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.     

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.     

The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects

Myocutaneous (MC) free flaps are useful for many reconstructive indications. Perforator flaps have become standard of care. The anterolateral thigh flap (ALT) donor site is popular. With the ALT flap varying sizes of vastus lateralis (VL) muscle can be harvested as a MC flap. The skin islands of these flaps have a great range of freedom when dissected on their perforator. It was hypothesised that the VL–ALT perforator flap would offer adequate tissue volume combining maximal freedom in planning with minimal donor site morbidity. From November 2001 to February 2003 a free partial VL with ALT perforator flap was used in 11 patients to reconstruct large defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura, or osteosynthesis material, open sinuses, and lack of muscular bulk. Flaps were planned as standard ALT flaps, after which three types of dissection were performed: I. true MC flap; II. muscle flap with a skin island on one perforator, which could be rotated up to 180°; III. chimera skin perforator flap with muscle being harvested on a separate branch from the source vessel or on a side branch of the skin perforator. Mean skin size of the MC-ALT flaps was 131 cm². Mean muscle part size of the MC-ALT flaps was 268 cm³. Muscular parts were custom designed for all defects. No total or partial flap failures were seen. Colour mismatch was seen in 6 of 8 patients, when skin was used in the facial area in this all white population. Excessive flap bulk was found in 8 of 11 patients at 6 weeks, however, only in 2 of 11 patients after 6 months. Patients were satisfied with the functional result (8 of 11 patients) as well as the cosmetic result of their reconstruction (7 of 11 patients). All less satisfied patients had received their flap for external facial skin reconstruction. Donor site morbidity was minimal. The combined free partial VL with ALT perforator flap proved valuable as a (chimera type) MC flap with maximal freedom of planning to meet specific reconstructive demands and minimal donor site morbidity.     

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.     

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.     

Pectoralis major myocutaneous flap for reconstruction of defects following resections in head and neck area

Pectoralis major myocutaneous flap (PMMF) has become the standard for reconstruction of major defects in head and neck area. Eleven cases, operated over a three year period, in which PMMF was used for reconstruction have been reviewed retrospectively. Nine patients had oral squamous cell carcinoma, one had a basal cell carcinoma of the external ear and one had lost skin and soft tissue of neck following synergistic gangrene. Ten of the eleven flaps survived (success rate 91%). One of the three rib grafts used to reconstruct mandible got infected and had to be removed. Three patients developed wound infections and one had a temporary orocutaneous fistula which closed spontaneously. This brief experience confirms the reliability and efficiency of PMMF for head and neck reconstruction.     

ACL reconstruction in children with open physes

Flap reconstruction of the vulva and vagina following gynecological ablative procedures has become an integral part of the management of gynecological oncology patients. The benefits of flap reconstruction, including early primary healing, improved cosmesis over skin grafting, and prolonged secondary wound healing, have been well accepted. Additionally, the creation of a neovagina or neovulva often restores the sexual function and positive body image of the patient lost to radical procedures. The gracilis musculocutaneous flap has been used extensively in flap reconstruction but reports of partial flap necrosis and the need for extensive dissection of both thighs have led to alternative flap choices. The rectus musculocutaneous flap, with its hardier cutaneous blood supply, is often too bulky and difficult to inset delicately around the preserved urethral and vaginal cuff. The umbilicus has the required soft tissue, and its conically contoured depression allows for delicate insetting of the rectus abdominis musculocutaneous flap around the urethral cuff. We present 2 patients who underwent vertical rectus musculocutaneous flaps with umbilical soft tissue to restore urinary function and to create a cosmetic nonfunctional vagina.     

The structure of the L3 loop from the hepatitis delta virus ribozyme: a syn cytidine

Insufficiency of tissues and progressive contraction usually restrict the application of prosthetic devices in anophthalmic eye sockets. To achieve a successful reconstruction, the plastic surgeon has to form a socket that has proper dimensions and is completely covered by a well vascularized epithelial surface. Eye socket reconstruction with free skin, mucous membrane, or dermis-fat grafts usually remains unsatisfactory in severe cases. We have used a prefabricated temporal island flap to solve this difficult problem since 1983. In this method, a full-thickness skin graft is applied over the temporal fascia to create a prefabricated island flap based on the superficial temporal vessels. This flap is transposed into the eye socket 3 weeks later. Some modifications in flap design have been done to get better fitting of the prosthesis since that time. Thirty-three patients with constricted eye sockets that could not use prosthetic devices were treated with prefabricated temporal island flaps since 1983. The follow-up period was between 1 and 13 years. Eye sockets with adequate size and volume were created in all patients, and the results were successful. This method prevented secondary graft shrinkage, and the prefabricated island flaps preserved their dome shape during the follow-up period. We believe this method is a useful one in the treatment of the contracted socket.     

Clinical application of thoraco-umbilical skin flap

Since 1987 we have successfully used thoraco-umbilical skin flaps as free transplants to repair 8 cases of severe burn scar deformities of jaw-neck and hand regions, thoraco-umbilical insular skin flaps to each case of congenital vaginal atresia, severe vulval scar due to sulfuric acid burn and large penal tissue defect accompanied with severe urethral leakage. This flap has the following advantages: namely definite anatomical position, larger vascular diameter, fight large skin flap area, and similar skin completion as that of the jaw-neck region. Therefore they are the ideal substitute for the repair of soft tissue defects of jaw-neck region as well as extremities. The flap has long vascular pedicle, abundant vascularization, easy transportation and it is suitable to be a retrograde insular flap for repairing of vulval tissue defect, reformed penal vaginoplasty.     

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.     

Ipriflavone

Soft-tissue repair in the hand often requires skin flaps due to exposure of bone, tendons, nerves, and arteries. However, alternatives for flap surgery are very limited, especially in dealing with palmar hand reconstruction. In the present report, the dorsal branch of the ulnar nerve and its accompanying artery were studied anatomically, and a neurocutaneous flap distally based on these structures was developed. The flap was raised on the medial aspect of the hand and distal half of the forearm, and its rotation point was located dorsally near the metacarpalphalangeal joints. The clinical use of this flap for the repair of skin defects in the hand is reported. All the clinical flaps survived completely, including a 3.5 x 13-cm large flap. Donor site morbidity was minimal. This flap represents a new alternative in hand reconstruction.     

The principle of Colson's flap applied to facial reconstruction

Reconstruction of facial skin defects after cancer surgery or trauma with conventional flaps can give a poor cosmetic result when a thick flap is used to replace thin skin. The thickness of the flap can be a disadvantage to replacing a thin skin. Defatting the flap can resolve these situations, using the principle of Colson's flap. This operative procedure is safe, and improves the cosmetic results. The authors report a series of 21 full-thickness skin defects located at the junction of two or three regional units. The defects were repaired with total or partial undermining flap (frontal, nasoiabial, cheek flaps). The viability of these reconstructions was perfect and the cosmetic results fairly esthetic in comparison with conventional flaps.     

Repair of central upper lip (philtral) surgical defects with island pedicle flaps

BACKGROUND: Surgical defects of the central upper lip (philtrum) are a particularly difficult area to achieve satisfactory cosmetic and functional repair. Reconstruction of the central upper lip has been accomplished primarily through the use of side-to-side closure, bilateral advancement or rotation flap, and full-thickness graft. Repair may be complicated by distortion of the vermilion border, obliteration of the normal contour of the philtrum, eclabium, and trapdooring of the flap. OBJECTIVE: We review the options for reconstruction of this area and describe our experience using an island pedicle flap to complete reconstruction. METHODS: Four patients presented with basal cell carcinomas of the mid upper lip (philtrum). Tumors were cleared by Mohs micrographic surgery. Reconstruction was achieved by island pedicle flaps utilizing donor tissue from the superior philtrum. RESULTS: The patients had excellent cosmetic results with minimal distortion of the vermilion border or obliteration of the philtrum or philtral ridges. Scars healed in a nearly imperceptible fashion, keeping within one cosmetic unit (the philtrum) without extending along the vermilion border as seen in bilateral advancement or rotation flaps. CONCLUSIONS: Island pedicle flaps may be an effective cosmetic and functional repair of selected surgical defects of the central upper lip involving the philtrum.     

Resurfacing a circumferentially degloved hand by using a full-thickness skin graft harvested from an avulsed skin flap

Twelve patients with circumferentially degloved hands were treated with full-thickness skin grafts harvested from defatted avulsed flaps. All injuries were industrial accidents caused by various roller machines, not crush injuries. Of these 12 patients, 9 patients were degloved from the wrist level and 3 patients were degloved from the forearm. There were 11 distally based skin flaps and one flap was completely detached. Four patients were avulsed distally to the mid palm, with volar neurovascular bundles damaged at the "fenestrae" of the palm, which resulted in devascularization of the involved fingers. Among them, distal fingers were successfully revascularized by microsurgical techniques in 3 patients. The full-thickness skin grafts were prepared from the attached, avulsed skin flap to avoid junctional hypertrophic scarring. The graft was then secured to its anatomic position with multiple skin staples to improve skin graft take. Initial take of the graft averaged 93% (range, 85%-100%). Compared with conventional methods, this approach provides a higher rate of skin take and better cosmetic and functional results.     

DNA variation in a 5-Mb region of the X chromosome and estimates of sex-specific/type-specific mutation rates

Owing to its unique anatomic arterial supply and dual nerve innervation, the first web space of the foot can be used to harvest various sizes and shapes of flaps, which the authors have classified into four types according to their usage in hand reconstruction. This in turn depends on the site, shape, and size of the soft-tissue defect in the hand. Web skin flaps (n = 8) were used in prevention of contracture in the first web space and for proximal finger reconstruction. Two-island skin flaps (n = 4) were used to resurface the pulp defect in two adjacent fingers. In severe adduction contracture of the first web space, fill-up web flaps (n = 10) were used to replace the volume defect after a release procedure in the hand. Adjuvant web flaps (n = 9) were used in wrap-around procedures, in dorsalis pedis flap transfer, and in vascularized joint transfer to supplement the main flaps and to restore sensation in the reconstructed area. In the past 10 years up to February of 1998, a total of 31 patients with soft-tissue defects in the hand and fingers were reconstructed using the web space free flap with flap survival rate of 100 percent. The mean static 2-point discrimination was 8.5 (7.2 to 10) mm, and the mean first web angle was 86 degrees. The advantage of the first web space flap from the foot is that it can easily be harvested to match various sizes and shapes of defects in the hand and fingers. In addition, because of the anatomic similarity in contour, thickness, texture, and nerve innervation with the hand, the sensory restoration is excellent with minimal morbidity at the donor site. By classifying the flaps into four types according to various sizes, shapes, and the site from which the flap are harvested, clinical usefulness in various types of hand and finger reconstruction was confirmed.     

Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals

When inversion of combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has become impossible or has not led to functional results, alternative vaginoplasty techniques should be considered. Colocolpopoiesis involves major surgery and often leads to disappointing long-term results. An Abbé-McIndoe vaginoplasty applying split-thickness skin grafts often does not provide favorable results in the scarred area encountered after complications of skin flap inversion surgery. Because thicker skin grafts show less tendency to shrink, the use of a full-thickness skin graft has been advocated for vaginoplasty in females. In this paper, we present our technique of successful secondary vaginoplasty applying full-thickness skin grafts in six male-to-female transsexuals. In patients with sufficient groin and abdominal skin to spare, a miniabdominoplasty allows for acceptable donor site scarring combined with correction of the abdominal skin surplus. In flat-tummied patients, the conventional abdominoplasty will allow for sufficient skin to be harvested to ensure successful secondary vaginoplasty. Abdominoplastic vaginoplasty has been proven to provide a good alternative whenever a laparotomy is not favored or is contraindicated in secondary cases.     

Second free flaps in head and neck reconstruction

Over the past decade, free-tissue transfer has greatly improved the quality of oncology-related head and neck reconstruction. As this technique has developed, second free flaps have been performed for aesthetic improvement of the reconstructed site. This study evaluated the indications for and the success of second free flaps. Medical files for patients who underwent second free flaps for head and neck reconstruction at the University of Texas M.D. Anderson Cancer Center, from May 1, 1988 to November 30, 1996, were reviewed. The flaps were classified as being either immediate (done within 72 hr) or delayed (done within 2 years) reconstructions. Indications, risk factors, recipient vessels, outcome, and complications were analyzed. Of the 28 patients included in this study, 12 had immediate (nine as salvage after primary free flap failure, and three for reconstruction of a soft-tissue defect), and 16 had delayed second free flaps (two for reconstruction of a defect resulting from excision of recurrent tumors, and 14 for aesthetic improvement). Reconstruction sites included the oral cavity in 18 patients; the midface in six; the skull base in two; and the scalp in two. The success rate for the second free flaps was 96 percent. Five patients had significant wound complications. In a substantial number of cases, identical recipient vessels were used for both the first and second free flaps. The authors conclude that second free flaps can play an important role in salvaging or improving head and neck reconstruction in selected patients. In many cases, the same recipient vessels can be used for both the first and second flaps.     

Free skin transplantation in the maxillo-facial area. Report on 172 cases

Between 1971 and 1977, in the department of maxillo-facial surgery (University of Tübingen) 160 patients were treated by 172 free skin grafting in the oral and maxillo-facial region. In 140 cases split skin grafts, in 32 cases full-thickness skin grafts were used. The aesthetic and functional results were very good to satisfactory in 98.3% (169 out of 172 grafts), in 1.7% (3 cases) did skin grafting have to be repeated.     

Bilateral breast reconstruction: conventional versus free TRAM

Free TRAM flap transfer is now routinely offered to patients requiring breast reconstruction. This study compares results of conventional superior-pedicled TRAM flaps and free TRAM flaps in bilateral breast reconstructions. A total of 92 breasts were reconstructed in 46 patients. Eighteen patients had free TRAM flap reconstructions, and 28 patients were reconstructed with conventional TRAM flaps. Comparison of average operative blood loss and average operative time for the two techniques showed blood loss of 575 cc and an operative time of 9.6 hours for the free TRAM reconstructions and a blood loss of 313 cc and an operative time of 6.6 hours for the conventional TRAM reconstructions. For free TRAM flap reconstructions, both blood loss and operative time decreased significantly between the first and second group of nine patients: from 819 to 360 cc of blood loss and from 10.5 to 8.9 hours of operative time. Partial flap loss (skin and fat necrosis) and fat necrosis only occurred in 13 and 7 percent, respectively, of conventional TRAM flaps, but neither occurred in free TRAM flaps. However, early in the series, three free flaps were lost in two patients, requiring implant placement. Bilateral breast reconstruction using the free TRAM flap may offer a lower complication rate than the conventional TRAM flap by virtue of improved blood supply and less abdominal wall disruption. Surgeons, however, are forewarned that this procedure has a steep learning curve, and surgeons lacking microsurgical expertise may be better served by the conventional TRAM flap.     

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.