Superior gluteal artery perforator free flap for breast reconstruction

The purpose of this paper is to present a new method of breast reconstruction utilizing skin and fat from the buttock without muscle sacrifice. Cadaver dissections were done to study the musculocutaneous perforators of the superior gluteal artery and vein. Eleven breasts were reconstructed successfully with skin/fat flaps based on the superior gluteal artery with its proximal perforators. Long flap vascular pedicles allow the internal mammary or thoracodorsal vessels to be used as recipient vessels. This new technique has several advantages over the previously described gluteus maximus myocutaneous flaps, including long vascular pedicle and no muscle sacrifice.     

Treatment of complex postoperative lumbosacral wounds in nonparalyzed patients

Postoperative infections after back operations can produce complex wounds with myonecrosis, deep dead space, and exposed orthopedic hardware, bone, and dura. Three ambulatory patients with complex postoperative back wounds that resulted from infections were treated successfully with antibiotics, debridement, irrigation, and closure of deep dead space with a superior gluteal muscle flap. Several surgical maneuvers can be performed to increase the length of the superior gluteal muscle flap. The inferior portion of the gluteus maximus was left intact to preserve gluteus maximus function. All three patients obtained healed wounds. The exposed A.O. plating system was not removed. There has not been any recurrence of infections. The superior gluteal muscle flap is a reasonable flap to fill deep dead space in the low back and has some advantages over free flaps.     

Superior gluteal vessel as recipient for free flap reconstruction of lumbosacral defect

When the lumbosacral soft-tissue defect cannot be closed with a local flap, the option of a free flap should be considered. However, very few cases of free flaps have been reported, the reason being mainly difficulties in finding a suitable recipient vessel. Several vessels, such as inferior gluteal vessel, extension of thoracodorsal vessel with vein graft were reported as recipient vessels, but each one had its own drawbacks. The superior gluteal vessel has been used as a donor vessel in breast reconstruction after mastectomy but is thought to be undesirable as a recipient for microvascular anastomosis, mainly because of technical difficulty. From May of 1993 to March of 1997, five patients (one man and four women) received microvascular transfer of latissimus dorsi myocutaneous flaps using the superior gluteal vessel as a recipient. Their ages ranged from 11 to 64 years (mean 44 years of age). The causes of lumbosacral defects were tumor (1), trauma (1), radiation (2), and pressure sore (1). Before free flap transfer, the patients received an average of 2.8 operations for sacral lesions. Mean follow-up period was 12.4 months (2 to 40 months). A lateral approach was used to the superior gluteal vessel after elevation and retraction of gluteus maximus muscle. A thoracodorsal artery and vein were anastomosed to superior gluteal artery and vein in three cases, whereas in two cases, one artery and two veins could be anastomosed. All the flaps survived with complete recovery from sacral lesions. During the follow-up period, one case of partial skin graft necrosis and one case of a small superficial pressure sore developed, but there was neither dehiscence nor recurrence. The superior gluteal vessel is large in caliber, constant, with numerous branches, lying in proximity to the lesion, and relatively unaffected despite previous radiation. The technical difficulties with the deep location and short pedicle length can be overcome with some modifications in approach to the vascular pedicle. The superior gluteal artery and vein can be used as a recipient for the free tissue transfer when the lumbosacral defects cannot be covered with a conventional method.     

Unilateral multilayered musculocutaneous V-Y advancement flap for the treatment of pressure sore

We have devised a modified technique using the gluteus maximus musculocutaneous flap as multilayered sliding V-Y advancement to cover pressure sores on the sacral area. Nine patients with relatively large (average 7 x 7 cm) sacral grade IV pressure sores underwent unilateral multilayered V-Y advancement flap. All patients were followed for a minimum of 8 weeks. The mean postoperative follow-up was 32.3 months, with a range of 24 to 39 months. Using this technique, the success of surgery, i.e., the percentage of sores that healed, was 100 percent in our patients. The advantages of this technique include sufficient advancement of the flap, coverage of large ulcer defects using only a unilateral musculocutaneous flap, and preservation of the contralateral gluteus maximus muscle for future use.     

Gluteal compartment syndrome: case report

A compartmental syndrome can occur in any space limited by fascia or skin. A case of a gluteal compartment syndrome is reported, apparently from prolonged pressure after a drug overdose. Clinical features were a painful expanding gluteal mass with sciatic nerve dysfunction. Fasciotomy of the tensor fascia lata and the overlying fascia of the gluteus maximus resulted in rapid relief of symptoms.     

Comparative pathogenesis of human WA1 and Babesia microti isolates in a Syrian hamster model

The medial thigh flap is a perforator-based flap nourished with septocutaneous or muscle perforators originating from the femoral vessels. To date, 8 patients have been repaired with this flap and extended or connected flaps including this flap: 4 patients with lower leg defects and 4 patients with intraoral and neck defects. The advantages of this flap are (1) several pedicle perforators exist for this flap, which makes possible duplicated vascular anastomoses to establish reliable circulation of the transferred flap; (2) the flap can be extended or connected to other neighboring flaps in the anterior thigh, so that extensively wide defects can be closed in one stage; (3) the great saphenous vein can be simultaneously used as a vein graft or for venous drainage for the flap; (4) the anterior branch of the femoral nerve can be used for sensory potential; and (5) there is minimum morbidity of the donor defect and a large dominant vessel for the leg can be preserved. The suitable indications for this flap are defects after removal of skin cancer in the foot or lower leg and wide defects after resection of head and neck cancer, which can be reconstructed with the flap connected to neighboring skin flaps. The disadvantages of this flap are that it has a small, short vascular pedicle and the bulkiness of the flap's fatty tissue often requires thinning.     

Closure of multiple pressure sores with split total thigh flap

Pressure sores remain a pervasive and recurrent problem in the chronically bedridden and immobilized insensate patient populations, such as those with spinal cord injury. Various musculocutaneous flaps based on muscles of the buttock and thigh are routinely used to close primary, uncomplicated ulcers. The gluteus maximus, tensor fascia lata, and posterior thigh muscles, for example, can be used to close the majority of primary defects. In the case of extensive and recurrent ulceration, however, particularly when the hip joint or proximal femur is infected or marked heterotopic ossification is present, these conventional flaps are inadequate. The total thigh flap offers a solution to some of these problems by providing a large volume of tissue as a unit to cover the defects, particularly in cases in which other reconstructive options have been exhausted. We describe a modification in the total thigh flap procedure by splitting the flap according to its vascularity to achieve closure of multiple pressure ulcers in a one-stage procedure.     

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.     

Myocutaneous flap as reliable defect coverage in high grade pelvic decubitus ulcers. Classification, therapeutic concept and presentation of personal patient sample of 16 years

Infected pelvic pressure sores of Campbell stages IV-VII require soft tissue reconstruction, which means stable, multi-layered filling cover of the defect and reliable prophylaxis of relapse. Myocutaneous flaps meet these conditions well. Depending on the extent and the area of the sore, with predilection for the sacrum, the ischial tuberosity and the femoral trochanter, the gluteus maximus, biceps femoris and tensor fasciae latae muscles are most often used for myocutaneous flaps. Primary sutures, split skin grafts or local fasciocutaneous flaps are often sufficient treatment for smaller, superficial defects. Between 1981 and 1996, 133 patients (average age 50 years) with 212 pelvic pressure sores of all stages were treated in our clinic. After radical decubitus excision with pseudotumor technique and resection of the osseous prominences, one-stage reconstruction of solitary as well as multiple defects was performed with myocutaneous flaps in 135 cases. The postoperative general complication rate for all treatments was about 10-30%. With regard to the muscle flaps, one third healed without any problems, partial flap necrosis occurred in 6% and there was total loss of flap in 2% of all myocutaneous flaps. According to present knowledge, myocutaneous flaps seem to be the most reliable method for definitive covering of deep pelvic pressure sores, independent of the cause of the ulcer.     

Remnant-like particle cholesterol levels in patients with dysbetalipoproteinemia or coronary artery disease

Fibula osteocutaneous free tissue transfer to reconstruct the oromandibular complex is a widely recommended technique following oncologic resection. Preoperative determination of adequate perfusion to the donor extremity is necessary to assure lower extremity viability after flap harvest. Vascular variations and/or peripheral arterial occlusive disease (PAOD) may exist whereby sacrifice of peroneal vessels can cause ischemia to the lower leg and foot. Additionally, variability of cutaneous perforators can make the fibula skin paddle viability unpredictable. Color flow Doppler (CFD) is a reliable modality to preoperatively assess the lower extremity in fibula osteocutaneous free tissue transfer patients. Prospective CFD examination of 38 consecutive patients (76 legs) considered for fibula free flap reconstruction was performed. A standard protocol was designed to evaluate the lower extremity vasculature and identify cutaneous perforators with CFD. Findings were studied with respect to flap choice, operative findings, and reconstruction outcomes. Number of cutaneous perforators and their impact on skin paddle design were also recorded. Color flow Doppler's ability to image peroneal vessels as well as determine collateral and distal perfusion were effective. CFD accurately identified bilateral vascular anomalies in one patient (2.6%), and significant arterial disease in three patients (7.9%). Cutaneous perforators were also accurately mapped and confirmed intraoperatively in 31 patients. In several instances, the information provided by the CFD examination altered flap selection, 4/38 patients (10.5%), or skin paddle design, 5/32 patients (15.6%). Color flow Doppler allowed successful fibula transfer in all the free flap candidates with normal exams. It has the advantages of low cost and no morbidity. CFD allows for accurate mapping of fibula cutaneous perforators which facilitates skin paddle design. We recommended the use of preoperative CFD in all patients being considered for fibular free flap surgery.     

Sacrococcygeal and transsacral epidural anesthesia in the laboratory pig: a model for experimental surgery

We present a selected group of patients (18) who underwent excision of various malignant skin lesions in the leg, and had the defect resurfaced with V-Y advancement flaps. The mobility and reliability of this type of flap was enhanced by raising it as a fasciocutaneous flap based on one or two leg perforators. As patients were mobilised as soon as they recovered from the operation, there was minimal postoperative morbidity. This type of flap has the added advantage of leaving no significant donor defect and therefore better cosmesis.     

Surgical cover of dorsolumbar radionecrosis. Apropos of 6 cases

Thoracolumbar radionecrosis may be difficult to cover. We often use muscular or myocutaneus flaps available in this location, mainly the latissimus dorsi flap. It can be used as a pedicle, free, or especially a "reversed" flap with lumbar pedicles. However in our experience and in the literature this reversed flap is difficult to use because of the morbidity of the flap, transposed without its main pedicle. The authors consider the current methods of cover by flaps in six cases and in the literature. Surgical possibilities are now more numerous. First, a latissimus dorsi muscular flap autonomized by vascular delay, half-free flap, or a flap with the lengthening of its pedicle is possible. Second, we can also use an intercostal island flap for the back and a gluteal thigh flap in the lumbar region.     

The distally based forearm island flap in hand reconstruction

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.     

The anatomic basis of the gracilis perforator flap

Another perforator flap, the gracilis perforator flap, has recently been added to the armamentarium of reconstructive surgeons. A detailed study of the anatomy of this flap was undertaken in this study. Forty-seven dissections were performed in cadavers and clinical cases of gracilis muscle harvesting for various reconstructive reasons. According to our findings, at least one musculocutaneous perforator of large calibre was found in the majority of the dissections performed (87%), emanating from the proximal third of gracilis. All the perforators were located within a radius of 7 cm from the point of entrance of the gracilis main vascular pedicle. In their majority, they emanated proximal to that point (83%) from the middle part (anteroposterior axis) of the muscle (62%). The intramuscular course of the perforators was easily followed and few muscular branches were encountered, before they joined the main vascular pedicle. A sensory branch of the anterior obturator nerve, accompanying the perforators, was occasionally found (29%). Finally, a superficial vein, branch of the greater saphenous, was always found within the skin territory of the flap in all dissections performed in cadavers.     

Fruits of technology--must we feed an aged patient at all costs?

The authors present a study of the intrinsic anatomy of the gluteus medius m, and of its innervation through the caudal branch of the superior gluteal n. The existence of an intramuscular tendon in the thickness of the gluteus medius was constantly prooved in 40 muscles. The relations of the intrinsic fibrous structure of the muscle and its innervation were studied. The authors deduce from that the topography of a gluteus medius incision, with respect to a safety area towards its innervation, which leads to an exposure of the acetabulum that is satisfying and gives opportunities of a sound repair after the surgery of the hip joint through the transgluteal approach. They propose the "anterior hemimyotomy of the gluteus medius m" designation.     

A case of multiple muscular abscesses of the lower limbs by Staphylococcus aureus after chemotherapy for lung cancer

A 67-year-old male was admitted to our hospital because of lung cancer and interstitial pneumonia. Cisplatin, vindesie and mitomycin C were administered for treatment of lung cancer. The leucocyte-counts declined to 1700/microliter on the eighth day after the chemotherapy. Though granulocyte colony-stimulating factor was administered, pain in the right thigh and high grade fever developed. Because Staphylococcus aureus was isolated from the blood specimen, piperacillin was administered. But the high grade fever continued and the pain was expanded to the right hip, left hip, thigh and leg. Because a computed tomograph of the lower limbs showed low density areas in bilateral gluteus maximus muscle right adductor magnus muscle, left biceps femoris muscle and left soleus muscle and the culture of an aspirate from abscess of right leg detected S. aureus, multiple muscular abscesses of the lower limbs was confirmed. We changed the antibiotics from PIPC to imipenem/cilastatin and minocycline on nineteenth day after the chemotherapy. His symptoms improved after the change of antibacterial agents. But he died of acute exacerbation of interstitial pneumonia, after about two months of the chemotherapy. Muscular abscesses of the limbs are very rare in Japan. Only four cases with muscular abscess of the limbs were reported in Japan, since 1988. This case suggests that a muscular abscess must be considered in the differential diagnosis of fever in patients with neutropenia.     

An alar base flap to correct nostril and vestibular stenosis and alar base malposition in rhinoplasty

Nostril and vestibular stenoses can be properly reconstructed by composite grafts from the alar lobule or ear. However, when alar base malposition accompanies the nostril stenosis, composite grafting will enlarge the nostril but not correct the alar base displacement. An alar base flap designed as a crescent adjacent to the alar base, elevated, and transposed on subcutaneous and musculocutaneous perforators corrects the nostril stenosis and repositions the alar base simultaneously. Anterior, active rhinomanometry demonstrates a substantial increase in mean nasal airflow from this reconstructive maneuver alone. The author has used the flap successfully in 29 secondary rhinoplasty patients; survival has been uniformly complete even when the donor tissue has been scarred or burned. All rhinoplasties were performed endonasally, however; the survival of this flap performed simultaneously with open rhinoplasty has not been established.     

Alterations of lymphocyte subsets in patients with recurrent fetal wastage positive for antiphospholipid antibodies treated with Chinese herbal medicine

The delay technique is an established method of enhancing flap survival. This investigation attempts to determine which of two delay techniques results in the best delay effect by measuring their relative abilities to capture adjacent vascular territories in a rat model. A dorsal flap based on the iliac branch of the iliolumbar artery with a captured random zone corresponding to the axial territory of the lateral thoracic artery was used in the evaluation. Sprague-Dawley rats (350-400 g) were randomly assigned into three groups. Group I was the control group. In group II, the circumferential borders of the animal's dorsum were incised without undermining and the dominant pedicle of the lateral thoracic flap was divided. In group III, the medial and lateral borders of the flap were incised and undermined as a bipedicled flap, violating the musculocutaneous perforators. The dominant pedicle of the lateral thoracic artery was also divided. Group III had the greatest survival with only 9% of flap area necrosis compared to 28% and 21% for groups I and II, respectively. These differences were statistically significant. The results suggest that musculocutaneous perforators provide a substantial vascular source to the tissue at risk and should be considered in selecting a delay technique.