Clinical application of expanded free flaps based on primary or secondary vascularization

Prefabricated free flaps using an expansion technique were used for four reconstructive cases, including two leg reconstructions and two facial reconstructions. In this series, the prefabricated free flaps created by using the expander were classified into two types: the expanded flap based on the conventional vascular pedicle, which is called the expanded flap with primary vascularization; and the expanded flap based on the vascular pedicle in the carrier, which is called the expanded flap with secondary vascularization. The expanded flap with primary vascularization that is created in the trunk has a good indication for leg reconstruction, because it provides an wide and thin flap with minimal donor site morbidity. The expanded flap with secondary vascularization created in the pectoral region has a good indication for facial reconstruction, because it provides good color and texture matches. Although there are some disadvantages in the tissue expansion technique, the prefabricated free flaps using the expander are very effective in facial and leg reconstruction.     

Superiority of the microvascularly augmented flap: analysis of 50 transverse rectus abdominis myocutaneous flaps for breast reconstruction

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. In this series, the incidence of flap-site complications, including total flap loss, partial flap loss, and fat necrosis, was lowest in the microvascularly augmented flap group. Particularly, incidence of partial flap loss in the microvascularly augmented flap group was significantly lower than in the unipedicled flap group (p < 0.01). These outcomes demonstrated the superiority of the microvascularly augmented TRAM flap for breast reconstruction.     

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.     

Prevalence of ICD-10 harmful use of alcohol and alcohol dependence among the rural population in Udmurtia

Aggressive treatment of thoracic malignancy may be complicated by complex defects in the chest wall. These may be associated with serious complications such as chronic infection, respiratory or cardiac failure, or major haemorrhage. Closure of the defect and restoration of the integrity of the chest wall is important for both functional and cosmetic reasons. Local flaps are often used, but may be inadequate or unavailable. Reconstruction with free flaps is better in these cases, as this provides as much abundant well-vascularised tissue as is required. We present 12 patients treated successfully for complex chest wall defects using various forms of local and free flap reconstruction. There were five complications, three healed spontaneously and two required secondary procedures before they healed.     

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.     

The pectoralis major myocutaneous flap in oral and maxillofacial reconstruction: a retrospective analysis of 50 cases

PURPOSE: This article retrospectively reviews 50 consecutive pectoralis major flaps used in oral and maxillofacial reconstruction with respect to reliability and complications. PATIENTS AND METHODS: Fifty patients had reconstruction of postcancer resection defects of the oral cavity and maxillofacial region. The age and sex of the patients and site of defect were analyzed. The design of the pectoralis major flap and complications encountered were documented. RESULTS: There were three cases (6%) of flap failure and an additional three cases (6%) in which 40% or more of the skin paddle sloughed. Orocutaneous fistula was rare. The use of an osteomyocutaneous flap with a rib gave poor results for mandibular reconstruction. CONCLUSION: The pectoralis major flap is reliable, and the complications seen in this series were comparable to other large series in the literature. Despite the increased use of microvascular flaps, the pectoralis major flap remains an excellent reconstructive choice for large soft tissue defects in the oral cavity.     

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.     

A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction

The present article describes a method that preserves circulation during the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin island's central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction.     

Omentum flap versus pectoralis major flap in the treatment of mediastinitis

The outcome of mediastinal reconstruction during the past 10 years at the "Instituto Nacional de Cardiología Ignacio Chávez" (INCIC), Mexico City was compared. A total of 7136 patients were submitted to open heart surgery. Eighty-two patients (1.15 percent) developed mediastinitis, and 33 patients (0.46 percent) developed sternal osteomyelitis. Only patients who developed mediastinitis with sternal osteomyelitis were included in the study. Reconstruction was performed either with a major omentum flap (12 patients) or a pectoralis major flap (21 patients). The sepsis-related mortality rate was higher in the pectoralis group (28.6 percent) than in the omentum group (0 percent) (p < 0.05). All of the postoperative deaths of the pectoralis group were caused by septic shock; in the omentum group, there were no such deaths. It is concluded that mediastinal reconstruction using the omentum flap in patients with mediastinitis secondary to open heart surgery is associated with fewer septic complications than using the pectoralis major flap.     

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE: Reconstruction of soft tissue defects on the lower half of the leg. DESIGN: The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus. MATERIALS AND METHODS: Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years). MEASUREMENTS AND MAIN RESULTS: Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally. CONCLUSIONS: The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.     

Omental transfer for salvage of the moribund lower extremity

Use of omental flaps is well documented in soft tissue reconstruction of the head and neck, chest wall, and abdomen. Three cases of omental transfer for soft tissue reconstruction of the lower extremities are presented. In two patients, free vascularized omental flaps were used to cover deep soft tissue defects over the lower leg and in one patient, a pedicle flap was used to cover a deep groin defect extending into the hip joint. In all patients, use of an omental graft allowed revascularization and subsequent wound healing with good cosmetic results.     

Free tissue transfer in the management of burns

Although the majority of burn wounds undergoing surgical treatment require only excision with split-skin grafting, the introduction of free microvascular tissue transfer has allowed for the preservation of otherwise unsalvageable deep burn injuries and the resurfacing of burn scars in areas with no available local tissue. A total of 1699 patients with burn injuries were admitted to the Burns Unit in Newcastle upon Tyne in the 5 years 1989-1993. During this period 604 patients (35.5 per cent) required surgical treatment of their burns. Of these patients 582 (96.4 per cent) underwent excision of their burns with split-skin grafting, 13 (2.1 per cent) of the patients required local flap cover and nine patients (1.5 per cent) had free tissue transfer. Free flap loss in this study was 22 per cent in burns patients as compared to only 3 per cent in patients undergoing microsurgical reconstruction for other reasons.     

Timing of management of severe injuries of the upper extremity by free flap-plasty

From October 1986 until December 1993, fifty-five patients with severe injuries to the upper extremity were treated with 59 free flaps. The mean follow-up period was 34 months (8 TO 87 months). The average hospital stay was 19 days (8 to 40 days). Depending on the timing of reconstruction, the patients were divided into three groups: emergency reconstruction (within 24 hours after injury), delayed reconstruction (up to seven days) and late reconstruction (after seven days). In this paper we present our regime of treatment of severe upper extremity injuries using a free flap and discuss the principles of free flap choice.     

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.     

A comparison of artificially-depleted, lyophilized coumarin and fresh coumarin plasmas in thromboplastin calibration. European Concerted Action on Anticoagulation

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.     

Evaluation of optimal measuring site and index by QDR4500A for postmenopausal bone loss]

Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.     

Preexpansion of the tensor fasciae latae for free-flap transfer

Preexpansion has become an established technique to prefabricate elective free flap transfers. We report the use of the tensor fasciae latae flap as a donor site in two cases for reconstruction of a burn scar neck contracture and an unstable contralateral below-knee amputation stump, of which other donor sites were ruled out either by the patients' condition or by choice. Implantation and transfer were straightforward and the donor sites of very large flaps were minimized by preexpansion. The preexpanded muscle fasciocutaneous flaps were transplanted with microsurgical anastomoses of the vessels. Apart from a small area of necrosis at the distal tip of the flap developing on the sixth postoperative day, which we excised in a second operation, there were no major complications. The advantages of the combination of preexpansion and free flap transfer as well as the unique anatomical and functional qualities of this musculocutaneous unit are emphasized.     

Pediatric vascular trauma. Manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment

Twenty pediatric patients with a mean age of 9.2 years exhibited 21 injuries to arteries of an extremity and underwent operation. Included were 12 iatrogenic injuries and nine non-iatrogenic penetrating injuries. Femoral, brachial, popliteal, radial, axillary, iliac, and tibial arteries were sites of vascular trauma. Long-term follow-up, averaging 36 months, was possible in 14 patients. Postoperative scanograms, digital impedance plethysmographic studies, and bone age roentgenograms were routinely obtained. Limb length disparities greater than 5 mm, extremity blood pressure differentials greater than 10 mm Hg, and bone age retardation were encountered. Proper treatment of pediatric patients with acute arterial injuries of an extremity requires early operative intervention and continuous postoperative follow-up during years of active growth. If chronic arterial insufficiency ensues, arteriographic studies should be obtained and arterial reconstruction undertaken.     

Multiple overlapping Wiktor stenting for the treatment of diffuse lesions of small coronary arteries]

The plastic qualities and vascular reliability of the frontal flap have been widely used for reconstruction of facial tissue. We revised the files of 105 patients who had undergone surgical repair of facial tissue loss with frontal flaps. The epidemiology, etiology of the repaired tissue loss and indications for frontal flap as well as the various techniques were analyzed: 66.7% of the patients were over 60 years of age; 74% had ambulatory surgical repair; 54.4% of the repaired tissue losses were situated in the nasal region; 80% of the losses were due to tumoral formations. The median flap was the most widely used (23.2%).     

Clinical morphology of pneumoconiosis]

Different methods of primary mandibular reconstruction carried out at the Tata Memorial Cancer Hospital range from the pectoralis major myocutaneous or osteomyocutaneous composite flap, which is the most frequently performed procedure, to a free vascularised composite tissue transfer with microvascular anastomosis, including, iliac crest free vascularised bone grafts or radial artery forearm flap free vascularised radius bone grafts, free vascularised fibular bone grafts and silastic mandibular implants. The clinical results of immediate mandibular reconstruction with a silastic mandibular implant (SMI) in 69 patients is presented. Out of the 69 cases, 2 patients died in the early post-operative period. Twenty (30%) SMI were retained for a period of 1 year to 5 years. Forty seven (70%) SMI were retained for a period of less than 1 year. These implants have been used in a variety of cases, with or without major flap reconstruction, where a skeletal support was indicated, especially after mandibular arch resection. The results of this series indicates the importance of these implants as a short term spacer, even in advanced, fungating lesions of head and neck cancer where the risk of infection, haematoma and salivary leak is very high. Bone replacements were undertaken at a later date in suitable cases. The effects of preoperative chemotherapy and radiotherapy on the retention of these implants has also been studied.