Osteofasciocutaneous Flap Research Articles

Fibular osteofasciocutaneous flap in computer-assisted mandibular reconstruction: technical aspects in oral malignancies.

SUMMARYVirtual surgical planning technology in head and neck surgery is witnessing strong growth. In the literature, the validity of the method from the point of view of accuracy and clinical utility has been widely documented, especially for bone modelling. To date, however, with its increased use in head and neck oncology, and consequently the increased need for bone and soft tissue reconstruction, is important to carry out the virtual programme considering not only bone reconstruction but also all aspects related to the reconstruction of soft tissue using composite flaps. We describe our approach to virtual planning in the case of composite flaps. The study reports six consecutive patients with malignant disease requiring mandibular bone and soft tissue reconstruction using fibular osteocutaneous flaps. In all six patients, the resection and reconstruction were planned virtually focusing on the position of cutaneous perforator vessels in order to schedule fibula cutting guides. There were no complications in all six cases. The technique described allowed us to schedule composite fibula flaps in mandibular reconstruction virtually with good accuracy of the position of the bone segment in relation to the cutaneous paddle, important for soft tissue reconstruction. Despite the limited number of cases, the preliminary results of the study suggest that this protocol is useful in virtual programmes using composite flaps in mandibular reconstruction. Further investigations are needed.

Le lambeau ostéo-fascio-cutané antébrachial radial dans la reconstruction maxillo-faciale

Maxillofacial defects often affect various type of tissues and require reconstruction using composite flaps. The radial forearm osteofasciocutaneous free flap is one of the least used. We present the preliminary results of maxillofacial reconstruction using this free flap. We reviewed the records of patients having undergone a radial forearm osteofasciocutaneous flap procedure between 2009 and 2011. Mandibular defect were staged according to HCL classification. Maxillary defects were staged according to Cordeiro and Santamaria's classification. Functional results (swallowing and speech) were assessed at the sixth month. The mean age of the 10 patients was 60.2 years. The average length of bone defect was 8 cm. The average cutaneous defect area was 36.8 cm(2). The mandibular defect was LCL in six cases, L in one case, and C in one case. The two cases of maxillary bone loss were classified IIIa. Six of the 10 microsurgical anastomoses were contralateral to the lesion. There was no reconstruction failure. Three patients had mild speech disorders, five had moderate speech disorders, and two major speech disorders. Four patients had a normal food intake, three patients needed mixed food, and three patients liquid food. The indications of radial forearm osteofasciocutaneous free flap for complex maxillofacial reconstructions should be extended. Its vascularization is less compromised by arteritis. Its pedicle may be long and adequate for a contralateral anastomosis. It is reliable and easy to harvest. But the bone quality is not as good as fibula.

Acute compartment syndrome following fibula flap harvest for mandibular reconstruction

Donor site morbidity for free fibula osteofasciocutaneous flaps has rarely been reported in the literature. We report on a case of acute compartment syndrome (ACS) in a 22-year-old male, following fibula flap harvest for mandibular reconstruction and arising after post-ischemic reperfusion damage. Dissection during this patient’s surgery was unusually difficult. The skin defect was covered with a loose dressing while waiting for secondary grafting. Intracompartmental pressures measured by the Wick catheter technique confirmed the diagnosis of ACS. ACS is an unexpected complication after fibula flap harvest since the three compartments of the leg are opened during surgery. Only four cases of ACS have been reported in the literature. Analysis of this serious complication might lead to changes in the routine use of the pneumatic tourniquet in some selected cases. New automatic tourniquet systems might also be advantageous in such cases.

High-grade oncocytic mucoepidermoid carcinoma of the minor salivary gland origin: a case report with immunohistochemical study

An oncocytic mucoepidermoid carcinoma arising from the minor salivary gland origin is extremely rare. We report on a 44-year-old man with a high-grade oncocytic mucoepidermoid carcinoma originating in the minor salivary gland of the posterior mandible. All tumor cells showed the expected pattern of immunoreactivity, with positive results for the antimitochondrial antibody and p63, and negative results for the androgenic receptor antibody. Microscopically, the tumor was considered to be a high-grade carcinoma in the grading systems of the Armed Forces Institute of Pathology and Brandwein. The patient underwent a partial mandibulectomy, and the lesion was reconstructed with a right fibula osteofasciocutaneous flap under general anesthesia. The patient is currently under long-term follow-up.

Clinical application of modified deep inferior epigastric perforator flap

Objective To improve the techniques of harvesting the deep inferior epigastric perforator (DIEP) flap and broaden the clinical application of the flap. Methods A modified DIEP flap (or DIEP osteofasciocutaneous flap with iliac or rib) involving perforating vessels of the bilateral deep inferior epigastric vasculature with a muscle cuff was used to cover large defects of the extremities. There were 5 cases of defects of the forearm and 6 cases with defects of the hand and wrist. The areas of the defects were 10.0 cm × 5.0 cm to 45.0 cm × 20.0 cm. All flap transfers were done in the emergent setting. Results 10 of the 11 flaps survived completely while one flap survived with partial necrosis. Follow up ranged from 3 to 61 months. The flaps healed well. Function of the hand was satisfactory. There was no abdominal wall hernia at the donor sites. Conclusion The modified DIEP flap involving bilateral pedicles is the procedure of option for reconstruction of large defects. Key words: Surgical flaps; Wounds and injuries; Reconstructive surgical procedures

A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: Experience in 37 patients

Herein, we present our latest protocol of following three operative stages for complete phalloplasty, applied in 37 female-to-male transsexuals: first, mastectomy, ovariohysterectomy, urethral lengthening, vaginectomy, colpocleisis, and neourethra prelamination; second, neophallus creation with free sensate osteofasciocutaneous fibula (n = 31) or radial forearm (n = 6) flap; and third, urethral connection, neoscrotum formation, and testicle prosthesis implantation. Occasionally, wound healing disturbance and slight asymmetry of the breasts was observed, as well as colpocleisis revision needed. Partial flap necrosis took place in 6 patients, while 12 presented urethral stricture and 6 a fistula. Despite inferior neophallus sensibility, patients whose neophallus was created using fibula flap experienced better sexual intercourse. However, overall patients' satisfaction was superior. The applied protocol demonstrates the effectiveness of such a multistage and interdisciplinary approach for female-to-male transsexuals, offering an essential improvement of their quality of life, concerning their successful integration into the reassigned gender position in the society.

A Novel Use of the Beanbag for Intraoperative Positioning during Dissection of the Fibular Flap

Sir: The fibular flap, first described by Taylor et al. in 1975,1 has tremendous utility for a variety of reconstructive needs, including head and neck, upper and lower extremity, and genital reconstruction. Traditionally, the procedure has required an assistant to hold the leg and maintain it in the appropriate position for dissection of the flap. Because an individual whose sole job it is to hold the leg may be unavailable (particularly with the 80-hour work week), we describe a novel use of the beanbag device for intraoperative positioning, which obviates the need for an assistant to hold the leg and renders the dissection of the flap a one-person undertaking. The positioning is described as follows (Figs. 1 and 2):Fig. 1.: The patient’s leg is positioned on the beanbag, demonstrating the support of the ankle and thigh that enables easy access to the lateral leg.Fig. 2.: After draping, the leg is in position without any support other than the beanbag under the drapes. The patient is placed supine on the operating table. The beanbag is placed under the leg to be used for the flap with the split end placed proximally. The distal end of the beanbag is positioned under the patient’s heel with a piece of foam placed on top of the bean bag to protect against prolonged pressure. The distal end of the beanbag is folded up to maintain the ankle in 90 degrees of flexion. Proximally, the bag is folded to provide support for the posterior thigh, again with foam placed under the thigh to protect the skin against prolonged pressure. Suction is applied to the beanbag, after which the leg should be held in the proper position to allow for unassisted dissection of the fibular flap. This method of positioning (though there is something of a learning curve) may be applied safely to patients undergoing this procedure, with modifications made for patient morphotype and surgeon comfort. In addition, as described, it leaves the thigh free for applying a sterile tourniquet and obtaining a skin graft should one be needed either at the recipient site of the flap or at the donor site in cases where an osteofasciocutaneous flap is needed. For dissections of the fibular flap, the commonly available beanbag may be positioned under the leg such that it obviates the need for an assistant to hold the leg and renders the dissection of the flap a single-handed undertaking. Mark T. Villa, M.D. Joyce Aycock Amir Dorafshar, M.D. Lawrence J. Gottlieb, M.D. Section of Plastic and Reconstructive Surgery University of Chicago Chicago, Ill. DISCLOSURE None of the authors has a financial interest in the content of this article.

Reverse Posterior Interosseous Flap in Childhood

Restoration of complex hand defects in children is still problematic because of the limited choices of treatment. The reverse posterior interosseous flap is a versatile flap, with successful results shown in adults. The purpose of this study was to highlight the utility and versatility of the flap and to simplify the technique for ease of harvest in the pediatric age group. Complex hand defects were repaired using this flap in 10 children. Ages of the patients averaged 9.1 years. Fasciocutaneous and osteofasciocutaneous flaps were used in 7 and 3 children, respectively. All flaps survived completely. The average time of bone union was 3 months. This flap can be used with safety and versatility in coverage of children's upper limb. The diameter of the vessels is not a handicap in the flap dissection. Harvest of the flap is easy and rapid, and the operation time is short, as in adult patients.

Versatility of the Lateral Arm Free Flap in Various Anatomic Defect Reconstructions

The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.

Two-stage reconstruction of a massive gun-shot wound of the midface with a free radial forearm flap and a parietal osteofasciocutaneous flap

Treatment of midface gunshot injuries and their reconstruction remains one of the difficult problems of reconstructive surgery. Several flaps have been described for the reconstruction of total lip and nasal defects. We present a case of a gunshot wound to the midface in which a two-stage procedure was performed. In the first stage, a free radial forearm flap was successfully transferred for the reconstruction of the total nose. In the second stage, total upper lip reconstruction was achieved using a parietal osteofasciocutaneous flap pedicled to the parieto-temporal fascia based on the superficialis temporal artery. At a mean follow-up period of 18 months, near-normal functional and cosmetic results were obtained.

Osteofasciocutaneous flap based on the dorsal ulnar artery. A new option for reconstruction of composite hand defects

Since the initial description of the dorsal ulnar artery fasciocutaneous flap by Becker and Gilbert in 1988 many modifications have been introduced to allow more versatility to the flap. The authors describe the dissection technique of an osteofasciocutaneous flap based on the dorsal ulnar artery and present a clinical case where this flap has been used to reconstruct a bone defect of the fifth metacarpal.Up to one third of the outer cortex of a long bone is supplied by the periosteal arterioles. This permits the inclusion of a small amount of ulnar cortical bone in the dorsal ulnar flap to reconstruct compound defects of the hand.The essential precaution is not to disrupt the continuity formed by the posterior border of the ulna, the periosteum, bony attachments of the flexor carpi ulnaris and extensor carpi ulnaris muscles, fascia and the skin. This flap allows the transposition of optimal soft tissue coverage to the hand with vascularised bone preserving the main arteries to the hand.

Long-term fate of the bony component in neophallus construction with free osteofasciocutaneous forearm or fibula flap in 18 female-to-male transsexuals.

Female-to-male transsexuals have been operated on in the authors' department since 1975. Between 1981 and 1995, 46 patients underwent neophallus construction with a free osteofasciocutaneous forearm or fibula flap. The bony part of these flaps is embedded in tissue with excellent blood circulation, has no contact with the skeleton, and is free of mechanical stress. To evaluate the long-term fate of the bony component of these flaps, the authors examined 18 of the 46 patients (39.1 percent) who had received a neophallus by means of one of these methods (12 with forearm and six with fibula flap) and who were willing to participate in the updating of the results of the previous two decades; this represented a follow-up of 5 to 112 months postoperatively (average, 27.4 months). The following investigations were undertaken: clinical and radiologic examination, bone scintigraphy, magnetic resonance imaging, and histologic examination of the neophallus bony component. In all patients, the clinical examination showed no significant variations in the shape and rigidity of the neophallus bone. The radiologic examination showed a compact bone structure, and the magnetic resonance imaging proved the vitality of the neophallus in all patients, with no significant changes over time. Bone scintigraphy did not prove to be useful in determining the long-term fate of the neophallic bony component. Histologically, subperiosteal neoformation of fibrous bone was shown, whereas the lamellar cortical bone was predominantly avital. The results of this study reveal the vitality of the bony component in neophallus construction with free osteofasciocutaneous flaps. Even 112 months after the procedure, it provided sufficient stiffness for sexual intercourse. This continuing adequate rigidity of the bony component, in addition to the well-known advantages of the free osteofasciocutaneous flap, is further evidence of its usefulness in neophallus construction.

Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction.

Female-to-male transsexuals have been treated by the authors since the 1970's, using different operative methods. Since 1981, these patients have received neophallus construction with free sensate osteofasciocutaneous forearm flaps and, since 1993, with free sensate osteofasciocutaneous fibula flaps. In order to evaluate the usefulness of these flaps, the authors performed, in 24 patients (12 with forearm and 12 with fibula flaps), the following examinations: clinical and radiologic evaluations of the neophallus and its donor site, as well as patient questionnaires. In all patients, subjective findings and clinical examinations showed no significant variations in neophallus size and form. Patients with fibula flaps had better sexual intercourse, although their neophallus sensibility was minor, when compared to the forearm flap patients. Donor-site morbidity was moderate in both groups. On radiologic examination, robust, calcified bone structure, and no fracture of the neophallus bone and its donor site, as well as no instability of the ankle joint (in the fibula flap patients) were found. These findings further support the use of these free sensate osteofasciocutaneous flaps for neophallus construction. In the authors' opinion, it is the patient who must decide which method should be used for neophallus construction.

The free medial scapular osteofasciocutaneous flap for head and neck reconstruction

A modification of the scapular free flap has been developed using the medial ridge of the scapula. This variation preserves the advantages of the previously described lateral scapular flap, providing abundant hairless skin and soft tissue, adequate bone for mandibular reconstruction, and a primarily closed asymptomatic and inconspicuous donor site. It adds the advantage of a longer vascular pedicle and enhanced versatility because it is independent of the parascapular artery. Furthermore, it eliminates the disadvantage of rotator cuff muscle weakness associated with the lateral scapular flap. Multiple skin paddles subtended by the common circumflex cutaneous scapular artery and the interconnecting dorsal thoracic fascia were used in 4 of the 9 patients in our series. The ability of this somewhat thinner bone to incorporate biointegrable implants is unproven.

Thumb reconstruction by the posterior interosseous osteocutaneous flap

An island osteo-fasciocutaneous flap, based on the posterior interosseous vessels, is described for thumb reconstruction. The artery supplies the fascial plexus of the posterior forearm as well as the superficial and deep extensor muscles. A vascularised bone segment of the upper third of the ulna can be harvested, including a cuff of the extensor pollicis longus muscle. The flap was used successfully in two clinical cases.