The use of free rectus abdominis myocutaneous flap to close the empyema space with alveolar fistula--a case report

A 59-year-old man, who had had right middle and lower lobectomy for pulmonary tuberculosis, admitted for the treatment of empyema with fistula. Closure of empyema space with free rectus abdominis myocutaneous flap was performed following open window thoracotomy and thoracoplasty. As he previously underwent two major operation, lobectomy by posterolateral approach and gastrectomy for gastric ulcer, free rectus abdominis flap was chosen instead of omental flap or latissimus dorsi myocutaneous flap. Postoperative CT film showed that this flap was filled up in all interstices of the empyema cavity. The pedicle vessels to this flap are large enough to provide long stalks, so microsurgical anastomosis can be accomplished safely. The use of free rectus abdominis myocutaneous flap is one of a useful maneuver for chronic empyema with fistula.     

Use of ultrasonography to evaluate muscle thickness and blood flow in free flaps

The purpose of this study was to investigate the common belief that a microvascular transfer of a non-innervated free muscle flap loses muscle bulk over time. Sixteen patients (latissimus dorsi = 8, rectus abdominis = 7, and gracilis muscle = 1) were evaluated an average of 41 months after free flap transfer. Latissimus dorsi and lower extremity flaps displayed significantly more swelling than the other flaps. Flap bulk was measured by ultrasound. The mean thickness of upper extremity flaps was 10.3 +/- 1.8 mm (control muscles 11.8 +/- 2.8), lower-extremity 14.5 +/- 3.7 mm (control muscles 10.9 +/- 0.7), latissimus dorsi 14.3 +/- 2.2 mm (control muscles 10.3 +/- 0.8, P = 0.018), and rectus abdominis 11.2 +/- 1.2 mm (control muscles 12.4 +/- 1.9). Color Doppler ultrasonography was used to detect the pedicles of the free flaps and also to measure the peak velocity of blood flow intramuscularly and in the pedicles. In the upper extremities (n = 5) the pedicles could be found in only 20% of cases whereas in the lower extremities (n = 11) 91% of pedicles were located. (P = 0.013). Peak flow within the free flaps was significantly higher in the lower extremity (50% of the peak flow of the common femoral artery) than in the upper extremity (5% of the peak flow of the common femoral artery, P = 0.013). This study demonstrated that non-innervated free muscle flaps in the extremities maintain the original muscle thickness, although lower extremity and latissimus dorsi flaps have a trend to be thicker. Most pedicles of free muscle flaps in the upper extremities could not be located by ultrasound. However, flaps in the lower extremities most often have patent pedicles and also more vigorous intramuscular blood flow.     

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.     

Sensate myocutaneous latissimus dorsi flap

A case using a sensate myocutaneous latissimus dorsi flap for oral defect reconstruction is reported. Preparation of the cutaneous branches of a latissimus dorsi autologous transfer and their subsequent anastomoses with sensitive nerves at the recipient site resulted in superficial and deep sensibility of the transfer, following a short rehabilitation period. As early as 4 months postoperatively, pain and pressure sensations could be evoked in the flap. Sharp and blunt discrimination and sense of vibration were found 6 months postoperatively. Nine months postoperatively, caloric differentiation could be elicited.     

Changes in pulmonary artery size before and after total cavopulmonary connection

The aim of any abdominal wall reconstruction is maximal functional stability and adequate soft tissue coverage. The anatomy, elevation and clinical application of the myofascial tensor fasciae latae transposition flap and of the microvascular musculocutaneous latissimus dorsi free flap are presented. Repairing extensive fascial defects and recurrent hernias with the tensor fasciae latae transposition flap provides strong, dynamic, and functional reconstruction of fascial continuity to prevent a further recurrence. Adequate functional and aesthetic repair of a full-thickness abdominal wall defect can be optimally managed by the innervated microsurgical latissimus dorsi free flap.     

Vertical double flap design for repair of wide defects of the lower limb, using combined ascending scapular and latissimus dorsi flaps

Two cases are presented in which a scapular osteocutaneous flap and a latissimus dorsi musculocutaneous flap were applied as combined flaps with a single pedicle, to repair massive soft-tissue defects resulting from tibial hemisection in the lower limb. In each case, the oval-shaped donor site was divided into two parts (an ascending scapular flap and a latissimus dorsi flap, respectively) to repair the resected area, using a vertically designed, combined flap from the dorsolateral region. Consequently, after flap elevation, the donor site could be closed primarily and functions of the affected limb could be completely reconstructed. For reconstruction of defects too large to be covered with a single flap, the vertical double flap design of a combined ascending scapular and latissimus dorsi flap is a good alternative. It has the merits of easy dissection, broad area skin coverage and it also provides a composite flap that contains a scapular bone graft. Moreover, it allows a simple microsurgical anastomosis, as well as direct closure of the donor site. In addition, when the recipient site is on the lower leg, flap elevation can be carried out simultaneously with surgery at the recipient site. This means that the operative time can be shortened.     

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.     

Effects of sodium nitroprusside and phenylephrine on blood flow in free musculocutaneous flaps during general anesthesia

BACKGROUND: Hypoperfusion and necrosis in free flaps used to correct tissue defects remain important clinical problems. The authors studied the effects of two vasoactive drugs, sodium nitroprusside and phenylephrine, which are used frequently in anesthetic practice, on total blood flow and microcirculatory flow in free musculocutaneous flaps during general anesthesia. METHODS: In a porcine model (n = 9) in which clinical conditions for anesthesia and microvascular surgery were simulated, latissimus dorsi free flaps were transferred to the lower extremity. Total blood flow in the flaps was measured using ultrasound flowmetry and microcirculatory flow was measured using laser Doppler flowmetry. The effects of sodium nitroprusside and phenylephrine were studied during local infusion through the feeding artery of the flap and during systemic administration. RESULTS: Systemic sodium nitroprusside caused a 30% decrease in mean arterial pressure, but cardiac output did not change. The total flow in the flap decreased by 40% (P < 0.01), and microcirculatory flow decreased by 23% in the skin (P < 0.01) and by 30% in the muscle (P < 0.01) of the flap. Sodium nitroprusside infused locally into the flap artery increased the total flap flow by 20% (P < 0.01). Systemic phenylephrine caused a 30% increase in mean arterial pressure, whereas heart rate, cardiac output, and flap blood flow did not change. Local phenylephrine caused a 30% decrease (P < 0.01) in the total flap flow. CONCLUSIONS: Systemic phenylephrine in a dose increasing the systemic vascular resistance and arterial pressure by 30% appears to have no adverse effects on blood flow in free musculocutaneous flaps. Sodium nitroprusside, however, in a dose causing a 30% decrease in systemic vascular resistance and arterial pressure, causes a severe reduction in free flap blood flow despite maintaining cardiac output.     

Acute adenosine treatment is effective in augmentation of ischemic tolerance in muscle flaps in the pig

The objective of the present project was to investigate the efficacy and mechanism of acute (10-minute) adenosine treatment for augmentation of ischemic tolerance in muscle flaps in pigs. Varying doses of adenosine were infused into 28 latissimus dorsi muscle flaps through the axillary artery (0, 0.5, or 2.0 mg per flap) and 22 gracilis muscle flaps through the medial circumflex femoral artery (0, 10, or 20 mg per flap) over 10 minutes. Ten minutes after adenosine infusion, these muscle flaps were subjected to 4 hours of sustained warm global ischemia. In addition, one group of latissimus dorsi muscle flaps (n = 6) received a 10-minute intraarterial adenosine infusion (0.5 mg) at the beginning of reperfusion. Muscle biopsies (n = 4 or 5) for adenosine triphosphate (ATP) analysis were obtained before and after adenosine infusion and at the end of 4 hours of ischemia. The extent of muscle infarction was assessed at 48 hours of reperfusion by the tetrazolium dye staining technique. Muscle blood flow in latissimus dorsi muscle flaps was measured at the end of adenosine infusion (0 or 0.5 mg per flap, n = 8) by the radioactive microsphere (15-microns) technique. It was observed that adenosine, at all doses tested, significantly (p < 0.05) reduced the extent of muscle infarction in latissimus dorsi muscle flaps (control, 40.3 +/- 2.2 percent; 0.5 mg, 20.6 +/- 1.6 percent; 2.0 mg, 18.2 +/- 1 percent) and gracilis muscle flaps (control, 31.0 +/- 1.5 percent; 10 mg, 14.3 +/- 3 percent; 20 mg, 11.6 +/- 1.2 percent). Preischemic adenosine treatment (0.5 mg per flap) was associated with maintenance of a significantly (p < 0.05) higher muscle content of ATP in latissimus dorsi muscle flaps at the end of 4 hours of ischemia compared with saline-treated ischemic controls. Postischemic adenosine treatment did not protect latissimus dorsi muscle flaps against infarction. Furthermore, adenosine treatment did not have any significant effect on mean systemic arterial blood pressure or muscle blood flow in latissimus dorsi muscle flaps. It is concluded that acute (10-minute) preischemic adenosine treatment is effective in augmentation of ischemic tolerance in muscle flaps and that this protective effect of adenosine may be, at least in part, the result of slowing muscle ATP depletion during sustained ischemia. The possible mechanisms of this adenosine-induced energysparing effect are discussed.     

The use of microvascular free flaps in the repair of the skin of the upper limb

Between 1980 and 1992 microsurgical free flaps were used in 35 patients for the repair the of skin defects in the upper limb. Twenty six patients were male and nine female. The scapular flap was done in 16 cases, the lateral flap in seven, the dorsalis pedis in four, the neurovascular first web space in four, the latissimus dorsi in two, the radical forearm flap in one and the gracilis in other one. The survival rate in this series was 88.57%. Early free flaps were performed in 12 patients of whom one developed infection at the recipient site. Two-point discrimination was achieved in four thumbs reconstructed with the neurovascular first web flap. No complications occurred at the donor areas.     

Use of 20 cm or longer interposition vein grafts in free flap reconstruction of the trunk

Between January of 1993 and September of 1995, six microsurgical free tissue transplants were performed using saphenous vein grafts ranging from 20 to 39 cm in length. All six free flaps survived. Two wounds were caused by radiation injury and two by tumor resection. The remaining two free flaps were performed for contour deformity and spinal cord coverage. All of the recipient sites were located on the trunk. In each case, an arteriovenous loop was created before the microvascular anastomosis to the free flap. There was one arterial thrombosis requiring thrombectomy and revision of the anastomosis. Three patients developed minor wound complications that responded to local wound care. Each of the flaps successfully provided wound coverage, and in two cases the flaps tolerated further radiation results. Long interposition vein grafts can be used for difficult microsurgical reconstructive procedures with reliable results when no local recipient vessels are available. Versatility is therefore afforded in placement of the flap and the choice of recipient vessels, making this option a useful one in the treatment of complex wounds of the trunk.     

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.     

Sensory recovery in noninnervated radial forearm free flaps in oral and oropharyngeal reconstruction

BACKGROUND: Reinnerveration of free flaps used in oral and oropharyngeal reconstruction may provide a high level of sensory return. Spontaneous recovery of sensation in noninnervated flaps may also occur. OBJECTIVE: To evaluate the extent of spontaneous sensory return among patients who underwent radial forearm free flap reconstruction in the oral cavity and oropharynx. METHODS: A total of 40 patients were evaluated by 2 independent examiners. The median patient age was 60 years, and the median time from surgery was 47 months. A total of 29 patients had received postoperative radiotherapy. The mean flap size was 25 cm2. The following sensory modalities were tested: light touch, pinprick, hot and cold, and moving and static 2-point discrimination. RESULTS: Recovery of sensation of at least 1 modality was noted in 32 patients (80%), however, only 5 patients (13%) had return of all 5 modalities. Eight patients (20%) had no sensory return. There was a trend to improved sensory recovery in flaps placed in the alveolar and retromolar trigone areas; however, on multivariate analysis, sensory return could not be predicted by any of the following factors: patient age, flap site, flap size, length of follow-up, and use of postoperative radiotherapy. CONCLUSIONS: Complete sensory recovery was uncommon, unpredictable, and variable, although some recovery of sensation occurred in 80% of patients. It is not valid to rely on spontaneous sensory recovery for sensory innervation of free flaps. Correlation of sensory return with function is still needed.     

Modifications of the paraspinous muscle flap: anatomy and clinical application

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.     

Free split and segmental latissimus dorsi muscle transfer in one stage for facial reanimation

The authors report the experience in facial reanimation using free innervated split and segmental latissimus dorsi muscle flap one-stage transfer in 86 patients with longstanding facial palsy. The segmental latissimus dorsi was taken from the distal part of the muscle so that the muscle flap had an ultra-long neurovascular pedicle of 13 to 17.5 cm in length. The muscle flap was made thinner by splitting the segmental muscle. The split segmental muscle flap was transferred to the paralyzed side of the face with its ultra-long neurovascular pedicle passing through a tunnel in the upper lip to the normal side of the face. The neurovascular pedicle of the muscle flap was anastomosed with the facial nerve, artery, and veins, respectively, on the normal side of the face. The operation was designed without the cross-facial nerve graft stage. From 1986 to October of 1997, 86 patients with long-standing facial paralysis were treated in our department. The duration of facial palsy in this series ranged from 1.5 to 51 years. A satisfactory result was obtained in 80 cases, evaluated at 8 months to 2 years postoperatively. The expression movement of the soft tissues of the face can be seen not only over transferred muscle but also on the paralyzed muscle covered by the splitting muscle flap. It is supposed that this is the result of muscle-muscle neurolization. Study of 66 specimens of latissimus dorsi muscle in the cadavers is discussed.     

Zonal expression of angiotensin II-AT1-receptor genes in rat kidneys

The trapezius osseomyocutaneous flap is the only pedicled flap that is able to transfer vascularized bone for mandibular reconstruction as well as skin for intra-extra oral reconstruction. The trapezius muscle also helps to fill the defect created by the neck dissection and covers the vessels of the neck. This flap has been used in our maxillofacial surgery service during the past 14 years. In spite of having incorporated microvascular flaps in our reconstructive techniques it continues to be one of the flaps we use in selected patients for bone and soft tissue compound defects of the oral cavity. We describe in this article our experience using this flap with dental implants in order to achieve a functional reconstruction. We also discuss when we use this flap for mandibular reconstruction and when a free vascularized flap is used.     

Poland's syndrome and vascular malformations

Unilateral hypoplasia of the breast and the pectoralis muscle with a missing anterior axillary fold as part of Poland's syndrome are of major concern, especially for women. The latissimus dorsi is one of the most suitable flaps for breast and anterior thorax reconstructions but it may be hypoplastic or absent. If so, a free tissue transfer of the contralateral latissimus dorsi muscle is the next possible option for reconstruction. As Poland's syndrome is additionally associated with vascular malformations of the diseased hemithorax such as hypoplastic or missing vessels, a preoperative angiography is mandatory for planned microvascular tissue transfer.     

Interpreting laser Doppler recordings from free flaps

Although the transfer of free flaps is nowadays accomplished with an increasing degree of safety, thrombosis of the microvascular anastomoses is still a problem. In order to avoid delay in re-operating, various methods for objective blood flow monitoring have been tried, among them Laser Doppler Flowmetry (LDF). When one reviews the literature, it is apparent that opinions differ about whether or not LDF is a reliable technique for this purpose. To focus on the need to interpret continuous recordings, this paper reports our findings in six latissimus dorsi free flaps chosen from our series of LDF monitoring procedures. One uneventful flap, no. 1, had an immediate postoperative LDF value of 4.5 perfusion units (PU). LDF values improved during the recovery period and the graphic recording showed fluctuations due to normal physiological variations of the blood flow in the flap. Another uneventful flap, no. 4, showed the same pattern, though at an appreciably lower level, 2 PU, on average. Flap no. 2 had an acceptably high value of 3.5 PU despite suffering a venous thrombosis. However, the LDF recording showed no fluctuations and the value declined gradually. Another flap, no. 3, showed fluctuations and blood flow was normal although the value decreased to 2.5 PU. In flap no. 5, any value between 2 and 3.5 PU could be obtained merely by adjusting the position of the probe in the holder. In no. 6, the LDF value suddenly dropped, accompanied by a decrease in the total amount of backscattered light, indicating venous obstruction which was confirmed at re-operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Using 2-step PCR and restriction endonuclease digestion to detect K-ras mutation in paraffin-embedded tissues: is it reliable?

BACKGROUND: Among the myocutaneous island flaps applied for reconstruction of large soft-tissue defects after ablative surgery for malignomas, the pectoralis major flap is the one most frequently used. In comparison, the sternocleidomastoid myocutaneous island flap is not as popular. METHODS: We report on our experiences with the superiorly based sternocleidomastoid myocutaneous (SCM) island flap (cutaneous island of 6-8 cm in diameter) in seven consecutive cases after resection of malignomas of the oral cavity and the pharynx. The vascularization from the occipital artery is additionally supplied by preserving the platysma during preparation of the SCM flap. RESULTS: Only one total cutaneous necrosis was observed in a patient who had received prior radiation. In the other 6 cases no major complications (necrosis or fistula) occurred. CONCLUSION: When the preservation of the sternocleidoid muscle does not compromise oncologic principles as in cases with limited lymphe node involvement (N0-N1), the SCM flap appears to be a useful and simple technique, particularly in female patients compared with the pectoralis major flap, in addition to others.