Single Free Flap Research Articles

Microsurgical Reconstruction of the Nasal Lining

Reconstruction of isolated nasal lining defects can be extraordinarily daunting. This report defines the uniqueness of the surgical challenges inherent to reconstruction of the nasal lining and overviews the authors' approach to management. A retrospective review was performed of 11 consecutive patients presenting for reconstruction of the nasal lining alone during the period from October of 1996 through March of 2003. There were four men and seven women with an average age of 49.2 years. The average follow-up was 4.2 years. Five patients required reconstruction of the total nasal lining (floor, columella, vestibule), and the remaining reconstructions involved subtotal components. Coincidental necrosis of the nasal lining during total/subtotal nasal reconstruction was the most common cause. A single microsurgical free flap was used in eight patients (six radial forearm flaps). Three patients required two free flaps. There were no flap failures. Thirteen of 14 free flaps healed primarily. Dehiscence of the flap/nasal septal juncture occurred in one cocaine-injured nose. Ten of 11 patients demonstrated patent, functional nasal airways postoperatively. Reconstruction of the nasal lining, alone, is a very challenging endeavor that demands careful surgical planning and precise technical execution. The use of microsurgical transfer for these defects allows considerable latitude for duplication of the missing complex three-dimensional anatomy and avoids sullying the adjacent facial soft tissues. Because of the adverse condition of the local tissues, the majority of these cases could not have been brought to a successful conclusion without the use of free tissue transfer, and this is particularly relevant in the cocaine-injured nose.

La revascularisation digitale ectopique temporaire

We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and the dorsum of the hand. Two of the amputated digits, that were considered to be replantable, were implanted on the dorsum of the left foot. The hand defect was covered with a pedicle groin flap. After six weeks, the two ectopically implanted fingers were transferred to their proper anatomical site. Several reconstructive procedures were performed later, in order to lengthen the first ray of the injured hand, and to deepen the first web space. Satisfactory functional results were recorded after eighteen months of follow-up. The second patient concerns a 45-year-old male patient, who had a gun shot accident of his right hand. The injury resulted in a composite tissue loss of the hand with complete amputation of his four long fingers. All fingers were implanted on the left forearm, while the hand defect was reconstructed using an osteocutaneous free flap of the iliac crest. Six weeks after the initial procedure, the ectopically implanted digits were transferred — as a single free flap — to the hand. We described with details the local conditions of the injured hands in both cases, and discuss the reasons we decided to perform this sophisticated method in order to preserve the viability and function of those totally amputated fingers. The recipient sites were selected in a distance from the injured area, always considering the availability and size of appropriate recipient vessels, and the safety of the surgical procedure. We agree that the whole concept of this procedure is very demanding, and requires several microsurgical operations with high risk of complications. However, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage multiple amputated digits, by preserving the anatomy and restoring the function of severely injured hands.

Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.

Mimicking lip features in free-flap reconstruction of lip defects

This paper introduces a technique of lip reconstruction using free flaps in which recognisable landmarks are mimicked by strategic placement of flap junctions. The technique was applied in 15 patients undergoing reconstruction of combined cheek and lip defects using single (n= 9) or double (n= 6) free flaps. Attention to flap design and strategic placement of flap junctions successfully created the vermilion-cutaneous junction, oral commissure and labiomental groove. The presence of these distinguishing features improved the appearance of the reconstructed lip.

Simultaneous Two Free Flaps for Head and Neck Reconstruction

The use of the free tissue transfers Improves the functional and cosmetic results of the head and neck reconstruction. Because a large composite defect or bilateral defects can not be reconstructed with a single free flap in one-staged operation, simultaneous double free flaps are used to achieve the reconstructive goals. Iii 1999, five patients of head and neck defects were reconstructed immediately with two free flaps. Four patients of primary buccal cancer and one recurrent tongue cancer were all squamous cell carcinoma The combined free anterolateral thigh flap and free fibular osteocutaneous flap were used for the large through-and- through oromandibular defects after the buccal cancei resection as well as for the oropharyngeal-mandibular defect after the ablation of the recurrent tongue cancer One patient of synchronous bilateral buccal cancers underwent the reconstruction with bilateral free anterolateral thigh flaps. Nine of the 10 flaps survived. One anterolateral thigh flap in the patient of bilateral buccal cancers suffered from venous thrombosis, which had been explored but failed. The radial forearm flap was salvaged and survived well later, Minor complications including one wound infection and one skin graft loss of donor site were noted and healed after debridement and skin graft. The combined anterolateral thigh flap and fibular flap have played an important role in the reconstruction of the oromandibular composite defects.

Free flap coverage for knee salvage.

Soft-tissue reconstruction using free flaps was reviewed in 11 consecutive knee wounds complicated by joint exposure or adjacent osteomyelitis and unavailability of adequate local flaps. Ten free muscle flaps and one fasciocutaneous flap were used successfully. Eight limbs presented with wide exposure of the knee joint, including 4 patients with wound infection involving the joint. Three other patients suffered osteomyelitis immediately adjacent to the knee. All knees were successfully salvaged with a single free flap operation, except for one knee that required a second free flap after flap necrosis. Follow-up in nine flaps ranged from 7 weeks to 19 months (mean, 12 months). For patients without preexisting conditions affecting the knee, free flap coverage provided excellent return of knee function. The choice of recipient vessels was determined mainly by the region of the knee requiring coverage. The recipient arteries utilized included the distal superficial femoral artery, anterior tibial artery, popliteal artery, and small arteries, which included the saphenous artery and descending branch of the lateral circumflex femoral artery. The use of small arteries and venae comitantes as recipient vessels increased the effective reach of the free flaps and eliminated the need for vein grafts.

The problem of bilateral foot reconstruction after severe burns

Reconstruction of bilateral, distal lower limb defects presents a major reconstructive challenge. In the patient with a major burn injury, however, the problem of bilateral foot reconstruction is compounded by both the limited availability of normal unscarred donor sites and by the limited availability of recipient vessels. A case is presented where bilateral dorsum of foot defects in a patient with a 50% surface area burn were successfully reconstructed using a single parascapular free flap. The problems presented by this case are discussed.

The Stacked Transverse Rectus Abdominis Musculocutaneous Flap Revisited in Breast Reconstruction

Since its original description, the transverse rectus abdominis musculocutaneous (TRAM) flap has been used primarily as a single pedicle, bipedicle, or free flap procedure for breast reconstruction. A fourth option, rarely used in the past, involves using two single pedicle flaps to reconstruct only one breast by using the flaps in a "stacked" or overlapping configuration. Until now, this stacked technique has been used primarily for radical mastectomy defects. Stacked TRAM flaps are useful for four additional situations beyond the radical defect. In patients with meager abdominal donor tissues, stacked TRAM flaps may be the best way to provide the required central tissue volume in the small surface area of the reconstructed breast. In patients with a long thorax and good breast projection, overlapping or partially stacking the two flaps can best solve the problems of surface area and projection simultaneously. For patients with large projecting breasts without significant ptosis, the stacking option may best duplicate the original breast shape. Finally, for women who want their reconstruction larger than the original, the second flap can serve as an autologous augmentation. Ten patients with stacked TRAM flaps are presented, covering all of these indications. All patients achieved excellent functional and aesthetic outcomes. The stacked TRAM flap option is an effective, safe, and reliable method of achieving excellent results in difficult situations.

The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy‐mandibulectomy defects

The loss of motor and sensory function of the tongue following ablative surgery has a devastating effect on oral function. At the present time, there is no way to restore lost tongue musculature following partial glossectomy. The use of sensate cutaneous flaps has been shown to restore sensory feedback to reconstructed areas of the oral cavity. No single composite flap supplies a sensate soft-tissue component together with an osseous component of sufficient bone stock for functional mastication. In this article, the combination of the radial forearm free flap with the iliac crest osteocutaneous or osteomyocutaneous free flap is reported. The radial forearm free flap was used to resurface the resected portion of the tongue to provide maximum mobility and sensation. The lingual nerve was the recipient nerve for anastomosis to the antebrachial cutaneous nerves in all but one case. The iliac bone was used to reconstruct the mandible, with the iliac skin paddle or the internal oblique muscle used to reconstruct the neoridge. This combination of flaps was used in 10 patients. There was one flap failure due to vascular kinking from "piggybacking" the iliac crest to the distal end of the radial forearm flap. As a result, the use of two separate sets of recipient vessels is now advocated. Although a single composite free flap offers an excellent form of oromandibular reconstruction in most cases, it has been shown that oral function deteriorates when large areas of anesthesia are present in the oral cavity. We believe that this combination of two free flaps offers an opportunity for superior function in select patients with significant glossectomy and/or large mucosal defects.