Vascularized Muscle Flap Research Articles

Multiple pellets expectoration: bronchial repair by using a costal cartilage graft

Foreign body expectoration resulting from penetrating thoracic injury is an extremely rare condition. It requires bronchoscopy for diagnosis, and if there is a bronchial wound with a large tissue defect, costal cartilage grafting covered with a vascularized muscle flap is suggested as a good alternative for the treatment.

Early internal fixation and soft tissue cover of severe open tibial pilon fractures.

We studied 32 consecutive patients with open distal tibial pilon fractures. All patients had radical debridement with immediate skeletal stabilisation and early soft-tissue cover with a vascularized muscle flap. The minimum follow-up was 1 (range 1-8) year. There were four superficial infections, two deep infections and two amputations. There were no long-term problems with union and no patient required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were significant differences from the US norm in physical function score ( p<0.01), role physical score ( p<0.05) and physical component score ( p<0.01). Physical component score of 38.5 was significantly better ( p<0.01) when compared with amputees from severe lower-extremity trauma. Our protocol for management resulted in a good functional outcome with low infection and amputation rates.

Vascularized temporalis muscle flap for the treatment of otorrhea. Technical note.

The surgical treatment for cerebral spinal fluid (CSF) fistulas provides closure of the bone and dural defects and prevents the recurrence of brain herniation and CSF fistula. The two main approaches used are the transmastoid and middle fossa ones. The authors review the results of performing a modified middle fossa approach with a vascularized temporalis muscle flap to create a barrier between the repaired dural and bone defects. Fifteen consecutive cases of CSF fistulas treated at the authors' institution were retrospectively reviewed. All patients presented with otorrhea. Eleven patients had previously undergone ear surgery. A middle fossa approach was followed in all cases. The authors used a thin but watertight and vascularly preserved temporalis muscle flap that had been dissected from the medial side of the temporalis muscle and was laid intracranially on the floor of the middle fossa, between the repaired dura mater and petrous bone. The median follow-up period was 2.5 years. None of the patients experienced recurrence of otorrhea or meningitis. There was no complication related to the intracranial temporalis muscle flap (for example, seizures or increased intracranial pressure caused by muscle swelling). One patient developed hydrocephalus, which resolved after the placement of a ventriculoperitoneal shunt 2 months later. The thin, vascularized muscle flap created an excellent barrier against the recurrence of CSF fistulas and also avoided the risk of increased intracranial pressure caused by muscle swelling. This technique is particularly useful in refractory cases.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (&gt; 72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Book review

Since its original description in the British Medical Journal in 1978, the treatment of lymphatic fistulas in the groin remains contentious. Lymph leaks remain a common cause of morbidity in patients who have undergone groin dissection. The aim of this review was to examine the evidence for prevention and treatment of lymphatic fistulas after arterial surgery in the groin.A systematic review of the English language literature was undertaken to determine the success of the various treatment options described.A comprehensive literature search identified 46 studies describing several treatment options for lymphatic fistulas. A qualitative synthesis of these studies was performed. There was no consensus definition of lymphatic fistula. Treatments reviewed were: conservative management; lymphatic ligation; vascularized muscle flaps; and negative pressure wound therapy (NPWT). Due to poor study quality and the paucity of data no one treatment could be identified as superior.There was no quantifiable cut-off for either the amount of lymphatic output or number of days postoperatively that leakage continued to help determine when conservative measures should be abandoned and surgical intervention undertaken. There is some evidence supporting use of vascularized muscle flaps to reduce the volume of lymphatic drainage and help prevent secondary graft infection. The use of NPWT is also promising, but must be weighed against the associated risk of anastomotic bleeding and requirement for additional inpatient stay.

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis

A new technique using vacuum-assisted closure was successfully applied in 3 patients with poststernotomy mediastinitis. After surgical debridement, this vacuum-assisted closure technique has made it possible to avoid the need for secondary surgical closure (including direct secondary surgical closure and secondary surgical closure by use of vascularized muscle flaps). A healed stable sternotomy wound can be achieved using this new technique.

Closure of chronic abdominal wall defects: a long-term evaluation of the components separation method.

Incisional hernias and abdominal wall defects are frequently iatrogenic problems that have been found to complicate as many as 11% of all abdominal operations. Current techniques for closure of large, chronic abdominal wall defects have limitations. The use of local musculofascial flaps rather than fascial patches (i.e., the tensor fascia lata) or synthetic material for the repair of chronic abdominal wall defects is preferable. The superiority of innervated muscle flaps that provide dynamic abdominal support has been demonstrated. This report focuses on patients with chronic abdominal wall defects in whom previous techniques have failed. An algorithmic approach to planned reconstruction is presented utilizing the "components separation" technique as its foundation. Thirty-seven patients who underwent abdominal reconstruction following this algorithm are reviewed and their clinical course is outlined. The components separation technique provides a compound innervated and vascularized muscle flap for dynamic support of the reconstructed abdominal wall. The experience documented here and by others suggests that this technique is a safe and effective method for reconstructing the abdominal wall in patients with recurrent herniation. Enterocutaneous fistulas, however, continue to present a challenge to the surgeon.

前腕軟部組織欠損に対する筋（皮）弁の経験

Two cases of forearm tissue defects were treated by free vascularized musculocutaneous flap or free vascularized muscle flap transplantation. Case 1 who received a press injury and had an infection in the left forearm suffered complete median nerve palsy. Free vascularized rectus abdominis flap (9×12cm) was transplanted following debriedement of infected tissue. Thirteen months later, this patient has returned to his original job. Case 2 received two operations against soft tissue sarcoma in the right forearm before she visited our hospital. Tissue defect following wide recection of synovial sarcoma in the right forearm was reconstructed by free vascularized latissimus dorsi musculocutaneous flap (24×15cm). The right hand of this patient is useful with a simple elbow orthosis seven months after the last operation.

The long-term success of skeletal muscle in aortic repair

To determine the efficacy of skeletal muscle for aortic repair, 23 swine underwent repair of descending thoracic aortic defects. In one group, a vascularized muscle flap was used to patch a 2- to 3-cm aortic defect. In two other groups, a short segment of aorta was removed and a 2-cm tube graft of freshly harvested but devascularized skeletal muscle or Vicryl mesh was used to repair the aorta. Swine were followed for up to sixteen months after implantation. There were no deaths or graft-related complications in the vascularized muscle patch group, and after sixteen months, there were no stenoses or aneurysmal dilatations of the flaps. Histologically, a nature pseudointimal layer had been deposited under the muscle flap and was grossly indistinguishable from normal arterial wall. In the group that received devascularized muscle tube grafts, however, suture line dehiscences occurred in 3 of 7 animals within two weeks of operation. There were no dehiscences in the 9 recipients of a Vicryl tube graft, a finding suggesting that deposition of pseudointimal elements was rapid enough to ensure vascular integrity as the Vicryl was absorbed. Postmortem examination of these animals demonstrated stenoses ranging from 30 to 50%, thereby indicating a lack of growth in the new pseudointimal wall. These results demonstrate the long-term reliability of vascularized skeletal muscle for use in major vascular reconstruction, and suggest the beneficial effects of avoiding prosthetic material and promoting optimal pseudointimal formation.

A Heterotopic Autoinnervated Urinary Neosphincter

Twenty-six female adult New Zealand white rabbits underwent surgical denervation of a gracilis muscle to study the possibility of developing an autologous neosphincter innervated by the pudendal nerve. The study was conducted in 2 phases. In both Phase I and Phase II, the study group had the motor nerve to the gracilis, a branch of the obturator nerve and the pudendal nerve coapted in the perineum. The control group was left denervated. In Phase I, all muscle flaps were wrapped around the urogenital sinus. In Phase II, the muscle flaps were returned to their anatomic location. With bulbocavernosus reflex testing, 89 percent of the reinnervated group and 60 percent of the denervated group from Phase I and 86 percent of the reinnervated group and none of the denervated group from Phase II had a contractile response in the muscle flap. In Phase II, histologic examination of the gracilis muscle was suggestive of an early change in muscle myofiber physiology from fast twitch to slow twitch in the reinnervated group only. In the rabbit, a transplanted vascularized muscle flap, cross-innervated by the pudendal nerve has a reproducible response to bulbocavernosus reflex testing. This suggests that a transplanted muscle might be able to assume some of the characteristics of the voluntary urinary sphincter. The rabbit is a useful model in which to investigate the potential of the heterotopic neosphincter.

Vascularized muscle flaps for life-threatening mediastinal wounds in children

Vascularized muscle flaps have been shown to be highly effective in adults for complicated mediastinal and thoracic wounds. They result in infection control, wound coverage and preservation of life. Minimal experience exists with the use of these techniques in children. We review, our experience with vascularized muscle flaps between 1985 and 1993 in treating life-threatening mediastinal wounds in 8 children. The 8 patients ranged in age fom 1 day to 10 years; mean age was 2 years. Two patients had mediastinitis; one had an exposed Gore-Tex graft and the other had an exposed homograft conduit. One patient had a midline defect with exposed right ventricle immediately beneath the skin. One patient had trachael dehiscence after repair of an acquired tracheo-esophageal fistula from battery erosion. One patient with Marfan's syndrome had a pectus deformity and an unstable sternum after emergent reoperation for a false aortic aneurysm. Two neonates had their sternum left open with a temporary Silastic skin patch after orthotopic cardiac transplantation because of swelling of the donor heart. One transplant patient had wound dehiscence. Vascularized muscle flaps used to heal the mediastinal wounds in this group included pectoralis major (10), rectus abdominis (3), and cervical strap (1). One infant with asplenia and an exposed Gore-Tex graft that had a delayed vascularized muscle flap died of Candida sepsis. Seven of 8 patients (85%) healed their mediastinal wound. Prompt recognition of thoracic wound complications facilitates immediate surgical intervention to obtain primary closure with vascularized muscle flaps, which promotes rapid healing in these children.

Use of vascularized muscle flaps in repair of complex abdominal wall defects

Use of vascularized muscle flaps in repair of complex abdominal wall defects

The Long-term Success of Skeletal Muscle in Aortic Repair

To determine the efficacy of skeletal muscle for aortic repair, 23 swine underwent repair of descending thoracic aortic defects. In one group, a vascularized muscle flap was used to patch a 2- to 3-cm aortic defect. In two other groups, a short segment of aorta was removed and a 2-cm tube graft of freshly harvested but devascularized skeletal muscle or Vicryl mesh was used to repair the aorta. Swine were followed for up to sixteen months after implantation. There were no deaths or graft-related complications in the vascularized muscle patch group, and after sixteen months, there were no stenoses or aneurysmal dilatations of the flaps. Histologically, a mature pseudointimal layer had been deposited under the muscle flap and was grossly indistinguishable from normal arterial wall. In the group that received devascularized muscle tube grafts, however, suture line dehiscences occurred in 3 of 7 animals within two weeks of operation. There were no dehiscences in the 9 recipients of a Vicryl tube graft, a finding suggesting that deposition of pseudointimal elements was rapid enough to ensure vascular integrity as the Vicryl was absorbed. Postmortem examination of these animals demonstrated stenoses ranging from 30 to 50%, thereby indicating a lack of growth in the new pseudointimal wall. These results demonstrate the long-term reliability of vascularized skeletal muscle for use in major vascular reconstruction, and suggest the beneficial effects of avoiding prosthetic material and promoting optimal pseudointimal formation.

Efficacy of muscle flaps in the treatment of prosthetic vascular graft infections

Prosthetic vascular graft infection requires graft removal and often leads to limb loss. To determine whether vascularized muscle flaps could alter the course of graft infection, 18 mongrel dogs (18–29 kg) were randomized to one of three groups and underwent unilateral carotid artery bypass with 6-mm × 4-cm PTFE grafts. At implantation, the grafts were inoculated with Staphylococcus aureus, 2 × 10 7 organisms/wound. On Day 3, dogs with patent grafts underwent wound debridement, irrigation, and closure, and the treatment to which they had been randomized was carried out. Group A ( n = 4, controls) received only dicloxacillin, 500 mg po bid, beginning on Day 4. Group B ( n = 5) underwent transfer of a vascularized sternocephalicus muscle flap around the infected graft, but received no antibiotics. Group C ( n = 5) underwent muscle transfer as in Group B and were given dicloxacillin as in Group A. Dogs were followed until anastomotic disruption occurred or for 60 days. Quantitative bacterial cultures were taken from sternocephalicus muscle and wound fluid at the time of debridement and at sacrifice. All dogs that received antibiotics without flaps or flaps without antibiotics (Groups A and B) experienced anastomotic disruption. Dogs that received both antibiotics and flaps (Group C) had a significantly lower incidence of hemorrhage (20%, P < 0.05). At sacrifice, fewer bacterial colonies were cultured from muscle flaps of Group C as opposed to Group A dogs (0.05 ± 0.02 × 10 5 vs 0.79 ± 0.31 × 10 5, P < 0.05). Muscle flaps with antibiotic therapy may prove to be effective treatment for infected prosthetic vascular grafts.

Use of muscle flaps in the treatment of infected sternotomy.

Deep wound infection after open-heart surgery remains a major problem. In this paper potential indications and techniques for use of muscle flaps in the treatment of chronic sternal infections are discussed and the authors' early experience with such treatment is presented. A well vascularized muscle flap fills out the defect, may help to control infection, and accelerates healing. After adequate excision of infected tissue, bone and cartilage, the resulting defect is covered with a muscle flap immediately or after a period of open treatment. Coverage with a flap of pectoralis major muscle was used in five patients 3 weeks to 6 months after cardiac surgery. Primary healing occurred in two patients, secondary healing in one and healing with residual fistula in one patient. In the fifth case there was uneventful recovery with primary healing until death occurred from cerebral haemorrhage after 3 weeks. Use of muscle flaps seems to be a valuable complement in the management of severe sternotomy infections.

A successful approach to vertebrobasilar aneurysms

✓ The authors present a surgical technique for approaching vertebrobasilar area aneursysm. The dural and clival defect is obliterated by means of a live vascularized muscle flap. A regimen of antimicrobial prophylaxis is described.