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.     

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 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.     

A locus for autosomal recessive hypodontia with associated dental anomalies maps to chromosome 16q12.1

Lumbosacral defects on 20 patients were covered with a perforator-based flap. Cutaneous perforators derived from the 9th and 10th intercostal arteries, the 4th lumbar artery, and multiple gluteal perforators that penetrate the gluteus maximus muscle were used as vascular pedicles. Minor complications occurred in five cases. Using this method, minimal morbidity of the donor site is expected because the gluteus maximus need not be sacrificed. Accordingly, perforator-based flaps are especially indicated for ambulatory patients, but for paraplegic patients as well. Even in the event of recurrence, another perforator-based or musculocutaneous flap can be elevated from the ipsilateral side because of the presence of multiple perforators in the lumbosacral and gluteal regions.     

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.     

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.     

A modified design of the buried radial forearm free flap for use in oral cavity and pharyngeal reconstruction

OBJECTIVE: We present a new design for the radial forearm flap that includes a small monitor segment that is connected to the primary skin paddle by a fascial subcutaneous segment of tissue. This design modification permits buried flaps to be easily monitored and provides vascularized tissue coverage of the flap vessels as well as the great vessels in the neck. Immediate augmentation of the radical neck deformity can be achieved. SETTING: This study was conducted at a referral center. PATIENTS: Fifteen patients with squamous cell cancer of the pharynx and tongue base were included in this study. The defects in these patients were judged to be best reconstructed with a radial forearm free flap. RESULTS: All free flaps in this series survived. There was one case, described in detail, in which the fascial subcutaneous portion of the flap was exposed to salivary contamination. The flap vessels remained well protected and flap viability was unimpaired.     

Mode of vascularization of control and basic fibroblast growth factor-stimulated prefabricated skin flaps

This study, using 62 rabbits, examines the rate and pattern of vascular outgrowth from a subcutaneously implanted vascular pedicle, how the newly formed vessels connect to preexisting skin vessels, and whether local application of basic fibroblast growth factor can accelerate the angiogenic process. When the femoral artery and vein of rabbits are implanted beneath the skin, angiogenesis from both the pedicle and small blood vessels within the adjacent skin begins within 3 days. Perfusion with India ink reveals connections between the pedicle and dermal vessels as early as 5 days after implantation of the pedicle. Provided the pedicle does not thrombose, skin flaps based on it may survive completely when elevated as early as 2 weeks after implantation. Flap survival depends on the development of a small number of vascular connections between vessels arising from the pedicle and preexisting dermal vessels. If elevation is delayed until 4 weeks after implantation a flap may survive even if its pedicle has thrombosed. Prolonged release of basic fibroblast growth factor adjacent to the pedicle significantly increases the survival of flaps elevated 1 week after implantation but does not alter the survival of flaps elevated at 2 and 4 weeks.     

Two-stage arterialized flow-through venous flap transfer for third-degree burn defects on the dorsum of the hand

A modified, two-stage arteriovenous flow-through venous flap was designed to repair skin defects due to third-degree burns on the dorsum of the hand in four patients. Two weeks after plasty of an arteriovenous (A-V) shunt between the greater saphenous vein and dorsalis pedis artery, the arterialized flow-through venous flap was transferred using the greater saphenous vein as the pedicle. The size of the flaps utilized ranged from 7 x 13 cm to 9 x 13 cm. In three patients the entire flap survived without complication. In one patient whose flap had only one drainage vein, the flap survived with superficial necrosis of about 10 percent of the flap at the borders. During the 2 weeks after A-V shunt creation, the authors believe that microcirculation around the arterialized vein probably develops, contributing to better irrigation and thereby to flap survival. Using this two-stage procedure, it might be feasible to obtain larger grafts and to attain a higher flap survival rate.     

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.     

Total knee arthroplasty covered with pedicle peroneal flap

Three cases of total knee arthroplasty (TKA) covered with pedicle peroneal flaps are reported. One peroneal flap was performed after TKA to correct post-TKA skin necrosis. Two peroneal flaps were performed before TKA to replace previous traumatic scar formed around the knee. All three TKAs were successful after the procedure. The thickness, elasticity, appearance, and durability of the peroneal flaps were more suitable for the skin around the knee than the gastrocnemius muscle flap or the local fasciocutaneous flap. As the peroneal flap was elevated as a pedicle flap, freedom of transfer was good, microanastomosis was not necessary, and no donor sites were needed from the contralateral limb. Scar tissue around the knee can be effectively replaced by the pedicle peroneal flap before TKA.     

One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.     

Repair of large chest wall defects using pedicle flaps

Three cases of chest wall resection illustrate the use of three different full thickness pedicle flaps which can be used to cover almost any area of the anterior chest wall. The medially based acromiothoracic flap was swung inferiorly to cover a lateral defect. Laterally based abdominal wall and axillary flaps were used to cover more medial defects. In case III bilateral axillary flaps were necessary to cover a huge central defect after resection of the anterior sternum and anterior cartilages of seven ribs for a sebaceous carcinoma.     

Clinical scrutiny of the de facto superiority of proximally versus distally based fasciocutaneous flaps

Just as the dogma that skin flap survival depends on rigid length-to-width ratios has been refuted as a consequence of advances in understanding the anatomical basis of the cutaneous circulation, the generalization that distally based flaps are inherently inferior to proximally based flaps also deserves to be challenged. All else being equal, the truly critical factor for flap viability in either case is the nature of their intrinsic blood supply rather than any arbitrary configuration or orientation. Previous laboratory evidence has proved this fact and is now further validated by a clinical experience with 194 local fascia flaps in 174 patients. There was a 22.2 percent overall incidence of complications, but no statistically significant difference in this rate was observed whether the flap was distally based (18.8 percent of 16 flaps) or proximally based (23.5 percent of 162 flaps) (p = 0.669). Major complications, usually a failure of the intended coverage, actually were more common for proximally based flaps (12.9 percent) than those distally based (6.3 percent), although not statistically different (p = 0.436). Bipedicled fasciocutaneous flaps, which should have had augmented perfusion from their dual sources of inflow, sustained complications in 12.5 percent of 16 flaps. Although none was classified as a major problem, again no difference was apparent when compared with proximally based (Pprox = 0.316) or distally based (pdis = 0.626) flaps. Some caution is prudent in interpreting these retrospective data, not because of an admitted bias for more frequent selection of proximally based flaps, but because the choice for any of these local fasciocutaneous flap always followed a careful assessment of the status of the fascial plexus adjacent to any defect. Audible or color Doppler ultrasound localization of available cutaneous perforators can predetermine the feasibility of any option, thereby ensuring a reasonable success rate regardless of pedicle orientation.     

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.     

Role of the perforating vein in vascular pedicle of free forearm flap

An innovation in the preparation of the vascular pedicle of the free radial forearm flap is presented. While the radial artery is commonly used as the arterial pedicle of the flap, either the cutaneous venous system or the radial comitant vein (deep venous system) is used as the venous pedicle. The perforating vein communicates between these two venous systems at the cubital fossa, and we confirmed its presence in all but one of more than 180 cases. When the vascular pedicle is dissected proximally to the perforating vein contained in the flap, the venous drainage of both the deep and cutaneous systems can be restored by anastomosis of only one vein: the cutaneous or the radial comitant vein. On the other hand, the flap can be raised with the radial vessels (without the cutaneous vein) at the start of surgery, and a large caliber cutaneous vein, such as the median cubital, the cephalic, or the basilic, can be used for anastomosis in cases where the cutaneous veins in the distal forearm are too thin, or where the radial comitant vein is composed of two thin separated veins. We believe that preserving the perforating vein would make the forearm flap more reliable and more convenient in reconstructive surgery.     

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.     

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.     

Arteriovenous cross-flow flap in rats: a novel skin flap

Angiosomes are blocks of tissues, composed of the integument and underlying deep structures, supplied and drained by a named artery and its accompanying vein. The purpose of the current study is to describe a new principle, which allows extension of the territory of an angiosome into the adjacent angiosome, thus enabling the creation of a large skin flap (arteriovenous cross-flow flap). Epigastric skin flaps, measuring 8 x 8 cm, were raised in 30 Sprague-Dawley male rats. In group A (single-pedicle flap), the flaps were based on the epigastric artery and vein on the ipsilateral side, and the contralateral pedicle was divided. In group B (cross-flow flap), the epigastric vein on the ipsilateral side and the epigastric artery on the contralateral side of the flap were divided. In group C (skin graft), the vascular pedicles were divided bilaterally. A definitive assessment was made on the seventh day. Digital images of the flaps were analyzed using an imaging software and the areas of skin survival and necrosis were determined. Lead oxide microangiogram was performed in another set of flaps both acutely and 1 week after flap elevation. The percent survival flap area in group A was 69.94, in group B was 89.07, and in group C was 13.00. All the groups are statistically different, with a p value < 0.001. The microangiograms showed striking differences in the vascular pattern in the cross-flow and the single-pedicle flaps. It is clearly demonstrated that the arteriovenous cross-flow flaps have increased survival of skin when compared with the conventional axial-pattern 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.