Flap Harvest Technique Research Articles

Extended Transverse-oblique Back Flap for Myelomeningocele Defect Closure: A Case Series of 10 Patients.

Background:Myelomeningocele is the most common phenotype of congenital neural tube defects. Various reconstructive techniques have been described for soft tissue coverage following myelomeningocele repair, one of which is the use of dorsal intercostal artery perforator based flaps. The aim of this study was to describe our experience with the use of a transverse-oblique back flap that can be reliably extended to the anterior axillary line for closure of myelomeningocele defect. This pedicle transposition flap is based on thoracic or lumbar paraspinal perforators that originate from the dorsal intercostal arteries.Methods:This is a retrospective two center case-series where all patients who underwent myelomeningocele defect closure with extended transverse-oblique flap over three years period were included. Patients’ clinical data, surgical variables, and outcomes were documented and analyzed using descriptive measures. Flap harvest technique is also delineated in the present study.Result:Ten newborns (7 baby girls and 3 baby boys) who underwent a surgical closure of the myelomeningocele defect with an extended transverse-oblique back flap during the first week of life were included in the analysis. The defect was most commonly located in the lumbosacral area (50%) followed by the lumbar area (40%), with an overall average surface area of 22 ± 8.32 cm2. Common encountered complications include venous congestion to the distal part of the flap and minor wound dehiscence of less than 0.5 cm, all were managed conservatively. There were no incidences of flap loss or full necrosis. Primary closure of the donor site was possible in all cases.Conclusions:In the current series, the extended transverse-oblique back flap provided a safe and reliable coverage for myelomeningocele defect. Such a flap does not jeopardize other regional fasciocutanous or musclocutaneous flaps that might be needed for soft tissue coverage later in life for this population. It also obviates the placement of skin suture line over the repaired neural tube, thus yielding a durable coverage with no major complications or functional disability.

The Revolving Door Flap: Revisiting an Elegant but Forgotten Flap for Ear Defect Reconstruction.

Background The revolving door flap, although well described in the literature, is not widely used in general plastic surgery practice. The flap has been used for anterior auricular and conchal defects and is considered elegant for its unique flap design and peculiarity of flap harvest. However, due to its use for a very specific purpose and unique flap harvest technique that may be difficult to grasp, the flap is not very popular in reconstructive practice. Objectives This study aims to evaluate the understanding and learning curve of the revolving door flap, assess surgical outcome, and reemphasize its utility and elegance in reconstruction of ear defects. Methodology This is a case series of nine surgeries performed between January 2014 and 2018. Three cases were performed by the senior author and six cases by two junior authors. Patients were observed for complications and aesthetic outcomes. Results The mean dimension of the flaps was 27.22 mm × 22.78 mm. The mean operative time was 56.56 minutes (standard deviation 22.50, standard error of the mean 7.5). Flap congestion was noted in three cases postoperatively which resolved completely by the second week. Major “pinning” of the ear was noted in four cases. Conclusion Though infrequently performed, the revolving door flap has an easy learning curve once the proper harvest technique and flap movement has been grasped. The flap harvest is convenient, safe, and yields predictable results. Not only is total or partial flap loss extremely rare, the flap is sensate, color match is good, auricular contour is maintained, and the donor site can be closed primarily and remains well hidden.

Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome

As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome. Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated. At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated. Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

From Open to Robotic-assisted Latissimus Dorsi Muscle Flap Harvest.

Background:The latissimus dorsi muscle is the largest muscle in the body. The classic open flap harvest technique of this muscle results in a long posterolateral thoracic vertical oblique incision that can leave an unappealing scar. The minimally invasive robotic approach has the potential to reduce scar length and to overcome technical limitations of endoscopic techniques.Methods:Six robotically assisted latissimus dorsi muscle flaps were harvested by a single surgeon. One was used as reversed turnover pedicled flap based on lumbar perforators for lumbosacral bone coverage, another flap was transposed for a Poland syndrome anterior axillary line reconstruction, and the remaining 4 were dissected as free flaps for upper and lower limb reconstruction. All 6 procedures used a short 5-cm axillary crease incision along the posterior axillary fold and two 8-mm port incisions for robotic access.Results:The first robotic flap harvest was converted to the classic open technique due to malposition of the 2 lower port incisions too close to the latissimus dorsi anterior border. The 5 other flaps were successfully transferred without flap or donor site complications. The average flap dissection time was 110 minutes; latter surgeries took less time than the early surgeries as the surgeon became more familiar with the robotic system and due to the use of a newer system.Conclusion:Robotic-assisted latissimus dorsi muscle flap harvest is a safe, reproducible, and effective tool that offers precise dissection control and that leaves a minimal thoracic scar.

Vascularized lymph node transfer with submental free flap

Limb lymphoedema is common in patients who have undergone inguinal or axillary lymph node dissection. Lymphoedema seriously impacts the patient's quality of life by inducing adipogenesis, fibrosis and repeated episodes of lymphangitis and cellulitis. Following failure of compression therapies, several curative or symptomatic surgical options have been proposed over recent decades, such as liposuction or lymphovenous anastomosis.Vascularized lymph node transfer techniques have recently been described, with promising results. Vascularized lymph node transfer with submental free flap appears to be the most reliable of these technique, associated with the lowest morbidity. The flap harvesting technique presents several specific differences compared to conventional submental free flap. A good knowledge of neck anatomy is essential and multimodal and multidisciplinary management is often required.In the light of a case report, we describe the basic submental free flap technique for vascularized lymph node transfer for the treatment of lower limb lymphoedema. This technique may be used by head and neck surgeons performing flap harvest, as well as plastic surgeon surgeons or gynaecologists ensuring long-term management of these patients.

A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction.

The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist. A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science. The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic. This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.

Clinical effects of scapular region flaps pedicled with circumflex scapular artery in the reconstruction of axillary burn scar contractures

Objective: To explore the clinical effects of scapular region flaps pedicled with circumflex scapular artery in the reconstruction of axillary burn scar contractures. Methods: From December 2008 to December 2018, 21 patients with axillary burn scar contractures were admitted to our department. There were 12 male patients and 9 female patients, aged 2-48 years, with an average of 17.4 years. According to the characteristics of axillary scar contractures, the patients were divided into type Ⅰ of 5 patients, type Ⅱ of 2 patients, type Ⅲ of 5 patients, and type Ⅳ of 9 patients. The preoperative abduction ranges of shoulder joint were 20-150°, with an average of 68.33°. The wound areas after resection and release of scar contractures ranged from 12 cm×4 cm to 33 cm×11 cm, with an average of 18.13 cm×5.41 cm, and the wounds were repaired with scapular region flaps pedicled with circumflex scapular artery in the areas of 14 cm×5 cm-35 cm×14 cm, with an average of 20.19 cm×7.71 cm. The donor sites of 5 patients were expanded prior to flap repair operation, and the other 16 patients were repaired by direct transfer of flaps. The donor sites were closed directly. The type, number, and transfer way of scapular region flaps were calculated, and the improvement of abduction angle of shoulder joint and condition of the flaps were observed during follow-up after operation. Results: There were 5 ascending scapular flaps, 13 scapular flaps, and 3 parascapular flaps. The flaps were transferred through open wounds in 18 cases, subcutaneous tunnel in 1 case, and trilateral foramia in the remaining 2 cases. All the flaps survived after operation. During follow-up of 3 months to 5 years, with an average of 19.4 months, the abduction angles of shoulder joints were 90-180°, with an average of 137.62°, which showed that the abduction function of shoulder joint improved obviously. The texture of flap was soft, and the color of the flap was close to the surrounding skin. The patients and/or their family members were satisfied with the operation results. Conclusions: The scapular region flap pedicled with circumflex scapular artery has a lot of advantages, including a long vascular pedicle, simple technique for flap harvest, a hidden donor site, and flexible and diverse transfer mode of flap. It is an effective option for clinical reconstruction of severe axillary burn scar contracture.

Detailed Vascular Anatomy and Flap Harvest Technique of the Serratus Anterior/Rib Composite Flap.

The hemodynamics of blood flowing from the anterior serratus to the ribs has yet to be analyzed in detail in serratus anterior/rib composite flaps. The authors focused on new blood circulation, whereby the slip arteries branched from the serratus anterior branch, off the thoracodorsal artery and the intercostal arteries, directly through the interconnecting vessels (axial route). The authors analyzed in detail the hemodynamics of serratus anterior/rib composite flaps and developed a new method for flap elevation. The axial route was identified and analyzed by performing macroscopic autopsies of formalin perfusion-fixed cadavers involving three-dimensional computed tomographic angiography and vascular corrosion casting. Flap elevation was performed with new blood circulation, which included the axial route, and blood flow was evaluated using indocyanine green fluorescence angiography. The interconnecting vessels penetrated the intercostal muscles at a mean distance of 4.5 cm from the anterior margin of the attachment sites of the serratus anterior muscle to the ribs and at a mean distance of 7.4 cm from the costochondral junction. The interconnecting vessels had a mean diameter of 0.5 mm. Vascular corrosion casting helped identify multiple capillaries that were distributed from the intercostal arteries to the periosteum of the ribs. In addition, intraoperative indocyanine green fluorescence angiography confirmed blood flow from the slip arteries to the intercostal arteries. Good blood flow in harvested graft tissue can be achieved by including the axial route with the periosteal blood circulation at the rib attachment sites of the serratus anterior in a serratus anterior/rib composite flap.

Factors that predict deep inferior epigastric perforator flap donor site hernia and bulge

Deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. Attention is now being focused on the impact of DIEP flap harvest technique on abdominal hernia rates. The aim of this study was to evaluate DIEP abdominal wall morbidity in relation to flap harvest and fascial closure technique. A retrospective analysis of patients undergoing DIEP flap breast reconstruction between 2012 and 2016 was performed. Post-operative evaluation of the abdominal wall integrity was performed by an operating consultant. The rectus fascia was closed using one of three techniques. The study included 202 patients, in whom 234 DIEP flaps were performed. Eight patients (3.4%) developed a clinically evident abdominal bulge post-operatively and one (0.5%) had a hernia. Harvesting two or more perforators was more likely to result in post-operative abdominal hernia/bulge than taking a single perforator (p = .032). Using a perforator from the lateral row or both rows was more likely to result in a hernia/bulge than if a single medial perforator was harvested (p = .026). Comparison of the rectus fascia closure technique did not show any statistically significant difference in abdominal wall morbidity. Consideration should be given towards perforator selection when harvesting a DIEP flap. Where appropriate, a suitable single medial row perforator with a favourable suprafascial course should be chosen. This study has not shown mesh-free fascial closure to be inferior to mesh-supported closure. Careful consideration to the role of synthetic mesh within this patient cohort should be given.

The chimeric lateral femoral condyle flap for reconstruction of a long bone defect in the hand

The medial femoral condyle when based on the descending genicular artery (DGA) or superomedial genicular artery (SMGA) has a reputation as an excellent source of a vascularised bone flap, that also allows combinations as a chimeric flap with other soft tissue components including skin perforator flaps for reconstruction of complex defects in the hand. In a similar fashion the superolateral genicular artery (SLGA) supplies the lateral femoral condyle (LFC), that can also support different types of bone flaps including chimeric designs. The pertinent surgical anatomy and flap harvesting techniques are described in detail. A representative case example using a chimeric LFC flap to provide vascularized corticocancellous bone to replace a metacarpal shaft with a perforator flap for sentinel flap monitoring demonstrates the potential versatility of this donor site.

Abstract 77: Outcomes Analysis of Goldilocks Mastectomy and Breast Reconstruction: The Mayo Clinic Experience

PURPOSE: The Goldilocks mastectomy procedure involves local contouring of completely autologous breast tissue created by preserving and de-epithelializing the residual mastectomy flap. This technique provides patients with an option for post-mastectomy breast reconstruction alternative to simple mastectomy without reconstruction, complex autologous flap harvesting techniques, or the use of artificial implants. The purpose of this study was to provide outcomes data for 172 Goldilocks mastectomy procedures performed at a single tertiary academic center analyzing complication rate, relevant comorbidities, and adjuvant cancer treatment impacting functional and aesthetic outcomes. This is the largest series of Goldilocks mastectomy procedures to be reported to date. METHODS: Relevant comorbidities and complication data were collected. Patients who had prior surgical procedures before presenting to our institution were designated as such. Specific breast cancer pathology and previous breast therapy were indicated. Data relevant to the Goldilocks reconstruction at our institution were collected, including laterality of procedure(s), indication (i.e. prophylactic or therapeutic), whether a tissue expander or an implant was placed at the time of the Goldilocks procedure or at any point following the procedure, the number of procedures needed for the entire reconstructive regimen, and any specific revision procedures, if needed (i.e. fat grafting, mastopexy, augmentation, or scar revision). RESULTS: A total of 95 patients underwent reconstruction with Goldilocks procedure. 82.1% (78) of cases were bilateral, and 17.8% (17) were unilateral reconstructions. Breast cancer pathology results included: DCIS 27.3% (26), LCIS 5.26% (5), stage I 11.57 (11), stage II 23.1% (22), stage III 23.1% (22), inflammatory 5.3% (5), BRCA prophylactic 11.5% (11), other 2.1% (2), and recurrent cancer 6.3% (6). Pre-operative radiation therapy was given in 7.4% (7) of patients, while post-operative radiation therapy was given to 6.31% (6) of patients. 22.1% (21) of patients received chemotherapy and 17.8% (17) received hormone therapy. Previous breast reconstruction history included implant-based reconstruction in 3.15% (3), autologous 1% (1), multiple attempts 1% (1), and failed reconstruction 1% (1). Reconstruction types included Goldilocks-only in 58% (53) of patients, Goldilocks + tissue expander in 35.8% (34), and Goldilocks with implant in 10.5% (10). 45.3% (43) of patients underwent adjuvant fat grafting, 7.3% (7) underwent concurrent mastopexy, 5.2% (5) underwent concurrent breast augmentation, and 14.7% (14) had scar revision procedures performed at the time of Goldilocks procedure. Complications included: seroma 6.3% (6), hematoma 4.2% (4), cellulitis 4.2% (4), wound dehiscence 4.2% (4), DVT/PE 1% (1), readmission 1% (1), needed take back to OR 9.5% (9), needed explant 7.4 %(7), or other complications 3.1% (3). CONCLUSION: Goldilocks mastectomy procedures are a useful adjunct in reconstruction, and can also be used in implant-based reconstruction, providing a dermal sling to build an internal bra and scaffold for the implant. Patients who have relevant medical comorbidities or who decline traditional methods of reconstruction can greatly benefit from Goldilocks mastectomy. There may be substantial utility in considering Goldilocks procedures during pre-operative planning in patient-centered care along the reconstructive ladder, as this approach has the ability of being modified with additional procedures such as fat grafting or implant placement. J. Oliver: None. A. Chaudhry: None. S. Alsubaie: None. J. Martinez-Jorge: None.

Reconstruction of the mandibular condyle using the microvascular lateral femoral condyle flap

The lateral femoral condyle (LFC) flap is a new flap first reported in 2015 for the treatment of osteomyelitis in hand surgery. This paper introduces a technique of osteochondral LFC flap harvest for mandibular condyle reconstruction and reports on the use of this flap in temporomandibular joint reconstruction. For condyle resection, a pre-auricular approach saving the temporal artery and vein is performed. A step osteotomy technique is used for condyle resection. LFC harvesting starts with dissection of the popliteal artery and vein. The superior genicular artery and vein are identified and followed along their periosteal branches. An osteochondral flap according to the condyle defect is harvested from the anterior pole of the knee. The flap is banded according to the defect and fixed to the mandibular neck with three miniscrews. Follow-up computed tomography scans should be performed at 1 week, 6 months, and 1year after surgery. The case of a 58-year-old female patient with osteomyelitis of the left mandibular condyle after multiple preoperative therapies is reported. The LFC flap technique was used for left condyle reconstruction, resulting in good functional and morphological outcomes at the 6-month postoperative follow-up. In conclusion, the osteochondral LFC flap is a new and promising technique for mandibular condyle reconstruction for special indications.

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction.

As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. In an effort to expand on Nahabedian's 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.

Laparoscopic harvest of the gastro-omental free flap for reconstruction after total pharyngolaryngectomy: Operative technique.

Circumferential defects following salvage pharyngolaryngectomy present significant challenges in reconstructive surgery. The gastro-omental free flap has been shown to reduce the incidence of major fistula and catastrophic complications. The current technique for harvest of the flap requires laparotomy, which is potentially associated with significant post-operative complications. Laparoscopic harvest of the gastro-omental free flap can negate some of the risks associated with open surgery. We describe here the operative technique for laparoscopic gastro-omental free flap harvest for use in reconstruction following total pharyngolaryngectomy. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1696-1698, 2017.

Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes–depleted Patient

The greater omentum is supplied by the right, middle, and left omental arteries, which arise from the right and left gastroepiploic arteries. All or part of the greater omentum can be harvested based on this blood supply for free tissue transfer. It has stimulated new interest in its use as the donor site in the treatment of lymphedema. For patients who have failed other management options or have limited peripheral lymph node donor sites, the greater omental lymph node flap may offer the best chance for lymphedema treatment. We report a 59-year-old woman with a history of left breast cancer who was treated with left modified radical mastectomy and axillary lymph node dissection and developed left upper extremity Grade IV lymphedema. She received vascularized groin lymph node transfer and lymphaticovenous anastomosis, but the result was not satisfactory. She also had nasopharyngeal cancer that was treated with radiotherapy to the head and neck, making use of the submental lymph nodes flap impossible. Due to a lack of other options of lymph node donor sites, the split greater omental lymph node flap (GOLF) was used. After surgery, it showed an arm circumference reduction of 42.9% above the elbow and 36.4% below the elbow at an 8-month follow-up. There was no intraabdominal complication. The split GOLF has shown good results in a peripheral lymph node-depleted lymphedema patient. Using a laparoscopic technique for flap harvest has less risk of donor site morbidity and hides scarring.

A novel nasoseptal flap harvesting technique in revision expanded endoscopic transsphenoidal approaches.

To describe the technique of harvesting the nasoseptal flap (NSF) in revision-expanded endoscopic approaches (EEA). We retrospectively analyzed four cases of endoscopic skull base reconstruction (ESBR) following revision EEA done for pituitary adenoma recurrence. The presence of an intact mucoperiosteum between the nasal septum and the roof of the choana as judged on a preoperative endoscopic and radiological assessment was considered to be sufficient for the presence of a viable pedicle. By strategic placement of the incisions, the entire bilateral posterior nasal septal mucoperiosteum was raised in the NSF containing the remnant vascular pedicle. ESBR was performed with multilayer grafting of the dural defect, and the NSF was placed onto the bony margins of the defect. All patients had successful skull base reconstruction with the NSF raised by this technique as none of them developed postoperative cerebrospinal fluid leak. Though the number of patients in this study is small, we would like to present the concept of harvesting the NSF in revision surgery, wherein neither measuring the surface area of the pedicle nor the acoustic Doppler assessment of the pedicle is required.

Management of difficult recipient vessel preparation in microsurgical reconstruction for oral and maxillofacial defects with free flaps

Objective To investigate the management of difficult recipient vessel preparation in microsurgical reconstruction for oral and maxillofacial defects with free flaps and to assess the clinical outcome. Methods A total number of 739 patients with oral and maxillofacial defects underwent consecutive free flap reconstruction with 761 free flaps from May, 2012 to May, 2015. There were 37 patients who could not find or lack of proper recipient vessels for microvascular anastomosis during operation. Among them, 22 were recurrent oral cancer after tumor ablation, 10 of them undrewent post-operative radiotherapy; 5 were second primary oral cancer, 7 diagnosed with osteoradionecrosis, and 3 suffered from oral and maxillofacial defect and deformity caused by trauma or inflammation. Forty free flaps including 23 anterolateral thigh flaps. (ALT) , 10 fibular flaps and 7 radial forearm flaps were harvested. Methods and techniques used during the operation, instant patency rate after anastomosis, the overall survival rate of free flaps, and post-operative complications were recorded. Results Ninety-one anastomoses were performed between 87 pairs of vessels in 37 patients. Fifty recepient vessels were located on ipsilateral side of neck, and the most frequently used recipient vessels were those preserved or not being damaged in former operation and radiation, former transferred free flap vascular pedicles and residual ends of the ligated vessels. Thirty-seven recepient vessels were found on the contralateral side of neck. Thirty-one cases of long-pedicle flap harvesting, 2 cases of vein and artery grafting, 4 cases of vessel transposition, 5 cases of phleboplasties, 9 cases of end-to-side anastomoses, and 1 case of flow-through technique were applied in recipient vessels preparation alone or in combination. The patency rate of anastomosis during operation was 100% and the overall survival rate of free flaps was 97.5%. Conclusion Recurrent oral cancer after tumor ablation, second primary oral cancer, osteoradionecrosis and deformity caused by trauma and inflammation are the main reasons of unsuitable recipient vessel conditions in microsurgical reconstruction for oral and maxillofacial defects. Methods including long-pedicle flap harvesting, venous grafting, vessel transposition, phleboplasty, end-to-side anastomosis and flow-through technique applied alone or in combination are still reliable choices for management of neck difficult recipient vessel preparation and anastomosis. Key words: Maxillofacial defects; Surgical flaps; Recipient vessels; Microsurgery

An Alternative Method for Facial Resurfacing

Prefabrication of supraclavicular skin provides a useful source for flaps congruent with the face skin. Among various vascular sources that have been used for this purpose, anterolateral thigh fascia seems to represent a greater value because of having a long and strong vascular pedicle and negligible donor-site morbidity. In this regard, we present a technical report on using the lateral circumflex femoral artery perforator flap harvest technique in preparing an anterolateral thigh fascia flap for the prefabrication of the supraclavicular skin. The technique proved successful in resurfacing the facial skin of a young female patient with a giant congenital melanocytic hairy nevus on the left side of her face.

Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores

Despite advances in reconstruction techniques, the treatment of sacral sores remains challenging to plastic surgeons. The superior gluteal artery perforator (SGAP) flap is reliable and preserves the entire contralateral side as a future donor site. The ipsilateral gluteal muscle is preserved, and the inferior gluteal artery flaps are viable. However, dissection of the perforator is tedious and may compromise the perforator vessels. Between April 2003 and March 2013, we performed two modified flap-harvesting techniques: a rotational and a tunnel method, with only a short pedicle dissection to cover 30 sacral defects. Patient characteristics including sex, age, cause of sacral defect, flap size, perforator number, use and postoperative complications were recorded. All flaps survived except two, which developed partial flap necrosis and were finally treated by contralateral V-Y advancement flap coverage. The mean follow-up period was 14.8 months (range, 3-24 months). No flap surgery-related mortality or recurrence of sacral pressure sores or infected pilonidal cysts were noted. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. The advantages of our modification procedure include shorter operative time, lesser bleeding and lesser pedicle trauma, which make the SGAP flaps an excellent choice for sacral sore coverage.

The Diagonal Upper Gracilis (DUG) Flap

INTRODUCTION: The transverse upper gracilis (TUG) has been successfully used for autologous breast reconstruction. However, concerns regarding wound healing, lymphedema, and cosmesis at the donor site have limited its widespread use. The Profunda Artery Perforator (PAP) flap is a useful alternative that has addressed some of the morbidity associated with the TUG. However, the PAP flap may result in distortion of the gluteal crease and lead to sensory changes in this region. In this study we describe a new flap design: the DUG (Diagonal Upper Gracilis) flap. The axis of the DUG flap skin paddle is oriented in an oblique and posterior fashion parallel to Langer’s lines. This allows recruitment of a wider skin paddle with less tension on the line of closure. The lymphatics from the lower extremity are avoided and the scar is not visible on frontal and lateral views. The purpose of this study was to describe the technique for flap harvest and evaluate its outcomes. METHODS: A retrospective study was performed on 9 consecutive patients who underwent 10 DUG flaps. Preoperatively, magnetic resonance angiography was used to identify the optimal donor thigh. Donor site morbidity and surgical complications were evaluated. RESULTS:Operative Technique - The anterior border of the skin paddle is oriented along the prominence of the adductor longus and curved posteriorly. A symmetric ellipse is then completed, parallel to Langer’s lines (Figure 1). Dissection begins along the anterior edge of the flap and carried down through the adductor longus fascia. The fascia is reflected medially, exposing the gracilis pedicle which is mobilized to its origin from the profunda femoris artery.Figure 1: DUG Flap pre-operative markings.Clinical Outcomes - Two flaps were performed for partial breast reconstruction and eight flaps were used for post-mastectomy reconstruction. All flaps survived. The flap weighs ranged from 114 grams to 210 grams. There were no surgical complications at the donor site. All patients ambulated without restriction on post-operative day one. All donor sites healed uneventfully without pain, seroma, or lymphedema (Figure 2). There was no palpable fat necrosis to date.Figure 2: Donor site.CONCLUSION: The DUG flap is a safe and effective alternative for breast reconstruction. An obliquely oriented skin paddle as opposed to a transverse skin paddle allows for greater recruitment of tissue with less tension on closure, avoids lymphatics, and does not distort the gluteal fold.