstruction outcomes. The increased use of postmastectomy radiation therapy in patients with early-stage breast cancer has increased the complexity of planning for immediate breast reconstruction. Studies have evaluated the outcomes of breast reconstruction performed before radiation therapy, revealing a high incidence of complications and poor aesthetic outcomes [3]. Moreover, immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. Multidisciplinary breast conference identification of early breast cancer patients at high risk for radiation therapy has evolved a unique and highly successful 'delayed immediate' reconstruction [4] approach that preserves the aesthetic outcomes of immediate reconstruction and avoids radiation injury to the reconstructive tissues. This is accomplished by utilizing a filled subpectoral tissue expander to temporarily preserve the breast skin envelope until the final tissue pathology is confirmed and the patient either goes on to definitive reconstruction or to radiation therapy with the expander deflated. A total of 28 high-risk early breast cancer patients have undergone the delayed immediate approach with 20 patients (71%) not ultimately requiring radiation therapy. Nineteen patients in the non-radiated group (95%) have now completed definitive reconstruction, primarily with the use of autologous tissues. The eight patients who required radiation have completed the radiation therapy and six (75%) have undergone tissue re-expansion and skin-preserving delayed reconstruction designed to be as similar in outcome to immediate reconstruction as possible. The complication rate for the initial expander placement at the time of mastectomy was 18% for all patients. Five nonradiated patients (25%) had complications in the second stage of definitive reconstruction and one patient (17%) following radiation therapy had complications in the skin-preserving delayed reconstruction. Finally, following the successful experience of the delayed immediate approach for early breast cancer patients, 17 advanced stage patients with planned postoperative radiation therapy also had the opportunity for skin-preserving tissue expansion prior to radiation therapy upon multidisciplinary approval. All the patients received neoadjuvant chemotherapy. Five of the patients (29%) had complications in the first stage of expander placement but two patients (12%) have now completed definitive reconstruction following radiation therapy with re-expansion of preserved breast skin and have experienced no complications. Immediate reconstruction minimizes incisional scars on the breast and improves overall breast contour, shape, and appearance. The improved aesthetic outcomes over delayed reconstruction, achieved as well by these diverse skin-preserving 'delayed immediate' approaches without significant incidents of complications, has convinced many breast cancer patients to view mastectomy with reconstruction as a viable and positive treatment choice.

Repair of palm penetrating wound with microsurgical composite dorsalis pedis flap

目的 介绍应用足背复合串联皮瓣修复合并组织缺损手掌贯通伤的方法.方法 2001年1月-2003年9月,对7例严重手掌贯通伤,应用足背串联双叶皮瓣携带趾伸肌腱、跖背皮神经和自体髂骨植骨进行移植修复.结果皮瓣全部成活,经6个月～3年随访,手部外形满意,皮瓣质地柔软,两点分辨觉达6～8mm,植骨完全愈合,手指运动TAM达健侧75％.结论应用足背复合串联皮瓣加植骨,可同时修复手掌、背侧皮肤软组织、骨、肌腱和神经的缺损,为治疗严重手外伤提供了一种有效,简单的手术方法。

Ectopic bone formation in rats: comparison of biphasic ceramic implants seeded with cultured red bone-marrow cells in a pedicled and a revascularized muscle flap (Master class in plastic surgery)

A series of studies have been carried out with the aim of developing a method for microsurgical reconstruction of bone defects with the help of tissue-engineering techniques. In this study we determined how microsurgery affects the bone-forming capacity of the final construct. Sixteen ceramic implants together with cultured cells were implanted into the adductor thigh muscle flap of the rat. The flap was enveloped by a silicone sheet. After 4 weeks, the pedicles of eight flaps were cut and directly anastomosed microsurgically. The other eight flaps were given a sham operation, in which all branches of the pedicle were cut and ligated, but the main pedicle was left intact. Four weeks after the second surgery, all implants were harvested and analyzed by histology and histomorphometry. The histological appearance of the bone was found to be similar in both groups. Histomorphometry did not reveal statistically-significant differences in bone formation. Thus, we conclude that in a rat model viable microsurgical bone flaps can be obtained by using a cell-based tissue-engineering approach.

Alloplastic mandibular reconstruction and microsurgical flaps. A analysis of success determinant factors

Alloplastic mandibular reconstruction and microsurgical flaps. A analysis of success determinant factors

Plastic replacement defect of laryngopharynx by visceral microsurgical colon-omental flap

Plastic replacement defect of laryngopharynx by visceral microsurgical colon-omental flap

Microsurgical latissimus dorsi flap in a case of breast aplasia caused by radiation therapy

The use of ionizing radiation in the breast region while a patient is at developmental age is still responsible for most monolateral hypoplasias and iatrogenic-based breast asymmetries. These alterations often involve several anatomical structures, thus causing severe hypoplasia of the breast and muscle tissues and stiffness of soft tissues, with atrophic and cicatricial skin. Reconstruction methods vary from case to case, but most of the time reconstruction with a homolateral latissimus dorsi with or without a breast implant seems most suitable. In some cases, however, this is not a viable alternative due to particular general and local conditions, making it necessary to consider other solutions. We present the case of a young prepubertal patient who came under our observation due to a radiotherapy outcome in the right breast and thoracic region; she had been previously subjected to breast reconstruction elsewhere, with the fitting of a subcutaneous prosthesis. Due to the patient's particular general and local conditions and the pathological involvement of the homolateral thoracic musculature, to improve the clinical picture, we deemed it appropriate to use the microsurgical reinnervated contralateral latissimus dorsi muscle, which so far has enabled us to obtain considerable and lasting results.

Microsurgical free flaps in reconstructive surgery: A 5-year, one team experience in 150 consecutive cases

Microsurgical free flaps in reconstructive surgery: A 5-year, one team experience in 150 consecutive cases

PD.46 Microsurgical free flaps in reconstructive surgery: A 5-year one team experience with 135 consecutive cases

PD.46 Microsurgical free flaps in reconstructive surgery: A 5-year one team experience with 135 consecutive cases

Actinomycosis complicating fibula flap mandible reconstruction: a report of two cases

Two patients undergoing fibula flap mandible reconstruction developed chronic intraoral wounds and salivary fistulae. After initial attempts at salvage, tissue biopsies demonstrated Actinomycosis infection. With antibiotic treatment and debridement, one reconstruction was salvaged while one was lost. Actinomycosis infection should be considered a possible agent in chronic wounds complicating mandible reconstructions with microsurgical flaps.

Surgical Treatment the Sequelae of High Voltage Electrical Injury of Hand and Forearm

Ten patients with electrical injury (over 3000 V) of the forearm and hand were operated on during the period of 11.6±3.1 months after accident. Soft tissue plasty with free microsurgical flap and simultaneous tendon and nerve plasty with nonvascularized autograft was performed in eight patients. In two patients with extensive soft tissue defects microsurgical flap included musculus latissimus dorsi that was reinnervated using the anastomoses with anterior interosseous nerve. For the restoration of sensation along the palmar surface of the hand, transposition of ulnar nerve segment on a vascular pedicle from the arm to the forearm was performed. Although no severe postoperative complications developed all patients required tendolysis and transposition of tendons for the restoration of tendon function. Those additional interventions provided the restoration of the wrist grip and social rehabilitation of all patients.

Mandibular reconstruction with microsurgical bone flap and dental implants.

Functional reconstruction of the mandible following resection or traumatic injury depends on the bony reconstruction and support dental implants. Microsurgical bone flaps allow the transfer of bone and soft tissue with a rich vascular supply and provide a firm basis for placement of dental implants in mandible reconstruction. Endosseous dental implants may improve functional restoration by ensuring the stable dentition essential for normal mastication and speech. In this review article, donor sites of microsurgical bone flaps, criteria for placement of dental implants, timing for dental implantation, bone resorption, role of radiotherapy and hyperbaric oxygen, and success rate of dental implants are discussed.

Concept of arteriovenous loupes in high-risk free-tissue transfer: history and clinical experiences.

The present study describes the concepts of arteriovenous (A-V) loupes prior to microsurgical free flap transfer in a selected high-risk group of patients. A one-stage concept was employed in 26 patients; 5 patients underwent two-stage flap transfer. Seven thrombotic occlusions of the A-V fistula or flap vessels were recorded; 6 patients underwent successful revision. Overall flap survival was 96.8% and compared favorably to reports in the literature. Defect coverage could be achieved in all but one case. It can be concluded from the data that in selected high-risk patient groups, i.e., following radiation, compound trauma, chronic infection, or multiple comorbidities, the creation of an A-V fistula prior to flap transfer may facilitate innovative reconstructive solutions.

Treatment of post-traumatic tibial osteomyelitis using microsurgical flaps.

Between 1994 and 1998, the authors treated 70 patients presenting with post-traumatic tibial osteomyelitis. Eighty-five percent were males, with a mean patient age of 32 years. The mean duration of the disease was 2 years. Fifty-one percent were of type IV in the Cierny-Mader classification. The mean follow-up period was 36 months. Case management was through thorough debridement, antibiotic therapy, and soft-tissue reconstruction using free flaps: latissimus dorsi (39.4 percent), scapular (28.2 percent), lateral arm (19.7 percent), and anterior serratus (12.7 percent). To evaluate the results, the control of infection and the quality of the soft tissue repaired were considered. The success rate was 90 percent. The authors conclude that their described method constitutes an effective treatment for post-traumatic tibial osteomyelitis.

Clinical Case Experience Using Microsurgical Venous Flaps for Soft-Tissue Coverage of the Lower Extremity

Numerous venous flap models have been experimentally introduced and clinically attempted in reconstruction of soft-tissue defects. The authors report experience in soft-tissue coverage with microsurgical saphenous venous flap transfers in five patients with lower-extremity wounds. Four of these flaps failed postoperatively. Unhealthy recipient beds and inflamed veins were potential causes for these flap failures. Easy dissection without sacrifice of the artery would seem to provide an ideal situation for venous flap utilization, but this rate of failure prohibits recommendation of this flap in large, traumatic wounds.

A variety of methods for penile reconstruction

The authors have used microsurgical methods for one-stage phalloplasty in 63 penile reconstructions performed over the past 12 years. These operations account for about 10% of the free tissue microsurgical transfers performed in their clinic. Usually a one-stage microsurgical phalloplasty is performed using a combination of the techniques of Biemer, Trengove-Jones, and Gilbert together with the author's own way of sculpturing the glans. Several nontypical methods using multiple flap combinations were used in collaboration with Santi and Berrino in the Instituto Nazionale per la Ricerca sul Canro, Genoa (Italy) and Dominici and Pacifici at the University of Perugia (Italy). The authors were responsible for the idea of constructing a skin tunnel inside the penis using two microsurgical free flaps which allows insertion of a temporary inner stiffener. From the microsurgical point of view, this procedure should be considered a "flap within a flap."

Monitoring flap for buried free tissue transfer: its importance and reliability.

To improve the success rate of microsurgical flap transfers into a buried area, it is important to monitor the circulation of the flap during the early stage. A monitoring flap includes such advantages as simplicity, reliability, noninvasiveness, and the ability to continuously monitor the vascular status of various buried flaps. This article describes experiences related to the importance and reliability of a monitoring flap. A total of 109 flaps in 99 patients were treated with buried free flaps, including a monitoring flap, between 1990 and 1999. Forty-nine patients received a tubed free radial forearm flap with a skin-monitoring flap, and six received a free jejunal flap with a jejunal segment monitoring flap for the reconstruction of the esophagus. Vascularized fibular grafts with a skin monitoring flap or peroneus longus muscle monitoring flap were used for reconstructing the mandible in six patients and for treating osteonecrosis of the femoral head in 48 flaps in 38 patients. Monitoring flap abnormalities were indicated in 14 flaps; therefore, immediate revisions were performed on the pedicle of the monitoring flap and microanastomosis site. Among these 14 flaps, nine showed true thrombosis and five showed false-positive thrombosis. Among the nine flaps that showed true thrombosis, five were salvaged and four were finally lost. The false-positive thrombosis in the five flaps was attributed to torsion or tension of the perforator of the monitoring flap in three flaps, an unclear determination in one flap because the monitoring flap size was too small, and damage to the perforator in the last flap. The total thrombosis rate was 8.3 percent (nine of 109), and the failure rate of the free tissue transfer was 3.7 percent (four of 109). The overall sensitivity of the monitoring flap was 100 percent, the predictive value of a positive test was 64 percent (nine of 14), and false-positive results occurred in 36 percent (five of 14). The salvage rate was 55.6 percent. To improve the reliability of a monitoring flap, it is recommended that the size of the flap be larger than 1 x 2 cm to assess the arterial status, and that a perforator with the appropriate caliber be selected. When a monitoring flap is fixed to a previous incision line or a newly created wound, any torsion or tension of the perforator should be avoided. In conclusion, the current results suggest that a monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of a buried free flap.

Monitoring Flap for Buried Free Tissue Transfer: Its Importance and Reliability

To improve the success rate of microsurgical flap transfers into a buried area, it is important to monitor the circulation of the flap during the early stage. A monitoring flap includes such advantages as simplicity, reliability, noninvasiveness, and the ability to continuously monitor the vascular status of various buried flaps. This article describes experiences related to the importance and reliability of a monitoring flap. A total of 109 flaps in 99 patients were treated with buried free flaps, including a monitoring flap, between 1990 and 1999. Forty-nine patients received a tubed free radial forearm flap with a skin-monitoring flap, and six received a free jejunal flap with a jejunal segment monitoring flap for the reconstruction of the esophagus. Vascularized fibular grafts with a skin monitoring flap or peroneus longus muscle monitoring flap were used for reconstructing the mandible in six patients and for treating osteonecrosis of the femoral head in 48 flaps in 38 patients. Monitoring flap abnormalities were indicated in 14 flaps; therefore, immediate revisions were performed on the pedicle of the monitoring flap and microanastomosis site. Among these 14 flaps, nine showed true thrombosis and five showed false-positive thrombosis. Among the nine flaps that showed true thrombosis, five were salvaged and four were finally lost. The false-positive thrombosis in the five flaps was attributed to torsion or tension of the perforator of the monitoring flap in three flaps, an unclear determination in one flap because the monitoring flap size was too small, and damage to the perforator in the last flap. The total thrombosis rate was 8.3 percent (nine of 109), and the failure rate of the free tissue transfer was 3.7 percent (four of 109). The overall sensitivity of the monitoring flap was 100 percent, the predictive value of a positive test was 64 percent (nine of 14), and false-positive results occurred in 36 percent (five of 14). The salvage rate was 55.6 percent. To improve the reliability of a monitoring flap, it is recommended that the size of the flap be larger than 1 × 2 cm to assess the arterial status, and that a perforator with the appropriate caliber be selected. When a monitoring flap is fixed to a previous incision line or a newly created wound, any torsion or tension of the perforator should be avoided. In conclusion, the current results suggest that a monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of a buried free flap. (Plast. Reconstr. Surg. 110: 1249, 2002.)

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients.

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.

Microsurgical Tissue Transfer for Rehabilitation of the Patient With Cleft Lip and Palate

Abstract Objective: Three case reports of microsurgically revascularized tissue transfer for secondary closure of complex oronasal fistulae in cleft lip and palate patients are reported. One scapular and two radial forearm flaps were used in that respect; the scapular flap was transferred without a skin paddle and was left for secondary epithelialization whereas iliac crest bone was transplanted in the two patients with the forearm flaps in a further surgical step. Conclusions: These microsurgical flaps represent solutions in selected cases of oronasal fistulae in patients with cleft lip and palate with extensive scarring, large defects, or both. Alternative free flaps of the vast spectrum available today, however, also deserve consideration.