Oblique Flap Research Articles

Multi-flap reconstruction for a recurrent giant phyllodes tumor

Few case reports have discussed the incidence and management of giant recurrent phyllodes tumors with borderline to malignant features. We report that of a recurrent case in a 57-year-old female who underwent wide excision with en bloc resection of the 3rd to 7th right anterior ribs and upper abdominal wall. Rigid chest wall reconstruction was achieved using methyl methacrylate and synthetic mesh. This is the first reported case wherein three locoregional flaps, namely the latissimus dorsi, thoracoepigastric and extended external oblique flaps were used to cover a defect measuring 1452 cm2 in size. With this combination of flaps, deformity was minimized, and the resultant outcome was aesthetically and functionally acceptable. Reconstructive goals of intrathoracic organ protection, restoration of chest wall rigidity, maintenance of adequate respiratory function and soft tissue closure were achieved. Careful planning and individualized treatment together with multidisciplinary collaboration remains vital in the successful management of large recurrent malignant phyllodes tumors.

Oblique Axis Hypothenar Free Flaps: Tips for Harvesting Larger Flaps with Minimal Donor Site Morbidity

Background Hypothenar free flaps (HTFFs) have been widely used for reconstructing palmar defects. Although previous anatomical and clinical studies of HTFF have been conducted, this technique still has some limitations. In this study, we describe some tips for large flap design that allows for easy harvesting of HTFFs with minimal donor site morbidity. Methods A total of 14 HTFF for hand defect reconstruction were recorded. The oblique flap was designed in the proximal HT area following relaxed skin tension line along the axis between fourth web space and 10 mm ulnar side of pisiform. A flap pedicle includes one or two perforators with ulnar digital artery and HT branch of basilic vein. In addition, innervated HTFF can be harvested with a branch of ulnar digital nerve. Electronic medical records were reviewed to obtain data on patients' information, operative details, and follow-up period. In addition, surgical outcome score was obtained from the patient, up to 10 points, at the last follow-up. Results Mean harvest time was 46 minutes, and two perforators were included in 10 cases. The mean flap area was 10.84 cm 2 . There were no problems such as donor site depression, scar contracture, keloids, wound dehiscence, numbness or neuroma pain at donor sites, and hypersensitivity or cold intolerance at flap site, either functionally or aesthetically. Conclusion Palmar defect reconstruction is challenging for hand surgeons. However, large HTFF can be harvested without complications using the oblique axis HTFF technique. We believe our surgical tips increase utility of HTFF for palmar defect reconstruction.

Peacock crown feather technique for oblique flap tear of the meniscus - Technical note

Options for meniscal repair are plenty, but optimal usage of these techniques is imperative to achieve meniscal healing and simultaneously minimize meniscal trauma. In this technical note, a particular suture configuration called the Peacock Crown feather stitch has been described especially for the oblique flap tears.

A4 Pulley Reconstruction Using the Superficialis Oblique Flap and the Transverse Double Loop Techniques: A Biomechanical Evaluation Using a Chicken Model.

The pulley system plays an important role in flexion mechanism. Reconstruction after trauma can be challenging. Numerous techniques have been described with several drawbacks. Herein, we describe the superficialis flap oblique technique for A4 pulley reconstruction using an animal model. Forty-two fresh legs of 21 eight-week-old chickens were used to evaluate the maximum flexion angle (MFA) and force at maximum flexion (FMF) in intact and sectioned A4 pulley equivalents of the third digit after reconstruction with the transverse double loop (TDL) technique and the superficialis oblique flap (SOF) technique. Biomechanical measurements were obtained in an exclusively designed instrument. Descriptive statistics were reported, and mean differences between the reconstructive techniques were analyzed. Intact and severed A4 pulley equivalent average MFA were 96.50° ± 1.70° and 115.60° ± 1.50°, respectively. Average FMF were 8.16 ± 0.23 psi with the intact pulley and 6.92 ± 0.20 psi with the sectioned pulley (P < 0.001). After reconstruction with TDL and SOF techniques, the legs reached an average MFA at the distal interphalangeal joint of 98.13° ± 1.20° and 96.90° ± 1.30°, respectively. Mean MFA difference was 1.23° (P = 0.03). Force at maximum flexion was 8.12 psi and 8.10 psi for the TDL and SOF techniques (P = 0.6), respectively. The authors believe that SOF technique for A4 pulley reconstruction can be used as first option when available, taking into account its theoretical advantages and its proven biomechanical characteristics. Long-term functional results should be assessed to translate these results into the clinical setting.

The Superiorly Based Partial Rectus Abdominis and External Oblique Flap for Lower Pole Coverage in Prosthetic Breast Reconstruction: A Prospective Cohort Study of 47 Consecutive Flaps.

This study evaluated health related quality of life and morbidity in patients who had a superiorly based partial rectus abdominis and external oblique (SPREO) flap for lower pole coverage as a component of 2-stage prosthetic breast reconstruction. A prospective cohort study of patients undergoing immediate and delayed 2-stage breast reconstruction including a SPREO flap for lower pole coverage was conducted. The BREAST-Q and a study-specific questionnaire were used to determine outcomes after this procedure. BREAST-Q questionnaires were completed preoperatively and postoperatively and compared with normative values. BREAST-Q questionnaires were completed by 27 women. The mean patient age was 54.3 ± 9.6 years. Mean BREAST-Q scores improved significantly between preoperative and postoperative time points in Satisfaction with Breasts (preoperative 43.2 ± 26.9, postoperative 66.2 ± 19.5, P = 0.001) and Psychosocial Wellbeing (preoperative 59.4 ± 16.4 postoperative 75.5 ± 19.4, P = 0.002). Mean scores were not significantly different in the domains Physical Wellbeing Chest, Physical Wellbeing Abdomen and Sexual Wellbeing. Postoperative BREAST-Q scores were significantly higher (P < 0.05) than previously published normative scores in Satisfaction with Breasts. This study reports the use of the SPREO flap for lower pole coverage in 2-stage prosthetic breast reconstruction and demonstrates that it may be a useful addition to the existing repertoire of flaps used in breast reconstruction.

Revisiting the musculocutaneous external oblique flap as a versatile alternative in large thoracic wall defects

BackgroundThe external oblique myocutaneous flap has been previously described for reconstruction of chest-thoracic wall defects smaller than 400–500 cm2. However, it is utilized less often than workhorse flaps such as the omental, pectoralis, rectus abdominis, and latissimus dorsi myocutaneous flaps as many plastic surgeons are not aware that the flap can cover larger areas than previously documented.Case presentationWe report a 57-year-old female tobacco user who underwent a resection of a grade 3 breast angiosarcoma resulting in a high left chest wall soft tissue defect approximating 900 cm2. The patient underwent an external oblique myocutaneous pedicle flap reconstruction of the defect, most notably in anticipation of postoperative adjuvant radiation therapy. No gross flap complications and or patient impairment were noted. Thirteen months status post flap reconstruction, the patient underwent an aortic valve replacement requiring re-elevation of the same flap for exposure. The flap demonstrated excellent viability during the procedure and postoperatively.ConclusionThe pedicled external oblique myocutaneous flap should be considered when reconstructing larger high chest wall defects when other more common flaps used in chest reconstruction may not be indicated. The external oblique myocutaneous flap is an excellent tool in the armamentarium of any reconstructive surgeon; it is a straightforward and versatile flap that can be safely and reliably used in durable reconstruction of defects of the chest wall and covers defects larger than previously described in the literature.

Abstract P4-13-12: Immediate one-stage implant-based breast reconstruction without an acellular dermal matrix in Japanese breast cancer patients

Abstract Background. In immediate one-stage implant-based breast reconstruction, acellular dermal matrix (ADM) has been usually used due to cover the outside part of the pectoralis major muscle in the world. Unfortunately, ADM is not approved in Japan yet. Therefore we have performed safety one-stage implant-based breast reconstruction without ADM according to several unique technics in our institution and obtain the excellent results. We report single institution experience using the retrospective medical data. Methods. We chose the surgical method of immediate breast reconstruction (autologous and prosthetic) according to patient's preference, breast volume and cancer condition in early breast cancer patients (pts). Two hundred fifty four early breast cancer pts underwent immediate artificial breast reconstruction from January 2014 to March 2017 in our institution. Thirty seven pts were excluded in this analysis because of preplanned the expander insertion. ALLERGAN Natrelle 410 series were used as the silicon breast implant (SBI). We performed three unique steps to determine the one-stage SBI cases as follow. ICG fluorescence imaging to confirm the blood flow state of the chest skin after mastectomy is used as standard method. If there is a defective contrast region, we remove these area. And then, serratus anterior muscle/fascial and external oblique fascial flap is elevated to completely cover the SBI together with the pectoralis major muscle so that the between mastectomy field and the SBI insertion section are isolated. We used sizer to confirm the skin tension and form of breast. After confirming these steps, we adopted cases whether SBI insertion can be safety done. We evaluated the total cosmetic finding based on three categories of inframammary fold position, balance of both breast size and form at half year after operation. If the difference between both inframammary fold positions was under 1cm, if compensatory pad is not necessary with underwear, if the protrusion of the lower pole is sufficient compared with the contralateral side, we gain the point one on each categories in each cases. The total cosmetic evaluation was classified as three categories. Good, fair and poor were defined as gained 3 points, 2 points and 0/1 points, respectively. Results. Among 217 planned immediate prosthetic breast reconstruction pts, 186 pts (85.7%) were succeed one-stage implant-based breast reconstruction. Among 186 pts, the median age was 47 years old (23-75), median body weight was 53kg (35-84), median body mass index was 21.08 kg/m2(16.20-29.41), removed breast volume was 240g (56-522) and implant volume was 220cc (90-425). Implant removed in one case because of complications and infection was occurred in five cases. The revision surgery was performed in one cases because of malposition. Among all pts, the good, fair and poor of total cosmetic evaluation is 84.3%, 13.5% and 2.2%, respectively. Conclusions. Immediate one-stage implant-based breast reconstruction without ADM may be useful and safe procedure according to our unique technics in early breast cancer patients who hope the immediate prosthetic breast reconstruction in Japan. Citation Format: Okumura S, Tatibana S, Narita C, Hyodo I, Sawaki M, Hattori M, Yoshimura A, Ishiguro J, Kotani H, Gondo N, Adati Y, Iwata H, Kamei Y. Immediate one-stage implant-based breast reconstruction without an acellular dermal matrix in Japanese breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-12.

The Superiorly Based Partial Rectus Abdominis and External Oblique Flap: A New Technique for Breast Asymmetry Reconstruction.

Summary:Breast asymmetry has a wide spectrum of presentations with several employable strategies for surgical correction. Historically, the external oblique muscle has proven to be a versatile flap option for the reconstruction of both local and distant defects. It has also been described for use in breast reconstruction for coverage of the lower pole of implant prostheses. The external oblique muscle flap can be harvested in several ways to capture overlying fat and skin. In this study, we describe the use of a superiorly based partial rectus and external oblique flap for surgical correction of lower pole breast hypoplasia. This flap provides vascularized autologous volume to the lower pole of the breast with minimal donor morbidity. Other advantages of this flap are that it can increase the nipple to inframammary fold distance and lower the inframammary fold. This technique represents an evolution of an under-utilized flap and is the first study describing the use of the external oblique flap in the management of breast asymmetry.

Reconstruction of extensive thoracic wall defect using the external oblique myocutaneous flap: An analysis on 20 Chinese patients with locally advanced soft tissue sarcoma.

Soft tissue sarcomas are rare neoplasms that can occur in the thoracic wall, abdominal wall, extremities, and inguinal region. Wide local resection, with precise histological margin control, results in large skin defects that are challenging to close. Various repair procedures, such as vertical rectus abdominis flaps (VRAM), latissimus dorsi flaps, and tensor fascia lata (TFL) flaps are used to cover broad thoracic wall defects. Although the cosmetic reconstruction results of using these flaps are often excellent, each has significant drawbacks. The external oblique musculocutaneous flap is a simple and safe surgical procedure for covering thoracic wall defects. This study aimed to retrospectively assess the safety and technique of using the external oblique musculocutaneous flap to cover large thoracic wall defects after radical excision of locally advanced sarcomas in 20 patients at a single institution. From January 2006 to December 2016, 20 Chinese patients with large advanced sarcomas on their trunks received wide local resection, with precise histological negative margins. The external oblique musculocutaneous flap, mobilized from the ipsilateral abdominal wall, was harvested to cover broad thoracic wall defects. Among the 20 sarcoma patients (12 females and 8 males, ranging in age from 25 to 73 years), there were five patients with primary tumors and 15 patients with recurrent tumors. The median tumor diameter was approximately 15.3 cm. After excising the lesion, the median time to cover the defect with the external oblique myocutaneous flap was 66 min. The average blood loss when harvesting the flap was approximately 48 mL. For the 20 patients in our cohort, the external oblique flap achieved closure of defects measuring an average area of 256 cm2 . No other flaps or reconstruction techniques were used to cover the large defects in this study. There were no deaths directly related to the flap reconstruction procedures. The external oblique musculocutaneous flap was a safe and reliable method of covering broad thoracic wall defects after radical tumor excision.

Abdominoplasty with Scarpa's Fascia Advancement Flap to Enhance the Waistline.

Abdominoplasty for body contouring has evolved from focusing primarily on modification of the skin flap and underlying rectus diastasis repair, to the association of liposuction and limited undermining techniques. While plication of the midline diastasis reliably improves anterior posterior dimensions, it has a more limited effect on the waist contour. Nahas suggested that increasing the width of the plication of the anterior rectus sheath may be responsible for displacement of the contours of the abdomen, yielding unnatural results.1 In an attempt to achieve reliable waist modification, different techniques have been published. L-shaped external oblique muscle plication, multidirectional abdominal wall plication, and advancement of the external oblique muscle flaps have been described.2 Plication of the external obliques demonstrates limited mobility and the creation of widely undermined external oblique flaps is typically beyond the scope of the standard outpatient procedure. It has been suggested that the preservation of Scarpa's fascia during abdominoplasty may lead to a decrease in postoperative complications.3,4 Friedman et al suggested that up to 17% of the lymphatic drainage of the abdominal wall is maintained if dissection is performed above Scarpa's fascia.5 The use of Scarpa's fascia to enhance the waist line definition during abdominoplasty has been limited. Mossaad et al used a medial directional pull on Scarpa's fascia in an effort to define the waistline as a modification of the lipoabdominoplasty technique described by Saldanha et al.6-9 Mossaad's technique removes a full thickness midline strip of subcutaneous tissue below the umbilicus down to the rectus sheath, extending approximately 4 cm lateral to the midline on each side. Tissue advancement was achieved only through lipo-mobilization using standard liposuction techniques with o undermining above the umbilicus other than the midline. Mallucci presented a refinement to traditional abdominoplasty using a superficial fascial …

Soft Tissue Muscle Flaps for Coverage of Chest Wall Resections

Chest wall resection is indicated most often for primary chest wall tumors but may also be required for solitary metastases, infection, or for resection of devitalized tissue following radiation. Whether the chest wall defect is reconstructed with prosthetic material or not depends on its size and location. Resections >25 cm2 or resection of four or more ribs generally require some sort of rigid or flexible or prosthetic material in order to preserve chest wall mechanics. In most instances, it is ideal to cover any prosthetic material with healthy, well-vascularized tissue, which mitigates severe consequences if wound separation, breakdown, or infection were to occur. There are a variety of pedicled muscle flaps that can be rotated to cover most chest wall defects, of which the most commonly used are the pectoralis major and the latissimus dorsi. Both are easily harvested by general thoracic surgeons. Lesser used muscle flaps such as the rectus abdominis, external oblique and trapezius or flaps that require free tissue transfer usually require the expertise of a reconstructive surgeon. Thus, it is ideal to manage larger chest wall reconstructions in a multidisciplinary approach. Though frequently used for intrathoracic translocation, the omentum is less utilized for chest wall coverage, however, it can be a useful second option in cases where rotational muscle flaps are not available or have failed. This review will describe the flaps commonly used for chest wall reconstruction.

Effects of microarterial anastomosis torsion on survival of oblique groin flap in rats

A microanastomosis might tolerate a torsion up to 360°, but the effects of arterial microanastomosis torsion on the survival of the flap it supplies are unclear. The aim of this study was to investigate the consequences of microarterial anastomosis torsion on the groin flap in rats. Forty Sprague-Dawley rats were divided into five groups. An oblique groin flap was harvested as an island flap and a patch-to-side arterial anastomosis was performed with torsion angles of 0°, 90°, 180°, 270°, and 360°. Six of eight flaps in Group I (0° torsion), six of eight flaps in Group II (90°), three of eight flaps in Group III (180°), and none of the flaps in Groups IV and V (270° and 360°) were found to be viable after 1 week. The patency and flap survival rates observed in Groups II, III, IV, and V were compared with those in Group I using Fisher's exact test. The patency rates and flap survival rates in Groups IV and V were significantly lower compared with those in Group I. Our data show that skin flaps can survive even if their arterial pedicle is anastomosed with a torsion of up to 180°.

Synthetic and Biological Mesh in Component Separation

Definitive repair of recurrent ventral hernias using abdominal wall reconstruction techniques is an essential tool in the armentarium for general and plastic surgeons. Despite the great morbidity associated with incisional hernia, no consensus exists on the best means for treatment (Korenkov et al, Langenbecks Arch Surg. 2001;386:65-73). Ramirez et al (Plast Reconstr Surg. 1990;83:519-526) describes the "component separation" technique to mobilize the rectus-abdominus internal oblique and external oblique flap to correct the defect. This retrospective institutional study reviewed 10 years of myofascial flap reconstruction from 1996 to 2006 at Thomas Jefferson University Hospital and revealed an 18.3% recurrence rate in 545 component separations. We identified obesity (body mass index >30 kg/m2), age >65 years old, male gender, postoperative seroma, and preoperative infection as risk factors for hernia recurrence.

Results of Arthroscopic All-Inside Repair for Lateral Meniscus Root Tear in Patients Undergoing Concomitant Anterior Cruciate Ligament Reconstruction

To evaluate the effectiveness of all-inside repair of posterior lateral meniscus root full-thickness tears with preoperative and postoperative magnetic resonance imaging (MRI) and to propose a system of classifying posterior lateral meniscus root tears. From June 2003 to March 2007, 27 (6.95%) of a consecutive series of 388 anterior cruciate ligament reconstructions had a concomitant posterior lateral meniscus root tear. Of the patients, 25 (92.6%) were followed up for a more than 1 year. There were 22 male and 3 female patients, with a mean age of 28.8 years. The mean timing of surgery after injury was 40.8 months. The preoperative and postoperative MRI scans were analyzed and compared. We classified posterior lateral meniscus root tears according to arthroscopic findings. There was no postoperative effusion, joint-line tenderness, or positive McMurray provocation testing observed at the last follow-up. No statistically significant improvement was observed in the coronal plane in the 18 follow-up MRI scans (P = .096); however, sagittal extrusion improved significantly (P = .007). Posterior lateral meniscus root tears were classified based on arthroscopic findings: type I, oblique flap; type II, T shape; type III, longitudinal cleavage; or type IV, chronic inner loss. A type I tear was found in 7 patients, type II in 4, type III in 4, and type IV in 10. After repair of posterior lateral meniscus root tears, MRI showed that the displaced lateral meniscus was reduced, mainly in the sagittal plane. Posterior lateral meniscus root tears were classified based on arthroscopic findings: type I, oblique flap; type II, T shape; type III, longitudinal cleavage; or type IV, chronic inner loss.

External Oblique Musculocutaneous Flap for Chest Wall Reconstruction

External Oblique Musculocutaneous Flap for Chest Wall Reconstruction

The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction

The middle third defects of the face following total or partial oncologic maxillectomy include very important facial structures, both for esthetical and for functional reasons. Among the outcomes, large oronasal or oromaxillary fistulas due to destruction of big bone segments and soft tissues have long been the consequences of such extensive surgical ablations. In the last few years, immediate reconstruction of maxillary bones and soft tissues has proved to be a reliable morphofunctional reconstruction technique following surgery for large oncological defects or the late effects of radiation therapy. Among other free flaps such as composite fibula, composite scapula, or composite radial, the use of vascularized iliac crest with the internal oblique flap has become our flap choice for morphofunctional maxillary reconstruction for bone segments within 6-15 cm of length, and when there is no need for overlying facial skin or oral sphincter reconstruction. The advantages of this composite bone flap are its available large and resizable bone stock; the quality of the bone for transfer (optimal height, depth, and contour to maintain a good facial profile); and the possibility to properly reconstruct the oral lining, orbital content; and maxillary soft tissues with a portion of the internal oblique muscle flap raised with the same pedicle. In addition, this flap's soft tissue will epithelialize during the healing stages.

Pedicled Internal Oblique Rotational Muscle Flap for Reconstruction of Lateral Pelvic Defects

Various local and distant flaps have been used to repair pelvic defects, including sartorius, rectus abdominis, rectus femoris, tensor fascia lata, vastus lateralis, gracilis, and omentum, each with benefits and disadvantages. The pedicled internal oblique rotational muscle flap has been described to cover pelvic wounds but may be underutilized. We present our experience with 5 pedicled internal oblique flaps in 4 patients (3 male, 1 female). The mean patient age was 32 years (23-47 years), and the mean follow-up was 8 months. All patients required coverage of the lateral pelvis after failure of conservative measures. There were no major complications. One patient experienced decreased sensation in the lateral femoral cutaneous nerve distribution, which resolved fully within 3 months. The internal oblique muscle provides local soft-tissue coverage with a predictable blood supply, and its proximity to the pelvis offers an alternative for reconstruction of lateral pelvic defects, with minimal associated morbidity.

Athletic Pubalgia

Athletic pubalgia, or "sports hernia," affects people actively engaged in sports. Previously described in high-performance athletes, it can occur in recreational athletes. It presents with inguinal pain exacerbated with physical activity. Examination reveals absence of a hernia with pubic point tenderness accentuated by resisted adduction of the hip. Diagnosis is by history and physical findings. Treatment with an internal oblique flap reinforced with mesh alleviates symptoms. A retrospective review from December 1998 to November 2004 for patients with athletic pubalgia who underwent operative repair was performed. Descriptive variables included age, gender, laterality, sport, time to presentation, outcome, anatomy, and length of follow-up. Twelve patients, 1 female, with median age 25 years were evaluated. Activities included running (33%), basketball (25%), soccer (17%), football (17%), and baseball (8%). The majority were recreational athletes (50%). Median time to presentation was 9 months, with a median 4 months of follow-up. The most common intraoperative findings were nonspecific attenuation of the inguinal floor and cord lipomas. All underwent open inguinal repair, with 9 being reinforced with mesh. Four had adductor tenotomy. Results were 83.3% excellent and 16.7% satisfactory. All returned to sports. Diagnosis of athletic pubalgia can be elusive, but is established by history and physical examination. It can be found in recreational athletes. An open approach using mesh relieves the pain and restores activity.

Use of vascularized iliac crest with internal oblique muscle flap for mandible reconstruction

In the last decade, immediate reconstruction of maxillary bones following extensive trauma, large oncological defects, or late effects of radiation therapy has proved to be a reliable morpho-functional reconstruction technique. Use of the vascularized iliac crest with an internal oblique flap has become our flap of choice for mandible reconstruction when there is no need for overlying facial skin or oral sphincter reconstruction, and for bone segments within 6-15 cm of length. The advantages of this composite bone flap are the large and resizable bone stock available, the quality of bone transferred with an optimal height, depth, and contour of bone to maintain a good facial profile, and the possibility to reconstruct properly the oral lining, with a portion of the internal oblique muscle flap raised with the same pedicle that epithelializes during the healing stages. We present the experience of the Department of Maxillofacial Surgery of "S. Maria della Misericordia" Regional Hospital in Udine, Italy.

Le lambeau de grand dorsal à palette oblique en bas et en avant en chirurgie reconstructrice mammaire

Breast reconstruction with latissimus dorsi myocutaneous flap is a reliable technique. Its width is limited to between 10 and 12 cm if direct closure of the donor site defect is required. We report a study with assessment of the dorsal skin laxity in 25 women, simulating vertical, horizontal and reverse oblique flap. The average width was 12.5 cm (11.6 to 14 cm) for reverse oblique flap, 9.4 cm (8 to 11 cm) for vertical and 9.2 cm (8 to 10.6 cm) for horizontal flap. Our studysuggests that the reverse-oblique flap provides a wider flap and reduces the donor site morbidity.