Myocutaneous Island Flap Research Articles

Extended lower trapezius island myocutaneous flap in the repair of postburn axillary contracture.

Extended lower trapezius island myocutaneous flap in the repair of postburn axillary contracture.

Scientific basis and clinical application of myocutaneous island flaps in head and neck reconstruction

Myocutaneous island flaps represent the workhorse of head and neck reconstruction because they offer dependable, well-vascularized tissue, especially for preirradiated areas. Soft tissue defects following either ablative tumor surgery or facial trauma can be replaced adequately and reliably, thus providing effective and aesthetically pleasant results.

頚部島状筋皮弁による口腔内再建 筋皮弁の基部と血流について

頚部島状筋皮弁による口腔内再建 筋皮弁の基部と血流について

Reconstruction of an elbow destroyed in gas explosion with total elbow replacement: a case report

A 25-year-old man severely injured his left elbow and lost his right hand in a gas explosion. The left forearm fracture was plated, the elbow debrided, an external fixator was applied, and the skin defect closed using local flaps and a split skin graft. Six months later the elbow was immobile due to an intra-articular fibrosis; a fully constrained hinged elbow replacement (Protetim) was implanted. Five weeks later there was a wound breakdown due to infection; the prosthesis became exposed. To salvage the limb, a latissimus dorsi myocutaneous neurovascular island flap was used to cover the soft tissue defect. Postoperative progress was uneventful and 30–100° of elbow flexion was achieved. One year later, the elbow replacement loosened without evidence of infection and it was replaced with a semiconstrained Coonrad-Morrey joint (Zimmer). In addition, the enlarged medullary canal of the humerus and ulna was packed with a morsalized homologous bone graft. One year after the revision and 3 years after the initial injury, the elbow is fully stable and pain-free with 5–120° of flexion and 40° of rotation. The patient works as a tradesman and is satisfied with the preserved function of his left hand.

Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery.

The lower trapezius island myocutaneous flap is a useful flap in head and neck reconstruction. It is thin and pliable and can reach defects in most areas of the head and neck. Its usefulness in head and neck reconstruction has often been limited or discouraged by reports of significant failure rates. In this study, the vascular anatomy and clinical use of the extended lower trapezius myocutaneous flap based solely on the dorsal scapular artery system are elucidated, and experience gained performing 20 flaps over the past 5 years by using the extended lower trapezius myocutaneous flap is reported. The vascular anatomy of the dorsal scapular artery system is reviewed in 13 fresh cadaveric dissections by using methylene blue, latex injection studies, and radiologic examination.

Tangentially Split Gluteus Maximus Myocutaneous Island Flap Based on Perforator Arteries for the Reconstruction of Pressure Sores

Tangentially Split Gluteus Maximus Myocutaneous Island Flap Based on Perforator Arteries for the Reconstruction of Pressure Sores

Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores.

From 1995 to 1997, the authors used tangentially split gluteus maximus myocutaneous island flaps based on the musculocutaneous perforator arteries for the reconstruction of pressure sores located in the trochanteric, sacral, and ischial regions of 30 ambulatory and paraplegic patients. The postoperative follow-up period was 18 months. Postoperative electromyograms were performed on the ambulatory patients to compare the function of the gluteus maximus muscles on each side. There were one major and two minor postoperative complications. There was no total flap loss. The major advantage of this technique is the preservation of most of the gluteus maximus for stair climbing and single-limb support in the ambulatory patient. The tangentially split gluteus maximus myocutaneous island flap is recommended as the procedure of choice for closure of sacral, ischial, and trochanteric ulcers in both the ambulatory and nonambulatory patient.

Clinical review of 11 cases treating by peroneal island flap, peroneal free flap or peroneal myocutaneous island flap of skin ulcer of lower extremity

Clinical review of 11 cases treating by peroneal island flap, peroneal free flap or peroneal myocutaneous island flap of skin ulcer of lower extremity

Use of a nitric oxide precursor to protect pig myocutaneous flaps from ischemia-reperfusion injury.

Nitric oxide is a radical with vasodilating properties that protects tissues from neutrophil-mediated ischemia-reperfusion injury in the heart and intestine. Previous studies in our laboratory suggested that L-arginine, a nitric oxide precursor, can protect skin flaps from ischemia-reperfusion injury. In this study, we examined the effects of L-arginine on the survival of myocutaneous flaps in a large animal model and established whether this effect was mediated by nitric oxide and neutrophils. Two superiorly based 15 x 7.5 cm epigastric myocutaneous island flaps were dissected in 15 Yorkshire pigs weighing 45 to 50 kg. One of the flaps was subjected to 6 hours of arterial ischemia and then reperfused for 4 hours (ischemia-reperfusion flaps), whereas the other flap was used as a non-ischemic control (non-ischemia-reperfusion flaps). The flaps were divided into four groups: control non-ischemia-reperfusion flaps that received only saline (group I); ischemia-reperfusion flaps that were treated with saline (group II); and flaps treated with either L-arginine (group III) or Nomega-nitro-L-arginine methylester (L-NAME), a nitric oxide synthase competitive inhibitor, plus L-arginine in equimolar amounts (group IV). These drugs were administered as an intravenous bolus 10 minutes before the onset of reperfusion, followed by a 1-hour continuous intravenous infusion. Full-thickness muscle biopsies were taken at baseline, 3 and 6 hours of ischemia, and 1 and 4 hours of reperfusion. The biopsies were evaluated by counting neutrophils and measuring myelo-peroxidase activity. At the end of the experiment, skeletal muscle necrosis was quantified using the nitroblue tetrazolium staining technique, and a full-thickness biopsy of each flap was used for determination of water content. Statistical analysis was performed using analysis of variance and the Newman-Keuls test. Non-ischemia-reperfusion flaps showed no muscle necrosis. Ischemia-reperfusion flaps treated with saline had 68.7 +/- 9.1 percent necrosis, which was reduced to 21.9 +/- 13.6 percent with L-arginine (p < 0.05). L-NAME administered concomitantly with L-arginine demonstrated a necrosis rate similar to that of saline-treated ischemia-reperfusion flaps (61.0 +/- 17.6 percent). Neutrophil counts and myeloperoxidase activity after 4 hours of reperfusion were significantly higher in ischemia-reperfusion flaps treated with L-NAME and L-arginine as compared with the other three groups (p < 0.05). Flap water content increased significantly in ischemia-reperfusion flaps treated with saline and L-NAME plus L-arginine versus non-ischemia-reperfusion flaps (p < 0.02) and L-arginine-treated ischemia-reperfusion flaps (p < 0.05). There was no difference in flap water content between ischemia-reperfusion flaps treated with L-arginine and non-ischemia-reperfusion flaps. Administration of L-arginine before and during the initial hour of reperfusion significantly reduced the extent of flap necrosis, neutrophil accumulation, and edema due to ischemia-reperfusion injury in a large animal model. This protective effect is completely negated by the use of the nitric oxide synthase blocker L-NAME. The mechanism of action seems to be related to nitric oxide-mediated suppression of ischemia-reperfusion injury through neutrophil activity inhibition.

Island orbicularis oculis myocutaneous flap from the upper eyelid for lower eyelid reconstruction

An island myocutaneous flap of orbicularis oculis for reconstruction of central lower eyelid defects is presented. This flap is able to cover anterior lamellar defects extending up to 2/3 of the lower eyelid. It is also suitable for full thickness defects when the posterior lamellar involvement is less than 1/3 and can be closed primarily. In our hands this flap proved to be a good alternative to the classic reconstructive methods for the lower eyelid, since in one operation it offers the same skin quality, exactly fitting the defect, with a low complication rate. This reconstructive method for lower eyelid defects is safe, relatively simple and provides good functional and aesthetic results.

The myocutaneous sternocleidomastoid flap for reconstruction of the mouth cavity and pharynx

Among the myocutaneous island flaps applied for reconstruction of large soft-tissue defects after ablative surgery for malignomas, the pectoralis major flap is the one most frequently used. In comparison, the sternocleidomastoid myocutaneous island flap is not as popular. We report on our experiences with the superiorly based sternocleidomastoid myocutaneous (SCM) island flap (cutaneous island of 6-8 cm in diameter) in seven consecutive cases after resection of malignomas of the oral cavity and the pharynx. The vascularization from the occipital artery is additionally supplied by preserving the platysma during preparation of the SCM flap. Only one total cutaneous necrosis was observed in a patient who had received prior radiation. In the other 6 cases no major complications (necrosis or fistula) occurred. When the preservation of the sternocleidoid muscle does not compromise oncologic principles as in cases with limited lymphe node involvement (N0-N1), the SCM flap appears to be a useful and simple technique, particularly in female patients compared with the pectoralis major flap, in addition to others.

大胸筋皮弁の生着因子に関する検討

In the present study, we analysed patient characteristics and other factors related to flap viability in 19 patients who underwent reconstructive surgery using a pectoralis major myocutaneous island flap in our department over 6+ the past eight years. In these 19 patients (15 males and 4 females), the flap was used on the luminal side of the oral cavity and oropharynx after radical surgery for the treatment of carcinoma of the tongue (10 cases), carcinomas of the oral floor and gingiva (5 cases), and oropharyngeal carcinoma (1 case). Wound complications in the island flap or cervical skin incision site occurred in 11 out of 19 patients, and included partial necrosis of the island flaps (8 cases), dehiscence of the cervical skin incision site (7 cases), dehiscence of the island flap margin (3 cases) and so on. All four of the patients with diabetes mellitus had some wound complications. A comparison of blood data a month before surgery patients with and without wound complications, revealed the mean value of total protein to be significantly lower in the group with wound complications than that in the group without wound complications. A comparison of blood data one month after surgery revealed a significantly higher leukocyte count in the group with wound complications than in the group without wound complications. When a comparison of the incidence of wound complications was made between the group with radiation therapy and that without radiation therapy, the former group showed a higher incidence of complications in the cervical skin incision site than the latter group did, in cases of cervical irradiation.

Selective transposition of the pectoralis major myocutaneous flap: an electromyographic evaluation

Although it has been postulated that the segmental anatomy of the pectoralis major muscle should allow intact motor function to be preserved at the donor site after a myocutaneous island flap has been transposed, the functional outcome of this “selective” harvesting technique has not been previously investigated. In this study the degree of innervation of the residual pectoralis major muscle on the chest after traditional (10 patients) and “selective” (10 patients) pectoralis major myocutaneous flap transposition has been evaluated using postoperative electromyography. According to the data obtained, while an intact innervation of the external segment is maintained utilizing both techniques, it is impossible to preserve functional innervation of the remaining sternocostal strip medial to the donor site during a pectoralis major myocutaneous flap transposition, even after its “selective” harvesting.

The sternocleidomastoid myocutaneous flap: a reappraisal

The sternocleidomastoid myocutaneous flap was described 40 years ago. However, its reliability has been a matter of discussion, mainly because of its random blood supply and subsequent tendency to necrosis. This paper describes the use of the sternocleidomastoid island myocutaneous flap, superiorly based, in 10 patients with good results. In these patients, the superior thyroid artery was sacrificed and the skin paddle was incised directly over the muscle, as described by Ariyan. We believe this approach assures the usefulness of the flap and justifies its expanded utilization.

ISLAND FLAPS INCLUDING THE BEZIER TYPE IN THE TREATMENT OF MALIGNANT MELANOMA

Despite the trend in current surgical practice in the treatment on melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a facial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the dermatomes, which act as an aid memoire upon which the flaps are marked.

Bronchopleural fistula after pneumonectomy: Repair and prevention with a deepithelialized latissimus dorsi myocutaneous island flap

Bronchopleural fistula after pneumonectomy: Repair and prevention with a deepithelialized latissimus dorsi myocutaneous island flap

V‐Y ADVANCEMENT HAMSTRING MYOCUTANEOUS ISLAND FLAP REPAIR OF ISCHIAL PRESSURE ULCERS

Thirty-seven ischial pressure ulcers were repaired in 27 patients (eight quadriplegic, 19 paraplegic) between 1988-1993 using the V-Y advancement hamstring myocutaneous island flap. Twenty-one ulcers (57%) arose de novo and 16 were recurrent, with five patients having bilateral ulcers. The average duration of the ulcer was 5 months (range 1-30). All ulcers extended through the deep fascia (clinical grade IV), with the average diameter being 4.7 cm (range 2-10). There were four major flap complications (11%). All but one of the ulcers healed at discharge (97%). Mean follow up was 20 months (range 5-54) in 21 patients (78%), with six patients being lost to follow up. Seven of the 21 (33%) patients developed recurrent ulcers, with four of these having flap re-advancement with successful healing, and one patient having two re-advancements. Overall, 18 of the 21 (86%) patients with follow up had healed ulcers at time of follow up. The V-Y advancement hamstring myocutaneous island flap is versatile, reliable, easy to perform, has few complications, and can be re-advanced in the event of recurrence.

A reappraisal of the platysma myocutaneous island flap: A follow-up study of the functional outcome after reconstruction of the floor of the mouth

The functional results of primary reconstruction of the floor of the mouth after ablative surgery for oral cancer using a platysma myocutaneous island flap are reviewed. Seventeen patients who had simultaneous neck dissection, tumor resection, and reconstruction were evaluated. It appears from this study that primary reconstruction of the floor of the mouth with a platysma flap is not ideal. This is believed to be due partly to the high occurrence of direct, postoperative complications.

Reconstruction of the mons pubis with a myocutaneous island flap of the rectus abdominis muscle.

Reconstruction of the mons pubis with a myocutaneous island flap of the rectus abdominis muscle.

Differential release of endothelin in myocutaneous island flaps in response to gradually insetting venous stasis or arterial ischemia

Endothelin (ET) provokes strong and sustained contraction in preparations of isolated vascular smooth muscle, and the production of ET is thought to increase secondary to increased wall shear stress and hypoxia. The release of ET and blood flow distribution between arteriovenous shunts and capillaries were studied in autoperfused myocutaneous pig island flaps during graded arterial or venous blood flow reduction (N = 12). A group comprising four flaps was not exposed to blood flow reduction and served as controls. Total flap blood flow (venous outflow [VO]) was reduced in 1-hour periods to 50%, 25%, and 0%. Downregulation of VO caused a lower capillary blood flow (CBF) at 25% ( P < .05) and at 50% ( P < .05) in flaps exposed to venous stasis as compared with flaps with arterial ischemia. The reduction in blood flow was paralleled by decreasing oxygen consumption, although flaps with venous stasis had lower oxygen consumption than flaps exposed to arterial ischemia ( P < .05). ET was found to be released from these island flaps before blood flow was reduced. Gradual arterial clamping caused a statistically significant ( P < .05) decrease in the release of ET from 8.7 ± 1.3 fmol/min before ischemia to 4.1 ± 1.7 at 50% blood flow and 4.1 ± 1.0 at 25% blood flow. In contrast, the release of ET with venous stasis remained unchanged at a level of 7.5 ± 1.6 fmol/min before blood flow reduction, 7.3 ± 0.7 at 50% blood flow, and 8.5 ± 1.6 at 25% blood flow. These data suggest a relationship between CBF, intravascular pressure, and ET production. Determining whether intravascular pressure or hypoxia are the reasons for maintained ET release in response to venous stasis or whether a persistently high ET release during venous stasis causes reductions in CBF requires further study.