Pedicled Myocutaneous Flap Research Articles

Late necrosis of a pedicled rectus abdominis myocutaneous flap

Flap neovascularization is an important plastic surgery phenomenon, which allows the pedicle to achieve an alternative blood supply basis for pedicled flap autonomization. Numerous historical flaps have been described which provided the clinical evidence of its occurrence Neovascularization is assumed to happen between flap and recipient bed and numerous experimental and clinical studies have documented this phenomenon. There are, however, some literature reports of late flap failure due to lack of neovascularization. We present a case report that reinforces such findings, with a late rectus abdominis myocutaneous flap failure due to documented axial venous obstruction 4 months after inset.

A rare case of fungal osteomyelitis of the ribs requiring surgical reconstruction

I report a rare case of fungal osteomyelitis of ribs in a 23 year old male who presented with multiple discharging sinuses on the right side of the chest. The patient did not respond to medical management with fluconazole and ultimately surgical treatment in the form of excision of affected ribs and reconstruction with a pedicled myocutaneous latissimus dorsi flap had to be done. Fungal osteomyelitis although uncommon must always be thought of when treating a case of osteomyelitis of the ribs.

Case series: pedicled vertical rectus myocutaneous flaps for cover of breast and perineal defects—a 2-year review in our centre

Colorectal carcinoma is the most common cancer afflicting both Singaporean men and women; whereas, breast carcinoma is the most frequent female-specific cancer according to the report published by the Singapore Cancer Registry on cancer trends from 2003 to 2007. As such, breast and perineal defects requiring soft tissue cover is a challenging occurrence after initial tumour surgery by the breast and colorectal surgeons, especially for fungating breast tumours and very low colorectal carcinomas, respectively. In Tan Tock Seng Hospital prior to 2007, many of these patients may have had their wounds skin-grafted or allowed to heal by secondary intention. This often involved prolonged hospital stay, difficult wound care and significant morbidity as well as a negative impact on the quality of life for these patients. Pedicled vertical rectus myocutaneous (VRAM) flaps were then introduced for cover of these defects as an effective method of reducing these negative aspects of patient care. This case series aims to review the efficacy of the VRAM flap in achieving this within a 2-year period. Over this period, the VRAM flap has shown to decrease length of hospital stay, reduction of the duration to commencement of adjuvant therapy, and also decrease in the difficulty of wound care as well as the complication rate.

Use of the Pedicled Tensor Fascia Lata Myocutaneous Flap in the Salvage of Upper Extremity High-Voltage Electrical Injuries

High-voltage electrical burns of the upper extremity are often limb threatening. Typically, emergency fasciotomies are followed by serial debridements until only viable tissue remains. After debridement, flap coverage is required to preserve viable but exposed tendons, nerves, vessels, bones, and joints and to salvage these seriously injured upper extremities. Flap options are generally limited to large pedicle flaps or free tissue transfer. Despite the array of flaps available, surgical options become limited when upper extremity injuries are extensive or the initial flap fails. The most commonly used pedicle flap, the groin flap, may not provide adequate soft tissue coverage in these cases. In addition, free tissue transfer can be difficult due, in part, to the uncertainty in determining the complete zone of injury and whether the flap recipient vessels are suitable for the transfer.An ideal flap for coverage would be relatively thin and pliable; have a constant, reliable pedicle; and be large enough to cover wounds of significant size. Few surgeons have experience with the pedicled tensor fascia lata (TFL) flap for upper extremity coverage. The authors demonstrate its use in the salvage of extensive upper extremity injuries on three limbs in two patients. We believe that this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required. PATIENT 1: A 23-year-old man sustained severe electrical burns to his right upper extremity. After serial debridements, a pedicled TFL myocutaneous flap was used to provide soft tissue coverage of this extensive injury. The flap was delayed at 2 weeks and inset at 3 weeks. There was complete survival of the flap, leading to salvage of the extremity. PATIENT 2: A 27-year-old man sustained bilateral upper extremity electrical burns. Initial free tissue transfers to both arms were unsuccessful. The patient subsequently underwent simultaneous bilateral pedicled TFL myocutaneous flaps. Both flaps were delayed at 2 weeks and divided at 3 weeks. There was complete flap survival bilaterally, leading to salvage of both upper extremities.Limb salvage in severe upper extremity electrical injuries is difficult even in the best circumstances. Dependable flap coverage is mandatory to prevent infection and avoid the need for early or late amputation. The pedicled TFL flap in our series of patients has served to be a dependable flap in these severe upper extremity injuries and should be added to the surgical armamentarium of those caring for these difficult surgical problems.

Infratemporal fossa reconstruction following total auriculectomy: An alternative flap option

Reconstruction following oncologic resection in the head and neck is complex due to large surgical defects left after removal of skin, subcutaneous, and skeletal structures. It is essential to adequately fill the defect as well as provide an acceptable tissue match in terms of tone, texture, thickness and contour. A 55-year-old male presented with an advanced melanoma in the right pre-tragal area. Surgical resection was performed including a total auriculectomy. A tunnelled right supraclavicular artery island (SAI) flap was used to repair the surgical defect. A Doppler probe ensured adequate circulation within the flap, especially in the distal tip. Reconstruction using the SAI flap after oncologic ear resection reduced operating room time, required less technical expertise, and provided excellent tissue match compared to more traditional methods of surgical defect reconstruction including free flaps, local flaps, and pedicled myocutaneous flaps. Successful use of the SAI flap in this case further expands the flaps versatility. We recommend that the reconstructive surgeon consider the SAI flap when presented with challenging infratemporal fossa and lateral skull base cases.

Myocutaneous Pedicle Flap Combined with a Free Skin Graft for Upper Eyelid Reconstruction

Purpose: Repair of large upper eyelid defects can be accomplished by both 1-stage and 2-stage techniques some of which are complicated and time consuming. I here present a simple 1-stage technique for upper eyelid reconstruction.Methods: The records and the peroperative and postoperative photographs of two patients who underwent reconstruction of large full-thickness upper eyelid defects after tumor removal were reviewed. The posterior lamella was reconstructed with lip mucosa in one patient and with a hard palate graft in the other. The anterior lamella was reconstructed with a myocutaneous pedicle flap from the remaining upper eyelid with its base medially or laterally. The resulting skin defect under the eyebrow was covered by a free skin graft from the contra lateral upper eyelid.Results: In both patients the flap healed without necrosis or any other complications. In the case where the posterior lamella was reconstructed with lip mucosa the cosmetic appearance was excellent, and the cornea remained unaffected throughout the postoperative period. In the case where a hard palate graft was used the cosmetic appearance was good, but the corneal epithelium developed an edema and a soft contact lens was needed. The visual acuity was 20/20 and 20/40, respectively, 3 months postoperatively.Conclusion: Large upper eyelid defects can successfully be reconstructed by a pedicle flap from the infra brow area, which subsequently is covered by a free skin graft.

One-Stage Posttraumatic Bladder Reconstruction and Soft-Tissue Coverage of the Lower Abdomen or Perineum

Mutilating injury on pelvis may be complicated by urinary bladder ruptures and soft-tissue avulsion of the lower abdominal wall or perineum. With retraction of the avulsed abdominal wall or perineum, as well as bladder tissue loss secondary to trauma or infection, direct closure the injured bladder often leads to excessive tension, resulting in ischemia and eventual failure of repair. The authors successfully managed 4 patients with such injuries using the pedicled vastus lateralis myocutaneous flap. No major complications occurred and intact bladders were confirmed with cystograms. Three (75%) of them were able to void normally within 1 year. It is concluded that the pedicled vastus lateralis myocutaneous flap is an ideal option for posttraumatic bladder reconstruction and soft-tissue coverage of the lower abdomen or perineum; whereas the undersurface of the muscle serves as a substitute for the missing bladder wall, the remaining part of the muscle, as well as the subcutaneous fat, provide sufficient bulk for dead space obliteration.

The Pedicled Transverse Rectus Abdominis Myocutaneous Flap: Indications, Techniques, and Outcomes

Breast reconstruction has evolved significantly during its short, 40-year history. What began as limited reconstruction through the use of local skin flaps has now become an entire array of procedures including novel autologous flaps and new techniques in implant/expander use. Throughout this evolution, the primary goal of reconstruction has always remained the same: to recreate the most natural breast mound possible. In the early 1980s, autologous tissue was at the forefront of breast reconstruction, and the pedicled transverse rectus abdominis myocutaneous (TRAM) flap quickly became the reconstructive method of choice for tissuebased reconstruction. Despite the advent of microsurgery, advances in perforator-based flap design, and increasing procedural complexity, the pedicled TRAM flap is still one of the most common methods of autologous reconstruction performed today. In properly selected patients, the pedicled TRAM flap can provide a natural appearing breast mound with limited morbidity and superior patient satisfaction.

Poland Syndrome

Poland syndrome is characterized by hypoplasia or absence of the breast or nipple, hypoplastia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of costal cartilages or ribs 2, 3, and 4 or 3, 4, and 5. The chest wall defect is often associated with a lung hernia. Clinical manifestations are extremely variable and rarely are all the features recognized in 1 individual. Fortunately it is invariably unilateral, allowing for an easier reconstruction. Single-stage reconstruction of the chest wall combined with simultaneous augmentation mammoplasty and transfer of an island pedicle myocutaneous flap of latissimus dorsi muscle are major improvements over previous multiple-stage procedures that provide less satisfactory cosmetic results in management of patients with Poland syndrome. Poland syndrome is characterized by hypoplasia or absence of the breast or nipple, hypoplastia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, and absence of costal cartilages or ribs 2, 3, and 4 or 3, 4, and 5. The chest wall defect is often associated with a lung hernia. Clinical manifestations are extremely variable and rarely are all the features recognized in 1 individual. Fortunately it is invariably unilateral, allowing for an easier reconstruction. Single-stage reconstruction of the chest wall combined with simultaneous augmentation mammoplasty and transfer of an island pedicle myocutaneous flap of latissimus dorsi muscle are major improvements over previous multiple-stage procedures that provide less satisfactory cosmetic results in management of patients with Poland syndrome.

Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease – A 12 year experience

We have reviewed all the cases of flap reconstruction following resection of a gynaecological malignancy at the Royal Marsden Hospital over 12 years from 1993 until 2005. Forty-six patients were identified who required 53 flaps. The predominant site of the primary tumour was vulva, accounting for 83% of the cases, with cervix, ovary, vagina and endometrium making up the remainder. Squamous cell carcinoma was the most common histological type, accounting for 71% of cases, with adenocarcinoma, Paget disease, leiomyosarcoma, melanoma and basosquamous carcinoma making up the remainder. Most patients (73%) had recurrent disease at the time of reconstruction and most patients (80%) had been treated with radiotherapy either before and/or after surgery. Local flaps accounted for 49% of the reconstructions performed, with 16 rhomboid flaps, five lotus petal flaps and five advancement flaps. Of the pedicled myocutaneous flaps, there were 21 rectus abdominis flaps, four gracilis flaps and one tensor fascia lata flap. There was one free flap. The complication rate was 53%, with wound breakdown predominating. The 5 year survival was 14%, with 67% of patients surviving 1 year. This group of patients often have advanced disease and a limited life span. The complications associated with performing a major reconstructive procedure need to be balanced against the potential wound problems associated with leaving these advanced tumours untreated surgically.

Oropharyngeal Reconstruction for Advanced Cancer

Objective To assess perioperative morbidity, functional outcomes, and survival following microvascular and regional flap reconstruction of the oropharynx after advanced oncologic resection. Methods 65 patients underwent oropharyngeal reconstruction for late stage primary (35.4%), second primary (10.8%), or recurrent (53.8%) oropharyngeal and oral cavity squamous cell carcinoma at a tertiary cancer center between 1997 and 2007. 50 (76.9%) males and 15 (23.1%) females with a median age of 59.2 years (range 28.6 to 76.1 years) were reconstructed with rectus myocutaneous free flaps (30.8%), anterolateral thigh free flaps (27.7%), radial forearm free flaps (20%), pectoralis myocutaneous pedicled flaps (15.4%), and fibula osseocutaneous free flaps (6.2%). Results The median follow-up time following oropharyngeal reconstruction was 36.3 months (range 1.3 to 144.2 months). There were no complete flap failures and only 1 partial flap failure. 32 (49.2%) patients experienced postoperative complications including 11 wound infections/dehiscences, 7 fistulas, 7 donor site complications, and 11 postoperative pneumonias. Mean intensive care unit nights and total days hospitalized were 2.8 and 9.6, respectively. Of 56 patients undergoing a tracheostomy, 48 (73.8%) were decannulated a median of 13 days (range 5 to 426 days) following surgery. 42 (64.7%) remained at least partially feeding tube-dependent, but 41 (63.1%) attained at least 80% oral speech intelligibility. 3-and 5-year overall survivals following reconstruction were 49.1% and 37.3%, respectively. Conclusions Selected patients who undergo reconstruction for extensive oropharyngeal defects following surgery for advanced cancer can attain long-term survival. While most patients achieve decannulation and functional speech, almost 2/3rds remain feeding tube-dependent.

Seizure-Like Activity and Prolonged Central Nervous System Side Effects After Intravenous Sedation

105:2440, 2000 11. Nisanci M, Turegun M, Er E, et al: Reconstruction of the middle and lower face with three simultaneous free flaps: Combined use of bilateral fibular flaps for maxillomandibular reconstruction. Ann Plast Surg 51:301, 2003 12. Zhang C, Zhang Z: Reconstruction of mandible with fibular flap and dental implant distractor: A new approach. Chin Med J 115:1877, 2002 13. Barton FE Jr, Spicer TE, Byrd HS: Head and neck reconstruction with the latissimus dorsi myocutaneous flap: Anatomic observations and a report of 60 cases. Plast Reconstr Surg 71:199, 1983 14. Hayden RE, Kirby SD, Deschler DG: Technical modifications of the latissimus dorsi pedicled flap to increase versatility and viability. Laryngoscope 110:352, 2000 15. Shigemitsu K, Naomoto Y, Haisa M, et al: A case of thyroid cancer involving the trachea: Treatment by partial tracheal resection and repair with a latissimus dorsi musculocutaneous flap. Jpn J Clin Oncol 30:235, 2000 16. Wu LY, Halim AS, Sain AH: Laminated pedicled latissimus dorsi myocutaneous flap for single-stage reconstruction of a composite anterior neck and tracheal defect. J Otolaryngol 34:69, 2005 17. Zbar RI, Funk GF, McCulloch TM, et al: Pectoralis major myofascial flap: A valuable tool in contemporary head and neck reconstruction. Head Neck 19:412, 1997 18. Liu R, Gullane P, Brown D, et al: Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: A retrospective review of indications and results in 244 consecutive cases at Toronto General Hospital. J Otolaryngol 30:34, 2001 19. Vartanian JG, Carvalho AL, Carvalho SM, et al: Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. Head Neck 26:1018, 2004 20. Wei FC, Chen HC, Chuang CC, et al: Fibular osteoseptocutaneous flap: Anatomic study and clinical application. Plast Reconstr Surg 78:191, 1986 21. Jones NF, Monstrey S, Gambier BA: Reliability of the fibular osteocutaneous flap for mandibular reconstruction: Anatomical and surgical confirmation. Plast Reconstr Surg 97:707, 1996 22. Ferri J, Piot B, Ruhin B, et al: Advantages and limitations of the fibula free flap in mandibular reconstruction. J Oral Maxillofac Surg 55:440, 1997 23. Chang YM, Santamaria E, Wei FC, et al: Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg 102:680, 1998

Wide en bloc extra-articular excision of the elbow for sarcoma with complex reconstruction

We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular en bloc excision. All had a pedicled myocutaneous latissimus dorsi rotation flap for soft-tissue cover and reconstruction of the triceps. Wide negative surgical margins were obtained in all five patients. No local wound complications or infections were seen. There were no local recurrences at a mean follow-up of 60 months (20 to 105). The functional results were excellent in four patients and good in one. Longer term follow-up is necessary to confirm the durability of the elbow reconstruction.

Giant phyllodes tumour of the breast

Phyllodes tumours are fibroepithelial lesions and count for 0.4% of breast tumours. Telling the difference between phyllodes tumours and fibroadenomas is sometimes difficult but of importance because wide resection is the mainstay of treatment for phyllodes tumours. We present a female patient, 55 years old with a giant phyllodes tumour (38 x 31 x 23 cm) of the breast. The breast reconstruction was done using a pedicled transverse rectus abdominis myocutaneous (TRAM) flap.

Oncoplastic Techniques Allow Breast-Conserving Treatment in Centrally Located Breast Cancers

Operative techniques for oncoplastic reconstruction combine oncologic extirpation of the tumor with immediate reconstruction of breast shape and symmetry. These techniques are increasingly being used for breast-conservation therapy of centrally located breast carcinomas. The goal of this study was to provide an overview of the various surgical options for oncoplastic treatment of central breast carcinomas. From September of 1998 through January of 2005, 31 women (median age, 61 years) were treated for 32 centrally located breast carcinomas by breast-conserving therapy. There were 27 invasive tumors (median size, 13.5 mm), and five patients had ductal carcinoma in situ (median size, 39.6 mm). One patient received chemotherapy preoperatively for tumor reduction. A total of 11 patients had a positive lymph-node status, and 21 patients had a free sentinel node. The various surgical techniques included a central lumpectomy with direct closure (n = 6), central lumpectomy with inverted T-closure (n = 2), a circumareolar, Benelli-type closure (n = 2), a modified Grisotti-flap closure (n = 9), and a mammaplasty-type closure with an inferiorly based pedicle (n = 13). In 27 patients, a contralateral procedure was undertaken (bilateral carcinoma or symmetrizing mammaplasty). Two patients required a secondary mastectomy because of ductal carcinoma in situ with positive surgical margins in the final histology. They were treated by immediate reconstruction with an implant and a pedicled myocutaneous latissimus dorsi flap, respectively. In a median follow-up of 33.8 months, there were no local recurrences in the remaining breast or axilla, but two patients developed distant metastases. Breast carcinoma of small size that occurs in a central location can be safely treated oncologically by breast conservation therapy. The use of various oncoplastic techniques yields very satisfactory aesthetic results.

Outcome of Pectoralis Major Myomammary Flap for Post‐mastectomy Breast Reconstruction: Extended Experience

In the past decade there has been an enormously expanding interest among rural Egyptian patients, relatives, and treating oncologists in post-mastectomy reconstruction as an integral part of patient care. We introduced our technique of pectoralis major myomammary cutaneous flap for single-stage reconstruction of large breasts, nipple, and areola. The new technique is based on performing modified radical mastectomy in the classic manner, and then using a pectoralis major myocutaneous pedicled flap from the other side in breast reconstruction. The flap is based on the pectoral branch of the thoracoacromial artery, and a sector from the medial part of the healthy breast with its overlying skin and a part of the nipple-areola complex is included with the flap. This technique was used in our center in one 118 patients, with very promising results. Major flap necrosis was not observed in patients treated with this technique, and there were no local recurrences observed during the follow-up period. Excellent cosmetic results were achieved in 49 of the 118 (41.5%) cases. We recommend this new technique as a single-stage, simple solution for reconstruction of large breasts after mastectomy.

A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores

We describe island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transfer through a subcutaneous tunnel, the flap is transferred directly through the upper thigh to the ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treated between May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateral thigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty in transferring the flap to reach the ischial defect in any patient. The length of the pedicle ranged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which was located at the distal third of the thigh. We conclude this flap can be added to the repertoire for the treatment of recurrent, difficult ischial pressure sores.

The Use of the Occipital Scalp Rotational Flap for Reconstruction after Lateral Temporal Bone Resection.

Introduction: Oncologic surgery of the lateral skull base can result in complex defects exposing middle ear and mastoid contents as well as nearby dura and major neurovascular structures. Inadequate coverage can result in wound breakdown and severe complications such as osteomyelitis and meningitis, with the potential to delay adjuvant therapy. Previously described techniques such as pedicled myocutaneous flaps and free tissue transfers provide adequate soft tissue coverage, but come with significant donor site morbidity and may not be appropriate for individuals with poor baseline health status. This article describes the use of the occipital scalp rotational flap, based on the occipital artery, as an alternative reconstructive technique for lateral temporal bone defects in patients with significant medical comorbidities.

Lower Island Trapezius Flap Reconstruction of Lateral Skull Base Defects

Introduction: Reconstruction of soft tissue defects after temporal bone resection can vary from simple overclosure of the external auditory canal to complex flap closure. Large defects typically require reconstruction with locoregional pedicled myocutaneous or distant free myocutanaeous flaps. While microvascular free tissue transfer is an excellent option from a functional and cosmetic standpoint, patients often have significant comorbidities that increase perioperative risk during extended procedures. The pedicled lower island trapezius flap provides a reliable, cosmetically acceptable coverage in this patient population.

Giant rodent ulcer of the elbow requiring defect coverage by preconditioned latissimus dorsi pedicled myocutaneous flap following excision

Giant rodent ulcer of the elbow requiring defect coverage by preconditioned latissimus dorsi pedicled myocutaneous flap following excision