Pre-expanded Flap Research Articles

Utilization of two methods assisting perforator identification for brachial artery perforator propeller flap application

The brachial artery perforator propeller (BAPP) flap has the advantages of both local and perforator propeller flaps, and it remains relatively underused partly because of the anatomical variations of perforators in the medial arm. We aimed to review our preliminary experience using two different methods for perforator localization of a BAPP flap, including the application of a refined coordinate system (the ABC system) in the medial arm and indocyanine green angiography (ICGA). We evaluated the advantages and disadvantages of these methods and selected the optimal examination mode depending on detailed clinical settings. The perforator was identified for each patient using the ABC system and/or ICGA, depending on the clinical setting. Twenty-two patients underwent soft-tissue reconstructions with 22 BAPP flaps, and perforator localization for all the flaps was performed before surgery using the ABC system. Thirty-one perforators were localized before surgery and marked accordingly, all of which were visualized during surgery, except two, which were not found during the surgery. ICGA was used in six pre-expanded flaps at both stages of surgeries. Twenty-seven perforators were detected before surgery, and all of them were identified during surgery; the previously localized perforators found using the ABC system in the six patients were all reidentified using ICGA. Both the ABC system and ICGA were found to be useful for preoperative perforator localization in BAPP flap transfers. Each method has its unique downsides; however, they can supplement each other to facilitate safe and effective flap elevation. Therefore, selection of the optimal method based on the clinical settings is recommended.

Facial Defects With Infraorbital and Zygomatic Area Reconstruction Using an Expanded Flap Based on the Orbicularis Oculi Muscle: A Long-Term Follow-up.

Reconstruction of facial soft-tissue defects may pose a dilemma for plastic surgeons, as the flaps must be reliable to obtain a natural appearance while minimizing donor site morbidities. This clinical study describes a reconstructive method for infraorbital and zygomatic defects using a pre-expanded rotation flap based on the orbicularis oculi muscle (OOM). The surgeries were subdivided into 2 stages. In the first stage of the operation, a 100 to 200mL expander was placed underneath the temporal area through a hairline incision. In the second stage, after adequate inflation of the expander, the pre-expanded rotation flap based on the OOM of the lower eyelid was raised from lateral to medial to cover the facial defects. In this single-center study from February 2010 to February 2017, 16 patients underwent facial defect reconstruction using the pre-expanded flap based on the OOM. All of the defects were located at the infraorbital and zygomatic regions, and their sizes ranged from 3.0 4.0 to 7.0 14.0cm. The causes of these defects included postburn scars (37.5%), melanocytic nevus (50%), and hemangiomas (12.5%). In all cases, good coverage was provided for the defects that were in the medial cheek or lower eyelids. There were no flap losses of any kind. There were no major complications, and all minor incidences were treated by minimal procedures. The patients were followed up after surgery, with the follow up ranging from 6 months to 108 months. The follow-up data included postoperative consultations, the defect size, the need for further procedures and the degree of satisfaction. The pre-expanded rotation flaps in the lateral facial area based on the OOM can ideally and safely be applied for facial defect reconstruction owing to their reliable blood supply and excellent texture match.

Alternative strategy to treat keloid and hypertrophic scar surgically

Background: Hypertrophic scars and keloids are fibro-proliferative disorders that may arise after any deep cutaneous injury caused by trauma, burns, surgery, etc. Hypertrophic scars and keloids are cosmetically problematic, and in combination with functional problems such as contractures and subjective symptoms including pruritus, these significantly affect patients’ quality of life. We describe pre-expanded flap for surgical treatment of keloid or hypertrophic scar. The aim of our study is to show the promising results of pre-expanded flaps in keloid and hypertrophic scar.Method: Retrospective analysis of the data of patients with keloid or hypertrophic scar over chest having treatment in a tertiary centre between September 2019 to December 2021.Result: Out of 12 patients 9 patients healed with ordinary scar and 3 developed partial scar site hypertrophies. 10 patients believed that the esthetic results were good while 2 patients felt just satisfied with the results.Conclusion: Pre-expanded skin flap is an effective and safe surgical method for reconstruction after keloid/hypertrophic scar resection. It offers another useful and successful surgical choice for large keloid treatment. By our study it is concluded that pre-expanded flaps provide excellent result in treatment of keloid/hypertrophic scar in child and adolescent age group.

Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction

Pre-expanded pedicled flaps possess a more flexible transfer pattern and higher tissue utilization than random flaps, but the perfusion is fully dependent on the chosen axial vessels. A precise mapping of the vessels would assist the surgical design and increase the likelihood of success. The application of Infrared thermography (IRT) has been previously reported for perforator location. The aim of this study is to report the use of IRT in mapping the course and distribution of axial vessels in the pre-expanded flap to guide the designing and harvesting. Patients who underwent head and neck reconstruction using pre-expanded flaps were included. After tissue expansion, IRT was used to mark the vessel distribution along the expanded flap. The results were compared with color Doppler ultrasound (CDU) and/or computed tomographic angiography (CTA). The flap was designed and raised based on the pre-operative marking by IRT. The mark was verified intraoperatively. A total of 26 expanded flaps were performed, including 20 pedicled flaps and 6 free flaps. IRT succeeded to map the vessel distribution in all cases. All marked results were verified by CDU, CTA, and intraoperative dissection (26/26, 100%). IRT showed more comprehensive distribution of vascular branches than CDU or CTA, and could be utilized intraoperatively to identify the arteries. IRT provides accurate and comprehensive mapping of the axial vessel distribution in the pre-expanded flaps, assisting with flap design and harvest. It is easy to use and non-invasive as an important tool pre- or intraoperatively to ensure the safe elevation.

Postburn Neck Reconstruction With Preexpanded Upper Back Perforator Flaps: Free-Style Design and An Update of Treatment Strategies.

For extensive postburn neck deformities, the preexpanded flaps in the upper back region were used and gained a uniform skin appearance and esthetic contours. Free-style perforator-based free-tissue transfer that represents the most recent advance in reconstructive surgery may provide more versatility of these flaps. We retrospectively reviewed 31 patients treated at our institution for postburn neck contracture from March 2010 to May 2016. Various upper back flaps were designed according to the dominant perforators and the shape of the defect after fully releasing the neck contracture. Thirty-one patients received neck reconstructions with the versatile applications of the preexpanded upper back perforator flaps. Tip necrosis was observed in one case, and the others survived completely. The donor sites were all primarily closed. No incision dehiscence was observed. The free-style design has significantly increased the potential and versatility of the upper back flaps in reconstruction of severe neck scar contracture.

Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps

The pedicled paraumbilical flap is a reliable tissue transfer for hand and forearm reconstruction. However, its size, pedicle length and/or thickness limit its application in resurfacing of extensive defects of the upper limb. To conquer those limitations, this flap was pre-expanded for 10–24 weeks prior to transfer in 25 patients and used as a pedicle flap to cover upper extremity defects. Extensive defects of upper limb were reconstructed by the pre-expanded paraumbilical flaps. The flaps ranged in size from 10cm×8cm to 30cm×14cm. The donor sites were closed directly in all cases. All flaps survived, but two had partial flap necrosis due to venous congestion or infection. With pre-transfer expansion, a large, well-perfused abdominal pedicle flap can be raised and transferred based on the paraumbilical perforators. This pre-expanded flap might be useful in the patients who have the extensive upper limb defects and sufficient time to allow tissue expansion.

Preexpanded Pedicle Medial Arm Flap: An Alternative Method of Massive Facial Defect Reconstruction

This article aims to describe the application of the preexpanded pedicle medial arm flap in facial reconstruction and the authors' experiences solving the problems that appeared during the whole reconstruction procedure. A tissue expander was placed in the medial arm region and serially inflated for approximately 3months. Then, the preexpanded flap was prepared as a tube flap and transferred to the face. The pedicle was divided 3weeks later, and the flap was used to resurface the facial defect. Since 2005, the preexpanded pedicle medial arm flap has been used in face reconstruction for 9 patients ranging in age from 9 to 31years. There were no perioperative complications or flap loss. The donor sites all were closed directly. In the authors' experience, a flap as large as 10×20cm could be raised and safely transferred without flap necrosis. The results indicate that the application of the preexpanded pedicle medial arm flap can be one option for reconstruction of massive facial defects.

Resurfacing of Lower Face Scars With a Pre-expanded Flap From the Neck

Postburn scars of the lower face often cause serious deformities and dysfunction. Conventional methods including skin grafts and free flaps always lead to unsatisfactory outcomes. In this article, we describe a series of 8 patients with scars of the lower face treated with an expanded neck flap. Tissue expanders were implanted into the neck and inflated for 3 to 5 months. The expanded flap was then advanced cephalically to resurface the scars of the lower face. The mean follow-up period was 13 months. All 8 flaps survived well except 2 patients developed slight necrosis at the distal edge. The flaps were well matched to the surrounding skin with respect to color, texture, and thickness. The cervicomental angle appears normal. The range of mouth opening increased. In patients with lower face scars and a sufficient unharmed neck flap, use of a pre-expanded neck flap was suitable.

Preexpanded Vertical Trapezius Musculocutaneous Flap for Reconstruction of a Severe Neck Contracture After Burn Injury

Preexpanded flaps are a method to replace a larger postburn contracture area. We describe the use of a preexpanded vertical trapezius musculocutaneous flap for reconstruction of a severe mentosternal contracture in a 10-year-old male patient with second- to third-degree burn wounds. A 500 cm(3) rectangular-shaped tissue expander was inserted under the trapezius muscle via a lateral incision in first stage. Two months later, after serial expansion of the expander, the neck scar was excised. The preexpanded flap (size = 27 x 9 cm) was harvested and rotated into the defect. The donor site could be closed primarily. The flap totally survived. The hospital stay was 7 days. After 6 months follow-up, a significant improved range of motion with good esthetic outcome was achieved. The use of a preexpanded trapezius flap can provide thin, large, and pliable tissue for reconstruction of a severe mentosternal scar contracture with excellent functional outcomes.

Postburn Head and Neck Reconstruction in Children With the Fasciocutaneous Supraclavicular Artery Island Flap

Postburn deformities or scar contractures in the head and neck region of children represent a challenge with unique problems compared with the rest of the body. Fourteen children suffered from neck contractures following burns, and 4 children required reconstruction following panfacial burn deformities. The experience of late-phase secondary burn reconstruction in the head and neck region of 18 pediatric patients (age range, 9-17 years) with 22 fasciocutaneous supraclavicular island flaps, including 5 preexpanded flaps, is reported. Clinical follow-up was performed between 10 and 29 months postoperatively. High functional and esthetic requirements could be fulfilled in all patients. Flap complications occurred in 9%, with low donor site morbidity (9%). The fasciocutaneous supraclavicular artery island flap is reliable and safe for immediate or late resurfacing of facial defects and to release cervical contractures. Customized flap design with tissue expansion without the need for microsurgery allows extended indications and optimized skin utilization, while good texture and color match is generally difficult to achieve in the head and neck region of severely burned children.