Well-vascularized Flap Research Articles

Repair of a recurrent rectovaginal fistula using gluteal-fold flap: Report of a case

Various surgical procedures have been reported for the repair of a rectovaginal fistula, but a failure of the initial repair leads to difficulty in the second and later operations. This report presents the case of a 58-year-old woman with a recurrent rectovaginal fistula after a low anterior resection for rectal cancer who achieved a good outcome following a repair using a gluteal-fold flap. We therefore conclude that the transfer of a well-vascularized gluteal-fold flap may be a safe and reliable method to repair a rectovaginal fistula with a large diameter following repeated recurrence.

Rotation Mastopexy: An Anatomical Approach

Corduff and Taylor [1] from Australia reported on their technique for vertical mastopexy with the use of a large vascularized flap rotated to fill the upper pole of the breast. They present 25 patients, over 2 years, who have undergone the procedure; 18 were primary mastopexies and 7 were mastopexies after implant removal. The authors were very clear when they declared that ‘‘the goals of a mastopexy are to restore shape and volume,’’ but the biggest difficulty is to maintain this shape for long-term follow-up. If we do not use an implant, the goal is to remove the tissue from the inferior pole to avoid an earlier bottoming out. The challenge is how to do it. The authors rotate a flap from the lower breast gland as a medial pedicle flap into a pocket beneath the upper pole. They describe the anatomy and explain the technique very well. However, I did not see differences between their technique and Hall-Findlay’s technique [2]. Hall-Findlay uses a medial pedicle flap to move and fill the upper pole, but she does not undermine the upper pole as the authors do. Maybe this is the only difference between the two techniques. The authors wrote in the Introduction: ‘‘Techniques have been described using small glandular flaps transposed to increase projection [2–7], but these do not adequately fill out the upper pole.’’ Therefore, the authors’ ideas conflict with the already established technique, as Hall-Findlay (ref. 6 in Corduff and Taylor) and Graf and Biggs (ref. 2 in Corduff and Taylor) [3] described, in which they rotate flaps from the middle and inferior pole of the breast, respectively, to fill the upper pole. Regarding Graf’s technique, the main goal is upper-pole fullness, where a chest wall-based flap is moved superiorly, passing under a loop of the pectoralis muscle flap, and is fixed to the upper pole reaching the second intercostal space. This provides a long-lasting result with upper-pole fullness. We can add new techniques and new approaches but never try to decrease the merits of the already described techniques. In breast mastopexy, no one is perfect because the breast is a not a fixed organ and changes with the aging process. Every technique seeks to maintain the results for long-term follow-up, but only a few have reached these goals. We can observe in this paper (Figs. 7–10) that the postoperative results are similar to many techniques with the upper pole not completely full as the authors try to show. When we have so many different techniques to fix one problem, it means that no one is perfect; as Tom Biggs always says: ‘‘No key fits every lock.’’ We have to analyze every case and try to use the best for each case. One of the important aspects is the skin quality of the patients. It sometimes guides the final result regardless of the technique used. I agree with some of the authors’ points regarding attempts to improve upper-pole fullness in mastopexy by using well-vascularized flaps when the patient has enough breast tissue to use. I congratulate the authors for embracing this challenge, treating breast ptosis with the patient’s own tissues to obtain a successful result with mastopexy. Certainly there is no one right way to do this. It will depend upon the experience and preference of the surgeon and on each individual pattern of the breast. R. M. Graf (&) Division of Plastic Surgery, Hospital de Clinicas, School of Medicine, Federal University of Parana, Rua Solimoes 1175 Merces, Curitiba, PR 80810-070, Brazil e-mail: ruthgraf@bighost.com.br

Galeal Flap Based on Superficial Temporal Vessels for Oral Cavity and Pharynx Reconstruction – An Anatomical Study

Despite the advances in microvascular free tissue transfer for intraoral reconstruction, this surgery is not recommended for all patients. In specific cases, the pedicled temporoparietal galeal flap may be an option for reconstructive procedures in the head and neck regions. The objective of this paper is to present the anatomical aspects of a galeal flap based on the superficial temporal vessels and to test its potential for reconstructing diverse sites of the oral cavity and pharynx. We performed 40 dissections on 34 fresh adult cadavers. The flap vascular anatomy was studied by injecting latex into the superficial temporal vessels. A standardized square-shape flap measuring 10 x 10 cm(2), pedicled on the superficial temporal vessels, was raised. Oral cavity and oropharynx reconstruction simulations were performed after flap transposition into the mouth by passing it under the zygomatic arch. Hypopharyngeal reconstruction was tested by transposing the flap to the neck under the facial nerve. After latex injection, a rich vascular network over the temporoparietal galea was observed directly from the superficial temporal artery, and a well-vascularized flap based on this vessel was raised. In the reconstruction simulations, the flap was shown to be suitable for the coverage of hypothetical defects in most oral cavity and pharyngeal sites, mainly the retromolar trigone, tonsil area, and buccal mucosa. A galeal flap based on the superficial temporal vessels presents favorable anatomical characteristics for oral cavity and pharyngeal reconstruction.

Iatrogenic vesicovaginal multioperated fistula in a 6 year old girl. What is the best approach?

Purpose Vesicovaginal fistula is an uncommon clinical entity in pediatric urology practice. We present the video of a 6 year old girl who underwent elsewhere at the age of 3 months a nephroureterectomy due to nonfunctional ureterohydronephrotic right system. The patient developed a vesicovaginal fistula and since then she had undergone one open and another endoscopic unsatisfactory attempt to treat the fistula, before she was referred to our institution. Material and methods We performed a cystogram that confirmed the fistula and showed left vesicoureteral reflux. The cystoscopy showed an infratrigonal fistula close to the previous right ureteral orifice. We decided to do a transvesical approach and were able to identify the defect. With cautious dissection of the bladder wall, we managed to isolate it from the vaginal wall. The fibrotic tissue was excised and the vagina was closed in two layers through the bladder. We used fibrin glue and prepared an omentus flap that was mobilized laterally to the bladder up to the trigonal area that was used to cover the vaginal suture. At last, we closed the posterior wall of the bladder that was previously attached to the fistula and a cystostomy tube was left for 4 weeks leaving the contralateral ureter untouched. Results The patient had a satisfactory result and after cystostomy tube removal the fistula was indeed closed. Conclusions Infratrigonal vesicovaginal fistulas in children, differently from adults should be better treated through the abdomen, observing the general principles of fistula closure: complete isolation of the organs involved, removal of fibrotic tissue, closure in various layers, use of fibrin glue and interposition of well-vascularized flaps.

Isolated cervical esophageal reconstruction for rare esophageal tumors

Isolated defects in the cervical esophagus in patients who have not undergone total laryngectomy are uncommon. We report 2 cases of rare esophageal tumors requiring reconstruction of the cervical esophagus after tumor resection. The patients were a 51-year-old woman with an esophageal granular cell tumor and a 54-year-old woman with an esophageal schwannoma. Both defects were reconstructed with a radial forearm flap. A small subclinical leak developed in 1 patient and healed spontaneously within 2 weeks. At 1 year and 2 years of follow-up, both patients were consuming a normal diet and had normal voices. A thin and well-vascularized flap such as the radial forearm flap is essential for reconstructing an isolated cervical esophageal defect so as to maximize functional outcome.

Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.

Closure of Meningomyelocele Defects With Bilateral Modified V-Y Advancement Flaps

Although several different methods were described in the literature, closure of large meningomyelocele defects presents a challenging problem. Wound dehiscence may lead to devastating complications. In this paper, the efficacy of the bilateral modified V-Y advancement flap procedure was investigated in terms of simplicity, donor-site morbidity, and reliability. The authors presented 10 neonates treated with a modified subcutaneous advancement procedure. Unlike the typical V-Y advancement techniques, the apical extensions of the "V" flaps were elevated based on the paraspinous perforators. A standard closure algorithm was not followed, as the well-vascularized apical extensions facilitated intraoperative decision making for the most appropriate adaptation pattern, depending on the size, shape, and localization of the defect. As well as that, transposition of these apical flaps to the defect site was further supported by the advancement of the V-Y flaps to decrease the tension along the closure. Mean follow-up period was 13.6 months (range 3-37 months), and no complications that might be attributable to the operative procedure were observed. Utilization of bilateral modified V-Y flaps for the closure of large meningomyelocele defects is a simple and effective procedure. Main advantages of the method described in this paper may be listed as follows: simplicity, reliability due to coverage of the defect with well-vascularized flaps, minimal bleeding, decreased operative time, and no donor-site morbidity.

Scrotal dartos flap for the prevention of the urethrocutaneous fistula on hypospadias urethroplasty

Urethrocutaneous fistula is a common complication of urethroplasty for severe hypospadias, even when a microsurgical technique is applied. From June 2001 to July 2003, we applied the scrotal dartos flap wrapping technique to prevent the occurrence of urethrocutaneous fistula in 14 patients with hypospadias. Hypospadias was repaired without fistula formation in all but one patient, who developed a tiny fistula which was later closed successfully by a simple procedure. We recommend the scrotal dartos wrapping technique for covering the neourethra with a well-vascularized flap because of fewer complications, although the procedure to obtain the vascularized flap may take longer.

Rectovaginal radiation fistula repair using an obturator fasciocutaneous thigh flap

Background. Rectovaginal fistulae are a known complication of pelvic radiotherapy utilizing locally applied isotope implants. Most often, either permanent colostomy or reconstruction with a well-vascularized flap is necessary. Traditional techniques for fistula repair utilize bulky muscle flaps, disfiguring pudendal artery flaps or may require laparotomy. Case. We describe the management of a 26-year-old woman with a large radiation-induced rectovaginal fistula. A fasciocutaneous medial thigh flap based on terminal branches of the obturator artery and vein was used without colostomy and resulted in pain-free sexual function and minimal vulva disfigurement. Conclusion. A medial thigh fasciocutaneous flap without muscle can be transferred into the vagina on the obturator vessels and may become the preferred method for managing large rectovaginal fistulas.

Miringoplastia com a utilização de um novo material biossintético

A miringoplastia é uma cirurgia com a finalidade de controlar a infecção no ouvido médio, reconstruir o mecanismo de transmissão sonora para a janela oval e proteger a janela redonda. São descritos diversos materiais para reconstruir a membrana timpânica, destacando-se a fáscia do músculo temporal, pericôndrio do tragus, cartilagem, dura-máter, tecido placentário, entre outros. OBJETIVO: Este trabalho tem objetivo de demonstrar o efeito de um novo biomaterial, a membrana de látex natural com polilisina, desenvolvida no laboratório de Neuroquímica do Departamento de Bioquímica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - USP. FORMA DE ESTUDO: Coorte Longitudinal. MATERIAL E MÉTODO: O biomaterial utilizado é estimulante da neovascularização e crescimento tecidual organizado em diferentes órgãos e tecidos, sendo um material inócuo e não rejeitado pelo organismo. Foi usada a biomembrana de látex com polilisina como um implante transitório para o fechamento da perfuração da membrana timpânica. A membrana foi colocada na face externa dos bordos da membrana timpânica e a fáscia temporal na face interna da mesma. Foram estudadas 238 orelhas com perfuração de membrana timpânica por seqüela de otite média crônica, submetidas a miringoplastia com enxerto de fáscia de músculo temporal e a membrana de látex natural, com idades de 7 a 76 anos. Apresentavam uma ou mais miringoplastias anteriores sem sucesso 41 dos casos. RESULTADO: Como ressaltamos preliminarmente, verificamos pega do enxerto em 90,5% das orelhas (181), sendo fechamento de perfuração amplas, 96; médias, 73 e 12 pequenas. Verificamos intensa vascularização em 100% dos enxertos, o que não é habitual quando não se usa a membrana de látex natural. CONCLUSÃO: Conclue-se que o biomaterial usado merece nossa atenção quanto ao seu uso como implante transitório em miringoplastias, melhorando o processo de revascularização da membrana timpânica remanescente.

Urothelial ingrowth over demucosalized gastrocystoplasty: an experimental study.

To evaluate histopathologically the ingrowth of urothelium over a demucosalized gastric flap used for augmentation, as such flaps increase the capacity of the bladder if the urothelium can cover the seromuscular patch. The study included eight male dogs; the urinary bladder was widely divided at its dome anteroposteriorly to receive a seromuscular gastric flap, sutured to the edges of the urinary bladder. Before and 1 month after surgery the changes in bladder capacity and pressure were recorded, and urothelial ingrowth assessed histopathologically. Two of the eight dogs died; the increase in mean bladder capacity in the remaining dogs was 20% and the decrease in mean intravesical pressure 34%. Gross pathological examination of the urinary bladder showed good 'take' of the gastric flap by the urinary bladder. Histopathologically, there was good healing of the flap, active ingrowth of urothelium, and no mucosal re-growth. Bladder augmentation with a demucosalized gastrocystoplasty allows the creation of a large compliant urinary bladder with few complications caused by the incorporation of the enteric or gastric epithelium into the urinary bladder. The stomach has a rich blood supply, allowing the harvesting of a well-vascularized flap, and urothelial ingrowth over this flap in the present study was significant.

Management of Oroantral Fistula and other Sinus-Related Complications

Summary Perforation of the maxillary sinus during dentoalveolar surgery is a relatively common occurrence. Most of these communications close spontaneously if the sinus is healthy However, the presence of preexisting sinus infection or the introduction of a foreign body through the opening can lead to formation of an oroantral fistula. The successful management of such cases depends on elimination of infection, removal of the foreign body, when present, and closure of the fistula with a well-vascularized flap that is not under tension and that places the suture line on solid bone. Many procedures that fulfill these criteria have been described, and the surgeon should select the simplest method that suits the clinical situation.

Industrial high-voltage electrical burn of the skull, a preventable injury

Deep burns of the scalp and skull are often caused by high-voltage electrical injuries. Patients with such injuries should be referred to regional burn centers that are prepared to excise necrotic burn tissue and cover the devitalized bone with a well-vascularized flap. Strategies for prevention of these electrical burns are discussed.

Radiation Injury

Principles of radiation including physics and cellular mechanism are reviewed with emphasis on acute and chronic effects on healing after radiation therapy. Pathophysiology of radiation injury includes decreased vascularity, hypoxia, and impaired leukocyte function. Management of radiation wounds generally requires extensive debridement and well-vascularized flap coverage.

The Chondrocutaneous Helical Rim Advancement Flap of Antia and Buch

The cutaneous surgeon commonly encounters defects of the helix, as 2-4% of all skin cancers occur at this site. We report our experience with 47 patients using the chondrocutaneous helical rim advancement flap of Antia and Buch. Incisions are made from the defect inferiorly into the lobule and, when necessary, superiorly along the helical sulcus into the helical crus. The postauricular skin is extensively undermined to allow maximal movement of the resulting broadbased, well-vascularized flap(s). We experienced very favorable results using this technique with our patients. No necrosis due to ischemia occurred in any of our cases. Hematomas formed postoperatively in two patients, but healing proceeded uneventfully after removal of coagulated blood. This technique is an excellent method of repairing many defects of the helical rim. Its advantages include technical simplicity, little risk of tip necrosis, patient convenience, and superior cosmesis.

Free temporoparietal fascia flap in reconstruction of the lower extremity.

Twenty-one patients with open wounds of the non-weight-bearing foot or the ankle underwent coverage with a free temporoparietal fascia flap and split-thickness skin graft. Our indications for this thin, well-vascularized flap included osteomyelitis and exposed tendon, bone, or fixation hardware. The pliability of the flap allowed superior restoration of natural anatomical contours. Only one flap was completely lost (95.2% overall success). There were four cases (20%) of partial flap loss, none of which required flap revision or a new flap. Four patients (19%) experienced transient donor-site alopecia, and one patient suffered transient palsy of the temporal branch of the facial nerve. One patient (4.7%) had an area of persistent scar alopecia in the temporal scalp after a donor-site hematoma that required revision under local anesthesia. Follow-up was available on 95% of the patients and averaged 20 months (range, 1-54 months). All patients resumed weight-bearing ambulation within 1 month from operation using unmodified footwear. The free TPF flap is a reliable coverage option, with long-term durability and minimal donor-site morbidity, for relatively superficial wounds of the distal lower extremity.

Iatrogenic Nostril Stenosis

Nostril stenosis is an infrequent finding that often has an iatrogenic cause. It is a very difficult problem to resolve and usually requires several months of prosthetic support in order to counteract the recurrence of internal scarring and shrinking. We present a 4-year-old child with a monolateral iatrogenic nostril stenosis. A satisfactory and stable correction was obtained using a "piercing" flap taken from the labial vestibule. The use of a nasal stent (not placed immediately and worn only at night) was necessary for only 2 months. This technique has a number of advantages: the absence of external scars, little or no tendency to recurrence due to the absence of contraction provided by the well-vascularized flap tissue, and the ease and rapidity of the surgical procedure.

Extended use of scrotal septal island skin flap for the repair of penile hypospadias.

In this article, one-stage repair of complicated cases of penile hypospadias when there is no penile skin available for safe reconstruction is described. An island of the most median hairless part of the scrotal skin around the median raphe was used as a skin flap based on its scrotal septal pedicle with an extended and free arc of rotation for repair of distant urethral defects. The bilaterally stretched, most median area of scrotal skin is almost hairless. This well-vascularized flap was used in reconstruction of 18 patients with recurrent, complicated, proximal, and distal penile hypospadias from January 1989 through July 1993. Of these, 17 patients were post pubertal and 1 was prepubertal. A maximum of 5 years and a minimum of 8 months follow-up showed no hair growth problems. Complications were sacculation of the reconstructed urethra in 1 patient, meatal stenosis in 1 patient, and urethral fistula in 1 patient. Technique refinements and encouraging results as well as complications are discussed.

Pelvic, Vaginal, and Perineal Reconstruction in Radical Pelvic Surgery

Radical pelvic surgery creates exceptional reconstructive challenges. The introduction of large, well-vascularized compound muscle-skin flaps placed at the time of radical surgery has enhanced prevention of major infectious and healing complications and improved the ability to deal with subsequent complications. The distally based rectus abdominis muscle-skin flap is the most useful unit because of its location, size, and reliability. A variety of regional flaps are suitable in specific reconstructive situations. Use of the flaps requires an extensive knowledge of their vascularization, variations, arcs of rotation, and history of reliability, as well as familiarity with alternative reconstructions that can be employed when the flap of first choice is not available.

Radiation-Related Wounds Of The Chest Wall

Irradiation-associated chest wall lesions pose a significant health hazard to the patient. The principles of management include (1) biopsy of any open wounds to rule out the recurrence or persistence of tumor, (2) aggressive debridement of all offending tissues, and (3) reconstruction with well-vascularized flap tissue. Numerous questions arise regarding the practical management of these patients. The controversies that have arisen during our management of more than 100 of these patients have been discussed. It is appropriate to perform reconstruction following nonhealing of a superficial ulcer or immediately following the excision of a full-thickness chest wall defect. Hyperbaric oxygen can serve as a useful adjunct. It is rarely necessary to use a prosthetic material for the purpose of chest wall stabilization during the reconstruction of full-thickness defects. Paradoxic chest wall movement in the postoperative period does not significantly affect pulmonary function tests and is generally a transient problem. Subtotal excisions are frequently necessary. As long as all of the necrotic or tumor-bearing tissue has been fully removed, these wounds can be expected to heal in most instances by placing vascularized tissue into the defect. Operative sites in previously irradiated chest wall tissue can be expected to heal if proper and careful surgical technique is employed. Nevertheless, there is a risk of wound breakdown following any surgery in irradiated tissue. Finally, we believe it is appropriate to proceed with aesthetic recontouring of chest wall deformities associated with irradiation exposure.