Use Of Pedicled Flap Research Articles

Use of pedicled flaps after oncologic resections in pediatric patients.

The aim of this study is to review the indications of pedicled flaps and analyze the results.A observational retrospective study of under 18-year-old oncology patients who required reconstructive surgery with pedicled flaps between 2011 and 2022 was performed. Demographic and clinical variables, indications, complications, and outcomes were collected.236 patients were reviewed and 13 met inclusion criteria, eight girls and five boys (mean age: 10.6years). Indications were Ewing's sarcoma (5), osteosarcoma (5), neuroblastoma, desmoid tumor, and neurofibroma. Preoperative PET-CT, MRI and bone scintigraphy were performed. The flaps were used on costal and extremity reconstruction: latissimus dorsi (5), pectoralis (2), medial gastrocnemius (2), combined latissimus dorsi, trapezius and serratus muscle, biceps femoris, fascio-neuro-cutaneous saphenous and cutaneous advancement-rotation. Two were performed on allograft and eight on prosthesis. All allowed immediate and complete closure. Six patients received intraoperative radiotherapy. One flap infection and two vascular complications were reported, a total necrosis, which required a new flap, and a partial necrosis, treated with a local plasty. Chemotherapy was resumed after 21days (15-31). Mean follow-up time was 5.34years.Flaps are an effective therapeutic option allowing reconstruction of large defects after pediatric oncologic surgeries. The most frequent complication was vascular.

Infrahyoid flap—a good substitute for free flaps in oral reconstruction during the COVID‐19 pandemic

AbstractAimDuring the coronavirus disease 2019 (COVID‐19) pandemic, experts have recommended simplifying the process of reconstruction following the extirpation of head and neck cancer by favouring the use of pedicled flaps over free flaps. This approach reduces the duration of the operation and mitigates the risk of free flap failure, which can be exacerbated by the hypercoagulopathy state seen in infected patients. We aim to contribute our experience with the pedicled infrahyoid flap, a procedure not previously reported in Hong Kong.Patients and MethodsWe conducted a retrospective study including patients who underwent infrahyoid flap reconstruction following resection of oral cavity cancer. Data for a total of nine patients were retrospectively retrieved from the hospital's computerised systems, and these patients were evaluated for demographic information, clinicopathologic parameters as well as oral function and reconstruction outcomes.ResultsAmong the nine infrahyoid flaps used, eight were myocutaneous flaps and one was a muscle flap. The dimensions of the flap skin ranged from 24.0 to 46.72 cm2. All of the flaps, with the exception of one case that experienced epidermolysis of the flap skin, exhibited complete survival. Fortunately, the epidermolysis healed without complications, such as the development of an orocutaneous fistula. The average time required for flap harvesting was approximately 1 hour. All nine patients were able to resume oral feeding and achieved satisfactory speech outcomes. Seven of these patients survived without any tumour recurrence, but unfortunately, two patients died due to lung metastases.ConclusionsThe infrahyoid flap proves to be a viable alternative to free flaps for the repair of medium‐sized oral defects, especially in compromised patients and during the COVID‐19 pandemic.

Latissimus Dorsi and DIEP Flaps for Pharyngeal Reconstruction: A Novel Indication.

Complex pharyngeal defects after tumor resection remain a challenging dilemma for reconstructive plastic surgeons. They often benefit from pedicled or free flaps reconstruction to maintain continuity of the aerodigestive tract and protect the great vessels. While pedicle pectoralis major myocutaneous flaps or supraclavicular flaps have been described, microvascular free flaps have largely replaced the use of pedicle flaps. We describe our experience with subtotal and total pharyngeal reconstruction utilizing tubed DIEP (n = 2) and latissimus dorsi free flaps (n = 2). All four patients were smokers and received prior radiation. All patients were able to resume a regular diet and did not suffer any recipient or donor site complications. There were no fistula or total flap losses. In our experience, DIEP and latissimus dorsi free flaps can serve as a valid alternative to radial forearm, jejunal and anterolateral thigh flaps for pharyngeal reconstruction.

Vascularized Bone Flaps for Salvage Ankle Fusion

Objective: The ankle is a critical load-bearing joint for the lower extremity that is prone to damage from a variety of causes. Achieving stable bony fixation is paramount to restoring function after ankle injury. Initial attempts at fixation with hardware may fail, or large bone deficits may make primary fixation impossible. Vascularized bone grafts can be used to create stable and functional reconstruction of the ankle. Methods: We reviewed our experience using vascularized bone flaps to achieve bony ankle fusion in patients with unstable ankle joints. We then developed indications for whether the use of pedicled flaps versus free tissue transfer will best accomplish successful fusion. Results: At our institution, a single surgeon has performed 6 cases of vascularized bone grafts for ankle fusion. Three of these were pedicled fibula flaps and three were free fibula flaps. One of the free fibula flaps had persistent non-union and was salvaged with a medial femoral condyle free flap to achieve bony fusion. All patients had improved pain and were able to bear weight on the ankle joint post-operatively. Pedicled fibula flaps can be used when there is avascular necrosis of the talus or distal tibia, non-union after ankle fusion, failed total ankle replacement, or for large bony defects. Free fibula flaps are required when there is non-union of the distal fibula, if there is need for tibiotalocalcaneal fusion, and therefore need to extend the fibula to the calcaneus, or if the lateral malleolus has been already taken down during prior ankle fusion. Conclusion: Ankle reconstruction presents a challenging problem, but vascularized bone grafts can provide stable and functional results for patients. Using the indications we have developed for the use of pedicled flaps versus free tissue transfers can help other surgeons tackle these difficult cases. Corresponding Author: Gretchen Stieg MD, Department of Plastic & Reconstructive Surgery Detroit Medical Center/Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, Email: [email protected], Phone: (407) 252-0909

Free Your Mind, Not Your Flap.

Summary:The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.

Root Coverage Predictability in the Treatment of Gingival Recessions on Mandibular Anterior Teeth.

Mandibular anterior teeth are most frequently affected by gingival recession. However, data regarding mucogingival treatment aimed at root coverage in this specific location are limited. The purpose of this study was to systematically review the scientific literature and to use the meta-analytic approach to address the following focused question: "What is the effectiveness of different surgical approaches on clinical and patient-related outcomes in the treatment of buccal gingival recessions on mandibular anterior teeth?" Studies were located by searching 3 electronic databases (Medline, Scopus, and Cochrane databases) and cross-referencing. Randomized and nonrandomized studies including at least 1 arm involving the use of pedicle flaps and/or free soft tissue grafts in the treatment of gingival recessions (recession type [RT] 1 and RT2) located on the buccal aspects of mandibular centrals, laterals and canines, were included in the analysis. Primary outcome was mean root coverage (mRC), expressed in percentage, based on a 3- to 12-mo follow-up observation. A Bayesian single-arm network meta-analysis was performed to identify a treatment hierarchy of the different surgical techniques. Sixteen studies, with a total of 23 arms, were included in the quantitative analysis. The greatest mRC is associated with laterally positioned flap (LPF) + connective tissue graft (CTG) (91.2%) and tunnel (TUN) + CTG (89.4%), whereas LPF alone, coronally advanced flap (CAF) + CTG, and free gingival graft (FGG) showed lower mRC (79.1%, 78.9%, and 68.5% respectively). TUN + CTG provides significantly greater mRC compared to CAF+CTG. No difference among the procedures could be observed in terms of keratinized tissue width gain. Treatment hierarchy generated by an arm-based network meta-analysis model suggested that tunnel and laterally positioned flap, both in combination with connective tissue graft, may provide the greatest mean root coverage in the treatment of mandibular anterior recessions. The results of the present systematic review can be used by clinicians when deciding which approach to adopt when treating buccal gingival recessions on mandibular anterior teeth. In particular, procedures based on a laterally positioned flap or a tunneling technique, both in combination with connective tissue graft, seem to be the most predictable therapeutic decision.

Contemporary reconstruction after complex facial trauma.

Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.

Abstract: 17.00 Freestyle Pedicled Perforator And Propellar Flaps: Anatomic Studies And Clinical Application

INTRODUCTION: Freestyle perforator flaps have been described for soft tissue reconstructions throughout the body. The flaps are designed in accordance to the defect, the surrounding available perforators, and excess regional tissue. Knowledge of the anatomic angiosomes and respective perforators provide a broad spectrum of available pedicled flaps for the reconstructive surgeon. We present our anatomic studies and the clinical application of freestyle perforator flaps in the trunk, head and neck, and limb. MATERIALS AND METHODS: Cadaveric anatomic studies were performed to identify reliable perforators based on individual angiosomes. In clinical cases, perforator-preserving incisions were used without the use of a hand-held Doppler or pre-operative imaging. Freestyle fasciocutaneous perforator flaps were harvested following subfascial identification of the largest perforator(s). Flaps were designed based on the defect size, location of the recipient site, and nearby available tissue. Dissection of the perforator was continued to its main vascular trunk for optimal mobility and rotation of the flap. Flaps were rotated or tunneled for final inset, and those that extended into a tertiary angiosome were supercharged as necessary. RESULTS: From January 2012 to June 2015, 42 patients were reconstructed with freestyle perforator flaps without the aid of handheld Doppler or pre-operative imaging. Donor sites were primarily closed in 83.3% of the cases. Total complication rate was 21.4%, with 7 patients (16.7%) presenting with distal flap necrosis. All healed with re-advancement of the flap or dressings. There were no complete flap losses. All defects were adequately closed with the designed flaps. CONCLUSIONS: Understanding of the anatomic perforasomes throughout the body provides the astute reconstructive surgeon with ample reconstructive options for the use of pedicled flaps. Freestyle perforator flaps are a safe and reliable option for trunk, head and neck, and limb soft tissue reconstruction and do not require the use of handheld Doppler or preoperative imaging.

The use of pedicled musculocutaneous flap of the trapezius muscle for the treatment of skin defect after two stage thoracic spine stabilisation – case report

Musculocutaneous flaps play an important role in modern reconstructive surgery. They are useful in the treatment of primary traumatic skin lesions and secondary lesions formed during complicated healing of the surgical wounds. The case of 60 years old woman undergoing complicated healing of the wound after spine surgery is presented. The patient was qualified to spine surgery due to metastatic tumour caused by the lung cancer. The use of pedicled flap facilitated healing of the wound; thus, there was no need to remove implants stabilising pathologically fractured spine. The issue of ‘reconstructive ladder’ is discussed in the paper with various treatment options. Indications, surgical technique and postoperative care are thoroughly discussed providing an overview on this valuable method of treatment which allows a successful termination of complicated wound healing process.

Reverse Medial Hemisoleus Flaps for Coverage of Distal Third Leg Wounds: A Technical Trick.

Traditionally, free tissue transfer has been used to cover wounds of the distal third of the leg. Advances in flap anatomy, elevation, and surgical techniques have allowed the use of pedicled flaps to avoid the use of free tissue transfer in certain situations. The authors describe a technique for using a reversed medial hemisoleus flap to provide soft tissue coverage for wounds of the medial distal leg. In the senior authors experience, the use of this flap has achieved wound coverage in 100% of patients with smaller wounds (≤50 cm) of the medial leg.

Dorsal hand coverage

Dorsal hand coverage

Fibroma of the external nose

AbstractDefects of the external nose of any origin difficult tolerated as it causes disfigurement of the face. That is why any cosmetic defects of the nose are severe traumatic factor, regardless of gender and age of the patient.IntroductionThe use of pedicled flap helped to avoid the negative aspects of the classical “Italian” rhinoplasty, such as prolonged immobilization, and the ability to multi‐stage stem necrosis in the transfer process due to lack of blood supply to the axis, which brought great inconvenience to the patient.ResultsPatient S., 33goda, turned 5 years first appearance of Education of the left wing and nose. Diagnosis: Fibroma tip and the left wing of the nose (histological diagnosis is the same). We removed under local anesthesia education within the healthy tissue to cartilage, a defect oval 32,0 x 28,0mm. Is cut skin and fat flap pedicled from the left nasolabial fold, which moved to the defect and sutured in layers. On the 12 day cut off pedicle and made the correction.DiscussionIt should be emphasized availability of flaps, a cut from the skin of the forehead which is not always justified, and the only method of rhinoplasty. Its use is most effective when combined rhinoplasty. However, this method also many stages are not perceived by patients due to the fact that leaves rough, sometimes deforming noticeable scars on her forehead. Multi‐stage operation is uncomfortable for patients.ConclusionsTo date, we have used with great success Acute dermal fat flap of nasolabial folds. This method allows simultaneously closed a defect, perform simple technical and patient in a short time back into everyday life. This method we used in 37 cases, with good long‐term results.

Pedicled flaps in endoscopic skull base reconstruction: review of current techniques.

To discuss the current applications and indications for the use of pedicled flaps in the reconstruction of endoscopic skull base defects. Current trends in endoscopic skull base surgery include the use of vascularized pedicled flaps rather than free tissue grafts (autograft or allograft) for the repair of anterior cranial base defects. In particular, recent evidence-based algorithms for skull base reconstruction suggest that use of pedicled flaps for clival defects and high-flow cerebrospinal fluid (CSF) leaks may reduce the incidence of postoperative CSF leaks. The primary workhorse continues to be the nasoseptal flap (NSF); however, other options exist in cases wherein this flap is unavailable because of prior sacrifice or unable to reach the area of interest (e.g., defects adjacent to the frontal recess). Adoption of vascularized pedicled flaps over the last decade, particularly the recently popularized NSF, has greatly reduced complications associated with endoscopic skull base surgery. The need for vascularized flap reconstruction is governed primarily by defect size and location, and by the presence of a high-flow CSF leak. Additional vascularized flaps can be used in conjunction with the NSF, or as an alternative when the NSF is unfavorable or unavailable.

Subunit principle of vulvar reconstruction: algorithm and outcomes.

BackgroundVulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction.MethodsFrom 2007 to 2013, 43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was 61.1 years. The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps.ResultsThe main complications were that of long term hypertrophic and/or unaesthetic scarring of the donor site in 4 patients. Twenty-two patients (51%) were able to resume sexual intercourse. There were no complications of flap loss, wound dehiscence, and urethral stenosis.ConclusionsWe present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity. The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects. From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.

Management of Urethral Stricture in Women

We describe the diagnosis and treatment of urethral strictures in women. We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Gingival recession: part 3. Surgical management using free grafts and guided tissue regeneration

This paper is the third in a three part series looking at the aetiology and management of gingival recession. Part 1 in this series discussed the aetiology of gingival recession and the non-surgical management. Part 2 discussed in detail the factors affecting the outcome of periodontal surgery and the use of pedicle flaps. This paper aims to discuss the surgical options available to correct localised recession defects using free grafts and guided tissue regeneration.

Forequarter Amputation Combined With Chest Wall Resection: A Single-Center Experience

Forequarter amputation combined with chest wall resection is a rarely performed procedure. Six patients were treated for advanced malignancies with this operation in our institution since 1993. Uncontrollable pain, lymphedema, loss of function of the affected limb and, in some patients, localized ulceration of the tumor at the time of presentation, provided the indication for the operation. All patients underwent radical amputation of the upper limb and the structures of the shoulder girdle, in combination with resection of the thoracic chest wall in an extent of 2 to 7 ribs. Chest wall reconstruction was achieved by implantation of a polytetrafluoroethylene patch (n=5) or a combination of a metal implant (Stratos System R, MedXpert GmbH, Heitersheim, Germany) and a polytetrafluoroethylene patch (n=1). Myocutaneous coverage of the defects was achieved by use of pedicled flaps from adjacent tissue (n=3) or by free myocutaneous flaps harvested from the amputated forearm (n=3). No perioperative mortality occurred; however, significant morbidity was seen after the use of the free forearm flaps based on occurring vascular problems. All 3 patients had to undergo surgical revision of the flap. Survival ranged from 5 to 50 months (median=23.5 months) with 3 patients still alive at the time of this investigation. Forequarter amputation in combination with chest wall resection is a feasible and potentially curative treatment for malignant tumors of the shoulder girdle with invasion of the chest wall. The operation results in immediate palliation and long-term survival can be obtained in selected cases.

Reconstruction of complex thoraco-abdominal defects with extended anterolateral thigh flap

Background:The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage.Materials and Methods:From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft.Result:All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance.Conclusion:Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.

A Case-Matched Controlled Study on High-Voltage Electrical Injuries vs Thermal Burns

The aim of this study was to provide an increased level of evidence on surgical management of high-tension electrical injuries compared with thermal burns using a case-controlled study design. Sixty-eight patients (64 males, 4 females, aged 33.7 +/- 13 years) with high-tension electrical burns were matched for age, gender, and burnt extent with a cohort of patients sustaining thermal burns. Data were analyzed for cause of accident (occupational vs nonoccupational), concomitant injuries, extent of burn and burn depth, surgical management, complications, and hospital stay. High-tension electrical burn patients required an average of 5.2 +/- 4 operations (range, 1-23 operations) compared with 3.3 +/- 1.9 (range, 1-10 operations) after thermal burns (P = .0019). Amputation rates (19.7% vs 1.5%), escharotomy/fasciotomy rates (47% vs 21%), and total hospitalization days (44 d vs 32 d) were significantly higher in high-tension electrical injuries (P < .05). Creatinine kinase levels were significantly elevated during the first 2 days in patients with subsequent amputations. Free flap failure was observed during the first 4 weeks after the trauma, whereas no flap failure occurred at later stages. Local, pedicled, and distant flaps were used in 15% of the patients. The mortality in both groups was 13.2% vs 11%, respectively (nonsignificant). High-voltage electrical injury remains a complex surgical challenge. When performing free flap coverage, caution must be taken for a vulnerable phase lasting up to 4 weeks after the trauma. This phase is likely the result of a progressive intima lesion, potentially hazardous to microvascular reconstruction. The use of pedicle flaps may resemble an alternative to free flaps during this period.

Distal Urethral Reconstruction of the Glans for Penile Carcinoma: Results of a Novel Technique at 1-Year of Followup

No satisfactory techniques are available to replace the anatomy and function of the penile glans after radical surgery for penile carcinoma. We report a new technique of glans reconstruction using distal urethra. We evaluated anatomical, physiological and esthetic features as well as short-term and long-term clinical outcomes. A total of 14 patients with a mean age of 54 who had squamous penile carcinoma underwent glans reconstruction after simple glansectomy in 8 and after amputation of the distal third of the shaft in 6. Glans sensibility, erectile function, ejaculation, orgasm, penile length, local recurrence, patient and partner satisfaction, and quality of life were evaluated before and after the operation. Mean followup was 13 months. All patients noticed subjective and objective thermal and tactile epicritic sensibility in the area of the neoglans. Ten of 14 patients (71%) noticed spontaneous and/or induced rigid erections. Interestingly International Index of Erectile Function scores in the ejaculation and orgasm domains did not significantly change in the period before and after surgery. No local disease recurrence or penile retraction were reported at long-term followup. Reconstructive glanuloplasty with distal urethra in penile tumor surgery is an innovative, easy and rapid surgical technique with appreciable functional and esthetic results.