Well-vascularized Flap Research Articles

The Surgical Anatomy of the Scalp

Cadaveric dissections and surgical observations have led to the description and clarification of the boundaries. blood supply, and nomenclature of the layers of the scalp. Special attention was directed to the layer of "loose connective tissue" that lies beneath the entire galea and above the cranial periosteum centrally, and the temporalis fascia laterally. It has been named the subgaleal fascia (SGF). The subgaleal fascia is a trilaminar structure with unusual potential in reconstructive surgery. Histologic study reveals the subgaleal fascia to be composed of a central dense collagenous layer surrounded by vascularized areolar tissue. It is readily dissected from surrounding galeal and periosteal layers. The subgaleal fascia was probably included in previously described "pericranial flaps," which were often based beyond the periosteum. The blood supply of the subgaleal fascia originates from the proximal portion of the peripheral vessels of the scalp and continues within the areolar lamina. The subgaleal fascia is an exceptionally thin, malleable, and well-vascularized flap useful for facial reconstruction.

Iliac Versus Cranial Bone for Secondary Grafting of Residual Alveolar Clefts

Secondary bone grafting of the maxilla in the mixed transitional dentition stage has become a well-accepted procedure in the surgical protocol for rehabilitation of patients with residual alveolar clefts. This retrospective study was undertaken to evaluate and compare the long-term results obtained with iliac or cranial cancellous bone graft material in the area of alveolar clefts and was based on the independent experience of two plastic surgeons from the same center using exclusively cranial or iliac cancellous bone, respectively. The criteria for surgery were similar. The surgical technique, with the exception of the bone-grafting material, also was similar, and all patients were treated by the same group of orthodontists. Fifteen patients from each group, from a total of over 100 patients, were randomly selected and included in the study. All patients were followed up from 18 to 60 months. Operative and perioperative parameters, donor-site morbidity, and long-term results were evaluated, compared, and analyzed. There were no significant differences between the two groups, and equally good results in terms of bone incorporation, tooth eruption, and appearance were obtained with both iliac and cranial bone grafts. We conclude from our study that successful bone grafting is primarily achieved by adherence to meticulous surgical technique, simultaneous closure of coexisting oronasal or palatal fistulae, use of cancellous bone particles only, and coverage of the grafts with well-vascularized flaps. The source of bone graft does not seem to primarily influence the success of the outcome.

Salvage of chronically exposed Gore-Tex vascular access grafts in the hemodialysis patient.

Exposure and infection of a Gore-Tex vascular access graft often results in removal of the graft. Salvage of the graft is possible, however, with the use of well-vascularized muscle flaps. In 1982, Hodgkinson was the first to use a sublimis muscle flap to cover an exposed vascular access graft. We used the flexor carpi ulnaris and flexor digitorum superficialis to cover exposed Gore-Tex grafts in nine patients. The sublimis was used to cover distal graft exposures, and the longer flexor carpi ulnaris muscle was used to cover more proximal sites. Multiple exposures required both flaps or combinations of muscle flaps and local rotation flaps. Eight of nine chronically exposed grafts were salvaged using these techniques; a graft was removed from one patient because of diffuse unrecognized graft bed infection. Disability is minimized by using only part of the sublimis, and loss of the flexor carpi ulnaris is compensated by local muscles with similar actions. Vascular puncture can be continued during healing.

Microsurgical hypospadias repair.

Successful primary hypospadias repair depends on careful execution of surgical principles, particularly during the urethroplasty portion of the procedure. These principles include careful tissue handling, development of well-vascularized flaps, and avoidance of placing sutures in the uroepithelial surface. Despite meticulous repair, the complication rate requiring secondary surgery is 15 to 30 percent. For the past year, the authors have utilized an operating room microscope, microsurgical instruments, a specially designed microsuture, and a Biooclusive dressing to decrease the postoperative morbidity and subsequent complications requiring secondary surgery (6.5 percent). A comparison of 50 hypospadias patients on whom no microsurgical repair had been used was made with 62 patients on whom microsurgical techniques were employed. The nonmicrosurgical group had 17 complications, 12 of which required reoperation (24 percent). The microsurgical group had 8 complications, 4 of which required reoperation (6.5 percent).

Carcinoma of the Tongue and Tonsil (Oropharynx)

In this article, the multidisciplinary approach to the management of carcinomas of the tongue and oropharynx has been emphasized. The decision for the primary mode of therapy will depend on the multiple factors discussed herein. However, a surgeon skilled in the management of head and neck tumors, including major reconstructive techniques, should lead the team. Most patients with head and neck carcinoma present with lesions that are relatively far advanced, and the combination of surgical excision and radiation therapy has proved to be the best method of controlling this disease. Even when cure is unlikely, the palliation of the patient by proper resection and immediate reconstruction, followed by adequate radiation therapy, can provide significant palliation and, it is hoped, avoid the horribly painful and agonizing death that ensues from massive local recurrence in the head and neck. Modern reconstructive techniques allow for reasonable aesthetic and functional restoration, which can be performed in a single stage at the time of the ablation of the tumor. Healing with these well-vascularized flaps is predictable and allows the patient to get to the radiation therapist within the early postoperative period. A full tumoricidal dose of radiation therapy can then be instituted with the expectation that the reconstruction with the vascularized tissue will withstand the irradiation well. This avoids the increased complication rates associated with operating in irradiated fields and gives the radiation therapist a better chance for effective therapy with a markedly reduced tumor load. These tumors remain one of the most obstinate problems that surgeons face today. However, an aggressive approach to control local disease remains the best therapy and offers the patient the only chance for cure. These are difficult patients to manage from many aspects. I believe that the statement made by Dr. Charles Mayo in 1905 remains timely: "A large part of abdominal work is recreational as compared with the work of what might be called the heavy surgery of the neck."

Clinical anatomy of the internal oblique muscle.

In recent years microvascular free tissue transfer has become a well accepted reconstructive technique. The current trend in flap research seems to be the development of more refined flaps to meet specific needs with minimal donor site morbidity. The internal oblique muscle provides a broad, thin, well-vascularized flap which is ideally suited for restoration of contour with excellent aesthetic results. In addition, the iliac crest may be raised in continuity based on the same vascular pedicle, i.e. the deep circumflex iliac vessels. The purpose of this article is to describe the anatomic details necessary for the clinical application of this versatile flap. Thirty specimens of the internal oblique muscle flap were dissected and studied using Microfil injection techniques, including xerograms. In about 80 percent of the flaps, a single ascending branch of the deep circumflex iliac artery (DCIA) enters the undersurface of the muscle, arborizing within the muscle. In the remaining 20 percent, two or three branches enter the muscle separately, originating on the DCIA. The arc of rotation extends into the ipsilateral groin for coverage of exposed femoral vessels, along the pubis and the anterior perineum. The length of the vascular pedicle is to 6 to 7 cm and the vessel diameter is 2.0 to 3.0 mm, making the flap suitable for free tissue transfer.

Histologic changes in skin implanted into the larynx and trachea by myocutaneous flap reconstruction.

Skin is the tissue most readily available for relining the walls of the reconstructed larynx or trachea. Its use has been condemned in the past because of potential contracture, complications have occurred when free, split-thickness grafts were used. We studied the changes that develop within skin that is transferred into the lumen of the airway as part of a vascularized sternohyoid myocutaneous flap. Twenty-one dogs underwent reconstruction of laryngotracheal defects by a vascularized myocutaneous flap. The closely shaved and chemically depilated skin included in this reconstruction was ultimately found to be well healed to the adjacent mucosa. Flaps as large as 8 cm2 survived with no evidence of scaling, crusting, or contracture. The cutaneous appendages in the flaps were compared with those found in adjacent skin near the donor site. After proper depilation there was involution of cutaneous appendages. Scarring of the dermis appeared to add support to the grafts. Our findings demonstrate that the rotary door sternohyoid myocutaneous flap is a reliable, well-vascularized flap that can have extensive application in laryngotracheal reconstruction.

Gluteal thigh flap repair of chronic perineal wounds.

Since the introduction of the gluteal thigh flap in 1979, we have had the opportunity to study and modify this reconstructive technique in over 40 patients. Our successful experience with the gluteal thigh flap in six consecutive patients with difficult, nonhealing perineal pelvic sinuses has increased our confidence with this modality and led to a modified technique. Bilateral deepithelialized and well-vascularized flaps are harvested from the posterior thighs and transferred to the perineal wounds on pliable musculofascial pedicles through the ischiorectal space. Proper filling of the pelvic space requires adequate debridement, which may include release of a bottleneck narrowing of the sacral promontory. Donor site morbidity is minimal and temporary. Follow-up periods of 8 months to 5 years have revealed no wound recurrence.

Toxic lesions of the hand associated with chemotherapy

New agents used in cancer chemotherapy are continually appearing which, in turn, leads to newer patterns of toxicity. This report reviews experience with some upper extremity lesions associated with chemotherapy. Doxorubicin extravasation caused deep soft tissue necrosis that was successfully managed by aggressive excision and delayed coverage with a well-vascularized flap. Bleomycin resulted in palmar swelling, erythema, and digital pulp necrosis, which healed secondarily. Intravenous nitrogen mustard caused an immediate, and alarming, perivenous hyperpigmentation that was painless but long lasting. Bacille Calmette-Guerin immunotherapy was followed by a large, localized skin slough that was indolent, painful, and healed secondarily. 5-Fluorouracil was associated with permanent, dark pigmentation of the hands along with slough of the digital pulps. The myelosuppression resulting from combination therapy may also predispose these patients to fulminant hand infections, which can be lethal.

Immobilization of the mandible in oral cancer therapy

After resection of the mandible, wound complications can be minimized and functional and aesthetic disabilities reduced by (1) immobilization of the soft tissue wound by intermaxillary-mandibular immobilization of the remaining mandible, (2) the liberal use of well-vascularized flaps for intraoral wound closure, and (3) the limited use of prostheses except when required to suspend the hyoid bone or prevent displacement of the rami.