Pedicled Flap Reconstruction Research Articles

A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy

Muscle flaps are often used in the prevention and treatment of pharyngocutaneous fistula following total salvage laryngectomy in the setting of chemo-radiated neck for laryngeal carcinomas. We report our experience with the gracilis free muscle flap compared to the pedicled pectoralis major for the prophylaxis of fistula formation. Forty-nine patients with radio-recurrent laryngeal carcinoma over ten years who underwent salvage laryngectomy and either immediate free gracilis (22 patients) or pedicled pectoralis major muscle flap (27 patients) reconstruction were reviewed. There were 12 complications in pectoralis major flap group and eight in gracilis flap group. Most of these occurred early in the post-operative period. These were related to poor wound healing with the pectoralis major flap reconstructions. Fistulation rates were similar in the two groups (Pectoralis major: 6/27, gracilis: 5/22). In our experience, the gracilis free muscle flap is a good reconstructive option in the prevention of pharyngocutaneous fistula formation following salvage laryngectomies. It is at least equivalent to a pectoralis muscle flap in the prevention of fistulae, but we prefer the gracilis for many reasons, including ease of harvest and preservation of the pectoralis major flap for future reconstructions.

Salvage Surgery for Locally Recurrent Pharyngeal Squamous Cell Carcinoma after Definitive Radiotherapy or Chemoradiotherapy

Objectives: A local recurrence of pharyngeal carcinoma (PC) after definitive radiotherapy (RT) or chemoradiotherapy (CRT) is correlated to a poor prognosis. Therefore, the objective of the current study was to analyze the efficacy of salvage surgery for patients with locally recurrent PC after RT or CRT. Methods: We retrospectively reviewed the clinical charts of patients with PC treated between 2001 and 2011 at the University of Tokyo Hospital and enrolled 222 patients, including 106 with oropharyngeal carcinoma (OPC) and hypopharyngeal carcinoma (HPC) who received definitive RT or CRT. Local recurrence developed in 63 patients (26 OPC and 37 HPC), of whom 44 (18 OPC and 26 HPC) underwent salvage surgery. Initial treatments were radiotherapy, radiotherapy with induction chemotherapy, and concurrent chemoradiotherapy in 13, 11, and 20 patients, respectively. The median radiation dose was 70 Gy. Results: Resection of the local recurrence was combined with free or pedicle flap reconstruction in 38 patients and was performed without reconstruction in 8. Twenty-eight patients simultaneously underwent laryngectomy and resection. The median overall survival (OS) and median disease-free survival (DFS) after salvage surgery was 16 and 10 months, respectively. The DFS of HPC patients (median, 15 months; 2-year OS rate, 43%) was significantly longer than that of OPC patients (median, 7 months; 2-year OS rate, 12%; P = 0.01). Conclusion: The prognosis of locally recurrent PC remains poor despite the technical feasibility of salvage surgery, with the prognosis for HPC being significantly better than that for OPC.

The Pectoralis Major Myocutaneous Pedicled Flap

The pectoralis major myocutaneous pedicled flap is a commonly used flap for reconstructive head and neck surgery, but associated with high complication rates. The purpose of this study was to evaluate a refined surgical technique that can reduce flap complications and compare the proposed technique with the conventional surgical technique. A retrospective analysis was performed on 35 consecutive patients affected by malignant tumors of the head and neck, who underwent a pectoralis major myocutaneous pedicled flap reconstruction in our institution, between 2004 and 2009. Patients were divided into 2 groups: group 1 treated by the classic surgical technique, and group 2 treated by the refined surgical technique. Our main outcome measures were the success of the reconstructions and the complications. The overall complication rate in patients who underwent our revisited surgical technique was significantly lower than that in patients who underwent conventional surgical technique (P = 0.001). The results of our study reinforce the value of the pectoralis major flap in the reconstruction of head and neck defects and shows how little refinement of the surgical technique can significantly reduce the onset of complications.

Pedicled Flap Reconstruction of the Lateral Skull Base

Background: Similar to all head and neck defects, the advent and increased enthusiasm for microvascular free flap reconstruction has changed the reconstruction of the lateral skull base. As surgical techniques and expertise continue to improve, lateral skull base reconstruction continues to evolve. Microvascular techniques, however, require increased operative time, lengthened hospital stay, and adequate donor and recipient vasculature. As our population ages and comorbidities increase, there is a need for better expertise in simpler yet equally effective reconstruction of the lateral skull base.

Perforator-Based Myocutaneous Pedicle Flap for Reconstruction of a Large Defect of the Posterior Ear

Perforator-Based Myocutaneous Pedicle Flap for Reconstruction of a Large Defect of the Posterior Ear

Anatomical Study of Supraclavicular Perforator Artery and its Clinical Application as Sensate Supraclavicular Artery Propeller Flap in the Reconstruction of Post Burns Scar Contracture Neck

Post burns scar contracture of neck has severe functional and aesthetic considerations. The mortality and morbidity from burns has reduced considerably for the last six decades does not truly reflect whether the victim can lead a normal life, as the head and neck region is an aesthetically demanding area to resurface because of high visibility. The use of supraclavicular perforator artery flap is a well described and established technique. In our study after understanding intricacy of the supraclavicular artery perforator anatomy as it is used as sensate pedicled flap for reconstruction of post burns contracture of neck, we have established that sensation from middle supraclavicular nerve represents an extremely versatile and useful option for resurfacing post burns scar contracture of neck. Anatomical study of 10 fresh cadavers in which 20 transverse cervical vascular system traced up to the thyrocervical trunk and various findings noted and applied clinically on 16 patients, we conclude supraclavicular artery propeller flap provides good aesthetic and functional results.

Perforator-Based Myocutaneous Pedicle Flap for Reconstruction of a Large Defect of the Posterior Ear

Perforator-Based Myocutaneous Pedicle Flap for Reconstruction of a Large Defect of the Posterior Ear

Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: Is there an increased risk of postoperative cerebrospinal fluid leak?

The development of expanded endoscopic endonasal approaches (EEAs) has allowed resection of cranial-base lesions beyond the sella. One major criticism is an increased risk of postoperative cerebrospinal fluid (CSF) leakage because of the larger skull base defect. We evaluated our experience with vascularized pedicled nasoseptal flap (PNSF) reconstruction and compared the postoperative CSF leak rates between patients undergoing endoscopic transsphenoidal (transsellar) approaches versus expanded EEA (transplanum-transtuberculum, transcribriform, transclival). Retrospective analysis at a tertiary care medical center. A retrospective review of a prospective database was performed on patients who underwent PNSF reconstruction for intraoperative high-flow CSF leaks after EEA between December 2008 and August 2011. Demographic data, repair materials, surgical approach, and incidence of postoperative CSF leaks were collected. Thirty-seven transsellar defects (group I) were repaired with a PNSF, and 32 expanded EEA defects (19 transplanum-transtuberculum, 10 transcribriform, three transclival) (group II) were repaired with a PNSF. No postoperative CSF leaks occurred in group I. One delayed postoperative CSF leak was encountered in group II leading to a 3.1% leak rate in that group. The incidence of postoperative CSF leakage was not significantly different between the two groups (P > .05). Our overall success rate in this series using a PNSF was 98.6%. Based on our data, there is no significant increased risk of postoperative CSF leak between transsellar and expanded EEA defects when a PNSF is used. The potential risk of postoperative CSF leaks associated with larger defects created through expanded EEA can be minimized by multilayered closure with a PNSF and meticulous surgical technique.

Skull base reconstruction: an updated approach.

The authors' goal was to develop an updated and comprehensive algorithm for skull base reconstruction based on data from the 10-year period following their initial report. Reconstructive outcomes were analyzed from 250 patients undergoing skull base reconstruction from 2000 to 2009. Thirty-nine local or regional pedicled flap reconstructions and 211 free flap reconstructions were performed. Free flaps were usually selected over pedicled flaps for patients with a history of prior surgery, irradiation, or chemotherapy (p = 0.003, p < 0.001, and p = 0.04, respectively). Reconstructions were performed for 36 region I defects, 39 region II defects, 124 region III defects, and 51 defects involving more than one region. Complications occurred in 29.6 percent of patients. There were no significant differences in the overall complication rates between pedicled and free flap reconstructions (p = 0.70). The recipient-site complication rate decreased from 31 percent in the authors' prior report to 18.4 percent. A facial nerve repair was performed in 30 patients. By 12 months, 75 percent of patients had signs of reinnervation. Recovery was not significantly less likely in patients with preoperative weakness, postoperative irradiation, or age 60 years or older (p = 1.00, p = 1.00, and p = 0.11, respectively). Based on the largest series of skull base reconstructions to date, the authors recommend pedicled flaps for limited defects because of minimal donor-site morbidity and shorter operative times and hospital stays. For extensive defects and cases involving prior surgery, irradiation, or chemotherapy, free flaps are preferred. Facial nerve repair should be attempted whenever feasible, even in the setting of preoperative weakness, anticipated postoperative irradiation, or advanced age. Therapeutic, III.

Surgical reduction of hypertrophy of the labia minora

Objective To evaluate postoperative satisfaction, including improvements in quality of life, among patients who had undergone labia minora reduction. Methods In a retrospective descriptive study, women who had undergone labiaplasty for hypertrophy of the labia minora between January 2005 and December 2009 were contacted by telephone. The women were asked to answer a satisfaction survey evaluating the esthetic and functional results of the surgery. Results Among 21 patients who had labiaplasty using either a pedicle flap reconstruction (n = 18, 86%) or a nymphectomy technique (n = 3, 14%), 18 (86%) were contacted successfully and took part in the survey. All of the contacted patients were satisfied with the overall outcome of the surgery, with a mean rating of 8.7 out of 10 at a median follow-up of 17 months (interquartile range 6–25 months). From an esthetic point of view, all 18 patients reported an improvement in comfort with respect to any form of original functional discomfort. Concerning sexuality, 95% of the sexually active patients had originally described some form of physical or psychologic discomfort, and all of them reported total disappearance of this symptomatology. Conclusion Labiaplasty provided overall satisfaction in terms of improvements in patient quality of life and sexuality.

HEAD AND NECK RECONSTRUCTION

Background: The pectoralis major myocutaneous pedicle flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Despite the use of free flaps, this flap is still considered the mainstay of head and neck reconstruction. The flap is usually associated with a high incidence of complications compared with the free fasciocutaneous flaps yet its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction. It is type V muscle flap with the dominant vascular supply from the pectoral branch of thoracoacromial artery. Objective: To share our experience of pectoralis major myocutaneous pedicle flap in selected cases of head and neck reconstruction. The indications, type of reconstruction and complications of the flap utilization were evaluated. Patients and Methods: Between March 2005 and August 2010, a 37 head and neck reconstructive procedures using the PMMPF were carried out. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the postoperative complications were all documented. Results: Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity (25 patients); oropharynx/ hypopharynx, (7 patients); and neck or face (5 patients). Of the 37 PMMPF reconstructions, 30 flaps were carried out as primary reconstructive procedures, whereas 7 flaps were "salvage" procedures. Twentyfive patients (67.59%) had complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co- morbidities, and in oral cavity reconstructions. Conclusions: The pectoralis major myocutaneous pedicled flap is still an acceptable method of head and neck reconstruction. It is fast, reliable, provides safe repair and is indicated especially where bulk is needed.

Cent cinquante-sept lambeaux pédiculés utilisés dans la reconstruction des membres inférieurs : étude rétrospective sur dix ans

The aim of this study was to review and present our experience with pedicled flap reconstruction of lower limb defects with particular reference to choice of flap, complications and pre-existing health disorders. A retrospective review of lower limb reconstructions by pedicled flaps was carried out by the plastic and reconstructive surgery unit at Marseille's hospitals from January 1st, 1997 to December 31st, 2007. This study evaluated patients satisfaction and complications rate. During 10 years, 152 patients had 157 local flap reconstructions of lower limb defects. General patients satisfaction was 94% with 80% good or very good results and 20% of medium results. There were 16 immediate complications with three total necrosis, four partial necrosis, six hematoma, and three infections. There were nine late complications including wound dehiscence and graft instability. There were 11 functional sequels and 40 aesthetic sequels secondary to flaps. The current study presented our experience with locoregional flap reconstruction of lower limb defects. Lower limb reconstruction used a lot of locoregional flaps which had their own advantages and disadvantages. Their indication depended on the fiability and quality of the donor site.

Endoscopic Endonasal Approach for Clipping of Ruptured and Unruptured Paraclinoid Cerebral Aneurysms: Case Report

We present a case in which clip ligation of both a ruptured and an unruptured paraclinoidal segment aneurysm is performed with only the endoscopic endonasal approach in 1 setting. A 42-year-old woman, a Hunt and Hess grade 2 patient, presented with aneurysmal subarachnoid hemorrhage. An arteriogram revealed an irregular 10-mm right paraclinoidal aneurysm projecting posteromedially and a 5-mm wide-necked right ophthalmic artery aneurysm projecting superomedially. The patient was taken to the operating room where clipping of both aneurysms was performed through the use of an endonasal endoscopic approach with a pedicled nasoseptal flap reconstruction. Such an approach allowed excellent visualization without drilling of the clinoid process or mobilization of the optic nerve and potential control of the proximal and distal internal carotid artery. An intraoperative arteriogram showed obliteration of both aneurysms with patency of the surrounding vasculature. The patient did well postoperatively and was subsequently discharged home without any neurological deficits. An endoscopic endonasal approach was immediately safe and effective for the clipping of both paraclinoidal aneurysms. Although there were benefits achieved from this particular unconventional approach, surgical clipping via traditional craniotomy and endovascular coiling are the established methods of aneurysm treatment and should always be primarily considered. More cases will determine the efficacy and safety of this approach, which should be attempted only by very experienced teams trained in both cerebrovascular and endonasal neurosurgery.

Pelvi-perineal flap reconstruction: normal imaging appearances and post-operative complications on cross-sectional imaging

Radical pelvic surgery is often required in patients with advanced, persistent or recurrent gynaecological and anorectal malignancies. In the last decade, pedicled flap reconstructions have been increasingly used for pelvic floor and neovaginal reconstruction, introducing well-vascularised non-irradiated tissue into the wound cavity and hence reducing wound complications. The aim of this pictorial review is to describe the normal post-operative cross-sectional imaging appearances of the most commonly used pelvi-perineal flap reconstructions and to illustrate the complications that may arise at the flap donor and recipient sites.

Immediate latissimus dorsi pedicle flap reconstruction following the removal of an eight kilogram giant phyllodes tumour of the breast: a case report

IntroductionPhyllodes tumors account for less than 1% of breast tumors in women, and giant phyllodes tumors are those that are larger than 10 cm in diameter. Removal of such large tumors places a huge burden on the surgeon to reconstruct a breast that is aesthetically acceptable by the patient. We report what may be the largest giant phyllodes tumor and, most likely, the first latissimus dorsi flap used to cover such a large defect caused by the resection.Case presentationWe report the case of a 36-year-old Malaysian woman who presented with a three-year history of gradually increasing swelling of the left breast, with skin changes. Examination revealed a huge, globular, lobulated mass measuring 400 mm by 350 mm. The patient had a mastectomy with an immediate latissimus dorsi pedicled myocutaneous flap reconstruction. The breast weighed 8.27 kg, and ex vivo, the tumor measured 280 mm by 250 mm by 180 mm. Histopathologic analysis confirmed the diagnosis as a giant phyllodes tumor. At 12-month follow-up, the patient reports no complications and is satisfied with the aesthetic outcome.ConclusionGiant phyllodes tumors are very rare tumors that can reach up to 40 cm in diameter. Reconstruction of such a defect is a great challenge, and we report what we believe is the first latissimus dorsi flap to cover successfully a defect of approximately 400 mm by 350 mm.

Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage

The superior epigastric artery (SEA), a terminal branch of the internal mammary artery, is analogous to the deep inferior epigastric artery (DIEA) in that it supplies a large number of perforators that are clustered together. This allows tissue from the superior abdomen to be used as a pedicled flap for reconstruction. A reliable and well-perfused pedicled flap can be based on this cluster of perforators, hence the term 'pedicle cluster perforator flap'. We present a case of a patient with recurrent angiosarcoma, who required total anterior chest wall reconstruction. This was achieved using bilateral pedicled SEA perforator flaps for complete coverage. To our knowledge, this is the first documented case of bilateral pedicled perforator flap reconstruction for complete chest wall reconstruction.

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Comparison of Morbidity, Functional Outcome, and Satisfaction following Bilateral TRAM versus Bilateral DIEP Flap Breast Reconstruction

The potential for donor-site morbidity associated with bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has led to the popularization of deep inferior epigastric artery perforator (DIEP) flap reconstruction. This study compares postoperative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction. One hundred five women with bilateral pedicled TRAM flaps were compared with 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Postoperative follow-up data were obtained through Short Form-36, Functional Assessment of Cancer Therapy-Breast, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys. The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data were otherwise similar. Abdominal hernias occurred in three TRAM patients (2.9 percent) and in no DIEP patients, whereas abdominal bulges occurred in three TRAM patients (2.9 percent) and four DIEP patients (6.9 percent); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Postoperative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the Medical Outcome Study Short Form-36 subjective energy category (p = 0.01) and mean Functional Assessment of Cancer Therapy-Breast score (p = 0.01). This study suggests no significant differences in donor-site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction.

Objective improvement in upper limb lymphoedema following ipsilaterall latissimus dorsi pedicled flap breast reconstruction – a case series and review of literature

We present a series of three patients whose upper limb lymphoedema (following total oncologic mastectomy and level III axillary clearance) resolved significantly after ipsilateral pedicled latissimus dorsi (LD) flap breast reconstruction. A retrospective review of the medical records of patients who had undergone oncologic mastectomy and level III axillary clearance with subsequent LD pedicled flap reconstruction was carried out. Individuals who had undergone review and treatment by the lymphoedema service were identified and patients with incomplete pre- or post-operative records were excluded. A minimum follow-up period of 2 years of conservative therapy, as well as 2 years post-operatively was undertaken. The rate of improvement of lymphoedema following conservative therapy was, on average, 0.095 mL/week and reached a plateau at 2-year follow-up. Following latissimus dorsi flap breast reconstruction, the rate of improvement in lymphoedema increased in all three cases, with an average improvement of 2.55 mL/week and remained sustained in the follow-up period. Pedicled myocutaneous flap reconstruction of the ipsilateral breast proved to be a useful treatment for upper limb lymphoedema in our series. This adds an important dimension to the assessment and treatment of patients with upper limb oedema resulting from mastectomy and axillary clearance.

Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects

With the advent of microsurgery the pedicled flap is considered by many to be an outdated surgical option. To explore the relationship between flap survival and pre-morbid risk factors, conduct a comparative analysis of flap and systemic morbidities and complete a cosmesis and functionality assessment for oral and oropharyngeal reconstruction patients. 114 patients, over a 13-year period, who had a one-stage reconstructive procedure employing the pectoralis major myocutaneous flap (PMMF) or radial forearm-free flap (RFFF). Variables, including age, smoking and radiation exposure were not statistically significant predictors of flap survival probability. Atelectasis was a significant post-op finding of RFFF patients. Flap dehiscence of >50% was a significant morbidity of PMMF. No statistical difference in cosmetic deformity, diet and socialisation was noted. Pectoralis major myocutaneous flap remains an enduring and safe flap; however, the RFFF has markedly improved speech performance over the PMMF.